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34 Occupational Therapy International, 8(1), 34–48, 2001 © Whurr Publishers Ltd

Description of self-care training

in occupational therapy: Case
studies of five Kenyan children with
cerebral palsy

SUSANNE GUIDETTI Department of Public Health and Caring Sciences,

Uppsala University, Uppsala, Sweden, and Department of Occupational
Therapy, Karolinska Hospital, Stockholm, Sweden
INGRID SÖDERBACK Department of Public Health and Caring Sciences,
Uppsala University, Uppsala, Sweden, and Department of Rehabilitation
Medicine, Karolinska Hospital, Stockholm, Sweden

ABSTRACT: The purpose of this prospective case study design was to describe the
changes in dressing skills for five Kenyan children with cerebral palsy who participat-
ed in a 10-week occupational therapy intervention programme. The training sessions
were individually designed to meet the needs of the child. The children’s perfor-
mances on undressing and dressing and the time these tasks took was used as a base-
line and outcome measure. These measurements were documented by video films
and then analysed using visual inspection and converted into the scores of the Klein-
Bell Activities of Daily Living (ADL) Scale. The results for each child were analysed
using a simplified version of the Reliability Change Index. The results showed that
four of the five children improved their ability to dress and that the children increased
their time to undress significantly (p<0.05). Three children needed more time and
two children needed less time for dressing (p<0.05). The results were influenced by
the activity limitations among these children and the environmental, social back-
grounds, cultural and economic situation unique to Kenya. It is recommended that
case study research be used to validate clinical practice in paediatric occupational
therapy and to understand cultural differences and its impact on health care.

Key words: Activities of Daily Living (ADL), case study, cerebral palsy, occu-
pational therapy outcome.

Introduction

The practice of occupational therapy is affected by the economy of the country,

the healthcare system, the culture and the accessibility of healthcare services.
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Case studies of five Kenyan children with cerebral palsy 35

This study was carried out in Kenya which has its own unique culture, social
system and healthcare practices.
To date, no research study has examined the effect of occupational therapy
intervention on the self-care skills of children with cerebral palsy living in
Kenya. This clinical research study was carried out by the first author who
spent three years as an occupational therapy volunteer in Kenya. The main
purpose of this study was to understand how occupational therapy as practised
in Sweden can be adapted to assist children with cerebral palsy in Kenya.

Occupational therapy in Kenya

This study was carried out in Nairobi, Kenya. An occupational therapy train-
ing programme was started in 1968 at the Kenya Medical Training College.
Thirty students are admitted to the programme each year. Occupational ther-
apists in Kenya have limited opportunities to perform research and then have
limited access to international contacts because of inadequate financial
resources. The occupational therapy department at the state-wide hospital in
Nairobi does not have access to computers.
More than 600 occupational therapists are employed in Nairobi. Of the
occupational therapists in Kenya about 60% treat children with cerebral palsy
(CP). The primary frames of reference taught in the occupational therapy
training programme in Kenya are the Jean Ayres Sensory Integration Theory
(Ayres, 1972; Chu, 1989), Berta Bobath’s Neuro-Developmental Frame
of Reference (Bobath, 1978; Lilly and Powell, 1990) and Margareta Rood’s
theory (Rood, 1952; Randolph, 1975).
The practice of occupational therapy is highly influenced by the Kenyan
child’s environment, playmates, extended family and the more natural way
of belonging to the community (personal communication, an officer from
the Ministry of Health). For example, individuals in the child’s entire
social circle participate in occupational therapy during home-based reha-
bilitation.

