Sala kahle: Stay well

Week 6: 23-27 May

The 6 weeks on Community have been a flying carpet under my feet, carrying me with breath-taking speed through the rich world I have been living side by side with all my life, but have never before explored with such depth. There have been stomach-churning lows and dizzying highs (literally and figuratively... some houses perch on the edge of some pretty precarious cliffs...), but all meld together in retrospect to form a beautiful tapestry of the Community experience.

 

 

 

Beginning to emerge from our six weeks of community immersion, I have never felt more in tune with my own country, and yet, at the same time, so distant. I understand the lives of my fellow countrymen with so much more depth, yet the knowledge that due to the circumstances of my birth, there will always be an invisible divide between me and the majority of the country's population makes me sometimes feel like a tourist in my own country.

 

 

Although we are 21 years into democracy, the racial divisions- often along financial lines- are very much still evident, one of the many remnants of the Apartheid regime (Elfers, 2012). It is rare to find a person of European or Indian origin in the 'townships', making Michaela and I particularly visible.

Walking through the community, I have attracted far more attention than I am usually comfortable with, being very distinctly 'different' from the average people passing through the clinic, hostels and community at large. With my isiZulu skills (finally) improving a little, I can pick up the occasional curious phrase or comment, but by the time I string together enough words to respond, the moment has usually passed, or one of my (lifesaving) isiZulu colleagues has stepped in to explain. I have to admit that I have, on occasion, pretended to understand less than I do, especially when shady characters in the hostels ask for my number or when the alcohol-drenched woman followed us around asking for a house...

 

The younger schoolchildren are particularly fascinated, making a game out of poking their faces into the library for the full 30 minutes of break-time to call out a friendly 'Hi!' to us, one of the few English words they know (Michaela and I finally took to hiding in the corners so we could eat our lunch in some degree of peace...).

 

Our 'difference' posed some important considerations for intervention. There sometimes seems to be a sense of respect for people of lighter skin, or the perception that these individuals are more educated than the local people. This can effect our ability to build an equal partnership between us and community members, which is a critical aspect of achieving relevant and effective community-based rehabilitation (Head, 2007). Often, our suggestions are simply accepted without critiquing our approach based on their own first-hand experience within the community. This occurred when discussing cases with the CCGs, when they would rely a lot on our professional knowledge, but offer little insight from their perspective until prompted. 

On the other hand, we sometimes experienced the other end of the spectrum, where community members viewed us as 'outsiders', who can never understand the reality they face, something that is compounded by the fact that we are young, and only students. This was experienced to some degree within the teacher workshops, when we were greeted by blank looks, until we prompted discussion by explaining that our intervention can only be successful if we receive the valuable input that years of experience has equipped them with. That was the point at which the deep issues faced by these teachers emerged: the reality that their voices are rarely heard by parents, and by the Government. They have attempted to highlight systemic issues, such as the condoned pass system, that have resulted in children who are unable to read or write being allowed to progress to Grade 7 . Due to this system, these teachers are faced with overcrowded classrooms containing a range of children with various learning difficulties that they don't have the capacity or training to deal appropriately with. 

 

 

The system of condoned passes has been one that has attracted debate over the past few years. While South African Education minister Angie Motshekga acknowledged in 2014 that the condoned pass system is not working, she stated that holding learners back discouraged them, causing an increased likelihood of them dropping out before completing their schooling (Mlambo, 2014). Ursula Hoadley, an associate professor in the University of Cape Town’s (UCT) school of education, is in agreement with this, stating that “The quality of teaching and learning in South Africa is low and so is our remediation support offered to pupils who fail. If you make kids repeat...they are not going to learn much more. It is better to let pupils progress to the next grade in the hopes that they acquire at least some new skills.” (John, 2015).

These concerns are vital for us to be aware of, as, not only does it directly relate to our scope of practice, but also determines the classroom dynamic in which the children we work with must function. It highlights the importance of the Government opening school-based Occupational Therapy posts, to provide very necessary support and intervention to these children, as well as to the teachers who face the burden of dealing with issues outside their training.

 

This block has had moments that have restored my faith in humanity, and moments that have shattered it. I have seen the face of this country that inspires hope, and that which induces deep sense of despair.  Seeing the resilience of some people against the circumstances in which they find themselves filled me with a deep respect, like the young Boccia player who is determined to form a team within the community, or the young mother who, despite living in a rock-and-wooden-slatted informal house, always looks smart in beautiful hairstyles, walks up and down the steep hill to her home to fetch water with a smile, and repeat the same songs over and over to her child in the hope that he will learn a word, or repeat just one sound back to her. On the other hand, there were others, who shut down their dreams at the smallest hint of resistance, like the mother who believed her child would never progress and gave up on her child's school application every time a requirement came up that she felt incapable of dealing with.

 

I have met people who have highlighted my own misconceptions and stereotyped thinking patterns and reinforced more securely than ever that the series of events and circumstances that define us is not a linear progression, but a complex, dynamic interplay of factors. It's easy to put people in boxes: the mother who does not want therapy is simply uneducated and unmotivated; the community caregiver assigned to a client is overworked and undertrained; the child who is acting out in class has never been taught proper behaviour. However, this block has pushed us beyond these superficial observations to consider what in the very fabric of the community has caused these symptoms in these particular individuals. And while this has allowed us to direct our therapy more effectively, we often arrived at the harsh realisation that we are sometimes merely treating the symptoms, and that there is very little we can do as therapists about the deep, systemic issues ingrained within our country. 

