C o m m u n i t y R e p o r t T h e R o l e o f t h e C o m m u n i t y B a s e d R e h a b i l i t a t i o n W o r k e r w i t h i n t h e P r i m a r y H e a l t h C a r e S e r v ic e o f t h e O d i D i s t r i c t NP TAUKOBONGABSTRACT: Introduction: There has not been agreement within the Health Care Services regarding the role o f Community Based Rehabilitation (CBR) workers. The training o f CBR workers continues although the process was not widely supported and the CBR worker’s function has not been clarified yet CBR programmes are included in the training o f students. A im : The aim is to identify and describe the role o f the CBR workers within the Odi District Health Service (DHS) and determine whether they are fulfilling the rehabilitation arid development functions envisaged by the WHO model o f CBR programmes. Methodology: Qualitative and quantitative research methods were used. These included a questionnaire; observations o f the daily tasks o f the CBR workers and interviews with members o f the District Health Service (DHS) o f the Odi district, clients and CBR workers. Open and axial coding were used in data analyses. Data from the different sources were triangulated to ensure trustworthiness. Results: The skills performed by CBR workers have produced a change in the lifestyle o f the disabled people and the initiated projects are benefiting the fam ilies o f the disabled people within the CBR programme as well as their com­ munity. There seems to be a break down o f communication between the District Health Manager (DHM) and the supervisor o f the CBR workers. A lack o f communication within the DHS affects the functions o f the CBR workers. Conclusion: It is concluded that, although the tasks o f the CBR workers within the Odi DHS are not supported, they produce a positive impact on the quality o f life o f the disabled within the CBR programme. The CBR w orkers’ contri­ bution towards community development, although on a small scale, proves that they operate within the World Health Organization’s (WHO) guidelines fo r CBR. KEYWORDS: COMMUNITY BASED REHABILITATION WORKERS, PRIMARY HEALTH CARE SERVICE, DISTRICT HEALTH SERVICE IN TR O D U C TIO N The escalating num ber o f people with disabilities, especially in the developing countries, has becom e a cause for concern am ongst health professionals as well as health organisations. In 1969 the International Society for Rehabilitation o f the Disabled found that: • the pace o f training rehabilitation professionals was inadequate to m eet the increase in health related dem ands; • help could be given to the disabled in d e v elo p in g c o u n trie s u sin g m ethods consistent w ith available resources and the cultural as well as social patterns in these countries (Expert report, 1969). B ased on these fin din g s the In te r­ national Society for Rehabilitation o f the D isabled recom m ended a change in tech­ nology, service delivery and a new type o f manpower. This then saw the birth of Com m unity Based R ehabilitation (CBR) which was first introduced in ten countries betw een 1979 and 1981 (W HO, 1981). H elan d er (1994) d efin es C B R as a strategy for enhancing the quality o f life o f d isab led people. T his strategy was developed by the W H O follow ing the A lm a -A ta d e c la ra tio n and the recom ­ m endations by the International Society fo r R e h a b ilita tio n o f the D isa b le d (W HO, 1981). India was am ongst the first c o u n tries to in tro d u ce C B R p ro ­ gram m es with the aim o f alleviating the shortage o f rehabilitation professionals. Through CB R program m es, the disabled people w ere assisted tow ards im proving th e ir fu n c tio n a l a b ilitie s as w ell as addressing the w elfare o f their fam ilies and comm unity. Kenya initiated CBR program m es to provide rehabilitation services for the d is­ abled in their com m unities where a defi­ nite need was identified (Kumar, 1996). A gain in A gentina a CBR program was initiated in La R ioja province w hich cu r­ ren tly serves 72% o f the p o pu latio n (M omm , Konong, 1991). T here are m any more countries utilising the CB R pro­ gram m es around the world especially in developing and under-developed coun­ tries (W HO, 1991). The above m entioned are but a few o f those countries in which the prim ary goal is to im prove rehabilita­ tion services as well as health service delivery through CB R .