W o r k s h o p R e p o r t A r e T h e r a p i s t s A w a r e o f t h e N e e d s o f P e o p l e w i t h D i s a b i l i t i e s ? A B S T R A C T : This article challenges therapists to fin d out what the needs o f people with disability are before planning community based rehabilitation services. It also establishes that therapists and people with disabilities have different ideas about the needs o f people with disability. KEYWORDS: NEEDS, PEOPLE WITH DISABILITIES, COMMUNITY BASED REHABILITATION (CBR) PETRICK M, HOMER S, EVANS R T he em phasis o f Health Care Ser­ vices in South A frica is shifting towards prim ary health care, of w hich Com m unity Based Rehabilitation (CBR) is an integral part (Office of the Deputy President, 1997). In 1994 CBR was defined as “a strategy within com m u­ nity developm ent fo r the rehabilitation, equalisation o f opportunities and social integration o f all people with disabilities” (IL O /U N E S C O /W H O , 1994). T h is is “ im p lem en ted through the co m b in ed effort o f disabled people them selves, their fam ilies and com m unities, and the appro­ priate health, vocational and social ser­ vices.” The white paper for the transfor­ mation o f the health system in South A frica also clearly states that all health workers and professionals should com m it them selves to im proving the health status o f all people in their catchm ent areas and not only have a responsibility tow ards the people attending their clinics/ hospitals (D epartm ent o f Health, 1997). Therapists are therefore expected to offer services within the fram ew ork o f CB R (Teager, 1998). This is new to m any South African therapists, who may conse­ quently feel that they lack the necessary skills. In A ugust 1997 a w orkshop on Com m unity Based Rehabilitation (CBR) was held as part o f the U niversity o f the W itw atersrand Faculty of H ealth Scien­ ces Seventy-fifth Jubilee Congress. This w orkshop aim ed to help therap ists plan CB R serv ices by: eq u ip p in g therap ists with some Strategic planning skills, teach- CORRESPONDENCE: Petrick M BSc (Physiotherapy) W its-Tintsw alo CRW TP PO B ox 558 A cornhoek, 1360 Tel: (013) 797 0058 (w) (0 1 5 )7 9 3 3991 (h) ing them p articip ato ry rural appraisal techniques (Kumar, 1998), bringing them together with people with disabilities, and ch alleng in g the stereo ty p es o f p ro fes­ sional know ledge. T he first part o f the w orkshop, i.e. establishing the needs of people with disability, is presented here. It is hoped that by presenting the outcom e o f the w orkshop therapists will gain a clearer idea o f attitude shifts needed in order to develop com prehensive primary health care in terms o f rehabilitation. M E T H O D In order to plan a CBR program m e, therapists need to discover what the needs o f people with disability in the com m u­ nity are (H elander, 1992). T h erap ists (physiotherapists, speech therapists and occupational therapists) participating in the w orkshop w ere put into one group (n= 20). A gro u p o f v o lu n tee rs from People fo r Awareness o f D isability Issues (PAD1) and from the D isabled S tu d en ts’ Prog ram m e at the U n iv ersity o f the W itw atersrand (all with disabilities) were put into another group (n=10). Each group then had to discuss what they felt were the needs o f people with disability, using a Venn diagram (Kumar, 1998), which is a participatory rural appraisal tool. The Venn diagram was done as follows: T he groups firstly had to decide what the needs o f people with disability in the com m unity are. Each group was given the sam e num ber o f circles o f different sizes: large, m edium , sm all and very small. T he groups then decided which of the needs they had identified w ent onto w hich circle: A big need w ould go on the large circle, a very small need w ould go on the very small circle etc. O nce each circle had a need w ritten onto it, the group then had to organise the circles into a pattern so that the needs that w ere related in som e w ay w ere put together. N eeds that did not have any relationship to each o ther could be put separately. The pattern o f circles was then displayed on the w all and d escrib ed verbally. T his arrangem ent o f circles is called a Venn d iagram (Kumar, 1998). There w ere a few blind people in the group with disabilities. O ne o f the blind students therefore typed the needs identi­ fied by this group in Braille. The B raille strips w ere then attached to the correct circles. The needs w ere also written in pen onto the circles. O nce the two groups had com pleted this exercise they presented their diagram s to each other. T he people with disabilities show ed their Venn d ia­ gram in B raille first, before show ing the w ritten