Persons with disabilities

Persons with disabilities were included in this study to establish the suitability of the indicators especially as it was noted that patient and doctors expectations of the doctor’s role in rehabilitation may differ. The outcome of the MBChB rehabilitation training programme is to equip graduates with the knowledge, skills and attitudes to manage persons with disabilities in the primary health care context of SA. As the MBChB programme is delivered primarily in the WC the relevant population for this study was thus persons with disabilities who have been managed by the primary health care system of the WC.

The 2001 population census defined disability as a lack of “full participation in life activities” which is in line with the ICF, and reported a prevalence of 4,1% (186 850 disabled persons) in the WC with a national prevalence of 5%. All of these individuals could have been managed by the public and/or private health sector and were considered members of this population. No recent statistics could be sourced and the results of the 2011 census results will only be published in 2013 (StatsSA website accessed 28/01/2012).

4.3.9.2 Study sample group

The inclusion criteria for this sample was that participants must  have lived with their disability for more than a year

 have received medical treatment at a primary health care facility (public or private) in the WC following their disabling event.

As the definition of disability is complex, patients with health conditions or impairments commonly associated with disabilities as described in the literature such as such as stroke, head injury, amputation, spinal cord affliction, cerebral palsy, psychiatric, intellectual or visual impairment were included in this sample. Participants included adults and children of any age. As these participants had to complete a researcher administrated questionnaire,

the patients were required to speak English or Afrikaans. Xhosa speaking participants would be accommodated as the researcher had access to an interpreter, however other languages of SA were excluded. Illiterate or patients with communication or cognitive problems, or children too young to communicate meaningfully with the researcher were also not excluded, although in this case the carer was interviewed and would reflect the opinions of the patient from the carer’s perspective.

The purpose of including this sample was not to evaluate the programme but to review the suitability of the indicators. As this was an initial exploratory process, considering the paucity of the literature, two facilities that would provide the relevant sample participants were considered. The first was CSI, which is a protected workshop in the WC for persons with any disability. At the time of identifying a sample they had 156 such persons in their employ. The manager of the facility was contacted telephonically and confirmed by e-mail, for permission to involve the CSI workers in this study and for CSI to identify a range of health conditions according to the inclusion criteria. The names of ten patients were provided. Although this list included additional health conditions, the original list was not fully covered.

The second facility considered was the WCRC which holds out patient clinics, each day being for different groups of health conditions or problems (general neurology, spinal cord afflictions, amputations, seating, DG assessment and a general clinic for persons with disabilities). Patients other than first time attendees would have been referred to community facilities after their initial visit or admission. The Head of the WCRC was contacted personally for permission and the researcher identified a further eight patients from the various outpatient clinics according to the inclusion criteria. To expand on these views four persons with disabilities involved in advocacy roles e.g. involved with QASA and the WCRC Facility Board were further selected. This sample of convenience thus included 22 sample participants.

All the required health conditions and impairments were covered in this sample as detailed in appendix 16d. An additional three health conditions or impairments were offered (hearing impairment, musculoskeletal conditions and epilepsy) by participants. All participants had been managed at a public or private community facility. The mean age of the participants was 36 (range 13-57) years and the mean number of years living with a

disability 19 (range 1-55) years. The interpreter’s service was not used. One child was included and the carer provided the information required.

Five patients did not consider themselves to be disabled for the following reasons: one considered disability to be of a physical nature, another considered acquired impairments to be a disability. Three coped well with their situation so did not feel disabled and one was hoping to recover so would prefer not be classified disabled at this point in time. Two patients had previously been involved with the US MBChB programme as case subjects, but did not consider themselves to be disability experts. Nine other participants in this sample considered themselves as experts in disability and rehabilitation.