Discussing these issues together during our tutorials was an amazing experience, as we were able to see things from a slightly different angle, each experiencing a phenomenon differently based on our background and worldview. The tutorials challenged me to question every opinion I held, to determine what in my upbringing and value system contributed to that opinion, and how my internal bias would affect the way I approached a certain situation. In this way, I learnt more about myself than in any other module, by constantly monitoring and reflecting on my own performance. Going forward into the next block, I know this skill will be useful not just in future modules, but in my daily interactions as well.

 

 Like this year, this block has pushed me to my limits. I have developed a fighting spirit I never thought I would ever possess, seen it crushed again and again by barriers that keep arising, and fired it up all over again.  I have learnt the value of taking a moment to step back and regroup- to switch off my OT brain for a moment, immerse myself in other pursuits, and return refreshed to scale the mountain ahead. At times I have felt that I fell short, and experienced the frustration of being incapable of achieving a goal that once appeared within reaching distance. However, this has made the moments of actually achieving a goal all the more valuable. Community has not just allowed me to direct the lens outwards at the community and its workings, but also inwards into my own strengths and weaknesses as a therapist, and as a human being.

 

 

 

Mlambo, S. (2014, August 22). Angie says condoned passes not working. Retrieved from the Daily News: http://www.iol.co.za/dailynews/angie-says-condoned-passes-not-working-1739801 on 27 May 2016.

 

John, V. (2015, January 7). Motshekga sows confusion about pushing up pupils. Retrieved from the Mail and Guardian: http://mg.co.za/article/2015-01-07-motshekga-sows-confusion-about-pushing-up-pupils on 27 May 2016.

 

 

Head, B. (2007). Community Engagement: Participation on Whose Terms? Australian Journal of Political Science. 42 (3). 441-454.

Elfers, R. (2012, October 17). Apartheid impacts are still felt in South Africa. Retrieved from the Enumclaw Courier Herald: http://www.courierherald.com/opinion/174619881.html on 27 May 2016.

 

Nonetta (2007). Deviant Art. Retrieved from: http://nonnetta.deviantart.com/art/Despair-vs-Hope- on 261225951 on 27 May 2016

Immersion

Week 5: 16-20 May

Spending so much of our time working with those who have disabilities or some form of functional impairment, we sometimes slip into the unconscious habit of believing that this is the norm. Over the past four weeks, we have interacted with depressed mothers, burnt out caregivers, children who would never achieve what their parents dreamed of for them, and people who had suffered more loss than all of us put together.
This week, moving around the community and getting to know the actual people on the street: the municipal workers running the poverty alleviation programme, the brick-makers, the mielie-ladies, and the friendly old ladies selling cupcakes, was a ray of sunshine into our souls. There is an underlying sadness within the community, as so many people fall into the category of 'have-not's'. However, there is a deep resilience among many people within the community, which we were privileged to witness this week.

 

The sound of a ladle scraping across the bottom of a pot had never before evoked such emotion in me. Standing next to the Poverty Alleviation container in my role as the 'guardian of the bread' on Tuesday, I watched the long line of people trailing around the container and out into the parking lot. In their hands, each person held a bowl, an ice-cream tub, a Styrofoam container or a faded margarine tub to collect their 3 ladles of steaming hot chicken-feet soup the municipal workers had prepared. At first, I greeted each person as they passed by to collect their soup, but it became harder and harder to meet their eyes as I noticed the holes in their clothes or shoes, the threadbare packets in which they had brought the small, well-worn containers, and the way they humbly accepted the soup with both hands and a slightly bowed head, the cultural equivalent of sincere gratitude.

As the line progressed and the level of the soup began to steadily drop, I could se my colleagues also becoming anxious as we mentally compared the number of people to amount of soup remaining. Hearing that inevitable scrape of the ladle against the base of the pot, and looking up to see the line of people with empty containers, who had heard it too, and knew what it meant, was heart-breaking.

 

For some reason, the vulnerability of their position was painful to witness. To me, being in such a dependent position, relying on others for basic needs is a terrifying thought. And yet, the humility of these individuals was humbling. Standing in neat, orderly lines after collecting their cardboard number, every person we interacted with was polite, courteous, and dignified.

Speaking to the co-ordinator of the programme, she echoed a similar sentiment. For 12 years, she had been in charge of the Poverty Alleviation programme. 'Sometimes it is painful when the food is not enough, but the people, most of the time, they understand. They say, "There were too many of us today."' This statement stuck with me, because it broke down the perception I had unconsciously held: that there would be a mad rush for the food as each person put his or her own basic needs over the needs of another. It was a reminder that as much as we explore and attempt to remove our biases, there is always a reference point from which we come that defines how we perceive others.

 

However, for those 7 or 8 people who had missed out this week, there were a hundred others who had received a hot meal. Even though our role in providing that meal had been minimal, it was gratifying to know that we had been part of making someone's day just a little better.

 

This week had already taken a positive turn from Monday, watching the sports hall fill up for our Boccia Sports Awareness Day (much later than expected, but what with African time and the massive M19 protest traffic jam, we were grateful it was only an hour and a half's delay...).

