CBR AhmedRefat

Community-Based Physiotherapy
Basic Concepts
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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

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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

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y The most recent definitions of disability come from
the: International Classification of Functioning, Disability and Health (ICF), which states that disability is: y 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.,

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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 .

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Peoples 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 .

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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

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Approximately 10% of the worlds population lives with a disability .. People with disabilities constitute the worlds largest minority. An estimated 80% of people with disabilities live in developing countries An estimated 15 20% of the worlds poorest people are disabled No rehabilitation services are available to people with disabilities in 62 countries .
Disability : Global Statistics

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Only 515% 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 .
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Origen of the " Community-based physiotherapy / rehabilitation (CBR)" concept

y 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 Organizations (WHO) goal of health for all . This strategy was intended to enhance the quality
of life for people with disabilities through community initiatives.

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y 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 lowincome countries .
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y 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 Childrens Fund (UNICEF) became involved, recognizing the need for a multisectoral approach.
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y 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 .
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y 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.
y ( ILO, UNICEF, WHO. CBR: joint position paper ; 2004 ).
There are currently 3 meanings attached to 'CBR':

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(1) Community Based Rehabilitation (CBR): as 'people
taking care of themselves' (2) (2) Community Based Rehabilitation: as a Concept and as an Ideology CBR as a concept and an ideology, promotes a decentralized approach to rehabilitation service-delivery (3) (3) Community Based Rehabilitation Programs, Projects and Organizations (mostly by NGOs)
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Elements of CBR
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y Essential Elements of CBR y CBR requires community and DPO/PWD Disabled People's
Organisations
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

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y 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:
y I.
National level support through policies, co-ordination
and resource allocation. y II. Recognition of the need for CBR programmes to be based on a human rights approach. y III. The willingness of the community to respond to the needs of their members with disabilities. y IV. The presence of motivated community workers.
Support for CBR

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Multi-sectoral Support for CBR

y 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

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y 1 Support from the y y y y y y
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
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y 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. y The principles outlined below are overlapping, complementary and inter-dependent
Principles of CBR
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1. 2. 3. 4. 5. 6. 7. 8. 9.
Inclusion Participation Empowerment Equity Self -advocacy Facilitation Gender sensitivity and special needs Partnerships Sustainability
Principles of CBR
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y 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. y 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
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y 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
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y 4- Equity
y CBR emphasizes equality of opportunities and rights
equal citizenship. y 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
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y 5- Self Advocacy.,
y 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.
y
Principles of CBR
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y 6- Facilitation
y 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.
y 7- Gender sensitivity and special needs
CBR is responsive to individuals and groups within the community with special needs.
Principles of CBR
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y 8- Partnerships
y CBR depends on effective partnerships with community-based
organizations, government organizations and other organized groups.
y 9- Sustainability
y 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

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y 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 . y The matrix consists of five key components: the health, education, livelihood, social and empowerment components. Within each component there are five elements.
CBR Matrix
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Elements of Health Components -1

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1- Health promotion
y Health promotion aims to increase control over
health and its determinants. y 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.

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2- Prevention
y 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.

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3- Medical care
y 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.

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4- Rehabilitation
y 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. y 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.

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5- Assistive devices
y 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). y 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.
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Desired Outcome and the Role of CBR

in each Elements of Health Component
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1- Health Promotion,
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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

y 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. y 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,
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Desirable outcomes
y People with disabilities and their families are reached by
the same health promotion messages as are members of the general community. y Health promotion materials and programmes are designed or adapted to meet the specific needs of people with disabilities and their families. y 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,
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Desirable outcomes
y 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. y The community provides a supportive environment for people with disabilities to participate in activities which promote their health. y CBR programmes value good health and undertake health-promoting activities in the workplace for their staff.
2- Prevention ,
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The role of CBR

y 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,
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Desirable outcomes
y People with disabilities and their families have
access
to health information and services aimed at preventing health conditions. y People with disabilities and their families reduce their risk of developing health problems by taking up and maintaining healthy behaviours and lifestyles. y 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,
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Desirable outcomes
y 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. y 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
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Goal
y People with disabilities access medical care, both
general and specialized, based on their individual needs.
The role of CBR

y 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,

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Desirable outcomes
y 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. y People with disabilities and their families access activities that are aimed at the early identification of health conditions and impairments (screening services).
y Medical care facilities are
inclusive and have improved
access for people with disabilities.

3- Medical Care -cont,

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Desirable outcomes
y People with disabilities can access
surgical care to minimize or self-
correct impairments, thus contributing to improved health and functioning.

y People with disabilities and their families develop
management skills whereby they are able to ask
questions, discuss treatment options, make informed decisions about medical care and manage their health conditions.
y 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,
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Goal
y People with disabilities have access to rehabilitation
services which contribute to their overall well-being, inclusion and participation.
The role of CBR

y 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,
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Desirable outcomes
y People with disabilities receive individual
assessments and are involved in the development of rehabilitation plans outlining the services they will receive. y 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,
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Desirable outcomes
y 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. y Basic rehabilitation services are available at the community level. y Resource materials to support rehabilitation activities undertaken in the community are available for CBR personnel, people with disabilities and families. y CBR personnel receive appropriate training, education and support to enable them to undertake rehabilitation activities.
4- Rehabilitation-cont,
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Rehabilitation services
y (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). y 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
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y Goal
y People with disabilities have
assistive devices that are of good quality and enable them to participate in life at home and work and in the
community.
access to appropriate
y The role of CBR

