Rehabilitation is important for persons with disabilities as it contributes to their sense of autonomy, self-worth and social participation, and improves their quality of life. Improving the quality of rehabilitation services requires the dialogue of patients’ perceptions with those of service providers, in order to recommend informed reform.
The objective was to explore the experiences of persons with physical disabilities and service providers, regarding the multi-disciplinary rehabilitation services provided at a community-based out-patient rehabilitation centre.
A qualitative, exploratory study design was used to collect the data. A focus group was conducted with conveniently selected persons with physical disabilities. Three in-depth interviews were conducted with purposively selected key informants. All ethical considerations were adhered to during the implementation of the study.
Patients and service providers had different experiences regarding accessibility to rehabilitation services, and similar experiences with patient education and intensity of rehabilitation. Although the patients experienced that the service providers had sufficient knowledge and skills to manage them, services providers expressed that they lacked certain skills.
The experiences expressed highlighted the need to improve rehabilitation services in terms of increasing the capacity of service providers and providing transport services for persons with disabilities.
The number of people living with a disability is increasing. The rate of disability ranges from 11.8% in higher income countries to 18.0% in lower income countries, in those aged 18 years and older (World Health Organisation
Furthermore, rehabilitation is a concept that is aimed at enabling PWDs, allowing them to reach and maintain their optimal physical, sensory, intellectual, psychological and social functional levels (United Nations
Seeking to ascertain patients’ perceptions regarding rehabilitation programmes and services, is important for advocating change (DOH 2000). This is also important as clinicians and patients could have different views on outcomes, post-illness (Hewlett
In South Africa, rehabilitation can be provided at in-patient settings, out-patient settings and, to a lesser extent, in the patients’ homes and communities. A few studies have reported on the PWDs’ experiences regarding rehabilitation services in the Western Cape, South Africa (De la Cornillere
Although there were studies conducted at some community health centres in the Western Cape, the information is based only on patients’ experiences. According to Wottrich
This paper provides the findings of a study that focused on the experiences of both the patients and the service providers to rehabilitation services, currently provided by a multi-disciplinary team at a rehabilitation centre in the Western Cape. The objectives of the study were to explore the perceptions and opinions of persons with physical disabilities, as well as services providers’ experiences regarding the following:
service providers’ knowledge of the disability
treatment and skills training
interaction with service providers
information obtained from the service providers
accessibility to rehabilitation services
patient participation and involvement in the rehabilitation
the structure of rehabilitation sessions.
The objectives of the study are based on certain principles of community-based rehabilitation. An important goal of community-based rehabilitation is to empower people with disabilities, their families and communities. In doing so rehabilitation services need to be accessible and involve people with disabilities and their families in the rehabilitation process (WHO 2011).
The study was conducted at an outpatient rehabilitation centre in the Cape Town Metro health district. Rehabilitation services at this centre are provided by one full-time physiotherapist and one occupational therapist respectively. Part-time speech and language therapy services are also provided to patients with physical and psychosocial impairments and disabilities. The services rendered at this centre include preventive, promotive, curative and rehabilitation services. Health conditions that are treated at this centre include:
orthopaedic
neurological
surgical
gynaecology and obstetrics
paediatric
respiratory.
The occupational therapy department commonly provides services to between 59–154 patients, whereas physiotherapy services are rendered to between 65–325 patients per month. At the centre, speech therapy services are provided by students and between 20–120 patients utilise this service per month.
The study population consisted of patients with physical disabilities and service providers working at the out-patient rehabilitation centre. Patient records of those aged 18 years and above who received rehabilitation during 2009, were divided into groups and, thus, stratified according to the seven most common physical health conditions managed at the specific rehabilitation centre. The study was carried out during 2010, which means that the population of patients that received rehabilitation services during the preceding year (2009) was eligible for participation, as they had completed their respective programmes. This was also undertaken to limit the degree of recall bias, which is inherent to qualitative studies. The conditions were:
spinal cord injuries
head injuries
strokes
amputees
fractures and dislocations
osteoarthritis
neuromuscular afflictions.
