Persons with neuromuscular diseases (NMDs) often experience complex rehabilitation needs due to the disease’s impact on their functioning and progression of their diseases. As a consequence of legislation and “policy power”, community-based health professionals function as gatekeepers to the rehabilitation trajectory for persons with NMDs in a field where the other professionals are the specialists.To investigate community-based health professionals’ reflections on and behaviors regarding collaboration with a tertiary rehabilitation hospital in a cross-sectorial rehabilitation care model with the overall aim of providing high quality rehabilitation for persons with NMD.The design is qualitative and uses interpretive description methodology and the theoretical lens of Edgar Schein’s three levels of organizational culture and leadership.n = 10) and seven individual interviews (n = 7). In addition, 151 pages of observation data were generated. The study adheres to the COREQ guidelines.An ethnographic fieldwork was conducted from September 1, 2019 to January 30, 2020. Eighty-four community-based health professionals were included and 17 of them were interviewed in four semi-structured focus group interviews (The analysis showed three themes of importance for the collaboration: Policy and legislation navigation represented that collaboration on rehabilitation was affected by legislation as a management tool with “the case” as the core element, and goal dilemmas. Cross-sectorial knowledge exchange promoted collaboration on coordinated and facilitated rehabilitation and knowledge sharing as a firm anchoring. Patient ownership negotiations implied collaboration was influenced by knowledge founded power and gatekeeping as a navigation tool.Three levels of organizational culture and leadership were identified, and this overall structure guided the community-based health professionals in their work and in the complex organizational landscape of collaboration between disconnected healthcare systems. The findings provided insight into behavior and attitudes and the content and the values held by the professionals collaborating across sectors. Future collaboration in rehabilitation models should be multiprofessional and team based. The findings emphasize that it is imperative that managements and professionals strive to strengthen the structure of the collaborative team spirit because this will ensure well-planned, coordinated, and conducted rehabilitation for persons with NMD and enable and support future cross-sectorial collaboration in this rehabilitation model for these persons. Persons living with neuromuscular diseases (NMDs) are highly dependent on specialist rehabilitation services to live an independent everyday life –3. ThrouThe term NMD covers amyotrophic lateral sclerosis (ALS) and several chronic hereditary NMD subtypes, which together form a heterogeneous population in terms of symptoms, functioning, and disease progression . PersonsDisconnected healthcare systems are common all over the world and are responsible for challenges related to cross-sectorial collaboration between healthcare professionals, where patients can be lost or abandoned in the “gap” between systems –12. In DIn the primary care sector, the local CBHPs are legislatively in charge of assessing the rehabilitation needs of the persons with NMD, and they authorize the needed services like personal assistance, help, care, and/or assistive devices according to the Social Services Act, the Active Employment Effort Act, and the Danish Health Act –19. TherA tertiary rehabilitation service  to facilitate cross-sectorial collaboration in the field of NMD is represented by The National Rehabilitation Center for neuromuscular diseases (RCFM), a national highly specialized private hospital under the National Board of Health , 20. TheThe World Health Organization defines rehabilitation as a process aimed at enabling persons with rehabilitation needs to reach and maintain their optimal physical, sensory, intellectual, psychological, and social functioning. Rehabilitation provides disabled people with the tools they need to attain independence and self-determination . RehabilThe design was qualitative in accordance with interpretive description methodology , 23.Interpretive description draws upon established qualitative research methodologies and represents a theoretical framework that can be used to identify challenges in clinical nursing practice. The methodology is inductive and entails coherent conceptual description and in-depth interpretation of relationships and patterns within the phenomenon being examined to improve practice , 23.To analyze, decipher, and understand the organizational cultural levels among the two collaborating sectors in this study, the theoretical lens of Edgar Schein’s three levels of organizational culture and leadership was applied . CultureThe study was conducted in the context of the RCFM at the outpatient hospital clinic, the CBHPs’ offices, or at the homes of persons with NMDs throughout the country.From August 1, 2019 to January 30, 2020, the first author recruited participants, and from September 1, 2019 to January 30, 2020, she conducted an ethnographic fieldwork comprising semistructured individual and focus groups interviews and participant observations. The sampling was purposive and consisted of CBHPs as the primary participants; the secondary participants were the healthcare professionals from the RCFM that collaborated with the CBHPs and persons with NMDs . We aimeIncluded were CBHPs who worked with the assessment of the rehabilitation needs of persons with NMDs and who authorized rehabilitation services like personal assistance, help, care, and/or assistive devices according to the Social Services Act, Active Employment Effort Act and Danish Health Act. The healthcare professionals included had to have collaborated with the RCFM within the last 3 months. Healthcare professionals with no knowledge of NMDs and the RCFM were excluded.To recruit participants for the interviews, the first author contacted by email the managements in the three largest municipalities in Denmark  and one medium sized municipality  and asked them to appoint CBHPs who collaborated with the RCFM and met the inclusion criteria. To generate observation data, the first author shadowed the healthcare professionals at the RCFM when they collaborated with the CBHPs at the outpatient clinic at the RCFM or in the homes of the persons with NMDs homes across the whole country.In all, 84 CBHPs  were included as the primary participants Table . The secData were generated during the fieldwork and consisted of interview data and observation data.n = 10) and seven semi-structured individual interviews (n = 7). The interview guide for all interviews  related to understand CBHPs’ reflections on and behavior in the collaboration culture revolving around rehabilitation for persons with NMDs. Key questions in the interview guide were: What are your thoughts on what is meaningful for persons with NMDs in their everyday lives? What are your perceptions of collaboration with the field of NMDs? What do you find of value in relation to multiprofessional collaboration on rehabilitation for persons with NMDs? What do you find of value in relation to cross-sectorial collaboration on rehabilitation for persons with NMDs? What are you perception of the cross-sectorial collaboration within the field of NMDs? What is of value when working with persons with NMDs in disconnected healthcare systems? What are your thoughts on collaborating with a tertiary hospital on rehabilitation for persons with NMDs? When do you believe a collaboration on a rehabilitation process for persons with NMDs works the best? How would you describe your collaboration with tertiary hospitals (like the RCFM)? Follow-up questions were related to concerns, challenges, roles, interactions, communication, and cooperation.Of the 84 participants who were observed during the fieldwork, 17 CBHPs were interviewed in four semi-structured focus group interview  discussed needs for rehabilitation initiatives with the person with NMD and the professional from the tertiary hospital. She spoke directly to the person with NMD who had applied for a wheelchair saying: “Typically a wheelchair is used within the home when the disease has progressed more than yours has. When you apply for a wheelchair, it has to be made clear that it is an obvious need and would provide significant relief during your everyday life”. Turning to the professional from the hospital, she referred to the specific law on this subject.In collaboration at meetings or examinations in the homes of the persons with NMD, it was frequently observed and overheard how the CBHPs used laws and amendments as a lever in their argumentation for postponement or refusal of rehabilitation services. The CBHPs specifically pointed to the fact that policies and legislations made their work easier in some ways. Conversely, some of the participants argued that governance made their work somewhat more difficult and rigid because it left no room for trying out different solutions. In relation to this, some of the participants explained that at times they wished that they were not as bound by governance as they were and instead could provide the rehabilitation initiatives needed by the persons with NMD. However, in their collaboration with the hospital professionals, their strongest argument appeared to be that they could obviously only provide services that they had legal authority to provide.“It tends to create challenges if the hospital professionals go ahead and suggest rehabilitation interventions or solutions – and the person with NMD applies for them. Then we must decide whether to authorize the solution, and when we reject it, the persons with NMD often gets very upset with us. I think these events are unfortunate and that the professionals at the tertiary hospital need to be as updated on the policies and legislations as possible – they change constantly. The principles on which decisions are based often change. They do”. .CBHPs used reference to policies and legislations as their management tools during interviews and observations, and thus governance was a core element in their work and collaboration with the hospital professionals. It could be observed how they repeatedly called attention to what “the law” allowed but they mainly referred to what its limits were. The CBHPs tended to talk mostly in terms of legislation, when collaborating, and referred to paragraphs and sections in the law and what these meant with regard to their possibility to provide rehabilitation services.“Of course, we must make ourselves acquainted with what sort of “thing” the specific diagnosis is because it does matter if it is ALS or another diagnosis. So, of course, we do study the diagnoses the persons have. But the diagnosis itself does not “release” a service as such. That comes down to the functioning of the person”. .Several of the participants described that being proactive regarding their executive duties and applying for assistive devices before they were actually needed was exceptionally important with ALS due to the rapid progression of the disease. If need be, they acted based on the available information and knowledge, knowing full well that more information and knowledge would provide them with better qualifications to act.A discussion was heard between two CBHPs regarding the written report from the tertiary hospital as a management tool during “case work”. They explained that they copy-pasted certain text elements from the report to build stronger written arguments in case documents when applying for rehabilitation services like assisted help or personal care. .The CBHPs explained how lack of specific diagnosis-related knowledge tended to affect the case work and authorizations for rehabilitation services negatively – underscoring the importance of access to the knowledge possessed by the professionals from the tertiary hospital.The CBHPs explained their opinions in more detail during interviews, and it was also observed that “the case” was put before the person. This CBHPs explained that their behavior was rooted in a “legislation culture” rather than in the person with NMD in need of rehabilitation, sometimes with consequences for the outcome of the specific case. The CBHPs explained that they were not willing to apply for assistive aid if they felt that aids did not make sense in relation to governance, for instance, they rejected applications for extensive renovations of houses because of the costs incurred. In such “cases”, they could also argue that the hospital professionals at times showed up too late to collaborate or to provide the written neuromuscular report that was used to strengthen some applications. They further explained that they did not always wait for the hospital professionals to show up, but acted on the knowledge they had at the time, which was mainly concerned with legislation and not facilitated by specific knowledge of the NMDs.During a meeting at the home of a man with a NMD, it was observed that the professionals from the hospital sought to discuss diagnosis-related challenges, whereas the CBHPs took the law and governance as a starting point. The CBHP had many questions related to the arrangement of the bathing situation for the person with NMD in her assessment of the need for an authorization for a remodeling of the bathroom. She observed the man with NMD in various situations in the bathroom and discussed issues related to solving the case in relation to the possibilities within the legislation. However, the person with NMD mentioned other worries than the bathroom. He was worried about being home alone because of the risk of falling. The hospital professionals were talking about a ramp for the wheelchair to get in and out of the house. As the meeting progressed, the three parts kept arguing in different directions. Finally, the CBHP, disregarding everything else going on, concluded that she thought the bathroom could be remodeled within the possibilities of the legislation. .At times, the CBHPs argued that the collaboration with the tertiary hospital worked well despite different cultures and goals, and it appeared satisfactory regarding the solutions reached during meetings because all those present had a contribution to make. There seemed to be an uncertainty, however, related to what the persons with NMD specifically needed, which might relate to the lack of shared goalsetting. The CBHPs stated that these uncertainties could be related to different persons being responsible for these “NMD cases” in the local community care setting, which, as a consequence, meant that the competences and knowledge on NMD was at risk of being watered down, with a negative outcome for the persons with NMD.