Discussion Forum 1

[kbalsara]

1. What evidence do I have (or need) to identify those factors and levels posing the greatest barriers to rehabilitation in my population?
2. How does my own professional expertise and organizational access suggest where I might be most be effective in developing and launching an intervention?
3. What formative research might be needed to understand the precise intervention that would be most appropriate and impactful towards overcoming the challenges I identify?
4. When considering potential interventions, what factors related to implementation do I need to consider?
5. What implicit biases may be at work in my culture or context and how do those implicit biases impact an individual’s ability to access and benefit from rehabilitation?

[Oda Msuha]

After surveying and obtain number of people with disability, i will assess the targeted group to find out their needs and barriers toward accessibility of rehabilitation services.
considering few number of rehabilitation expertise who are specialized in certain rehabilitation field like orthopedics, neurology, pediatric, Cardiopulmonary e.t.c I would like to engage on rehabilitation research towards new intervention to enhance development and implementation of rehabilitation strategic plan on improving rehabilitation services in my population.
Needs assessment, stakeholders analysis and context analysis which include social-economic, cultural and environment challenges together with quantitative and qualitative data collection on people with disability needs with expert consultation will be the most appropriate and impactful towards overcoming rehabilitation challenges.

[Oda Msuha]

Also feasibility, acceptability and adaptability of selected intervention are key factor to facilitate implementation again considering resource requirements, sustainability and how they will be monitored and evaluated while integrated with existing system.
Some of biases that affect rehabilitation intervention include social economic bias, disability bias and beliefs bias that impact rehabilitation services on quality of care and treatment plan.

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1.
Insensitivity and lack of awareness of the role of culture can make rehabilitation difficult, particularly in multicultural, multiracial and multilingual.
Stigma. Negative attitudes and erroneous beliefs about disability has resulted in stigma, which has be defined as an attribute possessed by a person or group that is regarded as undesirable or discrediting. For persons with disabilities and their families, stigma often results in a lowering of status within

2. As a nurse i
specialize in helping people with disabilities and chronic illness attain optimal function, health, and adapt to an altered lifestyle.as a Rehabilitation nurse i assist patients in their move toward independence by setting realistic goals and treatment plans.

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Rehabilitation Interventions
Online Course: Introduction to Rehabilitation Interventions
Introduction
If we consider the definition of rehabilitation as “a set of measures that assist individuals who experience, or are likely to experience, disability to achieve and maintain optimal functioning in interaction with their environments”, then rehabilitation is in effect composed of multiple components or “interventions” to address issues related to all domains within the World Health Organisation’s International Classification of Functioning, Disability and Health (ICF) including: body functions and structures, capacity for activities, the performance of activities, participation, environmental/contextual factors, and personal factors.[1]

Most individuals participating in rehabilitation require interventions addressing one, many or all of the components of the ICF that are contributing to reduced functioning, with the overriding goal of rehabilitation being to utilise appropriate interventions that allow the individual to optimise their function.[1] Given this, individuals with health conditions or injuries may require rehabilitation at various points in time across the course of their lifespan. The timing and type of intervention that a rehabilitation provider selects depend greatly on several factors which include: the aetiology and severity of the person’s health condition; the prognosis; the way in which the person’s condition affects their ability to function in their environment; as well as the individual’s identified personal goals and what it is they want to achieve from the rehabilitation process.

Outcome Orientated
Goal setting in rehabilitation forms the basis for the selection of rehabilitation interventions which can include goals related to mobility, self-care, communication, and cognition and on more specific activities related to play, education, work, employment, socialisation, and quality of life. Different rehabilitation settings may vary in their capacities to provide specific intensities of therapies, and rehabilitation itself may vary in its intensity, generally measured by the frequency and duration of individual interventions or treatment sessions. The selection of rehabilitation interventions and intensity of rehabilitation should always be based on the individual patient’s needs, which should include their tolerance of therapeutic activities. More importantly, rehabilitation interventions should be generally outcome-oriented, in that rehabilitation goals are developed to achieve a specific outcome that is based on the following five broad areas:

Prevention of the loss of function
Slowing the rate of loss of function
Improvement or restoration of function
Compensation for loss of function (compensatory strategies)
Maintenance of current function
Role of Rehabilitation Interventions
Rehabilitation intervention is provided across the whole range of healthcare settings including the primary care setting, in the acute hospital setting (during an inpatient episode or as an outpatient referral) or in the community settings. The breadth of rehabilitation means that a range of organisations may contribute to meeting a person’s individual needs. Rehabilitation intervention is essential in helping to address the impact of: [2]

Physical or Movement Problems such as impaired motor control; reduced range of movement; reduced balance, strength or cardiovascular fitness; loss of limbs; fatigue; pain or stiffness.
Sensory Problems such as impairment of vision or hearing; loss of or altered sensation of touch or movement; pain; sensory processing difficulties.
Cognitive or Behavioural Problems such as lapses in memory and attention; difficulties in organisation, planning and problem-solving.
Communication Problems such as difficulties in speaking; using language to communicate; understanding what is said or written.
Psychosocial and Emotional Problems such as the effects on the individual, carer and family of coping with a new health condition or living with a long-term condition. These can include stress, depression, loss of self-image and cognitive and behavioural issues.
Mental Health Conditions such as anxiety; depression; obsessive/compulsive disorders; schizophrenia; eating disorders; post-traumatic stress disorder and dementia.
Medically Unexplained Symptoms where a holistic approach is needed to ensure the best possible support for both mental and physical wellbeing.
Classification of Interventions
Rehabilitation interventions are hugely diverse and, except in rare instances, require the involvement of many different health and rehabilitation professionals and cross multiple disciplines often at the same time, which as a result make the classification of rehabilitation interventions quite complex. It is this complexity that makes the classification of rehabilitation interventions a challenge, and as a result, there is still no classification that has been universally accepted across all fields of rehabilitation currently, despite several attempts made to develop a classification system to fully describe rehabilitation interventions.[3]

Levack and Dean have outlined three key reasons for this:

Firstly, rehabilitation interventions are not only about the intervention itself and what the healthcare professional does but are significantly influenced by experience and relationships and how the healthcare professional engages and interacts with the individual and other significant people in their lives. It is within these interactions that rehabilitation interventions now work towards changing how patients think about their disability, their motivation for rehabilitation, their self-efficacy and the way they participate within therapeutic activities.[3]
Secondly, most rehabilitation interventions do not work on one component or domain alone but rather involve a number of interacting components.
Example: An occupational therapist may use a simple cooking activity to help an individual regain skills in activities of daily living following a stroke. While the primary focus may be on cooking, the activity itself also incorporates strengthening of weak muscles in a hemiplegic arm and leg (standing in the kitchen, lifting and using kitchen utensils, and bending and reaching); retraining of balance (standing and moving around the kitchen); cardiovascular exercise; conditioning and fatigue management; training in the use of assistive technology (mobility aids and adapted kitchen implements) and cognitive retraining (following a recipe, safe use of an oven). Concurrently, the occupational therapist may also use the same therapy session as an opportunity to provide some education on the nature of stroke and how to adjust for the loss of function on return home, as well as providing general emotional counselling and support. Furthermore, a collaborative approach can be taken to address the patient’s various functional limitations by using the same task but combining the session with another member of their rehabilitation team (e.g. the speech-language therapist or physiotherapist).[3]
rehabilitation interventions can be provided for within a group environment or individually across a broad range of rehabilitation settings from a hospital environment, to primary care and community-based settings such as the home, work, local gym etc. Each approach has its own advantages and disadvantages but no matter what pPhysiopedia
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Rehabilitation Interventions
Online Course: Introduction to Rehabilitation Interventions
Introduction
If we consider the definition of rehabilitation as “a set of measures that assist individuals who experience, or are likely to experience, disability to achieve and maintain optimal functioning in interaction with their environments”, then rehabilitation is in effect composed of multiple components or “interventions” to address issues related to all domains within the World Health Organisation’s International Classification of Functioning, Disability and Health (ICF) including: body functions and structures, capacity for activities, the performance of activities, participation, environmental/contextual factors, and personal factors.[1]

