Community Occupational Therapy

COMMUNITY OCCUPATIONAL
THERAPY
HDOT 210
Sir OAK
(ACCRA SCHOOL OF HYGIENE)
+233249702470

COURSE DESCRIPTION
 This course is designed to provide the student with the
practical knowledge in the concepts of community,
societal structure and the importance of meaningful
occupation. Emphasis is laid on WHO model of
Community Based Rehabilitation (CBR) and how the
therapist could work with other Medical and Dental
Team (MDT) members to sustain this community
rehabilitation model.
 The aim of this course is to make therapy services
accessible, acceptable, and affordable in the
community setting.

Course Content
 Definition of basic terms and concepts
 Health in the context of community
 Community
 Community Health
 Community – based practice
 Community – built practice
 Community capacity building
 Community-centered
 Community partnership
 Community practice
 Social structure and social organisation

Course content cont…
 Occupation
 The concepts of community, societal structure and the
importance of meaningful occupation.
 concepts of meaningful occupation.
 The concept of Community Based Rehabilitation (CBR) and
Clinical decision making.
 WHO model of CBR
 Role of the therapist in the community in relation to CBR
 constraints faced in scaling up access to CBR and compliance
with intended design.
 Process of planning and setting up of CBR

Course content cont…
 The role of Occupational Therapy Practitioners in
the community
 Models of practice in the community
 Explore the barriers and opportunities for people
with disabilities in the community.
 Process of proposal writing and applying for funds.

Course objective
By the end of the course, student should be able to:
o define the basic terms and concepts.
o explain the influence of the environment on
enabling occupation.
o describe the concepts of community, societal
structure and the importance of meaningful of
meaningful occupation.
o explain the concept of CBR and clinical decision
making.
o describe the WHO model of CBR

Course objective cont…
o identify different stakeholders in CBR.
o describe the role of the therapist in the community in
relation to CBR.
o outline the advantages and disadvantages of community
centered rehabilitation and the concept of improvisation.
o mention the process of planning and setting up of CBR.
o list the model of practices in the community.
o state the barriers and opportunities for people with
disabilities in the community.
o practice proposal writing and applying for funds.

TEACHING AND LEARNING METHODS
- Group Presentations
- Role play
- Problem based Learning approach
- Practical Demonstration
- Assignments
- Questions and answers
- Field trip

References and further readings
 Canadian Association of Occupational Therapists (1997). Enabling Occupation: An
Occupational Therapy Perspective. Ottawa, ON: CAOT Publications ACE.
 Christiansen C, Baum C (1997). Enabling Function and Well-being (2nd edn).
Thorofare, NJ: Slack.
 Csikszentmihalyi M, Csikszentmihalyi I (1988). Optimal Experience: Psychological
Studies in Flow in Consciousness. New York, NY: Cambridge University Press.
 CBR: A strategy for rehabilitation, equalization of opportunities, poverty reduction
and social inclusion of people with disabilities (Joint Position Paper 2004).
 Clark, F., Jackson, J., Carlson, M., Chou, C. P., Cherry, B. J., Jordan-Marsh, M., . . .
Azen, S. P. (2012). Effectiveness of a lifestyle intervention in promoting the well-
being of independently living older people

Basic terms and concepts
 Health in the context of community
o The WHO defines health as “a state of
complete physical, mental and social well-
being and not merely the absence of disease
or infirmity”
o Health has been comprehensively defined in
the profession of Occupational Therapy as:

Health in the context of community cont…
o the absence of illness, but not necessarily disability;
a balance of physical, mental, and social well-being
attained through socially valued and individually
meaningful occupation; enhancement of capacity
and opportunity to strive for individual potential;
community cohesion and opportunity; social
integration, support, and justice, all within and as
part of a sustainable ecology. (Wilcock, 2006, p. 110)

o Both definitions acknowledge that health is not only about
disease state.
o In community practice, OT practitioners must retain a broad
view of health in order to implement successful health-
related programs because the extrinsic factors of health
cannot be denied.
o For example, when conducting an OT evaluation in the home,
the practitioner can explore the impact the environment has
on the client’s occupational engagement and easily visualize
the barriers to transfers or mobility that the client may face
in the home.