“Concurrently, we address NMD during our meetings because it is so important to be upfront with the different initiatives and how things progress in these cases. We cannot just sit and wait like in other cases. We do have a huge workload, and this might have an influence on some of the cases that need prioritization, and we do need a little knowledge on this specific group, but we don’t have it. No one has been appointed especially to be responsible for this task.” .It was heard during the interviews and observed that the exact goal of the rehabilitation initiative shifted in focus and at times seemed indistinct or blurry – not only to the professionals, who each had their own goals, but also to the person with NMD, who at times verbalized yet another goal. The unclear overall aim of the rehabilitation plan seemed to present dilemmas during the observed interactions in the collaborations. The persons with NMD seemed to focus on a wish to solve challenges in everyday life, the hospital professionals had an eye for the diagnosis-specific challenges often related to enhancing functioning, whereas the CBHPs focused on legislation and laws.“That's what is so good about it. Take the case where I participated. We had a network meeting in the home of the person with NMD – you know there were people representing the local community care setting, from the public day-care facilities, and from what we call the children’s therapy who are our therapists. In addition, our occupational therapist participated; she works with housing adjustments and stuff like that. I participated and then there were professionals from the tertiary hospital, and people from special counseling who had contributed to assessing the boy. In that way we all got to see each other, get acquainted with each other, and get a good discussion going, all of us. In that way we were able to make a shared rehabilitation plan … you know where we go from here. Making sure that we all worked in the same direction so to speak – all professional experts no matter where you work”. .The CBHPs mentioned these collaborative meetings several times and the value of being together physically – all in the same room. Moreover, they emphasized how much easier things progressed and were coordinated in a positive manner once you knew the other professionals and understood what they represented. Amidst examinations, this shared facilitation and coordination of rehabilitation initiatives was also observed repeatedly and acknowledged by the persons with NMD and their relatives.In the process of a network meeting in the house of a girl with NMD, it was observed how a plan was coordinated in collaboration. The girl needed a new wheelchair, and the professionals from the tertiary hospital offered to pass the information on to a colleague who was a specialist occupational therapist who could help with the adjustments of the new wheelchair but also could help make it possible for the girl to drive around on the school premises. The teacher (No. 6) from the school talked about the accessibility at the school in general and classroom placement. The girl’s mother contributed with knowledge and needs regarding the new chair. The hospital physiotherapist offered to coordinate help in the future and informed the mother about who to contact in the local community care setting.The professionals in both healthcare systems contributed with the specific knowledge they possessed to ensure the best possible support and rehabilitation plan for the persons with NMD. The CBHPs argued how important the cross-sectorial collaboration with the tertiary hospital was for the rehabilitation to be coordinated and facilitated well. Often the hospital professionals were responsible for setting up the meetings and gathering the relevant people to participate based on their specific competences. However, the CBHPs explained how they were the “local” and nearest professionals and that, therefore, they were in a better position to follow-up on and execute plans that had been decided upon. Nevertheless, they explained that the facilitating and coordinating role was enforced by a culture of working together with the hospital professionals who had knowledge about the specific NMD diagnoses and related rehabilitation needs. One CBHP said:The CBHP  was asking the hospital physiotherapist about how to interpret a physical score that the physiotherapist used during examinations. They discussed the score, and the hospital physiotherapist explained how the specific NMD affects the body and muscles, and she explained about relevant exercises for the physiotherapist to do together with the person with NMD. The physiotherapist demonstrated the exercises on the boy who was being examined. The boy had spasms during the exercises and the two professionals carried on discussing how his muscles reacted and about muscle power and which exercises to do and which to avoid. The hospital physiotherapist added that she would share the discussed knowledge in the written report she would forward after the meeting.When sharing knowledge, the collaboration at times seemed to work so well that the professionals could get carried away and had long professional discussions on NMD symptoms and needs. At times, issues were discussed and decisions made over the head of the person with NMD and their relatives (even though present), and the communication ended up being “a case discussion” between the professionals while the persons with NMD listened.Knowledge sharing was described as a core element in the collaboration between the professionals in both healthcare systems. The CBHPs possessed specific knowledge on possibilities and/or obstructions in relation to governance, policies, and the specific laws. The hospital professionals had specialist knowledge about the NMDs and the needs of the persons with specific diagnoses as well as the relevant legislation. The two groups adhered to some of the same legislation but used it differently, with the CBHPs being managed by the community care setting’s financial framework in relation to what services they authorized. The two group of professionals explained they benefitted from a culture of collaborating and sharing their specific knowledge with the shared overall aim of helping persons with NMD in the best possible way. The CBHPs described in detail how they used the hospital professionals’ specialized knowledge of NMD to understand the disease and the related needs better. Their better understandings of the detailed needs related to the precise diagnosis strengthening the CBHPs’ arguments in cases and applications for rehabilitation initiatives. The CBHPs revealed that they valued the knowledge sharing during the collaboration they had with the professionals at the hospital.“They came from the hospital last winter and gave a lecture on ALS. That was so worthwhile for us. It was one of the nurses and in such ways we could do even more to collaborate on knowledge sharing between us. We provide each other with valuable knowledge. They nourish us with knowledge on what is going on within the field of disability “outside” the jurisdiction, and about the newest research and evidence on NMD. At the same time, we can contribute with what is going on regarding governance and legislations and what challenges we encounter in the local community care setting. In that way we can guide each other and together upgrade the work in the field of rehabilitation”. .Overall, the CBHPs explained that the exchange of specialized knowledge on NMD was invaluable “gold” and that they were heavily dependent on it in their case work. Nevertheless, The CBHPs also emphasized the value of contributing with their knowledge to help the person with NMD in the best way and the value of the synergy in exchanging information and knowledge.Throughout a school meeting there seemed to be an ongoing fight for power founded in knowledge. The professionals tried to work out rehabilitation initiatives for a teenage girl with NMD, but it was observed recurringly how this was challenged by the professionals from the community-based care setting. A female teacher (No. 154) and a male social educator, (No. 153) participated in the meeting at the girl’s school with a physiotherapist and an occupational therapist from the tertiary hospital. The hospital professionals informed about a prior meeting the same day in the home of the girl with NMD and elaborated on the symptoms of the NMD like falling over, fatigue, spasms, and difficulties with riding a bike. The physiotherapist explained the related needs for the girl during school hours and addressed how these could be supported and relieved. The teacher (No. 154) seemed either uninterested or pointed out how things were during school hours and how they chose to support the girl. The social educator (No. 153) seemed more interested and sought consensus in the group; however, it appeared difficult for him since the teacher kept either demonstratively reading something on her computer or suddenly, when possibilities for the girl with NDM to have a quiet moment were addressed, adding things like: “Our strategy for all classes is to have only a few students in the classroom, keep the noise level low – that’s our strategy in all classrooms, not just the one class room where XX is.”As shown in the above, the collaboration could, at times, be hindered by the participation of hospital professionals in only one or two meetings and by their not being a part of the local community care setting surrounding the persons with NMD. During some collaboration situations, the CBHPs resented being told “what to do” or “how to act” by the hospital professionals and this led to a feeling of not being good or sufficient enough, which seemed to ruffle their professional pride. The CBHPs argued that they acknowledged the specialized knowledge that the hospital professionals had, but that it was their patients and their decisions that determined what rehabilitation initiatives were authorized and they hinted that also knew the patients best.“If you take that little boy with NMD we visited and assessed in his home, where we discussed if a case involving remodeling the house was relevant now or later … In that case I sort of found myself in a dilemma, since the parents had been told [by the hospital professionals] to expect and anticipate that a renovation of their house would be authorized. But I wondered if it was necessary and things like that. We had a good discussion that we [the CBHPs] in the end won because we possess the authority power to decide what aid is given and possess the competences to make the decisions. We have the decision-making power to say – we’ll look at it again within a foreseeable period, it will happen eventually”. .Although the CBHPs explained during interviews that collaboration with the tertiary hospital professionals was seamless, the observations revealed in more detail how challenges occurred. The interviews and the observations provided insight into an ongoing discourse on the “ownership” of the person with NMD, like who knew the person best or who could decide in what direction things should progress in relation to rehabilitation solutions. The CBHPs referred to the person with NMD as “my patient”, as did the professionals at the hospital. During meetings, specific knowledge of the persons with NMD and in addition specialized knowledge – on either legislation for the CBHPs or detailed knowledge of the disease for the hospital professionals – were used as reinforcements when trying to win an argument.During a meeting in the home of a couple where the man had ALS, a nurse from the hospital and a CBHP professional participated. The CBHP  introduced herself and explained that she represented the local community care authorities regarding everything relating to personal care and assistance and she then added: “You get the help that you need according to the Social Services Act”. She shared a pamphlet with information regarding possibilities for rehabilitation according to the legislation. She further mentioned that it would be easier for her to authorize rehabilitation services in the future because she had now seen the couples’ house. “I think that it would be a good idea for you to become affiliated with the local home care nurse as soon as possible”. The couple nodded agreement.The professionals from the tertiary hospital used their knowledge on legislation to inform the patient about possibilities such as those available through the CBHPs. The CBHPs, however, also made it clear that the local community care setting oversaw the provision of services for the person with NMD. The CBHPs emphasizing the importance of being involved in the case at an early stage because they knew what would be needed and could either authorize help or help the persons with NMD navigate in the system so that they could seek out the best help. These clearly mapped “boarders” of who “owned” the responsibility or the possibilities for providing rehabilitation services appeared to promote the development of two parallel healthcare systems – instead of a collaboration. Moreover, this division blurred the shared goal of providing the best possible help and rehabilitation for the persons with NMD.In the quest to show ownership of the patients, the CBHPs emphasized how they were the ones in charge of what was being authorized according to the legislation. The CBHPs explained that, as time progressed, they had acquired more experience and knowledge about NMD, and they could, therefore, make well-informed decisions on the cases they “owned” without necessarily having to collaborate with the tertiary hospital around them. During observations, it became more evident how the CHBPs used their authority and legal framework as a gatekeeping tool.