The black hole of dealing with a disability diagnosis: Views of South African rural parents.

BACKGROUND: Lack of support systems in the management of health and rehabilitation related problems, including the stigma of giving birth to a child with disability, results in some parents ignoring the doctor's prognosis of lifelong disability. OBJECTIVES: The study was conducted in the Eastern Cape province (ECP) of South Africa (SA) on parents' views in caring for children with disability in an area with minimal health facilities in a rural setting. METHOD: Data was collected using exploratory descriptive qualitative methods. A Xhosa-speaking researcher facilitated six focus group discussions and conducted one individual in-depth interview with 37 parents or caregivers of children with disability residing at Happy home. Only one father was interviewed. Thematic analysis was used in interpreting data obtained from interviews. RESULTS: The findings revealed themes indicating key concerns of parents, which were as follows: challenges with disability diagnosis, negative attitudes of health professionals, health and rehabilitation related problems, and lack of support from families and community. CONCLUSION: Caring for children with disability in a rural setting where services are minimal or not available to the poorest people who mostly need such services is not easy. Thus, to respond appropriately to the health and support needs of children with disability, it is crucial to understand the social context and needs of their families and caregivers. Due to size of the study, findings cannot be generalised. Recommendations are made for further studies to explore the vital issues affecting parents of children with disabilities.

Exploring the inclusion of teaching and learning on assistive products in undergraduate curricula of health sciences faculties at three South African Universities.

BACKGROUND: Providers must be knowledgeable on policy, systems and products to provide a person centred service and prescribe the most appropriate assistive product for each user. AIM: This study aimed to determine to what extent teaching and learning on assistive products are included in undergraduate curricula of the Health science faculties at three universities in the Western Cape Province of South Africa. METHODS: Data were gathered through a cross sectional survey. Fifteen programmes were approached of whom eight participated. Information on teaching on assistive products was sourced from purposively identified key informants, through e-mail questionnaires. Descriptive analysis was done. RESULTS: A total of 104 assistive products were included in the eight programmes. Manual wheelchairs were the only product for which teaching was underscored by policy guidelines. Handheld mobility devices and wheelchairs were covered by five programmes. Teaching on assistive products for self-care, participation in domestic life, indoor and outdoor activities, employment and leisure was limited. Thirty seven products listed on the GATE List of 50 were taught by at least one of the programmes. Teaching and examination were theoretical in nature and occurred in professional silos. Clinical exposure was often incidental. For many products none of the four service delivery steps were covered. CONCLUSION: Assistive products were included in all the participating undergraduate programmes. The range of included products and the level of training were insufficient to prepare graduates to effectively address user's needs. Newly appointed graduates will require early in-service training to ensure appropriate assistive product service delivery.Implications for rehabilitationUndergraduate teaching on assistive products is provided in professional silos.Not all products on the GATE APL of 50 are included in under graduate teaching.Teaching does not always ensure a proficiency level that will support graduates to provide an independent AT service.

Access to primary care for persons with spinal cord injuries in the greater Gaborone area, Botswana.

BACKGROUND: People with spinal cord injury (SCI) often have great need for healthcare services, but they report access challenges. Primary care access to people with SCI has not been explored in Botswana. OBJECTIVE: This study aimed to identify barriers and facilitators that users with spinal cord injuries experience in accessing primary care services in the greater Gaborone area, Botswana. METHODS: A quantitative, cross-sectional, observational study was conducted. Data were collected with a structured questionnaire from 57 participants with traumatic and non-traumatic SCI. Descriptive and inferential analysis was performed. RESULTS: The male to female ratio was 2.8:1. The mean age of participants was 40 years (standard deviation 9.59). Road traffic crashes caused 85% of the injuries. Most participants visited primary care facilities between 2 and 10 times in the 6 months before the study. Participants were satisfied with the services (63%) and felt that facilities were clean (95%) and well maintained (73.5%). Preferential treatment, respect, short waiting times and convenient hours facilitated satisfaction with services. Availability was hampered by insufficient provider knowledge on SCI as indicated by 71.9% of participants, and shortage of consumables (80.7%). Structural challenges (42.1% could not enter the facility by themselves and 56.5% could not use the bathroom) and lack of height-adjustable examining couches (66.7%) impeded accessibility. Cost was incurred when participants (64.9%) utilised private health services where public services failed to address their needs. CONCLUSION: Primary care services were mostly affordable and adequate. Availability, acceptability and accessibility aspects created barriers.

