The move towards community-based rehabilitation in industrialised countries: are we equipped for the challenge?

BACKGROUND: Recent challenges to health systems in industrialised countries (e.g., health trends, workforce shortages, geographical dispersion, changing demographics and the growing demand for hospital beds) have prompted a rise in popularity of services loosely labelled community-based rehabilitation (CBR). The rise of CBR is based on the assumption that these models of service delivery have the potential to address some of these challenges by promoting efficient use of community resources. However, due to the way in which CBR has evolved in industrial countries, there is considerable ambiguity surrounding the concept, and even more uncertainty about the methods by which its implementation can be fostered. PURPOSE: To explore the CBR in an industrialised country and the implications of its implementation for the health workforce, health systems and service delivery. METHOD: This article reviews existing literature to explore the concept of CBR as it is applied in industrialised countries. It examines the possible implications of adopting CBR into health systems, including the need for conceptual clarity, a competency frameworks and ongoing professional development. CONCLUSION: This article has shown that for CBR is to become a viable model for the delivery of health services in industrialised countries, a competency framework is needed, together with strong leadership to facilitate the translation of theory into practice. Further, collaboration is required among practitioners, policy makers, unions, consumers, educators and professional associations to support this transformation.

The experiences of leaders of self-management courses in Queensland: exploring Health Professional and Peer Leaders' perceptions of working together.

This paper describes the experiences of volunteers who have been trained to deliver the Stanford Chronic Disease Self-Management Program course. In Queensland, Australia, Leaders usually work in pairs (a Health Professional Leader (HPL) and a Peer Leader (PL)). Qualitative data were collected to explore volunteers' experiences as Leaders and their opinions about working together to deliver self-management courses. The data were collected from September 2005 to December 2005. In-depth, semistructured telephone interviews were conducted with a purposive sample of 34 Leaders (17 PL, 17 HPLs). Thematic analysis revealed two core themes that described Leaders' perceptions and experiences of working relationships between HPLs and PLs: (i) The Value of Working Together and (2) Relationship Tensions. Both HPLs and PLs believed that working together represented 'the best of both worlds' and that the combination of peers and health professionals enhanced the sustainability of the approach. However, a number of tensions were revealed that undermined the development and sustainability of these working relationships. From HPLs' perspective, the benefits of working with volunteer PLs did not always justify the 'burden'. Finding the 'right person' for the PL role was difficult and a higher value was often placed on the contribution of professionals. The tensions that were most prominent for PLs were grounded in the disparity between their status and that of HPLs, their lack of ownership over courses coupled with lack of a strong voice in the co-Leader relationship, and the absence of connection and engagement among Leaders. Working relationships between HPLs and PLs have potential to deliver positive outcomes for people with chronic disease, but the current study has highlighted the necessity of developing a culture of mutual respect and a system that values both forms of knowledge and expertise (i.e. experiential and professional).

The spaces between: partnerships between women researchers and Indigenous women with disabilities.

PURPOSE: To understand the experiences of Indigenous Australian women with chronic illnesses and disabilities and their views about a way forward in relation to partnerships in research and community-supported problem-solving. METHOD: Using a participatory action research framework, five Indigenous women participated in a group meeting and interviews with academic women researchers to discuss their health and disabilities in order to generate solutions that could address health disparities among Indigenous women. RESULTS: Five themes describe the experiences of these Indigenous women when considering their personal histories, interactions with formal service systems, and their aspirations for the future: (i) Ongoing influence of history, (ii) systemic lack of respect, (iii) social context of health, (iv) moving forward in positive ways, and (v) research partnerships as a way forward. The data raised critical questions about the role of research, including, 'Who has the right to tell the stories of the women?'. CONCLUSIONS: We show how a small research project conducted in collaboration with five Indigenous women developed into a significant research partnership and resulted in a better understanding of the issues that must be addressed by research in future. It is suggested that through such partnerships underserved women can best be served by research.

Recovery following stroke: the role of self-management education.

Current stroke rehabilitation tends to focus on the bio-medical course of disability, often responding to psychological and social issues only when they have been implicated in crises. Although this situation is costly, little evidence exists in relation to how psychological and social outcomes can be facilitated or how psychosocial decline can be prevented. In the area of adjustment following traumatic injury, there has been some suggestion that rehabilitation should focus on the expansion of resources, skills and self-efficacy as this will enable individuals to cope more effectively with their medical condition and circumstances. The current study was a longitudinal randomised controlled trial involving 100 people with stroke, 58 of whom were randomly allocated to an intervention based on the notion of psychosocial skill expansion. All were patients of a major hospital in Queensland, Australia. An existing self-management intervention (The Chronic Disease Self-Management Course, Lorig et al., 2001) was used to operationalise the concept of psychosocial skill expansion. The control group reported declines in functioning during the first year following stroke in the areas of family roles, activities of daily living, self-care and work productivity, that were not reported by the intervention group. Although the groups had reached similar levels by one year post-stroke, this intervention may have a protective function, presumably by improving capacity to manage the functional requirements of daily life. However, the intervention did not appear to have its impact through self-efficacy, as was expected, and failed to influence outcomes such as mood or social participation. Nevertheless, the intervention warrants further investigation, given that it appears to improve rehabilitation outcomes, at least in the short-term.