“The whole point of my position is to function as a navigator for the person with NMD, and sort of get to know the family and sort out what challenges they encounter, what they consist of, and what rehabilitation initiatives are needed, and to facilitate their journey forward to the different actors and departments in the local community care setting. I don’t have authoritative power in my position as such, but I function as the extended arm of the person with NMD, you could say … and I make everyday life easier to cope with.” .Nevertheless, the CBHPs stressed that they needed and trusted the hospital professionals’ expertise but that they did not like being pressured to make decisions or authorize services that they did not find appropriate or needed. The CBHPs described that they sometimes felt that the tertiary hospital “ganged up” with the person with NMD and their families, for instance, “promising” them services without legal grounding. In such cases, the CBHPs revealed that they tended to feel like outsiders when they took part in meetings, despite representing the local instance responsible for the help and support needed by the person with NMD.Our findings showed that the culture and values in the two healthcare organizations were complex and challenged during collaboration on rehabilitation for persons with NMDs . We idenCore elements in rehabilitation teamwork among organizations consist of shared commitment; an understanding of and meaning given to the collaborating team by other healthcare professionals; shared and explicit rehabilitation goals, agreed roles and responsibilities. This delineates the unique and shared areas of authority within the team and an interdependence between team members when making decisions and when undertaking rehabilitation initiatives . Lack ofRehabilitation is a complex process, and a shared goal set together with the persons with NMD should be a core component in all collaboration among the healthcare professionals .The general intent of the various legislations used as management tools in the two healthcare settings in our study is to promote the patients’ best interests; hence, it is important that their content and structure are clear to the professionals in each sector and enable them to be certain about their roles and expectations in the collaboration. With regard to arguments and interprofessional power, governance and legislations can become the center of the collaboration and be expressed as strong arguments based on care and health, as was the case with the hospital professionals in the present study. A contextual understanding of the identified elements influencing collaboration in the rehabilitation model for persons with NMDs becomes crucial for the outcome of the rehabilitation and for understanding the content and structures affecting the whole rehabilitation process.A way to make structures in the collaboration more visible and central in the collaboration process among the professionals could be the use of the Chronic Care Model (CCM). The CCM has throughout more than a decade been a commonly adopted approach to improve care initiatives, and evidence supports the use of the CCM to guide practice changes . A CochrTeamwork is effective and essential for rehabilitation, and in our study two teams  collaborated in one larger team. Rehabilitation teams usually consist of professionals from many different fields to ensure a broad range of competencies to meet the potential challenges a person with NMD may encounter . ResearcThe rehabilitation teams in cross-sectorial settings should make an effort to clearly define roles and allocation of responsibilities to increase trust, openness, respect, and equality . This isOur study sample included various professionals with different backgrounds representing various areas of legislation and governance and was large for a qualitative study. Even though it could be argued that this broad sampling might have influenced the findings by thinning them out, we consider the broad representation a strength because we were looking for trends and patterns in the field of collaboration among the two healthcare systems more than the obtaining of in-depth knowledge from only a few individual participants. To enhance credibility and trustworthiness in the study, several measures were undertaken. Before the onset of the study a thorough explorative process with involvement of six persons with NMD and their relatives was carried out, and all were engaged in commenting on and developing the project protocol regarding relevance, aims, methods, ethics, and perspectives. Based on feedback from these six persons, the perspective of the project was broadened to include persons with ALS, which had not been the initial plan.The first author was not known by the participants before the study and was at the time of the fieldwork new in the field of NMD, which may have reduced any preunderstanding and enhanced an objective data generation. The second author, however, had many years of experience within the field of NMD, which strengthened our team in relation to posing pertinent interview questions and making salient observations. Moreover, the interview and observation guide were followed during the fieldwork to ensure the cogency and unification of the data , 23. TheThe present study provided insight into the reflections and behavior of CBHPs in their collaboration with the professionals at a tertiary hospital. Our findings illustrated the artefacts and espoused values but also the basic underlying assumptions that drove the behavior in the collaboration among the professionals in the two organizations. Through the analytical lens of Edgar Schein’s three levels of organizational culture and leadership, we identified an overall structure guiding the CBHPs in their work and the complex organizational landscape of collaboration between disconnected healthcare systems. Policy and legislation navigation represented collaboration on rehabilitation as it was affected by having to work with legislation as a management tool, with “the case” as the core element and goal dilemmas. Cross-sectorial knowledge exchange promoted collaboration on coordinated and facilitated rehabilitation and knowledge sharing as an anchoring. Patient ownership negotiations hampered collaboration and were influenced by care negotiations founded in knowledge that was either legislation bound or founded in knowledge on NMDs. Together the three themes intercorrelated and intwined, representing facilitators and barriers to seamless cross-sectional collaboration between healthcare systems. The best solution for optimal management of such complex rehabilitation challenges could be to keep striving for smoothly working collaborative multiprofessional teams of professionals leading toward the agreed common goals. Therefore, managerial focus should be on strengthening the multiprofessional team spirit among the teams working across sectors and setting goals together with the persons with NMD to ensure that everyone is working in the same direction. Finally, it is important that managements and professionals strive to strengthen the collaborative team spirit to enhance benefits for persons with NMDs and ensure well-planned, coordinated, and conducted rehabilitation that will enable and support future cross-sectorial collaboration in rehabilitation models for persons with NMD.


Functioning is critical to obtaining health as defined by the World Health Organization, “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”Second, the development of the rehabilitation workforce is hindered by the weakness of rehabilitation in health systems in general. Many countries experience various limitations in rehabilitation leadership and governance, financing, data, assistive technology, equipment and infrastructure, and services. These limitations contribute to the scope and complexity of workforce challenges because health systems are dynamic and interconnected, meaning that deficiencies in one area (such as leadership or data) will affect other areas. Therefore, even targeted approaches to workforce strengthening must acknowledge and consider the broader health system context. The performance of the rehabilitation workforce is greatly affected by how well it is enabled by the system in which it operates. Even the most well educated and trained workforce will struggle when not incentivized, supported, valued or adequately equipped.Third, the multiplicity of occupations encompassed within the rehabilitation workforce presents a challenge for advocacy. Independent efforts to communicate the need for and contribution of each rehabilitation occupation may overwhelm ministries of health and education. More than six different rehabilitation occupations exist , but manBox 1The rehabilitation workforce is not strictly defined; variations exist in how it is interpreted and composed in different countries and contexts. However, rehabilitation is characterized by a focus on functioning, with rehabilitation workers delivering interventions that help people with health conditions perform to optimal levels in their daily lives. These interventions may address challenges in mobility, communication, cognition or mental health that are limiting the independence or participation of people with health conditions.Rehabilitation interventions are delivered by a diverse range of occupations, such as audiologists, occupational therapists, physiotherapists, physical and rehabilitation medicine doctors, prosthetists and orthotists, and speech and language therapists, among others.Bringing the rehabilitation workforce in line with other health occupations requires coordinated actions across sectors, including health, education, labour and finance. For strategies to make a meaningful impact on the rehabilitation workforce, they need to be evidence informed. Here we point to three health policy and systems research questions that can guide and accelerate efforts towards strengthening the rehabilitation workforce.Health policy and systems research focuses on what works, for whom and under what conditions.First, what factors influence how rehabilitation workers are understood and valued by the broader health workforce, the public and policy-makers in different contexts? This question is critical to addressing all challenges, but particularly that of under prioritization. How the rehabilitation workforce is understood and interpreted may vary considerably. For example, in some contexts the workforce may be strongly associated with the disability agenda and perceived to be the responsibility of social affairs, while other countries will consider it to be a core component of the health workforce. Furthermore, what policy-makers value and subsequently prioritize is shaped by many factors, including population needs, resource availability, historical priorities and many others.Second, how can the rehabilitation workforce be optimized to expand access to essential rehabilitation interventions? This question seeks information to better understand the composition, organization and operation of rehabilitation and other health occupations to deliver rehabilitation. These factors are likely to be highly context specific and affect workforce production and employment, as well as task sharing. This question is a critical health policy and systems research question, as it responds to the situation of rehabilitation workforce in many contexts , whereby a health system must make the most efficient use of a very limited pool of workers.Third, how can the public and private sectors work together to address labour market failures of the rehabilitation workforce? The private sector has tremendous potential to both cause and address labour market failures through influencing the production and absorption of workers.We need to address the scarcity of health policy and systems research relevant to the rehabilitation workforce. The questions posed above are by no means exhaustive but represent areas of knowledge that have the potential to accelerate the development of the rehabilitation workforce and subsequently strengthen health systems. The information gained through this research will serve to deepen our understanding of the problem, but also contribute to the implementation of context-specific solutions.


