Comprehensive Needs Assessment to Ensure Appropriate Rehabilitation Training for Community-Based Workers and Caregivers in India

Abstract

Importance: Rehabilitation researchers and occupational therapy practitioners frequently conduct projects that involve the provision of services or the dissemination of knowledge in low- and middle-income countries (LMICs); however, the needs assessment process underlying these transcultural projects is often underreported.

Objective: To identify a comprehensive set of feeding-related training needs that reflect the culture, resources, and service delivery practices in the West Bengal region of India and that will be used to develop video-based training modules that are contextually relevant and support decentralized training of community-based rehabilitation workers and caregivers of children with cerebral palsy (CP).

Design: Mixed methods design using focus groups and observations.

Setting: Community setting in rural, suburban, and urban locations in West Bengal, India.

Participants: Caregivers of children with CP and community-based rehabilitation workers with experience working with children with CP.

Outcomes and Measures: Focus groups and in-home mealtime observations.

Results: Several findings suggest training priorities that were not anticipated. Caregivers commonly fed children by means of hand feeding while sitting on the floor. Children were fed a limited variation of food consistencies, often in positions of neck hyperextension. Water was frequently used to stimulate swallowing. Caregivers struggled to help children with oral hygiene practices after meals.

Conclusions and Relevance: A thorough needs assessment yielded insights that can favorably alter the trajectory of transcultural service and research projects. For occupational therapists who provide advice on practice, continuing education, or research in a transcultural project, the findings underscore the value of engaging local stakeholders and using firsthand observation.

What This Article Adds: The rigorous, multistakeholder needs assessment process described herein can serve as a road map for researchers and occupational therapy practitioners conducting transcultural projects in LMICs.

A rigorous, multistakeholder needs assessment process can serve as a road map for researchers and occupational therapy practitioners conducting transcultural projects in low- and middle-income countries.

Many universities are initiating international collaborations to improve health in low- and middle-income countries (LMICs) while enriching the experiences of occupational therapy students (Suarez-Balcazar et al., 2015; Witchger Hansen, 2015). The World Federation of Occupational Therapists (2014) has urged occupational therapists to develop collaborative relationships with international organizations to share research, education, and technology addressing transnational, global health issues. In pursuit of that goal, occupational and physical therapists have begun taking an active role in training community-based rehabilitation (CBR) workers to implement disability-related services in resource-poor regions. In LMICs such as India, health workers tend to migrate to urban areas, and infrastructural barriers prevent people from accessing health care workers (Hamblin et al., 2008). CBR workers are typically members of the community (Pallas et al., 2013) who have been trained to provide a limited set of services in regions in which there are few fully trained rehabilitation professionals (Cleaver & Nixon, 2014; Hamblin et al., 2008). Families in LMICs, including those in West Bengal, India, rely heavily on CBR workers for disability-related education and services (Hamblin et al., 2008; Mannan et al., 2012).

Transcultural projects that attempt to apply research and practice evidence from high-income countries to meet the needs of LMICs often fail because of a lack of prioritization of or sensitivity to the needs of the local context (Bergström et al., 2012; Madon et al., 2007; Suarez-Balcazar et al., 2015). A thorough needs assessment can yield key insights that can favorably alter the trajectory of transcultural service and research projects and avoid the possibly false assumption that the needs and priorities of the target regions are the same as those of the region in which training materials are being developed. Unfortunately, the needs assessment process is often underreported in descriptions of transcultural projects involving training and service provision.

In this article, we describe a comprehensive needs assessment process that was part of a multiyear project between researchers in the United States and a nongovernmental organization (NGO) in India. With the hope of leveraging outside occupational therapy expertise, a West Bengal–based NGO had initially reached out to the U.S.-based team to express their acute need to train CBR workers in adaptive feeding strategies for caregivers of children with cerebral palsy (CP). The NGO staff further indicated a preference for training modules in a portable audiovisual medium to mitigate geographic barriers that limit CBR workers’ use of centralized continuing education programs. The long-term aim was to develop video-based training modules that address their needs and support decentralized training. Toward that end, in the current study we sought to obtain a thorough perspective on feeding-related issues that are most problematic for caregivers and to understand those needs in the context of regional culture, resources, and service delivery practices.