(H elander, 1994) In the Republic o f South A frica (RSA), the shortage o f rehabilitation professio­ nals, with subsequent lack o f rehabilitation services to the m ost needy (rural areas), prom pted the inception o f the CBR con­ cept. In response, also, to the call “H ealth f o r a ll by the y e a r 2 0 0 0 ” the associations fo r o ccu p atio n al therapy, sp eech and hearing therapy and physiotherapy nom i­ nated a com m ittee in 1987 w hich was mandated to look into the training o f CBR workers as an initial step towards adopting the concept o f CBR. The com m ittee was th e re fo re c a lle d the C o m m itte e on Com m unity Rehabilitation W orkers and co n sisted o f rep resen tativ es from the three associations m entioned above. In this process, the com m ittee circulated a C O RRESPO N D EN C E: M s N.P. Taukobong D epartm ent o f Physiotherapy M E D U N SA 0204 Tel: (012) 521 4485 S A Jo u r n a l o f Ph y s io t h e r a p y 1 9 9 9 V o l 5 5 N o 1 19 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) docum ent containing a proposal for the training of CBR w orkers to all institutions training health professionals. This d o cu ­ m ent requested constructive com m ents regarding this initiation o f training CBR w o rk ers in R SA . T h ere w as total re je c ­ tion o f the co n cep t by som e academ ic institutions yet the training w ent on, with re su lta n t e stab lish m en t o f train in g in A lex an d ra C lin ic am o n g st the first e s ta ­ blished, in the early 9 0 ’s. T here are now a num ber o f established centres around RSA. In it’s council m eeting of the 31st M arch 1997, the South A frican Society for Physiotherapy (SASP) discussed the issue o f CB R w orkers as reh ab ilitatio n professionals. N o conclusion was reached at the end with regards to the position of the CB R w orkers w ithin the rehabilitation services, yet a num ber o f CBR workers are e m p lo y e d in the p h y s io th e ra p y departm ents o f certain hospitals. Som e o f the CBR w orkers have physiotherapists as designated supervisors. All these issues are disturbing as they affect people who are functioning within the health services, whilst having no attachm ent to a particular profession. The N ational M inister o f H ealth has expressed total rejection o f this category w hich she refers to an “a d d itio n a l c a te ­ g o ry" yet there are CBR w orkers p ractis­ ing around the country. (D RC w orkshop report, 1996). The pos­ sibility exists that the M inister o f Health is also concerned about who is going to pay this additional category o f health w orker w hose role has yet to be fully defined. All these problem s or issues could be attributed to lack o f know ledge about the c o n trib u tio n o f CB R w o rk ers tow ards rehabilitation o f the disabled, or their role as reh ab ilita tio n p ro fessio n als. T he re ­ searcher believes that if the role o f the CB R w o rk er can be d escrib ed , those rejecting them could be made to under­ stand their contribution in the health care system . These people may be m ade to eventually change their m inds, w hilst those who cannot make decisions will be assisted in reaching acceptable decisions. THE A IM The aim o f the study was to identify and describe the role o f the CBR w orkers w ith in the PH C serv ices o f the Odi D istrict. T h e secondary objective w as to determ ine w hether they are fulfilling the rehabilitation and developm ent functions as described in W H O guidelines fo r CBR program . M E T H O D O L O G Y Sample Using the reform ed RSA health system fram ew o rk , the d istrict health structu re was used for selecting the sample. There a re tw o e x is tin g C B R p ro g ra m m e s , nam ely the W interv eld t and O ukasie, w hich fall under the Odi district in the N orth West Province. The sam ple inclu­ ded the D istrict H ealth M anager (D H M ), the P rim ary H ealth C are (PH C ) nurse, the p hysiotherapist (designated reh ab ili­ tation co-o rd inato r and CB R w o rk er’s su p e rv iso r), a C B R w o rk er from each p rogram and the clients w ithin the m en­ tioned CB R program m es. DESIGN A qualitative desig n w as used em plo y ­ ing the triangulation technique. The tech­ nique included: 1. A self developed questionnaire, based on the guidelines fo r CB R described by W H O, com pleted by the CBR workers and co n ta in in g open and close ended questions covering - dem ography, to establish area o f resi­ dence, training and em ploym ent. - referrals: to establish any referral system and by w hom the clients are referred. - a ssessm ent: to identify the aspects assessed, identification o f the mobility- aids needs; as w ell as needs fo r adap­ tive devices and if they w ere assisted in identifying the clients problem s. - treatment: to identify m eans o f reach­ ing the clients, w here the clients are treated, w hether the fam ily m em bers are involved and the procedures per­ form ed as well as supervision by reh a­ bilitation professionals. - projects: to identify projects initiated and w hether they generate funds. - general: to acquire any useful know ­ led ge reg ard in g th e ir role in the co m ­ munity. 