Rehabilitation services are an integral part of patient care, but in many developing countries, they are not prioritized and either unavailable or easily accessible to those who need them. Although the need for rehabilitation services is increasing in Honduras, rehabilitation workers are not included in the health care model that guides the care provided to communities, particularly in rural and remote areas. To understand the need for providing impactful rehabilitation services in disadvantaged communities, we explored the education and perception of the community relating to rehabilitation, investigated training available for rehabilitation workers, and examined the rehabilitation processes and practices in Northern Honduras from stakeholders’ experiences.We utilized a qualitative descriptive and interpretive approach grounded in case study methodology to understand rehabilitation education, process, and practice in Northern Honduras. Three rehabilitation centres were purposefully selected as the cases, and participants consisted of rehabilitation workers and managers from these centres. We collected data via interviews and focus group sessions. We analyzed the data via thematic analysis using NVivo version 12.In Northern Honduras, rehabilitation workers' limited training and continuing education, along with awareness about rehabilitation by community members and other health providers influence rehabilitation care. Although policies and initiatives to support people with disabilities and the broader community in need of rehabilitation exist, most policies are not applied in practice. The sustainability of rehabilitation services, which is rooted in charity, is challenged by the small range of funding opportunities strongly affecting rehabilitation care processes and clinical practices. The lack of trust and awareness from the medical profession towards rehabilitation workers sets a major barrier to referrals, interdisciplinary work, and quality of life for individuals in need of rehabilitation.This study advances knowledge of the need to increase understanding of rehabilitation care among community members and health providers, improve care processes and resources, and foster interprofessional practice, to enhance the quality of care and promote equitable care delivery, especially in rural and remote communities.The online version contains supplementary material available at 10.1186/s12913-022-08875-6. Globally, an estimated 1 in 3 people today live with a health condition that can benefit from rehabilitation services , highligMany people require rehabilitation services, but these issues are particularly challenging for people with disabilities (PWD). Disability prevalence is rising due to health and demographic trends . The wayHonduras, an LMIC in Central America, has a population of 9.9 million people and a life expectancy at birth of m/f 67/73 years . The NatModels are tools that define the basis upon which government and society can devise strategies for meeting the needs of PWD. Society’s adoption of a model  can shape how organizations and our environments should be structured. The literature has discussed the medical and social models of disability to a great extent; and the charity model and human rights model (to name a few) to a lesser degree. The charity model, which is often used in Honduras, branches out from the medical model. This model has been used for fundraising and portrays PWD as those to care for or to pity. The predominant idea of the “care culture”, the institutionalization and segregation, plus the medically classification of disability and treatment, disempower people in need of rehabilitation, making them dependent and recipients of charity. Institutions and organizations, and recipients of rehabilitation donations, also follow the donors' expectations and priorities, making it impossible for them to be responsive to the real needs of people in need of rehabilitation.On the other hand, in the social model, disability is a condition of interconnected elements perceived as related to social situations. Biological conditions are secondary to social conditions that oppress or liberate PWD . The socAlthough in Northern Honduras, the charity model is adopted to provide rehabilitation services, there is a gap in the service delivery. Despite the increasing need for rehabilitation services in Northern Honduras, there is a shortage and unequal distribution and availability of rehabilitation workers in the region. This shows the importance of understanding the factors that influence their ability to provide impactful rehabilitation services in disadvantaged communities. Our study uses a cross-disciplinary approach to offer an extended “window” into Honduran’s rehabilitation education and Honduras’ rehabilitation practice and processes. In this article, we examined the education and awareness/perception of the community regarding rehabilitation in Honduras, investigated the training available for rehabilitation workers and strategies to sustain their engagement, and explored the rehabilitation processes and practices in Northern Honduras from stakeholders’ experiences.Our study utilized a qualitative descriptive and interpretative approach grounded in case study methodology  to underThe WHO global disability action plan 2014–2021 , WHO Reh“a set of interventions designed to optimize functioning and reduce disability in individuals with health conditions in interaction with their environment.” https://www.who.int/news-room/fact-sheets/detail/rehabilitationOur study uses the WHO definition of rehabilitation: The team consisted of bilingual  and Native Spanish  and Anglophone  researchers, rehabilitation clinicians, and community members from Honduras, Colombia, and Canada. The authors are all female health professionals and researchers. VU, JB, MLB, and KP are experienced qualitative and health service researchers with expertise in research methods and community involvement. IC is a physiotherapist, LMUC is a speech therapist, and EP is an occupational therapist, and EM is a functional therapist, physical therapist, and Honduran rehabilitation academic. They all are front line and academic rehabilitation workers in Latin America.To obtain an in-depth appreciation of rehabilitation, we included individuals knowledgeable about rehabilitation in the region in the study. We purposefully selected three rehabilitation centres in Northern Honduras as the cases. We chose these centres because due to our pre-existing collaboration with the centres. Some members of this team had collaborated with local organizations and health providers and conducted training workshops there to advance system changes and advance rehabilitation care . As suchWe developed semi-structured interview and focus group guides . Following (or in between) examinations, we shared critical reflections on the interviews that facilitated discussion of different perspectives. We took a collaborative approach to the analysis to draw on the diverse disciplinary and interpretative skills of each team member. We discussed each team member’s relationship with the data and acknowledged its role in guiding research decisions.We recruited sixteen participants to reach content saturation. Participants were both male and female, with varying years of experience ranging from one to nine years, involved in rehabilitation services in different capacities and have been broadly classified into two categories, i.e., as a manager of a rehabilitation facility (M) and as a rehabilitation worker (RW). Table In summary and as described further in detail, participants across sites shared similar perceptions of rehabilitation in Northern Honduras despite their involvement/role in rehabilitation services. We present their perceptions under three major themes: education, process, and practice. Table Education as a broad theme in our study context relates to the perception of rehabilitation as a profession by the community and other healthcare professionals . Also, education relates to limited knowledge of rehabilitation organizations by the general population, lack of community awareness of people in need of rehabilitation, the information provided to the community, training of parents and family members, stigma, social inclusion, and support programs for people in need of rehabilitation. Education also delves into formal education training needs for health professionals, named academic programs , continuing education for rehabilitation workers, peer learning, and strategies to sustain their ongoing learning engagement. There was mention of within-country educational inequalities associated with the geographical distribution of educational institutions. This represents a missed opportunity to focus on human capital and efforts to have widespread benefits in rehabilitation for Northern Honduras communities.“the knowledge that the community has is very little (RW).” A participant noted,There are many people in [city]who do not know who we are, taxi drivers, people who ask us where we work? We give them the location and they tell us they have never been there, or sometimes people arrive who tell us they did not know that this organization existed (RW).”