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An invaluable experience: Physiotherapy in Sierra Leone

A trip to Sierra Leone before the current ebola outbreak taught physios Krupa Karavadia and Priya Gami how to overcome challenging circumstances. They share their experiences.

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In 2012 we travelled to Sierra Leone with the Better Lives Foundation (BLF), a charity that aims to improve health and education in developing countries.

In 2010 BLF launched a primary healthcare clinic in the remote village of Yonibana. This camp is currently run three times a year by general and healthcare volunteers, providing free healthcare to local people.

The charity is also supporting local students with their education to become trained medical and healthcare professionals with the hope that the hospital could be open and run on a daily basis.

Sierra Leone is one of the poorest African nations, having come through a decade of devastating civil war. Although rich in natural resources, 70 per cent of its five million people live below the poverty line, with the average wage in remote villages like Yonibana being less than 60p a day. Medical care is also scarce.

The camp had established teams including GPs, paediatricians, gynaecologists, a surgical team, a dental team and pharmacists, but we were the first physiotherapists.

Having worked in the NHS for four years since graduating, we wanted to take the knowledge and skills we’d gained from working in various settings and use our experience to make a difference in a more challenging environment by establishing the camp’s inaugural physio service.

Back-breaking work

Our patients were predominantly from agricultural and trading backgrounds, involving heavy lifting and repetitive manual tasks. It is commonplace for workers to carry goods on their heads and for children to carry their younger siblings for long periods.

We also noticed manual workers and farmers tended to adopt sustained flexed postures while working and demonstrated poor lifting techniques. Given the lifestyle of this population, musculoskeletal (MSK) injuries and chronic pain are frequent problems and the majority of referrals we saw were for back, neck and shoulder pain.

Other patients had acute and chronic traumatic injuries, such as untreated fractures, burns and limb amputations. Some children had congenital and developmental deformities and other patients had neurological conditions. Most of our referrals came from the GPs.

The physiotherapy clinical area was based outside where we assessed our patients individually. A local physiotherapy student assisted with interpretation.

Focus on self-management

The main focus of our treatment was to offer long-term solutions and prevention strategies, with the aim of reducing the need for medication. We placed emphasis on educating patients in how to self-manage their conditions.

Most of the teaching centred on back care, including demonstrating correct lifting techniques and stressing common unsafe manual handling practices. Information leaflets with basic diagrams were given to these patients, which seemed to be greatly appreciated.

We also spread the message on the importance of short periods of daily exercise for general health by teaching patients, local volunteers and outreach workers simple stretching and strengthening exercises, and for a few patients breathing and relaxation exercises.

Sharing knowledge

As well as educating our patients, we played a pivotal role in training our physiotherapy student, Kadiatu, in the theory and practical aspects of physiotherapy. By working and observing us closely, she acquired many new skills and towards the end of our stay was assessing and treating patients with our guidance.

There is no established training facility or programme for studying physiotherapy in Sierra Leone. Teaching Kadiatu was incredibly fulfilling, and we hope she can develop into a skilful physiotherapist who will play a vital role at Yonibana hospital.

While we were fortunate to have an abundance of rollator frames and elbow crutches, wheelchairs and walking sticks were in limited supply. Gait re-education often proved difficult on uneven terrain but could be helped by exchanging an oversized bamboo stick, used to support patients with significant gait abnormalities, with a correctly measured mobility aid. This had a considerable effect on people’s gait pattern, satisfaction levels and comfort.

Challenges and reflections

Working in a completely different environment and culture inevitably posed challenges. We were initially apprehensive about how physiotherapy as a new service would be perceived, with most patients having little or no awareness of our role.

It was disappointing that our treatment was, at times, not acknowledged or taken on board by some patients. There were, however, many occasions where we felt we had made a huge difference and this satisfaction was enough to keep us motivated and enthused for each patient.

We couldn’t change our patients’ labour intensive lifestyles but education in how to prevent MSK complaints still served a useful purpose for which patients were grateful.

One of the biggest challenges we faced was the reliance on ‘quick fix’ painkillers, and many locals had waited days for our camp to arrive only to be given a week’s supply of analgesia. We feel that changing this mindset to long-term self-management will take several years of education.

Despite having our student to help interpret our sessions, the language barrier still posed a significant problem. It was particularly difficult when our student was unavailable and we faced a busy clinic with most patients being non-English speaking. At these times we relied on diagrams, non-verbal communication strategies and the basic Creole terms we had learnt.

Since returning to the UK, we are much more attentive when addressing language barriers and cultural differences with our patients.

Our time in Sierra Leone was an invaluable experience.

We now appreciate how much can be done using simple items around you and being creative with treatment techniques – a useful perspective we can carry forward in our everyday working lives. It made us feel fortunate to have access to healthcare.

We feel very privileged to have been part of the BLF team and to have volunteered with a charity that is helping to provide jobs, education and a sustainable healthcare facility for the village of Yonibana.

Krupa Karavadia is a senior physiotherapist at Croydon Health Services NHS trust and Priya Gami is a senior physiotherapist at Harley Street at University College Hospital, London.

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