From the most common health conditions, three patients were conveniently selected to take part in the study. A total of 21 conveniently-selected patients were telephonically informed about the study and their consent was sought. In total, 11 consented to participate in a focus group discussion (FGD) which was later held at the rehabilitation centre. Of those, six were female and the mean of age of the participants was 54.82 years. Participants’ characteristics are presented in
Patients’ characteristics.
Name | Age | Gender | Patient’s condition |
---|---|---|---|
P1 | 66 | Female | Osteoarthritis |
P2 | 47 | Male | Rotator cuff repair |
P3 | 54 | Female | Rheumatoid arthritis |
P4 | 55 | Female | Frozen shoulder |
P5 | 52 | Female | Stroke |
P6 | 77 | Male | Osteoarthritis |
P7 | 44 | Male | Stroke |
P8 | 52 | Male | Frozen shoulder |
P9 | 70 | Female | Osteoarthritis |
P10 | 26 | Male | Amputation |
P11 | 60 | Female | Osteoarthritis |
An exploratory descriptive qualitative methodology was used to collect the data. This design provides a comprehensive summarisation of experiences that deal with the
In both the FGD and the in-depth interviews that lasted for approximately 45 minutes to an hour, the researcher used an interview guide to explore the experiences regarding rehabilitation services. The FGD with the patients explored the following:
the service providers’ knowledge and skills training
interaction between patients and service providers
information obtained by patients
accessibility to rehabilitation services
patient participation and involvement in rehabilitation
structure of rehabilitation services.
The focus group was only conducted once and lasted for approximately 45 minutes. The same semi-structured guide was used for the in-depth interviews with the service providers.
The service providers were interviewed at the rehabilitation centre at a time convenient for them. The interviews ranged from 45 minutes to one hour, the researcher conducted the interviews and took the field notes. Two trained research assistants assisted in conducting interviews in Afrikaans.
The focus group discussion and the interviews were tape-recorded and transcribed verbatim. The data were thematically analysed, using content analysis as the strategy. The transcripts in Afrikaans were professionally translated from Afrikaans to English. The English transcripts were translated back into Afrikaans to verify accuracy of the information. The data were coded into pre-determined themes according to the objectives of the study and related literature. Initially, the transcripts were read a few times for familiarisation, to obtain a sense of the whole, and to become increasingly immersed in the data. During the first reading, open coding was applied to elicit all possible meanings of the texts. After open coding, sub-themes were created using patient-characteristic words (in-vivo) in order to stay close to the data and to fulfil the inductive approach of ensuring that the experiences of participants emerged from the data (Sandelowski & Barroso
Four qualitative criteria for trustworthiness were applied in this study: credibility, transferability, dependability and confirmability (Lincoln & Guba
Written informed consent was obtained from each participant prior to the FGD and in-depth interviews, and they were ensured of their right to withdraw from the study at any time. The information sheet and consent form were translated from English to Afrikaans for participants who were not fluent in speaking and reading English. In addition, the FGD participants verbally agreed that any information discussed in the focus group would be kept confidential. This made them conscious in advance of their ethical responsibilities. At the end of the FGD and in-depth interviews participants were again given the option to consent or to withdraw from the study.
To preserve the anonymity of the participants’ information, the researcher used pseudonyms to identify participants P1–P11, and service providers SP 1–3, throughout the study, thus, concealing the participants’ names and other personal information provided. All participants consented to have their interview recorded.
The themes were based on the participants’ experiences on the pre-determined thematic domains, such as:
the service providers’ knowledge and skills training
accessibility of services
the interaction of patients with their service providers
patients’ involvement and participation in rehabilitation
provision of information
structure and organisation of rehabilitation sessions.
Knowledge regarding disability and treatment, as well as skills training amongst service providers, were the primary issues that arose under this theme. The findings of the study revealed that some participants expressed the view that the service providers always knew what they were doing and the conditions they dealt with. They also expressed that at times service providers managed patients based on the diagnosis made by the doctor; ‘The people treating us here are well educated, they are very good’ (P2); ‘I have not been here for a while but I experienced they knew what was wrong with me’ (P6); ‘I always knew I would be fine, because I felt these people [
Although most participants trusted the service providers’ knowledge, the service providers experienced that they were not knowledgeable enough to deal with all types of disabilities, as expressed by one of the service providers in the following quote: ‘I lack some knowledge on certain conditions, like paediatrics, stroke, that we normally see here at this centre’ (SP1); ‘We do not have the expertise in all domains, so sometimes we may refer the patients because of this’ (SP2).