“The importance of rehabilitation awareness and the establishment of role clarity was echoed by all participants. They described that there was a need for the general population and other health professionals, particularly medical doctors (MD)s, to be educated on the works of rehabilitation organizations and services, this is because, “I feel that there is a lack of knowledge about the rehabilitation area and I think we have to work in this aspect, with doctors (M).”Managers of rehabilitation centers reflected on the complexity of navigating referrals to medical doctors due to a lack of awareness of the role and function of the rehabilitation profession. As others in the network of rehabilitation care  became more aware of the rehabilitation profession, the role clarity (and recognition of the profession) was gradually established. Participants recognized the value of organizational support and the discourse from all participants showed a shared agreement on the need for awareness and knowledge of rehabilitation services by physicians. Medical doctors were portrayed as having minimal to no understanding of what rehabilitation services entail. Unfortunately, physicians' lack of knowledge or understanding presently undermines the rehabilitation healthcare profession and does not actively demonstrate acceptance and integration of rehabilitation within healthcare services, impacting the lives of those with disabilities and their families. In the words of a participant,“Physical therapy is not well perceived by doctors, they think we are massage therapists and occupational therapists, who play with patients and put them to make crafts. When that ideology comes from above, and it becomes a culture problem, and also an education problem (RW).”A key characteristic of the rehabilitation worker-physician relationship is trust and knowledge of each other's skills. There is considerable setting-dependent variability in the number of physicians that work with the rehabilitation centres in Northern Honduras. At this stage, the development of trust is influenced by the physician’s understanding that the rehabilitation worker is knowledgeable and critical to helping the individual’s rehabilitation process. In addition, participants identified that rehabilitation workers were more likely to work in isolation and disconnected from other health professionals. Despite the perceived value of working collaboratively with physicians and rehabilitation workers to make prompt care decisions, participants noted that discrimination and hierarchical structure within the health profession relations limits care. Case in point, a participant stated,“we want to execute as an institution by offering workshop, by providing education, there is included what is the part of inclusion, what is the part of sensitization and promotion of this type of activities for the population in general to remove that stigma, remove that desensitization from seeing patients, people with disabilities or with a condition that they are something rare that they are not ordinary or true people (M).”The information and awareness provided to the community on rehabilitation workers’ role and their tasks within the disability field could impact the population’s perception of rehabilitation. In line with this thought, a participant noted,“people with disabilities are discriminated against and I think that has a lot to do with the culture (M.)” Another participant explained further that,“culture affects non-inclusion, because when the population does not have an education in relation to people with disabilities, either a disability or a condition, there is a certain grade of stigmatization towards that person depending on the condition or type of condition, whether intellectual, or the condition of the person (M).”For PWD, socially related practices such as support systems, stigma, and social inclusion influence rehabilitation practice in Northern Honduras. The stigma associated with disability affects rehabilitation practice, as stated by a participant, inclusion workshops, teacher training, teachers from different public and private schools give trainings, talks and schools for parents (M).”Nonetheless, educational programs for careers of people in need of rehabilitation often incorporate, ““at least knowing more about the treatments that are given to patients (RW)”, which will influence the sustained engagement of rehabilitation workers. Rehabilitation workers are willing to learn and improve skills,“we have to work more on trying to get more workshops... because that helps the employees too, they want to participate and they want to know, they want to get stimulation and help (M).”All participants articulated training needs and gaps to, “if supervision and collaboration we can make videoconferences right? one day, one hour, once a month, to start forming what is the network of rehabilitators (M).” Another participant mentioned the merit of peer learning via which rehabilitation workers are,able to exchange and present those cases that are difficult or between themselves they also support each other and if we have that evidence based on practice…, they meet to analyze the difficult cases they have and how to help this type of people (M).”“Furthermore, it was expressed that providing access to peer learning, training, and networking opportunities for rehabilitation workers could also increase engagement. As noted by a participant, In all settings, the rehabilitation worker’s enthusiasm, self-organization, and role awareness enables the rehabilitation provider to either change perceptions or find strategies to maximize efficiencies.In our study’s context, process as a theme speaks to activities, actions, service delivery models, and developments that influence rehabilitation care in the country, such as access to services and the practice of associating disability with need or misfortune .It is called Social Security, but not everybody has access to it. It is mostly for the people who work for the government or private institutions that they pay a fee to be part of this social security (M).”“The rehabilitation centre managers emphasized the impact of policies on the process of rehabilitation care in Honduras. For example, support from social insurance was mentioned to be limited and, in some instances, non-existent. A participant stated,Across all settings, funding was consistently identified as a challenge. Rehabilitation service provision in Northern Honduras is rooted in charity, which relates to how the institutions fund themselves and provide services. It also speaks of the cultural views and values Honduras as a society place on individuals with disabilities. In line with this charitable way of providing rehabilitation services, funding comes from multiple sources, including annual efforts from local/national fundraising activities, international donors, or directly from individuals’ fees. The challenge of these different sources is the dependency on intermittent short-stream funding and its impact on the centers and health professionals’ future and sustainability. In general, there is no single clear funding source but a multitude of donations and fundraising activities sustaining the rehabilitation centres. This funding approach perpetuates the practice of aiding the needy/disabled ingrained in the country and culture.“this is voluntary work, so sometimes we work approximately 10 h and more, we also take care of activities so that the center works (M).” Community fundraising events provide funding for the centre. A participant voiced, “basically, we sustain ourselves with the marathon, and with the contribution of the companies and the socially responsible people and institutions (M).” Another participant mentioned other activities conducted to raise funds,“We focus on making raffles, selling meals, we organize bingos. In some of the activities we have to use some money, for example, when there is bingo we give gifts, we go to the commercial houses who donate us gifts for bingo activities, the bingo practically leaves us a profit of approximately 50,000.00. The roasted meats that we cook add more work, we manage to sell them, but it is a very exhausting job, and we are volunteers who all work, we are all very busy, but we dedicate part of our time to carry out these activities in order to support the center (M).”The managers of rehabilitation centres indicated that their position(s) ) were predominantly established by voluntary support from individuals. For instance, a participant indicated, “No fee is charged, what we have in the different rooms… are urns with keys so that people voluntarily contribute what they can contribute and whoever does not, is not charged anything (M).”Additionally, voluntary donations from service users at the centres contribute to the financial resource,“We are providing a service to all, right? The only true requirement is the doctor's reference. We do not have support from the government or from any other institution (M).”Furthermore, participants indicated that there was limited support from the government. As stated, “Well politically, they go to the centers, they look for a person who needs a chair, a crutch and they give it and take photos and this and that but the support itself that this person need, he/she does not have it; I could point out that I do this and that, but the community does not receive the support as it should be (M)”.A clear example of rehabilitation centres’ neediness and helplessness is the dependence on charitable support propagandized by aspiring political leaders who make promises to support rehabilitation services during campaigns but often do not follow through, thereby impacting the care. As articulated by a participant,They have to bring a copy of their ID, they have to bring a referral from a doctor, but that is not inconvenient because everybody gets it. And, for getting the appointment, they do not need to come over here, they just call us (M).”“Access to services was impacted by various factors, including administrative process, infrastructure, number and quality of rehabilitation workers, the geographical distribution of rehabilitation centres, and challenges and obstacles for people in need of rehabilitation. Participants indicated there were no administrative barriers, especially regarding referral to centres. Most centres have chosen to operate an open-door policy due to inadequate physician-rehabilitation provider collaboration, as stated above. For instance, a participant noted,“The referral is made by any doctor, we do not have a specific doctor, but there are several doctors who are referring patients (M).” However, “even though these patients do not have a referral, they are always looked after and some of these patients go because they tell them to go to the centre (M).” Also, there is often “a waiting list, like for one week (M)” due to the increasing demand for rehabilitation services.A referral is essential to receiving services, but this process is centered on the doctor’s decision (their knowledge and beliefs in the rehabilitation profession), “Rehabilitation services for people with disabilities are…not… distributed evenly in Honduras (M).” This results in inequity in the provision of rehabilitation services, subsequently causing permanent disabilities, “because they did not have a place where they could receive therapy during their first 48 to 72 h (RW).” Another participant conveyed, “The distances to reach the rehabilitation center are very long and usually, these people are mostly poor and have difficulty moving from their