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How did the WTCR originate and develop? An outline of our transitions as a working group is presented below, illustrated by four different areas focused on by the group.
Frans Vreede, rehabilitation physician, founded the Working Group on Transcultural Rehabilitation (WTCR) in 1976. He was a strong and wise person who inspired many with his clear mind, life experience, and authenticity. The WTCR was a sounding board giving him the opportunity to develop, clarify and transfer his ideas, in particular regarding his “Daily Living” concept. The core of that concept is summarised below.
| The “Daily Living” Concept The first dimension: break-down of the concept of Daily Living (DL). The “highest” level is Ideas in Daily Living (IDL), long-term ideas, values and aspirations. The “middle level” is Activities of Daily Living (ADL), daily activities steered by short-term intentions through which one realizes the higher level IDL. The “lower level” is Operations for Daily Living (ODL), components for activities, consisting of physical and mental exertions and appearances, usually performed automatically, which together enable higher level ADL. The second dimension: Context. Activities of Daily Living cannot exist without Context. Vreede distinguishes five components: Performance, Product, Place, Period and Persons. The third dimension: the distinction between usual or own and unusual or alien activities for a particular person. |
Episode 1: Counselling at a distance and community based rehabilitation
The aim of the Working Group at its start was Counselling at a Distance for workers in rehabilitation projects abroad. Advice was based on our own experiences and on learning from each other.
We also focused our attention on Community Based Rehabilitation (CBR). We studied and developed ideas on customised CBR aligned health systems from different countries. Two conferences allowed us to invite and meet international experts on CBR: Crippling disorders in Children – a global problem, NVTG, Amsterdam 1992, and the 1st World Congress of the International Society of Physical and Rehabilitation Medicine ISPRM, Amsterdam 2001.
Episode 2: Transcultural aspects and functioning
We realised that transcultural problems also exist in the Netherlands, affecting the outcomes of rehabilitation for migrants and refugees. Our experiences and understanding were bundled in a booklet edited by Han Bakker. [1] We also realised that besides understanding transcultural factors, the essence of our advice required deeper understanding and analysis of human functioning, based on the principle of empowerment. At that time, the conventional framework of functioning worldwide was still a “work in progress” by the WHO, referred to as International Classification of Impairment, Disability and Handicap (ICIDH). So to be able to clarify the essence of rehabilitation, irrespective of location, we immersed ourselves in the subject of human daily living, using Vreede’s ideas. [2] This study resulted in a model of human functioning for description and for analysis. It was operationalised in a revision of the curriculum for postgraduate training in rehabilitation medicine. [3] From there, further study resulted in a PhD thesis on rehabilitation medicine. [4]
The present WHO document, International Classification of Functioning, Disability and Health, the ICF, is not single-minded. It recommends that people develop their own theory and model according to their situation. Between 1988 and 2011 “Transcultural rehabilitation” was a mandatory course for residents in rehabilitation medicine. It consisted of case presentations of transcultural rehabilitation problems in the Netherlands, with the main focus on communication. For residents in tropical medicine and international health, the WTCR organised an annual course day on ‘Rehabilitation in Developing Countries’, as it was then called.
Episode 3: Research and low health literacy
The disappointing outcomes in rehabilitation for non-native patients was thought to be a transcultural phenomenon, but we could not identify the specific factors involved. In the late 1990s, the focus of the WTCR on the disappointing results of rehabilitation for refugees and migrants led to research grants from the Health Research Promotion Programme (“Stimuleringsprogramma Gezondheidsonderzoek”). The research focused on assessing to what extent the outcomes of rehabilitation care were worse for refugees and migrants than for native people, and what factors were associated with such outcomes. From the WTCR, Jos Dekker contributed greatly to this research, also enabling Maurits Sloot and Janke Oosterhaven to obtain their doctorate. [5, 6]
| Health literacy is the ability to obtain, read, understand, and use healthcare information in order to make appropriate health decisions and follow instructions for treatment. |
The research showed that low health literacy explains the non-optimal outcome better and more completely rather than the term “transcultural phenomenon”. Health literacy is associated with a number of domains that influence health: 1) the level of knowledge and information; 2) life style; 3) the use of (and accessibility of) health care; 4) communication with health worker; 5) self-management and use of medicines; 6) culture-based differences in explanatory models. These factors explain how low health literacy goes with higher levels of morbidity and lower life expectancy. Karin Schepman and Marga Tepper wrote an article on this subject well worth reading. [7] The term “low health literacy” seems to blame the patient. But in fact the way health-care institutions operate is not always tuned to their clients. Indeed, research shows that the outcomes of rehabilitation care can be significantly improved, e.g., by adapting education, stimulating participation of relatives, improving access to interpreter services, and providing more time for consultations.
