Running Head: MAIR OT NEEDS ASSESSMENT 1

Occupational Therapy Needs Assessment for Moulay Ali Institute for Rehabilitation:

A Neurological Therapy Clinic in Marrakech, Morocco

Caitlin Winters, OTS

University of Utah
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Occupational Therapy Needs Assessment for Moulay Ali Institute for Rehabilitation:

A Neurological Therapy Clinic in Marrakech, Morocco

The purpose of this paper is to determine how to incorporate occupational therapy skills

and knowledge into a curriculum-based program for the Moulay Ali Institute for Rehabilitation

(MAIR) in Marrakech, Morocco. The needs assessment involved in-person interviews with the

director of the clinic, in-person and teleconference interviews with the therapists, individual and

group discussions with the clients and their families, in-clinic observations, and home

evaluations. Special considerations and analysis were given based on political, cultural,

socioeconomic, and educational differences due to the location of the clinic. After thorough

analysis of the MAIR clinic and an in-depth review of the therapists’ skills and experience,

emphasis for this program was placed on developing a therapist training program to increase

general evaluation skills, and incorporate outcome measures into evaluation and on-going

rehabilitation. Through the comprehensive analysis of the clinic and extensive literature review

on relevant topics, a formal occupation-based program was developed and proposed to meet the

needs of MAIR, and to assist with the sustainability and successful future of the clinic.

Description of Setting

Community Background

Healthcare. Morocco’s readily available healthcare system is divided into the public and

private sectors. Although the citizens of the country have easy access to affordable public

healthcare options, the system is corrupt and unsupportive of neurological rehabilitation services.

Many doctors in the country have been trained within the French model of healthcare which

predominantly recognizes a bottom-up approach to rehabilitation. For this reason, many medical

professionals feel that because neurological conditions, such as cerebral palsy, are unable to be
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treated medically, there is little hope for such patients to make improvements and to lead

productive lives. (M. Sbai, personal communication, October 4, 2018).

Morocco’s healthcare system is corrupted to the extent that it is difficult for many people

to receive high-quality services. The public hospital in Marrakech possesses advanced treatment

and assessment equipment (MRI, surgical, CAT scan, etc.), but it is common for the hospital to

tamper with the equipment so that it is non-functional, and can therefor refer patients to the

private hospitals. Procedures are much more expensive at private facilities which limits the

patients who are able to receive services due to the cost. If procedures are performed and paid

for, the public hospital then receives a monetary reward for providing the referral. Within both

the private and public hospitals, there is very little concern for accuracy and detail when

performing medical procedures. This can be detrimental to the patient’s health and overall

function (M. Sbai, personal communication, October 5, 2018)

From a public health standpoint, preventative medicine is limited or nonexistent. There is

little to no prenatal education or care which leads to increased risk for unsafe pregnancy or birth.

It is also common for individuals in Moroccan culture to marry and conceive children within

their immediate families. These are two potential theories in regards to the approximately 25,000

new cases of cerebral palsy in Morocco each year (M. Sbai, personal communication, October 4,

2018). Lastly, it is very common for patients in the hospital, or quickly following discharge, to

pass away from urinary tract infections and decubitus ulcers due to limited training on

preventative measures and treatment (M. Sbai, personal communication, October 8, 2018).

Geographic. Marrakech, Morocco is centrally located within the country and has a

population of approximately 976,000 people (Central Intelligence Agency, 2018). The MAIR

clinic itself is located within the heart of the city and is easily accessible by public transportation.
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Many of the clinic’s patients travel from the countryside in order to receive services which can

take up to an hour and a half in each direction. The climate in Morocco is typical of

Mediterranean countries which consist of hot dry summers and mild wet winters (Brown &

Miller, 2018). The nature of the soil and climate in the country sustains extensive agricultural

industry and provides many citizens with jobs year around.

Morocco typically experiences rainy season that can last from October to April.

Unexpected downpours can lead to dangerous road conditions which makes transportation

challenging. This is especially true in the rural areas where dirt roads are characteristic of the

landscape (Brown & Miller, 2018). Extensive rain or excessive heat commonly prevents many of

MAIR’s patients who live in the country from being able to travel to the clinic (C. Elghazi,

personal communication, October 11, 2018).

Religion. Approximately 99% of Morocco’s population practices the Islamic religion. Of

that 99% virtually all of the individuals are Sunni Muslims (Central Intelligence Agency, 2018).

Religious practices of Sunni Muslims include praying five times a day versus three, crossing

their arms during prayer, and other various religious beliefs. Sunni Muslims recognize several

religious holidays such as Eid Al-Adha, Eid Al-Fitr, and the holy month of Ramadan in which

they either choose or are required to fast and rest during the day (S. Berrada, personal

communication, October 5, 2018). Prayer time is so dedicated to their culture than many

businesses will close for a significant time during the middle of the day and for short periods

during other prayer times. Especially for adult populations, the ability to engage in traditional

prayer practice is commonly a top priority for occupational therapy goals.

Nature of households. Morocco is a patriarchal society that exists within a collectivist

culture. Moroccan culture highly values the family unit and believes strongly in the family
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working together to accomplish goals. It is important to consider that due to the groupthink

mentality, an individual’s desires are often disregarded if they do not align with what the family

thinks is best. Like many other cultures around the world, it is noted that the Islamic faith, and

therefor Moroccan culture, has a low tolerance for change. It is believed that by keeping the

family unit close and of similar mindset, there is less desire to modify certain aspects of

everyday life or act outside of cultural norms (Depauw University, n.d.).

Moroccan culture not only keeps the nuclear family close, but incorporates extended

family into this unit as well. It is common for extended families to live in close proximity to one

another and to help care for children and elderly family members together (I. Bentahar, personal

communication, October 3, 2018). Moroccans feel that it is their duty to care for their elders and

will either welcome them into their home, or pay for the home in which the elder is living

(Depauw University, n.d.).

Culture. It is of upmost importance to consider that Moroccan culture believes that

mothers of children with special healthcare needs are being cursed for wrongdoings that were

committed before the child was born. This creates a sense of shame that the child’s mother must

bear indefinitely. Teenage pregnancy and pregnancies as a result of rape, commonly results in

the baby being abandoned in order to not bring shame to the woman’s family. Women who are in

these situations will be abandoned by their families if they choose to keep their children. The

children are taken in by local orphanages and are commonly treated at MAIR due to neurological

conditions as a result of poor prenatal care and genetic predispositions (M. Sbai, personal

communication, October 12, 2018).

