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Research Article
The Development of a Vocational Rehabilitation Program to
Assist Individuals With MDRTB and TB in Returning to Work
Mogammad Shaheed Soeker and Ayesha Jainodien
Occupational Therapy Department, University of the Western Cape, Cape Town, South Africa
Correspondence should be addressed to Mogammad Shaheed Soeker; msoeker@uwc.ac.za
Received 26 August 2024; Accepted 12 December 2024
Academic Editor: Stefania Costi
Copyright © 2025 Mogammad Shaheed Soeker and Ayesha Jainodien. Occupational Therapy International published by John
Wiley & Sons Ltd. This is an open access article under the terms of the Creative Commons Attribution License, which permits
use, distribution and reproduction in any medium, provided the original work is properly cited.
Background: Individuals diagnosed with tuberculosis (TB) and multidrug-resistant (MDR) TB may struggle to return to work
after they have completed a rehabilitation program. Multidrug-resistant tuberculosis (MDRTB) has been seen as a condition
that is resistant to treatment, hence causing individuals to be economically in-active for considerable periods of time.
Objective: The aim of the current study was to explore the views of individuals living with MDRTB, individuals with TB, and
health professionals treating individuals with TB and MDRTB about the development of a vocational rehabilitation program.
Method: The researchers used an exploratory descriptive research design, and semistructured interviews were conducted with five
key informants and four participants who were diagnosed with pulmonary tuberculosis (PTB) and MDRTB. Thematic analysis
was used in order to analyse the study findings. The current study is the second of two articles. The first article focused on
barriers and facilitators linked to returning to work for individuals living with TB and MDRTB. The current article focuses on
the development of a vocational rehabilitation program.
Results: The findings of the original study revealed five themes; however, for the purpose of this article, only two themes will be
presented, namely, Theme 1: promoting a holistic model and Theme 2: the use of resources for activity engagement. The latter
theme contributed to the participant’s view of the development of a vocational rehabilitation program.
Conclusion: The study provided a description of the components of a vocational rehabilitation program that has been adapted
from the Model of Occupational Self-Efficacy (MOOSE). The above program has been designed for individuals diagnosed with
PTB/MDRTB and has the potential to assist them in returning to work. It is suggested that vocational rehabilitation programs
be incorporated into general medical programs that focus on improving the functioning of individuals diagnosed with PTB/
MDRTB.
Keywords: adaptations; client-centred approach; occupational therapy; perception; qualitative research; return to work; self-
efficacy; tuberculosis; vocational rehabilitation; young adults
1. Introduction
1.1. Epidemiology of Tuberculosis (TB). TB has been seen as a
devastating disease that has affected millions of individuals
throughout the world and has been viewed as a public health
threat. The World Health Organization (WHO) reported
that in 2024, 2.5 million people became sick with TB in
Africa, thus contributing to a quarter of new TB cases world-
wide. WHO reported that in 2022, about 424,000 people
died from the disease in the African region (1.267 million
globally) [1]. Over 33% of TB deaths occur in the African
region. TB has been regarded as one of the 10 leading causes
of death in developing countries. Furthermore, according to
WHO [2], it is reported that the risk of HIV positive people
developing TB is about 40% more when compared to HIV
negative people, with many individuals diagnosed with
HIV residing in African countries. The WHO reported that
1.25 million people died from TB in 2023 (including 161,000
people with HIV), thus confirming TB as the leading cause
of death from a single infectious agent [1].
The cases of TB incidence are still very high in develop-
ing countries such as South Africa [3]. Although South
Wiley
Occupational Therapy International
Volume 2025, Article ID 9914578, 12 pages
https://doi.org/10.1155/oti/9914578
Africa has made good strides in decreasing the mortality
related to the disease, the incidence of TB in South Africa
remains at 468 per 100,000 of the population [3]. TB is the
leading cause of death among young adults who are in the
most productive years of their lives [4].
On average, 47.3% of individuals diagnosed with TB lose
out on work productivity while they are recovering [4]. The
above may have an economic impact on communities to the
extent that up to a third of individuals who complete TB
treatment are still unemployed [5]. Some of the common
symptoms related to TB that influence an individual diag-
nosed with TB’s ability to return to work are low physical
endurance, loss of motivation, and a loss of self-esteem [6].
Other psychosocial factors include the stigma that society
has towards individuals with TB due to the fear of becoming
infected by them [7]. The worker roles of individuals diag-
nosed with TB are affected, as they often struggle to com-
plete work tasks due to their symptoms of low physical
endurance [5]. It could be argued that due to the unemploy-
ment rate, individuals with TB could experience stigma in
the workplace as they may not be accommodated in the
workplace. This may result in these individuals experiencing
low self-esteem and negatively affecting their ability to hold
jobs when becoming reinfected [5]. Many of these individ-
uals may have low self-esteem and could struggle to main-
tain work when they get reinfected. Society may stigmatise
individuals with TB and in particular multidrug-resistant
tuberculosis (MDRTB), thus reinforcing low self-esteem
among individuals diagnosed with TB [8, 9].