Children in Kenya
One in every 10 children in Kenya dies before his or her fifth birthday.
Because of the social traditions and taboos in Kenya concerning individuals
with disabilities, some parents and communities hide their children with
disabilities (Neckmar, 1995). Therefore, it is not known for certain how many
children with disabilities in Kenya are in need of treatment or receive rehabil-
itative services such as occupational therapy. It is commonly supposed that
6–7% of the Kenyan population have disabilities and that about 700 000–
800 000 children up to the age of 16 years are disabled (Molgaard, 1992).
Health care and occupational therapy provided in public institutions are free
of charge for children up to five years old.
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36 Guidetti and Söderback

Children with cerebral palsy

Children with cerebral palsy develop more slowly than typical children of com-
parable age (Bax, 1964). Most children with developmental disabilities experi-
ence delays or difficulties in acquiring self-care skills (Henderson, 1995). It is
essential that training should be available at the earliest possible time for chil-
dren with cerebral palsy. The treatment of these children is probably one of the
most challenging tasks for occupational therapists (Freeman, 1995).
For children with cerebral palsy, many activities such as dressing are diffi-
cult. The lack of fine-motor control results in difficulties in handling smaller
objects such as buttons. Trying to put one’s arm through a sleeve is a challenge
to anyone with spasticity or muscle deficiency (Borg and Forsberg, 1994).

Society’s impact on children’s mastery of self-maintenance tasks

In every society, children are expected to gradually achieve independence in
their performance of self-care activities. The normal level of independence in
self-care skills depends on the child’s biological age and cultural tradition.
According to Bernard (1978) and Frank (1994), social values influence a child’s
perception of the importance of independence in self-care. Each culture deter-
mines the most appropriate time for a child to learn a skill. Within the broad
culture, families influence the performance of everyday skills (Bernard, 1978).
In large families, for example, older children may need to give more practi-
cal assistance in chores, while younger children are able to learn everyday
activities from their siblings. Cultural, class and family variables influence the
timing and acquisition of independence in self-care for young children.
The consequences of culture vary. For example, in most western societies
children are expected to be toilet-trained and to be self-sufficient in eating,
dressing and hygiene when entering the first year of school (Amato and
Ochiltree, 1986).

Children’s normal mastery of undressing and dressing

Development of skills

Self-care activities include such basic functions as eating, dressing, bathing

and the use of the toilet (Klein, 1983). A child who dresses independently
benefits from not having to rely on a caregiver. Thus, the child has control of
his or her time and is able to have more time for play (Case-Smith, 1994).
Children strive for and demand independence as a natural stage in their
development. They want to master skills and often say ‘I can do it myself’
(Henderson, 1995). Mastery of a self-care task is achieved through extensive
practice until it is performed naturally (Eliasson, 1992).
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Case studies of five Kenyan children with cerebral palsy 37

The child’s mastery of self-care skills depends on his or her motor control
and sensory, perceptual and cognitive abilities. Among these, body positions,
changes of body posture and particularly the coordination of hand functions
are the most important abilities (Eliasson, 1995). The extent to which chil-
dren use their arms and hands influences the speed with which they learn to
perform self-care activities independently. Human hands are probably the
most effective tools used in various tasks in self-care, such as the actions of
putting on and taking off clothes (Inomata and Simizu, 1991), tying shoes or
buttoning up clothes. Most of the self-care skills require bilateral actions
(Eliasson, 1995; Stilwell and Cermak, 1995).

Description of the child’s ages when mastering undressing

Children’s interest in taking clothing off begins in the first year of life
(Gesell et al., 1940; Henderson, 1995). Comparing dressing with undressing,
the latter is easier for all children, since it requires fewer action sequences
and only simple perceptual skills are needed. Pulling up one’s pants requires
more strength and bilateral coordination than getting them down and kick-
ing them off (Henderson, 1995). Furthermore, in this activity, the child does
not need to know which is the front or back of the garment or to separate
left from right (Klein, 1983). Most children can take off their clothing, and
want to, between two and a half to four years old (Klein, 1983; Eliasson,
1995).

