POSITION STATEMENT

 

Occupational Therapy Assocation of South Africa position statement on rehabilitation

OTASA, Marion Fourie

 

INTRODUCTION AND PURPOSE

The World Health Organization states that "rehabilitation is instrumental in enabling people with disabilities whose functions are limited¹ to remain in or return to their home or community, live independently, and participate in education, the labour market and civic life."²

The purpose of this paper is to state the Occupational Therapy Association of South Africa's (OTASA) position on rehabilitation and how rehabilitation relates to occupational therapy's scope of practice.

 

STATEMENT OF POSITION

1. The term rehabilitation is understood to include habilitation (referring to people who acquire disabilities congenitally or early in life).

2. There is convincing evidence that early, intensive and coordinated multi-disciplinary rehabilitation significantly reduces the impact of a broad range of health conditions and thus disability.

OTASA regards rehabilitation as the essential link between medical intervention and the resumption of participation in a full round of daily occupations which in turn brings meaning, purpose and satisfaction in life and allows the individual to realise his / her potential.

3. OTASA regards rehabilitation as a human rights issue.

This position is informed by the Constitution of the Republic of South Africa³, the United Nations Convention on the Rights of Persons with Disabilities⁴ as well as the core values^a of the profession.

All people have the right to access appropriate health care. In addition, viewed from an occupational therapy perspective, all people have the right to:

• Participate in a range of occupations^b that enable them to flourish, fulfil their potential, and experience satisfaction in a way consistent with their culture and beliefs⁵.

• Engage fully in society.

In its essence, the outcome of rehabilitation is resumption of a full and meaningful life and preservation of the dignity of the individual.

4. OTASA affirms that:

• Rehabilitation is required when a health condition or barriers in the environment result in residual impairment, activity limitations or participation restrictions.

• People across the age spectrum with a variety of health conditions (physical / mental health / sensory / developmental) may require rehabilitation.

• Rehabilitation typically commences once the health condition is stabilised. It is a process which may have multiple stages and culminates with integration into family, community and economic life.

• Early access to rehabilitation is required to achieve the best possible outcome.

• The knowledge, skills and expertise of a variety of categories of health care and other professionals may be required, simultaneously or at different times, during rehabilitation.

• Rehabilitation reaches beyond the health sector, encompassing and including the involvement of many other sectors e.g. education, transportation, social services, labour, housing.

• Rehabilitation occurs in a variety of settings - hospitals, specialised rehabilitation units, in the community, in homes and work places.

• Rehabilitation is a goal-oriented and time-limited process.

 

OCCUPATIONAL THERAPY AND REHABILITATION:

1. Occupational therapists are committed to advance the right of all people - including people with disabilities - to develop their capacity and power to construct their own destiny through occupation.

Occupational therapists have particular expertise and a set of skills which are used to:

• Explore the individual's pre-morbid occupational profile.

• Address limitations in functioning which impact on ability to perform daily occupations.

• Identify challenges / obstacles to occupational engagement and find solutions to these challenges / obstacles.

Strategies may include (but are not restricted to):

• Changing the manner in which occupations are performed.

• Modifying the environment

• Using assistive technology

• Facilitating engagement in a full round of necessary and preferred daily occupations.

The broad goals of rehabilitation and occupational therapy are very closely aligned.

2. Consistent with occupational therapy's commitment to client-centred intervention, the individual receiving rehabilitative intervention is centrally placed in the rehabilitation team. Rehabilitation cannot be imposed. The individual is viewed as a respected partner and his/her involvement and self-determination regarding all aspects of the rehabilitation process is imperative.

The involvement of family members/caregivers is also important.

3. In addition to facility-based rehabilitation programmes, occupational therapists are committed to community based rehabilitation (CBR) - a strategy within community development for the rehabilitation, equalisation of opportunities and social integration of people with disabilities.⁶Occupational therapists may be involved in CBR in training / education or working 'hands-on' in communities.

4. Occupational therapists have a particular role to play in vocational rehabilitation - a rehabilitation strategy that aims to "enable a disabled person to secure, retain and advance in suitable employment and thereby to further such person's integration or reintegration into society."⁷Services provided in vocational rehabilitation depend on the needs and goals of the client, employer or insurer, and the environment in which the work takes place.

 

CONCERNS REGARDING REHABILITATION IN SOUTH AFRICA

"Unmet rehabilitation needs can delay discharge, limit activities, restrict participation, cause deterioration in health, increase dependency on others for assistance, and decrease quality of life. These negative outcomes can have broad social and financial implications for individuals, families, and communities."⁸

OTASA wishes to draw particular attention to the following concerns:

1. Access to rehabilitation services in South Africa is limited. Many factors contribute in this regard including (but not limited to) human resources and staffing norms, geographical location of facility-based services and difficulties accessing transport.

• Analysis of the importance - and indeed funding - afforded to medical intervention vs rehabilitation services reveals a fundamentally flawed view of what is needed to facilitate recovery from illness or injury and reintegration into full and meaningful lives following such illness or injury.

• It could be said that rehabilitation is viewed as a relatively unimportant secondary service for individuals with impairments.⁹

• Ironically, the consequences of lack of adequate rehabilitation is experienced in 'downstream' expenses for the state in the health sector, e.g. readmission for complications such as pressure sores, but also in a variety of other sectors, e.g. increased need for social grants, schools, etc.

