Annals of International Occupational Therapy

Original Research 

From Dependence to Interdependence: A Holistic Vocational Training Program for People With Disabilities in Tanzania

Anne Marie Witchger Hansen, EdD, OTR/L, FAOTA; Meghan Blaskowitz, DrPH, MOT, OTR/L

Abstract

Background:

People with disabilities in Tanzania are often feared, hidden from neighbors, considered a burden on their families, and sometimes even killed. Occupational therapists can play a critical role in decreasing stigma and improving vocational skills training for people with disabilities on both a micro- and a macro-level.

Goal:

The primary purpose of this study was to evaluate the outcomes of a vocational training program in Tanzania, operated by the Spiritans, a Catholic missionary community, by measuring participants' interdependence in daily life activities before enrollment in the program and after graduation.

Methods:

Of 450 students who had graduated from the program before 2012 (the year that this program evaluation occurred), 97 volunteered to be assessed by the research team after graduation. Between 2012 and 2015, the occupational therapy researcher (the principal investigator) and three teachers made routine follow-up visits to the 97 graduates based on the graduates' availability. A 3-point rating scale was developed by the research team and used to assess participants' levels of interdependence.

Results:

The study found statistically significant improvements in all six areas of occupational performance: (a) self-care and personal hygiene; (b) household activities; (c) farming; (d) animal husbandry; (e) community and church participation; and (f) income-generating activities.

Conclusion:

Outcomes of this study should be interpreted cautiously because of its retrospective design. However, the findings suggest that there is a critical need to conduct additional research on the effect of occupational therapy-focused, holistic vocational training programs for people with disabilities, particularly in low- and middle-income countries. [Annals of International Occupational Therapy. 2018; 1(3):157–168.]

Abstract

Background:

People with disabilities in Tanzania are often feared, hidden from neighbors, considered a burden on their families, and sometimes even killed. Occupational therapists can play a critical role in decreasing stigma and improving vocational skills training for people with disabilities on both a micro- and a macro-level.

Goal:

The primary purpose of this study was to evaluate the outcomes of a vocational training program in Tanzania, operated by the Spiritans, a Catholic missionary community, by measuring participants' interdependence in daily life activities before enrollment in the program and after graduation.

Methods:

Of 450 students who had graduated from the program before 2012 (the year that this program evaluation occurred), 97 volunteered to be assessed by the research team after graduation. Between 2012 and 2015, the occupational therapy researcher (the principal investigator) and three teachers made routine follow-up visits to the 97 graduates based on the graduates' availability. A 3-point rating scale was developed by the research team and used to assess participants' levels of interdependence.

Results:

The study found statistically significant improvements in all six areas of occupational performance: (a) self-care and personal hygiene; (b) household activities; (c) farming; (d) animal husbandry; (e) community and church participation; and (f) income-generating activities.

Conclusion:

Outcomes of this study should be interpreted cautiously because of its retrospective design. However, the findings suggest that there is a critical need to conduct additional research on the effect of occupational therapy-focused, holistic vocational training programs for people with disabilities, particularly in low- and middle-income countries. [Annals of International Occupational Therapy. 2018; 1(3):157–168.]

People with disabilities make up approximately 10% of the world's population. This equates to 650 million people worldwide, one third of whom are children (World Health Organization, 2011). The prevalence of certain disabilities is on the rise, particularly intellectual disabilities and autism spectrum disorders (Centers for Disease Control and Prevention, 2015). This increasing trend creates a greater demand for health and rehabilitation services as well as vocational training programs. More than 80% of people with disabilities reside in low- and middle-income countries, where poverty and limited access to health services affect their development and lead to severe occupational deprivation (Sofo & Wicks, 2017; Wilcock, 2006).

People with disabilities in Tanzania are frequently ostracized and excluded from normal day-to-day activities within their families, in the workplace, and in their villages and communities. Stigma surrounding disability is deeply embedded within Tanzanian culture. A survey of sub-Saharan health care professionals and family members found that 41% believed that autism spectrum disorders were not biomedical conditions, but instead had spiritual or supernatural causes (Bakare et al., 2009). Anthony (2009) also found that health care professionals, family, and community members in Ghana held health beliefs that disability occurred as a result of “retribution from a higher power, curses, and magical forces such as witchcraft or juju” (p. 11). People with disabilities in Tanzanian society are often feared, hidden from neighbors, considered a burden on their families, and sometimes even killed. Without support and services, people with disabilities often lead lonely, unfulfilling lives, with few basic human rights or opportunities to be productive members of their communities.