o In the community context of OT practice, the definition of
health moves away from the medical definition. Health is
viewed as the ability to engage in occupation.
o The inability to engage in occupation, whether caused by
physical, mental, social, or environmental challenges, leads
to many problems with maintenance of health and well-being.
o On the other hand, the health status of an individual and a
community may be affected by forces beyond individual or
group behaviours. External forces, such as transportation,
socioeconomic status, and health disparities, greatly affect
the health of a community.

o By considering these external factors, OT
practitioners can explore alternative methods for
engaging community members in health maintenance
because they understand the complexity of the
human experience.
Exercise 1
With an example each, explain four (4) external forces
beyond individual or group behaviours which can affect
one’s health.

o The role of the OT practitioner in community practice is
to explore occupational engagement in broad sense.
He/She must understand the context and conditions
beyond physiologic problems that affect health status.
o Community characteristics, including but not limited to
socioeconomic status, culture, political, infrastructure,
public transportation, availability of healthcare
services, and geographical location, affect community
health status.

o OT practitioner practicing in the community
setting need not fully understand all the factors
that create community context but must
acknowledge their existence and impact on the
health status and well-being of the community
and its members.

Basic terms and concepts cont…
 Community
o Community is a collection of people identified by
common values and mutual concern for the
development and well-being of their group or
geographical area.
o Communities are not simply defined by geographical
location but refer to a person’s natural environment,
that is, where the person works, plays and performs
other daily activities (Brownson, 1998)

Community cont…
o Communities are individuals tied together by
occupational engagement and a collective sense of
meaning.
o In Occupational Therapy, an essential conception of
community is one that considers groups of people
engaged in a collective occupation.
o In other words, just as individuals have unique
occupations, so do communities.

 Social structure
o the term ‘structure’ refers to the way the parts of
anything relate to one another. (that is an ordered
arrangement of parts)
o Sociologically speaking, structure refers generally to an
arrangement which in some way restricts or directs
human behaviour. It is patterns of organization which
dictate human behaviour.

Social structure cont…
o Social structure refers to the way the units of a group
or a society relate to one another. Eg. family, school,
hospital, police, army, association, office, NGO,
institutions, groups, factory, etc.
o Social structure shapes our behaviour and attitude in a
continuous process. This process in turn, is closely
related to our status or position within the structure
of society

 Characteristics of social structure
o Social structure must be based upon the
following principles:
1) Normative system:
 Normative system renders the society with the ideas
and values.
 The institutions and associations are inter-related
according to these norms.
 The individuals perform their roles in accordance
with the accepted norms of the society.

 For instance, old age home is still not practice in
Ghana as it is in America. The difference lies in the
normative structure, which inculcates different values.
Consequently, differences can be seen in the social
structure of these two societies.
2) Position system:
 This refers to statuses and roles of the individuals.
 Proper functioning of social structure depends upon
proper assignment of roles and statuses.

 All of us occupy several positions at the same time.
You may be simultaneously a son or a daughter and a
student.
 Position may either have a great deal of prestige or
it may carry less prestige.
 Obviously, your status changes as your particular
positions change in life and society.
3) Sanction system:
 For the proper enforcement of norms, every
society has a sanction system.

 It may also be understood from the perspective rewards
and punishment or penalties a society prescribes.
 The stability of social structure depends upon the
effectiveness of the sanction system, which tells a great
deal about the social and political environment of the
country.
4) A system of anticipated response:
 The anticipated response system calls upon the
individuals to participate in the social system.
 It points to the fact that individuals must realize their
duties and should make efforts to fufill them.
 Depending on this, social structure can work
successfully.

Community – based practice
The location in which occupational therapy services
are provided.
Community – built practice
Uses a capacity-based approach to explore the
community needs and build programs to address those
community-specified needs.
Community capacity building
Exploring and understanding a community’s potential
or ability to address health problems.

Community-centered
Applying a client-centered approach to a community.
Community partnership
When the community and the healthcare
practitioner collaborate on identifying needs and the
program is developed in collaboration.
Community practice
When OT practitioners use their skills to explore the
determinant of health beyond the physical and take
on a system approach to understanding health and
disease.