2. Observations, a visit to the two pro­ gram m es was conducted to obtain relia­ bility in as far as handling o f clients is concerned. The CB R w orkers activities o b se rv ed inc lu d ed a ssessm en t, treat­ ment, fam ily involvem ent, treatm ent area and m eans o f reaching the clients. 3. Interviews w ere conducted with all the m em bers o f the district rehabilitation team including the DH M to determ ine the truth-value as w ell as consistency of the inform ation obtained from the q u es­ tionnaires and observations. In order to identify w hether the needs o f the clients are m et certain clients, selected by a sam ple o f con v en ien ce, w ere inter­ view ed from the tw o program m es. TH E RESULTS The results obtained from the investiga­ tion will be sum m arised using the fol­ low ing fram ew ork (figure 1) which re­ flects the W H O guidelines fo r CBR as well as the activities w ithin the Oukasie and W interveldt CB R program m es: DISCUSSION T h e v isio n o f the N atio n al H ealth D epartm ent in RSA, is to ensure improved quality o f service at all levels hence the reform ed D istrict H ealth System s (DHS) (D epartm ent o f health, 1995; A frican N ational Congress, 1994). T he districts are m anaged by the D H M with his/her m anagem ent team . His responsibilities include ensuring that there is a rehabilita­ tion plan and that all services rendered within the district are well co-ordinated (H elander, 1994). The results revealed that there was no rehabilitation plan. A lack o f allied health professionals was cited as the main reason. On the other hand it was m entioned that there was a m echanism w ithin the district for ensuring that the c o m m u n ity lev el p ro g ram m es such as CBR program m es, w ork in har­ mony with the o th er health delivery ser­ vices in the district. M urphy et al (1992) fully supports such endevours by stating that W H O regards CBR as an integral p art o f PH C thus it is im portant for health m anagers to take cognisance o f that fact. H elander (1994) further stipulates that the CB R aspects, w hich ensure success of the program m e, should also be an under­ taking o f the rehabilitation p rofessional’s responsibility as well. The study how ever show ed that the supervisor is not in­ v olved at all and therefore has no respon­ sibilities within the CBR program m es. T his non involvem ent becam e apparent w hen the DH M stated that he does not f e e l the existance o f CBR w orkers and cannot com m ent on their contributions w ithin the district services. The DHM reported this lack o f feeling is, maybe, attributed to the fact that he receives no input from the physiotherapist/supervisor. This break in com m unication therefore explains the reason for the stated fears by the CBR w orkers. M om m et al, ( 1991); M urphy et al (1992) and other authors also agree that the success o f the CBR program m e is driven by the rehabilitation professional’s involvem ent. It is believed that the service could spread even further through this involvem ent as m entioned 20 S A J o u r n a l o f P h y s io th e r a p y 1 9 9 9 V o l 55 N o 1 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) FIGURE I: SUMMARY OF THE RESULTS The RSA health system is divided into three tiers I \ Tertiary Health Care Primary Health Care Secondary Health Care CBR is an integral part of this level The DHM is the head of the DHS and is also responsible for community level services. He has no rehabilitation plan but a mechanism is in place for ensuring development within the district health service. There is a break in communication within the rehabilitation service. The CBR workers are fearful of their future as rehabi­ litation staff as well as members of the health team. They voiced lack of recognition as professionals. Aspects of a successful CBR Expected CBR worker's skills - rehabilitation plan - identification of disability - active referral system - a b ility to assess limitations - monitoring system - ability to treat with simple - support structure - involvement of NGO's methods The physiotherapist is the designated supervisor and rehabilitation co-ordinator. She/he is not involved in the CBR services. She/he does not facilitate nor participate in the implementation of the CBR aspects, the PHC nurse has more contact with the CBR workers and refers clients regularly to the CBR program. The CBR workers exhibit the ability to perform expected skills. They are supervised by the allied health professionals