Socioeconomic. The poverty level in Morocco has steadily declined since the beginning

of the 21st century. As of 2014, monetary poverty in the country fell to 4.8% and consumption
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per capita increased to an annual rate of 3.3% (The World Bank, 2018). Unfortunately, a

significant gap remains between poverty levels in urban versus rural areas. This fact is identified

by higher consumption rates and quickly declining poverty rates in urban areas. It is

hypothesized that the general decline in poverty numbers in urban and rural areas is due to

overall growth of the country and continual growth of agricultural gross domestic product (The

World Bank, 2018).

Interestingly, although the actual percentage of those living in poverty continues to

decline, the perception of being impoverished continues to increase. From 2007 to 2014,

subjective poverty levels have gone from 41.8% to 45.1%. This number also increased

significantly in rural areas (55.3%) meaning that over half of the rural population considers

themselves poor (The World Bank, 2018). This perceived poverty may significantly impact how

an individual chooses to use their expendable income. According to Morocco World News,

Morocco is ranked amongst countries with the smallest disposable income per month. The

average monthly income in the country falls between $400 to $700 dollars (Barakah, 2015). This

may influence a person’s decision on spending for things like food, clean water, or medication

versus traveling to the city to see a rehabilitation specialist.

Education. Morocco’s primary education system consists of 6 years of primary school

(ages 6-11), 3 years of lower secondary (ages 12-14), and 3 years of upper secondary (ages 15-

17). Although Morocco has a primary level enrollment of approximately 61% of all children

ages 6-11, only 4% will actually complete their primary education. Overall, only 51% of youth

ages 15-24 have completed primary school, and around 26% of youth have no formal education

at all (Education Policy and Data Center, n.d.).

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The overall illiteracy rate in Morocco is approximately 43%. There is a higher estimation

amongst woman at 54.7% (Semlali, 2010). Various reasons for these rates are proposedly

attributed to low daily attendance rates, absenteeism of educators, and multi-lingual classrooms.

It is common for adult patients or caregivers of patients at MAIR to be unable to read or write

(M. Sbai, personal communication, October 20, 2018). This is an important fact to consider

when implementing various evaluation materials, or self-questionnaires in the clinic setting.

Unemployment Rates. As of 2008, the unemployment rate in Morocco was 9.8% of the

total population. Adversely, there is significant gender discrepancy in employment rates amongst

women in the country, which is made apparent by the 27.5% unemployment rate of Moroccan

women. Furthermore, 50.1% of woman who hold higher education diplomas are unemployed

(Semlali, 2010).

Clinic Background

History. The Moulay Ali Institute for Rehabilitation is a private, non-profit clinic that

was conceived out of a lack of rehabilitation services in Morocco and the region overall. The

MAIR clinic is the result of the Director’s promise to develop such services after his brother

(Moulay Ali) passed away due to complications following traumatic brain injury. Following his

accident, Moulay Ali’s family searched extensively for therapy services in Morocco without

results, and eventually received effective speech, physical, and occupational therapy in the

United States (U.S.). Unfortunately, Moulay Ali was forced to return to Morocco due to travel

visa discrepancies, and he eventually passed away due to massive abdominal infection following

chronic constipation. Had Moulay Ali received effective neurological therapy services upon

returning to Morocco, he may still be alive today (M. Sbai, personal communication, September

10, 2018).
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As a result of his passing, Moulay Ali’s brother, Doctor Mohammed Sbai, founded the

non-profit Zahara Charity, in order to train physical therapists in Morocco to provide

neurologically comprehensive rehabilitation services, and to open an out-patient clinic to meet

the healthcare needs of the population. Doctor Sbai, a trained neuroscientist, relied heavily on his

American colleagues and connections to pioneer the charity, and officially opened the clinic

doors in Marrakech in 2015. The mission of the MAIR clinic states that “to trigger a neuroplastic

change is the foundation of our therapy. To accomplish maximal recovery is our most important

goal.”

Target population. The Moulay Ali Institute for Rehabilitation is a private, non-profit

out-patient facility that provides neurological-rehabilitative services to pediatric and adult

patients with congenital and acquired conditions such as cerebral palsy, traumatic brain injury,

spinal cord injury, stroke, and many others. Currently, the clinic treats primarily pediatric

patients, a majority of whom have various forms of cerebral palsy. There is also a significant

demand for increased adult services, but due to the limited number of therapists, the clinic is

restricted in how many patients can receive services.

Equipment and Interventions. The MAIR clinic is equipped with many of the typical

exercise machines that would be found in a physical therapy gym in the U.S. The therapists

commonly utilize a stair climber, arm bike, Bioness, Solo-Step, and Locomat in order to increase

strength, range of motion, and to provide gait training to patients diagnosed with cerebral palsy

and other neurological conditions. Most interventions at the clinic are focused on biomechanical

principals and incorporate stretching, strengthening exercises, and upright tolerance.

The therapists also utilize positioning interventions in which the child is held in an

upright position using special chairs, standing boards, pillows, or the wall. This is done in hopes
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of utilizing neuroplasticity in the brain to retrain the body to utilize core muscles in a

neurotypical manner. The gym is filled with exercise balls, oral-motor tools, scooters, visual

scheduling aids, tools to assist with activities of daily living, therapy appropriate toys, ultrasound

and electrical stimulation units. The clinic is in possession of most of the occupational therapy

tools that would be utilized in practice in the U.S., but unfortunately the equipment is greatly

underutilized.

Therapist Education Each of the therapists at the clinic received three years of post-

primary school training in a physical therapy (PT) program. The three therapists attended private

university where they paid approximately three hundred dollars per month for tuition and fees.

The curriculum for the PT degree in Morocco is similar to that of a physical therapy assistant in

the U.S. During the three-year PT program, students receive approximately three hours of

training on how to treat neurological conditions (M. Sbai, personal communication, September

10, 2018).