4.4 Research methods and instruments

The WFME global standards for basic medical education were used as a framework for this study. Of the many articles describing the process to develop the standards, no reference was made to pre-existing tools. In studies using the standards to evaluate their curricula, no tools were included (Khattab, Badrawi, Sheba, et al, 2004). Interviews and questionnaires were used to obtain quantitative and qualitative data from sample participants using a mixed research method. A sequential exploratory strategy was used in the initial stages of the study to develop the indicators and questionnaires. A sequential explanatory strategy was used to clarify certain indicators after the analysis of the data from the questionnaires (Kroll, Neri & Miller, 2005).

Four questionnaires were designed to obtain quantitative data from direct stakeholder groups to provide a measure of compliance of the programme as well as recommendations for improvement to the programme. Five questionnaires were also designed to obtain quantitative data from indirect stakeholder groups to verify the indicators developed for this study. The instruments also contained questions to explore associated questions raised in the literature review. Quantitative and qualitative data obtained from the questionnaires was collected and analysed simultaneously in a concurrent design. This mixed method of research, as described by Kroll, Neri and Miller (2005) is well suited for evaluation studies where the qualitative component may provide answers to “why things work or not” and the quantitative component may measure to “what extent the programme is successful”. The author’s further comment that this mixed method encourages active consumer participation which is encouraged by the WFME standards.

Although the methods and instruments chosen were convenient in terms of cost and time, the disadvantages were considered during development and administration of the tools. This included possible poor response rates, poor quality of information gained against closed questions, the respondents’ incentive to participate, honesty and recall the respondents’ interpretation of the question and the researcher’s interpretation of the response.

4.4.1 Development of research methods and instruments

The application of these two methods to the nine population samples (with two student sample groups) resulted in the development of two interview schedules and nine questionnaires as tabled below.

Table 4.4: Summary of the methods to be applied to the various study samples and instruments to be used

Study samples Methods Instrument: see

Appendix no:

1 Management of US, FHS In depth interview with Head

CCE 7a

2 Chairpersons of clinical modules Questionnaire ₈

3 CRS management Questionnaire

Interview with Head CRS

9 7b 4 Rehabilitation programme lecturers, site co-

ordinators, facilitators and assessors

Questionnaire

10

5a Student sample group 1 (Third year students) Questionnaire _11a

5b Student sample group 7 (Sixth year students) Questionnaire _11b

6 General practitioners Questionnaire ₁₂

7 Rehabilitation doctors Questionnaire

13 8 Inter or multidisciplinary team members working

with persons with disabilities in the community

Questionnaire

14

9 Persons with disabilities Questionnaire ₁₅

The indicators were applicable to any rehabilitation programme and so worded. The instruments, however, although based on the indicators, were worded specifically for this study to evaluate the Rehabilitation programme of the MBChB curriculum of the US.

4.4.1.1 Interviews

From the outset an in depth, one-on-one interview was planned with the Head of the CCE. An interviewing schedule was prepared for the meeting (Appendix 7a). The interview provided information which assisted in the development of the questionnaires as well as data against selected indicators where the information was not otherwise available.

An in-depth one-on-one interview was conducted with the head of the CRS according to the interviewing schedule in appendix 7b. The focus was on aspects over which she has sole control in the light of the quantitative results obtained from the questionnaires. Although time consuming, these interviews were essential where data could not be obtained form other sample groups.

In addition participants completing questionnaires were requested to volunteer contact details should the researcher identify the need to clarify answers or selectively conduct interviews with them. At the time of data analysis the module chairs and two members of sample 4 were further contacted to clarify their roles as lecturers, site-coordinators, facilitators and assessors. No interviews were required.

For completeness sake it must be mentioned that the researcher has had conversations with various people in order to formulate a framework for this study as referred to in this narrative. Of particular note was a more formal interview with Professor P Van Niekerk who represented SA representative on the WFMEs team for development of the Global Standards for basic medical education, who gave guidance in using these standards in evaluating a programme rather than a curriculum for which the standards were intended. This interview was conducted during the literature review and he was not deemed a study participant.