Method

The project involved a long-distance collaboration between the Indian Institute of Cerebral Palsy (IICP), a regional NGO based in West Bengal, and occupational therapy researchers at the University at Buffalo, State University of New York. Established in 1974, the IICP is a specialist resource center that serves people with CP. It is based in Kolkata and works in partnership with NGOs in West Bengal and 11 other states in India. The IICP hosts fieldwork students and interns from all over the world and provides an orientation packet and cultural training for all outside scholars before formal interaction with local families takes place.

Design

A mixed methods design was used to collect data from three sources: (1) focus groups (n = 4) with caregivers (n = 34), (2) focus groups (n = 3) with CBR workers (n = 19), and (3) in-home mealtime observations (n = 14). Separate focus groups were conducted with CBR workers and caregivers to increase within-group homogeneity and foster open discussions among peers with similar perspectives (Morgan, 1998). Focus groups “give a voice to marginalized groups” and are used “where there is a difference in perspective between the researchers and those with whom they need to work” (Morgan, 1996, p. 133). The group format empowers participants to control their interactions with outside researchers, who can be viewed as authoritative (Hennink, 2017). Participants may “query each other and explain themselves to each other” (Morgan, 1996, p. 139), which provides valuable insight into the diversity of participant experiences. The focus groups were led by the (female) first author and principal investigator (PI; Sutanuka Bhattacharjya), who was accompanied by a male IICP staff member to engender trust among local participants. The method of the study was discussed with IICP staff, who suggested numerous refinements to the method, focus group questions, and in-home assessment. The institutional review board at the University at Buffalo approved the data collection method.

Participants

The IICP facilitated access to key groups of local stakeholders. Participants were recruited from the IICP’s network of partner NGOs throughout West Bengal. To recruit a sample that reflected the density of West Bengal’s living environments and diversity of caregiver experiences, participants were purposively recruited from rural, suburban, and urban areas. The partner NGOs selectively contacted two populations: (1) CBR workers (age ≥18 yr) known to be working with children with CP and (2) caregivers (age ≥18 yr) known to have a child with CP who was experiencing difficulty with mealtime. Those who expressed interest were informed of the time and location of the focus groups. Interested caregivers were also given information about scheduling an in-home observation. The partner NGO staff were unaware of the actual participants in the focus groups and in-home observations. Five caregivers participated in both an in-home observation session and a focus group.

In consideration for their time, focus group participants received a meal that was provided during the focus group. At the conclusion of in-home observations, the research team provided participating caregivers with recommendations for feeding-related accommodation strategies. Both forms of compensation were recommended by the IICP to (1) mitigate the potential for excessive influence of monetary payments and (2) address the needs of families, who often expect that foreign researcher visits are an opportunity to obtain expert clinical advice.

Instruments

The focus group questions were developed in collaboration with the host organization and then translated to Bengali by a local high school teacher with an advanced degree in Bengali literature. The questions were then back translated from Bengali to English by a staff member from the host organization. All discrepancies between the original version and the back-translated versions of the questions were discussed and resolved among research team members.

Focus Groups With Community-Based Rehabilitation Workers

The focus group questions were created by the research team to elicit discussion of specific feeding difficulties faced by CBR workers when working with families of children with CP. Sample questions included the following

In your experience, what types of difficulties do parents face when feeding children with CP?

How common is it for parents to have access to adaptive seating arrangements?

What does mealtime interaction between the child and the feeder look like?

What are the feeding-related suggestions and interventions that you provide to caregivers?

Focus Groups With Primary Caregivers

The focus group questions were created by the research team to elicit discussion of specific mealtime-related difficulties experienced by caregivers. Sample questions included the following:

For your child, what are his/her specific difficulties in regard to mealtime?

