Anticipated Barriers to Implementation of Community-Based Rehabilitation in Ribeirão Preto, Brazil

Regina Célia Fiorati, Regina Y. Dakuzaku Carretta, Karine Pereira Joaquim, Aline Ferreira Placeres, Tiago Silva Jesus

Abstract


Purpose: Disability is a global health and a global development concern. To address both issues, a community-based rehabilitation (CBR) approach is increasingly recommended to meet a spectrum of needs, especially for people with disabilities. It is first necessary to understand the perceptions of local, frontline providers, in order to design effective measures for implementing CBR programmes. This paper aimed to understand the conceptions of Primary Healthcare Providers (PHPs) - serving a sub-urban, socially-vulnerable territory in Brazil - about: 1) disability, 2) rehabilitation, and 3) the possible local implementation of a CBR strategy, including any anticipated barriers.

Method: Cross-sectional, exploratory qualitative research was based on focus groups conducted between 2013 and 2016. It involved a total of 78 PHPs serving the western region of the Ribeirão Preto municipality in São Paulo, Brazil. Data analysis was based on Habermas’ critical hermeneutics approach.

Results: PHPs understood disability mostly within the biomedical paradigm. Similarly, the predominant conception of rehabilitation was focussed on enabling individuals’ capacity, more than their environment. For local CBR implementation, the barriers that were anticipated were: 1) difficulties in managing and running action across sectors, and 2) the broader socio-political environment that hardly empowers civil society and is affected by power differentials.

Conclusion and Implications: While local PHPs identified important CBR implementation barriers which are contextual in nature, the predominant conceptions of disability and rehabilitation (i.e., biomedical, impairments-based) also act as a barrier. Contextual and cognitive barriers must both be addressed when envisioning a local CBR implementation.


Keywords


People with disabilities; rehabilitation; CBR; primary healthcare

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References


Abdi K, Arab M, Rashidian A, Kamali M, Khanken HR, Farahani FK (2015). Exploring barriers of the health system to rehabilitation services for people with disabilities in Iran: A qualitative study. Electron Physician; 7(7): 1476-85. https://doi.org/10.19082/1476. PMid:26767101. PMCid:PMC4700893

Agho AO, John EB (2017). Occupational therapy and physiotherapy education and workforce in Anglophone sub-Saharan Africa countries. Hum Resour Health; 15(1): 37. https://doi.org/10.1186/s12960-017-0212-5. PMid:28606103. PMCid:PMC5469184

Almeida MC, Campos GWS (2002). [Policies e care models in the health and rehabilitation of people with disabilities in Brazil: Analysis of measures in the last two decades] in Portuguese. Rev. Ter. Ocup. Univ. São Paulo; 13(3): 118-26. https://doi.org/10.11606/issn.2238-6149.v13i3p118-126. https://doi.org/10.11606/issn.2238-6149.v13i3pi-i

Andrade LOM, Pellegrini-Filho A, Solar O, Rigoli F, de Salazar LM, Serrate PCF, Ribeiro KG, Koller TS, Cruz FN, Atun R (2015). Social determinants of health, universal health coverage, and sustainable development: Case studies from Latin American countries. Lancet; 385: 1343–51. https://doi.org/10.1016/S0140-6736(14)61494-X

Aoki M, Oliver FC (2013). [People with disabilities living in a peripherical neighbourhood in São Paulo: Study of their needs] in Portuguese. Cad. Ter. Ocup. UFSCar, São Carlos; 21(2):391-398.

Bampi LNS, Guilhem D, Alves ED (2010). Social model: A new approach of disability theme. Rev. Latino Am Enfermagem; 18(4): 816-823. https://doi.org/10.1590/S0104-11692010000400022. PMid:20922331

Bunning K, Gona JK, Odera-Mung'ala V, Newton CR, Geere JA, Hong CS, Hartley S (2014). Survey of rehabilitation support for children 0-15 years in a rural part of Kenya. Disabil Rehabil; 36(12): 1033-41. https://doi.org/10.3109/09638288.2013.829524. PMid:23991677. PMCid:PMC4086233

Chatterji S, Byles J, Cutler D, Seeman T, Verdes E (2015). Health, functioning, and disability in older adults--present status and future implication. Lancet; 385(9967): 563-75. https://doi.org/10.1016/S0140-6736(14)61462-8

Clarke S, Barudin J, Hunt M (2016). Ethics and community-based rehabilitation: Eight ethical questions from a review of the literature. Physiother Can; 68(2): 197-205. https://doi.org/10.3138/ptc.2015-35GH. PMid:27909367. PMCid:PMC5125488

Cleaver S, Nixon S (2014). A scoping review of 10 years of published literature on community-based rehabilitation. Disabil Rehabil; 36(17): 1385-94. https://doi.org/10.3109/09638288.2013.845257. PMid:24151820

Como E, Batdulan T (2012). The role of community health workers in the Mongolian CBR programme. Disability, CBR & Inclusive Development; 23: 14-33. https://doi.org/10.5463/dcid.v23i1.96

Conill E (2008). [Historic and conceptual essay about primary health care: Challenges for the organisation of basic services and a family health strategy in urban centres, Brazil] in Portuguese. Cad Saúde Pública; 24(Sup 1): S7-S27.

