Inclusive Health

Theresa Lorenzo, Shireen Damonse, Madie Duncan, Sumaya Gabriels, Judith Mahlangu, Nafisa Mayat and Fatima Peters.

In South Africa, the national policy on re-engineering primary health care supports the implementation of nurse-led, ward-based outreach teams with community health workers. The Western Cape Department of Health uses community-orientated primary care (COPC) as an implementation framework for the improvement of primary level district health services.  Ward-based outreach teams of rehabilitation care workers (RCWs) led by rehabilitation therapists were implemented in two peri-urban health districts to introduce rehabilitation in COPC.

Cognisant of the need to promote rehabilitation in primary care, the WCDoH initiated a partnership with the Division of Disability Studies at the University of Cape Town (UCT) in 2012 to develop a mid-level rehabilitation worker training programme for the province. A one-year Higher Certificate in Disability Practice (HCDP) was designed by a team of rehabilitation therapists and disabled persons, which was registered with the South African Qualification Authority (SAQA) at Level 5 of the National Qualification Framework⁸. HCDP alumni are called ‘rehabilitation care workers’ (RCWs) to distinguish them from community rehabilitation workers (CRWs) who have a two-year diploma in community based rehabilitation (CBR). The RCWs would bridge the gap in meeting the health and disability needs of communities within the primary level of the PHC system.  

Research process

A collaborative inquiry was implemented with members of the primary level rehabilitation teams in the two subdistricts of the Cape Town metropole and one rural district to explore the contribution of these rehabilitation teams to COPC. Qualitative descriptive data were collected during three narrative action reflection workshops. Data were deductively coded and categorized using the principles and 10 elements of COPC.

Findings:

Eight categories emerged from the triangulation of data that reflect the perspectives of rehabilitation team in the metropole on the COPC

• We map the community with disability in mind
• We extend the reach of rehabilitation by task sharing/shifting
• Our rehabilitation programmes are comprehensive
• We facilitate equitable services for persons with disability
• We provide holistic-minded care to persons with disability and their households
• Our rehabilitation statistics at primary level are almost zero
• Our work aligns with the CBR matrix
• We have primary care lessons to share

Findings from the rehabilitation team providing services in rural farming communities revealed that a different set of rehabilitation competencies are applicable compared to those competencies needed in better-resourced urban settings.

• Rural rehabilitation services are sparsely spread between tertiary and secondary level facilities and primary level clinics where limited space and resources make continuity of care difficult. 
• Therapists’ work focuses on the impairment(s) of individual clients as there is only one therapist per profession covering a heavy caseload across a large rural sub-district.  Through bidirectional task-sharing and task-shifting of basic rehabilitation competencies, the rehabilitation team can advance disability inclusive community development in rural areas.
• There are no community-based interventions in rural areas for persons with disabilities such as home visits, support groups or wellness hubs.
• Community health workers in rural areas are not trained in disability or CBR. Upskilling community health workers with competences in community-based inclusive development can address the rehabilitation service gaps faced by persons with disabilities and their families.
• Ward-based teams led by rehabilitation professional supervising RCWs will strengthen the rural health system at primary level as health outcomes of rural populations with disability will be improved through intersectoral collaboration.

The inclusion of rehabilitation in COPC will require health system planners to apply broader conceptual frameworks inclusive of disability and support capacitation of a mid-level rehabilitation workforce.

Project 1: Student Mental Health and Wellbeing

This project explores promoting mental health and wellbeing in the context of higher education.

Studies include:

Leigh Ann Richards: Navigating participation in university life: experiences of marginalised students in South Africa accessing student support.

Roshan Galvaan, Fadia Gamieldien and Sharon Kleintjes , Anthea Hansen, Clement Nhunzvi, Jacomijn Hofstra, Lies Korevaar: A scoping review of the Conceptual frameworks and practice approaches to Supported Education programmes in higher education institutions

Roshan Galvaan, Fadia Gamieldien and Sharon Kleintjes: A whole university approach to student mental health and wellbeing

Meghan Krenzer and Roshan Galvaan: Promoting Belonging in Higher Education through occupation-based community development implementation practices in a university setting

Project 2: Promoting healthy futures through belonging and voice in South Africa

This project aims to enable youth to take action and create systems that promote active inclusion, participation and belonging in local institutions and communities. This occurs through action-research and implementation practices in local schools, with local community stakeholders and health systems as part of the MasterCard Foundation funded Healthy Futures South Africa project. Collaborators include colleagues from multiple disciplines, and we work across community, health and basic education contexts.

Collaborators: Roshan Galvaan; Kristen Abrahams; Pam Gretschel; Shamila Manie; Nafisa Mayat; Sumaya Gabriels; Tania de Villers; Fadia Gamieldien; Buhle Maseko-Arthur

Buhle Maseko-Arthur; Liesl Peters and Roshan Galvaan: Exploring belonging in South African High Schools

Project 3: Strengthening social transformation and transdisciplinarity in Human Services

Sidney Muchemwa; Roshan Galvaan; Fadia Gamieldien: a qualitative inquiry on the experiences of the triple planetary crises amongst adults with common mental health conditions in Zimbabwe

Fadia Gamieldien Katherine Sorsdahl; Roshan Galvaan; Bronwyn Myers: An exploration of recovery among persons with severe mental health conditions in South Africa

Project 4: Transformation through Higher Education Curricula

Sumaya Gabriels and Leigh Ann Naidoo: Exploring the role of a Higher Certificate (NQF level 5) in developing personal and professional capabilities: The case of the Higher Certificate in Disability Practices

Tess Padayachee PhD Disability Studies Completed 2024; Postdoctoral Fellowship, Inclusive Practices Africa Research unit (2025)

Project: Strengthening Health Systems

A case study of factors influencing primary healthcare “Continuity of Care” for Persons with Disabilities

Background: “Continuity of Care” refers to how a patient experiences care over time and is considered to be a central pillar in the delivery of high-quality person-centred healthcare. In South Africa (SA), Persons with Disabilities experience a range of structural barriers to health services and even when access to health services is realised, poorly integrated health systems and services, limited human resources and poor awareness of the needs of Persons with Disabilities results in unmet healthcare needs. Given the rapidly transforming healthcare context of SA and the adoption of progressive policies towards the realisation of universal health coverage, an understanding of how the health system is responding to the “Continuity of Care” needs of Persons with Disabilities through policy and practice is valuable step towards realising the goal of integrated person-centered health systems; particularly in the delivery of primary healthcare (PHC)(World Health Organization, 2018a).

