Background
Rationale for study
Methods
Realist synthesis
Realist synthesis adaptation
Scoping—question and initial theory
Search process
Selection and appraisal of documents
Data extraction
Analysis and synthesis process
Delphi survey
Results
Realist synthesis
Document characteristics
Description | Source | |
---|---|---|
Cadres | Lay health workers | (Mijnarends et al., 2011); (Rahman et al., 2008); (Como and Batdulam, 2012); (Rahman, 2007); (Armstrong et al., 2011); (Raja, 2012); (Lund et al., 2013); (Ayoughi et al., 2012); (Balaji et al., 2012); (Murray et al., 2011); (Chatterjee, 2003); (Claussen, 2005); (Johnson, 2004); (Llewellyn et al., 2012) |
Community-based rehabilitation workers | (Mijnarends et al., 2011); (Grut, 2004); (Magallona and Datangel, 2012); (Sharma, 2003); (Penny et al., 2007); (Eide, 2006); (Nilsson, 2005); (Deepak, 2010); (Rule, 2013); (Deepak, 2011); (Jadin, 2005); (Children, 2010); (Mendis, 2009); (Llewellyn et al., 2012) | |
Mid-level rehabilitation workers | (Rule, 2013); (Chappell, 2009); (Llewellyn et al., 2012); (Dawad and Jobson, 2011); (Finkenflügel and Rule, 2008) | |
Paraprofessionals | (Bass et al., 2013); (Llewellyn et al., 2012) | |
Nurses | (Mijnarends et al., 2011); (Lund et al., 2013) | |
Physicians | (Mijnarends et al., 2011); (Ayoughi et al., 2012); (Penny et al., 2007); (Ng et al., 2009); (Chatterjee, 2003); (Raja, 2012); (Llewellyn et al., 2012) | |
Occupational/physiotherapists | (Penny et al., 2007); (Llewellyn et al., 2012); (Ng et al., 2009); (Adams et al., 2012); (Finkenflügel and Rule, 2008) | |
Community groups | (Hartley, 2003); (Deepak, 2010) | |
Other | (Chatterjee, 2003); (Raja, 2012); (Adams et al., 2012); (Ng et al., 2009); (Llewellyn et al., 2012) | |
Requirements | 4 years post-primary | (Bass et al., 2013) |
Secondary school | (Rahman et al., 2008); (Murray et al., 2011); (Rahman, 2007) | |
10 years of school | (Balaji et al., 2012) | |
From communities | (Rahman et al., 2008); (Balaji et al., 2012); (Penny et al., 2007); (Chatterjee, 2003); (Claussen, 2005); (Jadin, 2005); (Bass et al., 2013); (Rahman, 2007); (Lund et al., 2013) | |
Literate | (Lund et al., 2013) | |
Min. 1 year experience | (Bass et al., 2013) | |
Training | 6 sessions | (Adams et al., 2012) |
2–5 days | (Rahman, 2007); (Ng et al., 2009); (Armstrong et al., 2011); (Lund et al., 2013) | |
1–2 weeks | (Como and Batdulam, 2012); (Ng et al., 2009); (Claussen, 2005); (Bass et al., 2013) | |
6 weeks | (Claussen, 2005); (Bass et al., 2013) | |
40–60 days | (Balaji et al., 2012); (Chatterjee, 2003) | |
100 days | (Children, 2010) | |
3.5 months | (Ayoughi et al., 2012) | |
2 years | (Rule, 2013); (Ayoughi et al., 2012); (Chappell, 2009); (Dawad and Jobson, 2011) | |
Refreshers indicated | (Rahman, 2007); (Grut, 2004) | |
Supervision | Weekly | (Magallona and Datangel, 2012) |
Monthly | (Balaji et al., 2012) | |
2 months | (Grut, 2004) | |
Quarterly reviews | (Balaji et al., 2012) | |
Ratio | 1:20 HH | (Lund et al., 2013); (Deepak, 2010) |
1:100 HH | (Rahman et al., 2008) | |
1:15–30 | (Balaji et al., 2012); (Chatterjee, 2003); (Hartley, 2003); (Bass et al., 2013) | |
1:50–70 | (Nilsson, 2005) | |
1:100 | (Claussen, 2005) | |
1:500 | (Lund et al., 2013) |
Context mechanism outcome configurations and theory refinement
Framework themes/statements | Evidencea
| Avg.b
| SD |
---|---|---|---|
1. What are the competencies needed to deliver and manage quality rehabilitation services? | |||
Within the delivery of rehabilitation services, there should be the designation of a specific rehabilitation coordinator/focal person who oversees the process. | 4.33 | 0.77 | |
Multidisciplinary supervision should be available to support the implementation of rehabilitation practices at all levels. | 4.17 | 0.86 | |
All cadres of rehabilitation workers should receive specific training on advocacy and empowerment and be able to undertake endeavours that promote these within their communities to complement the work of disabled people's organisations (DPOs). | 4 | 0.91 | |
Experience and educational requirements for rehabilitation workers will be set depending on context and cadre; however, all workers, especially those at the community level, should have: strong social skills, sensitivity to others’ views and a commitment to working with persons with disabilities. | 4.56 | 0.78 | |
Rehabilitation services (including the additional training and supervision specific to rehabilitation), should be incorporated into all generic community health workers’ current service provision role. | [75] |
3.83
|
0.98
|
