14
	Education of Personnel: the Key to 
	Successful Community Based Rehabilitation

	Padmani Mendis

Community-Based Rehabilitation (CBR) is a relatively new strategy which is increasingly being adopted by developing countries to improve the quality of life of their people who have disabilities.  It is 'new' as a strategy and it is based conceptually on a 'new' synthesis of ideas.  But many of these ideas however have been known for a long time and some have been documented in various forms by several persons at different times.
	What is 'new' about CBR is this.  Other approaches to rehabilitation in use up to now, focus on providing individuals who have a disability with the training opportunities and other interventions that they need to overcome the consequences of their disabling condition on themselves.  The aim of these rehabilitation approaches is to enable individuals to achieve as much functional and economic independence as possible.  Yet however functionally and economically independent these people become, they continue to be outside the mainstream of community life.  CBR therefore seeks first to change the principal cause of the situation of people who have disability: namely the negative attitudes of individuals, communities and  society-at-large towards disability and people who have disability. 
	CBR strives to ensure that individuals, communities and society accept the equal rights of individuals who have disability. Only then can interventions with people who are disabled bring them a place in society.  CBR seeks first to promote a positive change in attitude among the people with whom individuals who have disability interact.  Without this attitude change the situation of people with disabilities remains the same.  As can be seen from the struggle of the disability movements even in the industrialised countries, functional and economic independence have not brought them an equal status in society.
	Since it addresses this underlying social cause, CBR must then be viewed as a process of 'social development'.  Other approaches we have used up to now by and large view rehabilitation as a separate programme and focus largely on individuals who have disability and on providing separate services for them.
	Attitude change is of course very difficult to bring about, and especially so when attitudes towards people who have disability have deep-seated cultural and social roots. As in other development activities, experience in CBR indicates that desired social changes come about when communities take responsibility for bringing about the desired changes.  Hence the words 'community-based' should be taken to mean 'community-responsibility' for the rehabilitation of their members who have disability.  In CBR, individuals and communities take responsibility for improving the lives of members who have disability and their efforts are supported by professionals who  work outside these 'nuclear communities'.
	Whereas before, professionals conventionally have been service providers, the role called for them in CBR is primarily  a supportive one.  Thus the provision of services has to be seen in a new perspective and a new sensitivity, respecting the right of individuals who have disability, their families and nuclear communities to make decisions in matters which concern themselves.  

Who Needs Education?
This new perspective calls for an emphasis on education as a priority for the development of CBR.  For instance, Figure 1 illustrates some aspects of the CBR Structure that we are attempting to develop in Sri Lanka; a structure that is common with many other developing countries.  It is based on the needs of individuals who have a disability, their families and communities.  Besides being needs-based, the programme also rests on community participation, promoted and supported by professionals, and by the local government at each administrative level.  All of these groups need education in CBR. 
	Education first for people who have disability and their families, to make them aware of their rights, and to make available to them the knowledge and skills they need to take control of their lives.   

	Insert Figure 1 here

	Education also for those who take leadership within communities, and for community workers, so that they may be in a position to share the processes and the benefits of development with their members who have disability.
	Education too for professionals and administrators, so that they may be willing to support and to share their knowledge and skills with the groups listed above.  
	This paper will therefore share some of our experiences in Sri Lanka of the education of these four groups of people - individuals who have disability and their families, community workers, community leaders and rehabilitation professionals.  (The education of administrators in government and non-government services is also an important aspect of the educational strategy although that is not covered here.)