Most individuals participating in rehabilitation require interventions addressing one, many or all of the components of the ICF that are contributing to reduced functioning, with the overriding goal of rehabilitation being to utilise appropriate interventions that allow the individual to optimise their function.[1] Given this, individuals with health conditions or injuries may require rehabilitation at various points in time across the course of their lifespan. The timing and type of intervention that a rehabilitation provider selects depend greatly on several factors which include: the aetiology and severity of the person’s health condition; the prognosis; the way in which the person’s condition affects their ability to function in their environment; as well as the individual’s identified personal goals and what it is they want to achieve from the rehabilitation process.

Outcome Orientated
Goal setting in rehabilitation forms the basis for the selection of rehabilitation interventions which can include goals related to mobility, self-care, communication, and cognition and on more specific activities related to play, education, work, employment, socialisation, and quality of life. Different rehabilitation settings may vary in their capacities to provide specific intensities of therapies, and rehabilitation itself may vary in its intensity, generally measured by the frequency and duration of individual interventions or treatment sessions. The selection of rehabilitation interventions and intensity of rehabilitation should always be based on the individual patient’s needs, which should include their tolerance of therapeutic activities. More importantly, rehabilitation interventions should be generally outcome-oriented, in that rehabilitation goals are developed to achieve a specific outcome that is based on the following five broad areas:

Prevention of the loss of function
Slowing the rate of loss of function
Improvement or restoration of function
Compensation for loss of function (compensatory strategies)
Maintenance of current function
Role of Rehabilitation Interventions
Rehabilitation intervention is provided across the whole range of healthcare settings including the primary care setting, in the acute hospital setting (during an inpatient episode or as an outpatient referral) or in the community settings. The breadth of rehabilitation means that a range of organisations may contribute to meeting a person’s individual needs. Rehabilitation intervention is essential in helping to address the impact of: [2]

Physical or Movement Problems such as impaired motor control; reduced range of movement; reduced balance, strength or cardiovascular fitness; loss of limbs; fatigue; pain or stiffness.
Sensory Problems such as impairment of vision or hearing; loss of or altered sensation of touch or movement; pain; sensory processing difficulties.
Cognitive or Behavioural Problems such as lapses in memory and attention; difficulties in organisation, planning and problem-solving.
Communication Problems such as difficulties in speaking; using language to communicate; understanding what is said or written.
Psychosocial and Emotional Problems such as the effects on the individual, carer and family of coping with a new health condition or living with a long-term condition. These can include stress, depression, loss of self-image and cognitive and behavioural issues.
Mental Health Conditions such as anxiety; depression; obsessive/compulsive disorders; schizophrenia; eating disorders; post-traumatic stress disorder and dementia.
Medically Unexplained Symptoms where a holistic approach is needed to ensure the best possible support for both mental and physical wellbeing.
Classification of Interventions
Rehabilitation interventions are hugely diverse and, except in rare instances, require the involvement of many different health and rehabilitation professionals and cross multiple disciplines often at the same time, which as a result make the classification of rehabilitation interventions quite complex. It is this complexity that makes the classification of rehabilitation interventions a challenge, and as a result, there is still no classification that has been universally accepted across all fields of rehabilitation currently, despite several attempts made to develop a classification system to fully describe rehabilitation interventions.[3]

Levack and Dean have outlined three key reasons for this:

Firstly, rehabilitation interventions are not only about the intervention itself and what the healthcare professional does but are significantly influenced by experience and relationships and how the healthcare professional engages and interacts with the individual and other significant people in their lives. It is within these interactions that rehabilitation interventions now work towards changing how patients think about their disability, their motivation for rehabilitation, their self-efficacy and the way they participate within therapeutic activities.[3]
Secondly, most rehabilitation interventions do not work on one component or domain alone but rather involve a number of interacting components.
Example: An occupational therapist may use a simple cooking activity to help an individual regain skills in activities of daily living following a stroke. While the primary focus may be on cooking, the activity itself also incorporates strengthening of weak muscles in a hemiplegic arm and leg (standing in the kitchen, lifting and using kitchen utensils, and bending and reaching); retraining of balance (standing and moving around the kitchen); cardiovascular exercise; conditioning and fatigue management; training in the use of assistive technology (mobility aids and adapted kitchen implements) and cognitive retraining (following a recipe, safe use of an oven). Concurrently, the occupational therapist may also use the same therapy session as an opportunity to provide some education on the nature of stroke and how to adjust for the loss of function on return home, as well as providing general emotional counselling and support. Furthermore, a collaborative approach can be taken to address the patient’s various functional limitations by using the same task but combining the session with another member of their rehabilitation team (e.g. the speech-language therapist or physiotherapist).setting or structure is involved, rehabilitation should always be designed to meet the individual needs of each patient. Given this, being able to adapt, modify, create and be flexible are vital skills required by rehabilitation professionals in order to be able to adapt interventions and therapeutic activities depending not only on the particular spectrum of impairments that someone might present with, but also on the specific goals of rehabilitation for that individual, the environmental context under which a patient is performing targeted activities, and on their personality and personal interests.[3]
Example: An athlete following an ACL injury may start their early rehabilitation individually within the physiotherapy clinical for individual assessment and treatment. This may also be incorporated with some group-based activity with teammates within the gym, where they get to train with teammates while working on their own specific rehabilitation programme and goals. As they progress through their rehabilitation programme and work towards a return to play, rehabilitation may continue to include both individuals, small groups and team-based activities, but may be field or court-based to prepare for a return to competition.
4.
Educate. Rehabilitation is not a magic pill, and education is the vital aspect of the rehabilitation process throughout all stages that ensure the individual and their support structures have a good understanding of what is going on, in order to set realistic expectations and set SMART goals.
5. Some culture believe poses as a barrier yet rehabilitation would not be full achieved

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1. From Rapid Assistive Technology Survey 2023 which was done in Uganda the Main barrier to wards access to rehabilitation services was that most individuals did not have knowledge where the services were being offered and those who had an idea failed to access the rehabilitation services due to lack of transports since in Uganda rehabilitation health service have not been well allocated in the main stream primary health care plan due to lack of a national strategic plan for rehabilitation and Assistive technology services.
This left rehabilitation services at only national and regional referral hospitals.
The lack of a clear policy on provision of rehabilitation services as made these services very hard to access and very expensive since the lack of policy as creates a vacuum as to regards budget allocation to wards rehabilitation and ATs services in Uganda.
There is also limited advance knowledge on provision of Rehabilitation and AT services in Uganda for example the use of 3D technology as not been rolled out into the government orthopaedic workshops. The clinical health worker who handle out patients have limited knowledge on rehabilitation and AT service, this as lead to missed diagnosis of patients who would have benefited from Rehabilitation services because of not being referred to the right department.

