Magister Scientiae (Physiotherapy) - MSc(Physio) / People with disabilities (PWD) often come from disadvantaged communities and struggle to access health and rehabilitation, education and employment. This leads to poorer health outcomes, lower education achievements, and higher rate of unemployment in comparison to people without disabilities. Therefore there is a need to empower PWD to remove all barriers which prevent them from participating in all aspects of their communities. In South Africa, 5% of the population is disabled and in a worldwide review conducted on access to rehabilitation services, it was reported that South Africa provided 21% to 40% of the disabled population with rehabilitation services. In 2012 the Department of Health (DOH) trained a new cadre of community health worker (CHW) in the field of rehabilitation in order to improve PWDs‘ access to health services. As a result, health professionals in the Western Cape became concerned about the role of this new cadre of rehabilitation care worker in PHC and CBS. The aim of this study was therefore to explore health professionals‘ perceptions of the newly trained rehabilitation care workers (RCWs). Q methodology was selected as an appropriate research design to meet the objectives of this study as it can be used to analyse opinions, perceptions and attitudes. The study population consisted of all the health professionals who engaged with the RCWs in the clinical workplace during their clinical practice module. A convenient sample of sixteen health professionals participated in this study. Ethics approval was obtained to conduct this study and all participants gave written consent to participate in this study. The researcher gathered all the viewpoints of the health professionals regarding the new rehabilitation care workers (RCWs) by conducting focus group discussions and document analysis. Statements were then drawn up based on the health professionals' viewpoints. The participants then ranked these statements from strongly agree to strongly disagree on a Q data score grid, in a process called Q sorting. The completed Q data score grids, called Q sorts, were then entered into PQMethod software programme for statistical and factor analysis. From the results of this Q analysis, two factors emerged which were analysed and interpreted. A factor is representative of participants with similar opinions. The participants loading onto Factor one and Factor two shared similar opinions of the RCWs. The results indicated that the participants were of the opinion that RCWs‘ role would be to strengthen primary health care (PHC) and community-based rehabilitation (CBR) and promote the participation of PWD in society. The results suggested that the RCWs were capable of improving the quality of life of PWD by empowering PWD to become actively involved in all aspects of community life. The participants felt that the RCWs would be included in the health system by working at intermediate care centres (facility-based) and in the community (home-based). However, the participants agreed that the RCWs must work under the direct supervision of qualified health professionals. Participants loading onto Factor one and Factor two further agreed that RCWs worked well in the structured environment of intermediate care health facilities. They felt that it would be beneficial for RCWs to be employed at these health facilities as the RCWs reduced the workload of the health professionals. From the results, it was also found that health professionals were of the opinion that the RCWs displayed positive attitudes and good professional behaviour in the clinical environment. Health professionals however identified gaps in the knowledge of the RCWs and a lack of skills to perform certain tasks. However, health professionals agreed that the RCWs' skills will develop and improve with time and exposure. This study showed that health professionals had positive perceptions of the RCWs and this could indicate that RCWs will be well accepted by health professionals as part of the PHC team. This could lead to the effective utilisation of RCWs in community-based rehabilitation. Recommendations can be made to the developers and implementers of the RCW training curriculum to make adjustments to the curriculum so as to address the lack of knowledge and skills in certain aspects of health and disability. It can further be recommended that South Africa's National DOH capitalise on these positive perceptions and train more RCWs to extend rehabilitation and health services to more underserved communities. This will assist the South African Government in ensuring that more PWD receive rehabilitation and become included in all aspects of their communities as is envisaged in the 2020/2030 health plan.

Philosophiae Doctor - PhD / Community Based Rehabilitation (CBR) is used internationally, to address the lack of access of People with Disabilities (PwD) to rehabilitation services. Physiotherapy is one of the rehabilitation services offered to PwDs at community level, through CBR. In Sudan, Ahfad University for Women (AUW) offers a Bachelor degree in Physiotherapy, which integrates a CBR module into the curriculum, since 2007. The aim of this current study was to investigate the CBR components of the current physiotherapy curriculum at AUW, to determine whether they should, and could be expanded. The Mix method study design was employed, with a mixed research methodology, containing both qualitative and quantitative approaches for data collection. The components of CBR, present in the current physiotherapy curriculum at AUW were identified, using the constructive alignment framework, and content analysis for data analysis. The PWD’s needs of rehabilitation services in Sudan were established, using a questionnaire survey among users at various rehabilitation centres in Khartoum State. The CBR components that needed to be adapted in the physiotherapy curriculum at AUW were identified, using focus group discussions and in-depth interviews with AUW physiotherapy students and a CBR expert. Finally, the CBR components were revised and adapted, using a collaborative approach during workshops with AUW staff and clinicians. It was concluded that, in order to address the rehabilitation needs of PwDs, the CBR module needed to include additional components, to align the course content, teaching and learning techniques, as well as assessment tasks, with the intended learning outcomes of physiotherapy students. The components in the CBR matrix, such as livelihood and empowerment, were deemed important to provide students with knowledge, skills and competence. Additionally, providing information about assistive devices was deemed vital in rehabilitation. A significant relationship (P<0.05) was observed between the provision of information on assistive devices, and the maintenance thereof, as well as the benefits to users, respectively. Ultimately, commencing CBR placements in the fourth year, as is currently the norm, was deemed too late; therefore, it was suggested that community visits in the first and second years of physiotherapy studies, be included in the CBR course curriculum.