outside their district services. Their skills have influenced the life of disabled members of the community involved in the CBR program Quality of life of a disabled - emotional stability - functional independence - social integration - economical independence Clients and the CBR workers have established projects for which they are jointly responsible. The projects do produce products which are needed and used by the community, although on a small scale. Community development - established projects - funds generated - funds received from outside sponsors S A J o u r n a l o f P h y s io th e r a p y 1 9 9 9 V o l 55 N o 1 21 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) by the PHC nurse w hen she said “ There are m any disabled p eople who need this service a n d to reach all o f them the CBR w orker needs the assistance o f a p ro fes­ sional p erso n ” . The results also revealed that the CBR workers are supervised by allied health professionals outside the d is­ trict health system which may be another contributing factor tow ards their fears . Both CBR workers com m enced this service as volunteers w ithin their com m u­ nities before they w ere trained as CBR w orkers, w hich is one o f the im portant principles o f a CBR program m e ( M urphy et al, 1992). In the spirit o f “M asakhane” in the RSA, the national governm ent is trying to im part a sense o f responsibility am ongst com m unity m em bers (A frican N ational Congress, 1994). It is evident that the CB R workers at W interveldt and O ukasie, have exhibited this social re­ sponsibility by striving to help their own com m unity m em bers to im prove their way o f life. T hese endevours should be seen as a basis for governm ent as well as com m unity support which w ere found to be very minimal w ithin both programm es. The CB R w o rk er’s skills as stipulated by the W H O m odel (M urphy et al, 1992; H elander, 1994 ) w ere all exhibited by the tw o CB R w orkers w ithin the CBR pro­ gram m es. T his im plies that the CBR w orkers, using these skills, are capable of influencing the functional abilities o f the disabled people. A ccording to the rehabilitation defini­ tion by the W H O in 1981 the existence of social integration reveals that the aim o f rehabilitation has been achieved (Expert report, 1969; Helander, 1994). This has been the case with the studied CB R p ro ­ g ram m es as depicted from som e o f the clien t’s responses such as: “/ now fe e l like a norm al p erson again because I am not a fraid to associate with m em bers o f my com m unity”. This impact has also been show n in a study conducted at Tintsw alo about the CBR w o rk er’s influence on the disabled (Dolan et al, 1995). It is evident tha t som e o f the ex istin g C B R p ro ­ gram m es within RSA are com parable to program m es in other countries that are successful (K ijanski, 1995; Tiroler, 1995; Kumar, 1996). Com m unity developm ent has occurred as evidenced by established projects al­ though on a small scale because o f m ini­ mal or lack o f funding from the outside sponsors. The disabled people are gene­ rating funds from the projects which is som e sign o f developm ent. (M urphy et al, 1992) T he projects generate a source of incom e for supporting the disabled and their fam ilies. The products produced, such as vegetables and candles, are rele­ vant to the needs o f the com m unity as both W interveldt and O ukasie are very poor and under - developed. This means that the projects are in line with other pro­ je cts in developing countries, which meet the needs o f the poor com m unities and contributes tow ards com m unity develop­ m ent ( M urphy et al, 1992; Kumar, 1996). CO NCLU SIO N It is concluded that the CBR w o rk er’s in the Odi district are producing a positive impact on the em otional, social, functional and econom ical needs of the disabled com m u n ity m em bers involved in the CBR program m es although their tasks are difficult. Com m unity developm ent exists through the established projects, although on a sm all scale, hence their role is c o n ­ sistent with the envisaged functions o f the W H O m odel for CBR. LIMITATIONS T he study was conducted am ongst the CBR workers at W interveldt and O ukasie only and whilst there are a number o f CBR workers around the country the results cannot be generalized. R EC O M M EN D ATIO N S It would be interesting to learn about the im pact produced by other CBR p ro ­ gram m es within the country with the view o f further supporting the role o f the CBR worker. T he researcher believes that such a know ledge w ould m otivate for recogni­ tion o f the CBR workers. 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