term s. T he headings o f the thera­ pist group w ere then also typed in B raille and put onto their Venn diagram . O nce the Venn diagram s w ere com ­ pleted, the people with disabilities unfor­ tunately had to leave, as they had to attend lectures. The rest o f the workshop was spent using o ther Participatory Rural A p p raisal too ls to draw up a strategic plan to m eet the needs o f people with d is­ abilities. RESULTS Figures 1 and 2 show the Venn diagrams com pleted by the people with disabilities and the therapists respectively. T he two groups saw the needs o f peo­ ple with disability in the com m unity very differently. T he only sim ilarities w ere that both groups assigned the sam e im portance to the needs for finance and social interac­ tion. Finance was put on a medium sized circle by both groups, while both groups put social and spiritual needs and social interaction on a small sized circle. All the o th er elem ents in the Venn d ia­ gram s w ere different. T he people with disabilities d ealt with “real life practicali­ ties” or activities o f daily living (such as m ainstream education, accessibility, trans- 26 SA J o u r n a l o f Ph y sio t h e r a p y 1999 V o l 55 No 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 1: PEOPLE WITH DISABILITY'S VENN DIAGRAM Accessibility port) (figure 1), w hile the therapists ten­ ded to deal with “concepts” (such as em ­ pow erm ent and independence) (figure 2). In addition, the three biggest needs iden­ tified by therapists and people with dis­ ability differed com pletely: T herapists stated these as being “em pow erm ent” , “a clien t centred approach” and “positive a ttitu d e ” (figure 2), w hile p eo p le with disability stated these as being “em ploy­ m e n t” , “ m ain stream e d u catio n ” and “accessibility” (figure 1). T herapists assigned the need for assis­ tive devices to the very sm all circle (fi­ g u re 2), w h ile p e o p le w ith d isa b ility assigned it to a m edium circle (figure 1). The needs for resources, independence, em pow erm ent, a client centred approach and positive attitude w ere only m entioned by the therapists (figure 2). T hese w ere the main needs identified by therapists. On the other hand, the needs that were only m entioned by people with disability in c lu d e d c o u n s e llin g , c a re e r ch o ic e , accessibility (note this was a main need o f the people with disabilities) and disability grants (which was seen as separate from finance) (figure 1). In the next part o f the w orkshop, after the people with disabilities had left to attend their lectures, the therapists used the list o f needs they had draw n up (not the list draw n up by the people w ith d is­ abilities) in order to w ork out a strategic p la n to m eet the needs o f p e o p le w ith d isabilities. SA J o u r n a l o f Ph ysio th er a p y 1999 V o l 55 No 1 27 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. ) DISCUSSION T his exercise dem onstrated that thera­ pists do not really know w hat the needs o f people with disability are. Therapists dealt with “concepts”, while people with d is­ abilities dealt with “practicalities” . Could it be that we m ean the same thing but speak different languages, o r could it be that we work from opposite ends o f the spectrum ? Perhaps positive attitudes and a client centred approach are therapists’ needs fo r su ccessfu l interactio n with clients rather than the needs o f the client. A positive attitude that leads to em pow er­ m ent o f p eo p le w ith d isab ility and a clie n t-c e n tre d ap p ro ach by th e ra p ists could, however, result in m ainstream edu­ cation, em ploym ent and accessibility. We should guard against sem antics hindering the trust betw een a client and a therapist, as well as goal setting and progress. To avoid conflict, goals should be decided on join tly between people with disabilities and therapists and those goals should be m easurable (O ffice o f the D eputy Pre­ sident, 1997). Rehabilitation also needs to be m ade u n derstan d ab le to all (P hilp ot and Pillay et al, 1995; H elander, 1992). T his im plies using sim ple words, explain­ ing w hat therapists can and cannot offer and ensuring that clients know all the options available to them, including those outside the therapist’s professional realm . T h erap ists need to ask them selves if clients understand w hat they m ean, w hat they can do and the process o f doing it. T herapists also need to understand what the client means or needs in rehabilitation, w hile clarifying the processes and time plans fo r clients to reduce frustration. T he people with disabilities’ focus on needs such as education and career during this w orkshop w ere understandable, as they were students at the