Community-based rehabilitation workers should be multi-skilled and supported to take a holistic problem-based approach, with appropriate referral mechanisms to other more specialised service providers. | 4.06 | 0.94 | |
Skill-set mix | |||
In some situations, a community rehabilitation cadre should be trained with a broad range of generic rehabilitation skills (rehabilitation skills that are applicable to a large number of service users) and comprehensive knowledge on disability. | 4.39 | 0.5 | |
In some situations, a community rehabilitation cadre should be trained with specialised context specific rehabilitation skills. | [77] | 4.06 | 0.87 |
In some situations, a community rehabilitation cadre should be trained with generic rehabilitation skills (rehabilitation skills that are applicable to a large number of service users) as well as one specialised area of rehabilitation. | [87] | 4.06 | 0.42 |
2. Who should be trained to develop the competencies required for the delivery and management of rehabilitation services at each level of the health care system? | |||
Persons with disabilities (including different types of disabilities) should be encouraged and supported to train as rehabilitation workers so that the service reflects the communities they serve. | 4.33 | 0.59 | |
Different workforce mixes are going to be required in different contexts, and service providers should be open to a combination of: specialists, generic community rehabilitation cadres, and a cadre combining some specialist and some generic skills. | 4.28 | 0.75 | |
While generic community health workers should be aware of the rehabilitation needs of persons with disabilities and be able to make appropriate referrals, it is not realistic to expect them to provide these services in addition to their current service provision role. |
3.5
|
1.25
| |
Community-based rehabilitation workers are an effective means of identifying and targeting persons with disabilities. | 4.78 | 0.43 | |
With appropriate training and availability of referral supports, community-based rehabilitation workers can provide services to persons with both physical and mental disabilities. | 4.56 | 0.61 | |
3. What are the strategies which work to enable rehabilitation personnel to develop and maintain the competencies required for the delivery of rehabilitation services? | |||
Clear job descriptions and expectations for all rehabilitation cadres should be developed collaboratively with the workforce, managers/implementers and government bodies. | 4.72 | 0.46 | |
Training of the rehabilitation workforce should involve persons with disabilities (including different types of disabilities), in the planning and delivery of the training courses. | 4.5 | 0.62 | |
Training of rehabilitation workers should use a context sensitive, rights-based approach and encourage problem-based learning and discussions. | 4.5 | 0.78 | |
Supervision of the rehabilitation workforce should be supportive and involve frequent practice observation and meetings that adopt collaborative problem-solving approaches. | 4.67 | 0.48 | |
The self-efficacy of rehabilitation workers, specifically those in lower level cadres, is important for job commitment, satisfaction and subsequently retention and motivation of workers. | 4.28 | 0.57 | |
Community rehabilitation workers require respect and recognition as professionals, which includes certification and acknowledgement of their decision-making abilities, opportunities for further training and career advancement and where feasible, should be financially compensated for their work. | 4.22 | 0.94 | |
The area of rehabilitation is a delicate and stressful area and requires self-awareness on the part of the health worker and requires the provision of time and spaces for consistent reflection and supportive debriefing for healthcare workers. | [85] |
4.28
|
1.02
|
4. What are the strategies which work to increase the supply and improve the distribution of rehabilitation personnel required for the delivery of rehabilitation services? | |||
The rehabilitation workforce should be structured through an integrated tiered system, from community work to facility-based services with appropriate supervision at each level. | 4.28 | 0.57 | |
Community rehabilitation services can be effectively provided by shifting some rehabilitation tasks from conventionally trained rehabilitation professionals to cadres with a shorter length of training. | 4.39 | 0.78 | |
Transport, compensation, and material resources should be targeted in order to provide a working environment that will be able to retain rehabilitation workers. | 4.5 | 0.62 | |
Persons with disabilities should be involved in the selection of community-based rehabilitation workers. |
3.94
|
0.72
| |
