Manguzi Rehabilitation Department routinely collects detailed data on wheelchairs/buggies issued, returned and clients re-seated. This allows us to track the percentage of users with basic, as compared to intermediate or advanced seating needs- which assists us in motivating for further training for our therapists as well as managing follow up re-seating appointments at our remote/outreach seating clinics. We also track sizes, types of wheelchair and accessories issued and returned, which helps us develop a realistic procurement plan and budget for the following year.
We have a daily (free) wheelchair repair service based at the hospital and run by two local wheelchair users, on stipend from DPSA/DoH. Not only does the service offer maintenance and repairs, but clients also get psychosocial support and helpful advice from our wheelchair repairmen, and are referred to the therapist on hand to reassess current seating. We also have a returns policy, whereby if a client no longer requires a wheelchair, they are encouraged to return it so that it can be refurbished and re-issued. With our close relationship with the community health workers, who provide door to door visits in the community, we are able to keep our budget for procuring new wheelchairs much lower. An average 10 wheelchairs are issued monthly, with 44 wheelchairs being repaired and 4 wheelchairs returned.
Manguzi Rehab has also started a wheelchair outreach seating clinic twice monthly this year, in order to improve access to follow up seating and repair services. Clients from the targeted area receive a personal phone call in advance, as well as support from the community health workers, to attend the outreach clinics near their homes. Re-assessment and re-seating are done at the same time as maintenance and repairs.....usually in the clinic parking lots due to a lack of space- armed with a sharp carving knife and a bakkie full of spares, foam, glue and emergency replacement wheelchairs of various sizes (we learned the hard way after trying to repair a very broken wheelchair for four hours at a clinic- sometimes it is best to cut your losses and re-issue!). The head physio is becoming an expert at sharpening a knife on a brick, and has developed an enviable sun tan. But the work is paying off- we have tripled our re-seating service utilization in the last two months.
Outreach seating and repairs clinic in a parking lot
Manguzi Skills Development Initiative, an NPO which supports ongoing skills development and training for Manguzi Hospital healthcare professional staff, has furthermore received funding from Discovery Fund to strengthen the quality of neuro rehabilitation delivered in the area. This fund supports Manguzi rehab staff in attending the basic, intermediate and advanced WHO-accredited seating courses (through Western Cape Rehab Center), Basic CP (therapists and assistants), NDT and Bobath courses (through SANDTA) and counselling courses- as well as bringing SASCA teams to Manguzi to provide training weekends for local staff and engaging in an in-service training/benchmarking program where Manguzi nursing and rehab staff are sent for a week to the privately-operated Jam Rehab Center, and the recent initiative towards sending clients and caregivers for Peer Supporter training.
ORTHOTICS AND PROSTHETICS
Home-made prosthetic leg: client was over-joyed to find out that she could recieve a proper prosthesis for free.
This clinic is held once a month at the rehabilitation department. It is serviced by two orthotists from Wentworth hospital, flown in by the Air Mercy Services (Red Cross). Clients are measured on their first visit and fitted on the follow up visit the following month. For the under 5 year olds and those receiving disability grants/old age pensions, the service is free. Those patients who do not fit these criteria pay a nominal fee for their prostheses/orthoses. Appliances available include:
- CP moulded chairs
- Moulded boots/sole raises/callipers/roll toes/insoles
- Suspension belts
- Corsets, aircasts, hinged knee braces, posterior spinal support braces
- Upper and lower limb prostheses with rudimentary joints
- Breast prostheses
Clients are then followed up afterwards at their closest clinic for rehabilitation with the new orthotic/prosthesis.
We have 16 arthritis groups at various remote clinics. For entry into a group, the person must be screened by a physiotherapist for eligibility, and have received sufficient individual sessions prior to joining the group. The groups are supervised by a community health worker trained in the basic exercises and arthritis education, and exercise in the community between clinic days. On clinic days, the members health cards are reviewed by a physiotherapist, any specialist appointments noted, and general performance reviewed. Group members with new, specific complaints are seen individually, with the aim of reintegrating them as soon as possible.