 

This day was one of the first times I have seen people with disabilities, and those without, able to engage together in an activity, without one having the advantage over another. The beauty of Boccia is that it allows every individual to play to his or her strength. Whether by using ramps for those with minimal voluntary movement, or assistive devices such as head pointers, each individual is able to use his or her residual skills to play the game (ThisAbility, 2011). I had the opportunity to play side by side with a young man with cerebral palsy, and I have to admit, he outplayed me by far. When the KZN Boccia champion and community member (a young man with muscular dystrophy, whose dream had inspired Monday's sports day) was given a chance to showcase his skills, you could have heard a pin drop in the shocked silence that followed his perfect throw, before the applause rang out across the hall. With the facilitation of occupational engagement being such a critical part our role as OTs, in a community where people with disabilities experience occupational deprivation on a daily basis, this event will remain of the highlights of my student experience.

 

 

Throughout the week, we continued our attempts to engage as much as possible with the people in and about the community.

 

I spoke with the friendly lady at the entrance to the clinic, who, without fail, greets us with a smile and a loud welcome every morning. She sells sweets, chips and the most amazing carrot muffins that she and her friend bake every morning to sell to people passing into and out of the clinic. Her job does not pay a lot. Unlike the R12 muffins at the campus cake shop, hers are just R3, as most of her customers cannot afford to pay exorbitant amounts of money for luxuries like cake. She says she wants to get a job as a domestic worker in an affluent area, where the pay would be better, but she is old, and from her spot outside the clinic, she is able to meet a range of new people to interact with every day. Studies have shown that social interaction in the elderly is instrumental in maintaining health and wellbeing (Thomas, 2011). Hence, this woman, engaging every day with new people, forging new connections and making the world a happier place, one cupcake at a time, is fulfilling an important life role that many other elderly people unfortunately are not able to experience due to illness or disability.

 

 

Stopping on the side of the road, we met Joe, a brick-maker, who had been working for 10 years under the tutelage of his boss. Brick-making had never been his dream growing up, but he enjoys working with sand, and it pays the bills, allowing him to fulfil his family roles. If something comes up that pays more, Joe said, he would take another job, but a stable job in the community is a valuable thing, and not something to be given up lightly. Spending 2-3 days waiting for each lot of bricks to dry, and making up to 300 bricks a day, Joe sells bricks to people from both outside and inside the community. An interesting community dynamic emerged when talking to Joe: Although his bricks lay outside all night when he goes home, he says no one steals them anymore because the people living around keep a watchful eye and will report to him if anyone attempts to walk off with a brick or two. We often make the assumption that these communities are unsafe places because of poverty and opportunistic crime. However, when community members themselves begin to take responsibility for the safety of their own communities, there is no room for crime to flourish.

 

Walking through the town, we met the Mielie lady: a cheerful round woman roasting fresh mielies on a grill, with a towering pile of raw mielies next to her. Her business acumen was inspiring: she had found a supplier in Richmond who brought her a truck-full of mielies fresh from the farm every morning. She then sold the raw mielies to mielie-ladies all over the community every morning, who would roast and sell them to passers-by. She had been selling mielies in that spot for 20 years and it was her life. Her business skill had been obtained through years of experience instead of any formal training. This sort of experiential skill is valuable in a community such as this one, where knowing the dynamic of the community and where the opportunities are, are an integral part of success.

 

 

Engaging with people in the community was an amazing experience. After spending time with community members who have borne the brunt of the adverse living conditions within the community, in small, cramped houses, with the additional burden of disability or illness, I had unconsciously begun to project their bleak, jaded worldviews onto the other members of the community facing similar living conditions. But if this week proved anything, it was that the human spirit is an amazing thing in the way it can endure and find a way to thrive.

 

 

Thomas, P.A. (2011) Trajectories of Social Engagement and Limitations in Late Life. Journal of Health and Social Behavior, 52(4), 430-443.

 

QuotesGram (2016). Never ask questions quotes. Retrieved from http://quotesgram.com/never-ask-questions-quotes/ on 20 May 2016.

 

ThisAbility (2011). Let's Play Boccia. Retrieved from: http://www.thisability.co.za/sports&recreation.php?id=4#.Vz9WQtFunIU on 20 May 2016.

 

Joe (2016). Interview with students

The Big B: When carers stop caring

Week 4: 9-13 May

 

The experience of studying occupational therapy is, to me, much like juggling a dozen balls at one time, as we try hold all our theory in our minds at once, apply it practically, and still lead some semblance of a functional life outside the course content. This week, I had the sense that all those little balls finally succumbed to gravity and dropped in a clatter to the ground.

 

 

First to abandon ship was my body, succumbing to a nasty cold doing the rounds in our class, leaving me a miserable wreck trying to focus on essays and case presentations with whatever brain cells were still functioning.

Sports was definitely out given the state of my body, so I'm now behind on my karate training, with grading coming up in just a few weeks.

Family commitments were the next to drop, as all my time at home during the week began to be dedicated to solitary work on my laptop or sleep, with me only emerging at mealtimes and, even then, thinking about something I had due the next day.

My involvement in student organisations was pushed to the back of my mind, leaving a pile of admin to follow up on to ensure projects go according to plan. 

And my OT skills lie scattered all over my brain, leaving holes in my intervention programmes, and making me doubt my competence as a healthcare professional. The pile of theory books I've had on my desk for months (and accounted an atrocious number of library fines on) still remain largely unread, only paged through when I am looking for a particular piece of information

 

 

So now, with all the little balls lying haphazardly on the ground, I am free to take a step back and survey the situation. Why have things begun to unravel, and how can I knit them all back together tighter than before?