Dennis R, Caytano A, Elkins J (2016). Community-based rehabilitation services in low and middle-income countries in the Asia-Pacific region: Successes and challenges in the implementation of the CBR matrix. Disability, CBR & Inclusive Development; 27(2): 112-127. https://doi.org/10.5463/dcid.v27i2.542

Durham J, Brolan CE, Mukandi B (2014). The convention on the rights of persons with disabilities: A foundation for ethical disability and health research in developing countries. Am J Public Health; 104(11): 2037-43. https://doi.org/10.2105/AJPH.2014.302006. PMid:25211760. PMCid:PMC4202975

Fiorati RC, Elui VMC (2015). [Social determinants of health: Inequities and social inclusion of people with disabilities] in Portuguese. Rev. Latino-Am. Enfermagem; 23(2): 329-36. https://doi.org/10.1590/0104-1169.0187.2559. PMid:26039305. PMCid:PMC4459008

Ganle JK, Otupiri E, Obeng B, Edusie A, Ankomah A, Adanu R (2016). Challenges women with disability face in accessing and using maternal healthcare services in Ghana: A qualitative study. PLoS One; 11(6): e0158361. https://doi.org/10.1371/journal.pone.0158361

PMid:27347880. PMCid:PMC4922658

García-Ramírez JA, Vélez-Álvarez C (2013). [Latin America in face of the social determinants of health: public policies implemented] in Spanish. Rev. salud pública; 15 (5): 731-742. Available from: https://revistas.unal.edu.co/index.php/revsaludpublica/article/view/39459. [Accessed on 15 Nov 2017].

Gilmore B, MacLachlan M, McVeigh J, McClean C, Carr S, Duttine A, Mannan H, McAuliffe E, Mji G, Eide AH, Hem KG, Gupta N (2017). A study of human resource competencies required to implement community rehabilitation in less resourced settings. Hum Resour Health; 15(1): 70. https://doi.org/10.1186/s12960-017-0240-1. PMid:28938909. PMCid:PMC5610467

Grandisson M, Hébert M, Thibeault R (2014). A systematic review on how to conduct evaluations in community-based rehabilitation. Disabil Rehabil; 36(4): 265-75. https://doi.org/10.3109/09638288.2013.785602. PMid:23614357. PMCid:PMC3913006

Grandisson M, Thibeault R, Hérbert M, Cameron D (2016a). Expert consensus on best evaluative practices in community-based rehabilitation. Disabil Rehabil; 38(5): 499-510.

https://doi.org/10.3109/09638288.2015.1044030. PMid:25959000

Grandisson M, Hérbert M, Thibeault R (2017). Practice guidelines for programme evaluation in community-based rehabilitation. Disabil Rehabil; 39(12): 1243-1251. https://doi.org/10.1080/09638288.2016.1189604. PMid:27347694

Gudlavalleti MV, John N, Allagh K, Sagar J, Kamalakannan S, Ramachandra SS - South India Disability Study Evidence Group (2014). Access to health care and employment status of people with disabilities in South India, the SIDE (South India Disability Evidence) study. BMC Public Health; 1125: 14. https://doi.org/10.1186/1471-2458-14-1125

Habermas J (1988). [Theory of the communicative action] in Spanish. 2nd Edition, Madrid, Spain: Taurus.

Hartley S, Yousafzai A, Kaahwa MG, Finkenflugel H, Wade H, Seeley J, Drachler ML, Bazirake G, Alavi Y, Mucurnguzi E, Mataze NW (2017). Community action research in disability (CARD): An inclusive research programme in Uganda. Disability, CBR & Inclusive Development; 28: 5-92. https://doi.org/10.5463/dcid.v1i1.630

Health Ministry, Brazil (2010). [National Policy for the Health of People with Disabilities] in Portuguese. Brasília : Editora do Ministério da Saúde. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/politica_nacional_pessoa_com_deficiencia.pdf. [Accessed on 14 Nov 2017].

Iemmi V, Gibson L, Blanchet K, Suresh K, Rath S, Hartley S, Murthy G, Patel V, Weber J, Kuper H (2015). Community-based rehabilitation for people with disabilities in low- and middle-income countries: A systematic review. Campbell Systematic Reviews. 15.