beginning o f their adult lives. Other groups o f people with disability may have listed other needs, w hile the sam e could also be said fo r the group o f therapists. It is interestin g to note that people with disability expressed disability grants and finance as different needs. This could m ean that people with disability that are able to work need the ability to earn money, w hile som e people with disabilities are unable to work and are dependant on grants. It is rem arkable that the therapists did n ot p erceiv e accessib ility as a need o f people with disabilities. This is considered as an im portant need for people with dis­ abilities (O ffice o f the D eputy President, 1997). L ack o f identification with people with disability or lack o f experience with disability outside o f the “institution” or hospital may have accounted fo r this d is­ crepancy. “E m pow erm ent” and “client- centred” can be seen as the changes the therapist has to make. T hese are “ w oolly” term s show ing that the therapists do not have the “nuts and bolts” o f w hat people with disabilities need. The m uch sm aller im portance assigned to the need for assistive devices by thera­ pists com pared to people with disabilities was also notable. A ssistive devices play an im portant role in the lives o f people with disabilities (O ffice o f the Deputy President, 1997), yet therapists often do not educate people with disabilities about the o p tio n s they h a v e w ith assistiv e devices, nor do they give them much choice in the selection. For com m unity based rehabilitation to be successful, the needs o f people with disability need to be considered. This is an im portant aspect o f the key principles o f C B R , as d e s c rib e d by H e la n d e r (1992), the 1994 Joint Position Paper on C B R (ILO, U N E SC O et al, 1994) and the W its-Tintswalo Com munity Rehabilitation W orker Training Program m e (Philpot and Pillay et al, 1995). As the second part o f the w orkshop was based on using the needs identified on the Venn diagram s to develop a strategic plan fo r CBR, it cam e as a surprise to the faci­ litators o f the w orkshop that the therapists continued using the needs list they had draw n up, ignoring the list o f the people with disabilities. A lthough they had seen that their needs list did not correspond with the list o f the people with disabilities, they silen tly and u n co nscio u sly w orked out a strategic plan fo r their list only. T herapists need to start w orking with people with disabilities as equal partners (Helander, 1992). The national organisa­ tions for people with disabilities have an im portant role to play to facilitate this process (O ffice o f the D eputy President, 1997). A ccepting attitudes to people with disabilities (Philpot and Pillay et al, 1995; O ffice o f the D eputy President, 1997 ) are easily spoken about, but often not p rac­ tised, as we saw during this workshop. A ttitudes are difficult to change (Payne, 1998; O ffice o f the D eputy President, 1997), but this is c le a rly n ec essary (Helander, 1992). Ideally the facilitators should have ensured that the people with disabilities w ere able to attend the whole w orkshop. It is o b vio u s that therap ists and p eo p le w ith d isab ilitie s need to develop strategic plans fo r CB R together (O ffice o f the D eputy Presid en t, 1997) and that it is not good enough for thera­ pists to gather inform ation about needs and then not use it. C O NCLU S IO N T he w orkshop illustrated that therapists w ere not aw are o f the needs o f people with disabilities. In order fo r it to be effective, com m unity based rehabilitation has to aim at the needs o f people with dis­ abilities and not at w hat therapists think these needs are. T h erap ists need to be exposed further to the needs o f people with disabilities and work out jo in t solu­ tions on how these needs can be met. Participatory rural appraisal techniques can be used fo r this jo in t venture. E D IT O R 'S NOTES T he “p eople w ith d isab ility ” group may well be a biased group as they w ere mainly university students. However, this does not negate the m essage o f this article - therapists are not alw ays in touch with the needs o f their clients. Furtherm ore we cannot generalise - different groups o f people with d isability will surely have different needs. REFERENCES D epartm ent o f H ealth 1997 R epublic o f South Africa, G overnm ent Gazette, vol 382, no. 17 9 10, N otice 667 o f 1997: W hite paper for the trans­ form ation o f the health system in South A frica, pp 13, 36 H elander E 1992 P rejudice and D ignity - an Introduction to C om m unity B ased R ehabili­ tation, p p 3 5 ,106-109. 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