 

The dreaded 'B' word is one that has cropped up more frequently than ever this year. We have seen therapists, caregivers, clients and colleagues go through it, and seen first hand what happens when people just stop caring. Before this year, it was difficult to understand why a mother would be unwilling to carry over a home programme that would benefit her child, or why a therapist would go through years of training only to sit in air-conditioned offices and play Candy Crush for most of the working day. Perhaps these people are just immoral and heartless fiends, but a more compelling reason that has become increasingly publicised, is that these people may have started off with the best intentions, but have fallen victim to Burnout.

 

According to Smith, Segal and Segal (2016),

"Burnout is a state of emotional, mental, and physical exhaustion caused by excessive and prolonged stress. It occurs when you feel overwhelmed and unable to meet constant demands. As the stress continues, you begin to lose the interest or motivation that led you to take on a certain role in the first place."

 

 

I have seen this in the mothers of children I have worked with, who have no motivation to provide the stimulation their child needs, and who are unwilling to meet us halfway in the therapeutic process. Living in a society where minimal or no support is provided to the caregivers of children with illnesses or disability, the constant stress of having to deal with the challenges of raising these children places these women at high risk of burnout (Uren, 2013). For us, working with these caregivers can be immensely frustrating. Being met with resistance to what we perceive as sincerely-intended help is often demotivating, and can lead to our own experiences of burnout as we put in significant effort and yield minimal results. For this reason, understanding the concept of burnout, and how to deal with it, as well as reviewing the socio-cultural dynamic of these caregivers is of critical importance in working with these individuals.

 

 

Gerry (2013) describes ten signs of burnout, including exhaustion, lack of motivation, frustration, cognitive problems such as decreased attention or memory, deteriorating occupational performance, interpersonal problems, being preoccupied with work,  decreased satisfaction, and health problems.

I know these signs well. Not only have I seen them in my colleagues and in my clients, but I have noticed them increasingly in myself. A study conducted by Painter, Akroyd, Eliott and Adams (2009) showed that occupational therapists have a high rate of emotional exhaustion, particularly when working with chronic care clients. To be efficient healthcare workers, even now at an undergraduate level, it is important that we tackle the issue of burnout so that we can function effectively, and provide the best care possible.

 

 

 

 

Gerry (2013) describes some steps to deal with burnout:

 

• Schedule relaxation time, dedicated towards rejuvenating the mind and body.

Over the past few months, I have noticed that I find it difficult to completely relax, even in activities that I had previously found calming, something that other students have also expressed. There is always the nagging sensation in the back of my mind that something needs to be done, preventing me from being able to relax fully. However, one way I have recently found to combat this is to write down all the things running through my mind beforehand (hand it over to the paper) so that I can achieve a better state of relaxation.

For many of the clients we work with who experience burnout, relaxation time is not easy to achieve, especially if they have a child and home that need constant attention. Hence, achieving this would involve an in-depth analysis of the resources and opportunities available, to determine where and how best to incorporate relaxation into a busy schedule in an under-resourced context.

• Get enough sleep

This one I have down:) Sleep is a non-negotiable.

For many people we work with, however, sleep is not necessarily a given. Sometimes waking in the early hours of the morning to begin the household or childcare tasks, caregivers, particularly those who care for multiple individuals, may not be getting sufficient, or quality, sleep.

• Unplug: do not allow work stress into personal or family time

Unfortunately, as a student, our home environments are also our work environment. Coming home after a day of working in the community, I still have to switch on my laptop and start typing up session plans, blogs, essays or letters for projects, while following the work-related discussions on all the 23 active WhatsApp groups on my phone.  Setting aside dedicated no-work hours may assist with this, as the lines between personal time and work time are often blurred.

For primary caregivers, the home environment is the environment in which their primary care function occurs. They are 'on-duty' for 24 hours daily, leaving no escape from the burden of care, unless they are lucky enough to have the support of someone else to provide assistance with care while they engage in other pursuits. Hence, providing some form of community support, allowing them a break in the care routine, is an important part of intervention.

 

• Cultivate a balanced, rich lifestyle beyond work

 

Balance has become the new buzz word in health. Incorporating physical recreation, social interaction, community participation and family time into my lifestyle have always been important for me, and I still maintain all these roles. However, these aspects are the first to be reduced when OT course demands intensify. This causes internal role conflict, as these non-work roles are of immense value to me, yet must be deprioritised.

For many people within the community, caregivers in particular, balance is not easy to maintain, given the heavy burden of care many of them face, as well as the lack of opportunities for meaningful recreation within the community. This may result in a routinized, monotonous and unfulfilling lifestyle, which can exacerbate feelings of dissatisfaction and burnout.

 

Solving the issue of burnout is not an easy task. As with any health issue, prevention is better than trying to treat the symptoms, or to trace back the symptoms to a cause which may have become more complex over time. Some of the simplistic ideas provided by articles on coping with burnout do not take into consideration the socio-cultural context of many of the people we work with, and the impact that the lack of physical, financial, social and cultural resources has on the ability of these individuals to make effective lifestyle changes. It is important for us as healthcare providers to recognise the symptoms of burnout both in our clients and in ourselves, so that we can create the support and lifestyle changes necessary for productive and meaningful function, and quality of life.

