ECFR FINAL REPORT 2017

rapid assessment of the disability and rehabilitation of ex-mine workers living in: lesotho

swaziland

south africa

mozambique

2017

final report ENHANCING CARE FOUNDATION

ENHANCING CARE FOUNDATION FINAL REPORT: MARCH 2017

abbreviations

glossary

CCOD ������������ Compensation Commissioner for Occupational Diseases

Impairment The International Classification of Functioning, Disability and Health (ICF) define impairment as any loss or abnormality of psychological, physiological or anatomical structure or function.

MBOD ����������� Medical Bureau for Occupational Diseases ADL’s ������������� Activities of Daily Living BME �������������� Benefit Medical Examination DOH ��������������� Department of Health DOL ���������������� Department of Labour DMR �������������� Department of Mineral Resources TEBA ������������� The Employment Bureau of Africa ECF ���������������� Enhancing Care Foundation ODMWA ������� Occupational Diseases in Mines and Works Act COIDA ���������� Compensation of Occupational Injuries and Diseases Act WHO �������������� World Health Organisation Rehab ����������� Rehabilitation SADC ������������ Southern African Development Community MDA �������������� Miners Development Agency CHW �������������� Community Healthcare Worker ICF ������������������ International Classification of Functioning, Disability and Health SAFOD ��������� Southern African Federation for the Disabled UNCRDP ����� United Nations Convention on the Right of Disabled Persons CBR ��������������� Community Based Rehabilitation OHS ��������������� Occupational Health and Safety MHSC ����������� Mine Health and Safety Council MHSA ����������� Mine Health and Safety Act NIHL ������������� Noise Induced Hearing Loss CMSA ������������ Chamber of Mines South Africa TB ������������������� Tuberculosis SDG ��������������� Sustainable Development Goals PLWD ������������ People Living with Disability MDG �������������� Millennium Development Goals ILO ����������������� International Labour Organisation OT ������������������� Occupational Therapist PT ������������������� Physiotherapist RMA �������������� Rand Mutual Assurance IOD ����������������� Injury on Duty FSDRSA ������ Framework and Strategy for Disability and Rehabilitation Services in South Africa WHODAS ���� The World Health Organisation Model Disability Survey

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abbreviations & glossary

Disability The International Classification of Functioning, Disability and Health states that a disability is an umbrella term to cover impairments, activity limitations, and participation restrictions and reflects the interaction between features of a person’s body and features of the society in which he or she lives.

Activities of Daily Living or Daily Tasks These are routine activities that people tend do every day without needing assistance. There are six basic ADLs: eating, bathing, dressing, toileting, transferring (walking) and continence.

Occupational Therapy extends this to work/play, leisure/ social participation and sleep/rest.

Functioning This is the ability of an individual to perform their activities of daily living within the context of their social and physical environment Rehabilitation This is the process of treatment to restore or recovery from an injury, illness, or disease to as normal a condition as possible. It involves helping a person restore lost skills and so regain maximum self-sufficiency or independence in their day to day activities.

Compensation This is something, typically money, awarded to someone in recognition of loss, suffering, or injury.

Accessibility In relation to health care, this involves the timely access to or use of health care systems to achieve the best health outcomes. It includes gaining entry into the health system and place of care where patients can receive needed services. Accessibility in healthcare is about the right service at the right time and the right place.

Acceptability In healthcare acceptability is largely subjective and can constitute a range of factors including but not exclusive to: affordability; cleanliness; professionalism; appropriate skills; caring attitudes; accessibility; timeliness etc.

Injury Physical harm or damage to someone’s body caused by an accident or an attack.

Heat Maps A heat map is a graphical representation of data (often showing density or distribution) where the individual values contained in a matrix are represented as colours.

contents background............................................................................ page 8

1 2 3 4 5

executive summary....................................................................18 activity 1............................................................................................................. 22 1 purpose.........................................................................................................................22 2 methodology..................................................................................................23 3 results.......................................................................................................................... 24 4 discussion............................................................................................................. 34

activity 2........................................................................................................... 37 1 purpose......................................................................................................................... 37 2 methodology................................................................................................. 38 3 results.......................................................................................................................... 46 4 discussion.............................................................................................................. 57

activity 3.......................................................................................................... 60 1 purpose........................................................................................................................60 2 methodology.................................................................................................60 3 results.......................................................................................................................... 63 4 discussion............................................................................................................. 66

activity 4...........................................................................................................69 1 purpose........................................................................................................................ 69 2 methodology................................................................................................. 69 3 results.......................................................................................................................... 70 4 discussion..............................................................................................................73

appendices.................................................................................................... 78 appendix 1.......................................................................................................................78 appendix 2...................................................................................................................... 91 appendix 3.................................................................................................................. 107 appendix 4................................................................................................................. 109 appendix 5.................................................................................................................... 113 appendix 6.................................................................................................................... 115 appendix 7.................................................................................................................. 126 appendix 8.................................................................................................................. 136

South Africa has around 2 million ex-mine workers.

World Bank

references..........................................................................138

images: supplied, shutterstock.com

contents

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ENHANCING CARE FOUNDATION FINAL REPORT: MARCH 2017

background South Africa is recognized as a world leader in the mining industry with a valuable concentration of raw materials including platinum, gold and diamonds.

It is an integral sector of the Southern African economy employing around 500 000 workers and has a legacy of about 2 million ex-mine workers. The sector

also contributes to the economy of the region through the remittances of migrant workers from across the Southern African Development Community (SADC) and provinces across South Africa. The sector currently boasts more than 100 000 workers from Lesotho, Swaziland and Mozambique.

“I want to be a relevant contributor towards the growth of the economy.�

(Lesotho)

The overall aim of the project was therefore to provide valuable information to better understand the plight of the injured exmine workers, inform key stakeholders of the needs and challenges and propose a model for service delivery to support future services.

Table 1 Migrant Mineworkers in South Africa, 1920-2010 The Employment Bureau of Africa (TEBA)

year

1920 1940 1960 1980 1995 2000 2010

rsa

74,452 178,708 141,406 233,055 122,562 99,575 152,486

mozambique

77,921 74,883 101,733 39,636 55,140 57,034 35,782

lesotho

10,439 52,044 48,824 96,308 87,935 58,224 35,179

swaziland

3,449 7,152 6,623 5,050 15,304 9,360 5,009

% non-RSA

(migrant mine- workers)

57

49

62

44

58

57

34

8

background

related. A paucity of literature relating to the experiences, challenges and needs of ex-mine workers with occupational injuries makes it difficult to identify gaps in knowledge and awareness relating to the topic. This raises the concern that those with occupational injuries may be a forgotten population not to be ignored.

The World Bank, therefore, commissioned the Enhancing Care Foundation (ECF) to conduct an assessment of the disability and rehabilitation of former mine workers from South African mines living in four Southern African countries: Lesotho; Mozambique; South Africa and Swaziland.

Duration: The project commenced on 1st July 2016 and closed on 31st March 2017.

Under direction of the World Bank, the project was conceptualized as follows:

table 2: Development Activities World Bank DGF 2016 Original Activity Concept

Agreed Activity for Project

Identify the number and location of ex-mineworkers with disabilities and categorize the types of disabilities of exminers in the four targeted countries

Identify the number and location of ex-mine works with disabilities and categorise the type of injury of ex-miners in the four countries set against the rehabilitation facilities available to them

Identify rehabilitation services currently available to ex-miners in the four targeted countries and their needs and challenges including acceptability and accessibility of compensation and rehabilitation services

Survey a sample of injured ex-mine workers and understand their needs and challenges including the acceptability and accessibility of compensation and rehabilitation services

activity

Carry out specialized disability assessments among a sample exminers in the four targeted countries

Carry out specialized disability assessments among a sample exminers in the four targeted countries

activity

Develop a service delivery model for vocational rehabilitation using information obtained from activities 2 and 3

To develop a service delivery model for the rehabilitation of injured ex-mine workers with the information obtained from activity 2 and 3.

activity

1

activity Mineworkers face high risks of occupational injury and disease, including hearing loss, due to the very nature of the work being high risk and hazardous. Workrelated accidents from such risks are often catastrophic and life changing and injuries can include loss of a limb(s), head injuries, hearing and visual impairments leading to disability and an impact on daily life.

The treatment, monitoring and care for ex-mine workers facing occupational injury is challenging on various levels.

Historically, there has been a fragmented response to services across various levels for both former and current mine workers in Southern Africa. This includes government, country borders and sectorial

Project Conceptualisation:

2 3 4

The four activities highlighted above were crucial to gain a better understanding of the plight of the injured ex-mine workers and ensure a relevant model for future support services in this sector.

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ENHANCING CARE FOUNDATION FINAL REPORT: MARCH 2017

figure 2: International Classification of Health and Functioning

Setting the Context: Defining/Understanding Disability and Rehabilitation

health condition (Disorder or Disease)

figure 1: understanding disability

Article 3 of UNCRPD Disability is defined as resulting “from the interaction between persons with impairments and attitudinal and environmental barriers that hinders their full and effective participation in society on an equal basis with others”

body functions & structures (Impairments)

To understand health and function in context, the World Health Organisation (WHO) established the International Classification of Functioning, Disability and Health (ICF) that has assisted in describing health and disability at both individual

and population levels (Figure 1). The ICF was officially endorsed by all 191 WHO Member States in the fifty-fourth World Health Assembly on 22 May 2001 as the international standard to describe and measure health and disability.

The areas with the highest level of disability: Northern Cape; Free State, Eastern Cape and Northwest province are also the areas with the highest labour sending populations for mines in South Africa. Comparison of data from 2011 Census SA with ex-mine worker population distributions – MBOD

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background

participation (Restrictions)

contextual factors

Disability is not just a health problem. It is a complex phenomenon, reflecting the interaction between features of a person’s body and features of the society in which he or she lives. Overcoming the difficulties faced by people with disabilities requires interventions to remove environmental and social barriers World Health Organisation

Activity (Limitations)

environmental factors

personal factors

The ICF is operationalized through the WHO Disability Assessment Schedule (WHODAS 2.0), which was developed through a collaborative international approach with the aim of developing a

single generic instrument for assessing health status and disability across different cultures and settings.

Disability in this study was classified as follows:

table 2: classifying disabilities classification

brief explanation

Mild disability

Some difficulty with Activities of Daily Living, but minor

moderate disability

Dependent in 35%+ of ADL’s

severe disability

Bed Bound or dependent for 70%+ of ADL’s

Statistics on Disability There are approximately one billion people who are living with disabilities globally. This represents at least 15% of persons in the world who are faced with barriers that impede their full participation in an integrated society daily. 80% of these individuals reside in low to middle income countries (LMICs). It states that 15% of the population globally present with disabilities and that a physical disability is the most common. The 2011 Census of South Africa looked specifically at the

profile of persons with disabilities and found that approximately 10% of the population in South Africa experienced some form of disability. Both the 2011 Census of SA and the Framework and Strategy for Disability and Rehabilitation in South Africa (FSDRSA) 2015 - 2020 make note of the fact that disability percentages increase with age.

This can pose a challenge in identifying if ex-mine workers are disabled because of age related deterioration or because of prolonged exposure to mining or both.

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ENHANCING CARE FOUNDATION FINAL REPORT: MARCH 2017

Disability and poverty perpetuate and reinforce each other. The relationship between disability and poverty is understood as complex, bi-directional, context dependent and residing in multiple mechanisms. Disability arises from an interaction between a person with impairment and their environment.

Depending on the nature of this interaction there may be a resultant participation restriction or exclusion from valued roles in society which may be exacerbated by poverty.

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background

un de r life

The majority of mineworkers assessed in activity 2 and 3 hailed from rural contexts. Rural underdevelopment and poverty endure as contributors to poorer social determinants of health and a higher burden of disease. Disability is often viewed as a cause and consequence of poverty. Poorer people and people living in poorer contexts are more vulnerable to disability. These include, inter alia, multiple barriers to mobility, activities of daily living and social participation. The barriers of having to travel long distances to access amenities, rough and difficult terrain, lack of accessible transport and often lack of access to running waiter, sanitation and electricity, predispose minor impairments to be far more significant. This cycle of poverty, ill health and disability in represented in Figure 3.

or h im pa e ir

ty er

multiple health risks

poor access to health care

ill health

More complex and enduring health needs, increasing barriers to health care access

s ca t pa nd ti rt a e k on icip at io n i n wor car .h f o us ehold burden o

lo u ed

Rural Contexts and Impact of Poverty on Disability Healthcare can neither be universal nor equitable if it is less accessible to some sections of society than it is to others. This affects a large proportion of the disabled population who already live with a disability and the many more at risk due to health conditions and environmental factors particularly those living in conditions of poverty and where access to general health services is poor.

v po

po

m

Kate Sherry, Rural Health Activist, Health System Strengthening for responsive and equitable services in Primary Healthcare (South Africa)

figure 3: Cycle of poverty, ill-health and disability

mes: residual tco ou d to disabilty lea th al nts e

“The rights of poor communities in rural areas are systematically violated, both through living conditions that perpetuate poverty and through the administrative injustices of a foundering bureaucracy. People with disabilities are excluded from the few opportunities that do exist, and seem invisible ‌â€?

Status on the Disability and Rehabilitation in the 4 Countries The United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) (2008) provides clear guidance on the approach, treatment and rights of persons with disabilities ranging from access, mobility, work, health services, community life and rehabilitation.

The African Disability Year Books in addition to specific policies sourced from each country, served as the primary documents in determining the status of

disability and rehabilitation in the four countries. The following thematic tracks were identified and are reported in Table 3.

Identification of the status of the United Nations CRPD in the specific country Disability Statistics Ministry responsible for Disability and Rehabilitation Legislation that includes disability and rehabilitation Policies and Procedures that address disability and rehabilitation

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Ministry responsible for disability

Statistics relating to Disability Disability Statistics

Signatory to UNCRPD

ENHANCING CARE FOUNDATION FINAL REPORT: MARCH 2017

lesotho

mozambique

south africa

swaziland

Ratified on 2 December 2008

Became a signatory in 2010 to both CRPD and optional protocol Ratified on 31 December 2010

Became a signatory in 2007 to both CRPD and optional protocol.

Ratified on 30 November 2007

Became a signatory in 2007 to both the CRPD and its optional protocol.

Ratified on 24 September 2012

2002: 4,2% of total population 2009: 3,7% of the total population

2007 Census Data 475 011 with disability 2,5% of the population

2001 Census and 2011 Census are not comparable due to the change in approach in the disabilityrelated questions.

2001 Census Data 2 255 982 people 5% of population have a disability 2011 Census Data 2 339 000 people 5,2% of population have a disability

171 347 people with disabilities 16,8% of total population Prevalence of disability in Swaziland is higher than the average found in other developing countries (which is at 10% of the total population) 82% of people with disabilities live in rural areas

The Department of Disability Services in the Ministry of Social Development

Ministry for Women and Social Action The Ministry of Health provides rehabilitation centres and the Ministry of Women and Social Action is responsible for coordinating psychosocial and economic reintegration activities, which include community-based rehabilitation. Therefore, physiotherapy and orthopaedic services are provided by both ministries.

Department for Women, Children and People with Disabilities (DWCPD) established in May 2009 and incorporates the former Office on the Status of Disabled Persons

National Disability Unit A Community-Based Rehabilitation Programme was established in 1990 which was later upgraded to a National Disability Unit in 2000.

The National Disability Unit was first housed by the Ministry of Health and Social Welfare. In 2008, the Unit was transferred to the Deputy Prime Minister’s Office under the Department of Social Welfare.

Article 37 Citizens with a disability shall fully enjoy the rights enshrined in the Constitution Article 125(1) persons with disabilities shall have a right to special protection by family, society and the state Article 125(3) the state shall promote the creation of conditions necessary for the economic and social integration of the disabled Article 125(5) states that the state shall encourage the establishment of associations of the disabled Article 95 states that all citizens shall have the right to assistance in the case of disability or old age, therefore, the state shall promote and encourage the creation of conditions for realising this right

Section 9(1) provides for equal protection and benefit of the law, and a right to non-discrimination to everyone.

Section 9(3) and 9(4) are the only sections which directly addresses disability in the Constitution.

The South African Bill of Rights (Chapter 2 of the Constitution) apply to ‘everyone’ and therefore most of these rights would also be applicable to and include persons with disabilities

Disability in the Constitution

Section 33 Provides for rehabilitation, training and social resettlement of persons with disabilities.

14

background

Section 14, a clause on the fundamental rights and freedoms of the individual, provides for disability in 14(1)(e) and 14(3) which prohibit discrimination on the basis of disability.

Section 20 provides for equality before the law.

Section 30 provides for the rights of persons with disabilities to respect human dignity and enact laws for the protection of persons with disabilities.

Rehabilitation Rehabilitation promotes and restores independence in all aspects of daily life following an injury. As well as promoting an individual’s independence and rights, rehabilitation promotes participation in society so that an injured worker can play an equal role in their communities; continuing to work and supporting families, extended families and thereby contributing to the economy and their social security.

Rehabilitation should ideally occur within the context of the physical and social environment. Variation exists between the four countries in terms of provision, access and acceptability of rehabilitation in general, let alone anything specific to ex-mine workers. While rehabilitation facilities exist, they are not always easily accessible and are also limited by the lack of equipment needed to carry out the rehabilitation. Included in these challenges is dearth of rehabilitation specialists available and the core rehabilitation team.

The impact of a health condition or disability is experienced differently for each individual and is influenced by a variety of factors. The ICF is thus expanded beyond the limited medical view which focusses on impairment as the only cause of disability and necessitates the need for rehabilitation.

Rehabilitation is a process involving a multiprofessional team of healthcare workers who are focussed on an individual’s ability to be re-integrated into society. For optimal rehabilitation, health practice needs to be structured within an integrated service delivery framework that addresses many core principles.

Rehabilitation Services currently available to mine workers who have sustained an Injury For mine workers who sustain an injury, timely and appropriate rehabilitation has been shown to improve health outcomes and enable them to manage the resulting disability. Rehabilitation reduces the negative impacts of long term sickness absence, further promoting participation in society as well as the individual’s independence and their rights. Vocational rehabilitation for mine workers has also been shown to aid in the return to work or suitable alternative employment, which in turn also has socio economic and health benefits. While today, most large scale mines comply with national OHS legislation, there is variation in the provision of rehabilitation to injured ex-mine workers that leads to inequity in the quality and access of services.

Broadly speaking, rehabilitation for mine workers occurs as follows: Acute rehabilitation This is largely done in acute hospital settings following injury and in parallel to the injured mine worker becoming medically fit. The mines in South Africa have historically had hospitals which cater of mine employees.

However, this has now almost completely changed, with these services, including rehabilitation being outsourced.

Post-acute rehabilitation which, depending on extent of injury and need, may be undertaken in a rehabilitation facility or as an outpatient.

This is predominantly outsourced

As well as promoting and restoring independence in daily life, rehabilitation also promotes participation in society so that an injured worker can continue to work, support families and participate in their communities.

ECF Finding

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ENHANCING CARE FOUNDATION FINAL REPORT: MARCH 2017

“I have to go to Johannesburg every six months to collect medication and would like to receive my medication in Mbabane where it is closer.”

(Swaziland)

16

background

nowadays and it is recognised that the quality, monitoring and control of this rehabilitation is lacking. This is concerning as the right amount and quality of rehabilitation, the right place and at the right time, greatly improves an injured mine worker’s ability to return to employment.

Vocational rehabilitation often occurs at this point, involving assessment against job profiles; rehabilitation to return to existing work roles; work-hardening or re-skilling. For injured mine workers, the outcomes of vocational rehabilitation programmes can take one of the following paths: – Return to original mining job – Return to original mining job but modified to suit worker capability (reasonable adjustments to either the job role or the environment) – Return to a different mining job following rehabilitation and training – Recommendations that an individual is no longer fit to do any job on the mine and then advocates for compensation and adaptation to the individual’s home environment (if required) and the supply of appropriate assistive devices. It has been noted that re-skilling to a job that is unrelated to the mines is at the discretion of the mine human resource department. However, it is unclear to what extent this occurs, if it is monitored or controlled and what the outcomes are.

Ongoing rehabilitation to address any deterioration in conditions/ injuries which may reduce levels of independence. Depending on need, ongoing rehabilitation should occur within the context of the physical and social environment and as such is mainly domiciliary based. This can include adaptation to the home environment; provision of equipment as a compensatory approach to increase independence and reintegration into everyday life. This may involve, for

example, the provision/maintenance of equipment such as artificial limbs or hearing aids and presents itself as an ongoing need. It is this aspect that is the focus of the rehabilitation for ex-mine workers.

Noise Induced Hearing Loss Noise is one of the most hazardous exposures for mine workers. In the mining industry, noise competes as a hazardous agent with respirable dust (respiratory disease) and repetitive trauma (Roberts, Sun & Neitzel, 2016; Donaghue, 2004).

In some countries, like the USA, the prevalence of hazardous noise exposures in the mining sector is so great that it is mine workers who report more hearing problems than any other type of worker (Matetic, Randolph & Kovalchik, 2010).

However, consider how hearing loss, an insidious, slowly occurring disability, is viewed relative to the highly visible and immediate disabling effects of e.g., a hand crushed in a machine injury. The relative invisibility of noise effects on mine workers’ hearing has been skewed by various factors. For example, political ideologies have resulted in research that marginalised and/or ignored noise-induced hearing loss in black African mine workers by focussing on white mine workers (e.g., see Hessel & Sluis-Cremer, 1987). Furthermore, noise has been studied, rather simplistically, as a single hazardous agent (Pillay, 2001). This is despite the known accumulative effects on the body when noise is combined with exposures to agents like chemical vapours and vibration (Morata, Themann, Randolph, Verbsky, Byrne, & Reeves, 2005). The sum effect of such thinking has led to ex-mine workers not benefiting from newer laws and practice standards in occupational health and safety that emerged in the last few decades.

Critically, due to changes in the legislative landscape, ex-mine workers who have left the mining sector would have been under a different set of legislation especially in

South Africa, pre-1994 (with significant amendments occurring especially in, e.g., 2003 and 2013). Currently noise exposure levels in an 8-hour working day should not exceed the occupational exposure limit (OEL) of 85 dBA. It is generally accepted, while debated, that noise between 80dBA to 90dBA becomes dangerous to the auditory system (Basner, Babisch, Davis, Brink, Clark, Janssen, & Stansfeld, 2014; Rawool, 2012).

workers with approximately two million exmine workers, many of whom are migrant workers from within and outside South Africa (SA News, 2016).

Noise is one of the most hazardous exposures for miners.

Most mine workers are exposed to hazardous noise levels is an incontestable circumstance. Globally, over 360 million people have hearing impairments, with approximately 80% in low- and middle income countries (WHO, 2015).

Unfortunately, NIHL has been inadequately reported in professional literature with data on the prevalence of hearing loss in mine workers greatly lacking.

According to leading South African audiologist Dr Edwards there are approximately 15 audiologists who provide clinical, mainly diagnostic services to the mining industry (personal communication: 12th November 2016). These audiologists are in Rustenburg, Witbank and Welkom and are there are also a group of audiologists who work directly for the mines, with a smaller group of audiologists to whom mining companies may make direct referrals. The number/availability of this workforce needs to be considered in relation to the fact that there currently there are approximately 500 000 mine

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ENHANCING CARE FOUNDATION FINAL REPORT: MARCH 2017

executive summary Background South Africa is recognised as a world leader in the mining industry. The sector plays a key role in the Southern African economy as a former employer to 2 million ex-mine workers and around 500 000 current mine workers. The country’s mines attract labour from Southern African Development Community (SADC) countries and provinces across South Africa.

Occupational health has long been at the forefront of addressing the debilitating consequences of mine work, given its high risk of injury. Work-related accidents from such risks are often catastrophic and life changing and injuries can include loss of a limb(s), head injuries, hearing and visual impairments leading to disability and an impact on daily life.

The treatment, monitoring and care for ex-mine workers and mine workers with occupational injury poses multiple

activity

Identify the number and location of ex-mine works with disabilities and catego-rise the type of injury of exminers in the four countries set against the rehabilitation facilities available to them

activity

Survey a sample of injured ex-mine workers and understand their needs and challenges including the acceptability and accessibility of compensation and rehabilitation services

1 2

activity

3

activity

4

18

Carry out specialised disability assessments among a sample ex-miners in the four targeted countries

To develop a service delivery model for the rehabilitation of injured ex-mine workers with the information obtained from activity 2 and 3.

executive summary

challenges. Historically, there has been a fragmented response to services across various levels for both former and current mine workers in Southern Africa. This includes government, country borders and sectoral related and raises concern over the effectiveness of such services.

Project Conceptualisation Aimed at encouraging a greater understanding of the occupational health of ex-mine workers, the World Bank commissioned the Enhancing Care Foundation (ECF) to conduct an assessment of the disability and rehabilitation of former mine workers from South African mines living in 4 Southern African countries: Lesotho; Mozambique; South Africa and Swaziland.

This project was not conceptualised as research or a study but as an investigative and exploratory account to describe the situation of injured ex-miners. This was because of a focus on occupational disease and limited knowledge and awareness of the impact of mining related injuries on the exmine workers and to understand what the gaps may be and if more should be done.

The overall development objectives were therefore to increase knowledge, awareness and understanding of the plight of injured ex-mine workers. This would inform key stakeholders of the needs and challenges and help propose a model for service delivery to support future services.

Duration: The project started on 1st July 2016 and closed on 31st March 2017.

Key Activities The project delivered against a key results framework and refined development activities in collaboration with the World Bank as table (left):

Project Aims

Methodology

Activity 1 A desktop review of the following: Literature, context and policy/legislation for ex-mine workers Key stakeholders and their roles Sources of data relating to number and location of injured mine workers and place this information in a heat map.

Rehabilitation services available to exmine workers

Establishing Priorities: This project was designed within an exploratory multimethod approach towards meeting the outcomes of the project framework. The design was informed by existing systems within the southern African context and streamlined to ensure in-depth understanding of the ex-mine worker’s plight within the four countries.

Activity 2 Fieldwork in each of the 4 countries involving: A survey questionnaire of approximately 600 injured ex-mine workers on their perceptions of accessibility and acceptability of rehabilitation services and compensation A focus group discussion in each country with injured ex-mine workers on their perceptions of accessibility and acceptability of rehabilitation services.

Activity 3 Fieldwork in each of the 4 countries involving: 20 disability assessments in each country of the injured ex-mine workers to understand the impact of the injury.

30 noise induced hearing loss screens across each country of ex-mine workers with reported hearing loss to understand if they show signs of noise induced hearing loss.

Activity 4 A desktop review incorporating the findings from Activity 2 and 3: To develop and explain a model for the rehabilitation of injured ex-mine workers To develop and explain a model for managing noise induced hearing loss

Approach to each Activity Activity 1 was geared towards an investigation into the location of ex-mine workers and the disability and rehabilitation issues experienced by those affected. Two desk-top reviews and the generation of geographical heat maps provided essential data for this purpose.

The desk-top reviews placed these findings within the African context by an exposition of the policies and legislation around disability and rehabilitation and the experiences of Persons living with Disability.

Activity 2 included a survey and focus groups with a cohort of ex-mine workers aimed at unpacking the realities of the ex-miners’ experiences of the disability and rehabilitation processes.

Activity 3 involved detailed disability assessments and NIHL screening that provided critical insights into the actual impact of the ex-mine workers injuries on their ability to engage in meaningful activities and their overall quality of life.

Activity 4 culminated in a rehabilitation model (including a model for hearing loss) that is proposed for the ex-mine workers in the four countries based on data retrieved from the prior three stages.

These models highlight essential principles that are necessary to ensure uptake, with recommendations for implementation, monitoring and evaluation.

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ENHANCING CARE FOUNDATION FINAL REPORT: MARCH 2017

Results Activity 1 The desktop review established

a paucity of literature relating to the topic and a lack of a comprehensive database of ex-mine workers to identify their number and location, let alone categorise their injury. 4 sources of data emerged from RMA, MBOD, DOL, ECF questionnaires but information from each had limitations.

Activity 2 703 questionnaires were

completed across the 4 countries with the following results: - Accessibility: On average, respondents from Swaziland were more satisfied with their access to health services compared to respondents from other countries.

This was followed by South Africa and Lesotho with Mozambique showing the lowest level of tolerance towards accessibility.

- Acceptability: respondents from Swaziland were more accepting of the health services provided to them compared to other countries, followed

by Lesotho and Mozambique with South Africa showing the lowest level of acceptability.

The results also show that only 42.32% were receiving money/pension due to compensation for their injury and only 13% had not been paid even though they had applied for money because they were injured.

Data from the focus groups confirmed that accessibility and acceptability were also issues in addition to the challenges of living within rural settings, sustaining their livelihoods and the burden that injuries and the resulting disability has on families.

Activity 3 105 disability assessments

were completed and in almost all groups, access to rehabilitation, equipment, home adaptations and assessment for NIHL were identified as needs. In addition, the need to continue to remain relevant and contribute to their households financially was noted.

From the 212 people screened to detect

20

executive summary

the presence of NIHL, the findings suggested that NIHL is present amongst the ex-mine worker population.

Activity 4 A service delivery model for rehabilitation and for NIHL was developed.

Both models incorporate the reality of ex-mine workers having to access both the private and public health systems.

One-stop service centres could be seen as places for the single points of entry for the provision of services or a central referral hub of access and onward referral for the ex-mine worker.

Three levels of care are incorporated into the rehabilitation model: Institution-Based Rehabilitation, Rehabilitation at Community Care and Primary Health Care Clinics (CHC & PHC) and home based rehabilitation.

The NIHL model involves a screening service connected to follow up medical and audiological intervention, of which there are two streams, viz. (a) a fast track service dubbed the FITT track (fast, important, treatment and therapeutic) and the (b) extended auditory rehabilitation (EAR) track.

Recommendations A more comprehensive and up to date master database of ex-miners needs to be developed in collaboration with key stakeholders.

An independent and detailed analysis of all the rehabilitation services available to ex-mine workers across the four countries needs to be completed.

Rehabilitation post injury needs to be reviewed to prevent future injured mine workers from becoming ex-mine workers prematurely or without the benefit of skills development.

It is recommended that raising awareness of the mine workers’ rights in terms of compensation, benefits and advice on financial planning comes under the remit of the Mining Quality Authority in collaboration with the mining sector.

Integrated, accessible and sustainable services across statutory, voluntary and private organisations is needed to deliver rehabilitation for ex-mine workers.

It is recommended that a workshop be conducted with the key stakeholders to discuss the feasibility of the proposed models for rehabilitation and NIHL, with a focus on the provision of sustainable services, to gather collective knowledge in an appreciative way and find solutions to moving services for ex-mine workers forward within an appreciative framework.

An independent analysis and review of the 1-stop service centres and other organisations with good footprints in the 4 countries needs to be conducted to identify their scope and potential in providing rehabilitation and equipment or being referral hubs to, access a raft of services and programmes to address the various needs identified for the ex-mine workers, including screening and onward referral to establish NIHL, making suggestions for how the above can be implemented.

Programmes of sustainable livelihoods for ex-mine workers need to be reinforced. It is recommended that an independent review of existing community-private partnership models around sustainable livelihoods be undertaken to inform potential models that may suit the ex-mine worker populations and their communities.

Conclusion While challenges may have existed in the past in terms of occupational health and safety on the mines and rehabilitation post injury, these are being improved through the work of the MHSC and amendments to the MHSA. Due to the nature of an occupational injury being immediate, the treatment and input

by RMA and the Compensation Fund through COIDA has been relatively well managed with the majority of ex-miners receiving compensation of some form..

Depending on the type of injury, many returned to work through vocational rehabilitation programmes.

However, for those who returned to their home countries because they could no longer work on the mines, access to ongoing rehabilitation, finances and resources are frequently limited. With a significant amount of focus on ex-mine workers with occupational lung diseases and TB, the injured ex-mine workers have become a forgotten population and the combination of their injury, age, poverty and the rural environment has all impacted on increasing their disability. Combined with limited access to rehabilitation services and a lack of knowledge and awareness of their rights to benefits and programmes of support, the burden on their families and loss of roles and function within their households and communities is noted.

More needs to be done to develop an integrated and coordinated approach to addressing their needs through inter-sectoral collaboration and accessible points of entry to a network of services and support.

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01

The mining industry contributed R262 billion to South Africa’s GDP in 2015�

Department of Mineral and Resources annual report 2015-2016

activity 1

south africa employs approximately

1 purpose The purpose of Activity 1 was to conduct a comprehensive desktop review of literature, stakeholder databases and other sources of information to identify the number and location of ex mine workers with injuries; categorise their disabilities and map this against rehabilitation services available to them. Table 1 highlights the approach taken to Activity 1.

460 000 mineworkers

Table 1 approach taken towards activity 1

22

task

aim

implementation

1 2 3 4

Context Analysis and Understanding

To set the scene for the project and create an understanding of the topic.

Desktop Review by project team

To review literature relating to ex-mine workers from the 4 countries injured while working on the mines in South Africa and their resulting disability and rehabilitation

Desktop review with support of Technical experts

To review policy and legislation specifically relating to compensation and health and safety on the mines.

Desktop review and liaison with key stakeholder and informants

To identify the key stakeholders involved Review of the directly with injured ex-mine workers and organisation, clarify their roles and responsibilities. management and infrastructure relating to injured ex-mine workers

Desktop review and liaison with key stakeholders and informants

5

Review of Databases relating to the number and location of exmine workers

To identify and analyse sources of data relating to the number and location of injured ex-mine workers in the four countries and categorisation their disabilities.

Desktop review and liaison with key stakeholders and informants

6

Identification of rehabilitation facilities in the 4 countries

To identify the rehabilitation services available to the ex-mine workers in the 4 countries where fieldwork took place, including the type of rehabilitation and professional cover.

Desktop review with support of in country key informants.

7

Generation of geographical heat maps

To produce heat maps from the sources of data identified on the number and location of the injured ex-mine workers against a backdrop of rehabilitation services available to them.

Data sourced from key stakeholders were available, geo-coded and IT company synthesized into heatmaps with rehab facilities data.

literature review Review of Policy and Legislation

section 1 activity 1

2 METHODOLOGY 2.1 Desk-Top Review (please see Appendices of the two completed Reviews) Two reviews were conducted. Review 1 focussed on peer-reviewed literature from 1996 to 2017 in addition to grey literature such as key policies, project reports, and progress reports related to ex-mine workers, census information across all four countries, literature describing disability and rehabilitation, strategies, and

frameworks for rehabilitation, including policy and legislation related to disability and rehabilitation.