How is your child positioned when feeding?

What strategies have you tried with feeding, and how did they work? How did you learn about these strategies?

What help or advice would you like to receive regarding feeding your child?

In addition, two mealtime-related questions were included in the demographic questionnaire for caregivers to rate: (1) “How stressed is your child during mealtime?” and (2) “What is the severity of feeding difficulties for your child?”

In-Home Observations

An adapted version of the modified Functional Feeding Assessment (mFFA; Gisel, 1994) was used to capture the amount of physical and environmental support provided by the feeder to the child during mealtimes. For the current study, the mFFA was adapted to quantify the nature and frequency of physical and environmental supports provided by caregivers in response to specific difficulties children experience during feeding episodes. The presence (or absence) of such supports provided a relative indication of the need for adaptive mealtime strategies. Before formal data collection, an occupational therapy graduate student (Rachel Schraeder) conducted seven practice observations of children with CP in the United States (n = 4) and India (n = 3) under the supervision of the PI (Sutanuka Bhattacharjya) in the United States and IICP staff in India.

Procedure

To reflect a diverse range of service delivery settings, the local NGOs scheduled focus group sessions with caregivers and CBR workers in urban (n = 2), suburban (n = 1), and rural (n = 1) locations. The NGOs also scheduled in-home mealtime observations with families who lived near the focus group locations. In cases in which a caregiver was interested in both an in-home observation and the focus group, the in-home session was conducted before the focus group session to ensure that the feeding strategies caregivers used were not influenced by information they learned during the focus group discussions. All data collection procedures were conducted in Bengali. An IICP team member accompanied the U.S.-based researchers in all focus groups and in-home observations to ensure that regional customs and ethical standards were upheld and to provide participants a sense of comfort and security with the research team.

Focus Groups

Participants completed a demographic questionnaire before taking part in focus groups so that their ratings would not be biased by the focus group discussions. Each group was facilitated by the PI, a native Bengali speaker and female pediatric occupational therapist licensed to practice in both India and the United States and, at the time of data collection, a doctoral candidate in the United States. The prepared list of discussion questions was used to foster initial discussion among the participants. Additional probing questions were asked as needed to encourage in-depth descriptions of their experiences. The focus groups included 8 to 10 participants and lasted 40 to 60 min.

In-Home Observations

The in-home observations were conducted by the third author (Rachel Schraeder), an English-speaking female occupational therapy graduate student from the United States; she was accompanied by an independent female translator and an IICP representative. The observations lasted an average of 20 to 40 min, depending on the pace of feeding. At the conclusion of the observation, the research team provided basic feeding advice to the caregivers as appropriate to improve the child’s positioning and neck posture during feeding, introduce appropriate food textures, facilitate chewing of food, and reduce the risk of aspiration by using thickened liquids.

Methodological Integrity

Trustworthiness—that is, the validity and reliability of qualitative research (Curtin & Fossey, 2007; Shenton, 2004)—was maximized through eight factors:

The PI, a U.S.-licensed pediatric occupational therapist with a strong background in research methodology, had previous experiences as a focus group moderator and as an occupational therapy clinician in India. She conducted preliminary visits to the IICP and the local NGOs to establish a working relationship and build personal trust (Shenton, 2004).

All methodological decisions were discussed with IICP staff to ensure relevance to the local context.

Data were triangulated across multiple data collection techniques (i.e., focus groups, survey ratings, and clinician observations), sources (i.e., caregivers, CBR workers, and therapist observation), and sites (i.e., urban, suburban, and rural) to increase convergence and corroboration of data (Curtin & Fossey, 2007; Shenton, 2004; Thurmond, 2001).

To foster consistency of data collection, all focus groups were conducted by the PI, and all in-home observations were conducted by the third author.

All focus group discussions were audio recorded to ensure transparency of the process and accuracy of the qualitative data set.

During the focus groups, participant honesty was encouraged by explaining that there was “no right answer” to the questions. An iterative form of questioning was used (Shenton, 2004) to enhance clarity. In addition, the PI paraphrased participants’ responses to verify interpretation of statements (Shenton, 2004).