 Community Health
This refers to both private and public efforts of
individuals, groups and organizations to
promote, protect and preserve the physical,
mental, social and spiritual health of those in a
community.

 Occupation
o Occupation refers to groups of activities and tasks of everyday life,
which are named, organized, and given value and meaning by
individuals and a culture.
o Occupation is everything people do to occupy themselves,
including looking after themselves (self-care), enjoying life
(leisure), and contributing to the social and economic fabric of
their communities (productivity).
o Yerxa et al. (1989) refer to occupation as being self-initiated
(meaningful), goal-directed (purposeful), socially sanctioned and
personally satisfying.

The Concept of meaningful occupation
 Occupation is meaningful when it allows an individual to
fulfil a goal that is personally or culturally important.
 It is purposeful when it is determined by the individual’s
unique needs and interests in a particular environmental
context.
 Finally, occupations are more likely to be effective if they
provide a source of choice and control, that is, not only
occupations that fit the personal and environmental
resources of the individual but also those that provide
opportunities for the individual to decide what to do.

What’s the OTs concern in the community?
 Occupational Therapists are concern with the
interactions among:
o Person
o Environment
o Occupation

Occupation
EnvironmentPerson
Occupational
Performance
OP
Person – Environment – Occupation (PEO) model

o Based on the person–environment–occupation (PEO)
model, occupational performance is defined as the
dynamic experience of a person engaged in purposeful
activities and tasks in the environment (Law et al., 1996).
o The environment, defined as ‘those contexts and
situations which occur outside individuals and elicit
responses from them can have an enabling or
constraining effect on the performance of occupations.
PEO model cont…

o Enabling refers to ‘processes of facilitating, guiding,
coaching, educating, prompting, listening, reflecting,
encouraging, or otherwise collaborating with people’
o There is flow results when there is a match between
the perceived skills of the individual and the
perceived demands of the environment (Jacobs,
1994; Emerson, 1998).
PEO model cont…

o The flow experience is characterized by
the ability to concentrate on the activity,
a sense of control over one’s actions,
a clear sense of purpose ... [and]
a sense that the activity is rewarding in and of itself’
(Emerson, 1998: 39).
o Csikszentmihalyi (1990) suggests that flow enhances
activation, motivation, concentration and creativity
and, furthermore, that performance improves by
increasing the amount of time spent in ‘flow’.
PEO model cont…

o According to Csikszentmihalyi (1988), to remain in
flow, an individual needs to ‘increase the complexity of
the activity by developing new skills and taking on new
challenges’ (p.30).
o As the individual meets and masters new challenges,
satisfaction results is assured. However, that the
optimal experience needs to encompass the ‘just-right’
challenge: too much challenge can increase stress
and lead to anxiety and too little challenge can result
in boredom and apathy.
PEO model cont…

o In summary, occupation is seen as both a means
(process) and an end (outcome).
o Occupation is meaningful if it is either intrinsically
rewarding in terms of process, that is, satisfying and
pleasurable in the eyes of the individual, or extrinsically
rewarding in terms of outcome, that is, purposeful and
productive in the eyes of society.
o In ideal conditions, individuals engage in occupations
that are both pleasurable in terms of process and
purposeful in terms of outcome.
Summary of concept of meaningful occupation

o For the purposes of this course, ‘meaningful’ is therefore
defined as both pleasurable and purposeful.
o In the clinical arena, meaningful occupation is related to
engaging in pleasurable tasks and activities (in terms of
means or process) that enable the client to move
towards improved health, function or quality of life (in
terms of end or outcome).
Summary of concept of meaningful occupation cont…

Occupational performance of meaningful
activities
Person’s with disabilities typically requires some
intervention in the :
o Person and Environment Fit
o Limitations in Activities of Daily Living

Physiological
Cognitive
PERSON
(Intrinsic factors)
Spiritual
Neurobehavioral
Psychological
OCCUPATION Social support
Social & Economic
systems
ENVIRONMENT
(Extrinsic factors)
Culture & values
Built Env’t & Technology
Natural Environment
Occupational
Performance
&
Partcipation
PERFORMAN
CE
Humans as occupational beings – PEOP model.
WELL BEING QUALITY OF LIFE
Source: Christiansen C.H. & Baum C.M (2005) Occupational Therapy
performance participation and well-being. Thorofare. NJ: slack. Inc.