Some Fundamental Concepts in Education for CBR
The process of education in CBR, as in any other field, should be dynamic; changing in response to changing situations and demands.  This paper discusses educational needs in the context of the current phase of CBR development globally; that is, when programmes are being set up and while others are still in their early stages of development.  As CBR grows and expands to reach more people who have disability, educational programmes will need to adapt to the changing needs of people who have a disability.
	In order to ensure that the needs of people who have disability are being met in the most effective and efficient way, education must seek ways of ensuring its relevance.  For this to happen, educational programmes must consider two vital aspects.
	First, they must be based on the needs of people who have disability.  Although there is a fundamental similarity in the situation of people who have disability in developing countries, varying social, economic, political and cultural environments have to be taken into account.  Thus educational programmes have to adapted anew for each country.
	Second, educational programmes must have built-in systems of continual self-evaluation so that they detect and adapt to changing needs of the people they are serving.  
	Both these points are largely neglected areas in present-day CBR education.  Too often educational curricula are designed by those with little understanding of CBR and with little contact with people who have disability.  Hence courses are based on what are perceived to be the needs of people who have disability.
	Third, education itself is too often seen as a 'sharing' of information and technology (i.e. knowledge and skills) that is brought about from 'outside' or from the 'top'.  Rather education should be viewed as process which leads people to grow and develop their understanding and to find their own solutions.  This is facilitated through the use of 'learner-centred' teaching methods, such as discussions, problem solving and project work, rather than the more favoured lectures and talks.
	These three points need to be focused on to a greater extent in order to ensure that the educational programmes remain relevant and that they will provide the necessary foresight to take CBR forward.  

Education of Professionals
Professionals workers are taken up first because it is here that change is required most.  This group includes any paid workers who are involved closely at present with people who have disability.  They are usually employed in health, social welfare and education sectors, as well as in voluntary organizations.  The group includes therapists, social workers and school teachers.  People with a disability who work as professionals in any of the above sectors would also fall into this category.
	Two forms of educational input are needed for professional workers.  First, short courses for those already in service, to meet the immediate and urgent need for programme initiators, teachers and managers at support levels.
	Second, adapting the basic curricula of existing professional education for therapists and teachers.  Where no courses exist, then new styles of courses need to be considered.  Professional training is required in order to meet the longer-term need for programme sustainability, especially to produce generalist workers at middle levels.
	The Disability Studies Unit of the Faculty of Medicine of the University of Kelaniya, Sri Lanka, has, for the last two years, been implementing short courses for two groups of students; Sri Lankan nationals and for international participants.  Some aspects of these two types of courses are shared below.

International courses
These courses run full-time for six weeks and the participants are professional workers (including administrators) who are presently working in CBR or those who intend to do so in the very near future. 
	In all, 44 people have participated in the two courses held thus far; a third is planned for 1995.  They have all come from developing countries in Africa, South America and Asia with sponsorship obtained from various bilateral donors, UN agencies and international NGOs.

Course Objectives:  The course aims at enhancing the teaching and managerial capabilities of participants.   To achieve this overall objective, the course aims specifically at developing in participants the necessary attitudes, knowledge and skills so that they will be able to:

	respond with sensitivity to the needs of people who have disabilities, their families and communities, and to promote their empowerment;
	assist/support communities to plan, implement and monitor their own programmes;
	analyse community structures, activities, resources and support systems, and to facilitate and promote their coordinated use;
	make detailed plans for phased district/regional programme development;
	interact and collaborate effectively as members of interdisciplinary groups.

Course Content:  Each course day consists of seven sessions of 45 minutes duration.  The course content can be grouped into the following modules:

	Insert photo 14.1 here 

1. Disability concepts and the situation of people who have 
		disability (34 sessions);
2. Community development and support systems (22 sessions);
3. Rehabilitation programme development (86 sessions);
4. Field work and analysis (50 sessions);
5. Adult teaching and learning (20 sessions);
6. Appropriate technical aids (20 sessions);
7. Course opening and closing, introductions, assessment 
		of participants' learning, course evaluation (20 sessions).

Resource persons are drawn from other countries as well as Sri Lanka.  Learner-centred, participatory teaching is used whenever possible.  Course evaluation includes an ongoing evaluation of sessions/modules by participants, an end-of-course evaluation to give an overall perspective and a post course evaluation, 18 months after completion.