The groups used to attend ‘hydrotherapy’ at Kosi Mouth Beach once every 6 months. This was more an incentive to comply with group exercises than the clinical benefit of hydrotherapy. Furthermore, the hydrotherapy addressed social and belief systems: The sea is believed to have healing properties, and the placebo effect of it assists members for months afterwards. The majority of people in the area have also never been to the sea: doing something new that no one else in the community has done benefits members on an emotional level. Unfortunately our pool of hospital vehicles has dwindled over the last few years, and despite management's best efforts, even getting a vehicle to perform clinic and home visits can be unreliable. We have thus, sadly, had to put hydrotherapy on hold until we have reliable and available transport again (anyone want to donate a 4x4?).
TB WARD EXERCISE GROUPS
Patients in MDR TB wards are often forced to remain in the ward for 2-6 months, depending on their access to treatment and support at home. This does not bode well for social, emotional or physical aspects of life. The rehabilitation department, in addition to individual treatment sessions for bed-ridden clients, provides daily exercise and dance sessions, as well as daily sewing/craft groups, self care groups (nails, hair, etc) and hosts a patient-health care worker tea every month where ward issues are discussed, problems ironed out, and healthy lifestyle/adherence talks are done.
MALNUTRITION AND PAEDIATRIC WARD STIMULATION GROUP:
This happens daily in the occupational therapy room with the occupational therapists and speech therapists (occasionally joined by the dietician). Children from paediatric and malnutrition ward come up with their mothers (if they are available) to the OT room for play time, personalized therapy interventions and health education (for the mothers). This ensures that mothers:
- understand the cause and long term implications of their child’s condition
- get advice on how to prevent it, as well as how to manage it currently
- understand how to continue stimulating their children at home- specific interventions are prescribed per child
Preparing mothers early and throughout their stay in the ward has been shown to be very important in reducing re-admissions and promoting follow up visits at clinics.
The majority of our new children with cerebral palsy are identified in our flagship screening/early identification High Risk Baby program, before they are 1 years old.This not only assists us in reducing secondary complications associated with late referral, but also ensures that the mother has a relationship with the department BEFORE diagnosis. This early identification and support has revolutionized our CP Program- every hospital should have an active-surveillance High Risk Baby program run and managed by therapists!
Children between the ages of 1 and 20 with CP or atypical neuro development receive treatment, group education, peer support and assistive devices at their closest health care facility (hospital or clinic). Each child receives an assessment and personalized goal setting, with reassessment 6 monthly. Assessments are done by the multi-disciplinary team and include GMFCS, MACS, CFCS and the ICF Framework.
Individual sessions are used to achieve set personal goals- individual goal setting by parents and caregivers and reassessment of these goals, however small, provide parents and caregivers with evidence of improvement.
Group sessions address 24 hour positioning, handling techniques, ADL tasks, play, low cost toy making, behaviour, communication, schooling options and planning for the future. The groups provide emotional and practical support to mothers, addressing generic problems and intervention strategies as well as tailoring individual programmes for each child. The groups also enable therapists to provide appropriate assistive and mobility devices to children and give mothers a floor for discussion. Groups enable mothers and caregivers to support each other in their communities and face challenges together as a group. Interpersonal learning between parents is more beneficial than diadactic theory. Groups are run by speech/language and occupational therapists and technicians, and children and their caregivers attend monthly. All junior therapists and technicians have attended a one week post-graduate course on the assessment and treatment of CP. The Chief and ASssistant Director Occupational Therapists are NDT trained.
A new development is the financing of one OTT and 2 parents to attend Peer support training via the Mother-to-Mother parent facilitator training offered by Malamulele Onwards!This will enable them to implement peer support workshops at clinic groups and the DPO-run Day care Center for children with disabilties, as well as further capacitate and upskill our OTT in implementing 24 hour postural management for effective Block Therapy for selected children at hospital level.
Selected home visits are done according to need, and the Community Health Workers are also regularly enlisted to provide support and trace children and caregivers who have fallen off the system/ are a known concern.
MENTAL HEALTH CLINIC
All clients currently on the register are undergoing a multi-disciplinary team (occupational therapist, a doctor, a social worker, a psychologist and a mental health care nurse) review and DSM-V diagnoses, psychosocial assessment, MDT management plans and medication are given. Home visits are done and support groups are slowly being initiated at clinic level (they are dependant on the MHCU review process taking place and the geographical area of residence of the client). Admissions are also assessed and discharged by the same team. Once a month, the MHC clinic is visited by a psychiatrist flown in by Air Mercy Services. Research on 'The reasons psychiatric patients default treatment at manguzi Hospital' is being conducted by the Assistant Director Occupational Therapist for her Masters in Public Health. Selected community health workers have received training on the reasons behind defaulting, and how they can provide the psychosocial support required to keep the client in the system, and identify early warning signs of relapse. Community outreach, home visits and clinic systems need to be strengthened in due time.
