Community Based Rehabilitation CBR

Community-Based Physiotherapy
Basic Concepts
1

‫العالج الطبيعي المجتمعي‬
‫مفاهيم أساسية‬

DR. AHMED-REFAT REFAT
T I B A H U N I V E R S I T Y, K S A
1432 H.

Dr. Ahmed Refat AG Refat

Basic Concepts – 1: Health
2

1- Health
it is “a state of complete physical, mental and social
well-being and not merely the presence of disease or
infirmity” .

Health is a valuable resource that enables people
to lead individually, socially and economically
productive lives, providing them with the
freedom to work, learn and engage actively in
family and community life.


2- Disability & Rehabilitation
3

 The most recent definitions of disability come from
the: International Classification of Functioning,
Disability and Health (ICF), which states that
disability is:
 An “umbrella term for impairments, activity
limitations or participation restrictions” , which result
from the interaction between the person with a
health condition and environmental factors (e.g. the
physical environment, attitudes), and personal
factors (e.g. age or gender).


2-Disability & Rehabilitation- cont.,
4

Convention on the Rights of Persons with Disabilities,
which states that disability is:
An evolving concept and “results from the interaction
between persons with impairments and attitudinal
and environmental barriers that hinders their full and
effective participation in society on an equal basis
with others” .


5

People‟s experiences of disability are extremely
varied. There are different kinds of
impairments and people are affected in different ways.
Some people have one impairment, others multiple;
some are born with an impairment, while others may
acquire an impairment during the course of their life

The Convention on the Rights of Persons with
Disabilities describes people with disabilities as
“…those who have long-term physical, mental,
intellectual or sensory impairments…” .


6

Disability is no longer viewed as merely the result of
impairment. The social model of disability has
increased awareness that environmental barriers to
participation are major causes of disability. The
International Classification of Functioning, Disability
and Health (ICF) includes body structure and function,
but also focuses on „activities‟ and „participation‟ from
both the individual and the societal perspective.


Disability : Global Statistics
7

• Approximately 10% of the world‟s population lives with a disability ..
• People with disabilities constitute the world‟s largest minority.
• An estimated 80% of people with disabilities live in developing countries
• An estimated 15 –20% of the world‟s poorest people are disabled
• No rehabilitation services are available to people with disabilities in 62
countries .
• Only 5–15% of people with disabilities can access assistive devices in
the developing
world
• Children with disabilities are much less likely to attend school than
others
• People with disabilities tend to experience higher unemployment and
have lower earnings than people without disabilities .


8

Origen of the " 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.


9

 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 .


10

 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.


11

 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 .


12

 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.
 ( ILO, UNICEF, WHO. CBR: joint position paper ; 2004 ).


Elements of CBR
13

 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.


Sustainability of CBR Programmes
14

 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.


Support for CBR
15

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.


Support for CBR
16

 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



Principles of CBR
17

 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


Principles of CBR
18

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


Principles of CBR
19

 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.


Principles of CBR
20

 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.


Principles of CBR
21

 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.


Principles of CBR
22

 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.



Principles of CBR
23

 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.


Principles of CBR
24

 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.


Common Framework of CBR Programmes
25

 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.


CBR Matrix
26


Elements of Health Components -1
27

1- Health promotion
 Health promotion aims to increase control over
health and its determinants.
 The wide range of strategies and interventions
available are directed at strengthening the skills of
individuals and changing social, economic and
environmental conditions to alleviate their impacts on
health.


28

2- Prevention
 Prevention is very closely linked with health
promotion. Prevention of health conditions (e.g.
diseases, disorders, injuries) involves primary
prevention (avoidance), secondary prevention (early
detection and early treatment) and tertiary
prevention (rehabilitation) measures. The focus of
this element is mainly on primary prevention.


29

3- Medical care
 Medical care refers to the early identification,
assessment and treatment of health conditions and
their resulting impairments, with the aim of curing or
limiting their on individuals. Medical care can take
place at the primary, secondary or tertiary level of
the health-care system.


30

4- Rehabilitation
 Rehabilitation is a set of measures which enables
people with disabilities to achieve and maintain optimal
functioning in their environments; it is relevant both for
those who acquire disabilities during their lifetime and for
those who have disabilities from birth.
 Rehabilitation services range from the basic to the
specialized and are provided in many different locations
e.g. hospitals, homes and community environments.
Rehabilitation is often initiated by the health sector but
requires collaboration between all sectors.


31

5- Assistive devices
 A device that has been designed, made or adapted to assist a
person to perform a particular task is known as an assistive
device. Many people with disabilities benefit from the use of
one or more assistive devices. Some common types of
assistive devices are: mobility devices (e.g. walking sticks,
wheelchairs), prostheses (e.g. artificial legs), orthoses (e.g.
hand splint), visual devices (e.g. glasses, white canes) and
hearing devices (hearing aids).
 To ensure that assistive devices are used effectively,
important aspects of their provision include user education,
repair, replacement and environmental adaptations in the
home and community.


32

Desired Outcome
and the Role of CBR
in each Elements
of Health Component


1- Health Promotion,
33

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.


1- Health Promotion-cont,
34

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.


1- Health Promotion-cont,
35

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.


2- Prevention ,
36

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).


2- Prevention -cont,
37

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.


2- Prevention -cont,
38

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.


3- Medical Care
39

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.


3- Medical Care -cont,
40

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).
 • 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.


4- Rehabilitation,
41

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.


4- Rehabilitation -cont,
42

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.


4- Rehabilitation -cont,
43

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.


4- Rehabilitation-cont,
44

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.


5- Assistive Devices
45

 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.


5- Assistive Devices-cont,
46

 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.
 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.


Literature Cited
47
 1- WHO: Community-based rehabilitation guidelines
http://www.who.int/disabilities/cbr/guidelines/en/index.html

 2- World Bank: Community Based Rehabilitation (CBR)
: http://go.worldbank.org/FC3XJWLK00

 3- The United Nations Economic and Social Commission for Asia and the Pacific (ESCAP)
Understanding Community-Based Rehabilitation
http://www.unescap.org/esid/psis/disability/decade/publications/cbr.asp

 4- CBR: A Strategy for Rehabilitation, Equalization of Opportunities, Poverty Reduction and Social Inclusion of People
with Disabilities (Joint Position Paper 2004)
http://whqlibdoc.who.int/publications/2004/9241592389_eng.pdf

 5. Declaration of Alma-Ata: International conference on primary health care, Alma-Ata, USSR, 6–12
September 1978, Geneva, World Health Organization, 1978 (www.who.int/hpr/NPH/docs/declaration_
almaata.pdf, accessed 10 August 2010).

 6. International Labour Organization, United Nations Educational, Scientific and Cultural Organization,
World Health Organization. CBR: A strategy for rehabilitation, equalization of opportunities, poverty
reduction and social inclusion of people with disabilities. Joint Position Paper 2004. Geneva, World Health Organization,
2004
(www.who.int/disabilities/publications/cbr/en/index.html, accessed 10 August 2010).

Dr. Ahmed Refat AG Refat www.SlideShare.net/AhmedRefat

‫شكرا‬
48

Thank You

Ahmed-Refat

Community Based Rehabilitation CBR

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