4.4.1.2 Questionnaires

As this research intended to gain the input from a wide variety of populations and because there were a large number of indicators, questionnaires were primarily used. This methodology was considered appropriate for this study as the problem as discussed in Chapter 1 had already been identified and where the indicators and methods needed to be verified. Methods such as focus group discussions or a larger number of in-depth interviews were considered inappropriate as the problems had already been largely identified These qualitative methods would be suitable in the future for further exploration

of specific problem areas identified (Social Research Methods website accessed 18/04/2011).

The questionnaires were divided into two parts. Part A established the pre-existing knowledge of and involvement of the respondent with the US MBChB Rehabilitation programme, knowledge of undergraduate MBChB rehabilitation training at other universities in SA, educational back ground, clinical and rehabilitation experience, and personal experience of disability to establish credibility and representivity of the sample as well as to confirm that respondents fell within the inclusion criteria for each sample.

Each question in Section B of the questionnaire was developed for each sample group in line with the indicators. Not all indicators were relevant to all stakeholders but each indicator was evaluated by obtaining information from as many sources as possible in order to reduce bias. The numbering of the indicators was used as cross reference in each of the questionnaires. In this way all information pertaining to a particular indicator as gained from various sources could be collectively analysed. These questionnaires are contained in appendices 8-15 as listed in table 4.4 above. The samples invited to respond to each indicator are also tabled in appendix 6b.

Questions against a particular indicator were worded differently for direct and indirect samples so as to establish compliance with the indicator or validate the indicator. For example lists of educational methods, health conditions, bio psychosocial problems, assessment methods, etc as established from the literature and the researcher’s experience were used in the indicators for this study. Table 4.5 below shows how questions were individually worded and numbered a, b, c, d, etc to extract different information from different samples to provide information against a single indicator.

Table 4.5: Example of relationship of indicators to questions posed for different samples Number of indicator Indicator Number of question

Question Sample Comment

2.22 Students are made aware with the health conditions frequently causing disability in their local health context

2.22a Medical students are

made aware of the

following health

conditions which cause disability in SA during the MBChB rehabilitation programme. Module Chairs CRS management, Lecturers, facilitators, site co-ordinators and assessors

Student group 7

A list of conditions is provided and respondents should mark all relevant option.

An “other”

category is also provided

2.22b Are there any additional health conditions that should be covered by the rehabilitation programme Module Chairs CRS management, Lecturers, facilitators, site co-ordinators and assessors

Student group 7

Open question in addition to the listed options

2.22c List the heath conditions which you consider to cause disability in SA and which should be taught in a disability and rehabilitation

programme

Student group 1 Open question

only

2.22d Which of the listed heath conditions that cause disability have you dealt with in the last six months in your practice

GPs A list of conditions

is provided and respondents should mark all relevant options. Closed question

Which of the listed heath conditions that cause disability have you seen in your community

Persons with disabilities A list of conditions is provided and respondents should mark all relevant options. Closed question

2.22e What other health conditions that cause disability have you dealt with in your practice in the last six months

GPs Open question in

addition to the listed options

Are there any additional heath conditions that you have seen

Persons with disabilities Open question in addition to the listed options 2.22f Which of the listed heath

conditions should be taught to medical students in a disability and rehabilitation programme Rehabilitation doctors Interdisciplinary team members A list of conditions is provided and respondents should mark all relevant options. Closed question

2.22g What other health

conditions should be taught to medical students in a disability and rehabilitation training programme Rehabilitation Doctors Interdisciplinary team members Open question in addition to the listed options

The direct samples informed the study of what the students have received as well as other conditions they feel the students should be exposed to. The third year students from the perspective of not having had any rehabilitation training had free range to initiate a list of conditions. 2.22d and 2.22e had two differently worded questions for GPs and persons with disabilities respectively but were both establishing the health conditions present in the community and were thus grouped together. The rehabilitation doctors and professional team members provided opinion from a specialist point of view what students should be taught rather than enquiring as to what heath conditions they have seen as they form a specialised referral base (Friedlingsdorf & Dunn, 2007).