Review 2 focussed on an in-depth literature review of published and unpublished (gray) literature relating to Noise-Induced Hearing Loss, using EBSCO host, Pubmed, Medline, Sco-pus and OVID. Search terms included noise, occupational hearing loss, noise-induced, ear protective devices mining, sub-Saharan Africa, Lesotho, Mozambique, Swaziland, South Africa.

figure 1 Desktop Review Process for Review 1

identification

Records identified through database searching (n=153)

Additional records identified through other sources (n=0)

Records after duplicates identified (n= 153)

screening

eligibility

records screened (n= 153)

records excluded (n= 60)

Full-text articles assessed for eligibility (n=93)

Full-text articles excluded (n=30)

Studies included in synthesis (n =63)

included

Compensation (6) Context of PWDs (11) Occupational Health and Injuries (18) Policies (10) Rehabilitation (18)

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ENHANCING CARE FOUNDATION FINAL REPORT: MARCH 2017

24

section 1 activity 1

The data from the Department of Mineral Resources between 2003-2013 on fatalities and injuries is highlighted in Figure 2 showing that health and safety in the mining industry have had a downward trend.

166

127

123

112

93

2010

2011

2012

2013

3.1 Injury, Disability and Rehabilitation in Mine Workers

3118

172

3363

fatalities 66% decline

3396

4180

injuries 27% decline

3453

Rehabilitation promotes and restores independence in all aspects of daily life following an injury. As well as promoting an individual’s independence and rights, rehabilitation promotes participation in society so that an injured worker can play an equal role in their communities; continuing to work and supporting families, extended families and thereby contributing to the economy and their social security.

Rehabilitation should ideally occur within

Only two studies, one in South Africa, highlighted the psychological trauma experienced by miners, which includes PTSD.

3626

2.3 Identifying the Rehabilitation Facilities in the Four Countries

The results are aligned to the aims of activity 1. These include a description of the injury, disability and rehabilitation in ex-mine workers, policy and legislature relating to compensation and health and safety on the mines, a description of key stakeholders involved with ex-mine workers, the number and location of injured ex-mine workers and rehabilitation services available to them in the four countries.

pressure, strain or rock bursts which result in uncontrolled release of rock.

figure 2 department of mineral resource: fatalities and injuries 2014

3967

From the filtered databases, this information was then geo-coded for the co-ordinates of the towns where the exmine worker lived to plot them onto the geographical maps. These geographical maps or heat maps showed distribution (location of injured ex-mine workers, as well as the location of the rehabilitation facilities available against the location of the injured ex-mine workers).

3 RESULTS

In South Africa, falling of ground, transport incidents, and general mining accidents (inhaling dangerous fumes, being struck by an object, and falling from heights) and general conveyance accidents result in most of the injuries reported. Falls of ground is a term describing the unexpected movement of rock mass and gravity and/or

3979

The project team identified the basic public rehabilitation facilities available across the four countries where the fieldwork took place. The task was not to evaluate the effectiveness and application of these facilities for ex-mine workers but to give a location of the facilities to show availability and access for the ex-mine worker population. In each country a technical expert was engaged, to find rehabilitation facilities that could be available to the ex-mine workers and the extent of service provision. Key informant interviews were conducted with therapists in each of the countries.

4312

From the literature, engagement with key stakeholders and the databases they hold, it was quickly proven that there was no one source of data relating to the number and location of living injured ex-mine workers across the targeted countries including the categorization of their injury or disability. Different stakeholders held several types and quality of data and the support for Activity 1 was thus variable.

Primary sources of data for this activity were identified as (i) RMA, (ii) DOL, (iii) MBOD/CCOD. Each dataset was filtered to establish a clean dataset relating to the number, location, and type of injury, the following parameters were considered, (i) Having a town name where they lived and (ii) having an injury or disability type declared. Unpopulated fields on the datasets or irrelevant fields (e.g. noninjured mineworkers from MBOD/CCOD database) were filtered from the datasets.

Categorisation of Injures by Data Source, reveals that across most of the datasets (MBOD; DOL; RMA and ECF Fieldwork) the main categories of injury are those to: lower limbs; upper limbs, multiple injuries, NIHL and Spinal Cord.

3661

(Lesotho)

the context of the physical and social environment.

4300

“I want to be a relevant contributor towards the growth of the economy.”

2.2 Identifying the Number and Location of Ex-Mine Workers: Heat Map Generation

3.1.1 Injuries resulting from working in the Mine There was a paucity of literature on specific injuries that mineworkers in Southern Africa experience. Most mention physical injuries but do not mention specific diagnosis. In Zimbabwe, miners reported injuries on the arms, leg, head, and the trunk. Additionally, there are head injuries due to falling objects and back injuries due to heavy lifting that is part of the job requirements. In South Africa, back and lower limb injuries are most common. In Ghana and Zimbabwe miners who worked in small gold mines reported spinal cord injuries, fractures, crush injuries, lacerations, and punctures. Appendix 3 –

271

247

200

200

220

2003 2004 2005 2006 2007 2008 2009

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ENHANCING CARE FOUNDATION FINAL REPORT: MARCH 2017

The high prevalence of disability in South Africa, Lesotho, Mozambique and Swaziland indicate a need for effective rehabilitation services’ ECF Finding 3.1.2 Noise induced hearing loss in mining

“They did not pay me a single cent; they just sent me back here because I was sick by then I could not walk without crutches” (South Africa)

Globally, over 360 million people have hearing impairments, with 80% in lowand middle-income countries (WHO, 2015). Unfortunately, NIHL has been inadequately reported in professional literature lacking data on the prevalence of hearing loss in mine workers. In Southern Africa, research on prevalence rates of NIHL in mine workers has been conducted in countries like Tanzania, Zimbabwe, Namibia, Ghana, and SA. In South Africa, the mining industry is regulated by the many standards and legislated guidelines regarding noise and noise-induced hearing loss management.

Notably, mine workers are covered under the Mining Health and Safety Act but may also be referred to within the Occupational Safety and Health Act. Significantly, mine workers from countries such as Swaziland, Mozambique, Botswana, and Lesotho are specifically covered under several legislative frameworks, such as that by the Departments of Labour and Health to give compensation, health and rehabilitation services, especially to mine workers.

3.1.3 Policies related to Disability and Rehabilitation and Mine Workers The African Disability Rights year books served as the primary documents in deciding the status of disability and rehabilitation, in addition to specific policies sourced from each of the four countries.

South Africa, Lesotho, Mozambique, and Swaziland are signatories to the United Nations Convention on Rights of Persons with Disabilities (UNCRPD) and in their constitutions have the protection of the rights of people living with disabilities (PLWD). Through these countries acceptance of the UNCRPD, provision for the protection of the rights of people with disability is assured and aims to provide persons with a disability access to healthcare and rehabilitation services.

26

section 1 activity 1

Despite the evidence intent to provide PLWDs access to rehabilitation, there appears to be a gap between the conceptualisation and implementation of the policies in these countries.

In addition, South Africa has a mining health and safety act, while the other countries have mining acts which do not deal with the rights of injured miners.

3.1.4 Experiences of persons with disabilities within the Southern African Context National census data on the prevalence of disability in South Africa, Lesotho, Mozambique and Swaziland was perused. In 2009, 3,7% of the Lesotho population had a disability with 2,5% of the Mozambique population indicating that they experienced some form of disability in the 2007 census. South Africa reported 5,2% of the population voiced having a disability in the 2011 census while Swaziland has the highest reported population with disability i.e. 16,2%. No explanation of the variance the number of person’s with disability was given in the literature.

Literature showed evidence of strong links between disability, poverty, and physical contextual factors. These factors negatively impact on the PLWD engagement in daily life task and further compound the exclusion from social and economic opportunities with an increased risk of contracting non-communicable diseases.

PWDs are also more vulnerable to physical, sexual and psychological abuse, and they are often easily exploited. Social marginalisation and material deprivation add to limited access to education and infrastructural challenges such as poor roads, costly transport, inaccessible terrains and poor access to health services contribute towards the marginalisation and the challenges faced by PWDs when attempting to integrate into the community.

3.2 Policy, Legislature and Literature relating to compensation and health and safety on the mines 3.2.1 The International Labour Organisation (ILO) Convention The ILO convention provides guidance on occupational health and safety relating to mining which is particularly relevant to mining in Southern Africa and to mine workers. The ILO Convention addresses workers’ rights to services that provide for

the prevention, detection and compensation of work-related injury, including emergency care, with rehabilitation and reasonable job security after injury and adequate inflation adjusted compensation. This is echoed in Article 12 of the Charter of Fundamental Social Rights in SADC which all countries relevant to this study have signed up to. The ILO conventions relating to rehabilitation and compensation which are relevant for mine workers and ex-mine workers are described in Table 5.

table 5: Overview of relevant ILO conventions convention aspect application ILO Convention No. 159

C159 on vocational rehabilitation and employment (disabled persons) convention

Provisions made for functional and vocational rehabilitation following an occupational injury

ILO Conventions No. 017

C017 is concerned with the compensation of occupational injuries

Employers are entitled to compensation

3.2.2 South African National Frameworks Relating to Mining 3.2.2.1 COIDA (1993) The main piece of legislature for injured mine workers in South Africa is the Compensation for Occupational Diseases and Injuries Act No. 130 of 1993 (COIDA). Under COIDA, all types of work relationships are covered including those which have been brokered and for employees no longer in employment but who develop an occupational disease.

In the latter, compensation is calculated based on earnings if the worker was still working. COIDA provides a system of no-fault compensation. The entire structure of the compensation scheme is defined in this act.

This includes who contributes to the fund; the amount of contribution, who is covered and types of injuries and diseases covered.

All employers are obliged to register with a carrier (like RMA or the Compensation Fund). Failure to register for compensation

is an offence. If an employee incurs an accident, they are entitled to compensation

by COIDA. An accident is defined by COIDA as a personal injury or death of the employee during their employment. There is a clear claims process under COIDA in Chapter 5. The employee must inform the employer where possible and the employee informs the carrier within seven days of being informed. Once severity is established, compensation is paid. The right to compensation stays even if the employer does not inform the designated carrier, although this is an offence and the employer can be liable for the full amount of compensation.

This act supports compensation for disablement caused by occupational injuries or diseases sustained or contracted by employees during their employment, or for death resulting from such injuries or diseases; and to provide for matters

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“The medical boarding letter from the mines is not acknowledged by some doctors as a result people are refused grants.”

(South Africa)

connected therewith. Under COIDA, injuries can be in the form of the following: ‘temporary partial disablement, in relation to an employee, means the temporary partial inability of such employee as a result of an accident or occupational disease for which compensation is payable to perform the whole of the work at which he or she was employed at the time of such accident or at the commencement of such occupational disease or to resume work at a rate of earnings not less than that which he or she was receiving at the time of such accident or at the commencement of such occupational disease’ ‘temporary total disablement, in relation to an employee, means the temporary total inability of such employee as a result of an accident or occupational disease for which compensation is payable to perform the work at which he was employed at the time of such accident or at the commencement of such occupational disease or work similar thereto’ ‘permanent disablement, in relation to an employee and subject to section 49, means the permanent inability of such an employee to perform any work as a result of an accident or occupational disease for which compensation is payable’ COIDA No. 130 of 1993 The right to compensation for temporary total or temporary partial disablement shall expire once the disablement has discontinued and the employee resumes work or any other work at his/her normal rate or more. Compensation can be awarded again for the temporary total or partial disablement if the disablement reoccurs or further medical assistance is needed requiring the employee to be off work – provided this intervention reduces the disablement.

28

section 1 activity 1

For permanent disablement, this can include partial loss of a limb, impairment or movement of a joint, loss of vision or hearing as per Schedule 2. Permanent disablement is assessed and if found between 1 and 30% is paid in the form of a lump sum and this is calculated in line with Schedule 4 of COIDA. If the permanent disablement is assessed at more than 30% the employee will receive a monthly pension for life. A constant attendance allowance is also payable where the employee’s disablement is such that they are dependent on another person to sustain their basic daily functions.

For mine workers, the Department of Labour provides compensation and unemployment insurance benefits through agencies or ‘carriers’ such as the Compensation Fund, the Unemployment Insurance Fund and Rand Mutual Assurance (RMA). For injuries on the mine, the mining companies either pay into the Compensation Fund or to Rand Mutual Assurance (RMA). RMA is the main body (or carrier) who under license of the Department of Labour, provide compensation to mine employees for disablement caused by occupational injuries or for death resulting from such injuries in terms of section 30 of the Compensation for Occupational Injuries and Diseases Act (COIDA) .

Description of benefits can include: Days off up to 75% of earnings (RMA pay full earnings) subject to earnings cap whilst recovering up to two years; Medical expenses either up to Maximum Medical Improvement (MMI) or two years; Compensation for Permanent Disablement if there is an impairment after MMI; Lump sum if permanent disability is assessed ≤ 30%; Pension if permanent disability is assessed ≥ 31%;

Ongoing medical expenses if further treatment is going to improve disablement for reported injury/disease; Fatal Pension – comprising of monthly pension, once-off lump sum for widows and funeral expenses; Constant Attendance Allowance (CAA) for pensioners assessed at 100% permanent disability and therefore incapable of performing daily activities; RMA pays a family allowance to pensioners assessed at 100% permanent disability and who has a spouse/spouses and more than one child under the age of 18, at the time of the accident.

An injury or disease which was reported by the employee or another person on behalf of the employee to the employer must be reported to RMA by the employer within the prescribed time for the liability assessment and acceptance. If liability is accepted the claimant may receive benefit entitlements prescribed by COIDA depending on the severity of the injury or disease. There are multiple offices across the four countries where compensation can be claimed.

3.2.2.2 The Mine Health and Safety Act (MHSA), 29 of 1996 The objectives of the MHSA are to: 1 Protect the health and safety of persons at mines 2 Get employers and employees to name hazards and eliminate, control and reduce the risks

3 To come in line with international law on health and safety at mines 4 Employees to be representative on health and safety committees and in health and safety matters at mines 5 Offer effective monitoring and enforcement of health and safety conditions and measures on mines 6 Support investigation and inquiry 7 To promote a culture of health and safety in the mines through training and cooperation between the state, mines, their employees and representatives In the South African Government Gazette on the 5th February 2016, under the Mine Health and Safety Act, 1996 (Act No 29 of 1996): Guideline for mandatory Code of Practice for Management of Medical Incapacity due to Ill Health and Injury: Part A: 1.3 was amended to say that: ‘An employee’s medical condition requires a program for effective management of such an employee. This should be interpreted in functional terms and in the context of the specific job requirements and/or specific job requirements of adjusted or alternative jobs considered during the management of such an employee.’

Furthermore, in Part A: 1.5 it says that: ‘The interpretation of this guideline should be applicable for the unique operational circumstances of all mining operations, e.g. small mines, open cast mines, underground operations, beneficiation plants, condensation plants or smelters.’

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3.3 Key Stakeholders involved with Ex-Mine Workers

table 5: Key Stakeholder Function and Level of Engagement Key Stakeholder

aim

level of engagement

Rand Mutual Assurance (RMA)

RMA is licensed by the Department of Labour to provide compensation to employees for disablement (caused by occupational injuries) or for disease (sustained or contracted in the course of employment), or for death resulting from such injuries or diseases in terms of section 30 of the Compensation for Occupational Injuries and Diseases Act (COIDA).

Accessed database of ex-mine workers and information about compensation process

Miners Development Agency

The MDA in partnership with services providers focuses on the facilitation of critical services to ex-employees in the mining, energy and construction sectors as well as their dependents and communities. The organisation places a central focus on its project management ability as a leverage point for delivering true value to Southern Africa’s mine working communities.

Accessed as a contractor to assist in the questionnaires in Lesotho and Free State and supported the co-ordination of focus group discussions, disability assessments and NIHL screening in Lesotho.

Department of Labour

The Department of Labour provides compensation and unemployment insurance benefits through agencies such as the compensation fund and the Unemployment Insurance Fund and through licensing the independent RMA and Federated Employers Mutual Association (FEMA) to provide compensation benefits.

Accessed database of ex-mine workers and information about compensation process

Departments of Health

Provide medical examinations and compensation as well as reviews claims for compensation from current and former mineworkers through the Medical Bureau for Occupational Diseases (MBOD) and the Compensation Commissioner for Occupational Diseases (CCOD).

Supported questionnaires, disability assessments and NIHL screening in Eastern Cape. Through the MBOD/ CCOD supported accessing database

The Employment Bureau of Africa (TEBA)

TEBA has diversified from being primarily a labour recruitment and management service provider to offering a number of additional services including human resources, social and financial services both during and post-employment. They serve mines and mineworkers in and around mining communities, but also serve them within their rural communities; and at times the mining companies pay for their services whilst their employees, the miners, benefit from these services, often at no cost to themselves or their families.

Accessed as a contractor to assist in the questionnaires in Mozambique and Swaziland and supported the co-ordination of focus group discussions, disability assessments and NIHL screening in Mozambique and Swaziland.

Department of Mineral Resources

The vision of the Department of Mineral Resources is to enable a globally competitive, sustainable and meaningfully transformed minerals and mining sector to ensure that all South Africans derive sustainable benefit from the country’s mineral wealth. This is achieved within our legislative framework and as the legitimate custodian of the country’s mineral wealth. DMR inspect the mines and ply a significant role in health and safety in the mines

Accessed for information relating to injuries and role in mine health and safety

The Chamber of Mines of South Africa

A mining industry employers’ organisation that supports and promotes the South African mining industry. The Chamber serves its members and promotes their interests by providing strategic support and advisory input and provides services to ex-miners through the “Mines 1970 Provident Fund” and the “Mines 1970 Unclaimed Benefits Preservation Pension Fund”.

Accessed for information relating to injury prevalence

Mine Health and Safety Council

The mandate of the MHSC is to: Advise the Minister of Mineral Resources on OHS legislation and research outcomes focussed on improving health and safety in the mines Oversee the activities of its committees Promote a culture of health and safety Review OHS in mines every 2 years through a summit (started in 1998) Liaise with the Mining Qualification Authority and other statutory bodies about mining health and safety

Accessed for information relating to occupational injury and health and safety on the mines

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section 1 activity 1

3.4 Number and Location of Injured Ex-Mine Workers Identifying the number and location of ex-mine workers and categorising their injury is challenging due to a paucity of literature and statistics relating to the ex-mine worker population. Datasets available for the heatmap generation is reflected in Table 6.

table 6: Datasets available for Heat Map Generation source

numbers received

numbers usable

6258

6200

66 279

2400

DOL

3756

398

ECF Fieldwork

696

696

RMA MBOD/CCOD

Source: Total

3.4.1 Geographical Heat Maps for Number and Location of Injured Ex-Mine Workers Please note the following limitations: The rehabilitation facilities were only identified in the areas where ECF conducted fieldwork The density may contain duplication but this does not change the distribution The ability of the rehabilitation facilities to provide rehab services was not fully analysed as part of this project.

Understanding the Heatmaps From the limited available dataset from the 4 sources, the heatmaps clearly show the density and distribution of the ex-mine workers set against a network of mainly public services, or those relevant to injured ex-mine workers, that could be accessed by them. This shows that there is a footprint of service centres that can be accessed by injured ex-mine workers, but the degree to which it meets their needs is unknown.

Source: Total

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“I have to go to Johannesburg every six months to collect medication and would like to receive my medication in Mbabane where it is closer.”

(Swaziland)

3.5 Rehabilitation Services available to ex-mine workers in the four countries 3.5.1 Access to Rehabilitation and Services offered within Sub-Saharan Africa The desktop review yielded data mainly from South Africa, with only three papers from other regions being sourced. The findings suggest that despite having primary health care clinics in South Africa, people with a disability still have difficulty accessing rehabilitation services. Furthermore, there are considerable challenges posed by the services now offered, such as lack of communication between service providers and lack of intersectoral partnership between various government sectors and non-governmental organizations.

The literature suggests that there is a need to have intersectoral collaboration, teamwork between health professionals, effective communication, and consultation with the community regarding services required to ensure that rehabilitation service delivery meets the needs of the community.

Additionally, people with disabilities should be empowered and aware of their rights in terms of their countries respective constitution and policies.

It was also found that there is a need to have a stronger focus on community-based rehabilitation, primary health care, and services delivered in the community. It was deemed important to improve the referral system to ensure patients are not lost in the system. For sustainable rehabilitation service delivery, there needs to be greater collaboration between health professionals and community-based rehabilitation workers These mid-level workers need more support and training to allow for efficient service delivery.

Suggested rehabilitation services included the provision of assistive devices (and mobility related ones), a focus on improving independence with daily living tasks, offering primary, secondary, and tertiary prevention, focusing on community reintegration and vocational rehabilitation.

The literature suggested a need to review vocational rehabilitation services.

Focusing on vocational rehabilitation services as a health problem posed a barrier and one author suggested that it needs an intersectoral approach between the department of labour, department of health, department of social welfare and education. Community members suggested that therapists should focus on income– generation projects. Others reported the need for return to work programs, prevocational services, the need to have follow–ups when placed back at work and help with reducing the stigma of working with a disabled person.

Finally, the need to address mental health and well-being of miners arose. There was a need to have services that discuss posttraumatic stress disorders.

3.5.2 Rehabilitation Services within the four countries While there are multiple sources of information relating to clinics and healthcare facilities across the four countries, not all offer services relating to the needs of

32

section 1 activity 1

the injured ex-mine workers in terms of rehabilitation and equipment. In most instances, these services were public and offered very basic physical rehabilitation with OT’s and PTs. More specific services, like prosthetics and audiology, were available but were limited and hence less accessible.

3.5.2.1 Lesotho There are few rehabilitation facilities in Lesotho and most of them do not have adequate human resources. A study

by Leshopo (2013) into disability and rehabilitation in Lesotho, rightly mentions that models for disability impact on social policies, practices, and legal frameworks and as such are always heavily debated.

In 2011, the Ministry of Health and Social Welfare in Lesotho tried to tackle issues of disability and produced the National Disability and Rehabilitation Policy (NDRP): Mainstreaming persons with disabilities into society. This policy takes a social model approach which places the problem away from the individual and towards society. In clause 12 of the policy, community-based rehabilitation is adopted as a key strategy in achieving the aims of the NDRP. Since May 2012, the Ministry of Social Development now leads on disability and rehabilitation but the policy does not go in-depth with rehabilitation issues such as referral pathway, or the provision and maintenance of aids and assistive devices.

There are no policies in Lesotho on donor funding relating to assistive devices and who/how to provide them to clients. Social development disability policy is more on advocacy, vocational rehabilitation, and the welfare of the clients. Rehabilitation professionals and services are mostly found in Maseru, the capital of Lesotho. People in the rural areas are struggling to get basic rehabilitation. The problem is compounded by a shortage of rehabilitation therapists.

3.5.2.2 Swaziland In Swaziland, the rehabilitation practitioners are currently working without an amended rehabilitation policy and although there is a health policy, there is little mention of rehabilitation. Preparations have begun for the setting up of departmental policies in the different hospital settings. There is also a committee comprising of various rehabilitation professionals that are working closely with the Ministry of Health to raise the profile of rehabilitation. The committee, together with all relevant rehabilitation professionals, have set goals, some of which include but are not limited to the following: Increase awareness of rehabilitation to the relevant policy makers, health professionals and the public.

Formulate, approve, adopt and implement policies.

Advocate for inclusion in the on-going health management information systems.

There is an existing and functional patient’s rights charter which applies to the exminers in Swaziland who visit any health care facility. Those aspects of note include: Patients right to access and care Participation in decision making Access to health care including awareness of rehabilitation.

Resources for rehabilitation and rehab professionals are found around the Mbabane and Manzini with little availability within the rural settings.

3.5.2.3 Mozambique A paucity of literature and information made it a challenge to review policy and uptake of rehabilitation within Mozambique.

Key informants were interviewed from the main public and private hospitals in Maputo and were not aware of any policies within the Department of Health relating

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‘We were supposed to expand our rehab unit to have a kitchen and bedroom facility for assessment and treatments but the money ran out, so we couldn’t get equipment needed.

We should also do home visits, but there is not the resource to do this, so the patients have to travel and come to us. Equipment is a real challenge due to the limited resources’ Mozambique OT, Hospital Centrale, Maputo

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section 1 activity 1

specifically to rehabilitation. It was reported that international conventions were not being implemented robustly on the ground.

Therapists performing rehabilitation were in Maputo, with some in the provincial hospitals.

Some of these therapies are not applicable or accessible to ex-mine workers and some of the therapeutic resources focus on paediatric and mental health or for inpatients only.

The key informants identified the following examples of the challenges faced (left).

3.5.2.4 South Africa An institutional analysis of the ability of the SA health system to deliver rehabilitation was undertaken by the Public Health Association of South Africa (PHASA) in 2012. It found that successful rehabilitation outcomes are often judged by the level of integration into main-stream society of people with residual impairments. They found that despite a progressive and enabling legislative framework in South Africa, services for people with disabilities are not meeting the needs of both adults and children with disabilities. It was noted from more recent emerging evidence that SA is struggling to offer effective, efficient, and fair rehabilitation services.

In comparison to the other countries in this study, South Africa has taken up international disability and rehabilitation policies and interpreted these into local policy that is addressing the issue of disability and rehabilitation, as shown in the 2015 – 2020 Framework and Strategy for Disability and Rehabilitation in South Africa.

RMA opened a new care facility for mine workers in Welkom, South Africa in 2016 as it was found that many of their pensioners, who suffered severe injuries, needed ongoing medical care.

The facility has over 120 beds and can offer rehabilitation to those pensioners who have undergone rehabilitation but need continued help with basic living skills.

RMA correctly finds that their pensioners are found across southern Africa, but are mainly from Lesotho, Eastern Cape, Free State, KwaZulu-Natal, and Gauteng. The facility is centrally located in Welkom to allow ease of access from these areas.

TEBA arranges free transport to and from the facility for pensioners, and their families can visit and stay on site.

The facility is also near several hospitals for medical treatment if needed. The concept is to give one-stop care and rehabilitation.

Where the injury does not allow the worker to return to his original work, they will be up-skilled at the facility so that they may either have the skills to move to another position or to follow a path of entrepreneurship. As this is a relatively new facility the effectiveness in this regard is not yet known.

4 DISCUSSION 4.1 Key Findings Despite policies for disability and rehabilitation being in place in most of the countries, there is often a lack of enactment of the policies that

safeguards the rights of persons with disabilities to access rehabilitation and health promotion services. This means the foundations of a rehabilitation infrastructure for injured ex-mine workers are either limited or lacking, affecting accessibility and acceptability.

Access to and the maintenance of equipment is an example of this.

From the desktop analysis, COIDA is a comprehensive act supporting the needs of injured mine workers. The MHSA together with the MHSC address issues to reduce injuries in the mines, but more needs to be done around the quality and monitoring of the rehabilitation post injury to further prevent mine workers from becoming ex-mine workers through a lack proper rehab.

Rehabilitation services need to have a stronger focus on community-based rehabilitation but this is geographically challenging in rural southern Africa.

Intersectoral collaboration across the key stakeholders for injured mine workers is needed to improve processes like referral networks to ensure the injured ex-mine worker is not lost in the system.

Unlike a physical injury from mining which presents itself at once and can be easily managed, NIHL is latent, developing over time. Ex-miners may not have had the benefits of baseline and regular testing to identify this compensable injury. A lack of knowledge and awareness from the ex-miner of this condition, combined with inadequate facilities to diagnose and treat, means the prevalence and cause of NIHL in ex-miners maybe more of a problem than meets the eye.

4.2 Challenges and Opportunities With very limited research into the topic of disability and rehabilitation of ex-mine workers living in southern Africa, finding key themes for this cohort with information to support the approach and method to this project was lacking.

1.1.2 Limited datasets Number, location and categorization of exmine workers’ injuries were difficult to find.

POPI (protection of personal information) laws in South Africa restricted the level of information in the datasets received.

This made it difficult to compare and correlate data sources.

RMA’s extensive database of injured miners was unable to identify if the miner was an ex-mine worker or deceased.

Only those who were declared as having a permanent disability under COIDA or in receipt of a pension from RMA could be reliably identified.

Not all dataset fields had parameters or categorisation. This was particularly the case of data retrieved from DOL and MBOD, where the injury type was not categorized. Although this would not be the remit of the MBOD data in any way.

It is believed that the number of injured ex-mine workers living across the four countries is much larger than the data available. However, without knowing if the mine workers are ex-mine workers or not, or if they are dead or alive, a comprehensive database from a sole source is difficult to prove.

1.1.3 Challenges in accessing rehabilitation facilities data The information gathered through this process was limited in that as a desktop review it primarily noted where the rehabilitation facilities were and only a general understanding of the type of rehab and rehab professionals at the sites was gleaned. Rehabilitation facilities in South Africa were only established where ECF conducted fieldwork (Eastern Cape and Free State) and challenges were experienced in sourcing comprehensive information.

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4.3 Recommendations 4.3.1 Developing a Master Database of Ex-Mine Workers

“They should have rehab to go to their jobs and they should have been given back their jobs, but many mine workers were sent back home without any support: without any opportunity to go back to work” (Mozambique’)

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section 1 activity 1

The current database and IT system at RMA is the most sophisticated and can be interrogated. It is therefore recommended that there is inter-sectoral collaboration across the key stakeholders to agree that one organization hold the master database and all key stake-holders with a role in mine and ex-mine workers provide information and resources to up-date and maintain this master database. This would need the following inter alia: A source to update changes of address to the dataset A source to identify if the mine worker is still employed or not A source to identify if the mine worker is deceased. This role used to be offered

by TEBA to the RMA database but was dropped in 2015.

Sophisticated software to assimilate multiple sources of information with a unique identifying number for each mine worker.

Possible tracking and tracing to identify injured ex-mine workers who are still alive.

The mine workers’ involvement and input would be needed and education made available to create an awareness of the benefits. For example, it would be up to the mine worker and/or families to alert the holder of the master database as to their change of address, that they have stopped working or that they have deceased.

4.3.2 Accessing information on Rehabilitation Services A detailed analysis of all the rehabilitation services available to ex-mine workers across the four countries needs to be completed. This analysis should cover the full remit of services for ex-mine workers. From this analysis, findings and recommendations should be presented to a multi-sectoral key stakeholder group with a

role in the rehabilitation of all mine workers to build networks and develop existing services with an integrated model.

The development of any rehabilitation services for injured ex-mine workers should consider aligning with the initiatives like the One-Stop service delivery framework which aims to improve service delivery to current and ex-mineworkers with respect to health, social and rehabilitation. This will be another point of entry for ex-mine workers to access rehabilitation. It is important that health and rehabilitation services are available at single points of care

4.3.3 Rehabilitation Post Injury To prevent mine workers from becoming ex-mine workers, an independent review and analysis need to occur of the rehabilitation following injury to the point of the mine worker retunring to the medical surveillance system at the mine, to identify gaps and challenges and make recommendations for improvement.

4.4 Conclusion A review of the literature highlighted paucity on the topic of an injured mine worker in Southern Africa, although where found, NIHL appeared to be a significant issue.

Robust data on the number and location of injured ex-mine workers across the four countries was also very limited, with the RMA delivering the most reliable data but only covering a small part of injuries declared under COIDA. The uptake and implementation of policy and legislation around disability and rehabilitation in the four countries is limited and varied, meaning that the injured ex-mine worker does not have the infrastructure to support their needs. The provision of rehabilitation is clearly an issue across all four countries and often given low priority considering the other healthcare issues that need to be addressed. Persons with disabilities and/ or injured mine workers need accessible rehabilitation that meets their needs but this is faced with multiple challenges.

02

activity 2 2.1 purpose The deliverable for this activity was as follows:

Survey a sample of injured ex-mine workers and understand their needs and challenges including the acceptability and accessibility of compensation and rehabilitation services.

This would be completed adopting a multiple methods approach using questionnaires and focus group discussions and later compare the findings with those from activity 1 and 3.

Primary objectives for this activity: 1 To conduct a survey within 8 months, of 600 ex-mine workers injured whilst working in mines in South Africa, and now living in their native countries, on their perceptions of rehabilitation and compensation services. Method: Questionnaire.

2 To conduct a survey of 4 focus group discussions (one in each country) within 8 months, using a sample of ex-miners injured while working in South African mines, and now living in their native countries on their perceptions of rehabilitation and compensation services. Method: Focus Group Discussions.

3 To triangulate the information obtained from objective 1 and 2 above to produce emerging themes and issues for discussion.

“The rural poor are more vulnerable to disability.”

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2.2 METHODOLOGY

2.2.2 Literature Review

2.2.1 Approach

Table 1 approach taken towards activity 2 task

aim

implementation

literature review

To review literature relating to surveys with this population and for tool design

Desktop Review by project team

methodology

To establish sample, process and structure

Desktop Review by project team

Tool design – Questionnaire & Focus Group

To design bespoke tools to capture the information

Desktop Review by project team

Stakeholder and contractor engagement

To brief in country high level and local stakeholders about project

See process discussion below.

Administration of questionnaire

To gather quantitative information relating to the accessibility and acceptability of rehab and compensation

Please see contractor table and detail below. Fieldwork conducted by contractors and government

Conducting Focus Group

To gather qualitative information to corroborate with information from the questionnaire and explore the topic further

Focus Groups arranged with contractors and government bodies

Analysis of data

To analyse and synthesize the quantitative and qualitative data establishing key themes to support Activity 4

Statistical and thematic analysis by statistician and technical experts

Write up of findings and discussion

To present information in the report

Completed by project team

The lack of adequate literature on this topic, specifically around rehabilitation and compensation for ex-mine workers injured while working on the mines in South Africa (or any other country for that matter), posed a challenge for this rapid assessment and findings should therefore be treated as exploratory with further research needed.

2.2.3 Stakeholder and Contractor Engagement The team found similar projects being conducted by other organisations in the same four countries. Health Focus, Live Mayo and the Medical Bureau for

Occupational Diseases (MBOD) and the Compensation Commissioner for Occupational Diseases (CCOD) under the Department of Health (DOH) South Africa were all dealing with ex-mine workers cohorts. This provided an ideal opportunity to work in parallel and synergies were soon identified that enabled collaborative working. The benefits of working in partnership included preventing duplication and expediting ECF’s deliverables within the limited time frames.

In collaboration, the following partnership building, and community mobilization process was used in each country in a phased approach:

Worked with key partners, completed country visits and engaged contractors to conduct fieldwork

There are approximately one billion people who are living with disabilities globally.

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healthcare can be neither universal nor equitable if it is less accessible to some sections of society than it is to others. phase 1: Partnership Building Process

The high-level stakeholder meetings occurred in each country as follows:

country

stakeholder meetings

lesotho

18 August 2016

mozambique

2 September 2016

south africa

1 August to 1 September 2016

swaziland

26 August 2016

The next phase involved community mobilisation, engagement, training and the completion of the questionnaires.

phase 2: community mobilisation

step 1

High Level Stakeholder Meetings held with senior officials in the MOH/DOH and MOL/DOL

step 1

step 4

District Stakholder Meetings were held with traditional leaders and government officials

step 2

Community mobilisation plans outlined

Further Consultation Meetings as required

step 4 step 3

Planning the outreach with local partners and country co-ordinators/ contractors

step 2

Completed forms were returned to Durban for capturing

Fieldworkers were trained to complete questionnaires

step 3

Fieldworkers deployed

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“The rights of poor communities in rural areas are systematically violated, both through living conditions that perpetuate poverty and through the administrative injustices of a foundering bureaucracy.