National Courses
Whereas many NGOs implement small and isolated CBR projects, the National Programme in Sri Lanka is the responsibility of the Ministry of Health and Social Welfare.  At the national level, all the sectors presently involved in making opportunities available and accessible to people who have a disability, come together in a national inter-sectorial body.  This includes representatives from the Ministries of Health, Social Services, Education and Labour, as well as representatives from the larger NGOs and UN agencies.  In this way, existing personnel and infrastructures are made most use of and each sector pays the salaries of its own personnel.
	As Figure 2 illustrates, in Sri Lanka's CBR strategy, professional support is made available to communities at a divisional level.  This is the most peripheral, administrative level; comparable to districts in most other countries.	In each division, a "core team" is being educated to provide the general programme support that communities have wanted as well as the necessary technical support.  The Divisional Core Team consists of a social service officer, a therapist and one other member selected by each division.  The third member has most often been community and rural development officers, local NGO workers and in a few instances, planning officers.  All members of teams have a basic professional education as well as varying periods of practical experience in their own fields.  They incorporate CBR tasks into their existing work.

	Insert Figure 14.2 here 

	To date, this strategy has been initiated in 20 of the 260 divisions in the country.
	All training is coordinated through a central inter-sectorial body which includes representatives from Health, Social Services, Education and Labour.  The Disability Studies Unit acts as a technical resource for the National CBR Programme and provides training for the the members of the core team.  In addition, the Unit's programme 'Partnership in CBR' seeks to strengthen the capacity of disability consumer organisations, and other disability-related NGOs, to participate actively in CBR.
	However the education of school teachers and of vocational training teachers for CBR is being undertaken by other Institutes and will not be dealt with in this paper.  Local administrative officials also have seminars and workshops on CBR.  

Course objectives:  The primary objective of the course is to prepare participants for the tasks which members of the divisional core teams are called on to perform.  These are, to:

1.	Work effectively as members of the CBR Divisional Steering Committees;
2.	Carry out social mobilization of communities so that:
	a) each community will set up a community rehabilitation committee to take responsibility for the maintenance of their programme, and,
	b) the community rehabilitation committee will select volunteers to implement the programme;
3.	Organize and conduct a training course for volunteers of at least two weeks duration and orient other community members/leaders as may be necessary.  (NB. The National Manual, Training in the Community for People with Disabilities is used as a tool for the community level.  This has been adapted from the W.H.O. Manual (Helander et al., 1989);
4.	Make regular home visits with volunteers so as to provide further teaching; help to solve problems and to monitor progress;
5.	Meet regularly with community rehabilitation committees for support and monitoring;
6.	Collect data, keep records and make reports to the divisional steering committee;
7.	Assist community rehabilitation committees to communicate with education officers and obtain educational opportunities for children who are not going to school;
8.	Assist community rehabilitation committees to communicate with labour officers and National Youth Service Council (NYSC) officers and NGOs, and obtain vocational training and job placement for youth and adults who need it;
9.	Ensure that those who need medical interventions are referred to the Medical Officer of Health, or to other health services, and that referrals are followed up.

Course Content:  The course is presently based around three modules.  

Module I - Programme Basis

	 situation of people who have disability;
	 attitudes towards disability and people who have 
		disability;
	 disability concepts;
	 CBR concepts and approach;
	 national strategy and the role of participants;

Module II - Technology

	 rehabilitation of people who have difficulty seeing;
	 rehabilitation of people who have difficulty moving;
	 rehabilitation of people who have difficulty hearing 
		and/or speaking;
	 rehabilitation of people who have difficulty learning 
		(mental retardation);
	 rehabilitation of adults who show strange behaviour 
		(mental illness);
	 rehabilitation of people who have fits (epilepsy);
	 rehabilitation of people who have multiple disabilities;
	 breast-feeding of infants who have disability;
	 early stimulation programmes for children who have 
		disability;
	 socialisation opportunities;
	 psychosocial needs;

Module III - Programme Implementation

	 interaction with individuals, families and communities 
		(interpersonal skills);
	 strategies for social mobilization;
	 location, identification and assessment of needs and 
		rehabilitation planning with and for individuals;
	 education system  and the role of the Ministry of 
		Education;
	 income generation for youth and adults and the roles of 
		the Dept. of Social Services, Ministry of Labour, National Youth Services Council and NGOs;
	 meeting medical needs and the role of the Ministry of 
		Health;
	 coordination with other sectors - state and non-
		governmental;
	 information gathering, record-keeping, reporting and 
		monitoring;
	 resource analysis and harnessing;
	 selection and training of volunteers;
	 divisional programme planning;