places to the center of rehabilitation (M).” Nonetheless, although the centre's aim was to primarily serve people with very limited economic resources, due to access issues, the centres now provide services to people of all social status.The geographical distribution of the rehabilitation centres limits service access since, “very scarce , and here in previous years we had to resort and look for physiotherapists in [country] (M).”The need for both human and physical resources was a repeated mutual opinion. Participants remarked that there was limited availability of rehabilitation workers at the centres (and in the northern parts of the country in particular), thus influencing access to care. A participant stated, “There is no way that these people can mobilize and it is difficult to think that a bus has access so that a person in a wheelchair or a person who does not have his vision can walk because there is no way to that … they can leave their homes (M).”Transportation and other disability-related challenges were equally regarded as a social factor that impacts rehabilitation practices, particularly as it relates to mobility. Regarding this, a participant conveyed that with limitations in ramp accesses at buildings and buses,“that limited us, that we did not have materials, ….as I said, maybe the limitations could also be the equipment in some centers (RW).” Another participant stated, “… we have quadriplegic patients that it is extremely difficult to mobilize, and they have to take them in an uncomfortable car (M).”Also, limitations in the availability of healthcare infrastructures, such as wheelchairs and hospital equipment, create a barrier to access. To emphasize this point, a participant stated, “the amount we serve is great so if you came in the morning, you would see children, you could see people at the gym (RW).” In some settings, other non-clinical services are also provided,I mean, that the organization always tries to ensure that the child is always fed, we always worry that the child is fed so that we can provide rehabilitation, we give them medicines, diapers (RW).”“In our study, practices refer to exercises and procedures that impact the provision of rehabilitation care. Practice-related sub-themes included clinical, social, and inter-professional practices in rehabilitation. The scope of services provided by the centres varied and were stated to be extensive and cover a range of services by some and was considered limited by others. The reach and number of service users was commented to be extensive; however these remarks are not reflective of ongoing practices based on observations from our fieldwork in the region, “the biggest limitation is the staff, the team (RS),” and “the centre has a very low number of professionals (RW).” The downside of the lack of human resources is that patients often wait longer for rehabilitation services demonstrating multiple inefficiencies. The gap in rehabilitation workers for various services influenced practice. For instance, a participant noted, “we would like to have a physiatrist [physical medicine and rehabilitation medical specialist], that is our dream, and a psychologist, exactly in terms of human resources that is what most urges us (M).” Notwithstanding the limitations in human and physical resources, rehabilitation services are provided to individuals from varied locations, “we already serve patients from several municipalities”, and often serve “…Approximately 40 to 50 patients every day (M).”Limited infrastructure, resources, and availability of trained providers impacted clinical practices. Two participants mentioned, in the center we try to ensure that the quality of service is good. We try to make it most appropriate and that mothers are well-educated and comfortable with the children (RW).” Two participants noted that they, “provide the patient with quality care and warmth to achieve adequate physical and mental rehabilitation, free of charge (M)”, and “if a satisfaction survey could be done, I think that people would say that they are super satisfied with the service (M).”Additionally, despite the limitation of rehabilitation workers, participants indicated that the quality of services provided was adequate, as stated, ““The employees teach them how to handle the child in their home, how to do the rehabilitation and then there is a specific day where they supervise it. Show me how you did the (exercises with the) child and then they are under supervision (M).”Socially related practices such as support systems such as self-support groups and the relationship between the centre and patients and families fostered care. In order to advance knowledge, parents and family members of PWD are trained at the centres to support care. As a participant stated,All participants buttressed the importance of inter-professional practice in rehabilitation, particularly the need for professional collaboration across interdisciplinary teams to further care.the relationship has to be very close because a patient goes through the center from physical therapy to speech therapy or occupational therapy or goes to psychology, and the same patient can go through four areas or five then, it is very close. They have to have a very close relationship (M).”“For example, a participant noted,In summary, our study shows how rehabilitation workers' training, ongoing education, and awareness about rehabilitation by community members and other health practitioners influence rehabilitation care in Honduras. Education is closely linked with interprofessional practice due to the perception of the predominant role of physicians in society and in providing access to services, particularly as it relates to the referral process of persons who need to access rehabilitation services. In Northern Honduras, a small pool of funding for rehabilitation services, which is rooted in charity in the region, is challenged by sustainability, which subsequently affects rehabilitation care processes and clinical practices.Our results indicated the importance of rehabilitation awareness amongst the general population and understanding and clarity of the roles of rehabilitation workers, particularly physicians. Similarly, a study in Honduras indicated that the attitude towards rehabilitation care amongst health professionals in Northern Honduras is positive, but health personnel in hospitals lack the knowledge and practices to treat people in need of rehabilitation and provide comprehensive treatment, which may explain the low rate of referral to rehabilitation services . Thus, eAs accentuated in our study, socially related practices, including stigma and lack of social inclusion, influence individuals in need of rehabilitation care obtained in Northern Honduras. For example, a study conducted in Roatan showed that how disability is perceived in Honduras is influenced by regional traditions; as such, there is low regional attendance of children with disabilities in schools . Hence tThe Honduran government has intimated support towards furthering rehabilitation care, as demonstrated in the signing of international agreements related to disability, still its policies are often irresponsive to the needs of PWD . DespiteOur study indicated that irrespective of available data on the geographical distribution of people in need of rehabilitation in Honduras and national policies that have been enacted to advance the care of PWD, there is limited application of the policies. For example, at the governmental level, since 2002, the Honduran territory has had specific information that characterizes PWD, having entered the identification of this group in the Permanent Household Survey . In addiRehabilitation services in Northern Honduras are provided via the charitable care model to advance care and promote positive community knowledge and attitude towards disability . This isFurthermore, access to services for people in need of rehabilitation is framed around the practice structure and the referral pathway for rehabilitation care. Referrals are mostly provided and centralized around medical doctors. Rehabilitation workers are unable to make any referrals and connect with other professionals to further patient care. This issue is not unique to Honduras. For example, Ragupathi et al.  noted thIn addition, Honduran’s rehabilitation workers such as functional therapists have not been able to attain professional status, which is a major barrier to enabling them to take more prominent roles in patient care and provide patient referrals . Given tOur study showed that the geographical distribution of health facilities, the limited availability of rehabilitation workers at the centres in Northern Honduras, and physical infrastructure are crucial in advancing access and rehabilitation care. A systematic review of access to rehabilitation in LMICs suggested that PWD are not receiving a range of specific health services required to improve functioning , which mAs reported by Mejia et al. (2014), there are twenty-six rehabilitation centers in Honduras, and only seven of these centers have a rehabilitation specialist, highlighting the need to train rehabilitation workers since there is an unsatisfied demand due to the increase in chronic non-communicable diseases, life expectancy, and the consequences of accidents and violence in the country . There hOur study has highlighted the need for interprofessional practice and education. The hierarchical structure within interprofessional relations is linked with interprofessional education (IPE) and the perception of the prominent role of physicians in society. IPE is needed to respond to the changing demands of the environment, and Honduras has made some efforts/inroads in this regard, which have been led by the Pan American Health Organization and the World Health Organization (PAHO/WHO), and regional technical meetings have been held in which Honduras has participated, creating the Regional Network of Interprofessional Education of the Americas (REIP) . One of The multidisciplinary research team that included researchers and clinicians internationally and from the region fostered rich interpretive and analytical discussions grounded in the context of ongoing rehabilitation practices in Northern Honduras. All authors are affiliated with the same rehabilitation network as such, are biased toward rehabilitation care in Northern Honduras. Nonetheless, we utilized several strategies to ensure that the results reflected participants’ discussions and our collective experiences with rehabilitation education and practice in Northern Honduras fostered a rich data interpretation. Our study would have provided a broader perspective on rehabilitation education, practice, and process with the inclusion of the voices of service users, i.e., people in need of rehabilitation and family members. Nonetheless, we were able to report the perspectives of individuals who were fully engaged and involved in providing rehabilitation services in different capacities from various locations; thus findings are likely representative and relevant to rehabilitation care in the region.Our study in Northern Honduras highlights the gaps in rehabilitation education, processes, and practice. It is imperative to increase the understanding and awareness of rehabilitation care among community members and health providers to improve attitudes toward disability and care practices. We recommend strengthening capacities and improving quality service by furthering internal training within institutions to meet the high demands of specialized services and build the necessary competence to meet the needs of the population . CommuniSupplementary file1. COREQ checklist (PDF 453 KB)Supplementary file2. Focus Group and Interview Guide Questions (DOCX 22 KB)Below is the link to the electronic supplementary material.


