The role of rehabilitation care workers in South African healthcare: A Q-methodological study

Extended High-Frequency Audiometry for Ototoxicity Monitoring: A Longitudinal Evaluation of Drug-Resistant Tuberculosis Treatment

PURPOSE

The aim of this study was to describe extended high-frequency (EHF) pure-tone audiometry monitoring of ototoxicity in a longitudinal treatment program for drug-resistant tuberculosis (DRTB).

METHOD

This was a retrospective record review of longitudinal conventional (0.25-8 kHz) and EHF (9-16 kHz) audiometry for ototoxicity monitoring of DRTB patients undergoing treatment at community-based clinics between 2013 and 2017. Data from 69 patients with an average age of 37.9 years (SD = 11.2, range: 16.0-63.8 years) were included. Patients were assessed by primary health care audiologists (87%) or community health workers (13%) using portable audiological equipment. The average length of time between initial and exit assessments was 84.6 days (SD = 74.2, range: 2-335 days).

RESULTS

EHF ototoxicity of a mild or greater degree of hearing loss (> 25 dB HL in one or both ears across frequencies) was evident in 85.5% of patients' posttreatment, compared with 47.8% of patients across conventional frequencies. EHF audiometry demonstrated an ototoxic shift (American Speech-Language-Hearing Association criteria) in 56.5% of cases compared with 31.9% when only conventional audiometry was considered. Mean hearing deterioration for patients was significant across EHFs (9-16 kHz) bilaterally (p < .05). Absent EHF thresholds at the initial assessment, owing to maximum output limits, was a limitation that occurred most frequently at 16 kHz (17.4%, 24/138).

CONCLUSIONS

EHF audiometry is most sensitive for the early detection of ototoxicity and should be included in monitoring programs. Clinical ototoxicity monitoring protocols should consider shortened assessment approaches that target frequencies most sensitive to ototoxicity, including EHFs.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21651242.

Views of health care users and providers: Solutions to improve the prevention of secondary health conditions among people with spinal cord injury, South Africa

Study design

Explorative- qualitative study.

Objective

This study explored solutions to improve the prevention of secondary health conditions in people with spinal cord injury.

Setting

Rehabilitation hospital, South Africa.

Methods

Face to face semi-structured interviews were conducted with 21 therapists and 17 people with spinal cord injury at a public rehabilitation hospital. All the interviews were transcribed verbatim. Content analysis was conducted on the transcripts to identify proposed solutions to improve the prevention of secondary health conditions.

Results

The main theme that emerged was access to adequate health care. The categories linked to the main theme were: availability of health services, patient-centred care, strengthening rehabilitation care, access to resources and training health professionals.

Conclusions

Access to adequate health is central to preventing and managing secondary health conditions. Care for people with spinal cord injury needs to be empowering and address rehabilitation care needs across the lifespan. The proposed solutions will inform the development of a prevention care model for secondary health conditions in people with spinal cord injury.

Views of community health workers on the integration of a physiotherapist into a ward-based outreach team

Background

Due to changes in the disease profile and lifestyle of individuals in South Africa, the limited health care facilities available have experienced congestion and overcrowding, affecting health care service delivery. Ward-based outreach team (WBOT) programmes were implemented to strengthen primary health care, improve access and alleviate the congestion occurring at these facilities. However, WBOTs have limitations in terms of medical knowledge and rehabilitative skills.

Objective

To explore the views of community health workers (CHWs) on the integration of physiotherapists into WBOTs.

Method

A qualitative research design making use of focus group discussions (FGDs) was used. Through purposive sampling, 58 CHWs who were members of WBOTs were recruited. The WBOTs were from 10 selected primary health care centres in the Tshwane district, Region 2. Six FGDs were conducted. The audio-recorded data were transcribed verbatim. The transcripts were transported into NVivo 12 for thematic analysis.

Results

The views of the CHWs were that the WBOTs can benefit from having a physiotherapist as a member of the team. The WBOTs do not have adequate skills to attend to the physiotherapy needs of communities. People in the community have challenges in accessing physiotherapy services, and physiotherapy services can enhance the performance of the WBOTs by providing training to the WBOTs and providing clinical services to community members.

Conclusion

Community-based rehabilitative services with a physiotherapist as part of the WBOTs can enhance and strengthen the services of the WBOTs, which can improve the treatment outcomes for communities.

Clinical implications

The WBOTS will be empowered to provide clinical services to the vulnerable people in the community that they serve.

Impactful educational transitions: Crossroads for physiotherapy education in South Africa?

Background

Global changes in physiotherapy entry-level educational programmes to exit with a Doctorate or Master's degree have consequences if physiotherapy education, worldwide, is to remain professionally competitive. However, within the South African context, such global competitiveness should be carefully considered against the national healthcare needs and implementation of the National Health Insurance (NHI) programme, with a bigger emphasis on a skilled mid-level workforce, including physiotherapy technicians or community rehabilitation workers.

