A model rural rehabilitation service station in China– Evaluation after 5 years

A simple setup for rehabilitation training was established in 2007 in a rural area of Shanxi Province, China. It made use of an underused facility created for elderly people’s leisure time. Simple equipment for rehabilitation training was provided free for the users, and instructions were given by rehab experts, Traditional medical doctors, and social workers.

This rural Service Station must be the first of its kind in rural China and deserves scrutinizes for its unique nature. After 5 years of service, a service evaluation of its service nature, service providers, users, and special orientations was completed. It is hoped that this Service Station could be taken as a model of similar rural development in China.

Introduction

Shanxi Province of China is one of the least developed areas of the country. The rural population is deficient in medical facilities and the young people prefer going to work in the cities, thus leaving the elderly and very young members behind. County hospitals and rural clinics provide reasonable services to sick people but facilities are basic and hospital orientated.

Rehabilitation Services for the needy are also hospital-based and are provided mainly by Traditional Chinese Medical Practitioners who rely mostly on manipulation, exercises, acupuncture, and sometimes herbal therapy.

Since 2005, a team of rehabilitation experts from Hong Kong, consisting of surgeons, nurses, physio and occupational therapists, have been working closely with a County Hospital in Bei-Ling village of Shanxi, to help the local population: the post-stroke elderlies and those with orthopedic problems. A rural-based village house is converted into a simple, user-friendly setup after 2 years of planning for simple rehabilitation training. Training equipment is installed in the setup. Users could freely use the facilities and infrequent but regular instructions are obtained from visiting experts.

The rural rehabilitation station

The Rural Rehabilitation Station (RRS) was established in 2007 in the village of Bei-Ling within the county of Fu-Ping in Shanxi Province, China. It was created to provide a practical venue for the local inhabitants who need basic rehabilitation facilities because of physical disabilities of varying severities or simply for those elderly undergoing bitter deterioration related to aging. RRS is labelled as a “Station” because of its limited capacity.

The RRS serves as a vivid example of rural development in response to the Central Policy of Rehabilitation Services in 2016 [1] and Establishment Instructions given lately in 2021 [2,3].

The 2003 SARS epidemic crisis in China has served as a serious reminder to China’s Health Policy Planning that practical infrastructures need to be established in all rural areas to get prepared to combat the threat of epidemic invasions which may come under unpredictable occasions. The Bei-Ling RRS borrowed such a single storey, four rooms hardware to be converted into a rehabilitation venue, harbouring the basic equipment and offering free uses, as well as instructive training to the rural inhabitants in the vicinity [4].

Following our last report on its establishment and early experience we intend to give a proper review and evaluation, now that five year’s services have been completed Figure 1.

Figure 1: Rehabilitation Room at the Centre (Picture taken by Centre Staff 2022).

Who provides the services?

In spite of the obvious shortages of expertise in the rural areas in China, with regard to hospital practices, and more seriously outside hospitals, the serving team of RRS comprising part-time health workers and social workers, has insisted on a comprehensive approach, i.e., the multi-directional care considerations.

Technical instructions and guidance are given by the part-time care of staff from the rehabilitation ward of the nearby County Hospital. They are mainly Chinese Medicine doctors who are experts in massage, exercise, and acupuncture. They come to serve the RRS weekly and under special circumstances. When they are not available, villagers who come for training have to manage on their own, to be supervised by fellow trainees or volunteers. Incidental hazards are unlikely because only equipment with perfect safety assurances is available.

The multi-directional service refers to the physical, psycho-social support given on the spot, followed by home visits, to be delivered by one medico-social worker and her assistants. This specialty of social work has only started its development in China lately and a scarcity of trained workers is expected. RRS has been fortunate to get support from a non-government registered social organization service (Qin Huai Social Work Service Centre) for the medico-socio-psychological needs of the clients. The very limited number of workers have dedicated commitments, from on-site assistance to home visits [5].

Who receives the services?

Those coming to RRS include discharged individuals from nearby hospitals, rural dwellers suffering from different degrees of disability, and the elderly affected by different forms of physical and mental deficiencies. The social workers are taking a very liberal attitude towards those indicated for service since Bei-Ling has been deficient in such related care and RRS has bravely taken up the role of an experimental trial model. Once the service started, additional referrals come from official charity bodies in the county and the local Rehabilitation Society. Neighbourhood referrals are also unique for rural dwellers.

The tiny RRS structure also serves as a happy grand-parent-childrens’ gathering station as could be imagined since it is freely open to the rural area during regular hours.

Service recipients are able to appreciate the physical training-family involvement and social care of the RRS spirit. Unlike most hospital settings where service is limited to technical support, RRS involvement of the family takes care of mood responses to the service, and human interactions in the service procedures. The unique medico-social service is well appreciated [6].