In addition, some participants in the study experienced that their service providers were adequately skilled to deal with their conditions. Whilst others revealed that their service providers misdiagnosed their conditions, which influenced the treatment.
‘I came to be treated for my back. When I started doing the exercises I felt it was not my back, but my hip. Then I had to go back for x-rays’. (P9)
‘The same thing happened to me, they treated me for rheumatoid arthritis but it was not, it was osteoarthritis’. (P6)
In both the FGD and in-depth interviews, there were some key issues that arose within this pre-determined theme. A lack of accessibility to suitable transport to attend the rehabilitation centre was expressed by both patients and service providers. Although the service providers thought that the rehabilitation was accessible resulting from the presence of ramps and rails patients still experienced having problems with accessibility at the centre. Participants in the current study expressed their concerns that were related to delayed and inaccessible transport to the rehabilitation facility, as expressed by participants:
‘The bus takes long to come. When it comes, we are already late for our appointments’. (P7)
‘… we don’t want to get wet during winter … if there was a car from the rehabilitation centre it would be a lot more comfortable and easier … then we would always make it to the appointment’ (P4)
‘... those benches in the waiting room are too low for patients to sit on’ (P9)
‘I don’t think patients struggle while accessing the centre because the gate is not far from the building. There is a ramp that wheelchair-users can use when coming in and out of the building. There is also a toilet handle for wheelchair-users while using the toilet’ (SP1)
The participants’ experiences regarding their interaction with service providers were related to their being respected, appreciated and cared for. This was resulting from the fact that the service providers were able to provide time to relate to and communicate with them. The experiences of the participants in the current study were confirmed by their service providers’ responses when asked about their relationship with patients. This is illustrated in the quotations below.
‘… they are loving people and show respect towards the patients’ (P8)
‘They are always aware when you have pain and they react positively and loving throughout the treatment’ (P2)
‘I usually make sure that I am not only treating the patients throughout the session. I make time to relate to my patients so that I may avoid them seeing me as someone superior’ (SP1)
‘we make time for the patients, despite the workload. We try to see a patient as an individual and try to assist the patient the best we can. We talk to them regarding their disabilities’ (SP2)
The participants and the service providers reported positive experiences with the patients’ participation and involvement in rehabilitation. The participants expressed that service providers gave them the opportunities to express personal goals for rehabilitation and also explained treatment procedures. The following quotations illustrate these experiences:
‘I had to sit with my therapist and tell her I want to be able to use my hand and build another room on to my house’ (P7)
‘… whenever I came here she (service provider) would ask me what I want to do’ (P10).
‘The first thing I do is that I ask my patients what they want to achieve before we start the treatment. Both the patient and I work to achieve what he/she wants’ (SPA).
‘I encourage patients to keep on exercising to keep them engaged in their rehabilitation, so that they can be able to do what they used to do before’ (SP3)
There was agreement between the services providers and participants’ experiences regarding the provision of information. Both reported that information was provided using visual aids. The participants also expressed experiencing information provided by the service providers as detailed and relevant to their condition.
‘The service provider talked and explained to me, using the x-ray, exactly what was the problem I had and where it was in the body’. (P1)
‘… before I started my treatment here, which is very good compared to other places (other facilities), the therapist explained to me what was wrong with me. I received a form which explained my problem’. (P10)
‘… a stroke patient, he/she will be provided with information regarding his/her condition and the exercises that he/she needs to do at home’. (SP2)
‘There are different posters up in the rehab centre where they can get more information. They ask for any other information they need. We usually help them. We also have health promotion talks. We invite different health promoters to come and teach our patients about different health risks like HIV/AIDS’. (SP)
The main aspects that were highlighted by both the patients and the service providers within this theme were length of sessions and appointment schedules. The participants wanted longer treatment sessions, whilst the service providers highlighted that they could not increase frequency and length of rehabilitation sessions resulting from a lack of staff.