In addition to receiving a degree in physical therapy, the therapists also receive continual

training from physical and occupational therapists, and medical doctors from the U.S. As a result

of training that comes primarily from the U.S., the ability to speak English is a requirement for

working at the clinic. In brief, trainings have included feeding techniques, positioning strategies,

gait training, splint making, wound care, and skin care management. The lead therapist also spent

four weeks in Salt Lake City observing and working with patients at NeuroWorks, and at the

University of Utah therapy clinics. Following her training in the U.S., it was then her

responsibility to return to MAIR and provide further training for her fellow therapists.

There is currently no set curriculum for neurologically specific interventions for the

therapists at the MAIR clinic. When a new therapist is hired, he or she spends approximately one
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month observing and learning the strategies that the therapists have adopted as neurologically

relevant treatment interventions. He or she is required to compile research and learn about

common conditions that are seen and present that information to the therapists that are currently

working at the clinic. When the new therapist displays confidence and knowledge of the

conditions and treatment methods, he or she then begins treating patients independently.

Patient Evaluation and Discharge. New patients are evaluated by either Doctor Sbai or

the lead therapist, Imane Bentahar. The initial meeting includes gathering a comprehensive

medical and psychosocial history, determining goals of the patient or caregiver, and explaining

the expectations of the patient if he or she is going to be treated at the clinic. Occasionally, the

patient has medical records from the hospital, and this information will also be reviewed. The

initial meeting can take up to two hours depending on the amount of information that the new

patient provides (M. Sbai, personal communication, October 9, 2018). Due to the high demand

for therapy services, the new patient must be willing and committed to adhering to a rigorous

home program and in-person sessions three to five times per week, if the clinic choses to treat

them.

The second session consists of further testing and evaluation to determine specific areas

of deficit. Therapists primarily perform gait and positioning observation, strength, and range of

motion measurements. Little to no quantitative data is recorded during the evaluation process

which leads to difficulties in tracking patient progress. According to Doctor Sbai, since opening

its doors in 2015, the clinic has only discharged one patient due to goals being achieved. In

addition, he also noted that they will dismiss patients from services if they are not adhering to

their specified home program (personal communication, October 3, 2018).

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Funding and future plans. Funding for the clinic is generated primarily from

philanthropic donations from the Salt Lake City Rotary Club, the Sorenson Foundation, and

individual donors. The MAIR clinic relies heavily on professionals from the U.S. who volunteer

their time to provide training to the therapists. The patients are billed on a sliding scale for

services, which is determined by an interview with a licensed social worker. The social worker

gathers data such as household income, number of individuals living in the home, and

transportation costs, and determines a reasonable cost for each therapy session for each patient.

The cost of each session ranges from fifty centys to twenty dollars, and the patients attend

sessions three to five times per week. Patients file claims for reimbursement from their insurance

companies following each session. They receive 30-50% compensation for what they have

already paid MAIR directly. Unfortunately, insurance companies can deny claims at will, which

deters some patients from seeking services altogether (I. Bentahar, personal communication,

October 9, 2018).

Due to a majority of the MAIR patients having little to no expendable income, the clinic

produces minimal profit from payment for services. Many of the individuals that are currently on

the waiting lists have the means to pay full price for services. This is a major incentive for

increasing their ability to see more patients.

As the clinic continues to grow and gain notoriety for making successful progress with

patients with neurological conditions, the next phase of the project is to open a small

neurological rehabilitation hospital based on the American model of healthcare and

rehabilitation. This facility would include acute, in-patient and out-patient services, and would

incorporate therapy interventions such as hippotherapy and therapeutic gardening. The building

would also contain a classroom and housing suites for visiting healthcare professionals from the
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U.S. It is Doctor Sbai’s goal to create a sustainable neuro-therapy training curriculum to build

the knowledge and skills of therapists in Morocco. In order to open the facility, Doctor Sbai will

need to raise 5-7.5 million dollars from charitable donors in the U.S. (M. Sbai, personal

communication, October 12, 2018).

Programming Strengths and Areas for Growth

Director and Therapist Perspective

Director. Prior to the two-week visit to MAIR, the director (Doctor Sbai) was emailed a

list of questions in relation to the clinic’s strengths, areas of growth, and general clinic logistics.

Throughout the duration of the visit, informal conversations further examined strengths and

weakness of the clinic comprehensively. Doctor Sbai stated that he feels like the current

strengths of the clinic include the dedication of the current therapists, the progress that is

occurring with many of the patients diagnosed with cerebral palsy, and the commitment to

therapy that is shown by the patients’ caregivers. Some weaknesses of the clinic included the

limited amount of clinic space, lack of administration, unstructured protocols for evaluation and

discharge, and lack of neuro-therapy training curriculum for new therapists. He expressed a great

challenge with hiring new therapists due to the prestige of the clinic and individuals wanting to

use the position as a short-term “resume builder” (M. Sbai, personal communication, October 3,

2018). In order to avoid this, Doctor Sbai asks potential therapists to sign a ten-year contract in

which he offers pay and benefits comparable to that of a coveted public-sector therapist position,

in addition to continual training from professionals from the U.S. This also results in a challenge

because it is difficult for therapists to commit to the ten-year contract. For a full list of questions

and responses please see appendix A.

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Therapists. The three therapists were asked about the clinic’s strengths and areas for

growth during a video teleconference prior to visiting MAIR, and in-person throughout their

busy daily schedules. Major themes in relation to the clinic’s strengths included the ability of the

therapists to work as a team to fully understand all of the patients at MAIR, to work together to

come up with the best ideas for treatment, their commitment to learning treatment interventions

within a transdisciplinary model, and the ability to see many of the patients multiple times per

week due to a lack of limitations from insurance companies. They also recognized that they felt

very confident in their ability to provide gait training and general biomechanical treatment

interventions. Lastly, they felt that one of the ultimate strengths of MAIR was Doctor Sbai’s

strong male presence which greatly influenced the patients’ and caregivers’ buy-in and

commitment to therapy services.

