CBR Guidelines

Community-Based Rehabilitation
Health component
WHO Library Cataloguing-in-Publication Data
community-based rehabilitation: cBr guidelines.
1.rehabilitation. 2.disabled persons. 3.community health services. 4.health policy. 5.human rights.
6.social justice. 7.consumer participation. 8.guidelines. I.world health organization. II.Unesco.
III.International labour organisation. Iv.International disability development consortium.
IsBn 978 92 4 154805 2 (nlm classification: wB 320)
© World Health Organization 2010
all rights reserved. Publications of the world health organization can be obtained from who Press,
world health organization, 20 avenue appia, 1211 geneva 27, switzerland (tel.: +41 22 791 3264;
fax: +41 22 791 4857; e-mail: bookorders@who.int). requests for permission to reproduce or
translate who publications – whether for sale or for noncommercial distribution – should be
addressed to who Press, at the above address (fax: +41 22 791 4806; e-mail: permissions@who.int).
the designations employed and the presentation of the material in this publication do not
imply the expression of any opinion whatsoever on the part of the world health organization
concerning the legal status of any country, territory, city or area or of its authorities, or concerning
the delimitation of its frontiers or boundaries. dotted lines on maps represent approximate border
lines for which there may not yet be full agreement.
the mention of specific companies or of certain manufacturers’ products does not imply that
they are endorsed or recommended by the world health organization in preference to others of
a similar nature that are not mentioned. errors and omissions excepted, the names of proprietary
products are distinguished by initial capital letters.
all reasonable precautions have been taken by the world health organization to verify the
information contained in this publication. however, the published material is being distributed
without warranty of any kind, either expressed or implied. the responsibility for the interpretation
and use of the material lies with the reader. In no event shall the world health organization be
liable for damages arising from its use.
design and layout by Inís communication – www.iniscommunication.com
Printed in malta
cBr guidelines
Health component
Table of contents:
Preamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Health promotion . . . . . . . . . . . . . . . . . . . . . . . 11
Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Medical care . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Assistive devices . . . . . . . . . . . . . . . . . . . . . . . . 57
wHO Llbrary Catalogulng-ln-Publlcatlon Data
community-based rehabilitation: cBr guidelines.
1.rehabilitation. 2.disabled persons. 3.community health services. 4.health policy. 5.human rights.
6.social justice. 7.consumer participation. 8.guidelines. I.world health organization. II.Unesco.
III.International labour organisation. Iv.International disability development consortium.
IsBn 978 92 4 154805 2 (nlm classification: wB 320)
© World Health Organization 2010
all rights reserved. Publications of the world health organization can be obtained from who Press,
world health organization, 20 avenue appia, 1211 geneva 27, switzerland (tel.: +41 22 791 3264;
fax: +41 22 791 4857; e-mail: bookorders@who.int). requests for permission to reproduce or
translate who publications – whether for sale or for noncommercial distribution – should be
addressed to who Press, at the above address (fax: +41 22 791 4806; e-mail: permissions@who.int).
the designations employed and the presentation of the material in this publication do not
imply the expression of any opinion whatsoever on the part of the world health organization
concerning the legal status of any country, territory, city or area or of its authorities, or concerning
the delimitation of its frontiers or boundaries. dotted lines on maps represent approximate border
lines for which there may not yet be full agreement.
the mention of specific companies or of certain manufacturers’ products does not imply that
they are endorsed or recommended by the world health organization in preference to others of
a similar nature that are not mentioned. errors and omissions excepted, the names of proprietary
products are distinguished by initial capital letters.
all reasonable precautions have been taken by the world health organization to verify the
information contained in this publication. however, the published material is being distributed
without warranty of any kind, either expressed or implied. the responsibility for the interpretation
and use of the material lies with the reader. In no event shall the world health organization be
liable for damages arising from its use.
design and layout by Inís communication – www.iniscommunication.com
Printed in malta
PreamBle l
Preamble
The rlght to health wlthout dlscrlmlnatlon ls captured ln varlous lnternatlonal lnstru-
ments. The Constltutlon of the world Health Organlzatlon (wHO) states that “enìoyment
of the hlghest attalnable standard of health ls one of the fundamental rlghts of
every human belng wlthout dlstlnctlon of race, rellglon, polltlcal bellef, economlc or
soclal condltlon” (1).
The Unlted Natlons Conventlon on the Plghts of Persons wlth Dlsabllltles (CPPD)
addresses the rlght to health for people wlth dlsabllltles. Artlcle 25 requlres States to
“recognlze that persons wlth dlsabllltles have the rlght to the enìoyment of the hlghest
attalnable standard of health wlthout dlscrlmlnatlon of dlsablllty” and, together wlth
Artlcles 20 (accesslblllty) and 26 (habllltatlon and rehabllltatlon), outllnes measures
States Partles should undertake to ensure that people wlth dlsabllltles are able to access
health servlces that are gender-sensltlve, lncludlng health-related rehabllltatlon (2).
Unfortunately, evldence shows that people wlth dlsabllltles often experlence poorer
levels of health than the general populatlon (3) and face varlous challenges to the enìoy-
ment of thelr rlght to health (4).
The rlght to health ls not only about access to health servlces: lt ls also about access to
the underlylng determlnants of health, such as safe drlnklng water, adequate sanlta-
tlon and houslng. The rlght to health also contalns freedoms and entltlements. These
freedoms lnclude the rlght to be free from nonconsensual medlcal treatment such as
experlments and research and the rlght to be free from torture or other cruel, lnhuman
or degradlng treatments. The health-related entltlements lnclude the rlght to a system
of health protectlon: the rlght to preventlon, treatment and control of dlseases: access
to essentlal medlclnes: and partlclpatlon ln health-related declslon-maklng (4).
Communlty-based rehabllltatlon (C8P) programmes support people wlth dlsabllltles
ln attalnlng thelr hlghest posslble level of health, worklng across ñve key areas: health
promotlon, preventlon, medlcal care, rehabllltatlon and asslstlve devlces. C8P facllltates
lncluslve health by worklng wlth the health sector to ensure access for all people wlth
dlsabllltles, advocatlng for health servlces to accommodate the rlghts of people wlth
dlsabllltles (5) and be responslve, communlty-based and partlclpatory (6).
Although C8P has hlstorlcally focused on the health sector, as health ls lnnuenced by
many factors, there ls a need for multlsectoral collaboratlon and lncluslon (7) and for
C8P programmes to work across many dlnerent sectors, such as educatlon and employ-
ment. Glven the slze of the toplc of health, thls component focuses prlmarlly on those
C8P actlvltles that take place wlthln the health sector.
2 cBr gUIdelInes > 2: health comPonent
ß0X 1
Thalland has a long and successful hlstory of prlmary health care whlch, over tlme, has
evolved through many lnnovatlve strategles and actlvltles. |n many provlnces, prlmary
health care ls based around networks of satelllte unlts called prlmary care unlts, whlch are
connected to and supported by large central hospltals. |n zoo6, one of these hospltals,
Slchon Hospltal, lntroduced communlty-based rehabllltatlon (C8P) to thelr network of
prlmary care unlts. The Tha-Hln prlmary care unlt ls part of thls network. |t ls located ln a
rural area and has a team of health personnel lncludlng a famlly doctor, a pharmaclst,
nurses and health workers. 8efore C8P was lntroduced, thls team mostly carrled out general
health promotlon and preventlon actlvltles. However, wlth the addltlon of C8P, the team
also became responslble for ldentlfylng people wlth dlsabllltles and addresslng both thelr
general and thelr speclñc health-care needs.
The maìor focus of C8P was to provlde health servlces for people wlth dlsabllltles on thelr
“doorsteps”. A home health-care scheme was establlshed (whlch ls also for older people
and people wlth chronlc health condltlons), provldlng a dlrect llnk to Slchon Hospltal.
Home vlslts are conducted on a regular basls by members of the Tha-Hln team and a
physlcal theraplst from Slchon Hospltal, enabllng people to avold unnecessary and costly
travel. A protocol was also establlshed for home-based rehabllltatlon. Local volunteers and
famlly members were tralned to provlde baslc rehabllltatlon (l.e. dally llvlng skllls tralnlng)
to people wlth dlsabllltles and were encouraged to promote lncluslve educatlon for
chlldren wlth dlsabllltles. The multldlsclpllnary approach has ensured that all people wlth
dlsabllltles are able to access health care and rehabllltatlon servlces ln thelr communltles as
well as referral servlces at Slchon Hospltal when needed.
A zoo8 evaluatlon concluded that the C8P programme had been enectlve ln provldlng
a range of health-care servlces for people wlth dlsabllltles and thelr famllles, lncludlng
early ldentlñcatlon of people wlth dlsabllltles and early lnterventlon, health promotlon
and rehabllltatlon lncludlng functlonal tralnlng and provlslon of asslstlve devlces. Overall,
quallty of llfe has been enhanced for all people wlth dlsabllltles wlth lmprovements ln
thelr lndependence, moblllty and communlcatlon skllls. Parents
of chlldren wlth dlsabllltles have also been
provlded wlth better support. Good worklng
relatlonshlps have been establlshed between
all key stakeholders (Slchon Hospltal,
the prlmary care unlt and the
communlty) and lncluslon of
local volunteers and moblllzatlon
of other resources have
created a sense of communlty
empowerment and ownershlp.
Taking health services to the community
Thalland Thalland
PreamBle 3
Goal
People wlth dlsabllltles achleve thelr hlghest attalnable standard of health.
The role of CBR
The role of C8P ls to work closely wlth the health sector to ensure that the needs of
people wlth dlsabllltles and thelr famlly members are addressed ln the areas of health
promotlon, preventlon, medlcal care, rehabllltatlon and asslstlve devlces. C8P also needs
to work wlth lndlvlduals and thelr famllles to facllltate thelr access to health servlces and
to work wlth other sectors to ensure that all aspects of health are addressed.
Desirable outcomes

People wlth dlsabllltles and thelr famlly members have lmproved knowledge about
thelr health and are actlve partlclpants ln achlevlng good health.

The health sector ls aware that people wlth dlsabllltles can achleve good health and
does not dlscrlmlnate on the basls of dlsablllty and other factors such as gender.

People wlth dlsabllltles and thelr famlly members have access to health-care and reha-
bllltatlon servlces, preferably ln or close to thelr communltles and at anordable cost.

Health and rehabllltatlon lnterventlons enable people wlth dlsabllltles to become
actlve partlclpants ln famlly and communlty llfe.

There ls lmproved collaboratlon across all development sectors, lncludlng educatlon,
llvellhood and soclal sectors, to achleve good health for people wlth dlsabllltles.
Key concepts
Health
What is health?
Health has tradltlonally been deñned as the absence of dlsease and lllness. However, as
deñned by wHO, lt ls a much broader concept – lt ls “a state of complete physlcal, mental
and soclal well-belng and not merely the presence of dlsease or lnñrmlty” (1). Health ls
a valuable resource that enables people to lead lndlvldually, soclally and economlcally
productlve llves, provldlng them wlth the freedom to work, learn and engage actlvely
ln famlly and communlty llfe.
4 cBr gUIdelInes > 2: health comPonent
ß0X 2
Khurshlda was born deafbllnd ln a small vlllage of 8arabankl Dlstrlct, ln Uttar Pradesh, |ndla.
when Satyabhama, a C8P worker tralned by Sense |nternatlonal |ndla, met her, Khurshlda
was :o years old and had spent most of her llfe lylng ln a dark corner of the famlly home
completely lsolated from her communlty. She was completely dependent on her mother
for all her needs and was unable to communlcate. Satyabhama worked hard wlth Khurshlda
to teach her dally llvlng and communlcatlon skllls. Khurshlda began to respond posltlvely
by slttlng up, eatlng meals wlth her famlly and playlng wlth toys. She began to learn the
language of touch, dlscoverlng that by pulllng at her mother’s sarl lt would make her stay
a llttle whlle longer. wlth tlme, Satyabhama was able to take Khurshlda by the hand and
encourage her to take her ñrst steps outslde the famlly home. She may not have heard the
blrds slng or seen the sun, but the expresslon on her face showed that she loved the feel of
the gentle fresh breeze agalnst her face. The C8P programme was able to help Khurshlda’s
famlly obtaln a dlsablllty certlñcate for her, whlch enabled access to a wlde range of servlces.
The programme also asslsted Khurshlda’s mother to access treatment for tuberculosls.
Satyabhama contlnues to work wlth Khurshlda and ls now teachlng her slgn language. |t wlll
be a long ìourney for Khurshlda and her famlly, but wlth the support of the C8P programme
they are worklng towards the full lncluslon of Khurshlda ln the llfe of her communlty.
Khurshida
|ndla |ndla
Determinants of health
A person’s health status ls lnnuenced by a wlde range of personal, economlc, soclal and
envlronmental factors. These factors are commonly referred to as determlnants of health
and are outllned below (adapted from (8)).

Genetlcs – lnherltance plays a part ln determlnlng the llfespan, healthlness and the
llkellhood of developlng certaln lllnesses.

|ndlvldual behavlours and llfestyle – dlet, actlvlty, smoklng, drlnklng and how we deal
wlth llfe’s stresses all anect health.

|ncome and soclal status – the greater the gap between rlch and poor people, the
greater the dlnerences ln health.

Lmployment and worklng condltlons – people ln employment are healthler, partlcu-
larly those who have more control over thelr worklng condltlons.

Lducatlon – low educatlon levels are llnked wlth poor health, more stress and lower
self-conñdence.

Soclal support networks – greater support from famllles, frlends and communltles ls
llnked to better health.

Culture – customs and tradltlons and the bellefs of the famlly and communlty all
anect health.

Gender – men and women suner from dlnerent types of dlseases at dlnerent ages.
PreamBle 5

Physlcal envlronment – safe water and clean alr, healthy workplaces, safe houses, com-
munltles and roads, all contrlbute to good health.

Health servlces – access to and use of servlces lnnuence health.
Some of these factors can be controlled, e.g. a person can choose healthy or unhealthy
behavlour. However other factors, such as genetlcs, cannot be controlled.
Disability and health
Health for All was a global health obìectlve set by wHO durlng the l978 prlmary health
care conference ln Alma-Ata. Thlrty years later, communltles globally have yet to achleve
thls obìectlve and many groups of people, lncludlng people wlth dlsabllltles, stlll experl-
ence poorer states of health than others.
To ensure that people wlth dlsabllltles achleve good levels of health lt ls lmportant to
remember that:

people wlth dlsabllltles need health servlces for general health-care needs (e.g. health
promotlon and preventlon servlces and medlcal care) llke the rest of the populatlon,
lncludlng dlnerent needs ln dlnerent phases of llfe:

whlle not all people wlth dlsabllltles have health problems related to thelr lmpalr-
ments, many wlll requlre speclñc health-care servlces, lncludlng rehabllltatlon, on a
regular or occaslonal basls and for llmlted or llfelong perlods.
Health care
Health-care provision
Health care wlthln each country ls provlded through the health system, whlch comprlses
all those organlzatlons, lnstltutlons, resources and people whose prlmary purpose ls to
promote, restore or malntaln health. whlle ultlmate responslblllty for the health system
lles wlth the government, most health care ls provlded by a comblnatlon of publlc, prl-
vate, tradltlonal and lnformal sectors (9).
The 2008 world Health Peport emphaslzes the essentlal role of prlmary health care ln
achlevlng health for every person (10). Prlmary health care ls essentlal heath care made
unlversally accesslble to lndlvlduals and famllles at a cost they can anord. |t ls the ñrst
level of contact wlth the natlonal health system for lndlvlduals, famllles and communl-
tles and brlngs health care as close as posslble to where people llve and work (11).
Barriers to health-care services for people with disabilities
The poor health that people wlth dlsabllltles may experlence ls not necessarlly a dlrect
result of havlng a dlsablllty. |nstead lt can be llnked to dlmcultles ln accesslng servlces
and programmes (12). |t ls estlmated that only a small percentage of people wlth dls-
abllltles ln low-lncome countrles have access to rehabllltatlon and approprlate baslc
6 cBr gUIdelInes > 2: health comPonent
servlces (5). The barrlers to health-care servlces that people wlth dlsabllltles and thelr
famlly members may face lnclude:

absent or lnapproprlate pollcles and leglslatlon – where pollcy and leglslatlon do exlst,
they may not be lmplemented or enforced and can be dlscrlmlnatory and/or obstruc-
tlve regardlng the provlslon of health servlces to people wlth dlsabllltles:

economlc barrlers – health lnterventlons such as assessments, treatments and medl-
catlons often requlre out-of-pocket payments, presentlng dlmcultles for people wlth
dlsabllltles and thelr famllles who are llkely to have llmlted lncome for health care (see
|ntroductlon: Poverty and dlsablllty):

physlcal and geographlcal barrlers – lack of accesslble transport and lnaccesslble
bulldlngs and medlcal equlpment are examples of common barrlers, as well as the
llmlted health-care resources of rural areas (where many people wlth dlsabllltles llve)
and the long dlstances to reach servlces ln blg cltles:

communlcatlon and lnformatlon barrlers – communlcatlng wlth health workers may
be dlmcult, e.g. a person who ls deaf mlght ñnd lt dlmcult to communlcate hls/her
symptoms to a doctor and health lnformatlon ls often not avallable ln accesslble for-
mats, such as plcture formats for people wlth lntellectual lmpalrment:

poor attltudes and knowledge of health workers about people wlth dlsabllltles –
health personnel may have lnapproprlate attltudes, be preìudlced or lnsensltlve and
lack awareness and often lack the knowledge, understandlng and skllls to manage
health lssues for people wlth dlsabllltles:

poor knowledge and attltudes of people wlth dlsabllltles about general health care
and servlces – people wlth dlsabllltles may be reluctant to use health servlces: many
also have llmlted knowledge about thelr rlghts and health lssues and about what
health servlces are avallable.
Some people wlth dlsabllltles may be more vulnerable to dlscrlmlnatlon and excluslon
than others. They may suner double or multlple dlsadvantages, for example due to the
type of dlsablllty they have, thelr age, gender and/or soclal status (13) and so ñnd lt more
dlmcult to access health-care servlces. C8P programmes should be partlcularly mlndful
of the followlng groups: women, chlldren and older people wlth dlsabllltles: people wlth
multlple lmpalrments e.g. those who are both deaf and bllnd, or who have lntellectual
lmpalrments, dlsabllltles and H|v/A|DS, mental health problems, leprosy, or alblnlsm
(see Supplementary chapters).
Inclusive health
“|ncluslve educatlon” has become a wldely recognlzed concept and ls lncreaslngly belng
lmplemented ln educatlon systems throughout the world. |t refers to educatlon that
welcomes all people, lncludlng those wlth dlsabllltles, to partlclpate fully ln regular com-
munlty schools or centres of learnlng (14) (see Lducatlon component). Slmllarly, the
concept of lncluslve health ls now belng promoted by C8P programmes to ensure health
PreamBle 7
systems recognlze and accom-
modate the needs of people wlth
dlsabllltles ln thelr pollcles, plannlng
and servlces dellvery. |t bullds on
the prlmary health care “Health for
All” concept, that health care should
be “…accesslble to lndlvlduals and
famllles ln the communlty through
thelr full partlclpatlon and at a cost
that the communlty and the country
can anord…” (11).
|ncluslve health means that all lndlvlduals can
access health care lrrespectlve of lmpalrment, gender, age, colour, race, rellglon and
socloeconomlc status. To ensure thls, health-care servlce provlders need to have posltlve
attltudes towards dlsablllty and people wlth dlsabllltles and have approprlate skllls, e.g.
communlcatlon skllls to accommodate the needs of people wlth dlnerent lmpalrments.
The whole envlronment needs to change so that nobody ls actlvely, or passlvely, dls-
crlmlnated agalnst: one way of achlevlng thls ls by ensurlng that people wlth dlsabllltles
and dlsabled people’s organlzatlons (DPOs) are actlve partlclpants ln the plannlng and
strengthenlng of health-care and rehabllltatlon servlces.
ß0X 3
Muhammad Akram ls from Slndh Provlnce, Paklstan. He became deaf as a teenager due
to an lllness. The followlng anecdote descrlbes hls experlence of vlsltlng a doctor wlth hls
famlly. “8elng deaf | was always unaware of what they were talklng about. |f | asked the
doctor a questlon he usually replled that he had told my famlly everythlng. And lf | asked
my famlly a questlon they always sald “don’t worry, nothlng speclal” or “we wlll tell you
later”. Nobody really told me anythlng – | ìust had to take the tablets. No-one used slgn
language and nobody had the tlme or wllllngness to communlcate wlth me uslng pen and
paper. Over tlme | began to lose my conñdence and became very dependent on others.
After ìolnlng a C8P programme | slowly galned conñdence and developed the courage
to face the challenges myself. | started refuslng to take a famlly member wlth me to the
doctor. Thls forced the doctor to communlcate wlth me dlrectly ln wrltlng. Some doctors
stlll ask me to brlng someone wlth me on my next vlslt but | always tell them that | am an
adult. | feel good as | have developed self-conñdence and have also helped to ralse the
proñle of dlsablllty by educatlng medlcal professlonals.”
Paklstan Paklstan
The courage to overcome barriers
8 cBr gUIdelInes > 2: health comPonent
CBR and the health sector
C8P programmes can facllltate access to health care for people wlth dlsabllltles by work-
lng wlth prlmary health care ln the local communlty, provldlng the much needed llnk
between people wlth dlsabllltles and the health-care system. |n many countrles, e.g.
Argentlna, |ndonesla, Mongolla and vlet Nam, C8P programmes are dlrectly llnked wlth
the health-care system – they are managed by the mlnlstry of health and lmplemented
through thelr prlmary health care structures. |n other countrles, C8P programmes are
managed by nongovernmental organlzatlons or other government mlnlstrles, e.g. soclal
welfare, and ln these sltuatlons close contact must be malntalned wlth prlmary health
care to ensure that people wlth dlsabllltles can access health care and approprlate reha-
bllltatlon servlces as early as posslble.
Elements in this component
C8P programmes recognlze, support and advocate a number of key aspects of health
care for people wlth dlsabllltles. These are conslstent wlth best practlce (5,15) and are
outllned below.
Health promotion
Health promotlon alms to lncrease control over health and lts determlnants. The wlde
range of strategles and lnterventlons avallable are dlrected at strengthenlng the skllls
of lndlvlduals and changlng soclal, economlc and envlronmental condltlons to allevlate
thelr lmpacts on health.
Prevention
Preventlon ls very closely llnked wlth health promotlon. Preventlon of health condltlons
(e.g. dlseases, dlsorders, lnìurles) lnvolves prlmary preventlon (avoldance), secondary
preventlon (early detectlon and early treatment) and tertlary preventlon (rehabllltatlon)
measures. The focus of thls element ls malnly on prlmary preventlon.
Medical care
Medlcal care refers to the early ldentlñcatlon, assessment and treatment of health con-
dltlons and thelr resultlng lmpalrments, wlth the alm of curlng or llmltlng thelr lmpacts
on lndlvlduals. Medlcal care can take place at the prlmary, secondary or tertlary level of
the health-care system.
Rehabilitation
Pehabllltatlon ls a set of measures whlch enables people wlth dlsabllltles to achleve and
malntaln optlmal functlonlng ln thelr envlronments: lt ls relevant both for those who
PreamBle 9
acqulre dlsabllltles durlng thelr llfetlme and for those who have dlsabllltles from blrth.
Pehabllltatlon servlces range from the baslc to the speclallzed and are provlded ln many
dlnerent locatlons e.g. hospltals, homes and communlty envlronments. Pehabllltatlon
ls often lnltlated by the health sector but requlres collaboratlon between all sectors.
Assistive devices
A devlce that has been deslgned, made or adapted to asslst a person to perform a par-
tlcular task ls known as an asslstlve devlce. Many people wlth dlsabllltles beneñt from the
use of one or more asslstlve devlces. Some common types of asslstlve devlces are: mobll-
lty devlces (e.g. walklng stlcks, wheelchalrs), prostheses (e.g. artlñclal legs), orthoses (e.g.
hand spllnt), vlsual devlces (e.g. glasses, whlte canes) and hearlng devlces (hearlng alds).
To ensure that asslstlve devlces are used enectlvely, lmportant aspects of thelr provl-
slon lnclude user educatlon, repalr, replacement and envlronmental adaptatlons ln the
home and communlty.
health PromotIon ll
Health promotion
Introduction
The Ottawa Charter for Health Promotlon (l986) descrlbes health promotlon as the pro-
cess of enabllng people to lncrease control over and to lmprove, thelr health (16).
Health promotlon focuses on addresslng those determlnants of health that can poten-
tlally be modlñed, such as lndlvldual health behavlours and llfestyles, lncome and soclal
status, educatlon, employment and worklng condltlons, access to approprlate health
servlces and the physlcal envlronment (17). Health promotlon does not requlre expen-
slve drugs or elaborate technology: lnstead lt uses soclal lnterventlons, whlch, at the
most baslc level, requlre a personal lnvestment of tlme and energy (18), e.g. health pro-
motlon campalgns.
The health potentlal of people wlth dlsabllltles ls frequently overlooked and as a result
they are often excluded from health promotlon actlvltles. Thls element ls about the
lmportance of health promotlon for people wlth dlsabllltles. |t provldes suggestlons for
C8P programmes on how to facllltate access to health promotlon actlvltles for people
wlth dlsabllltles and how to lmplement baslc actlvltles where necessary. |t ls lmportant to
remember that as health promotlon focuses on changlng a wlde range of determlnants
of health, lt lnvolves many dlnerent sectors, and not ìust the health sector.
l2 cBr gUIdelInes > 2: health comPonent
ß0X 4
|n some Afrlcan cultures, alblnlsm ls belleved to be a result of a mother havlng a “sexual
relatlonshlp” wlth evll splrlts durlng pregnancy. Havlng a chlld wlth alblnlsm ls consldered
lmmoral, and both the famlly and chlld are subìect to dlscrlmlnatlon and stlgmatlzatlon
wlthln thelr communltles. Chlldren wlth alblnlsm remaln hldden and thelr fundamental
human rlghts are denled, lncludlng thelr rlght to health.
Kwale Dlstrlct Lye Centre (KDLC) ln Kenya has a C8P programme whlch focuses on
allevlatlng dlscrlmlnatlon and stlgmatlzatlon towards chlldren wlth alblnlsm ln thelr homes,
schools and communlty envlronments. To ensure these chlldren achleve thelr hlghest
attalnable standards of health, the C8P programme uses a varlety of health promotlon
actlvltles and lnterventlons lncludlng:
• sensltlzlng communlty members and communlty leaders, vlllage health commlttees,
school teachers and women’s groups, to brlng about changes ln perceptlons, attltudes
and treatment of people wlth alblnlsm:
• educatlng parents so that they are able to promote and protect thelr chlld’s health, e.g.
as people wlth alblnlsm are at rlsk of sun damage, KDLC provldes educatlon about the
lmportance of uslng sunscreen and protectlve clothlng, such as long-sleeved shlrts and
trousers:
• formlng partnershlps wlth local hotels to encourage guests to donate sunscreen and
unwanted ltems of clothlng before they leave, whlch can be glven to those ln need:
• conductlng eye assessments to detect vlsual lmpalrments, whlch are common among
people wlth alblnlsm, and provldlng glasses and low-vlslon devlces where requlred.
The success of thls
C8P programme ls
llnked to the strong
worklng relatlonshlp
that KDLC has developed
wlth both the health and
the educatlon sectors.
Chlldren wlth alblnlsm
are now lntegrated
lnto malnstream
schools.
Overcoming stigma and prejudice
Kenya Kenya
health PromotIon l3
Goal
The health potentlal of people wlth dlsabllltles and thelr famllles ls recognlzed and they
are empowered to enhance and/or malntaln exlstlng levels of health.
The role of CBR
The role of C8P ls to ldentlfy health promotlon actlvltles at a local, reglonal and/or
natlonal level and work wlth stakeholders (e.g. mlnlstrles of health, local authorltles)
to ensure access and lncluslon for people wlth dlsabllltles and thelr famlly members.
Another role ls to ensure that people wlth dlsabllltles and thelr famllles know the lmpor-
tance of malntalnlng good health and encourage them to actlvely partlclpate ln health
promotlng actlons.
Desirable outcomes

People wlth dlsabllltles and thelr famllles are reached by the same health promotlon
messages as are members of the general communlty.

Health promotlon materlals and programmes are deslgned or adapted to meet the
speclñc needs of people wlth dlsabllltles and thelr famllles.

People wlth dlsabllltles and thelr famllles have the knowledge, skllls and support to
asslst them to achleve good levels of health.

Health-care personnel have lmproved awareness about the general and speclñc
health needs of people wlth dlsabllltles and respond to these through relevant health
promotlon actlons.

The communlty provldes a supportlve envlronment for people wlth dlsabllltles to
partlclpate ln actlvltles whlch promote thelr health.