Debriefing sessions were held with IICP staff after every regional visit, and data summaries were reviewed by IICP staff to ensure accurate interpretation (Shenton, 2004).

The data were subject to peer scrutiny at local and national seminars and conferences where the PI discussed preliminary results and received feedback from experts in the field of rehabilitation.

Analysis

The PI translated and transcribed the audio-recorded focus group discussions from Bengali to English. An independent bilingual translator verified transcription accuracy. The two discussed any ambiguities to reach a consensus version of the focus group transcriptions. Participant comments were discretely coded by themes or categories. The stages of swallowing described by Korth and Rendell (2015) were used as an initial classification structure for comments relating to swallowing. Where applicable, data extracts were highlighted and coded into categories predefined by the stages of swallowing. Once this phase was complete, the remaining data extracts were assigned primary and secondary codes on the basis of their semantic meaning. The data extracts were subsequently sorted and grouped by their primary and secondary codes to identify the most prevalent themes. Quantitative data from the caregiver ratings from focus groups and adapted mFFA ratings from the in-home observations were descriptively analyzed and assimilated with the focus group findings.

Results

Thirty-four caregivers and 19 CBR workers were recruited from rural (n = 11 and 4 respectively), suburban (n = 8 and 4), and urban (n = 15 and 11) areas. The majority of focus group participants (31 of 34 caregivers and 16 of 19 CBR workers) were female, and all participants for the in-home observations were female (n = 13). Families reported that, in general, the primary feeder was the mother, grandmother, sister, or aunt. Caregivers indicated that 32% of the children with CP had no difficulty with eating, 12% had mild difficulty, 27% had moderate difficulty, and 29% had severe difficulty. The caregivers also indicated that, during mealtime, 53% of the children were under very little stress and 47% were under a lot of stress.

The overall findings were broken down into three themes: (1) mealtime experiences of caregivers and CBR workers, (2) existing mealtime-related service delivery practices, and (3) unmet needs that require training.

Mealtime Experiences of Caregivers and Community-Based Rehabilitation Workers

Tables 1 through 4 summarize key results in three areas: (1) positioning and access to special furniture (Table 1), (2) phases of swallowing (Table 2 and Table 3), and (3) oral health and social interaction (Table 4). CBR workers reported that children were often fed with their neck in hyperextension, an event that was frequently noted during in-home observations (n = 11/14). Caregivers reported feeding their child primarily mashed foods, which was also noted across in-home visits. None of the caregivers reported using, or were observed to use, thickened liquids when feeding their child. Several caregivers reported that their child coughed after being fed water, and the practice of using water as a swallowing stimulus was reported by CBR workers and noted many times (n = 11/14) during in-home observations. Mouth rinsing was not observed during the in-home observations. Caregivers reported that their child’s oral–motor difficulties hampered mouth rinsing after meals, and mouth rinsing was not observed during any in-home visits.

Table 1.

Findings Related to Positioning

Source	Finding
Contextual Factors
Caregivers	• Caregivers preferred to sit on the floor during mealtimes with the child lying on their lap.
CBR workers	• Special chairs were available from NGOs at no cost. Families had to visit the NGO twice: (1) to measure the child and (2) to receive the chair. • Access to special chairs was hampered for rural families who did not have the financial means to travel to the NGO with their child. • Some caregivers stored the chair for safekeeping and never used it.
Observations	• 11 of 14 children were fed while sitting on the floor.
Difficulties
Caregivers	• Uncertainty about how to use the special seats led to occasions when the child slid to one side of the chair or had inadequate head and trunk support.
CBR workers	• Caregivers preferred to feed children in a supine position on their lap, often with neck hyperextension, to minimize food loss and hasten the mealtime process. • Caregivers had difficulty positioning older children on their lap, especially those without head control or sitting balance. • CBR workers were unsure of correct positioning recommendations. • Caregivers were often unaware of correct positioning on the chair.
Observations	• One-half (7 of 14) of caregivers fed the child in a prone or supine position on the floor or semireclined on their lap. • >75% (11 of 14) fed the child with the neck in a hyperextended position. • 7 of 14 children were fed in a sitting position; most (5 of 7) exhibited a slouched trunk posture.