 

Smith, M., Segal, J., Segal, R. (2016).Preventing Burnout: Signs, Symptoms, Causes, and Coping Strategies. Retrieved from http://www.helpguide.org/articles/stress/preventing-burnout.htm on 13 May 2016.

 

Gerry, L.M. (2013). 10 Signs You're Burning Out -- And What To Do About It. Retrieved from http://www.forbes.com/sites/learnvest/2013/04/01/10-signs-youre-burning-out-and-what-to-do-about-it/#2eba7fa15e01 on 13 May 2016

 

Painter, J., Akroyd, D., Elliot, S., Adams, R.D. (2003). Burnout Among Occupational Therapists. Occupational Therapy In Health Care. 17(1). 63-78

 

Uren, S (2009). An Investigation into the Emotional Experience of Caregiving. University of the Witwatersrand: Johannesburg

 

Community in Context: A Community Perspective on Global Events

Week 3: 3-6 May 2016

Spending a while in the community, it's easy to forget that a world exists beyond it, filled with a billion other communities, each with its own particular phenomena, it's own strengths, and its own pertinent issues. However, despite our global diversity, some issues are interesting in the way they recur in communities, countries and continents throughout the world. One of these is the global refugee crisis, which has seen the massive migration of people across continents in search of a safer place to live, work and raise their children.

"We are currently witnessing the largest and most rapid escalation ever in the number of people being forced from their homes.

Millions of people are fleeing conflict in Syria, Iraq, Afghanistan and Ukraine, as well as persecution in areas of Southeast Asia and Sub-Saharan Africa, creating the highest level of displacement since World War II"

(IRIN, 2016) 

 

 

 

 

The Occupational Therapy model on the Ecology of Human Performance places a great deal of emphasis on the way in which the context in which a person functions affects their ability to carry out occupational tasks, stating that context is 'a lens from which persons view their world'. (Dunn, Brown, McGuigen, 1994: p. 595). This model states that a person constructs their sense of self or identity in the context of their environment  (Dunn, Brown, McGuigen, 1994).

 

For people fleeing from one hostile context to another, which may be equivalently  hostile, and the instability this causes, it is therefore understandable that function and engagement in occupation may be affected.

  

 

Upon our entry to the community, we were informed that one particular client should be referred to only by the first initial of her name. It was important that no one in the community were informed of her (clearly foreign) name, as this may pose a threat to the individual, given the recent xenophobic flashpoints in the country and her illegal immigrant status. I went over to this individual's home to get a first hand account of what it feels like being a foreigner in a country whose people have exhibited xenophobic tendencies on multiple occasions. She expressed ' It is a nice place, but the people here do not like me. I hear them [her neighbours] talking bad things about me'. She also informed us that she would be sending her child back to her home country, so she could grow up amongst other children of the same nationality, possibly so that she would not face discrimination as a result of her being 'different'. For this woman, living in a community in which she feels unwelcome limits her motivation to engage effectively within it. She does not go out much, only interacts with the few friends she has who are more open-minded about her situation, and does not make use of many of the community resources.

 

 

Speaking to a native member of the community about  people from other countries coming into ours as a result of conflict in their home country, or in search of work, he echoed a sentiment common to many people, "They come, and they take our jobs'. He expressed that while he 'feels for them', he feels they should stay in refugee camps, so that they cannot 'steal jobs' and 'sell drugs'.

 

This perception of foreigners poses a potential cause of occupational deprivation, as these individuals, whether through stigma, physical intimidation, or legislative barriers, are often prevented from engaging in meaningful work, social and leisure functions (Whiteford, 2005). As a result, they are stuck in the situation many refugees globally find themselves in: 

“We’re in a situation where refugees can’t work, they can’t go back, they can’t leave their homes, [but] eventually they need to eat.”

— Patricia Safi, lawyer providing legal assistance to refugees

(IRIN, 2016)

For many of these people, who possess highly valued skills sets, and therefore a high sense of personal causation, but are unable to use them due the effects of the environment, this occupational deprivation becomes even more poignant.

 

 

 (IRIN, 2015).

 

As occupational therapists in this changing dynamic, we need to be prepared to face the repercussions of this phenomenon. With an influx of new cultures and nationalities, our idea of cultural competence will have to be expanded. Not only do we have to understand the complex and unique cultural identity of a person within their environment, but we need to now begin to understand the dynamic culture of a person whose identity has been thrown into flux by the transition from one context to another. Added to this, the increase in disabilities caused by the conflict situations these people are attempting to escape is likely to increase the demand for our services, meaning that we will have to improve our efficiency at all levels of practice to cope with this potential increased demand.

 

 

Unfortunately, there is no quick fix to this issue, both globally or locally. While legislative changes are occurring internationally in response to the massive migratory shift we are currently seeing, the integration of these displaced communities into the societies they now find themselves, and their ability to function optimally within them, will require change at both the political and social levels. Apart from the various logistical issues that come with the massive influx of new people into a country, the stereotyped, and often negative, perceptions of native people towards those from other countries will also need to be addressed before these individuals will be able to achieve optimal occupational performance within their new environment.

 

 

IRIN (2016). The Global Migrant and Refugee Crisis. Retrieved from http://newirin.irinnews.org/global-refugee-crisis/ on 5 May 2016.

