Participant characteristics
Ten nurses participated in the FGD. Among them, 70% were females and 30% were males. The participants’ ages ranged from 30 to 60 years, with an average age of 42.1 years. The participants’ professional experience in outpatient services was between 3 and 24 years (Table 1).
Main findings
Data analysis revealed three major themes that are described in Table 2.
Nurses’ understanding and experience with rehabilitation services
All participants understood that rehabilitation is the process of restoring the functional ability of someone after an injury, a disease, or a health condition. According to them, the purpose of rehabilitation is to help someone regain a normal or near to normal functional life. Participants acknowledged the importance of rehabilitation in the restoration of the functional ability of persons who encountered disabilities. One participant defined rehabilitation as:
‘The process of returning people to the life where they were before they had a health problem’. (Participant 9).
Another participant affirmed:
‘Yes, what I can say, is those people who have encountered disabilities need to return to their normal lives, just as they were before’. (Participant 5)
Participants identified some examples of how rehabilitation can be used to restore the functional ability of a person with a disability. They emphasized the importance of replacement of an injured body part with assistive devices. As an example, participants mentioned; an amputated person due to an accident can walk again by using a prosthesis. The participants understood that the replacement of a lost or damaged organ or limb is part of rehabilitation services. Participants mentioned that:
‘If a person had an accident and the leg gets amputated, rehabilitation would be giving that person a prosthesis to help him/her walk again as they used before having an accident’. (Participant 9).
‘Someone may be visually impaired. They may need glasses to help them see clearly as they used to do. Additionally, someone may have a hearing disability and may be able to regain hearing. Another example is a person who may become injured in the leg and be helped to obtain a prosthesis. (Participant 7).
Participants understand that rehabilitation and assistive devices can help to restore the functional abilities of people with disabilities and enable them to participate in the community.
Disability cases presented at the health center and the unmet needs of rehabilitation services
Study participants discussed rehabilitation needs in primary care by identifying disability cases mostly encountered at the health center in the outpatient services. They included:
Mobility related disabilities
Overall, participants mentioned that mobility related disabilities are not treated at health centers. For example, people with amputated legs, people with injuries such as fractures, and people with paralyzed body parts do not receive rehabilitation care at health centers. Participants stressed lack of rehabilitation services for persons with mobility related issues as:
‘There are people who come here with valgus, to seek services that would help then heal their feet or legs. Unfortunately, they didn’t receive the services needed. (Participant 1).
‘For people with physical disabilities, we receive them and issue a transfer to a hospital where they can be assisted, as we don’t have prosthetics to give them. They come, and we transfer them to the hospital for follow-up care’. (Participant 6).
The above expressions highlight limited knowledge on rehabilitation care and unavailability of assistive products at health centers. Scarcity of rehabilitation professionals and required equipment or materials hinders delivery of quality rehabilitation services.
Sensory and vocal disabilities
People with sensory and vocal related disabilities such as persons with hearing and speaking disabilities, seek rehabilitation services at health centers. Unfortunately, participants mentioned that these services are not available at all health centers. Participants explained that:
‘I believe there are no other disabilities we can address at our health center, as we don’t have specialized health care providers, except for the ophthalmologist who can help with vision issues. However, for those with speech impairments, we do not have any services for them at the health center to assist them’. (Participant 6).
‘If for instance, you receive a person with a speech impediment, it may have resulted from sickness or something else. We don’t have the equipment to assess that, that is why we transfer them to the hospital because they have that equipment and skills’. (Participant 7).
‘I would like to talk about people with hearing impairment. We often encounter them but most of the time we don’t have enough skills, as nurses to communicate with such person so that he/she can listen to the message we are trying to transmit. We listen to such person, but we don’t have skills on how to talk properly to that person so that they would understand. communication with them is an issue especially those who have both hearing and speech impediment’. (Participant10)
Congenital malformations and developmental delays among children
Participants reported instances of impairments in children, observed in outpatient services at the health center. These included children born with clubfoot, limb abnormalities, developmental delays, speech and hearing problems, and epilepsy. However, the rehabilitation services required for these children are not provided at the health center. Participants reflected:
‘We always receive children who were born with a congenital malformation or were born prematurely or with trisomy, but we don’t treat them because we don’t know those cases’.(Participant 6).