Objectives

These competing interests are carefully considered, against the theoretical background of international DPT training; human resource and financial constraints in the South African healthcare sector; reforms of the South African health and educational sectors intended to address the inequalities of the past; the need for quality healthcare delivery and the professional reputation of physiotherapy in South Africa.

Methods

A framework for physiotherapy education in South Africa, to move on from the current educational crossroads, is proposed through an integration of multiple theoretical perspectives.

Results

The framework is based on the current challenges being experienced in physiotherapy education and healthcare service delivery, which could be addressed by changes in the education sphere.

Conclusion

The baseline suggestions for (re)considering the current education environment for physiotherapy, as proposed in my article, are to ensure that the profession remains relevant and able to confront the current changes presented by the South African healthcare system, including the implementation of the NHI plan, whilst remaining globally aligned and competitive.

Clinical implications

The suggested, reconsidered, educational framework for physiotherapy in South Africa could become pivotal in advancing the profession on both a national and international level, through further critical conversations.

A longitudinal community-based ototoxicity monitoring programme and treatment effects for drug-resistant tuberculosis treatment, Western Cape

Background

South Africa has a high burden of drug-resistant tuberculosis (DRTB) and until recently, ototoxic aminoglycosides were predominant in treatment regimens. Community-based ototoxicity monitoring programmes (OMPs) have been implemented for early detection of hearing loss and increased patient access.

Objectives

A longitudinal study was conducted to describe the service delivery characteristics of a community-based OMP for DRTB patients facilitated by CHWs as well as observed ototoxic hearing loss in this population.

Method

A descriptive retrospective record review of longitudinal ototoxicity monitoring of 194 DRTB patients undergoing treatment at community-based clinics in the city of Cape Town between 2013 and 2017.

Results

Follow-up rates between consecutive monitoring assessments reached as high as 80.6% for patients assessed by CHWs. Few patients (14.2% – 32.6%) were assessed with the regularity (≥ 6 assessments) and frequency required for effective ototoxicity monitoring, with assessments conducted, on average, every 53.4–64.3 days. Following DRTB treatment, 51.5% of patients presented with a significant ototoxic shift meeting one or more of the American Speech-Language-Hearing Association (ASHA) criteria. Deterioration in hearing thresholds was bilateral and most pronounced at high frequencies (4 kHz – 8 kHz). The presence of pre-existing hearing loss, human immunodeficiency virus co-infection and a history of noise exposure were significant predictors of ototoxicity in patients.

Conclusion

DRTB treatment with kanamycin resulted in significant deterioration of hearing longitudinally, predominantly at high frequencies. With ongoing training and supportive supervision, CHWs can facilitate community-based ototoxicity monitoring of DRTB patients. Current protocols and guidelines may require reassessment for appropriate community-based ototoxicity monitoring.

Community-Based Ototoxicity Monitoring for Drug-Resistant Tuberculosis in South Africa: An Evaluation Study

In response to the drug-resistant tuberculosis (DRTB) ototoxicity burden in South Africa, ototoxicity monitoring has been decentralised, with community health workers (CHWs) acting as facilitators. This study describes a community-based ototoxicity monitoring programme (OMP) for patients with DRTB. Findings are compared to the recommended guidelines for ototoxicity monitoring, the OMP protocol and published studies. This was a retrospective study of longitudinal ototoxicity monitoring of 831 patients with DRTB, using data collected at community-based clinics in the City of Cape Town between 2013 and 2017. Approximately half (46.8%) of the patients had an initial assessment conducted in accordance with the OMP protocol recommendations, and follow-up rates (79.5%) were higher than those of a similar DRTB programme. However, patients in this study were not monitored within the timeframes or with the regularity recommended by the guidelines or the OMP protocol. Extended high-frequency pure-tone audiometry (27.5%) was underutilised by testers and data recording was inconsistent (e.g., 37.7% of patient gender was not recorded by testers). Community-based OMP using CHWs to facilitate monitoring showed improvement over previous hospital-based reports, with more accessible services and higher follow-up rates. However, to improve OMP outcomes, OMP managers should reassess current protocols and data recording practices.

A scoping review of Q-methodology in healthcare research

BACKGROUND

Q-methodology is an approach to studying complex issues of human 'subjectivity'. Although this approach was developed in the early twentieth century, the value of Q-methodology in healthcare was not recognised until relatively recently. The aim of this review was to scope the empirical healthcare literature to examine the extent to which Q-methodology has been utilised in healthcare over time, including how it has been used and for what purposes.