C8P programmes value good health and undertake health-promotlng actlvltles ln
the workplace for thelr stan.
l4 cBr gUIdelInes > 2: health comPonent
Key concepts
Health promotion for people with disabilities
Health promotlon ls often vlewed as a strategy to prevent health condltlons: lt ls not
often assoclated wlth people wlth dlsabllltles because dlsablllty ls vlewed as a conse-
quence of not utlllzlng health promotlon (19). A person wlth paraplegla as a result of
splnal cord lnìury, for example, may not be consldered a good candldate for health pro-
motlon as her/hls health has already been anected by lnìury.
Many people wlth dlsabllltles have as much need for health promotlon as does the gen-
eral populatlon, lf not more (3). People wlth dlsabllltles are at rlsk of the same health
condltlons as people ln the general populatlon but they may also have addltlonal health
problems due to greater susceptlblllty to health condltlons (related or not to thelr dls-
abllltles) (20). Often, people wlth dlsabllltles and thelr famlly members have very llttle
awareness of how to achleve or malntaln good health.
Barriers to health promotion
People wlth dlsabllltles often experlence poorer levels of health than the general popu-
latlon because of the many barrlers they face when trylng to lmprove thelr health (see
above: 8arrlers to health-care servlces for people wlth dlsabllltles). Deallng wlth these
barrlers wlll make lt easler for people wlth dlsabllltles to partlclpate ln health promo-
tlon actlvltles.
Health promotion for family members
Many people wlth dlsabllltles requlre support from others, partlcularly famlly members.
Pamlly members may experlence problems related to the care of people wlth dlsabllltles
lncludlng stress-related physlcal and emotlonal lllness, reduced ablllty to care for other
chlldren, reduced tlme and energy for work, reduced soclal lnteractlon and stlgmatlza-
tlon (21). Malntalnlng the health of famlly members ls essentlal (see Soclal component:
Personal asslstance).
Health promotion action
The Ottawa Charter for Health Promotlon outllnes ñve areas for actlon whlch can be used
to help develop and lmplement health promotlon strategles (16).
l. Build healthy public policy
Develop leglslatlon and regulatlons across all sectors whlch protect the health of
communltles by ensurlng safer and healthler goods and servlces, healthler publlc
servlces and cleaner, more enìoyable envlronments.
health PromotIon l5
2. Create supportive environments for health
Make changes ln the physlcal and soclal envlronments to ensure that llvlng and work-
lng condltlons are safe, stlmulatlng, satlsfylng and enìoyable.
3. Strengthen communities
Adopt communlty approaches to address those health problems that have strong
envlronmental, socloeconomlc and polltlcal components. Lmpower communltles
to set prlorltles, make declslons and plan and lmplement strategles to achleve bet-
ter health.
4. Develop personal skills
Develop people’s skllls by provldlng lnformatlon and health educatlon to enable
them to exerclse more control over thelr health and envlronment and make better
cholces to lmprove thelr health status.
5. Reorient health services
The health sector must move lncreaslngly towards health promotlon, beyond lts
responslblllty of provldlng cllnlcal and curatlve servlces.
Health promotlon strategles can be applled to dlnerent:

populatlon groups, e.g. chlldren, adolescents, older adults

rlsk factors, e.g. smoklng, physlcal lnactlvlty, poor dlet, unsafe sex

health or dlsease prlorltles, e.g. dlabetes, H|v/A|DS, heart dlsease, oral health

settlngs, e.g. communlty centres, cllnlcs, hospltals, schools, workplaces.
|ndlvlduals have enormous potentlal to lnnuence thelr own health outcomes and par-
tlclpatory approaches ln health promotlon are lmportant as they allow people to exert
greater control over the factors whlch anect thelr health. Health lssues need to be
addressed through worklng wlth others rather than by dolng thlngs for them.
Suggested activities
Health promotlon actlvltles are very dependent on local lssues and prlorltles, so the
actlvltles outllned here are general suggestlons only. C8P programmes need to develop
a good understandlng of the communltles ln whlch they work by maklng contact wlth
communlty members and groups already worklng towards lncreased control over the
factors whlch anect thelr health.
Support health promotion campaigns
Health promotlon campalgns can posltlvely lnnuence the health of lndlvlduals, commu-
nltles and populatlons – they can lnform, encourage and motlvate behavlour change.
C8P programmes can promote better health for people wlth dlsabllltles by:

ldentlfylng exlstlng health promotlon campalgns operatlng at communlty, reglonal
or natlonal level and ensurlng that people wlth dlsabllltles are actlvely targeted and
lncluded ln these campalgns:
l6 cBr gUIdelInes > 2: health comPonent

actlvely partlclpatlng ln health promotlon campalgns and assoclated events, ralslng
the proñle and awareness of dlsablllty:

encouraglng health promotlon campalgns to show posltlve lmages of people wlth
dlsabllltles, e.g. by deplctlng people wlth dlsabllltles on posters and blllboards for
messages lntended to reach the entlre populatlon:

ensurlng exlstlng health promotlon campalgns utlllze approprlate formats for peo-
ple wlth dlsabllltles, e.g. that publlc servlce announcements are adapted for the deaf
communlty wlth text captlonlng and slgn language lnterpretatlon:

ldentlfylng exlstlng resources wlthln the communlty
(e.g. communlty spokespersons, newspapers, radlo,
televlslon) and encouraglng them to lncrease thelr cov-
erage of dlsablllty-related health lssues – lt ls lmportant
to ensure that any coverage ls respectful of the rlghts and
dlgnlty of people wlth dlsabllltles:

supportlng the development of local health promotlon cam-
palgns to address dlsablllty-related lssues that are not covered
by exlstlng campalgns.
Strengthen personal knowledge and skills
Health lnformatlon and educatlon enables people wlth dlsabllltles and thelr famllles
to bulld the knowledge and llfe skllls necessary for malntalnlng and lmprovlng thelr
health. They can learn about dlsease rlsk factors, good hyglene, healthy eatlng cholces,
the lmportance of physlcal actlvlty and other protectlve factors through structured ses-
slons (lndlvldual or small group). C8P personnel can:

vlslt people wlth dlsabllltles and thelr famllles ln thelr homes and talk about how to
malntaln a healthy llfestyle, glvlng practlcal suggestlons:

collect health promotlon materlals (e.g. booklets, brochures) and dlstrlbute them to
people wlth dlsabllltles and thelr famllles:

adapt or develop health promotlon materlals to make them accesslble to people wlth
dlsabllltles, e.g. people wlth an lntellectual dlsablllty wlll requlre materlals that are
slmple and stralghtforward wlth baslc language and relevant plctures:

lnform people wlth dlsabllltles and thelr famllles about local health promotlon pro-
grammes and servlces that wlll enable them to acqulre new knowledge and skllls to
remaln healthy:

develop speclñc educatlon sesslons, lf necessary, for people wlth dlsabllltles whose
needs are not belng met by those targetlng the general communlty:

ensure that a wlde range of teachlng methods and materlals are used ln educatlon
sesslons to relnforce learnlng and understandlng, e.g. games, role plays, practlcal dem-
onstratlons, dlscusslons, storytelllng, problem-solvlng exerclses:

focus on asslstlng people wlth dlsabllltles and thelr famllles to become assertlve and
conñdent ln the presence of health-care provlders to enable them to ask questlons
and make declslons about thelr health:

provlde tralnlng for lndlvlduals wlth dlsabllltles, ln partnershlp wlth the health sector,
to enable them to become health promotlon educators.
health PromotIon l7
Link people to self-help groups
Self-help groups enable people to come together ln small numbers to share common
experlences, sltuatlons or problems wlth each other (see Lmpowerment component:
Self-help groups). Por many people the opportunlty to recelve support and practlcal
advlce from someone else who has a slmllar problem ls more useful than recelvlng
advlce from a health worker (22). Self-help groups are mentloned throughout thls com-
ponent because they can contrlbute to better health for people wlth dlsabllltles and
thelr famlly members. C8P programmes can:

connect people wlth dlsabllltles and thelr famllles to exlstlng self-help groups ln thelr
communltles to meet thelr speclñc health needs, e.g. groups of people wlth splnal
cord lnìurles, or anected by leprosy, or llvlng wlth H|v/A|DS, or who are parents of
chlldren anected by cerebral palsy:

encourage people wlth slmllar experlences of dlsablllty to come together to form
new self-help groups where sultable groups do not already exlst – ln small vlllages, lt
may be dlm cult to establlsh such a group and l:l support from a peer may be more
approprlate:

encourage self-help groups, ln partnershlp wlth others, to partlclpate actlvely ln
health-promotlng actlvltles ln thelr communltles, e.g. by organlzlng health camps
and observlng world Health Day, world Mental Health Day and the |nternatlonal Day
of Persons wlth Dlsabllltles.
ß0X S
wlth the support of a C8P programme ln Pledecuesta, Colombla, a group of people wlth
splnal cord lnìurles formed a self-help group. They felt they had been glven lnadequate
health lnformatlon – regardlng self-care, preventlon of ulcers and urlnary problems – ln the
hospltals where they were treated. Lxperlenced members of the group were supportlve of
new members who had recently acqulred a splnal
cord lnìury and helped them to develop
ways of coplng by showlng them how
to use thelr resldual abllltles and
asslstlve devlces. The C8P
programme organlzed an
lnteractlve sesslon wlth hospltal
speclallsts durlng whlch group
members could ask questlons to
clarlfy thelr doubts.
Managing health through self-help groups
Colombla Colombla
l8 cBr gUIdelInes > 2: health comPonent
Educate health-care providers
Health-care provlders are a trusted source of health-related lnformatlon and have the
potentlal to posltlvely lnnuence the health of others. C8P programmes need to work wlth
these provlders to ensure they have adequate knowledge about dlsablllty and lnclude
people wlth dlsabllltles ln all thelr health promotlon actlvltles.
|t ls suggested that C8P programmes:

orlent health workers (e.g. prlmary health care personnel) towards dlsablllty and
lnform them of the challenges faced by people wlth dlsabllltles and thelr famllles:

help health workers understand the lmportance of communlcatlng wlth people wlth
dlsabllltles ln a respectful and nondlscrlmlnatory manner and provlde them wlth prac-
tlcal demonstratlons to facllltate learnlng:

show health professlonals how they can make slmple adaptatlons to lnterventlons to
ensure that thelr health messages are understood:

encourage health professlonals to use a varlety of medla and technologles when plan-
nlng and developlng health lnformatlon and programmes for people wlth dlsabllltles.
Create supportive environments
C8P programmes can work wlth communlty health centres, hospltals, schools, worksltes
and recreatlonal facllltles and wlth key stakeholders to create supportlve physlcal and
soclal envlronments for people wlth dlsabllltles, as well as to enable them to achleve
optlmal health by:

ensurlng that envlronments promote healthy llfestyles and that speclñc health pro-
motlon programmes and servlces are physlcally accesslble for people wlth dlsabllltles:

creatlng partnershlps between urban, soclal and health planners and people wlth dls-
abllltles to create and lmprove physlcal and archltectural accesslblllty:

creatlng opportunltles to enable people wlth dlsabllltles to partlclpate ln recreatlonal
actlvltles, e.g. support wheelchalr users to organlze a wheelchalr football match at a
local sports faclllty (see Soclal component: Pecreatlon, lelsure and sport):
ß0X 6
C8P programmes can work wlth dlsabled people’s organlzatlons to develop approprlate
educatlon materlals and methods to lnform people who are bllnd or who have low vlslon
about H|v/A|DS and to lnform health-care servlces about the speclñc needs of thls group.
Por example the Afrlcan 8llnd Unlon produced a “traln the tralner” manual on H|v/A|DS to
facllltate the lncluslon and partlclpatlon of bllnd and partlally slghted persons ln H|v/A|DS
educatlon programmes.
Train the trainer
Afrlca Afrlca
health PromotIon l9

ensurlng accesslble and safe publlc transport, because problems wlth transport can
cause people wlth dlsabllltles to face lsolatlon, lonellness and soclal excluslon:

addresslng, through educatlon and tralnlng, any mlsconceptlons, negatlve attltudes
and stlgma that exlst wlthln the health sector and communlty towards people wlth
dlsabllltles and thelr famllles:

organlzlng cultural events to address problematlc health lssues wlthln the communlty
through dance, drama, songs, ñlms and puppet shows.
ß0X 7
A C8P programme ln Alexandrla (Lgypt) organlzes an annual summer camp where chlldren
wlth dlsabllltles, thelr famllles and communlty volunteers go together for group holldays.
The emphasls ls on spendlng lelsure tlme together, lmprovlng
health status, playlng and enìoylng belng together as a larger
famlly or group of frlends. The C8P programme also
collaborates wlth the local Paralymplcs commlttee,
parents’ organlzatlons and dlsabled people’s
organlzatlons to organlze an annual sports day ln the
clty stadlum.
Healthy lifestyles
Lgypt Lgypt
Become a health promoting organization
Health promotlon wlthln workplaces has the capaclty to lmprove stan morale and skllls,
ìob performance and, ultlmately, health. Organlzatlons that lmplement C8P programmes
should focus on promotlng the health of thelr stan by:

provldlng tralnlng and educatlon to all stan, regardless of the level at whlch they work,
on ways to lmprove and malntaln thelr health:

provldlng a safe and healthy envlronment, e.g. a nonsmoklng envlronment, healthy
meals, safe water and sanltary facllltles, reasonable worklng hours, safe transport
optlons:

developlng pollcles and practlces wlthln the organlzatlon whlch promote health, e.g.
pollcles agalnst dlscrlmlnatlon, preìudlce and stlgma, harassment, as well as tobacco,
drug and alcohol use:

encouraglng stan to be good role models ln thelr communltles, settlng good exam-
ples for others by adoptlng healthy behavlours.
PreventIon 2l

Prevention
Introduction
The maln focus of preventlon ln health care ls to stop health condltlons from occurrlng
(prlmary preventlon). However, preventlon also lnvolves early detectlon and treatment
to stop the progresslon of a health condltlon (secondary preventlon) and management
to reduce the consequences of an exlstlng health condltlon (tertlary preventlon). Thls
element malnly focuses on primary preventlon.
Prlmary preventlon may lnclude: prlmary health care: prenatal and postnatal care:
educatlon ln nutrltlon: lmmunlzatlon campalgns agalnst communlcable dlseases: meas-
ures to control endemlc dlseases: safety regulatlons: programmes for the preventlon
of accldents ln dlnerent envlronments, lncludlng adaptatlon of workplaces to prevent
occupatlonal lnìury and dlseases: and preventlon of dlsablllty assoclated wlth pollutlon
of the envlronment or armed connlct (23).
|t ls estlmated that, through better use of prlmary preventlon and health promotlon, the
global burden of dlsease could be reduced by as much as 70% (10). Lven so, lt ls com-
monly belleved that preventlon (as for health promotlon) has llttle, lf any, role ln the
management of health for people wlth dlsabllltles.
Health care for people wlth dlsabllltles usually focuses on speclallzed medlcal care and
rehabllltatlon. However, as prevlously mentloned, people wlth dlsabllltles are at rlsk of
other health condltlons and also at rlsk of secondary condltlons resultlng from thelr prl-
mary health condltlons (24).
1ust llke health promotlon, preventlon requlres the lnvolvement of many dlnerent sec-
tors. wlthln the health sector, prlmary health care plays an lmportant role and slnce C8P
programmes are most closely
llnked wlth prlmary health
care, they can play a
slgnlñcant role ln pro-
motlng and support-
lng preventlve health
care for people wlth
dlsabllltles.
22 cBr gUIdelInes > 2: health comPonent
BOX
In Chamarajnagar, one of the poorest districts of Karnataka, India, the quality of life is very
poor, particularly for people with disabilities. While Mobility India (MI), a nongovernmental
organization, were carrying out a CBR project with the support of Disability and
Development Partners UK, they discovered that many community members did not have
access to basic sanitation facilities. Most people travelled far from their houses to use open
felds. This was very dif cult for people with disabilities, and more so for women with
disabilities.
The Indian Government ofered grants to families to construct toilets and MI assisted
people with disabilities and their families in Chamarajnagar to construct accessible toilets.
Using existing community-based networks and self-help groups (SHG) to assist with
this new project, MI organized street plays and wall paintings to raise awareness about
hygiene and the role proper sanitation plays in preventing health problems. As people
became interested and motivated, MI agreed to work with them to facilitate access to
basic sanitation.
Government ofered a grant to each family, funding the remaining amount was dif cult
for most people, particularly people with disabilities. With fnancial support from MIBLOU,
Switzerland and local contributions, MI was able to construct  good quality accessible
toilets. SHG members were asked to select poor households with disabled family members
who had the greatest need for a toilet. They also coordinated the construction work in
partnership with families and ensured proper use of funds.
Many people with disabilities no longer need to crawl or be carried long distances for
their toileting needs. They have become independent and, importantly, have been able
to reclaim their dignity. Their risk of developing health conditions associated with poor
sanitation has also signifcantly reduced. Seeing the success of the MI project, the Indian
Government has since increased the amount of the grant and directed local authorities to
release these funds immediately.
People with and without
disabilities are benefting
from this project, and it is
gradually being scaled up to
become a district-level project.
Chamarajnagar will soon
become a district where people
have toilets in their houses, or at
least near to their homes.
Living with dignity
India India
The total cost to construct one toilet was an estimated US$ . While the Indian
PreventIon 23
Goal
People wlth dlsabllltles are less llkely to develop health condltlons, related or unrelated
to thelr lmpalrments, that anect thelr functlonlng and overall health and well-belng: and
famlly members and other communlty members are less llkely to develop health condl-
tlons and lmpalrments assoclated wlth dlsablllty.
The role of CBR
The role of C8P ls to ensure that communltles and relevant development sectors focus
on preventlon actlvltles for people both wlth and wlthout dlsabllltles. C8P programmes
provlde support for people wlth dlsabllltles and thelr famllles to ensure they can access
servlces that promote thelr health and prevent the development of general health con-
dltlons or secondary condltlons (compllcatlons).
Desirable outcomes

People wlth dlsabllltles and thelr famllles have access to health lnformatlon and serv-
lces almed at preventlng health condltlons.

People wlth dlsabllltles and thelr famllles reduce thelr rlsk of developlng health prob-
lems by taklng up and malntalnlng healthy behavlours and llfestyles.

People wlth dlsabllltles are lncluded and partlclpate ln prlmary preventlon actlvltles,
e.g. lmmunlzatlon programmes, to reduce thelr rlsk of developlng addltlonal health
condltlons or lmpalrments.

All communlty members partlclpate ln prlmary preventlon actlvltles, e.g. lmmunlza-
tlon programmes, to reduce thelr rlsk of developlng health condltlons or lmpalrments
whlch can lead to dlsablllty.

C8P programmes collaborate wlth the health and other sectors, e.g. educatlon, to
address health lssues and provlde support and asslstance for preventlon actlvltles.
Key concepts
Risks to health
Plsk factors lnnuence a person’s health and determlne the llkellhood of lnìury, lllness
and dlsease. People everywhere are exposed to many health rlsks throughout thelr llves.
Some of the leadlng rlsk factors lnclude: belng underwelght: unsafe sex: hlgh blood pres-
sure: tobacco consumptlon: alcohol consumptlon: unsafe water, sanltatlon and hyglene:
lron deñclency: and lndoor smoke from solld fuels (25).
Preventlon actlvltles reduce the rlsks to health of lndlvlduals and communltles. whlle
some rlsk factors, e.g. famlly hlstory, are beyond a person’s control, others, e.g. llfe-
style and physlcal and soclal envlronments can be altered, potentlally malntalnlng and
24 cBr gUIdelInes > 2: health comPonent
lmprovlng health status. The health sector can play a slgnlñcant role ln addresslng these
rlsk factors.
Three levels of prevention
Preventlon lnterventlons can be at one of three levels.
l. Primary prevention – the phrase “preventlon ls better than cure” ls one that many
people are famlllar wlth and ls the focus of prlmary preventlon. Prlmary preventlon
ls dlrected at avoldance and uses lnterventlons that prevent health condltlons from
occurrlng (17). These lnterventlons are malnly almed at people (e.g. changlng health
behavlours, lmmunlzatlon, nutrltlon) and the envlronments ln whlch they llve (safe
water supplles, sanltatlon, good llvlng and worklng condltlons). Prlmary preventlon
ls equally lmportant for people wlth and wlthout dlsabllltles and ls the maln focus
of thls element.
2. Secondary prevention ls the early detectlon and early treatment of health condl-
tlons, wlth the alm of curlng or lessenlng thelr lmpacts. Lxamples of early detectlon
lnclude mammograms to detect breast cancer and eye examlnatlons to detect cat-
aracts: examples of early treatment lnclude treatment of trachoma wlth antlblotlcs
to prevent bllndness, multldrug treatment of leprosy to prevent dlsease progresslon
and approprlate handllng of a fractured bone to promote proper heallng and preven-
tlon of deformlty. Secondary preventlon strategles for people both wlth and wlthout
dlsabllltles are dlscussed ln the Medlcal care element below.
3. Tertiary prevention alms to llmlt or reverse the lmpact of already exlstlng health con-
dltlons and lmpalrments: lt lncludes rehabllltatlon servlces and lnterventlons that
alm to prevent actlvlty llmltatlons and to promote lndependence, partlclpatlon and
lncluslon. Tertlary preventlon strategles are dlscussed ln the elements on Pehablllta-
tlon and Asslstlve devlces.
Fig 1: Three levels of prevention
Tertlary
Secondary
Prlmary
PreventIon 25
ß0X 9
Anlta ls a <o year-old woman who llves ln Khandale vlllage, sltuated ln a hllly area of Palgad
Dlstrlct, Maharashtra, |ndla. One day Anlta sustalned a small lnìury to her rlght foot. She
qulckly developed paln ln her leg and after a few days lt turned black. Her son took her
to Allbaug Hospltal, :<km away, where they advlsed her to go to a speclallzed hospltal ln
Mumbal, :oo km away. Health personnel ln Mumbal lmmedlately dlagnosed Anlta wlth
dlabetes and amputated her rlght leg below the knee as lt had developed gangrene.
|mmedlately followlng surgery, Anlta’s famlly took her back to thelr vlllage as they could not
anord to stay ln the clty. Anlta was unable to walk so her son had to carry her on hls back.
The vlllage health worker lnformed Anlta and her famlly about a C8P programme that
provlded free health servlces for people who had lost a llmb. Anlta vlslted the C8P
programme at the health centre close to her vlllage. Her amputated stump was checked
to ensure proper heallng and her left leg/foot was assessed to check for early sensory and
clrculatlon changes. Anlta learnt about dlabetes and how to control the condltlon wlth
medlclne, regular exerclse and dlet. She has also learned about proper foot care to prevent
her left leg from belng amputated ln the future. Anlta was glven crutches and tralned ln
how to use them.
Later a team of health professlonals vlslted the health centre and ñtted Anlta wlth a
prosthesls and a good palr of shoes to ensure her left foot was protected from lnìury. She
was glven galt tralnlng to ensure she could walk properly wlth her prosthesls and C8P
personnel constructed parallel bars outslde her hut so she could practlse walklng wlth
her prosthesls at home. Gradually Anlta’s conñdence lmproved, untll she was able to walk
lndependently wlth her prosthesls and return to household tasks and work ln the ñelds.
She contlnues to take her medlcatlon on a regular basls and has regular health check-ups.
Anlta says that her quallty of llfe has lmproved and wlth the help of the C8P programme
and others she has succeeded ln preventlng further health compllcatlons as a result of
her dlabetes.
Anita stands tall
|ndla
What does prevention mean for people with disabilities?
Llke everybody, people wlth dlsabllltles are exposed to rlsk factors for whlch they requlre
routlne preventlve health care, e.g. lmmunlzatlons. However, they may also requlre tar-
geted and speclallzed lnterventlons because often they are more vulnerable to the
health rlsks present ln the communlty. Por example, ln sltuatlons of poverty people
wlth dlsabllltles have the least access to safe water and sanltatlon facllltles. Poor access
to these facllltles can force them to follow unhyglenlc practlces, puttlng thelr health at
rlsk and contrlbutlng to keeplng them poor and unable to lmprove thelr llvellhoods
26 cBr gUIdelInes > 2: health comPonent
(26). |n these sltuatlons, speclal facllltles or modlñcatlons may need to be provlded for
people wlth dlsabllltles.
People wlth dlsabllltles are also at rlsk of secondary condltlons (l.e. health problems or
compllcatlons whlch are related to thelr prlmary health condltlon). Lxamples lnclude:
pressure sores, urlnary tract lnfectlons, ìolnt contractures, paln, obeslty, osteoporosls
and depresslon. These secondary condltlons can be addressed wlth early lnterventlon
and many of them can be prevented altogether. Por example, a person wlth paraplegla
can prevent pressure sores wlth good skln care and prevent urlnary tract lnfectlons wlth
good bladder management.
ß0X 10
Handlcap |nternatlonal supported the establlshment of a Splnal Cord |nìury department
at a rehabllltatlon hospltal ln Ho Chl Mlnh Clty, vlet Nam. C8P personnel worklng ln
thls department were responslble for followlng up dlscharged patlents, wlth the alm of
preventlng secondary condltlons and ensurlng thelr home envlronments were wheelchalr-
accesslble. C8P personnel trled to ensure follow-up for all patlents, but due to llmlted
human resources and the large coverage area, only z<% of lndlvlduals were seen and often
those ln greatest need were mlssed. Medlcal and C8P personnel declded to lmplement
a new system whereby patlents were prlorltlzed – home vlslts were provlded for hlgh-
rlsk lndlvlduals and telephone calls and educatlon booklets were provlded for low-rlsk
lndlvlduals. As a result, the rehabllltatlon hospltal has seen a decrease ln readmlsslons. Thls
lnltlatlve has also proved to be more cost-enectlve and less stressful for C8P personnel.
Making home environments accessible
vlet Nam vlet Nam
What does prevention mean for people without disabilities?
Preventlon ls ìust as lmportant for people wlthout dlsabllltles as lt ls for those wlth dls-
abllltles. Many health condltlons assoclated wlth lmpalrment and dlsablllty can be
prevented, e.g. 80% of all bllndness ln adults ls preventable or treatable and approxl-
mately half of all chlldhood bllndness can be avolded by treatlng dlseases early and by
correctlng abnormalltles at blrth, e.g. cataract and glaucoma (27). The Plfty-elghth world
Health Assembly resolutlon on Disability, including prevention, management and reha-
bilitation (wHA58.23) (28) urges Member States to lncrease publlc awareness about the
lmportance of the lssue of dlsablllty and to coordlnate the enorts of all sectors to par-
tlclpate ln dlsablllty preventlon actlvltles.
Sensltlvlty ls requlred when promotlng programmes or lnltlatlves that are focused on
preventlng health condltlons and lmpalrments assoclated wlth dlsablllty because many
people wlthln the dlsablllty communlty may ñnd thls threatenlng or onenslve and vlew
lt as an attempt to prevent people wlth dlsabllltles from exlstlng. There should be no
PreventIon 27
connlct between preventlon lnterventlons that try to reduce dlsablllty-related health con-
dltlons and those that malntaln and lmprove the health of people wlth dlsabllltles (29).
Suggested activities
As preventlon ls closely assoclated wlth health promotlon and medlcal care, lt ls lmpor-
tant to note that there ls overlap between the suggested actlvltles mentloned ln all three
elements and lt ls suggested that all three be read together. The maln focus here ls on
prlmary preventlon actlvltles: vlolence and H|v are not lncluded, as they are addressed
ln the Soclal component and the Supplementary chapter on C8P and H|v/A|DS.
Facilitate access to existing prevention programmes
C8P programmes can gather lnformatlon about exlstlng preventlon actlvltles ln thelr
communltles and work wlth preventlon programmes to lnclude people wlth dlsabllltles,
thus ensurlng greater coverage. C8P programmes can:

ensure that people wlth dlsabllltles and thelr famllles are aware of
the types of preventlon actlvltles avallable ln thelr communltles:

ensure thathealth personnel are aware of the needs of people
wlth dlsabllltles:

ensure that lnformatlon about preventlon actlvltles ls avall-
able ln approprlate formats and ln a varlety of locatlons
close to where people llve:

determlne lf locatlons where preventlon actlvltles take
place are physlcally accesslble and lf not, provlde prac-
tlcal ldeas and solutlons to make them accesslble:

determlne whether preventlon servlces can be
provlded ln alternatlve locatlons, e.g. ln home envlron-
ments, when access ls dlm cult.
ß0X 11
A health centre run by a nongovernmental organlzatlon ln the Korogocho area of Nalrobl,
Kenya, was not wheelchalr-accesslble owlng to a number of steps. As a result, vacclnatlon
programmes were not accesslble for people wlth physlcal dlsabllltles (e.g. chlldren wlth
cerebral palsy), so health workers would dlrect famllles to a rehabllltatlon centre ln the clty.
The C8P programme organlzed a meetlng to dlscuss the lssue wlth health workers and a
slmple solutlon was ldentlñed whereby the health centre agreed to vacclnate chlldren wlth
dlsabllltles on the ground noor of the bulldlng.
Meeting the needs of wheelchair users
Kenya Kenya
28 cBr gUIdelInes > 2: health comPonent
Promote healthy behaviours and lifestyles
Healthy behavlours, such as not smoklng, drlnklng only small amounts of alcohol,
healthy eatlng, exerclslng regularly and wearlng condoms durlng sex, can reduce the
rlsk of developlng health problems. Preventlon programmes often use health promotlon
strategles to encourage healthy behavlours, e.g. awareness campalgns to communlcate
preventlon messages wlthln communltles and educatlon for lndlvlduals. See element on
Health promotlon for suggested actlvltles to promote good health behavlours.
Encourage immunization
wlthln each communlty, lmmunlzatlon programmes should be avallable for speclñc
dlseases and for hlgh-rlsk groups, e.g. pollomyelltls, dlphtherla, tetanus and measles vac-
clnatlons for lnfants and young chlldren and tetanus vacclnatlon for pregnant women.
C8P programmes can:

become actlvely lnvolved ln awareness campalgns to promote lmmunlzatlon for all
communlty members lncludlng people wlth dlsabllltles:

make contact wlth prlmary health care workers to educate them about the lmpor-
tance of lmmunlzatlon for people wlth dlsabllltles, especlally chlldren wlth dlsabllltles,
desplte exlstlng lmpalrments:

work wlth prlmary health-care servlces to ensure that people wlth dlsabllltles and thelr
famlly members are able to access vacclnatlon programmes ln thelr communltles:

ensure that people recelvlng support and asslstance from C8P programmes have
recelved the recommended lmmunlzatlons, e.g. chlldren wlth dlsabllltles, thelr broth-
ers and slsters, pregnant mothers of chlldren wlth dlsabllltles:

provlde lnformatlon about the locatlon of safe and reputable servlces for people who
have not recelved recommended lmmunlzatlons and support them to access these
servlces as necessary:

work wlth prlmary health-care servlces to make alternatlve arrangements for people
who are unable to access vacclnatlon programmes, e.g. chlldren wlth dlsabllltles who
are not attendlng school.
ß0X 12
The natlonal C8P programme ln Malaysla works very closely wlth prlmary health-care
servlces to ensure that people wlth dlsabllltles are able to access those actlvltles conducted
by prlmary health care personnel, lncludlng rubella lmmunlzatlon for young mothers and
lmmunlzatlon programmes for chlldren.
Saving young lives
Malaysla Malaysla
PreventIon 29
Ensure proper nutrition
Poor nutrltlon (malnutrltlon) usually results from not gettlng enough to eat and poor
eatlng hablts and ls a common cause of health problems. Lnsurlng adequate food and
nutrltlon ln communltles ls the responslblllty of many development sectors wlth whlch
C8P programmes need to collaborate. |n relatlon to the health sector, some suggested
actlvltles for C8P programmes lnclude the followlng:

ensure that C8P personnel are able to ldentlfy people (both wlth and wlthout dls-
abllltles) wlth slgns of malnutrltlon and provlde referral to health workers for proper
assessment and management:

encourage the use of lron-rlch and vltamln-rlch foods that are locally avallable, e.g.
splnach, drumstlck leaves, whole gralns, papaya frult – demonstratlng low-cost, nutrl-
tlous reclpes ls one way to encourage people to eat nutrltlous foods:

ensure that chlldren wlth dlsabllltles get sum clent and approprlate food to eat – chll-
dren wlth dlsabllltles are often neglected, especlally those wlth feedlng problems:

ldentlfy people wlth dlsabllltles who have feedlng dlm cultles, e.g. chlldren wlth cer-
ebral palsy who have chewlng and swallowlng problems, and provlde referrals to
speech and language theraplsts where posslble:

provlde slmple suggestlons to famllles about ways
to asslst people wlth dlsabllltles to eat and drlnk,
e.g. proper posltlonlng to make feedlng safer and
easler:

ldentlfy nutrltlon lnltlatlves avallable ln the com-
munlty and ensure that people wlth dlsabllltles
can access these, e.g. chlldren wlth dlsabllltles
are actlvely lncluded ln programmes whlch
monltor growth and provlde mlcronutrlents
and supplementary food:

promote breastfeedlng and encourage preg-
nant women to attend antenatal care for lron and follc
acld supplements (see Pacllltate access to maternal and chlld
health care, below).
30 cBr gUIdelInes > 2: health comPonent
ß0X 13
The Sanìlvlnl Trust ln 8angalore, |ndla, has been worklng wlth women and chlldren for
over a decade. One of lts maln lnterventlons has been to address the lssue of malnutrltlon
ln chlldren, especlally those below ñve years of age. Convlnced that ln many chlldren
belonglng to poor famllles malnutrltlon occurs durlng the transltlon from breast mllk to
seml-solld foods to solld foods, due to nonavallablllty of sultable food, the Trust provldes
a nutrltlonal supplement – an energy-proteln-rlch powder – to all malnourlshed chlldren
once a month. volunteers are tralned to prepare the supplement and dlstrlbute lt to needy
chlldren after ldentlfylng them. Mothers are glven nutrltlon educatlon and shown how to
prepare low-cost nutrltlous meals uslng locally-avallable gralns and vegetables. Sanìlvlnl
also works ln collaboratlon wlth other organlzatlons that provlde rehabllltatlon for chlldren
wlth dlsabllltles, by provldlng them the nutrltlonal supplement. Chlldren wlth speclal
needs, e.g. those wlth feedlng problems, have used the supplement conslstently and have
beneñted enormously from lt.
Afreen ls nlne years old and has cerebral palsy. She llves wlth her parents and two slsters
ln |llyasnagar slum, 8angalore. Her parents work for a dally wage of Ps ;o ln a local factory.
Her famlly mlgrated to 8angalore when Afreen was slx years old. Due to a compllcatlon
durlng her dellvery, Afreen developed cerebral palsy. She was fed only on llquld foods
and as a result was malnourlshed and bedrldden, poorly developed and had frequent
dlarrhoea and selzures. The C8P worker was unable to glve Afreen any form of therapy due
to her condltlon, so she was glven the nutrltlonal supplement and over a perlod of one
year Afreen gradually lmproved ln health and developed strength. Afreen now goes to the
coachlng centre for therapy and stlmulatlon: her famlly ls overìoyed at her lmprovement
and her mother ls able to lntroduce her to other foods.
Gaining strength through nutrition
|ndla |ndla
Facilitate access to maternal and child health care
Antenatal care, skllled care durlng dellvery and postnatal care reduce the rlsk of mothers
and bables developlng health condltlons and/or lmpalrments that may lead to dlsabll-
lty. C8P programmes should:

ldentlfy maternal health servlces avallable ln the communlty, e.g. antenatal care:

provlde all women wlth lnformatlon about maternal health servlces and encourage
them to access these:

provlde addltlonal support for women wlth dlsabllltles when access to maternal
health-care servlces mlght be dlm cult, e.g. provlde advocacy where dlscrlmlnatlon ls
present wlthln the health-care system:

refer women and thelr famllles for genetlc counselllng where they have speclñc ques-
tlons or concerns related to current or future pregnancles, e.g. a couple wlth a dlsabled
chlld mlght ask lf thelr next chlld wlll lnherlt the same condltlon/lmpalrment:
PreventIon 3l

advlse health servlces about access lssues for pregnant women wlth dlsabllltles, e.g.
provlde suggestlons about approprlate communlcatlon methods and how to make
hospltals/dellvery rooms accesslble:

ñnd out lf there are tralnlng programmes for tradltlonal blrth attendants operatlng
ln the local communltles and ensure that these programmes lnclude lnformatlon on
dlsablllty and early recognltlon of lmpalrments:

encourage famllles to reglster chlldren wlth dlsabllltles wlth the local authorltles at
blrth.
ß0X 14
|n some vlllages of north-west Mongolla, many women have hlp dlslocatlon. when these
women become pregnant, they ñnd that the addltlonal welght puts extra stress on thelr
hlps, worsenlng thelr paln and dlsablllty. The Natlonal C8P programme ln Mongolla works
wlth these women, provldlng advlce regardlng planned lntervals between pregnancles
and adequate rest durlng the later stages of pregnancy.
Easing the stress of pregnancy
Mongolla Mongolla
Promote clean water and sanitation
water and sanltatlon measures contrlbute to lmprovlng healthy llvlng and mlnlmlzlng
dlsablllty. C8P programmes can help to ensure that the needs of people wlth dlsabllltles
are consldered by:

talklng to people wlth dlsabllltles and thelr famlly members about the barrlers they
face when accesslng and uslng water and sanltatlon facllltles, e.g. people wlth dlsablll-
tles may be unable to access water sources because
they llve too far away, the terraln ls too rough and/
or the method for obtalnlng water from the wells ls
too dlm cult:

maklng local authorltles and water and sanltatlon
organlzatlons aware of these barrlers and provldlng
suggestlons and ldeas for ways to overcome the bar-
rlers ln partnershlp wlth people wlth dlsabllltles and
thelr famlly members:

lobbylng and worklng wlth local authorltles to
adapt exlstlng facllltles and/or bulld new facllltles,
e.g. lnstalllng ralsed tollet seats and handralls to pro-
vlde support for people who are unable to use a squat
latrlne:

encouraglng communlty members to support and asslst people wlth dlsabllltles
where needed, e.g. encourage nelghbours to accompany a person wlth a dlsablllty
when fetchlng water.
32 cBr gUIdelInes > 2: health comPonent
Help to prevent injuries
Many dlsabllltles are caused by accldents at home, at work or ln the communlty. Often
adults and chlldren wlth dlsabllltles are also at hlgher rlsk of lnìury. C8P programmes
can play a role ln lnìury preventlon ln thelr communltles by:

ldentlfylng the maìor causes of lnìury ln the home and communlty (e.g. burns, drown-
lng, road accldents) and ldentlfylng those groups most at rlsk (e.g. chlldren):

creatlng awareness ln the communlty about the common causes of lnìurles and how
to prevent these: thls mlght lnclude a health promotlon campalgn (see Health pro-
motlon element):

worklng wlth local authorltles and communlty groups regardlng actlons to take to
reduce the occurrence of lnìurles ln the home and communlty, e.g. to prevent lnìurles
durlng blg festlvals:

provldlng suggestlons for famllles about how to prevent lnìurles ln the home, e.g.
watchlng chlldren when they are near water or open ñres, keeplng polsons locked
away and out of reach of chlldren, keeplng chlldren away from balconles, roof edges
and stalrs and not allowlng chlldren to play wlth sharp obìects:

provldlng educatlon for employers and workers about how to prevent lnìurles ln the
workplace, e.g. wearlng approprlate safety equlpment on constructlon sltes (shoes,
helmets, gloves, earplugs):

provldlng educatlon for schoolchlldren about road safety, e.g. on how to cross roads
safely, wearlng seatbelts ln motor vehlcles and wearlng helmets when rldlng blcycles
and motorblkes.
Help to prevent secondary conditions
People of all ages wlth dlsabllltles are at rlsk of secondary condltlons. C8P programmes
can promote prlmary preventlon strategles to reduce the llkellhood that people wlth
dlsabllltles wlll develop these condltlons. |t ls suggested that C8P programmes should:

ensure that people wlth dlsabllltles and thelr famlly members are aware and knowl-
edgeable about the secondary condltlons commonly assoclated wlth thelr dlsabllltles,
e.g. people wlth splnal cord lnìurles or splna blñda (and thelr famllles) should be aware
that they are at a hlgh rlsk of developlng urlnary tract lnfectlons:

asslst people wlth dlsabllltles and thelr famllles to ldentlfy strategles to prevent sec-
ondary condltlons from developlng, e.g. adoptlng healthy llfestyle behavlours such
as exerclse and good nutrltlon, havlng regular health check-ups, malntalnlng good
hyglene and ìolnlng self-help groups:

ensure that any asslstlve devlces provlded to people wlth dlsabllltles do not create
rlsks for secondary condltlons, e.g. that prostheses ñt properly and do not cause red
marks whlch can lead to pressure sores.
medIcal care 33
Medical care
Introduction
Medlcal care can be deñned as the ldentlñcatlon, assessment and treatment of health
condltlons and/or resultlng lmpalrments. Medlcal care can: provlde a cure (e.g. treat-
ment of leprosy or malarla), reduce the lmpact (e.g. treatment of epllepsy), and prevent
avoldable lmpalrments (e.g. treatment of dlabetes to prevent bllndness). Access to qual-
lty medlcal care, when and as often as needed, ls crltlcal for malntalnlng good health
and functlonlng (30), partlcularly for people wlth dlsabllltles who may experlence poor
levels of health.
|n the Preamble, we referred to the Conventlon on the Plghts of Persons wlth Dlsabllltles,
Artlcle 25, and the measures States Partles are requlred to undertake regardlng health
servlces for people wlth dlsabllltles, lncludlng: provldlng people wlth dlsabllltles wlth
the same range, quallty and standard of free or anordable health care and programmes
as provlded to other people: provldlng those health servlces as needed by people wlth
dlsabllltles speclñcally because of thelr dlsabllltles, lncludlng early ldentlñcatlon and
lnterventlon as approprlate: and provldlng servlces as close as posslble to people’s own
communltles (2).
The Standard Pules on the Lquallzatlon of Opportunltles for Persons wlth Dlsabllltles
(23) also outllne a llst of responslbllltles for States regardlng medlcal care and hlghllght
medlcal care as a precondltlon for equal partlclpatlon ln all llfe actlvltles.
wlth guldance from the Conventlon and Standard Pules, C8P personnel can work wlthln
thelr communltles to ensure that people wlth dlsabllltles are able to access lncluslve,
approprlate and tlmely medlcal care.
34 cBr gUIdelInes > 2: health comPonent
BOX
Irene and Mohammed live in the United Republic of Tanzania. They were overjoyed when
Adnan was born as they already had a six-year-old daughter and had waited a long time
for another child. When Adnan was approximately two months old they noticed that his
head appeared to get smaller. Irene and Mohammed took Adnan to the local hospital for
medical care. An X-ray was taken after which the doctors told Irene and Mohammed that
there was nothing to worry about. However as Adnan grew older it became obvious that he
was unable to perform simple tasks or follow basic instructions and his behaviour become
increasingly challenging. He also experienced regular convulsions. Irene explains, “He never
spoke or made much sound so I never thought he understood anything and I didn’t really
talk to him. What was the point? But his behaviour got worse and worse.”
Adnan only started walking at the age of four and when he was playing in the street one
day, a passer-by, recognizing that Adnan had an intellectual impairment, told Irene and
Mohammed about the local CBR programme run by a nongovernmental organization
called Comprehensive Community Based Rehabilitation in Tanzania (CCBRT). Adnan’s
parents contacted CCBRT and requested support and advice. Mama Kitenge, a CBR worker,
started visiting their home regularly, providing education and therapy. She also helped the
family access medical care to manage his convulsions. As a result, Adnan now takes regular
medication to control his epilepsy.
Irene said “Before I joined the programme, Adnan was unable to do anything himself. He
couldn’t eat or dress himself or wash his hands. He was not a settled, happy child. He just
has been really helpful, especially in instructions. Now I talk to him all the time and he
understands what I say. He can carry water, feed himself and wash his face. I have shown
him the way back home from the water point many times, always pointing out the same
things to look for, so now
he knows his way back
home if he gets lost.
He takes his epilepsy
medicines regularly
and does not have
fts. It is a big change
from before.”
Adnan’s big change
Tanzania Tanzania
walked around all day and often got lost. I did not know what to do with him. The training
medIcal care 35
Goal
People wlth dlsabllltles access medlcal care, both general and speclallzed, based on thelr
lndlvldual needs.
The role of CBR
The role of C8P ls to work ln collaboratlon wlth people wlth dlsabllltles, thelr famllles and
medlcal servlces to ensure that people wlth dlsabllltles can access servlces deslgned to
ldentlfy, prevent, mlnlmlze and/or correct health condltlons and lmpalrments.
Desirable outcomes

C8P personnel are knowledgeable about medlcal care servlces and able to facllltate
referrals for people wlth dlsabllltles and thelr famllles for general or speclallzed medl-
cal care needs.

People wlth dlsabllltles and thelr famllles access actlvltles that are almed at the
early ldentlñcatlon of health condltlons and lmpalrments (screenlng and dlagnostlc
servlces).

Medlcal care facllltles are lncluslve and have lmproved access for people wlth
dlsabllltles.

People wlth dlsabllltles can access surglcal care to mlnlmlze or correct lmpalrments,
thus contrlbutlng to lmproved health and functlonlng.

People wlth dlsabllltles and thelr famllles develop self-management skllls whereby
they are able to ask questlons, dlscuss treatment optlons, make lnformed declslons
about medlcal care and manage thelr health condltlons.

Medlcal care personnel have lncreased awareness regardlng the medlcal needs of
people wlth dlsabllltles, respect thelr rlghts and dlgnlty and provlde quallty servlces.
Key concepts
Types of medical care
Many health systems ln low-lncome countrles have three levels of health care: prlmary,
secondary and tertlary. These are usually llnked to each other by a referral system, e.g.
prlmary health care workers refer people to secondary care when needed. whlle there
ls often overlap between each level, e.g. prlmary health care mlght be provlded ln a
place that normally provldes secondary health care, lt ls lmportant for C8P personnel
to understand the baslc dlnerences between the levels so they can facllltate access for
people wlth dlsabllltles and thelr famlly members.
36 cBr gUIdelInes > 2: health comPonent
Primary level of care refers to basic health care at the community level. It is usually
provided through health centres or clinics and is usually the frst contact people have
with the health system. Medical care provided at primary level includes short simple
treatments for acute conditions (e.g. infections) and routine management of chronic
conditions (e.g. leprosy, epilepsy, tuberculosis, diabetes). CBR programmes work at the
community level and so work closely with primary health-care services (14).
Secondary level of care refers to more specialized medical services that are provided
by large clinics or hospitals which are usually present at the district level. Primary health
care provides an important link to secondary care through referral mechanisms.
Tertiary level of care is highly specialized medical care. It is provided by specialized med-
ical professionals in association with nurses and paramedical staf and involves the use
of specialized technology. These services are provided by large hospitals usually located
in major cities at the national or regional level. Medical care provided at the tertiary level
might include brain surgery, cancer care or orthopaedic surgery.
Medical care for people with disabilities
Medical staf often refer people with disabilities to rehabilitation services for general
medical care instead of treating them at primary health care facilities. This is because
they lack the awareness that, like the general population, people with disabilities may
acquire a general health condition at any stage throughout their life for which they will
need medical care, particularly primary health care. For example, medical care may be
needed for respiratory infections, infuenza, high blood pressure, middle ear infections,
diabetes, tuberculosis or malaria.
Health-care personnel have an important role to play in the early identifcation of condi-
tions that can lead to impairments. It is important that all health conditions are identifed
and treated early (secondary prevention). Some health conditions, if left untreated or
uncontrolled, can lead to new impairments or exacerbate existing impairments in peo-
ple with disabilities. Early intervention is less traumatic, is cost-efective and produces
better outcomes.
Many people with disabilities also have specifc medical care needs for limited or lifelong
periods of time, e.g. people with epilepsy or people with mental health problems may
require drug regimens over a long period of time. Some people with disabilities may
also require surgery to address their impairments.
medIcal care 37
ß0X 16
Lpllepsy (selzures) ls a chronlc neurologlcal dlsorder whlch commonly leads to dlsablllty,
partlcularly ln developlng reglons. People wlth epllepsy and thelr famllles often suner from
stlgma and dlscrlmlnatlon. There are many mlsconceptlons and myths regardlng epllepsy
and lts approprlate treatment. Pecent studles ln both hlgh-lncome and low-lncome
countrles have shown that up to ;o% of newly dlagnosed chlldren and adults wlth epllepsy
can be successfully treated (l.e. thelr selzures completely controlled) wlth antl-eplleptlc
drugs. After two to ñve years of successful treatment, drugs can be wlthdrawn ln about ;o%
of chlldren and 6o% of adults wlthout relapses. However approxlmately three fourths of
people wlth epllepsy ln low-lncome countrles do not get the treatment they need (+:).
Epilepsy
Surgery
Surgery ls a part of medlcal care and ls usually provlded at the secondary or tertlary levels
of the health-care system. Some types of surgery can correct lmpalrments or prevent or
llmlt deformltles and compllcatlons that may be assoclated wlth lmpalrments. Lxamples
of surgery lnclude removal of cataracts that are causlng vlsual lmpalrment, orthopaedlc
surgery to address fractures or splnal deformltles and reconstructlve surgery for cleft llp
and palate, burns, or leprosy.
There are many thlngs to conslder before surgery ls undertaken. Pamllles may have
llmlted knowledge and understandlng regardlng surgery, so they must be lnformed
properly about the beneñts and consequences. Surglcal care ls often very expenslve
and, wlthout soclal securlty or health lnsurance, lt wlll be dlm cult to access for poor
people. Successful outcomes from surgery are dependent on comprehenslve follow-
up – followlng surgery, people may requlre further medlcal care, therapy and asslstlve
devlces, so close llnks are requlred between medlcal and rehabllltatlon professlonals. |t
ls lmportant to remember that surgery alone cannot address all problems that may be
related to lmpalrment and dlsablllty.
38 cBr gUIdelInes > 2: health comPonent
ß0X 17
Patrlck, from Kyenyoìo Dlstrlct ln Kenya, was born ln :o8; wlth clubfeet. Hls slster Sara was
also born wlth clubfeet. Patrlck says that he stayed wlth the dlsablllty untll :; years of age
when he heard a radlo announcement asklng chlldren wlth dlsabllltles to go to Kamwengye
town. “Por all these years, | was always lsolated among my peers. when | heard the radlo
announcement | had mlxed feellngs, | was not sure that somethlng could be done about
my feet. 8ut ñnally | went to the Kamwengye Outreach Centre. | found lots of other chlldren
wlth dlsabllltles there as well. | never knew that other people were golng through slmllar
experlences. After two surgerles my feet were corrected and above all | am happy that | can
put on regular shoes now, somethlng that was a dream. walklng ls easler each passlng day.
My younger slster, who ls now :a years, also had surgery. |t ls very lmportant to know for
all communltles, that medlcal and rehabllltatlon servlces for chlldren wlth dlsabllltles are
avallable and posslble. People ln our area were not aware of these servlces. Sara and myself,
we are dolng our best to lnform our famllles, frlends and communlty about such servlces.
we, together wlth other people wlth dlsabllltles, are part of the soclety and want to be
engaged ln normal actlvltles ln churches, schools and other groups. Lver slnce my slster and
| were operated on, many people now belleve that lt ls posslble that other chlldren wlth
dlsabllltles can regaln thelr lost hope.”
Learning about possibilities
Kenya Kenya
Self-management
Self-management (also commonly referred to as self-care or self-care management)
does not mean managlng your health wlthout medlcal lnterventlon. Self-manage-
ment lnvolves people taklng control over thelr health – they are responslble for maklng
lnformed cholces and declslons about medlcal care and for playlng an actlve role ln car-
rylng out care plans to lmprove and malntaln thelr health. |t requlres a good relatlonshlp
between lndlvlduals and thelr health-care personnel to ensure that good health out-
comes are achleved. People who self-manage thelr care:

communlcate regularly and enectlvely wlth health personnel:

partlclpate ln declslon-maklng and care plannlng:

request, obtaln and understand health lnformatlon:

follow a treatment reglmen that has been drawn up wlth health personnel:

perform approprlate self-care actlvltles, as agreed wlth health personnel.
Self-management ls lmportant for people who experlence a llfelong dlsablllty, e.g. para-
plegla, or a chronlc condltlon such as dlabetes. Health workers may lgnore the role whlch
people wlth dlsabllltles and thelr famllles can play ln self-management. Lqually, lndlvldu-
als may lack the skllls to ensure they take lncreased responslblllty for thelr own health.
medIcal care 39
Self-help groups can provide a good opportunity for people with disabilities to learn
about self-management through the sharing of knowledge and skills with others. Often
valuable information is learnt regarding available medical-care resources, how to nego-
tiate the health-care system efectively and how to manage existing health conditions.
BOX
The Italian association Amici di Raoul Follereau (AIFO/Italy) together with the Disability and
Rehabilitation team at the World Health Organization and Disabled People International,
carried out research across several countries to determine whether people could learn self-
management skills and play a more active role in improving their own medical care if they
got together as a group of people with disabilities with similar medical care needs. Pilot
projects were asked to: identify and create groups of people with disabilities with similar
medical care needs; identify the main medical care needs; in collaboration with health
professionals, provide knowledge and skills for self-care for addressing the identifed
needs; assess if the quality of self-care and medical care by people with disabilities and/or
family members had improved; and determine if the knowledge and skills of people with
disabilities was recognized and given some role within the medical care system.
A pilot project in El Salvador focused on spinal cord injury. AIFO/Italy, in partnership with
Don Bosco University and Instituto Salvadoreño Para La Riabilitación de Inválidos, worked
with  people with spinal cord injuries and their families from the areas of San Salvador
and the village of Tonacatepeque. Four self-help groups were formed and regular meetings
were held. Members of these groups identifed their major medical care needs which
included: urine, bladder and kidney issues; pressure sores; joint stifness; and sexuality
and parenthood-related issues. Health professionals involved in the project provided
self-management skills training to address the issues that had been identifed. Over time,
members of the self-help groups and health professionals involved in the project began
to change their thinking. They realized that with proper support and training, people with
spinal cord injury could manage their health and achieve a better quality of life. They also
realized that health professionals needed to look beyond their traditional medical roles
and facilitate and promote self-management/care – a concept of shared responsibility.
Members of the self-help groups went on to form their own association called ALMES
(Asociación de Personas con Lesión Medular de El Salvador).
Strength in numbers
E l S alvador
40 cBr gUIdelInes > 2: health comPonent
Suggested activities
C8P programmes can carry out the followlng actlvltles to promote access to medlcal
care for people wlth dlsabllltles.
Gather information about medical services
Knowledge of the medlcal servlces avallable at prlmary, secondary and tertlary levels of
the health system ls essentlal for asslstlng people wlth dlsabllltles and thelr famllles to
access medlcal care and support. C8P programmes can:

ldentlfy exlstlng medlcal servlces at the local, dlstrlct and natlonal levels, ensurlng that
government, prlvate and nongovernmental servlce provlders are ldentlñed, lncludlng
provlders of tradltlonal medlclne, lf relevant:

lnltlate contact wlth the servlce provlders and gather lnformatlon regardlng the type
of medlcal care provlded, accesslblllty, costs, schedules and referral mechanlsms:

complle a servlce dlrectory to ensure that all lnformatlon ls accesslble for C8P per-
sonnel, lndlvlduals and communltles – ensure servlce dlrectorles are avallable ln local
languages and accesslble formats and made avallable ln places where health care ls
provlded.
Assist with early identifcation
C8P programmes can:

establlsh a mechanlsm for the early lden-
tlflcatlon of health condltlons and
lmpalrments assoclated wlth dlsablllty
ln partnershlp wlth prlmary health care
personnel:

ldentlfy screenlng actlvltles almed at
the early ldentlñcatlon of communl-
cable or noncommunlcable dlseases,
e.g. tuberculosls, leprosy, ñlarlasls, rlver
bllndness, dlabetes, cancer:

provlde lnformatlon to people wlth
dlsabllltles and thelr famllles about the tlmlng and locatlon of screenlng actlvltles
and ensure they are able to access these:

ensure members of famllles that have a hlstory of genetlc or heredltary condltlons,
e.g. muscular dystrophy, are referred to approprlate medlcal facllltles for assessment
and counselllng:

be aware of secondary condltlons, e.g. pressure sores that are assoclated wlth par-
tlcular dlsabllltles and check for these when worklng wlth people wlth dlsabllltles:

ldentlfy people wlth lmpalrments ln the communlty who may beneñt from surgery.
medIcal care 4l
ß0X 19
C8P programmes run by two nongovernmental organlzatlons ln the Mandya Dlstrlct of
|ndla collaborate wlth the natlonal leprosy programme. They are lnvolved ln awareness-
ralslng actlvltles provldlng lnformatlon about the early slgns and symptoms of leprosy
and encouraglng people wlth suspected leslons to vlslt thelr nearest prlmary health care
servlce. People who are dlagnosed wlth leprosy commence a 6–:z month treatment
reglmen, whlch ls provlded free by the prlmary health care servlce. |f people fall to attend
treatment, the prlmary health care servlce requests the C8P programme to follow up these
lndlvlduals.
Joining forces to provide care
|ndla |ndla
Ensure access to early treatment
C8P programmes can promote and encourage collaboratlon between people wlth dls-
abllltles, thelr famllles and prlmary health care workers to lncrease access to medlcal
care servlces at all levels. Suggested actlvltles lnclude:

checklng wlth health workers to make sure people wlth dlsabllltles who have been
lncluded ln screenlng actlvltles are provlded wlth follow-up medlcal care lf requlred:

checklng wlth health workers to make sure referrals have been made for people wlth
dlsabllltles who requlre access to secondary and tertlary levels of health care:

advocacy, e.g. C8P personnel who know slgn language may accompany deaf per-
sons to health facllltles to ensure that they are able to communlcate thelr needs and
understand the lnformatlon belng provlded and support them to access approprlate
treatment:

ralslng awareness about the barrlers that prevent access to medlcal care and worklng
wlth others to reduce or ellmlnate these barrlers – lnnovatlve mechanlsms may be
requlred to address some barrlers, e.g. the costs assoclated wlth medlcal care:

ldentlfylng gaps ln servlce provlslon for people wlth
dlsabllltles and explorlng, wlth others (e.g. people wlth
dlsabllltles, famlly members, medlcal stan, pollcy-
makers), ways ln whlch these gaps can be
reduced or ellmlnated.
42 cBr gUIdelInes > 2: health comPonent
ß0X 20
Clubfoot or congenltal foot deformltles are blrth defects that often lead to dlsablllty ln low-
lncome countrles. The Communlty Agency for Pehabllltatlon and Lducatlon of Persons wlth
Dlsabllltles, 8ellze (CAPL-8ellze), recognlzed that lt was a slgnlñcant lssue for chlldren ln
8ellze. |n partnershlp wlth the |nternatlonal Hospltal for Chlldren and the Mlnlstry of Health,
CAPL-8ellze developed a programme to ensure the early ldentlñcatlon and treatment of
chlldren wlth clubfoot.
Local doctors, theraplsts and rehabllltatlon ñeld om cers were tralned to embrace the
Ponsetl method, a nonsurglcal method to correct clubfoot deformltles at a very early age
uslng gentle manlpulatlon, serlal castlng and spllntlng. Through lts C8P personnel, CAPL-
8ellze ldentlñed chlldren at a very early age and referred them to medlcal care servlces for
correctlon of clubfoot. Although thls was orlglnally a local nongovernmental organlzatlon
lnltlatlve, lts success has led to the development of a natlonal clubfoot programme.
Building on success
8ellze 8ellze
Facilitate access to surgical care
Some people wlth dlsabllltles may requlre surglcal care. when comblned wlth follow-up
care and rehabllltatlon, surgery can correct lmpalrments, prevent them from becomlng
worse and contrlbute to lmproved functlonlng. C8P programmes can:

explore what surglcal optlons are avallable for people wlth dlsabllltles and partlcularly
whether fundlng optlons are avallable:

before surgery takes place, check to ensure that people wlth dlsabllltles and thelr fam-
lly members have been well lnformed of the posslble rlsks and beneñts of surgery and
that they are aware of the costs and duratlon of the entlre surglcal/treatment plan:

followlng surgery, check to ensure that people are recelvlng approprlate follow-up
from surglcal and nurslng teams and rehabllltatlon professlonals (e.g. physlotheraplsts,
occupatlonal theraplsts, prosthetlsts/orthotlsts) to maxlmlze the beneñts of surgery
– C8P can asslst ln ensurlng a smooth transltlon from medlcal care to rehabllltatlon.
Promote self-management of chronic conditions
C8P programmes can asslst people wlth dlsabllltles and thelr famllles to become aware
of thelr rlght to medlcal care and to learn skllls that enable them to manage thelr chronlc
health condltlons. |t ls suggested that C8P programmes:

work dlrectly wlth people wlth dlsabllltles to encourage them to take responslblllty
for thelr own health by seeklng approprlate medlcal care and maklng healthy llfestyle
cholces and to ensure they are able to understand and follow medlcal advlce:
medIcal care 43

develop or adapt exlstlng materlals/publlcatlons that provlde medlcal lnformatlon
about health condltlons lnto formats that are approprlate for people wlth dlsabllltles
and thelr famlly members, e.g. ln slmple language, wlth slmple sketches or plctures
and translated lnto local languages:

llnk people wlth dlsabllltles to self-help groups to enable them to learn about self-
management through the sharlng of knowledge and skllls wlth others – they can
learn valuable lnformatlon about what resources are avallable for medlcal care, how
to enectlvely negotlate the health-care system and how to manage exlstlng health
condltlons.
ß0X 21
|n Nlcaragua, there are “clubs” for people wlth chronlc condltlons, e.g. hlgh blood pressure
or dlabetes. These clubs, or support groups, add to the enorts of the health-care system
by ensurlng that people are able to take responslblllty for the management of thelr own
health and prevent the development of further condltlons
and lmpalrments. |n the meetlngs, people talk about thelr
problems, learn how to self-monltor thelr health
condltlons and explore solutlons such as developlng
healthy llfestyles. Club management commlttees carry
out fundralslng actlvltles to help cover the costs of
medlclnes and laboratory tests, whlch are not usually
provlded by the health system. The C8P programme
collaborates wlth these support groups to ensure that
people wlth dlsabllltles are lncluded.
Partnerships to create change
Nlcaragua Nlcaragua
Build relationships with medical care providers
Medlcal personnel often have llmlted knowledge about dlsablllty and how best to ena-
ble access for people wlth dlsabllltles to medlcal care servlces. 8y maklng contact wlth
these servlces and bulldlng relatlonshlps wlth stan, C8P programmes can develop a
network whlch facllltates referrals and comprehenslve medlcal care for people wlth dls-
abllltles. C8P programmes can:

promote awareness among medlcal personnel about the health needs of people wlth
dlsabllltles and thelr famllles:

organlze lnteractlve sesslons between lndlvlduals and groups of people wlth dlsablll-
tles, famlly members (where relevant) and medlcal personnel to enable dlscusslon of
key lssues related to dlsablllty, e.g. access lssues and sharlng of experlences:
44 cBr gUIdelInes > 2: health comPonent

encourage medlcal personnel to lnvolve people wlth dlsabllltles and thelr famlly
members ln the development of medlcal treatment/care plans:

request medlcal servlces to provlde educatlon and tralnlng for C8P personnel so they
are able to asslst wlth early detectlon, provlde referrals to approprlate servlces and
provlde follow-up ln the communlty:

work ìolntly wlth communlty health programmes to ensure that people wlth dlsablll-
tles can access the beneñts of these programmes.
ß0X 22
A C8P programme ln South Sulawesl, |ndonesla, has a multlsectoral team lncludlng vlllage
health workers, prlmary-school teachers and communlty volunteers, many of whom have
dlsabllltles or are famlly members of a person wlth a dlsablllty. The C8P team has regular
tralnlng sesslons wlth personnel from all levels of the health system. These tralnlng sesslons
provlde great opportunltles for networklng, promotlon of the medlcal care needs of
people wlth dlsabllltles and promotlon of the role of C8P and medlcal care servlces.
Awareness raising in Indonesia
|ndonesla |ndonesla
rehaBIlItatIon 45
Rehabilitation
Introduction
As highlighted in the Preamble, access to rehabilitation is essential for people with
disabilities to achieve their highest attainable level of health. The Convention on the
Rights of Persons with Disabilities, Article 26, calls for “appropriate measures, including
through peer support, to enable persons with disabilities to attain and maintain maxi-
mum independence, full physical, mental, social and vocational ability and full inclusion
and participation in all aspects of life...” (2).
The Standard Rules on the Equalization of Opportunities for Persons with Disabilities
state that rehabilitation measures include those which provide and/or restore functions,
or compensate for the loss or absence of a function or a functional limitation (23). Reha-
bilitation can occur at any stage in a person’s life but typically occurs for time-limited
periods and involves single or multiple interventions. Rehabilitation may range from
more basic interventions such as those provided by community rehabilitation work-
ers and family members to more specialized interventions, such as those provided by
therapists.
Successful rehabilitation requires the involvement of all development sectors including
health, education, livelihood and social welfare. This element focuses on those measures
to improve functioning that are ofered within the health sector. It is important to note
however that health-related rehabilitation services and
the provision of assistive devices are not necessarily
managed by the ministry of health (see Reha-
bilitation services).
46 cBr gUIdelInes > 2: health comPonent
ß0X 23
The Assoclatlon for the Physlcally Dlsabled of Kenya (APDK) has been provldlng
comprehenslve rehabllltatlon servlces ln Kenya for the past <o years, reachlng over <oo ooo
people wlth dlsabllltles. As a result of several partnershlps, APDK has been able to establlsh
a natlonal rehabllltatlon network conslstlng of nlne maln branches, z8o assoclated outreach
centres and many communlty-based rehabllltatlon programmes: these provlde servlces
such as therapy, asslstlve devlces and support for surglcal lnterventlons.
One of APDK’s successful partnershlps has been wlth the Mlnlstry of Medlcal Servlces
(formally the Mlnlstry of Health). Over the past +o years, APDK has worked closely wlth thls
Mlnlstry to ensure that quallty rehabllltatlon servlces are accesslble to as many people as
posslble. Slx of the nlne APDK branches are located wlthln government hospltals and the
Mlnlstry of Medlcal Servlces has provlded over <o health workers, mostly theraplsts and
technlclans, to work ln these branches. The Mlnlstry provldes the salary for most of these
health workers whlle APDK funds the programme costs.
APDK establlshed thelr ñrst C8P programme ln thelr Mombasa branch ln :ooz. Slnce zooo,
they have extended these programmes to the maìor slums ln Nalrobl ln order to reach
those people wlth dlsabllltles who are most vulnerable. C8P programmes provlde home-
based rehabllltatlon and are an lmportant referral llnk to APDK outreach centres and
branches. wlth ñnanclal support from C8M and Klndernothllfe, APDK has employed +z C8P
personnel to work ln these programmes whlle the government has funded several therapy
posltlons.
APDK ls a successful example of a publlc–prlvate partnershlp and demonstrates how
centre-based rehabllltatlon and communlty-based rehabllltatlon can work together to
provlde rehabllltatlon
servlces for people llvlng
ln both urban and rural
areas. |n zoo8 alone,
approxlmately <z ooo
Kenyan people recelved
rehabllltatlon servlces
from APDK.
Forging public–private partnerships
Kenya Kenya
rehaBIlItatIon 47
Goal
People wlth dlsabllltles have access to rehabllltatlon servlces whlch contrlbute to thelr
overall well-belng, lncluslon and partlclpatlon.
The role of CBR
The role of C8P ls to promote, support and lmplement rehabllltatlon actlvltles at the
communlty level and facllltate referrals to access more speclallzed rehabllltatlon servlces.
Desirable outcomes

People wlth dlsabllltles recelve lndlvldual assessments and are lnvolved ln the devel-
opment of rehabllltatlon plans outllnlng the servlces they wlll recelve.

People wlth dlsabllltles and thelr famlly members understand the role and purpose
of rehabllltatlon and recelve accurate lnformatlon about the servlces avallable wlthln
the health sector.

People wlth dlsabllltles are referred to speclallzed rehabllltatlon servlces and are pro-
vlded wlth follow-up to ensure that these servlces are recelved and meet thelr needs.

8aslc rehabllltatlon servlces are avallable at the communlty level.

Pesource materlals to support rehabllltatlon actlvltles undertaken ln the communlty
are avallable for C8P personnel, people wlth dlsabllltles and famllles.

C8P personnel recelve approprlate tralnlng, educatlon and support to enable them
to undertake rehabllltatlon actlvltles.
Key concepts
Rehabilitation
Pehabllltatlon ls relevant to people experlenclng dlsablllty from a broad range of health
condltlons and therefore the CPPD makes reference to both “habllltatlon” and “rehablllta-
tlon”. Habllltatlon alms to asslst those lndlvlduals who acqulre dlsabllltles congenltally or
ln early chlldhood and have not had the opportunlty to learn how to functlon wlthout
them. Pehabllltatlon alms to asslst those who experlence a loss ln functlon as a result of
dlsease or lnìury and need to relearn how to perform dally actlvltles to regaln maxlmal
functlon. Habllltatlon ls a newer term and ls not commonly used ln low-lncome coun-
trles, therefore these guldellnes use the term “rehabllltatlon” to refer to both habllltatlon
and rehabllltatlon.
48 cBr gUIdelInes > 2: health comPonent
Rehabilitation interventions
A wlde range of rehabllltatlon lnterventlons can be undertaken wlthln the health sector.
Conslder the examples below.

Pehabllltatlon for a young glrl born wlth cerebral palsy mlght lnclude play actlvltles to
encourage her motor, sensory and language development, an exerclse programme to
prevent muscle tlghtness and development of deformltles and provlslon of a wheel-
chalr wlth a speclallzed lnsert to enable proper posltlonlng for functlonal actlvltles.

Pehabllltatlon for a young boy who ls deafbllnd mlght lnclude worklng wlth hls parents
to ensure they provlde stlmulatlng actlvltles to encourage development, functlonal
moblllty tralnlng to enable hlm to negotlate hls home and communlty envlronments
and teachlng approprlate communlcatlon methods such as touch and slgns.

Pehabllltatlon for an adolescent glrl wlth an lntellectual lmpalrment mlght lnclude
teachlng her personal hyglene actlvltles, e.g. menstrual care, developlng strategles
wlth the famlly to address behavloural problems and provldlng opportunltles for
soclal lnteractlon enabllng safe communlty access and partlclpatlon.

Pehabllltatlon for a young man wlth depresslon mlght lnclude l:l counselllng to
address underlylng lssues of depresslon, tralnlng ln relaxatlon technlques to address
stress and anxlety and lnvolvement ln a support group to lncrease soclal lnteractlon
and support networks.

Pehabllltatlon for a mlddle-aged woman wlth a stroke mlght lnclude lower llmb
strengthenlng exerclses, galt tralnlng, functlonal tralnlng to teach her to dress, bath
and eat lndependently, provlslon of a walklng stlck to provlde support for balance
dlmcultles and exerclses to facllltate speech recovery.

Pehabllltatlon for an older man who has dlabetes and recently had both legs ampu-
tated below the knee mlght lnclude strengthenlng exerclses, provlslon of prostheses
and/or a wheelchalr and functlonal tralnlng to teach moblllty and transfer skllls and
dally llvlng skllls.
Rehabilitation services
Pehabllltatlon servlces are managed by government, prlvate or nongovernment sec-
tors. |n most countrles, the mlnlstry of health manages these servlces: ln some countrles,
however, rehabllltatlon servlces are managed by other mlnlstrles, e.g. by the Mlnlstry of
Labour, war |nvallds and Soclal Analrs ln vlet Nam and by the mlnlstrles of soclal welfare
ln |ndla, Ghana and Lthlopla. |n some countrles, servlces may be managed through ìolnt
partnershlps between government mlnlstrles and nongovernmental organlzatlons, e.g.
ln the |slamlc Pepubllc of |ran, Kenya and Chlna.
Servlces are provlded by a broad range of personnel lncludlng medlcal professlonals
(e.g. nurses, physlatrlsts), therapy professlonals (e.g. occupatlonal theraplsts, physlo-
theraplsts, speech theraplsts), technology speclallsts (e.g. orthotlsts, prosthetlsts) and
rehabllltatlon workers (e.g. rehabllltatlon asslstants, communlty rehabllltatlon workers).
Pehabllltatlon servlces can be onered ln a wlde range of settlngs, lncludlng hospltals,
cllnlcs, speclallst centres or unlts, communlty facllltles and homes: the phase durlng
rehaBIlItatIon 49
whlch rehabllltatlon occurs (e.g. the acute phase followlng an accldent/lnìury) and the
type of lnterventlons requlred usually determlne whlch settlng ls approprlate.
|n low-lncome countrles and partlcularly ln rural areas, the range of rehabllltatlon serv-
lces avallable and accesslble ls often llmlted. There may only be one rehabllltatlon centre
ln the maìor clty of a country, for example, or theraplsts may be avallable only ln hospl-
tals or large cllnlcs. Therefore communlty-based strategles such as C8P are essentlal to
llnk and provlde people wlth dlsabllltles and thelr famllles wlth rehabllltatlon servlces.
Community-based services
Hlstorlcally, C8P was a means of provldlng servlces focused on rehabllltatlon to people
llvlng ln low-lncome countrles through the use of local communlty resources. whlle the
concept of C8P has evolved lnto a broader development strategy, lnvolvement ln the
provlslon of rehabllltatlon servlces at communlty level remalns a reallstlc and necessary
actlvlty for C8P programmes.
Pehabllltatlon at speclallzed centres may not be necessary or practlcal for many people,
partlcularly those llvlng ln rural areas and many rehabllltatlon actlvltles can be lnltlated
ln the communlty. The wHO manual on Training in the community for people with dis-
abilities ls a gulde to rehabllltatlon actlvltles that can be carrled out ln the communlty
uslng local resources (32).
Communlty-based servlces may also be requlred followlng rehabllltatlon at speclallzed
centres. A person may requlre contlnued support and asslstance ln uslng new skllls and
knowledge at home and ln the communlty after he/she returns. C8P programmes can
provlde support by vlsltlng people at home and encouraglng them to contlnue reha-
bllltatlon actlvltles as necessary.
where rehabllltatlon servlces are establlshed ln the communlty, close llnks must be
malntalned wlth referral centres that oner speclallzed rehabllltatlon servlces. The needs
of many people wlth dlsabllltles change over tlme and they may requlre perlodlc sup-
port ln the long term. Successful rehabllltatlon depends on strong partnershlps between
people wlth dlsabllltles, rehabllltatlon professlonals and communlty-based workers.
50 cBr gUIdelInes > 2: health comPonent
ß0X 24
Ll, a mlddle-aged wldow, llves wlth her elderly mother and three chlldren ln the Olng Hal
provlnce of Chlna. Her whole famlly depended on her before an accldent ln October zoo+.
Ll fell from a helght whlle repalrlng her house and sustalned a splnal fracture, resultlng ln
weakness and sensory loss ln both legs. After she was dlscharged from hospltal, she stayed
ln bed all day and nlght. Swelllng qulckly developed ln both her legs and she requlred full
asslstance from her chlldren to turn ln bed, bathe, change her clothes and use the tollet.
Ll soon lost her conñdence and trled to commlt sulclde several tlmes: fortunately, she
was unsuccessful.
A vlllage rehabllltatlon om cer from a local C8P programme came to vlslt Ll and provlded her
wlth home-based rehabllltatlon. Ll was taught new ways of completlng dally llvlng actlvltles
uslng her resldual abllltles. She was glven lnformatlon about her dlsablllty and learnt how
to prevent bed sores and urlnary tract lnfectlons. Her famlly and frlends were taught how
to make a slmple walklng frame for her to practlse standlng and walklng. They also made
a slmple tollet bowl to solve the problem of golng to the tollet. The County Pehabllltatlon
Centre provlded crutches and a wheelchalr. wlth tlme and practlce Ll was able to stand and
walk lndependently wlth crutches and use a wheelchalr for longer dlstances.
Step by step, Ll bullt up her conñdence. She was soon able to manage her own dally
actlvltles, whlch lncluded cooklng for her famlly, an actlvlty she really enìoyed. Ll also
opened a mlll, provldlng her wlth a source of lncome whlch, together wlth a small monthly
llvlng allowance from the County Mlnlstry of Clvll Analrs, allows her once agaln to care for
her famlly and be conñdent about the future.
Li’s journey to independence
Chlna Chlna
Rehabilitation plans
Pehabllltatlon plans need to be person-centred, goal-orlented and reallstlc. when devel-
oplng a plan, a person’s preferences, age, gender, socloeconomlc status and home
envlronment need to be consldered. Pehabllltatlon ls often a long ìourney, and a long-
term vlslon ls requlred, wlth short-term goals. valuable resources can be wasted when
rehabllltatlon plans are not reallstlc.
Many rehabllltatlon plans fall because people wlth dlsabllltles are not consulted: lt ls
lmportant to ensure that thelr oplnlons and cholces lnnuence the development of the
plan and that the realltles of thelr llves, ln partlcular the lssue of poverty, are consldered.
Por example, a plan that requlres a poor person llvlng ln a rural area to travel frequently
to the clty for physlotherapy ls llkely to fall. Pehabllltatlon personnel need to be lnnova-
tlve and develop approprlate rehabllltatlon programmes whlch are avallable as close as
posslble to home, lncludlng ln rural areas.
rehaBIlItatIon 5l
Pehabllltatlon needs may change over tlme, partlcularly durlng perlods of transltlon,
e.g. when a chlld starts school, a young adult starts work, or a person returns to llve ln
her/hls communlty followlng a stay ln a rehabllltatlon faclllty. Durlng these transltlons,
adìustments wlll need to be made to the rehabllltatlon plans to ensure the actlvltles
contlnue to be approprlate and relevant.
Suggested activities
Identify needs
8efore maklng a rehabllltatlon plan and startlng actlvltles, lt ls lmportant for C8P per-
sonnel to carry out a baslc assessment wlth an lndlvldual and hls/her famlly members to
ldentlfy needs and prlorltles. Assessment ls an lmportant sklll, so C8P personnel should
recelve prlor tralnlng and supervlslon to ensure competency ln thls area. To ldentlfy a
person’s needs lt can be helpful to conslder the followlng questlons.

what actlvltles can they do and not doI

what do they want to be able to doI

what problems do they experlenceI How and when dld these problems beglnI

what areas are anectedI e.g. body, senses, mlnd, communlcatlon, behavlourI

what secondary problems are developlngI

what ls thelr home and communlty sltuatlon llkeI

|n what way have they adìusted to thelr dlsabllltyI
Accurate lnformatlon can be obtalned by revlewlng past medlcal records, observlng the
lndlvldual, performlng a baslc physlcal examlnatlon of the lndlvldual and through dls-
cusslons wlth the lndlvldual, famlly members and lnvolved health professlonals/servlces.
|t ls lmportant to keep a record of the lnltlal assessment and future consultatlons, so an
lndlvldual’s progress can be monltored over tlme. Many C8P programmes have devel-
oped assessment forms and progress notes to make thls easler for thelr stan.
Facilitate referral and provide follow-up
|f, followlng the baslc assessment, C8P personnel ldentlfy a need for speclallzed reha-
bllltatlon servlces, e.g. physlotherapy, occupatlonal therapy, audlology, speech therapy,
they can facllltate access for people wlth dlsabllltles by lnltlatlng referrals. The followlng
actlvltles are suggested.

|dentlfy rehabllltatlon referral servlces avallable at all levels of the health system.

Provlde lnformatlon regardlng referral servlces to people wlth dlsabllltles and thelr
famllles, lncludlng locatlon, posslble beneñts and potentlal costs.

Lncourage people wlth dlsabllltles and thelr famllles to express concerns and ask
questlons about referral servlces. Help them to seek addltlonal lnformatlon lf requlred.
Llnks can be made wlth other people ln the communlty who experlence slmllar prob-
lems and have beneñted from the same or slmllar servlces.
52 cBr gUIdelInes > 2: health comPonent

Lnsure people wlth dlsabllltles and thelr famlly members glve lnformed consent
before any referral ls made.

Once a referral ls made, malntaln regular contact wlth the servlces and lndlvlduals
lnvolved to ensure that appolntments have been made and attended.

|dentlfy what support ls requlred to facllltate access to servlces (e.g. ñnanclal, trans-
port, advocacy) and how thls can be provlded. Por example, lf advocacy ls requlred,
C8P personnel can accompany people to thelr appolntments.

Provlde follow-up after appolntments to determlne whether ongolng support ls
needed, e.g. rehabllltatlon actlvltles may need to be contlnued at home.
Speclallzed rehabllltatlon servlces are often based ln large urban centres and thls can
restrlct access for people llvlng ln rural/remote areas. Conslderatlon must be glven to
the costs assoclated wlth a vlslt to the clty, lncludlng transport, food, accommoda-
tlon and loss of dally wages: many servlces also requlre out-of-pocket payments. C8P
programmes should be aware of ñnanclal constralnts and ensure that a wlde range of
optlons are lnvestlgated lncludlng government and/or nongovernmental organlzatlon
schemes, bank loans and communlty support.
ß0X 2S
The C8P programme ln the |slamlc Pepubllc of |ran encourages vlllage health workers
and C8P personnel to ldentlfy people wlth dlsabllltles early and refer them to the prlmary
health-care servlces ln the communlty. Pollowlng referral, a moblle team of rehabllltatlon
personnel vlslt the home to provlde home-based rehabllltatlon. |f speclallzed lnterventlons
are requlred, referral ls made to a tertlary-level care centre, usually ln the provlnclal
headquarters or capltal clty. Pollowlng rehabllltatlon at a speclallzed centre, people are
referred back to the prlmary health-care servlces, whlch work wlth the C8P programme to
ensure that rehabllltatlon actlvltles are contlnued, lf necessary. The moblle team provldes
follow-up to monltor progress and provlde further asslstance when requlred.
No place too far from services
|ran |ran
Facilitate rehabilitation activities
C8P programmes can facllltate home and/or communlty-based therapy servlces and
provlde asslstance to people wlth a wlde range of lmpalrments, enabllng them to maln-
taln and maxlmlze thelr functlon wlthln thelr home and communlty.
Provide early intervention activities for child development
Lvery chlld goes through a learnlng process enabllng hlm/her to master lmportant skllls
for llfe. The maìor areas of chlld development lnclude: physlcal development, speech and
language development, cognltlve development and soclal and emotlonal development.
rehaBIlItatIon 53
Delays ln development occur when a chlld ls unable to reach the lmportant mllestones
sultable for hls/her age group. Through early lnterventlon, chlldren at rlsk of, or wlth,
developmental delay are ldentlñed as early as posslble and provlded wlth focused reha-
bllltatlon lnterventlons to prevent or lmprove thls delay.
The presence of a dlsablllty, e.g. cerebral palsy, bllndness or deafness, can result ln devel-
opmental delay and restrlct a chlld’s ablllty to partlclpate ln regular actlvltles such as
playlng wlth other chlldren and golng to school. C8P personnel can provlde early lnter-
ventlon actlvltles, usually home-based, to encourage slmple and enìoyable learnlng
opportunltles for development. C8P programmes can also encourage parents to meet
together to share ldeas and experlences and facllltate playgroups, so thelr chlldren learn
to play wlth other chlldren, learn new skllls and lmprove ln all areas of development.
ß0X 26
The C8P programme ln Alexandrla, Lgypt, has several clubs that meet weekly ln dlnerent
parts of the clty, lncludlng ln a local stadlum and a mosque. Parents come wlth thelr
chlldren who have dlsabllltles to partlclpate ln actlvltles organlzed by the C8P programme
and communlty volunteers. There ls a range of fun actlvltles for chlldren, e.g. slnglng and
danclng contests, and parents are glven the opportunlty to talk and share thelr experlences
wlth one another and to attend tralnlng sesslons.
Fun for families
Lgypt Lgypt
Encourage functional independence
Punctlonal lnterventlons alm to lmprove an lndlvldual’s level of lndependence ln dally
llvlng skllls, e.g. moblllty, communlcatlon, bathlng, tolletlng, dresslng, eatlng, drlnklng,
cooklng, housework. |nterventlons are dependent on a person’s age, gender and local
envlronment and wlll change over tlme as she/he makes a transltlon from one llfe stage
to another. C8P personnel can provlde:

tralnlng for people wlth dlsabllltles and thelr famllles about the dlnerent ways to carry
out actlvltles:

educatlon for famllles on how to best asslst people
wlth dlsabllltles ln functlonal actlvltles to maxlmlze
thelr lndependence:

tralnlng ln the use of asslstlve devlces, e.g. walklng/
moblllty devlces to make actlvltles easler:

educatlon and lnstructlon on speclñc technlques used
to address lmpalrments, e.g. muscle weakness, poor
balance and muscle tlghtness, whlch lmpact a per-
son’s ablllty to carry out actlvltles: thls mlght lnclude
strengthenlng, stretchlng and ñtness programmes.
54 cBr gUIdelInes > 2: health comPonent
ß0X 27
Shlrley llves ln a vlllage ln Guyana. She ls bllnd and because of thls her mother was afrald
to allow her to go outslde the house alone, fearful that she would hurt herself. when C8P
volunteers vlslted Shlrley’s house, they talked to her mother and sald that lt was posslble
to teach Shlrley how to move outslde lndependently. |t was dlm cult to convlnce Shlrley’s
mother. The C8P volunteer asked Paullne, a C8P reglonal coordlnator, to vlslt the house. As
Paullne was bllnd herself, the C8P volunteer thought that she would be a good example
and motlvator for both Shlrley and her mother. Shlrley’s mother agreed and a rehabllltatlon
plan was made to facllltate greater functlonal lndependence for Shlrley. Shlrley made rapld
progress and ls now able to move around her communlty lndependently wlth the help of a
whlte cane. She has become an actlve member of the local C8P commlttee and a member
of the dlsabled people’s organlzatlon.
Learning to view life diferently
Guyana Guyana
Facilitate environmental modifcations
Lnvlronmental modlñcatlons may be necessary to lmprove the functlonal lndependence
of a person wlth a dlsablllty. C8P personnel may facllltate envlronmental modlñcatlons at
an lndlvldual level (ln the home), e.g. ramps for wheelchalr access, handralls near steps,
tollet adaptatlons and wldenlng doorways, or at communlty level, e.g. modlñcatlon of
the school envlronment, publlc bulldlngs or work places (see Asslstlve devlces element).
ß0X 28
An elderly grandmother ln the vlllage of Thal 8lnh, vlet Nam, had dlabetes and low vlslon.
She needed to go to the tollet frequently, especlally durlng the nlght, and as the tollet was
outslde ln the courtyard she had to wake a famlly member to accompany her. A volunteer
from the local C8P programme advlsed the famlly to ñx a cord from her bed to the tollet, so
that durlng the nlght she could follow the cord to the tollet wlthout
waklng her famlly. A slmple envlronmental modlñcatlon ensured thls
grandmother’s lndependence.
A grandmother fnds her way
vlet Nam vlet Nam
rehaBIlItatIon 55
Link to self-help groups
C8P programmes promote self-help groups where people wlth slmllar lmpalrments or
slmllar rehabllltatlon needs come together to share lnformatlon, ldeas and experlences.
C8P programmes can encourage lnteractlons between these groups and rehabllltatlon
professlonals to enable mutual understandlng and collaboratlon.
ß0X 29
A C8P programme ln a poor area of Greater Mumbal, |ndla, often lnvolves stan from
rehabllltatlon lnstltutlons as tralners and teachers for C8P personnel. The C8P programme
found that many famllles wlth people wlth dlsabllltles were afrald of golng to referral
hospltals for e.g. ear, nose and throat (LNT), or ophthalmology care. So vlslts to referral
hospltals were organlzed for small groups of people wlth dlsabllltles and thelr famlly
members, to explaln how these hospltals worked and how people could access the dlnerent
servlces. Some professlonals from the hospltals were lnvlted to cultural events organlzed by
the C8P programme and glven communlty recognltlon for thelr support. Many speclallzed
hospltals agreed to charge subsldlzed fees for people referred by the C8P programme.
Recognising the support of hospitals
|ndla |ndla
Develop and distribute resource materials
Dlsablllty booklets and manuals can be a useful tool for rehabllltatlon. These resources
can be used by C8P personnel and by people wlth dlsabllltles and thelr famlly members
to gulde rehabllltatlon, partlcularly where access to rehabllltatlon professlonals ls llm-
lted. These resources may also provlde valuable lnformatlon for the wlder communlty as
well as the many dlnerent servlces and sectors lnvolved ln rehabllltatlon actlvltles. The
followlng C8P actlvltles are suggested.

Locate exlstlng resource materlals. These may be avallable through government
mlnlstrles, Unlted Natlons bodles, dlsabled people’s organlzatlons or natlonal and
lnternatlonal nongovernmental organlzatlons, and many can be accessed from the
|nternet, e.g. Training in the community for people with disabilities (32) and Disabled
village children (33).