2. Availability of rehabilitation services to individuals with certain health conditions is far more limited than for other health conditions. Traumatic brain injury¹⁰, stroke¹¹ and mental health conditions¹² are but some examples in this regard.

3. There is further an inequality in access to rehabilitation services between those who have health insurance and those who do not. That having been said, having private health insurance does not necessarily guarantee access to well-coordinated and comprehensive rehabilitation.

4. There is a strong correlation between disability and poverty. Poverty is both a cause and a consequence of disability. Poor people and those with disabilities are amongst the most marginalised in society. Where poverty and disability co-exist, exclusion and vulnerability reach critical proportions. Accessing rehabilitation services is particularly problematic for poor people¹³ not least because of difficulties travelling to/from sites where such services are offered.

Inadequate rehabilitation can contribute to:

• Loss of means of generating an income (particularly if one acknowledges that the majority of poor people rely on their physical capabilities to generate any form of income).

• Perpetuation of unnecessary hardship and suffering.

• Additional (avoidable) emotional difficulties in some cases.

5. Many people who have sustained relatively minor injuries (e.g. simple fractures, dislocations, soft tissue injuries) for which adequate medical / surgical intervention was provided in the acute stage, present with unnecessary ongoing residual impairment (such as restricted range of movement, muscle weakness, reduced tolerance for physical activity and ongoing pain to name but a few examples).

Lack of access to proper / adequate rehabilitative intervention in the post-acute phase appears to be a major causative factor in such cases.

Of particular concern is the fact that some have lost the jobs they held at the time of the injury event, while many others have not been employed since the injury event due to residual impairment.

This has major consequences for these individuals and their families, as well as the economy of our country and the viability of such institutions as the Road Accident Fund and the Compensation Commissioner from whom compensation may be claimed.

6. Whilst progressive legislation¹⁴ and guidelines¹⁵ are in place to protect disabled workers and facilitate their employment, occupational therapists are made aware of loss of employment due to acquired disability on a regular basis. This too has major consequences for these individuals and the economy of our country.

 

ACKNOWLEDGEMENTS

Marion Fourie initiated the position statement and contributed substantially to its content.

 

REFERENCES

1. World Health Organization. International Classification of Functioning, Disability and Health. Geneva: World Health Organization. 2001.         [ Links ]

2. World Health Organization. "Rehabilitation." Disability and Rehabilitation. 2016. <http://www.who.int/disabilities/care/en/> (2 Nov 2016).         [ Links ]

3. Republic of South Africa. The Constitution of the Republic of South Africa. 1996. <http://www.justice.gov.za/legislation/constitution/saconstitution-web-eng.pdf > (2 Nov 2016).         [ Links ]

4. United Nations. Convention on the Rights of Persons with Disabilities. New York: United Nations; 2006.         [ Links ]

5. World Federation of Occupational Therapists. Position Statement on Human Rights. World Federation of Occupational Therapists; 2006.         [ Links ]

6. World Federation of Occupational Therapists. Position Statement on Community-based Rehabilitation. World Federation of Occupational Therapists; 2004.         [ Links ]

7. International Labour Organization. Vocational Rehabilitation and Employment of Disabled Persons. Appendix 1 Texts of Convention No. 159 and Recommendation No. 168 Vocational Rehabilitation and Employment (Disabled Persons) Convention; 1983 (No. 159). 1983. http://www.ilo.org/public/english/standards/relm/ilc/ilc86/r-iiilba.htm (2 Nov 2016).         [ Links ]

8. World Health Organization. World Report on Disability. Geneva: World Health Organization; 2011.         [ Links ]

9. Skempes D, Stucki G. Bickenbach J. Health-Related Rehabilitation and Human Rights: Analyzing States' Obligations under the United Nations Convention on the Rights of Persons with Disabilities. Archives of Physical Medicine and Rehabilitation. 2015; 96(1): 163-173.         [ Links ]

10. No rehab for brain trauma patients. GEMS. URL: https://www.gems.gov.za/default.aspx?E7WPHHEoLltQ5J3WPqKHkQ (Accessed 10/04/15).         [ Links ]

11. Cawood J. Rehabilitation Outcomes of Uninsured Stroke Survivors in the Helderberg Basin. Unpublished M. Phil (Rehabilitation) Dissertation. Stellenbosch University; 2012.         [ Links ]

12. South African Federation for Mental Health. Making mental health a South African priority. < http://www.safmh.org.za/images/Treat-mentFacilities.pdf> (10 April 2015).         [ Links ]

13. Duncan EM, Watson RM. The occupational dimensions of poverty and disability. PLAAS. Working Paper 14; 2009.         [ Links ]

14. Employment Equity Act (55/l998).

15. Code of Good Practice: Key Aspects on the Employment of People with Disabilities; Department of Labour.

 

 

a Altruism, equality, freedom, justice, dignity, truth and prudence are generally accepted as the core values of occupational therapy.
b In occupational therapy, occupation refers to the everyday activities that people do to occupy their time and bring purpose and meaning to life. Occupations include things that people need to, want to or are expected to do.
DATE RATIFIED BY THE COUNCIL OF OTASA 13/07/2016