2. The all solution to all these barriers will be the development of the Uganda national strategic plan for rehabilitation and Assistive technology which in is in its final stage. This will address the challenge of population sensitization on the access to rehabilitation services.
Integration of rehabilitation services into the primary health care package will bring services closer to the people to solve the change of transportation through community based health care program.
Health Professional association should embrace CPDs to enable their professionals acquired the most current trends in technology. The government should facility its rehabilitation health workers to attain more advanced training so that they can use the most current technology in providing rehabilitation services for exampling 3D printing of stamp sockets and braces.

3. More research should be carried our access the health workers knowledge gap towards rehabilitation and AT service provision.

4. Factors to consider during implementation include;
The intervention must be satisfactory to the involved stakeholders and its express good intentions for the population of Uganda.
The intervention sound relevant and cost effective to implement. The intervention should be applicable to our local setting.
The intervention should be easily integrated in the Uganda national health care package and should be sustainable for along time.
5. Implicit biases towards rehabilitation include stereotyping the people from educated well off families to be understanding of the rehabilitation self care than those from rural poor un educated communities. This Implicit makes most health workers to give more attention to those from the elite class during rehabilitation.

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Social Ecological Interventions in Uganda

Rehabilitation is a complex process that requires a multifaceted approach to address the various barriers faced by individuals. This 5th module highlights the importance of considering social ecological factors when designing and implementing interventions, emphasizing the influence of individual characteristics, household dynamics, community norms, institutional policies, and public policy.

Identifying Intervention Levels;

To effectively address rehabilitation barriers in Uganda, it is essential to identify the levels that pose the greatest challenges. This requires gathering evidence through assessments, surveys, and qualitative research to understand the specific factors influencing rehabilitation outcomes. For instance, research in Ugandan communities may reveal that stigma and discrimination at the community level are significant barriers to accessing rehabilitation services, while lack of resources and support within households hinder individuals’ ability to participate in rehabilitation programs.

Leveraging Professional Expertise and Organizational Access

The choice of intervention level also depends on the expertise and organizational access of healthcare professionals and rehabilitation organizations. In Uganda, where mental health services are often limited, partnerships with NGOs can expand the reach of interventions. For example, NGOs can implement community-based awareness campaigns to reduce stigma and discrimination, while rehabilitation centers can provide specialized services for individuals with complex needs.

Formative Research for Intervention Design

Formative research is crucial to tailor interventions to the specific needs of the population. This involves collecting qualitative and quantitative data to understand the perspectives and experiences of individuals with disabilities, their families, and community members. Through formative research, researchers can identify the most appropriate intervention strategies, such as culturally sensitive therapy approaches or community-based support groups.

Implementation Considerations

Implementing social ecological interventions requires careful planning and consideration of various factors. These include resource availability, sustainability, cultural appropriateness, and community engagement. Interventions should be feasible to implement and sustained over time to ensure long-term impact. Engaging communities in the planning and implementation phases is essential to foster ownership and increase the likelihood of success.

Addressing Implicit Biases

Implicit biases, which are unconscious beliefs and attitudes, can significantly impact an individual’s ability to access and benefit from rehabilitation. In Ugandan society, biases related to mental illness, disability, and socioeconomic status may hinder individuals’ opportunities for rehabilitation. Addressing implicit biases through training, community education, and policy changes can create a more inclusive environment for people with disabilities.

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1. What evidence do I have (or need) to identify those factors and levels posing the greatest barriers to rehabilitation in my population?
In order to identify the factors and levels that present the greatest barriers to rehabilitation in Kenya, I need to conduct a survey. For example, the rapid Assistive Technology Assessment (rATA) is a population-based household survey conducted in Kenya in 2020. This survey measured the need, demand, supply, user satisfaction, and barriers to accessing assistive technology. To understand the multilevel and intersectional factors associated with barriers to access and the benefits of rehabilitation services, a study will be conducted using the socioecological framework to assess the current situation in Kenya. Additionally, reference can be made to population surveys, census data, and the Rehabilitation and Assistive Technology Strategy of 2022-26 in Kenya.
2. How does my own professional expertise and organizational access suggest where I might be most be effective in developing and launching an intervention?
As rehabilitation focal person, I will collaborate with stakeholders to create an intervention that garners broad support and readiness for implementation. I will foster a culture of collective responsibility for developing, implementing, and embedding the intervention into routine practice. Within the organization, I will prioritize ensuring the availability of resources, enhancing workforce capacity, and cultivating a culture of motivation that supports evidence-informed interventions
3. What formative research might be needed to understand the precise intervention that would be most appropriate and impactful towards overcoming the challenges I identify?
We need to conduct formative research using both qualitative and quantitative methods to understand the specific intervention that would be suitable and effective at multiple levels in addressing the identified challenges. To achieve this, we will use a variety of methods, including telephone interviews, surveys and checklists, semi-structured interviews, and focus group discussions.
4. When considering potential interventions, what factors related to implementation do I need to consider?
In implementation of a potential intervention, there are factors to be considered that include:
a) Acceptability – considering if the intervention is satisfactory, agreeable or palatable to all stakeholders
b) Adoption- The uptake of the intervention by stakeholders
c) Feasibility-consider if the intervention can be successful carried out in my organization
d) Cost- cost of the intervention should be considered
e) Fidelity- whether the intervention will be implemented as per the protocol
f) Penetration- integration of intervention across settings
g) Sustainability-long term maintenance of an intervention in settings and at times integrated in the routine work.

5. What implicit biases may be at work in my culture or context and how do those implicit biases impact an individual’s ability to access and benefit from rehabilitation?
Implicit bias refers to the unconscious attitudes, prejudices, and judgments that we unknowingly hold about people or groups. In my culture or context, various implicit biases may affect individuals’ access to and benefit from rehabilitation, such as gender, socioeconomic status, age, race, ethnicity, disability, employment status, and education level. These biases contribute to health disparities and can significantly hinder individuals from accessing and benefiting from rehabilitation.

[Hoang Thuy Dung]

1. I need evidence from surveys, medical records, interviews, and observational studies. Additionally, reviewing existing literature and analyzing demographic data can reveal patterns and trends, while stakeholder feedback offers insights into systemic and personal challenges faced by the population.
2. Your professional expertise enables you to identify and address clinical challenges, tailor interventions to patient needs, and apply specialized knowledge in rehabilitation techniques. Organizational access provides resources, collaborative networks, and policy influence, allowing you to effectively develop, implement, and advocate for interventions that are practical, sustainable, and well-supported.
3. in my opinion, Formative research needed includes:

Needs Assessment: Surveys, interviews, and focus groups to identify specific needs and preferences of the target population.
Pilot Studies: Small-scale trials to test the feasibility and effectiveness of proposed interventions.
Stakeholder Engagement: Involving patients, families, and healthcare providers in the design and feedback process to ensure practical and acceptable solutions.
Gap Analysis: Evaluating current services to determine what is lacking and where improvements are needed.
4. When considering potential interventions, the following factors are crucial:
Resource Availability: Financial, human, and material resources.
Training and Support: Adequate staff training and ongoing support.
Scalability and Sustainability: Long-term viability and ability to scale up.
Monitoring and Evaluation: Continuous assessment and improvement.
Cultural Sensitivity: Appropriateness for the target population.
Stakeholder Buy-in: Support from patients, families, and providers.
Policy Compliance: Adherence to relevant regulations.
5.

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Q1. What evidence do I have (or need) to identify those factors and levels posing the greatest barriers to rehabilitation in my population?

