Lecture for physical therapy student community based Rehabilitation

Introduction Community based Rehabilitation In physical Therapy

1. SPECIAL EDUCATION & COMMUNITY BASED REHABILITATION   Muhammad Shahzad MSPH BS Prosthetics and Orthotics Senior lecturer and HOD prosthetics and Orthotics Dep.

2. Course objective This course intends to give the physiotherapy students basic knowledge about various types of disabilities existing in special children. The knowledge ranges from physically handicapped to intellectually disabled children. It also gives information about various existing approaches for the effective rehabilitation and teaching methods

3. Disability A disability is any condition of the body or mind (impairment) that makes it more difficult for the person with the condition to do certain activities (activity limitation) and interact with the world around them (participation restrictions).

4. There are many types of disabilities, such as those that affect a person’s: Vision Movement (Physical) Thinking Remembering Learning Communicating Hearing Mental health Social relationships

5. According to the World Health Organization, disability has three dimensions Impairment  in a person’s body structure or function, or mental functioning; examples of impairments include loss of a limb, loss of vision or memory loss. Activity limitation , such as difficulty seeing, hearing, walking, or problem solving. Participation restrictions  in normal daily activities, such as working, engaging in social and recreational activities, and obtaining health care and preventive services.

6. Disability can be Related to conditions that are present at birth and may affect functions later in life, including cognition (memory, learning, and understanding), mobility (moving around in the environment), vision, hearing, behavior, and other areas. These conditions may beDisorders in single  genes  (for example,  Muscular Dystrophy) Disorders of  chromosomes  (for example, Down Syndrome); and The result of the mother’s exposure during pregnancy to infections (for example, rubella) or substances, such as alcohol or cigarettes.

7. Disability association Associated with developmental conditions that become apparent during childhood (for example,  autism spectrum disorder  and  attention-deficit/hyperactivity disorder or ADHD) Related to an injury (for example,  traumatic brain injury  or  spinal cord injury external icon ). Associated with a longstanding condition (for example, Diabetes), which can cause a disability such as vision loss, nerve damage, or limb loss. Progressive (for example, Muscular Dystrophy ), static (for example, limb loss),

8. Impairment   Impairment  is an absence of or significant difference in a person’s body structure or function or mental functioning. For example, problems in the structure of the brain can result in difficulty with mental functions, or problems with the structure of the eyes or ears can result in difficulty with the functions of vision or hearing.

9. Structural impairments  are significant problems with an internal or external component of the body. Examples of these include a type of nerve damage that can result in Multiple sclerosis,or a complete loss of a body component, as when a limb has been amputated. Functional impairments  include the complete or partial loss of function of a body part.   Examples of these include pain that doesn’t go away or joints that no longer move easily.

10. Activity limitation and participation restriction The World Health Organization (WHO) published the International Classification of Functioning, Disability and Health (ICF) in 2001. The ICF provides a standard language for classifying body function and structure, activity, participation levels, and conditions in the world around us that influence health. This description helps to assess the health, functioning, activities, and factors in the environment that either help or create barriers for people to fully participate in society.

11. According to the ICF: Activity  is the execution of a task or action by an individual. Participation  is a person’s involvement in a life situation

12. categories of activities and participation The ICF includes the following in the categories of activities and participation: Learning and applying knowledge Managing tasks and demands Mobility (moving and maintaining body positions, handling and moving objects, moving around in the environment, moving around using transportation) Managing self-care tasks

13. categories of activities and participation Managing domestic life Establishing and managing interpersonal relationships and interactions Engaging in major life areas (education, employment, managing money or finances) Engaging in community, social, and civic life

14. It is very important to improve the conditions in communities by providing accommodations that decrease or eliminate activity limitations and participation restrictions for people with disabilities, so they can participate in the roles and activities of everyday life.

15. Rehabilitation The action of restoring someone to health or normal life through training and therapy after imprisonment, addiction, or illness The action of restoring someone to former privileges or reputation after a period of disfavour The action of restoring something that has been damaged to its former condition

16. " Community-based physiotherapy / rehabilitation (CBR)" concept The declaration of Alma-Ata in 1978 was the first international declaration advocating primary health care as the main strategy for achieving the World Health Organization‟s (WHO) goal of “health for all” . This strategy was intended to enhance the quality of life for people with disabilities through community initiatives

17. Community-Based Physiotherapy Following the Alma-Ata declaration, WHO introduced CBR. In the beginning CBR was primarily a service delivery method making optimum use of primary health care and community resources, and was aimed at bringing primary health care and rehabilitation services closer to people with disabilities, especially in low-income countries .