The purpose of the study is to contribute to the development of a tool that can support the rehabilitation care worker towards intervention planning and the monitoring of their clients. The National Health Insurance and the Framework and Strategy for Disability and Rehabilitation of the South African Department of Health are strategies to work towards accessible, affordable, equitable and quality health care, which includes health promotion, disease prevention, curative, rehabilitation and palliative services for all South Africans. Both strategies emphasise the use of community health workers and mid-level workers as a key component of primary health care. In the Western Cape provincial Department of Health a new cadre, namely the rehabilitation care worker has been introduced as a member of the rehabilitation team. The introduction of the rehabilitation care worker is still in the pilot phase. The rehabilitation care workers face many barriers to providing effective care. One such challenge is the lack of a contextually relevant resource tool to collect information on the rehabilitation and health needs of persons with disabilities. The aim of the study was to develop a contextually relevant resource tool that would support the rehabilitation care worker in understanding and documenting how the rehabilitation and related health needs of persons with disabilities are met in home- and community-based settings. Three specific objectives were defined: i) to develop the content and domains of the rehabilitation and health information tool; ii) to establish the validity (face and content) of the rehabilitation and health information tool; and, iii) to test the application of the rehabilitation and health information tool on a sample of persons with disabilities. This study was an exploratory descriptive study adopting a sequential mixed methods design. There were two phases in this study. Phase 1 involved qualitative research methods in the development of the rehabilitation and health information tool through the use of document review and a focus group discussion with experts. Phase 2 of the study involved quantitative research methods in the field testing of the rehabilitation and health information tool by the rehabilitation care workers on a sample of persons with disabilities. The results of phase 1 included the development of the rehabilitation and health information tool, which was deemed by the experts to be a comprehensive, contextually relevant tool with face and content validity and could be easily administered by the rehabilitation care worker. The conceptual framework of the International Classification of Functioning, Disability and Health provided domains that could comprehensively document the multidimensional needs of persons with disabilities. The result was a draft rehabilitation and health information tool with 17 questions ranging across the domains of activities of daily living, sexual health, health behaviours, barriers and facilitators to good health, finance and understanding of disability. Changes were proposed to the wording, layout and flow of the tool and the persons with disabilities’ goals were included as an element . The inclusion of the end users as experts in the development resulted in a richer understanding needed for the shaping of this tool. The results of phase 2 highlighted that the rehabilitation and health information tool was able to describe the rehabilitation and health needs of persons with disabilities. Additionally the tool was able to document the specific goals of the persons with disabilities which is useful to plan and monitor intervention. The rehabilitation care workers reported the tool to be useful, easy to use, and provided a structured manner to collect information. They also reported that it was useful in stimulating conversations on sensitive topics. However, it was indicated that it took too long to complete and there were components that were incomplete. The rehabilitation and health information tool requires further refinement, validation and further follow-up testing before it can be formally adopted and implemented as part of the rehabilitation care worker’s standard practice.

Disability and arthritis in Mexico are important public health problems. There is a need to develop rehabilitation interventions aimed at reducing the prevalence and disabling effects of arthritis in low socioeconomic communities in this country. This thesis reports findings from the initial execution of a mixed-methods participatory research program. This program was designed to develop, implement and evaluate a community-based rehabilitation program to decrease disability of people living with arthritis in the municipality of Chankom, a low-income rural Mayan community located in Southeast Mexico. Epidemiologic results showed a high prevalence of arthritis in Chankom associated with low levels of wealth and high body mass index. In addition, arthritis was associated with a higher prevalence of disability in this municipality. Further results showed that people who live with osteoarthritis in Chankom perform standardized and real-life activities with significant levels of disability. This disability was associated with levels of wealth, pain, muscle strength, self-efficacy, and physical activity. Ethnographic results showed that: a) arthritis reduces the health-related quality of life of people in Chankom through a process of disablement, b) people living with arthritis need access to culturally sensitive healthcare, and c) there are availability, attainability and acceptability barriers to accessing culturally sensitive health services in this municipality, which result from power imbalance between indigenous and non-indigenous people. The work presented in this thesis is the extensive examination of the problems associated with arthritis in Chankom, using quantitative and qualitative methods. Our findings justify the need to develop health policies and interventions to prevent and decrease the disabling effects of arthritis in this marginalized community. Moreover, these findings will support the creation of a culturally sensitive, community-based rehabilitation program, as a multi-level strategy to promote social development and improve health-related quality of life of people living with arthritis in the municipality of Chankom. / Thesis / Candidate in Philosophy / There is a need to develop rehabilitation interventions aimed at reducing the onset and disabling effects of arthritis in poor areas of Mexico. This thesis reports findings from the initial implementation of a research project designed to decrease disability of people living with arthritis in Chankom, a poor rural Mayan community located in Southeast Mexico. These findings show that arthritis is common in Chankom and it is related to having problems performing usual activities, which reduce people’s quality of life. People living with arthritis in Chankom need culturally appropriate healthcare services; however, they don’t obtain these due to different barriers associated with their indigenous background. Consequently, it is necessary to design health policies and interventions to decrease the disabling effects of arthritis in Chankom. The findings of this thesis will help creating a rehabilitation program that increases access to appropriate healthcare, improving function and quality of life of Chankom’s inhabitants.