Rehabilitation programs such as work-hardening pro-
grams and supported employment programs have been
commonly used in order to enhance the work skills of per-
sons with disabilities [10]. However, it could be argued that
there are minimal to no vocational rehabilitation programs
that specifically focus on enhancing the work skills of indi-
viduals with pulmonary tuberculosis (PTB) and MDRTB in
South Africa and other countries. The Model of Occupa-
tional Self-Efficacy (MOOSE) has been used with great suc-
cess in South Africa, especially in enhancing the work skills
and self-efficacy beliefs of individuals with disabilities [11].
Soeker, Abbas, and Karachi [12] have applied the rehabilita-
tion model in different contexts and with individuals with
diagnoses ranging from traumatic brain injury, stroke, and
schizophrenia. Therefore, as a result of the poor return to
work rates of individuals with TB and the fact that individ-
uals with PTB and MDRTB may have reduced self-efficacy
beliefs, the authors explored ways of adapting the MOOSE
in order to enhance the work skills of individuals living with
PTB and MDRTB.
1.2. Description of the MOOSE. The MOOSE is a vocational
rehabilitation model that consists of four stages that are con-
ducted by the occupational therapist treating the individual
diagnosed with PTB and/or MDRTB. Stage 1 is termed a
strong belief in functional ability. Self-reflection is the goal
of this stage of the model; the individual is allowed to self-
reflect on the incident (this could be the cause of the illness),
therefore creating an opportunity for introspection. The
process of introspection allows the individual to recognise
and actively manage any emotions related to their circum-
stances [13]. Stage 2 is called the use of self; during this stage,
the individual takes control of their life and develops a plan
to overcome the difficulties they experienced with the assis-
tance of the occupational therapist. The purpose of rehabil-
itation is to enhance their functional skills such as
cognition and endurance [13]. Stage 3 is called the creation
of competency through occupational engagement; during this
stage, the individual’s (patient) perception of their worker
role changes from a worker needing assistance to a more
positive independent worker role. This stage focuses on
enhancing the individual’s work-related skills, such as com-
puter literacy, driving skills, and communication skills. This
subsequently improves their work performance [13]. Stage 4
of the model is called capable individual. This stage is char-
acterised by an improvement in the individual’s volition and
their worker role to the extent that they can successfully
engage in work tasks, which then leads to an improved sense
of self-efficacy. In this stage, the individual will be involved
in test placements where they can actually practice their
skills in real work settings. During the last stage of the
model, the occupational therapist gradually reduces the
amount of support provided, as the aim is to enable the indi-
vidual who is receiving treatment to function indepen-
dently [13].
In the current study, the MOOSE was adapted after the
interviews were conducted with the research participants.
The interviews were therefore used in order to adapt the
MOOSE in order to enhance the work skills of individuals
diagnosed with PTB and MDRTB. The steps of the MOOSE
are graphically described in Figure 1.
1.3. Aim. The aim of the current study was to explore the
views of individuals living with MDRTB, individuals with
TB, and health professionals treating individuals with TB
and MDRTB about the development of a vocational rehabil-
itation program adapted from the MOOSE.
2. Methods
A qualitative exploratory descriptive research design was
used in order to describe the experiences of individuals with
PTB/MDRTB and key informants (i.e., occupational thera-
pists and physiotherapists) about their views of enhancing
rehabilitation and in particular in adapting the MOOSE as
a viable vocational rehabilitation program that would aid
individuals with PTB/MDRTB in returning to work. Purpo-
sive sampling was used in order to select the participants.
Nine participants were selected to participate in the study
[14]. The number of research participants is based on the
need to obtain detailed qualitative data on the usefulness of
the MOOSE in treating individuals with PTB. According to
Creswell [15], a sample size of between five and 25 is
regarded as appropriate for qualitative studies, as the pur-
pose of qualitative studies is to obtain an in-depth under-
standing of phenomena. The sample of nine individuals
was therefore regarded as appropriate for the study. The
purpose of the study was to understand the experiences of
individuals with PTB/MDRTB and health professionals
2 Occupational Therapy International
involved in the treatment of PTB and MDRTB about return-
ing to work after they have completed rehabilitation.
3. Participants
The key informants consisted of five rehabilitation special-
ists using the following inclusion and exclusion criteria.
For inclusion in this study, eligible participants had to be
health rehabilitation experts such as occupational therapists
or physiotherapists who have worked with PTB or MDRTB
clients for at least 6 months and were involved or experi-
enced in getting PTB and MDRTB clients back to work.
The second group of participants for this study consisted
of four individuals living with PTB and MDRTB who have
returned to work after completing rehabilitation at the TB/
MDRTB specialist hospital. Individuals were included in
the study if they were diagnosed with PTB and MDRTB.
Individuals must have been employed before participating
in the rehabilitation program at the TB/MDRTB specialist
hospital.
