The call for institutions of higher education to foster interaction with communities and ensure training is responsive to the needs of communities is well documented. In 2011, Stellenbosch University collaborated with the Worcester community to identify the needs of people with disabilities within the community. How the university was engaging with these identified needs through student training still needed to be determined.
This study describes the engagement process of reciprocity and responsivity in aligning needs identified by persons with disability to four undergraduate allied health student training programmes in Worcester, Western Cape.
A single case study using the participatory action research appraisal methods explored how undergraduate student service learning was responding to 21 needs previously identified in 2011 alongside persons with disability allowing for comprehensive feedback and a collaborative and coordinated response.
Students’ service learning activities addressed 14 of the 21 needs. Further collaborative dialogue resulted in re-grouping the needs into six themes accompanied by a planned collaborative response by both community and student learning to address all 21 needs previously identified.
Undergraduate students’ service learning in communities has the potential to meet community identified needs especially when participatory action research strategies are implemented. Reciprocity exists when university and community co-engage to construct, reflect and adjust responsive service learning. This has the potential to create a collaborative environment and process in which trust, accountability, inclusion and communication is possible between the university and the community.
Rural health science training is not a new concept, particularly for medical students globally. The earliest account of this in South Africa was in KwaZulu-Natal in the 1940s and later in 1992 with the Allied Health Sciences (AHS). In a study by Pillay et al. (
Stellenbosch University’s (SU) Ukwanda Centre for Rural Health established the first rural clinical school (RCS) as an official rural campus to Tygerberg Faculty of Medicine and Health Sciences (FMHS) in 2011. The purpose of this school was to equip students with the skills and willingness to work in rural and underserved areas (Van Schalkwyk et al.
While the university was in the preparatory stages for the placement of students in this rural school, a conference was collaboratively hosted by the Faculty of Theology, the Centre for Rehabilitation Studies (CRS) and the Department of Psychology at SU with the theme Disability, Theology and Human Dignity. This was SU’s first international interfaculty conference. The third day of this conference was held at the campus of the National Institute for the Deaf in Worcester with the goal of meeting with a group of persons with disabilities in Worcester. The rationale for this was to get an understanding of the needs of persons with disability in Worcester as the FMHS at the time was busy developing an RCS for students’ rural placement. From this third day of the conference, a two-page list of needs was then developed and handed over to clinical facilitators of the above-mentioned divisions. These expressed needs are tabulated in
This was also a helpful internal process for SU to further discuss the issues of disability and human dignity within a broader university strategy. The Hope project, which is SU’s institutional response to issues of poverty and vulnerability in Africa, chimes closely to some of the 2011 conference recommendations and the needs that had been specified by persons with disabilities in Worcester. Subsequent to this, the CRS started planning how to ensure that clinical facilitators that are placing students in Worcester with the goal of responding to the needs of persons with disabilities in that area are using the list to guide them in placement of students (Ned et al.
This article therefore focuses on how academic coordinators responded to the list of needs as expressed by persons with disability through the students’ rural clinical practice blocks in Worcester.
The RCS is a small campus consisting of six clinical educators and ten support staff with an average of 50 students on the campus at any one time. Ukwanda Centre for Rural Health focuses on rural placement training, where the Worcester community, students and academic coordinators work closely together. The school encourages collaboration and innovative academic development. Students from the four disciplines are placed in their final year for short clinical block rotations. A portion of students are placed at rural sites and others at urban sites in a 1-year cycle (Pillay et al.
These sites included areas where persons with disabilities sought health care and sheltered work opportunities. These were centres specifically for persons with disability and centres for early childhood development. The sites for training were identified by the academic coordinators who were resident in the community and had been working with the local health system for between 2 and 10 years. The selection was based on needs analyses conducted with the staff at potential training sites, prior to this current project and before the introduction of the CRS. Of the 19 sites, ten of them accommodated more than one division’s students at a time, allowing for Inter-professional education and collaborative practice (IPE) to occur at these sites. The 19 placement sites were predominantly primary health care and community-based services. The students were involved in service learning at clinics, mobile clinics, special schools, non-governmental organisations (NGOs), rehabilitation centres, early childhood development crèches, private practices, hospitals and primary schools.
