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Khasnabis C, Heinicke Motsch K, Achu K, et al., editors. Community-Based Rehabilitation: CBR Guidelines. Geneva: World Health Organization; 2010.

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Community-Based Rehabilitation: CBR Guidelines.

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Rehabilitation

Introduction

As highlighted in the Preamble, access to rehabilitation is essential for people with disabilities to achieve their highest attainable level of health. The Convention on the Rights of Persons with Disabilities, Article 26, calls for “appropriate measures, including through peer support, to enable persons with disabilities to attain and maintain maximum independence, full physical, mental, social and vocational ability and full inclusion and participation in all aspects of life...” (2).

The Standard Rules on the Equalization of Opportunities for Persons with Disabilities state that rehabilitation measures include those which provide and/or restore functions, or compensate for the loss or absence of a function or a functional limitation (23). Rehabilitation can occur at any stage in a person's life but typically occurs for time-limited periods and involves single or multiple interventions. Rehabilitation may range from more basic interventions such as those provided by community rehabilitation workers and family members to more specialized interventions, such as those provided by therapists.

Successful rehabilitation requires the involvement of all development sectors including health, education, livelihood and social welfare. This element focuses on those measures to improve functioning that are offered within the health sector. It is important to note however that health-related rehabilitation services and the provision of assistive devices are not necessarily managed by the ministry of health (see Rehabilitation services).

BOX 23Kenya

Forging public–private partnerships

The Association for the Physically Disabled of Kenya (APDK) has been providing comprehensive rehabilitation services in Kenya for the past 50 years, reaching over 500 000 people with disabilities. As a result of several partnerships, APDK has been able to establish a national rehabilitation network consisting of nine main branches, 280 associated outreach centres and many community-based rehabilitation programmes; these provide services such as therapy, assistive devices and support for surgical interventions.

One of APDK's successful partnerships has been with the Ministry of Medical Services (formally the Ministry of Health). Over the past 30 years, APDK has worked closely with this Ministry to ensure that quality rehabilitation services are accessible to as many people as possible. Six of the nine APDK branches are located within government hospitals and the Ministry of Medical Services has provided over 50 health workers, mostly therapists and technicians, to work in these branches. The Ministry provides the salary for most of these health workers while APDK funds the programme costs.

APDK established their first CBR programme in their Mombasa branch in 1992. Since 2000, they have extended these programmes to the major slums in Nairobi in order to reach those people with disabilities who are most vulnerable. CBR programmes provide home-based rehabilitation and are an important referral link to APDK outreach centres and branches. With financial support from CBM and Kindernothilfe, APDK has employed 32 CBR personnel to work in these programmes while the government has funded several therapy positions.

APDK is a successful example of a public–private partnership and demonstrates how centre-based rehabilitation and community-based rehabilitation can work together to provide rehabilitation services for people living in both urban and rural areas. In 2008 alone, approximately 52 000 Kenyan people received rehabilitation services from APDK.

Goal

People with disabilities have access to rehabilitation services which contribute to their overall well-being, inclusion and participation.

The role of CBR

The role of CBR is to promote, support and implement rehabilitation activities at the community level and facilitate referrals to access more specialized rehabilitation services.

Desirable outcomes

  • People with disabilities receive individual assessments and are involved in the development of rehabilitation plans outlining the services they will receive.
  • People with disabilities and their family members understand the role and purpose of rehabilitation and receive accurate information about the services available within the health sector.
  • People with disabilities are referred to specialized rehabilitation services and are provided with follow-up to ensure that these services are received and meet their needs.
  • Basic rehabilitation services are available at the community level.
  • Resource materials to support rehabilitation activities undertaken in the community are available for CBR personnel, people with disabilities and families.
  • CBR personnel receive appropriate training, education and support to enable them to undertake rehabilitation activities.