Conversely, the therapists noted that it is often times difficult to gain patients’ and

caregivers’ commitment to therapy when Doctor Sbai is not present. This is mainly due to the

culture of the Morocco being predominantly patriarchal and all of the therapists at MAIR are

woman. In addition, they noted that they felt limited by the small clinic space and the inability to

hire new therapists due to the ten-year contract commitment. Finally, the therapists expressed

that they were not confident in their ability to treat cognitive and behavioral deficits, and clients

with autism spectrum disorder (ASD). They noted that they are seeing more and more patients

who are diagnosed with ASD in additional to the magnitude of complex cases of cerebral palsy.

Client and Parent Perspective

As many of the clients at MAIR are children and are non-verbal, perspectives from this

group of individuals came primarily from the client’s mothers. Data in regards to strengths and

weaknesses of MAIR was gathered via conversations during home visits and during the monthly
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mother’s support group. Almost all of the mothers expressed that they felt that MAIR was the

only place that gave them hope that their children had a future. They stated that they felt

supported and empowered by the therapists, Doctor Sbai, and each other. A major theme in

support of MAIR was that by committing to in-clinic therapy sessions and home exercise

programs, they were seeing great progress with their children. The mothers had very little to say

in regards to areas of growth for the clinic, except to recommend more advanced treatment

options such as TheraSuit Therapy.

Graduate Student Perspective

A combination of research, semi-structured interviews, observation, and reflection were

conducted in order to gain a comprehensive understanding of the MAIR clinic and its strengths

and areas for growth.

Strengths. The current structure of the clinic and experience of the therapists supports

biomechanical interventions for the treatment of the patients’ neurological conditions and related

deficits. The therapists are well skilled in regards to gait training, postural interventions,

stretching and strengthening exercises. They do an exceptional job of including the patients’

mothers during the treatment sessions and designing home exercise programs to encourage

further progress. Due to the lack of restraints from insurance companies, the ability to see

patients multiple times per week for an undesignated length of treatment, further enables the

therapists to practice interventions that will theoretically lead to neuroplastic changes. In

addition, the ability of the clinic to sustain itself by charging patients on a sliding scale allows

access to therapeutic treatment that some patients may not be able to afford otherwise. Overall,

the MAIR clinic is the only place in Morocco that provides therapy, support, and hope to the
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patients and their families in the midst of a medical culture that does not believe in treatment and

remediation of neurological conditions.

Areas for growth. Upon in-depth observation and reflection, the clinic is greatly limited

by the gross amount of need to provide services and the lack of structural organization. The

clinic would greatly benefit from a simple electronic scheduling system and documentation

training that quantitatively showed the progress of each patient. By incorporating a few, simple,

standardized outcome measures to the evaluation process and daily treatment or re-evaluation

notes, the clinic could use this data to show progress and justify continued grants and funding

from their current donors. In order to incorporate these outcome measures, set protocols for

evaluation and training on evaluation techniques need to be implemented.

While it is a great benefit that the quantity of therapy is not limited by insurance

companies, it is difficult to increase the number of patients (especially those who can afford to

pay) without hiring more therapists or having a set protocol for patient discharge. In order to hire

and train more therapists, an established transdisciplinary neuro-therapy curriculum needs to be

adopted in order to provide comprehensive therapy services to MAIR’s patients. It is necessary

for this curriculum to include evaluation and discharge protocols, documentation standards, and

evidence-based interventions from occupational, physical, and speech therapy, in addition to

training on common medical concerns such as wound care and intermittent self-catheterization.

This curriculum will require special considerations in relation to cultural sensitivities, and level

of therapist education upon initiation. In regards to specific occupational therapy interventions,

the current therapists would benefit from additional training on how to implement occupation-

based treatment, play therapy, cognitive strategies, and sensory integration. From an outside
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perspective, the MAIR clinic has a bright future as long as administrative and therapeutic

protocols are well established and implemented.

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Literature Review for the Development of an Occupational Therapy Evaluation Protocol at the

Moulay Ali Institute of Rehabilitation in Marrakech, Morocco

A literature review was completed in order to better understand the occupational needs of

the Moulay Ali Institute of Rehabilitation (MAIR) client population; to examine the research on

developing occupational therapy (OT) programs in underserved areas around the world.

Particular emphasis was placed on OT’s role in neurological rehabilitation, cultural

understanding of occupation, relevant quantitative evaluation measures, and what OT services

look like in locations similar to Morocco. CINHAL, google scholar, and the University of Utah

online library catalogs were searched for relevant peer-reviewed articles. Search terms included:

occupational therapy, programs, neurological disorders, Africa, developing countries,

evaluation, cerebral palsy, participation, stroke, traumatic brain injury and environment. Due to

the availability of full-text research articles, most of the articles in this review were located using

the University of Utah online library catalogs. An article was either kept or discarded based on

relevance to this topic area, the language in which the article was published, and the date of

publication. Eighteen articles were kept for this review.

Occupational Therapy and Neurological Disorders

Characteristics of neurological disorders were examined in order to gain a more

developed perspective in regards to the needs of the clients at the MAIR clinic, and potential

evaluation measures to incorporate in this program design. Conditions of interest included

cerebral palsy, stroke, traumatic brain injury, and spinal cord injury due to the prevalence of

diagnosis within the MAIR clinic’s client population. A broad view of these characteristics was

considered because of the spectrum of limitations that neurological disorders encompass.

Influences on Participation
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Motor impairments. According to the Mayo Clinic (2016), varying motor impairments

of individuals with CP may include hypertonia or hypotonia, spasticity, ataxia, tremors or

involuntary movements, athetosis, delayed achievement of movement milestones, difficulties

with gait, lack of oral-motor coordination, excessive drooling, delays in speech, lack of fine

motor movements, and seizures. These motor deficits may affect one side of the body more than

the other, lower body more than upper body, or may affect motor control of the entire body. If

continued therapy is not provided, individuals with CP may develop “movement disorders or

worsened neurological symptoms over time” (Mayo Clinic, 2016).

Additional motor impairments of disorders such as stroke, TBI, and SCI vary depending

of the severity and location of the neurological damage. According to Gillen (2013), damage that

occurs in vascular areas of the motor cortex may lead to contralateral hemiparesis or hemiplegia,

contralateral visual field deficit, deficits in the muscles involved in the production of speech,

and/or muscle spasticity or tone. Motor impairments that occur in other areas of the brain may

include choreic movements, limb ataxia, gait ataxia, balance issues, impaired eye movements

and conjugate eye gaze (Gillen, 2013).

