Examining the Availability and Accessibility of Rehabilitation Services in a Rural District of South Africa: A Mixed-Methods Study

Group Physical Therapy Programs for Military Members With Musculoskeletal Disorders: A Pragmatic Randomized Controlled Trial

OBJECTIVE: To compare the effects of personalized, supervised group-based programs (ie, group physical therapy programs) and usual one-on-one physical therapy care (ie, usual physical therapy care) on disability for military personnel suffering from low back pain, rotator cuff-related shoulder pain, patellofemoral pain syndrome, or lateral ankle sprain. Secondary outcomes were pain severity, pain-related fear, health-related quality of life, and patients' satisfaction with their condition and care. DESIGN: Non-inferiority pragmatic randomized clinical trial. METHODS: One hundred twenty military personnel from the Canadian Armed Forces, experiencing 1 of 4 targeted musculoskeletal disorders, were consecutively recruited and randomly assigned to group physical therapy programs or usual physical therapy care. Disability, pain severity, pain-related fear, and health-related quality-of-life outcomes were measured at 6, 12, and 26 weeks after baseline. Satisfaction with treatment was evaluated at the end of the intervention. Intention-to-treat analyses using linear mixed models with random effects were used to compare the effects of interventions. Chi-square tests were used to compare satisfaction. RESULTS: There were no significant Time × Group interactions for any of the primary and secondary outcomes (Time × Group: P>.67). Satisfaction with treatment also did not differ between groups (P>.05). Statistically significant and clinically important improvements were observed in both groups for all outcomes after 12 weeks (Time effect: P<.01), except for health-related quality of life (P = .13). CONCLUSION: Group physical therapy programs were not inferior to usual physical therapy care for managing pain, functional capacity, and patients' satisfaction with care of military personnel presenting with various musculoskeletal disorders. Both interventions led to clinical and statistical improvement in pain and function in the mid and long term. Group physical therapy could be an effective strategy to enhance access to care. J Orthop Sports Phys Ther 2024;54(6):1-10. Epub 26 Mar 2024. doi:10.2519/jospt.2024.12342.

Let the records speak: an exploration of rehabilitation services offered in primary healthcare, Johannesburg metropolitan district

BACKGROUND

Primary healthcare in South Africa aims to transform the national health system by emphasising community-based care and preventive strategies. However, rehabilitation services, particularly for individuals with disabilities and chronic non-communicable diseases, are often overlooked in primary healthcare. This study aimed to investigate the provision of primary healthcare rehabilitation services in the Johannesburg Metropolitan District by exploring client sociodemographics and variations in services provided by rehabilitation professionals.

METHODS

A retrospective review of clinic rehabilitation records from 2011 to 2020 was conducted at nine provincially funded community health centres (CHCs) offering rehabilitation services. Stratified sampling facilitated record selection based on rehabilitation service type and year. A specifically designed data extraction tool captured demographics, disabilities, rehabilitation received, and referral sources. Descriptive analysis used means, standard deviations, and frequencies.

RESULTS

The findings show a diverse client population with a wide age range, with a significant proportion falling into the < 5 years and 30-49 years age groups. Neuromusculoskeletal and movement-related disabilities were most prevalent, affecting approximately two-thirds of clients. Referral sources were often undocumented, and inconsistent discharge information with no record of patient follow up, highlighted the need for improved documentation practices. Clinic visits were the primary service delivery mode, followed by limited home visits and outreach services. Occupational therapy and physiotherapy were the most used services. Speech and language therapy services were underused, and some CHCs lacked audiology services. There were variations in the number of individual and group sessions provided by the different rehabilitation services, and there were age- and disability-specific differences in service use.

CONCLUSION

This study offers insights into rehabilitation service provision in the Johannesburg Metropolitan District and enhances our understanding of rehabilitation services in primary healthcare settings. It underscores the importance of a multidisciplinary rehabilitation team to address diverse rehabilitation needs, improving documentation and discharge practices, expanding service delivery models, and reducing disparities in service use. The findings inform strategies for optimising service delivery, workforce, resource allocation, and intersectoral collaboration to ultimately enhance the quality and accessibility of integrated rehabilitation services.

Integration of rehabilitation services in primary, secondary, and tertiary levels of health care systems in low- and middle-income countries: a scoping review

PURPOSE

Integration is a concept that seeks to strengthen the delivery of services to ensure people receive a continuum of care across the health system. We conducted a scoping review to explore how rehabilitation services have been integrated into health systems in low- and middle- income countries (LMICs).

MATERIALS AND METHODS

We conducted a scoping review using Valentijn's Rainbow Model of Integrated Care (RMIC) as an organising framework. The key enablers of integration of rehabilitation were extracted, charted and summarised according to the RMIC framework.