Note. CBR = community-based rehabilitation; NGO = nongovernmental organization.

Table 2.

Findings Related to Phases of Swallowing

Source	Finding
Contextual Factors
Caregivers	• Several caregivers primarily fed mashed food to the child. • Caregivers were not aware of thickened liquids or how to prepare them.
CBR workers	• Caregivers were reluctant to feed small food pieces because of a fear the child would choke.
Observations	• Primary use of hand feeding and occasional use of spoon feeding during mealtimes was noted. Forks or sporks were not used for feeding. • Liquid was fed using a spoon or by pouring a controlled amount of liquid into the child’s mouth. Straws were not used for drinking. • Mashed food and watery liquids were used most often.
Difficulties With Oral Preparatory Phase (e.g., Opening Mouth, Taking Food Into Mouth)
Caregivers	• No difficulties were reported for the oral preparatory phase.
CBR workers	• Some children did not open their mouth to take food.
Observations	• >75% of the children could not perform oral preparatory components measured by the adapted mFFA. • 11 of 14 children were fed water that was poured into their mouth from a cup or a spoon.
Difficulties With Oral Phase (e.g., Chewing and Tongue Movements)
Caregivers	• Chewing of food was the most commonly reported concern. • Some children were unable to chew harder foods (e.g., guava or chicken). • Drooling and spillage of food or fluid were common concerns.
CBR workers	• Adequate chewing of food was a common concern; several reported that some children held food in their mouths instead of swallowing. • Drooling, food or fluid spillage, and absence of lip closure were common.
Observations	• Children experienced difficulty with lateral tongue movements and clearing food from the sides of their mouth (8 of 14); many could not maintain lip closure while swallowing (7 of 14). • Caregivers provided minimal oral–motor facilitation during feeding.
Difficulties With Pharyngeal Phase (e.g., Initiation of Swallowing)
Caregivers	• Swallowing was not initiated. Some children pocketed food in their mouth and swallowed later. • Water was given to children to manage coughing.
CBR workers	• Some children pocketed food in their mouth and swallowed it later. • Caregivers fed water to the children to initiate swallowing of a food bolus, which often led to coughing.
Observations	• Many caregivers (5 of 14) fed the children a bolus of food and then a spoonful of water to facilitate swallowing.

Note. CBR = community-based rehabilitation; mFFA = modified Functional Feeding Assessment.

Table 3.

Observed Frequencies of Swallowing Difficulties During Spoon Feeding

Phases of Swallowing	Observer Rating, n (%)
Phases of Swallowing	0	1	2	3	4	5	6
Oral preparatory phase
Holds head steady, slightly forward in midline	3 (21)	0	3 (21)	1 (7)	1 (7)	1 (7)	5 (36)
Opens mouth at sight of food	3 (21)	1 (7)	1 (7)	1 (7)	2 (14)	0	6 (43)
Brings upper lip down and forward over spoon/hand	11 (79)	0	1 (7)	0	0	0	2 (14)
Pulls lower lip inward under spoon/hand	9 (64)	0	4 (29)	0	0	0	1 (7)
Clears excess food off lips with tongue	14 (100)	0	0	0	0	0	0
Oral phase
Lips active during chewing	4 (29)	1 (7)	6 (43)	0	3 (21)	0	0
Controlled jaw movements	3 (21)	0	6 (43)	0	2 (14)	0	3 (21)
Tongue stays behind incisors	0	0	2 (14)	0	3 (21)	0	9 (64)
Moves food from side to side with tongue	7 (50)	0	3 (21)	0	1 (7)	0	3 (21)
Clears food from sides of mouth	9 (64)	0	0	1 (7)	0	0	4 (29)
Pharyngeal phase
Transports solids to back of mouth	5 (36)	1 (7)	2 (14)	1 (7)	0	0	5 (36)
Keeps lips closed while swallowing	8 (57)	0	2 (14)	0	2 (14)	0	2 (14)

Note. N = 14 in-home observations. 0 = absent; 1 = PF (<50% times); 2 = SP (<50% times); 3 = PF (50%–89% times); 4 = SP (50%–89% times); 5 = PF (>90% times); 6 = SP (>90% times); PF = present with facilitation; SP = spontaneously present.