Description of the child’s ages when mastering dressing

Dressing is difficult for all children before the age of six, because it requires
well-developed sensorimotor and perceptual functions (Eliasson, 1995). The
child’s ability to perform the tasks of loosening laces and comprehensive but-
toning requires complex finger dexterity. Children of two to three years old
are able to button a garment, whereas their ability to master the task can
depend on the location of the button (Klein, 1983; Inomata and Simizu,
1991; Henderson, 1995).
Upper-body garments and dresses are ranked more difficult than putting on
trousers. Normally, a child aged four years is able to dress himself or herself
with supervision to locate the heel of the sock, to consistently identify the
front and the back of garments and to button them (Klein, 1983).
At the age of five, a typical child will be able to dress unsupervised, includ-
ing buttoning and tying and untying knots (Klein, 1983). Putting on shoes is
one of the most difficult actions in dressing because the child needs to distin-
guish the right and left shoe from each other and to tie the shoelaces. This
developmental task is difficult to learn and typically will be performed inde-
pendently by the age of six (Klein, 1983).
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38 Guidetti and Söderback

The treatment/learning process

According to Gentile (1992), therapists intervene in the learning process in

order to assist the child’s development of skills in functional and relevant
tasks. Learning is gained through practising a skill.
In the therapeutic setting play often becomes a tool for the occupational
therapist in teaching self-care skills to children with disabilities. Play activities
tend to follow a therapeutic or an educational plan (Tobias and Goldkopf,
1995). The methods that are used in self-care training for children must be
tailored to each child’s developmental age, learning style and ability (Pedretti,
1996). In developing therapeutic goals the therapist observes the child’s
movements and occupational performances preferable in a natural setting
(Gentile, 1992; Pedretti, 1996). For example, such movements as holding
arms and legs out from the body show the child’s understanding of the dressing
process (Henderson, 1995).
To accomplish this learning and therapeutic process an occupational thera-
pist has four tools: a) verbal instructions, b) supplementary visual input, c)
positioning or passive movement of the child, and d) structuring the environ-
ment for practice.
Sisson et al.’s (1988) study of the guidance procedure for teaching self-
dressing skills with two children with multiple handicaps showed that the
children were eventually able to learn the dressing skills. Prehension skills are
also essential for undressing and dressing (Haney, 1998). A study by Barnes
(1989) showed that children with cerebral palsy did not improve their pre-
hension skills with weight-bearing exercises.
The aim of this prospective case study was to describe the changes in the
dressing and undressing skills of five children before and after participating in
an occupational therapy programme. The children all had cerebral palsy and
lived in Kenya.

Method

Design

The study followed a prospective case study design. A pre-measure of three

assessments of self-care was followed by a 10-week intervention programme of
occupational therapy twice a week for 60 minutes. A post-measurement fol-
lowed, which included three assessments of self-care (Ottenbacher et al., 1988).

Participants
The five children were selected by the first author in cooperation with
Kenyan occupational therapists who worked at a state hospital, a children’s
home and a teacher at a Swedish nursery school. The children selected for
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Case studies of five Kenyan children with cerebral palsy 39

this study had the potential to perform self-care activities and were recom-
mended for occupational therapy. The criteria for selection were a diagnosis of
cerebral palsy, an age between four and seven years old and available to par-
ticipate in undressing and dressing activities. The children’s parents or care-
givers gave information about the children’s ages, diagnoses, impairments and
activity limitations, and gave their permission for the children to participate
in the study.

Assessment instrument
In this study the dressing part of the Klein-Bell Activities of Daily Living
Scale (Klein and Bell, 1982) was used. It includes 65 items (103 scores),
resulting in 100% mastery of dressing. Four items – taking out clothes from
the cupboard, the bra, the hat and the prostheses – were excluded, because
they were not relevant to the study.
The complete Klein-Bell Scale measures skills in performance of basic
activities of daily life: dressing, bathing/hygiene, elimination, functional
mobility, eating and emergency communication. The scale includes 170 items
which are scored from 0 to 313 points. A score of 313 points is comparable
with 100% mastery of activities of daily living skills. Using a version for chil-
dren of the Klein-Bell Activities of Daily Living Scale the test–retest reliabili-
ty coefficient was 0.98 (Law and Usher, 1988).