‘I just want slightly longer sessions with them [
‘… and we need them [
‘I sometimes need more time and capacity to book them (patients) in because we are under staffed’. (SP2)
‘… but during November and December … there are waiting lists for patients. There no students at the centre to help, but we try our best to accommodate all the patients even though it’s not easy’. (SP3)
The aim of the study was to explore the experiences of both patients and service providers with multi-disciplinary rehabilitation services at a community-based rehabilitation centre.
The current study findings revealed that some participants expressed that the service providers were knowledgeable in regard to the conditions they managed. These findings are consistent with those in a qualitative study conducted in Sweden by Wottrich
Whilst service providers reported that they lacked knowledge and training in some disabilities, their patients demonstrated a level of trust in the competency and knowledge of their service providers. It is not unusual that service providers could develop some gaps in their scope of practice. A lack of knowledge by service providers about the patients’ disabilities could be the result of inadequate knowledge (Wottrich
Both services providers and patients agreed that challenges existed with accessing the centre resulting from a lack of appropriate transport. The participants expressed that they had challenges related to limited availability and inaccessibility of transport. These findings are consistent with those of Kahonde
Both patients and service providers reported that a positive relationship existed between patients and service providers at the centre. The findings regarding the interaction of service providers with patients are consistent to those of Darrah
Patients and service providers had positive opinions regarding the patients’ participation and involvement in rehabilitation. Patients in FGD reported that their service providers gave them opportunities to identify their goals and explained the procedures of the treatment. This was confirmed by the service providers in their interviews. This finding was in contradiction to findings in a study conducted by (Wottrich
Both patients and service provides concurred that visual aids were used to provide patients with information about certain conditions. In addition participants also reported that they received most of the information they needed from their service providers. The information regarding the patients’ disability and the treatment provided was well explained by the service providers. The inclusion of education is an important component of patient management as it facilitates adherence to treatment and also decreases mortality and morbidity (Lynggaard
Both patients and service providers expressed the need to increase time spent in rehabilitation. These findings are similar to those of Lopopolo (
This study presents some limitations. The study adopted focus group discussions which involved groups of people gathering the data related to the patients’ experiences regarding the rehabilitation services. The data were, therefore, not collected in a participant’s natural setting, which could have curtailed the freedom to speak freely. Furthermore, the targeted selection excluded those with speech and hearing impairments. For this reason the current study information cannot be generalised beyond the boundaries of the out-patient rehabilitation centres and the specific diagnostic groups. Future studies should include all representative diagnostic groups.
Based on the design and limitations of the study, we identified the need for health-policy makers to improve the means of ensuring that rehabilitation facilities are adequately resourced to provide appropriate levels of quality care. On a macro-level, the results indicate that the government sectors in South Africa need to develop public transport systems that are accessible and affordable to persons with disabilities, to assist them to attend rehabilitation sessions. Increased home-based programmes could also be implemented to increase access to rehabilitation services.
Patients and service providers had similar experiences regarding accessibility of rehabilitation services, patient education and intensity of rehabilitation. They differed with regards to knowledge and skills of service providers and accessibility within the rehabilitation centre. The experiences expressed highlighted the need to improve rehabilitation services in terms of increasing the capacity of service providers, and providing transport services for persons with disabilities.
The authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article.
The study was part of A.K.’s (University of Rwanda) master’s thesis, which was part of a bigger study. The bigger study evaluated the Rehabilitation at Four sites in the Western Cape. All the authors: C.G. (Stellenbosch University), G.M. (Stellenbosch University), N.M. (University of the Western Cape), C.J. (Karolinski Health Institute), S.S. (Stellenbosch University), A.K. (University of the Western Cape) were researchers on the bigger project and were therefore involved in the conceptualisation of the study and developing of instruments. N.M. and A.R. (University of the Western Cape) were the thesis supervisors and assisted with the qualitative analysis. A.K. drafted the article and all the other authors commented before final submission.