There were 9 disabled persons and 24 persons of caregiver team. Health education and practice program about disability person rehabilitation (4 activities: ...
COMMUNITY BASE REHABILITATION FOR MOBILITY AND PHYSICAL DISABILITY AT MOO 7 THA KHAO PLEUK SUB-DISTRICT, MAE CHAN DISTRICT, CHIANG RAI PROVINCE, THAILAND. Wachirawit Parunawin¹, Phitnaree Thutsanti¹, Sawetachai Punkeaw2,Kanda Sritrakul2 , Pilasinee Wongnuch1, Niwed Kullawong1, Rachanee Sunsern1 and Phitsanuruk Kanthawee1 ¹Public Health Major, School of Health Science, Mae Fah Luang University Chiang Rai, Thailand ²Thakhaopleuk Health Promoting Hospital, Thakhaopleuk sub-district, Mae Chan district, Chiang Rai Province, Thailand ___________________________________________________________________________ Abstract Background: Disabled people are who living with disabilities in either physical or mental impairment. Disabilities were not affected only themselves but also their family and community. There are 23 disable persons living in the community of Moo 7 TKP village, Mae Chan district, Chiang Rai province. Lacking of trained caregiver and community system, their health status were not concerned and improved. Objectives: This project aimed to establish community base rehabilitation system by community care team for the disabled people. The system was based on participation of people in the community and family caregiver to promote their better quality of life of either the disability people or their family members. Method: The action research by community participation was conducted in the Moo 7 Tha Khao Pleuk village. There were 9 disabled persons and 24 persons of caregiver team. Health education and practice program about disability person rehabilitation (4 activities: setting up the caregiver team; evaluation; intervention; rehabilitation) were performed. Four questionnaires was used as tools to assess the basic needs of people with disabilities, Activities of Daily Living (ADL), quality of life (QOL) and knowledge of self-care and disabled personal care. The descriptive statistic was employed to analyze characteristics of participant and paired t-test to compare the difference of the basic needs, ADL, QOL and the knowledge of both disabled people and caregiver team. Result: The caregiver team for disabled persons in the community of Moo 7 Tha Khao Pleuk village was established. Most of disable persons all complained about taking care from other people. After the intervention program, we found that QOL score of people with disabilities was significantly increased from 83.7 (moderate qualities of life) to 107.4 scores (good quality of life) (P=0.002) while caregivers are not significantly decreased (P=0.303). The means score of knowledge of caregiver for taking care of people with disabilities were also increased from 12.8 to 14.4 (P=0.008). However, mean ADL score of disable persons was not difference. Conclusion: This project could enhance the quality of life of people with disabilities and improve the knowledge of caregiver team. __________________________________________________________________________ Keywords: Disability, Mobility and Physical disability, Community Base Rehabilitation (CBR)
83
Rationale and Background Disabled people are who living with disabilities in either physical or mental impairment. It can be classified into 6 types for impairments including impairment of Vision, Hearing, Mobility and Physical, Psychiatric, Cognitive or learning and Autistic (1) and disabilities might cause by accident, genetic, birth defect, chronic disease and unknown of etiology. Disabilities were not affected only themselves but including their family and community. The trends of disabilities were increasing according to increasing of ageing and chronic disease. According to the survey of World health Organization (WHO) since 2011, found that there were 785 million (15.6%) persons who age 15 years and older live with disabilities. In the same year Global Burden of Disease estimate was estimate that 190 million (3.8%) have severe disabilities (2). In 2015, the World Health organization was reported that there 1 billion people living with disabilities or one in seven and half of them cannot accesses to health care services even they have the same general health care need as others (3). Furthermore found that most of disabilities are live in Asia and Pacific countries (4). In Thailand the situation of disabilities were also tend to increasing. In 2010 there were 122,615 (0.19%) persons live with disabilities and increased to 153,472 (0.24%) in 2013 and in 2015, there were 1,642,448 persons confronted with disabilities in Thailand, mean that that 2.5 % of Thai population were experienced with disability. When separated by gender found that 883,342 (53.78%) were male and 759,106 (46.22%) are female and most of them were people age above 60 years old which is elder about 51.12% and people age between 15-60 years old which is work force period about 46.08%. In addiction from the report of the situation of people with disabilities in Thailand 2015, found that there were 801,604 (48.81%) persons are suffer with mobility and physical impairment, second with hearing about 282,144 (17.18%) and third with vision about 178,559 (10.87%) respectively. and found that 30.14% of disabilities are caused by chronic disease such as Hypertension, Diabetes, Epilepsy, and, etc. 30.99% with unspecified causes of disabilities. Moreover found that most of disabilities in Thailand were people that And most of them were live in the Eastern north of Thailand about 650,626 (39.61%) persons and follow by Northern about 389,898 (23.74%) persons. The Ministry of Social Development and Human Security (MSDHS) was reported the situation of disabilities persons who was registered since 1994 to September 30, 2015, found that there were 36,174 (2.20%) persons of people with disabilities living in Chiang Rai. There are 19,675 (54.38%) of male and 16,499 (45.62%) of female. And most of them were mobility and physical impairment about 16,161(44.67%) persons, second with hearing impairment about 9,601 (26.54%) persons and third with vision impairment about 2,973 (8.21%) persons . From the information of Tha Kao Pluek (TKP) sub-district health promoting hospital, in 2015 reported that the totals of disabilities that’s registered and have the disabilities identity card were about 100 persons in TKP sub-district. About 23(23%) of people with disabilities are live in Moo 7 Tha Kao Pluek village and 13(56.52%) persons of them were mobility or physical disabilities. Disabilities people have many barriers than non- disabled such as inadequate policies and standard, negative attitude from teacher, others friends and even family member, in adequate of funding support from government, and problem with health care services. Theses barrier might affect to people with disabilities such as the health outcome; people with disabilities might have risky behavior such as smoking, poor diet, and physical inactivity. In addiction they also higher risk to expose to the violence and moreover unmet need of the rehabilitation service or assistive devices can result in poor outcomes including activity limitation and 84
reduce quality of life. Because of people with disability may need to have assistive devise for doing their activity, or medical care that may cause extra cost, thus why people with disabilities and their household are likely to have problem with poverty.(5,6) People with disabilities are dependency may need help from others; most of support and help of them are come from their family member which sometime might cause stress, isolation and lost socioeconomic opportunity. From the world report on disability was recommended to use Community Based Rehabilitation (CBR) to addressing barriers to health care and rehabilitation. Because it has been successful to setting facilitating access for people with disabilities to exiting services and in screening and promoting preventive health care services even less of resources. Therefore, conduct this project is aim to create community base rehabilitation system by community care team for disabled people in Moo7 TKP village, Mae Chan district, Chiang Rai province by base on the participation of people in the community and family caregiver to promote better quality of life of either disability people and their family member for living in social as general people. Literature Review Community Based Rehabilitation (CBR) is “strategy within general community development for the rehabilitation, poverty reduction, equalization of opportunities and social inclusion of all people with disabilities”. (7) CBR was initialed after the international conference on primary health care since 1978 following the declaration of Alma-Ata. CBR are strategy which aim to promote rehabilitation services for people with disabilities, equalization of opportunities and coordination of disabled person, their household and community by use the local resources as optimal. From the study of Sunsern, R. was stated 4 principle for CBR as, CBR is active strategy which can access people with disabilities in community by themselves, their family and participation of community and it was emphasizes on the development of community by the collaboration of each sector in community about rehabilitation for disabled by use local resources. The implementation should be based on community need, focus on finding and improve capability of people with disabilities, empower them to live in community with freedom in each dimension of community, moreover it should be conduct by finding and use local resources as mainly. CBR also have assumption including the participation of disabled persons at the beginning, second the objective of CBR should aim to improve qualities of life of people with disabilities for independent living. Third should working with community to promote positive attitude for people with disabilities and to motivate people in community for support and coordinate in the program, lastly it should flexible, suitable for characteristic of community. And key success factor of CBR include the awareness of problem with disabilities and coordination of household of people with disabilities and communities, second factor were using of local resources for development and rehabilitation for people with disabilities and following by improve skill and knowledge for either people with disabilities or caregiver to empower them to better manage their health because it can improve health out come and reduce health care cost. And finally, participation of people with disabilities and their 85
household with implementation in all process since start, can lead to sustainable development. (8) The implementation of CBR include 4 steps, there were start with situation analysis; which involve collecting the real situation in the community and figure it out, for example knowing the total number of people with disabilities and type of disabilities, include age, gender, educational level and health condition, etc. know stakeholder; such as disabled person, household with disabilities person, government sector or non-government sector, know problem and setting objective; to finding out the real problem of disabilities person, for example problem of rehabilitation accessible of people with disabilities, or environment and transportation problem, etc. Finding out local resources for understanding context of either people with disabilities, families and communities in order to plan and design the CBR project, or progrmme. Following by planning and design by set priority of problem, generate goal and objective include indicator, and then set up implementation plan. Come up with programme implementation and monitoring, and last with evaluation of programme or project. Objectives 1. To set up Thakhaopleuk Caregiver Team for disabled persons. 2. To enhance knowledge and skill for taking care disabled persons for caregiver. 3. To improve the quality of life of disabled persons and caregiver team. 4. To encourage Community Base Rehabilitation for type 3 mobility and physical disability in Moo 7 Ban Thakhaopleuk ,Thakhaopleuk sub-district, Chiang Rai province.