HEALTH EDUCATION PROGRAMMES
Community Health Education
At hospital level, these include ante- and post natal education classes and Kangaroo mother care. Within the community, community health workers and NGO lay caregivers recieve training on the identification and basic handling of strokes, cerebral palsy and develeopmental delays.
All high-risk mothers attend antenatal clinics at the hospital, which are offered once a week. All attendees recieve education from Manguzi rehab department staff member, including the introduction of the High Risk Baby Program- what is is and why it exists. The ANC discussions have a strong EMTCT (Elimination Mother to Child Transmission) focus. These sessions are run by our rehabilitation assistant who has extensive experience in these areas. Posters, education pamphlets, health talks and discussions are used in education. Topics covered include:
- healthy lifestyle and regular check ups
- VCT and post-natal PCR testing of babies
- Diet (for mothers) and feeding (emphasis on exclusive breastfeeding and the PMTCT guidelines) for babies
- Traditional beliefs (regarding traditional medication and disability) and customs: their impact and interaction with current health care practices
- Milestone development and stimulation
- Interventions available
- The High Risk Baby Program: what is considered a 'risk'factor, and how to identify a developmental delay.
Post-natal and Kangaroo Mother Care:
All facility births recieve education and assistance in kangaroo mother care. Post-natal education is done daily in maternity ward by the same rehabilitation assistant. The kangaroo care is run in conjunction with a KMC-trained nurse.
HIGH RISK BABY PROGRAMME
High risk babies are any baby born with complications. These include low birth weight, HIV exposure (targeting babies whose mothers have high viral loads/low CD4 counts), low APGARS, jitters, seizures, congenital abnormalities, twins, jaundice, meconium aspirate, or to young mothers or mothers with mental health care needs, amongst others. These children are significantly more at risk of developing a delay or disability and thus require an intensive screening programme to ensure early identification and intervention. This is our ‘High Risk Baby Clinic’.
In short, the baby is referred to us after birth, where we spend consecutive days educating the mother on the reason for entry into the programme and developmental milestones. We also answer any question she may have, and discuss barriers to follow up. The baby's suck is assessed and specific feeding advice or intervention is given where necessary. Upon discharge, we screen the baby for reflexes, feeding, tone, vision and hearing- although the hearing test is very rudimentary, and unfortunately we have been requesting an OAE screener for a few years now- so that all neonates can be screened for congenital hearing loss- to no effect. Chances remain slim with the current climate of cost cutting austerity measures (anyone want to donate??).
The baby is then screened at 3, 6, 9 and 12 months at their closest clinic for developmental milestones, providing education and intervention as indicated along the way. The database is updated monthly, and any children who have missed their appointments home directions are given to their community health worker who traces them and brings the child and mother to the following clinic. We currently enter 30 neonates per month into the program.
During the 0-12 month program, the mother is also expected to understand how to interpret the growth chart on the baby’s Road to Health card, and have shown compliance with immunizations, weighing and any additional tests required. After 12 months, if there is no sign of a developmental delay, we encourage the caregiver to continue with the High Risk Baby Program- but only following up every 6 months until 5 years. This enables us to screen for cognitive-perceptual and sensory impairments, which would not be as obvious in the 0-12 month program.
If there are signs of CP or developmental delay during the 0- 12 months, the mother and child are seen individually on a monthly basis, and then channelled into the appropriate program.
Our Speech Therapist spear-heading this flagship program has just attended a 4 day course on the neuro-developmental management of the neonate- watch this space for innovative changes to our services according to the latest evidence base!