Employment Disparities for People With Disabilities

In 2002–2003, the World Health Organization conducted a World Health Survey that gathered employment data for people with and without disabilities in 15 lowand middle-income countries throughout Africa, South America, the Middle East, and Asia. Researchers found that employment rates for people with disabilities were consistently lower than those for people without disabilities in 13 of the 15 countries. Statistically significantly lower rates of employment were found among people with disabilities in 9 of the 15 countries. Barriers to obtaining employment for people with disabilities included a lack of access to formal education and vocational training, misconceptions about their ability to perform job duties, discrimination, and labor policies that were overprotective and deterred employers from hiring people with disabilities because of extra costs (World Health Organization, 2011). Residing in a rural area was also a significant predictor for low employment rates among people with disabilities in Bangladesh and West Africa (Mizunoya & Mitra, 2013).

Few studies have examined the role of occupational therapy in vocational training; the literature on vocational training is typically related to people with psychiatric and/or intellectual disabilities who reside in Organisation for Economic Cooperation and Development (OECD) countries (Chuang, Hwang, Lee, & Wu, 2015; Gal, Selanikyo, Erez, & Katz, 2015; Lloyd & Waghorn, 2007; Tan, Li, & Tan, 2016). In addition, few studies have examined vocational training for people with disabilities in low- and middle-income countries. This gap in the literature is especially pronounced for people with disabilities in African nations. Although vocational training programs are found throughout Africa (Comprehensive Community Based Rehabilitation in Tanzania, 2017; Usa River Rehabilitation and Training Center, 2017; Vlachos, 2008), few programs report participant outcomes. Therefore, the effect of vocational training on the self-care skills, employability, and overall human rights of people with disabilities is not known.

The Role of Occupational Therapy in Vocational Training

The literature describing occupational therapy practice in Africa, specifically Tanzania, is limited. African occupational therapists (OTs) work in a variety of settings, including hospitals, schools, prisons, nongovernmental organizations, community-based practice settings, and community-based rehabilitation centers (Alers & Crouch, 2010). They assume a variety of roles in direct intervention, parent and caregiver education, program development, consultation, community education on disability, in-home human immunodeficiency virus/acquired immune deficiency syndrome programs, and palliative care.

People with disabilities have a variety of occupational needs. Occupational therapists can play a critical role in addressing these needs on both a micro- and a macro-level. Participation in employment activities (including volunteering, income-generating activities, and part- or full-time work) is vital for people with disabilities because it fosters improved social connections and social capital, greater personal pride and satisfaction, higher earning power, and overall improved quality of life (Lysaght, Ouellette-Kuntz, & Morrison, 2009). Employment opportunities help to close wage disparity and socioeconomic status gaps for people with disabilities, ultimately improving their social standing as well as their access to basic human rights (Lysaght, Ouellette-Kuntz, & Morrison, 2009). In rural areas of low-income countries, income-generating activities are often the desired employment outcome overall rather than part- or full-time employment (Winters et al., 2009). These income-generating activities can include self-employment, either alone, with family members, or as a group; making and selling a product (e.g., clothing, furniture); providing a service (e.g., hairdressing, repairing motorcycles); or selling and trading goods (e.g., running a farm stand selling vegetables) (Khasnabis, Heinicke-Motsch, & Achu, 2010).

Traditionally, OTs working in OECD countries support people with disabilities in the occupation of work through activity analysis and targeted skills training in instrumental activities of daily living (IADLs), social skills, vocational skills, and community mobility and integration (Dorsey & Mahoney, 2015). Many governments in low- and middle-income countries, however, cannot afford to hire full-time OTs to meet the demand and adequately address the needs of people with disabilities. Therefore, OTs working in role-emerging, community-based practice settings in Tanzania are increasingly challenged to provide macro-level interventions for people with disabilities, taking the lead in the development and evaluation of vocational training programs as well as providing ongoing consultation and train-the-trainer support for community-based rehabilitation staff (Holmes & Scaffa, 2009a, 2009b). Buys (2015) and an expert panel of 35 South African OTs established 16 professional competencies that African therapists should possess to adequately address the needs of people with disabilities in vocational settings. Holmes and Scaffa (2009a) surveyed OTs on their perceptions of the competencies required for occupational therapy practice in role-emerging settings, and they found a greater need for education and training in the areas of program development, program evaluation, consultative services, and knowledge of community systems.

Olkokola Vocational Training Center

Olkokola Vocational Training Center (OVTC) is an 18-month residential vocational training program that was established in 1989 as a ministry of the Congregation of the Holy Spirit (Spiritan Missionaries) in the Catholic Archdiocese of Arusha in northern Tanzania. The program accepts a cohort of students annually. Olkokola Vocational Training Center aims to empower students with disabilities, teach them skills to develop a vocational trade, and enhance their engagement in activities of daily living (ADLs) and social integration within their communities.