86
Conceptual Framework: Innovative Care for Chronic Conditions (ICCC)
Figure 1: Show Innovative Care for Chronic Conditions framework This research used Innovative Care for Chronic Conditions and focus on Triangle base about patients and families, community partners, and health care team. It is framework for health care systems to improve care for chronic conditions. The ICCC Framework is comprised of fundamental components within the patient, health care organization and community, and policy levels. These components are described as “building Caregiver team” that can be used to create or re-design health care systems to more effectively manage long term health problems. Research Methodology Study design This study is Action Research (AR) which aim to resolve problem, develop activity by adjust and change by stakeholder or problem owner.This is a research process that resembles a spiral of thinking consider and actions called Interacting spiral (Stringer,2007) consists of 3 phases that Look, Think and Act. As shown Figure 2.
87
Figure 2: Show interacting spiral between Look, Think, and Act.
Source: Stringer, E.T.Sction Research, p.19, permission of Sage Publications.
1999 by Sage Publications Reprinted by
Target population In Moo 7 Takhaopleuk sub district, Number of registered disabled people totaled 23 persons. (Thakhaopluek Health Promoting Hospital) which can be classified as disabled found that Types 2 hearing disability 3 persons, Types 3 Mobility and Physical impairment 14 persons, Types 5 Cognitive and Learning 3 persons. And in this project was selected only mobility and physical impairment include 14 persons And target population of this project is 50 persons that composed of stakeholders from all sectors in the study area and experts about caring for disabled. Researchers selected a sample size consist of 1. Types 3 Mobility and Physical impairment 14 persons. 2. Thaokhaopleuk Caregiver Team (TCT) include 36 people divided to 2.1 Families of disabled persons
10 persons
2.2 Village Head Man and Village Health Volunteer 15 persons 2.3 Health Care Setting 2.4 Other volunteers
5 persons 6 persons
Duration February to April , 2016 Instrument Instrument was used in this study include 4 questionnaires for both people with disabilities and caregiver teams. First are questionnaire for pre-test and post-test was created and was test valid by three expertises include research advisor and physical therapist. Second the World 88
Health Organization Quality of Life BREF Thai (WHOQOL-BREF-THAI) version for assesses the quality of life of both people with disabilities and caregiver team. WHOQOLBREF-THAI) (9) which includes four qualities of life domains: physical health, psychological health, social relationships, environment and overall quality of life. The assessment would divide in to 3 level were bad, fair and good. And the third is the World Health Organization Disabilities Assessment Schedule 2.0 (WHODAS 2.0)(10) in Thai version. It contain 36 items, each items were assigned score as none, mild, moderate, severe, and extreme. It was used for assess basic need of people with disabilities that covers 6 domain of function including cognition; understanding and communication, mobility; abilities of moving and getting around in home and outside, self-care; it was include personal hygiene, bathing, dressing, and eating, getting alone; it means interaction or relationship with others, life activities; include the responsibilities in house, leisure, in work or in school and last with participation; participation in communities activities. The forth are Barthel Index of Activities of Daily Living (ADL), (11) it was use to assess the ability for doing daily activities of people with disabilities. This questionnaire composed of 10 items, covers abilities for control bowels, bladder, toilet use, grooming, dressing, bathing, and feeding, etc. and score were count for 120 with lower score indicate increased disabilities. Data collection Questionnaires were performed by face to face interview for disabled part and by selfadministrated for Caregiver team. Purposive sampling technique was use for Caregiver team. Before making questionnaire the oral consent was conducted to disabled persons and Caregiver team. Caregiver Team who are responsibility was collected the questionnaires for disabled persons. Study Flow The study flow in this research based on WE CAN DO by TIM framework. According to Sunsern,R. noted that WE CAN DO by TIM is the process of continue care that its unified interaction for compliance plan, reflect action, development, and evaluation by base on family and community.