The newly synthesized nicotinonitrile compounds 2–7 were characterized based on FTIR, 1H-NMR, and 13C-APT NMR spectra as well as elemental microanalyses. The target compounds 2–7 were screened for their toxicity effect against M. cartusiana land snails and were compared to Acetamiprid as a reference compound. The results demonstrated that the nicotinonitrile-2-thiolate salts 4a and 4b had good mortality compared with that of Acetamiprid. The results of the in vivo effect of the prepared nicotinonitrile molecules 2, 4a, and 4b on biochemical parameters, including AChE, ALT, AST, and TSP, indicated a reduction in the level of AChE and TSP as well as an increase in the concentration of transaminases (ALT and AST). A histopathological study of the digestive gland sections of the M. cartusiana land snails was carried out. The nicotinonitrile-2-thiolate salts 4a,b showed vacuolization, causing the digestive gland to lose its function. It could be concluded that the water-soluble nicotinonitrile-2-thiolate salts 4a,b could be adequate molluscicidal molecules against M. cartusiana land snails.A new series of nicotinonitrile derivatives  Mollusca is the second largest phylum of the animal kingdom, and it is probably the third most important animal group after arthropods and vertebrates ,2. Land I and Imidacloprid II are pyridine-containing neonicotinoid derivatives with molluscicidal activity [I was shown to have molluscicidal activity against Eobania vermiculata (E. vermiculata) land snail species, while Imidacloprid II exhibited a toxic effect against the eggs of E. vermiculata [III had a potent toxic effect against Mythimna separata (M. separata), with LC50 of 42.7 mg/L, compared with that of Avermectin, with LC50 of 29.6 mg/L [IV and V indicated strong aphidicidal activity against the adult cowpea aphid after a 24 h treatment, with LC50 values of 0.12 and 0.17 ppm, respectively, compared with that of Acetamiprid, with LC50 of 0.078 ppm [Pyridines broadly exist in nature and have various biological activities, including antimicrobial, anticancer, antioxidant, and insecticidal activities ,17,18,19activity ,25  or chloro (5) atoms. In addition to that, the amino group was converted to the corresponding quaternary ammonium salt: piperidinium or morpholinium nicotinonitrile thiolate salts . Further, the lead template 2 underwent further structural extension with either aryl amide (6a–c) or 4-methylbenzenesulphonamide (7)  . In addi1 was synthesized via the reaction of p-methoxy acetophenone and p-chlorobenzaldehyde in the presence of ethanolic NaOH [2 was synthesized by the cyclization of chalcone derivative 1 with malononitrile in refluxing pure ethanol in the presence of ammonium acetate. The structure of 2-aminonicotinonitrile 2 was confirmed on the basis of IR, 1H-NMR, and 13C-APT NMR spectra. The IR spectrum of compound 2 showed absorption bands at 3457, 3365, and 2205 cm−1, corresponding to the NH2 and CN groups, respectively. The 1H-NMR spectrum of compound 2 displayed three singlet peaks at δ 7.23, 6.97, and 3.82 ppm due to the protons of H-5 of pyridine ring, amino group, and OCH3, in addition to four doublet signals at δ 8.11, 7.70, 7.62, and 7.04 ppm, corresponding to the aromatic protons. The 13C-APT NMR spectrum of compound 2 showed peaks at δ 117.05, 114.01, and 85.49 ppm assigned for the nitrile group, C-5, and C-3 of the pyridine ring, respectively. 2-oxopyridine-3-carbonitrile derivative 3 was afforded by cyclization of the chalcone 1 with ethyl cyanoacetate in pure ethanol in the presence of ammonium acetate. The product was obtained as an amido tautomer, which is more stable than an imido tautomer. The structure of 3 was established by the presence of bands in the IR spectrum at 3502 and 1601 cm−1, characteristic of NH and C=O of the amide function, respectively. This was also confirmed by the presence of a singlet 1H-NMR peak at 12.70 ppm, corresponding to the amide NH 2, and O(CH2)2 groups, respectively, in addition to four doublet signals at δ 8.23, 7.75, 7.67, and 7.09 ppm, attributable to the aromatic protons. The 13C-APT NMR spectrum of 4b showed peaks at δ 115.82 and 100.80 ppm, corresponding to the nitrile group and C-3 of the pyridine ring, respectively, and two signals for four methylene carbon atoms at δ 66.21 and 49.08 ppm, corresponding to the methylene groups of the morpholine ring. In addition, the reaction of pyridine molecule 3 with POCl3 in the presence of N,N-dimethylaniline afforded the target 2-chloronicotinonitrile molecule 5. The structure of the obtained compound 5 was confirmed on the basis of the spectral data. The 1H-NMR spectrum elicited the absence of the amidic NH proton signal; in addition, the 13C-APT NMR spectrum confirmed the carbon skeleton due to absence of signal, corresponding to C=O of the pyridone ring of the precursor molecule 3  for active nicotinonitrile molecules are calculated and listed in 4a,b recorded LC50 values of 2.90 and 3.03 mg/mL, respectively, compared with that of Acetamiprid, with LC50 of 0.93 mg/mL. The results of toxicity screening experiments showed a correlation between the structural investigation of nicotinonitrile molecules 2–7 and their toxic effect against M. cartusiana land snails. In general, the nicotinonitrile molecule containing an amino substituent showed a better molluscicidal effect against M. cartusiana land snails than that of the compounds with other substituents. In addition, the replacement of the amino substituent with either aryl amide or the 4-methylbenzenesulphonamide group resulted in a complete loss of toxic effect against M. cartusiana land snails. Importantly, the corresponding quaternary ammonium salts, piperidinium or morpholinium nicotinonitrile-2-thiolate salts, exhibited a higher molluscicidal activity against M. cartusiana land snails than the rest of the compounds did. This may be attributed to presence of negative and positive charges, which increase the penetration through the cell membrane [4a,b looked promising after further structural modification, which will be discussed in a future study.The mortality of nicotinonitrile molecules membrane . A compa2, 4a, and 4b on some biochemical parameters in M. cartusiana land snails was investigated. The levels of acetylcholinesterase (AChE), alanine transaminase (ALT), and aspartate aminotransferase (AST) activities as well as the total soluble protein (TSP) were measured following the treatment of M. cartusiana land snails with nicotinonitrile compounds 2, 4a, and 4b at their LC50 values for 72 h. The results, demonstrated in 2, 4a, and 4b reduced the level of AChE by 1.09-, 1.29-, and 1.24-fold, respectively, compared with that of the no-treatment control . On the contrary, compounds 2, 4a, and 4b increased the level of ALT by 1.15-, 2.48-, and 1.66-fold, respectively, in comparison with that of the no-treatment control -3-(4-chlorophenyl)-1-(4-methoxyphenyl)prop-2-en-1-one (1). The structure of these newly synthesized nicotinonitrile compounds 2–7 was characterized and confirmed using IR, 1H-NMR, and 13C-APT NMR spectra as well as elemental microanalyses. Bioassays were conducted for the molluscicidal activity of the synthesized nicotinonitrile compounds 2–7 against M. cartusiana land snails. The results revealed that nicotinonitrile-2-thiolate salts 4a and 4b had a good mortality effect  compared with that of Acetamiprid (with LC50 of 0.93 mg/mL) as a reference compound. The results of the in vivo impact of nicotinonitrile molecules 2, 4a, and 4b on biochemical biomarkers, including AChE, ALT, AST, and TSP, indicated a reduction in the levels of AChE and TSP as well as a significant rise in the concentrations of transaminases (ALT and AST). A histopathological study of the digestive gland sections of M. cartusiana land snails was carried out. Nicotinonitrile-2-thiolate salts 4a,b showed vacuolization, causing the digestive gland to lose its function. It could be concluded that the water-soluble nicotinonitrile-2-thiolate salts 4a,b could be adequate molluscicidal molecules against M. cartusiana land snails, which could be beneficial in the near future for further structural modification when searching for potent molluscicidal molecules.In this study, a new series of nicotinonitrile derivatives 1H-NMR and 13C-APT NMR spectral data and elemental microanalyses were performed to substantiate the chemical structures of the prepared nicotinonitrile derivatives 2–7. For experimental details, see To identify the melting points, 1.To a well-stirred ethanolic solution of sodium hydroxide , 4-methoxy acetophenone  was added, and the mixture was stirred at room temperature for 10 min before an equimolar amount of 4-chlorobenzaldehyde  was added. The reaction mixture was stirred at room temperature for 12 h. The solvent was evaporated under vacuum, and then the remained residue was suspended in water and neutralized with diluted. HCl. The obtained solid residue was filtered off, dried, and crystallized from methanol to give compound −1): 3011 (νH aromatic), 2962 , and 1655 (νC=O). 