To pinpoint the factors and levels that pose the greatest barriers to rehabilitation in a population, it is crucial to have access to rehabilitation data at different levels, including the individual (user level), facility level, and population level. By gathering data at these diverse levels, I will obtain the evidence necessary to identify the barriers to rehabilitation, thus enabling me to pinpoint the specific factors and levels causing these barriers.

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1) Evidence is vital to determine barriers in accessing rehabilitation and Assistive technology. Some strategies to gather evidence in this regard could be by conducting survey, research with service users, service providers, caregivers to get data/information.
In Nepal, a nationwide population-based household survey was conducted from 7 December 2021 to 27 December 2021 using the WHO rapid Assistive Technology Assessment (rATA) questionnaire. Key findings related to barriers in accessing assistive technology were-
Barriers to access AT by sex:
-Among the male participants who had unmet needs of AT, majority of them reported lack of support (44.6%) as the reason for not having the product needed followed by unaffordability (36.2%).
– Among the female participants who had unmet needs of AT, majority of them reported lack of time (44.3%) as the reason for not having the product needed followed by unaffordability (41.2%).
Barriers to access AT by age groups:
Among <5years age group participants who had unmet needs of AT, cent percent of them reported unsuitability of AT as the reasons for not having AT.
-Among participants who were between 5-17 years and who had unmet needs of AT, majority of them (82.8%) reported unaffordability as the reasons for not having AT
-Among participants who were between 18-65 years and who had unmet needs of AT, majority of them (41%) reported lack of time as the reasons for not having AT
-Among participants who were >65 years and who had unmet needs of AT, nearly half of them (49.7%) reported unaffordability as the reasons for not having AT

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1. What evidence do I have (or need) to identify those factors and levels posing the greatest barriers to rehabilitation in my population? In or for me to have evidence in Uganda setting have to gather demographics data conduct survey community interviews look through their policy and I identify rehabilitation barriers while reviewing and analyzing literature for common barriers to correlates and highlights challenges and common barriers

2. How does my own professional expertise and organizational access suggest where I might be most be effective in developing and launching an intervention? My professional expertise and organizational access might be most effective through leveraging my knowledge of population access to resources and ability to influence policy and policy changes within the organization

3. What formative research might be needed to understand the precise intervention that would be most appropriate and impactful towards overcoming the challenges I identify?
Formative type of research might be needed to understand the intervention as it may involve needs assessment ,piloting Testing stakeholder interviews and literature review to comprehend specific challenges and targeted needs of the population

4. When considering potential interventions, what factors related to implementation do I need to consider?
considering potential intervention, I would consider factors like cost effectiveness, feasibility, resources available, training needs, potential barriers and evaluation methods during planning the implementation of potential interventions

5. What implicit biases may be at work in my culture or context and how do those implicit biases impact an individual’s ability to access and benefit from rehabilitation?
Implicit being state a state of unconscious attitude ,beliefs and reactions toward social group and others washout intending to act that way ,and in that way, implicit biases impacts greatly on self periconception, decision making, institutional policies and cultural norms leading to discriminatory practices ,policy making is influence by implicit baises of policy makers resulting into laws regulations that inadequately affects marginalized groups reinforcing social inequalities

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1. What evidence do I have (or need) to identify those factors and levels posing the greatest barriers to rehabilitation in my population?
There some research which are done to identify the barriers e.g. (Shayo, M.J. and Van den Bergh, G., 2015. Physiotherapy management of idiopathic clubfoot in Tanzania: experiences and challenges. Physiotherapy, 101, pp.e1374-e1375), which identified barriers in different levels including individual level lack of awareness and poor knowledge regarding clubfoot was a barrier to treatment, due to poor individual knowledge some family conflict existed and caused separation, at the level of institution few were trained on Ponsati methods of clubfoot management therefore treatment was inconsistent and varied from one institution to another; at the community level we found that stigma was a problem (clubfoot was associated with being cursed and in some tribes as a blessing that the family will have more cattle therefore they preferred not to take the child for treatment. Women and children had less rights in some society especially in rural society women would have been blamed for bringing a lame child to the family and led to less priority in rehabilitation services
2. How does my own professional expertise and organizational access suggest where I might be most be effective in developing and launching an intervention?
As a follow up of the same study in no 1 above effort was made to educate physiotherapists in the use of Ponseti methode for clubfoot management, as a physiotherapist and trainer I contacted the TCCO team which was receiving support from Miracle feet who provide training to staff and support clinics in Tanzania to provide Ponseti treatment. Now the clinics providing Ponseti treatment in Tanzania are many, and the supervision is led by MDH, I am a Ponseti trainer and a supervisor of clinics supported by Miracle feet in Northern Zone of Tanzania. What is provided is by Ponseti clinics is parental education (to affect the individual and house hold level), training to Ponseti providers and peripheral health centres(to build capacity a the institution level), creating awareness in the society (schools, religious gatherings and local government meetings). We are working close with the govement to include Ponseti method of clubfoot management in the curricula and in the implementation og the National Rehabilitation Action Plan.
3. What formative research might be needed to understand the precise intervention that would be most appropriate and impactful towards overcoming the challenges I identify?
Currently we need to evaluate the impact of the existing program and do and explorative research to identify the need in this particular group, because the country large and the whole country is not covered. Some areas are covered yet we have a large area which is not covered
4. When considering potential interventions, what factors related to implementation do I need to consider?
For the evaluation mentioned in no. 3 above we will explore the following, acceptability of the treatment, commitment of the ministry of health to absorb the implementation into the system and budget if at all it is acceptable to the society, the intervention is carried out successfully and there is a training program which exists and it is used for African countries which ensures fidelity, however the extent that we can reach all children born with clubfoot in Tanzania need more evidence as we haven’t yest ensured sustainability in case the donor withdraws.
5. What implicit biases may be at work in my culture or context and how do those implicit biases impact an individual’s ability to access and benefit from rehabilitation?
Social economical groups and women

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1. What evidence do I have (or need) to identify those factors and levels posing the greatest barriers to rehabilitation in my population?

According to BMC Pulic Health publication 2019, a study on Prevalence and factors associated with utilization of rehabilitation services among people with physical disabilities in Kampala, Uganda. Utilization of rehabilitation services among people with physical disabilities in Kawempe division, Kampala, Uganda, Factors that were significantly associated with utilization of rehabilitation services among people with physical disabilities at multivariable logistic regression analysis included; age , socioeconomic status, education level and awareness of the population about the rehabilitation services
The study revealed a prevalence of 26.4% of the utilization rehabilitation services among people with physical disabilities in Kawempe division, Uganda. Factors that were significantly associated with utilization of rehabilitation services included; age, socioeconomic status, education level and awareness of the participants about the services. Therefore, the government and other relevant stake holders should increase sensitization and awareness of rehabilitation services, their benefits and facilities providing such services to people with physical disabilities, healthcare professionals and the general public.

Furthermore, in depth research is needed to get the up-to-date data on utilization of rehabilitation services basing on race, gender, culture, religion, economic status among others.

2. How does my own professional expertise and organizational access suggest where I might be most be effective in developing and launching an intervention?
As a medical social worker, I am most effective in developing and launching an intervention through, aiding and counselling persons with disability through obtaining AT benefits, coordinating resources to help PWDs, mentoring different stakeholders on how to offer respectful care to diverse populations and how to recognize and address their unconscious beliefs about various social groups.