Objectives: The study asks the question of how “Continuity of Care” for Persons with Disabilities can be strengthened within the PHC context in South Africa. Therefore, the aim of the study was to investigate the experiences and expectations of Persons with Disabilities regarding “Continuity of Care”; establish how health system actors understood “Continuity of Care” and responded to the expectations of Persons with Disabilities and finally assess the potential influence of PHC policies on “Continuity of Care” for Persons with Disabilities.

Study Design and methods: This exploratory case study used a critical social theory (Weaver & Olson, 2006) and a health policy and systems approach (Gilson, 2012) to better understand how primary healthcare “Continuity of Care” for Persons with Disabilities can be strengthened. The Conceptual Framework for Health Systems Responsiveness (Mirzoev & Kane, 2017) informed the case study design by exploring how Persons with Disabilities experienced “Continuity of Care” and supported a deeper understanding of health systems gaps through perspectives of service providers in responding to the “Continuity of Care” needs of Persons with Disabilities. The study was conducted within the context of the SA primary healthcare policy and implementation in an urban suburb in the city of Durban, KwaZulu Natal in South Africa. The study included multiple data collection methods including interviews, focus group discussions, document reviews and analysis of relevant policies using an adapted EquiFrame (Amin, 2011). Qualitative data was analysed thematically using inductive and deductive analysis.

Results: Participants with disabilities were found to experience high levels of primary healthcare discontinuity resulting from known factors such as lack of reliable and accessible transport, negative attitudes of health facility staff and sub-optimal management of clinic and outreach services. New insights that were found to negatively affect “Continuity of Care” for Persons with Disabilities included the combined influences of institutional distrust; the medical model as a legacy of apartheid; incoherence in policies supporting “Continuity of care” and poor user-centred design practices in the delivery of new innovations that were unresponsive to the needs of persons with disabilities. Positive influences on “Continuity of Care” included emergent community leadership, family resilience to navigate through treatment uncertainty and supportive servant leadership styles of healthcare providers. Results of the study point to the need for an expanded understanding of “Continuity of Care” within an African paradigm where care continuity extends beyond the health facility and with a stronger emphasis on community driven models of care that respect the role and influence of traditional health practitioners and cultural practices. xviii

More research is needed to better understand institutional distrust and how traditional western models of healthcare can be re-shaped to deliver services 

Prof Mershen Pillay

Swallowing Disabilities & Food Sovereignty: Inclusive Practices Africa Collaboration

Dysphagia affects approximately 8% of the global population (Byeon, 2022), with community prevalence ranging between 2% to 20% depending on the population studied (Adkins et al., 2020), and Africa showing particularly high prevalence rates of up to 64.2% (Kazeminia et al., 2022). Food sovereignty—the right of communities to define their own food systems and access culturally appropriate, nutritious food—becomes critically important for people with swallowing disabilities who require modified textures and specialised feeding approaches. In urban settings, individuals with dysphagia often depend on expensive commercial thickeners and processed foods, while rural communities may lack access to healthcare services but possess traditional food preparation knowledge that could be adapted for safe swallowing. A collaboration with Inclusive Practices Africa would establish community-based programmes that strengthen food sovereignty by training local food producers and healthcare workers in dysphagia-friendly preparation methods, developing region-specific screening tools, and creating sustainable food production systems that serve both urban and rural populations. This partnership would implement a framework referred to as THRIVE - Tackling Hunger with Research and Innovation in Vulnerable Environments. THRIVE focuses on food production, preparation, texture modification, and risk management—while advocating for policies that recognise people with swallowing disabilities and their food sovereignty to ensure that all people can participate meaningfully in their community's food systems regardless of their swallowing abilities.

References

Adkins, C., Takakura, W., Spiegel, B. M. R., Lu, M., Vera-Llonch, M., Williams, J., & Almario, C. V. (2020). Prevalence and characteristics of dysphagia based on a population-based survey. *Clinical Gastroenterology and Hepatology*, 18(9), 1970–1979.e2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7180111/

Byeon, H. (2022). Research progress in the risk factors and screening assessment of dysphagia in the elderly. *Frontiers in Medicine*, 9, 1021763. https://www.frontiersin.org/articles/10.3389/fmed.2022.1021763

Kazeminia, M., Salari, N., Vaisi-Raygani, A., Jalali, R., Abdi, A., Mohammadi, M., Daneshkhah, A., Hosseinian-Far, M., & Shohaimi, S. (2022). The global prevalence of oropharyngeal dysphagia in different populations: A systematic review and meta-analysis. *Journal of Translational Medicine*, 20(1), 175. https://translational-medicine.biomedcentral.com/articles/10.1186/s12967-022-03380-0

Pillay, M., & Kathard, H. (2018). Renewing our cultural borderlands: Equitable Population Innovations for Communication (EPIC). *Topics in Language Disorders*, 38(2), 151–168.