Each division had their own academic objectives for the student rotations. The primary focus areas were as follows:
Summary of divisional rotations.
Divisions (all final year students) | Physiotherapy | Human nutrition | Speech, language and hearing therapy | Occupational therapy |
---|---|---|---|---|
Year started | 2011 | 2012 | 2013 | 2013 |
Types of rotations a student can do at the RCS in Worcester | Community block Paediatric neurology Adult neurology |
Ukwanda block Community nutrition Food service management Therapeutic nutrition |
Community block |
Physical rehabilitation Psychosocial interaction Community interaction Learning and development |
Length of rotations (weeks) | 6 | 6 | 8 | 6 |
Number of rotations per year | 5 | 4 | 3 | 4 |
Number of students per rotation | 2–3 | 2–4 | 8–10 | 2 |
RCS, rural clinical school.
The objective of this study was to describe the process the university (divisional clinical coordinators in collaboration with the CRS) followed to engage with the needs of persons with disabilities in the Worcester community, through the placement of the AHS students. There is less documentation of the engagement process that takes place between the university and the community. More specifically, this article, firstly, describes the university’s participatory process of responding and, secondly, identifies what is the list of needs that was responded to by the AHS student training at the RCS from 2011 to 2013, followed by recommendations by the community moving forward and plans implemented since.
A single participatory case study in Worcester with persons with disabilities and the community was undertaken following the list of needs they expressed in 2011. Framed within a participatory action research (PAR) approach, this case study methodology was particularly suited with the intention to gain an in-depth understanding into how the undergraduate rural student service learning was unfolding and responding to the expressed needs in this context (Stake
The study site has well-established disability institutions such as National Institute for the Deaf (NID), Institute for the Blind and DEAFNET with international footprints, exposing the various stakeholders that are also involved in continuously addressing needs of persons with disabilities. The list expressed by persons with disabilities highlighted a case for exploration of a collaborative and coordinated response to these expressed needs. It is within this context that the case was formulated. The rurality of the Worcester area within the Western Cape Province also added another context to the case formulation. This case study was the response of the academic coordinators to the expressed list of needs of persons with disabilities. The participatory nature and inclusion of various stakeholders acted as a better fit with the case study in shedding light on multiple perspectives relating to a collaborative response to the needs (O’Leary
In this regard, this tradition of qualitative inquiry was deemed appropriate to use while situating each stakeholder in its historical, political, economic and socio-cultural contexts demanding multiple data sources. This case study was approached in a manner suggested by Stake (
Ontologically and epistemologically, this process was couched within the transformative paradigm which allows for recognition of unequal power held by theorists, the researcher and the participants who may hold dissonant perspectives on disability needs and how to effectively respond. This was an attempt to deconstruct the subjugated views (Henning &Van Rensburg
We applied for ethical clearance from the university and were informed that ethical clearance was not needed and advised to rather apply when interventions begin. The project was interpreted as consultative workshop which does not need ethical approval. Although participatory research is inherently ethically good compared to traditional research, it is also prone to issues of unequal power relations which may result in ethical challenges in partnerships. Thus, the feedback from ethics was concerning particularly because it may speak to poor recognition of PAR as a valid research methodology within the health sciences. This project had an advisory committee which consisted of different representatives from disabled people’s organisations in Worcester. This committee served (amongst other things) to coordinate the activities of the project as well as to ensure the participation and inclusion of persons with disabilities.
Further details are described in the following sections explaining the steps taken in this engagement process.
The RCS AHS coordinators were tasked with preparing a response to how the students’ clinical rotations had been developed around the original needs identified for people with disability. These coordinators received the two-page list of needs for the first time in 2014 and were asked to assess how the AHS students’ training at the RCS was addressing some of these needs identified in 2011. Despite seeing the document for the first time, since the AHS coordinators who were only involved at the RCS after 2011, they engaged with the list of 21 needs, and compared them to the objectives of the clinical activities and the placement of the students. Alignments were noted, gaps were identified and their reflective response was presented to the Worcester community on 27 June 2014. The audience included persons with disabilities from the community, various representatives of disabled people’s organisations and various representatives from service providers across sectors, local government and the academic coordinators. The scope of this work did not document the type of disabilities which were represented in the audience. However, disabled people’s organisations that were present mainly focused on visual, physical and hearing impairments.