Jesus TS, Landry MD, Dussault G, Fronteira I (2017). Human resources for health (& rehabilitation): Six rehab-workforce challenges for the century. Hum Resour Health; 15: 8.

https://doi.org/10.1186/s12960-017-0182-7. PMid:28114960. PMCid:PMC5259954

Junior RM, Coimbra M, Matos YS (2012). [Health law] in Portuguese. São Paulo: Ministério Público, Centro de Apoio Operacional das Promotorias de Justiça Cível e de Tutela Coletiva.

Khan F, Amatya B, Mannan H, Burkle FM Jr, Galea MP (2015). Rehabilitation in Madagascar: Challenges in implementing the World Health Organisation Disability Action Plan. J Rehabil Med; 47(8): 688-96. https://doi.org/10.2340/16501977-1995. https://doi.org/10.2340/16501977-1941. https://doi.org/10.2340/16501977-1999. PMid:26181910

Krug E, Cieza A (2017). Strengthening health systems to provide rehabilitation services. Bull World Health Organ; 95(3): 167. https://doi.org/10.2471/BLT.17.191809. PMid:28250526. PMCid:PMC5328120

Leão TM, L IMSO (2011). [Health law and people with disabilities: analysis of the protection network in Brazil] in Portuguese. In: Lima IMSO, Pinto ICM, Pereira SO (Eds). [Public Policies and people with disabilities: Human rights and health]. Salvador: EDUFBA: 73-89.

Lukersmith S, Hartley S, Kuipers P, Madden R, Llewellyn G, Dune T (2013). Community-based rehabilitation (CBR) monitoring and evaluation methods and tools: A literature review. Disabil Rehabil; 35(23): 1941-53. https://doi.org/10.3109/09638288.2013.770078. PMid:23574396

MacLachlan M, Swartz L (2009). Disability and international development: Towards inclusive global health. New York: Springer-Verlag. https://doi.org/10.1007/978-0-387-93840-0

Mason C, Weber J, Atasoy S, Sabariego C, Cieza A (2017). Development of indicators for monitoring community-based rehabilitation. PLoS One; 12(6): e0178418. https://doi.org/10.1371/journal.pone.0178418. PMid:28575102. PMCid:PMC5456090

McIntosh D (1994). Language, self and lifeword in Habermas's Theory of Communicative Action. Theory Soc; 23: 1-33. Available from https://link.springer.com/content/pdf/10.1007/BF00993671.pdf. [Accessed on 4 Dec 2017]. https://doi.org/10.1007/BF00993671

McVeigh J, MacLachlan M, Gilmore B, McClean C, Eide AH, Mannan H, Geiser P, Dutine A, Mji G, McAuliffe E, Srunt B, Amin M, Normand C (2016). Promoting good policy for leadership and governance of health related rehabilitation: A realist synthesis. Global Health; 12(1): 49. https://doi.org/10.1186/s12992-016-0182-8. PMid:27558240. PMCid:PMC4997679

Mitra S, Findley PA, Sambamoorthi U (2009). Healthcare expenditures of living with a disability: Total expenditures, out-of-pocket expenses, and burden, 1996 to 2004. Arch Phys Med Rehabil; 90(9): 1532-40. https://doi.org/10.1016/j.apmr.2009.02.020. PMid:19735781

Mitra S, Palmer M, Kim H, Mont D, Groce N (2017). Extra costs of living with a disability: A review and agenda for research. Disabil Health J; 10(4): 475-484. https://doi.org/10.1016/j.dhjo.2017.04.007. PMid:28501322

Mlenzana NB, Frantz JM, Rhoda AJ, Eide A (2013). Barriers to and facilitators of rehabilitation services for people with physical disabilities: A systematic review. Afr J Disabil; 2(1): 22. https://doi.org/10.4102/ajod.v2i1.22. PMid:28729982. PMCid:PMC5442576

Müler JSN, Artman E (2012). [Policy, management and participation in health: Reflection based on Habermas' Theory]. In Portuguese. Ciênc Saúde Coletiva; 17(12): 3407-16.

Munthali A, Swartz L, Mannan H, MacLachlan M, Chilimsnpunga C, Makupe C (2017). "This one will delay us": Barriers to accessing healthcare services among persons with disabilities in Malawi. Disabil Rehabil; 26:1-8. https://doi.org/10.1080/09638288.2017.1404148. PMid:29172751

Neille J, Penn C (2015). Beyond physical access: a qualitative analysis into the barriers to policy implementation and service provision experienced by persons with disabilities living in a rural context. Rural Remote Health; 15(3): 3332. Available from: www.rrh.org.au/journal/article/3332. PMid:26268958

Oliver FC, Carvalho AM (2007). [Community-based rehabilitation] in Portuguese . In: Cavalcanti A, Galvão P (Eds). [Occupational Theraphy: Fundaments and practice] in Portuguese. Rio de Janeiro: Guanabara.