Group Presentation.
Using the PEOP model
above, explain the
statement “humans are
occupational being”

Community-Based Service (CBS)
 A strategy that equalizes opportunities and social integration of all
people with disabilities.
 CBS is more comprehensive than rehabilitation; includes a broad
range of health-related services such as:
o prevention and health promotion,
o acute and chronic medical care,
o habilitation and rehabilitation.
 CBS can be direct and indirect service provision; an orientation to
collective health needs in homes, workplaces and community agencies
with a goal of making clients and practitioners becoming an integral
part of the community.

Essence of Community Coalitions
 In order for a community to work together for a common
purpose, there is the need for partnerships and coalition
among members of the following organisations and
constituencies in the community:
o Healthcare organisations
o Government agencies
o Neighbourhood alliances
o Education related groups and organisations
o Advocacy groups
o Business organisations
o Rental outlets
o Local media

The Community OT service
 The community OT services provide help for
people of all ages who experience difficulty
coping with everyday activities due to disability,
illness and/or the aging process
 The aim of the OT is to provide a comprehensive
service to enable people to remain as
independent as possible within the community.

OT and community level interventions
 An Occupational Therapist have to view the
community as a client and assess the following
variables:
o Demographic information about the community
o Risk factors and health behaviours
o Health knowledge, attitudes and beliefs
o Cultural habits, preferences and sensitivities
o Environmental barriers
o Availability of social support and health related
services
o Effective motivators for change

Brain teaser
Outline six (6) attributes and
skills an OT practitioner in a
community should have.

Attributes and skills of community OT practitioner
 Professional autonomy
 Flexibility and tolerance for ambiguity – (positive attitude &
hopeful)
 Collaboration and excellent interpersonal communication
 Strong organizational skills and problem solving skills
 Ability to network
 Program planning and evaluation skills – (visionary)
 Good public relations skills and awareness
 Comfort with indirect service provision
 Grant-writing skills
 Culturally competent – (respectful and non-judgemental)

The Community Occupational Therapy (OT) clinic
 The community OT clinic provides quality assessment, direct service and
consultation for children and adults.
 It is a model clinic providing holistic therapeutic intervention enhancing:
o Sensory integration
o Developmental approach
o Behavioral approach
 The therapist work collaboratively with clients and their families within
the clinic and the community-based settings for those with:
i. Developmental disorders iv. Physical challenges
ii. Learning disabilities v. Neurological conditions
iii. Behavior disturbances

Community OT clinic client populations
 Client populations cut across the life – span (all ages)
 Most medical specialty populations eg. cardiac, pulmonary, orthopedic,
rheumatology, ophthalmology, optometry, pediatrics, geriatrics, mental
health, hand and upper extremity, community support grouping of client
populations.
NOTE:
 OTs focus on assisting people to engage in daily life activities that they
find meaningful and purposeful.
 OTs understand occupations and use of occupation to affect human
performance and improve the effects of disease and disability.

Goals of community OT clinic
Community Occupation Therapy Clinic is develop to meet the following goals:
I. Provide quality, specialized OT evaluation and treatment intervention to
clients.
II. Provide in-service training to pre-schools, schools, parent support
programs and agencies in the community.
III. Provide observational opportunities and resources for individuals seeking
a care in Occupational Therapy.
IV. Provide field work placements for Occupational Therapy interns
v. Provide research opportunities for students and faculty.

Categories of community OT services
Community OT services are divided into five (5) primary categories:
(a) Treatment
Treatment designed to improve skills in self-care, productivity and to
promote independence.
(b) Assistive Technology
Assistive technology includes assessment for equipment needs including
mobility aids/wheelchair and assessments to determine the need for
vehicle and home modifications.
(c) Maintenance
Maintenance assessment of workers need for ongoing support, if
required.

Categories of community OT services cont…
(d) File Review
Regular file review helps in determining the
progress of community services as well as
identifying key gaps for further research.
(e) Time Sensitive Referrals
Time sensitive referral for medically urgent
situations only.