Statistical methods
Statistical analyses were carried out using the Statistical Package for the
Social Sciences (SPSS) (SPSS, 1997). Changes on the pre- and post-test
results of the Klein-Bell Activities of Daily Living Scale were calculated using
the Reliability Change Index (Ottenbacher et al., 1988). In this study a sim-
plification method was used, as recommended when very few cases are avail-
able (Söderback, 1991: 42).

Process
The measures of pre- and post-test were determined by observation of the
children during their performance of undressing and dressing, usually involv-
ing a T-shirt, a dress, a jacket and a pair of shorts or trousers, socks and shoes.
The observations were documented by videotaping. The videotapes were used
to perform an analysis of the children’s undressing and dressing skills and the
time it took to dress and undress. These visual inspections of the video results
were converted into the Klein-Bell Activities of Daily Living Scale scores
(Klein and Bell, 1982).
The pre-tests were followed by 60 minutes of occupational therapy
training sessions twice a week for each child (Table 2). These sessions were
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40 Guidetti and Söderback

conducted by the child’s regular occupational therapists and/or occupational

therapy students supervised by the first author. The parents of three of the
children occasionally attended these sessions.
The children learned the techniques of dressing and undressing during
play. The training sessions were individually designed and performed in col-
laboration with Kenyan occupational therapists.

Results

The participating children (Sara, Vera, Rose, John and Anna) and their ages,
diagnoses, major impairments and living conditions are presented in Table 1.

Description of the children at pre-test

The children’s self-care skills were videotaped during three sessions and used
as baseline data. The children’s ability to undress and dress is shown in
Table 2.
Sara was unable to button up her clothes and to put on her socks. She had
problems in grasping and holding her clothes and she mostly used only her
right hand in these activities. She had problems in initiating the
undressing/dressing activities. An adult usually helped her. She had difficulties
in concentrating and was distractible during observation. She was able to
walk, stand and sit by herself.
Vera had problems with motor control, such as holding and gripping
objects, and in fine motor control activities such as using buttons. She was
unable to walk and stand by herself with assistance. She could not initiate talk
but she was able to repeat words. She had difficulties with concentration and
was distractible during the activities. She was able to sit by herself, understand
verbal instructions and recognize her parents.
Rose succeeded in dressing independently at times. She was unable to walk
and to stand by herself, but she could accomplish this with assistance. She
could not follow verbal instructions. She did not talk in whole sentences, but
was able to repeat words mostly in Kiswahili with difficulties. She did not
seem to understand the meaning of the words. She was able to eat slowly by
herself but when drinking she used both her hands.
John had a problem in knowing when to initiate self-care activities. He was
unable to button garments, he had difficulty with knowing the front from the
back of a T-shirt and in recognizing left and right shoes. He could not manage
the toilet at home because it was just a hole in the floor and he lacked the bal-
ance control needed for that purpose. He had problems with fine motor con-
trol such as handling objects. He had difficulties with concentration and was
distortable. He was able to walk but he could not jump or run and he often
lost control of his balance. He spoke mostly his tribal language but did under-
stand English. He was able to follow simple verbal instructions.
 OTI 8(1) crc

TABLE 1: Description of the participants (n=5) and their parents (n=8)

1/2/02

Participants Age Diagnosis Impairments Living condition Mother’s Father’s Remarks

work work

Sara 5 Cerebral palsy Spastic left side An only child living Housewife Senior citizen No remarks
11:39 AM

since birth together with her parents

Vera 4 Cerebral palsy Affected left hand, An only child living Health care Businessman She did not play
caused by meningitis right leg and foot together with her parents with other children
at two years old at home
Page 41

Rose 5 Cerebral palsy caused Hypertonic in upper Living together with her parents, Housewife Priest The family live in a
by malaria infection and lower body, an older brother and a younger sister apartment with one
with meningitis at nystagmus, hydrocephalus, room. She plays with
two months old uncontrolled head-shakings other children