Each training cohort includes 30 students, with approximately 15 female and 15 male participants. Most OVTC students are enrolled from the Arusha and Manyara regions of Tanzania. Admission to the program is not contingent on ethnic origin, religious affiliation, socioeconomic status, or ability to pay the associated program fees. The only criterion for admission to the Center is that participants must be living with a physical disability.

All students reside at the Center in one of two simple, one-story, one-room, cement block dormitories for the duration of the 18-month program. In addition to housing, the Center compound includes an outdoor kitchen with large cooking pots and charcoal stoves, outdoor sinks for washing clothes, a soccer field, a garden, and a small barn and grazing area for cows, goats, and rabbits. Local Tanzanian teachers provide vocational skills training in four classrooms that were converted from large shipping containers.

The Role of Occupational Therapy at Olkokola Vocational Training Center

An OT, trained and licensed in an OECD country, serves as a consultant to the OVTC training program, in collaboration with a physical therapist (PT). An OT has consulted with the Center on how to make the program more holistic since its inception in 1989. The Center began using the knowledge and skills of an occupational therapy consultant in a more intentional and robust way 7 years ago, when the OVTC program director and staff began collaborating with the OT on gathering data for this program evaluation project.

The OT serves as a resource for the director and staff throughout the 18-month program and is available by phone at any time. Occupational therapy and physical therapy consultants conduct comprehensive assessments of student performance during the first month of the program, with the input of OVTC teachers. Initial assessments are based on an intake of each student's history and observations of the participant performing functional ADLs, IADLs, and mobility skills. The OT and PT then make recommendations for supports that are needed, such as calipers, wheelchairs, and workspace adaptations, to ensure full participation in the student's chosen vocational trade.

During this initial assessment, the OT also explores students' experiences with stigma and acceptance or rejection at school, at home, and in the community. The OT also identifies any barriers and supports for the vocational training process. The OT asks open-ended questions to explore each individual's psychosocial needs, self-efficacy, and self-esteem to determine how the Center can assist in preparing the family and local community for the graduate's return posttraining. The OT collaborates with Center staff to plan necessary environmental supports and adaptations and provide emotional and psychological support to meet occupation-focused needs. In this way, the OT carries out a “train-the-trainer” role. The therapists, in collaboration with the OVTC staff, created standard occupational therapy and physical therapy assessments to obtain a comprehensive picture of each participant's strengths, needs, and interests and enable the program to track desired occupational performance outcomes. Assessment tools are reviewed on a regular basis, and necessary adaptations are made.

At the end of the 18-month program, the OT makes recommendations for supports and adaptations that the graduate may need for a successful transition to home and community. The OT also provides recommendations to family members and community leaders on how to effectively support graduates in developing income-generating activities within their villages after the completion of training.

Health Assessments and Wellness Program

A health care professional affiliated with the onsite health dispensary at OVTC assesses each student's medical, orthopedic, and nutritional needs. Each student is also given a vision test, a dental checkup, human immunodeficiency virus/acquired immune deficiency syndrome testing, and deworming, as needed. After these comprehensive assessments, the Center provides each student with individualized medical treatment, surgery, orthopedic care, and/or mobility equipment, as needed. During the 18-month program, students participate in a health and wellness program that includes exercise, nutritional counseling, and recreational sports.

Olkokola Holistic Vocational Training

At OVTC, each student is introduced to four vocational trades during the first month of the program: carpentry, masonry, agriculture and veterinary, and tailoring. Students then choose a vocational concentration that suits their strengths and interests. After the students choose a trade, they receive hands-on technical training in their chosen vocation. This training prepares them to return home with a useful trade that can be practiced in their village as an income-generating activity, thus leading to a more meaningful and engaging life.

Tailoring students learn how to create patterns and sew clothing, such as shirts, skirts, trousers, dresses, school uniforms, and handbags by hand or with the use of a sewing machine. Masonry students learn how to sketch three- to four-room cement block houses, build foundations and walls, and plaster and paint a house. Carpentry students are trained in making furniture, such as chairs, beds, and benches, as well as windows and doors. They also learn how to roof a house. Agriculture and veterinary students learn farming techniques as well as how to diagnose, treat, and provide preventive care to farm animals.