y 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,
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yDesirable outcomes
y CBR personnel are knowledgeable about
devices, including the types available, their
assistive
functionality and suitability for different disabilities, basic fabrication, availability within communities and referral mechanisms for specialized devices. y People with disabilities and their families are
knowledgeable about assistive devices and

make informed decisions to access and use them.
5- Assistive Devices-cont,
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y Desirable outcomes
y 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. y Local people, including people with disabilities and their families, are devices and undertake simple repairs and maintenance.
able to fabricate basic assistive
y Barriers preventing access to assistive devices, such as

their assistive devices needed.
inadequate information, financial constraints and centralized service provision, are reduced. y Environmental factors are addressed to enable individuals to use
in all locations where they are
Literature Cited
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y
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

y y 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
y
5. Declaration of Alma-Ata: International conference on primary health care, Alma-Ata, USSR, 612 September 1978, Geneva, World Health Organization, 1978 (www.who.int/hpr/NPH/docs/declaration_ almaata.pdf, accessed 10 August 2010).
y
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).
y
www.SlideShare.net/AhmedRefat
Example CMR- P
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Example CMR- P
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y The main objectives of the
program are: 1- Change the community perceptions toward disability and create a new and positive community outlook (changing attitudes). y 2- Transfer knowledge to the community through community education and other activities. y 3- Improve the quality of life of the disabled people by maximizing their independence and self reliance. 4- Promote the policy of early detection and early intervention. 5- Promote school mainstreaming for disabled children in the area. 6- Mobilize the local community through their engagement and y 7- participation in the programe activities. 8- Strengthen the capacity of the program through continuing education for the team (formal and informal training).
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y General objectives:
The main goal is to reach the largest possible number of disabled people in their direct environment to meet their needs with reliance o community resources ad community involvement, seeking to promote social welfare and achieve full social integration of persons with disability within their communities.
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y Objectives:
1. Achieve social integration for disabled persons in all life aspects. 2. Ensure equal opportunities, social justice and protect human rights. 3. Improve the quality of life of the disabled people by maximizing their independence and self reliance. 4. Change the community perceptions and attitudes toward persons with disability and their rights. 5. Promote the policy of early detection and early intervention and link CBR with PHC activities.
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y Programs services:
1. Home visits to disabled persons and training of family members to improve their skills and abilities to participate in the family and social life. 2. Preventive activities: tests and education aimed at early detection of disabilities. 3. Community activities: including community education on the rights of disabled persons and their social integration. 4. Capacity building: Including ongoing education for the staff and regular training sessions for volunteers from the local communities on CBR, voluntary work, rights, gender, democracy, psychosocial support, and self organization of disabled persons. 5. Coordination and networking with local institutions on rehabilitation and disability issues. 6. Psychosocial support to disabled persons and their families. 7. Community surveys in all the villages of the area on disability, as well as other studies and research related to the Program.
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y http://www.disabilityworld.org/01-
02_01/news/cbreditorial.htm
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Ahmed-Refat

CBR AhmedRefat

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Community-Based Physiotherapy

DR. AHMED-REFAT REFAT

Dr. Ahmed Refat AG Refat

Basic Concepts 1: Health

2- Disability & Rehabilitation

y The most recent definitions of disability come from

2-Disability & Rehabilitation- cont.,

Dr. Ahmed Refat AG Refat

2-Disability & Rehabilitation- cont.,

2-Disability & Rehabilitation- cont.,

Dr. Ahmed Refat AG Refat

Disability : Global Statistics

Disability : Global Statistics

Dr. Ahmed Refat AG Refat

Origen of the " Community-based physiotherapy / rehabilitation (CBR)" concept

of life for people with disabilities through community initiatives.

y Following the Alma-Ata declaration,

Dr. Ahmed Refat AG Refat

y During the 1990s, along with the growth in number of

Dr. Ahmed Refat AG Refat

y In 2003, an International consultation to review

y CBR is implemented through the combined efforts

Dr. Ahmed Refat AG Refat

There are currently 3 meanings attached to 'CBR':

(1) Community Based Rehabilitation (CBR): as 'people

Dr. Ahmed Refat AG Refat

Dr. Ahmed Refat AG Refat

Dr. Ahmed Refat AG Refat

Dr. Ahmed Refat AG Refat

Sustainability of CBR Programmes

y Country approaches to implementing CBR vary a

National level support through policies, co-ordination

Support for CBR

Multi-sectoral Support for CBR

Dr. Ahmed Refat AG Refat

Support for CBR

y 1 Support from the y y y y y y

Dr. Ahmed Refat AG Refat

y CBR facilitates access to basic needs, and at the

Dr. Ahmed Refat AG Refat

Dr. Ahmed Refat AG Refat

Dr. Ahmed Refat AG Refat

Dr. Ahmed Refat AG Refat

Dr. Ahmed Refat AG Refat

organizations, government organizations and other organized groups.

Dr. Ahmed Refat AG Refat

Common Framework of CBR Programmes

y In light of the evolution of CBR into a broader

Dr. Ahmed Refat AG Refat

Dr. Ahmed Refat AG Refat

Elements of Health Components -1

Dr. Ahmed Refat AG Refat

Elements of Health Components -2

Dr. Ahmed Refat AG Refat

Elements of Health Components -3

Dr. Ahmed Refat AG Refat

Elements of Health Components -4

Elements of Health Components -5

Desired Outcome and the Role of CBR

Dr. Ahmed Refat AG Refat

Dr. Ahmed Refat AG Refat

Dr. Ahmed Refat AG Refat