Course outcomes:  The impact of the training and of programme development are presently being monitored by the Disability Studies Unit and CBR Unit of the Ministry of Health and Social Welfare.  This is done mostly through field visits, although a reporting system is also being developed.
	At present, the preliminary course lasts 15 days, with upgrading courses to follow.  Upgrading courses are being developed based on the needs detected through field monitoring.

Educating Communities - Social Mobilisation
The wider community also needs education about CBR.  The objective of education in relation to communities is to procure their active participation in the CBR process.  We call this "social mobilization", while in other countries it may be called social animation or community preparation.
	Social mobilization is carried out by the Divisional Core Teams using non-formal educational methods as a continuous component of programme development.  During their training, Divisional Core Teams learn how to approach communities and to identify persons who are most influential in each community.  One method used is discussion with the formal and informal leaders in one-to-one situations or in small groups, and then reaching the rest of the community through them using the traditional communication network in each community. 
	Another method is to  participate in community gatherings and meetings and so discuss with community members directly. 
	We view education or social mobilization as a process of discussion with the community leadership and membership, that will lead to the setting up by the community of a 'Community Rehabilitation Committee' who will take particular responsibility for improving the lives of their members who have disability.  We have found that these Committees are vital to ensure community ownership of their programmes, as well as to both maintain and sustain the programme.
	The process of education through discussion generally includes the following aspects: 

		information about the CBR programme, implications for the role of the community and responsibilities; 
		awareness of problems arising from a disability and the factors that cause them;
		awareness of the needs of, and a wish to improve the quality of life of community members who have disability;
		awareness of how, and to what extent, the community can use its own resources to develop programmes
		accessibility of information and technology (knowledge and skills) to meet the special needs of members who have disability;
		supports available from other levels to make accessible the services and interventions that the community cannot provide;
		examples of other programmes; the factors which account for success and constraints;
		responses to questions.

In our experience, information dissemination must be a continuous part of the CBR programme in order to maintain community participation in it.

Education of Community Workers
In Sri Lanka, community CBR workers are selected by each community and they work on a voluntary basis. They are mostly youth, although recently the middle-age group is increasingly taking on this role.  Their minimum level of education is generally 10th Grade (General Certificate of Education Ordinary Level) although many have had a 12th Grade education (i.e. 'A' Level). These Community Workers most often are members of  community organizations and are involved in promoting many development activities of which CBR is one.  The others could include women's programmes, poverty alleviation and  health promotion.

Course Length:   The Introductory Course is a minimum of 14 days, followed by a continuous period of field teaching.  The teaching of community workers is the responsibility of the Divisional Core Team and their training continues during regular home visits.

Course Objectives:  Again, the course objectives are defined by the tasks that community workers will be called upon to perform. They have to be able to:

		involve the community in the rehabilitation programme;
		locate and identify people who have disability, and determine their rehabilitation needs, if any;
		to find a "trainer" for each person with a disability through discussion with the individual and the family, and plan interventions to meet the identified needs,  using the CBR Manual as a tool;
		guide, support and motivate individuals and family members to continue the rehabilitation process until needs have been met; detect problems and constraints, and discuss these with the divisional core team who act as mid-level CBR support workers. 
		seek the cooperation of school teachers for getting children into schools, and refer problems to the community rehabilitation committee;
		to find income generation activities for youth and adults through discussion with the community rehabilitation committee;
		refer to health workers those individuals who need medical interventions;
		assess progress, keep records, and report to community rehabilitation committee and to divisional core team;
		continue the programme in their own community.

NB. The Manual 'Training in the Community for People with Disabilities' (WHO 1983), adapted to our situation, is used as a basic tool by Community Workers.

Course Content:  The Content of the Introductory Training Course follows below. Field teaching continues to meet emerging needs and is used to strengthen weak areas.  Further courses for community workers will follow according to need.