The perceived needs-access gap for health services among persons with disabilities in a rural area within South Africa.

Purpose: Health should be a universal phenomenon. However, little is known about the relationship between disability status and health issues - particularly in rural areas. This study looks at health issues of persons with disabilities in Madwaleni, a rural impoverished area in South Africa in 2011, and compares them to persons with no disabilities. Materials and Methods: Standardized questionnaires were used in the survey to assess disability and health status. The sample comprised of 773 individuals - 322 persons with disability and 451 comparisons (without disability) - covering 527 households. Children under the age of five were excluded from the sample. We used purposive sampling. Results and Conclusion: This study found that persons with disabilities have poorer reported health outcomes than persons with no disabilities. There is also an association between disability severity and mental health issues as assessed by the GHQ-12. A significantly higher percentage of persons with disability did not get health care when needed. Persons with disabilities also have less favorable attitudes toward competence of health care workers. This study has shown greater health needs and less satisfaction with services, which strongly indicates insufficient access for persons with disabilities in a rural impoverished are within South Africa. Implications for rehabilitation Persons with disabilities in rural South Africa have poorer reported health outcomes. Persons with disabilities have less favorable attitudes towards competence of health care workers in rural South Africa. Better access to health care for persons with disabilities is needed in rural South Africa.

Suitability of 'Guidelines for Screening of Prosthetic Candidates: Lower Limb' for the Eastern Cape, South Africa: A qualitative study.

BACKGROUND: Major lower limb amputation has a severe impact on functional mobility. Mobility can be salvaged with a prosthesis, but this is not always the best option. It is often difficult to decide whether to refer someone for a prosthesis or not. A prosthetic screening tool 'Guidelines for Screening of Prosthetic Candidates: Lower Limb' was developed and is used for prosthetic prescription in parts of the Western Cape province of South Africa. OBJECTIVES: This study aimed to explore the suitability of the tool 'Guidelines for Screening of Prosthetic Candidates: Lower Limb' for use in the Eastern Cape province of South Africa. METHOD: A qualitative study was conducted with conveniently sampled occupational therapists (OTs) (n = 10), physiotherapists (PTs) (n = 12) and prosthetists (n = 6) in government employment in the Buffalo City Metro Municipality. Participants were trained in the use of the tool and used it for four weeks with patients. Their experiences of the tool were assessed through three focus group discussions with emergent themes being identified during inductive data analysis. FINDINGS: Participants indicated that the tool could assist with prosthetic prescription, goal setting, communication and teamwork. They thought that the tool was multidisciplinary in nature, comprehensive and practical. Findings showed a lack of teamwork in this study setting. Resistance to change and a lack of time might also hamper implementation of the tool. CONCLUSION: The tool can assist with managing the backlog for prostheses and to guide prosthetic prescription in the Eastern Cape province. CLINICAL IMPLICATIONS: A prosthesis can help to salvage functional mobility after lower limb amputation. However, not all people who had above knee amputation manage to walk with a prosthesis. The tool reported on in this article provides information that can guide prosthetic prescription and rehabilitation goals.

The African Indigenous Lens of Understanding Spirituality: Reflection on Key Emerging Concepts from a Reviewed Literature.