4. Procedure
The research participants were selected by viewing the hos-
pital records of individuals diagnosed with PTB and
MDRTB held at hospitals that specialize in treating individ-
uals with PTB/MDRTB. The researchers used one hospital
in Cape Town that specializes in the treatment of individuals
diagnosed with PTB and/or MDRTB. Through a telephone
call, the participants were given brief information about
the study, and the researcher ensured that the participants
met the criteria for inclusion and then arranged an appoint-
ment to discuss possible participation and interest. Once
individuals indicated that they were interested in the study,
they were requested to provide informed consent. All of
the introductory meetings and interviews took place in the
occupational therapy departments at the hospitals.
5. Data Collection
Two individual semistructured interviews were completed
with each one of the five key informants and four partici-
pants about returning to work after they had completed their
rehabilitation. The researcher used a semistructured inter-
view guide, with open-ended questions focusing on the bar-
riers or challenges that the research participants experienced
when using MOOSE. Other open-ended questions focused
on the facilitatory factors or positive factors of the MOOSE
that helped individuals with PTB and MDRTB enhance their
work skills. Finally, the last open-ended question focused on
the views of the research participants about what changes
could be made to the MOOSE in order to enhance its useful-
ness in order to improve the work skills of individuals diag-
nosed with PTB and/or MDRTB.
6. The Process Followed to Adapt the
MOOSE in Order to Treat
Individuals With TB/MDRTB
The program that used MOOSE as a framework was adapted
by means of reviewing the literature related to individuals
with TB/MDRTB, the perspectives of both individuals with
TB/MDRTB, and key informants about adapting MOOSE
as a program to treat individuals with TB/MDRTB. The pro-
posed adaptations to the MOOSE were described, and its
layout is in a table format (this can be viewed in Table 1).
For the purpose of this article, Table 1, which is the outcome
of the study, will be presented in the results section of this
article.
7. Analysis and Trustworthiness
In this study, the eight steps of Tesch’s [16] qualitative data
analysis methods were used in order to formulate themes. In
the first step, the researcher reads the interview transcripts
and documents ideas of significance related to the study. In
Step 2, similar topics or meanings related to the study were
extracted and grouped together. In Steps 3–7, descriptive
codes were formed that eventually resulted in the subcate-
gories and categories being formed. In Step 8, the finalized
themes were formed and presented. The trustworthiness of
the qualitative study was formed by the researchers using
the strategies advocated by Krefting [17], namely, four basic
criteria, namely, truth value, applicability, consistency, and
neutrality of data.
8. Ethics
The guidelines advocated by WHO [18] were used in order
to promote ethics related to research by foregrounding the
rights of the research participants. The participants were
provided with a document describing the aim of the study,
particularly concepts such as informed consent, anonymity,
confidentiality, and nonmaleficence.
Occupational self ecacy
An occupational therapy practice model
for the return of the brain injured individual to work
Participation in occupational
role with maximum independence
Resumption of
occupational roles
Improvement of
functional skills
Reective
cycle Phase one
A strong belief in
functional ability
Phase two
Use of self
Phase three
Creation of competenc
y
through occupational
engagement
Phase four
Capable individual
Critical contacts Critical contacts
Injury
Occupational self ecacy
4
3
2
1
Figure 1: Model of Occupational Self-Efficacy.
3Occupational Therapy International
Table 1: Adapted model of occupational self-efficacy.
Activities Therapist role Assessment Clinical
outcomes Session Core
constructs
Time
frame
Treatment
approach
Program
structure
Adapted Model of Occupational Self-Efficacy—Stage 1
Stage 1: Stage 1 will occur over a duration of 1 week
Role play
A client-
centred
approach to
treatment will
be used.
The client’s
insight into the
diagnosis will
be assessed.
Assessment
of specific
components
(i.e., range of
motion,
muscle
strength,
sensation,
conation,
and
cognition)
Stage 1: A
strong belief in
functional
ability
•This stage is
aimed at
introspection
and self-
reflection on
the incident
and the feelings
surrounding
their new life
circumstances
post-TBI.
•The outcome
of this phase is
very similar to
the first stage of
the original
model. Using
the Gibbs
reflective cycle,
with focusing
on
introspection.
The client
reflects on the
change that has
occurred and
needs to have
insight into his/
her diagnosis
and accept his/
her new
capabilities and
challenges with
the goal of
going back to
the workplace.
60 min
session
The client
reflects on the
physical,
emotional, and
psychological
changes.
Focusing on
then and now.
Telling the
group, the
problem,
getting
feedback from
peers.
3×60
min
sessions
once a
week
Group
therapy
Components
to improve:
- Social skills
- Arousal
level
- Cognitive
behaviour
skills
- Creative
skills
-Reflection
- Self-image
Simulated work
activities
•Modapts
•Valpar
•Work
samples
45 min
session
Simulated work
tasks that are
specific to the
client.
Focus on work-
hardening
skills.