 

Dunn, W., Brown, C., McGuigan, A. (1994). The Ecology of Human Performance: A Framework for Considering the Effect of Context. The American Journal of Occupational Therapy 48(7). pp. 595-607

 

 IRIN (2015). Photo Feature: Humans of Syria. Retrieved from http://newirin.irinnews.org/humans-of-syria on 6 May 2016

 

Whiteford, G. E. (2005). Understanding the Occupational Deprivation of Refugees: A Case Study from Kosovo. Canadian Journal of Occupational Therapy 72 (2) pp.  78-88                                    

Feet on the ground: Facing the reality of community healthcare in South Africa

The initial 'tourist phase' over, having already marvelled at the disparities between 'my' life and 'theirs', the reality of community hit me right in the chest this week like a foam-covered morning star. Hard enough to jolt me into the harsh reality of the community, but soft enough that I know I will be able to get my breath back in time and keep moving forward. So many stories, so many wounds, but too few ears and too few Band-Aids.

 

 

The shortcomings of the public healthcare system were made visible this week with my home visit clients, when the realities of healthcare provision in lower socio-economic sectors of society became glaringly obvious.

In the first week, I had accepted the situations these people had found themselves in as an inescapable part of the 'rural' experience. This week I started to question:

 

Why did the mother of the little child we had been visiting not even know the diagnosis of her child? Had no healthcare professional explained the diagnosis to her or indicated what the medication she gave the child was for, let alone given her a home programme to follow for the past few years?

If Mr J, my elderly CVA client, had been born into a different family just a few kilometres east, would he have been left to lie in bed for 6 months, in a dark, unventilated room, with flies buzzing around his necrotic pressure sores, attracted by the overpowering smell of dying flesh?

 

It's easy to write off these situations as a direct result of poverty. However, given that every person in the country- no matter their financial status- has the fundamental right to quality healthcare, I have to ask myself the question, 'How and why has the healthcare system failed this city?' (And yes, I've probably watched one too many episodes of Arrow...)

 

Moving into the glorious age of democracy in 1994, reform of the healthcare system was put into motion. The Reconstruction and Development Programme and the National Health Act were put in place to equalise healthcare and combine fragmented health services into a more comprehensive care model (Venturino, 2013). The focus of health intervention shifted from a curative model, which was often more expensive and time-consuming, to a preventative model, also prioritising community-based healthcare, in an effort to make healthcare more accessible to people living away from the city ( Venturino, 2013).

 

 

 

However, although access to healthcare and equitable health expenditure has been accomplished, the overall health outcomes in the country still remain poor (Harrison, 2009). In terms of the Millennium Development Goals, South Africa still falls short of many MDG targets (Centre for Rural Health, 2013).  This may be due to a variety of reasons, amongst them being financial constraints of the government, as well as the quadruple disease burden prevalent in the country, resulting from having one of the highest HIV/AIDS rates globally, predisposing HIV + patients to a range of opportunistic infections and disabling conditions, running parallel with the cycle of poverty that many South Africans remain trapped in (Venturino, 2013). Engelbrecht and Crisp (2010: pg.196) state,

It must be stated that, in theory, the current health system provides universal coverage. Yet, from a service delivery, resourcing and quality perspective, the distribution and level of services is inequitable with many communities and patients experiencing great difficulty in accessing the public health system. Furthermore, both the public and private health sectors of the South African health system are unsustainable and fail the challenges of coverage, quality and cost.

The gaping divide between private healthcare, accessible to the rich, and public healthcare, available to those who cannot afford private care, has become more significant, with the quality of public healthcare provided below that anticipated (Englebrecht and Crisp, 2010). 

 

 

 

As part of the Government's plan to provide community-centred healthcare, one of the mechanisms that has been put into place to cope with the heavy patient burden is the provision of community caregivers (CCGs), health workers from within the community who are responsible for ensuring that adequate care is provided to individuals upon their return to the community from the clinic or hospital (Centre for Rural Health, 2013).

 Ideally, the role of the CCG would be to carry over treatment into the home setting, to ensure that the health of the individual is maintained. However, when I consider that the caregiver assigned to Mr J had not even picked up that he was developing pressure ulcers, meaning that she had not checked that he had been turned regularly, let alone engaged him in a home rehabilitation programme, it raises the question, 'How well are the community caregivers trained?' More specifically to us as healthcare professionals (in training), how have we role-released to the CCGs so that they can carry over the correct therapy in our absence?

 

 In an ideal world, when Mr J received his diagnosis (and was properly explained the implications of this diagnosis, in the presence of his caregiver), he would have been assigned to an occupational therapist, physiotherapist, speech therapist, and perhaps a dietician. Prior to his return home, the team would have been informed of his discharge, and of the CCG assigned to Mr J, allowing them to put together a home programme, provide the relevant training and role release to the CCG, as well as schedule intermittent follow up visits to the client, to ensure his care was proceeding optimally. Mr J would be taking life easy, enjoying his retirement.

 

However, Mr J is now in hospital, malnourished, weak and unmotivated, being treated for conditions that were preventable, had the healthcare team, including Mr J's primary caregiver, all been on the same page.

As occupational therapists, we are a finite human resource. We don't have the capacity to see every person that requires our care, and this week's mad dash to fit all our home visit clients into our schedules was testament to this. There was the dilemma of wanting to provide as much care as possible to as many people, while knowing that we cannot approach new clients without knowing that we have the capacity to follow up with them. It is for this reason that carry-over and caregiver role-release is so important.