In this paper, we will present a reflection on reviewed literature on African indigenous understanding of spirituality, highlighting the influence of this concept on notions of the self, motivation and well-being. The indigenous understanding of spirituality is central to the understanding of the self as distinct, but positioned within the relational-collective self. This African indigenous perception of the self is grounded within the autonomous experience of the tenets of spirituality, which is explored in this paper through the lens of self-determination theory. The experience of autonomy, which is represented in this paper as choice and consent, competence and relatedness within spirituality, is considered as an intrinsic motivation factor for African indigenous communities to achieve well-being. Hence, we argue for the relevance of identifying and exploring ways that an understanding of the African indigenous spiritual belief systems, and the various ways that this understanding impacts on well-being for African indigenous communities, can be unearthed and scrutinized.

Lessons from the pilot of a mobile application to map assistive technology suppliers in Africa.

A pilot project to develop and implement a mobile smartphone application (App) that tracks and maps assistive technology (AT) availability in southern Africa was launched in Botswana in 2016. The App was developed and tested through an iterative process. The concept of the App (AT-Info-Map) was well received by most stakeholders within the pilot country, and broader networks. Several technical and logistical obstacles were encountered. These included high data costs; difficulty in accessing AT information from the public healthcare sector, the largest supplier of AT; and the high human resource demand of collecting and keeping up-to-date device-level information within a complex and fragmented supply sector that spans private, public and civil society entities. The challenges were dealt with by keeping the data burden low and eliminating product-level tracking. The App design was expanded to include disability services, contextually specific AT categories and make navigation more intuitive. Long-term sustainability strategies like generating funding through advertisements on the App or supplier usage fees must be explored. Outreach and sensitisation programmes about both the App and AT in general must be intensified. The project team must continually strengthen partnerships with private and public stakeholders to ensure ongoing project engagement. The lessons learnt might be of value to others who wish to embark on initiatives in AT and/or implement Apps in health or disability in southern Africa and in low-resourced settings around the world.

Assistive technology policy: a position paper from the first global research, innovation, and education on assistive technology (GREAT) summit.

Increased awareness, interest and use of assistive technology (AT) presents substantial opportunities for many citizens to become, or continue being, meaningful participants in society. However, there is a significant shortfall between the need for and provision of AT, and this is patterned by a range of social, demographic and structural factors. To seize the opportunity that assistive technology offers, regional, national and sub-national assistive technology policies are urgently required. This paper was developed for and through discussion at the Global Research, Innovation and Education on Assistive Technology (GREAT) Summit; organized under the auspices of the World Health Organization's Global Collaboration on Assistive Technology (GATE) program. It outlines some of the key principles that AT polices should address and recognizes that AT policy should be tailored to the realities of the contexts and resources available. AT policy should be developed as a part of the evolution of related policy across a number of different sectors and should have clear and direct links to AT as mediators and moderators for achieving the Sustainable Development Goals. The consultation process, development and implementation of policy should be fully inclusive of AT users, and their representative organizations, be across the lifespan, and imbued with a strong systems-thinking ethos. Six barriers are identified which funnel and diminish access to AT and are addressed systematically within this paper. We illustrate an example of good practice through a case study of AT services in Norway, and we note the challenges experienced in less well-resourced settings. A number of economic factors relating to AT and economic arguments for promoting AT use are also discussed. To address policy-development the importance of active citizenship and advocacy, the need to find mechanisms to scale up good community practices to a higher level, and the importance of political engagement for the policy process, are highlighted. Policy should be evidence-informed and allowed for evidence-making; however, it is important to account for other factors within the given context in order for policy to be practical, authentic and actionable. Implications for Rehabilitation The development of policy in the area of asssitive technology is important to provide an overarching vision and outline resourcing priorities. This paper identifies some of the key themes that should be addressed when developing or revising assistive technology policy. Each country should establish a National Assistive Technology policy and develop a theory of change for its implementation.

Factors related to environmental barriers experienced by persons with and without disabilities in diverse African settings.