People with disabilities are excluded from the few opportunities that do exist, and seem invisible …”

Kate Sherry, Rural Health Activist, Occupational Therapist Health System Strengthening for responsive and equitable services in Primary Healthcare (South Africa)

Phase 1 and 2 were also critical in establishing the foundations for ECF to conduct the disability assessments and noise-induced hearing loss screening in each country. Stakeholders were informed of all aspects of the study through meetings both at senior and local level.

The following contractors were engaged with by ECF in each country in phase 2:

country

contractor rationale

lesotho

Mineworkers Development Agency (MDA)

Good footprint in Lesotho and engaged in ex-mine worker challenges Utilised by partners targeting same cohort

1 The Employment Bureau of Africa (TEBA) 2 Justapaz

TEBA: good foot print and role with exmine workers Justapaz: Utilised by partners targeting same cohort but for those not in receipt of an RMA pension.

south africa

1 Eastern Cape: Local Government with Community Health Care workers 2 Free State: MDA

Community Health Workers in Eastern Cape had good footprint into rural areas and working with partners on ex-mine workers MDA: good footprint and knowledge and engaged in ex-mine worker challenges

swaziland

TEBA

Good foot print and role with ex-mine workers

mozambique

For the Focus Group Discussions, this involved the ex-mine workers, their families and community health workers and was facilitated by ECF with support of the in country organisation/contractor who had been involved in the injured ex-mine workers project. For logistical reasons, only 1 focus group was held in each country.

2.2.4 Design A multiple methods approach was used because it helps improve the accuracy of the results and compensates for the weaknesses or biases of one method over another allowing for a more valid picture

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section 2 activity 2

from the findings. Emphasis was placed on the quantitative method with the qualitative aspect providing depth. We triangulated the findings from the multiple sources of data: which included: questionnaires; FGD’s; direct and participant observations, to enrich the findings.

2.2.6 Sampling

method: sample: sample strategy: selection criteria: 1 Had to be an ex-mine worker, injured while working on the mines in South Africa 2 Ensuring the sample population was from both urban and rural settings across the 4 countries 3 Ensuring sample population was both ambulatory and non-ambulatory 4 Either in receipt of compensation or never been through the compensation process under COIDA

method: sample:

sample strategy:

2.2.5 Research Population: The research population is defined as ex-mine workers who were injured from working on the mines in South Africa and live in Lesotho, Mozambique, South Africa and Swaziland.

selection criteria: 1 As above for ex-mine worker 2 Family members/carers who accompanied the ex-miner 3 Community Health Workers who had a role with injured ex- miners in the area

Due to the impracticality of physically tracking and tracing an unknown cohort of injured ex-mine workers within the project time frames, the team achieved this using the following multi-pronged approach: Community workers working in the countries were trained and given questionnaires to administer at the homes of the ex-mine workers. This was done in two ways: Through identifying injured/disabled ex-mine workers during the track and trace programme or referral by them to other injured former mine workers. This approach was mainly used in South Africa as part of a workforce already in place and familiar with the community.

At Mobile clinic events hosted by the MBOD across the 4 countries as part of the compensation process. This approach was used in mainly in South Africa, Lesotho and Swaziland, as it was identified that many of the ex-mine workers attending had injuries or through word of mouth informed others to attend the mobile clinics in case they too were due compensation During collection of pension at TEBA offices by ex-mine workers. This approach was used mainly in Swaziland and Mozambique.

By using databases of ex-mineworkers with injuries held by various organisations and deploying field workers to interview the ex-mine worker at their homes. This approach was mainly used in Lesotho and South Africa.

By asking those interviewed exmineworkers for details, if they were aware, of other ex-mineworkers who were disabled from being injured while working in the mines. A follow up was then done at those homes by fieldworkers. This approach was used in South Africa and Lesotho where the presence of fieldworkers or community healthcare workers were already available in the field.

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“Questionnaires were done by trained and educated members within each country and in the local language.” Project team member 2.2.7 Ethical Considerations The project followed good clinical practice

“They must pay me because I got sick,” he says.

“I’m not angry.

All they must do is pay me.”

(South Africa)

Participants first language used throughout the process.

Verbal consent to participation was sought as opposes to written to account for possible issues around literacy.

Confidentiality was highlighted prior to participant engagement and reinforced Participant anonymity was highlighted and maintained through secure storage and encryption of electronically held personal information.

Participation was voluntary at a time and place that was convenient and accessible to the participant.

Participants were informed that this was a preliminary exploratory study and they would not receive payment for their participation.

The survey questionnaire was piloted prior to commencement to ensure it was suitable for this purpose.

The questionnaire and focus group discussion questions were shown and discussed with a local person of the same culture to ensure questions were culturally sensitive and relevant.

Written information about the project and risks was made available

2.2.8 Study Instruments: a) Quantitative Method - Questionnaire A bespoke questionnaire was developed based on literature search to inform the methodology, approach and design of the questionnaire was conducted.

Six key areas were identified to explore the topic in the questionnaire, namely: Demographics Work History Injury Accessibility Acceptability Services received today

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section 2 activity 2

See Appendix 4 – Questionnaire on the Accessibility and Acceptability of Rehabilitation Services v11 Demographic details were asked of the ex-mine worker as research indicates that those in rural areas are often disadvantaged in terms of access to healthcare and other services.

The questionnaire consisted of multiple choice and yes/no questions. Questions were also designed to be simple for ease of participants understanding.

Potentially complex or foreign concepts, like daily tasks; rehabilitation; treatment was introduced to the ex-mine worker, once consent was achieved, to clarify terminology. Participants were encouraged to seek clarification on any questions if required.

The 32-item questionnaire had four questions which provided a skip pattern where the response to the ‘yes/no’ question would decide the route taken and hence the number of questions answered. These are as follows: 1 ‘Did you have an injury while working on the mine?’ If the ex-mine worker provided a ‘no’ response, then the questionnaire would not be administered and a further 3 questions (Section 6 of Appendix 4) were asked only to establish the cause of their injury and if a pension is received. This data would be represented separately in the analysis of the findings.

2 ‘Were you able to go back to work after your injury?’ If the mine workers answered ‘yes’, a further 3 questions were asked to gain more information about the treatment and care surrounding the return to work and if they returned to their original role or not. This was important to understand more about the receipt of vocational rehabilitation, where this took place and if it made for reasonable adjustments to return to their existing or other job. Literature and policy/legislation

indicate that this should be mandatory practice from 2016, however vocational rehabilitation for ex-mine workers over the past 20 to 40 years is very varied and the lack of this could be having potential impacts on sustainable livelihoods.

3 ‘Did you receive help or treatment that showed you how to get back to doing your daily tasks after injury?’

If the ex-mine worker indicates ‘yes’ an additional 4 questions are asked about the accessibility of the rehabilitation received. In many instances, due to the variation in the past regarding rehabilitation and depending on the nature of the injury, rehabilitation was varied or may not have been seen as necessary or appropriate.

4 ‘Do you receive care or treatment for your injury now?’ It is perceived that the majority of ex-mine workers would answer ‘no’ but stakeholder engagement and understanding from Activity 1 indicates that those with a permanent disability and went through the RMA process would continue to receive care and treatment relating to their condition for the rest of their lives. It was therefore important to understand more about this aspect of their care today as it relates to accessibility and acceptability.

The questionnaire was administered by trained and educated members of the contracted organisations within each country.

b) Qualitative method – Focus Group Discussions A focus group schedule based on the following three thematic areas was developed (See appendix 5 for Focus Group Paperwork): types of difficulties quality of life today types of services/support needed Focus Group Discussions (FGD’s) were considered an attractive and feasible option as they enable one to explore and interrogate ideas, feelings, opinions and to hear first-hand about people’s experiences quickly and in greater detail. One focus group was completed in each country. The groups were organized by the contractors used within the countries. They contacted and arranged for participants to attend and paid them a stipend to cover the costs of transport and the provision of a meal.

The FGDs were made up of the following participants is each country:

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“I want to return to work so that I can support my family.”

(South Africa’)

country

organiser/ contractor

participants

lesotho

Mineworkers Development Agency (MDA)

Ex mine Workers Family/Carers MDA employees dealing with ex-mine worker issues

mozambique

The Employment Bureau of Africa (TEBA)

Ex mine Workers Family/Carers Ex-mine worker’s Association members

swaziland

The Employment Bureau of Africa (TEBA)

Ex mine Workers Family/Carers Ex-mine worker’s Association members

south africa

Eastern Cape:

Ex mine Workers Family/Carers Ex-mine worker’s Association members

BlueSky Business Enterprises

Facilitators from ECF who had previous experience in conducting FGD’s jointly facilitated the FGD’s with the contractor, who had been briefed on the process and mechanisms involved in conducting the FGD’s, and who would provide interpretation. All interviews were taperecorded and notes taken as appropriate.

Participants were provided with verbal information about the purpose of the study and rationale for the FGD’s

2.10 Data Analysis a) Quantitative Method - Questionnaire Data processing and analysis were performed and summarized using frequencies and percentages, in both graphical and tabular forms. Categorical measures of accessibility to occupational health services were transformed into a composite accessibility score (%) whereas categorical measures of acceptability of occupational health services were transformed into a composite acceptability score (%). These scores were compared across countries using a strip-plot in Stata which showed means (µ) and score distributions by country.

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section 2 activity 2

b) Qualitative Method – Focus Groups

“Health services should be closer to where ex-mine workers live.”

(Mozambique’)

than ¾ worked in the gold mine. The clear majority (61%) operated heavy machinery during their tenure at the mines, and almost everyone interviewed (97.5%) was injured in one way or another while working in the mines. Of those injured at work, 79% had

figure 1 Distribution of location of injury among survey participants

Discussions were audio taped, transcribed and translated where necessary. These transcriptions were augmented by field notes. Data were transcribed verbatim and analysed using content analysis, with inductive reasoning. NVIVO version 11 software was used for organisation of data.

18%

ears

82%

17%

back

83%

16%

right hand

84%

16%

left leg

84%

15%

eyes

85%

right leg

86%

left hand

88%

head

92%

5%

right arm

95%

5%

both legs

95%

4%

left arm

96%

both arms

99%

14%

2.3 RESULTS

12%

Quantitative Method – Questionnaire Activity 2 had a response rate of 703 participants from all four countries combined. The tables of results are in Appendix 6 – Tables and Analysis of questionnaire data. Below are the highlights of this analysis.

1.1 Respondents’ characteristics From the analysis of respondents’ demographic, health and occupational characteristics (n=703), most respondents (76%) were aged between 50 and 70 years, 46% were from South Africa, followed by Mozambique (28%). A large proportion of respondents had served in the mines for more than 15 years (66%), 37% and 35% were employed as miners or mining support staff at the mine respectively, and more

the injury for more than 8 years, and only 65.7% could return to work post the injury.

Treatment for injury was received mostly at the hospital mine (51%) and almost every one injured indicated that they received treatment (96%).

8%

1%

yes

no

Fig 1 shows that hearing loss constituted the highest burden of injury in the study sample (18%), followed by back injury (17%), then right hand injury (16%), left leg injury (16%) ad eye injury (15%). A very small proportion reporting having been injured on both arms (1%).

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1.2 Accessibility and acceptability of receives received a) Accessibility Respondents’ perceptions about the accessibility of occupational health services

were measured using five measures which are summarised in Fig 2. Composite scores which were computed from these measures were summarised by country and are presented in Fig 3.

figure 2 Participants views on the accessibility of occupational health services (n= 391-395)

“I bought a wheelchair that I bought from someone who got it from a government hospital.”

figure 4 Participants views on the acceptability of occupational health services (n= 400-403) Felt welcome and cared for while they were being treated?

89%

Happy with the care or treatment they received?

81%

Received care or treatment for their injury soon after being injured

93%

Felt that they received enough care or treatment?

79%

Place where help was received after the injury was far from their home

72%

Receive any equipment, like a wheelchair, to help them get about?

59%

Received help or treatment that showed them how to get back to doing their daily tasks after injury

58%

Felt that they need more equipment to help them with their daily tasks?

37%

Had to pay for transport to get to the place where they received the care or treatment for their injury

19%

Family members involved in their care or treatment?

37%

Had to pay for any of the care or treatment received after their injury

12%

Someone came to see how they managed at home after their injury?

21%

yes

no

Changes made to their home to make it easier for them to get about or do their daily tasks?

yes

(South Africa)

As shown in Fig 2, 93% of respondents received care or treatment for their injury after being injured but 72% of these reported that the place where they received care after the injury was far from their home. Only 56% were informed on how to get back to doing their daily tasks after injury, but very few (19%) had to pay for transport to access health services, or pay for services rendered (12%).

On average, based on the mean composite accessibility scores (%) of the country of origin, respondents from Swaziland were more satisfied with their access to health services compared to respondents from other countries, a result which was significant (χ2(2) = 65.266, p = 0.0001).

Mozambique had the lowest level of tolerance towards accessibility.

b) Acceptability As shown in Fig 2, 93% of respondents received care or treatment for their injury after being injured with 72% reporting that the place of treatment was far from their home. Only 56% received information on coping with their daily tasks after injury.

Very few (19%) had to pay for transport to access health services, or pay for services rendered (12%).

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section 2 activity 2

11%

Respondents’ perceptions about the acceptability of occupational health services were measured using eight measures which are summarised in Fig 4. Composite percent scores which were computed from these measures were summarised by country and are presented in Fig 5 of the Appendix.

Fig 4 shows that most were happy with the treatment received (81%) and felt welcomed and cared for whilst on treatment (89%). Most also felt that the care and treatment was adequate (79%).

However, only 21% indicated that a carer had visited them at home to evaluate their coping skills after their injury. A small proportion (11%) adapted their home environments to ease their daily tasks.

It also shows respondents from Swaziland as more accepting of the provision of health services compared to other countries, based on the mean composite acceptability scores (%). This difference was also statistically significant (χ2(2) = 36.635, p = 0.0001), with South Africa showing the lowest mean composite acceptability score.

no

1.3 Current health status and services received The survey showed that 71% of respondents still struggled to go about their daily tasks because of injury at the time of the survey, while only 27% still received care or treatment for their injury. A very small proportion reported now receiving care or treatment from the main hospital in their town, hospitals run by RMA, a local clinic near their village, or a care provider who visits their home. Only 16% indicated that they received care from a doctor.

Significantly few others were being seen by a physiotherapist (5.69), an occupational therapist (1.7%), a nurse (9%), and a community caregiver (1.3%).

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The results also show that only 42.32% were receiving money/pension due to injury but only 13% had not been paid even though they had applied for money because they were injured. Very few had to pay someone to look after them (14%).

1.4 Relationship between use of heavy machinery and location of injury

figure 6 Visualisation of the multiple binary logistic regression model showing predictors of the returning to the mine for work after injury: Adjusted Odds Ratios (OR), 95% Confidence Intervals (CI), and significance levels (‘**’ < 0.01, ‘*’ < 0.05)

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section 2 activity 2

There was a significant relationship between the use of heavy machinery and hearing loss (injury of the ear) but not with any other type of body injury (p=0.011).

Another notable relationship was observed with the injury of the right arm but this was not statistically significant at any level of significance lower than 0.1%.

1.5 Relationship between ability to perform daily tasks and participant’s health occupational and demographic characteristics: There was a significant relationship between the inability to perform daily tasks and having suffered a head injury (p=0.004), and injury on both legs (p=0.001), but not any other potential predictor.

1.6 Relationship between returning to work at the mines after injury and participants’ health, occupational and demographic characteristics Returning to work at the mine after suffering an injury was associated with the position held by the study participant at the mines before the injury (p=0.001), working in a platinum mine (p=0.001), having suffered a back injury (p=0.001) and hearing loss (p=0.032).

Other predictors were not associated with returning to work at the mine after suffering an injury.

These relationships are further explored in multiple binary logistic regression model showing predictors of the returning to the mine for work after injury. This predicted that working at the platinum mine, having suffered a back injury, having operated heavy machinery, and noise-induced hearing loss (injury of the ear) were the only statistically significant predictors of returning to work after suffering an injury.

The odds of not returning to work were 83% higher among those who had a back pain compared to those who didn’t have it (AOR=1.83, 95% CI=1.21 - 2.77, p=0.003), whereas those who had hearing loss were 43% more likely to return to work compared to those who had not suffered hearing loss (AOR=0.57, 95% CI=0.36 - 0.89, p=0.016). Similarly, the odds of not returning to work were 45% higher among those who operated heavy machinery compared to those who didn’t (AOR=1.45, 95% CI=1.04 – 2.03), p=0.029). There was also a 19% chance of those who worked in the platinum mines to return to work compared to those who worked in other types of mines. The regression model is further presented graphically in Fig 6.

Despite policy being in place in most of the countries, there’s a lack of enactment of the policies that ought to be safeguarding the rights of persons with disability and ensure that they have access to rehabilitation and health promotion services.

Qualitative Method – Focus Groups A profile of the disabled ex-mine workers that took part in the focus groups in the various countries appears in Table 1.

Table 1 Profile of the Disabled Ex-Mine Workers country

ex-mine worker

type of injury

lesotho

SM QZ HL SM PP MM

Injury to Right Leg Left Leg Amputation Bilateral Leg Amputations Left Leg Amputation Left Below Knee Amputation Right Hand Amputation

EASTERN CAPE

MQ MP MJ TM MZ MN BM

Wheelchair bound Lower Limb Injuries SCI (Paraplegic) Hearing and Visual Difficulties Head Injury, #Jaw, Right Hearing Loss Bilateral LL and UL injuries Blindness

mozambique

DN FM HS

Amputation Amputation SCI (Paraplegic)

swaziland

TD SS RD EM JH

Left Leg Amputation SCI (Paraplegic) with UL injuries SCI Wheelchair Bound Lower Back Injuries

Five main themes emerged from the focus group discussions that occurred with these exmine workers from the four countries. These included the rural realities, the implications for the family, financial constraints, the challenge in sustaining their livelihoods, challenges in access to health services and the need for rehabilitation and return to work programmes.

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“I would like an indoor flushing toilet as the outside toilet is not wheelchair friendly.”

theme 2: implications for families The participants relied on their families to help them, which is extremely taxing on the health and well-being of their caregiver/ family member. Caregiver burden arises as result of the conflict of caregivers trying to meet the demands of the care giving role, to the detriment of meeting their own or their family’s basic needs.

(Swaziland)

theme 1: rural realities The participants needed support and assistance to complete their basic hygiene and daily life tasks. The terrain and the physical environmental challenges posed by their rural context, exacerbated the difficulties experienced by the participants and limited their ability to be maximally self-sufficient.

The following quotes illustrate the challenges:

Mobility is often restricted by the uneven terrain. This makes accessing their outdoor toilets difficult and creates obstacles for the participants’, even if they have a wheelchair, to leave their homes to access the community or even just mobilise around their house. This further isolates the participants’ who have to rely on family members to carry them to the nearest area with public transport or assist them to the toilet or around their home. Additionally, participants highlighted the issue of access to wheelchair friendly transport. Currently, participants have to hire a private motor vehicle which is expensive.

“But to move I need to have someone to help me because of the yard that is convoluted.”

(South Africa)

“I have to be carried to get to the main road as it is gravel; very slippery and steep for my wheelchair” (Swaziland)

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“He (my son) is the only one who helps me but now he has back problems from pushing me and carrying me where my wheelchair cannot get to.”

(Swaziland)

“When I (wife) have to go out I have worry about whether my husband is coping at home alone” (Swaziland)

The culture and belief –systems in the community about the role of the caregiver or spouse and the resultant stigma, can also limit the family from engaging in tasks to sustain the needs of the family. The following highlights one such example:

“The community thinks I (wife) am shunning my husband when I try to get work. They think I would rather be away than be with him daily due to his condition.”

(Lesotho)

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theme 4: sustaining livelihoods

theme 3: financial constraints: “There’s just not enough money.”

Participants stressed their desire to sustain their livelihoods. A recurrent theme that emerged centred on possibilities within their rural environments.

“Society and government has abandoned me.” (Ex-mine worker, Lesotho) This statement by an ex-mine worker echoes the expressions of many of the participants. The burden of financial

“The money is not enough because I always end up borrowing from people.”

“My children have to alternate the years they go to school because of no funds to have them all go at the same time” (Swaziland)

“When I was working, money was deducted and I was told I will get my money when I retire, but I did not retire, I was injured.”

(Mozambique)

(South Africa)

section 2 activity 2

limitations on the family and implications resounded throughout the focus group discussions.

Interestingly, participants also voiced an innate need to still be relevant, as described by an ex-mine worker from Lesotho, who conveyed his needs as follows:

Many of the ex-mine workers described the loss of their worker role as having serious implications on their families. Wives and children were most affected, with some of the verbatim responses indicated the burden placed on the family:

(Swaziland)

“They did not pay me a single cent: they sent me back here because I was sick by then and can’t walk without crutches” 54

“If I can get a dairy cow so can both feed off it and be able to sell the milk and earn some income.” (Lesotho)

“My wife has to find ways to earn some income and is constantly searching for work as a maid.”

(Swaziland)

A few participants also appeared to be unhappy and dissatisfied with the pensions they had been receiving as well as over a lack of clarity over deductions that occurred whilst they were in the employ of the mines.

“…if I can also have egg laying hens to sell eggs and feed the family as well”

“I want to be a relevant contributor towards the growth of the economy.”

(Lesotho)

(Lesotho) Moreover, several participants tried to give solutions to their (mine) employer on ways in which they felt they needed aid for sustaining their livelihoods. Once more these were centred on farming activities:

“I want help in the farm like a tractor instead of hiring people to work for me since I cannot work.”

(Mozambique)

“I would like help to get farming equipment to make a living to support my family.”

“I asked the mining company to use my money to buy farming equipment but until today nothing has happened.”

(South Africa)

(Lesotho)

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There needs to be stronger focus on community-based rehabilitation, primary health care and services delivered in the community”

2.4 DISCUSSION 2.4.1 Key Findings The combined findings from both the questionnaire and the focus groups were as follows:

Rural Realities:

theme 5: ACCESS TO SERVICES AND RETURN TO WORK PROGRAMMES The participants voiced difficulty in accessing health services which were far from their homes. This was made worse by the lack of transport or costs in hiring transport to access health services. The suggestion was that clinics and services be closer to residence of ex-miners.

The participants also voiced a need for access to rehabilitation services. There were reports of annual reviews of the participants’ condition in some countries.

Rehabilitation services were perceived to assist with improving the participants’ abilities, as illustrated by this quote:

The need for home modifications and assistive devices such as wheelchairs or alternative forms of transport, which were more suited for rural use, were raised.

For example, “having no ramp makes it difficult for me to get around” (Swaziland) and alternative forms of transport were suggested such as:

The participants voiced wanting to have the opportunity to return to work. There was limited access to rehabilitation and return to work programmes as result the participants went home after being injured, as there were no opportunities to try for jobs with less physical demands.

“I had physiotherapy in 2010 and saw improvement with my mobility... I feel having a physiotherapist to assist wheelchair bound ex-miners will help.” (Swaziland)

“I would like a quadbike to get around as I get tired easily on the farm.”

(South Africa)

“I would love to work but my physical problems make it difficult to perform physically demanding tasks.”

(Lesotho)

“I’d like to go back to work but there is no work.” (Mozambique’) 56

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The realities of living in a rural environment pose challenges and further disable many of the injured ex-miners, affecting their level of independence. Indoor toilets, running water and to a lesser extent electricity, are often disabling factors for the injured mine worker but are difficult to resolve due to lack of infrastructure in rural settings.

Accessibility of rehabilitation and healthcare services: This was identified as difficult and disabling for the ex-mine worker. Getting to services, architectural and home environmental barriers were all identified as contributing factors. RMA contract TEBA to give home modifications and equipment across the four countries and this appears to be working well. However, perceived needs vs actual needs and lack of awareness around rights and compensation following injury sometimes led to the lack of appropriate intervention.

Acceptability of rehabilitation and healthcare services: Acceptability was variable across the four countries with South African feeling the least satisfied. This could be due to personal factor or elements relating but this is inclusive.

Implications on Family: Community cultural and belief systems on the role of the caregiver or spouse and the

resultant stigma can also limit the family from engaging in tasks to sustain the needs of the family and therefore potential loss of income from caregivers. Under COIDA there are benefits, that can be accessed for attendance allowances and other benefits but the ex-mine workers’ knowledge and awareness of these may be lacking, or at the time of injury it may not have been seen to be necessary or they did not meet the criteria. The literature is quite clear about the cycle of poverty and disability on health and the addition of the aging ex-mine working all compound this.

Financial Constraints: The burden of financial constraints as a major theme including the implications this has on their families and quality of life. In some instances, mine workers felt abandoned by their employees or let down by the system. While progress is being made to reduce injuries on the mines in South Africa, the injured ex-mine worker may have been prematurely dismissed without the proper rehabilitation to ascertain their ability to return to work, leading to a lack of adequate income or the ability to return to the job market, especially in the physical demanding jobs of the mines.

Pensions were not enough to live on and in some instances provided an income below the poverty line.

Sustaining Livelihoods: The loss of an occupational role such as work, because of an occupational injury often leaves the person afflicted with feelings of loss and an inability to sustain themselves. In the context of rurally impoverished southern Africa, it is

Poverty together with a disability has a negative effect on those affected as it makes it difficult for them to engage in daily life tasks.

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“The loss of an occupational role such as work, because of an occupational injury often leaves the person afflicted with feelings of loss and an inability to sustain themselves.” ECF team member common for the injured ex-mine worker to stress their desire to sustain their livelihoods, not only for financial reasons, although this is often the primary reason, but also to feel like they have a sense of purpose and contribute to sustaining themselves and their families.

Combined with this is an innate need to feel and remain relevant. Participants provided solutions on ways in which they felt they required assistance for sustaining their livelihoods. Unsurprisingly, this often centred on farming activities across the four countries and particularly for rural dwelling ex-mine workers. These highlights and supports training, capacity building, and skills development programs and projects.

Access to return to work programmes:

“My wife has to fetch water for me to bath.”

(South Africa)

A review of the rehabilitation processes following injury raised questions about the effectiveness of the rehabilitation process, echoed through discussions with key stakeholders.

Knowledge and awareness This activity highlighted that knowledge and awareness around the ex-miners’ rights in terms of compensation, benefits and financial aspects, was possibly limited.

A theme also emerged from the literature.

The Financial Services Bureau shows that there are unclaimed benefits with regards to ex-mine workers and this example is indicative of ex-miners not being aware of their rights or knowing they can claim benefits.

Challenges and Opportunities Interviewer bias can be expected as the fieldworkers and focus group facilitators’ presence during the interviews and focus groups might have influenced the outcome of the findings. In some instances, particularly in the focus groups, participants may not have answered the questions in detail or sometimes exaggerated their problems with the hope that they would get added support.

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This could be a limitation because the answers will not reflect a true picture of a phenomenon being studied.

There is insufficient literature on the topic of injured ex-mine workers and their needs and challenges relating to compensation and rehabilitation. While there could be correlations from the themes from the literature that was available and the desktop review in Activity 1, it is important to note that this rapid assessment must be seen as exploratory, producing additional information relating to the topic.

With limited literature and research specifically relating to conducting questionnaires with this research population, the questionnaire developed may not have been sensitive enough to explore rehabilitation and compensation.

The focus groups yielded the best data but discussing finances and compensation with the cohort is complex and difficult to explore without a detailed assessment of this.

The delay in accessing and understanding the data relating to the research population was a key limitation to this study. The key stakeholders with data relating to the number and location of injured ex-mine workers took time to offer this information. The project could not delay starting while waiting for this information, due to the project time frames. Hence a convenience and purposive sample sample was used based on information available and sources relating to the location of injured ex-mine workers.

RECOMMENDATIONS Access to rehabilitation and compensation services which includes equipment needs to improve across all countries. With the introduction of two, one-stop service centres in each of the countries, facilities should be available to support the ex-mine workers, either in terms of equipment or signposting to services or creating

awareness. It is therefore recommended that an independent assessment and review of the one-stop service centres occurs, including engagement with key stakeholders to identify the potential collaboration and support that can occur to address the needs identified through this project.

The Mining Quality Authority is responsible for improving skills development and training within the mining sector and it is recommended that raising awareness of their rights in terms of compensation, benefits and advice on financial planning comes under their remit in collaboration with the mining sector.

Rehabilitation post injury needs to be reviewed and quality standards and monitoring practices put into place between DMR, MHSC, RMA and the mining companies to maximize rehabilitation and therefore potential to

return to work. It is recommended, as in activity 1, that an independent analysis of this outsourced rehabilitation occurs and suggestions for the monitoring of quality, quantity and inspection of these services are presented to the MHSC, DMR, RMA and mining companies.

Factors that decide acceptability in terms of rehabilitation and compensation for this cohort need to be better established before research into this topic continues.

Ex-mine workers who are injured from working on the mines and return home, need to have support and guidance for sustaining their livelihoods.

Organizations, like the MDA and many others need to develop a collaborative approach to addressing these needs in combination with the Department of Labour and the mining houses.

Compensation is not enough on its own and a more detailed analysis and review of sustainable livelihood programs that occur across the four countries is highly recommended, including identifying the gaps, commonalities, and potential areas for collaboration

3 CONCLUSIONS There are commonalities between the results from the questionnaire and FGD’s, and the emerging themes are congruent with findings from the literature. This data would suggest that accessibility and to a less extent the acceptability of rehabilitation and compensation services requires addressing through a comprehensive model.

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03 “Many ex-mine workers said they found socialising in their communities difficult due to their injuries.”

ECF Finding

activity 3 1 PURPOSE The purpose of this activity was to gain a deeper insight into the impact of the ex-mine workers’ injuries on their daily tasks. It’s important to note that an injury does not necessarily translate to a disability. An injury only results in a disability when the person is unable to engage in their daily tasks within the context of their social and physical environment due to that injury. From the desktop review in activity 1, it was identified that noise induced hearing loss (NIHL) was an issue with ex-mine workers. Therefore, the primary objectives for this activity were: 1 To complete, within 8 months, detailed disability assessments on a sample of approximately 20 ex mine workers in each country to better understand their levels of disability from injuries sustained from working on the mines in South Africa.

2 To screen, within 8 months, approximately 30 ex-mine workers with hearing loss in each country to understand if they show signs of NIHL from working on the mines in South Africa.

2 METHODOLOGY 2.1 Initial Consultation and Briefing (Stakeholder engagements) High level stakeholder meetings were held with government officials from the departments of labour and the departments of health in each country to brief them on the project. This also included briefings on tracking and tracing of ex-mine workers with occupational diseases, to prevent duplication and ensure rapid uptake of the project. (See Activity 2; Section 2.2.3).

2.2 Research Population and Sampling The research population was defined as those ex-mine workers who participated in activity 2 or who had been identified as

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having an injury and/or relating disability from working on the mines in South Africa.

2.2.1 Sampling: Disability Assessments A purposive sample of ex-mine workers from the participant list of activity 2 was selected based on specific selection criteria.

Ex-mine workers location: Due to the large distances and time taken to travel to the ex-mine worker’s homes, it was important that wherever possible participants were co-located to reduce the travel time and complete this activity within the project timeframes.

Type of injury: If the participant in activity 2 indicated that their injury was minor, for example, superficial damage to skin and musculature, these were excluded from the assessments based on a generalisation that such minor injuries would not always impact on independence in daily tasks within the context of the social and physical environment.

2.2.2 Sampling: NIHL Screening A purposive sample of ex-mine workers were selected based on specific selection criteria.

Those ex-mine workers who indicated on the questionnaire in activity two that they had hearing problems or had operated heavy machinery for extended periods, were identified for screening.

Participants were recruited at benefit medical examinations (BME’s), held by the Medical Bureau for Occupational Diseases (MBOD) in two of the countries (South Africa and Swaziland). Those participants who self-reported hearing problems were selected for NIHL screening.

2.3 Instrument Development 2.3.1 Assessing Disability Literature and information from the World Health Organisation (WHO) was considered

to be the most relevant and convenient for this study’s purpose because of its international recognition. The following tools and guidelines were reviewed around assessing disability: The World Health Organisation Disability Assessment Schedule: (WHODAS 2.0) Functional Screening for Older Adults in the Community: Health Promotions Board – Ministry of Health Singapore Clinical Practice Guidelines June 2010 The World Health Organisation Model Disability Survey (WHODAS) Considering the above and literature relating to the topic, no single tool would have been applicable for assessing ex-mine workers holistically in terms of their level of functioning and disability within the context of their physical and social environment.

However, aspects of all the above were taken into consideration, including using a model of occupational performance, to develop a tool for assessing disability in ex-mine workers. The World Health Organisation Disability Assessment Scale, (WHODAS 2.0), a generic instrument for assessing health and disability with standardized disability levels and profiles, was considered the most relevant tool to base the assessment of exmine workers on for the following reasons: Collaborative international research was involved in developing WHODAS 2.0. This included: critical reviews of conceptualization and measurement of functioning and disability as well as a review of existing instruments; crosscultural application study spanning 19 countries around the world; reliability and validity field studies including two waves of international testing using a multicentre design with identical protocols.

WHODAS 2.0 is applicable across cultures, in all adult populations and is linked to the concepts of the International Classification of Functioning, Disability and Health (ICF).

2.3.2 Disability Assessment Tool Ex mine-workers were asked to provide their demographic details and location. The latter was important as research indicated that those living with a disability in rural areas are far worse than urban dwellers.

The tool was discussed and evaluated electronically with a small peer group of Occupational Therapists who had been briefed on the project scope to ensure it was holistic; descriptive enough in terms of the classifications of impairment; barriers, functioning and occupational performance, and detailed enough to establish a degree of disability. Consensus was then reached amongst the peer group that the tool was fit for this specific purpose pending minor changes to layout and content.

The project team thereafter piloted the tool in Lesotho with support of the Mineworkers Development Agency (MDA) to ensure it was sensitive in capturing the aspects concerned with disability and user friendly for ex-mine workers. Lesotho was chosen for this pilot as it was the first country where ECF made contact with the government and obtained permission to begin the project. The MDA there was also proactive in providing support to the project which enabled the team to roll out the project within that country. (See Appendix 7 Assessment of Health and Functioning)

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2.3.3 Noise Induced Hearing Loss (NIHL) Screening with use of Audiometer

“Life at home is difficult due to the little amount of money I receive monthly” (South Africa)

For the NIHL screening, a screening audiometer was used in the three countries where audiologists could be sourced, excluding Mozambique. The qualified audiologists were local therapists and used calibrated equipment. The report generated from the audiometers’ software displays pattern of hearing loss that constituted the data set. Standard screening protocols were used - see Appendix 2 for further details.