Additionally, students develop life skills, such as performing self-care, washing clothes, cooking, and caring for a garden and farm animals (cows, goats, chickens) to gain confidence in living their lives to the fullest. Olkokola Vocational Training Center students learn how to read and write Swahili, the national language of Tanzania, because many of them are fluent only in their tribal languages. Students also learn business skills, such as mathematics, entrepreneurial skills, and effective workplace communication. A secondary outcome of the program is the development of skills in social interaction and forming friendships. Because many students have been socially isolated up until their attendance, the program encourages social interaction through formal and informal activities, such as dancing, drumming, listening to music, creating handicrafts (i.e., beading, weaving), playing soccer, and going on community outings to cultural sites.

At the conclusion of the 18-month training program, students, teachers, and staff celebrate the students' accomplishments with a special dinner and festivities at the Center. One year after graduation, OVTC staff members visit the graduates to see how actively engaged they are in their homes and communities.

Study Goal

The primary purpose of this study was to evaluate outcomes of the OVTC vocational training program by measuring participants' dependence and interdependence in daily activities before enrollment in the program and after graduation. The program director and the research team embarked on this program evaluation project to better understand the effect of the vocational training, use the results of this evaluation to advocate for additional funding streams, and make necessary enhancements to the program to better support the program participants. The following question was posed by the program director, staff, and research team: What effect does a holistic vocational training program have on the daily occupations (i.e., ADLs, IADLs, farming, animal husbandry, community participation, income-generating activities) of OVTC graduates from enrollment to posttraining follow-up?

There is significant need for a program evaluation of this nature. As more OECD countries shift away from institutional care to individualized services for people with disabilities (Beadle-Brown, Mansell, & Kozma, 2007; National Council on Disability, 2012), community-based practice models are in high demand. Although community-based vocational training programs have increased throughout Africa and among other indigenous populations (Comprehensive Community Based Rehabilitation in Tanzania, 2017; Usa River Rehabilitation and Training Center, 2017; Vlachos, 2008; Windley, 2017), few, if any, have reported program outcomes. The results of this study can inform OTs, program administrators, and interprofessional public health practitioners as they work to positively support people with disabilities in Tanzania and beyond.

Methods

This program evaluation project was conducted to measure the change in OVTC participants' skills in self-care, household management, farming, animal husbandry, community participation, and vocational activities at the time of enrollment in the program and 3 years after graduation.

Participants

Study participants (n = 97) included adolescents and adults, 16 to 40 years of age, who participated in the 18-month OVTC program during the years 1980 to 2012. To attend the OVTC program, participants must be 14 years or older, have a physical disability, and express an interest in developing a vocational trade in an effort to obtain income-generating activities in their village after training.

Of 450 OVTC students who had graduated from the program before 2012 (the year that this program evaluation occurred), 97 volunteered to be assessed by the research team after graduation. Between 2012 and 2015, the occupational therapy researcher (the principal investigator) and three OVTC teachers made routine follow-up visits to the 97 graduates, based on graduate availability, whether the program identified them as still being alive, and the ability of the research team to access them in rural areas via rough terrain. In line with cultural practices in Tanzania, staff members did not make appointments for these follow-up visits because graduates who live in rural areas do not have cell phones or landlines. During the visit, the research team explained the study in detail to each graduate. For graduates who expressed an interest in participating, the team obtained signed informed consent to participate. During visits from the research team, other graduates from the village occasionally arrived and also asked to be interviewed.

Tools

For the purposes of this study, a 3-point Likert rating scale, developed by the research team and OVTC teachers, was used to rate performance in six occupational performance areas according to the following ratings: Interdependent (3), Needs Some Assistance (2), and Dependent (1). The simplicity of this 3-point scale is culturally and contextually appropriate among major Tanzanian tribes because “answering in threes” is common practice. For example, when engaging in daily conversation, responses are commonly given as “good, bad, so-so” or “high, low, 50/50,” and pain ratings are expressed as “1, 2, or 3.”

The highest rating on the scale was “Interdependent” (3), rather than “Independent,” to reflect cultural values about disability. Interdependence is a common expression that reflects satisfaction with life in Tanzanian culture and other cultures around the world (Grills, 2015; Pooremamali, Ostman, Persson, & Eklund, 2011; Zea, Quezada, & Belgrave, 1994). The concepts of communal familialism, reciprocity, and interdependence, or the idea that people with disabilities exist within a community to which they contribute and from which they receive support, dominate cultural values in Tanzania (Grills, 2015; Zea, Quezada, & Belgrave, 1994). The use of the rating “Independent” in this study resonates with the African notions of koinonia, through love, and botho, through interconnection. The OVTC offers people with disabilities the opportunity to achieve “interdependence” as a sense of belonging, accepting of each other's gifts and abilities, and connecting with one another to facilitate the graduates' contribution to their families and communities (Leshota, 2015). Therefore, the research team determined this to be the most appropriate and culturally accepted way to rate occupational performance. In contrast to the stigma and discrimination experienced by people with disabilities throughout Tanzania, OVTC offers people the opportunity to achieve “interdependence” as a sense of belonging, accepting of each other's gifts and abilities, and connecting with one another to facilitate the graduates' contribution to their families and communities (Leshota, 2015).