 

According to Uren (2009: p 116),

"knowledge provided an integral component of the caregivers’ competence and informed their perception of their professional identity as a formal caregiver. Their ‘ownership’ of this knowledge created the perception of caregiving as a privileged or restricted profession, in this manner attaching prestige to the professional identity. This provides the individual with sense of importance and increases the significance of his/her role"

 

If we can provide the primary caregiver with sufficient skills, support and motivation, we can lessen our burden and still ensure the client is receiving appropriate and relevant carry-over care in our absence.

 

When working in the community, and seeing the vast needs of the people in relation to our ability to satisfy these needs as healthcare professionals, it is difficult to prevent a sense of frustration and perhaps despondency from developing.

The reality we are faced with is that there are multiple issues, at a political, social, financial and organisational level, that prevent the provision of efficient and effective healthcare. When we see qualified OTs who spend a significant amount of time doing nothing of consequence, even though there's a mountain of work waiting outside the door of the hospital or clinic, we often become angry or indignant in the knowledge that they are doing an injustice not just to our profession, but to the people we serve. However, perhaps they have looked into the abyss that is the over-burdened health system, and that view has snuffed out the flame that once fuelled their passion for their profession.

For us, emerging into the same world, with the same problems, it is imperative that we learn to draw our gaze back to the small accomplishments we make every day, to continuously rekindle the enthusiasm within us and make sure that we remain burning steadily bright, carrying the torch for our profession.

 

 

 

 Venturino, M. (2013). Health Care Reform in the US and in South Africa: Does New Policy Cure the Disease or Merely Alleviate the Symptoms? Africa Institute of South Africa. Policy Brief no. 90. Electronic copy retrieved from http://www.ai.org.za/wp-content/uploads/downloads/2013/07/Health-Care-Reform-in-the-US-and-in-South-Africa.pdf

 

Centre for Rural Health (2013). The perceived roles of CCGs and acceptability of implementing a community-based maternal, neonatal, child and women's health intervention in KZN, South Africa. Retrieved from crh.ukzn.ac.za/.../cframewrok_report_1March_final_AP_14_45.sflb. on 27 April 2016.

 

Harrison, D. (2009). An Overview of Health and Healthcare in South Africa 1994-2010: Priorities, Progress and Prospects for New Gains. National Health Leaders' Retreat: Muldersdrift.

 

Engebrecht, B., Crisp, N (2010). Improving the Performance of the Health System. South African Health Review 2010. pp. 194-205

 

Uren, S (2009). An Investigation into the Emotional Experience of Caregiving. University of the Witwatersrand: Johannesburg.

 

 

 

 

 

 

 

Through the bus window: Initial Impressions of Community-based Rehabilitation

Week 1: 18-22 April

For the first few days of our Community block, it was overwhelming to transition from a structured Paeds context, to the dynamic nothing-goes-according-to-plan total immersion that is Community-based Rehabilitation. Greeted by a flaming pile of rubble blocking our entrance to the community on Day 1, we all suspected then, as we know now, that this block is going to shake us right out of our comfort zones.

 

Driving home after the first day in the community, on an even tarred road, watching the green trimmed lawns and large, well maintained homes flit by, I thought of other roads I had passed just a few hours ago: heavily potholed and stone-littered, marked with the black burn marks of recent protests and flanked by crumbling homes and ramshackle informal dwellings.

 

 Laptop in front of me, sitting in my comfy chair, with the breeze wafting in from the beautiful  garden outside my burglar-guarded windows  as I typed up some work that evening, I thought of another home I had been in that day. Accessible only by the narrow dirt and gravel path sloping downwards towards the battered wooden front door, the home was small, cramped and dark, the only source of light being the natural light streaming in through the holes in the roof and a small unlit candle on the surface.

 

Leaving the community on the first afternoon, and experiencing the sudden transition from the run-down, clearly poverty stricken community to the beautiful, well-fenced suburbs, I felt a huge invisible divide. Those high walls held within them not just wealth , but the promise of opportunities for improvement that many people caught in the poverty cycle would never be able to dream of achieving.

 

According to Statistics South Africa, the country's Gini coefficient (the degree of inequality between its people ranging from a 0 or total equality to 1, or total inequality) currently rests at a concerning 0,65 (Statistics South Africa, 2014).

This means that, in conjunction with, or perhaps running parallel to, the other issues plaguing the country, such as crime, corruption and drought, South Africans still face major wealth inequality. This may exacerbate tension within the country as frustration rises among those who feel short-changed by the system.

 

 

We saw a glimpse of this frustration on our first day, as we carefully drove around flaming barricades made of rocks, cans and tree branches that blocked entrance to the community. The protests had already died down by the time we arrived , but the impact of them was still visible. Taxi's and cars transporting labourers and teachers had not been allowed entrance meaning that the community lost the day's productivity. Schoolchildren milled about outside the school grounds , sent home early as the schools had decided to close for the day. The clinic waiting area was half-empty, as many people had been unable to obtain public transport from their home. And yet, despite the clear ramifications of the protests, when we decided to ask around about the reason for the strike, only one out of the five people we approached was able to explain the grievances.

 

 

It appeared that the protests we had stumbled upon centred around the housing crisis, with community residents upset at the mismanagement of the allocation of the newly built houses within the area. According to the woman we spoke to, people from outside the area were receiving houses, while people from within the area, who had been on the waiting list for years , had not been allocated homes.
The housing crisis is not a new phenomenon in South Africa. In 1994, when the new Government came into power, the urban housing backlog was already standing at 1.5 million housing units, growing at a rate of 178000 units a year (AfricaCheck, 2014). By 2011, the number of informal dwelling in the country sat at 1.9 million, making up 13% of all households in the country(AfricaCheck, 2014). According to the Financial and Fiscal Commission (FFC), it would cost R800 billion to eradicate the housing backlog by 2020 (FFC, 2013).