The evaluation

The model RRS needs a serious evaluation and analysis so that adjustments and enforcements could be proposed. Self-evaluation is the only way to achieve this goal for the fact that RRS is a totally new and independent project. The serving team of a dozen workers has diligently kept monthly records on routines, services, and special activities which would serve them well to give an intentionally unbiased, objective view. The management committee consisting of the service leaders, four social service experts in China, and two others from Hong Kong, has been holding biennial meetings which will also contribute towards the general assessment of the events and achievements.

Readers need to be aware that in the rural setting of remote North-West China, this service center has been functioning as a rather primitive Charity Unit with limited resources and the professional supervision has been basic and not research orientated. The evaluation taken place did not reach the professional standard expected by the research experts. The evaluation has been an overall judgement on the Centre’s Practicality, the service details its pros and cons which will help with future planning. We did not follow a specific methodology, nor did we issue standard questionaries for data analysis. In short, the process was mainly an attempt at comprehensive opinion gathering.

Results of the opinion gathering of the people involved over the past years could be given under specific categories of information source: from the users, the service providers, the rural administrators, and reflections related to current rural/county policies.

The Key Findings are as follows:

i. From the users: The daily walk-in users were happy with the facilities which gave them freedom of utilization on their own intentions while at the same time, advice and instruction could be obtained from rehabilitation experts from the hospital on weekly basis.

Special users referred for specific training could not get frequent regular instructions from the part-time Chinese Medicine instructor; yet they appreciated fully the convenience which spared them from lengthy travels to the county hospital, long waitings, and costs.

Users had close relatives sharing the experience offered by the RRS and the warm interactions with the social worker concerned. They expressed hearty appreciation.

ii. From the service providers: The unique RRS project had been a fresh experience for the expert service providers who needed to squeeze out spare time (usually once a week) to contribute their expertise. The outside hospital environment had been a new challenge and experience. Chinese Medicine experts enjoyed the friendly warm environment when they offered manual and advisory services in the presence of relatives and friends. Their unique attitude and enthusiasm were particularly appreciated by the advisory experts.

The Rehabilitation expert in charge of the county hospital unit was a key member in the planning of RRS and he came to the RRS from time to time for coordination purposes. The outside hospital inspections allowed him to better arrange the technical details of his standard hospital service.

Social workers working closely with medical experts was an ideal arrangement for rehabilitation. The busy schedule of both streams of workers prevented harmonious arrangements even in advanced urban communities in affluent countries; and without a doubt in rural China, desperately deficient of experts. Rural areas like Bei-Ling could be totally ignorant about the role of the social worker. However, the social workers involved in the RRS project insisted to maintain a busy schedule shared between their hospital, commitment to charity work, and the project. They appreciated the challenge of the pioneering work which had been very much reflected in their general story-telling narrations and particularly in relation to their home visits. One could solidly consider their work outstanding and epoch-making.

iii. From the rural administrators: The Administration Committee of the Bei-Ling village had been supportive of the idea of establishing an RRS in the village, very much so because of the embarrassment that the single-storey building earmarked for welfare activities of the elderlies had been laid idle since its establishment and no solid planning on its practical use was available. The RRS had been a fruitful practical conversion that earned the rural peoples’ full support: not only were the elderlies taken care of, but their family members were also clients of service. More importantly, the RRS reflected well the Bei-Ling Administration’s close adherence to the National Policy of offering substantial rehabilitation services for the disabled and elderly.

The Rural Administration had been offering relevant support directly and indirectly related to its jurisdiction. Although, the RRS was a totally local establishment of rural nature, supported on the technical side by the County Hospital and on the financial side by a Hong Kong-registered charity association independent of the bureaucracy of Shanxi Province, the Rural Administration had accepted the arrangement with goodwill.

China had been so serious with rehabilitation services that the Country-wide National Rehabilitation Association (NRA) had working offices in all cities and counties. The NRA office of Fu-Ping County was well aware of the establishment of the RRS and encouragement had been offered all along, together with inspections and fact-finding visits.

iv. Reflections on Current Community Policies: Since 2017-2018, instructions have been given by the Central Administration that rural county districts should enhance their regional ability to achieve better welfare and maintenance of social harmony among the people [7,8].

As a direct follow-up and development of the implementation, Shanxi Civil Service Authority has started an ambitious program involving the Street-level provision of a “Social Work Station” to coordinate multiple welfare areas of social assistance, social order, elderly and child care, etc. The emphasis is on the modern development of a professional approach, considered as an appropriate follow-on of successful anti-poverty achievements. The ambitious plan includes the provision of at least five staff members in each station, three of which should have proper social work training. (https://mzt.shaanxi.gov.cn/html/zx/gzdt/202208/32975.html)

Taking a critical look at the current strength of social work services in China, the direction of development can only be a future goal, which would take years to go near the expectation.

Looking at the establishment of the RRS model which has followed a direction of professional collaboration between the county hospital and social workers; dedicated to rural services relevant to rural administrative needs: the directives given by the Central Government have been effectively followed.

The evaluation done seriously by the rural staff jointly with advisers, as discussed above has resulted in a consensus positive endorsement and appreciation of the performance of RRS. Subsequently, the unique features of the RRS that have supported its steady development to reach the current level need to be further understood and analyzed.