1×45
min
session
once a
week
Individual
therapy
Components
to improve:
- Endurance
- Muscle
strength
- Range of
motion
- Self-image
Adapted Model of Occupational Self-Efficacy—Stage 2
Stage 2: Stage 2 will occur over a duration of 2 weeks
Skill
training—Microsoft
Word
The therapist
will facilitate
basic training
on Microsoft
Word to those
participants
who fit the
criteria.
- Work
samples (e.g.,
Modapts and
Valpar)
- Assessment
of specific
components
(i.e., range of
motion,
muscle
strength,
sensation,
conation,
Stage 2: Use of
self
•During this
stage, the client
regains control
of their life
situation and
realizes their
potential.
•During this
stage, the
participant
should have
60 min
session
Focus on
critical
thinking skills
and problem-
solving.
Encourage the
client to find
logical and
practical
solutions to
problems.
5×60
min
sessions
for 1
week.
Group
therapy.
Components
to improve:
- Memory
- Sequencing
- Attention
span
- Concept
formation
- Problem
solving
4 Occupational Therapy International
Table 1: Continued.
Activities Therapist role Assessment Clinical
outcomes Session Core
constructs
Time
frame
Treatment
approach
Program
structure
and
cognition)
- Assessment
of work
abilities (i.e.,
work habits,
work
competence,
and work
endurance)
insight into his/
her coping
strategies and
enhance their
sense of self-
efficacy.
•Patients
should be
competent in
understanding
the meaning of
self-efficacy
before entering
the next stage.
Adapted Model of Occupational Self-Efficacy—Stage 3
Stage 3: Stage 3 will occur over a duration of 2 weeks
Work-specific skills
The therapist
will facilitate
the activity and
assess the
participant’s
engagement in
the activity.
- Assessment
of specific
components
(i.e., range of
motion,
muscle
strength,
sensation,
conation,
and
cognition)
- Assessment
of work
abilities (i.e.,
work habits,
work
competence,
and work
endurance)
Stage 3:
Creation of
competency
through
occupational
engagement
•In this stage,
the client
continually
improves so
their view of
themselves is
shifted from a
sick role (or I
am unable to)
to a more
positive and
independent
role.
•During this
phase, the
client is given
the
opportunity to
equip
themselves
with the
necessary skills
in order to
return to work.
•This allows
for the
improvement
of a positive
sense of self-
efficacy. This
sense of
independence
could be
measured by a
functional
independence
60 min
session(s)
Allowing the
client to find
ways to solve
their own
problems at
work.
3×60
min
sessions
for 1
week
Individual
therapy
Components
to improve:
- Endurance
- Muscle
strength
- Memory
- Sequencing
- Problem
solving
- Instruction
retention
- Safety with
tools
Curriculum vitae
writing and
professional
behaviour
The therapist
will facilitate
basic training
on how to
construct a
curriculum
vitae and
conduct oneself
in a
professional
manner during
job interviews.
60 mi
session(s)
Encourage the
client to reflect
on the physical
demands of the
job and the
possible
workplace
scenarios they
might be faced
with that could
be challenging.
Brainstorming
practical
solutions to
problems.
5×60
min
sessions
for 1
week
Group
therapy
Components:
- Memory
- Sequencing
- Attention
span
- Concept
formation
- Problem
solving
- Social
conduct
- Time
management
- Coping
skills
5Occupational Therapy International
Table 1: Continued.
Activities Therapist role Assessment Clinical
outcomes Session Core
constructs
Time
frame
Treatment
approach
Program
structure
measure.
•The client
will be able to
engage in
simulated tasks
as per the
requirement of
the job
description
identified.
•The client
will be involved
in work test
placements for
brief periods of
time
Adapted Model of Occupational Self-Efficacy—Stage 4
Stage 4: Stage 4 will occur over a duration of 1 week
Coping skills and
conflict
management
The therapist
will facilitate
life skill groups.
- Assessment
of work
abilities (i.e.,
work habits,
work
competence,
and work
endurance)
Stage 4: The
capable
individual.
•At this stage,
the client has
successfully
engaged in
work tasks that
ultimately
improve their
volition and
worker role.
Their view of
themselves
improves as
they succeed in
work-related
occupations.
•During this
phase, the
client is placed
into the open
labour market
or learnership
facility This
will provide the
client with a
sense of
independence
and allow them
to feel a greater
sense of self
confidence and
improve their
self-efficacy
levels.
60 min
session
The client
should be
encouraged to
discuss how
they are coping
within the
workplace.
Once a
week
Group
therapy
Components
to improve:
- Self-
confidence
- Problem-
solving skills
-Reflection
- Coping
skills
6 Occupational Therapy International
9. Results
The participants described the various factors that contrib-
uted to the development of a holistic model of rehabilitation.
Their ages ranged between 39 and 56 years. Only one partic-
ipant was under 40 years old. Four participants were
between the ages of 40 and 50, five between the ages of 50
and 60, and none above 60 years of age. Seven of the partic-
ipants were female, and two were male [14]. Participant
demographic data are provided in Table 2 (see Table 2).