Concerning the above-mentioned reflection of how the clinical programmes might be able to meet some of the identified needs expressed during the disability conference in 2011, it was revealed that the service learning of students at Ukwanda spoke to 14 of the 21 needs identified, a summary of which is presented in
List of needs identified with students and staff activities.
List of needs identified in 2011 | Influence of RCS students on meeting these needs | Influence of RCS staff on meeting these needs | Gaps identified and suggestions going forward to meet the needs identified |
---|---|---|---|
1. A work group be established to take forward issues and suggestions arising from presentations and discussions during the conference | No response | A working group consisting of both the CRS and RCS staff was formed to mediate issues between the faculty to guide the training of students and how students could engage with the community | Innovative solutions required for the different outcomes for each division, different planning times, different sites, different rotations |
2. A reference committee consisting of representatives of the seven disability groupings for the workgroup be selected | Community participation and mobilisation to align needs with training using community-based needs analysis | No response | The DoH raising issues that community service therapists lack basic skills for working in rural settings post their training |
3. Clarify terminology | Understanding of disability and the related conceptual frameworks | Understanding of disability and the related conceptual frameworks | There was a need to plan the offering of accredited workshops to keep students up to date with the recent understandings and underpinnings of disability |
4. Include in ECD and primary education the support of parents to enrich parenting skills in raising their children with disability | ECD screening at Empilisweni Clinic performed by all AHS, including education to mothers via private discussion and talks in the waiting area, Vukuhambe Centre for Children with Disability were assessed and treated by PT and SLHT students as well as at ASD where they worked with the PT students, PT students were also involved with children with disability and their parents at Breede Valley APD | HN, SLHT and PT coordinators included ECD in assessment criteria and outcomes for the students rotation in Worcester | OT students were unable to assist with ECD at Vukuhambe, ASD and APD due to other clinical commitments |
5. Include aspects of disability in curricula of all levels of education | No response | SLHT coordinator was aware and involved in disability education in second and third year teaching | Important for the RCS coordinators to have a better idea of the theoretical training of the students prior to their arrival at the RCS for practical training as the HN, PT and OT coordinators were not aware how and when this is done during the undergraduate theoretical curriculum |
6. Listing of needs identified by conference participants, e.g. mobility matters, access to entire building and not just part of it, transport, interpretation preferences | No response | Physical: Accessible |
Information: No facilities (Braille, Sign Language and Loop systems) |
7. Needs assessment of persons with disabilities in rural communities involving municipalities and government departments | Intervention based on needs of persons with disabilities assessed during home visits/consultations/Hospice Rehab centre and academic hospital ward round |
All coordinators had to do a needs analysis of the Worcester area including NGO, DoH input prior to student placement |
More regular contact with DoE and DSD as well as municipality |
8. Assessment of resources to appropriately address the identified needs, keeping in mind the uniqueness of the needs of different disabilities | At each of the sites mentioned below, the involved disciplines specifically assessed needs on a health, social and environmental level:
HN, PT, OT, Medics, SLHT – Avian Park PT, SLHT – Hospice Rehab Centre HN – Nutrition quality monitoring at DoH clinics PT – Ergonomic assessments and individual home visits |
Staff encouraged students to evaluate and refer patients using forms based on the ICF framework |
Mobility, access and transport – Major issues for sustainability of projects |
9. Sharing of resources between all stakeholders | No response | Human resources were shared: Avian Park Service Learning Centre, all sites where students are involved. Physical resources were shared:
Avian Park Service Learning Centre was shared with community members (soup kitchen and swop shop) and Hospice RCS Campus: Multisectoral action team and DoH could make use of facilities for free if staff members were invited |
The coordinators realised on reflection that each of the sites where their students are placed also share resources by means of access to files, rooms for treatment or admin, sometimes also staff |
10. Research strategies to put theory into practice in ways that meet the needs of people with disabilities in rural areas | The following studies and presentations were given by students: |
No research unit available at RCS | Opportunity – Shop front for research enquiries where community can approach the university via the rural clinical school to request research in a certain area of need |