The roles of OT Practitioners in the community
 There is no specific standards for community practice;
however, because of the nature of the community
practice, specific roles and responsibilities have
emerged.
 These roles are often not practice-based but describe
the general characteristics a practitioner needs to be
successful in community settings.
 These include:

The roles of OT Practitioners in the community
1) Advocacy
2) Assessment skills
3) Capacity building skills and
4) The ability to apply the principles of occupation in a
community context.
NB: These roles and responsibilities are broad and each
community practitioner will find different
activities associated with each of these generalized
roles.

Advocacy
 In community practice, OT practitioners are required
to advocate for clients for multiple reasons.
 Advocacy is part of the principles and values of the
profession (AOTA, 1993).
 Although advocacy is important in all OT practice
settings, it takes on a unique role in community
settings where you may work with an underserved
population that cannot afford services (Jensen &
Royeen, 2002)

Advocacy cont…
 The practitioner must discover and explore feasible
approaches to address health issues in the
community, which requires advocacy on many levels,
from:
i. educating community members on the roles of OT
practitioners to
ii. advocating for the needs of the underserved
communities (Herzberg & Finlayson, 2001)

Examples of areas an OT practitioner can advocate for:
 Identifying a health problem and developing a
program to address this problem is a form of
advocacy.
 Writing a grant to fund services is also a form of
advocacy. Especially when funding streams are
eliminated or threatened as a result of political
debate, economics, trends, or changes in
administration.

Examples of areas an OT practitioner can advocate for:
 Practitioners must also advocate for
promotion of inclusion of all in the community
(Grady, 1995) because community involvement
is an important component of quality of life
and self-esteem for individuals.
 In community practice, an OT practitioner
may be called to contact or communicate
with political officials to voice support for
initiatives.

Advocacy cont…
 In summary, Occupational Therapy roles in
advocacy comprises of :
 Education
 Addressing unmet health needs
 Serving the underserved through health-
related programs
 Promoting inclusion
 Political advocacy

Assessment Skills
 In community program development, most
interventions are for a group and not for an
individual; therefore OT practitioners in community
practice must learn how to assess groups of people
regarding occupational engagement and
performance.
 This requires skills in multiple data collection
methods and data analysis.

Assessment Skills cont…
 According to Fazio, 2008, assessment skills requires
an understanding of:
a) epidemiology
b) how community data can be used in program
development and
c) grant writing
 In addition to gathering initial assessment data, OT
practitioners in the community must collect
ongoing evaluation data to ensure that programs
address their intended purposes.

Assessment Skills cont…
 Assessment also helps to build evidence and
science-driven approaches that are necessary to
justify funding and development of community
practice in the field of Occupational Therapy.
NB: Outcome data from assessment can be used in
advocacy by demonstrating a need and justify
how a program can affect a community’s health
in a positive and effective way.

Building Community Capacity
 Community capacity building can be defined as
exploring and understanding a community’s
potential or ability to address health problems
(Chino & DeBruyn, 2006).
 In identifying problems or needs, in every
community, the OT practitioners must look beyond
need to identify capacity and assets for addressing
health issues.

Building Community Capacity cont…
 To engage community capacity building, OT
practitioners must be community-centered and
apply client-centered practice to the community.
 In client-centered practice, practitioners seek to
understand the goals of the community members in
a similar way as to how they seek to understand
the individual client in the traditional therapist-
client interactions (McColl, 1998)

Building Community Capacity cont…
 Community interventions that are based on and
developed using community-identified needs
build upon community strengths and have been
successful (Elliott, O’Neal, & Velde, 2001).
 OT practitioners must understand the
occupational profile of the community to develop
meaningful interventions that are based on
occupational preferences.

Applying Occupation in the Community context
 OT practitioners are experts on occupation and have argued that
occupation is a ‘fundamental prerequisite of wellbeing and linked it
to an individual’s state of happiness, self-esteem and physical and
mental health (Wilcock, 2006)
 However, in community practice, practitioners must understand
occupations both on the individual and community levels. Because
illness and health are affected by disease as well as external
context and health infrastructure, OT practitioners must transform
traditional beliefs about occupation to apply occupation on multiple
levels.
 Occupation can be applied in the community context through
program development and grant writing.