A rating of “Interdependent” (3) was assigned to participants who required 25% or less assistance to complete any of the six occupational performance tasks; a rating of “Needs Some Assistance” (2) was assigned to participants who required 26% to 75% assistance; and a rating of “Dependent” (1) was assigned to those who required 76% to 100% assistance.

Data Collection

Study data were collected for 97 graduates who attended OVTC from 1989, the year the program was established, until 2012, which represented 22% of the total OVTC graduate pool. Researchers rated each participant's performance in six occupational performance areas using the 3-point Likert rating scale developed by the research team. After consent was obtained from each participant, the occupational therapy researcher retrospectively reviewed the participant's medical chart from the time at OVTC, including OT and PT initial assessments and teacher observation notes. Based on her review of these initial assessments and teacher observation notes, the researcher assigned the participant pretraining ratings using the 3-point scale for each of the six occupational performance areas. The research team used the same 3-point rating scale to assign posttraining ratings during the in-person follow-up assessment of participants in their home, community, and work environments. To increase the utility of the 3-point rating scale and the accuracy of researcher ratings, in-person follow-up assessments were based on observation, and open-ended questions were translated into the participant's preferred language.

The six occupational performance areas for which pre- and posttraining ratings were assigned included: (a) self-care and personal hygiene (i.e., similar to ADLs, this category included toileting, grooming, and bathing); (b) household activities (i.e., similar to IADLs, this category included washing clothes, fetching water, cooking, and cleaning); (c) farming (i.e., planting, growing, and harvesting crops); (d) animal husbandry (i.e., caring for farm animals, such as feeding cows, goats, chickens, and rabbits; milking the cows; and taking the animals to pasture); (e) community and church participation (i.e., attending and participating in weekly community meetings and church or mosque gatherings); and (f) income-generating activities (i.e., self-employment, employment with family members or as a group, making and selling a product, providing a service, or selling and trading goods on a part- or full-time basis).

Data Analysis

Participant demographics were collected from medical and school records and the OVTC program director, headmaster, teachers, and staff. Descriptive statistics for the sample are shown in Table 1 and Table 2. Chi-square goodness of fit tests were run for each outcome to assess for changes in pre- and posttraining ratings. The tests were set up under the expectation that, if no change occurred, posttraining ratings should be distributed across the scale in the same way as pretraining ratings. Additionally, Wilcoxon signed rank tests were used to assess for overall significant improvements in ratings for each of the six occupational performance areas from pre- to posttraining.

Participant Characteristics

Table 1:

Participant Characteristics

Characteristics of Olkokola Vocational Training Center

Table 2:

Characteristics of Olkokola Vocational Training Center

Results

The study sample (N = 97) is representative of various age groups, tribal affiliations, diagnoses, and disabilities from the larger population in the area. Table 1 provides a summary of the individual characteristics of the study participants. Almost two thirds of the participants were male (65%) and 21 to 30 years old (71%). Mean age of the sample was 25.7 years. Most participants were from the Maasai (30%), Iraqw (28%), Meru (22%), or Mbugwe (8%) tribes, all of which are native to northern Tanzania.

Of the participants, 38% had musculoskeletal disorders, followed by intellectual disabilities (16%), congenital conditions (15%), and neurological issues (14%), including limb abnormalities, clubfoot, and elephantiasis. Of those with musculoskeletal conditions, most had diagnosed skeletal fluorosis (16%) or upper or lower extremity amputations (11%).

Table 2 summarizes the OVTC graduate data for the study participants. Most participants graduated between 2000 and 2012 (95%). Olkokola Vocational Training Center program participants chose to concentrate on one of four vocational trades during their 18-month tenure in the program: tailoring, masonry, carpentry, or agriculture and veterinary. Program participants recruited during the study period most often focused their apprenticeship on tailoring (52%) or carpentry (21%).