METHODS

A search of three electronic databases (Scopus, EBSCO-CINAHL Complete, Medline) was conducted. No date restriction was applied. A title and abstract review, followed by a full-text review, was conducted by a team of five reviewers. Included articles were English-language, peer-reviewed journal articles that used Q-methodology (both Q-sorting and inverted factor analysis) in healthcare settings. The following data items were extracted into a purpose-designed Excel spreadsheet: study details (e.g., setting, country, year), reasons for using Q-methodology, healthcare topic area, participants (type and number), materials (e.g., ranking anchors and Q-set), methods (e.g., development of the Q-set, analysis), study results, and study implications. Data synthesis was descriptive in nature and involved frequency counting, open coding and the organisation by data items.

RESULTS

Of the 2,302 articles identified by the search, 289 studies were included in this review. We found evidence of increased use of Q-methodology in healthcare, particularly over the last 5 years. However, this research remains diffuse, spread across a large number of journals and topic areas. In a number of studies, we identified limitations in the reporting of methods, such as insufficient information on how authors derived their Q-set, what types of analyses they performed, and the amount of variance explained.

CONCLUSIONS

Although Q-methodology is increasingly being adopted in healthcare research, it still appears to be relatively novel. This review highlight commonalities in how the method has been used, areas of application, and the potential value of the approach. To facilitate reporting of Q-methodological studies, we present a checklist of details that should be included for publication.

A Situational Mapping Overview of Training Programmes for Community-Based Rehabilitation Workers in Southern Africa: Strategies for Strengthening Accessible Rural Rehabilitation Practice

In 2018, the United Nations global report showed that people with disabilities, who make up 15% of the worlds' population, have poorer health and rehabilitation access (SDG 3). Without improving the needed person-centered health and rehabilitation services at household level, SDG 3 cannot be achieved. This includes addressing human resource shortages through training multi-skilled community based rehabilitation workers (CRWs) to build rural workforce capacity and enhance the lives of people with disabilities, particularly in LMICs where the need is higher but resources are lower. However, to date, there is no documentation and analysis of existing training and its scope for this workforce in LMICs. A situational mapping overview was undertaken to review the current status of rural rehabilitation training programs offered in Southern Africa for CRWs. CRWs are rehabilitation personnel, based in the home/community, who are not professionals (without a bachelor qualification) but render non-institutional rehabilitation and inclusive development in communities, under the supervision of rehabilitation practitioners. Information on these programs was obtained using a two-step process. Firstly, a descriptive list of university courses for rehabilitation workers offered in the Southern African countries was collected via an internet and literature search. Secondly, detailed information about the disability and rural rehabilitation courses was collected from the respective institutions and their designated websites. There are six training courses targeted at CRWs or disability practitioners with a disability focus being offered at universities in Southern Africa, five of these in South Africa and one in Zimbabwe. Additionally, four training courses are offered as online/open resources by global organizations and are self-directed with no accreditation. While other key competencies feature, none of these programmes' learning outcomes make direct reference to the rural practice context and its complexities in relation to disability and poverty. The situational mapping overview shows limited training targeted at CRWs in Southern Africa, to effectively facilitate rural rehabilitation, poverty reduction and social inclusion. There is a need for an articulated community-orientated rural training to respond to the unmet needs. This may require a different set of competencies and assessment standards for trainees as well as additional competencies for their supervisors and mentors.

Changing demographic trends among South African occupational therapists: 2002 to 2018

BACKGROUND

South Africa's quadruple burden of disease, coupled with health system challenges and other factors, predicts a high burden of disability within the population. Human Resources for Health policy and planning need to take account of this challenge. Occupational therapists are part of the health rehabilitation team, and their supply and status in the workforce need to be better understood.

METHODS

The study was a retrospective record-based review of the Health Professions Council of South Africa database from 2002 to 2018. The data obtained from the Health Professions Council of South Africa was analysed for the following variables: geographical location, population groups, age, practice type and sex. Data was entered on a Microsoft Excel spreadsheet and analysed using the Statistical Package for the Social Sciences (SPSS version 22.0).

RESULTS

In 2018, there were 5180 occupational therapists registered with the Health Professions Council of South Africa with a ratio of 0.9 occupational therapists per 10 000 population. There has been an average annual increase of 7.1% over the time period of 2002-2018. The majority of occupational therapists are located in the more densely populated and urbanised provinces, namely Gauteng, Western Cape and KwaZulu-Natal. Most of the registered occupational therapists are under the age of 40 years (67.7%). The majority (66%) are classified as white followed by those classified as black and coloured. Females make up 95% of the registered occupational therapists. Nationally, 74.8% of occupational therapists are deployed in the private sector catering for 16% of the population while approximately 25.2% are employed in the public sector catering for 84% of the population.

CONCLUSIONS

Under-resourcing and disparities in the profile and distribution of occupational therapy human resources remain an abiding concern which negatively impacts on rehabilitation service provision and equitable health and rehabilitation outcomes.