Skills required for community practice
 OT practitioners in the arenas of community
health, public health, community-based practice,
and community-built practice, and community-
built practice requires a unique set of skills to
achieve success. These include the following:
 Consultancy
 Education
 Autonomy
 Client-centered practice
 Clinical reasoning

Skills required for community practice cont…
 Health promotion
 Networking
 Management skills
 Program evaluation skills
 Cultural awareness
 Team skills
 Fidler(2001) states that ‘ responding to the varied needs,
interests and welfare of a community will differ in
orientation, attitudinal and knowledge base from the one
that currently guides our education and practice’(p.8)

Skills required for community practice cont…
 Despite the above facts, some skills required for
community practice transfer easily from the clinical
setting to a community practice setting, whereas
others require development and experience.
 For example, an OT practitioner in community
settings can find a role in consultancy when serve
on the board of directors by providing advice as an
expert in occupation or some other component of
the profession.

MODELS OF PRACTICE IN THE COMMUNITY
 In occupational therapy, there are two main
approaches to practice, namely:
 Community-based practice
 Community-built practice
 OT practitioners must decide which approach
works best for the needs of their practice and the
community.

Community-based practice
 Community-based practice is the location in
which occupational therapy service are provided.
 In this model, specific locations within the
community context are identified and the skilled
of and roles that OT practitioners can play in the
setting are described.
 Examples include adult daycare programs, driving
rehabilitation programs, and health promotion
programs.

Community-based practice cont…
 According to Wittman and Velde (2001),
community-based practice “refers to skilled
services delivered by health practitioners using an
interactive model with clients”(p.3)
 For community-based practice, OT practitioners
must move away from the medical model and
focus on health promotion and disease prevention
approach to health delivery (Scaffa, 2001)

Community-based practice cont...
 Program development is a significant component
of community practice. It can be compared to the
occupational therapy process and include the
following steps: preplanning, needs assessment,
plan development, implementation, evaluation
and institutionalization (Brownson, 2001)
 The community-based practice approach transfers
practice skills from the clinical setting to a
population-based program development model.

Community-Built Practice
 Community-built occupational therapy programs
are “open systems in constant interaction with
their physical, natural, temporal, social and
political environment” (Elliott et al., 2001,p,106).
 The basis of the community-built practice model
is collaboration with a strength-based approach
and “ends when the client-defined community has
effectively built the capacity for empowerment”
(Wittman & Velde, 2001, p.3).

Community-Built Practice cont…
 Community-built practice is founded on the
following principles:
1. Each community member and community has
strength:
o Each community member and community is
evaluated for strengths.
o Practice focuses on health promotion, wellness
and recognizes the ability of each individual and
community to build capacity for success.

o It is assumed that the community will embrace the
practice and at some self-defined point, no longer
need the OT services.
2. Community members are equal partners in
program development, implementation, and
evaluation:
o Community members are the experts in the
community’s culture, dynamics, politics, and health
issues and are the strongest resource of any
community program.

3. Community members “own” the program:
o The community program should not depend on
experts or “outsiders” to be successful but should
become embodied by the community. The ultimate
goal of community-built practice is for the community
to assume responsibility for the program.
4. The OT practitioner must be culturally aware for
the program to succeed:
o Cultural awareness and cultural desire are skills
required of the practitioner for the program
activities to have an impact.

Community-Based Practice versus
Community-Built Practice
 Community-based practice focuses on applying
the concepts of occupational therapy practice to
community settings to develop programs that
address occupational needs.
 Community-built practice utilizes a collaboration
model and focuses on the needs and capacities of
the community and its members. Hence,
community is built with the OT practitioner as
facilitator.

Concept of Community Based Rehabilitation (CBR)
Introduction
 There are an estimated one billion people with
disabilities globally, corresponding to about 15%
of the world’s population (WHO 2011). Among
them, 80% of people with disabilities live in
low- and middle-income countries.
 A large number of disabled persons, especially
in the developing world, have no access to
institutional rehabilitation services that are
usually based in big cities with a limited service
capacity.

How do you determine your disabled
community?
 People with disabilities include those who
have long-term physical, mental, intellectual
or sensory impairments, which in interaction
with various barriers may hinder their full and
effective participation in society on an equal
basis with others (UN 2008; WHO 2011).