11. Equal study opportunities for people with disabilities | Centre for Student Counselling and Development (Disability Unit) on main campus in Stellenbosch |
RCS campus: |
RCS campus: |
12. (a) Joint efforts in public education and training in communities regarding awareness and sensitisation | HN, OT, SLHT, PT – At all sites where students are clinically involved the community assists with their practical training |
Training regarding using the ICF – Western Cape DoH |
There is definitely scope for more public education and training around disability in terms of awareness and sensitisation. This can be done by talks, small group discussions, role modelling disabled community members, video material at schools and for students at the RCS |
12. (b) Establish and maintain a data base to be a source of information and an instrument of empowerment, e.g. in negotiations for services and lobbying for rights | No response | No response | No database existing for information |
13. Enter into memorandums of understanding with communities, organisations of persons with disabilities and service providers in the interest of people with disabilities in alignment with the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD and the White Paper of December 2015 on the same) | PT Students have knowledge of the UNCRPD prior to start of rotation | Ukwanda Centre for Rural Health have a Memorandum of Understanding (MOU) with Boland Hospice with regard to making use of the community care workers to help train students on the platform | Issues of consent for treatment and admission in hospitals are inconsistent at each site and for each professional body |
14. Co-hosting of conferences on an annual basis | No response | Annual Rural Research Days with Anova Health Institute regarding health and wellness issues in the community and beyond has taken place annually from 2013 |
Opportunities for hosting collaborative community partnership functions where students and their community partners could present on projects that were initiated in areas around the RCS |
15. (a) Sensitising and engaging (e.g. using disabled coaches, advocates, etc.) church communities and ministers/pastors to make it possible for people with disabilities to fully participate in all aspects and every level of church life (e.g. a ramp to the pulpit) | No response | No response | None – Need help from municipality and DSD |
15. (b) Establish a forum of people with disabilities to share information and to speak collectively on needs and human right issues | No involvement | No involvement at this stage – Except on the day this was presented | Needs to be frequent and INCLUSIVE to increase community awareness and potentially increase the SUSTAINABILITY of student run support groups |
16. Continue to involve international experts in the conference | No involvement at this stage | No involvement | No gap identified |
17. More involvement of people with disabilities in future conferences as well as action plans arising from these conferences | No involvement | Persons with disabilities are specifically invited to submit an abstract, to present a workshop or presentation on building resilience in people with disabilities at the National Rural Health Conference, which was held in Worcester in 2014 | |
18. Look at the possibilities of establishing special interest groups for different fields and disabilities | No involvement | No involvement | No involvement at this stage |
19. Joint efforts by SU and Free State University training professional interpreters to assist students with disabilities to gain access to training in fields they prefer | No involvement | No involvement | Not initiated yet |
20. Assist and partner with organisations working in the field of disabilities to achieve goals of empowerment | Sites that cater for persons with disabilities are involved with our students practical training which has led to reciprocal empowerment | Partnerships have been developed with sites that cater for persons with disabilities to empower both students and the site | Reciprocal capacity building joint workshops |
21. Improving existing assistive devices and self-training toolkits (e.g. speech reading, lip speaking, electricity meters, etc.) for students with a diversity of hearing loss | Do not have RCS students who require these services as yet; however, there is a university mandate to cater for students with hearing loss |
No involvement yet | No involvement yet |
AHS, Allied Health Sciences; APD, Association for Persons with Disabilities; ASD, Association for Persons with Sensory Disabilities; CDC, Community Day Clinic; CRS, Centre for Rehabilitation Studies; DoE, Department of Education; DSD, Department of Social Development; ECD, early childhood development; ICF, International Classification of Functioning, Disability and Health; HN, Human Nutrition; MOU, memorandum of understanding; MSAT, Multi Sectoral Action Team; NID, National Institute for the Deaf; NGO, non-governmental organisations; OT, Occupational Therapy; PT, Physiotherapy; RCS, rural clinical school; RHAP, Rural Health Advocacy Project; SLHT, Speech Language and Hearing Therapy; UNCRPD, United Nations Convention on the Rights of Persons with Disabilities; WHO, World Health Organization.