One participant had missing rating scale data; this individual was removed from the analysis, and the results are based on the 96 participants who had complete data ratings. The cross-tabulations for each outcome are shown in Table 3 and indicate participant posttraining ratings relative to their pretraining ratings. Along with cross-tabulations, chi-square goodness of fit test results are also reported. The results from the chi-square goodness of fit tests indicate that significant changes occurred in all six occupational performance outcomes between pre- and posttraining ratings. For self-care and personal hygiene, the largest change was moving from “Needs Some Assistance” (2) to “Interdependent” (3) (28.1%). For household management skills, 22.9% of participants moved from “Dependent” (1) to “Interdependent” (3). In addition, 34.4% moved from “Needs Some Assistance” (2) to “Interdependent” (3). For farming skills, the largest shifts were 29.2% of participants moving from “Needs Some Assistance” (2) to “Interdependent” (3) and 15.6% moving from “Dependent” (1) to “Interdependent” (3). For animal husbandry skills, the largest shift occurred in the 23.7% of participants who moved from “Needs Some Assistance” (2) to “Interdependent” (3). For community integration, the largest shift was the 62.5% of participants who moved from “Needs Some Assistance” (2) to “Interdependent” (3). Lastly, for income-generating activities, the largest shifts were the 72.9% of participants who moved from “Dependent” (1) to “Interdependent” (3) and the 14.6% who moved from “Needs Some Assistance” (2) to “Interdependent” (3).

Percentage of Pre- and Posttest Ratings

Table 3:

Percentage of Pre- and Posttest Ratings

Consistent with the chi-square results, the Wilcoxon signed rank test results showed that most participants had higher posttraining ratings than pretraining ratings. Table 4 shows the Wilcoxon signed rank test results along with the number and percentage of participants who had higher ratings after training, lower ratings after training, and ratings that remained unchanged from pre- to posttraining. As recommended by Pallant (2007), effect sizes were calculated based on Rosenthal's formula (1984) to indicate how much change occurred between pre- and posttraining ratings. Cohen (1988) gave criteria for interpreting effect sizes on measures of association, where r = |.1| represents a small effect size, r = |.3| represents a medium effect size, and r = |.5| represents a large effect size. Based on these criteria, medium to large effects in posttraining improvements were found among all occupational performance areas.

Differences in Ratings Before and After Vocational Training

Table 4:

Differences in Ratings Before and After Vocational Training

Discussion

The current study is one of the first to evaluate outcomes of a holistic vocational training program in Tanzania, East Africa. Although the results of this program evaluation should be interpreted cautiously and the outcomes cannot be directly attributed to the program itself, the findings show that occupational performance ratings improved from pre- to posttraining. Statistically significant improvements were found in skills in self-care, household management, and farming and animal husbandry as well as community and church participation and income-generating activities from initial enrollment in the program to follow-up assessment. These occupations are highly valued in Tanzanian culture.

The most significant finding was participants' increased involvement in income-generating activities from pre- to posttraining. Students who enter OVTC typically have few, if any, employable skills and work-related behaviors. However, almost 94% of the participants in this sample moved from dependence toward greater interdependence in income-generating activities. A similar study of vocational education and training programs for indigenous people with disabilities in Australia found improvement in vocational skills and increased employment rates after completion of vocational education and training apprenticeships (Windley, 2017). Although the program completion rate for indigenous people with disabilities was 13%, lower than the completion rates for nonindigenous groups, 68% to 74% of indigenous participants who completed the program obtained employment after training. Although this vocational training program did not take place in East Africa, its outcomes parallel those of the current study and indicate a need to further examine the effect of vocational training on people with disabilities in rural areas of lowand middle-income countries.

A Holistic Approach to Vocational Training

Long-term supports and services for people with disabilities in OECD countries are increasingly shifting away from institutional care to person-centered, community-based practice settings (Beadle-Brown et al., 2007; Claes, Van Hove, Vandevelde, van Loon, & Schalock, 2010; National Council on Disability, 2012; Robertson et al., 2006). However, many traditional disability services still function in silos (e.g., most vocational training programs focus solely on clients' work skills and rarely address social skills, self-care skills, or degree of community integration), and employment rates among people with disabilities continue to be much lower than those among people without disabilities. With its community-based nature, the scope of holistic services provided, its 18-month duration, and a focus on supporting the transition to home and community life, the OVTC program provides a unique approach to vocational training. Although this sample is not representative of a broader population of people with disabilities, the improvements noted among study participants in all occupational performance areas from pre- to posttraining, particularly in income-generating activities, show the positive influences of holistic vocational training on people with disabilities.