How do you determine your disabled community cont…
 The International Classification of Functioning,
Disability and Health (ICF) illustrated this view of
disability as health condition that may lead to an
impairment. For instance,
o polio can lead to muscle weakening and
consequently to physical impairment.
o a cataract causes clouding of the lens in the eye
and then visual impairment.
o dementia is caused by brain damaging diseases,
which cause cognitive impairment.

How do you determine your disabled community cont…
 Impairment may lead to reduced activities. In
the previous examples, polio may lead to
difficulties in walking, cataract in self-care
and mobility, and dementia in self-care.
 These limitations in activities can restrict full
participation in aspects of society, such as
exclusion from employment or education, thus
resulting in disability.

Introduction cont…
 People with disabilities are often excluded
from education, health, employment and
other aspects of daily life, and are generally
poorer.
 It is therefore widely argued that the
Millennium Development Goals and the post-
2015 targets cannot be achieved without
integrating disability issues into the agenda.

 The concept of Community-Based Rehabilitation (CBR)
was proposed by the World Health Organization (WHO) in
the late 1970s to increase the coverage of rehabilitation
services for disabled persons.
 Initially CBR focused on medical and functional aspects of
rehabilitation needs. Soon afterwards other agencies of
the United Nations, United Nations Organization for
Educational, Scientific and Cultural Development
(UNESCO) and International Labour Organization (ILO)
proposed similar approaches for dealing with the
educational and occupational aspects of rehabilitation.

 Implementations of field activities based on this
approach, which values existing resources, skills
and capacities in the families and communities,
were known as the “WHO Model”, “UNESCO
Model” and “ILO Model” of CBR.
 Gradually it became clear that, for CBR to be
effective, disabled persons require a multisectoral
approach that covers all aspects of life.

 It was also evident that these activities related
to medical, social, psychological, educational
and occupational aspects have limited impact on
the lives of persons with disabilities and their
families unless:
a) attitudes towards disables change in the
communities,

b) there are effective national policies and laws
which guarantee equal opportunities to all
citizens, and
c) unless persons with disability themselves have
the possibility of making choices and are
empowered to take decisions concerning their
own lives.

 This evolution in the concept of CBR resulted
in a collaboration involving WHO, UNESCO and
ILO in 1994.
 A paper entitled Joint Position Paper on CBR
ensued, which attempted to go beyond the
different “models”.
 It defines CBR as:

 A strategy within general community
development for rehabilitation, equalisation
of opportunities and social inclusion of all
children and adults with disabilities.
 CBR is implemented through the combined
efforts of people with disabilities themselves,
their families and communities, and the
appropriate health, education, vocational and
social services.

o CBR is delivered within the
community using
predominantly local
resources, to ensure that
the interventions are
locally appropriate and low
cost.
o CBR is therefore a
multisectoral, ‘bottom-up’
strategy.

ASSIGNMENT
Identify six (6) CBR programmes run in Ghana.

THE CBR MATRIX
 The CBR matrix (WHO 2010) provides a basic
framework for CBR programmes.
 It highlights the need to target intervention in
five key components:
1. health,
2. education,
3. livelihood,
4. social and
5. empowerment.

The CBR Matrix cont…
 Each component includes five elements where
the different activities are listed.
 A CBR programme is formed by one or more
activities in one or more of the five components.
The focus can be on providing new services as
well as promoting inclusion of people with
disabilities into existing services.
Health education Livelihood Social Empowerment

The CBR Matrix cont…
 Each CBR programme is not expected to
implement every component of the CBR matrix,
but will vary depending on the needs of their
users.
 CBR programmes are therefore very diverse.

Role of the OT in the community in relation
to CBR matrix.
1. The Health Component
The goal of the health component is that people
with disabilities achieve their highest attainable
standard of health. It includes the following:
 promotion (e.g. providing messages specifically to
people with disabilities or ensuring that ongoing
health promotion efforts are inclusive of people
with disabilities)

Role of the OT … cont…
 prevention (e.g. preventing impairments or
preventing illness among people with disabilities)
 medical care (e.g. collaborating with local
healthcare facilities in the community to ensure
that they are inclusive and accessible to people
with disabilities)
 rehabilitation (e.g. practising mobility exercises
and adapting the physical environment)

 provision of assistive devices (providing
locally made and appropriate mobility and
other aids).
NB: These interventions therefore target
improvements in knowledge, health and
clinical outcomes, and reduced impairments.