>Magister Scientiae - MSc / Physiotherapy services for disabled children and their families have conventionally been received at a hospital or school for children with special educational needs in the main towns and cities of South Africa. Community-Based Rehabilitation (CBR) programmes were proposed and established as an additional approach to Institutional-Based Rehabilitation to address the need for accessible resources for these families. In this study the author evaluated two CBR programmes for disabled children and their main caregivers in two separate low socioeconomic peri-urban areas of Cape Town. The programme, a weekly group meeting, included physiotherapy interventions to assist the development and functional abilities of the children by means of activities that the caregivers could include in daily home care. They handled their own children following demonstrations and correction of handling skills by the author. The majority of the caregivers were mothers. Their children, less than 13 years old, were severely intellectually impaired. Some with concomitant physical disabilities. The author implemented the interventions of the CBR programme and she required to understand the impact on the particpants in a study using qualiative research methods. In the pilot programme the attendant members were individually interviewed, after her withdrawal, for their opinions of the outcomes. Evaluation documentation.ofjheir children and CBR programme records were related to the caregivers' responses. From the pilot study experiences the author felt that additional methods of data collection would result in a greater understanding of the impacts of the interventions. Expanded methods of research were utilised in the study of the second group. During the interventions at group meetings the author used field notes to record observations. Participant observation allowed the author to analysis the responses of the participants. Focus group interviews assisted in understanding external factors influencing the participants as well as their needs. Individual interviews, after the closure of the CBR programme, allowed the participants to express their views of the interventions. Documentation of the individual evaluation of each child was related to the views expressed by the caregivers. Common meanings and themes were explored in the analysis of the various data collected. Analysis revealed that interventions of education and training for the caregivers improved their knowledge and understanding of the impairments and disability of their children. The children benefited functionally from their families increased skills and knowledge. Through discussion with other families at group meetings, the caregivers had an understanding of other disabilities in children and developmental outcomes possible for their own child. The caregivers were more confident to address the negative perceptions of disability in their communities. It is recommended that physiotherapists implementing any interventions for disabled children should ensure that the caregivers are partners in planning and selection of interventions and that their needs are addressed. Community participation in Community-Based Rehabilitation programmes was required for the participants to become self-reliant and solve their own needs as well as for the programme to be sustainable. This was demonstrated in only one of the programmes.

MPH / Department of Public Health / Background: Globally, more than one billion people, or approximately 15% of the world’s population are living with some form of disability and 80% of them are found in developing countries. There are different types of disability; these include sensory, neurological, physical, intellectual, cognitive and psychiatric disabilities. Persons with disabilities may require specialized care, resources and commitment which place a very high demand of time and responsibilities on the one caring for them. Therefore, Community-Based Rehabilitation (CBR) was promoted by the World Health Organisation (WHO) as a strategy to respond to the needs of persons with disabilities, through the provision of basic services at community level, particularly in developing countries with limited resources. Methodology: The purpose of this study was to explore and describe the challenges faced by Community-Based Rehabilitation caregivers for persons with disabilities in Vhembe District, South Africa. A qualitative phenomenological design was used to explore and develop an in-depth understanding of the CBR caregiver’s challenges. The study was conducted in three Community-Based Rehabilitation centres located within Vhembe District with a sample size of six caregivers who were purposively selected. An interview guide was developed as an instrument for data collection. Data was collected through in-depth individual interviews and analyzed using thematic analysis. Results: Six main themes emerged from the data which shed light on the CBR caregiver’s challenges, namely; Poor relationships between caregivers, government v department and families, unavailability of material and human resources, poor funding system, caregivers’ well-being, education and training and the coping strategies of CBR caregivers Conclusion: This study pointed out that there is a need for intervention from different stakeholders such as government departments, family members of persons with disability, and the community members as well for CBR caregiver’s challenges to be resolved or minimized.

Community-based Rehabilitation (CBR) emerged as a response to the failure of the conventional rehabilitation system in developing countries. CBR involves service provision to People with Disabilities (PWDs), changing community attitudes towards disability and transferring knowledge and skills to PWDs, their families and their community. The study investigated the impact of the CBR strategy on PWDs and their families within the Oniipa Constituency in Namibia. The study used a mixed methods research approach and adopted explorative and descriptive research designs. It determined that CBR has initiated positive change processes in community attitudes and increased social integration of PWDs. The study recommends reviewing the definition of CBR, providing financial incentives to CBR Volunteer Workers and reviewing the current legislations on disability in Namibia. A final recommendation is that government should formalise disability studies in the country through the provision of accredited training courses to ensure greater assistance to PWDs and their families. / Public Administration / M.P.A.

PHDRDV / Institute for Rural Development / Institute for Rural Development and Poverty Alleviation