DISABLED PEOPLES ORGANIZATION
Our DPO is made up of a core 6 exco members, plus satellite groups. Our DPO has partnered with Section 27, and is currently involved in pressurizing the Dept of Education for better access to, and better quality of, special schooling and skills training for children with disabilities in the district.
discussions at community meetings
SIGN LANGUAGE TRAINING
This by no means substitutes for an official program, but was born out of necessity and a need to harness local skills and resources. It serves more as a sensitization and rudimentary teaching intervention, than it does in teaching functional communication. In 2006 the district provided an accredited sign language course for occupational therapists and community assistants. Upon completion, Manguzi hospital then contacted two twins with impaired hearing who had completed schooling at Vuleka (school for those with profound hearing loss) and asked them whether they would not come once a month for a tea party so that the trained health workers could practice and keep up to date with the language. The twins agreed, and four years later we are using this monthly tea party to:
a) Sensitize hospital staff on Deaf culture and teach them a few basic signs- each group has a theme.
b) Teach parents of children with profound hearing loss (or those with loss of speech who can successfully use sign language) how to sign. This sensitizes parents to the communication needs of their children, provides them with hope and support (the groups being run by two Deaf women), and teaches them the basics of signing.
In return for their assistance, the therpists pay the twins' taxi fares and provide the tea. Parents whose children have not yet been placed (ie, have not yet learned sign language) are encouraged to attend as well, as an introduction and as a support function. Recently the audiologist and a DPO exco member (who works as a rehabilitation assistant in our department) have attended further sign language training, and an introductory DVD has been made by a previous speech-language therapist as a teaching resource.
SCHOOL ASSESSMENTS, SUPPORT AND PLACEMENTS
There are a number of ways that children can enter our schools programme, namely:
- referred in by the school health team
- referred in by the DPO br />
- self-referred by concerned parent
- referred in by teachers
Unfortunately many of these children are referred in very late, as they are ‘condoned’ (pushed up a year despite having failed) a few times before a teacher eventually gives up and seeks additional assistance.
A grade R class prior to screening
If the child is found to be under-performing at school, a full history (health, social and school) is taken by a therapist. Additional reasons for poor performance must be investigated, and if ruled out, then a full assessment of visual perception and concept development is done by the occupational therapist. This usually takes approximately one hour. A report for the teacher is then written, with recommendations. The parent is then counselled and further management discussed. If indicated the child is referred for an IQ assessment.
Currently we have too few occupational and speech language therapists to provide the classroom support required, especially considering the extent of the already existing barriers to inclusive education. We are thus only accepting children referred in, and are not actively screening for learning problems at schools. We have decided, considering current capacity and lack of potential for sustainability, to concentrate on mentoring children with disabilities integrated into mainstream schools. Support and mentoring is provided by our Occupational Therapy Technician and a member of the exco of the DPO. Children are followed up, and informal touch-down sessions occur. THIS IS NOT A REMEDIAL PROGRAM. Support can take the form of the following:
- education and awareness raising amongst classmates and amongst teachers
- classroom assessment and recommendations for the teacher
- regular follow up meetings with parents, teacher and the integrated child with a disability- this can cover a range of topics from physical access, to emotional support to social integration issues.
We also provide weekly 'concept development' and language stimulation group classes for the nearby crèche for children with disabilities (in addition to screening them for special school eligibility and trying to contact the Department of Health to asses and place them). Teacher support is also offered monthly at Bhekabantu Primary school, concentrating on getting the basics right in the lower grades.br />
Classroom support can be a challenge
Should the child require remedial education, then the onus is often on the parent to provide this between monthly visits to the occupational therapist. This can be a challenge, considering the low level of literacy of most parents in the area. Teachers at schools are often under-qualified, poorly supported with class sizes in excess of 60 children and forced to teach in inadequate environments with little to no resources- they often simply cannot provide additional attention for those that need it.
If moderate intellectual impairment is suspected, then a psychological assessment by our psychologist will be arranged, so that the process of placing the child at an appropriate school can be initiated (this can take 3 years). Children with physical disabilities that cannot be integrated into mainstream education/ have additional intellectual impairment, as well as those with profound hearing loss and visually impaired children also require placement at appropriate schools. Currently we have a waiting list of over 300 children requiring placement at special schools/skills centres. Barriers to placement include the number of appropriate schools, the lack of hostel space and reservations on the part of the parent. Many of these children will simply never access appropriate education.
We are powerless to change the initial two barriers, but have initiated a partnership between Section 27 and our DPO, hoping that intense pressure on the DoE will assist in highlighting the issues our population face. We are hoping that better integration of programmes (such as the High Risk Baby Programme, the partnership with S'philisizwe DPO and S27, the Language stimulation and concept development groups, and CP programmes) as well as early identification and preparation of parents and children will reduce the number of drop outs of children placed at special schools, and increase the uptake of children.
Inadequate classroom facilities