3. What formative research might be needed to understand the precise intervention that would be most appropriate and impactful towards overcoming the challenges I identify?
The formative research I need would be based on needs assessment, ensuring leaders buy in the idea(religious and cultural, the political leaders), identifying priorities, then continuous monitoring and evaluation.

4. When considering potential interventions, what factors related to implementation do I need to consider?
I need to consider the cost implications, acceptability, perception from community, feasibility, fidelity, integration with other services on ground, political stability of an area, the sustainability of the program/intervention.

5. What implicit biases may be at work in my culture or context and how do those implicit biases impact an individual’s ability to access and benefit from rehabilitation?
Implicit biases means having unconscious negative attitude, mindset, behavior impacting on others in the society, in specific a certain social group. For example it can be towards a certain gender, race, religion, culture, economic status. This creates a barrier to benefiting from rehabilitation where people cannot access certain services due to biased policies, unequal resource distribution ,knowledge gap thus a barrier in benefitting from rehabilitation.

[Oda Msuha]

1.Evidence needed to identify the factors and levels posing the greatest barriers to rehabilitation in my population includes
– qualitative and quantitative data infrastructures,(ie presence or absence of ramps) cultural and political barriers with luck of funding to facilitate rehabilitation services, few or limited number of expertise together with present of marginalized social categories like gender and socioeconomic status of the individual in need of rehabilitation services.
2.How does my own professional expert and organizational access suggest where I might be most effective in developing and launching an intervention;
Since I am general practitioner I might be effective in either levels from primary (ie includes from household intervention as our institution involved in home based care to community level) and according to the context and condition expertism.

3. Formative research needed to understand the precise intervention would be;
-Qualitative research, where individual or client will be interviewed to learn more about the challenge they face to obtain rehabilitation services and knowledge about rehabilitation care that will suggest the best intervention that will help improve access to care and address individual health inequities. Also it will aid in assessing the acceptability of the intervention.

4. When considering potential intervention, the following factors related to implementation are needed to consider;
– acceptability – is intervention agreeable to the situation
-Adoption- looks on commitment of stakeholders to the intervention
-Cost- is the suggested intervention cost effective
-Feasibility – can it be successful if carried out in our setting or organization
-Fidelity can it be carried out according to the intended protocol
– Penetration to what extent can the chosen intervention be integrated across sittings.
– Sustainability, can it be sustainably maintained in the long term
The given intervention should be (timely, safe and patient centered)

5 Implicit biases that may be at work in my culture or contex may include
Biases against persons based on their
Gender, Ethnicity, Race, Income level, Social status, Education level, Employment, health status, Mental status etc
These may impact those individuals interaction with rehabilitation care as;-
Individual may face disparities in the assessment and diagnosis of conditions requiring Rehabilitation as patient may receive inaccurate diagnosis based on their race, gender or /and socioeconomic status.
Certain group may receive less attention or less treatment options (recommendations) due to their gender or social status.
Patient from marginalized social categories (ie race, gender etc) May face barriers like limited referrals, limited availability of care.
Adherence and outcome may be poor because patient or individuals who are discriminated in their care may not adhere to rehabilitation plan or attended follow up appointment or trust their care provider. Addressing these biases involve awareness, training and system change to ensure equity to access to rehabilitation care to all population.

[Zaynab Khalfan]

1. What evidence do I have (or need) to identify those factors and levels posing the greatest barriers to rehabilitation in my population?
In Tanzania context the possible factor that have greater chance of being a barrier in implementing rehab program are
Resource: there is few or in no technical expert and rehab equipment (ie assistive technology)
Rehab indicator in health information system: in Tanzania context DHIS2 is the main warehouse that aggregate data from primary facility to finalise the health data but in this DHIS2 tool there is no indicator for rehab program that hinder to evaluate the rehab intervention
Policy: the guideline to support implementation of rehab intervention is very challengeable that possibly hinder the whole implementation of rehab program
Community perception: community tend to describe victim with disability as non-function that made most of them develop stigma that influence them not to engage in productivity
The level of obstacle are stated from individual, household ,institution, community and lastly superstructural

2. How does my own professional expertise and organizational access suggest where I might be most be effective in developing and launching an intervention?
The most effective part that can be addressed are clinical case and data analysis
By ensuring that every staff committed to his work so to ensure DALY is increased and prevent premature death
Data analysis is a crucial aspect in rehab program as it will stand to evaluate the economic evaluation of an intervention.

3. What formative research might be needed to understand the precise intervention that would be most appropriate and impactful towards overcoming the challenges I identify?
The commonly formative research to be used are
Needs Assessment: Conduct a thorough needs assessment to identify specific barriers and gaps in current rehabilitation services.
Literature Review: Review existing literature on successful interventions in similar contexts to inform your approach.
Pilot Studies: Implement pilot studies to test the feasibility and effectiveness of potential interventions on a small scale before broader implementation

4. When considering potential interventions, what factors related to implementation do I need to consider?
Implementation Factors to Consider:
Resource Availability: Assess the availability of financial, human, and technological resources needed for the intervention.
Stakeholder Engagement: Engage key stakeholders, including patients, healthcare providers, and administrators, to ensure buy-in and support.
Training and Support: Develop training programs for staff to ensure they are equipped to implement the intervention effectively.
Scalability and Sustainability: Consider how the intervention can be scaled up and sustained over time.

5. What implicit biases may be at work in my culture or context and how do those implicit biases impact an individual’s ability to access and benefit from rehabilitation?
Implicit Biases Impact:
Racial and Ethnic Bias: Biases against certain racial or ethnic groups can lead to disparities in rehabilitation referrals and quality of care, reducing access and benefits for these populations.
Socioeconomic Bias: Assumptions about individuals from lower socioeconomic backgrounds may affect the resources allocated to their care and their adherence to rehabilitation programs.
Age Bias: Older adults might receive less aggressive or comprehensive rehabilitation due to assumptions about their recovery potential.
Disability Bias: Biases against individuals with disabilities can lower expectations for their improvement, impacting the quality and intensity of care provided.
Gender and Weight Bias: Gender stereotypes and weight biases can influence treatment recommendations and the level of encouragement patients receive.
Addressing Biases:
Training and Education: Provide implicit bias training for healthcare providers to raise awareness and reduce the impact of biases on decision-making.
Standardized Protocols: Implement standardized protocols to ensure consistent and equitable care across all patient groups.
Patient Advocacy: Promote patient advocacy initiatives to empower patients to voice their concerns and needs, ensuring their perspectives are considered in care planning.

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02. . How does my own professional expertise and organizational access suggest where I might be most be effective in developing and launching an intervention?
Given my specialized knowledge and available resources, I am confident in my ability to develop and implement a highly effective telehealth intervention for neuromusculoskeletal disorders. Despite the limited availability of centers in Tanzania, there is significant potential for implementing telehealth for a range of rehabilitation services that include assessment, monitoring, therapy, prevention, supervision, education, consultation, and counselling to reach a larger and growing population.

03. What formative research might be needed to understand the precise intervention that would be most appropriate and impactful towards overcoming the challenges I identify?
The formative research encompasses various methods including interviews, surveys, focus groups, and usability testing. When recruiting participants, it’s crucial to select individuals who accurately represent your target user group. It’s essential to ensure a diverse range of participants to capture various perspectives and insights, and to use the evidence to guide my intervention.