Cognitive impairment. According to Gillen (2009), cognitive impairments can be

predicted based on the location of damage in the brain. For example, damage in the right

hemisphere may lead to attention deficits, unilateral neglect, visuospatial impairments, left visual

field cut, left-sided motor apraxia, and reduced insight. However, left sided damage may result

in: expressive or receptive aphasia, bilateral motor apraxia, decreased organization and

sequencing, or a right visual field cut (Gillen, 2009). Cognitive impairments may also be

classified specifically by the location in the cortical lobes of the brain such as difficulties with

organizing, problem solving, attention, memory, judgement, emotional regulation and speech in
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a damaged frontal lobe. Damage to the occipital lobe may lead to deficits in visual reception, and

visual recognition of shapes and colors, while damage in the temporal lobe may cause problems

with receptive language, interpretation of music, verbal and visual memory (Gillen, 2009).

Environmental influences on participation. It was of particular interest to examine the

direct relationship between environmental barriers, neurological disorders, and participation due

to nature of occupational therapy, and the lack of environmental accessibility in Morocco

overall. According to Wong et al. (2017), participation in everyday activities following acquired

neurological disorders, such as stroke, TBI, or SCI, are directly correlated to environmental

factors. In addition, children with cerebral palsy who experience motor or cognitive deficits also

face similar challenges when trying to engage in such occupations. These factors may include

physical environmental barriers, social attitudinal barriers, and lack of access to technology and

information (Wong et al., 2017). Unfortunately, non-existent accessibility laws in Morocco result

in factors such as non-accessible multi-story buildings, limited doorway widths, challenges with

taking public transportation, and lack of useable sidewalks and crosswalks. In addition,

disabilities in general are considered a social stigma in most Islamic countries (Rathore, New, &

Iftikar, 2011). All of these external influences on disability greatly effect a person’s capacity to

engage in meaningful daily activities.

Occupational Therapy Role in Treatment

Interventions. Healthcare systems in the United States and other westernized countries

recognize and value, the role that occupational therapists play in the rehabilitation of

neurological conditions. As with any population with which occupational therapists work, it is

within the scope of practice to provide assessment of client factors, activity demands, and

environmental factors in order to design therapeutic interventions to promote successful

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participation in meaningful occupations (Rao, 2012). Within the neurological rehabilitation

setting, client factors that occupational therapists may address include deficits in motor

movements, cognition, and visual perceptions. These deficits are examined in order to determine

how they impact a person’s ability to engaging in daily activities. According to Doucet (2012),

evidence-based interventions and new therapeutic technologies for neurological rehabilitation

include constraint-induced movement therapy (CIMT), rhythmic auditory stimulation, visual

feedback, neuromuscular electrical stimulation (NMES), Bioness H200, SaeboFlex, and virtual

reality. In addition, visual perceptual skills of children with CP have shown to greatly improve

through the use of cognitive-perceptual and perceptual motor interventions during occupational

therapy sessions (Ramkumar & Gupta, 2016).

Evaluation Strategies. Thorough evaluation of neurological deficits is necessary when

designing effective treatment plans; emphasis was placed on this topic in order to better

understanding current best-practice using functional assessment measures. Research by Bhatia &

Joseph (2001) supports that it is common for physicians and parents in developing countries to

only recognize obvious deficits of CP, such as not walking or speaking. Many characteristics of

neurological disorders manifest as cognitive or visual-perceptual deficits. Therefore, it is

imperative that children with CP, and any patient with neurological conditions, receive

comprehensive assessment in order to receive the most beneficial therapy services (Bhatia &

Joseph, 2001). A study by Schneider, Gurucharri, Gutierrez, and Gaebler-Spira (2001)

determined that it was also necessary to incorporate health-related quality of life measures in

addition to function-based measures when assessing children with CP. This was made evident by

the lack of correlation between life satisfaction and functional level of ability (Schneider et al.,

2001).
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A study by Walmsley et al. (2018) determined that a large portion of occupational

therapy assessments of individuals with neurological conditions in Australia involved clinical

observations of functional tasks and non-standardized assessments. On the contrary, a recent

study by Stapleton and McBrearty (2009), which specifically targeted occupational therapists

working with adults in Ireland, found that it was common to use standardized assessments during

evaluation periods. Stapleton and McBrearty determined that the top five standardized

assessments for neurological conditions (primarily stroke) were the Folstein Mini Mental State

Examination, the Rivermead Behavioral Memory Test, the Functional Independence Measure,

the Barthel Index, and the Chessington Occupational Therapy Neurological Assessment Battery.

These standardized assessments in combination with structured functional observation provided

the therapists with a comprehensive understanding of the client’s occupational deficits, and a

necessary platform from which to design treatments (Stapleton & McBrearty, 2009).

Research by Bourke-Taylor and Hudson (2005) supported the idea that developing

countries in which the therapists had received very little higher education training were reliant on

occupational therapists that practiced Western-based therapy in order to gain evaluation skills.

According to Bourke-Taylor and Hudson’s findings, developers of OT programs in the

Dominican Republic found that it was the most effective to design a descriptive-based evaluation

in which the therapists would ask questions such as “Describe where you live… What are you

responsible for at home? And, what type of work do you plan on returning to?” By doing this,

the evaluation process was simplified and resulted in the therapists gaining a better

understanding of what was meaningful and important to the client (Bourke-Taylor & Hudson,

2005).

Occupational Therapy in Developing Countries

MAIR OT NEEDS ASSESSMENT 22

Cultural Differences

Collectivism versus independence. In the practice of occupational therapy, holistic,

culturally-sensitive approaches to services are predominant in treatment interventions and is the

foundation for a significant amount of research around the world. As determined by a study that

included participants from Morocco, individuals in countries around the world place a strong

emphasis on the idea that occupations are not only important to the individual person, but are

interconnected with the community as a whole (Zango-Martin, Flores-Martos, Moruno-Millares,

& Björklund, 2015). According to the same study, “it is not possible to approach occupation,

health, and well-being without considering the social value connected with the context.”

Considering the opposing individualistic cultural constructs of OT training programs in the

United States, it is important to focus OT training in collectivist societies with the ultimate

therapeutic goals of achieving interdependence versus independence (Zango-Martin et al., 2015).