Othero MB, Dalmaso ASW (2009). [People with disabilities in primary care: Speeches and practice in a health-school centre]. Interface - Comunic., Saúde, Educ. 13(28): 177-88. Available from: http://www.redalyc.org/articulo.oa?id=180114106015. [Accessed on 14 Nov 2017].

Othero MB, Ayres JM (2012). Healthcare needs of people with disabilities: Subjects' perspectives through their life histories. Interface - Comunic., Saude, Educ; 16(40): 219-33.

Patel S, Alavi Y, Lindfield R, Kuper H (2013). The impact of rehabilitative services in the lives of adults and children with disabilities in low-income and middle-income countries: An assessment of the quality of the evidence. Disabil Rehabil; 35(9): 703-12. https://doi.org/10.3109/09638288.2012.705949. PMid:22897156

Prince MJ, Wu F, Guo Y, Gutierrez Robledo LM, O'Donnell M, Sullivan R, Yusuf S (2015). The burden of disease in older people and implications for health policy and practice. Lancet; 385(9967): 549-62. https://doi.org/10.1016/S0140-6736(14)61347-7

Rimmer JH, Chen MD, Hsieh K (2011). A conceptual model for identifying, preventing, and managing secondary conditions in people with disabilities. Phys Ther; 91(12): 1728-39. https://doi.org/10.2522/ptj.20100410. PMid:22003160

Rocha EF, Oliver FC, Castiglioni MC, Lopes ME (2011). [Access and accessability of people with disabilities to health services under the Unique Health System] In Portuguese. In: Lima IMSO, Pinto ICM, Pereira SO (Eds). [Public Policies and people with disabilities: Human rights and health] in Portuguese. Salvador: EDUFBA: 215-241.

Skempes D, Stucki G, Bickenbach J (2015). Health related rehabilitation and human rights: Analysing States' obligations under the United Nations Convention on the rights of persons with disabilities. Arch Phys Med Rehabil; 96(1): 163-73. https://doi.org/10.1016/j.apmr.2014.07.410. PMid:25130185

Souza FR, P. A (2012). [People with disabilities: Between the necessity and the health care]. Cad. Ter. Ocup. UFSCar; 20(2):229-237. https://doi.org/10.4322/cto.2012.024

Szwarcwald CL, Mota JC, Damacena GN, Pereira TGS (2011). Health inequalities in Rio de Janeiro, Brazil: Lower healthy life expectancy in socioeconomically disadvantaged areas. Am J Public Health; 101(3):517-23. https://doi.org/10.2105/AJPH.2010.195453

PMid:21233437. PMCid:PMC3036699

United Nations [online]. Disability-inclusive sustainable development goals. Availabe from: http://www.un.org/disabilities/documents/sdgs/disability_inclusive_sdgs.pdf [Accessed on: 20 Oct 2017].

van Hees S, Cornielje H, Wagle P, Veldman E (2015). Disability inclusion in primary health care in Nepal: An explorative study of perceived barriers to access governmental health services. Disabilty, CBR & Inclusive Development; 5: 99-118. https://doi.org/10.5463/dcid.v25i4.373

Vergunst R, Swartz L, Hem KG, Eide AH, Mannan H, MacLachlan M, Mji G, Braathen SH, Schneider M (2017). Access to healthcare for persons with disabilities in rural South Africa. BMC Health Serv Res; 17(1): 741. https://doi.org/10.1186/s12913-017-2674-5. PMid:29149852. PMCid:PMC5693516

Visagie S, Eide AH, Dyrstad K, Mannan H, Swartz L, Schneider M, Mji G, Munthali A, Khogali M, van Rooy G, Hem KG, MacLachlan M (2017). Factors related to environmental barriers experienced by persons with and without disabilities in diverse African settings. PLoS ONE; 12(10): e0186342. https://doi.org/10.1371/journal.pone.0186342. PMid:29023578. PMCid:PMC5638520

World Health Organisation (2001). ICF: International Classification of functioning, disability, and health. Geneva: WHO.

World Health Organisation (2010). Community-based rehabilitation: CBR guidelines, Geneva: WHO.

World Health Organisation and World Bank (2011). World Report on Disability, Geneve: WHO.

World Health Organisation (2017). Rehabilitation 2030: A call for action. The need to scale up rehabilitation. Geneve: WHO. Available from: http://www.who.int/disabilities/care/NeedToScaleUpRehab.pdf?ua=1, [Accessed on 14 Nov 2017].

Wylie K, McAllister L, Davidson B, Marshall J (2016). Communication rehabilitation in sub-Saharan Africa: A workforce profile of speech and language therapists. Afr J Disabil; 5(1): 227. https://doi.org/10.4102/ajod.v5i1.227




DOI: https://doi.org/10.5463/dcid.v29i1.701



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