Due to issues of transporting medical equipment across country borders, one type of audiometer could not be used across all three countries. However, to ensure consistency, all screening results were reviewed and consolidated by an independent audiologist for consistency.

2.4 Approach to Data Collection 2.4.1 Recruitment and Selection of Professionals for Disability Assessment and NIHL Screening Occupational Therapists and Audiologists were sourced in-country through therapy networks and via databases. The project management team utilised in country therapists as they had: Local knowledge of the countryside and geographical locations of where the injured ex-mine workers lived, Were able to speak the local language Had an understanding of cultural sensitivities Were registered to practice in those countries Had access to equipment (particularly the audiometer for NIHL screening) to conduct work in country without facing cross border issues relating to equipment.

All therapists were contracted via a service level agreement, based on their rates of pay, and provided with the scope and timeframes for the assessment. Their qualifications and eligibility to work in the country were verified.

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2.4.2 Data Collection Procedure The disability assessment places the professional within the context of their home environment and attempts not only to quantify the level of disability but truly highlight the impact their injury has on their daily lives. The phenomena that was explored through this activity is that the injured ex-mine workers’ lives are impacted through an occupational injury, affecting their quality of life today.

The time taken to assess one ex-mine worker within their homes in rural Southern Africa, spanned on average an hour (for the assessment) and approximately two hours of travel time. This meant that a maximum of 2-3 assessment could only occur per day.

For the NIHL screening, ex-mine workers reported to a venue, and hence more assessments were possible in a short period of time. The screening also only takes about 20 minutes. The availability of therapists was a factor in ensuring that more assessments within the timeframe were possible.

For the disability assessments, therapists visited the homes of the ex-mine workers (both rural and urban) and completed an assessment. For the NIHL screening, a venue was organised by the incountry contractors or at benefit medical examinations to screen for NIHL. Ex minworkers who had to travel to the venue were paid a stipend and provided with a meal.

Disability assessments were completed and individually summarised and then summarised as part of a table within each country. An overall summary report of all the assessments was also completed.

The audiologists screened the ex-miner using the audiometer which generates results fed into specialised computer software. Questions were also asked around work history – which fed into the same software.

“More awareness is needed to educate ex-miners on their compensation rights.”

ECF Recommendation

2.5 Ethical Considerations Principles related to good clinical practice were observed during the assessment and screening processes.

Where the participant volunteered through informed consent, the disability assessment was done at a time and that was convenient and accessible to the participant. For the NIHL screen, this was done at a local venue where participants had to travel for the screening, they were reimbursed for their travel and provided with stipend for a meal and drink.

Written information about the project and risks was available to all participants and the therapists were all briefed to provide this information orally. All participants provided their informed consent.

Where unmet needs were identified from the disability assessments and NIHL screens these were referred onto local providers wherever possible to address.

2.6 Data Analysis Disability assessments are a descriptive account of an individual’s ability to function within the context of their environment, hence, it is therefore difficult to draw correlations between each assessment.

Therefore, the information gathered for the disability assessments were descriptive and sought to identify patterns within the study sample using frequencies and percentages.

For the NIHL, the data were analysed in Tableau by computing frequencies and related percentages.

3 RESULTS 3.1 Disability Assessments Number of Assessments: A total of 105 disability assessments were completed in each country.

country number lesotho mozambique south africa swaziland total

31 6 46 19 105

Age and Gender: Ages ranged between 48 years and 85 years with the mean age of 61 years. All the ex-mine workers were men (100%).

Context and access to care: Most of the injured ex-mine workers seen were from rural areas (74.29%) across the four countries with 25.71% from urban areas in Lesotho and Mozambique. Outdoor access in terms of the home environment was more of an issue for the rural ex-miner along with access to health care in general, including rehabilitation.

Cause of injuries: Rockfalls (10.5%) were the predominant cause followed by those relating to mining machinery and locomotives.

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Compensation: 47.61% of the ex-mine workers across all four countries received an RMA pension. All the ex-mine workers assessed in Mozambique (100%) and majority in Swaziland (94.76%) reported receiving an RMA pension. This is because the ex-mine workers were identified through the TEBA database of ex-mine workers who paid the RMA pension. However, this was slightly different in Lesotho where 48.38%

of the ex-mine workers assessed were in receipt of an RMA pension and 17.39% in South Africa.

Classification and Level of Disability: From those assessed across the four countries the majority were identified to have mild disabilities, followed by moderate and then severe.

Table 1 Classification of Disabilities amongst ex-miners Assessed classification explanation

disabilities & functional challenges

N/A

11.43

Mild Disability

Some difficulty with ADL’s but minor

48.57

Moderate Disability

Dependent in 35%+ of ADL’s

32.38

Severe Disability

Bed Bound or dependent for 70%+ of ADL’s

6.67

Bed Bound or dependent for 70%+ of ADL’s

0.95

severe

Amputations above and below knee – unilateral and bilateral Spinal cord injuries and paraplegia Injuries to eyes and ears Due to the nature of the injuries, much of the ex-miners in this category were wheelchair users.

Spinal cord injuries Amputations

impairments

Decreased endurance and ability to carry out manual handling tasks, such as farming, carrying water or heaving objects.

In a percentage of these, lung related conditions were a contributing factor. Most these ex-mine workers utilised some form of walking aid such as sticks, crutches or below knee prostheses.

Pain and decreased range of movement frequently identified as limiting factors Visual and hearing loss Difficulty with mobility

Decreased endurance.

Visual and hearing loss Difficulty with mobility and wheelchair use, increased by challenging terrains

Difficulties with mobility Difficulties with all ADLs

functional implications

Difficulties with accessing the home environment, particularly outdoors Difficulty accessing services, including health care Difficulty tending to farming activities for the rural dwellers Difficulty with ADL’s that required heaving lifting and moving such as domestic activities involving carrying water or tending to the laundry.

However, in this category, most of the mine workers could tend to their personal care and assist around the house, although it was evident from the majority of the assessments that the injured ex-miner did not perform domestic activities like laundry and cooking which were left to the women of the household. This could predominantly be perceived as a cultural factor.

Difficulties with accessing the home environment, indoors but mostly outdoors Difficulty accessing services and utilising transport Difficulty tending to alternative forms of income generating activities Difficulty with personal care, requiring assistance or set up of the environment Difficulty with domestic ADL’s like laundry and cooking In this category, most of the mine workers required some form of assistance to tend to their personal care be that to assist in completing the task or to set up the environment. E.g.: filling a bowl with water and placing this in a place to wash. They were predominantly dependent with their domestic activities.

Required full assistance with all personal care and domestics Unable to access services

idendified needs

Adjustments to prostheses New walking aids Rehabilitation for mobility NIHL assessments Visual assessments Investigation and treatment for lung related disorders

Equipment and home modifications Update of mobility and prosthetic equipment NIHL assessments Rehabilitation

Equipment and home modifications Update of wheelchairs

ECF Finding

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moderate

Amputations to fingers and toes Back and head injuries Unilateral below knee amputations Injuries to eyes and ears General soft tissue and skeletal injuries

“Most ex-mine workers’ hearing losses are highly likely due to noise exposure”

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mild

main injury types

% of total ex- mine workers

No Disability

Severe Disability (but unrelated to mining)

summary of results

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General Findings Social Context: Many of the ex-mine workers were living with and providing for extended family members. This placed financial pressure as the overall household income was limited. In some instances, the ex-mine worker reported difficulties in community engagement due to their injuries.

Work: Most reported as being retired or unemployed. Those in rural areas reported subsistence farming as a key occupation but indicated their injuries made this challenging.

This is congruent with the findings from the focus group discussions in activity 2.

Participants also expressed the need to feel relevant in their roles and contribute towards sustaining their households.

3.2 Results of NIHL Screening Please see Appendix 8 – Tables and Analysis of NIHL Screening: There are two key findings from our initial phase describing the nature and severity of the hearing status of ex-mine workers: Hearing loss is a significant problem in this ex-mine worker population.

– As many as 94% are affected by hearing losses of varying degrees.

Most ex-mine workers’ hearing losses are highly likely due to noise exposure.

– 69.8% have signs of noise-induced hearing loss.

4 DISCUSSION 4.1 Key findings Disability Assessments A pattern emerged from the disability assessments relating to the need for equipment, rehabilitation and access to their environment, congruent with the findings from activity 2 questionnaires and focus groups.

Impairments mainly identified as pain, sensory and physical, impacted on the level of performance in their ADL’s. Of

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note, was a high incidence of those identified as requiring some sort of assessment for their hearing and vision.

The functional limitations identified fall in line with the categories from WHODAS 2.0 and are congruent with the findings from the questionnaires and focus groups in that access and ability to engage in daily task, often around sustaining themselves, is impaired.

Overall the findings would suggest that there is a need for access to ongoing or routine maintenance to maximise independence in daily tasks through ongoing rehabilitation, providing or updating equipment or general rehabilitation to reduce the impact of the impairment or disability in their ADL’s.

It is worth noting that a significant portion (49%) of the ex-mine workers assessed in the disability assessment, were RMA pensioners and thus received some home adaptations and equipment. However more could be done to ensure timely access and sustainability of service provision.

While an in-depth analysis and assessment of the financial position of the ex-mine worker’s household was not completed, the assessment tool identified that there were challenges relating to the financial sustainability of their households. In addition, ex-mine workers expressed that meaningful activities towards income generation and a feeling of purpose and role within the community be established.

NIHL Screening We can clearly state that significant numbers of ex-mine workers present with hearing loss, up to 94%. This figure is unusually high, almost 5 times more that the global average of 20% of the total population (WHO, 2012).

Hearing loss may occur naturally with age.

However, this may also be exacerbated by the workers’ hearing disability. Indeed,

94% of exminers suffer with hearing loss

most experience hearing losses that are between moderate and severe (28% to 40%). This pattern is unusually severe and highly prevalent. Normal aging results in various forms of (usually mild, perhaps moderate) hearing loss. That as many as 40% of these ex-mine workers suffer significant (disabling) hearing loss indicates contributing factors other than age.

Findings confirm that ex-mine workers were exposed to high levels of noise, without any protection.

It is therefore highly probable that their hearing loss is largely due to noise exposure in the mines and not just age related. This is supported with data that identified 111 out of 160 ex mine-workers with probable noise-induced hearing loss.

4.2 Challenges and opportunities Disability assessments need to be conducted within the context of environment. This meant that the project team had to assess at the ex-mine worker’s homes. Considering that the majority of those interviewed lived in rural areas, it was time-consuming to travel and find an ex-mine worker in rural Southern Africa which impacted on the number that could be completed.

One person’s disability cannot be compared to another’s disability based on the understanding that assessing disability must occur within the context of the physical and social environment. Hence the analysis could only be descriptive.

Identifying ex-mine workers for NIHL

Screening was challenging. In the absence of physical tracking, tracing or surveying all ex mine-workers, the location and number of which were unknown, we had to rely on known cohorts of ex-mine workers who either indicated that they had hearing difficulties, ear injuries or operated heavy machinery.

The absence of a baseline of the hearing ability of ex-mine workers poses a challenge in establishing noise-induced hearing loss, because of the multiple contributing factors.

Due to a dearth of available therapists across Southern Africa, sourcing therapists was challenging. The project team was unable to source audiologists in Mozambique and assessments were not completed in the Free State (South Africa).

Assessor bias may have influenced the outcome of the findings. Participants may have over exaggerated their disability. However, the use of qualified occupational therapists in the field of disability assessments are trained to identify if an activity performance is genuine.

There was not sufficient literature on the topic of injured ex-mine workers and the assessment of their disabilities. While there could be come correlations from the themes from the desktop review in Activity 1, it is important to note that this rapid assessment must be viewed as exploratory, producing new information relating to the topic.

Besides, the several logistical/practical

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Injuries of ex-mine workers need to be addressed holistically. It is more than just improving their mobility or independence in self-care. It is also about meaningful occupations that sustain their livelihoods.

ECF Recommendation

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implementation challenges and opportunities to consider, the one key challenge for aural rehabilitation is related to the issue of resources. Further hearing care management will be complicated by a lack of culturally and (this is vital) linguistically appropriate materials and service providers. This will require personnel like audiologists to incorporate a resource development phase prior to service delivery.

4.3 Recommendations Integrated, accessible and sustainable services across statutory, voluntary and private organisations is needed to deliver rehabilitation for ex-mine workers. The One-Stop Service Centres should be a single point of entry for injured exmine workers, operating as a referral hub, to access a raft of services and programmes to address the various needs identified for the ex-mine workers, including screening and onward referral to establish NIHL. In line with activity 2, it is recommended that an independent analysis and review of the 1-stop service centres be conducted to identify their scope and potential, making suggestions for how the above can be implemented.

In addition, a stakeholder event be planned to gather collective knowledge in an appreciative way for stakeholders to find solutions to moving services for ex-mine workers forward within an appreciative framework.

Programmes of sustainable livelihoods for ex-mine workers needs to be reinforced. It is recommended that

an independent review of existing community-private partnership models around sustainable livelihoods be undertaken to inform potential models that may suit the ex-mine worker populations and their communities.

Further testing to establish a clear diagnosis and pattern of individual’s hearing losses Provision of assistive listening devices, specifically hearing aids and consumables (mainly batteries) Provision of aural rehabilitation to manage difficult listening situations, to learn how to use the hearing aid/assistive listening device and maximise hearing functioning.

4.4 Concludions The impact of an injury on the ex-mine workers’ health and well-being cannot be considered only in terms of their ability to take care of themselves or mobilise within the context of the home environment.

Consideration must also be given to their meaningful engagement in activities that provide a sense of purpose, fulfilment, security and self-worth.

While there is a definite need for basic rehabilitation services within the community, the purpose of rehabilitation should be extended to ensure these ex-mine workers remain sustainable within in their communities as contributing members.

The hearing test results on this sample of ex-mine workers indicate that they have untreated hearing loss due to noise exposure in the mines. In order to redress this, the provision of hearing aids may not just restore hearing but be a form of restorative justice. Significantly, this technological solution (hearing aids) must be coupled with a focus on their lives as social and political citizens.

Therefore, comprehensive, planned aural rehabilitation must also be offered alongside hearing technologies for meaningful rehabilitation to occur.

activity 4 1 PURPOSE The purpose of this activity was to conduct a desktop review of literature in order to suggest a model for rehabilitation of injured ex-mine workers that is based on the findings of activity 2 and 3. The team employed two technical experts in the field of disability/rehabilitation and NIHL to assist in this activity. The primary objectives for this activity were: 1 To provide a comprehensive review of the literature relating to the topic and contextualise the setting in terms of rehabilitation in Southern Africa within 6 months.

2 To develop and explain a model for rehabilitation based on findings from the literature and activity 2 and 3 within 9 months.

3 To develop and explain a model for managing noise induced hearing loss for injured ex-mine workers based on the findings from the literature and activity 2 and 3 within 9 months.

2 METHODOLOGY

the issues facing ex-mine workers in terms of access to rehabilitation.

Step 3 Consultation with key informants and advocates within the field of disability and rehabilitation were conducted in order to understand contextual issues.

Step 4 Development of a model that considered principles identified from the literature and from engagement with relevant stakeholders.

Step 5 Exposure of the model to critique’ amongst public health and rehabilitation professionals.

2.2 Development of a Model for NIHL Data was collected mainly via an indepth literature review of published and unpublished (grey) literature using EBSCO host, Pubmed, Medline, Scopus and OVID. Search terms included noise, occupational hearing loss, noise induced, ear protective devices mining, sub-Saharan Africa, Lesotho, Mozambique, Swaziland, South Africa. Additionally, an expert reference interview was conducted with a notable expert researcher in the field of audiology.

04 ‘Disability needs to be appreciated within the context of the basic principles of human rights’ Enhanced Care Foundation

2.1 Development of a Model for Rehabilitation To develop a model that would be responsive to the needs of ex-mine workers in all four countries, the following steps were followed: Step 1 A scoping review of the literature served to assist in understanding disability and rehabilitation in the four countries. This was augmented by the desktop review from Activity 1. Data were collected mainly via an in-depth literature review of published and unpublished (grey) literature using EBSCO host, PubMed, Medline, Scopus and OVID. Step 2 Data from Activity 2 and 3 were reviewed towards an understanding of

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3 RESULTS 3.1 Rehabilitation Model for Ex-Mine Workers

figure 1 Proposed Rehabilitation Model

community rehabilitation (chc & phc Rehabilitation by trained mid-level healthcare workers in collaboration with community healthcare workers (CHWs). Training and monitoring occurs at the CHC and PHC level.

Rehabilitation services are offered at both community and hospital level.

Referral system between the two will ensure optimal care.

hospital (basic care) rehabilitation

Ex-mine worker should be able to access rehabilitation at hospital level and may be discharged directly from hospital level to home.

public health system

injured exmine worker

The ex-mine worker would access the public health system for all health related concerns including rehabilitation. He will enter the insured private health system for management of residual effects of the original injury sustained in the mine.

private health system

hospital (specialised care) rehabilitation

The ex-mine worker will have access to health care for the original injury sustained.

Access to assessment for noise induced hearing loss

home-based rehabilitation

one-stop service centre (monitoring & rehabilitation)

The right to equitable services for persons living with disabilities is supported by the four countries commitment to the UNCRPD and their various constitutions.

Notwithstanding this, the existence of policies does not always ensure effective implementation. The following three levels of care are thus incorporated into the model as ideal for rehabilitation for the ex-miner with a disability. The model incorporates the reality of ex-mine workers having to access both the private and public health system.

InstitutionBased Rehabilitation Within the model, it is envisaged that the client will be able to access institution-based rehabilitation (public or private; depending on the nature of the complaint) directly. There is also the possibility of referral between the CHC and PHC to the institution within the public sector. Referrals between these levels of care are essential in ensuring that the client receives the optimal rehabilitation and for carry-over into the home-setting. Most hospitals have a basic team of rehabilitation professionals, although a general shortage of health professionals has been noted in these countries. The issue around taskshifting and role sharing may be necessary in the care of these ex-mine workers that access the public health system.

“Mobility is often restricted by the uneven terrain. This makes accessing their outdoor toilets difficult and creates obstacles for the participants’, even if they have a wheelchair.”

ECF Finding

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Rehabilitation at Community Care and Primary Health Care Clinics (CHC & PHC) There is a global shortage of well-trained health workers, creating an essential need for sustainable development strategies for health systems. Key members at this level of care in these four countries may thus include either the presence of rehabilitation professionals and/or community healthcare workers that extend the services of the rehabilitation team. This level of service is included in the model within the public sector only.

CHWs are defined as “people chosen within a community to perform functions related to healthcare delivery, who have no formal professional training or degree”. CHWs screen, map, educate, link and extend PHC in the communities for which they are responsible and provide services to communities, families and individuals at community-based institutions or within their homes. This would be an integral level of care especially for those ex-mine workers that may not be able to easily access institution-based services.

Home Based Rehabilitation (HBR) HBR has a place in both the public and private referral process within the model. HBR has been shown to improve the quality of life including the physical and mental well-being of people living with a wide range of chronic diseases in resource rich settings. HBR forms a key component of a wider CBR approach and is also considered to be a particularly effective strategy in resource-poor settings where access to institution based rehabilitation is limited . In this model HBR falls within the domain of both the public and private service offerings.

TEBA and the national departments of health and social development are considered to be essential in the provision of services.

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We further plan to build two One Stop Centres in Lesotho, Mozambique and Swaziland respectively…these should be operational

by April 2017 and will greatly enhance service delivery for ex-mine workers.

figure2 Proposed Hearing Rehabilitation Model on-site/ mobile

hearing screening

G Oliphant, Deputy Minister of Mineral Resources, Department of Mineral Resources Annual Report 2015/2016, South Africa

3.2 Model for Hearing A basic profile of ex-mine workers’ hearing is first completed. Working on the assumption that ex-mine workers and/or their employers may not have records of their baseline hearing test especially if they left work in period between the mid-1990s until November 2003. Therefore, all exmine workers who have been identified/ self-report as eligible candidates will be screened after a 16 hour noise free period.

This is to prevent a temporary hearing threshold shift from occurring due to exposure to e.g., recreational noise (like music) or noise from home environments.

Typically, adult screening for occupational/ noise-induced hearing loss consists of a case history, physical evaluation of the ear and auditory or hearing screening, which are recommended for this screening activity for ex-mine workers, with modifications suitable to the context and population. If the candidates pass this screening, then they should still be eligible for a re-screening every six months so as to monitor their hearing as part of their being a high risk group with a history of noise (and/or ototoxic chemical) exposures in the workplace. Given that old (baseline, periodic and/or exit audiograms) may not be readily available, all those failing the screening test will be referred for a full diagnostic audiological assessment.

However, if audiograms are available (older baseline and especially exit audiograms)

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then the current screening test results must be compared to the previous results to ascertain if their hearing has deteriorated by 10% (or more) which will make them eligible for a full diagnostic audiological assessment.

Education should be provided to the candidate about the broader issues pertaining to this intervention, procedures/ process of hearing screening, whether there is a risk of their having a hearing disorder, follow-up procedures and the difference between screening and assessment/diagnostic audiology, all in accessible language(s). Critically, once the screening activity is connected to the intervention/follow up medical and audiological management of ex-workers’ hearing, it is not possible to offer all services at the same time. However, aspects of medical and audiological management will be offered insofar as is possible toward the one-stop service centre framework.

The screening service is connected to follow up medical and audiological intervention, of which there are two streams, viz. (a) a fast track dubbed the FITT track, or the fast, important, treatment and therapeutic [FITT] track and the (b) extended auditory rehabilitation [EAR] track.

on-site/ mobile

fast important treatment & theraputics (FITT) track

medical management (primary) (cerumen, foreign bodies, etc.)

case history

pass Re-screening and monitor every 6 months

physical evaluation outer, middle ear

on-site/ mobile/ tele-rehab (blended)

extended auditory rehabilitation (ear) track

medical management (advanced) (ENT: perforations, infections, impacted wax, etc.)

fail auditory (hearing) screening

audiological management (primary)

Pure tone air conduction

Assessment & Primary Management of Hearing Disability

education (legal, procedural)

Prescription: Assistive Listening Devices (ALDs), Hearing Aids

audiological management (advanced) Diagnostic Audiology (tinnitus, auditory processing, etc) ALD Evaluation & Fitting aural rehabilitation Hearing/communication intervention, psycho-social, educational and vocational management quarterly review One year post fitting

4 DISCUSSION 4.1 Unpacking the Rehabilitation Model for Ex Mine Workers Within the context of mineworkers who leave the health system of the mines and who enter the public health domain, a number of essential principles, that are transferable to all persons with disabilities living in these contexts, are necessary to ensure optimal quality of life. Congruent with this, there is this expectation that key stakeholders that have been identified within the mining and health sector,

including governments, civil society organizations and disabled peoples organizations, will have to work towards the creation of enabling environments and rehabilitation and support services for persons living with disabilities, based on steps outlined in the World Report on Disability. Likewise, the paradigmshift from a biomedical model towards a biopsychosocial model of care obliges rehabilitation professionals to holistically address barriers to rehabilitation of these ex-mineworkers in their restitution to care.

As such, the model that is proposed for ex-

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‘Inclusion of persons with disabilities requires a multifaceted response to counter issues around inequality and discrimination’ ECF Recommendation mine workers would need to address this dynamism towards integrated patient-care.

Moreover, given that disability needs to be appreciated within the context of the basic principles of human rights, due cognizance of community based rehabilitation and primary health care (PHC) becomes essential. Fortunately PHC shares with CBR the principles of human rights, equity and participatory development.

In incorporating CBR, one moves away from an individual approach focusing on rehabilitation to a more participatory and social approach in which persons with disabilities are seen as contributing members of a community with equal rights. Based on this, the individual and the relationships with stakeholders are essential in the model. The model assumes that the ex-mine worker living with a disability will enact his right to health at a

micro level where his specific community interfaces with the health and other systems. Defining the specific communities and key stakeholders in each of the four countries is essential in determining the interactions that would assist in the provision of integrated services to the exminer with a disability.

Inclusion of persons with disabilities requires a multifaceted response to counter issues around inequality and discrimination. This includes the broader context and an appreciation and understanding of the unique barriers that persons with disabilities experience across all sectors . Disability-inclusive development appears to still be novel in some contexts. Consequently, regional, national, and/or organisational strategies to improve disability inclusion is a necessary first step in including all sectors.

4.2 Unpacking the Hearing Rehabilitation Model All ex-mine workers who fail the screening will be managed via the FITT and/or EAR track for both their medical and audiological needs. Notably, the FITT track must occur alongside the screening programme as part of the attempt to deliver a one-stop service. Diagnostic audiometry must be performed by an audiologist/ medical specialist (ENT) and the ex-mine workers must not have been exposed 85 dBA in the preceding 16 hours (which excludes the use of earplugs/other HPDs).

The FITT track is focussed the goal of building up toward a clear diagnosis of NIHL as well as providing quality, basic medical and audiological services. While primary medical services may seem irregular given when the hearing loss may have occurred and its chronic nature, it is critical toward the goal of differentially diagnosing NIHL. Therefore, the nature of these services include the management of especially outer and middle ear medical issues that may stop someone from

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703

questionnaires were completed across 4 countries

progressing to the hearing screening and/or diagnostic audiology.

Additionally, workers (who fail the screening) will receive a primary (diagnostic) hearing assessment. It is suggested that the hearing assessment be completed with a mobile, diagnostic audiometer, the South African designed KuduWave audiometer. This automatic audiometer uses circumaural earcups over insert earphones, the audiometer hardware is contained within the earcups and connected to computer via a USB cable. Electronic patient response buttons are connected to the device so that the participants could indicate when they hear the presented tone. Importantly, the KuduWave design allows for testing to be completed without the need for a sound proof booth. Most of the primary audiological assessment may be completed with good success including pure tone (air/ bone conduction) audiometry, impedance audiometry, and related special tests for cochlear/retro-cochlear assessments.

Speech audiometry, while traditionally part of the conventional test battery will be a challenge to do given that there are no reliable/valid speech audiometry test materials in most of the target African languages (including Black South African languages) and requires a test environment (sound proof booths). However, it is anticipated that an adapted procedure involving the use of numbers/digits as

speech stimuli may be used, failing which this aspect is included in the EAR track which includes more advanced audiology assessments.

In addition, primary management of hearing disability strategies may be offered, and include teaching listening strategies, basic speech reading and aspects of auditory training. At this point it may also be possible to screen candidates’ eligibility for assistive listening devices [ALDs], more especially hearing aids.

Within the EAR track, the extended aural rehabilitation is the focus. Failure to provide rehabilitation or to merely (medically) manage the ex-mine worker’s ears does not constitute effective management of the person’s ability to live with his/her disability.

Therefore, advanced medical management will be provided so as to rule out and/ or manage outer/middle ear illnesses and essentially provide a ‘clear’ basis for the diagnosis and rehabilitation of NIHL. Critically, it is the diagnostic audiology component that will describe the nature of the person’s impairment and disability.

This is why advanced diagnostic testing (including specialised tests to diagnose tinnitus, auditory processing, etc.) is necessary. This testing may occur off-site at specialised facilities and/or via mobile or use of telehealth/telemedicine methods.

Importantly, aural rehabilitation, the ‘true’ goal of this entire exercise, should be provided as per need and may focus

It is essential to recognise: “the importance of accessibility to the physical, social, economic and cultural environment, to health and education and to information and communication, in enabling these persons with disabilities to fully enjoy all human rights and fundamental freedoms”.

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on minimizing NIHL deficits of function, activity, and participation. The focus on ex-mine worker’s quality of life is what this component of aural rehabilitation is about.

The following is suggested: sensory management to optimize auditory function, instruction in the use of technology and control of the listening environment, perceptual training to improve speech perception and communication, and counselling to enhance participation, and deal both emotionally and practically with residual limitations Aural rehabilitation must connect with the UN’s Sustainable Development Goals and work toward re-engagement of the person, especially as an economically active citizen. For a hearing impaired/deaf adult this requires auditory rehabilitation for vocational/occupational purposes and is about developing, (within the EAR track) a holistic citizen. This means that in order to develop a rehabilitation programme focussed on ‘sustainability’, aural rehabilitation must privilege the development of not just, for example, ‘sensory management’ or ‘perceptual training’ skills. Instead, we need to ask: What are these skills for? In answering this

question we need to address how we work meaningfully to develop these skills so that ex-mine workers’ communication results in ability to continue to learn, to work and to participate actively in their societies.

These forms of lifelong learning, labour/ vocational and social (re)integration is what is meant by the development of a holistic citizen. But how will these services be provided? Technically, services may be provided via various face-to face models and/or peripatetic, mobile or tele-medicine/ tele-rehabilitation formats.

While issues of service accessibility exist, what is critical to consider is who will deliver aural rehabilitation to a multilingual, multicultural population of ex-mine workers.

Rehabilitation services requires specific and specialised practices, resource availability, effective outcomes and measures of these outcomes amongst other critical social, cultural and economic development goals. These need to be embedded in a policy so that there are clear descriptions of what constitutes effective interventions for change. This is critical as not doing so will result in the provision of services at the micro level without sufficient design, monitoring and evaluation of their efficacy.

“Defining specific communities and stakeholders in each of the four countries is essential in determining whats needed for an ex-miner with a disability.”

5 RECOMMENDATIONS In order for the model of rehabilitative care for ex-mine workers to be implemented effectively, the following fundamental principles and values are considered necessary: A focus on health and rehabilitation provision and continuity of care at all levels of service provision – Improved accessibility for ex-mine workers to health services including rehabilitation – Appropriate and relevant service provision for ex-mine workers – Integrated service provision including community, primary health care and home based rehabilitation – Appropriate referral pathways between stakeholders towards co-ordinated care – Co-ordinated care pathways for exminers living with disability – Inclusion of vocational rehabilitation that is aligned to creating opportunities for reintegration, realignment and reskilling of mine workers Inter-sectoral collaboration between key stakeholders in order to strengthen service delivery for ex-mine workers – Effective communication between stakeholders involved in the care of ex-mine workers

Empowerment of the ex-mine workers with disability towards social inclusion and community participation – Inclusion of the voices of the disabled mine-workers and ground-workers as key informants – Creating awareness of the rights of ex-mine workers through education and empowerment drives on compensation and access to health services – Reskilling of mine workers prior to exit from the mining industry towards social justice – Provision of opportunities for sustaining livelihoods through community-private partnerships

6 CONCLUSION The current strengths of the models are that they are aligned to current systems that exist in the four countries, however generic in terms of the health systems and contextual factors within the four countries.

Opportunities that exist are potential social justice initiatives in sustaining livelihoods within the rehabilitation model with community-private partnerships.

ECF Finding

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05

appendix 1 A RAPID ASSESSMENT OF THE DISABILITY AND REHABILITATION OF EX-MINE WORKERS LIVING IN FOUR COUNTRIES IN SOUTHERN AFRICA: LESOTHO, MOZAMBIQUE, SOUTH AFRICA AND SWAZILAND Disability and Rehabilitation: A Desktop Review Introduction The Southern African region is the main producer of five major minerals namely diamonds, gold and platinum metals, chromium, cobalt, as well as one of three major producing regions of semi-precious stones (Granville, 2001). Mining has played a vital role in the economy of South Africa for over 100 years. According to the Department of Mineral and Resources annual report 2015-2016, the mining industry contributed R262 billion or 8% of the GDP in 2015. Mining is a significant contributor to employment in South Africa. In 2015, 457 698 individuals were employed by the sector, with each employee supporting four to five dependents (Mine SA Facts and Figures Pocketbook, 2016).

Historically, the South African mines additionally employed migrant workers from Lesotho; Mozambique, and Swaziland (Rees et al, 2010), hence a rapid analysis of ex-miner from SA mines would highlight the plight of ex-mineworkers from SA, Lesotho; Mozambique, and Swaziland.

South Africaâ&#x20AC;&#x2122;s Mine Health and Safety Act (MHSA) was introduced in 1996 to enhance safety and health. This Act considers unions, government and the mine owners to be joint stakeholders responsible for promoting a safe and healthy workplace within the mining industry. The Department of Mineral Resources (DMR) established the Mine Health and Safety Inspectorate to implement the directives of the Mine Health and Safety Act and ensure the regulation of health and safety for mine employees as well as residents of areas affected by mining operations (Chamber of Mines, 2016). The Chief Inspector of Mines has extensive authority, and may impose directives to prohibit certain work in certain areas, and/or activities. Since 1993, the annual number of fatalities has reduced from 615 to 73 in 2016. The reduction in fatalities has been attributed the safety initiatives adopted by the mining industry, Department of Mineral Resources and by the Chamber of mines under the directives from the Mine Health and Safety Council (MHSC). The Chamber of Mines of South Africa is a mining industry employersâ&#x20AC;&#x2122; organisation that supports and advocates for the South African mining industry. The organisations main function is to facilitate interaction among mining employers, to examine policy issues and communicate industry viewpoints.

Aim The aim of the integrative review was to explore the literature and policy information related to ex-mine workers. Specifically, to describe the context of the ex-mine workers from Lesotho; Mozambique, South Africa and Swaziland who were injured while working on the mines in South Africa and their resultant disabilities and the opportunities available for rehabilitation.

Methodology This review followed four steps as per Whittemore and Knaf (2005), namely conducting a literature search, data evaluation, data analysis, and presentation of themes. See Figure 1 Literature search: A search of, PubMed, EBSCOhost, and Google Scholar was conducted using the key words: Southern Africa, ex- mineworkers, disability, Injury, rehabilitation, chamber of mines, and policy on rehabilitation.

The inclusion criteria for electronic records included dissertations, primary source and peer review articles; records on miners on government sites. The review included literature from 1996 to 2017. Peer reviewed records were targeted to ensure the integrity of findings because they already have a level of scrutiny. Reports were excluded if the aim of the report was on illness rather than injury or disability. The review also included a search of grey literature and extensive consultation to identify relevant documents. Key policies, project reports, and progress reports regarding ex-miners were also reviewed.

Data evaluation: Titles of the paper used to select literature. The abstracts of the selected titles were then analysed to assess their relevance to the aim of the review. All records that addressed ex-miners or rehabilitation or context of disability were eligible for a full text review. A review of relevant bibliographies from the identified literature was conducted to further search for data.

Data analysis: Extracted data using a data extraction sheet and coded. Similar data was categorized and grouped together. An iterative process of examining data displays was adopted to obtain the themes. Conclusions were then drawn from the data.