To gain a more in-depth perspective on the idea of interdependence and community-

influence on occupation further research was conducted in order to understand rehabilitation

through the lens of a collectivist culture. In a study conducted by Al Busaidy & Borthwick

(2012), one of the difficulties of providing OT services in the country of Oman, as a Western-

trained therapist, was that families commonly impeded on the patients’ progress due to the

cultural responsibility of caregiving. They found that it was also difficult for patients to desire to

be independent and would say things like “‘What do you mean that my family won’t take care of

me? What do you think, I’ll be all alone? Why should I do this?’” (Al Busaidy & Borthwich,

2012). One study by Zango-Martin et al. (2015) found that the participants identified the most

important occupations to be those that were considered co-occupations, collective occupations,

and cooperative occupations. Co-occupations are those that were engaged in with two or more
MAIR OT NEEDS ASSESSMENT 23

people working towards a common goal. Collective occupations are considered activities that are

engaged in to provide social interaction. Lastly, cooperative occupations are those that are

carried out by a group of people that are working together towards one common goal (Zango-

Martin et al., 2015).

Challenges. Additional peer-reviewed articles were located in order to better understand

the challenges of starting occupational therapy clinics in developing countries. Research by

Bourke-Taylor & Hudson (2005), which examined ideas of developing an OT practice in the

Domincan Republic, determined that the major difficulties in the startup process included

cultural differences and feeling like “outsiders,” challenges related to working with local

therapists, and the reaction of clients to occupational therapy. The same study found that many

patients and caregivers did not understand or accept the concept of occupational therapy and

often felt like no services were being received at all. They determined that most patients were

only familiar with basic therapeutic modalities such as heat, passive and active range of motion

exercises, and gait training (Bourke-Taylor & Hudson, 2005).

In predominantly Islamic countries, it is difficult to fully understand the cultural impact

on OT services without examining the influence of gender issues on service delivery. A study by

Orabi, Dawson, Balloch, and Moore (2011) revealed that the cultural taboo of non-married men

and women making physical contact, made it difficult for female stroke survivors to receive

services, as a majority of physiotherapists in the Islamic country of Jordan are men. It was also

difficult for such women to receive preferred home therapy treatments, as men were typically the

only therapists employed in home-health settings (Orabi et al., 2011). Findings from a qualitative

study of 11 of the 15 occupational therapists working in country of Oman, identified similar

challenges with gender influences as those in Jordan (Al Busaidy & Borthwich, 2012). The
MAIR OT NEEDS ASSESSMENT 24

therapists from this study, who were all trained in westernized countries, expressed challenges

with establishing rapport with patients of the opposite sex, which ultimately hindered the

therapeutic progress. In addition, it was mostly unheard of to assess dressing or bathing

performance due to the cultural taboo of the patient exposing their body, regardless if the patient

was male or female (Al Busaidy & Borthwich, 2012).

Advantages of OT in developing countries. The lack of limitations on therapy services

from insurance companies in the country of Morocco leads to a greater likelihood of better

therapy outcomes and progression towards functional goals. According to a study of 162 children

with CP in South Korea, researchers Park & Kim (2018) found that OT and physical therapy

(PT) services that were provided at an intensity level of 3-11 sessions per week for 1 year

showed significant improvements in the ADL function. In addition, similar results showed a

significant correlation between more intensive OT and PT services and increased motor function

in patients who sustained traumatic brain injury (Cifu, Kreutzer, Kolakowsky-Hayner, Marwitz,

& Englander, 2003). Consequently, a study of 18 stroke survivors from Jordan found that

patients who only received the pre-determined 10 out-patient therapy visits, typically decreased

in function following discharge from services (Orabi et al., 2011). Aside from the amount of

therapy received, an additional benefit to decreased limitations from insurance companies is the

ability of patients to see providers in various settings. According to a study of 60 stroke survivors

in Nigeria, researchers Vincent-Onabajo and Mohammed (2018) found that a majority of

Nigerian stroke survivors preferred therapy treatment in out-patient or home settings versus those

received in hospital-based settings.

Another advantage to occupational therapy services in countries that live within a

collectivist culture, is the support that is gained from the family and community. While the idea
MAIR OT NEEDS ASSESSMENT 25

of interdependence may cause a shift in occupational goals, the support that is gained from

familial dedication and strength is insurmountable (Al Busaidy & Borthwick, 2012). Research by

Al Busaidy & Borthwick (2012), found that OTs in the Islamic country of Oman felt that due to

strong familial support, they were extremely confident that therapy services would continue at

home even after the patient was discharged from services.

Culture of occupational therapy. According to Al Bussaidy & Borthwick (2012),

“culture is viewed as the learned behaviors, values, norms and values, that are passed on from

generation to the next.” Watson (2006) goes on to emphasize the importance of considering that

the profession of occupational therapy itself has its own cultural set of theories of practice,

common language, norms, boundaries, rewards and consequences that have been passed on since

its inception. Watson goes on to explain that while OTs trained in westernized countries place

therapeutic emphasis on independence, it is important as a profession to understand that this may

not be the cultural practice and focus of occupational participation worldwide. Lastly, she goes

on to defend the fact that although every OT practices within a unique set of location-based

cultural norms around the world, we are all united by the common OT cultural belief in the

power and potential of occupation (Watson, 2006).

Summary

Although the current evaluation process at the MAIR clinic is able to produce a

somewhat adequate medical history and limited subjective data in regards to deficits effecting

functional activity, more can be done to produce objective, trackable data which can be used to

support the clinic overall. As made evident by this literature review, it is difficult to determine

best practice for the assessment of all neurological conditions due to: the grandiosity and

variance of deficits, the variety of standardized outcome measures that exist, and the value to
MAIR OT NEEDS ASSESSMENT 26

which occupational therapy places on clinical observation to determine functional deficits.

Furthermore, aside from intermittent trainings, the MAIR therapist’s current level of knowledge

is not only limited in comparison to westernized education, but void of occupational therapy

training entirely. This makes it difficult to rely on advanced OT evaluation measures without

considering that significant therapist training and support will be required.