Adapt materlals to sult local requlrements, glvlng speclal conslderatlon to cultural
dlnerences.

Translate exlstlng materlals lnto natlonal and/or local languages.

where exlstlng resources are not avallable, develop new materlals ln slmple language
to sult local needs.

Dlstrlbute resource materlals to all C8P personnel to carry wlth them when vlsltlng
people wlth dlsabllltles for rehabllltatlon.
56 cBr gUIdelInes > 2: health comPonent

Create resource unlts where materlals for people wlth dlsabllltles, famlly members
and other members of the communlty are avallable. The unlts may be located ln the
local development om ce, communlty health centre, or speclñc centres for people
wlth dlsabllltles.
ß0X 30
A C8P programme ln vlet Nam translated several exlstlng publlcatlons, lncludlng the
wHO C8P manual, lnto vletnamese to use for local purposes. |n addltlon they developed
thelr own materlals on speclñc concerns for people wlth dlsabllltles and thelr careglvers.
Health workers are always provlded wlth two coples of any resource materlal – one copy for
themselves and one copy for the people they are vlsltlng.
Translating resources into Vietnamese
vlet Nam vlet Nam
Provide training
C8P personnel need tralnlng to ensure they are able to facllltate access to rehabllltatlon
servlces and provlde approprlate servlces at communlty level. Many organlzatlons have
developed sultable tralnlng programmes. C8P personnel requlre a good understand-
lng of the role of rehabllltatlon personnel, e.g. physlotheraplsts, occupatlonal theraplsts,
speech theraplsts, audlologlsts, moblllty tralners, prosthetlsts/orthotlsts, medlcal and
paramedlcal personnel and of how they can be of beneñt to people wlth dlnerent
lmpalrments. C8P can also provlde educatlon to rehabllltatlon personnel to ralse thelr
awareness of the role of C8P and how lt can help them optlmlze thelr servlces (see
Management).
assIstIve devIces 57
Assistive devices
Introduction
Asslstlve devlces are external devlces that are deslgned, made, or adapted to asslst a
person to perform a partlcular task. Many people wlth dlsabllltles depend on asslstlve
devlces to enable them to carry out dally actlvltles and partlclpate actlvely and produc-
tlvely ln communlty llfe.
The Conventlon on the Plghts of Persons wlth Dlsabllltles, Artlcles 4, 20 and 26, asks
States to promote the avallablllty of approprlate devlces and moblllty alds and provlde
accesslble lnformatlon about them (2). The Standard Pules on the Lquallzatlon of Oppor-
tunltles for Persons wlth Dlsabllltles also call upon States to support the development,
productlon, dlstrlbutlon and servlclng of asslstlve devlces and equlpment and the dls-
semlnatlon of knowledge about them (23).
|n many low-lncome and mlddle-lncome countrles, only 5–l5% of people who requlre
asslstlve devlces and technologles have access to them (34). |n these countrles, produc-
tlon ls low and often of llmlted quallty, there are very few tralned personnel and costs
may be prohlbltlve.
Access to asslstlve devlces ls essentlal for many people wlth dlsabllltles and ls
an lmportant part of any development strategy. wlthout asslstlve devlces, peo-
ple wlth dlsabllltles may never be educated or able to work, so the cycle of
poverty contlnues. |ncreaslngly, the beneñts of asslstlve devlces are also belng
recognlzed for older people as a health promotlon and preventlon strategy.
58 cBr gUIdelInes > 2: health comPonent
ß0X 31
Communlty 8ased Pehabllltatlon 8lratnagar (C8P8) ls a nongovernmental organlzatlon
that has been worklng ln the eastern reglon of Nepal slnce :ooo. Currently lt ls worklng ln a:
vlllages of the Morang Dlstrlct and ln 8lratnagar Submunlclpallty, provldlng rehabllltatlon
servlces to more than +ooo chlldren and adults wlth dlsabllltles.
|n :oo;, C8P8 started a small orthopaedlc workshop to carry out mlnor repalrs of asslstlve
devlces, as many people wlth dlsabllltles had to travel to the capltal or nelghbourlng |ndla
for repalrs. Over tlme, C8P8 worked towards establlshlng a fully equlpped orthopaedlc
workshop. worklng ln partnershlp wlth Handlcap |nternatlonal (Nepal) they developed
a comprehenslve servlce whlch lncluded the fabrlcatlon, provlslon and repalr of asslstlve
devlces. Local people (women and men, wlth and wlthout dlsabllltles) were tralned as
technlclans ln Nepal and |ndla and lntegrated lnto the exlstlng C8P8 team. C8P8 now
provldes quallty orthoses (e.g. callpers, braces, spllnts), prostheses (e.g. artlñclal legs
and hands) and moblllty devlces (e.g. crutches, trlcycles, wheelchalrs) to people llvlng
wlth dlsabllltles ln :6 dlstrlcts of eastern Nepal. C8P personnel, theraplsts and workshop
technlclans all work hand-ln-hand to enhance the quallty of llfe of people wlth dlsabllltles.
One of the people to have beneñted from the orthopaedlc workshop ls Chandeswar.
He ls a rlckshaw-puller who worked hard untll he sunered an lnìury and had hls left leg
amputated. He lost hls lncome because he was no longer able to work as a rlckshaw-puller
and he lost hls savlngs because he needed to pay for hls medlcal care. Chandeswar was
ldentlñed by the C8P8 team worklng ln hls vlllage, who ñtted
hlm wlth a below-knee prosthesls and provlded rehabllltatlon
to ensure he was able to walk well wlth hls artlñclal leg and
learn how to pedal hls rlckshaw agaln. Now Chandeswar
ls back pedalllng hls rlckshaw around the busy streets of
8lratnagar and maklng a reasonable llvlng.
Seelng the beneñt to people such as Chandeswar, the
Presldent of C8P8 says: “we were carrylng out C8P for
many years but slnce we started provldlng quallty
asslstlve devlces we have become more enectlve,
our credlblllty has gone up and now we have a
great acceptance ln the communlty”.
Being able to work again
Nepal Nepal
assIstIve devIces 59
Goal
People wlth dlsabllltles have access to approprlate asslstlve devlces that are of good
quallty and enable them to partlclpate ln llfe at home and work and ln the communlty.
The role of CBR
The role of C8P ls to work wlth people wlth dlsabllltles and thelr famllles to determlne
thelr needs for asslstlve devlces, facllltate access to asslstlve devlces and ensure maln-
tenance, repalr and replacement when necessary.
Desirable outcomes

C8P personnel are knowledgeable about asslstlve devlces, lncludlng the types avall-
able, thelr functlonallty and sultablllty for dlnerent dlsabllltles, baslc fabrlcatlon,
avallablllty wlthln communltles and referral mechanlsms for speclallzed devlces.

People wlth dlsabllltles and thelr famllles are knowledgeable about asslstlve devlces
and make lnformed declslons to access and use them.

People wlth dlsabllltles and thelr famllles are provlded wlth tralnlng, educatlon and
follow-up to ensure they use and care for thelr asslstlve devlces approprlately.

Local people, lncludlng people wlth dlsabllltles and thelr famllles, are able to fabrlcate
baslc asslstlve devlces and undertake slmple repalrs and malntenance.

8arrlers preventlng access to asslstlve devlces, such as lnadequate lnformatlon, ñnan-
clal constralnts and centrallzed servlce provlslon, are reduced.

Lnvlronmental factors are addressed to enable lndlvlduals to use thelr asslstlve devlces
ln all locatlons where they are needed.
Key concepts
Common types of assistive device
Asslstlve devlces range from slmple, low-technology devlces (e.g. walklng stlcks or
adapted cups), to complex, hlgh-technology devlces (e.g. speclallzed computer soft-
ware/hardware or motorlzed wheelchalrs). |t ls helpful to conslder thls wlde varlety of
asslstlve devlces under dlnerent categorles.
60 cBr gUIdelInes > 2: health comPonent
Mobility devices
Moblllty devlces asslst people to walk or move and may lnclude:

wheelchalrs

trlcycles

crutches

walklng stlcks/canes

walklng frames/walkers.
Moblllty devlces may have speclallzed features to accommodate the needs of the user.
Por example, a person wlth cerebral palsy may requlre a wheelchalr wlth trunk/head sup-
ports to ensure he/she ls able to malntaln a good slttlng posltlon. The wHO guldellnes
on Provision of manual wheelchairs in less resourced settings (35) are a useful reference for
those people lnvolved ln the deslgn, productlon and dlstrlbutlon of wheelchalrs.
Positioning devices
People wlth physlcal lmpalrments often have dlmculty malntalnlng good lylng, standlng
or slttlng posltlons for functlonal actlvltles and are at rlsk of developlng deformltles due to
lmproper posltlonlng. The followlng devlces can help overcome some of these dlmcultles:

wedges

chalrs, e.g. corner chalrs, speclal seats

standlng frames.
Prosthetics, orthotics and orthopaedic shoes
These are usually custom-made devlces whlch replace, support or correct body parts.
They are deslgned, manufactured and ñtted ln speclallzed workshops or centres by
tralned prosthetlc/orthotlcs personnel and lnclude:

prostheses, e.g. artlñclal legs or hands

orthoses, e.g. splnal braces, hand/leg spllnts or calllpers

orthopaedlc shoes.
Daily living devices
These devlces enable people wlth dlsabllltles to complete the actlvltles of dally llvlng
(e.g. eatlng, bathlng, dresslng, tolletlng, home malntenance). There are many examples
of these devlces, lncludlng:

adapted cutlery and cups

shower seats and stools

tollet seats and frames

commodes

dresslng stlcks.
assIstIve devIces 6l
Vision devices
Low vlslon or bllndness has a great lmpact on a person’s ablllty to carry out lmportant
llfe actlvltles. A range of devlces (slmple to complex) can be used to maxlmlze partlclpa-
tlon and lndependence, lncludlng:

large prlnt books

magnlñers

eyeglasses/spectacles

whlte canes

brallle systems for readlng and wrltlng

audlo devlces, e.g. radlos, talklng books, moblle phones

screen readers for computers, e.g. 1AwS (1ob Access wlth Speech) ls a screen reader
programme.
Hearing devices
Hearlng loss anects a person’s ablllty to communlcate and lnteract wlth others: lt can
lmpact on many areas of development, e.g. speech and language and restrlcts educa-
tlonal and employment opportunltles, resultlng ln soclal dlscrlmlnatlon and lsolatlon.
Devlces lnclude:

hearlng alds

headphones for llstenlng to the televlslon

ampllñed telephones

TT¥/TTD (telecommunlcatlon devlces)

vlsual systems to provlde cues, e.g. a llght when the doorbell ls rlnglng.
ß0X 32
Anna ls a mother who llves ln Last Seplk provlnce of Papua New Gulnea. Her daughter Korls
was born deaf. Anna was very determlned to send her daughter to school and, through a
C8P worker tralned by Callan Servlces for Dlsabled Persons (a natlonal nongovernmental
organlzatlon), Anna became aware of a nursery school for deaf chlldren. 8efore attendlng
thls school, Callan Servlces arranged for the provlslon of hearlng alds: ear mould
lmpresslons were taken for Korls and when the hearlng alds were ready to be ñtted she
was sent to an audlologlst ln Port Moresby. Korls started attendlng school and also began
learnlng slgn language. wlth the help from asslstlve devlces and wlth the support of her
teachers, Korls soon became one of the top puplls ln her class.
Top of the class
Papua New Gulnea Papua New Gulnea
62 cBr gUIdelInes > 2: health comPonent
Communication devices
Augmentatlve and alternatlve communlcatlon devlces can asslst lndlvlduals who have
dlmculty understandlng and produclng speech. They are provlded to support speech
(augmentatlve), or to compensate for speech (alternatlve). Devlces lnclude:

communlcatlon boards wlth plctures, symbols or letters of the alphabet

request cards

electronlc speech output devlces

computers wlth speclallzed equlpment and programmes.
Cognitive devices
Cognltlon ls the ablllty to understand and process lnformatlon. |t refers to the mental
functlons of the braln such as memory, plannlng and problem-solvlng. 8raln lnìurles,
lntellectual lmpalrment, dementla and mental lllness are some of the many condltlons
that may anect an lndlvldual’s cognltlve ablllty. The followlng devlces can asslst lndlvldu-
als to remember lmportant tasks/events, manage thelr tlme and prepare for actlvltles:

llsts

dlarles

calendars

schedules

electronlc devlces, e.g. moblle phones, pagers, personal organlzers.
Selection of assistive devices
Appropriate technology
Many types of technology are not sultable for rural/remote areas and low-lncome coun-
trles. However, “approprlate technology” ls deslgned wlth conslderatlon glven to the
envlronmental, cultural, soclal and economlc factors that lnnuence communltles and
lndlvlduals. Approprlate technology meets people’s needs: lt uses local skllls, tools and
materlals and ls slmple, enectlve, anordable and acceptable to lts users. Asslstlve devlces
are technologles that must be carefully deslgned, produced and selected to ensure they
meet these crlterla.
assIstIve devIces 63
ß0X 33
The Asslsl Leprosy and C8P programme ln Andhra Pradesh, |ndla provlded sandals made of
black mlcrocellular rubber to people wlth leprosy who had lost sensatlon ln thelr feet and
were at rlsk of foot ulcers. |t became obvlous that many people who were provlded wlth
these sandals dld not use them. After talklng wlth these people, lt was dlscovered that by
wearlng the sandals they were subìect to soclal stlgma – the black sandals had become
easlly ldentlñable ln the communlty as shoes that only people wlth leprosy wore. As a result
the programme declded to use sandals avallable from the local market, modlfylng them
as necessary to sult the requlrements of people wlth leprosy. People began wearlng the
footwear as there was llttle vlslble dlnerence between thelr sandals and those that other
communlty members wore.
Wearing the same shoes
|ndla |ndla
Assessment
Asslstlve devlces need to be carefully selected and often speclally made and ñtted to
ensure they meet the lndlvldual’s needs. Poor selectlon and deslgn can lead to many
problems lncludlng frustratlon, dlscomfort and the development of secondary condl-
tlons. Por example, lt may be common practlce ln some countrles to dlstrlbute donated
or second-hand wheelchalrs on a large scale. whlle thls may have beneñts, lt also has the
potentlal to cause harm to users, e.g. the provlslon of a wheelchalr wlthout a cushlon to
a person wlth a splnal cord lnìury may cause a potentlally llfe-threatenlng pressure area
(see Preventlon element).
Comprehenslve assessment ls necessary to ensure asslstlve devlces meet the needs of
lndlvlduals wlthln thelr homes, schools and work and communlty envlronments. A com-
prehenslve assessment mlght lnclude a medlcal hlstory, a revlew of current functlon,
lndlvldual goals, an evaluatlon of exlstlng asslstlve devlces and a physlcal examlnatlon.
The approach to assessment should be multldlsclpllnary where posslble and lnclude
a wlde varlety of people, such as people wlth dlsabllltles, famlly members, theraplsts,
technlclans, teachers and C8P personnel.
64 cBr gUIdelInes > 2: health comPonent
Use of assistive devices
Barrier-free environments
Many people use thelr asslstlve devlces ln dlnerent places and lt ls lmportant to ensure
that all envlronments are barrler-free ln order for someone to achleve maxlmum func-
tlon and lndependence. Por example, a young woman uslng a wheelchalr must be able
to use lt to enter/exlt her home, move freely wlthln her home and access lmportant areas
(e.g. the bathroom), travel wlthln her communlty and access her workplace.
Adaptatlons/modlñcatlons to the physlcal envlronment lnclude lnstalllng a ramp where
there are steps, wldenlng a narrow doorway, reorganlzlng furnlture to lncrease the
amount of space for movement. |t ls also lmportant to conslder other aspects of the
envlronment, e.g. attltudes and support systems, whlch can also lnnuence a person’s
ablllty to use the devlce. Por example, a young boy who uses a communlcatlon board
lnstead of speech wlll need to use hls board both at home and at school, so lt ls lmpor-
tant that famlly members, schoolteachers and frlends are posltlve, wllllng and able to
use thls devlce wlth hlm.
when conslderlng envlronmental modlñcatlons, partlcularly wlthln the communlty, lt ls
helpful to conslder “unlversal deslgn” (36). Unlversal deslgn means deslgnlng products,
envlronments, programmes and servlces to be usable by all people (2), both wlth and
wlthout dlsabllltles.
ß0X 34
|n a vlllage ln the Thal 8lnh dlstrlct of vlet Nam, C8P volunteers motlvated communlty
members to lmprove the local brldge so that people uslng wheelchalrs as well as others
could pass over lt comfortably.
Bridging the community
vlet Nam vlet Nam
Suggested activities
Train CBR personnel
C8P personnel requlre tralnlng on asslstlve devlces to ensure that they are able to pro-
vlde accurate lnformatlon, referral and educatlon. Tralnlng may be speclñc, or lt may be
part of a course on rehabllltatlon. C8P personnel need knowledge about:

the common types of asslstlve devlce:

the purpose and functlon of asslstlve devlces:
assIstIve devIces 65

whlch baslc devlces can be prepared ln the communlty, e.g. crutches:

where speclallzed devlces, e.g. prostheses and hearlng alds, are avallable:

referral mechanlsms, to enable access to speclallzed devlces:

the fundlng optlons avallable for people who are unable to anord devlces.
Practlcal tralnlng ls also essentlal, partlcularly for C8P personnel who work ln rural/
remote areas, to ensure they can produce baslc asslstlve devlces and develop the skllls
and conñdence to work dlrectly wlth lndlvlduals who need the devlces. Por example,
C8P personnel may need to:

show a famlly how to bulld a wooden chalr wlth a strap to enable a chlld wlth poor
balance to slt uprlght:

show a famlly how to bulld parallel bars to enable walklng practlce at home:

show a famlly how to make a slmple walklng stlck for a person recoverlng from a stroke
to asslst her/hlm ln walklng:

teach a chlld wlth cerebral palsy, wlth no speech or coordlnated hand movement, how
to use a plctorlal communlcatlon board uslng her/hls eyes:

provlde lnstructlon to a bllnd person on the use of her/hls whlte cane.
ß0X 3S
The C8P programme ln South Sulawesl, |ndonesla, prepared an Asslstlve Devlce Pesource
Sheet llstlng the maln servlce provlders ln the provlnce who are able to supply and
repalr devlces. Thls resource sheet ls dlstrlbuted to all C8P personnel, ensurlng accurate
lnformatlon ls always avallable for people wlth dlsabllltles llvlng ln vlllages.
Information where it’s needed
|ndonesla |ndonesla
Build capacity of individuals and families
C8P personnel need to work closely wlth people wlth dlsabllltles and thelr famlly mem-
bers to ensure that they are:

aware of the dlnerent types of asslstlve devlce and how these can asslst lndlvlduals
to achleve lndependence and partlclpatlon:

lnvolved ln declslon-maklng regardlng the selectlon and deslgn of asslstlve devlces
– provldlng opportunltles for people to see and try asslstlve devlces wlll asslst them
to make lnformed declslons:

able to use thelr asslstlve devlces properly and safely and are able to perform repalrs
and malntenance to ensure long-term use:

able to glve feedback to referral servlces about any dlm cultles experlenced so that
adìustments can be made and dlnerent optlons consldered.
66 cBr gUIdelInes > 2: health comPonent
Thls health component hlghllghts the fact that self-help groups enable people to share
valuable lnformatlon, skllls and experlences. Self-help groups can be partlcularly ben-
eñclal when someone has llmlted access to rehabllltatlon personnel. Self-help groups
can support lndlvlduals to adìust to newly acqulred asslstlve devlces, educatlng them
on thelr care and malntenance and can provlde advlce on self-care, e.g. preventlon of
secondary compllcatlons and how to achleve optlmum functlon.
Train local artisans
|t ls unreallstlc to expect people llvlng ln rural
areas to travel to speclallzed centres to have thelr
devlces repalred and many people stop uslng
thelr devlces when they experlence problems.
Local artlsans can be tralned to make small repalrs
to asslstlve devlces such as orthoses, prostheses
and wheelchalrs, e.g. repalr orthoses by replac-
lng straps, screws or rlvets. C8P programmes can
ldentlfy local artlsans and facllltate thls tralnlng ln
partnershlp wlth technlclans.
Asslstlve devlces such as walklng stlcks, crutches, walk-
lng frames, standlng frames and baslc seatlng can also be produced by
local artlsans because they are slmple to make uslng locally avallable materlals. C8P pro-
grammes can ldentlfy local artlsans who are lnterested ln produclng them and facllltate
tralnlng.
ß0X 36
|n zooo, the Natlonal C8P programme ln Mongolla organlzed a tralnlng course for stan
worklng at the Natlonal Orthopaedlc Laboratory ln Ulaan 8aatar, to teach them how
to make slmple spllnts, seatlng devlces and moblllty devlces uslng local materlals and
approprlate technology. Now, whenever a C8P programme starts ln a new provlnce
of Mongolla, two local artlsans are ldentlñed and tralned at the Natlonal Orthopaedlc
Laboratory.
Learning how to make assistive devices
Mongolla Mongolla
assIstIve devIces 67
Facilitate access to assistive devices
Access to assistive devices may be limited by inadequate information, poverty, distance
and centralized service provision. CBR personnel need to work closely with people with
disabilities and their families to facilitate access to assistive devices by:

identifying existing service providers – local, regional and national – who produce
and/or supply a wide range of assistive devices (basic and specialized);

compiling detailed information on each service provider, including referral mecha-
nisms, costs and processes, e.g. administrative procedures, assessment procedures,
number of visits required for measurements and fttings and time for production;

ensuring this information is available in an appropriate format and is communicated
to people with disabilities and their families;

identifying funding options for people who are unable to aford the costs associated
with assistive devices – CBR programmes can facilitate access to existing government
or nongovernmental schemes and can raise their own funds and/or empower indi-
vidual communities to donate resources;

assisting people to complete relevant administration processes so they can obtain a
disability certifcate, which in many countries will enable them to access free devices;

partnering with referral centres, local authorities and other organizations to discuss
ways to decentralize service provision, e.g. mobile facilities;

providing transport for small groups of people from rural/remote areas to travel to
referral centres, ensuring prior arrangements are made with these centres.

providing home or community-based repair services for people living in rural/remote
areas, e.g. establish a mobile service or regular meeting point in the community for
people needing repairs to their devices.
BOX
The national disabled people’s organization in Lebanon launched a production unit for
wheelchairs and other assistive devices such as crutches, walkers, toilet chairs, orthopaedic
shoes and specialized seating systems. They also created fve distribution, repair and
maintenance workshops around the country to facilitate access to these devices. The
production unit and repair workshops employ people with disabilities. The disabled
people’s organization has also ensured an adequate national budget for assistive devices.
CBR programmes can now refer people who need assistive devices to these centres to
access assistive devices.
Accessing assistive devices
Lebanon Lebanon
Set up small-scale workshops
When referral services are not available, or barriers such as cost and distance cannot
be overcome, CBR programmes can consider setting up and/or supporting a small
68 cBr gUIdelInes > 2: health comPonent
workshop to meet local needs. Slmple devlces can be produced by locally tralned peo-
ple. 8oth the wHO CBR manual (32) and Disabled village children (33) provlde lnformatlon
about maklng asslstlve devlces ln the communlty uslng local resources.
ß0X 38
Cumura Hospltal ln Gulnea-8lssau has a small workshop for preparlng orthoses and two
people wlth dlsabllltles have been tralned as orthopaedlc technlclans to work here. Plndlng
approprlate materlals ls often a problem and lmportlng materlals ls very costly, therefore
the technlclans try to ñnd local solutlons for deslgns from other workshops. Por example
they have started to make a leather and plastlc spllnt for persons wlth foot-drop.
Finding local solutions
Gulnea-8lssau Gulnea-8lssau
People wlth dlsabllltles can also be tralned to make asslstlve devlces. Thls can generate
lncome and lead to thelr recognltlon as actlve contrlbutors to thelr communltles, to the
development of soclal networks and ultlmately to empowerment.
ß0X 39
Several C8P programmes ln 8angalore, |ndla, ldentlñed a group of :o young women
wlth dlsabllltles. All of these women faced dlsadvantages and dlscrlmlnatlon because
they were poor, uneducated, female and dlsabled – they were all seen as llabllltles wlthln
thelr famllles and communltles. |n :oo8 the :o women tralned as orthopaedlc technlclans
and were provlded wlth a loan from one of the C8P programmes to open a commerclal
workshop. Llfe has changed for the women slnce they started thelr buslness (Pehabllltatlon
Alds workshop by women wlth Dlsabllltles). The workshop started maklng a proñt from
the second year and by the end of the fourth year they had repald the whole loan. They
extended thelr buslness by becomlng
agents for several maìor companles that
manufactured asslstlve devlces and health-
care products and by establlshlng llnks
wlth maìor prlvate hospltals ln the clty. The
women are now earnlng good lncomes, have
good quallty of llfe and are seen as actlve
contrlbutors to thelr communltles. They are
marrled, are assets to thelr famllles and are
role models for many people wlth dlsabllltles.
Making a small business work
|ndla |ndla
assIstIve devIces 69
Network and collaborate
|n some countrles lt may not be feaslble to establlsh servlces that provlde a wlde range
of asslstlve devlces. Thls may be due to government prlorltles, llmlted resources, or
small populatlons. 8ut many asslstlve devlces wlll be avallable ln nelghbourlng coun-
trles, where they are llkely to be cheaper and easler to access than lmportlng them from
hlgh-lncome countrles. C8P programmes need to determlne what resources are avall-
able ln nelghbourlng countrles and collaborate wlth these countrles where posslble. |n
addltlon, C8P programmes need to develop strong llnks wlth lnternatlonal and natlonal
nongovernmental organlzatlons who are often actlve ln produclng and provldlng assls-
tlve devlces wlth a vlew to the development of sustalnable servlce provlslon.
Address barriers in the environment
very often there are barrlers ln the home, school, work or communlty envlronments that
make lt dlmcult for people to use thelr asslstlve devlces. C8P personnel requlre practlcal
knowledge regardlng these barrlers so they can work wlth lndlvlduals, famlly members,
communltles and local authorltles to ldentlfy and address them.
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assIstIve devIces 7l
28. Disability, including prevention, management and rehabilitation (world Health Assembly Pesolutlon
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29. Albrecht GL et al., eds. Encyclopedia of disability, vol. 2. Thousand Oaks, CA, Sage Publlcatlons, 2006.
30. Drum CD et al. Pecognlzlng and respondlng to the health dlsparltles of people wlth dlsabllltles.
Californian Journal of Health Promotion, 2005, 3(3):29–42 (www.csuchlco.edu/cìhp/3/3/29–42-drum.
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Recommended reading
A health handbook for women with disabilities. 8erkeley, CA, Hesperlan Poundatlon, 2007 (www.hesperlan.
org/publlcatlons_download.php, accessed 30 May 20l0).
Guideline for the prevention of deformities in polio. Geneva, world Health Organlzatlon, l990 (www.who.
lnt/dlsabllltles/publlcatlons/care/en/, accessed 30 May 20l0).
Hartley S (ed.). CBR as part of community development: a poverty reduction strategy. London, Unlverslty
College London Centre for |nternatlonal Chlld Health, 2006.
Hartley S, Okune 1 (eds.). CBR: inclusive policy development and implementation. Norwlch, Unlverslty of
Last Anglla, 2008.
Helnlcke-Motsch K, Sygall S (eds.). Building an inclusive development community: a manual on including
people with disabilities in international development programmes. Lugene, OP, Moblllty |nternatlonal, 2003.
Helping children who are blind. 8erkeley, CA, Hesperlan Poundatlon, 2000 (www.hesperlan.org/publlcatlons_
download.php, accessed 30 May 20l0).
Helping children who are deaf. 8erkeley, CA, Hesperlan Poundatlon, 2004 (www.hesperlan.org/publlcatlons_
download.php, accessed 30 May 20l0).
Integrating mental health into primary care: a global perspective. Geneva, world Health Organlzatlon/world
Organlzatlon of Pamlly Doctors (wonca), 2008 (www.who.lnt/mental_health/resources/mentalhealth_
PHC_2008.pdf, accessed 30 May 20l0).
Let’s communicate: a handbook for people working with children with communication difculties. Geneva,
world Health Organlzatlon, l997 (www.who.lnt/dlsabllltles/publlcatlons/care/en/, accessed 30 May 20l0).
Promoting independence following a spinal cord injury: a manual for mid-level rehabilitation workers. Geneva,
world Health Organlzatlon, l996 (www.who.lnt/dlsabllltles/publlcatlons/care/en/, accessed 30 May 20l0).
Promoting independence following a stroke: a guide for therapists and professionals working in primary health
care. Geneva, world Health Organlzatlon, l999 (www.who.lnt/dlsabllltles/publlcatlons/care/en/, accessed
30 May 20l0).
72 cBr gUIdelInes > 2: health comPonent
Promoting the development of infants and young children with spina bifda and hydrocephalus: a guide for
mid-level rehabilitation workers. Geneva, world Health Organlzatlon, l996 (www.who.lnt/dlsabllltles/
publlcatlons/care/en/, accessed 30 May 20l0).
Promoting the development of young children with cerebral palsy: a guide for mid-level rehabilitation workers.
Geneva, world Health Organlzatlon, l993 (www.who.lnt/dlsabllltles/publlcatlons/care/en/, accessed 30
May 20l0).
Rehabilitation for persons with traumatic brain injuries. Geneva, world Health Organlzatlon, 2004 (www.
who.lnt/dlsabllltles/publlcatlons/care/en/, accessed 30 May 20l0).
Where there is no doctor. 8erkeley, CA, Hesperlan Poundatlon, l992 (www.hesperlan.org/publlcatlons_
download.php, accessed 30 May 20l0).
The relationship between prosthetics and orthotics services and community based rehabilitation (CBR): a joint
ISPO/WHO statement. Geneva, wHO/|nternatlonal Soclety for Prosthetlcs and Orthotlcs (|SPO), 2003 (www.
who.lnt/dlsabllltles/technology/po_servlces_cbr.pdf, accessed 30 May 20l0).
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World Health Organization
Avenue Appia 20
1211 Geneva 27
Switzerland
Telephone: + 41 22 791 21 11
Facsimile (fax): + 41 22 791 31 11
ENGLISH
ISBN 978 92 4 154805 2
CBR MATRIX
HEALTH EDUCATION LIVELIHOOD SOCIAL EMPOWERMENT
Skills
development
Social
protection
Disabled
people’s
organizations
Personal
assistance
Relationships,
marriage and
family
Advocacy and
communication
Medical care
Secondary and
higher
Wage
employment
Culture and arts
Political
participation
Prevention Primary
Self-
employment
Rehabilitation Non-formal
Lifelong learning
Financial
services
Recreation,
leisure and sports
Self-help groups
Assistive
devices
Justice
Community
mobilization
Promotion Early childhood

WHO Library Cataloguing-in-Publication Data community-based rehabilitation: cBr guidelines. 1.rehabilitation. 2.disabled persons. 3.community health services. 4.health policy. 5.human rights. 6.social justice. 7.consumer participation. 8.guidelines. I.world health organization. II.Unesco. III.International labour organisation. Iv.International disability development consortium. IsBn 978 92 4 154805 2 © World Health Organization 2010 all rights reserved. Publications of the world health organization can be obtained from who Press, world health organization, 20 avenue appia, 1211 geneva 27, switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). requests for permission to reproduce or translate who publications – whether for sale or for noncommercial distribution – should be addressed to who Press, at the above address (fax: +41 22 791 4806; e-mail: permissions@who.int). the designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the world health organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. dotted lines on maps represent approximate border lines for which there may not yet be full agreement. the mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the world health organization in preference to others of a similar nature that are not mentioned. errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. all reasonable precautions have been taken by the world health organization to verify the information contained in this publication. however, the published material is being distributed without warranty of any kind, either expressed or implied. the responsibility for the interpretation and use of the material lies with the reader. In no event shall the world health organization be liable for damages arising from its use. design and layout by Inís communication – www.iniscommunication.com Printed in malta (nlm classification: wB 320)

cBr guidelines Health component
Table of contents:
Preamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Health promotion . . . . . . . . . . . . . . . . . . . . . . . 11 Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Medical care . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Assistive devices . . . . . . . . . . . . . . . . . . . . . . . . 57

.