5. What are the minimum requirements (i.e. ratio and competencies) of rehabilitation personnel needed for the delivery of rehabilitation services? | |||
Where a generic community health workforce exists, they should be trained in disability identification and awareness, rehabilitation referral, and basic service provision for persons with disabilities. | 4.56 | 0.51 | |
Community based workers should have a minimum generalist skill-set with specialised services being offered at the facility-based level. | 4.39 | 0.5 | |
All rehabilitation workers should be trained on case management, social protection, the CBR Matrix, monitoring and record-keeping. | 4.5 | 0.78 | |
All rehabilitation health workers should be trained on the CBR Matrix and the contextual challenges and practical opportunities for applying it in their area. | 4.44 | 0.7 | |
As rehabilitation workers often emotionally support persons with disabilities and their families, they should have basic counselling skills and an understanding of appropriate referral pathways and of their limits and when to refer. | 4.72 | 0.46 | |
Supervisors should be equally competent in the process skills of supervision and the technical skills of rehabilitation interventions. | 4.17 | 0.86 | |
6. What are the characteristics of the rehabilitation workforce that facilitate equitable access to rehabilitation services? | |||
The rehabilitation workforce configuration should be guided by community needs assessments targeting the characteristics of the workforce that will make it more acceptable and accessible to persons with disabilities and their families. | 4.5 | 0.62 | |
Community-based rehabilitation services should be accountable to the communities in which they work and these communities should have mechanisms to contribute feedback regarding the services they receive. | 4.39 | 0.7 |
1. The delivering of quality services by the rehabilitation workforce in less resourced settings requires multi-sectoral coordination and supportive supervision. Workers should be multi-skilled, with clinical training, advocacy and empowerment skills, and the skills to navigate and refer within the wider health system. While workers may focus on either physical or mental health rehabilitation, it is necessary that all have minimal skills in both disciplines to ensure referrals. |
2. The workforce delivering rehabilitation within communities should be comprised of individuals with disabilities and community lay workers. |
3. In order to maintain workforce competencies, there should be clear job descriptions, roles and responsibilities; adequate training and refresher training that takes a rights-based approach encouraging problem-based learning through a mix of theory and practice; supportive supervision with trained supervisors; an incorporation of worker self-efficacy, specifically to account for motivation and satisfaction; and appropriate support structures for workers, such as counselling services. The inclusion of persons with disabilities in the training and supervision should be a priority. |
4. To improve the distribution of community rehabilitation workers in less resourced settings, an integrated tier system that places workers in communities with links to more formalised services is necessary. Task-shifting of roles to lay-workers or lower cadres is appropriate to bring services to the communities especially in resource-constricted areas. Regardless of implementation models however, workers require appropriate resources and compensation (either financial or non-financial) for job performance. |
5. Minimum training requirements of a community rehabilitation worker should incorporate aspects of disability identification, referral techniques, record keeping, case management, and community advocacy and empowerment techniques. Community workers should be trained on basic counselling techniques and mental health referral mechanisms. Community rehabilitation workers should be knowledgeable on the CBR Matrix as well as social protection and the possible contextual challenges within their areas. |
6. To facilitate equitable access to community rehabilitation services, the workforce should be situated within community settings, with community ownership and participation throughout the design, selection and monitoring of workforce programmes. Mechanisms for feedback for both communities and the workforce need to be integrated into programmes, with a likely CBR focal person to monitor such initiatives. A community rehabilitation worker should be preceded by, and frequently updated with, a needs assessment with involvement from persons with disabilities and communities. |