Five themes emerged from the study, but for the purpose
of this article, only two themes will be described. The two
themes below focus mainly on the views of the research par-
ticipants with reference to recommendations related to
adapting the MOOSE for individuals diagnosed with PTB
and/or MDRTB.
Two themes were described, namely, Theme 1: promot-
ing a holistic model and Theme 2: the use of resources for
activity engagement. The latter theme contributed to the
participant’s view of the development of a vocational reha-
bilitation program. Table 3 describes the results of the study.
9.1. Theme 1: Promoting a Holistic Model. The above theme
represents the participants’comments on the adapted pro-
gram. The rehabilitation specialists reflected that the
adapted program focused on various areas impacting the
lives of TB and MDRTB patients and could therefore be con-
sidered a holistic approach to facilitating return to work for
this target group. The participants also indicated that the
adaptation assisted with community integration and return
to work as a rehabilitation intervention. The quote below
illustrates this theme:
So the program itself like I said, is a holistic program …
like prevocational skills training is one component of it, …it
includes like, life skills, education groups, support groups,
uhm just leisure, sport and leisure, and recreation, arts and
crafts and then substance abuse. (P1: rehab specialist)
Another participant indicated that the adapted program
recognizes the type of clients that will be engaging in the
rehabilitation program and their contextual reality. She said:
…when I say realistic, [it looks] at the context where
they coming from because some of them…some of them
don’t have the resources, uhm you know the resources to
achieve those goals, so we look at the context where they
coming from, the community…where they are going back
uhm so we try and make it as realistic as possible…(P4:
rehab specialist)
Theme 1 consisted of two categories, namely, developing
a client-specific program and therapist involvement.
9.1.1. Developing a Client-Specific Program Based on
Context. This category describes the focal point of the pro-
gram. Most of the participants felt that the adapted program
appeared to be guided by the needs of the clients/patients.
One participant explained that the tasks and activities pro-
posed for the client/patient to engage in are meaningful,
which in turn would benefit the client/patient. He said:
tasks [that] they can’t actually do [it] outside [is] not
really meaningful. So I think those [are the] kinds of things
to consider uhm when drawing up (program). (P1: rehab
specialist)
This was further captured by another participant, who
stated:
…programs [must be based] on what the patients’needs
are and what they say they’re interested in, if they don’t
come up with stuffthen we would recommend certain
things. (P2: rehab specialist)
The participants identified a number of features of the
adapted MOOSE which is an example of holistic
programming.
In addition to the program being context-specific, the
research participants advocated the need for TB survivors
to receive early intervention. One of the participants
indicated:
Equip them just to make sure they understand that it’s
not the end of road if you have the disease. It’s just, you must
make sure that you are going to finish your treatment. (TB2:
TB survivor)
9.1.2. Therapist Engagement in the Program. This category is
representative of the participant’s view of the extent of ther-
apist involvement in the activities included in the adapted
program. The category is described by two subcategories,
namely, Subcategory 1—understanding the client’s contex-
t—and Subcategory 2—the therapist as an external support
and motivation.
Activities such as curriculum vitae writing and group
work are labour-intensive. Participants expressed that the
adapted program may not be feasible given the limitations
of the public health care system. The participants identified
that group work is adopted as a compromise to ensure that
therapists can be involved with more clients at the expense
of depth work at an individual contact level. Individuals
who have been attending group Occupational Therapy
(OT) programs felt that it contributed to their individual
goals as well. The participant said:
I used to do that and then each and every day even on
Sundays I have to go to OT (group OT program) and then
doing the program, for me it was fine and good because it
made me feel comfortable and then believed in myself.
(TB2: TB survivor)
9.1.2.1. Understanding the Client’s Context. The participants
underscored the importance of understanding the popula-
tion of patients that are admitted for PTB and MDRTB
treatment. The ability of therapists to facilitate return to
work is predicated on the extent to which the target group
has a premorbid appreciation of employment and functional
work. The participants reflected that the PTB and MDRTB
patients might not have been employed prior to being
admitted to the hospital. A participant stated that some cli-
ents/patients would need a lot of education to understand
the worker’s role. Thus, in reviewing the adapted program,
participants identified that the inclusion of work-related
activities was contextually sensitive and relevant for the tar-
get group. Another participant described this by stating:
I was very emotional and I was very depressed and so at
the progress he helped me to overcome it and I do a lot of
7Occupational Therapy International
things here like I learn to work on a sewing machine and I
show the other patients what to do and work in groups
and I’m the one who show them what to do and how to
do it because needlework was my thing that I do yeah.
(TB3: TB survivor)
9.1.2.2. Therapist as External Support and Motivation. The
participants reported that the adapted program did not spe-
cifically speak to the role of therapists in providing support
and motivation to patients. The adapted program provided
appropriate activities for engagement with patients but did
not structurally provide for the explicit provision of support
and motivation to patients, given that patients have PTB and
MDRTB. In the adapted program, the therapists should
focus on enhancing the individual with TB/MDRTB’s moti-
vation to believe in themselves to engage in their worker
role.