Key concepts

Rehabilitation

Rehabilitation is relevant to people experiencing disability from a broad range of health conditions and therefore the CRPD makes reference to both “habilitation” and “rehabilitation”. Habilitation aims to assist those individuals who acquire disabilities congenitally or in early childhood and have not had the opportunity to learn how to function without them. Rehabilitation aims to assist those who experience a loss in function as a result of disease or injury and need to relearn how to perform daily activities to regain maximal function. Habilitation is a newer term and is not commonly used in low-income countries, therefore these guidelines use the term “rehabilitation” to refer to both habilitation and rehabilitation.

Rehabilitation interventions

A wide range of rehabilitation interventions can be undertaken within the health sector. Consider the examples below.

  • Rehabilitation for a young girl born with cerebral palsy might include play activities to encourage her motor, sensory and language development, an exercise programme to prevent muscle tightness and development of deformities and provision of a wheelchair with a specialized insert to enable proper positioning for functional activities.
  • Rehabilitation for a young boy who is deafblind might include working with his parents to ensure they provide stimulating activities to encourage development, functional mobility training to enable him to negotiate his home and community environments and teaching appropriate communication methods such as touch and signs.
  • Rehabilitation for an adolescent girl with an intellectual impairment might include teaching her personal hygiene activities, e.g. menstrual care, developing strategies with the family to address behavioural problems and providing opportunities for social interaction enabling safe community access and participation.
  • Rehabilitation for a young man with depression might include 1:1 counselling to address underlying issues of depression, training in relaxation techniques to address stress and anxiety and involvement in a support group to increase social interaction and support networks.
  • Rehabilitation for a middle-aged woman with a stroke might include lower limb strengthening exercises, gait training, functional training to teach her to dress, bath and eat independently, provision of a walking stick to provide support for balance difficulties and exercises to facilitate speech recovery.
  • Rehabilitation for an older man who has diabetes and recently had both legs amputated below the knee might include strengthening exercises, provision of prostheses and/or a wheelchair and functional training to teach mobility and transfer skills and daily living skills.

Rehabilitation services

Rehabilitation services are managed by government, private or nongovernment sectors. In most countries, the ministry of health manages these services; in some countries, however, rehabilitation services are managed by other ministries, e.g. by the Ministry of Labour, War Invalids and Social Affairs in Viet Nam and by the ministries of social welfare in India, Ghana and Ethiopia. In some countries, services may be managed through joint partnerships between government ministries and nongovernmental organizations, e.g. in the Islamic Republic of Iran, Kenya and China.

Services are provided by a broad range of personnel including medical professionals (e.g. nurses, physiatrists), therapy professionals (e.g. occupational therapists, physiotherapists, speech therapists), technology specialists (e.g. orthotists, prosthetists) and rehabilitation workers (e.g. rehabilitation assistants, community rehabilitation workers). Rehabilitation services can be offered in a wide range of settings, including hospitals, clinics, specialist centres or units, community facilities and homes; the phase during which rehabilitation occurs (e.g. the acute phase following an accident/injury) and the type of interventions required usually determine which setting is appropriate.

In low-income countries and particularly in rural areas, the range of rehabilitation services available and accessible is often limited. There may only be one rehabilitation centre in the major city of a country, for example, or therapists may be available only in hospitals or large clinics. Therefore community-based strategies such as CBR are essential to link and provide people with disabilities and their families with rehabilitation services.

Community-based services

Historically, CBR was a means of providing services focused on rehabilitation to people living in low-income countries through the use of local community resources. While the concept of CBR has evolved into a broader development strategy, involvement in the provision of rehabilitation services at community level remains a realistic and necessary activity for CBR programmes.

Rehabilitation at specialized centres may not be necessary or practical for many people, particularly those living in rural areas and many rehabilitation activities can be initiated in the community. The WHO manual on Training in the community for people with disabilities is a guide to rehabilitation activities that can be carried out in the community using local resources (32).

Community-based services may also be required following rehabilitation at specialized centres. A person may require continued support and assistance in using new skills and knowledge at home and in the community after he/she returns. CBR programmes can provide support by visiting people at home and encouraging them to continue rehabilitation activities as necessary.

Where rehabilitation services are established in the community, close links must be maintained with referral centres that offer specialized rehabilitation services. The needs of many people with disabilities change over time and they may require periodic support in the long term. Successful rehabilitation depends on strong partnerships between people with disabilities, rehabilitation professionals and community-based workers.