Occupational therapists use a person-centered approach to vocational skills training that can also be applied on a macro-level to develop holistic vocational training programs for people with disabilities. The effect of holistic vocational training on occupational performance outcomes, compared with more traditional training programs, warrants further investigation. Future research on holistic vocational training should focus on a variety of occupational performance outcomes beyond attainment of income-generating activities as well as on how greater interdependence in these occupational performance areas potentially predicts higher attainment of income-generating activities.

Occupational Therapy in Role-Emerging Settings

To adequately address the needs of people with disabilities in role-emerging, community-based practice settings, OTs must possess a wide range of skills. At OVTC, an OT from an OECD country typically provides consultative services to the Center's students, staff, and director in the areas of assessment, psychosocial and biomechanical interventions, environmental modifications, staff training, program development and evaluation, and data analysis. Buys (2015) and Holmes and Scaffa (2009a) identified competencies for OTs who wish to practice in role-emerging settings, including program development, program evaluation, evidence-based practice, and management skills, in addition to knowledge of community systems and health care policies. To better equip OTs in Tanzania to provide direct intervention and consultation in role-emerging, community-based practice settings, enhanced education, fieldwork opportunities, and mentorship are vital to broadening their skill sets.

Provision of Culturally Competent Occupational Therapy Assessment

This research team was challenged to find a culturally relevant assessment tool to adequately measure occupational performance outcomes in this Tanzanian context. Researchers discovered a mismatch between many standardized OT assessments that use “independence” as the end point on a rating scale. Contrary to “independence,” “interdependence,” which is highly valued by many African cultures, was used as the end point on the rating scale used in this study. The research team used this adapted measure to fit within the Tanzanian context and to emphasize interdependence as a desired occupational outcome.

Harb and Smith (2008) encouraged professionals to administer measurement tools that are in line with the cultural context. Hinojosa's (2002) American Occupational Therapy Association position paper, “Broadening the Construct of Independence,” encourages OTs to look beyond traditional definitions of independence and to support individuals in achieving independence as defined by their own culture. This study calls for OTs who work in low- and middle-income countries to create and validate culturally relevant assessments to more effectively evaluate outcomes for people with disabilities in these settings.

Limitations

A primary limitation of this study was measurement error as a result of the use of a nonvalidated rating scale to collect quantitative data on participants' occupational performance. Because of the restricted 3-point Likert ratings, the scale was not sensitive enough to detect differences in participants' functional levels, and ratings did not vary a great deal. Translation services provided during administration of the follow-up assessment and the lack of validation of the translated 3-point rating scale also may have introduced additional error during the assignment of participant ratings.

Systematic errors in measurement also may have occurred as a result of rater bias because participants' occupational performance preratings were assigned based on a retrospective review of medical charts. Preratings recorded from a review of participants' medical charts may have been inaccurate as a result of documentation errors among the OVTC OT, PT, teachers, or staff or the researcher's subjective interpretation of what was recorded in the chart. Because robust data collection and database management systems are not in place at the OVTC, researchers also could not determine the extent to which the study sample was representative of the larger OVTC graduate pool. According to the program director, this sample was adequately representative of the population served by the OVTC.

The retrospective nature of this study also posed further limitations that must be considered when interpreting the study results. The lack of randomization, lack of use of a control group, and inconsistent amount of time to follow-up assessment limited the researcher's ability to control for confounding of the intervention effect and generalize results to other populations of people with disabilities.

Future research should explore the validation and use of culturally relevant measurement tools in gathering occupational performance data. Follow-up studies are needed to more accurately measure outcomes of the OVTC and other holistic vocational training programs in African nations.

Conclusion

Before enrolling in the OVTC program, many students expressed frustration, hopelessness, loneliness, and minimal participation in everyday life. However, after participation in the program, students had the opportunity to meet others with disabilities who faced similar challenges and barriers as well as to give back to their villages using newly developed skill sets. The current study shows the potential positive outcomes of a holistic, person-centered vocational training program for people with disabilities and opens a dialogue on the ways in which OTs, other health professionals, and family and community members can support interdependence and employment outcomes for people with disabilities.

As cultural beliefs and attitudes toward people with disabilities in East Africa shift with Western educational and medical influences (Stone-MacDonald & Butera, 2012), people with disabilities are becoming more assimilated into rural community life. With this shift, programs that support people with disabilities must be evaluated and the findings made available to local and federal governments to determine best practice for this population. “Best practice” models must be integrated into Tanzanian health policies, with funding provided to reach an increased number of people with disabilities throughout Tanzania.

Taking a holistic occupational therapy approach to vocational training can create an enriching atmosphere where clients gain not only vocational skills but also social skills, life skills, and the self-efficacy needed to contribute meaningfully to their families and communities. The OVTC supports graduates to help them to overcome barriers of stigma and discrimination. This holistic program helps to move students from dependence to interdependence so that they can become respected members of Tanzanian society who live life to the fullest.

