A comparison of hospital-based and community-based models of cerebral palsy rehabilitation

Abstract

Cerebral palsy is a disabling and permanent condition which requires sustained rehabilitation over a long period of time. There is much debate as to which model of service delivery is most appropriate for children with cerebral palsy and their mothers. The aim of this study was to compare the efficacy and effectiveness of two models of service delivery currently offered in Harare, Zimbabwe. One of these is a hospital-based and the other a community-based service. A quasi-experimental study was done to determine the efficacy of two service delivery models from the perspective of caregivers and functional gains in children. Questionnaires were distributed to caregivers of children with CP at baseline and after three months. The caregivers were 46 in total, with twenty caregivers having children receiving rehabilitation services under an outreach program and 26 receiving services as outpatients at a central hospital. The caregivers’ health- related quality of life was assessed using the EQ-5D, the burden of care was measured using the Caregiver Strain Index, satisfaction with physiotherapy was assessed using the modified Medrisk satisfaction with physiotherapy services questionnaire and compliance was measured as an index of the met appointments from the scheduled appointments. Additionally, motor functional changes in children with CP were assessed at baseline and after three months using the Gross Motor Function Measurement (GMFM-88). Children receiving community based treatment children were significantly older than children in the hospital based group. However, the two groups were comparable in terms of sociodemographics of both children and caregivers at baseline. The correlation between age and change in score was tested and found to be non-significant (r=-.103, p=.497). Spearman’s rho indicated that as the level of severity increased in terms of GMFCS level, so the amount of improvement decreased (rho=-568, p<;.000). However, as age was significantly different between the two groups and there were more severely affected children in the community based treatment group, regression analysis was done to establish which factors predicted the amount of change in the GMFM Score. Dummy variables were created for the categorical variable of the group and the ordinal variable of GMFCS was dichotomised into level 3 and above and level 4 and below. The resulting model accounted for25% of the variance (adjusted R²= .25) after the score of one child was removed after residual analysis indicated that he/she had improved more than two standard deviations from the mean residual. The results indicate that, once age and category were controlled for, children in the community based treatment group improved 3.5 points more than children receiving hospital based services. Children who were more severely disabled showed 4.7 points less improvement, and for each month of age, children showed .04 less improvement, although this was not significant.