The right to health is not only about access to health services. access to essential medicines. medical care. including health-related rehabilitation (2). These freedoms include the right to be free from nonconsensual medical treatment such as experiments and research and the right to be free from torture or other cruel. CBR facilitates inclusive health by working with the health sector to ensure access for all people with disabilities. community-based and participatory (6). Although CBR has historically focused on the health sector. economic or social condition” (1). treatment and control of diseases. Unfortunately. religion. adequate sanitation and housing. prevention. PreamBle 1 . as health is influenced by many factors. such as education and employment. working across five key areas: health promotion. Given the size of the topic of health. together with Articles 20 (accessibility) and 26 (habilitation and rehabilitation). The Constitution of the World Health Organization (WHO) states that “enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race. outlines measures States Parties should undertake to ensure that people with disabilities are able to access health services that are gender-sensitive. it is also about access to the underlying determinants of health. The health-related entitlements include the right to a system of health protection. The United Nations Convention on the Rights of Persons with Disabilities (CRPD) addresses the right to health for people with disabilities. political belief. advocating for health services to accommodate the rights of people with disabilities (5) and be responsive. evidence shows that people with disabilities often experience poorer levels of health than the general population (3) and face various challenges to the enjoyment of their right to health (4). the right to prevention. and participation in health-related decision-making (4). The right to health also contains freedoms and entitlements.Preamble The right to health without discrimination is captured in various international instruments. rehabilitation and assistive devices. this component focuses primarily on those CBR activities that take place within the health sector. inhuman or degrading treatments. such as safe drinking water. there is a need for multisectoral collaboration and inclusion (7) and for CBR programmes to work across many different sectors. Community-based rehabilitation (CBR) programmes support people with disabilities in attaining their highest possible level of health. Article 25 requires States to “recognize that persons with disabilities have the right to the enjoyment of the highest attainable standard of health without discrimination of disability” and.

nurses and health workers. a pharmacist. this team mostly carried out general health promotion and prevention activities. In many provinces. Overall. including early identification of people with disabilities and early intervention. The major focus of CBR was to provide health services for people with disabilities on their “doorsteps”. primary health care is based around networks of satellite units called primary care units. Before CBR was introduced. mobility and communication skills. A  evaluation concluded that the CBR programme had been effective in providing a range of health-care services for people with disabilities and their families. enabling people to avoid unnecessary and costly travel.e. Parents of children with disabilities have also been provided with better support. However. The multidisciplinary approach has ensured that all people with disabilities are able to access health care and rehabilitation services in their communities as well as referral services at Sichon Hospital when needed. Home visits are conducted on a regular basis by members of the Tha-Hin team and a physical therapist from Sichon Hospital. which are connected to and supported by large central hospitals. the team also became responsible for identifying people with disabilities and addressing both their general and their specific health-care needs. In . 2 cBr gUIdelInes > 2: health comPonent . over time.BOX Thailand Taking health services to the community Thailand has a long and successful history of primary health care which. has evolved through many innovative strategies and activities. A protocol was also established for home-based rehabilitation. Local volunteers and family members were trained to provide basic rehabilitation (i. Good working relationships have been established between all key stakeholders (Sichon Hospital. A home health-care scheme was established (which is also for older people and people with chronic health conditions). The Tha-Hin primary care unit is part of this network. Sichon Hospital. providing a direct link to Sichon Hospital. It is located in a rural area and has a team of health personnel including a family doctor. health promotion and rehabilitation including functional training and provision of assistive devices. introduced community-based rehabilitation (CBR) to their network of primary care units. quality of life has been enhanced for all people with disabilities with improvements in their independence. one of these hospitals. daily living skills training) to people with disabilities and were encouraged to promote inclusive education for children with disabilities. with the addition of CBR. the primary care unit and the community) and inclusion of local volunteers and mobilization of other resources have created a sense of community empowerment and ownership.

There is improved collaboration across all development sectors. mental and social well-being and not merely the presence of disease or infirmity” (1). PreamBle 3 .Goal People with disabilities achieve their highest attainable standard of health. However. livelihood and social sectors. People with disabilities and their family members have access to health-care and rehabilitation services. medical care. rehabilitation and assistive devices. Health is a valuable resource that enables people to lead individually. as defined by WHO. Key concepts Health What is health? Health has traditionally been defined as the absence of disease and illness. it is a much broader concept – it is “a state of complete physical. The health sector is aware that people with disabilities can achieve good health and does not discriminate on the basis of disability and other factors such as gender. socially and economically productive lives. Desirable outcomes • People with disabilities and their family members have improved knowledge about • • • • their health and are active participants in achieving good health. to achieve good health for people with disabilities. preferably in or close to their communities and at affordable cost. CBR also needs to work with individuals and their families to facilitate their access to health services and to work with other sectors to ensure that all aspects of health are addressed. learn and engage actively in family and community life. The role of CBR The role of CBR is to work closely with the health sector to ensure that the needs of people with disabilities and their family members are addressed in the areas of health promotion. prevention. including education. providing them with the freedom to work. Health and rehabilitation interventions enable people with disabilities to become active participants in family and community life.

She may not have heard the birds sing or seen the sun. Education – low education levels are linked with poor health. eating meals with her family and playing with toys. Individual behaviours and lifestyle – diet. activity. but with the support of the CBR programme they are working towards the full inclusion of Khurshida in the life of her community. social and environmental factors. healthiness and the likelihood of developing certain illnesses. Khurshida was  years old and had spent most of her life lying in a dark corner of the family home completely isolated from her community. in Uttar Pradesh. discovering that by pulling at her mother’s sari it would make her stay a little while longer. Income and social status – the greater the gap between rich and poor people. drinking and how we deal with life’s stresses all affect health. Determinants of health A person’s health status is influenced by a wide range of personal. Khurshida began to respond positively by sitting up. particularly those who have more control over their working conditions. She began to learn the language of touch. The programme also assisted Khurshida’s mother to access treatment for tuberculosis. cBr gUIdelInes > 2: health comPonent . When Satyabhama. a CBR worker trained by Sense International India. • • • • • • • • 4 Genetics – inheritance plays a part in determining the lifespan. but the expression on her face showed that she loved the feel of the gentle fresh breeze against her face. Gender – men and women suffer from different types of diseases at different ages. met her. Social support networks – greater support from families. Satyabhama worked hard with Khurshida to teach her daily living and communication skills. smoking. India. Employment and working conditions – people in employment are healthier. With time. The CBR programme was able to help Khurshida’s family obtain a disability certificate for her. more stress and lower self-confidence.BOX India Khurshida Khurshida was born deafblind in a small village of Barabanki District. It will be a long journey for Khurshida and her family. the greater the differences in health. She was completely dependent on her mother for all her needs and was unable to communicate. Culture – customs and traditions and the beliefs of the family and community all affect health. Satyabhama was able to take Khurshida by the hand and encourage her to take her first steps outside the family home. These factors are commonly referred to as determinants of health and are outlined below (adapted from (8)). friends and communities is linked to better health. Satyabhama continues to work with Khurshida and is now teaching her sign language. which enabled access to a wide range of services. economic.

while not all people with disabilities have health problems related to their impairments. Health care Health-care provision Health care within each country is provided through the health system.g. Health services – access to and use of services influence health. cannot be controlled. Disability and health Health for All was a global health objective set by WHO during the 1978 primary health care conference in Alma-Ata. many will require specific health-care services. communities globally have yet to achieve this objective and many groups of people. families and communities and brings health care as close as possible to where people live and work (11). institutions. healthy workplaces. To ensure that people with disabilities achieve good levels of health it is important to remember that: • • people with disabilities need health services for general health-care needs (e. Some of these factors can be controlled. Thirty years later. health promotion and prevention services and medical care) like the rest of the population. including different needs in different phases of life. including rehabilitation. still experience poorer states of health than others. It is the first level of contact with the national health system for individuals. Primary health care is essential heath care made universally accessible to individuals and families at a cost they can afford.• • Physical environment – safe water and clean air. restore or maintain health. including people with disabilities. The 2008 World Health Report emphasizes the essential role of primary health care in achieving health for every person (10). communities and roads. It is estimated that only a small percentage of people with disabilities in low-income countries have access to rehabilitation and appropriate basic PreamBle 5 . While ultimate responsibility for the health system lies with the government. Instead it can be linked to difficulties in accessing services and programmes (12). such as genetics. e. resources and people whose primary purpose is to promote. traditional and informal sectors (9). which comprises all those organizations. on a regular or occasional basis and for limited or lifelong periods. private. Barriers to health-care services for people with disabilities The poor health that people with disabilities may experience is not necessarily a direct result of having a disability. all contribute to good health. a person can choose healthy or unhealthy behaviour. most health care is provided by a combination of public. safe houses.g. However other factors.

people with multiple impairments e. It refers to education that welcomes all people. many also have limited knowledge about their rights and health issues and about what health services are available. They may suffer double or multiple disadvantages. gender and/or social status (13) and so find it more difficult to access health-care services. for example due to the type of disability they have. economic barriers – health interventions such as assessments. understanding and skills to manage health issues for people with disabilities. those who are both deaf and blind. their age. the concept of inclusive health is now being promoted by CBR programmes to ensure health 6 cBr gUIdelInes > 2: health comPonent . Inclusive health “Inclusive education” has become a widely recognized concept and is increasingly being implemented in education systems throughout the world. children and older people with disabilities. or albinism (see Supplementary chapters). e. Some people with disabilities may be more vulnerable to discrimination and exclusion than others. The barriers to health-care services that people with disabilities and their family members may face include: • • • • • • absent or inappropriate policies and legislation – where policy and legislation do exist. disabilities and HIV/AIDS. as well as the limited health-care resources of rural areas (where many people with disabilities live) and the long distances to reach services in big cities. Similarly.g. be prejudiced or insensitive and lack awareness and often lack the knowledge. CBR programmes should be particularly mindful of the following groups: women. including those with disabilities. to participate fully in regular community schools or centres of learning (14) (see Education component). poor attitudes and knowledge of health workers about people with disabilities – health personnel may have inappropriate attitudes. leprosy.services (5).g. communication and information barriers – communicating with health workers may be difficult. poor knowledge and attitudes of people with disabilities about general health care and services – people with disabilities may be reluctant to use health services. they may not be implemented or enforced and can be discriminatory and/or obstructive regarding the provision of health services to people with disabilities. such as picture formats for people with intellectual impairment. mental health problems. physical and geographical barriers – lack of accessible transport and inaccessible buildings and medical equipment are examples of common barriers. treatments and medications often require out-of-pocket payments. presenting difficulties for people with disabilities and their families who are likely to have limited income for health care (see Introduction: Poverty and disability). a person who is deaf might find it difficult to communicate his/her symptoms to a doctor and health information is often not available in accessible formats. or who have intellectual impairments.

gender. colour. discriminated against. BOX Pakistan The courage to overcome barriers Muhammad Akram is from Sindh Province. nothing special” or “we will tell you later”. The following anecdote describes his experience of visiting a doctor with his family. that health care should be “… accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford…” (11). He became deaf as a teenager due to an illness. Pakistan. communication skills to accommodate the needs of people with different impairments. I feel good as I have developed self-confidence and have also helped to raise the profile of disability by educating medical professionals. I started refusing to take a family member with me to the doctor. religion and socioeconomic status.systems recognize and accommodate the needs of people with disabilities in their policies. After joining a CBR programme I slowly gained confidence and developed the courage to face the challenges myself. To ensure this. Over time I began to lose my confidence and became very dependent on others. No-one used sign language and nobody had the time or willingness to communicate with me using pen and paper. health-care service providers need to have positive attitudes towards disability and people with disabilities and have appropriate skills. or passively. And if I asked my family a question they always said “don’t worry. Some doctors still ask me to bring someone with me on my next visit but I always tell them that I am an adult. Inclusive health means that all individuals can access health care irrespective of impairment. age. race. “Being deaf I was always unaware of what they were talking about.” PreamBle 7 . one way of achieving this is by ensuring that people with disabilities and disabled people’s organizations (DPOs) are active participants in the planning and strengthening of health-care and rehabilitation services. planning and services delivery.g. If I asked the doctor a question he usually replied that he had told my family everything. This forced the doctor to communicate with me directly in writing. It builds on the primary health care “Health for All” concept. Nobody really told me anything – I just had to take the tablets. The whole environment needs to change so that nobody is actively. e.

Prevention Prevention is very closely linked with health promotion. Argentina. providing the much needed link between people with disabilities and the health-care system. Elements in this component CBR programmes recognize. Rehabilitation Rehabilitation is a set of measures which enables people with disabilities to achieve and maintain optimal functioning in their environments. e.15) and are outlined below. CBR programmes are directly linked with the health-care system – they are managed by the ministry of health and implemented through their primary health care structures. Prevention of health conditions (e. The focus of this element is mainly on primary prevention. assessment and treatment of health conditions and their resulting impairments. CBR programmes are managed by nongovernmental organizations or other government ministries. support and advocate a number of key aspects of health care for people with disabilities. In many countries. disorders. diseases. e. and in these situations close contact must be maintained with primary health care to ensure that people with disabilities can access health care and appropriate rehabilitation services as early as possible.CBR and the health sector CBR programmes can facilitate access to health care for people with disabilities by working with primary health care in the local community. secondary or tertiary level of the health-care system. economic and environmental conditions to alleviate their impacts on health. Medical care Medical care refers to the early identification.g.g. Indonesia. social welfare. The wide range of strategies and interventions available are directed at strengthening the skills of individuals and changing social. injuries) involves primary prevention (avoidance). These are consistent with best practice (5. with the aim of curing or limiting their impacts on individuals. Mongolia and Viet Nam. Health promotion Health promotion aims to increase control over health and its determinants. Medical care can take place at the primary. In other countries.g. secondary prevention (early detection and early treatment) and tertiary prevention (rehabilitation) measures. it is relevant both for those who 8 cBr gUIdelInes > 2: health comPonent .

made or adapted to assist a person to perform a particular task is known as an assistive device. Rehabilitation services range from the basic to the specialized and are provided in many different locations e.g. hand splint). replacement and environmental adaptations in the home and community. Rehabilitation is often initiated by the health sector but requires collaboration between all sectors. artificial legs). Some common types of assistive devices are: mobility devices (e. Many people with disabilities benefit from the use of one or more assistive devices.g. walking sticks.g. homes and community environments. To ensure that assistive devices are used effectively.g. Assistive devices A device that has been designed. glasses. hospitals. wheelchairs).g. orthoses (e. visual devices (e. repair. important aspects of their provision include user education.acquire disabilities during their lifetime and for those who have disabilities from birth. PreamBle 9 . prostheses (e. white canes) and hearing devices (hearing aids).

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This element is about the importance of health promotion for people with disabilities. their health (16). instead it uses social interventions. income and social status. it involves many different sectors. health PromotIon 11 . The health potential of people with disabilities is frequently overlooked and as a result they are often excluded from health promotion activities. which. education.g. employment and working conditions. health promotion campaigns. Health promotion focuses on addressing those determinants of health that can potentially be modified. It provides suggestions for CBR programmes on how to facilitate access to health promotion activities for people with disabilities and how to implement basic activities where necessary. access to appropriate health services and the physical environment (17). e. It is important to remember that as health promotion focuses on changing a wide range of determinants of health. such as individual health behaviours and lifestyles.Health promotion Introduction The Ottawa Charter for Health Promotion (1986) describes health promotion as the process of enabling people to increase control over and to improve. and not just the health sector. require a personal investment of time and energy (18). Health promotion does not require expensive drugs or elaborate technology. at the most basic level.

which are common among people with albinism. Having a child with albinism is considered immoral. The success of this CBR programme is linked to the strong working relationship that KDEC has developed with both the health and the education sectors. e. KDEC provides education about the importance of using sunscreen and protective clothing. To ensure these children achieve their highest attainable standards of health. Children with albinism are now integrated into mainstream schools. school teachers and women’s groups. including their right to health. schools and community environments. and both the family and child are subject to discrimination and stigmatization within their communities. Children with albinism remain hidden and their fundamental human rights are denied. as people with albinism are at risk of sun damage. Kwale District Eye Centre (KDEC) in Kenya has a CBR programme which focuses on alleviating discrimination and stigmatization towards children with albinism in their homes.BOX Kenya Overcoming stigma and prejudice In some African cultures. attitudes and treatment of people with albinism. • conducting eye assessments to detect visual impairments. • forming partnerships with local hotels to encourage guests to donate sunscreen and unwanted items of clothing before they leave.g. which can be given to those in need. such as long-sleeved shirts and trousers. village health committees. and providing glasses and low-vision devices where required. • educating parents so that they are able to promote and protect their child’s health. the CBR programme uses a variety of health promotion activities and interventions including: • sensitizing community members and community leaders. to bring about changes in perceptions. 12 cBr gUIdelInes > 2: health comPonent . albinism is believed to be a result of a mother having a “sexual relationship” with evil spirits during pregnancy.

local authorities) to ensure access and inclusion for people with disabilities and their family members. Desirable outcomes • People with disabilities and their families are reached by the same health promotion messages as are members of the general community. The role of CBR The role of CBR is to identify health promotion activities at a local. • Health promotion materials and programmes are designed or adapted to meet the specific needs of people with disabilities and their families. CBR programmes value good health and undertake health-promoting activities in the workplace for their staff. The community provides a supportive environment for people with disabilities to participate in activities which promote their health.g. 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. regional and/or national level and work with stakeholders (e. • People with disabilities and their families have the knowledge. ministries of health. • 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. health PromotIon 13 . skills and support to assist them to achieve good levels of health.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.

if not more (3). may not be considered a good candidate for health promotion as her/his health has already been affected by injury. 14 cBr gUIdelInes > 2: health comPonent . reduced ability to care for other children. Barriers to health promotion People with disabilities often experience poorer levels of health than the general population because of the many barriers they face when trying to improve their health (see above: Barriers to health-care services for people with disabilities). people with disabilities and their family members have very little awareness of how to achieve or maintain good health. Health promotion for family members Many people with disabilities require support from others. Often. reduced time and energy for work.Key concepts Health promotion for people with disabilities Health promotion is often viewed as a strategy to prevent health conditions. it is not often associated with people with disabilities because disability is viewed as a consequence of not utilizing health promotion (19). Maintaining the health of family members is essential (see Social component: Personal assistance). for example. Health promotion action The Ottawa Charter for Health Promotion outlines five areas for action which can be used to help develop and implement health promotion strategies (16). Build healthy public policy Develop legislation and regulations across all sectors which protect the health of communities by ensuring safer and healthier goods and services. particularly family members. People with disabilities are at risk of the same health conditions as people in the general population but they may also have additional health problems due to greater susceptibility to health conditions (related or not to their disabilities) (20). Many people with disabilities have as much need for health promotion as does the general population. reduced social interaction and stigmatization (21). A person with paraplegia as a result of spinal cord injury. 1. more enjoyable environments. Dealing with these barriers will make it easier for people with disabilities to participate in health promotion activities. Family members may experience problems related to the care of people with disabilities including stress-related physical and emotional illness. healthier public services and cleaner.

satisfying and enjoyable. older adults risk factors. smoking. communities and populations – they can inform. unsafe sex health or disease priorities. stimulating. CBR programmes need to develop a good understanding of the communities in which they work by making contact with community members and groups already working towards increased control over the factors which affect their health. community centres. Suggested activities Health promotion activities are very dependent on local issues and priorities. clinics. workplaces. Health issues need to be addressed through working with others rather than by doing things for them. diabetes. e. e. beyond its responsibility of providing clinical and curative services.2. 4. encourage and motivate behaviour change. make decisions and plan and implement strategies to achieve better health. Individuals have enormous potential to influence their own health outcomes and participatory approaches in health promotion are important as they allow people to exert greater control over the factors which affect their health. Reorient health services The health sector must move increasingly towards health promotion. e. so the activities outlined here are general suggestions only. 15 health PromotIon . heart disease. Support health promotion campaigns Health promotion campaigns can positively influence the health of individuals. 3. regional or national level and ensuring that people with disabilities are actively targeted and included in these campaigns. HIV/AIDS. Create supportive environments for health Make changes in the physical and social environments to ensure that living and working conditions are safe. Empower communities to set priorities. Strengthen communities Adopt community approaches to address those health problems that have strong environmental. Health promotion strategies can be applied to different: • • • • population groups. 5.g. physical inactivity. children.g. CBR programmes can promote better health for people with disabilities by: • identifying existing health promotion campaigns operating at community.g. adolescents. schools. hospitals. socioeconomic and political components. poor diet.g. oral health settings. e. Develop personal skills Develop people’s skills by providing information and health education to enable them to exercise more control over their health and environment and make better choices to improve their health status.

identifying existing resources within the community (e. e.g. provide training for individuals with disabilities. people with an intellectual disability will require materials that are simple and straightforward with basic language and relevant pictures. ensure that a wide range of teaching methods and materials are used in education sessions to reinforce learning and understanding. booklets.g. e. television) and encouraging them to increase their coverage of disability-related health issues – it is important to ensure that any coverage is respectful of the rights and dignity of people with disabilities. storytelling. encouraging health promotion campaigns to show positive images of people with disabilities. collect health promotion materials (e. inform people with disabilities and their families about local health promotion programmes and services that will enable them to acquire new knowledge and skills to remain healthy. discussions. supporting the development of local health promotion campaigns to address disability-related issues that are not covered by existing campaigns. Strengthen personal knowledge and skills Health information and education enables people with disabilities and their families to build the knowledge and life skills necessary for maintaining and improving their health. games.• • • • • actively participating in health promotion campaigns and associated events. e. newspapers. community spokespersons. They can learn about disease risk factors. by depicting people with disabilities on posters and billboards for messages intended to reach the entire population. brochures) and distribute them to people with disabilities and their families.g. focus on assisting people with disabilities and their families to become assertive and confident in the presence of health-care providers to enable them to ask questions and make decisions about their health. develop specific education sessions. role plays. e. radio. raising the profile and awareness of disability. to enable them to become health promotion educators. in partnership with the health sector. for people with disabilities whose needs are not being met by those targeting the general community. the importance of physical activity and other protective factors through structured sessions (individual or small group). giving practical suggestions. ensuring existing health promotion campaigns utilize appropriate formats for people with disabilities. problem-solving exercises. good hygiene.g.g. healthy eating choices. if necessary. 16 cBr gUIdelInes > 2: health comPonent .g. adapt or develop health promotion materials to make them accessible to people with disabilities. that public service announcements are adapted for the deaf community with text captioning and sign language interpretation. CBR personnel can: • • • • • • • • visit people with disabilities and their families in their homes and talk about how to maintain a healthy lifestyle. practical demonstrations.

groups of people with spinal cord injuries. to participate actively in health-promoting activities in their communities. They felt they had been given inadequate health information – regarding self-care. in partnership with others. or who are parents of children affected by cerebral palsy.g. CBR programmes can: • • • connect people with disabilities and their families to existing self-help groups in their communities to meet their specific health needs. e. prevention of ulcers and urinary problems – in the hospitals where they were treated. situations or problems with each other (see Empowerment component: Self-help groups). encourage people with similar experiences of disability to come together to form new self-help groups where suitable groups do not already exist – in small villages. For many people the opportunity to receive support and practical advice from someone else who has a similar problem is more useful than receiving advice from a health worker (22). encourage self-help groups. The CBR programme organized an interactive session with hospital specialists during which group members could ask questions to clarify their doubts. Colombia. Self-help groups are mentioned throughout this component because they can contribute to better health for people with disabilities and their family members. e. or living with HIV/AIDS.Link people to self-help groups Self-help groups enable people to come together in small numbers to share common experiences. it may be difficult to establish such a group and 1:1 support from a peer may be more appropriate.g. a group of people with spinal cord injuries formed a self-help group. World Mental Health Day and the International Day of Persons with Disabilities. health PromotIon 17 . BOX Colombia Managing health through self-help groups With the support of a CBR programme in Piedecuesta. or affected by leprosy. by organizing health camps and observing World Health Day. Experienced members of the group were supportive of new members who had recently acquired a spinal cord injury and helped them to develop ways of coping by showing them how to use their residual abilities and assistive devices.

leisure and sport). support wheelchair users to organize a wheelchair football match at a local sports facility (see Social component: Recreation.Educate health-care providers Health-care providers are a trusted source of health-related information and have the potential to positively influence the health of others. CBR programmes need to work with these providers to ensure they have adequate knowledge about disability and include people with disabilities in all their health promotion activities. BOX Africa Train the trainer CBR programmes can work with disabled people’s organizations to develop appropriate education materials and methods to inform people who are blind or who have low vision about HIV/AIDS and to inform health-care services about the specific needs of this group. primary health care personnel) towards disability and inform them of the challenges faced by people with disabilities and their families. social and health planners and people with disabilities to create and improve physical and architectural accessibility. Create supportive environments CBR programmes can work with community health centres.g.g. creating opportunities to enable people with disabilities to participate in recreational activities. as well as to enable them to achieve optimal health by: • • • ensuring that environments promote healthy lifestyles and that specific health promotion programmes and services are physically accessible for people with disabilities. creating partnerships between urban. schools. It is suggested that CBR programmes: • • • • orient health workers (e. hospitals. For example the African Blind Union produced a “train the trainer” manual on HIV/AIDS to facilitate the inclusion and participation of blind and partially sighted persons in HIV/AIDS education programmes. e. cBr gUIdelInes > 2: health comPonent 18 . worksites and recreational facilities and with key stakeholders to create supportive physical and social environments for people with disabilities. help health workers understand the importance of communicating with people with disabilities in a respectful and nondiscriminatory manner and provide them with practical demonstrations to facilitate learning. show health professionals how they can make simple adaptations to interventions to ensure that their health messages are understood. encourage health professionals to use a variety of media and technologies when planning and developing health information and programmes for people with disabilities.

• • • ensuring accessible and safe public transport. safe transport options. their families and community volunteers go together for group holidays. prejudice and stigma. playing and enjoying being together as a larger family or group of friends. organizing cultural events to address problematic health issues within the community through dance. The CBR programme also collaborates with the local Paralympics committee. as well as tobacco. setting good examples for others by adopting healthy behaviours. parents’ organizations and disabled people’s organizations to organize an annual sports day in the city stadium. healthy meals. addressing. BOX Egypt Healthy lifestyles A CBR programme in Alexandria (Egypt) organizes an annual summer camp where children with disabilities. because problems with transport can cause people with disabilities to face isolation. providing a safe and healthy environment. on ways to improve and maintain their health. negative attitudes and stigma that exist within the health sector and community towards people with disabilities and their families.g. encouraging staff to be good role models in their communities. health PromotIon 19 . any misconceptions. The emphasis is on spending leisure time together. Become a health promoting organization Health promotion within workplaces has the capacity to improve staff morale and skills. job performance and. health. drug and alcohol use. regardless of the level at which they work. reasonable working hours. a nonsmoking environment. e. developing policies and practices within the organization which promote health. loneliness and social exclusion. ultimately. drama. songs. through education and training.g. policies against discrimination. Organizations that implement CBR programmes should focus on promoting the health of their staff by: • • • • providing training and education to all staff. e. safe water and sanitary facilities. harassment. improving health status. films and puppet shows.