This paper explores differences in experienced environmental barriers between individuals with and without disabilities and the impact of additional factors on experienced environmental barriers. Data was collected in 2011-2012 by means of a two-stage cluster sampling and comprised 400-500 households in different sites in South Africa, Sudan Malawi and Namibia. Data were collected through self-report survey questionnaires. In addition to descriptive statistics and simple statistical tests a structural equation model was developed and tested. The combined file comprised 9,307 participants. The Craig Hospital Inventory of Environmental Factors was used to assess the level of environmental barriers. Transportation, the natural environment and access to health care services created the biggest barriers. An exploratory factor analysis yielded support for a one component solution for environmental barriers. A scale was constructed by adding the items together and dividing by number of items, yielding a range from one to five with five representing the highest level of environmental barriers and one the lowest. An overall mean value of 1.51 was found. Persons with disabilities scored 1.66 and persons without disabilities 1.36 (F = 466.89, p < .001). Bivariate regression analyses revealed environmental barriers to be higher among rural respondents, increasing with age and severity of disability, and lower for those with a higher level of education and with better physical and mental health. Gender had an impact only among persons without disabilities, where women report more barriers than men. Structural equation model analysis showed that socioeconomic status was significantly and negatively associated with environmental barriers. Activity limitation is significantly associated with environmental barriers when controlling for a number of other individual characteristics. Reducing barriers for the general population would go some way to reduce the impact of these for persons with activity limitations, but additional and specific adaptations will be required to ensure an inclusive society.

The experiences and challenges faced by rehabilitation community service therapists within the South African Primary Healthcare health system.

BACKGROUND: Twenty-two years after the promulgation of a plethora of progressive health policies since 1994, the South African public health system reflects a number of stumbling blocks regarding implementation. Rehabilitation professionals are not sufficiently equipped nor allowed the opportunity to comprehensively implement Primary Healthcare (PHC) from a bottom-up approach, thus engaging communities. Training on addressing social health determinants and their impact on ill-health and health outcomes is inadequate. The inadequate understanding of the advocacy role that rehabilitation professionals could play in addressing social health determinants remains a challenge in healthcare. Rehabilitation, a pillar of PHC, remains poorly understood in terms of its role within the health system. AIM: We argue for rehabilitation as a vehicle for addressing social determinants of health with community service practitioners playing a critical role in addressing the inequities within the healthcare package. SETTING: The article reflects the opportunities and challenges faced by rehabilitation community service therapists in the delivery of rehabilitation services in a rural area of the Eastern Cape province of South Africa. METHODS: A single case study from the perspective of a researcher was used to explore the experience and reflection of the first author during her community service as an occupational therapist. RESULTS: The case study highlights some existing gaps within the delivery of rehabilitation services in the rural Eastern Cape. A community service package with a specific approach towards addressing social determinants of health for persons with disability at a community level is suggested. CONCLUSION: Advocating for a rehabilitation service package to shift to community-based levels is critical. It is envisaged that a community-based approach will facilitate an understanding of the barriers faced by persons with disabilities as constituting disability, thus facilitating learning about the disabling consequences of the rural environment coupled with the system as experienced by persons with disabilities.

A study of human resource competencies required to implement community rehabilitation in less resourced settings.

BACKGROUND: It is estimated that over one billion persons worldwide have some form of disability. However, there is lack of knowledge and prioritisation of how to serve the needs and provide opportunities for people with disabilities. The community-based rehabilitation (CBR) guidelines, with sufficient and sustained support, can assist in providing access to rehabilitation services, especially in less resourced settings with low resources for rehabilitation. In line with strengthening the implementation of the health-related CBR guidelines, this study aimed to determine what workforce characteristics at the community level enable quality rehabilitation services, with a focus primarily on less resourced settings. METHODOLOGY: This was a two-phase review study using (1) a relevant literature review informed by realist synthesis methodology and (2) Delphi survey of the opinions of relevant stakeholders regarding the findings of the review. It focused on individuals (health professionals, lay health workers, community rehabilitation workers) providing services for persons with disabilities in less resourced settings. RESULTS: Thirty-three articles were included in this review. Three Delphi iterations with 19 participants were completed. Taken together, these produced 33 recommendations for developing health-related rehabilitation services. Several general principles for configuring the community rehabilitation workforce emerged: community-based initiatives can allow services to reach more vulnerable populations; the need for supportive and structured supervision at the facility level; core skills likely include case management, social protection, monitoring and record keeping, counselling skills and mechanisms for referral; community ownership; training in CBR matrix and advocacy; a tiered/teamwork system of service delivery; and training should take a rights-based approach, include practical components, and involve persons with disabilities in the delivery and planning. CONCLUSION: This research can contribute to implementing the WHO guidelines on the interaction between the health sector and CBR, particularly in the context of the Framework for Action for Strengthening Health Systems, in which human resources is one of six components. Realist syntheses can provide policy makers with detailed and practical information regarding complex health interventions, which may be valuable when planning and implementing programmes.