1H-NMR : 8.01 , 7.72 , 7.54 , 7.49 , 7.36 , 6.96 , and 3.87 . 13C-APT NMR : 188.6 (CO), 163.8 (Ar), 142.6 (CH-olefinic), 136.4 (Ar), 133.8 (Ar), 131.0 (Ar), 131.0 (Ar), 129.7 (Ar), 129.4 (Ar), 122.5 (CH-olefinic), 114.1 (Ar), and 55.7 (OCH3). Anal. Calcd. for C16H13ClO2 (272.73): C, 70.46; H, 4.80. Found: C, 70.53; H, 4.84.White crystals , m.p. 102–104 °C. IR , malononitrile , and excess ammonium acetate  was dissolved in absolute ethanol. The reaction mixture was heated under reflux temperature for 12 h. After cooling, the formed precipitate was filtered off, washed with ethanol, dried, and crystallized from absolute ethanol to get pure compound 2.A mixture of compound −1): 3457 (νN-H), 3365 (νN-H), and 2205 (νCN). 1H-NMR : 8.11 , 7.70 , 7.62 , 7.23 , 7.04 , 6.97 , and 3.82 . 13C-APT NMR : 161.1 (C-2 pyridine ring), 160.8 (Ar), 158.4 (Ar), 153.4 (Ar), 135.9 (Ar), 134.4 (Ar), 130.3 (Ar), 129.8 (Ar), 128.9 (Ar), 128.7 (Ar), 117.1 (C≡N), 114.0 (C-5 pyridine ring), 108.3 (Ar), 85.5 (C-3 pyridine ring), and 55.3 (OCH3). Anal. Calcd. for C19H14ClN3O (335.79): C, 67.96; H, 4.20; N, 12.51. Found: C, 68.06; H, 4.24; N, 12.42.Yellow crystals , m.p. 217–219 °C. IR , ethyl cyanoacetate , and 2.8 g of ammonium acetate in absolute ethanol (20 mL) was heated under reflux for 24 h. After completion of the reaction, the excess solvent was concentrated under vacuum, and the formed product was filtered off, dried, and crystallized from absolute ethanol to afford pure compound 3.A mixture of compound −1): 3493 (νN-H), 2218 (νCN), and 1740 . 1H-NMR : 12.70 , 7.90 , 7.75 , 7.64 , 7.07 , 6.79 , and 3.84 . 13C-APT NMR : 161.8 (C=O), 135.2 (Ar), 135.0 (Ar), 130.2 (Ar), 129.5 (Ar), 128.8 (Ar), 116.5 (C≡N), 114.4 (C-5 pyridone ring), and 55.5 (OCH3). Anal. Calcd. for C19H13ClN2O2 (336.77): C, 67.76; H, 3.89; N, 8.32. Found: C, 67.81; H, 3.84; N, 8.19.Yellow solid , m.p. 194–196 °C. IR  and 2-cyanothioactamide  in pure ethanol, the respective base (0.549 mmol) was added. The reaction mixture was heated to reflux temperature overnight. After completion of the reaction, the reaction mixture was poured onto a beaker containing ice water. A solid formed, and it was filtered off and crystallized from pure ethanol to give pure compound 4a,b.To a solution of compound −1): 3453 (νNH), 3291 (νNH), and 2163 (νCN). 1H-NMR : 8.26 , 7.85 , 7.75 , 7.67 , 7.07 , 6.74 , 3.85 , 3.52 , and 1.60 . 13C-APT NMR : 167.1 (C-2 pyridine ring), 164.9 (Ar), 161.6 (Ar), 157.9 (Ar), 153.0 (s), 135.0 (Ar), 134.8 (Ar), 130.6 (Ar), 129.3 (Ar), 129.3 (Ar), 128.9 (Ar), 124.4 (Ar), 115.8 (C≡N), 115.6 (Ar), 114.3 (C-5 pyridine ring), 100.7 (C-3 pyridine ring), 55.4 (OCH3), 49.7 (CH2N+CH2), 25.8 (CH2CH2 N+), and 24.0- (CH2CH2CH2). Anal. Calcd. for C24H24ClN3OS (437.98): C, 65.81; H, 5.52; N, 9.59. Found: C, 65.89; H, 5.59; N, 9.47.White crystal , m.p. 255–257 °C. IR : 3301 (νNH), 3205 (νNH), and 2156 (νCN). 1H-NMR : δ 8.23 , 7.85 , 7.75 , 7.67 , 7.09 , 6.90 , 3.85 , 3.67 , and 3.55 . 13C-APT NMR : 167.4 (C-2 pyridine ring), 164.5 (Ar), 161.6 (Ar), 158.0- (Ar), 153.0- (Ar), 135.0 (Ar), 134.8 (Ar), 130.6 (Ar), 129.3 (Ar), 129.0 (Ar), 124.2 (Ar), 115.8 (C≡N), 115.7 (Ar), 114.4 (Ar), 100.8- (C-3 pyridine ring), 66.2- (CH2OCH2), 55.5- (OCH3), and 49.1 (CH2N+CH2). Anal. Calcd. for C23H22ClN3O2S (439.96): C, 62.79; H, 5.04; N, 9.55. Found: C, 62.68; H, 4.97; N, 9.63.White crystal , m.p. 262–264 °C. IR  was dissolved in 5 mL of phosphorous oxychloride, and 0.5 mL of N,N dimethylaniline was added by drops. The reaction mixture was refluxed for 3 days. The reaction mixture was poured onto ice water. The obtained solid residue was filtered off, dried, and crystallized from absolute ethanol to give pure compound 5.Compound −1): 3076 (νH aromatic), 2938 , and 2224 (νCN). 1H-NMR : 8.23 , 8.19 , 7.82 , 7.70 , 7.11 , and 3.86 . 13C-APT NMR : 162.0 (C-2 pyridine ring), 154.9 (Ar), 134.1 (Ar), 130.8 (Ar), 129.5 (Ar), 128.9 (Ar), 127.8 (Ar), 118.5 (Ar), 115.3 (C≡N), 114.6 (C-5 pyridine ring), 105.3 (C-3 pyridine ring), and 55.5 (OCH3). Anal. Calcd. for C19H12Cl2N2O (355.22): C, 64.24; H, 3.41; N, 7.89. Found: C, 64.34; H, 3.49; N, 7.78.White powder , m.p. 157–159 °C. IR  and appropriate aroyl chloride (1.322 mmol) was dissolved in dry pyridine. The reaction mixture was heated at 60–70 °C for 3 days. After the completion of the reaction, the whole reaction mixture was poured onto ice water with continuous stirring, and the water phase was extracted with ethyl acetate. The combined organic extracts were washed with water and dried with Na2SO4, and the solvent was removed under reduced pressure. The precipitated solid product was filtered off and purified by either crystallization or column chromatography.A mixture of compound −1): 3261 (νN-H), 2218 (νCN) and 1668 . 1H-NMR : 11.33 , 8.25 , 8.09–8.06 , 7.81 , 7.70 , 7.60–7.57 , 7.10 , and 3.85 . 13C-APT NMR : 166.1 (CO), 161.6 (C-2 pyridine ring), 158.4 (Ar), 153.9 (Ar), 153.5 (Ar), 135.0 (Ar), 134.8 (Ar), 132.9 (Ar), 132.5 (Ar), 130.7 (Ar), 129.3 (Ar), 129.2 (Ar), 129.0 (Ar), 128.8 (Ar), 128.6 (Ar), 128.2 (Ar), 116.8 (Ar), 115.8 (C≡N), 114.3 (C-5 pyridine ring), 100.6 (C-3 pyridine ring), and 55.4 (OCH3). Anal. Calcd. for C26H18ClN3O2 (439.89): C, 70.99; H, 4.12; N, 9.55. Found: C, 71.08; H, 4.06; N, 9.47.Yellow crystals , crystallized from absolute ethanol, m.p. 211–213 °C. IR : 3222 (νN-H), 2222 (νCN), and 1666 . 1H-NMR : 11.71 , 8.42 , 8.27 , 8.10 , 7.82 , 7.71 , 7.10 , and 3.85 . 13C-APT NMR : 164.8 (CO), 161.6 (C-2 pyridine ring), 158.5 (Ar), 153.6 (Ar), 153.4 (Ar), 149.7 (Ar), 138.6 (Ar), 135.1 (Ar), 134.7 (Ar), 130.8 (Ar), 129.7 (Ar), 129.3 (Ar), 129.0 (Ar), 128.7 (Ar), 123.8 (Ar), 117.1- (Ar), 115.7 (C≡N), 114.4 (C-5 pyridine ring), 101.5 (C-3 pyridine ring), and 55.4- (OCH3). Anal. Calcd. for C26H17ClN4O4 (484.89): C, 64.40; H, 3.53; N, 11.55. Found: C, 64.32; H, 3.61; N, 11.59.White crystals , crystallized from ethyl acetate, m.p. 223–225 °C. IR : 3561 (νN-H), 2218 (νCN) and 1697 ; 1H-NMR : 8.11 , 7.93 , 7.83 , 7.75 , 7.71 , 7.32 , 7.01 , 3.80 , and 2.33 . 13C-APT NMR : 172.5- (CO), 161.8- (C-2 pyridine ring), 158.2- (Ar), 156.0- (Ar), 154.0- (Ar), 143.9- (Ar), 135.5 (Ar), 134.0- (Ar), 131.0 (Ar), 130.8 (Ar), 129.7- (Ar), 129.2 (Ar), 129.1 (Ar), 128.9 (Ar), 127.8 (Ar), 118.0 (Ar), 115.3 (C≡N), 114.4 (C-5 pyridine ring), 101.6- (C-3 pyridine ring), 55.4- (OCH3), and 21.1 (CH3). Anal. Calcd. for C27H20ClN3O2 (453.92): C, 71.44; H, 4.44; N, 9.26. Found: C, 71.35; H, 4.52; N, 9.33.White powder , the residue was purified with column chromatography (methylene chloride/hexane), m.p. 207–209 °C. IR  and 4-methylbenzenesulphonyl chloride  was dissolved in dry pyridine. The reaction mixture was heated at 60–70 °C for 3 days. After the completion of the reaction, the whole reaction mixture was poured onto ice water with continuous stirring, and the water phase was extracted with ethyl acetate. The combined organic extracts were washed with water and dried with Na2SO4, and the solvent was removed under reduced pressure. The obtained residue was purified with column chromatography (methylene chloride/hexane) to give pure compound 7.A mixture of compound −1): 3426 (νN-H), 2224 (νCN); 1H-NMR : 8.36 , 7.86–7.81 , 7.78–7.67 , 7.42 , 7.04 , 3.87 , and 3.32 . 13C-APT NMR : δ 162.0 (C-2 pyridine ring), 158.3 (Ar), 154.5 (Ar), 149.9 (Ar), 146.1 (Ar), 135.5 (Ar), 134.5 (Ar), 133.8 (Ar), 130.9 (Ar), 129.0 (Ar), 129.4 (Ar), 129.1 (Ar), 129.0 (Ar), 127.5 (Ar), 120.6 (Ar), 114.7 (C≡N), 114.3 (C-5 pyridine ring), 107.6 (C-3 pyridine ring), 55.5 (OCH3), and 21.2 (CH3). Anal. Calcd. for C26H20ClN3O3S (489.97): C, 63.73; H, 4.11; N, 8.58. Found: C, 63.82; H, 4.16; N, 8.50.White powder , m.p. 228–230 °C. IR , were prepared by mixing an appropriate amount of each compound with one drop of Tween 80 and one drop of DMSO until the compounds became completely soluble, followed by the addition of the appropriate volume of water to provide homogeneous suspension. Before starting the experiment, the snails were starved for 48 h. The snails were irradiated with water for activation. Thirty snails for each concentration were immersed in the corresponding solution of the tested compound for 30 s. A piece of fresh lettuce leaf was dipped for 30 s, and then every ten snails were introduced in a box supplied with a disc of lettuce. The boxes were covered with a muslin cloth and secured with a rubber band to prevent the snails’ escape. Ten snails were utilized as a control by immersing them in water containing one drop of Tween 80 and one drop of DMSO. A lack of contraction indicated death, and the dead snails were removed. The mortality percentage was calculated after 3 days and corrected by Abbott’s Formula. The LC50 values  for the active compounds were calculated.The molluscicidal activity test was conducted according to the guidelines of the World Health Organization (WHO), with a slight modification through the use of two mixed solvents to dissolve the nicotinonitrile compounds in order to study the effect of nicotinonitrile molecules d snails . Monacha2, 4a, 4b and Acetamiprid on the levels of AChE, ALT, AST as well as the TSP activities in M. cartusiana snails was determined [The in vivo impact of nicotinonitrile compounds termined ,35,36. SM. cartusiana land snails was conducted. They were observed by light microscopy after treatment with nicotinonitrile compounds 2, 4a, and 4b compared with that of the no-treatment control [2, 4a, and 4b with a concentration equal to the LC50 values, histological studies were performed. The shell of each snail was carefully broken, and the soft tissues were dissected out. The digestive gland and the intestines of the snail were placed in a petri dish containing isotonic buffer. The digestive gland was separated and fixed in 10% formalin. For histological studies, the organ was dehydrated using an ascending series of ethanol alcohol, cleared in xylene for 2 min, and then immersed in three changes: The first consisted of xylene + wax in ratio 1:1, and the second and the third are wax each for 1/2 h. Embedding in paraffin and blocking was carried out under vacuum. Serial transverse sections of 6–8 μm were mounted on clean slides without using any adhesive material. Ehleish’s haematoxylin and eosin were employed for general histological studies of the digestive gland.A histopathological study of the digestive gland sections of the  control ,38. Afte