Circumstances supporting the establishment of RRS

RRS has developed as a unique small rural Charity Organization in China supported by “Operation Concern” in Hong Kong.

The Operation Concern Charity was started in 1993 in Hong Kong by a group of surgeons, nurses, and rehabilitation workers giving free services to remote areas in China during the period that China was in much need of support. The services took the form of patient care and much effort was given to rehabilitation services which China very much lacked in that period. At its height of development, Operation Concern liaised with a dozen collaborative hospitals in remote areas in China to render service to people requiring rehabilitation, training to service providers, and some charity offers. It also participated in relief episodes during natural disasters like earthquakes.

The past thirty years of service in China have witnessed rapid development and persistent shortfalls in Medical Services. With the rapid clinical developments and hospital facilities in China, Operation Concern stopped offering technical support to hospitals after 2010. On the other hand, persistent shortfalls are observed in the broad rehabilitation field: remarkably in the need for social and psychological support while technical facilities were improving. Operation Concern hence carried on with strict rehabilitation orientations, trying to contribute more in the more deprived rural areas.

In addition, China’s anti-poverty policy worked so well that attention has shifted much to ways to maintain improved conditions, i.e., social stability, individual well-being, and special care to the needy, particularly in rural areas [9].

Operation Concern’s aspirations are assumingly, fatting well with the National Policy. RRS has managed to gain the right time to thrive.

Special working principles leading to acceptance and growth

From the very beginning, RRS is aware of the importance of the many working principles which supersede financial resources. The principles could be described as follows:

i. A comprehensive rehabilitation direction: While physical abilities require technical training, the related components: psychological support, home care, and an interpersonal relationship would need to be taken care of. This has led the way to “tripartite” care, which provides technical, instructions, interpersonal care, and home support. To the working group’s satisfaction, this approach has been much appreciated.

ii. Close collaboration between the traditional and hospital medical experts: While integrated care between traditional and modern hospital professionals is common and well advocated in China, this collaboration is particularly important in rural areas where the number of traditional experts dominates. In the tiny environment of RRS with limited training equipment, the contributions from the traditional experts using manual techniques have been the most innovative. In the RRS at Bei-Ling, this observation has been greatly acknowledged.

iii. Attempts to reach better professional levels: The shortage of special services like social work is widely felt all over China, more so in rural areas. The working team is trying to overcome the defect with in-service training (from on-site supervision to network facilitations), case consultations, and selective supervision. Team members and advisers have witnessed the achievements of the informal yet, serious participation, the commitment and enthusiasm shared, and the struggling efforts to recruit and train the non-professionals to reasonable levels of performance.

iv. Mobilizing the non-professional: The small working team with multiple commitments: from hospital counselling to home visits, is facing over-commitment realities. Mobilization of volunteers and training them for specific services could be helpful and proven valuable. The team also actively initiates the carers of clients with similar needs so that they could be initiated to help one another.

v. Special occasions: In rural areas, rural people are particularly conscious about celebrative events related to festive occasions like New Year’s Day and various important festivals. Special celebration activities have been arranged jointly with training workshops involving local and outside experts.

During the many crisis periods of the COVID pandemic, team members were required to stay home. With their experience in festive arrangements, they are more capable of organizing productive activities of educational value and instructive dimensions online so as to meet the needs of their clients at home.

Future outlook

The experience of RRS has given many positive messages endorsing its value and practicality. The unique direction of development adopted has also laid down valuable demonstrations of the requirements for similar establishments.

The County Office of the National Rehabilitation Association at Fu-Ping has started building a rural center with equivalent facilities and aspirations, sampled after the RRS. The central Policy of establishing “Social Work Stations” is an exciting development to look forward to. RRS has pioneered a model sample that would deserve further development.

It is the wish of RRS to carry on its pioneer role. Its limited external financial support could become healthier if Provincial or National funding could be gained in the near future. RRS should be proud that it has well supported the National Policy in a yet deficient area of community development in China. It would closely follow the broad direction of the National policy and yet try to develop a practical program of a comprehensive rehabilitation to provide technical needs and to promote family and social harmony. Through the empowerment and strengthening of care relations within the family, between families, and the community, one could be optimistic that the RRS model could serve as a good reference for rural development in China [10-19].

RRS has been a modest project. It has chosen the humble name of a “station”. Whether RRS would be capable of upgrading itself to a “Centre” depends on resources, National Policy support, and professional development in the Social Work field in China. No matter what will be the real situation, one could be optimistic that in a few years’ time, many centers and stations, carrying the role of Comprehensive Rehabilitation, will be found all over China.

Operation Concern Charitable, Hong Kong, a registered non-governmental charity organization has been responsible for funding involved in the function of the Rural Rehabilitation Service Station.

Professor Emeritus P.S. Mak of Hong Kong Polytechnic University has supervised the preparation of this manuscript.

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