John Not Cerebral palsy Unable to walk, crawl An only child living together with Housewife Manager at a The flat had one room
known diagnosis of or stand his parents mountain club and a pantry with just
≅ 4 unknown origin a hole in the floor as a
toilet
Anna Not Cerebral palsy Athetosis mostly in Living in a home for children where Nothing was Nothing was Anna’s mother had
known diagnosis of lower body, spastic her brother also lived. He had the known about known about left her at the
≅ 4 unknown origin upper body same symptoms of cerebral palsy as the mother the father children’s home
Anna had when she was two
years old
Case studies of five Kenyan children with cerebral palsy
41
 42
OTI 8(1) crc
1/2/02

TABLE 2: The results show the differences between pre-test and post-test (*p = <0.05) of undressing/dressing skills (n=5) according to the Klein-Bell
11:39 AM

Activities of Daily Living Scale and the time (´ = minutes and ´´ = seconds)
Guidetti and Söderback

Participants Period of Number of Klein-Bell Activities Time to undress Time to dress

observations sessions of Daily Living Scale
Page 42

% of child’s ability
to undress and dress

Post-test Pre-test Difference f* Post-test Pre-test d f* Post-test pre-test d f*

Sara 10 weeks 19 82 55 27 ns 4´ 22´´ 7´ 40´´ –3´ 18´´ sig 15´ 35´´ 19´ 40´´ 4´ 50´´ sig
Vera 10 weeks 20 62 46 16 ns 9´ 20´´ 6´ 15´´ 3´ 50´´ sig 11´ 60´´ 10´ 10´´ 1´ 50´´ ns
Rose 10 weeks 16 45 65 –20 ns 15´ 66´´ 12´ 26´´ 3´ 40´´ sig 10´ 80´´ 20´ 50´´ –8´ 30´´ sig
John 10 weeks 14 82.5 53 29.5 ns 13´ 10´´ 6´ 10´´ 7´ 00´´ sig 17´ 50´´ 20´ 50´´ –3´ 00´´ sig
Anna 10 weeks 8 74 44 30 ns 4´ 15´´ 6´ 15´´ –2´ 00´´ sig 19´ 80´´ 16´ 30´´ 3´ 50´´ sig

ns = not significant; sig = significant; * f is derived from the reliability coefficient value (Söderback, 1991)
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Case studies of five Kenyan children with cerebral palsy 43

Anna was dependent on others in using the toilet and in dressing. It was
difficult to understand what she was saying because of her poor oral motor
control. She spoke some English, but mostly Kiswahili. Anna was able to fol-
low verbal instructions such as ‘you can start to put on your T-shirt’. She was
independent in feeding. She used a wheelchair and was able to transport her-
self and to move herself from the wheelchair to the floor and back again.

Treatment interventions
The children participated in between eight and 20 treatment sessions of occu-
pational therapy.
Sara: The learning process was used most of the time. Sara was trained in
undressing and dressing at nursery school during swimming sessions. The
training was also performed during play, using Swedish pre-school play materi-
al, such as puzzles, Plasticine and painting. The purpose was to train Sara’s
hand functions in gripping and handling objects. She had the opportunity to
improve her balance by the ‘swinging train’ (Ayres, 1972; Chu, 1989), using
outdoor toys in an outdoor environment and playing with water.
Vera’s training in undressing and dressing was performed in the occupa-
tional therapy department at the hospital. The training was focused on a
teaching approach during the repeated undressing and dressing. The session
began with use of the same clothes and the same sitting position each time.
The sessions ended using play objects from the occupational therapy depart-
ment. The toys were of a simple design and mostly made of wood. Vera
trained herself to grip things by transferring objects such as sticks and cubes.
The balance-control training was done by sitting on a stool during all the
activities. Vera was also trained in balance by swinging (Ayres, 1972; Chu,
1989). During the training period, she developed her ability to stand and walk
and her talking increased.
Rose’s training in undressing and dressing was also done in the occupation-
al therapy department. Rose had a problem in holding objects. When she held
something, she would throw it away. Training was focused on a teaching
approach during the repeated undressing and dressing, each time in the same
way. The occupational therapist tried to draw Rose’s attention to verbal
instructions and also tried to give her cues that would make her start an activ-
ity (Hagedorn, 1995). She trained to control her dysfunctional grips by catch-
ing a ball and gripping sticks and cubes. Rose’s parents were taught to
understand the importance of using easy clothing to simplify dressing and
undressing. For example, they widened the collar of her sweater. The training
was also performed during play, using play objects from the occupational ther-
apy department.
John: The training was focused on a play approach, since he did not like to
dress and undress but was motivated by play. Training in dressing was focused
on helping him to put on one garment at a time. The training occurred in the
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44 Guidetti and Söderback