Table 4.

Mealtime Issues Related to Oral Health and Social Interaction

Source	Finding
Contextual Factors
Caregivers	• After every meal, rinsing the child’s mouth with water is customary.
Difficulties
Caregivers	• Rinsing the child’s mouth and brushing their teeth after meals was difficult.
Caregivers	• Bleeding gums and tooth decay were common.
CBR workers	• Rinsing the child’s mouth and brushing their teeth after meals was difficult.
CBR workers	• Bleeding gums and tooth decay were common.
Observation	• No caregivers were observed to rinse their child’s mouth or brush their teeth after the observed meal.
Social Interaction During Meals: Contextual Findings
Caregivers	• Approximately 15% (5 of 34) indicated that mealtime very negatively affected their relationship with their child.
Caregivers	• Several (5 of 33) indicated through ratings that their child’s mealtime very negatively influenced their relationship with other family members.
CBR workers	• In joint families, the other family members often were not happy about the extended time required to feed the child. This resulted in increased stress for the caregiver.
CBR workers	• Caregivers’ interactions were constrained by their limited communication strategies or time limitations.
Observations	• Caregivers primarily interacted with the child for instructions. Use of gestures or communication books was not observed for any caregiver.

Note. CBR = community-based rehabilitation.

Existing Mealtime-Related Service Delivery Practices

Caregivers from urban areas reported that they had previously received specific mealtime-related suggestions from physicians, the IICP, and other rehabilitation agencies regarding feeding strategies, positioning techniques, and environmental adaptations. One-half of rural caregivers had not spoken to anyone about their child’s feeding difficulties. Suburban caregivers, and roughly one-half of rural caregivers, had been told by some physicians that their child would eventually acquire typical feeding skills. CBR workers reported that they provided suggestions on appropriate sitting or a semireclined position for the child during mealtime, emphasized thorough chewing of food and mouth rinsing for the child, and described benefits of introducing variations in food texture. CBR workers also reported that in joint families—where two or more generations of families reside in a common residence—some family members were impatient with the extended time required to feed children with CP, causing increased stress for the caregiver.

Unmet Needs That Require Training

Caregivers reported that they would like further advice on correct positioning techniques and strategies for spoon feeding and self-feeding. CBR workers indicated that caregivers would benefit from learning about spoon-feeding techniques and oral–motor stimulation strategies that facilitate chewing and swallowing. CBR workers also reported that they would benefit from training related to spoon-feeding strategies.

Discussion

Triangulation of data from the CBR workers, caregivers, and in-home observations provided a comprehensive set of feeding-related training needs reflecting the culture, resources, and service delivery practices in West Bengal. Several mealtime practices were identified that diverge from Western culture. Caregivers typically sat on the floor during mealtime and fed their child by hand. Contextual factors such as these would need to be featured in training materials to enhance their relevance for caregivers and increase adoptability (Bergström et al., 2012).

The needs assessment process identified five priority training areas that we would have overlooked had we relied solely on our previous clinical experiences and the extant research literature:

Prevalence of neck hyperextension during feeding. Appropriate positioning strategies are not thoroughly understood by CBR workers and infrequently discussed with caregivers. Inappropriate positioning increases not only difficulty with swallowing but also the risk of choking (Andrew et al., 2012).

Limited variation of food consistencies. Although mashed food is easier to chew and swallow for a child with oral–motor difficulties, their acquisition of chewing and swallowing skills can be delayed if soft-solid and hard-solid foods are not introduced. Similarly, children with oral–motor difficulties have great difficulty swallowing thin liquids.