Despite the statistics being evident of fatalities and number of injuries being published, there is limited data on the types of injuries experienced by current and ex-mine workers.

To understand the context of the ex-mine workers from Lesotho; Mozambique, South Africa and Swaziland who were injured while working on the mines in South Africa there was a need to explore the literature related and their resultant disabilities and the opportunities available for rehabilitation.

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figure 1 Desktop Review Process

identification

Records identified through database searching (n=153)

figure 2 Overview of Themes emerging from the Literature Additional records identified through other sources (n=0)

Records after duplicates identified (n= 153)

screening

eligibility

records screened (n= 153)

records excluded (n= 60)

Full-text articles assessed for eligibility (n=93)

Full-text articles excluded (n=30)

Studies included in synthesis (n =63)

included

Compensation (6) Context of PWDs (11) Occupational Health and Injuries (18) Policies (10) Rehabilitation (18)

Injuries resulting from working in the mine Policies related to rehabilitation & mine workers

Access to rehabilitation with SubSaharan Africa

Experiences of person with disabilities within the Southern African context

Issues surrounding compensation & social protection

Findings and Discussion There were five main themes that emerged from the literature namely policies related to rehabilitation and mine workers, injuries resulting from working in the mine, experiences of person with disabilities within the Southern African context, issues surrounding compensation and access to rehabilitation with Sub-Saharan Africa. See figure 2 for overview of the themes.

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Table 1 Policies related to Rehabilitation and Mine Workers data

contribution

Disability Policy Audit in Namibia, Swaziland, Malawi and Mozambique Final report, 2008 National disability and rehabilitation policy Lesotho, 2011 Resolution no 20/1999 of 23 June 1999 Disability Policy, Mozambique National Disability Policy, Swaziland Integrated National Disability Strategy South Africa, 1997 National Rehabilitation Policy South Africa, 2000 Framework and Strategy for Disability and Rehabilitation Services in South Africa, 2015-2020 Leshota, L. P, 2013. Reading the National Disability and Rehabilitation Policy in the light of Foucault’s technologies of power: original research.

Lord, J., & Stein, M. A, 2013, Prospects and practices for CRPD implementation in Africa.

Constitution of Lesotho, Mozambique and Swaziland and the South African Bill of Rights Dayal, H. Institutional analysis of South African Health to deliver Rehabilitation services, Public Health Association of South Africa.

Mine Health and Safety act, 1996

South Africa, Lesotho, Mozambique and Swaziland are signatories on the United Nations Convention of Rights of Persons with Disabilities and have protection of the rights of PWD in their constitution.

The policies, the articles in their respective constitutions and through the countries signing of the UNCRPD, the above-mentioned countries make provision for protection of the rights of people with disability and aim to provide persons with disability access to healthcare and rehabilitation services.

Despite the evidence intent to provide persons with disabilities and access to rehabilitation, there appears to be a gap between the conceptualisation and implementation of the policies from the abovementioned countries.

Only South Africa has a mining health and safety act, whereas the other countries have mining acts which does not deal with the rights of injured miners.

Table 2 Policies related to Rehabilitation and Mine Workers data

contribution

Booyens, M., Van Pletzen, E., & Lorenzo, T. 2015. The complexity of rural contexts experienced by community disability workers in three southern African countries: original research.

Duncan, E. M., & Watson, R. 2009. The occupational dimensions of poverty and disability.

Loeb, et al 2008. Poverty and disability in eastern and western cape provinces, South Africa.

Kamaleri, Y and Eida, A. 2011. Living conditions amongst person with disability in Lesotho Chitereka, C. People with disability and the role of social worker in Lesotho Naidoo, D., Van Wyk. J and Joubert, J. 2017. Community stakeholders’ perspective on the role of occupational therapy in primary healthcare: implications for practice Graham, L et al, 2014. Poverty And Disability In South Africa Research Report Duncan, M., et al 2 012, ‘Rurality, poverty and disability: Strategies for community led action towards poverty alleviation and social inclusion’, Jelsma, J., 2007, ‘The determinants of health-related quality of life in urban and rural isiXhosa speaking people with disabilities,’ Neille, J. & Penn, C.., 2015, ‘The interface between violence, disability, and poverty stories from a developing country’, J Mitra, S.et al 2011. Disability and Poverty in Developing Countries: A Snapshot from the World Health Survey

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National census provides data on the prevalence of disability in South Africa , Lesotho, Mozambique and Swaziland. In 2009, 3,7% of the Lesotho population had disability with 2,5% of the Mozambique population indicting that they experienced some form of disability in the 2007 census. South Africa reported 5,2% of the population voiced having a disability in the 2011 census while Swaziland has the highest reported population with disability i.e: 16,2%. No explanation of the variance the number of person’s with disability was given in the literature.

Table 3 Injuries resulting from working in the mine data Lee, D et al, 2012. Morbidity and disability among workers 18 years and older in the Mining sector, 1997–2007.

Bambas-Nolen, L. et al, 2013. Case study on extractive industries prepared for Lancet Commission on Global Governance.

Chimamise, C. et al. 2013. Factors associated with severe occupational injuries at a mining company in Zimbabwe, 2010: a cross sectional study Zungu, L. I. (2013). Prevalence of post-traumatic stress disorder in the South African mining industry and outcomes of liability claims submitted to Rand Mutual Assurance Company.

Stojadinovi, S.et al. 2012. Mining injuries in Serbian underground coal mines–a 10-year study Chan, E. Y., & Griffiths, S. M. 2010. The epidemiology of mine accidents in China. T Hermanus, M. A. (2007). Occupational health and safety in mining-status, new developments, and concerns.

Dias, B. 2014. Musculoskeletal Disorders in the South African Mining Industry Smith, S. 2013. Injuries, illnesses, and fatal injuries in mining in 2010 Kyeremateng-Amoah, E., & Clarke, E. 2015. Injuries among artisanal and small-scale gold miners in Ghana.

Chamber of mines Integrated annual review 2015 Donoghue, A. M. (2004). Occupational health hazards in mining: an overview.

Hofmann, T and Kielblock, J. The assessment of functional work capacity in SA mining industry Edwards, A. L., & Kritzingert, D. (2012). Noise-induced hearing loss milestones: past and future.

Strauss, S. (2014). Technical Briefs. Journal of Audiology, 53(S2), S75.

Jeebhay, M., & Jacobs, B. (1999). Occupational health services in South Africa.

Kusena, W. 2014. Occupational hazards, injuries and illnesses associated with small-scale gold mining: case of Ward 19, Zvishavane, Zimbabwe.

Department of Mineral and Energy South African Statistics 2003 -2013

contribution There was a paucity of literature on specific injures that mineworkers in Southern Africa experience. Most mention physical injuries but do not mention specific diagnosis and occupational illness is more thoroughly explored.

In the United states, an estimated 22.2% of Mining sector workers reported some degree of hearing impairment, 4.7% some degree of visual impairment and 23.0% reported experiencing functional limitations. The functional limitations related to limited mobility and ability to return to the physical demands of the job. There was no mention of specific physical or mental injuries/diseases.

In Zimbabwe, miners reported injuries on the arms, leg, head and the trunk. This concurred with the experience of the Serbian miners who injuries their upper limb due to machinery and lower limbs due to stepping or kneeling on objects. Additionally, there are head injuries due to falling objects and back injuries due to heavy lifting that is part of the job requirements. This resonate with finding from South Africa, which indicate that back and lower limb injuries are most common musculoskeletal injuries.

In Ghana and Zimbabwe miners who worked in small gold mines reported spinal cord injuries, fractures, crush injuries, lacerations and punctures In South Africa, falling of ground, transport incidents, and general mining accidents (inhaling dangerous fumes, being struck by an object and falling from height) and general conveyance accidents result in most of the injuries reported. Falls of ground is a term describing unexpected movement of rock mass and gravity and/or pressure, strain or rock bursts which results in uncontrolled release of rock as a result.

Only two studies one in South Africa and one in china highlight the psychological trauma experienced by miners, which includes PTSD.

Literature showed evidence of strong links between disability, poverty and physical contextual. These factors negatively impact on the person with a disability’s engagement in daily life task and further compound the exclusion from social and economic opportunities and their increased risk of contracting non-communicable diseases.

PWDs are also more vulnerable to physical, sexual and psychological abuse, and they are often easily exploited. Social marginalisation, material deprivation added to limited access to education and infrastructural challenges such as poor roads, costly transport, inaccessible terrains and poor access to health services contribute towards the marginalisation and the challenges faced by persons with disability when attempting to integrate into the community.

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Table 4 Access to rehabilitation and services offered within Sub-Saharan Africa

Table 3 Issues surrounding compensation and social protection data

data

contribution

Kahonde, C.K., Mlenzana, N. & Rhoda, A., 2010, ‘Persons with physical disabilities’ experiences of rehabilitation services at Community Health Centres in Cape Town’.

Dayal, H. 2010. Provision of rehabilitation services within the District Health System-the experience of rehabilitation managers in facilitating this right for people with disabilities Grut, L., et al. 2012. ‘Accessing community health services: challenges faced by poor people with disabilities in a rural community in South Africa’ Rule, S., et al. (2006). Community-based rehabilitation: new challenges Haig, A. J. et al. 2009. The practice of physical and rehabilitation medicine in sub-Saharan Africa and Antarctica: a white paper or a black mark?

Luruli, R. E., et al. 2016. An improved model for provision of rural community-based health rehabilitation services in Vhembe District, Limpopo Province of South Africa Chappell, P., & Johannsmeier, C. 2009. The impact of community based rehabilitation as implemented by community rehabilitation facilitators on people with disabilities, their families and communities within South Africa.

Naidoo, D., Van Wyk. J and Joubert, J. 2017. Community stakeholders’ perspective on the role of occupational therapy in primary healthcare: implications for practice Sherry, K. 2015. Disability and rehabilitation: essential considerations for equitable, accessible and poverty-reducing health care in South Africa.

Mitra, S.; Posarac, A. and Vick, B. 2011. Disability and Poverty in Developing Countries: A Snapshot from the World Health Survey.

Visagie, S., & Swartz, L. 2016. Rural South Africans’ rehabilitation experiences: case studies from the Northern Cape Province: original research.

Naidoo, D., Van Wyk, J., & Joubert, R. W. 2016. Exploring the occupational therapist’s role in primary health care: Listening to voices of stakeholders.

Wegner, L., & Rhoda, A. (2015). The influence of cultural beliefs on the utilisation of rehabilitation services in a rural South African context: therapists’ perspective: original research.

Brooke-Sumner, C. et al. 2016. Bridging the gap: investigating challenges and way forward for intersectoral provision of psychosocial rehabilitation in South Africa.

Maja, P. A.et al. 2011. Employing people with disabilities in South Africa.

Mclean, K. N. 2012. Mental health and well‐being in resident mine workers: Out of the fly‐in fly‐out box.

World health organisation Concept Paper: Guidelines on HealthRelated Rehabilitation (Rehabilitation Guidelines) Gretschel, D. (2016). Levels of community integration achieved by adults with disabilities post discharge from a specialised in-patient rehabilitation unit in the Western Cape Coetzee, Z. et al. 2011. Re-conceptualising vocational rehabilitation services towards an inter-sectoral model.

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The data yielded was mainly from South Africa, with only three papers from other regions.

Despite having primary health care clinics in South Africa, people with a disability still have difficult accessing rehabilitation services. Furthermore, there are considerable challenges posed by the services currently offered such as lack of communication between service-providers and lack of intersectoral partnership between various government sectors such as department of health, department of labour and non-governmental organisations.

The data suggests that there is a need to have intersectoral collaboration, teamwork between health professionals, good communication and consultation with the community regrading services required to ensure that rehabilitation service delivery meets needs of the community. Additionally people with disability should be empowered and aware of their rights in terms of their countries respective constitution and policies. Heath professionals need to take into account the person with a disabilities history and current resources when planning intervention.

There is a need to have a stronger focus on community-based rehabilitation, primary health care and services delivered in the community and an improvement in the referral system to ensure patients are not lost in the system. Also for sustainable rehabilitation service delivery, there needs to be more collaboration between health-professionals and community based workers/community rehabilitation facilitators. These mid-level workers need more support and training to allow for efficient service delivery.

Suggested rehabilitation services included provision of assistive devices (not only mobility related ones), a focus on improving independence with daily living tasks, offering primary, secondary and tertiary prevention, focusing on community re-integration and vocational rehabilitation.

The data suggested a need to review vocational rehabilitation services. Focusing on vocational rehabilitation services as a health problem posed a barrier and one author suggested that it needs a intersectoral approach between department of labour, department of health, department of social welfare and education. Community members suggested that therapists should focus on income – generation projects. Others reported the need for return to work programmes, prevocational services, the need to follow –up when placed back at work and assistance with reducing the stigma of working with a disabled person.

Finally, the need to address mental health and well-being of miners arose. There was a need to have services that address post-traumatic stress disorders.

Ehrilich, R. A century of Miners Compensation in South Africa Compensation and other social protection benefits for workers and ex-workers in the mining sector, Department of Labour, 2014.

Portability and access of social security benefits by former mine worker, 2014, South African Trust and Ford Foundation Mpedi, G and Nyenti, M. Challenges experienced by former mineworkers in accessing social security in SADC Zvidzayi, T. Compliance with international standards on compensation for occupational injuries and diseases by Zimbabwe and South Africa, 2015 Tlhaole, T. Social protection arrangements for retired mineworkers with physical disabilities in Maseru urban, Lesotho, 2011.

contribution Literature emerged mainly from South Africa and Lesotho. Despite a system being in place, the current compensation system in south Africa does not appear to be efficiently serving its intended beneficiaries within the mining industry.

Some of the challenges include having difficulty accessing professional occupational health services and certification, submitting the cumbersome documents required for social security benefits, lack of understand/clarity on method used to calculate disability benefits and a weak SADC regional framework.

Tlhaole (2011) study illustrated that ex-miners in Lesotho were paid after delays of between three to 18 years. However, the stipend was insufficient for the ex-miner to sustain basic daily requirements such as purchasing fuel for fire and food hence ex-miners were living below the poverty line. This impacts injured ex-mine workers too.

This integrative review has attempted to synthesize literature and policy information related to ex-mine workers, their resultant disabilities and the opportunities available for rehabilitation.

The findings revealed that despite policy being in place in most of the countries, there is a lack of enactment of the policies that should be safeguarding the rights of persons with disability and ensure that they have access to rehabilitation and health promotion services.

The high prevalence of disability in South Africa, Lesotho, Mozambique and Swaziland indicate a need for effective rehabilitation services. Additionally, the concomitant effects of poverty need to be taken into account. Poverty together with having a disability and facing physical barriers in the community negatively effect on the person with a disability’s ability to engage in daily life tasks and further compounds the exclusion from social and economic opportunities and increase this vulnerable population’s risk of contracting noncommunicable diseases.

There was a paucity of literature on specific injures that mineworkers in southern Africa experience. The literature indicate that hearing impairments (Noise induced hearing loss) , visual impairments, injuries on the arms, leg, head and the trunk as well as spinal cord injuries, fractures, crush injuries, lacerations and punctures were more common injuries. The causes for the injuries ranged from falling objects, injuries due to conveyer belt dysfunction, heavy lifting to falling of ground, transport incidents, and general mining accidents (inhaling dangerous fumes. Falls of ground being the term describing unexpected movement of rock mass and gravity and/or pressure, strain or rock burst which results in uncontrolled release of rock. There is evidence that miners’ mental well- being need to be addressed especially as they are at risk for post-traumatic stress disorder.

There was a paucity of literature on rehabilitation services in Africa. Majority of the literature was South African based. It was evident that people with a disability still have difficulty accessing rehabilitation services. Furthermore, there are considerable challenges posed by the services currently offered such as lack of communication between service-

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providers and lack of intersectoral partnership between various government sectors such as department of health, department of labour and non-governmental organisations.

People with disability should be empowered and aware of their rights in terms of their countries respective constitution and policies. There is a need to have a stronger focus on community-based rehabilitation, primary health care and services delivered in the community and an improvement in the referral system to ensure patients are not lost in the system. Also for sustainable rehabilitation service delivery, there needs to be more collaboration between health-professionals and community based workers/community.

Suggested rehabilitation services included provision of assistive devices (not only mobility related ones), a focus on improving independence with daily living tasks, offering primary, secondary and tertiary prevention, focusing on community re-integration and vocational rehabilitation.

Finally, this review revealed that the current compensation system does not appear to be efficiently serving its intended beneficiaries within the mining industry. Some of the challenges include having difficulty accessing professional occupational health services and certification, submitting the cumbersome documents required for social security benefits, lack of understand/clarity on method used to calculate disability benefits and a weak regional framework to ensure that miners from Lesotho, Mozambique and Swaziland receive their payments. There are significant delays experienced in receiving benefits and often the stipend received was insufficient for the ex-miner to sustain basic daily requirements such as purchasing fuel for fire and food hence ex-miners were living below the poverty line.

Conclusion The review of the literature strongly suggests that there is a need to review how miners’ injuries are documented to ensure that there is sufficient awareness of the types of injuries. Additionally, there is a need to review the rehabilitation and compensation strategies currently used to deliver a service to the miners. There is a need to for intersectoral collaboration and development of a sustainable referral and rehabilitation service that meets the needs of the ex- miners. There is also a need for further research into current rehabilitation services offered in Lesotho, Mozambique and Swaziland.

References Granville, A. (2001). Baseline Survey of the Mining and Minerals Sector; Mining, Materials and Sustainable Development report. Last accessed April 22, 2005 at: http://www. mining.wits.ac.za.

Whittemore R, Knafl, K. (2005).The integrative review: updated methodology. Journal of advanced Nursing 52(5); 546-553.

Chamber of mines of South Africa. (2016) Safety in Mining Fact sheet 2016 Chamber of mines of South Africa. (2016)Mine SA 2016 Facts And Figures pocketbook.

Rees, D., Murray, J., Nelson, G., & Sonnenberg, P. (2010). Oscillating migration and the epidemics of silicosis, tuberculosis, and HIV infection in South African gold miners.

American journal of industrial medicine, 53(4), 398-404.

Mendis, P. ; Kachingwe, A., Khabale, I.K.,( 2009) Report: Evaluation of support to CBR programme in Lesotho, Norwegain Association of Disabled.

I Shale ‘Country report: Lesotho’ (2015) 3 African Disability Rights Yearbook 183-202 http://dx.doi.org/10.17159/2413-7138/2015/v3n1a8

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ECU Lopes ‘Country Report: Mozambique” (2013). 1 African Disability Rights Yearbook (2013) 245-260 http://www.adry.up.ac.za/index.php/2013-1-section-b-country-reports/ mozambique I Grobbelaar-du Plessis and C Grobler.(2013) African Disability Rights Yearbook: 307-340 http://www.adry.up.ac.za/index.php/2013-1-section-b-country-reports/south-africa SD Mavundla ‘Country report: Swaziland’ (2015) 3 African Disability Rights Yearbook 245264 http://dx.doi.org/10.17159/2413-7138/2015/v3n1a11 Lesotho Bureau of Statistics. (2006) http://www.bos.gov.ls/ Instituto Nacional De Estatistica (INE) (2007). Census 2007. http://www.ine.gov.mz/ operacoes-estatisticas/censos/censo-2007/rgph-2007/indicadores-socio-demograficosprovincia-de-gaza-2007.pdf/ Statistics South Africa. Census (2011). http://www.statssa.gov.za/Publications/P03014/ P030142011.pdf Swaziland Central Statistical Office Population and housing Survey (2007) Lord, J., & Stein, M. A. (2013). Prospects and practices for CRPD implementation in Africa. Afr. Disability Rts. YB, 1, 97.

Leshota, L. P. (2013). Reading the National Disability and Rehabilitation Policy in the light of Foucault’s technologies of power: original research. African Journal of Disability, 2(1), 1-7.

Department of Mineral and Resources (1996) Mine health and safety Act 1996, Act 29 of 1996. Pretoria Department of Labour (2014). Compensation and other social protection benefits for workers and ex-workers in the mining sector, Johannesburg.

South African Trust and Ford Foundation (2014) Portability and access of social security benefits by former mine worker, Pretoria Ehrlich, R. (2012). A century of miners’ compensation in South Africa. American journal of industrial medicine, 55(6), 560-569.

Zvidzayi, T. (2015). Compliance with international standards on compensation for occupational injuries and diseases by Zimbabwe and South Africa (Doctoral dissertation, University of the Western Cape).

Mpedi, G and Nyenti, M. (2014) Challenges experienced by former mine-workers in accessing social security in SADC. Retrieved from http://www.saspen.org/conferences/ FES-ILO-employment-injury-2014/PPT-Mpedi-Nyenti-Mineworkers_ILO-FES-Workshop_ Employement-Injury-Protection-Eastern-and-Southern-Africa_Harare_20-21-Oct-2014. pdf South African Trust and Ford Foundation (2014) .Portability and access of social security benefits by former mine worker, Johannesburg. Retrieved from http://www. southernafricatrust.org/wp-content/uploads/2015/05/the-portability-and-access-ofsocial-security-benefits-for-mine-workers-in-southern-africa.pdf Tlhaole, T. (2011). Social Protection Arrangements for Retired Mineworkers with Physical Disabilities in Maseru Urban, Lesotho (Doctoral dissertation, University of Witwatersrand).

Booyens, M., Van Pletzen, E., & Lorenzo, T. (2015). The complexity of rural contexts experienced by community disability workers in three southern African countries: original research. African Journal of Disability, 4(1), 1-9.

Duncan, E. M., & Watson, R. (2009). The occupational dimensions of poverty and disability. Institute for Land and Agrarian Studies (PLAAS). University of the Western Cape Loeb, M., Eide, A. H., Jelsma, J., Toni, M. K., & Maart, S. (2008). Poverty and disability in eastern and western cape provinces, South Africa. Disability & Society, 23(4), 311-321.

APPENDIx 1

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Kamaleri, Y and Eide, A.(2016)Living Conditions among People with Disabilities in Lesotho A National Representative Study SINTEF Technology and Society Global Health and Welfare , NORAD..Retrieved from http://www.washingtongroup-disability.com/wpcontent/uploads/2016/03/Report_Lesotho_310111.pdf Graham, L. Jacqueline Moodley, J., Ismail, Z. Munsaka, E., Ross, E. and Schneider, M. (2014) Poverty And Disability In South Africa Research Report. Retrieved from https:// www.uj.ac.za/faculties/humanities/csda/Documents/Poverty_Disability%20Report%20 FINAL%20July%202014%20Web.pdf Duncan, M., Sherry, K., Watson, R. & Booi, M. (2012) ‘Rurality, poverty and disability: Strategies for community led action towards poverty alleviation and social inclusion’, Towards Carnegie UCT Poverty and Inequality Conference. Theme: Capacitating for Change. Department of Health and Rehabilitation Sciences, Faculty of Health Sciences, University of Cape Town.

Jelsma, J. (2007)‘The determinants of health-related quality of life in urban and rural isiXhosa speaking people with disabilities,’ International Journal of Rehabilitation Research 30(2), 119–126. http://dx.doi.org/10.1097/MRR.0b013e32813a2e88.

Kahonde, C.K., Mlenzana, N. & Rhoda, A. (2010) ‘Persons with physical disabilities’ experiences of rehabilitation services at Community Health Centres in Cape Town’, South African Journal of Physiotherapy 66(2), 1–6.

Lorenzo, T., 2012, ‘Marrying community development and rehabilitation: Reality or aspiration for disabled people, Series No. 2, Disability Catalyst Africa, University of Cape Town, Cape Town.

Neille, J. & Penn, C.B. (2015) ‘The interface between violence, disability, and poverty stories from a developing country’, Journal of Interpersonal Violence, 1–25. http://dx.doi. org/10.1177/0886260515596332.

Department Of Health And Human Services Centers For Disease Control And Prevention National Institute For Occupational Safety And Health. (2012). Morbidity and disability among workers 18 years and older in the Mining sector, 1997–2007 Retrieved from https://www.cdc.gov/niosh/docs/2012-155/pdfs/2012-155.pdf Bambas-Nolen, L., Birn, A. E., Cairncross, E., Kisting, S., Liefferink, M., Mukhopadhyay, B., & Shroff, F. M. (2014). Case study on extractive industries prepared for The Lancet Commission on Global Governance. Oslo: University of Oslo. Retrieved from: https:// www. med. uio. no/helsam/english/research/global-governance-health/backgroundpapers/extrac-indus. pdf.

Chimamise, C., Gombe, N. T., Tshimanga, M., Chadambuka, A., Shambira, G., & Chimusoro, A. (2013). Factors associated with severe occupational injuries at mining company in Zimbabwe, 2010: a cross-sectional study. Pan African medical journal, 14(1).

Zungu, L. I. (2013). Prevalence of post-traumatic stress disorder in the South African mining industry and outcomes of liability claims submitted to Rand Mutual Assurance Company: original research. Occupational health southern Africa, 19(2), 22-26.

Stojadinović, S., Svrkota, I., Petrović, D., Denić, M., Pantović, R., & Milić, V. (2012). Mining injuries in Serbian underground coal mines–a 10-year study. Injury, 43(12), 2001-2005.

Chan, E. Y., & Griffiths, S. M. (2010). The epidemiology of mine accidents in China. The Lancet, 376(9741), 575-577.

Hermanus, M. A. (2007). Occupational health and safety in mining-status, new developments, and concerns. Journal of the Southern African Institute of Mining and Metallurgy, 107(8), 531-538.

Dias, B. (2014). Musculoskeletal Disorders in the South African Mining Industry (Doctoral dissertation).

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Smith, S. (2013). Injuries, illnesses, and fatal injuries in mining in 2010. Work place injuries. Retrieved from https://www.bls.gov/opub/btn/volume-2/injuries-illnesses-andfatal-injuries-in-mining-in-2010.htm Kyeremateng-Amoah, E., & Clarke, E. E. (2015). Injuries among artisanal and small-scale gold miners in Ghana. International journal of environmental research and public health, 12(9), 10886-10896.

Chamber of Mines of South Africa. Integrated Annual review 2015. Retrieved from file:///C:/ Users/naidoodes/Downloads/cmsa-annual-review-2015.pdf Chamber in the mines Safety fact sheet 2016. Retrieved from file:///C:/Users/naidoodes/ Downloads/8923_15_com_fs_safety_in_mining_lr%20(1).pdf Donoghue, A. M. (2004). Occupational health hazards in mining: an overview.

Occupational Medicine, 54(5), 283-289.

Hofmann, T. M., & Kielblock, J. (2007). The assessment of functional work capacity in the South African mining industry. Work, 29(1), 5-11.

Edwards, A. L., & Kritzingert, D. (2012). Noise-induced hearing loss milestones: past and future. Journal of the Southern African Institute of Mining and Metallurgy, 112(10), 865869.

Strauss, S. (2014). Technical Briefs. Journal of Audiology, 53(S2), S75.

Jeebhay, M., & Jacobs, B. (1999). Occupational health services in South Africa. South African health review, 29(19), 257-276.

Kusena, W. (2014). Occupational hazards, injuries and illnesses associated with small scale gold mining: case of Ward 19, Zvishavane, Zimbabwe. Midlands State University Institution Repository.

Dayal, H. (2010). Provision of rehabilitation services within the District Health System-the experience of rehabilitation managers in facilitating this right for people with disabilities.

South African Journal of Occupational Therapy, 40(1), 22-26.

Grut, L., Mji, G., Braathen, S.H., Ingstad, B.( 2012)‘Accessing community health services: challenges faced by poor people with disabilities in a rural community in South Africa’, African Journal of Disability 1(1), Art. #19, 7 pages.http://dx.doi.org/10.4102/ ajod.v1i1.19 Rule, S., Lorenzo, T., Wolmarans, M., Watermeyer, B., Swartz, L., Lorenzo, T. & Priestley, M. (2006). Community-based rehabilitation: new challenges. Disability and social change: A South African agenda, 273-290.

Haig, A. J., Im, J., Adewole, D., Nelson, V., & Krabak, B. (2009). The practice of physical and rehabilitation medicine in sub-Saharan Africa and Antarctica: a white paper or a black mark?. Journal of rehabilitation medicine, 41(6), 401-405.

Luruli, R. E., Netshandama, V. O., & Francis, J. (2016). An improved model for provision of rural community-based health rehabilitation services in Vhembe District, Limpopo Province of South Africa. African journal of primary health care & family medicine, 8(2), 1-10.

Chappell, P., & Johannsmeier, C. (2009). The impact of community based rehabilitation as implemented by community rehabilitation facilitators on people with disabilities, their families and communities within South Africa. Disability and Rehabilitation, 31(1), 7-13.

Sherry, K. (2015) Disability and rehabilitation: essential considerations for equitable, accessible and poverty-reducing health care in South Africa. South African Health Review 2014/2015 Health Systems trust. Retrieved from https://www.health-e.org.za/ wp-content/uploads/2015/10/HST-SAHR-2014-15-Complete.pdf.

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Mitra, S.; Posarac, A. and Vick, B. (2011) Disability and Poverty in Developing Countries: A Snapshot from the World Health Survey. World bank development, 41:1-18.

Retrieved from http://siteresources.worldbank.org/SOCIALPROTECTION/Resources/SPDiscussion-papers/Disability-DP/1109.pdf Visagie, S., & Swartz, L. (2016). Rural South Africans’ rehabilitation experiences: case studies from the Northern Cape Province: original research. South African Journal of Physiotherapy, 72(1), 1-8.

Marsay, G. (2014). Success in the workplace: from the voice of (dis) abled to the voice of enabled: original research. African Journal of Disability, 3(1), 1-10.

Naidoo, D., Van Wyk, J., & Joubert, R. W. (2016). Exploring the occupational therapist’s role in primary health care: Listening to voices of stakeholders. African Journal of Primary Health Care & Family Medicine, 8(1), 1-9.

Wegner, L., & Rhoda, A. (2015). The influence of cultural beliefs on the utilisation of rehabilitation services in a rural South African context: therapists’ perspective: original research. African Journal of Disability, 4(1), 1-8.

Brooke-Sumner, C., Lund, C., & Petersen, I. (2016). Bridging the gap: investigating challenges and way forward for intersectoral provision of psychosocial rehabilitation in South Africa. International journal of mental health systems, 10(1), 21.

Maja, P. A., Mann, W. M., Sing, D., Steyn, A. J., & Naidoo, P. (2011). Employing people with disabilities in South Africa. South African Journal of Occupational Therapy, 41(1), 24-32.

Mclean, K. N. (2012). Mental health and well‐being in resident mine workers: Out of the fly‐in fly‐out box. Australian Journal of Rural Health, 20(3), 126-130.

World health organisation Concept Paper: Guidelines on Health-Related Rehabilitation (Rehabilitation Guidelines) Retrieved from http://who.int/disabilities/care/rehabilitation_ guidelines_concept.pdf Gretschel, D. (2016). Levels of community integration achieved by adults with disabilities post discharge from a specialised in-patient rehabilitation unit in the Western Cape (Doctoral dissertation, Stellenbosch: Stellenbosch University). Retrieved from file:///C:/ Users/naidoodes/Downloads/gretschel_levels_2016.pdf Coetzee, Z., Goliath, C., van der Westhuizen, R., & Van Niekerk, L. (2011). Reconceptualising vocational rehabilitation services towards an inter-sectoral model. South African Journal of Occupational Therapy, 41(2), 32-37.

appendiX 2 A RAPID ASSESSMENT OF THE DISABILITY AND REHABILITATION OF EX-MINE WORKERS LIVING IN FOUR COUNTRIES IN SOUTHERN AFRICA: LESOTHO, MOZAMBIQUE, SOUTH AFRICA AND SWAZILAND Noise Induced Hearing Loss: A Desktop Review 1 Noise and (Ex) Mine Workers Noise is one of the most hazardous exposures for mine workers. In the mining industry, noise competes as a hazardous agent with respirable dust (respiratory disease) and repetitive trauma (Roberts, Sun & Neitzel, 2016; Donaghue, 2004). In some countries, like the USA, the prevalence of hazardous noise exposures in the mining sector is so great that it is mine workers who report more hearing problems than any other type of worker (Matetic, Randolph & Kovalchik, 2010). However, consider how hearing loss, an insidious, slowly occurring disability, is viewed relative to the highly visible and immediate disabling effects of e.g., a hand crushed in a machine injury. The relative invisibility of noise effects on mine workers’ hearing has been skewed by various factors. For example, political ideologies have resulted in research that marginalised and/or ignored noise-induced hearing loss in black African mine workers by focussing on white mine workers (e.g., see Hessel & Sluis-Cremer, 1987). Furthermore, noise has been studied, rather simplistically, as a single hazardous agent (Pillay, 2001). This is despite the known accumulative effects on the body when noise is combined with exposures to agents like chemical vapours and vibration (Morata, Themann, Randolph, Verbsky, Byrne, & Reeves, 2005). The sum effect of such thinking has led to ex-mine workers not benefiting from newer laws and practice standards in occupational health and safety that emerged in the last few decades.

The mining sector in South Africa is, and has always been, vital to the Southern African economy, employing approximately 500 000 workers with a legacy of approximately two million ex-mine workers - many of whom are migrant workers from within and outside South Africa (AllAfrica, 2016). The purpose of the bigger project is to provide valuable information about people who have been injured and disabled while working in mines and to describe access to care, treatment, rehabilitation and compensation – all data that the mine and health service authorities could use to inform their services. The bigger project also aims to highlight challenges faced by ex-mine workers to improve disability services.

In line with the broader project aims, the purpose of this review is to not only present the case for noise-induced hearing loss amongst ex-mine workers but to also offer a way of managing their hearing since leaving the mining industry in Southern African countries, including Lesotho, Mozambique, South Africa and Swaziland.

Noise, a disagreeable or undesired sound (Rawool, 2012), can be produced by many sources ranging from our vocal cords to a vibrating loudspeaker diaphragm or an operating machine tool. Occupational noise has been extensively researched as part of the occupation of mining where mine workers are exposed to noise. In mining, there are specific sources for noise.

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A note on methodology used to collect data for this review. Data was collected mainly via an indepth literature review of published and unpublished (grey) literature using EBSCO host, Pubmed, Medline, Scopus and OVID. Search terms included noise, occupational hearing loss, noise induced, ear protective devices mining, sub-Saharan Africa, Lesotho, Mozambique, Swaziland, South Africa. Additionally, an expert reference interview was conducted with a notable expert researcher in the field of audiology (see below).