One participant indicated this by stating:
I used to do that and then each and every day even on
Sundays I have to go to OT and then doing the program,
for me it was fine and good because it made me feel comfort-
able and then believed in myself. (TB2: TB survivor)
9.2. Theme 2: The Use of Resources for Activity Engagement.
Theme 2 addressed the resources for activity engagement in
the adapted program for patients with PTB and MDRTB.
The theme included two categories, namely, (1) resources
and a need for staffin public health care and (2) vocational
rehabilitation assessment tools.
9.2.1. Resources and a Need for Staffin Public Health Care.
In this category, participants underscored the importance
of considering the resources available in rehabilitation set-
tings where the adapted program would be implemented.
They identified that the lack of physical, human, and finan-
cial resources would pose a threat to the resumption of the
survivor’s worker role. Most participants were of the opinion
that improved services to the PTB and MDRTB survivors
could be delivered if they had the necessary resources. One
participant captured this description by stating:
Here at DP (name of hospital) we don’t really have an
existing program officially for people who need to or who
would want to return to work because uhm we don’t have
the you know…the necessary uhm how can I say…materials
or necessary equipment for that. (P4: rehab specialist)
Table 2: (a, b) Description of the demographics of participants for semistructured interviews.
(a)
Key informant Age Gender Qualification Years of experience
P1 (rehab specialist) 25 Female Bachelor’s degree in occupational therapy 3
P2 (rehab specialist) 30 Female Bachelor’s degree in occupational therapy 8
P3 (rehab specialist) 32 Female Bachelor’s degree in occupational therapy 10
P4 (rehab specialist) 28 Female Bachelor’s degree in occupational therapy 6
P5 (rehab specialist) 30 Male Bachelor’s degree in physiotherapy 6
(b)
Participant Age Gender Primary diagnosis
description Education Pre-MI occupation Classification of
occupation
RTW after
rehabilitation
TB1 (TB
survivor) 35 Female PTB Secondary Teller Light Yes
TB2 (TB
survivor) 53 Female PTB Secondary Support group
facilitator Medium Yes
TB3 (TB
survivor) 54 Female MDRTB Tertiary Nurse Medium Yes
TB4 (TB
survivor) 40 Male MDRTB Secondary Factory worker Medium Yes
Note: NB: classification of occupation. Light work is described as work where an individual lifts and carries no more than 10 kg occasionally. Medium work is
described as work where an individual lifts and carries no more than 25 kg [19].
Table 3: Themes and categories.
Theme 1
Promoting a holistic model
Categories
•Developing a client-specific program based on context
•Therapist engagement in the program
Theme 2
The use of resources for activity engagement
Categories
•Resources and staffin public health care
•Lack of vocational rehabilitation assessment tools
8 Occupational Therapy International
Another participant described this by stating:
…we’re very limited with resources, human and physi-
cal resources. (P2: rehab specialist)
These quotes illustrate the context within which the
adapted program would be used to facilitate return to work
for the targeted clinical group. This reality makes it neces-
sary to work collaboratively in order to manage the lack of
resources.
If we merged more often (work collaboratively) sur-
rounding our patients then it would definitely work a lot bet-
ter and the patient will have a better outcome (P3: rehab
specialist)
The participants felt that the adapted program lends
itself to collaborative service delivery. The activities included
may be labour-intensive, but the way in which it is compiled
allows rehabilitation specialists to work together if there are
human resource constraints. Collaboration made possible by
the interprofessional nature of the activities included in the
adapted program could be more of a benefit to the PTB
and MDRTB survivors. This category has two subcategories.
Below is a brief explanation of these subcategories.
9.2.1.1. The Lack of Resources Affects the Quality of
Treatment Provided. This subcategory conveys the partici-
pants’concerns that delivering good-quality rehabilitation
or intervention descriptions is contingent on sufficient
resources. Thus, the adapted program should be robust
enough to maintain its good quality despite the lack of
resources such as a lack of experience of therapists in work-
ing with individuals with TB/MDRTB. The participants were
of the view that maintaining the quality of the OT vocational
rehab program was helpful in getting them to achieve their
individual goals. One participant said:
Yes, I did achieve many goals because I did set the goals,
I remember the time I was admitted there I said: ‘I’m going
to achieve the goals’and then I said: ‘No the first week I
must finish this, I must do that’and now I finish this, and
this and then I start the other one. (TB2: TB survivor)
9.2.1.2. Skill Development. Participants in this study were of
the opinion that engagement in work skills was not focused
on enough during rehabilitation, as well as the promotion of
new work skills. They indicated that therapists often over-
looked vocational rehabilitation in favour of the physical
rehabilitation of the client/patient. Participants felt that the
adapted MOOSE specified activities that promoted skills
development during the rehabilitative phase. The above sub-
category indicates that rehabilitation services need to focus
more on skill development that promotes vocational rehabil-
itation. One participant said:
It helped me a lot and you know what, I’m not at work at
the moment but I do lot of things (work related products to
sell) and I sell it and to the people. (TB3: TB survivor)
9.2.2. Lack of Vocational Rehabilitation Assessment Tools.
This category represents the participants’perceptions of
the lack of vocational rehabilitation assessment tools that
are made available in government-run health institutions.