Closed (ordinal and categorical type responses) and open ended questions were used in both sections A and B. For questions requiring ordinal responses, a four point Likert scale as suggested by the statistician forced respondents to commit to either an ‘agree’ or ‘not agree’ response rather than marking a ‘neither agree or disagree’ option as offered in a three, five or seven, etc Likert scale. It was noted that this principle was never raised or exercised by other researchers in the literature reviewed for this study. The option of ‘not applicable’ should the respondent not have enough information to answer the question

was provided for these questions having ordinal responses. It was expected and confirmed that this was required for the theory block lecturers or theory module chair who may not have had sufficient knowledge to answer questions relating to the clinical modules.

For questions requiring categorical responses the questions clearly indicated if only one or more than one response was allowed. These types of questions were followed by an open question allowing the respondent to suggest additional options as in table 4.5 above. In this way the appropriateness and comprehensiveness of the indicators was established.

Sample 5 (group 1) was the only sample not to be provided with lists and were required to generate their own lists for health conditions and bio psychosocial problems and to initiate a list of the most and least useful educational, assessment methods and resources. Sample 5 (group 7) was asked, in additional to the established lists to add suggestions to expand the lists, and to initiate which educational methods and resources they found the most and least useful.

Samples 6, 7 and 8 asked respondents what undergraduate medical students need to learn about the medical management of persons with disabilities, what they need to learn from other disciplines and what they need to learn about community resources. Lists were not requested and space was provided for open narrative.

To complement this data three open ended questions were asked. The first was to provide any further personal information at the end of section A, should the respondent feel this was relevant. Section B asked directly involved participants for any further comment on the delivery of the programme under review and a further question for direct and indirect participants on any further comment on the administrative aspects of a rehabilitation programme. The former was intended to gain criticism of the programme or for suggestions for improvement to the programme. The latter was to expand on the indicators.

In order to avoid ambiguity, questions were predominantly worded positively and contained only one concept. This also made analysis of data straightforward. Questions were however specifically posed at intervals to avoid response set (Social Research Methods website accessed 18/04/2011). Another method used was to include two similar questions posed from apposing viewpoints but not necessarily mutually exclusive to increase

reliability of answers. Following the advice from this author, questions were not personal, the literacy level, especially when it comes to medical and educational terminology, was taken into account, and that the ordering of questions was considered.

4.4.2 Peer review of research methods and instruments

The interviewing schedules and sets of questionnaires were reviewed by selected individuals as listed in the table below. Contamination was avoided by involving persons who were not included in the study samples.

Table 4.6: Table of individuals who reviewed the questionnaires

Tool Selected individual

Interview schedule for Head CCE Head CRS

Interview schedule for Head CRS Current Rehabilitation Programme Co-ordinator

Questionnaires for Module Chairpersons, CRS Managers, CRS lecturers and facilitators

Previous Rehabilitation Programme Co-ordinator

Questionnaires for Third year students Second year SU student

Questionnaires for Sixth year students Students having completed the sixth year in the year preceding the study

Questionnaires for Primary Health care practitioners,

Head of Family Medicine, SU

Questionnaires for Rehabilitation Doctors Medical officer with one year’s experience working at the WCRC

Questionnaires for Team members Clinicians working at WCRC

Questionnaires for Persons with disabilities

Person with disability working at WCRC

These individuals were asked to comment on the content and relevance to the evaluation of a rehabilitation programme, on aspects effecting reliability such as layout and language use, as well as feasibility including the length of the instrument, time taken to complete it and practical application as suggested by Malterud (1995) and Kroll, Neri and Miller (2005). During this process the practicalities of administrating the questionnaires via e-mail

In document To evaluate and make recommendations for improvement to the MBChB Rehabilitation Programme of the University of Stellenbosch (Page 154-200)