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programmes for the prevention of accidents in different environments. However. as previously mentioned. This element mainly focuses on primary prevention. and prevention of disability associated with pollution of the environment or armed conflict (23). primary health care plays an important role and since CBR programmes are most closely linked with primary health care. education in nutrition. However. role in the management of health for people with disabilities. prevention also involves early detection and treatment to stop the progression of a health condition (secondary prevention) and management to reduce the consequences of an existing health condition (tertiary prevention). through better use of primary prevention and health promotion. prevention requires the involvement of many different sectors. Within the health sector. including adaptation of workplaces to prevent occupational injury and diseases.Prevention Introduction The main focus of prevention in health care is to stop health conditions from occurring (primary prevention). immunization campaigns against communicable diseases. Just like health promotion. it is commonly believed that prevention (as for health promotion) has little. ➾ PreventIon 21 . if any. It is estimated that. people with disabilities are at risk of other health conditions and also at risk of secondary conditions resulting from their primary health conditions (24). Even so. they can play a significant role in promoting and supporting preventive health care for people with disabilities. the global burden of disease could be reduced by as much as 70% (10). safety regulations. Primary prevention may include: primary health care. prenatal and postnatal care. measures to control endemic diseases. Health care for people with disabilities usually focuses on specialized medical care and rehabilitation.

The Indian Government offered grants to families to construct toilets and MI assisted people with disabilities and their families in Chamarajnagar to construct accessible toilets. India. 22 cBr gUIdelInes > 2: health comPonent . Seeing the success of the MI project. funding the remaining amount was difficult for most people. were carrying out a CBR project with the support of Disability and Development Partners UK. The total cost to construct one toilet was an estimated US$ . they discovered that many community members did not have access to basic sanitation facilities. or at least near to their homes. They also coordinated the construction work in partnership with families and ensured proper use of funds.BOX India Living with dignity In Chamarajnagar. As people became interested and motivated. They have become independent and. Their risk of developing health conditions associated with poor sanitation has also significantly reduced. one of the poorest districts of Karnataka. With financial support from MIBLOU. particularly people with disabilities. Switzerland and local contributions. This was very difficult for people with disabilities. importantly. and more so for women with disabilities. particularly for people with disabilities. Most people travelled far from their houses to use open fields. SHG members were asked to select poor households with disabled family members who had the greatest need for a toilet. a nongovernmental organization. MI agreed to work with them to facilitate access to basic sanitation. While the Indian Government offered a grant to each family. While Mobility India (MI). Many people with disabilities no longer need to crawl or be carried long distances for their toileting needs. MI was able to construct  good quality accessible toilets. MI organized street plays and wall paintings to raise awareness about hygiene and the role proper sanitation plays in preventing health problems. have been able to reclaim their dignity. and it is gradually being scaled up to become a district-level project. the Indian Government has since increased the amount of the grant and directed local authorities to release these funds immediately. Chamarajnagar will soon become a district where people have toilets in their houses. People with and without disabilities are benefiting from this project. the quality of life is very poor. Using existing community-based networks and self-help groups (SHG) to assist with this new project.

alcohol consumption. and family members and other community members are less likely to develop health conditions and impairments associated with disability. that affect their functioning and overall health and well-being. Some of the leading risk factors include: being underweight. unsafe sex. to address health issues and provide support and assistance for prevention activities. family history. 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). • People with disabilities are included and participate in primary prevention activities. e. Desirable outcomes • People with disabilities and their families have access to health information and services aimed at preventing health conditions.Goal People with disabilities are less likely to develop health conditions. to reduce their risk of developing additional health conditions or impairments. CBR programmes collaborate with the health and other sectors. unsafe water. Prevention activities reduce the risks to health of individuals and communities. and indoor smoke from solid fuels (25). All community members participate in primary prevention activities. high blood pressure. to reduce their risk of developing health conditions or impairments which can lead to disability. education. • People with disabilities and their families reduce their risk of developing health problems by taking up and maintaining healthy behaviours and lifestyles. illness and disease.g. e.g. others. e. are beyond a person’s control. tobacco consumption. Key concepts Risks to health Risk factors influence a person’s health and determine the likelihood of injury.g. immunization programmes. potentially maintaining and PreventIon 23 . e. iron deficiency.g. immunization programmes. related or unrelated to their impairments. lifestyle and physical and social environments can be altered. The role of CBR The role of CBR is to ensure that communities and relevant development sectors focus on prevention activities for people both with and without disabilities. People everywhere are exposed to many health risks throughout their lives. sanitation and hygiene.g. • • e. While some risk factors.

changing health behaviours.improving health status. nutrition) and the environments in which they live (safe water supplies. Primary prevention is equally important for people with and without disabilities and is the main focus of this element. Examples of early detection include mammograms to detect breast cancer and eye examinations to detect cataracts. good living and working conditions). 2. immunization.g. The health sector can play a significant role in addressing these risk factors. sanitation. Secondary prevention is the early detection and early treatment of health conditions. Fig 1: Three levels of prevention Tertiary Secondary Primary 24 cBr gUIdelInes > 2: health comPonent . multidrug treatment of leprosy to prevent disease progression and appropriate handling of a fractured bone to promote proper healing and prevention of deformity. 3. Tertiary prevention aims to limit or reverse the impact of already existing health conditions and impairments. participation and inclusion. it includes rehabilitation services and interventions that aim to prevent activity limitations and to promote independence. examples of early treatment include treatment of trachoma with antibiotics to prevent blindness. 1. Primary prevention – the phrase “prevention is better than cure” is one that many people are familiar with and is the focus of primary prevention. Secondary prevention strategies for people both with and without disabilities are discussed in the Medical care element below. with the aim of curing or lessening their impacts. Three levels of prevention Prevention interventions can be at one of three levels. Primary prevention is directed at avoidance and uses interventions that prevent health conditions from occurring (17). Tertiary prevention strategies are discussed in the elements on Rehabilitation and Assistive devices. These interventions are mainly aimed at people (e.

where they advised her to go to a specialized hospital in Mumbai. She was given gait training to ensure she could walk properly with her prosthesis and CBR personnel constructed parallel bars outside her hut so she could practise walking with her prosthesis at home. She quickly developed pain in her leg and after a few days it turned black.  km away. immunizations. Gradually Anita’s confidence improved. in situations of poverty people with disabilities have the least access to safe water and sanitation facilities. Her amputated stump was checked to ensure proper healing and her left leg/foot was assessed to check for early sensory and circulation changes. Poor access to these facilities can force them to follow unhygienic practices. Anita visited the CBR programme at the health centre close to her village. What does prevention mean for people with disabilities? Like everybody. Health personnel in Mumbai immediately diagnosed Anita with diabetes and amputated her right leg below the knee as it had developed gangrene. Anita was given crutches and trained in how to use them. The village health worker informed Anita and her family about a CBR programme that provided free health services for people who had lost a limb. putting their health at risk and contributing to keeping them poor and unable to improve their livelihoods PreventIon 25 . She has also learned about proper foot care to prevent her left leg from being amputated in the future. until she was able to walk independently with her prosthesis and return to household tasks and work in the fields. Anita was unable to walk so her son had to carry her on his back. Immediately following surgery. Anita learnt about diabetes and how to control the condition with medicine.BOX India Anita stands tall Anita is a  year-old woman who lives in Khandale village. For example. Anita says that her quality of life has improved and with the help of the CBR programme and others she has succeeded in preventing further health complications as a result of her diabetes. people with disabilities are exposed to risk factors for which they require routine preventive health care.g. She continues to take her medication on a regular basis and has regular health check-ups. Later a team of health professionals visited the health centre and fitted Anita with a prosthesis and a good pair of shoes to ensure her left foot was protected from injury. Her son took her to Alibaug Hospital. situated in a hilly area of Raigad District. they may also require targeted and specialized interventions because often they are more vulnerable to the health risks present in the community.  km away. regular exercise and diet. However. e. India. Maharashtra. Anita’s family took her back to their village as they could not afford to stay in the city. One day Anita sustained a small injury to her right foot.

g. Medical and CBR personnel decided to implement a new system whereby patients were prioritized – home visits were provided for highrisk individuals and telephone calls and education booklets were provided for low-risk individuals. Viet Nam. CBR personnel tried to ensure follow-up for all patients. 80% of all blindness in adults is preventable or treatable and approximately half of all childhood blindness can be avoided by treating diseases early and by correcting abnormalities at birth. management and rehabilitation (WHA58. health problems or complications which are related to their primary health condition). cataract and glaucoma (27). obesity. special facilities or modifications may need to be provided for people with disabilities.g. The Fifty-eighth World Health Assembly resolution on Disability. e. but due to limited human resources and the large coverage area. BOX Viet Nam Making home environments accessible Handicap International supported the establishment of a Spinal Cord Injury department at a rehabilitation hospital in Ho Chi Minh City.e. In these situations. pain. a person with paraplegia can prevent pressure sores with good skin care and prevent urinary tract infections with good bladder management. What does prevention mean for people without disabilities? Prevention is just as important for people without disabilities as it is for those with disabilities.(26). only % of individuals were seen and often those in greatest need were missed. As a result. Sensitivity is required when promoting programmes or initiatives that are focused on preventing health conditions and impairments associated with disability because many people within the disability community may find this threatening or offensive and view it as an attempt to prevent people with disabilities from existing. joint contractures. e. People with disabilities are also at risk of secondary conditions (i. urinary tract infections. osteoporosis and depression. This initiative has also proved to be more cost-effective and less stressful for CBR personnel. Examples include: pressure sores. There should be no 26 cBr gUIdelInes > 2: health comPonent . with the aim of preventing secondary conditions and ensuring their home environments were wheelchairaccessible. Many health conditions associated with impairment and disability can be prevented.23) (28) urges Member States to increase public awareness about the importance of the issue of disability and to coordinate the efforts of all sectors to participate in disability prevention activities. For example. CBR personnel working in this department were responsible for following up discharged patients. the rehabilitation hospital has seen a decrease in readmissions. These secondary conditions can be addressed with early intervention and many of them can be prevented altogether. including prevention.

g.g. it is important to note that there is overlap between the suggested activities mentioned in all three elements and it is suggested that all three be read together. e. As a result. determine whether prevention services can be provided in alternative locations. The main focus here is on primary prevention activities. in home environments. PreventIon 27 . ensure thathealth personnel are aware of the needs of people with disabilities. provide practical ideas and solutions to make them accessible. determine if locations where prevention activities take place are physically accessible and if not. Facilitate access to existing prevention programmes CBR programmes can gather information about existing prevention activities in their communities and work with prevention programmes to include people with disabilities. Kenya. ensure that information about prevention activities is available in appropriate formats and in a variety of locations close to where people live. so health workers would direct families to a rehabilitation centre in the city. was not wheelchair-accessible owing to a number of steps. CBR programmes can: • • • • • ensure that people with disabilities and their families are aware of the types of prevention activities available in their communities. Suggested activities As prevention is closely associated with health promotion and medical care. children with cerebral palsy). as they are addressed in the Social component and the Supplementary chapter on CBR and HIV/AIDS.conflict between prevention interventions that try to reduce disability-related health conditions and those that maintain and improve the health of people with disabilities (29). vaccination programmes were not accessible for people with physical disabilities (e. thus ensuring greater coverage. violence and HIV are not included. when access is difficult. The CBR programme organized a meeting to discuss the issue with health workers and a simple solution was identified whereby the health centre agreed to vaccinate children with disabilities on the ground floor of the building. BOX Kenya Meeting the needs of wheelchair users A health centre run by a nongovernmental organization in the Korogocho area of Nairobi.

make contact with primary health care workers to educate them about the importance of immunization for people with disabilities. especially children with disabilities. tetanus and measles vaccinations for infants and young children and tetanus vaccination for pregnant women. can reduce the risk of developing health problems. provide information about the location of safe and reputable services for people who have not received recommended immunizations and support them to access these services as necessary.g.g. work with primary health-care services to ensure that people with disabilities and their family members are able to access vaccination programmes in their communities. including rubella immunization for young mothers and immunization programmes for children.Promote healthy behaviours and lifestyles Healthy behaviours. BOX Malaysia Saving young lives The national CBR programme in Malaysia works very closely with primary health-care services to ensure that people with disabilities are able to access those activities conducted by primary health care personnel. ensure that people receiving support and assistance from CBR programmes have received the recommended immunizations. diphtheria. CBR programmes can: • • • • • • become actively involved in awareness campaigns to promote immunization for all community members including people with disabilities. children with disabilities. work with primary health-care services to make alternative arrangements for people who are unable to access vaccination programmes. immunization programmes should be available for specific diseases and for high-risk groups. See element on Health promotion for suggested activities to promote good health behaviours. their brothers and sisters. exercising regularly and wearing condoms during sex. healthy eating. children with disabilities who are not attending school. e. drinking only small amounts of alcohol. awareness campaigns to communicate prevention messages within communities and education for individuals.g. e. poliomyelitis. Prevention programmes often use health promotion strategies to encourage healthy behaviours. e. e. 28 cBr gUIdelInes > 2: health comPonent . despite existing impairments.g. Encourage immunization Within each community. such as not smoking. pregnant mothers of children with disabilities.

especially those with feeding problems. ensure that children with disabilities get sufficient and appropriate food to eat – children with disabilities are often neglected. PreventIon 29 . e. proper positioning to make feeding safer and easier. encourage the use of iron-rich and vitamin-rich foods that are locally available.Ensure proper nutrition Poor nutrition (malnutrition) usually results from not getting enough to eat and poor eating habits and is a common cause of health problems. Ensuring adequate food and nutrition in communities is the responsibility of many development sectors with which CBR programmes need to collaborate. e. In relation to the health sector. e. identify nutrition initiatives available in the community and ensure that people with disabilities can access these. children with cerebral palsy who have chewing and swallowing problems. drumstick leaves. nutritious recipes is one way to encourage people to eat nutritious foods. and provide referrals to speech and language therapists where possible.g. papaya fruit – demonstrating low-cost. below). promote breastfeeding and encourage pregnant women to attend antenatal care for iron and folic acid supplements (see Facilitate access to maternal and child health care. some suggested activities for CBR programmes include the following: • • • • • • • ensure that CBR personnel are able to identify people (both with and without disabilities) with signs of malnutrition and provide referral to health workers for proper assessment and management. whole grains.g. identify people with disabilities who have feeding difficulties. e. children with disabilities are actively included in programmes which monitor growth and provide micronutrients and supplementary food.g.g. provide simple suggestions to families about ways to assist people with disabilities to eat and drink. spinach.

g. have used the supplement consistently and have benefited enormously from it. Her parents work for a daily wage of Rs  in a local factory. provide advocacy where discrimination is present within the health-care system. refer women and their families for genetic counselling where they have specific questions or concerns related to current or future pregnancies. the Trust provides a nutritional supplement – an energy-protein-rich powder – to all malnourished children once a month. so she was given the nutritional supplement and over a period of one year Afreen gradually improved in health and developed strength.g. Facilitate access to maternal and child health care Antenatal care.g. Convinced that in many children belonging to poor families malnutrition occurs during the transition from breast milk to semi-solid foods to solid foods. The CBR worker was unable to give Afreen any form of therapy due to her condition. She was fed only on liquid foods and as a result was malnourished and bedridden. poorly developed and had frequent diarrhoea and seizures. provide all women with information about maternal health services and encourage them to access these. Afreen is nine years old and has cerebral palsy.g. by providing them the nutritional supplement. India. Afreen developed cerebral palsy. provide additional support for women with disabilities when access to maternal health-care services might be difficult. Sanjivini also works in collaboration with other organizations that provide rehabilitation for children with disabilities. She lives with her parents and two sisters in Illyasnagar slum. e. antenatal care. e. e. Bangalore. One of its main interventions has been to address the issue of malnutrition in children. CBR programmes should: • • • • identify maternal health services available in the community. has been working with women and children for over a decade. cBr gUIdelInes > 2: health comPonent 30 . Mothers are given nutrition education and shown how to prepare low-cost nutritious meals using locally-available grains and vegetables. Due to a complication during her delivery. Children with special needs.BOX India Gaining strength through nutrition The Sanjivini Trust in Bangalore. e. a couple with a disabled child might ask if their next child will inherit the same condition/impairment. Afreen now goes to the coaching centre for therapy and stimulation. those with feeding problems. Her family migrated to Bangalore when Afreen was six years old. due to nonavailability of suitable food. skilled care during delivery and postnatal care reduce the risk of mothers and babies developing health conditions and/or impairments that may lead to disability. her family is overjoyed at her improvement and her mother is able to introduce her to other foods. especially those below five years of age. Volunteers are trained to prepare the supplement and distribute it to needy children after identifying them.

e. encourage families to register children with disabilities with the local authorities at birth.g. making local authorities and water and sanitation organizations aware of these barriers and providing suggestions and ideas for ways to overcome the barriers in partnership with people with disabilities and their family members. When these women become pregnant. Promote clean water and sanitation Water and sanitation measures contribute to improving healthy living and minimizing disability. encouraging community members to support and assist people with disabilities where needed. worsening their pain and disability. lobbying and working with local authorities to adapt existing facilities and/or build new facilities. CBR programmes can help to ensure that the needs of people with disabilities are considered by: • • • • talking to people with disabilities and their family members about the barriers they face when accessing and using water and sanitation facilities. many women have hip dislocation.• • • advise health services about access issues for pregnant women with disabilities. providing advice regarding planned intervals between pregnancies and adequate rest during the later stages of pregnancy.g. e. encourage neighbours to accompany a person with a disability when fetching water. e. installing raised toilet seats and handrails to provide support for people who are unable to use a squat latrine. the terrain is too rough and/ or the method for obtaining water from the wells is too difficult. BOX Mongolia Easing the stress of pregnancy In some villages of north-west Mongolia. PreventIon 31 . they find that the additional weight puts extra stress on their hips.g. find out if there are training programmes for traditional birth attendants operating in the local communities and ensure that these programmes include information on disability and early recognition of impairments. e. provide suggestions about appropriate communication methods and how to make hospitals/delivery rooms accessible. The National CBR programme in Mongolia works with these women. people with disabilities may be unable to access water sources because they live too far away.g.

wearing appropriate safety equipment on construction sites (shoes. to prevent injuries during big festivals.g. Often adults and children with disabilities are also at higher risk of injury.g.g. wearing seatbelts in motor vehicles and wearing helmets when riding bicycles and motorbikes. roof edges and stairs and not allowing children to play with sharp objects. CBR programmes can play a role in injury prevention in their communities by: • • • • • • identifying the major causes of injury in the home and community (e. adopting healthy lifestyle behaviours such as exercise and good nutrition. working with local authorities and community groups regarding actions to take to reduce the occurrence of injuries in the home and community. ensure that any assistive devices provided to people with disabilities do not create risks for secondary conditions. It is suggested that CBR programmes should: • • • ensure that people with disabilities and their family members are aware and knowledgeable about the secondary conditions commonly associated with their disabilities.g. providing education for schoolchildren about road safety. burns. creating awareness in the community about the common causes of injuries and how to prevent these. at work or in the community. e. drowning.g.g. on how to cross roads safely. people with spinal cord injuries or spina bifida (and their families) should be aware that they are at a high risk of developing urinary tract infections. children).g.g. earplugs). keeping poisons locked away and out of reach of children. providing suggestions for families about how to prevent injuries in the home. 32 cBr gUIdelInes > 2: health comPonent . having regular health check-ups. CBR programmes can promote primary prevention strategies to reduce the likelihood that people with disabilities will develop these conditions. Help to prevent secondary conditions People of all ages with disabilities are at risk of secondary conditions. keeping children away from balconies. watching children when they are near water or open fires. gloves. helmets. providing education for employers and workers about how to prevent injuries in the workplace. road accidents) and identifying those groups most at risk (e. this might include a health promotion campaign (see Health promotion element).g. e. maintaining good hygiene and joining self-help groups. assist people with disabilities and their families to identify strategies to prevent secondary conditions from developing. that prostheses fit properly and do not cause red marks which can lead to pressure sores. e. e. e.Help to prevent injuries Many disabilities are caused by accidents at home. e. e.

providing those health services as needed by people with disabilities specifically because of their disabilities. The Standard Rules on the Equalization of Opportunities for Persons with Disabilities (23) also outline a list of responsibilities for States regarding medical care and highlight medical care as a precondition for equal participation in all life activities. treatment of leprosy or malaria).g. Access to quality medical care.g. With guidance from the Convention and Standard Rules. assessment and treatment of health conditions and/or resulting impairments. appropriate and timely medical care. Medical care can: provide a cure (e.g. treatment of diabetes to prevent blindness).Medical care Introduction Medical care can be defined as the identification. reduce the impact (e. and the measures States Parties are required to undertake regarding health services for people with disabilities. and providing services as close as possible to people’s own communities (2). CBR personnel can work within their communities to ensure that people with disabilities are able to access inclusive. medIcal care 33 . treatment of epilepsy). In the Preamble. when and as often as needed. and prevent avoidable impairments (e. including: providing people with disabilities with the same range. including early identification and intervention as appropriate. Article 25. quality and standard of free or affordable health care and programmes as provided to other people. is critical for maintaining good health and functioning (30). we referred to the Convention on the Rights of Persons with Disabilities. particularly for people with disabilities who may experience poor levels of health.

He couldn’t eat or dress himself or wash his hands. They were overjoyed when Adnan was born as they already had a six-year-old daughter and had waited a long time for another child. He can carry water. especially in instructions. Adnan’s parents contacted CCBRT and requested support and advice. What was the point? But his behaviour got worse and worse. started visiting their home regularly. He just walked around all day and often got lost. When Adnan was approximately two months old they noticed that his head appeared to get smaller. always pointing out the same things to look for. Irene explains.” 34 cBr gUIdelInes > 2: health comPonent . recognizing that Adnan had an intellectual impairment. He was not a settled. She also helped the family access medical care to manage his convulsions. An X-ray was taken after which the doctors told Irene and Mohammed that there was nothing to worry about. Mama Kitenge. told Irene and Mohammed about the local CBR programme run by a nongovernmental organization called Comprehensive Community Based Rehabilitation in Tanzania (CCBRT). “He never spoke or made much sound so I never thought he understood anything and I didn’t really talk to him. I did not know what to do with him. feed himself and wash his face. He takes his epilepsy medicines regularly and does not have fits. happy child.BOX Tanzania Adnan’s big change Irene and Mohammed live in the United Republic of Tanzania. providing education and therapy. Adnan was unable to do anything himself. I have shown him the way back home from the water point many times. Now I talk to him all the time and he understands what I say. As a result. Adnan now takes regular medication to control his epilepsy. Irene and Mohammed took Adnan to the local hospital for medical care. He also experienced regular convulsions. a CBR worker. so now he knows his way back home if he gets lost. The training has been really helpful. It is a big change from before.” Adnan only started walking at the age of four and when he was playing in the street one day. However as Adnan grew older it became obvious that he was unable to perform simple tasks or follow basic instructions and his behaviour become increasingly challenging. Irene said “Before I joined the programme. a passer-by.

based on their individual needs. their families and medical services to ensure that people with disabilities can access services designed to identify. it is important for CBR personnel to understand the basic differences between the levels so they can facilitate access for people with disabilities and their family members. Key concepts Types of medical care Many health systems in low-income countries have three levels of health care: primary.g. Medical care personnel have increased awareness regarding the medical needs of people with disabilities. The role of CBR The role of CBR is to work in collaboration with people with disabilities. both general and specialized. medIcal care 35 . These are usually linked to each other by a referral system. While there is often overlap between each level. discuss treatment options. prevent. Desirable outcomes • CBR personnel are knowledgeable about medical care services and able to facilitate • • • • • referrals for people with disabilities and their families for general or specialized medical care needs. e. People with disabilities can access surgical care to minimize or correct impairments. e. primary health care workers refer people to secondary care when needed. primary health care might be provided in a place that normally provides secondary health care. minimize and/or correct health conditions and impairments. Medical care facilities are inclusive and have improved access for people with disabilities. make informed decisions about medical care and manage their health conditions. respect their rights and dignity and provide quality services. secondary and tertiary. People with disabilities and their families access activities that are aimed at the early identification of health conditions and impairments (screening and diagnostic services). thus contributing to improved health and functioning.Goal People with disabilities access medical care.g. People with disabilities and their families develop self-management skills whereby they are able to ask questions.

These services are provided by large hospitals usually located in major cities at the national or regional level. This is because they lack the awareness that. middle ear infections. particularly primary health care. Medical care provided at the tertiary level might include brain surgery. people with disabilities may acquire a general health condition at any stage throughout their life for which they will need medical care. Early intervention is less traumatic. Secondary level of care refers to more specialized medical services that are provided by large clinics or hospitals which are usually present at the district level. diabetes). high blood pressure. Primary health care provides an important link to secondary care through referral mechanisms. diabetes. if left untreated or uncontrolled. e. It is usually provided through health centres or clinics and is usually the first contact people have with the health system. Many people with disabilities also have specific medical care needs for limited or lifelong periods of time. 36 cBr gUIdelInes > 2: health comPonent .g. like the general population. can lead to new impairments or exacerbate existing impairments in people with disabilities. Some health conditions.Primary level of care refers to basic health care at the community level. tuberculosis or malaria. Medical care for people with disabilities Medical staff often refer people with disabilities to rehabilitation services for general medical care instead of treating them at primary health care facilities. It is provided by specialized medical professionals in association with nurses and paramedical staff and involves the use of specialized technology. influenza. Health-care personnel have an important role to play in the early identification of conditions that can lead to impairments. Tertiary level of care is highly specialized medical care. It is important that all health conditions are identified and treated early (secondary prevention).g. epilepsy. For example. people with epilepsy or people with mental health problems may require drug regimens over a long period of time. tuberculosis. CBR programmes work at the community level and so work closely with primary health-care services (14).g. cancer care or orthopaedic surgery. medical care may be needed for respiratory infections. Some people with disabilities may also require surgery to address their impairments. Medical care provided at primary level includes short simple treatments for acute conditions (e. leprosy. is cost-effective and produces better outcomes. infections) and routine management of chronic conditions (e.

particularly in developing regions. medIcal care 37 . Surgery Surgery is a part of medical care and is usually provided at the secondary or tertiary levels of the health-care system. There are many misconceptions and myths regarding epilepsy and its appropriate treatment. Families may have limited knowledge and understanding regarding surgery. After two to five years of successful treatment. However approximately three fourths of people with epilepsy in low-income countries do not get the treatment they need ().BOX Epilepsy Epilepsy (seizures) is a chronic neurological disorder which commonly leads to disability. Some types of surgery can correct impairments or prevent or limit deformities and complications that may be associated with impairments. burns. People with epilepsy and their families often suffer from stigma and discrimination. Recent studies in both high-income and low-income countries have shown that up to % of newly diagnosed children and adults with epilepsy can be successfully treated (i.e. without social security or health insurance. There are many things to consider before surgery is undertaken. their seizures completely controlled) with anti-epileptic drugs. it will be difficult to access for poor people. or leprosy. people may require further medical care. Examples of surgery include removal of cataracts that are causing visual impairment. orthopaedic surgery to address fractures or spinal deformities and reconstructive surgery for cleft lip and palate. drugs can be withdrawn in about % of children and % of adults without relapses. therapy and assistive devices. so they must be informed properly about the benefits and consequences. Successful outcomes from surgery are dependent on comprehensive followup – following surgery. so close links are required between medical and rehabilitation professionals. It is important to remember that surgery alone cannot address all problems that may be related to impairment and disability. Surgical care is often very expensive and.