Participants underscored that work skills are often sacrificed
when there are financial constraints that impact material
resources. The category is further described with subcate-
gories relating to participants’experiences and perceptions
of vocational rehab standardized assessments and engage-
ment in vocational rehabilitation.
9.2.2.1. Usefulness of Vocational Rehab Standardized
Assessments. This subcategory conveys the description of
the usefulness of vocational rehabilitation standardised
assessments. Participants in this study were of the opinion
that standardised assessments would provide more of an
accurate representation of the client/patient’s work ability.
She described this by stating:
Looking at also getting equipment, and more standard-
ized tests where the work assessment, the result could be
more accurate. (P4: rehab specialist)
The participant further emphasized this point by saying:
The doctor will sometimes refer us, refer the patients to
us for a disability grant scheme, uhm but it’s not how can
I say…It’s very basic because we don’t like I said have the
necessary equipment like the Valpar and Modapts or all of
those things to actually assess them in the way that they sup-
posed to be assessed…(P4: rehab specialist)
9.2.2.2. Engagement in Vocational Rehabilitation. This sub-
category addressed the extent to which the adapted program
makes vocational rehabilitation tasks available for PTB
patients to engage in. One participant expressed that it
would be easier to encourage engagement in work-related
tasks or activities given that it is included in the adapted pro-
gram. The inclusion of vocation-related activities and skill
development will increase patients’interest, which in turn
will promote learning and engagement. One participant
identified that these aspects of the adapted program will
contribute to the sustainability of return to work and inte-
gration back into the community. One participant identified
that the adapted program should make the link between the
activities and the rehabilitation outcome clearer for patients
and therapists.
OT historically is known for just keeping you know that
whole “keeping people busy”the new shade term uhm but
they do not see what the purpose of the interventions are.
So there maybe there will be car washes and income gener-
ating activities, but the rest of the team they aware of what’s
happening but they do not understand the meaning behind
the activities. (P1: rehab specialist)
The above quote describes that clients/participants need
to understand why they are being taught new skills or engag-
ing in specific work-related tasks. This insight or linkage
between theory and practice was less apparent in traditional
OT interventions.
9.3. Recommendations to Enhance the MOOSE. The adapted
MOOSE program focuses on nine recommendations that
create the framework of the program. (1) Recommendations
were related to the use of various activities for enhancing the
functional limitations of the individual diagnosed with TB/
MDRTB. (2) There were recommendations related to the
therapist’s role; this describes the therapeutic approach to
9Occupational Therapy International
be used by the health professional. (3) There were amend-
ments to the assessment methods used that linked to the
stage of treatment. (4) There was information related to clin-
ical outcome(s) linked to each stage of the model that was
added. (5) Information related to the duration of the treat-
ment session was added. (6) This was followed by the core
constructs, illustrating what the therapist should focus on.
(7) Information related to the suggested time frame and
amount of treatment sessions was added. (8) Information
related to the suggested treatment approach that health pro-
fessionals should use was included. (9) Finally, information
related to program structure was added [14].
The latter components serve as an overarching frame-
work of the program that will enable the individual with
TB/MDRTB to engage with treatment from the start of the
program until the period when they complete the program.
The original stages of the MOOSE were consistent with the
adapted stages of MOOSE that were currently more suited
to enhance the work skills of individuals with PTB/MDRTB
(please see Table 1—adapted MOOSE).
10. Discussion
In the following section, the results that relate to the views of
both participants and rehabilitation experts regarding the
adapted MOOSE will be discussed. Themes 1 and 2, respec-
tively, related to the participants’views of the adapted
program.
10.1. Theme 1: Promoting a Holistic Model. Theme 1 “pro-
moting a holistic model”was viewed as suggestions to adapt
the content of the original MOOSE in creating the new
adapted MOOSE. The study participants expressed that the
rehabilitation program for patients with PTB and MDRTB
should be one that is holistic and focuses on all aspects of
improving one’s health and well-being. Asbjørnslett, Skar-
paas, and Stigen [20] explained that occupational therapy
is based on the philosophical core principals of providing
holistic and client-centred therapy [21]. Through the use of
holistic therapy, individuals have better health for longer,
and the older generations have more sense of hope that their
end of life can be pleasurable and good [22]. Thus, both the
adapted program and the implementing therapists must take
into consideration the context that the patient comes from
and the various areas that impact the lives of TB and
MDRTB patients. Community reintegration, family support,
prevocational skills, and work rehabilitation need to be
prioritised as these areas are often overlooked due to the
main focus being medical and physical rehabilitation.