89
90
Data analysis Data analysis was performed by used descriptive statistics such as frequency, percentage, mean, and standard deviation will be used for determine. Inferential statistic is paired t-test for compare the different of before and after implementation. Evaluation Key performance index
Evaluation method
Instrument
Knowledge of caregiver for taking care of people with disabilities is increase.
questionnaire
Pre-test and post-test questionnaire
An ability of doing daily activities of people with disabilities is increase.
questionnaire
Modified Barthel ADL questionnaire
Qualities of live of either people and care giver increase
questionnaire
WHOQOL-BREF-THAI questionnaire
Basic need of people with mobility and physical disabilities is decrease.
questionnaire
WHODAS 2.0 questionnaire
Ethical committee The participants in this research are people with disabilities. There are vulnerable groups so, ethic is important that we concern. All study forms and procedures were approved by the Committee for the Protection of Human Subjects of Mae Fah Luang University, Thailand. Results The characteristic of people with disabilities, total participant are divided into 2 group were people with disabilities and caregiver team. There are 9 person of people with disabilities most of them were age 60 above, 7 male (77.8%) and 2(22.2%) female and 66.7 of them are unemployment. Caregiver teams include 24 persons; they were age between 15 to 65 years old, 2(8.3%) persons of male and 22 (91.7%) persons of female, about 62.5% are married, then the most of their occupations is agriculturist at 73.9% as in table 1.
Table 1 The Characteristic of people with disabilities and caregiver team. 91
Characteristics Gender Male Female Age(year) 1-14 15-59 ≥60 Marital status Single Married Divorce/widow Education No education Primary school Secondary (M 1-3) High School (M4-6) Occupation Unemployed Agriculturist Trader/Merchant other
People with disabilities N(%)
Caregiver team N(%)
8(77.8%) 2(22.2%)
2(8.3%) 22(91.7%)
0(0%) 5(55.6%) 4(44.6%)
0(0%) 20(83.3%) 4(16.7%)
3(33.3%) 5(55.6%) 1(11.1%)
1(4.2%) 23(95.8%) 0(0%)
4(44.4%) 3(33.3%) 2(22.2%)
0(0%) 15(62.5%) 6(25.0%)
0(0%)
3(12.5%)
6(66.6%) 2(22.2%) 0(0%) 1(11.1%)
0(0%) 21(87.5%) 2(8.3%) 1(4.2%)
Table 2 the table is showing result of WHODAS score, QOL and ADL of people with disabilities before and after joint the implementation. Table 2 the QOL, WHODAS and ADL of people with disabilities. Variable Quality of life(n=9) Physical health Psychological health Social relationships Environmental Overall quality of life WHODAS(n=9) Cognition Mobility Self-care Getting along Life activities Participation ADL(n=9)
Pre-test Mean(SD)
Post-test Mean(SD)
df
P-value
21.4(3.8) 21.8(1.5) 9.3(1.0) 23.8(2.7) 83.7(7.4)
26.8(2.7) 26.8(3.2) 12.8(2.1) 32.6(5.3) 107.4(13.1)
8 8 8 8 8
0.011* 0.002* 0.003* 0.001* 0.002*
33.3(369) 65.3(59.6) 35.5(42.7) 26.8(35.3) 88.8(67.7) 83.7(31.5) 16.11(1.4)
27.7(31.2) 62.5(55.9) 35.5(42.7) 26.8(35.3) 85.5(63.3) 81.9(30.2) 16.88(1.1)
8 8 8 8 8 8 8
0.051 0.347 a a 0.347 0.225 1.11 92
a the correlation and t cannot be compute because the standard error of the difference if 0. Table 3 The table show the pre-test and post-test of caregiver Knowledge and QOL. Table 3 The QOL and Knowledge of caregiver team. Variable Quality of life (n=24) Physical health Psychological health Social relationships Environmental Overall quality of life Knowledge (n=24)
Pre-test Mean(SD)
Post-test Mean(SD)
df
P-value
24.4(2.8) 22.6(2.8) 10.5(1.8) 27.7(4.1) 92.3(9.7) 12.8(0.8)
23.7(3.4) 21.9(3.3) 10.4(1.4) 25.9(3.4) 88.6(9.6) 14.4(0.6)
23 23 23 23 23 23
0.443 0.392 0.793 0.045 0.187 0.008*
