Rehabilitation Contexts

Original Editors - Naomi O'Reilly and ReLAB-HS

Top Contributors - Naomi O'Reilly, Vidya Acharya, Kim Jackson, Tarina van der Stockt, Lucinda hampton, Oyemi Sillo, Jess Bell and Ashmita Patrao      

Introduction

The World Health Organisation defines social determinants of health as ‘the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life’, which are largely responsible for health inequalities, including inequity. In other words, a holistic view of the context in which healthcare is provided, is key to improving health equity. The biggest gains in health may not necessarily be achieved by improving healthcare alone but also through strategies to improve these social determinants.

One of the most important factors in rehabilitation is the impact of contextual factors, including the overall context in which rehabilitation takes place. We know that the environment is known to have a significant impact on treatment generally, therefore, the circumstances surrounding rehabilitation, from the situation before, during and after the event leading to a loss in function are all important factors to consider throughout the rehabilitation process. The context in which rehabilitation occurs greatly influences the range and availability of rehabilitation services and their utilization.

Low Resource Contexts

The effects of healthcare-related inequalities are most evident in low-resource settings, which are often not explicitly defined, and where umbrella terms that are easier to operationalise, such as ‘low-to-middle-income countries’ or ‘developing countries’, are often used. Without a deeper understanding of context, such proxies are pregnant with assumptions, insinuate homogeneity that is unsupported and hampers knowledge translation between settings.

Healthcare in many low resource settings is directed primarily at the curative or preventive aspects of the disease, with rehabilitation often viewed as a lower or lesser priority, despite the increased need for rehabilitation services within this context . Current evidence suggests that only 3% of individuals in low resource settings who need rehabilitation receive or have access to them (2, 4). A global survey of government action on the implementation of United Nations Standard Rules on Equalisation of Opportunities for people with a Disability highlights that rehabilitation policies were not adopted in 48 countries (42%), legislation on rehabilitation was not passed in 50% of member states, and rehabilitation programmes are not established in 46 countries (40%). Furthermore, specific budgets towards rehabilitation services are not present in at least a third of countries globally. Patient's personal factors (education, age, personal attitude, employment) and environmental factors (experience of healthcare staff, availability of specialized investigations, treatment, services, transportation, physical and architectural barriers) profoundly impact rehabilitation and functional outcome in developing countries, thus making it essential to recognize these contextual factors which hinder rehabilitation.

The term ‘low-resource settings’ could be expanded to nine themes that show that these settings are not unidimensional or dichotomous (i.e., adequate vs inadequate), yet rather reflect a complex network of inter-related resource limitations and concepts.

Conflict and Disasters Contexts

From the first world war to more recent disasters, such as the 2015 Nepal earthquake and the 2020 explosion in Beirut, Lebanon, the importance of integrating rehabilitation into emergency responses to conflicts and disasters has been clear. The World Health Organization emergency medical team standards and recommendations for rehabilitation, launched in 2016, signalled significant progress in recognising the role that rehabilitation professionals play and the necessity of early intervention. However, while the emergency medical community takes strides towards integrating early rehabilitation in conflict and disaster response, early rehabilitation remains an emerging area.

Rehabilitation professionals face unique challenges associated with complex trauma, injury surge and resource scarcity that many have never encountered before. Practical guidance to deliver quality early rehabilitation in these contexts is essential if conflict and disaster response is to evolve beyond its life- and limb-saving mandate to deliver care that maximises patient outcomes. Rehabilitation professionals need to be equipped with the knowledge and skills to meet patient needs and navigate the demands of emergency medical response. In humanitarian emergency situations such as during or post-conflict and natural disaster situations, the need for basic functional rehabilitation services is overwhelming and critical to preventing disability and improving the lives of people with disabilities.

Early Rehabilitation is now recognised as being an integral part of a patient’s recovery in conflicts and disaster situations. Starting in acute care, early rehabilitation can help prevent complications, speed recovery, and help ensure continuity of care. Rehabilitation professionals working in early rehabilitation need skills across a wide range of clinical areas, and in conflicts and disasters need to be able to manage challenges including large surges in patient numbers, limited equipment, and complex clinical presentations. Due to advances in response, management and post medical care in disaster situations, high mortality rates have gradually transitioned to increased morbidity rates.

Natural Disasters

Victims of natural disasters now have a higher chance of survival; they may, however, have disabilities which may significantly impact their physical and psychological health and affect their quality of life; patients with pre-existing disabilities and co-morbidities are also at the risk of higher mortality rate. Rehabilitation in natural disaster situations should be of utmost concern due to the vulnerability of the victims, some areas which need interventions in disaster situations include;

• Collaboration and governance
• Capacity building
• Person-centred multidisciplinary care
• Improved communication
• Increased public awareness and active participation/inclusion of disaster survivors/family/community partners
• Strengthen evidence-based information, education and access to information
• Strengthen community-based rehabilitation.

Watch the short video below entitled "Early rehabilitation in conflict and disaster: Nepal earthquake response". Note: HI stands for Humanity & Inclusion and is an independent and impartial aid organisation working in situations of poverty and exclusion, conflict and disaster.

Resources

Low Resource Settings

• Promoting the Development of Young Children with Cerebral Palsy: a Guide for Mid-Level Rehabilitation Workers
• Promoting the development of infants and young children with spina bifida and hydrocephalus : a guide for mid-level rehabilitation workers

• Promoting independence following a spinal cord injury : a manual for mid-level rehabilitation workers
• Physical and functional rehabilitation in long-standing (long-term) refugee camps
• A Market Landscape and Strategic Approach to Increasing Access to Digital Assistive Technology in Low- and Middle- Income Countries

Rehabilitation in Sudden Onset Disasters

• Rehabilitation in Sudden Onset Disasters
• Responding Internationally to Disasters
• The Role of Physical Therapists in Disaster Management

Early Rehabilitation in Conflict and Disasters

• Early Rehabilitation in Conflict and Disasters Field Handbook
• Early Rehabilitation in Conflict and Disasters Online Training
• Early Rehabilitation in Conflict and Disasters YouTube