10.1.1. Developing a Client-Specific Program Based on
Context. Participants of the current study felt that the
adapted program was informed by the needs of the clients/
patients. The needs of the client/patient thus guide which
areas of treatment require the most attention and interven-
tion, and subsequently which tasks or activities will be
meaningful to the client/participant. This notion was consis-
tent with Fisher and Martella [23], who explained meaning-
ful occupation as being the engagement or participation in
an activity, to the extent that a person values it. They stress
the importance of understanding occupation as a transac-
tional whole in which occupational and situational elements
interlink. This view of the occupational therapy profession
stems from evidence that was found through research, where
participation in meaningful occupations, including work,
generally leads to increased feelings of overall well-being
[24]. This finding is consistent with Bigelius, Eklund, and
Erlandsson [25], who stated that if occupations are not
meaningful, then they cannot be therapeutic. Lastly, Ikiugu
et al. [26] reported that researchers have come to the agree-
ment that meaningful occupations provide people with a
sense of control; it gives them an identity, allows for a con-
nection with other people, and develops competence and
self-expression. The adapted program was deemed suitable
for clients/patients who come from various types of contexts
so it is applicable to most people. Therefore, the types of
tasks and activities included were ones that either relate to
their previous worker role or ones that they have an interest
in, for the potential to learn a new skill. Rehabilitation spe-
cialists must endeavour to fully understand the context
where these clients/patients come from so that these patients
can acquire skills that are achievable or apply for jobs that
will be suitable for them. The adapted program retained a
staged approach so that the client/patient can start offat a
level that is suitable for him or her, where realistic goals
can be set, and engage in appropriate activities that will be
applicable to the level of work experience.
10.2. A Need for Resources Required for a Holistic
Rehabilitation Program. Theme 2 describes the resources
required in order to enable activity participation. It is impor-
tant for public rehabilitation facilities to be equipped with
enough staffto facilitate these programs, as well as have
therapists who will be available to facilitate treatment for
patients who have specific or individualised job roles. How-
ever, in this study, the participants relayed that there is a lack
of staffin the public health sector. Therefore, most interven-
tion programs are exclusively facilitated through group ther-
apy, so that they are able to assist all patients. However, this
is not always the best method of intervention, as every per-
son has individualised needs, and this limits the person
who comes from a different context and has different skill
capabilities. When clients/patients learn new skills, the ther-
apist will encourage and empower the patients to be able to
utilize those skills to find new jobs once they reintegrate back
into the community and explore new worker roles, or
encourage them to resume their previous worker role pro-
vided [27].
10.2.1. Lack of Vocational Rehabilitation Assessment Tools.
The lack of vocational rehabilitation assessment tools specif-
ically for the treatment of individuals with PTB and MDRTB
was seen as a limitation in the current study. Tools in this
study were seen as strategies to assess the functional limita-
tions but more specifically the work-related skills of the cli-
ents/patients. The utilisation of standardised tests was seen
as needs, example tests that could guide the therapist in
identifying their work abilities such as their work endurance,
10 Occupational Therapy International
ability to manage tools and equipment, ability to work with
coworkers, and their general work speed. According to van
Aswegen and Roos [28], they indicate that individuals with
TB, in general, have low physical endurance, and it could
therefore be argued that their ability to work an 8-h workday
will be compromised. It is therefore essential to improve the
client’s work endurance with relevant work-related tasks.
Furthermore, the ability to use work-related tools and com-
municate effectively with others by means of engaging in a
simulated work environment is seen as important, particu-
larly in enhancing their work skills.
11. Limitations to the Study
The recruitment of PTB survivors who returned to work was
challenging. Only one male participant was recruited in the
PTB and MDRTB survivors’subgroup. Despite concerted
efforts to recruit from both genders, it was difficult to iden-
tify male participants. From the health professional’s per-
spective who acted as key informants, it was difficult to
recruit male participants as the professions of occupational
therapy and physiotherapy are dominated by females.
Finally, the small sample size could be seen as another limi-
tation of the study.
12. Conclusion
The findings of the study described two themes, namely,
“promoting a holistic model”and “the use of resources for
activity engagement,”that provide information pertaining
to adapting the MOOSE. The adapted MOOSE provides a
detailed description of the use of a vocational rehabilitation
program that could be incorporated as part of a medical pro-
gram for the treatment of individuals with TB/MDRTB. The
importance of OT services in TB rehabilitation emerged
through the perception of the rehabilitation care specialists
as they identified the lack of public rehabilitation services
that focus on work rehabilitation. The revised program
describes the importance of having individuals with TB/
MDRTB access work-related intervention programs and
engages in work test placements as part of a general rehabil-
itation program.
Data Availability Statement
The data that support the findings of this study are available
on request from the corresponding author, Dr. Mogammad
Shaheed Soeker.
Ethics Statement
The researchers obtained ethics-related permission from the
University of Western Cape’s Biomedical Research Ethics
Committee before collecting research data. The research
participants provided informed consent before participating
in the study. The ethics approval number for the current
study is BM 15/6/6.
Disclosure
The current paper was originally part of one of the coau-
thor’s thesis, A.J.
Conflicts of Interest
The authors declare no conflicts of interest.
Funding
No funding was received to complete the project.
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