04. When considering potential interventions, what factors related to implementation do I need to consider?

I need to consider the following factors related to implementation:
(I) Acceptability: The satisfaction level of different stakeholders involved in the implementation with various aspects of the intervention, such as content, delivery, and complexity.
(II) Adoption: The rates at which the intervention is being taken up or used at the practitioner and/or healthcare organization level.
(III) Appropriateness: The suitability of the program for healthcare consumers, practitioners, and/or healthcare organizations.
(IV) Feasibility: The practicality of the intervention for everyday use at the practitioner and/or healthcare organization level.
(V) Fidelity: The delivery of the intervention as originally designed.
(VI) Implementation cost: Assessments of the marginal cost, cost-effectiveness, or cost benefit.
(VII) Penetration: The degree to which the intervention is integrated within healthcare organizations.
(VIII) Sustainability: The continued delivery of the intervention beyond the study period, including the characteristics of the implementation context that did or could influence the continuation of intervention delivery.

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1. For Needs Assessment: The evidence that i need to identify factors and levels posing the greatest barriers to rehabilitation in in my population may include Rapid Assessment Survey 2023 that is available and ready for use. More so there is Uganda Bueural of Statistics population Census carried out i 2024 tat may speak to the number of persons with Disabilities in Uganda. This kind of data will inform the interventions needed and perhaps identify the gaps as far as Rehabilitation is concerned. In addition to that more surveys, Medical records and Health Information Management System would sources for data to identify gaps.

2.By; Ensuring that all the information and communication on Rehabilitation and AT is inclusive for the public to be able to acquire knowledge on the same. Due to my expertise it should be deliberate that all the information is facilitated or oriented in away that it can be accessed by especially persons with Disabilities by use of braille and sign language formats and also translated into local languages to reach the most vulnerable people who include older persons and the illiterates.

3. The formative research that would be the most appropriate would be Community based /Household Survey/Research because all issues start in the community and end in the community and besides it is community people that may be facing such challenges when it comes to access to Rehabilitation

4.Development of a communication strategy on Rehabilitation and AT which may include activities such as Education via mass campaigns on rehabilitation since there is limited knowledge on it. This could be another way of sensitizing the population on especially what rehabilitation means, who is eligible for rehabilitation, among other areas.
More so there is need to have Uganda National Strategic plan for rehabilitation which will be a very crucial tool to inform the work plans of different stakeholders in the country.
In addition to that, Engagement of various stakeholders from national level up to communities. The policy makers : members of parliament should be engaged on rehabilitation needs for them to have knowledge that will inform their decisions during budget allocation.
Digitalization of rehabilitation in order to reach the hard to reach areas and persons who may be in need for rehabilitation for example by use of Telerehabilitation.
Strengthen Monitoring and Evaluation on Rehabilitation interventions is very critical
More research and Surveys

5. These are biases based on Disability, Gender, ethnicity, race, sexual orientation, income inequalities and levels, education attainment levels, employment status among others which will affect the impact of acceptability, adoption, cost, fidelity, penetration sustainability and monitoring and Evaluation in one way or the other.

[Albert Erongu]

1.
Needs assessment through surveys and research. the Systematic Assessment of Rehabilitation situation in Uganda (STARS) 2022 and rATA 2023 reflects on the gaps in accessing rehabilitation services. Access to rehabilitation facilities is one of the gaps due to the coverage, limited knowledge about rehabilitation services amongst the community members, poor support from caregivers, and costs associated with rehabilitation and AT services.

2. Integration of rehabilitation into the health system is the key to universal health coverage through training of PHC providers in lower health facilities to provider basic rehabilitation services, recruitment of rehabilitation professions

3.More research is required like surveys and the use of available literature through the different government ministries. The recently concluded Census plays a critical role in understanding the required interventions.

4.
• Feasibility – the extent to which the intervention can be successful must be determined.
• consideration of the intervention’s acceptibility by stakeholders.
• Sustainability; I will consider establishing strategies for how the intervention will be sustained over the long term
• The commitment and action from the relevant stakeholders to try the intervention.
• Fidelity-confidence that the intervention can be carried out according to the full and intended protocol
• The relevance and compatibility of the intervention with the particular stakeholder group or organization
• Penetration-consideration of the extent the intervention can be integrated across settings.
• Consideration of the intervention cost impact.

5.
Implicit biases may include biases against persons based on race, ethnicity, gender, socioeconomic status, education etc. However, not all biases in all societies, and not everyone will hold such biases. This affects how individuals interact with the healthcare system

[Yasmin Garcia Mendez]

What evidence do I have (or need) to identify those factors and levels posing the greatest barriers to rehabilitation in my population?
The is sociodemographic data but no other evidence a part from that as long as I know. I will need to do a literature search on the specific information needed. The STARS, ATA-C and rATA tools may help to collect specific information on factors at each specific level environment. For example, these tools might help to get information at the institutional and superstructural levels, and might proportionate few at the community level. rATA might help to get more information at the individual and household level but might need to be modified to get more information on the knowledge, skills and self-efficacy of the individual as well as the household support and social networks.
For AT intervention, I need to get information on public policy, institutional capacity and functioning, community barriers to access AT services, characteristics of the individual to select best AT intervention, barriers to access and use the AT, etc.

How does my own professional expertise and organizational access suggest where I might be most be effective in developing and launching an intervention?
I will be more effective in developing and launching an intervention at the superstructural level. As we work by providing technical support and cooperation to Ministries of Health in the region of the Americas. We don’t have contact with patients or their families, we can create impact by helping the governments to improve their policies, create their strategic plans on rehab and AT, supporting identifying priority actions to strengthen rehab in health sector, etc.

What formative research might be needed to understand the precise intervention that would be most appropriate and impactful towards overcoming the challenges I identify?
Research on interventions that affect and promote the governments uptake of initiatives to strengthen rehab in health systems and increase financing for AT and rehab. How to increase the governments interest and the political will for AT and rehab. How to increase political support.

When considering potential interventions, what factors related to implementation do I need to consider?
individual factos, household and familial factors, community factors, institutional factors, public policy factors.

What implicit biases may be at work in my culture or context and how do those implicit biases impact an individual’s ability to access and benefit from rehabilitation?
There are implicit biases related to the tone of the skin, socioeconomic status, disability, age, gender, and sexual orientations. Those factors impact the individuals ability to access and benefit from rehab in terms of affordability, effectiveness, equity, and time.

[Tshering Penjor]

1. What evidence do I have (or need) to identify those factors and levels posing the greatest barriers to rehabilitation in my population?
Ans= Some of the evidences that i would like to have is about the people’s knowledge, attitude and practice of rehabilitation in general so that i can know where the gap is.
2. How does my own professional expertise and organizational access suggest where I might be most be effective in developing and launching an intervention?
Ans= As my work area is at the hospital, it is more appropriate for me to provide the intervention at institutional level. But I can also do it at personal and community level.
3. What formative research might be needed to understand the precise intervention that would be most appropriate and impactful towards overcoming the challenges I identify?
Ans= Research on why people in my community faces less access to rehabilitation services.
4. When considering potential interventions, what factors related to implementation do I need to consider?
Ans= All the possible factors like personal, household, community, institutional and even the policy factors..
5. What implicit biases may be at work in my culture or context and how do those implicit biases impact an individual’s ability to access and benefit from rehabilitation?
Ans= Especially the socioeconomically deprived population. This impacts their accessibility to rehabilitation through affordability and transportation issues.