Post the responses of the coordinators, the audience which consisted of persons with disabilities, disabled people’s organisations and the academic coordinators further synthesised the needs. This is because it was clear that some of the needs were not yet being responded to through service learning. This shared dialogue led to a further synthesis of needs leading to the following themes which were highlighted as needing to be prioritised:
Use of the nominal group technique was helpful in re-grouping and prioritising these needs with the aim to plan actions for what was not yet being addressed and strengthen what is already existing. This was followed by a discussion on steps that need to be taken as a way forward.
A
to validate and improve the list of needs expressed
to play a leading role in suggesting a model for responding to these needs
to create and maintain links or community interaction between the RCS and the community
This working group was a good response aimed at ensuring that student service learning addresses the service needs at ground level if we are to have a disability responsive curriculum. It was realised that perhaps this is a participatory cycle that should be followed by divisions to inform each curriculum review stage as needs are constantly changing. This process followed in this response could be used as a methodology for each divisional curriculum review and perhaps even work on hosting combined curriculum reviews for the four different divisions to foster both integration and inter-professional education. Such a process would allow for the emergence of curriculum directly from the community as per the social constructionist view and use this as an ideological tool as well as a vehicle for social change (Cherrington
In terms of
Of equal importance was the identification of the need for the RCS coordinators to gain insight into when and how
Education and training in communities regarding
Students also engaged with health care workers at old age homes and in the community with regard to understanding disabling pathologies and environments. Some of the divisions gave regular talks on the local radio station Valley FM. SLHT students have been involved in lip-reading strategies for people with hearing loss, while human nutrition students received sessions from the NID on working with persons with hearing loss, deaf or hard of hearing prior to their food services training. Consequently, SLHT students developed various Alternative and Augmentative Communication Boards for patients in the community to enable the family and other AHS professions to effectively communicate better during therapy. Additionally, the AHS students were working at four sites where ECD was the focus of intervention. All AHS made the effort to include parents in the early development educational interventions to further build on the existing skills of parents in raising their children with disabilities.
Community members with disabilities equally played a role in sensitising our students and staff through their collaboration and participation in RCS students’ training. Many of these community members co-presented with the students at the annual Community Partnership Function and are valued for the contribution they make to student learning.
This study did not require ethical approval as no direct intervention or contact with human or animal subjects was needed.
Less has been written about research which engages community stakeholders and the need to understand this as part of co-constructing a socially responsive curriculum. The methodology we followed has characteristics of what Mitchell et al. (
It is also apparent that academia cannot initiate or support the necessary systems and programmes required by a community if it works independently. A collective, collaborative process needs to be followed before student placement to ensure that students respond to the needs within the community. This approach will enable community members to participate actively in meeting their own needs and will serve to enhance the sustainability of responsive interventions. The consequential establishment of trustful relationships is a key to opening up spaces for dialogue and integration of diverse knowledge. In this study, a dialogue was opened between the university, the community of persons with disabilities and sectors involved in serving this community.
Furthermore, such collaborations can contribute to building greater alignment between higher education institutional curricula and the community needs while also training students on how to respectfully work with communities from a bottom up approach. It is to be noted that the approaches to collaborative action are complex and time-consuming (Doherty & Couper
From this experience, we also argue that longer placements and more integrated rotations across the disciplines would bring a much more holistic interaction with the community thus enabling integrated responses to needs and models of best practice. It would also be critical for continuity of projects. Doherty and Couper (
The value of the already existing inter-professional collaboration in the response to the needs of the community cannot be emphasised enough. The joint efforts of all the AHS disciplines inadvertently addressed some of the community identified needs. If each discipline had contributed independently according to their silo disciplines, it would have been impossible to meet these needs.