BOX 24China

Li's journey to independence

Li, a middle-aged widow, lives with her elderly mother and three children in the Qing Hai province of China. Her whole family depended on her before an accident in October 2003. Li fell from a height while repairing her house and sustained a spinal fracture, resulting in weakness and sensory loss in both legs. After she was discharged from hospital, she stayed in bed all day and night. Swelling quickly developed in both her legs and she required full assistance from her children to turn in bed, bathe, change her clothes and use the toilet. Li soon lost her confidence and tried to commit suicide several times; fortunately, she was unsuccessful.

A village rehabilitation officer from a local CBR programme came to visit Li and provided her with home-based rehabilitation. Li was taught new ways of completing daily living activities using her residual abilities. She was given information about her disability and learnt how to prevent bed sores and urinary tract infections. Her family and friends were taught how to make a simple walking frame for her to practise standing and walking. They also made a simple toilet bowl to solve the problem of going to the toilet. The County Rehabilitation Centre provided crutches and a wheelchair. With time and practice Li was able to stand and walk independently with crutches and use a wheelchair for longer distances.

Step by step, Li built up her confidence. She was soon able to manage her own daily activities, which included cooking for her family, an activity she really enjoyed. Li also opened a mill, providing her with a source of income which, together with a small monthly living allowance from the County Ministry of Civil Affairs, allows her once again to care for her family and be confident about the future.

Rehabilitation plans

Rehabilitation plans need to be person-centred, goal-oriented and realistic. When developing a plan, a person's preferences, age, gender, socioeconomic status and home environment need to be considered. Rehabilitation is often a long journey, and a long-term vision is required, with short-term goals. Valuable resources can be wasted when rehabilitation plans are not realistic.

Many rehabilitation plans fail because people with disabilities are not consulted; it is important to ensure that their opinions and choices influence the development of the plan and that the realities of their lives, in particular the issue of poverty, are considered. For example, a plan that requires a poor person living in a rural area to travel frequently to the city for physiotherapy is likely to fail. Rehabilitation personnel need to be innovative and develop appropriate rehabilitation programmes which are available as close as possible to home, including in rural areas.

Rehabilitation needs may change over time, particularly during periods of transition, e.g. when a child starts school, a young adult starts work, or a person returns to live in her/his community following a stay in a rehabilitation facility. During these transitions, adjustments will need to be made to the rehabilitation plans to ensure the activities continue to be appropriate and relevant.

Suggested activities

Identify needs

Before making a rehabilitation plan and starting activities, it is important for CBR personnel to carry out a basic assessment with an individual and his/her family members to identify needs and priorities. Assessment is an important skill, so CBR personnel should receive prior training and supervision to ensure competency in this area. To identify a person's needs it can be helpful to consider the following questions.

  • What activities can they do and not do?
  • What do they want to be able to do?
  • What problems do they experience? How and when did these problems begin?
  • What areas are affected? e.g. body, senses, mind, communication, behaviour?
  • What secondary problems are developing?
  • What is their home and community situation like?
  • In what way have they adjusted to their disability?

Accurate information can be obtained by reviewing past medical records, observing the individual, performing a basic physical examination of the individual and through discussions with the individual, family members and involved health professionals/services. It is important to keep a record of the initial assessment and future consultations, so an individual's progress can be monitored over time. Many CBR programmes have developed assessment forms and progress notes to make this easier for their staff.

Facilitate referral and provide follow-up

If, following the basic assessment, CBR personnel identify a need for specialized rehabilitation services, e.g. physiotherapy, occupational therapy, audiology, speech therapy, they can facilitate access for people with disabilities by initiating referrals.The following activities are suggested.