As new therapists are brought onto the team, previous trainings will continually need to

be retaught in order to provide the same level of skills to each practitioner. In order to create an

efficient and effective training program for new therapists, a set curriculum needs to be

established to ensure that each person is receiving the necessary skills to provide comprehensive

neurological rehabilitation. At the foundation of providing effective neurological treatment, the

therapists must first be able to thoroughly evaluate the patient in order to determine what is truly

keeping a person from being able to engage in their daily occupations. In addition to training the

therapists on these evaluation skills, the data that is gathered needs to be done in a way that is

quantifiable, and effectively documented, to show the progress of the patient and the clinic

overall. This needs to be a priority in the process of developing the MAIR clinic in order to

continue to receive funding from current donors, and to recruit new funding sources and

stakeholders.

While designing the curriculum and therapy protocols, consideration should be given to

how westernized occupational therapy culture prioritizes self-sufficiency and independence. To

some extent, Moroccans continue to hold onto many of their traditional beliefs and cultural

norms. Contrary to what was found in this literature review, the families in Morocco were

perceived as wanting their children to be as independent as possible. Although it was difficult to

find research on rehabilitation in the country of Morocco itself, observations and discussions
MAIR OT NEEDS ASSESSMENT 27

with patients and families created a sense of progressive ideals that strongly coincide and support

the mission of MAIR and the power of occupation as a tool for recovery. As a result, goal

writing and treatment planning cannot be assumed to be focused on the independence, but should

remain entirely driven by what is most important and motivating to the client, their family, and

how that person can be a productive member of his or her community.

In order to maintain this client-centered practice, outcome measures can be incorporated

that quantify the clients’ or caregivers’ perceptions on quality of life. In conjunction with

function-based outcome measures, this data can give the therapists a solid foundation from which

to plan their course of treatment, while remaining culturally sensitive and focused on the needs

of the clients and their families. These measures need to be chosen systematically in order to

meet the needs of the patients, the limitations of the clinic, and the capabilities of the therapists.

With thoughtful deliberation and planning, this evaluation protocol can be designed to be truly

effective and help to sustain the services that are provided by the MAIR clinic.
MAIR OT NEEDS ASSESSMENT 28

References

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Bhatia, M., & Joseph, B. (2001). Rehabilitation of cerebral palsy in a developing country: the

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affected by stroke in Jordan. Disability, CBR and Inclusive Development, 22(1), 73-84.

Park, E. Y., & Kim, E. J. (2018). Effect of the frequency of therapy on the performance of

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Occupational Therapy-An International Journal, 10(3), 60-68.

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Watson, R. M. (2006). Being before doing: The cultural identity (essence) of occupational

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Wong, A. W., Ng, S., Dashner, J., Baum, M. C., Hammel, J., Magasi, S., ... & Goldsmith, A.

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MAIR OT NEEDS ASSESSMENT 32

Appendix A

Email Correspondence with Doctor Mohammed Sbai

Doctor Sbai’s responses are italicized and verbatim.

1. What is the length of stay for the MAIR clinic? Typical length of each session?
a. Patients usually come for a 45-90 mins session. Kids are usually kept under an
hour.
i. But for how long? One month, two months? A year?
b. One session/week for one month for TBI is their standard LOS
c. Being on time means different things to different patients
d. Some will have 1 session/day-- if they are progressing really well
e. Some patients have been at the clinic for 3 years,
2. How many patients are seen a day, and what percentage are adults vs. children?
a. We usually see between 15-25 patients per day, about 60-65% of them are kids
3. What current programs are you implementing at MAIR clinic (ex. Feeding, gait training,
ROM, etc.) and what programs would you like to implement in the future?
a. We are trying develop a comprehensive a approach but we do feeding, LT/Gait
training, sensory integration, cognitive therapy, ROM/stretching, some balance,
some vision therapy, we use FES on several setting (ERGYS, Tens units,
Bioness...)
4. What does funding look like for the clinic? How does Rotary club play a role in funding?
a. We are currently funded by grants from private foundations, Rotary has funded
the medical training that our staff received from US med professional both in
Morocco and US.
5. How many therapists are on staff? How many interpreters? Any other staff members and
what role do they play?
a. We used to have nine staff members but because some of them refused to sign
long-term contracts, we are now down to three therapists, we like to call them
"neuro-therapists". All our staff speak English and everything we do in the clinic
is in English. We have one person handling the front office. We also had interns
who usually rotate for 1-3 months.
6. Education of the therapists?
a. Have a 3 year degree after high school
b. Basic education about anatomy, etc.
i. PTA here has more education than their therapists
c. They currently call themselves ‘PTs’
7. How do you prioritize patient care/your waiting list?
a. We changed our strategy several times in the past. Now we are doing first come
first served, but we also look at the patient's condition and try to evaluate the
impact of our services. People who are good candidate for fast/effective recovery
are given priority. Since our paying patients are only about 30% of the total, we
also try to prioritize paying patients. Current recruitment of 10 for example would
have 6-7 paying and 3-4 non-paying.
MAIR OT NEEDS ASSESSMENT 33