Prevalent (and potentially dangerous) use of water as a swallowing stimulus. This is a dangerous practice that can result in choking and aspiration for children with swallowing difficulties. During in-home observations, the risks of this practice were immediately pointed out to caregivers for the safety of the child. Although risk of aspiration and choking is high in children with CP (Andrew et al., 2012), the existing literature does not call attention to this practice and its potential relationship to a lack of awareness about food textures.

Absence of basic oral hygiene for children with CP. Although it is customary in India to rinse one’s mouth with water after every meal, mouth rinsing was not observed during the in-home observations. Oral hygiene needs to be a part of future training.

General need for CBR workers and caregivers to receive training in adaptive feeding. CBR workers acknowledged numerous gaps in their knowledge of adaptive feeding strategies, including oral–motor stimulation, positioning, and food textures. Caregivers were largely unaware of opportunities for adaptive feeding strategies, so most had not considered asking for advice on feeding; thus, many of the unexpected caregiver practices described here reflect a lack of awareness that could be readily addressed through training.

The quantitative caregiver ratings from the demographic questionnaire aligned with the concerns that caregivers brought forward during focus groups. Overall, the findings illustrate the value of a comprehensive needs assessment as part of transcultural project. The process described herein is readily generalizable to other transcultural rehabilitation project contexts.

Conducting a long-distance transcultural project is expensive and time consuming, and it requires multiple international trips over an extended period of time. The most crucial element for success is partnering with a committed, competent, and respected host organization in the geographic region of interest. Developing a strong and reliable long-distance partnership takes time and effort as the partners develop mutual trust, rapport, and confidence. In our case, the IICP team and NGO staff were key informants whose contributions strengthened the research design, facilitated the process of participant recruitment, and ensured that participants were comfortable in the presence of the researchers during data collection sessions. In particular, the presence of NGO and IICP personnel for the focus groups and in-home observations fostered an atmosphere of trust among participants that enabled them to share their experiences without apparent inhibition. The success of needs assessment in a transcultural project begins with respecting the local culture and service delivery practices in the target region, which ideally leads to the empowerment of local health workers to be capable, confident service providers.

Limitations

This project has some limitations. First, items in the mFFA were reviewed by the host organizations but not otherwise tested for cultural fit with the community before data collection. Also, interrater reliability of the mFFA was not evaluated because of resource constraints. We mitigated this limitation by triangulating data from multiple stakeholders using multiple tools across multiple regional sites.

Implications for Occupational Therapy Practice

Our findings have the following implications for occupational therapy practice:

Occupational therapists who are exporting their knowledge, skills, and practices to different cultural environments should not make assumptions about the needs and priorities of the host environment.

Before specific interventions are proposed, a needs assessment should be conducted that considers local culture, resources, and service delivery practices and includes multiple stakeholder perspectives.

A thorough needs assessment process can illuminate key issues that affect the relevance and viability of transcultural projects, including the factors underlying problems and priorities, appropriate (and inappropriate) solutions to the problems, and implementation strategies that are relevant to the local culture and service delivery context.

For rehabilitation-related projects in developing countries, it is crucial for researchers and practitioners to collaborate with a host partner that is well connected to local networks of consumers, practitioners, and related NGOs.

Conclusion

The needs assessment process identified many feeding-related training priorities that we did not anticipate. These findings underscore the value of a thorough needs assessment for virtually any transcultural service or research project. The ideal process engages a variety of stakeholders using a variety of methods to obtain the most accurate possible picture of local needs.

Footnotes

Acknowledgments

This study was funded by the Office of Global Health Initiatives at the University at Buffalo, State University of New York, and the Center for International Rehabilitation Research Information and Exchange. We thank Arthur Goshin, Reena Sen, the HealthyWorld Foundation, team members at the Indian Institute of Cerebral Palsy, and partner NGOs (Sangam, Rama Krishna Mission, and Sevaks).

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