  • Identify rehabilitation referral services available at all levels of the health system.
  • Provide information regarding referral services to people with disabilities and their families, including location, possible benefits and potential costs.
  • Encourage people with disabilities and their families to express concerns and ask questions about referral services. Help them to seek additional information if required. Links can be made with other people in the community who experience similar problems and have benefited from the same or similar services.
  • Ensure people with disabilities and their family members give informed consent before any referral is made.
  • Once a referral is made, maintain regular contact with the services and individuals involved to ensure that appointments have been made and attended.
  • Identify what support is required to facilitate access to services (e.g. financial, transport, advocacy) and how this can be provided. For example, if advocacy is required, CBR personnel can accompany people to their appointments.
  • Provide follow-up after appointments to determine whether ongoing support is needed, e.g. rehabilitation activities may need to be continued at home.

Specialized rehabilitation services are often based in large urban centres and this can restrict access for people living in rural/remote areas. Consideration must be given to the costs associated with a visit to the city, including transport, food, accommodation and loss of daily wages; many services also require out-of-pocket payments. CBR programmes should be aware of financial constraints and ensure that a wide range of options are investigated including government and/or nongovernmental organization schemes, bank loans and community support.

BOX 25Iran

No place too far from services

The CBR programme in the Islamic Republic of Iran encourages village health workers and CBR personnel to identify people with disabilities early and refer them to the primary health-care services in the community. Following referral, a mobile team of rehabilitation personnel visit the home to provide home-based rehabilitation. If specialized interventions are required, referral is made to a tertiary-level care centre, usually in the provincial headquarters or capital city. Following rehabilitation at a specialized centre, people are referred back to the primary health-care services, which work with the CBR programme to ensure that rehabilitation activities are continued, if necessary. The mobile team provides follow-up to monitor progress and provide further assistance when required.

Facilitate rehabilitation activities

CBR programmes can facilitate home and/or community-based therapy services and provide assistance to people with a wide range of impairments, enabling them to maintain and maximize their function within their home and community.

Provide early intervention activities for child development

Every child goes through a learning process enabling him/her to master important skills for life. The major areas of child development include: physical development, speech and language development, cognitive development and social and emotional development.

Delays in development occur when a child is unable to reach the important milestones suitable for his/her age group. Through early intervention, children at risk of, or with, developmental delay are identified as early as possible and provided with focused rehabilitation interventions to prevent or improve this delay.

The presence of a disability, e.g. cerebral palsy, blindness or deafness, can result in developmental delay and restrict a child's ability to participate in regular activities such as playing with other children and going to school. CBR personnel can provide early intervention activities, usually home-based, to encourage simple and enjoyable learning opportunities for development. CBR programmes can also encourage parents to meet together to share ideas and experiences and facilitate playgroups, so their children learn to play with other children, learn new skills and improve in all areas of development.

BOX 26Egypt

Fun for families

The CBR programme in Alexandria, Egypt, has several clubs that meet weekly in different parts of the city, including in a local stadium and a mosque. Parents come with their children who have disabilities to participate in activities organized by the CBR programme and community volunteers. There is a range of fun activities for children, e.g. singing and dancing contests, and parents are given the opportunity to talk and share their experiences with one another and to attend training sessions.

Encourage functional independence

Functional interventions aim to improve an individual's level of independence in daily living skills, e.g. mobility, communication, bathing, toileting, dressing, eating, drinking, cooking, housework. Interventions are dependent on a person's age, gender and local environment and will change over time as she/he makes a transition from one life stage to another. CBR personnel can provide:

  • training for people with disabilities and their families about the different ways to carry out activities;
  • education for families on how to best assist people with disabilities in functional activities to maximize their independence;
  • training in the use of assistive devices, e.g. walking/mobility devices to make activities easier;
  • education and instruction on specific techniques used to address impairments, e.g. muscle weakness, poor balance and muscle tightness, which impact a person's ability to carry out activities; this might include strengthening, stretching and fitness programmes.

BOX 27Guyana

Learning to view life differently

Shirley lives in a village in Guyana. She is blind and because of this her mother was afraid to allow her to go outside the house alone, fearful that she would hurt herself. When CBR volunteers visited Shirley's house, they talked to her mother and said that it was possible to teach Shirley how to move outside independently. It was difficult to convince Shirley's mother. The CBR volunteer asked Pauline, a CBR regional coordinator, to visit the house. As Pauline was blind herself, the CBR volunteer thought that she would be a good example and motivator for both Shirley and her mother. Shirley's mother agreed and a rehabilitation plan was made to facilitate greater functional independence for Shirley. Shirley made rapid progress and is now able to move around her community independently with the help of a white cane. She has become an active member of the local CBR committee and a member of the disabled people's organization.