Barriers to the Implementation of the Health and Rehabilitation Articles of the United Nations Convention on the Rights of Persons with Disabilities in South Africa.

BACKGROUND: The United Nations (UN) Convention on the Rights of Persons with Disabilities (CRPD) is a milestone in the recognition of the human rights of persons with disabilities, including the right to health and rehabilitation. South Africa has signed and ratified the CRPD but still has a long way to go in reforming policies and systems in order to be in compliance with the convention. This paper seeks to fill a gap in the literature by exploring what the barriers to the implementation of the health and rehabilitation articles of the CRPD are, as identified by representatives of the disability community. METHODS: This investigation used a qualitative, exploratory methodology. 10 semi-structured interviews of a purposive sample of representatives of disabled persons organizations (DPOs), non-governmental organizations (NGOs), and service providers in South Africa were conducted. Participants were drawn from urban, peri-urban, and rural settings in order to reflect diverse perspectives within South Africa. Data was analysed using a multi-stage coding process to establish the main categories and relationships between them. RESULTS: Six main categories of barriers to the implementation of the health and rehabilitation articles of the CRPD were identified. Attitude barriers including stigma and negative assumptions about persons with disabilities were seen as an underlying cause and influence on all of the other categories; which included political, financial, health systems, physical, and communication barriers. CONCLUSION: The findings of this study have important implications for strategies and actions to implement the CRPD. Given the centrality of attitudinal barriers, greater sensitization around the area of disability is needed. Furthermore, disability should be better integrated and mainstreamed into more general initiatives to develop the health system and improve the lives of persons living in poverty in South Africa.

A protocol for the methodological steps used to evaluate the alignment of rehabilitation services in the Western Cape, South Africa with the National Rehabilitation Policy.

BACKGROUND: Rehabilitation medicine plays an integral part in attainment of optimal functioning after injury or disease. The National Rehabilitation Policy of South Africa (NRP) (2000) highlights the need for access to professional health care services, redistribution and optimal utilisation of resources and research in the field of disability and rehabilitation. The government further ratified the Convention on the Rights of Persons with Disabilities (CRPD) (2007), which validate the urgency in advancing the agenda of persons with disabilities. This paper outlines the methodological plan for evaluating rehabilitation services in the Western Cape, South Africa against the aims and objectives of the NRP as well as its principles and concepts. The evaluation process further focused on specific articles in the CRPD that were aligned with disability, health and rehabilitation. METHODS/DESIGN: A mixed-method design was used to evaluate the alignment of rehabilitation services with the NRP in the Western Cape. Four rehabilitation study settings were selected to ensure that both inpatient and outpatient rehabilitation levels of care were covered at different contexts (rural and peri-urban). The sites were checked for the most prevalent rehabilitation-related conditions to ensure the identification of suitable instruments for measuring rehabilitation outcomes. Each study setting was linked to two researchers with one exploring the rehabilitation organizational structure of the sites and the other exploring the client outcomes after receiving rehabilitation services. Patients were evaluated at baseline and discharge, within seven days after admission and seven days prior to discharge. The evaluation was based on the rehabilitation organizational capacity to provide patient-oriented rehabilitation and the measurement of rehabilitation outcomes. Kaplan's framework of organisational capacity was used in the context of each study setting. For the measurement of service users' outcomes, the International Classification of Functioning, Disability and Health was used (ICF). Standardised outcome measures were adopted for the domains of impairment, activity and participation. The World Health Organisation Community-Based Rehabilitation guidelines were used as guiding principles and concepts as suggested in the NRP. DISCUSSION: This is a groundbreaking methodological exploration that offers both study methods and instruments to measure rehabilitation services at both in-patient and out-patient rehabilitation services.