‘They are not very common; for instance, those born with what we call club feet have severe deformities of their feet are not treated at health centers’. (Participant 5).
Non-communicable diseases linked disabilities
The study participants observed non-communicable diseases, particularly hypertension as one of the causes of disabilities among older adults. Although health services for non-communicable diseases are available at health centers; however, when a person gets stroke and becomes paralyzed, they cannot find rehabilitation services at the health center. Participants explained:
‘I often see older people who have high blood pressure, in a short period the blood pressure will rise, and they will get a stroke. They become paralyzed, their legs can’t work, even their arms. People with paralyzed limbs face difficulty to access rehabilitation services. (Participant 5).
‘We also provide services for hypertension, diabetes, and asthma. There’s also an eye care service. However, we do not have a service for people who have paralysis’. (Participant 3).
All participants confirmed that they often encounter disability cases that need rehabilitation at the health center. However, participants emphasized the limited access to rehabilitation services among persons with disabilities due to deficiency of specialized rehabilitation services, trained health professionals and required equipment and materials at health centers. All of these hinder the availability of rehabilitation services at the health center level.
Navigating the current management practices of disability cases at rural health center
Nurses’ experience and practice in rehabilitation service delivery at health center
All participants reported receiving persons with disabilities in outpatient services. However, the management of disability cases depends on one’s knowledge of that condition and the availability of materials or equipment at the health center. Limited knowledge of rehabilitation services among nurses affects rehabilitation service delivery, hindering accurate diagnosis, and timely disability management. One participant stated:
‘For instance, if you receive an injured person with a broken femur, you write that you suspect a femur fracture, you don’t confirm it then transfer them to the hospital so that they do further examination’. (Participant 2).
In general nurses’ involvement in disability case management is limited to consultation and offer a transfer to the district hospital. Nurses believe that they cannot manage disability cases, as they are not professionally trained to manage such cases, and they also feel unqualified due to limited knowledge and lack of training in rehabilitation cases management.
Rehabilitation services delivered at rural health centers
All rehabilitation services are not available at health centers, only two different rehabilitation services are available at some of the health centers. For instance, mental health issues are treated at health centers, as many health centers have a mental health nurse and mental health services. Furthermore, a few participants mentioned that primary eye care services are also available at few health centers. This underlines the inequities in health service accessibility among persons with disabilities. Participants mentioned:
‘In general, there are mental health-related services at the health center. The government hired mental health nurses who provide services to people with mental health issue’. (Participant 5).
Few Health Centers have ophthalmology services that provide basic eye care to people with visual impairment. This service has trained professionals to provide needed rehabilitation care. However, participants mentioned that severe and complicated cases are transferred to the hospitals. Participants explained:
‘I would say we have a specific service at the health center to help people. Sometimes a person comes seeking treatment, claiming they cannot see. In that case, there is an ophthalmologist who performs basic exams called primary eye care to determine if the person is truly blind. If they find that the person is blind, they give a transfer to a hospital’. (Participant 6).
‘Ophthalmologists at the health center help people with visual problems, but when it is a case that needs complex care, they transfer them to the hospital for further management’. (Participant 10).
Despite the integration of mental and ophthalmology services at health centers, these services face challenges that impede comprehensive rehabilitation services delivery to all people in need.
Outreach model to deliver rehabilitation services at rural health center
Few participants mentioned outreach models as an innovative way of delivering rehabilitation services to the community. This occurs when rehabilitation specialists from hospitals reach out to the health centers or community to deliver rehabilitation services. This model mainly focuses on the identification of cases through screening and consultation. However, participants stressed inadequate sessions for outreach. They stated:
‘Another thing I want to add on those services for disabled people, sometimes hospital staff come to the health center, but they do that few times, a maximum of twice a year. You understand that two occasions are very few considering the number of people who need access to those services. I think they should increase their visit to health centers’. (Participant 9).‘
Most of the time health professionals from the hospital come to the community and do screening of people who have vision impairment, these are only doing screening and identifying cases, but they do not provide treatment’. (Participant 5).
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