 

According to the South African constitution,

“Everyone has the right to have access to adequate housing" (AfricaCheck, 2014). In line with this, the Housing Act has been implemented to facilitate a sustainable housing development process.

However, according to research conducted by the Socio-economic Rights Institute of South Africa, although "politicians and officials responsible for housing policy in SA, at all levels of the state, have sought to create the impression that housing allocation is a rational process, which prioritises those in the greatest need, and those who have been waiting for a subsidised house the longest”, “there are a range of highly differentiated, and sometimes contradictory, policies and systems in place to respond to the housing need” (SERI, 2013).  The process of housing allocation lacks transparency, as there is no clearly defined process or waiting list that is followed, and sometimes allows for corrupt practices to occur.

With this sort of mismanagement evident, it is understandable why many community members have lost faith in the government's management, and are resorting to illegal protest action, even though the repercussions of these, whether in terms of the physical destruction of property, or the upheaval it causes within the community, will have a negative fallout for the community.

Within the context of these pertinent community issues, which are only the tip of the iceberg, healthcare provision occurs on an entirely different level.

Our intervention within the community setting functioned at both an individual and collective group level.

 

On the individual level, we got in contact with the community caregivers and began the process of conducting home visits with individuals within the community who required rehabilitation. This aspect forms an integral part of the community approach, as many people cannot access the clinics due to poor infrastructure or lack of mobility devices.

 

The home visits also allowed us to understand, for the first time, the context of many of the clients we work with, in terms of the physical setting, the resources available to them and the barriers to function that are often present. Although we attempted to complete as many home visits as possible, we underestimated the degree of organisation required to maximise the efficiency of our visits. We would often be sitting in the bus waiting for students to complete a home visit, or waiting in the clinic for the bus to return with the students from other disciplines.

Finally, towards the end of the week, we had a lightbulb moment and devised a plan: we mapped out the locations of all our clients and worked out the best routes, and client combinations to allow us to complete as many visits as possible, and allow members of other disciplines to accompany us as well, so that we could work together at the same time, and learn from each other in the process. In my personal capacity, I feel that I need to revisit both my isiZulu notes, as well as some of my physical textbooks, to be properly equipped for my clients, going into the next week.

On a community level, we began work at two local primary schools, beginning the screening process with a new lot of children, while carrying over intervention with the children seen by the previous lot of students. Coming from the Paediatric block, this intervention merged the two blocks together well, but after conducting in-depth 2-hour long assessments on children, completing a 10-minute screen required a bit of adaptation… (at least we provided the speech therapists with some amusement as we ran- and skipped- around with the children like headless chickens...) Out of the 44 children due for assessment, we only completed 10 within the time allocation, prompting us to sit down and brainstorm some techniques to improve our efficiency for the next round of assessments.

 

The other project that we're all particularly excited about is the project aiming to increase the engagement of individuals with disabilities within the community (we're still working on a catchy name...). This week, we met an internationally recognised Boccia player with muscular dystrophy, who is keen to start his own Boccia sports group. Having built some links with with the community Youth Centre over the past week, we hope to start our project by getting dialogue going between the relevant stakeholders, and providing the necessary support to allow this talented individual to realise his dream and spark a dream in others as well.

Over the past week, I have had the opportunity to walk into the lives of people I would likely never have interacted with otherwise. I have met healthcare workers of various disciplines, and experienced the beauty of inter-disciplinary teamwork ( we hope to soon make that 'trans-disciplinary' as we figure out how to work better together and role-release more effectively...) and how we each have a vital part to contribute to the wellbeing of an individual.

I know that as I progress on this block, I will see my perceptions of the community evolve as I realise that I have brought my own preconceived ideas & stereotypes into the block , and as I begin to understand the cultural dynamic better from my vantage point as a healthcare provider. I know that I will later read over some things I have written, or some ideas I have  formulated and pick up some superficiality in my thinking or some flawed ideas.  I look forward to experiencing a positive shift in my thinking as I grow as a person and as a therapist, all part of the learning curve of the Community block.

 

 

You made it to the end:) Here's some South African funnies for you:

 

 

 

 

 

 

Statistics South Africa (2014, April, 3). Poverty Trends in South Africa. Retrieved from

http://www.statssa.gov.za/?p=2591

 

AfricaCheck (2014). FACTSHEET: The housing situation in South Africa. Retrieved from https://africacheck.org/factsheets/factsheet-the-housing-situation-in-south-africa/

 

Financial and Fiscal Commission (2013). Exploring Alternative Finance and Policy Options for Effective and Sustainable Delivery of Housing in South Africa. Retrieved from http://www.ffc.co.za/images/Front_page_news_items/Exploring_Alternative_finance_and_Policy_Options_for_Effective_and_Sustainable_Deliver_of_housing.pdf

 

Socio-Economic Institute of South Africa (2013).

‘Jumping the Queue’,Waiting Lists and other Myths:Perceptions and Practice around Housing Demand and Allocation in South Africa. Retrieved from http://www.seri-sa.org/images/Jumping_the_Queue_MainReport_Jul13.pdf