Exploring the interaction of activity limitations with context, systems, community and personal factors in accessing public health care services: A presentation of South African case studies.

BACKGROUND: There are many factors that influence access to public health services, such as the context people live in, the existing health services, and personal, cultural and community factors. People with disabilities (activity limitations), through their experience of health services, may offer a particular understanding of the performance of the health services, thus exposing health system limitations more clearly than perhaps any other health service user. AIM: This article explores how activity limitations interact with factors related to context, systems, community and personal factors in accessing public health care services in South Africa. SETTING: We present four case studies of people with disabilities from four low-resource diverse contexts in South Africa (rural, semi-rural, farming community and peri-urban) to highlight challenges of access to health services experienced by people with activity limitations in a variety of contexts. METHODS: One case study of a person with disabilities was chosen from each study setting to build evidence using an intensive qualitative case study methodology to elucidate individual and household experiences of challenges experienced by people with activity limitations when attempting to access public health services. In-depth interviews were used to collect data, using an interview guide. The analysis was conducted in the form of a thematic analysis using the interview topics as a starting point. RESULTS: First, these four case studies demonstrate that equitable access to health services for people with activity limitations is influenced by a complex interplay of a variety of factors for a single individual in a particular context. Secondly, that while problems with access to public health services are experienced by everyone, people with activity limitations are affected in particular ways making them particularly vulnerable in using public health services. CONCLUSION: The revitalisation of primary health care and the introduction of national health insurance by the Health Department of South Africa open a window of opportunity for policy makers and policy implementers to revisit and address the areas of access to public health services for people with activity limitations.

A description of assistive technology sources, services and outcomes of use in a number of African settings.

Purpose statement: The article explores assistive technology sources, services and outcomes in South Africa, Namibia, Malawi and Sudan. METHODS: A survey was done in purposively selected sites of the study countries. Cluster sampling followed by random sampling served to identify 400-500 households (HHs) with members with disabilities per country. A HH questionnaire and individual questionnaire was completed. Country level analysis was limited to descriptive statistics. RESULTS: Walking mobility aids was most commonly bought/provided (46.3%), followed by visual aids (42.6%). The most common sources for assistive technology were government health services (37.8%), "other" (29.8%), and private health services (22.9%). Out of the participants, 59.3% received full information in how to use the device. Maintenance was mostly done by users and their families (37.3%). Devices helped a lot in 73.3% of cases and improved quality of life for 67.9% of participants, while 39.1% experienced functional difficulties despite the devices. CONCLUSION: Although there is variation between the study settings, the main impression is that of fragmented or absent systems of provision of assistive technology. Implications for rehabilitation Provision of assistive technology and services varied between countries, but the overall impression was of poor provision and fragmented services. The limited provision of assistive technology for personal care and handling products is of concern as many of these devices requires little training and ongoing support while they can make big functional differences. Rural respondents experienced more difficulties when using the device and received less information on use and maintenance of the device than their urban counterparts. A lack of government responsibility for assistive device services correlated with a lack of information and/or training of participants and maintenance of devices.

Beyond the checklist: understanding rural health vulnerability in a South African context.