| Health literacy: 28% of adult Dutch people lack the right knowledge and skills to get adequate information about health.40% of people with low health literacy are native Dutch. |
Teaching within the Netherlands Society of Rehabilitation Medicine (VRA)-curriculum underwent a similar shift in content. The subject of low health literacy was given annually, starting ten years ago today, in cooperation with Pharos, a scientific organisation on health differences. In the NVTG-curriculum, the WTCR still organises the annual course day on ‘Rehabilitation in Low and middle-income countries’, as we call it now.
| A 60-year-old, living alone on the third floor of a porch house, is suffering consequences from stroke. If admitted, he would need much more functional improvement before returning home than someone with the same condition, married and living in a large bungalow. However, he might not be admitted in the first place, simply because he would occupy a rehab bed for “too long”. |
Episode 4: Human right to health and global health
Human Right to Health implies that people in society receive health care that meets the highest possible standard within that society. A couple of years ago, we became aware of the Human Rights to Health situation in rehabilitation care. It was an eyeopener that in the Netherlands health workers and health organisations could unknowingly violate human rights.
In order to make people more aware, the WTCR created a checklist based on the AAAQ Framework (where A’s stand for availability, accessibility and affordability and Q for quality). The toolkit is not meant to score quality of care, but to create awareness of aspects that need improvement. The toolkit and its use are described in an article by Schepman, Tepper and Schutte. [8]
To deploy children as an interpreter for consultation with their parents is a human right violation, as it may have serious psychological consequences.
| Health disparities are strongly related to differences in the socio-economic, educational, environmental and political situation. |
Global Health was put on our radar by the newsletter from KCGH sent on May 31st 2022. Soon after, an article appeared on Global Health and lack of Global Health perspective in rehabilitation care in the Netherlands. [9] Realising the relevance of the concept of Global Health made us integrate this concept in an already envisaged seminar (April 2023) on Rehabilitation, Systems Thinking, and Unexplained Conditions. This turned out to be a valuable introduction to Global Health.
Our future?
Short-term:
- A mini-symposium at the Dutch Congress on Rehabilitation Medicine in November 2023, entitled Equality, Equity and Social Justice: Strengthening rehabilitation practice in the Netherlands through global health.
- Guest editorship for Nederlands Tijdschrift voor Revalidatiegeneeskunde “Focus op toegankelijke zorg en inclusie” (Dutch Journal for Rehabilitation Medicine “Focus on accessible care and inclusion”).
Long-term: the WTCR strives for understanding rehabilitation care from a Global and Planetary Health perspective, promoting individual rehabilitation care, and respecting the Human Right to Health.
References
- Bakker H (red). 1989. Revalidatie en migranten. Amsterdam VU uitgeverij. 167p.
- Vreede F. 1993. A guide to ADL. The Activities of Daily Living. Delft Eburon. 149p.
- Van Dijk AJ, Dekker JHM, Pons C. 2006. Syllabus bij in-company cursus ‘Leerplan en Uitgangspunten’ vs 7. Available from authors.
- Van Dijk AJ. 2001. On Rehabilitation Medicine. A theory-oriented contribution to assessment of functioning and individual experience. Thesis TU Twente. Delft Eburon. 241p. Available from author.
- Sloots M. 2010. Drop-out from rehabilitation in non-native patients with chronic non-specific low back pain. 2010. Thesis VU Amsterdam.
- Oosterhaven J. 2020. Dropout in Chronic Pain Management. Thesis UvA Amsterdam..
- Schepman AHBC, Tepper M. 2015. De kracht en [on]macht van kennis – Gezondheidsvaardigheden in de praktijk. NTRevaGen.
- Schepman AHBC, Tepper M, Schutte E. 2021. Recht op Gezondheid in de Revalidatiegeneeskunde. NTRevaGen.
- Lucardie AT, Schutte E. 2022. Global’ revalidatiearts in opleiding. NTRevaGen