From the results, it is apparent that the AHS students, through their service learning on the RCS clinical training platform, are addressing some of the needs identified by persons with disabilities. However, many areas still need a stronger focus and commitment from the university. Stronger collaboration in the form of inter-professional education between the various AHS disciplines could enhance this commitment and facilitate a more comprehensive and coordinated response to the community needs through student service learning. Furthermore, such collaboration may lay a foundation for strengthened relationships and social impact between the community and the university.
Doing disability work requires reciprocity and responsiveness if we are to truly honour the inclusion saying ‘nothing about us, without us’. We learnt that reciprocity can only exist when both sides have a say and are actively participating in the collaboration. In this project, the reciprocity is evident in the sense that the community was able to express their needs to ensure that student training is servicing the hosting communities while the students were also provided with an opportunity for service learning that is community-based and community-led. The approach to the different activities facilitated a collaborative engaging process between stakeholders but equally the project was in its approach grounded, from the beginning, in principles of participation and inclusion. For instance, reflecting on the community’s needs and adjusting student’s programmes to speak to some of these needs facilitated a collaborative environment and process in which trust, accountability, co-listening, co-learning and communication were possible between the university and the community. This is to say that service learning should not only focus on upskilling the students but should also focus on serving the community in a manner that is beneficial to current needs and one that enables continuity. Given the human resource gaps, this is particularly significant in contexts where allied health practitioners are scarce at community level. This approach is integral to community-based rehabilitation principles of inclusion, participation of and giving voice to the community on how to work with communities through an empowering bottom up approach.
Additionally, reciprocity became evident as the students and staff were open to listening and learning from persons with disabilities and their lived experiences while they also willingly opened themselves to listen and learn from the staff and students. In this context, learning becomes reciprocal in the sense that everyone learns to listen to each other. This is how knowledge is produced conversationally and in relation to one another (Ned
Equally with capacity building, it was not only students whose needs were served through service learning in these communities, the project equally opened an opportunity for the disabled people’s organisations and practitioners to request accredited capacity building workshops as they saw the needs. Instead of going in with set topics of workshops from the university, the capacity building direction was fully led by the community stakeholders. This ensured that capacity building is relevant and beneficial to the community.
Each step of the interactive workshops was an opportunity for meaningful dialogic engagement between the university and the community such that all stakeholders got an opportunity to share their reflections and critique each other. These engagement processes certainly helped the coordinators in rethinking carefully about the service learning they facilitate with the students. They also deepened the understanding of the community, community dialogue and cultivated co-reflexivity. Often, reflexivity is emphasised only amongst researchers (Mitchell et al.
The most significant limitation of the project was that we did not have a monitoring and evaluation tool to assess whether the needs have now changed or whether the various activities assisted to address the needs fully. Therefore, progress was difficult to assess. If we were to redo this project, we would need to develop a monitoring and evaluation tool which should be developed upfront in the participatory processes to be able to assess social impact. More persons with disabilities could be involved in the different activities, especially in capacity building workshops, so that they can facilitate these workshops. Students could also be trained to take more of a facilitator role to ensure that they do not do ‘for’ but do ‘with’ during interventions to enable full participation of persons with disabilities and continuity. This small study was not representative of all persons with disabilities in this community. A follow-up larger study with more participation of persons with disabilities, especially those with sensory impairments, intellectual disability and mental health conditions, is needed.
The authors thank the participants of Worcester and Stellenbosch University involved in the workshops regarding ‘People with Disability in Worcester’.
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
J.V.M. was the project leader. L.N. was responsible for the coordination of the university’s response to people with disabilities and contributed substantially to the methodological discussion. H.B. made conceptual and editorial contributions to the article.
Funding from the ‘Fund for Innovation in Teaching and Learning’ provided by the Centre for Teaching and Learning at Stellenbosch University was used to conduct this study.
Data sharing is not applicable to this article as no new data were created or analysed in this study.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.