BACKGROUND: Vulnerability in the past has sometimes been measured and understood in terms of checklists or common understanding. It is argued here that vulnerability is a more complex issue than this. Although checklists of vulnerable groups are important, they do not capture the essence and dynamics of vulnerability. OBJECTIVE: The case of rural health vulnerability in South Africa is discussed to show that classifying people into vulnerable groups does not portray the complexity and intricacies of what it means to have vulnerability. We also wish to show that there are different kinds of vulnerabilities, and the difference between access vulnerability and illness vulnerability is highlighted. METHODS: As part of a larger study, this case study is presented to show how vulnerability in a poor rural community in South Africa has to be understood in a contextual and dynamic manner as opposed to a static manner. RESULTS: Family and social dynamics can influence health. For example, fractured families were seen as a vulnerable issue within the community, while being a person with a disability can lead to isolation and callous attitudes towards them. It is these family and social dynamics that lead proximally to vulnerability to ill health. CONCLUSIONS: A contextual approach can assist in giving a more layered understanding of vulnerability than a checklist approach can do. Interventions to change health cannot be addressed simply by medical means. Social conditions need to be changed, and part of changing social conditions is the process of assisting those who are isolated or experience themselves as vulnerable to reconnect with others in the community. Poverty leads to social exclusion; social and family inclusion may be key to well-being.

Promoting good policy for leadership and governance of health related rehabilitation: a realist synthesis.

BACKGROUND: Good governance may result in strengthened performance of a health system. Coherent policies are essential for good health system governance. The overall aim of this research is to provide the best available scientific evidence on principles of good policy related leadership and governance of health related rehabilitation services in less resourced settings. This research was also conducted to support development of the World Health Organization's (WHO) Guidelines on health related rehabilitation. METHODS: An innovative study design was used, comprising two methods: a systematic search and realist synthesis of literature, and a Delphi survey of expert stakeholders to refine and triangulate findings from the realist synthesis. In accordance with Pawson and Tilley's approach to realist synthesis, we identified context mechanism outcome pattern configurations (CMOCs) from the literature. Subsequently, these CMOCs were developed into statements for the Delphi survey, whereby 18 expert stakeholders refined these statements to achieve consensus on recommendations for policy related governance of health related rehabilitation. RESULTS: Several broad principles emerged throughout formulation of recommendations: participation of persons with disabilities in policy processes to improve programme responsiveness, efficiency, effectiveness, and sustainability, and to strengthen service-user self-determination and satisfaction; collection of disaggregated disability statistics to support political momentum, decision-making of policymakers, evaluation, accountability, and equitable allocation of resources; explicit promotion in policies of access to services for all subgroups of persons with disabilities and service-users to support equitable and accessible services; robust inter-sectoral coordination to cultivate coherent mandates across governmental departments regarding service provision; and 'institutionalizing' programmes by aligning them with preexisting Ministerial models of healthcare to support programme sustainability. CONCLUSIONS: Alongside national policymakers, our policy recommendations are relevant for several stakeholders, including service providers and service-users. This research aims to provide broad policy recommendations, rather than a strict formula, in acknowledgement of contextual diversity and complexity. Accordingly, our study proposes general principles regarding optimal policy related governance of health related rehabilitation in less resourced settings, which may be valuable across diverse health systems and contexts.

'You must carry your wheelchair'--barriers to accessing healthcare in a South African rural area.

BACKGROUND: There is international evidence that people with disabilities face barriers when accessing primary healthcare services and that there is inadequate information about effective interventions that work to improve the lives of people with disabilities, especially in low-income and middle-income countries. Poor rural residents generally experience barriers to accessing primary healthcare, and these problems are further exacerbated for people with disabilities. OBJECTIVE: In this study, we explore the challenges faced by people with disabilities in accessing healthcare in Madwaleni, a poor rural Xhosa community in South Africa. DESIGN: Purposive sampling was done with 26 participants, using semi-structured interviews and content analysis to identify major themes. RESULTS: This study showed a number of barriers to healthcare for people with disabilities. These included practical barriers, including geographical and staffing issues, and attitudinal barriers. CONCLUSIONS: It is suggested that although there are practical barriers that need to be addressed, attitudinal barriers could potentially be addressed more easily and cost effectively.

Experiences of patients and service providers with out-patient rehabilitation services in a rehabilitation centre in the Western Cape Province.

BACKGROUND: 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. OBJECTIVE: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.