1.1. Noise Sources in the Mining Industry Mine workers’ exposure to noise depends on the type of mining in which they are employed but is present in all mining areas across processing plants, surface and underground mines. Furthermore, the gold and platinum industry are nosier than other metal mining industries (e.g., iron, tin, manganese), followed by coal then diamond and other mines (Chamber of Mines of SA, 2016). Most mine workers are exposed to sounds where the time-weighted average (TWA) exceeds the legislated occupational exposure limit of 85dB. For about 25% of those exposed to excessive noise, their TWA exceeds 90dB (Bauer & Kohler, 2000, McBride, 2004). McBride (2004) illustrated in Table 1 (see below) noise sources and the sound pressure level ranges in various mining sites.

table 1: Estimates of noise exposure from plant and equipment (source: McBride, 2004) noise source Cutting machines Locomotives (electrical) Haulage truck Loaders Long-wall shearers Chain conveyors Continuous miners Loader-dumper Fans Pnematic percussion tools

range (db) 83-93 85-95 90-100 98 96-101 97-100 97-103 97-102 90-110 114-120

mid point 88 90 95 98 99 99 100 100 100 117

Quoting Bartholomae & Parker (1983), McBride highlighted the role of pneumatic percussion drills in mining, which continue as a major contribution to noise in mining, even in recent times (Edwards, Dekker & Franz, 2011; Phillips, Nelson & Ross, 2006).

These drills come in different types (e.g., hand-held, machine mounted) and are used for maintaining roadways for floor ‘dinting’ or roof ‘ripping’, used for roof-bolts or development work.

Other noise sources include noise from: ancillary equipment like fans and blowers for mines ventilation power pack and transmission (gear) systems (usually continuous noise) cutting head/armoured conveyor systems (usually impact noise)

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diesel powered load handlers/materials man carrying haulage equipment that generates transport and mechanical handling

noise with sources being engine, transmission and exhaust, diesel powered locomotives, man-riding cars from wheel-track (impulse noise, structural vibration) Phillips, Nelson & Ross (2006) reported evidence in the South African (SA) mining sector with pneumatic drills ranging from 114.4 dBA and ‘quiet’ drilling recorded at 85dBA. Edwards, Dekker & Franz (2011) reported average noise levels for drillers in SA gold mine workers at 105.5dBA. These same authors profiled noise exposure in SA mines and demonstrated a range of 63.9 to 113.5 dBA. What was concerning is their review of 73.2% mine workers’ exposures to noise levels higher than 85 dBA (Edwards, Dekker & Franz, 2011).

Additionally, explosive charges and blasting produce impulse noise. Such noise, depending on whether blasting occurs on the surface or underground will have differing effects due to factors like mine geometry, openings, wall surface structures and so on. Critically, noise samples taken at incidental points are never truly representative of exposures during workers’ actual work shifts as it varies in magnitude, tasks are non-continuous and workers physiological states interplay with exposures.

1.2 Noise induced hearing loss in mining When exposed to noise over a long period, usually (not always) for a few years, the result is permanent damage to the nerves responsible for hearing and processing sounds to brain.

Damage to the auditory nerve and its pathways that conduct sound to the brain is usually irreversible and is known as noise-induced hearing loss (NIHL).

Daily exposure levels (abbreviated as LEX) refers to the sound exposure averaged over eight (8) hours. As is known, sound pressure levels are measured in decibels (dB). There are three frequency weighting options that can be used for this purpose, viz., low, medium and high frequency weightings, labelled respectively as A, B and C. In occupational audiology, it is common for the A-weighting network to be used where energy is summed to allow simulation of the frequency response of the human ear at relatively low but clearly audible sounds (Rawool, 2012: 28). Noise exposure levels in an 8-hour working day (LEX,8h) should not exceed the occupational exposure limit (OEL) of 85 dBA. It is generally accepted, while debated, that noise between 80dBA to 90dBA becomes dangerous to the auditory system (Basner, Babisch, Davis, Brink, Clark, Janssen, & Stansfeld, 2014; Rawool, 2012).

Given the review of noise sources above, that the majority of mine workers are exposed to hazardous noise levels is an incontestable circumstance. Globally, over 360 million people have hearing impairments, with approximately 80% in low- and middle income countries (WHO, 2015). Unfortunately, NIHL has been inadequately reported in professional literature with data on the prevalence of hearing loss in mine workers greatly lacking. In some countries like the USA it is reported that NIHL is the most common occupational disease with about 22 million US workers exposed to hazardous noise levels at work, and, annually, an estimated US$242 million is spent on compensation for hearing loss disability (NIOSH, 2016). However, even in data-rich countries such as the USA, the UK and parts of Europe; the definition of what constitutes a NIHL distorts NIHL prevalence data amongst mine workers (McBride, 2004).

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Noise in peoples’ lives must be positioned holistically. Indeed, research extends into understanding occupational noise relative to one’s exposure to noise for recreational purposes (e.g. music); noise produced in homes by using toys, lawnmowers, home repair equipment; noise in schools (generated by children and classroom acoustics) and environmental noise (due to transportation, construction, public works (Rawool, 2012). Between these various exposures, it is critical that NIHL be understood as a disability. As a disability, there are several noise effects not only on the auditory system but also so-called ‘non-auditory’ health effects. The non-auditory effects of noise include annoyance, sleep disturbance, impairment of cognitive performance (Basner, et al, 2014) and cardiovascular disease, e.g. long-term exposure to environmental noise affects/ causes hypertension, ischaemic heart diseases, stroke (Babisch, 2011). Importantly, hearing loss impacts on one’s ability to communicate and leads to various psycho-social problems such as depression, anxiety and paranoia (Kochkin & Rogin, 2000; Appollonio, Carabellese, Frattola, & Trabucchi, 1996) with even mild hearing losses resulting in negative effects on one’s sense of independence and well-being (Scherer & Frisina, 1998).

It has also been established that hearing loss affects intimate and work relationships with feelings of frustration and antagonism between partners (Hetu, Jones & Getty, 1993) and fear and incompetence in the workplace (Erdman, Crowley, & Gillespie, 1984; Morata, et al, 2005). While little data exists regarding the non-auditory effects of NIHL amongst mine workers in general, we have every reason to suspect that the same issues described here also affect them given the nature of their hearing losses, work environments and suchlike.

2 The Nature of Hearing Disability in the Mining Sector in Southern Africa For purposes of this review, we focus on Lesotho, Mozambique, Swaziland and South Africa because this is where most mining occurs in Southern Africa. While this review focuses on mine workers in South Africa, it must be borne in mind that workers, especially ex-mine workers, migrated to South Africa from so-called ‘labour-sending’ countries Lesotho, Mozambique and Swaziland, besides internally migrating from rural South Africa.

Lie, et al (2016) reported that occupational noise exposure explains up to 21% of hearing losses amongst workers. Interestingly, this is lowest in the industrialized/economically developed high-income countries while highest in the low-middle income, economically developing countries. In this section, a review of the literature is provided to understand what this means for the selected countries, viz.: Lesotho, Mozambique, Swaziland and South Africa.

In Southern Africa, research on prevalence rates of NIHL in mine workers has been conducted in countries like Tanzania (Musiba, 2015), Zimbabwe (Chadambuka, Mususa & Muteti, 2015), Namibia (Barrion, 2015), Ghana (Amedofu, 2002) and SA. A recent SA study by Strauss, Swanepoel Becker, Eloff and Hall (2012) reported on the prevalence of NIHL in a large group of gold mine workers (N=57 714). They reported that, on average the cohort had a prevalence of 20.5% high-frequency hearing loss (calculated for 3-, 4-, and 6KHz) greater than 30 dB HL compared to 16% for the control group. Their findings indicated that, irrespective of whether mine workers participated in hearing conservation programmes or not, exposure to occupational noise was significantly associated with increased hearing thresholds across low and high frequencies. For this review, a relevant finding is that NIHL was determined to be more prevalent in the noise-exposed than the unexposed control group, especially in the group aged 36 – 45 years. This age range is

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relevant to the population of current ex-mine workers. Indeed, it has long been debated about whether age is a factor that needs to be accounted for when calculating NIHL. In part, that this study showed an age effect (also observed in their control group) is useful and embedded in their caution to account for age-related hearing loss when determining noise-induced hearing loss.

3 The Nature & Management of Noise & Hearing in Mining What is the ideal way to manage mine workers’ hearing? Of course, this question may be answered in a variety of ways: ‘Ideal’ may be the espoused versions via the legal fraternity, mining companies’ econometric versions or that which hearing health care professionals refer to as generally accepted, good clinical practice. What is significant to note is that there are no universally accepted, precisely aligned practices. However, it is possible to describe what occurs in the occupational safety and health world, usually engaged by medical practitioners, various health and safety personnel, audiologists and suchlike.

These stakeholders are one group who play a significant role in the hearing health care of mine workers. Other such stakeholders are described below including a review of their roles and responsibilities.

3.1 Stakeholders in Mining related NIHL At a macro-level, and established by the Mine Health and Safety Act (No 29 of 1996, as amended), the Mine Health and Safety Council is a national public entity (Schedule 3A) and consists of what is described as a tripartite board. This council is funded by public revenue and is accountable to Parliament. It is represented by the state, employer, and labour members. The MHSC board is chaired by the Chief Inspector of Mines.

Significantly, this tripartite relationship ensures worker rights and, as part of more recent efforts to restore ex-mine workers’ compensation claims (SA News, 2016). While the broader stakeholders for the mining industry is now well-established in South Africa, we need to identify especially the persons/stakeholders responsible for NIHL. Specifically for NIHL and mine workers, key stakeholders are the occupational safety and health personnel associated with mine companies, and consultant medical and audiology practitioners. Currently all major mining companies have occupational safety and health programmes focussed on hearing screening, usually/initially conducted by an audiometrist.

3.2 Hearing Conservation Programme: Legislative Aspects & Components In this section, the components of what is generally accepted as a hearing conservation programme in the mining sector (stemming from occupational safety and health environments) is described. The aim of this section is to both situate what should be occurring for mine workers in Southern Africa and also to describe what is actually occurring based on reported evidence from the literature and commentary from experts in the field. Critically, due to changes in the legislative landscape, ex-mine workers who have left the mining sector would have been under a different set of legislation especially in South Africa, pre-1994 (with significant amendments occurring especially in, e.g., 2003 and 2013). To explain this, a brief review is necessary of the legislation in health and safety regulations and standards specific to noise, hearing and hearing conservation.

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Aided by the Mineral and Petroleum Resources Development Act (MPRDA), South Africa’s mineral resources are administered by the Department of Mineral Resources (DMR).

Thus the MPRD Act is part of the broader regulation of safety and health in mines.

However, there are other Acts that guide how noise and workers’ hearing are managed, viz.: (i) the Mine Health and Safety Act (MHSA) which is based on a tripartite approach (of government, organised labour and mining companies) to safety and health; and (ii) the Occupational Diseases in Mines and Works Act (1973, ODMWA, last amended in 2002) which is administered by the Department of Health. The latter Act provides for the establishment of the Medical Bureau for Occupational Diseases (MBOD). Additionally, the Compensation Commissioner for Occupational Diseases is also provided for by the ODMWA as is the compensation system and fund administered by the Commissioner.

The Mine Health and Safety Inspectorate of the DMR regulates the health and safety of mineworkers. Since 1996, the MHSA provides a mine-level system where each shaft has its own health and safety committee. Adherence to official regulations and employee safety training is the responsibility of mine management and employee representatives.

In South Africa, the mining industry is regulated by the many standards and legislated guidelines regarding noise and noise-induced hearing loss management. Notably, mine workers are covered under the Mining Health and Safety Act but may also be referred to within the Occupational Safety and Health Act. The two significant Acts, viz.: Compensation for Occupational Injuries and Diseases Act (COIDA) and ODMWA provide compensations systems funded by employer premiums but administered by the state.

COIDA is consistent with ILO Convention 1964 (No.121), on Employment Injury Benefits.

It covers occupational injuries and diseases in all industries including those from the mining sector that are not covered by ODMWA, for example noise-induced hearing loss.

Significantly, mine workers from countries such as Swaziland, Mozambique, Botswana and Lesotho are specifically covered under several legislative frameworks, such as that by the Departments of Labour and Health to provide compensation, health and rehabilitation services especially to ex-mine workers. For example, the Department of Labour has licensed Rand Mutual Assurance (RMA) to facilitate compensation to Lesotho and Mozambique mine workers for illnesses, disability or death resulting in terms of section 30 of the (COIDA). In the section, below, is a list of standards and legislation that ought to be referred to when considering hearing conservation in mining. Of significance, is the years in which they were implemented and/or amended: Occupational Health and Safety Act, (Act 85 of 1993) and related Noise-Induced

Hearing Loss Regulations (No. R. 307, 7 March 2003) Occupational Diseases in Mines and Works Act (ODMWA), (Act 78 of 1973, last amended in 2002) and related regulations relating to the basis on which owners of controlled mines and controlled works shall pay amounts in respect of risk shifts worked – GNR 1338 of 23 October 1998; and including regulations of various types for benefits [GNR 1813 of 5 October 1973]; Increase of levies [GNR 1165 of 8 October 1999; GNR 227 of 17 March 2006; GNR 1009 of 26 October 2007; GNR 598 of 22 July 2011]; Amendment of Amounts to Increase Benefits – GNR 285 of 16 April 2010.

Mine Health and Safety Act (MHSA), 1996 (Act no. 29 of 1996), Regulation 9.2.

South African National Standards (SANS), 2013. SANS 10083:2013. The measurement and assessment of occupational noise for hearing conservation purposes. Edition 5.2 SABS 1451: Part I. South African Standard. Standard Specification for Hearing Protectors, Part I: Ear muffs (Definition of “SABS 1451 Part I” inserted by Regulation 2(d) of Government Notice R489 in Government Gazette 15560, dated 18 March 1994)

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SABS 1451: Part II. South African Standard. Standard Specification for Hearing

Protectors, Part II: Ear plugs (Definition of “SABS 1451 Part II” inserted by Regulation 2(d) of Government Notice R489 in Government Gazette 15560, dated 18 March 1994) Department of Minerals and Energy (DME), (2000). Guideline for the compilation of a mandatory code of practice on Minimum Standards of Fitness to Perform Work at a mine. DME 16/3/2/3 A1 Department of Minerals and Energy (DME), (2003). Mine Health and Safety Inspectorate guideline for the compilation of a mandatory code of practice for an occupational health programme (occupational hygiene and medical surveillance) for noise, DME 16/3/2/4 A3 DME (2016). Guideline of the Compilation of a Mandatory Code of Practice for the Management of Medical Incapacity due to Ill-Health and Injury. No. 39656.

Government Notice R149 in Government Gazette 39656 dated 5 February 2016.

Commencement date: 31 May 2016.

Compensation for Occupational Injuries and Diseases Act (COIDA) (Act 130 of 1993) with particular reference to Instruction 171 (Schedule 3) and the supplement entitled Determination of permanent disablement resulting from noise induced hearing loss and injury There are also standards that focus on hearing testing equipment regarding issues such as calibration of both fixed and mobile audiometers for air and bone conduction testing (SANS 10154-2012, SANS, 2012) and the test environment/booth (SANS 10182:2006, SANS, 2006). Additionally, there are newer government regulations on the standard threshold shift (dated 15 July 2016, effective 30th September 2016) which is described as a ‘proactive’ guidance note to align SA’s mining industry with international standards to effectively manage noise exposure toward improvement of health performance in mines.

This guidance note refers to the establishment of milestone or initial audiometric values against which subsequent hearing levels are measured to assess an average change in hearing of 10dB or more across the high frequencies.

Overall, what these standards and legislation do is address what is generally considered to be core components of a hearing conservation programme. While there are differing degrees of definition, the three core components (see Figure 1) of most hearing conservation programmes are: Engineering and environmental management Employer and employee management (mine worker, mining company administrators) Medical and rehabilitation management

A review of each component follows:

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figure 1: Components of a Hearing Conservation Programme Engineering & Environmental Management

Noise source control Equipment procurement and operational standards Noise (+other toxic agent) measurements Assess effectiveness of engineering & environmental

strategies also needs to be evaluated.

There are several medical and rehabilitation management strategies which include: monitoring (surveillance) of hearing comprehensive audiological, tinnitus and auditory processing evaluations risk and fitness to work assessments hearing protection and enhancement devices aural (and other) rehabilitation (e.g., assistive listening devices, psycho-social, personal and vocational interventions, etc.)

management strategies

Employer & Employee Management

Awareness, motivation, education, training and

counselling of workers, supervisors and managers Administrative control strategies (scheduling, work

organisation) Assess effectiveness of employer/employee

conservation strategies

Medical & Rehabilitation Management

Monitoring (surveillance) of hearing Comprehensive audiological, tinnitus and auditory

processing evaluations assess effectiveness of med./rehab measures Risk and fitness to work assessments hearing protection and enhancement devices Aural (and other) rehabilitation (e.g., assistive listening devices, psycho-social, personal and vocational interventions, etc.)

As may be noted in Figure 1, engineering and environmental management, prioritised as the first, critical point of noise management, is to control the noise at its source. This starts at the point of procurement. This is when decisions about the nature of equipment used in the mining sector should be evaluated, before/during purchase, for noise creation.

Similarly, already installed equipment should be evaluated for its operational impact on the production of noise. Significantly, it is well established that noise, even when below 82dBA increases a workerâ&#x20AC;&#x2122;s risk of hearing loss when s/he is using ototoxic medication (e.g. for TB or ARVs) or is exposed to ototoxic chemicals such as solvents or metals in the workplace (Staudt, 2016). Beyond measuring and controlling noise (and its combined effects with other ototoxic agents), the assessment of these controls must be evaluated for its efficacy â&#x20AC;&#x201C; ultimately on the hearing sensitivity of mine workers.

Employer and employee management refers to focussed, coordinated activities such as: Awareness, motivation, education, training and counselling of workers, supervisors and managers: specific topics in this domain may range from the nature of noise to the use of HPDs. Administrative control strategies could related to work/shift scheduling, work organization of roles/functions, etc.

Similar to the other components, the effectiveness of employer/employee conservation

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All of these aspects need to also be evaluated for their efficacy and/or impact on the person with the hearing impairment. Indeed, a Medical Incapacity Management Committee should be set up (as per Government Notice R149, Guideline for a Mandatory Code of Practice for the Management of Medical Incapacity Due to Ill-Health and Injury, commencement date: 31 May 2016.) to evaluate such mine workers medical and rehabilitation needs/status.

As may be noted in the figure, there are several inter-connected activities that occur between each component of the hearing conservation programme, ranging from the measurement and control of the noise source, the monitoring of hearing, education/ training for employers and mine workers to the assessment of the effectiveness of each management strategy. In essence, the employer (mining company, supervisor/manager) designs and is responsible for the implementation of a mandatory Code of Practice (COP) regarding the measurement and assessment of noise in the worksite/mine and must include details regarding the: a) Structure of the hearing conservation programme b) Noise measurement risk assessments, including: annual personal exposure measures (dosimetry) that sample/represent full work shifts [an annual Personal Noise Exposure Report should be compiled for review] noise measurements of (i) significant noise sources, workplace operations and activities that are deemed riskiest or with the greatest potential for noise; employees (numbers, occupations) exposed to noise levels of >82dBL Aeq,8h; [refer to Regulation 9.2 of the MHSA which specifies exposure measurement programme above 82dB(A)] nature of noise pattern e.g., intermittent, continuous; and duration and frequency of employee exposure; noise control measures such as engineering, administration, noise zone demarcation zones, personal protective equipment use c) Risk-based medical examination components (performed by an occupational health practitioner) which should include assessment of: external ear canal and middle ear (as possible) to decide eligibility for audiometry (pre-audiometric medical examination); and for compatibility/use of especially insertion hearing protection devices (HPD) special needs for HPD attenuation (based on previous audiometry), consider relevance of low-attenuation devices for communication in noise, audibility of warning signals mine workers risk of further noise exposure especially when previous audiometry signals high NIHL susceptibility need to refer to an Occupational Medical Practitioner prior to audiometry or the issuing of HPDs.

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The revised SANS 10083:2013 (section 3.1.7) strongly recommends that audiometrists are competent in otoscopy and should have successfully completed anatomy and physiology courses at a tertiary level. d) Hearing protection equipment policy details, aligned with SANS 1451-1, SANS 1451-2 or SANS 1451-3 (focused on HPDs), and regarding: issuing of free hearing protection to mine workers in demarcated noise zones compulsory use HPDs for all mine entering (for any period of time) a noise zone where 8 hour rating level equals or exceeds 85 dBA. This must be a supervised activity monitored by the employer. assessing the ergonomic suitability of HPDs per individual mine worker needs and following standard fitting procedures education/training on the use and maintenance of the HPDs issued to mine workers storage of HPDs should be ensured by the employer whereby a dust proof container must be provided, along with a storage space e) Medical surveillance (as regulated by Regulations 11.4.1 to 11.4.12 of the MHSA) programme details, including: Baseline, periodic screening (annually, for three years – SANS 083, 2013), monitoring and exit audiometry done by an (i) audiologist (Health Professions Council of South Africa [HPCSA] registered in speech therapy and audiology/audiology); (ii) a medical specialist in otorhinolaryngology (an ear, nose and throat specialist), (iii) an occupational medical practitioner; (iv) an audiometrist - registered with the HPCSA as an audiometrist/hearing aid acoustician with a certificate in audiometry as approved by the Departments of Labour or Minerals and Energy. Notably, baseline audiometry must not be done within a 16 hour period of noise exposure (HPD use not allowed) and screened at 500Hz, 1000Hz, 2000Hz, 3000Hz and 4000Hz. Baseline screening must include seasonal workers (SANS 083, 2013).

Diagnostic audiometry performed by (i) an audiologist or (ii) medical specialist (in otorhinolaryngology). Immediately before the test, mine workers must not have been exposed 85 dBA in the preceding 16 hours (and excludes HPD use).

– diagnostic evaluations must include pure-tone air and bone conduction – narrow-band or speech discrimination audiometry may also be used, as necessary – two diagnostic audiograms must be recorded during two different sittings, which may take place on the same day. If the two audiograms differ by more than 10 dB for either ear at any of the mandatory test frequencies, a third audiogram must be conducted during a third sitting to obtain consistent results. Should the third audiogram also indicate inconsistencies greater than 10 dB, the mine worker should be re-evaluated in six-months. Where consistent audiograms are not obtained, even after six months’ time, the subject may be referred for specialist evaluation to assess hearing loss.

Clinically, the first sign of NIHL is a small depression in the audiogram at 4 kHz (the audiometric ‘notch) that deepens and widens as the noise exposure continues. Such notches may occur because of other reasons - especially a 6 kHz notch that may be due to an incorrect audiometric standard at this frequency.

Critically, there is a guideline for a code of practice on Minimum Standards of Fitness to Perform Work which is performed by an ENT. Furthermore, reference should be made to the Compensation Commissioner’s Internal Instruction, “The Determination of Disability in Cases of Noise-induced Hearing Loss”. Failure to design and implement a Code of

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Practice as described above, may result in an administrative fine if the employer is in breach of the MHSA. Similarly, the mine worker/employee may face a criminal charge if she/he fails to adhere to the COP and take reasonable care to protect his/her hearing and regarding, e.g., use of hearing protection.

Hearing threshold levels for 500Hz, 1000Hz, 2000Hz, 3000Hz and 4000Hz of both ears are used to calculate the Percentage Loss of Hearing (PLH) for the employee (COIDA, Instruction 171). Actuarial tables, weighted in the speech frequencies, are used to calculate the PLH with a shift of 10% or more, being the criterion for regarding the employee as a possible candidate for compensation. The current earnings of the employee is used to calculate compensation. Additionally, one hearing aid is supplied to the compensated employee every five years with the proviso that s/he achieves a speech recognition threshold of greater than 40dB. There are several intervention measures (SANS: 083, 2013) that have to take place in the case of a PLH shift, see Table 1, below.

table 1 plh shift 3.2%

intervention Investigate: (i) reason for the shift, (ii) effectiveness of the HPD e.g., sufficient

attenuation? (iii) proper fit and use of the HPD Employee education/training Documentation and safe-keeping of the investigations

6.4%

10% or more

Same investigations as above Retrain employee Referral for diagnostic audiology Employee regarded as possible candidate for compensation Re-tested at a later stage (note 17.8 reviews the later stage) If the retest affirms the shift then the employee must be removed from the noise and

referred for a diagnostic audiogram. If this diagnostic audiogram confirms the shift, then the test date is recorded as when the hearing loss commenced.

>30%

Refer for medical opinion to ENT or if complicated

<30%

Refer to an Occupational Health Medical Practitioner if the shift is <30% and

uncomplicated – and if related to the mine/workplace, then the case should be reported as per the relevant legislation

Further to the data in Table 1, above, it is recommended the worker is removed from the noise zone as soon as possible. The employee should be provided with training and information before being allowed to re-enter the noise zone, especially if the employer demonstrated that the employee is at risk of a hearing loss. Furthermore, the HPD needs to be assessed for its effectiveness and its attenuation value must be taken into account.

Indeed, all employers need to ensure that the necessary action is taken to prevent a possible further PLH shift. However, if a loss of hearing sensitivity continues then the

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employee should be removed from noise zones permanently. Note that compensation (financial and other) may be part of this framework, but is usually the outcome of failure to manage/adhere to regulations in the workplace.

As stated in the introduction to this section, most of the standards, acts and regulations described above are either new or have been amended especially since 1993, 2003 and 2013 (milestone dates) that focused on improved hearing care for mine workers. These regulations may also cover, for Southern Africa, mine workers who hail from Lesotho, Swaziland and Mozambique given that mine workers, historically, were drawn from these areas/countries. The implication of this observation is critical for especially ex-mine workers. They may never have been beneficiaries of effective hearing screening and/or management – as per the newer Acts, regulations and standards. So, if a mine worker left the industry even as recently as 5 or 10 years ago, that s/he may have left work with a hearing loss is not merely likely but highly probable given the nature of noise and exposure management in mines.

4 Nature of Hearing Care Services Provided to Mine Workers For purposes of this report, hearing care services provided to currently employed mine workers and to ex-mine workers especially in the period since the new legislation (mainly 2003) and in the last 3 to 5 years with the Department of Mineral Resources focus’ on the revitalising of mining districts and their labour sending areas. For example, operation Ku-Riha has, since 2013, focussed on compensating ex-mine workers for especially occupational lung diseases. However, they are part of a large cohort of ex-mine workers who are not even aware of their compensation benefits (Jack, 2016).

To situate hearing conservation services, a review of current aspects of HCPs is necessary.

According to South African audiologist, Dr Anita Edwards, an expert in the field who has conducted NIHL research in mining; services currently provided to mine workers may be described as occurring over at least two levels in the mining sector. Firstly, occupational hygienists measure noise level exposures and put into place the necessary guidelines.

Occupational medical practitioners ensure that annual medical surveillance occurs. At the second level, noise exposed workers will have their hearing screened. Screening is usually conducted by nurses trained as audiometrists (dependant on the size of the organisation) who have usually completed a six week audiometry programme. Medical surveillance includes otoscopy and pure tone screening (also referred to as ‘testing’), 250Hz to 8 Hz, including 3kHz and 6kHz air conduction test. If there is a big change from the previous year, i.e., if there is a 10% PLH shift or more, then the audiometrist refers to an audiologist for a diagnostic test. The audiologists may be resident to the organisation, although this is a rarity and are almost always outsourced and usually to a private practitioner. Some small sized mining companies (vs the large and medium companies) may refer to public health care services.

According to Dr Edwards (personal communication); there are approximately 15 audiologists who provide clinical, mainly diagnostic services to the mining industry (personal communication: 12th November 2016). These audiologists are located in Rustenberg, Witbank and Welkom and are there are also a group of audiologists who work directly for the mines, with a smaller group of audiologists to whom mining companies may make direct referrals. The number/availability of this workforce needs to be considered in relation to the fact that there currently there are approximately 500 000

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mine workers with approximately two million ex-mine workers, many of whom are migrant workers from within and outside South Africa (SA News, 2016).

Diagnostic evaluations may include the use of electrophysiological audiological measures such as oto-acoustic emissions and auditory brainstem responses audiometry.

Furthermore, while speech audiometry is critical to determining the nature of the hearing loss, due to the majority of English/Afrikaans first language speaking audiologists in South Africa it is likely that not only are audiological services provided in e.g. ‘fanakalo’ (pidgin/ simplified isiZulu) or via interpreters, standardised test materials are not used as they do not exist. However, no matter where or how it is mine workers have their hearing assessed, it is more likely that if a hearing loss is identified then the worker is either re-assigned to another job and obtains compensation (usually calculated based on salary). Sometimes, mine workers receive hearing aids (depending on, e.g., RMA follow up/compensation) and even more rarely do they receive aural rehabilitation.

Furthermore, the mining companies almost always have training departments who are usually responsible for training workers on how to prevent a hearing loss. Edwards (2016, personal communication) reported that there are a number of in-house technical training courses, e.g. safety courses for blasting tickets (of competence) and operational management.Hearing conservation programmes were predominantly characterised, prior to the newer regulations and laws (reviewed above), with the monitoring of mine workers’ hearing and noise exposure management. As stated above, while the combined effects of ototoxic chemicals and noise has been established; at best there is some level of awareness in the mining sector (Edwards, 2016, personal communication), but it is certainly not central to hearing conservation programmes.

In the last 8-10 years the mining industry has targeted a reduction in the number of workers with a percentage loss of hearing (PLH) greater than 10% (goals were set for 2008). Similarly, mining companies’ espoused a desire to reduce machinery emitting noise levels of greater than 110 dBA by 2013. These targets represent the sectors’ attempts to improve the prevention of NIHL. While almost 5 years ago, Edwards (2012) reported 67% of South African mineworkers were exposed to noise levels of 85 – 105 dBA (TWA8h) and that between 1998 and 2003, R448 million was paid out in NIHL compensation claims (Hermanus, 2006). Currently, South African compensation laws are considered to be generous.

Mine workers are predominantly male, ages range from 20 years to 60 years with the vast majority being 20-40 years of age, and Black African. Older (ex) mine workers (about 5560 years) may have low levels of literacy as compared to younger, current mine workers who are more likely to have matriculated from high school. Edwards (2016, personal communication) is of the opinion that a hearing loss is almost certain for the vast majority of mine workers who have worked for at least 15 years of more; and for those who have worked for 25 years or more they are sure to have a mild/moderate hearing loss.

Mine workers exposed to noise bear the same vocational profile of those described above, in relation to noise sources and work as fitters/turners, riggers, drillers, etc. all of whom may be exposed to loud levels of noise of varying types, including impact noise.

The South African government has developed an initiative for current and ex-mineworkers to deliver health, social and rehabilitation services – alongside access to compensation

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and social protection benefits. This initiative is reinforced by government departments, employer organisations, labour unions, development partners, NGOs and ex-mineworker associations. This is being offered via a ‘One Stop’ service delivery framework that provides (i) a comprehensive database of all (current and ex-) mineworkers; (ii) mapping mine sites and services in relation to workers/ex-workers’ location; (iii) delivery of health, social and rehabilitation services; (iv) access to compensation services and (v) access to social protection benefits viz., Unemployment Insurance, Provident and Pension Funds.

5 References AllAfrica (2016). South Africa: Deputy Minister Godfrey Oliphant – Social Protection Benefits for ex-mineworkers. 22 July 2016. Retrieved on 10th October 2016. http://al lafrica.com/ stories/201607221023.html Amedofu, G.K. (2002). Hearing-impairment among workers in a surface gold mining company in Ghana. Afr J Health Sci.; 9(1-2):91-7.

Appollonio, I., Carabellese, C., Frattola, L. & Trabucchi, M. (1996). Effects of sensory aids on the quality of life and mortality of elderly people: A multivariate analysis. Age Ageing; 25:89-96.

Babisch, W. (2011). Cardiovascular effects of noise. In J.O. Nriagu (ed) . Encyclopedia of Environmental Health. Burlington: Elsevier: 532-42.

Bauer, E.R. & Kohler, J.L. (2000). In G.R. Bockosh, M. Karmis, J. Langton, M.K. McCarter & B. Rowe (eds.). Proceedings of the 31st Annual Institute on Mining Health, Safety and Research, Roanoke, Virginia, August 27-30. Blacksburg, VA: Virginia Polytechnic Institute and State University, Aug; :17-31.

Bartholomae, R.C. & Parker, R.P. (1983). Mining Machinery Noise Control Guidelines.

Report No. I 28.16/2:M66/8. Pittsburgh, PA: Bureau of Mines, United States Department of the Interior, 1983; 87.

Basner, M., Babisch, W., Davis, A., Brink, M., Clark, C. Janssen, S and Stansfeld, S. (2014).

Auditory and non-auditory effects of noise on health. Lancet. April 12; 383(9925): 1325–1332. doi:10.1016/S0140-6736(13)61613-X. Boothroyd, A. (2007). Adult aural rehabilitation: what is it and does it work. Trends Amplif.

11(2): 63-71. doi: 10.1177/1084713807301073 Chadambuka, A., Mususa, F. & Muteti, S. (2013). Prevalence of noise induced hearing loss among employees at a mining industry in Zimbabwe, African Health Sciences; 13 (4): 899–906. doi: 10.4314/ahs.v13i4.6 Carabellese, C., Appollonio, I., Rozzini, R., Bianchetti, A., Frisonni, G.B., Frattola, L., et al.

(1993). Sensory impairment and quality of life in a community elderly population. J Am Geriatr Soc; 41:401-7.

Chamber of Mines of South Africa (2016). Integrated Annual Review 2015. Johannesburg: Chamber of Mines. Accessed on 27/11/16. Available at: http://www.chamberofmines.org. za/industry-news/publications/annual-reports Dobie RA. The burdens of age-related and occupational noise-induced hearing loss in the United States. Ear Hear. 2008; 29(4):565–77.

Donoghue, A.M. (2004). In-depth reviews: occupational health hazards in mining: an overview. Occupational Medicine, 54:283–289 doi:10.1093/occmed/kqh072 Edwards, A., Dekker, J.J. & Franz, R.M. (2011). Profiles of noise exposure levels in South African mining. Journal of the Southern African Institute of Mining and Metallurgy; 11:315-22.

Erdman, S., Crowley, J. & Gillespie, G. (1984). Considerations in counseling for the hearing impaired. Hear Instr;35:50-8

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Hessel, P.A. & Sluis-Cremer, G.K. (1987). Hearing loss in white South African goldminers.

South African Medical Journal. 21:71(6): 364-7.

Hetu, R., Jones, L. & Getty, L. (1993) The impact of acquired hearing impairment on intimate relationships: Implications for rehabilitation. Audiology; 32:363-81.

Jack, S. (2016). 700 000 unclaimed ex-miners benefits. The New Age. 22 July 2016.

Accessed on 20th October 2016 from http://www.thenewage.co.za/700-000-unclaimedex-miners-benefits/ Kochkin, S. & Rogin, C.M. (2000). Quantifying the obvious: The impact of hearing instruments on the quality of life. Hear Rev; 7:6-34.