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1.What evidence do I have (or need) to identify those factors and levels posing the greatest barriers to rehabilitation in my population?
-The greatest barriers to rehbailitation in Nepal could be lack of adequate HR, Infrastructures, financing, leadership and integration of rehabilitation at all levels of healthcare system. There has been significant awareness among the leading entities in the government, stakeholders and user groups but still a lot more to do as an action in every corners of Nepal. Many developments, researches, studies are in place but need to align those evidences in practice. Need to apply evidence informed decision making in coming days.

2.How does my own professional expertise and organizational access suggest where I might be most be effective in developing and launching an intervention?
– At present, I am working as capacity building officer. Working closely with government entities at Institutional level and Intersectoral level would be effective.
3.What formative research might be needed to understand the precise intervention that would be most appropriate and impactful towards overcoming the challenges I identify?
-Rehabilitation gaps analysis(assessment) could be important at present to overcome challenges.

4.When considering potential interventions, what factors related to implementation do I need to consider?
-Implementation factors: at present implementation cost, penetration and sustainability needs to be considered.

5. What implicit biases may be at work in my culture or context and how do those implicit biases impact an individual’s ability to access and benefit from rehabilitation?
-implicit biases related to the socioeconomic status, disability, age, gender, and sexual orientations. Those factors impact the individuals ability to access and benefit from rehab in terms of affordability, effectiveness, equity, and time.

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1. What evidence do I have (or need) to identify those factors and levels posing the greatest barriers to rehabilitation in my population?

There is need to carry out socio demographic study which will help to highlight the factors posing barrier to rehabilitation. With my years of practice, l was able to identify some of the barriers to rehabilitation such as distances to the facilities that has rehabilitation services, cost of public transport, few facilities offering rehabilitation services, poor referral by other health professional and ignorance about rehabilitation services among others.

2. How does my own professional expertise and organizational access suggest where I might be most be effective in developing and launching an intervention?

At the moment working with ReLAB-HS as rehabilitation technical officer seconded staff to Ministry of Health offering technical support to the division of Disability and Rehabilitation, am able to voice my concern on taking rehabilitation services to the last mile by advising the division to adopt the WHO training of Basic Rehabilitation Package for primary health care workers to help in task shift.

3. What formative research might be needed to understand the precise intervention that would be most appropriate and impactful towards overcoming the challenges I identify?

Carry out a research with the title of rapid assessment on the status of rehabilitation services within the targeted population

4. When considering potential interventions, what factors related to implementation do I need to consider?

The factors l can consider are; Acceptability which highlight the perception among stakeholders that the intervention is “agreeable, palatable, or satisfactory”, feasibility which help to know Whether the intervention can be successfully carried out in my setting, the cost impact of the intervention; appropriateness which is the “perceived fit, relevance, or compatibility” of the intervention with the particular stakeholder group or organization

5. What implicit biases may be at work in my culture or context and how do those implicit biases impact an individual’s ability to access and benefit from rehabilitation?

The implicit biases in my culture are socioeconomic, gender, stigma about disability and age where the healthcare service provider sees like there is no need for older persons to seek rehabilitation services because they take it as a waste of time to rehabilitate them.

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1. What evidence do I have (or need) to identify those factors and levels posing the greatest barriers to rehabilitation in my population?
While a lot of evidence exists on barriers to access to rehabilitation, limited evidence exists on barriers to access assistive technologies. Conducting a market of most prevalent rehab conditions and associated ATs that are need to support rehab efforts will be helpful to understand barriers to access from a financial, supply, demand and regulatory perspective. Conducting a market diagnostic will require looking at existing census data, demographic health data, procurement data, policies/regulations related to AT procurement, distribution, financing, etc. among other things as well as conducting key informant interviews with stakeholders including patients, government, NGOs, etc. The outputs from this diagnostic analysis will help to identify what the barriers are as well as their root causes.

2. How does my own professional expertise and organizational access suggest where I might be most be effective in developing and launching an intervention?
Given that my organization focuses on health system strengthening at the national level, I may consider implementing institutional or superstructural interventions.

3. What formative research might be needed to understand the precise intervention that would be most appropriate and impactful towards overcoming the challenges I identify?
Key informant interviews with patients and key government stakeholders (MoH, Social Ministries, Prime Minister’s Office), would be integral to understand the priorities (i.e. from patients – which assistive technologies are most needed and which ones aren’t currently available; from governments – where do they see the biggest challenges; how does this link with existing priorities such as economic productivity, universal health coverage, etc.). This can help to prioritize the area of focus for the intervention.

4. When considering potential interventions, what factors related to implementation do I need to consider?
Interventions will have to garner leadership buy-in, particularly if thinking about superstructural interventions. A cost impact analysis as well as acceptability will need to be considered (i.e. if developing product standards for specific AT products in the country and adding them to a product priority list, then the standards will have to be acceptable by the users, and meet the needs/quality expectations of users, etc.) In addition, sustainability of the intervention will need to be considered (i.e. will there be long-term and predictable financing for these products in the future; what will be the sources, etc.)?

5. What implicit biases may be at work in my culture or context and how do those implicit biases impact an individual’s ability to access and benefit from rehabilitation?
Many assistive technologies require time and investment in proper fitting, maintenance and follow-up. If patients are living very far from where AT products/services are being delivered, providers may not prescribe them any because they fear patients will not adhere to the required plan for fitting and maintenance. Providers may also be hesitant to offer any financial means for covering transport costs to overcome adherence challenges, because of the implicit bias related to income levels and fear that the money that is to be used for transport will be used for other things such as food, clothing, school, etc.

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1. To identify the factors and levels posing the greatest barriers to rehabilitation in the Tanzanian population, you need evidence from national health surveys like the Tanzania Demographic and Health Survey (TDHS) for insights into service access disparities, and facility assessments such as the Service Availability and Readiness Assessment (SARA) to highlight infrastructural limitations. Qualitative studies involving interviews and focus group discussions with patients and healthcare providers can reveal cultural attitudes and societal factors affecting rehabilitation. Additionally, analyzing patient records and referral patterns, reviewing national health policies, and engaging in community-based participatory research can provide a comprehensive understanding of the systemic and community-level barriers to accessing and benefiting from rehabilitation services in Tanzania.

2. My expertise uniquely positions me to develop and launch health interventions that effectively address community needs. My clinical experience allows me to understand patient perspectives and health challenges. This combination enables me to identify specific health issues within the community, design evidence-based interventions, and leverage my organizational access to resources and networks for effective collaboration. My holistic understanding of health systems and patient care ensures that interventions are both practical and impactful, leading to sustainable improvements in community health outcomes.

3. To identify the most appropriate and impactful intervention, formative research should include conducting a community needs assessment through surveys, focus groups, and interviews to gather insights directly from community members about their specific health challenges and barriers. Additionally, a literature review of existing interventions in similar contexts can provide evidence-based strategies. Engaging key stakeholders, such as local health providers and community organizations, will help identify available resources and foster collaboration. Assessing the health behaviors and attitudes of the target population is crucial to ensure that the intervention aligns with their values. Lastly, pilot testing a small-scale version of the intervention can provide valuable feedback and allow for necessary adjustments before broader implementation.

4. When considering potential interventions, there is a need to account for several key factors related to implementation, including the availability of resources (financial, human, and material), the readiness and capacity of the target community, and existing infrastructure that can support the intervention. Stakeholder engagement is crucial to ensure buy-in and collaboration from local organizations and community members. There should also be a consideration for the training needs of personnel involved in delivering the intervention, as well as any regulatory or policy considerations that may affect implementation. Additionally, the scalability and sustainability of the intervention should be assessed to ensure it can be maintained long-term and adapted as needed to meet evolving community needs.