RESULTS

Of 4667 articles identified, 44 met inclusion criteria. Most studies focused on rehabilitation within secondary and tertiary level facilities, and described service models incorporating clinical, professional and functional integration characteristics. The geographical and clinical scope of rehabilitation models that demonstrate elements of integration from LMICs is limited.

CONCLUSION

The key enablers identified highlight the important role of responsive multidisciplinary care plans, and interdisciplinary guidelines, protocols and interprofessional education to support an integrated rehabilitation service model in LMICs.

Bridging the chasm between patients' needs and current rehabilitation care: perceptions of adults presenting for primary care in the Eastern Cape

BACKGROUND

The need for rehabilitation in low-to-middle income countries (LMICs) is rapidly increasing as more people are living longer with chronic diseases. Primary health care (PHC) is ideally placed to provide the spectrum of care required to meet most of the complex and evolving population's health needs locally. This study aimed to describe the patient journeys of adults attending primary care in the Eastern Cape province of South Africa to understand the factors that affected their access to primary care rehabilitation services (or the lack thereof) and obtain suggestions on how rehabilitation may be enhanced at primary care.

METHODS

A maximum variation sampling approach was used to purposefully select persons with varied chronic health conditions and demographic characteristics to gain diverse perspectives regarding their rehabilitation needs and ways in which the current rehabilitation services at primary care may be enhanced. Data were collected via face-to-face semi-structured interviews between March and June 2022 which were electronically recorded. Inductive thematic analysis of transcribed data was done and coded in Atlas.ti.22®.

RESULTS

Twenty-five adult patients participated in the study. The patients had different experiences at their local PHC facilities that affected their access to rehabilitation at primary care. The study found that most patients were not able to access rehabilitation at primary care. There were several personal and contextual factors that resulted in the patients having a low perceived need to receive rehabilitation that potentially lowered patients' demand for and utilization of rehabilitation at primary care. Patients suggested increasing rehabilitation workforce at primary care, improving availability of assistive devices, increasing their knowledge regarding rehabilitation, and facilitating socio-economic integration into their communities.

CONCLUSIONS

Patients attending primary care are not guaranteed access to rehabilitation by virtue of having entered the PHC system. It is important to consider the patient perspectives regarding their health needs and suggestions for enhancing care.

Stroke Rehabilitation in Low- and Middle-Income Countries: Challenges and Opportunities

ABSTRACT

Stroke remains the second leading cause of global disability with 87% of stroke-related disability occurring in low- and middle-income countries. In low- and middle-income countries, access to acute stroke interventions is often limited, making effective poststroke rehabilitation potentially the best available intervention to promote poststroke recovery. Here, we build on our experience as an illustrative example of barriers individuals with stroke face in accessing rehabilitation services and review the literature to summarize challenges to providing effective rehabilitation in low- and middle-income countries. First, we focus on barriers individuals with stroke face in accessing rehabilitation in low- and middle-income countries, including health system barriers, such as lack of national guidelines, low prioritization of rehabilitation services, and inadequate numbers of skilled rehabilitation specialists, as well as patient factors, including limited health literacy, financial constraints, and transportation limitations. Next, we highlight consequences of this lack of rehabilitation access, including higher mortality, poorer functional outcomes, financial burden, caregiver stress, and loss of gross domestic product at a national level. Finally, we review possible strategies that could improve access and quality of rehabilitation services in low- and middle-income countries, including creation of inpatient stroke units, increased training opportunities for rehabilitation specialists, task shifting to available healthcare workers or caregivers, telerehabilitation, and community-based rehabilitation services.

Non-use of healthcare services among persons with mobility impairments in Cofimvaba, South Africa

Background

Access to primary health care is a fundamental right for all. However, persons with disabilities are experiencing difficulties when accessing healthcare because of various environmental and personal barriers which may lead to nonuse of such services.

Objectives

This study aimed to identify the challenges leading to non-use of healthcare services among persons with mobility impairments in Cofimvaba.

Method

A descriptive qualitative design using snowball sampling was implemented. Semistructured interviews were conducted in isiXhosa with five participants who stopped accessing healthcare, using a self-developed interview guide. Inductive thematic analysis was used to develop codes and themes from the data.

Results

Study findings revealed major challenges experienced by persons with mobility impairments in accessing healthcare. These included inaccessible roads, geographic inaccessibility, financial accessibility and indirect cost of care, having little or not many health problems, physical infrastructure difficulties within facilities, and attitudinal barriers.

Conclusion

The findings indicated that persons with disabilities are experiencing a combination of structural and environmental challenges which make them stop accessing healthcare.

Contribution

The article shares insights on access challenges that influence non-use of the often-needed healthcare services within the context of rural areas.