Lie, A., Skogstad, M., Johannessen, H.A., Tynes, T., Mehlum, I.S., Nordby, K, Engdahl, B. & Tambs, K. (2016). Occupational noise exposure and hearing: a systematic review.

International Archives of Occupational Environmental Health; 89: 351-371. DOI 10.1007/ s00420-015-1083-5.

Matetic, R.J., Randolph, R.F. & Kovalchik, P.G. (2010). Hearing Loss in the Mining Industry: The Evolution of NIOSH and Bureau of Mines Hearing Loss Research in J.F. Brune (2010) (ed). Extracting the Science: A Century of Mining Research. Littleton, CO: Society of Mining, Metallurgy, and Exploration: 23-29 McBride, D. (2004). In-depth reviews: noise induced hearing loss and hearing conservation in mines. Occupational Medicine, 54:290-6. doi:10.1093/occmed/kqh075.

Mdaka, T.C. (2015). Assessment of noise levels in work areas at he Polokwane platinum smelter, South Africa. Unpublished masters dissertation, M.Sc. Faculty of Science & Agriculture, School of Molecular & Life Science: University of Limpopo, Turfloop Campus.

Morata, T.C., Themann, C.L., Randolph, R.F., Verbsky, B.L., Byrne, D.C., & Reeves, E.R. (2005). Working in noise with a hearing loss: Perceptions from workers, supervisors, and hearing conservation program managers. Ear Hear; 26:529-5.

Musiba, Z. (2015). The prevalence of noise-induced hearing loss among Tanzanian miners.

Occupational Medicine; 65: 386–390. Advance Access publication 28 April 2015 doi:10.1093/occmed/kqv046 National Institute for Occupational Safety and Health (NIOSH). (2016). Noise and Hearing Loss Prevention. Accessed 27 November 2016. http://www.cdc.gov/niosh/topics/noise/ Pillay, M. (2001). Hearing Conservation Programmes: For Employers/Workers? Paper presented at the American Academy of Audiology 14th Annual Convention. Philadelphia: USA. Philips, J.I., Nelson, G. & Ross, M.H (2006). Preventing adverse effects of noise and vibration in the South African mining industry, Afr Newslett on Occup Health and Safety 2006;16:33–35.

Rabothatha, S. (2016). Getting benefits to ill mine workers. The New Age. 27 July 2016.

Retrieved on 10th October 2016 from http://www.thenewage.co.za/getting-benefits-to-illmine-workers/ Rawool, V.W. (2012). Hearing Conservation: in occupational, recreational, educational, and home settings. Thieme: New York, USA. Roberts, B., Sun, K. & Neitzel, R. L. (2016). What can 35 years and over 700,000 measurements tell us about noise exposure in the mining industry? International Journal of Audiology, Published online 22 Nov 2016. http://dx.doi.org/10.1080/14992027.2016.1 255358 SA News (2016). Ex-mineworkers receive R59m in compensation. 22 Julu 2016. Accessed on 07 December 2016. http://www.sanews.gov.za/south-africa/ex-mineworkers-receiver59m-compensation Scherer, M.J. & Frisina, D.R. (1998). Characteristics associated with marginal hearing loss and subjective well-being among a sample of older adults. J Rehabil Res Dev; 35:420-6

APPENDIx 2

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Staudt, A.M. (2016). Effects of exposure to organic solvents and occupational noise on hearing loss and tinnitus in US adults from 1999 to 2004. Unpublished Doctoral Thesis.

The University of Texas School of Public Health, ProQuest Dissertations Publishing, 2016.

10183289.

World Health Organization (2016). Deafness and hearing loss. Factsheet No 300. Retrieved 0n 02 November 2016 from http://www.who.int/mediacentre/factsheets/fs300/en/ Legal Documents, Practice Standards & Guidelines Compensation for Occupational Injuries and Diseases Act (COIDA) with particular reference to Instruction 171 (Schedule 3) Department of Minerals and Energy (DME), (2000). Guideline for the compilation of a mandatory code of practice on Minimum Standards of Fitness to Perform Work at a mine. DME 16/3/2/3 A1 Department of Minerals and Energy (DME), (2003). Mine Health and Safety Inspectorate guideline for the compilation of a mandatory code of practice for an occupational health programme (occupational hygiene and medical surveillance) for noise, DME 16/3/2/4 A3 GUIDELINE FOR A MANDATORY CODE OF PRACTICE ON THE MINIMUM STANDARDS OF FITNESS TO PERFORM WORK ON A MINE Government Notice R147 in Government Gazette 39656 dated 5 February 2016. Effective date: 30 June 2016 Mine Health and Safety Act (MHSA), 1996 (Act no. 29 of 1996), Regulation 9.2.

Mine Health and Safety Act: Regulations: Guidance note for implementation of standard threshold shift in medical surveillance of noise induced hearing loss (Gazette 40142, Notice R839)] Published under GNR 839 of 15 July 2016 MINE HEALTH AND SAFETY ACT 29 OF 1996 Government Notice 967 in Government Gazette 17242 dated 14 June 1996. Commencement date: 15 January 1997 for all sections with the exception of sections 86(2) and (3), which came into operation on 15 January 1998. [Proc. No.4, Gazette No. 17725, dated 15 January 1997].

Occupational Health and Safety Act, (Act 85 of 1993) and related Noise-Induced Hearing Loss Regulations (No. R. 307, 7 March 2003) Occupational Diseases in Mines and Works Act, Act 78 SABS 1451: Part I. South African Standard. Standard Specification for Hearing Protectors, Part I: Ear muffs (Definition of “SABS 1451 Part I” inserted by Regulation 2(d) of Government Notice R489 in Government Gazette 15560, dated 18 March 1994) SABS 1451: Part II. South African Standard. Standard Specification for Hearing Protectors, Part II: Ear plugs (Definition of “SABS 1451 Part II” inserted by Regulation 2(d) of Government Notice R489 in Government Gazette 15560, dated 18 March 1994) South African National Standards (SANS), 2013. SANS 10083:2013. The measurement and assessment of occupational noise for hearing conservation purposes. Edition 5.2 SANS 11201: 2013 Acoustics, Noise emitted by machinery and equipment – Determination of emission sound pressure levels at a work station and at other specified positions in an essentially free field over a reflecting plane with negligible environmental corrections.

• SANS 10152 Calibration of pure-tone audiometers Part 1: Air conduction Calibration of pure-tone audiometers Part 2: Bone conduction • SANS 10154-2012 (SANS, 2012) • SANS 10182:2006 ‘The determination of the sound insulation performance of an audiometric booth or a mobile audiometric facility in a non-laboratory environment’ (SANS, 2006).

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appendiX 3 injury categorisation table 1: Categorisation of Injury from MBOD Data

table 2: Categorisation of Injury from RMA data

APPENDIx 3

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appendiX 4 table 3: Categorisation of Injury from DOL data

QUESTIONNAIRE OF ACCESSIBILITY AND ACCEPTABILITY OF REHABILITATION SERVICES FOR EX-MINE WORKERS WHO HAD AN INJURY AT WORK introduction Scripting for interviewer: ‘This questionnaire is part of the tracking and tracing of ex-mine workers and will help us understand more about what is happening for ex-mine workers who had an injury at work.

The questions that I will be asking you will help us get information about your experience of the help and support you received following your injury. The answers to the questions will help in developing services further.

This information will be kept confidential. In other words, no one will be able to identify that you were the one who answered these questions. So we need you to be as honest as possible about what you thought of the services.

Would you be willing to help us answer some short questions? It will take about 15 minutes.’

table 4: Categorisation of Injury from ECF fieldwork Data

If ‘No’, Interviewer thanks ex-mine worker.

If ‘Yes’, Interviewer thanks ex-mine worker and proceeds with the following:

‘Some of the questions we will be asking you about equipment. This means things like crutches or wheelchairs or like a special aid to help you get in and out of bed for example.

Some of the questions talk about daily tasks. This means things like getting washed or dressed or going to the toilet by yourself Also, when we speak about treatment, we mean all the help you received from nurses, doctors and therapists who helped you recover after your injury.

If you are unsure about what we are asking, please ask’

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APPENDIx 4

109

1

Did you have an injury while working on the mine?

NO

YES

If yes continue below. If no, go to SECTION 6 ENHANCING CARE FOUNDATION FINAL REPORT: MARCH 2017

2

How long ago were you injured at work?

3

Where on your body was your injury? (tick all that are applicable)

0-2 years

Head

2-4 years

Left Leg

4-8 years

Right Leg

Left arm Right arm Both arms SECTION 2: About Injury

Left hand your Right hand (continued) Eyes

4

8 years or more Both legs Back Ears

Were you able to go back to work after your injury

Yes No

If yes, complete questions 5, 6 and 7 below. If no, please go to SECTION 3)

registration (To be used in conjunction with Miners Register Form V12)

Ex-mine workers name: Contact number: Passport/ID number (if known):

5

Did they train you how to do your job again?

6

Where did you have you care and treatment? (tick all that are applicable)

YES

NO

At the hospital on the mine

At another hospital away from the mine

Other

I did not receive treatment

Address:

7

Industry Number:

Did you go back to your original job or did you get a new job? (please tick 1 box only) I went back to my old job

I went on to do a different job

Company number: Verbal Consent Obtained?

YES

NO

Gender:

MALE FEMALE

Date of Birth:

___/___/______ Date/Month/Year

Urban or Rural living

URBAN

RURAL

SECTION 1: ABOUT YOUR WORK HISTORY

1

2 3

4

5-10 years

10-15 years

15 years or more

What was your position? (please write in box here)

Platinum

Diamonds

Coal

Did you operate heavy machinery?

YES NO

Did you have an injury while working on the mine?

NO

YES

If yes continue below. If no, go to SECTION 6

2

How long ago were you injured at work?

3

Where on your body was your injury? (tick all that are applicable)

0-2 years

2-4 years

4-8 years

8 years or more

Head

Left Leg

Right Leg

Both legs

Left arm

Right arm

Both arms

Back

Left hand

Right hand

Eyes

Ears

4

Were you able to go back to work after your injury

Yes No

2

Was the place where you received the help after your injury far from your home?

Yes No

3

Did you have to pay for transport to get to the place where you received the care or treatment for your injury?

Yes No

4

Did you receive care or treatment for your injury soon after being injured?

Yes No

5

Did you have to pay for any of the care or treatment you received after your injury?

Yes No

Other

SECTION 2: About your Injury

1

Did you receive help or treatment that showed you how to get back to doing your daily tasks after your injury?

If no go to SECTION 5. If yes continue below

What types of mines did you mainly work at? (tick all that are applicable) Gold

1

How many years did you work on the mine?

0-5 years

SECTION 3: Accessibility (please circle yes or no)

SECTION 4: Acceptability (please circle yes or no)

1 2 3

Did you feel that you received enough care or treatment?

Yes No

Were you happy with the care or treatment you received?

Yes No

4 5

Were your family involved in your care or treatment?

Yes No

Did you receive any equipment, like a wheelchair, to help you to get about?

Yes No

6

Do you feel that you need more equipment to help you with your daily tasks?

Yes No

7

Did they come and see how you managed at home after your injury?

Yes No

8

Did they make any changes to your home to make it easier for you to get about or do your daily tasks?

Yes No

Did you feel welcome and cared for while you were

being treated? Yes No

Yes No

If yes, complete questions 5, 6 and 7 below. If no, please go to SECTION 3)

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5

Did they train you how to do your job again?

6

Where did you have you care and treatment? (tick all that are applicable)

At the hospital on the mine

YES

NO

At another hospital away from the mine

APPENDIx 4

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appendix 5

SECTION 5: SERVICES RECEIVED TODAY

1

Do you struggle today to go about your daily tasks because of your injury?

Yes No

2

Do you receive care or treatment for your injury now?

Yes No

If Yes, answer all questions in section 5. If No, go to question 6, 7 and 8 only

3

Where are you getting this from? (please tick 1 box only)

The main hospital in town

I go to a special hospital run by the Rand Mutual Assurance

Someone comes to my home

4

The local clinic in or near to my village

Doctor

Occupational Therapist Community Care Giver Do you find it easy to get to the place where you have your care and treatment?

Yes No

6

Do you have to pay for someone to look after you?

Yes No

7

Do you receive money or a pension because you are injured?

Yes No

8

Did you apply for money because you were injured and have not yet been paid?

Yes No

With age

I had an accident that was not related to work

I got a disease and this made me disabled Do you receive a pension or allowance?

3

If yes, who do you receive your pension/allowance from? (tick all that are applicable) Other

role (e.g. family member/ ex-miner/community care worker

disability type

consent y/n

Mineworkers Provident Fund

4 5

2

Sentinel

attendee name

3

I had an accident while traveling to and from the mine

no.

2

RMA

fsd unique id no

1

How did you become disabled? (tick all that are applicable)

The mine

country & region

scribe

SECTION 6: About your disability

date

facilitator

Physiotherapist

5

1

EX-MINE WORKER WITH INJURIES

location

Who do you get care or treatment from? (tick all that are applicable) Nurse

FOCUS GROUP PAPERWORK

Yes No

6 Scripting for facilitator: ‘Thanking for agreeing to speak to us about your injury or disability. We have asked you to talk to us because we want to find out more information about the challenges and difficulties you may have because of your disability in your everyday life. This will help us tell government and authorities where there are gaps or problems. This may help with services in the future.

The information you share with us today will be held confidentially. In other words, you won’t be identified about what you tell us today’

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Prompt Questions Please tell me about the types of difficulties you have at home which are due to your

injury or disability?

– Probe: • How has your disability affected the quality of your life?

• Do you have difficulty in getting washing and dressed?

• Do you have difficult looking after yourself in terms of cooking and cleaning?

• Do you find it difficult to get around your home to do what you need to do?

• Do you have to rely on someone to look after you?

What types of things would make your quality of life better for you at home given your

disability?

In your view, what types of services/support do you think should be available to ex-mine workers who have been injured?

– Probe: • Who do you think should receive such services?

• What do you think is the best way to ensure that those services are made available to those who need them?

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appendiX 6 Tables and Analysis of Questionnaires 1 Data analysis Data processing and analysis were performed in, Excel 2010, Stata 13, and R - studio version. 3.3.2. Subjects’ demographic, health and professional characteristics – which were largely measured as categorical variables - were summarised using frequencies and percentages, in both graphical and tabular forms. Categorical measures of accessibility to occupational health services were transformed into a composite accessibility score (%) whereas categorical measures of acceptability of occupational health services were transformed into a composite acceptability score (%). These scores were compared across countries using a strip-plot in Stata which showed means (µ) and score distributions by country.

Exploratory bivariate analysis was carried out using cross tabulation of dependant categorical variables [a) return to the mine after injury, and b) ability to perform daily tasks] and independent variables which included different types of disability suffered while working at the mines and the types of mines where ex-mineworkers worked.

Pearson’s Chi Square or Fisher’s exact tests were used to assess if there were significant relationships between categorical dependant variables and categorical independent variables. The independent variables with p-value less than 0.25 during bivariate analysis were selected as candidates for multivariate logistic regression analysis which sought to determine the predictors of returning to work at the mines after an injury. In the multivariate model, association between the dependant and independent variables were estimated using Odds Ratios (ORs) and 95% Confidence Intervals(CI). The ORs and Cis were plotted in R studio to enhance visual inspection of the relationships between the independent and dependant variables. Kruskal Wallis test was used to test if the composite accessibility scores and composite acceptability scores were significantly different across respondents’ countries of origin. Statistical association was considered significant if p-value is <0.05.

2 Results Activity 2 had a response rate of 703 participants from all four countries combined.

Demographic, occupational and health characteristics of these participants are presented in Table 1.

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2.1 Respondents’ characteristics table 1: Respondents’ demographic, health and occupational characteristics (n=703)# characteristic

n (%)

Age category 30-49 50-69 >70 country Lesotho Mozambique South Africa Swaziland

5-10 years 11-15 years >15 years

88(12.64) 193(27.73) 319(45.83) 96(13.79)

Miner Mining support staff Other

42(6.07) 86(12.43) 105(15.17) 459(66.33) 104(16.33) 239(37.52) 222(34.85) 72(11.30)

worked in a gold mine

606(86.20) 97(13.80)

Yes No worked in a platinum mine No worked in a diamond mine

6(0.85) 697(99.15)

Yes No

34(4.84) 669(95.16)

No

12(1.71) 691(98.29)

No

673(97.54) 17(2.46)

duration of the injury <2 years 2-4 years 5-8 years

40(6.17) 20(3.09) 73(11.27) 515(79.48)

As can be seen in Table 1, most respondents (76%) were aged between 50 and 70 years, 46% were from South Africa, followed by Mozambique (28%). A large proportion of respondents had served in the mines for more than 15 years (66%), 37% and 35% were employed as miners or mining support staff at the mine respectively, and more than ¾ worked in the gold mine. The clear majority (61%) operated heavy machinery during their tenure at the mines, and almost everyone interviewed (97.5%) was injured in one way or another while working in the mines. Of those injured at work, 79% had had the injury for more than 8 years, and only 65.7% could return to work post the injury. Treatment for injury was received mostly at the hospital mine (51%) and almost every one injured indicated that they received treatment (96%).

figure 1 Distribution of location of injury among survey participants 18%

ears

82%

17%

back

83%

16%

right hand

84%

16%

left leg

84%

15%

eyes

85%

right leg

86%

left hand

88%

head

92%

5%

right arm

95%

5%

both legs

95%

4%

left arm

96%

both arms

99%

able to return to work post injury Yes No

432(65.75) 225(34.25)

job retraining post injury Yes No

201(48.91) 210(21.09)

14%

received treatment and care at the mine hospital Yes No

12% 8%

362(51.49) 341(48.51)

received treatment & care from a hospital away from the mine No

32(4.55) 671(95.45)

1%

received treatment from other service providers Yes No Yes No Returned to original job Went to do a different job

yes

4(0.57) 699(99.43)

no

30(4.27) 673(95.73)

With regards to the location of injury, Fig 1 shows that hearing loss constituted the highest burden of injury in the study sample (18%), followed by back injury (17%), then right hand injury (16%), left leg injury (16%) ad eye injury (15%). A very small proportion reporting having been injured on both arms (1%).

255(64.23) 142(35.77)

2.2 Accessibility and acceptability of receives received

after the injury

worked in other types of mine Yes

Yes

did not receive treatment

worked in a coal mine Yes

417(61.60) 260(38.40)

injured working in the mine

Yes

87(12.38) 616(87.62)

Yes

No

>8 years

position at the mine Leadership

Yes

No

years of work at the mine <5 years

n (%)

operated heavy machinery

2(0.33) 56(9.18) 465(76.23) 87(14.26)

<30

characteristic

a)Accessibility * Miner – All descriptions which involved use of machinery or establishment of physical structures underground; Miner support staff – Electricians, plumbers, riggers, etc; Leadership – Team leaders, supervisors, etc; Other – Health and safety, catering, ‘boy’

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descriptions, and descriptions that weren’t discernible. # n does not always equal 703 across characteristics.

Not all respondents answered to all the questions.

Respondents’ perceptions about the accessibility of occupational health services were measured using five measures which are summarised in Fig 2. Composite scores which were computed from these measures were summarised by country and are presented in Fig 3.

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figure 2 Participants views on the accessibility of occupational health services (n= 391-395) Received care or treatment for their injury soon after being injured

93%

Place where help was received after the injury was far from their home

72%

Received help or treatment that showed them how to get back to doing their daily tasks after injury

56%

Had to pay for transport to get to the place where they received the care or treatment for their injury Had to pay for any of the care or treatment received after their injury

19% 12% no

As shown in Fig 2, 93% of respondents received care or treatment for their injury after being injured but 72% of these reported that the place where they received care after the injury was far from their home. Only 56% were informed on how to get back to doing their daily tasks after injury, but very few (19%) had to pay for transport to access health services, or pay for services rendered (12%).

figure 3 Strip-plot showing the distribution of composite accessibility scores by country of origin (n= 391-395)

Fig 3 shows that on average, based on the mean composite accessibility scores (%), respondents from Swaziland were more satisfied with their access to health services compared to respondents from other countries, a result which was statistically significant (2(2) = 65.266, p = 0.0001). Mozambique had the lowest level of tolerance towards accessibility.

section 5 APPENDICES

Respondentsâ&#x20AC;&#x2122; perceptions about the acceptability of occupational health services were measured using eight measures which are summarised in Fig 4. Composite percent scores which were computed from these measures were summarised by country and are presented in Fig 5.

figure 4 Participants views on the acceptability of occupational health services (n= 400-403)

yes

118

b) Acceptability

Felt welcome and cared for while they were being treated?

89%

Happy with the care or treatment they received?

81%

Felt that they received enough care or treatment?

79%

Receive any equipment, like a wheelchair, to help them get about?

59%

Felt that they need more equipment to help them with their daily tasks?

37%

Family members involved in their care or treatment?

37%

Someone came to see how they managed at home after their injury?

21%

Changes made to their home to make it easier for them to get about or do their daily tasks?

11% yes

no

It is seen in Fig 4 that majority were happy with the treatment they received (81), felt welcome and cared for while they were being treated (89%), and felt that they received enough care or treatment (79%). However, only 21% indicated that they someone came to see how they managed at home after their injury and a small proportion (11%) had changes made to their home to make it easier for them to get about or do their daily task.

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figure 5 Strip-plot showing the distribution of composite acceptability scores by country of origin (n= 400-403)

Table 2 shows that at the time of the survey, 71% of respondents reached still struggled to go about their daily tasks because of injury and only 27% still received care or treatment for their injury. A very small proportion reported currently receiving care or treatment from the main hospital in their town, hospital run by RMA, a local clinic near their village, or a care provider who visits their home. Only 16% indicated that they received care from a doctor. Significantly few others were being seen by a physiotherapist (5.69), an occupational therapist (1.7%), a nurse (9%), and a community caregiver (1.3%). The results in Table 2 also show that only 42.32 were receiving money/pension due to injury but only 13% had not been paid even though they had applied for money because they were injured. Very few had to pay someone to look after them (14%).

Again, as shown in Fig 5, respondents from Swaziland were more accepting of the health services provided to them compared to other countries, based on the mean composite acceptability scores (%). This difference was also statistically significant (2(2) = 36.635, p = 0.0001), with South Africa showing the lowest level of acceptability.

2.4 Relationship between use of heavy machinery and location of injury table 3 Relationship between use of heavy machinery and location of injury, using cross tabulations with Pearson Chi-square or Fisher’s exact tests and p-values Use of heavy machinery “Yes” – n (%) “No” – n (%)

variable Head injury Left leg injury Right leg injury

2.3 Current health status and services received

Both legs injury

table 2 Respondents’ opinions regarding the services they receive and where (n=703) # variable

Left arm injury “YES” – n (%)

“NO” – n (%)

Still struggle to go about daily tasks because of injury

454(71.38)

182(28.62)

Still received care or treatment for their injury

158(26.64)

435(73.36)

Getting care or treatment from the main hospital in town

75(10.67)

628(89.33)

Getting care or treatment from a special hospital run by RMA

109(15.50)

594(84.50)

Getting care or treatment from the local clinic in or near to their village

29(4.13)

674(95.87)

Getting care or treatment through some who comes to their home

16(2.28)

687(90.75)

Receive care or treatment from a nurse

65(9.25)

638(90.75)

Receive care or treatment from a doctor

116(16.50)

587(83.50)

Receive care or treatment from a physiotherapist

40(5.69)

663(94.31)

Receive care or treatment from an occupational therapist

12(1.71)

691(98.29)

Receive care or treatment from a community caregiver

9(1.28)

694(98.72)

Easy to get to the place where they have their care and treatment

87(49.71)

88(50.29)

Have to pay someone to look after them

76(13.94)

469(86.06)

Receive money/pension due to injury

226(42.32)

308(57.68)

Had not been paid even though they had injury and had applied for money

67(13.04)

447(86.96)

# n does not always equal 703 across characteristics. Not all respondents answered to all the questions.

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Right arm injury Both arms injury Back injury Left hand injury *: p-value for Chisquared (2) test or Fisher’s exact test (if expected cell count < 5) used to compare categorical variables by study arm

Right hand injury Eyes injury Ear injury

Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No

18(33.33) 242(38.84) 41 (35.96) 219 (38.90) 34 (35.05) 226 (38.97) 12 (35.29) 248 (38.57) 12 (46.15) 248 (38.10) 19 (51.35) 241 (37.66) 5 (62.50) 255 (38.12) 40 (33.90) 220 (39.36) 29 (34.52) 231 (38.95) 42 (37.17) 218 (38.65) 45 (44.12) 215 (37.39) 33 (27.97) 227 (40.61)

36(66.67) 381(61.16) 73 (64.04) 344 (61.10) 63 (64.95) 354 (61.03) 22 (64.71) 395 (61.43) 14 (53.85) 403 (61.90) 18 (48.65) 399 (62.34) 3 (37.50) 414 (61.88) 78 (66.10) 339 (60.64) 55 (65.48) 362 (61.05) 71 (62.83) 346 (61.35) 57 (55.88) 360 (62.61) 85 (72.03) 332 (59.39)

p-value

0.424 0.557 0.463 0.702 0.407 0.096 0.159 0.268 0.435 0.767 0.198 0.011

Table 3 shows that in the study sample, there was a significant relationship between the use of heavy machinery and hearing loss (injury of the ear) but not with any other type of body injury (p=0.011). Another notable relationship was observed with the injury of the right arm but this was not statistically significant at any level of significance lower than 0.1%.

APPENDIx 6

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table 4 Relationship between ability to perform daily tasks and participants’ health,

table 5 Relationship between returning to work at the mines after injury and participants’ health, occupational and demographic characteristics: Cross tabulations with Pearson Chi-square or Fisher’s exact tests and p-values

occupational and demographic characteristics: Cross tabulations with Pearson Chisquare or Fisher’s exact tests and p-values

able to perform daily tasks “Yes” – n (%) “No” – n (%)

variable Position at the mines Leadership Miner Mining Support Staff Other Worked in a gold mine

Worked in a platinum mine

Worked in a diamond mine

Operated heavy machinery

Was injured at work

Head injury

Left Leg injury

Right Leg injury

Both legs injury

Left Arm injury

Right Arm injury

Both Arms injury

Back injury

Left Hand injury

Right Hand injury

Eyes injury

Ears injury

Duration of the injury 0 -2 years ago 2 – 4 years ago 4 – 8 years ago More than 8 years ago

Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No

29 (31.87) 68 (30.77) 54 (25.96) 20 (31.25) 153 (27.52) 29 (36.25) 18 (23.08) 164 (29.39) 2 (40.00) 180 (28.53) 101 (26.72) 77 (31.82) 182 (28.66) 0 (0.00) 25 (45.45) 157 (27.02) 29 (26.61) 153 (29.03) 24 (25.00) 158 (29.26) 0 (0.00) 182 (30.08) 3 (11.54) 179 (29.34) 13 (37.14) 169 (28.12) 1 (14.29) 181 (28.78) 32 (28.83) 150 (28.57) 25 (30.49) 157 (28.34) 34 (30.63) 148 (28.19) 28 (26.67) 154 (29.00) 34 (29.06) 148 (28.52)

62 (68.13) 153 (69.23) 154 (74.04) 44 (68.75) 403 (72.48) 51 (63.75) 60 (76.92) 394 (70.61) 3 (60.00) 451 (71.47) 277 (73.28) 165 (68.18) 453 (71.34) 1 (100.00) 30 (54.55) 424 (72.98) 80 (73.39) 374 (70.97) 72 (75.00) 382 (70.74) 31 (100.00) 423 (69.92) 23 (88.46) 431 (70.66) 22 (62.86) 432 (71.88) 6 (85.71) 448 (71.22) 79 (71.17) 375 (71.43) 57 (69.51) 397 (71.66) 77 (69.37) 377 (71.81) 77 (73.33) 377 (71.00) 83 (70.94) 371 (71.48)

13 (37.14) 6 (31.58) 13 (18.84) 140 (28.51)

22 (62.86) 13 (68.42) 56 (81.16) 351 (71.49)

p-value

0.624 0.106 0.248 0.572 0.171 0.526 0.004 0.610 0.395 0.001 0.049 0.251 0.399 0.957 0.688 0.605 0.629 0.906

0.212

The Pearson’s Chi-square and Fishers exact test results in Figure 4 show that in the study sample there was a relationship between the ability to perform daily tasks and having suffered a head injury (p=0.004), and injury on both legs (p=0.001), but not any other potential predictor.

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variable

*: p-value for Chisquared (2) test or Fisher’s exact test (if expected cell count < 5) used to compare categorical variables by study arm

*: p-value for Chisquared (2) test or Fisher’s exact test (if expected cell count < 5) used to compare categorical variables by study arm

Position at the mines Leadership Miner Mining Support Staff Other Worked in a gold mine Yes

No Worked in a platinum mine Yes

No Worked in a diamond mine Yes

No Operated heavy machinery Yes No Was injured at work Yes No Head injury Yes No Left Leg injury Yes No Right Leg injury Yes No Both legs injury Yes No Left Arm injury Yes No Right Arm injury Yes No Both Arms injury Yes No Back injury Yes No Left Hand injury Yes No Right Hand injury Yes No Eyes injury Yes No Ears injury Yes No

return to work at mines after injury “Yes” – n (%) “No” – n (%) 24 (24.24) 96 (42.67) 58 (27.49) 23 (34.33) 190 (33.04) 35 (42.68) 44 (50.57) 181 (31.75) 1 (25.00) 224 (34.30) 142 (36.41) 74 (29.60) 223 (34.05) 1 (100.00) 17 (30.36) 208 (34.61) 42 (37.50) 183 (33.58) 32 (32.32) 193 (34.59) 15 (45.45) 210 (33.65) 7 (26.92) 218 (34.55) 11 (30.56) 214 (34.46) 4 (50.00) 221 (34.05) 56 (48.70) 169 (31.18) 25 (28.74) 200 (35.09) 33 (29.73) 192 (35.16) 30 (28.85) 195 (35.26) 31 (25.83) 194 (36.13)

75 (75.76) 129 (57.33) 153 (72.51) 44 (65.67) 385 (66.96) 47 (57.32) 43 (49.43) 389 (68.25) 3 (75.00) 429 (65.70) 248 (63.59) 176 (70.40) 432 (65.95) 0 (0.00) 39 (69.64) 393 (65.39) 70 (62.50) 362 (66.42) 67 (67.68) 365 (65.41) 18 (54.55) 414 (66.35) 19 (73.08) 413 (65.45) 25 (69.44) 407 (65.54) 4 (50.00) 428 (65.95) 59 (51.30) 373 (68.82) 62 (71.26) 370 (64.91) 78 (70.27) 354 (64.84) 74 (71.15) 358 (64.74) 89 (74.17) 343 (63.87)

p-value

0.001 0.085 0.001 0.696 0.075 0.165 0.521 0.426 0.662 0.164 0.422 0.631 0.345 0.001 0.245 0.271 0.206 0.032

APPENDIx 6

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figure 6 Visualisation of the multiple binary logistic regression

It is seen in Fig 5 that returning to work at the mine after suffering an injury was associated with the position held by the study participant at the mines before the injury (p=0.001), working in a platinum mine (p=0.001), having suffered a back injury (p=0.001) and hearing loss (p=0.032). Other predictors were not associated with returning to work at the mine after suffering an injury. These relationships are further explored in a binary multiple logistic regression analysis, the results of which are presented in Table 6 and Figure 6.

model showing predictors of the returning to the mine for work after injury: Adjusted Odds Ratios (OR), 95% Confidence Intervals (CI), and significance levels (‘**’ < 0.01, ‘*’ < 0.05)

table 6 Multiple binary logistic regression model showing predictors of the returning to the mine for work after injury: Regression coefficients(ß), Adjusted Odds Ratios (OR), 95% Confidence Intervals (CI), and p-values.

predictors Worked in a gold mine Yes

No Worked in a platinum mine Yes

No Operated heavy machinery Yes No Both legs injury Yes No Back injury Yes No Eyes injury Yes No Ears injury Yes No

ß

Adjusted OR (95% CI)

* -0.21 * -0.21 * 0.37 * 0.31 * 0.607 * -0.15 * -0.55

* 0.51(0.28 – 0.93 * 0.81(0.46 – 1.42) * 1.45(1.04 – 2.03) * 1.36(0.66 – 2.78) * 1.83(1.21 – 2.77) * 0.85(0.53 – 1.34) * 0.57(0.36 – 0.89)

p-value

0.457 0.042 0.029 0.386 0.003 0.505 0.016

The multiple logistic regression model presented in Table 6 was fitted on a sample of 703 individuals. The model predicted that working at the platinum mine, having suffered a back injury, having operated heavy machinery, and noise-induced hearing loss (injury of the ear) were the only statistically significant predictors of returning to work after suffering an injury. The odds of not returning to work were 83% higher among those who had a back pain compared to those who had it (AOR=1.83, 95% CI=1.21 - 2.77, p=0.003), whereas those who had hearing loss were 43% more likely to return to work compared to those who had not suffered hearing loss (AOR=0.57, 95% CI=0.36 - 0.89, p=0.016).

Similarly, the odds of not returning to work were 45% higher among those who operated heavy machinery compared to those who didn’t (AOR=1.45, 95% CI=1.04 – 2.03), p=0.029). There was also a 19% chance of those who worked in the platinum mines to return to work compared to those who worked in other forms of mines. The regression model is further presented graphically in Fig 6.

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APPENDIx 6

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health Medical information

appendiX 7

MEDICAL CONDITIONS: (please tick as appropriate)

assessment of health and functioning Registration name

assessors

designation

Client Name Date of Assessment Client Reference Number (MRFv12) Signed Consent to Assessment

Demographic information (To be used in conjunction with Miners Register Form V12)

Gender Date of Birth Country Region Urban or Rural

Male Female ___/___/______ Date/Month/Year

condition

P

Vision Loss Hearing Loss High Blood Pressure Diabetes Arthritis Heart Disease Chronic Bronchitis or Emphysema Silicosis or Pneumoconiosis or Mesothelioma Asthma Back Pain or disc problems Migraine (recurrent headaches) Stroke Depression or anxiety Other Comments

condition

P

Leprosy Amputation Polio Gastritis or Ulcer Tumour or Cancer Any injury not related to work (please specify in comments box) Dementia Kidney Disease Skin Diseases Tuberculosis Mental or behavioural disorders Sleep problems Tinnitus

Assessors:...........................................................................................................................

Date of Assessment:............................................................................................................

Client Reference Number: .............................................................. R Gray ECF Aug 16

MEDICATIONS AND MEDICAL TREATMENT RECEIVED: Do you have access to the medicines you need?

Yes

How do you get your medicines?

From a clinic or hospital

No When I am seen by RMA They are delivered to me I collect them from a pharmacy

Where do you go for your medical treatment?