1.	Introduction to Rehabilitation:
	(situation of people who have disability and community attitudes towards disability and people who have disability; disability concepts and rehabilitation needs; goals, components and methodology of CBR; role of community workers.)
2.	Aspects of Rehabilitation which are common to the different disabilities people may have:
	(social interaction; income generation; daily living activities; schooling; early stimulation; breast-feeding advice.)
3.	Meeting the special needs of people who have difficulty seeing:
	(possible problems faced by individuals, information for individuals and family, training, interventions for self-care and for orientation and mobility.)
4.	Meeting the special needs of people who have difficulty hearing and/or speaking:
	(communication, communication problems and information about possibilities; communication training techniques.)
5.	Meeting the special needs of people who have difficulty moving:
	(possible problems and information about possibilities; training techniques for daily living activities and for mobility including the making of simple appropriate aids and equipment; methods of preventing deformity.)
6.	Meeting the special needs of people who show strange behaviour (disability arising from mental illness):
	(resulting behavioural problems and advice to family about how to deal with them; restoring daily living activities; importance of referral and medication.)
7.	Meeting the special needs of people who have fits: (information about disability and advice to family about how to deal with it; importance of referral and medication.)
8.	Meeting the special needs of people who have difficulty learning (disability arising from mental retardation):
	(possible problems and information to the family about how to deal with them; training techniques for children and for adults.)
9.	Starting a CBR programme: 
	(role and responsibility of the community and how to involve them; role of people who have disability and how to involve them.)
10.	How to use the National Manual, Training in the Community for People who have Disabilities as a tool for carrying out the programme:
	(introducing the manual and how to use it; visiting households, locating and identifying people who have disabilities; finding out rehabilitation needs; selecting training material, planning and implementing the rehabilitation programme with each individual and family; keeping records, making reports, and making referrals; how to continue the community CBR programme; role in the prevention of disability).

Education for Families and Individuals with Disability 
All the educational approaches described above have one primary purpose - to reach individuals who have a disability and their families so as to empower them with the knowledge and skills that they need to strengthen positive relationships and to promote interactions among themselves and with the community.
	It is at this point that CBR programme development truly  begins.  Individuals who have a disability and their family members are located in their homes and are helped to vocalize their needs by the trained community workers.  Thereafter, the community workers share the knowledge and skills that they have and they use these in working  with individuals, families and communities to fulfil the person's needs.  Those needs that cannot be fulfilled at the home or community level are referred to the Divisional Core Team. Sometimes this may call for further referral to other agencies as in the case of very specialised needs.  Medical needs are referred to the Divisional Health Officer.

Conclusions
The paper has emphasized that the success of a CBR strategy rests on the quality of education made available to the key implementors - individuals who have disability and their families, community leaders and membership, community workers, professionals and administrators.  
	Sri Lanka's CBR strategy has been developing  over the last 13 years, but can be considered to be in its early stages. It is evolving as a multi-sectorial approach based on community participation and on supportive inputs at each level of the country's administrative system.  It's major weakness at the present time is the limited involvement of the Organizations of People who have Disability.  This will be addressed as a priority as further educational inputs are developed.

Reference

Helander, E., Mendis, P., Nelson, G. & Goerdt, A. (1989).  Training in the Community for People with Disabilities, 	Geneva: WHO 

Padmini Mendis worked with Einar Helander and Gunnel Nelson at the World Health Organisation on the evolution of Community Based Rehabilitation and is co-author of the manual: Training in the Community for People with Disabilities.
	She is Course Director at the Disability Studies Unit, University of Kelaniya, Sri Lanka and visiting lecturer at Uppsala University Sweden, where she was awarded an honorary doctorate in medicine for her contribution to the global development of CBR.  
	Since 1980 she has been on the WHO Expert Advisory Panel on Rehabilitation and has now visited over 25 countries to promote CBR programme development 

Contact Address
	Disability Studies Unit, Faculty of Medicine, 
	University of Kelaniya
	P.O.Box 06, Ragama, 
	Sri Lanka