8. How far are they traveling to get to the clinic? What type of transportation is needed? Is
public transportation accessible for individuals with special needs?
a. Most of our patients are within 30-60 mins traveling from the clinic while using
public transport, mostly buses. We have patients traveling several hours to get to
our clinic (those living deep in the countryside). But we have patients driving
their cars or motorbikes. Some patients come to us from different cities and they
usually rent a place or live with family in Marrakech. Some did come to us from
outside Morocco, like southern Spain and southern France. It is very hard if not
impossible for patients with special needs to use public transport.
9. How do people pay for services? How do you charge for different services (if you have
different charges)? Do you use a pay scale?
a. 70% of our patients are poor and don’t pay. When we opened the clinic three
years ago, 100% of our patients did not pay for services. The paying 30% are
cash paying with no insurance for most of them, but we have patients who are
using insurance to get reimbursed. Also not all paying patients pay us the same
rate. Very few can afford full rate ($20 per session). Most of them are between
$5-$10 per session. Some are as low as 50 cents per session. Recently, we
discovered that several patients have insurance and good financial means but
were not paying us. So we decided that starting this season, we will require
everyone to pay something to help our finances, get rid of the reputation that our
clinic could be easily taken advantage of and increase the involvement of families
in the therapy and the achievement of its goals. We noticed that non paying
patients became more involved and more appreciative to the whole process after
they started paying us something, even symbolic amounts.
b. CNOPS- insurance for those who work for the government
c. CNSS- private insurance
10. How do you envision occupational therapy being incorporated into the clinic? What do
you hope to achieve by incorporating OT services?
a. We are already incorporating OT stuff in our therapy model and it is and will
always be an important component. BTW the motto of our clinic is shown on a
banner inside the clinic and it says "to trigger a neuro-plastic change is the
foundation of our therapy, to achieve maximal recovery is our most important
goal". So we seek to incorporate anything that would lead us to these two things,
i.e., get the brain and the rest of CNS to relearn/adapt in order to perform lost
functions. OT is obviously very valuable for that.
11. What are your plans for the future?
a. We would like to establish our MAIR clinic as a excellent neuro-rehab facility
based on the model and the best standards of care found in the USA. We predict
that we will make MAIR the best in Morocco and Africa and one of the best
internationally. Clearly long-term vision is important for us: we do not want to
build a facility that will do good and disappear in 20-30 years from now. We are
determined that MAIR will be a center with a well established tradition for
excellence in the field of neuro-rehab, clinical and translational neurosciences
and related medical disciplines. Our hope is that once we have staff that are well
qualified for patient care and clinical research, we would build the phase-II of
MAIR OT NEEDS ASSESSMENT 34

our project that you could check out in this link:

https://www.youtube.com/watch?v=TFWgmDSobeo
12. Ultimately, what do you need or would you like us to contribute?
a. We would like you to teach our patients and staff something and hopefully you
will learn from them something. We can discuss the specifics during our
upcoming meeting. Plus, you all need to stay flexible and be ready to adjust your
plans and expectations until you are there. You may come up with an idea based
on what you experience in the first 24H of your stay
13. How are people referred to, or find out about, the clinic?
a. mostly word of mouth! but we are starting to get consistent referrals from local
doctors/hospitals/clinics. We just built our basic website (www.mair-rehab.com)
and we intend to hire and admin person who will use it for advertising, social
media etc...Our current space is very small (about 2700 sf), we are trying to move
into a 10,000-20,000sf. It is until then that we will increase our advertising.
Currently we are having hard time with the long waiting list.
14. What type of scheduling system do you use?
a. None. all is manual. We have an excel spreadsheet and home-made database. We
intend to use a professional database in near future with access/storage in the
cloud. I will send out an example of medical file that we are generating right now.
Financing is also done manually.
15. What is process for evaluating patients and planning their care? How do the therapists
determine exactly what they are going to do with a patient?
a. We usually interview the patients and take a look at their medical history if they
have something to go by. We then establish list of deficits that we can deal with
and in the context of their rehab goals and our expectations (prognosis, we
usually like to shoot for the stars) we start rehab at a very minimal level doing
easily feasible things. We then increase the level and complexity of therapy
approach based on results of the initial period (2-8 weeks). It is our plan to
establish specific therapy protocols as well as discharge plans in the near future
(during 2019-2020 period). This is something that we will do as part of our
upcoming neuro-therapy curriculum that we will build using help from the U and
several other US med institutions. This is actually something that you all could
contribute to.
16. How do the therapist currently document? Will we have access to charts to assess what
they are doing/plan of care?
a. As mentioned above we have home-made excel spreadsheets. I will share some
examples prior to your trip, and of course you will have access to all our data.
17. If they don’t do plans of care is this something we can build? (ie. protocol for
assessment/treatment)
a. Yes! We welcome that very much, as mentioned above.
18. I read online that the clinic is incorporating telehealth using TruClinic (as of 2014) - is
this something that is still happening? Is it working for your patients?
a. Yes, we are still using telemedicine, but we switched to gotomeeting app. We do
online consultations very often and that something that you could contribute to, if
interested.
19. What is your plan to make the clinic sustainable?
MAIR OT NEEDS ASSESSMENT 35

a. We need to thrive in becoming the best medical facility possible, that’s the quick
answer. For that we need to have full commitment from our staff and patients. As
you know, patients are the central piece and staff need to be excellent, but
patients/families need to do their best too. In other words, achieving excellent
results and establishing a reputation for excellence is key for our sustainability.
When you look at prestigious US medical institutions, they do what they do best
and the rest falls into place by default: patients satisfaction, staff's skills,
happiness and pride and of course the institution's financial stability.
20. What is currently working for the clinic, what needs improvement?
a. Our staff are very dedicated and it is always touching to observe them at work.
They really care for their patients and are highly committed to our project and
vision. Our team leader and lead therapist, Imane, she personify of all of that. I
am very proud of her. Our teamwork attitude has gotten a lot better as did our
internal communication. But we still need improvement on all fronts. The small
space is becoming more and more of a problem, but we are trying very hard to
get a bigger one. Our staff's skills are most likely the best in the country, but it is
also a country where there is very little access to adequate neuro-rehab. So keep
helping our staff develop their skills is essential to us now and for the foreseeable
future.
21. Are the Zahra charity and Neuroworks no longer assisting in funding the MAIR clinic
(like the Salt Lake Rotary Club is)?
a. Zahra Charity is the US non-profit that I started in 2009 with main goal of
establishing and growing MAIR. ZC is funding all MAIR operations using grant
from private foundations. Again rotary is funding the medical training for our
staff. We started using Neuroworx as a training site and we sponsored some of
their staff to go to Morocco and train our therapists. Unfortunately last year they
decided that they no longer wish to help us that way.
22. Target population - Would you say that this is children or cerebral palsy?
a. Yes, 60-65% of our patients are kids and the vast majority are CP patients. We
have few strokes, TBI, SCI and others
23. What would you say some strengths of the clinic are?
a. Excellent staff skills compared to what is being done in the country, subsequent
good results being achieved (you will see some of our success stories, I will let
staff share that), growing reputation in the local communities including medical
communities.
24. What are some weaknesses of the clinic?
a. admin is non existent right now, we need to establish comprehensive models for
patient's check-in, patient's financial assessment (eligibility dept missing!),
scheduling, therapy protocols, patient handling during therapy and discharge,
patient database....
MAIR OT NEEDS ASSESSMENT 36