To the local clinic or hospital To the RMA facility To my local doctor or traditional healer

How often do you see a doctor or a nurse?

Once a month Once a quarter Once a year When I need to

Do you receive treatment from a traditional healer or sangoma?

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Yes No

APPENDIx 7

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Impairment level of impairment qualifier INJURIES: (Please mark on the picture if the person has any missing limbs or deformities and give detail in the box below)

code 0 1 2

No impairment Mild Impairment Moderate impairment

level of impairment qualifier

code

Severe impairment Not applicable

3 n/a

visual assessment

area

left eye

right eye

qualifier

Injuries Visual Acuity (Snellen) Glasses

N/A

Comments/Possible cause of visual deficits:

auditory assessment

area

left ear

right ear

qualifier

Audiometric Assessment Hearing Aids

N/A

Do you or your family think that you may have hearing loss?

Yes

No

Can you hear when someone calls you?

Yes

No

If you are listening to the radio/TV, do you have to put it louder?

Assessors:...........................................................................................................................

Date of Assessment:............................................................................................................

Client Reference Number: .............................................................. R Gray ECF Aug 16

Do you struggle to hear in busy places where there is a lot of noise around you? auditory assessment

area number 1 2 3 4 5 6

detail

qualifier

Descripton/comments (if applicable)

qualifier

Descripton (if applicable)

Muscle Strength Joint Mobility/ROM Muscle Tone Involuntary movements Continence: Bladder Continence: Bowel Pain Vestibular cognitive

area Orientation Motivation Memory Concentration

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APPENDIx 7

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communication

area

qualifier

Descripton (if applicable)

Expressive Receptive

home

barrier qualifier

psychological

area

qualifier

Descripton (if applicable)

Interpersonal interactions Family relationships Informal social relationships Intimate relationships Depression

code 0

No Barriers Mild Barriers

1

Moderate Barriers

2

Severe Barriers

3

Complete Barriers

4

description of dwelling

Social Isolation

Type:

Formal

environment

Number of rooms: Build Structure

Social situation Who do you live with?

Informal

Bricks and Mortar Traditional

Spouse/partner

Quality in relation to neighbours

Minor children

Fair

Adult children

Poor

Extended family Others

social context How many people live with you?

How many people in your household have regular incomes?

Do you have a regular source of income?

Where do you get your income from?

How many dependents are in your home environment?

130

Number: Yes/No Pension Informal work Formal work Number:

Do you have a good relationship with the chief/traditional leader?

Yes/No

Does anyone within your home care for you?

Yes/No

If someone in your home cares for you, do they get an income for this?

Yes/No

Are you left alone for long periods during the day?

Yes/No

Do you belong to any ex-mine workers associations and which ones?

Yes/No

Do any friends or neighbours help you daily?

Yes/No

Do you ever feel like you have lost you role and power in the household?

Yes/No

section 5 APPENDICES

aspect comments

Number:

Good

qualifier

description of barrier/comments

Access into dwelling Access indoors Access to toilet/bathroom Electricity/Lighting Heating Water Waste Outdoors community

aspect

qualifier

description of barrier/comments

Are you able to go out?

Can you access Health Care Services?

Are you able to access shops?

Are you able to access Banks/ e-wallet/cell phone banking?

Assessors:...........................................................................................................................

Date of Assessment:............................................................................................................

Client Reference Number: .............................................................. R Gray ECF Aug 16

APPENDIx 7

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self-care

area

functioning

level of functioning

equipment used

performance qualifier

level of functioning

equipment used

performance qualifier

Grooming (shaving, hair, teeth)

Activities of daily living

Washing Dressing

level of functioning

code

Independent = can perform activity Minimal Assistance = requires set up of environment or use of equipment/ assistive device

I ASE

Moderate Assistance = requires assistance of a person to complete

A01

Fully dependent = unable to perform or assist in activity Activity not applicable

D

Performance Qualifier (WHODAS) No difficulty Mild difficulty Moderate difficulty Severe difficulty Extreme difficulty or cannot do Not applicable â&#x20AC;&#x201C; does not perform this activity

code 0 1 2 3 4 5

Drinking Taking medications domestic

area

Making a hot drink Cooking Laundry

level of functioning

equipment used

performance qualifier

Managing Finances Shopping Assisting others in the home

Indoor Outdoor

work

Steps

Please indicate which is applicable below: ____________________________________________ (1) Paid employment (please specify with who and what) _________________________________________ (2) Informal employment (please specify with who and what) __________________________________ (3) Unemployed and unable to work (health reason â&#x20AC;&#x201C; please specify) ___________________________________________________________________________________ (4) Retired (5) Non-paid work, such as volunteer/charity ______________________________________________________ (6) Unemployed and able to work

Stairs Lifting/Carrying Objects Driving/Transport (bicycle, motorbike, car, horse etc) Wheelchair mobility transfers

area

Eating

Cleaning

N/A

mobility

area

Toileting

level of functioning

equipment used

performance qualifier

Bed mobility In/out bed On/off chair

aspects

comments

performance qualifier

Do you feel you are able to do your work tasks well?

Are you able to get your work done in the time you need to do it?

On/off toilet In/out of bath In/out of shower In/out of car/bus/taxi In/out of wheelchair

Assessors:...........................................................................................................................

Date of Assessment:............................................................................................................

Client Reference Number: .............................................................. R Gray ECF Aug 16

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leisure

aspects

activities engaged in

performance qualifier

Are you able to engage in your community by yourself?

How much of a problem do you have doing things for yourself for relaxation or pleasure?

APPENDIx 7

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COMMUNITY

summary

FUNCTIONING ACTIVITIES OF DAILY LIVING

Activities of daily living

LEVEL OF INDEPENDENCE

PERFORMANCE QUALIFIER

MOBILITY

health

TRANSFERS

SUMMARY

SELF CARE DOMESTIC WORK LEISURE

LIST OF PROBLEMS/ISSUES

ACTIONS REQUIRED

COMPENSATION Compensation received?

1 2 3 4 5 6

yes

no

Who provided the compensation?

Lump sum or Pension?

Amount?

Assessors:...........................................................................................................................

Date of Assessment:............................................................................................................

Client Reference Number: .............................................................. R Gray ECF Aug 16

INJURY PRIMARY INJURIES

IMPAIRMENT

COMMENTS

IMPAIRMENT QUALIFIER

VISUAL AUDITORY PHYSICAL COGNITIVE COMMUNICATION PSYCHOSOCIAL

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APPENDIx 7

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appendiX 8 figure 1 shows that most respondents were aged between 55 and 65 years

figure 3 shows that only 13 individuals examined did not have hearing loss

figure 4 As shown in Fig 4, most ex-mineworkers assessed had an indication of noise-induced hearing loss

figure 2 shows that there was no relationship between NIHL and age. The mean and medial age were almost the same between the two groups (p<0.436)

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APPENDIx 8

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references (133) verified – Harvard Referencing Style Amedofu, G.K., 2002. Hearing-impairment among workers in a surface gold mining company in Ghana. African journal of health sciences, 9(1), pp.91-97.

Appollonio, I., Carabellese, C., Fratolla, L. and Trabucchi, M., 1996. Effects of sensory aids on the quality of life and mortality of elderly people: a multivariate analysis. Age and ageing, 25(2), pp.89-96.

Babisch, W., 2011. Cardiovascular effects of noise. Noise and Health, 13(52), p.201.

Bauer, E.R. & Kohler, J.L. 2000. In G.R. Bockosh, M. Karmis, J. Langton, M.K. McCarter & B. Rowe (eds.). Proceedings of the 31st Annual Institute on Mining Health, Safety and Research, Roanoke, Virginia, August 27-30. Blacksburg, VA: Virginia Polytechnic Institute and State University, Aug; :17-31.

Bartholomae, R.C. and Parker, R.P., 1983. Mining machinery noise control guidelines, 1983: bureau of mines handbook (No. PB-84-152958). Bureau of Mines, Pittsburgh, PA (USA). Pittsburgh Research Center.

Basner, M., Babisch, W., Davis, A., Brink, M., Clark, C., Janssen, S. and Stansfeld, S., 2014. Auditory and non-auditory effects of noise on health. The Lancet, 383(9925), pp.1325-1332.

Boothroyd, A., 2007. Adult aural rehabilitation: What is it and does it work?. Trends in Amplification, 11(2), pp.63-71.

Booyens, M., Van Pletzen, E. and Lorenzo, T., 2015. The complexity of rural contexts experienced by community disability workers in three southern African countries: original research. African Journal of Disability, 4(1), pp.1-9.

Chadambuka, A., Mususa, F. and Muteti, S., 2013. Prevalence of noise induced hearing loss among employees at a mining industry in Zimbabwe. African health sciences, 13(4), pp.899-906.

Carabellese, C., Appollonio, I., Rozzini, R., Bianchetti, A., Frisoni, G.B., Frattola, L. and Trabucchi, M., 1993. Sensory impairment and quality of life in a community elderly population. Journal of the American Geriatrics Society, 41(4), pp.401-407.

Chamber of Mines of South Africa, 2016. Integrated Annual Review 2015. Johannesburg: Chamber of Mines. Available from http://www.chamberofmines.org.za/industry-news/ publications/annual-reports Chamber of Mines Fact Sheet, 2016. Available from http://www.chamberofmines.org.za/ industry-news/publications/fact-sheets/send/3-fact-sheets/197-fact-sheet-safety-in-themining-industry.

Chamber of mines of South Africa, 2016. Mine SA 2016 Facts And Figures pocketbook. Available from http://webcache.googleusercontent.com/ search?q=cache:u28ga6hJ1aMJ:www.chamberofmines.org.za/industry-news/ publications/facts-and-figures+&cd=1&hl=en&ct=clnk&gl=za Chappell, N.L. and Cooke, H.A., 2010. Age related disabilities-aging and quality of life.

International encyclopedia of rehabilitation, pp.1-3.

Compensation and other Social Protection Benefits for Workers and Ex-Workers in the Mining Sector (2014). Available from https://www.health-e.org.za/wp-content/ uploads/2014/04/South-Africa-compensation-and-other-benefits-brochure.pdf.

Compensation for Occupational Injuries and Diseases Act (1997). Available from http:// www.labour.gov.za/DOL/downloads/legislation/acts/compensation-for-occupationalinjuries-and-diseases/amendments/Amended%20Act%20-%20Compensation%20 for%20Occupational%20Injuries%20and%20Diseases.pdf.

138

references

Coetzee, Z., Goliath, C., van der Westhuizen, R. and Van Niekerk, L., 2011. Reconceptualising vocational rehabilitation services towards an inter-sectoral model. South African Journal of Occupational Therapy, 41(2), pp.32-37.

Darzi, A.J., Officer, A., Abualghaib, O. and Akl, E.A., 2016. Stakeholders’ perceptions of rehabilitation services for individuals living with disability: a survey study. Health and quality of life outcomes, 14(1), p.2.

Dasgupta, A.K. and Harrison, J., 1996. Effects of vibration on the hand-arm system of miners in India. Occupational medicine, 46(1), pp.71-78.

Denscombe, M., 2014. The good research guide: for small-scale social research projects.

McGraw-Hill Education (UK).

Department of Labour South Africa: Employment Equity Act (No. 55 of 1998). Available from http://www.labour.gov.za/DOL/downloads/legislation/acts/employment-equity/ eegazette2015.pdf.

Department of Minerals and Energy (2003). Mine Health and Safety Inspectorate guideline for the compilation of a mandatory code of practice for an occupational health programme (occupational hygiene and medical surveillance) for noise, DME 16/3/2/4 A3. Available from http://www.mhsc.org.za/sites/default/files/Occupational%20 Health%20Programme%20on%20Thermal%20Stress%20Guideline-%20Final%20 Gazette_0.pdf Department of Mineral Resources 2015/2016 Annual report, 2016. Available from http:// www.dmr.gov.za/publications/annual-report.html.

Department of Health and Human Services Centers for Disease Control And Prevention National Institute For Occupational Safety And Health, 2012. Morbidity and disability among workers 18 years and older in the Mining sector, 1997–2007 Available from https://www.cdc.gov/niosh/docs/2012-155/pdfs/2012-155.pdf Department of Labour, 2014. Compensation and other social protection benefits for workers and ex-workers in the mining sector. Available from https://www.health-e.org.za/ wp-content/uploads/2014/04/South-Africa-compensation-and-other-benefits-brochure. pdf Department of Mineral Resources South Africa, 1996. Mine Health and Safety Act (Act no.29 of 1996). Government Gazette No 967. Available from http://www.dmr.gov.za/ legislation/finish/30-mine-health-and-safety/530-mhs-act-29-of-1996/0.html Dillip, A., Alba, S., Mshana, C., Hetzel, M.W., Lengeler, C., Mayumana, I., Schulze, A., Mshinda, H., Weiss, M.G. and Obrist, B., 2012. Acceptability–a neglected dimension of access to health care: findings from a study on childhood convulsions in rural Tanzania.

BMC health services research, 12(1), p.113.

Dobie, R.A., 2008. The burdens of age-related and occupational noise-induced hearing loss in the United States. Ear and hearing, 29(4), pp.565-577.

Donoghue, A.M., 2004. Occupational health hazards in mining: an overview. Occupational Medicine, 54(5), pp.283-289.

Donoghue, A.M., Sinclair, M.J. and Bates, G.P., 2000. Heat exhaustion in a deep underground metalliferous mine. Occupational and environmental medicine, 57(3), pp.165-174.

Donoghue, A.M. and Sinclair, M.J., 2000. Miliaria rubra of the lower limbs in underground miners. Occupational medicine, 50(6), pp.430-433.

Duncan, E.M. and Watson, R., 2009. The occupational dimensions of poverty and disability. Institute for Land and Agrarian Studies (PLAAS). University of the Western Cape.

Edwards, A.L. and Kritzingert, D., 2012. Noise-induced hearing loss milestones: past and future. Journal of the Southern African Institute of Mining and Metallurgy, 112(10), pp.865-869.

139

ENHANCING CARE FOUNDATION FINAL REPORT: MARCH 2017

Edwards, A.L., Dekker, J.J., Franz, R.M., Van Dyk, T. and Banyini, A., 2011. Profiles of noise exposure levels in South African mining. Journal of the Southern African institute of Mining and Metallurgy, 111(5), pp.315-322.

Ehrlich, R.I., Churchyard, G.J., Pemba, L., Dekker, K., Vermeis, M., White, N.W., Thompson, M.L. and Myers, J.E., 2006. Tuberculosis and silica exposure in South African gold miners. Occupational and environmental medicine, 63(3), pp.187-192.

Ehrlich, R., 2012. A century of miners’ compensation in South Africa. American journal of industrial medicine, 55(6), pp.560-569.

Elwan, A., 1999. Poverty and disability: A survey of the literature. Washington, DC: Social Protection Advisory Service.

Fisher, W. a, Fisher, J. D., & Harman, J. (2003). The Information – Motivation – Behavioural Skills Model : A General Social Psychological Approach to Understanding and Promoting Health Behaviour. Infection.

Friedman, A. J., Cosby, R., Boyko, S., Hatton-Bauer, J., & Turnbull, G. (2009). EvidenceBased Series 20-2 IN REVIEW Effective Teaching Strategies and Methods of Delivery for Patient Education Section 1: Guideline Recommendations Section 2: Evidentiary Base Section 3: EBS Development Methods and External Review Process.

Functional Screening for Older Adults in the Community: HPB – MOH Clinical Practice Guidelines, 2010. Available from https://www.moh.gov.sg/content/dam/moh_web/HPP/ Doctors/cpg_medical/withdrawn/cpg_Functional%20Screening%20for%20Older%20 Adult.pdf Gaede, B. and Versteeg, M., 2011. The state of the right to health in rural South Africa.

South African Health Review, 2011(1), pp.99-106.

Global Disability Watch, 2016. Disability in the SDGs: call for celebration? Available from http://globaldisability.org/2016/02/18/disability-the-sdgs-call-for-celebration Graham, L., Moodley, J., Ismail, Z., Munsaka, E., Ross, E. and Schneider, M., 2014.

Poverty and disability in South Africa. Research Report 2014. Johannesburg, Centre for Social Development in Africa, University of Johannesburg.

Granville, A., 2001. Baseline survey of the mining and minerals sector. Report for Southern Africa.

Guideline for a Mandatory Code of Practice on the Minimum Code of Practice on the Minimum Standards of Fitness to Perform Work on a Mine. Government Notice R147 in Government Gazette 39656, 2016. Available from http://www.gov.za/documents/minehealth-and-safety-act-guideline-mandatory-code-practice-minimum-standards-fitness Hall, R; Sage, S; Dodd, K. Fatal Occupational Injuries among South African Miners.

Accessed from http://enhs.umn.edu/current/injuryprevent/mininginjuries/trends.html Hanass-Hancock, J. and Nixon, S.A., 2009. The fields of HIV and disability: past, present and future. Journal of the International AIDS Society, 12(1), p.28.

Hessel, G.K., 1987. Hearing loss in white South African goldminers. South African Medical Journal, 71(6), pp.354-367.

Hétu, R., Jones, L. and Getty, L., 1993. The impact of acquired hearing impairment on intimate relationships: Implications for rehabilitation. Audiology, 32(6), pp.363-380.

Instituto Nacional De Estatistica (INE), 2007. Census 2007. Available from http://www.ine. gov.mz/operacoes-estatisticas/censos/censo-2007/rgph-2007 Jack, S., 2016. 700 000 unclaimed ex-miners benefits. The New Age. 22 July 2016.

Available from http://www.thenewage.co.za/700-000-unclaimed-ex-miners-benefits/ Jelsma, J., Maart, S., Eide, A., Ka’Toni, M. and Loeb, M., 2007. The determinants of health-related quality of life in urban and rural isi-Xhosa-speaking people with disabilities. International Journal of Rehabilitation Research, 30(2), pp.119-126.

140

references

Kabzems, V. and Chimedza, R., 2002. Development assistance: Disability and education in Southern Africa. Disability & Society, 17(2), pp.147-157.

Kahonde, C.K., Mlenzana, N. and Rhoda, A., 2010. Persons with physical disabilities’ experiences of rehabilitation services at Community Health Centres in Cape Town. South African Journal of Physiotherapy, 66(3), pp.2-7.

Kamaleri, Y. and Eide, A.H., 2011. Living conditions among people with disabilities in Lesotho. A national representative study.

Kochkin, S. and Rogin, C.M., 2000. Quantifying the obvious: The impact of hearing instruments on quality of life. Hear Rev, 7(1), pp.6-34.

Leshota, L.P., 2013. Reading the National Disability and Rehabilitation Policy in the light of Foucault’s technologies of power: original research. African Journal of Disability, 2(1), pp.1-7.

Lesotho Bureau of Statistics. Available form http://www.bos.gov.ls/ Loeb, M., Eide, A.H., Jelsma, J., Toni, M.K. and Maart, S., 2008. Poverty and disability in eastern and western cape provinces, South Africa. Disability & Society, 23(4), pp.311321.

Lopes, E.C.U., 2013. Mozambique. Afr. Disability Rts. YB, 1, p.245.

Lord, J. and Stein, M.A., 2013. Prospects and practices for CRPD implementation in Africa. Afr. Disability Rts. YB, 1, p.97.

Lorenzo, T., 2012. Marrying community development and rehabilitation: Reality or aspiration for disabled people.

Lie, A., Skogstad, M., Johannessen, H.A., Tynes, T., Mehlum, I.S., Nordby, K.C., Engdahl, B. and Tambs, K., 2016. Occupational noise exposure and hearing: a systematic review.

International archives of occupational and environmental health, 89(3), pp.351-372.

Matetic, R.J., Randolph, R.F. and Kovalchik, P.G., 2012. Hearing Loss in the Mining Industry: The Evolution of NIOSH and Bureau of Mines Hearing Loss Research.

Mavundla, S.D. ‘Country report: Swaziland’, 2015. 3 African Disability Rights Yearbook, pp. 245-264. http://dx.doi.org/10.17159/2413-7138/2015/v3n1a11 McBride, D.I., 2004. Noise-induced hearing loss and hearing conservation in mining.

Occupational Medicine, 54(5), pp.290-296.

Mdaka, T.C., 2015. Assessment of noise levels in work areas at the Polokwane Platinum Smelter, South Africa (Doctoral dissertation, University of Limpopo).

Mendis, P., Kachingwe, A. & Khabele, I.K., 2009, Report: Evaluation of support to CBR Programme in Lesotho, Norwegian Association of Disabled, Oslo. Available from https:// www.norad.no/en/toolspublications/publications/ngo-evaluations/2011/evaluation-ofsupport-to-cbr-programme-in-lesotho/ Mine Health and Safety Council Handbook, 2014. South African Mining Industry Journey to Zero Harm 2003 to 2013. Available from http://www.mhsc.org.za/sites/default/files/ The%20South%20African%20Journey%20to%20Zero%20Harm.pdf Mine Health and Safety Act: Regulations: Guidance note for implementation of standard threshold shift in medical surveillance of noise induced hearing loss (Gazette 40142, Notice R839)] Published under GNR 839 of 15 July 2016. Available from http:// www.polity.org.za/article/mine-health-and-safety-act-regulations-guidance-note-forimplementation-of-standard-threshold-shift-in-medical-surveillance-of-noise-inducedhearing-loss-gazette-40142-notice-r839-2016-07-26 Ministry of Health Singapore, 2010. Functional Screening for Older Adults in the Community: MOH Clinical Practice Guidelines June 2010. Viewed on the 22 July 2016 from: https://scholar.google.co.za scholar?q=Functional+Screening+ for+Older+Adults+in+the+Community:+MOH+Clinical+Practice+Guidelines+

141

ENHANCING CARE FOUNDATION FINAL REPORT: MARCH 2017

June+2010&hl=en&as_sdt=0&as_vis=1&oi=scholart&sa=X&ved=0ahUKEwiUgrDtv_OAhUC6RQKHY0bAigQgQMIGDAA Ministry of Health and Social Welfare, 2011. National Disability and Rehabilitation Policy: Mainstreaming persons with disabilities into society (NDRP), Maseru. Available from http://www.lnfod.org.ls/uploads/1/2/2/5/12251792/national_disabilty_and_rehabilitation_ policy_2011.pdf Mitra, S., Posarac, A. and Vick, B., 2013. Disability and poverty in developing countries: a multidimensional study. World Development, 41, pp.1-18.

Mlenzana, N.B., Frantz, J.M., Rhoda, A.J. and Eide, A.H., 2013. Barriers to and facilitators of rehabilitation services for people with physical disabilities: a systematic review: review article. African Journal of Disability, 2(1), pp.1-6.

Mont, D., 2007. Measuring disability prevalence. World Bank Social Protection Discussion Paper, 706.

Morata, T.C., Themann, C.L., Randolph, R.F., Verbsky, B.L., Byrne, D.C. and Reeves, E.R., 2005. Working in noise with a hearing loss: perceptions from workers, supervisors, and hearing conservation program managers. Ear and hearing, 26(6), pp.529-545.

Mpedi, G and Nyenti, M., 2015. Challenges experienced by former mine-workers in accessing social security in SADC. Available from http://www.saspen.org/conferences/ FES-ILO-employment-injury-2014/PPT-Mpedi-Nyenti-Mineworkers_ILO-FES-Workshop_ Employement-Injury-Protection-Eastern-and-Southern-Africa_Harare_20-21-Oct-2014. pdf Muga, E., 2003. Screening for disability in a community: the ‘ten questions’ screen for children, in Bondo, Kenya. African health sciences, 3(1), pp.33-39.

Murray, J., Davies, T. and Rees, D., 2011. Occupational lung disease in the South African mining industry: research and policy implementation. Journal of public health policy, 32(1), pp.S65-S79.

Musiba, Z., 2015. The prevalence of noise-induced hearing loss among Tanzanian miners.

Occupational Medicine, 65(5), pp.386-390.

National Department of Health South Africa, 2016. Framework and Strategy for Disability and Rehabilitation Services in South Africa 2015-2020. Available from http://www. health.gov.za/index.php/2014-03-17-09-09-38/strategic-documents/category/266-2016str?download=1569:framework-and-strategy-final-print-ready-2016 National Institute for Occupational Safety and Health (NIOSH). Noise and Hearing Loss Prevention. Available from http://www.cdc.gov/niosh/topics/noise/ Neille, J. and Penn, C., 2015. The Interface Between Violence, Disability, and Poverty Stories From a Developing Country. Journal of interpersonal violence, p.0886260515596332.

Nelson, D.I., Nelson, R.Y., Concha-Barrientos, M. and Fingerhut, M., 2005. The global burden of occupational noise-induced hearing loss. American journal of industrial medicine, 48(6), pp.446-458.

Ngwena, C., Grobbelaar-du Plessis, I., Combrinck, H. and Kamga, S.D., 2013. African Disability Rights Yearbook. Pretoria: Pretoria University Law. Noble, M. and Wright, G., 2013. Using indicators of multiple deprivation to demonstrate the spatial legacy of apartheid in South Africa. Social Indicators Research, 112(1), pp.187-201.

Landen, D.D., Fotta, B., Wang, R.C., Makowski, B.D., Tuchman, R.J. and Layne, L., 2000.

Injuries, Illnesses, and Hazardous Exposures in the Mining Industry, 1986-1995: A Surveillance Report.

Obrist, B., Iteba, N., Lengeler, C., Makemba, A., Mshana, C., Nathan, R., Alba, S., Dillip, A., Hetzel, M.W., Mayumana, I. and Schulze, A., 2007. Access to health care in

142

references

contexts of livelihood insecurity: a framework for analysis and action. PLoS Med, 4(10), p.e308.

Occupational Health and Safety Act, (Act 85 of 1993) and related Noise-Induced Hearing Loss Regulations (No. R. 307, 7 March 2003). Available from http://www.labour.gov.za/ DOL/downloads/legislation/regulations/occupational-health-and-safety/Regulation%20 -%20307%20-%20OHS%20-%20Noise%20Induced%20Hearing%20Loss.pdf Occupational Diseases in Mines and Works Act, Act 78. Available from http:// goldminersilicosis.co.za/wp-content/uploads/2012/12/Occupational-Diseases-in-Minesand-Works-Act-Act-78-of-1973-ODIMWA.pdf Phillips, J.I., Nelson, G. and Ross, M.H., 2006. Preventing adverse effects of noise and vibration in the South African mining industry. African Newsletter on Occupational Health and Safety, 16(2), p.33.

Public Health Association of South Africa, 2012. Capacity of the SA public health sector to deliver rehabilitation services: an institutional analysis. Available from https://www. phasa.org.za/capacity-of-the-sa-public-health-sector-to-deliver-rehabilitation-services-aninstitutional-analysis/ Rabothatha, S., 2016. Getting benefits to ill mine workers. The New Age. 27 July 2016.

Available from http://www.thenewage.co.za/getting-benefits-to-ill-mine-workers/ Ramlall, S., Chipps, J., Bhigjee, A.I. and Pillay, B.J., 2013. Screening a heterogeneous elderly South African population for cognitive impairment: the utility and performance of the mini-mental state examination, six item screener, subjective memory rating scale and deterioration cognitive observee. African journal of psychiatry, 16(6).

Rand Mutual Assurance Annual Report 2015. Available from http://randmutual.co.za/rmacontent/uploads/2016/06/RMA-ANNUAL-REPORT-2015-Final.pdf Rees, D., Murray, J., Nelson, G. and Sonnenberg, P., 2010. Oscillating migration and the epidemics of silicosis, tuberculosis, and HIV infection in South African gold miners.

American journal of industrial medicine, 53(4), pp.398-404.

Richard, M.A., 2000. A discrepancy model for measuring consumer satisfaction with rehabilitation services. Journal of Rehabilitation, 66(4), p.37.

Richards, R. and Bianco, A., 2007. Realising their rights? Self-assessed community needs in 30 settlements in South Africa: Economics Web Institute. Available from http://www. economicswebinstitute.org/essays/communityneeds.htm Roberts, B., Sun, K. and Neitzel, R.L., 2016. What can 35 years and over 700,000 measurements tell us about noise exposure in the mining industry?. International Journal of Audiology, pp.1-9.

Rohleder, P., Braathen, S.H., Swartz, L. and Eide, A.H., 2009. HIV/AIDS and disability in Southern Africa: a review of relevant literature. Disability and rehabilitation, 31(1), pp.51-59.

Rawool, V.W., 2012. Hearing Conservation: In Occupational, Recreational, Educational, and Home Settings.

SA News, 2016. Ex-mineworkers receive R59m in compensation. 22 July 2016.

Available from http://www.sanews.gov.za/south-africa/ex-mineworkers-receive-r59mcompensation SABS 1451: Part I. South African Standard. Standard Specification for Hearing Protectors, Part I: Ear muffs (Definition of “SABS 1451 Part I” inserted by Regulation 2(d) of Government Notice R489 in Government Gazette 15560, dated 18 March 1994). Available from http://store.sabs.co.za/pdfpreview. php?hash=cf8cb2089e08aeda96f8cd6faedd610dfaf5bd5e&preview=yes SABS 1451: Part II. South African Standard. Standard Specification for Hearing Protectors, Part II: Ear plugs (Definition of “SABS 1451 Part II” inserted by

143

ENHANCING CARE FOUNDATION FINAL REPORT: MARCH 2017

Regulation 2(d) of Government Notice R489 in Government Gazette 15560, dated 18 March 1994). Available from http://store.sabs.co.za/pdfpreview. php?hash=379e5fedc6bee047054daf0b3439674a1e69b212&preview=yes SANS 10083:2013. The measurement and assessment of occupational noise for hearing conservation purposes. Edition 5.2.

SANS 11201: 2013 Acoustics, Noise emitted by machinery and equipment – Determination of emission sound pressure levels at a work station and at other specified positions in an essentially free field over a reflecting plane with negligible environmental corrections.

SANS 10152 Calibration of pure-tone audiometers Part 1: Air conduction Calibration of pure-tone audiometers Part 2: Bone conduction.

SANS 10154-2012.

SANS 10182:2006 ‘The determination of the sound insulation performance of an audiometric booth or a mobile audiometric facility in a non-laboratory environment’ (SANS, 2006).

Saunders, G.H. and Griest, S.E., 2009. Hearing loss in veterans and the need for hearing loss prevention programs. Noise and Health, 11(42), p.14.

Scherer, M.J. and Frisina, D.R., 1998. Characteristics associated with marginal hearing loss and subjective well-being among a sample of older adults. Journal of rehabilitation research and development, 35(4), p.420.

Secretariat for the Convention on the Rights of Persons with Disabilities, Division for Social Policy and Development, Department of Economic and Social Affairs (DESA) Technical Note. Operationalizing the 2030 Agenda: Ways forward to improve monitoring and evaluation of disability inclusion United Nations. Available from http://www.un.org/ disabilities/documents/desa/operationalizing_2030_agenda.pdf Shale, I., 2015. Lesotho. Afr. Disability Rts. YB, 3, p.183.

Sherry, K., 2014. Disability and rehabilitation: essential considerations for equitable, accessible and poverty-reducing health care in South Africa.

Sherry, K., 2016. Occupations of citizenship: the missing layer in empowered engagement between rural people with disabilities and primary healthcare workers in South Africa (Doctoral dissertation, University of Cape Town).

Sluis-Cremer, G.K., Hessel, P.A., Hnizdo, E. and Churchill, A.R., 1986. Relationship between silicosis and rheumatoid arthritis. Thorax, 41(8), pp.596-601..

South African Trust and Ford Foundation (2014). Portability and Access of Social Security Benefits by Former Mine Workers, Johannesburg. Available from http://www. southernafricatrust.org/wp-content/uploads/2015/03/Portability-and-Access-of-SocialSecurity-Benefits-by-Former-Mine-Workers.pdf Statistics South Africa. Census (2011). Available from http://www.statssa.gov.za/ Publications/P03014/P030142011.pdf Staudt, A.M., 2016. Effects of exposure to organic solvents and occupational noise on hearing loss and tinnitus in US adults from 1999 to 2004.

Steen, T.W., Gyi, K.M., White, N.W., Gabosianelwe, T., Ludick, S., Mazonde, G.N., Mabongo, N., Ncube, M., Monare, N., Ehrlich, R. and Schierhout, G., 1997. Prevalence of occupational lung disease among Botswana men formerly employed in the South African mining industry. Occupational and environmental medicine, 54(1), pp.19-26.

Strauss, S., Swanepoel, D.W., Becker, P., Eloff, Z. and Hall III, J.W., 2014. Noise and agerelated hearing loss: a study of 40 123 gold miners in South Africa. International journal of audiology, 53(sup2), pp.S66-S75.

Swaziland Central Statistical Office Population and housing Survey (2007). Available from http://catalog.ihsn.org/index.php/catalog/4274

144

references

Tlhaole, T., 2011. Social Protection Arrangements for Retired Mineworkers with Physical Disabilities in Maseru Urban, Lesotho (Doctoral dissertation, University of Witwatersrand).

United Nations (2006). Convention on the rights of persons with disabilities and optional protocol. New York. Available from http://www.un.org/disabilities/convention/ conventionfull.shtml van Biljon, H.M., Casteljien, D., du Toit, S.H. and Soulsby, L., 2016. Opinions of occupational therapists on the positioning of vocational rehabilitation services in Gauteng Public Healthcare. South African Journal of Occupational Therapy, 46(1), pp.45-52.

Welaga, P., Hosegood, V., Weiner, R., Hill, C., Herbst, K. and Newell, M.L., 2009. Coming home to die? The association between migration and mortality in rural South Africa.

BMC Public Health, 9(1), p.193.

Whittemore, R. and Knafl, K., 2005. The integrative review: updated methodology. Journal of advanced nursing, 52(5), pp.546-553 World Health Organization (2001). WHODAS 2.0, WHO, Geneva. Available from http:// www.who.int/classifications/icf/more_whodas/en/ World Health Organization (2001). International classification of functioning, disability and health, WHO, Geneva. Available from http://www.who.int/classifications/icf/en/ World Health Organization (2005). Disability and rehabilitation WHO action plan 2006–2011. Available from http://www.who.int/disabilities/ publications/dar_action_ plan_2006to2011.pdf World Health Organization and World Bank (2011). World Report on Disability. Geneva.

Available from http://who.int/disabilities/world_report/2011/en/ World Health Organization (2016). Deafness and hearing loss. Factsheet No 300. Available from http://www.who.int/mediacentre/factsheets/fs300/en/ World Health Organization (2016). Uncovering health inequalities: a path towards leaving no one behind. Available from http://www.who.int/features/2016/health-inequalities/en/ Zvidzayi, T., 2015. Compliance with international standards on compensation for occupational injuries and diseases by Zimbabwe and South Africa (Doctoral dissertation, University of the Western Cape).

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