occupational therapy department using play objects such as play dough and a
string on which to thread marbles. The purpose was to train John’s hand func-
tion in handling objects. He also improved his balance by kicking a football,
doing throwing exercises, using a rocking horse and walking a tightrope. His
parents were taught to understand the importance of John being given time to
practise dressing skills at home.
Anna’s training in undressing and dressing was done in the occupational
therapy department at the children’s home. None of the children living here
had their own clothes. Therefore clothes suitable for and adapted to Anna
had to be found. This enabled her to practise dressing and undressing with
clothes that were recognizable to her. She had not previously been trained in
undressing and dressing skills. Her training was focused on a teaching
approach during the repeated undressing and dressing. She performed the
dressing after moving herself into a sitting position on a stool. New strategies
simplified her dressing operations – for example, by first pulling out one arm
and then the other in order to have both hands free to pull the sweater over
her head, and taking the shoe on to her lap to open the fastening and then
putting it back on the floor and sliding her foot into place in the shoe. The
training was also performed during play, using toys that had been donated.
The purpose was to help Anna to grasp objects, so that she could button
clothes. The occupational therapist adapted a sitting position, which reduced
Anna’s spasticity. She began lifting herself up by holding on to the wall,
which made it easier for her to dress and undress the lower parts of her body.

Evaluation summary
The results for undressing and dressing according to the Klein-Bell Activities
of Daily Living Scale (see Table 2) showed that four of the five children
improved their skills 16–30%. However, Rose’s skills decreased 20% although
the results were not statistically significant.
The results for four of the children showed improvement in time taken for
dressing. Two of the children had significantly decreased the time they took
for undressing, but three of the children had significantly increased the time
for undressing. Two of the children significantly decreased the time they took
for dressing and three of the children increased the time they took for dress-
ing. All the results were significant at the 0.05 level.

Discussion

The results of this study with five children with cerebral palsy show the
importance of considering cultural factors when training children in self-care
skills. The social, cultural and economic factors in Kenya affected the results
of the study. The pre- and post-test assessment using the Klein-Bell Activities
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Case studies of five Kenyan children with cerebral palsy 45