Discussion In this implementation found the quality of life of people with disabilities was increased in all domains after joint the project it may result from the increase in Knowledge of their caregiver about the way to support and taking care for people with disabilities because after implementation the result of knowledge of caregiver team was statistical significantly increasing at p-value 0.05. While both basic need and Activities of Daily Living (ADL) are not change it may result from the limitation of time for conducting the project because it was monitoring after I week of intervention. So the result may not accurate. Contrasted in care giver team the qualities of life of them are decreasing after joint this project, it may because of most of caregiver team were Village health volunteer and at the period of doing this project they must preparing themselves for joining Mae Chan Village Health Volunteer sport day competition, so the intervention may become as burden for them thus why the quality of life of caregiver are decreased. Limitation and Recommendation Duration for conducting of project is limited but the intervention are need some period of time for getting the result such as the intervention for people with disabilities for rehabilitate. And action research are qualitative study method it take time for collecting data and interpreting data because it was depend on the phenomena and situation that occur in community. So for this we recommend for local stakeholder, caregiver teams and local health promoting hospital continuous to monitoring and support the rehabilitation activities for people with disabilities, and assess the qualities of life, ADL and basic need for reassure the result again after 2 week, one month in order to solve and improve the intervention that meet the need of them. Conclusion After done this project found that this project was enhance the qualities of life of people with disabilities and improve knowledge of caregiver team for taking care of people with 93
disabilities, by the way basic need of people with disability and ADL are not achieved the goal of their need, also include the qualities of life of caregiver team are decreased. Acknowledgement People with disabilities and caregiver team of Moo 7 Tha Kao Pluek，Staff in Tha Kao Pluek Health Promoting Hospital for their assistance with data collection, for coordination with TOYOTA company, Ban Du branch Nang Lae , Chaing Rai province for financial support, Mrs.Sarapee Nopphakun Nurse from Huai Mah Hin Fon Health Promoting Hospital and Mr. Mongkollert InKamdang Physical therapist from Mea Chan Hospital to being guest speaker provide knowledge to caregiver team and rehabilitation for people with disabilities, Associate Professor Dr. Rachanee Sunsern Dean of school of Health Science, Aj. Pilasinee Wongnuch Aj. Dr. Pitsanurak Kantawee and Mr. Niwed Kullawong advisor, school of Health Science, Mea Fah Luang University References 1.Department of empowerment of persons with disabilities. (2015).types of disablilty. Retrived from.http://nep.go.th/th/disabilities-knowledge 2. World Health Organization.(2015). Disabilities and health. Retrieved 20/04/2016 from.http://www.who.int/mediacentre/factsheets/fs352/en/ 3. World Health Organization. (2016). Better heath for people with disabilities. Retrieved 20/04/2016 from.www.who.int/topics/disabilities-en-pdf,pdf?ua=1. 4. http://nep.go.th/site/default/files/flies/document/report_PWDs_Sep58.pdf. 5. World Health Organization.(2011).summary world report on disabilities. Retrieved 20/04/2016.From http://www.who.int/disabilities/world_report/2011/accessible_en.pdf 6. World Health Organization.(2011).world report on disabilities. Retrieved 20/04/2016.From file:///C:/Users/User/Downloads/9789240685215_eng%20(2).pdf 7. ILO,UNESCO,WHO. (2004). CBR: a strategy for rehabilitation , equalization of opportunities poverty reduction and socail inclusion of people with disability. Joint position paper. Geneva:ILO