Facilitate environmental modifications

Environmental modifications may be necessary to improve the functional independence of a person with a disability. CBR personnel may facilitate environmental modifications at an individual level (in the home), e.g. ramps for wheelchair access, handrails near steps, toilet adaptations and widening doorways, or at community level, e.g. modification of the school environment, public buildings or work places (see Assistive devices element).

BOX 28Viet Nam

A grandmother finds her way

An elderly grandmother in the village of Thai Binh, Viet Nam, had diabetes and low vision. She needed to go to the toilet frequently, especially during the night, and as the toilet was outside in the courtyard she had to wake a family member to accompany her. A volunteer from the local CBR programme advised the family to fix a cord from her bed to the toilet, so that during the night she could follow the cord to the toilet without waking her family. A simple environmental modification ensured this grandmother's independence.

Link to self-help groups

CBR programmes promote self-help groups where people with similar impairments or similar rehabilitation needs come together to share information, ideas and experiences. CBR programmes can encourage interactions between these groups and rehabilitation professionals to enable mutual understanding and collaboration.

BOX 29India

Recognising the support of hospitals

A CBR programme in a poor area of Greater Mumbai, India, often involves staff from rehabilitation institutions as trainers and teachers for CBR personnel. The CBR programme found that many families with people with disabilities were afraid of going to referral hospitals for e.g. ear, nose and throat (ENT), or ophthalmology care. So visits to referral hospitals were organized for small groups of people with disabilities and their family members, to explain how these hospitals worked and how people could access the different services. Some professionals from the hospitals were invited to cultural events organized by the CBR programme and given community recognition for their support. Many specialized hospitals agreed to charge subsidized fees for people referred by the CBR programme.

Develop and distribute resource materials

Disability booklets and manuals can be a useful tool for rehabilitation. These resources can be used by CBR personnel and by people with disabilities and their family members to guide rehabilitation, particularly where access to rehabilitation professionals is limited. These resources may also provide valuable information for the wider community as well as the many different services and sectors involved in rehabilitation activities. The following CBR activities are suggested.

  • Locate existing resource materials. These may be available through government ministries, United Nations bodies, disabled people's organizations or national and international nongovernmental organizations, and many can be accessed from the Internet, e.g. Training in the community for people with disabilities (32) and Disabled village children (33).
  • Adapt materials to suit local requirements, giving special consideration to cultural differences.
  • Translate existing materials into national and/or local languages.
  • Where existing resources are not available, develop new materials in simple language to suit local needs.
  • Distribute resource materials to all CBR personnel to carry with them when visiting people with disabilities for rehabilitation.
  • Create resource units where materials for people with disabilities, family members and other members of the community are available. The units may be located in the local development office, community health centre, or specific centres for people with disabilities.

BOX 30Viet Nam

Translating resources into Vietnamese

A CBR programme in Viet Nam translated several existing publications, including the WHO CBR manual, into Vietnamese to use for local purposes. In addition they developed their own materials on specific concerns for people with disabilities and their caregivers. Health workers are always provided with two copies of any resource material – one copy for themselves and one copy for the people they are visiting.

Provide training

CBR personnel need training to ensure they are able to facilitate access to rehabilitation services and provide appropriate services at community level. Many organizations have developed suitable training programmes. CBR personnel require a good understanding of the role of rehabilitation personnel, e.g. physiotherapists, occupational therapists, speech therapists, audiologists, mobility trainers, prosthetists/orthotists, medical and paramedical personnel and of how they can be of benefit to people with different impairments. CBR can also provide education to rehabilitation personnel to raise their awareness of the role of CBR and how it can help them optimize their services (see Management).

Copyright © World Health Organization 2010.

All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: tni.ohw@sredrokoob). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: tni.ohw@snoissimrep).

Bookshelf ID: NBK310933

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