2. The Education Component
oThe goal of the education component is that
people with disabilities access education and
lifelong learning, leading to fulfilment of their
potential, a sense of dignity and self-worth, and
effective participation in society.
oThis component focuses on increasing
attendance and duration of schooling by people
with disabilities as well as increasing participation
in non-school education.

 Examples include working together with teachers
in the local community to make appropriate
adaptations (e.g. accessible toilets and
specialized teaching assistants) that allow
children to attend school, or providing retraining
opportunities for people who develop disability
later in life (e.g. teaching Braille).

3. The Livelihood Component
o The livelihood component of the CBR matrix
has the goal that people with disabilities can
gain a livelihood, have access to social
protection measures and be able to earn
enough income to lead dignified lives and
contribute economically to their families and
communities.

o This component focuses on increasing inclusion in
employment and enhancing earning abilities for people
with disabilities and their families. This could include:
 skills development (e.g. computer training)
 financial services (e.g. microcredit schemes for people
with disabilities)
 promotion of wage employment (e.g. apprenticeships or
internships for people with disabilities)
 social protection programmes (e.g. disability pensions or
other benefit schemes).

4. The Social Component
o The goal of the social component is that people with
disabilities have meaningful social roles and
responsibilities in their families and communities, and
are treated as equal members of society.
o It focuses on improving social participation and
improving relationships. This can be achieved through:
• counselling to improve relationships and family life
• challenging negative attitudes and violence against
people with disabilities

• personal assistance to participate in family and
community life, to support self-care and maintain
dignity
• encouraging the inclusion of disabled people in
culture and arts, leisure and sports (e.g.
inclusive dance groups and art groups for people
with dementia)
• access to justice (e.g. providing information to
people with disabilities and their families about
their rights and how to turn to the justice system).

5. The Empowerment Component
o The goal of the empowerment component is
that people with disabilities and their family
members make their own decisions and take
responsibility for changing their lives and
improving their communities.
o This component concentrates on the
importance of empowering people with
disabilities, their family members and
communities to facilitate the mainstreaming
of disability across all sectors and to ensure
that everybody is able to access their rights. It
includes:

o enhancing communication (e.g. providing
regular information on CBR programmes
and emphasising benefits to the whole
community)
• facilitating social mobilisation to get
disability into the social consciousness of
the community (e.g. through community
parties)

• enabling the political participation of people with
disabilities in different levels of the political system
(e.g. encouraging people with disabilities to stand
for elections and lobbying for policy change)
o developing self-help groups to allow information
sharing and support among people with disabilities
and their families
• establishing Disabled People’s Organisations (DPOs)
to advocate for inclusion and change.

Constraints faced in scaling up access to CBR
and compliance with intended design
1. Lack of funding for the support of CBR
projects
o Where funding is available this is often not
sufficiently stable to plan for the long term,
and once the non-governmental organisation
removes the funding the CBR programme is
usually not sustainable.

Constraints faced in scaling up access to
CBR cont…
2. Lack of training of CBR field workers
o This reduces their effectiveness when
working in complex domains such as health
or education and leads to low recognition
by other professionals.
o This issue is further enhanced by the low
level of education of most CBR workers.

CBR cont…
3. Stigma and discrimination against people
with disabilities
o These factors may lead to low awareness of
disability, low uptake of services and low
community support of CBR programmes.

CBR cont…
4. Lack of access to specialist
services.
o CBR workers may wish to refer users to specialised
institutions (e.g. schools and rehabilitation
centres), but these are often not available in their
locality.

CBR cont…
o Similarly, the specialists who give expert
advice on particular issues (e.g. doctors
and social workers) are often not available
in CBR settings.
o A lack of access to assistive devices and
other environmental supports also hampers
the implementation of CBR.

Thank you
owusuowusu22@gmail.com

Community Occupational Therapy

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Community Occupational Therapy

Similar to Community Occupational Therapy (20)

Recently uploaded

Recently uploaded (20)

Community Occupational Therapy