18. During the 1990s, along with the growth in number of CBR programmes , there were changes in the way CBR was conceptualized. Other UN agencies, such as the International Labour Organization (ILO), United Nations Educational, Scientific and Cultural Organization (UNESCO), United Nations Development Programme (UNDP), and United Nations Children‟s Fund (UNICEF) became involved, recognizing the need for a multisectoral approach.

19. In 2003, an International consultation to review community-based rehabilitation held in Helsinki made a number of key recommendations . Subsequently, CBR was repositioned, in a joint International Labour Organization (ILO)/United Nations Educational, Scientific and Cultural Organization (UNESCO)/WHO position paper, as a strategy within general community development for the rehabilitation, equalization of opportunities, poverty reduction and social inclusion of people with disabilities

20. Community-Based Physiotherapy CBR is implemented through the combined efforts of people with disabilities themselves, their families, organizations and communities, and the relevant governmental and non-governmental health, education, vocational, social and other services.

21. Essential Elements of CBR CBR requires community and DPO involvement. But communities and DPOs cannot work alone to ensure equal opportunities for people with disabilities. National policies, a management structure, and the support of different government ministries, NGOs and other stakeholders (multi- sectoral collaboration) are also needed.

22. Sustainability of CBR Programmes Country approaches to implementing CBR vary a great deal, but they have some elements in common that contribute to the sustainability of their CBR programmes . These include:  I. National level support through policies, co-ordination and resource allocation.  II. Recognition of the need for CBR programmes to be based on a human rights approach.  III. The willingness of the community to respond to the needs of their members with disabilities.  IV. The presence of motivated community workers

23. Multi- sectoral Support for CBR  In CBR a multi- sectoral collaboration is essential to support the community, address the individual needs of people with disabilities, and strengthen the role of DPOs.

24. Support for CBR 1 Support from the Social Sector  2 Support from the Health Sector  3 Support from the Educational Sector  4 Support from the Employment Sector  5 Support from NGOs  6 Support from the Media

25. Principles of CBR  CBR facilitates access to basic needs, and at the same time promotes equal opportunities and equal rights. It is therefore a multisectoral strategy with some key principles to enable people with disabilities to participate in the whole range of human activities.  The principles outlined below are overlapping, complementary and inter-dependent

26. Principles of CBR 1. Inclusion 2. Participation 3. Empowerment 4. Equity 5. Self -advocacy 6. Facilitation 7. Gender sensitivity and special needs 8. Partnerships 9. Sustainability

27. Principles of CBR  1- Inclusion CBR works to remove all kinds of barriers which block people with disabilities from access to the mainstream of society. Inclusion means placing disability issues and people with disabilities in the mainstream of activities.  2- Participation CBR focuses on abilities, not disabilities. It depends on the participation and support of people with disability, family members and local communities. It also means the involvement of people with disabilities as active contributors to the CBR programme , from policy-making to implementation and evaluation, for the simple reason that they know what their needs are.

28. 3- Empowerment Local people – and specifically people with disabilities and their families, ultimately may make the programme decisions and control the resources. This requires people with disability taking leadership roles within programmes . It means ensuring that CBR workers, service providers and facilitators include people with disabilities and that all are adequately trained and supported. Results are seen in restored dignity and self-confidence.

29. 4- Equity CBR emphasizes equality of opportunities and rights – equal citizenship. Raising awareness CBR addresses attitudes and behaviour within the community, developing understanding and support for people with disabilities and ensuring sustainable benefits. It also promotes the need for and benefit of inclusion of disability in all developmental initiatives.

30. 5- Self Advocacy., CBR consistently involves people with disabilities in all issues related to their well-being. Selfadvocacy is a collective notion, not an individualistic one. It means self-determination. It means mobilizing, organizing, representing, and creating space for interactions and demands.

31. 6- Facilitation CBR requires multisectoral collaboration to support the community and to address the individual needs of people with disability, with the ultimate aim of an inclusive society. 7- Gender sensitivity and special needs CBR is responsive to individuals and groups within the community with special needs.

32. 8- Partnerships CBR depends on effective partnerships with community-based organizations, government organizations and other organized groups. 9- Sustainability CBR activities must be sustainable beyond the immediate life of the programme itself. They must be able to continue beyond the initial interventions, and be independent of the initiating agency. The benefits of the programme must be long-lasting.

33. Common Framework of CBR Programmes In light of the evolution of CBR into a broader multisectoral development strategy, a matrix was developed in 2004 to provide a common framework for CBR programme .  The matrix consists of five key components: the health, education, livelihood, social and empowerment components. Within each component there are five elements.