Expanding access to rehabilitation using mobile health to address musculoskeletal pain and disability

Introduction

Musculoskeletal (MSK) disorders such as low back pain and osteoarthritis are a leading cause of disability and the leading contributor to the need for rehabilitation services globally. This need has surpassed the availability of trained clinicians; even in urban areas where services and providers are thought to be more abundant, access can be challenged by transportation options and financial costs associated with travel, care and lost time from work. However, continuing standard of fully in-person rehabilitation care for MSK-associated pain and disability may no longer be necessary. With increased ownership or access to even a basic mobile phone device, and evidence for remote management by trained clinicians, some individuals with MSK disorders may be able to continue their rehabilitation regimen predominantly from home after initial evaluation in primary care or an outpatient clinic.

Methods

This manuscript describes application of a framework we used to culturally and contextually adapt an evidence-based approach for leveraging digital health technology using a mobile phone (mHealth) to expand access to rehabilitation services for MSK-associated pain and disability. We then conducted a multi-level analysis of policies related to the adapted approach for rehabilitation service delivery to identify opportunities to support sustainability.

Results

Our study was conducted in Tanzania, a lower-middle income country with their first National Rehabilitation Strategic Plan released in 2021. Lessons learned can be applied even to countries with greater infrastructure or fewer barriers. The seven-step adaptation framework used can be applied in other regions to improve the likelihood of local mHealth adoption and implementation. Our practice and policy assessment for Tanzania can be applied in other regions and used collaboratively with government officials in support of building or implementing a national rehabilitation strategic plan.

Conclusion

The work described, lessons learned and components of the plan are generalizable globally and can improve access to rehabilitation services using mHealth to address the significant and increasing burden of disability.

Organizational readiness and rehabilitation professionals' views on integrating telerehabilitation into service delivery and students' clinical training: A qualitative study

Objective

To assess the readiness of healthcare institutions that serve as clinical platforms for Stellenbosch University' rehabilitation students, and to explore the opinions of rehabilitation professionals regarding the integration of telerehabilitation (TR) into service delivery and students clinical training.

Methods

This study employed a qualitative research design and involved the participation of fourteen rehabilitation managers. Semi-structured interviews were conducted using both face-to-face and online platforms. Thematic analysis was employed to analyse the collected data.

Results

The readiness for implementing TR services varies across different dimensions. Facilities faced challenges related to funding for TR equipment and the absence of policies and guidelines, indicating a lack of financial and governance readiness. Rehabilitation professionals demonstrated high attitudinal readiness but low technical readiness due to a lack of knowledge and skills. Rehabilitation students particularly lacked practical experience, confidence, clinical reasoning and decision-making skills further contributing to low technical readiness.

Conclusion

Health care institutions are generally not ready for a successful implementation of TR. To improve the readiness, senior management should actively participate and provide financial support, develop policies, guidelines and training programs for rehabilitation professionals. Educational institutions should incorporate TR program into curricula to prepare students to gain practical experience and familiarity with the use of TR technology for their future clinical practice.

Cardiovascular diseases in Africa in the twenty-first century: Gaps and priorities going forward

In 2015, the United Nations set important targets to reduce premature cardiovascular disease (CVD) deaths by 33% by 2030. Africa disproportionately bears the brunt of CVD burden and has one of the highest risks of dying from non-communicable diseases (NCDs) worldwide. There is currently an epidemiological transition on the continent, where NCDs is projected to outpace communicable diseases within the current decade. Unchecked increases in CVD risk factors have contributed to the growing burden of three major CVDs-hypertension, cardiomyopathies, and atherosclerotic diseases- leading to devastating rates of stroke and heart failure. The highest age standardized disability-adjusted life years (DALYs) due to hypertensive heart disease (HHD) were recorded in Africa. The contributory causes of heart failure are changing-whilst HHD and cardiomyopathies still dominate, ischemic heart disease is rapidly becoming a significant contributor, whilst rheumatic heart disease (RHD) has shown a gradual decline. In a continent where health systems are traditionally geared toward addressing communicable diseases, several gaps exist to adequately meet the growing demand imposed by CVDs. Among these, high-quality research to inform interventions, underfunded health systems with high out-of-pocket costs, limited accessibility and affordability of essential medicines, CVD preventive services, and skill shortages. Overall, the African continent progress toward a third reduction in premature mortality come 2030 is lagging behind. More can be done in the arena of effective policy implementation for risk factor reduction and CVD prevention, increasing health financing and focusing on strengthening primary health care services for prevention and treatment of CVDs, whilst ensuring availability and affordability of quality medicines. Further, investing in systematic country data collection and research outputs will improve the accuracy of the burden of disease data and inform policy adoption on interventions. This review summarizes the current CVD burden, important gaps in cardiovascular medicine in Africa, and further highlights priority areas where efforts could be intensified in the next decade with potential to improve the current rate of progress toward achieving a 33% reduction in CVD mortality.