of Daily Living Scale and the time taken for the children to undress and dress
showed individual variations. Sara, Vera, John and Anna had developed their
undressing and dressing skills in a positive direction, although this was not
statistically significant. Furthermore, the patterns of the time taken to per-
form these undressing and dressing tasks were confusing. The paradox was
that the time taken for undressing as well as for dressing increased in three of
the five cases. This may be explained by the observation that children became
comfortable with the study environment. Although it took longer to undress
and dress, the children were mastering the skill and tried harder and harder to
succeed. From the video observations, it was noticeable that the children
developed their supportive actions, such as holding out arms and legs, stand-
ing, showing their understanding and motivation to dress. This supports what
Henderson (1995) described about children’s compliance in self-care skills.
The measurements of time and the use of the Klein-Bell Activities of
Daily Living Scale were valuable and are recommended for similar case stud-
ies. The Klein-Bell Activities of Daily Living Scale was sensitive to small
changes in dressing ability. The scale was used according to the original man-
ual but only those items applicable to children were assessed. The Klein-Bell
Activities of Daily Living Scale lacks a time assessment measure. Lynch and
Bridle (1989) also found the same problem and proposed that time assessment
be added to the Klein-Bell Activities of Daily Living Scale.
Another limitation of the Klein-Bell Activities of Daily Living Scale is
that it was developed and evaluated in the USA and needs to be adapted to
individuals with disabilities in Africa. It is difficult to determine whether cul-
tural factors influenced the results of the study.
Further research is recommended to evaluate children’s ability to learn
undressing and dressing skills, especially in diverse cultures. A randomized
controlled double-blind study would be appropriate to evaluate outcome
(Polit and Hungler, 1991). In contrast, this study was conducted as a quasi-
experimental single case design without a control group because of the cultur-
al factors in Kenya. The research required extensive documentation of the
defining treatment protocol and assessing outcome. This was difficult in this
environment because of hindrances such as a lack of secluded treatment areas
in the small and crowded occupational therapy departments. The treatment
sessions were performed in the child’s natural environment, often outdoors.
On the one hand this was judged as essential, but on the other hand it was
not optimal for the child’s concentration. The video camera itself evoked the
need for some explanation as to why such a distant cultural device was pre-
sent. It may have distracted the child during the assessment sessions.
Conducting this research project in Kenya was a challenge for the researcher.
It was difficult to randomize the sample because there was no register of
patients from which to select subjects. It was also difficult to follow up the chil-
dren who visited the state-wide hospital in Nairobi because their home addresses
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46 Guidetti and Söderback

were unknown and many Kenyans lack a telephone. All of these factors influ-
enced the planning of the study, and the choice of a case study design.
The economics of health care in Kenya influence who can afford occupa-
tional therapy. For example, occupational therapy is free for all children under
five years old. This causes many parents/caregivers to refrain from stating the
child’s true age. It also influences the occupational therapist’s intervention
plan and his/her judgement and evaluation of the child’s developmental skills.
The number of self-care training sessions varied among the children
depending on whether they had appointments for occupational therapy. In
addition, appointments were not kept because during the heavy rains the
roads were flooded and public transport often came to a complete standstill.
The Kenyan parents and caregivers chose the children’s clothing material
and the type of clothes that they wore and their dressing style. The clothes
that children wear in Kenya are not child-oriented, but are more like a copy of
adults’ clothes. The girls’ dresses, for example, were often back-buttoned with
small buttons and an excessive amount of material and frills. Children in
Kenya do not need as much clothing to practise with, because of the climate.
These factors definitely had an effect on the child’s accomplishments in self-
care, which may have influenced the assessments on the Klein-Bell Activities
of Daily Living Scale.
Among many positive things that influence Kenyan children’s develop-
ment in self-care is the large number of supporting adults, brothers and sisters
surrounding the child in the extended family in Kenya. This sometimes has
an effect on the training sessions and the children’s desire for functional
independence.
In conclusion, the results of this study showed that dressing skills can be
taught to children with cerebral palsy by incorporating skills training into play
activities in the natural environment. The cultural factors in Kenya were con-
sidered by the occupational therapists in designing the treatment programme.
The parents and caregivers were extremely important in supporting the occu-
pational therapist.

Acknowledgements

We wish to acknowledge the understanding and assistance of the parents, the

children and all the occupational therapists that the first author met in
Kenya. We thank Ann-Christin Eliasson, DrMedSci, for her contribution to
our knowledge of rehabilitation in occupational therapy, Franklin Stein, PhD,
FAOTA, for his outstanding wisdom in editing this manuscript, and Bengt
Ramund, statistician in the Department of Pedagogy, Uppsala University. For
financial support, we wish to thank Harriet Pandis, Head of the Occupational
Therapy Department in Karolinska Hospital, Sweden. The study is a short
version of a master’s thesis outlined at the Department of Public Health and
Caring Sciences, Section of Caring Sciences, Uppsala University, Sweden.
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Case studies of five Kenyan children with cerebral palsy 47

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Address correspondence to Ingrid Söderback, Department of Public Health and Caring

Sciences, Section of Caring Sciences, Uppsala University, Uppsala Science Park, S-75183
Uppsala, Sweden. Email: Ingrid.Soderback@ccs.uu.se