34. 1- Health Promotion Goal The health potential of people with disabilities and their families is recognized and they are empowered to enhance and/or maintain existing levels of health. The role of CBR The role of CBR is to identify health promotion activities at a local, regional and/or national level and work with stakeholders (e.g. ministries of health, local authorities)  to ensure access and inclusion for people with disabilities and their family members. Another role is to ensure that people with disabilities and their families know the importance of maintaining good health and encourage them to actively participate in health promoting actions.

35. Desirable outcomes People with disabilities and their families are reached by the same health promotion messages as are members of the general community. • Health promotion materials and programmes are designed or adapted to meet the specific needs of people with disabilities and their families. • People with disabilities and their families have the knowledge, skills and support to assist them to achieve good levels of health.

36. Desirable outcomes Health-care personnel have improved awareness about the general and specific health needs of people with disabilities and respond to these through relevant health promotion actions. • The community provides a supportive environment for people with disabilities to participate in activities which promote their health.  • CBR programmes value good health and undertake health-promoting activities in the workplace for their staff.

37. 2- Prevention The role of CBR  The role of CBR is to ensure that communities and relevant development sectors focus on prevention activities for people both with and without disabilities. CBR programmes provide support for people with disabilities and their families to ensure they can access services that promote their health and prevent the development of general health conditions or secondary conditions (complications).

38. Desirable outcomes • People with disabilities and their families have access to health information and services aimed at preventing health conditions. • People with disabilities and their families reduce their risk of developing health problems by taking up and maintaining healthy behaviours and lifestyles. People with disabilities are included and participate in primary prevention activities, e.g. immunization programmes , to reduce their risk of developing additional healthconditions or impairments.

39. Desirable outcomes All community members participate in primary prevention activities, e.g.immunization programmes , to reduce their risk of developing health conditions or impairments which can lead to disability. CBR programmes collaborate with the health and other sectors, e.g. education, to address health issues and provide support and assistance for prevention activities.

40. 3- Medical Care Goal People with disabilities access medical care, both general and specialized, based on their individual needs. The role of CBR The role of CBR is to work in collaboration with people with disabilities, their families and medical services to ensure that people with disabilities can access services designed to identify, prevent, minimize and/or correct health conditions and impairments.

41. Desirable outcomes • CBR personnel are knowledgeable about medical care services and able to facilitate referrals for people with disabilities and their families for general or specialized medical care needs. People with disabilities and their families access activities that are aimed at the early identification of health conditions and impairments (screening services).

42. Medical care facilities are inclusive and have improved access for people with disabilities.  • People with disabilities can access surgical care to minimize or correct impairments, thus contributing to improved health and functioning. People with disabilities and their families develop self-management skills whereby they are able to ask questions, discuss treatment options, make informed decisions about medical care and manage their health conditions. Medical care personnel have increased awareness regarding the medical needs of people with disabilities, respect their rights and dignity and provide quality services

43. 4- Rehabilitation 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.

44. 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

45. Desirable outcomes 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.

46. Rehabilitation services (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

47. 5- Assistive Devices Goal People with disabilities have access to appropriate assistive devices that are of good quality and enable them to participate in life at home and work and in the community. The role of CBR The role of CBR is to work with people with disabilities and their families to determine their needs for assistive devices, facilitate access to assistive devices and ensure maintenance, repair and replacement when necessary

48. Desirable outcomes CBR personnel are knowledgeable about assistive devices, including the types available, their functionality and suitability for different disabilities, basic fabrication, availability within communities and referral mechanisms for specialized devices. People with disabilities and their families are knowledgeable about assistive devices and make informed decisions to access and use them.

49. People with disabilities and their families are provided with training, education and follow-up to ensure they use and care for their assistive devices appropriately. Local people, including people with disabilities and their families, are able to fabricate basic assistive devices and undertake simple repairs and maintenance. Barriers preventing access to assistive devices, such as inadequate information, financial constraints and centralized service provision, are reduced. Environmental factors are addressed to enable individuals to use their assistive devices in all locations where they are needed.

50. Helping Hand Relief and Development are providing the community based rehabilitation services in Mansehra . Group 1. In list Health promotion activities they are doing and evaluate these activities in light of desirable goals. Group 2. In list diseases prevention activities they are doing and evaluate these activities in light of desirable goals.

51. Group 3. In list medical care activities they are providing and evaluate medical care in light of desirable goals. Group 4. In list rehabilitation services they are providing and evaluate rehabilitation services in light of desirable goals. Group 4. In list assistive devices they are providing and evaluate outcome of in light of desirable goals.