5. Implicit biases in my culture include stereotypes about certain demographics, leading to assumptions about their capabilities or willingness to engage in rehabilitation. These biases result in unequal treatment, where individuals from marginalized groups face barriers to accessing services due to stigma or a lack of culturally competent care. Consequently, these biases can hinder the effectiveness of rehabilitation efforts, as individuals may feel discouraged or unsupported, ultimately impacting their recovery and long-term outcomes.

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2. How does my own professional expertise and organizational access suggest where I might be most be effective in developing and launching an intervention?
Advocating and system mobilization to integrate rehabilitation into health system.

3) What formative research might be needed to understand the precise intervention that would be most appropriate and impactful towards overcoming the challenges I identify?
Rehabilitation situation/status assessment and analysis is important. Based on its findings on which specific building block the rehabilitation context/status has gaps needs to be well analyzed and formulate strategies and recommendations. Example if rehabilitation financing of a particular country is weak or if there is not much budget allocated for rehabilitation or allocated rehabilitation budget needs to be tracked from national health account then likewise, activities recommendation needs to be developed/ planned.

4) When considering potential interventions, what factors related to implementation do I need to consider?
Factors such as system readiness, stake holders’ acceptance, resource availability such as budget, human resource and timeline needs to be considered.

5) What implicit biases may be at work in my culture or context and how do those implicit biases impact an individual’s ability to access and benefit from rehabilitation?
Implementation biases such as against persons based on their gender, ethnicity, race, sexual orientation, income level, educational level, employment, health status. Those implicit biases can impact an individual’s ability to access and benefit from rehabilitation by getting delay in rehabilitation intervention, making high out of pocket expenditure.

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1. What evidence do I have (or need) to identify those factors and levels posing the greatest barriers to rehabilitation in my population?

Using the example of risk of falls in the elderly in NYC: I have statistical evidence from NYC.gov; the New York State Department of Health; CDC data. Additionally, there is hospital level data from emergency room, and injures that occur while inpatient at hospitals. Qualitative data such as surveys, key informant interviews would be helpful to identify at risk populations and their barriers to services for both treatment of falls, and more importantly to services targeting the prevention of falls. Perhaps NYC housing authority can provide information on age of tenants to help drive targeted interventions.

2. How does my own professional expertise and organizational access suggest where I might be most be effective in developing and launching an intervention?
As a physical therapist, I am more naturally drawn to the core levels of the social ecological model (SEM). I have years of targeted intervention therapy on an individual level. I also can impact the household level with home visits and home care through environmental modifications and family training. In the past, I have worked at inpatient rehab centers that incorporate community reintegration such as how to physically navigate public transportation. Patient education includes sharing information about community and transportation services, although that is often managed by the hospital social worker. I have less of an impact as we move to the outer rings of the SEM. As a therapist, I can impact the institutional level of our hospital system by giving feedback and being engaged with hospital wide meetings, although truthfully our voices are often drowned out in wider meetings. I am so interested in learning more about the policy interventions through the superstructural level of SEM through this GRLI experience.
3. What formative research might be needed to understand the precise intervention that would be most appropriate and impactful towards overcoming the challenges I identify?
-Quantitative, longitudinal research demonstrating effect of targeted fall prevention strategies in marginalized populations and outcomes.
-Qualitative research including surveys, key informant interviews and case studies can illustrate and inform the need to allocate resources in fall prevention interventions.
4. When considering potential interventions, what factors related to implementation do I need to consider?
In addition to the following factors, I would utilize the Heath Beliefs Model to maximize efficacy of my intervention. Modeling the Pressure Ulcer Education Program in spinal cord injured patients, I would target teaching to the susceptibility and severity of falls in the elderly; maximize self efficacy and address the benefits of fall prevention and the barriers to such a program.
– Acceptability – is intervention agreeable to the situation
– Adoption- looks on commitment of stakeholders to the intervention
– Cost- is the suggested intervention cost effective
– Feasibility – can it be successful if carried out in our setting or organization
– Fidelity can it be carried out according to the intended protocol
– Penetration to what extent can the chosen intervention be integrated across sittings.
– Sustainability, can it be sustainably maintained in the long term
The given intervention should be (timely, safe and patient centered)
5. What implicit biases may be at work in my culture or context and how do those implicit biases impact an individual’s ability to access and benefit from rehabilitation?
I work at a busy NYC hospital that sees a multicultural patient population. There are a lot of examples of implicit bias, from race to gender and myriad other examples in between. However, I am specifically thinking of age for my answer. I think that often older patients present in the hospital with altered mental status as a result of anesthesia effects of surgery or side effects of pain medicine. However, altered mental status may also indicate an underlying infection or other organic cause. In these cases, if the root cause is not addressed the patient may have, at best a limited ability to participate in rehab services, and at worst an increased risk for fall or worsening medical status. I think there is an implicit bias that diminished mental acuity is acceptable or more prevalent in elderly without proper assessment of patient prior level of functioning through chart history or patient family interview.

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1. What evidence do I have (or need) to identify those factors and levels posing the greatest barriers to rehabilitation in my population?
Understanding the root causes of challenges limiting access to Rehab services. I.e. Identifying groups of people that are not accessing rehab services and digging deeper to understand why

2. How does my own professional expertise and organizational access suggest where I might be most be effective in developing and launching an intervention?

3. What formative research might be needed to understand the precise intervention that would be most appropriate and impactful towards overcoming the challenges I identify?
– A pilot intervention to address an identified challenge

4. When considering potential interventions, what factors related to implementation do I need to consider?
Feasibility, acceptability, appropriateness,

5. What implicit biases may be at work in my culture or context and how do those implicit biases impact an individual’s ability to access and benefit from rehabilitation?
– gender, economic status, age, religion, tribe. All these can prevent an individual in getting equal access to services. For example, women may have a harder time accessing services than men. Additionally, older women might be ignored when getting services. In certain regions, some tribes might be ignored etc

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1. What evidence do I have (or need) to identify those factors and levels posing the greatest barriers to rehabilitation in my population?

Resp : To identify those factors posing the greatest barriers to rehabilitation in my population, i need evidence concerning the already existing rehab services and the level of their integration through systematic assessment of rehab in the healthcare system. I will also need to have information related to environmental factors that can be obtained through censuses, social registries or population surveys. I can also use some of the frameworks like the iPARIHS or CFIR or TDF to identify those barriers.

2. How does my own professional expertise and organizational access suggest where I might be most be effective in developing and launching an intervention?

Resp : As a physiotherapist in the CSO sector and with multilevel experience, i think i might be effective while developing and launching an intervention at individual, household, institutional and community level. Particularly i may also intervene very partially at superstructural level while supporting other multidisciplinary teams.

3. What formative research might be needed to understand the precise intervention that would be most appropriate and impactful towards overcoming the challenges I identify?

Resp : I think that a literature and documentation review combined with focus group discussions and in depth interviews might all be appropriate and impactful in deciding which strategy to use to overcome the identified challenges.

4. When considering potential interventions, what factors related to implementation do I need to consider?

Resp : Factors to consider are Acceptability, adoption, appropriateness, cost, feasibility, fidelity, penetration and sustainability.

5. What implicit biases may be at work in my culture or context and how do those implicit biases impact an individual’s ability to access and benefit from rehabilitation?

Resp : Like in other common context, implicit biases at work in my context include mainly income level, educational attainment, employment status, health status, mental health status, …

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