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Participant Characteristics

Individual variableTotal sample (N = 97)
Age, M (SD)25.7 (4.8)
  16–20 years16 (16.5)
  21–30 years69 (71.1)
  31–40 years12 (12.4)
Gender, n (%)
  Male63 (64.9)
  Female34 (35.1)
Tribe, n (%)a
  Maasai29 (30.2)
  Iraqw27 (28.1)
  Meru21 (21.9)
  Mbugwe8 (8.3)
  Chagga3 (3.1)
  Rangi2 (2.1)
  Sandawe2 (2.1)
  Other4 (4.2)
Diagnosis, n (%)b
  Musculoskeletal condition48 (38.4)
  Intellectual disability20 (16.0)
  Congenital condition19 (15.2)
  Neurological condition18 (14.4)
  Infectious disease13 (10.4)
  General medical condition5 (4.0)
  Trauma2 (1.6)
Intellectual disability, n (%)19 (19.6)

Characteristics of Olkokola Vocational Training Center

Program variableTotal sample (N = 97)
Vocational training focus, n (%)
  Tailoring50 (51.5)
  Carpentry20 (20.6)
  Masonry15 (15.5)
  Agriculture and veterinary12 (12.4)
Graduation year, n (%)
  1985–19891 (1.0)
  1990–19941 (1.0)
  1995–19993 (3.1)
  2000–20049 (9.3)
  2005–200951 (52.6)
  2010–201432 (33.0)

Percentage of Pre- and Posttest Ratings

Skill areaPretest rating, nPosttest rating, n (%)Chi-square goodness of fita
123
Self-care and personal hygiene11 (1.0)1 (1.0)5 (5.2)41.90 (p < .001)
20 (0)4 (4.2)27 (28.1)
30 (0)1 (1.0)57 (59.4)
Household activities15 (5.2)4 (4.2)22 (22.9)163.65 (p < .001)
20 (0)7 (7.3)33 (34.4)
30 (0)0 (0)25 (25.8)
Farming skills133 (34.4)4 (4.2)15 (15.6)180.27 (p < .001)
22 (2.1)2 (2.1)28 (29.2)
30 (0)0 (0)12 (12.5)
Animal husbandry skills129 (30.2)2 (2.1)7 (7.3)48.81 (p < .001)
21 (1.0)8 (8.3)23 (23.7)
31 (1.0)0 (0)25 (25.8)
Community and church participation11 (1.0)3 (3.1)8 (8.3)364.43 (p < .001)
21 (1.0)8 (8.3)60 (62.5)
30 (0)0 (0)15 (15.6)
Income-generating activities15 (5.2)6 (6.3)70 (72.9)7350.14 (p < .001)
20 (0)0 (0)14 (14.6)
30 (0)0 (0)1 (1.0)

Differences in Ratings Before and After Vocational Training

Skill arean (%)ZpEffect size
Higher posttraining ratingsNo change in ratingsLower posttraining ratings
Self-care and personal hygiene33 (34.4)62 (64.6)1 (1.0)−5.24.000−.38
Household activities59 (61.5)37 (38.5)0 (0)−6.94.000−.50
Farming skills47 (49.0)47 (49.0)2 (2.1)−6.02.000−.43
Animal husbandry skills32 (33.3)62 (64.6)2 (2.1)−4.59.000−.33
Community and church participation71 (74.0)24 (25.0)1 (1.0)−7.90.000−.57
Income-generating activities90 (93.8)6 (6.3)0 (0)−8.77.000−.63
Authors

Dr. Hansen is Scholar in Residence, Center for African Studies, and Dr. Blaskowitz is Assistant Professor, Department of Occupational Therapy, Duquesne University, Pittsburgh, Pennsylvania.

The authors have no relevant financial relationships to disclose.

The authors thank the Olkokola Vocational Training Center Staff, Fr. Pat Patten, Sinyati Mollel, Zablon Ole Muterian, and Elias Singo for their research collaboration; Anna Kateri Hansen and Katherine Witchger, who were research assistants; and Dr. Paul W. Scott for methodology review.

Address correspondence to Anne Marie Witchger Hansen, EdD, OTR/L, FAOTA, Scholar in Residence, Center for African Studies, Duquesne University, 600 Forbes Avenue, Pittsburgh, PA 15282; e-mail: hansen@duq.edu.

Received: November 05, 2017
Accepted: July 31, 2018
Posted Online: October 01, 2018

10.3928/24761222-20180926-01

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