His sister Sara was also born with clubfeet. Patrick says that he stayed with the disability until  years of age when he heard a radio announcement asking children with disabilities to go to Kamwengye town. My younger sister. schools and other groups. Sara and myself. Health workers may ignore the role which people with disabilities and their families can play in self-management. something that was a dream. Self-management is important for people who experience a lifelong disability. many people now believe that it is possible that other children with disabilities can regain their lost hope. from Kyenyojo District in Kenya. I found lots of other children with disabilities there as well. e. It is very important to know for all communities. Self-management involves people taking control over their health – they are responsible for making informed choices and decisions about medical care and for playing an active role in carrying out care plans to improve and maintain their health. are part of the society and want to be engaged in normal activities in churches. I was always isolated among my peers. 38 cBr gUIdelInes > 2: health comPonent . Equally. or a chronic condition such as diabetes. that medical and rehabilitation services for children with disabilities are available and possible. request. After two surgeries my feet were corrected and above all I am happy that I can put on regular shoes now.g. friends and community about such services. I never knew that other people were going through similar experiences. participate in decision-making and care planning. paraplegia. Walking is easier each passing day. follow a treatment regimen that has been drawn up with health personnel. individuals may lack the skills to ensure they take increased responsibility for their own health. People in our area were not aware of these services.BOX Kenya Learning about possibilities Patrick. I was not sure that something could be done about my feet. People who self-manage their care: • • • • • communicate regularly and effectively with health personnel. obtain and understand health information. was born in  with clubfeet. But finally I went to the Kamwengye Outreach Centre. together with other people with disabilities.” Self-management Self-management (also commonly referred to as self-care or self-care management) does not mean managing your health without medical intervention. Ever since my sister and I were operated on. also had surgery. as agreed with health personnel. We. perform appropriate self-care activities. we are doing our best to inform our families. When I heard the radio announcement I had mixed feelings. It requires a good relationship between individuals and their health-care personnel to ensure that good health outcomes are achieved. “For all these years. who is now  years.

medIcal care 39 . in collaboration with health professionals. how to negotiate the health-care system effectively and how to manage existing health conditions. worked with  people with spinal cord injuries and their families from the areas of San Salvador and the village of Tonacatepeque. bladder and kidney issues. pressure sores. AIFO/Italy. Four self-help groups were formed and regular meetings were held. They realized that with proper support and training. Often valuable information is learnt regarding available medical-care resources. joint stiffness. Pilot projects were asked to: identify and create groups of people with disabilities with similar medical care needs. assess if the quality of self-care and medical care by people with disabilities and/or family members had improved. carried out research across several countries to determine whether people could learn selfmanagement skills and play a more active role in improving their own medical care if they got together as a group of people with disabilities with similar medical care needs. Members of these groups identified their major medical care needs which included: urine.Self-help groups can provide a good opportunity for people with disabilities to learn about self-management through the sharing of knowledge and skills with others. members of the self-help groups and health professionals involved in the project began to change their thinking. Health professionals involved in the project provided self-management skills training to address the issues that had been identified. identify the main medical care needs. They also realized that health professionals needed to look beyond their traditional medical roles and facilitate and promote self-management/care – a concept of shared responsibility. and sexuality and parenthood-related issues. people with spinal cord injury could manage their health and achieve a better quality of life. Over time. and determine if the knowledge and skills of people with disabilities was recognized and given some role within the medical care system. BOX E l S alvador Strength in numbers The Italian association Amici di Raoul Follereau (AIFO/Italy) together with the Disability and Rehabilitation team at the World Health Organization and Disabled People International. provide knowledge and skills for self-care for addressing the identified needs. A pilot project in El Salvador focused on spinal cord injury. Members of the self-help groups went on to form their own association called ALMES (Asociación de Personas con Lesión Medular de El Salvador). in partnership with Don Bosco University and Instituto Salvadoreño Para La Riabilitación de Inválidos.

cancer. accessibility. if relevant. provide information to people with disabilities and their families about the timing and location of screening activities and ensure they are able to access these. ensure members of families that have a history of genetic or hereditary conditions. tuberculosis. district and national levels. initiate contact with the service providers and gather information regarding the type of medical care provided. identify screening activities aimed at the early identification of communicable or noncommunicable diseases.g. compile a service directory to ensure that all information is accessible for CBR personnel. including providers of traditional medicine. muscular dystrophy. individuals and communities – ensure service directories are available in local languages and accessible formats and made available in places where health care is provided.g.g. are referred to appropriate medical facilities for assessment and counselling. costs. river blindness. private and nongovernmental service providers are identified. Gather information about medical services Knowledge of the medical services available at primary. e. secondary and tertiary levels of the health system is essential for assisting people with disabilities and their families to access medical care and support. identify people with impairments in the community who may benefit from surgery. CBR programmes can: • • • identify existing medical services at the local. be aware of secondary conditions. filariasis. pressure sores that are associated with particular disabilities and check for these when working with people with disabilities. schedules and referral mechanisms. leprosy. ensuring that government. e.Suggested activities CBR programmes can carry out the following activities to promote access to medical care for people with disabilities. 40 cBr gUIdelInes > 2: health comPonent . Assist with early identification CBR programmes can: • • • • • • establish a mechanism for the early identification of health conditions and impairments associated with disability in partnership with primary health care personnel. diabetes. e.

the primary health care service requests the CBR programme to follow up these individuals.g. people with disabilities. e.g. identifying gaps in service provision for people with disabilities and exploring. which is provided free by the primary health care service. raising awareness about the barriers that prevent access to medical care and working with others to reduce or eliminate these barriers – innovative mechanisms may be required to address some barriers. Suggested activities include: • • • • • checking with health workers to make sure people with disabilities who have been included in screening activities are provided with follow-up medical care if required. If people fail to attend treatment. medIcal care 41 . Ensure access to early treatment CBR programmes can promote and encourage collaboration between people with disabilities. CBR personnel who know sign language may accompany deaf persons to health facilities to ensure that they are able to communicate their needs and understand the information being provided and support them to access appropriate treatment. They are involved in awarenessraising activities providing information about the early signs and symptoms of leprosy and encouraging people with suspected lesions to visit their nearest primary health care service.BOX India Joining forces to provide care CBR programmes run by two nongovernmental organizations in the Mandya District of India collaborate with the national leprosy programme. ways in which these gaps can be reduced or eliminated. People who are diagnosed with leprosy commence a – month treatment regimen. e. checking with health workers to make sure referrals have been made for people with disabilities who require access to secondary and tertiary levels of health care. the costs associated with medical care. medical staff. family members. advocacy. with others (e. their families and primary health care workers to increase access to medical care services at all levels. policymakers).g.

The Community Agency for Rehabilitation and Education of Persons with Disabilities. check to ensure that people are receiving appropriate follow-up from surgical and nursing teams and rehabilitation professionals (e. In partnership with the International Hospital for Children and the Ministry of Health. Belize (CARE-Belize).BOX Belize Building on success Clubfoot or congenital foot deformities are birth defects that often lead to disability in lowincome countries. CARE-Belize developed a programme to ensure the early identification and treatment of children with clubfoot. serial casting and splinting. its success has led to the development of a national clubfoot programme. check to ensure that people with disabilities and their family members have been well informed of the possible risks and benefits of surgery and that they are aware of the costs and duration of the entire surgical/treatment plan. CBR programmes can: • • • explore what surgical options are available for people with disabilities and particularly whether funding options are available. therapists and rehabilitation field officers were trained to embrace the Ponseti method. 42 cBr gUIdelInes > 2: health comPonent . occupational therapists. It is suggested that CBR programmes: • work directly with people with disabilities to encourage them to take responsibility for their own health by seeking appropriate medical care and making healthy lifestyle choices and to ensure they are able to understand and follow medical advice. CAREBelize identified children at a very early age and referred them to medical care services for correction of clubfoot. When combined with follow-up care and rehabilitation. physiotherapists. Local doctors. prevent them from becoming worse and contribute to improved functioning. recognized that it was a significant issue for children in Belize. surgery can correct impairments. Although this was originally a local nongovernmental organization initiative. Facilitate access to surgical care Some people with disabilities may require surgical care. following surgery. prosthetists/orthotists) to maximize the benefits of surgery – CBR can assist in ensuring a smooth transition from medical care to rehabilitation. Promote self-management of chronic conditions CBR programmes can assist people with disabilities and their families to become aware of their right to medical care and to learn skills that enable them to manage their chronic health conditions.g. before surgery takes place. Through its CBR personnel. a nonsurgical method to correct clubfoot deformities at a very early age using gentle manipulation.

family members (where relevant) and medical personnel to enable discussion of key issues related to disability. Club management committees carry out fundraising activities to help cover the costs of medicines and laboratory tests.• • develop or adapt existing materials/publications that provide medical information about health conditions into formats that are appropriate for people with disabilities and their family members. access issues and sharing of experiences. CBR programmes can: • • promote awareness among medical personnel about the health needs of people with disabilities and their families. or support groups. which are not usually provided by the health system. organize interactive sessions between individuals and groups of people with disabilities. learn how to self-monitor their health conditions and explore solutions such as developing healthy lifestyles. Build relationships with medical care providers Medical personnel often have limited knowledge about disability and how best to enable access for people with disabilities to medical care services. in simple language. CBR programmes can develop a network which facilitates referrals and comprehensive medical care for people with disabilities. In the meetings. high blood pressure or diabetes. add to the efforts of the health-care system by ensuring that people are able to take responsibility for the management of their own health and prevent the development of further conditions and impairments. there are “clubs” for people with chronic conditions.g. with simple sketches or pictures and translated into local languages. BOX Nicaragua Partnerships to create change In Nicaragua. e. people talk about their problems. how to effectively negotiate the health-care system and how to manage existing health conditions. The CBR programme collaborates with these support groups to ensure that people with disabilities are included. These clubs.g. medIcal care 43 . e. link people with disabilities to self-help groups to enable them to learn about selfmanagement through the sharing of knowledge and skills with others – they can learn valuable information about what resources are available for medical care.g. By making contact with these services and building relationships with staff. e.

work jointly with community health programmes to ensure that people with disabilities can access the benefits of these programmes. many of whom have disabilities or are family members of a person with a disability. These training sessions provide great opportunities for networking. request medical services to provide education and training for CBR personnel so they are able to assist with early detection. provide referrals to appropriate services and provide follow-up in the community. BOX Indonesia Awareness raising in Indonesia A CBR programme in South Sulawesi. 44 cBr gUIdelInes > 2: health comPonent . primary-school teachers and community volunteers. Indonesia. promotion of the medical care needs of people with disabilities and promotion of the role of CBR and medical care services.• • • encourage medical personnel to involve people with disabilities and their family members in the development of medical treatment/care plans. The CBR team has regular training sessions with personnel from all levels of the health system. has a multisectoral team including village health workers.

access to rehabilitation is essential for people with disabilities to achieve their highest attainable level of health. calls for “appropriate measures. Article 26. to enable persons with disabilities to attain and maintain maximum independence. It is important to note however that health-related rehabilitation services and the provision of assistive devices are not necessarily managed by the ministry of health (see Rehabilitation services). including through peer support. education. such as those provided by therapists. social and vocational ability and full inclusion and participation in all aspects of life. livelihood and social welfare. or compensate for the loss or absence of a function or a functional limitation (23). Successful rehabilitation requires the involvement of all development sectors including health. full physical. Rehabilitation may range from more basic interventions such as those provided by community rehabilitation workers and family members to more specialized interventions. rehaBIlItatIon 45 . The Convention on the Rights of Persons with Disabilities. The Standard Rules on the Equalization of Opportunities for Persons with Disabilities state that rehabilitation measures include those which provide and/or restore functions. mental. This element focuses on those measures to improve functioning that are offered within the health sector.. Rehabilitation can occur at any stage in a person’s life but typically occurs for time-limited periods and involves single or multiple interventions..” (2).Rehabilitation Introduction As highlighted in the Preamble.

One of APDK’s successful partnerships has been with the Ministry of Medical Services (formally the Ministry of Health). APDK is a successful example of a public–private partnership and demonstrates how centre-based rehabilitation and community-based rehabilitation can work together to provide rehabilitation services for people living in both urban and rural areas. approximately   Kenyan people received rehabilitation services from APDK. APDK has been able to establish a national rehabilitation network consisting of nine main branches. Over the past  years.  associated outreach centres and many community-based rehabilitation programmes. With financial support from CBM and Kindernothilfe.BOX Kenya Forging public–private partnerships The Association for the Physically Disabled of Kenya (APDK) has been providing comprehensive rehabilitation services in Kenya for the past  years. they have extended these programmes to the major slums in Nairobi in order to reach those people with disabilities who are most vulnerable. 46 cBr gUIdelInes > 2: health comPonent . to work in these branches. CBR programmes provide homebased rehabilitation and are an important referral link to APDK outreach centres and branches. As a result of several partnerships. APDK has worked closely with this Ministry to ensure that quality rehabilitation services are accessible to as many people as possible. In  alone. Since . assistive devices and support for surgical interventions. APDK established their first CBR programme in their Mombasa branch in . The Ministry provides the salary for most of these health workers while APDK funds the programme costs. reaching over   people with disabilities. Six of the nine APDK branches are located within government hospitals and the Ministry of Medical Services has provided over  health workers. these provide services such as therapy. mostly therapists and technicians. APDK has employed  CBR personnel to work in these programmes while the government has funded several therapy positions.

therefore these guidelines use the term “rehabilitation” to refer to both habilitation and rehabilitation. Key concepts Rehabilitation Rehabilitation is relevant to people experiencing disability from a broad range of health conditions and therefore the CRPD makes reference to both “habilitation” and “rehabilitation”. Resource materials to support rehabilitation activities undertaken in the community are available for CBR personnel.Goal People with disabilities have access to rehabilitation services which contribute to their overall well-being. education and support to enable them to undertake rehabilitation activities. rehaBIlItatIon 47 . CBR personnel receive appropriate training. People with disabilities are referred to specialized rehabilitation services and are provided with follow-up to ensure that these services are received and meet their needs. Basic rehabilitation services are available at the community level. people with disabilities and families. Rehabilitation aims to assist those who experience a loss in function as a result of disease or injury and need to relearn how to perform daily activities to regain maximal function. • 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. Habilitation is a newer term and is not commonly used in low-income countries. support and implement rehabilitation activities at the community level and facilitate referrals to access more specialized rehabilitation services. Desirable outcomes • People with disabilities receive individual assessments and are involved in the development of rehabilitation plans outlining the services they will receive. The role of CBR The role of CBR is to promote. inclusion and participation. Habilitation aims to assist those individuals who acquire disabilities congenitally or in early childhood and have not had the opportunity to learn how to function without them.

prosthetists) and rehabilitation workers (e.Rehabilitation interventions A wide range of rehabilitation interventions can be undertaken within the health sector. gait training. an exercise programme to prevent muscle tightness and development of deformities and provision of a wheelchair with a specialized insert to enable proper positioning for functional activities. services may be managed through joint partnerships between government ministries and nongovernmental organizations.g. Kenya and China. In some countries. menstrual care. War Invalids and Social Affairs in Viet Nam and by the ministries of social welfare in India. provision of prostheses and/or a wheelchair and functional training to teach mobility and transfer skills and daily living skills. rehabilitation assistants. • • • • • • Rehabilitation for a young girl born with cerebral palsy might include play activities to encourage her motor. functional mobility training to enable him to negotiate his home and community environments and teaching appropriate communication methods such as touch and signs. Services are provided by a broad range of personnel including medical professionals (e. in some countries. developing strategies with the family to address behavioural problems and providing opportunities for social interaction enabling safe community access and participation. Rehabilitation services Rehabilitation services are managed by government.g. training in relaxation techniques to address stress and anxiety and involvement in a support group to increase social interaction and support networks. Rehabilitation for a young boy who is deafblind might include working with his parents to ensure they provide stimulating activities to encourage development. the phase during 48 cBr gUIdelInes > 2: health comPonent . however. orthotists. e. e. Rehabilitation for an adolescent girl with an intellectual impairment might include teaching her personal hygiene activities. clinics. provision of a walking stick to provide support for balance difficulties and exercises to facilitate speech recovery.g. nurses.g. sensory and language development. physiatrists). Rehabilitation for an older man who has diabetes and recently had both legs amputated below the knee might include strengthening exercises.g. the ministry of health manages these services. specialist centres or units. Rehabilitation services can be offered in a wide range of settings. Consider the examples below. technology specialists (e. Ghana and Ethiopia. Rehabilitation for a middle-aged woman with a stroke might include lower limb strengthening exercises. bath and eat independently. occupational therapists. by the Ministry of Labour. Rehabilitation for a young man with depression might include 1:1 counselling to address underlying issues of depression.g. community facilities and homes.g. in the Islamic Republic of Iran. In most countries. e. speech therapists). including hospitals. functional training to teach her to dress. physiotherapists. community rehabilitation workers). private or nongovernment sectors. rehabilitation services are managed by other ministries. therapy professionals (e.

Successful rehabilitation depends on strong partnerships between people with disabilities. close links must be maintained with referral centres that offer specialized rehabilitation services. or therapists may be available only in hospitals or large clinics. involvement in the provision of rehabilitation services at community level remains a realistic and necessary activity for CBR programmes. the range of rehabilitation services available and accessible is often limited. Community-based services may also be required following rehabilitation at specialized centres. rehaBIlItatIon 49 . Community-based services Historically. Where rehabilitation services are established in the community. CBR was a means of providing services focused on rehabilitation to people living in low-income countries through the use of local community resources.g. Therefore community-based strategies such as CBR are essential to link and provide people with disabilities and their families with rehabilitation services. particularly those living in rural areas and many rehabilitation activities can be initiated in the community. CBR programmes can provide support by visiting people at home and encouraging them to continue rehabilitation activities as necessary. In low-income countries and particularly in rural areas. rehabilitation professionals and community-based workers. the acute phase following an accident/injury) and the type of interventions required usually determine which setting is appropriate. The WHO manual on Training in the community for people with disabilities is a guide to rehabilitation activities that can be carried out in the community using local resources (32). There may only be one rehabilitation centre in the major city of a country. for example. While the concept of CBR has evolved into a broader development strategy. A person may require continued support and assistance in using new skills and knowledge at home and in the community after he/she returns. Rehabilitation at specialized centres may not be necessary or practical for many people. The needs of many people with disabilities change over time and they may require periodic support in the long term.which rehabilitation occurs (e.

goal-oriented and realistic. They also made a simple toilet bowl to solve the problem of going to the toilet. in particular the issue of poverty. Her family and friends were taught how to make a simple walking frame for her to practise standing and walking. and a longterm vision is required. allows her once again to care for her family and be confident about the future. Step by step. a middle-aged widow. providing her with a source of income which. socioeconomic status and home environment need to be considered. When developing a plan. A village rehabilitation officer from a local CBR programme came to visit Li and provided her with home-based rehabilitation. Li was taught new ways of completing daily living activities using her residual abilities. Her whole family depended on her before an accident in October . which included cooking for her family. with short-term goals. gender. she stayed in bed all day and night. 50 cBr gUIdelInes > 2: health comPonent . After she was discharged from hospital. are considered. She was soon able to manage her own daily activities. Li soon lost her confidence and tried to commit suicide several times. Rehabilitation is often a long journey. age. Li built up her confidence.BOX China Li’s journey to independence Li. Many rehabilitation plans fail because people with disabilities are not consulted. it is important to ensure that their opinions and choices influence the development of the plan and that the realities of their lives. bathe. Li fell from a height while repairing her house and sustained a spinal fracture. change her clothes and use the toilet. she was unsuccessful. Valuable resources can be wasted when rehabilitation plans are not realistic. For example. resulting in weakness and sensory loss in both legs. together with a small monthly living allowance from the County Ministry of Civil Affairs. fortunately. Swelling quickly developed in both her legs and she required full assistance from her children to turn in bed. a plan that requires a poor person living in a rural area to travel frequently to the city for physiotherapy is likely to fail. an activity she really enjoyed. a person’s preferences. Rehabilitation personnel need to be innovative and develop appropriate rehabilitation programmes which are available as close as possible to home. Li also opened a mill. The County Rehabilitation Centre provided crutches and a wheelchair. including in rural areas. She was given information about her disability and learnt how to prevent bed sores and urinary tract infections. lives with her elderly mother and three children in the Qing Hai province of China. With time and practice Li was able to stand and walk independently with crutches and use a wheelchair for longer distances. Rehabilitation plans Rehabilitation plans need to be person-centred.

Assessment is an important skill. when a child starts school. body. including location. behaviour? What secondary problems are developing? What is their home and community situation like? In what way have they adjusted to their disability? Accurate information can be obtained by reviewing past medical records. mind. The following activities are suggested. following the basic assessment. communication. so an individual’s progress can be monitored over time. audiology. so CBR personnel should receive prior training and supervision to ensure competency in this area. observing the individual.g. Many CBR programmes have developed assessment forms and progress notes to make this easier for their staff. Help them to seek additional information if required.g. performing a basic physical examination of the individual and through discussions with the individual. occupational therapy. speech therapy. family members and involved health professionals/services. a young adult starts work. e. senses.Rehabilitation needs may change over time. particularly during periods of transition. it is important for CBR personnel to carry out a basic assessment with an individual and his/her family members to identify needs and priorities. Encourage people with disabilities and their families to express concerns and ask questions about referral services. e. physiotherapy. Provide information regarding referral services to people with disabilities and their families. It is important to keep a record of the initial assessment and future consultations. adjustments will need to be made to the rehabilitation plans to ensure the activities continue to be appropriate and relevant. CBR personnel identify a need for specialized rehabilitation services. or a person returns to live in her/his community following a stay in a rehabilitation facility. During these transitions. • • • • • • • What activities can they do and not do? What do they want to be able to do? What problems do they experience? How and when did these problems begin? What areas are affected? e. • • • Identify rehabilitation referral services available at all levels of the health system. rehaBIlItatIon 51 . To identify a person’s needs it can be helpful to consider the following questions. Facilitate referral and provide follow-up If. Links can be made with other people in the community who experience similar problems and have benefited from the same or similar services.g. possible benefits and potential costs. Suggested activities Identify needs Before making a rehabilitation plan and starting activities. they can facilitate access for people with disabilities by initiating referrals.

many services also require out-of-pocket payments. bank loans and community support. including transport. people are referred back to the primary health-care services. if advocacy is required.g.g. BOX Iran No place too far from services The CBR programme in the Islamic Republic of Iran encourages village health workers and CBR personnel to identify people with disabilities early and refer them to the primary health-care services in the community. food. enabling them to maintain and maximize their function within their home and community. Consideration must be given to the costs associated with a visit to the city. For example. The major areas of child development include: physical development. accommodation and loss of daily wages. advocacy) and how this can be provided. Identify what support is required to facilitate access to services (e. usually in the provincial headquarters or capital city. maintain regular contact with the services and individuals involved to ensure that appointments have been made and attended. transport. speech and language development. If specialized interventions are required. The mobile team provides follow-up to monitor progress and provide further assistance when required. a mobile team of rehabilitation personnel visit the home to provide home-based rehabilitation. rehabilitation activities may need to be continued at home. CBR personnel can accompany people to their appointments. Facilitate rehabilitation activities CBR programmes can facilitate home and/or community-based therapy services and provide assistance to people with a wide range of impairments. e.• • • • Ensure people with disabilities and their family members give informed consent before any referral is made. if necessary. financial. Specialized rehabilitation services are often based in large urban centres and this can restrict access for people living in rural/remote areas. referral is made to a tertiary-level care centre. Provide follow-up after appointments to determine whether ongoing support is needed. Once a referral is made. Following rehabilitation at a specialized centre. which work with the CBR programme to ensure that rehabilitation activities are continued. 52 cBr gUIdelInes > 2: health comPonent . CBR programmes should be aware of financial constraints and ensure that a wide range of options are investigated including government and/or nongovernmental organization schemes. Following referral. cognitive development and social and emotional development. Provide early intervention activities for child development Every child goes through a learning process enabling him/her to master important skills for life.

usually home-based. this might include strengthening. 53 rehaBIlItatIon . developmental delay are identified as early as possible and provided with focused rehabilitation interventions to prevent or improve this delay. housework. education and instruction on specific techniques used to address impairments. to encourage simple and enjoyable learning opportunities for development.g. Parents come with their children who have disabilities to participate in activities organized by the CBR programme and community volunteers. can result in developmental delay and restrict a child’s ability to participate in regular activities such as playing with other children and going to school. e.g. gender and local environment and will change over time as she/he makes a transition from one life stage to another. children at risk of. singing and dancing contests. There is a range of fun activities for children. or with. Interventions are dependent on a person’s age. Through early intervention. education for families on how to best assist people with disabilities in functional activities to maximize their independence. and parents are given the opportunity to talk and share their experiences with one another and to attend training sessions. e. poor balance and muscle tightness. drinking.g. so their children learn to play with other children. which impact a person’s ability to carry out activities.Delays in development occur when a child is unable to reach the important milestones suitable for his/her age group. Egypt. muscle weakness. learn new skills and improve in all areas of development. including in a local stadium and a mosque. dressing. CBR personnel can provide early intervention activities. cooking. e.g. stretching and fitness programmes. Encourage functional independence Functional interventions aim to improve an individual’s level of independence in daily living skills. e. bathing. cerebral palsy. training in the use of assistive devices. toileting. CBR personnel can provide: • • • • training for people with disabilities and their families about the different ways to carry out activities. The presence of a disability. eating. CBR programmes can also encourage parents to meet together to share ideas and experiences and facilitate playgroups. walking/ mobility devices to make activities easier. mobility. has several clubs that meet weekly in different parts of the city. communication. BOX Egypt Fun for families The CBR programme in Alexandria. e. blindness or deafness.g.

She has become an active member of the local CBR committee and a member of the disabled people’s organization.g. or at community level. Shirley’s mother agreed and a rehabilitation plan was made to facilitate greater functional independence for Shirley. 54 cBr gUIdelInes > 2: health comPonent . Viet Nam. toilet adaptations and widening doorways. BOX Viet Nam A grandmother finds her way An elderly grandmother in the village of Thai Binh. to visit the house. It was difficult to convince Shirley’s mother. Facilitate environmental modifications Environmental modifications may be necessary to improve the functional independence of a person with a disability.g. so that during the night she could follow the cord to the toilet without waking her family. had diabetes and low vision. As Pauline was blind herself. The CBR volunteer asked Pauline. When CBR volunteers visited Shirley’s house. especially during the night. a CBR regional coordinator. public buildings or work places (see Assistive devices element). ramps for wheelchair access. e. She needed to go to the toilet frequently. the CBR volunteer thought that she would be a good example and motivator for both Shirley and her mother. A volunteer from the local CBR programme advised the family to fix a cord from her bed to the toilet. Shirley made rapid progress and is now able to move around her community independently with the help of a white cane. modification of the school environment. She is blind and because of this her mother was afraid to allow her to go outside the house alone. and as the toilet was outside in the courtyard she had to wake a family member to accompany her. fearful that she would hurt herself. e. A simple environmental modification ensured this grandmother’s independence. handrails near steps. they talked to her mother and said that it was possible to teach Shirley how to move outside independently. CBR personnel may facilitate environmental modifications at an individual level (in the home).BOX Guyana Learning to view life differently Shirley lives in a village in Guyana.

Many specialized hospitals agreed to charge subsidized fees for people referred by the CBR programme. The following CBR activities are suggested. or ophthalmology care. Training in the community for people with disabilities (32) and Disabled village children (33). particularly where access to rehabilitation professionals is limited. nose and throat (ENT). These resources may also provide valuable information for the wider community as well as the many different services and sectors involved in rehabilitation activities. rehaBIlItatIon 55 . CBR programmes can encourage interactions between these groups and rehabilitation professionals to enable mutual understanding and collaboration. These may be available through government ministries. to explain how these hospitals worked and how people could access the different services. United Nations bodies. ear.Link to self-help groups CBR programmes promote self-help groups where people with similar impairments or similar rehabilitation needs come together to share information. The CBR programme found that many families with people with disabilities were afraid of going to referral hospitals for e. Adapt materials to suit local requirements. and many can be accessed from the Internet. develop new materials in simple language to suit local needs. India.g. Some professionals from the hospitals were invited to cultural events organized by the CBR programme and given community recognition for their support. • • • • • Locate existing resource materials. Where existing resources are not available. So visits to referral hospitals were organized for small groups of people with disabilities and their family members. ideas and experiences. Translate existing materials into national and/or local languages.g. e. These resources can be used by CBR personnel and by people with disabilities and their family members to guide rehabilitation. often involves staff from rehabilitation institutions as trainers and teachers for CBR personnel. Develop and distribute resource materials Disability booklets and manuals can be a useful tool for rehabilitation. giving special consideration to cultural differences. disabled people’s organizations or national and international nongovernmental organizations. BOX India Recognising the support of hospitals A CBR programme in a poor area of Greater Mumbai. Distribute resource materials to all CBR personnel to carry with them when visiting people with disabilities for rehabilitation.

Health workers are always provided with two copies of any resource material – one copy for themselves and one copy for the people they are visiting.• Create resource units where materials for people with disabilities. BOX Viet Nam Translating resources into Vietnamese A CBR programme in Viet Nam translated several existing publications. The units may be located in the local development office. including the WHO CBR manual. CBR personnel require a good understanding of the role of rehabilitation personnel. 56 cBr gUIdelInes > 2: health comPonent . community health centre. prosthetists/orthotists. speech therapists.g. Provide training CBR personnel need training to ensure they are able to facilitate access to rehabilitation services and provide appropriate services at community level. occupational therapists. physiotherapists. or specific centres for people with disabilities. mobility trainers. Many organizations have developed suitable training programmes. audiologists. medical and paramedical personnel and of how they can be of benefit to people with different impairments. family members and other members of the community are available. e. In addition they developed their own materials on specific concerns for people with disabilities and their caregivers. into Vietnamese to use for local purposes. CBR can also provide education to rehabilitation personnel to raise their awareness of the role of CBR and how it can help them optimize their services (see Management).

Without assistive devices. Articles 4. made. Many people with disabilities depend on assistive devices to enable them to carry out daily activities and participate actively and productively in community life. 20 and 26.Assistive devices Introduction Assistive devices are external devices that are designed. people with disabilities may never be educated or able to work. In many low-income and middle-income countries. assIstIve devIces 57 . production. Increasingly. so the cycle of poverty continues. The Standard Rules on the Equalization of Opportunities for Persons with Disabilities also call upon States to support the development. or adapted to assist a person to perform a particular task. the benefits of assistive devices are also being recognized for older people as a health promotion and prevention strategy. only 5–15% of people who require assistive devices and technologies have access to them (34). Access to assistive devices is essential for many people with disabilities and is an important part of any development strategy. In these countries. asks States to promote the availability of appropriate devices and mobility aids and provide accessible information about them (2). there are very few trained personnel and costs may be prohibitive. The Convention on the Rights of Persons with Disabilities. production is low and often of limited quality. distribution and servicing of assistive devices and equipment and the dissemination of knowledge about them (23).

who fitted him with a below-knee prosthesis and provided rehabilitation to ensure he was able to walk well with his artificial leg and learn how to pedal his rickshaw again. Working in partnership with Handicap International (Nepal) they developed a comprehensive service which included the fabrication. Chandeswar was identified by the CBRB team working in his village. Local people (women and men. crutches. with and without disabilities) were trained as technicians in Nepal and India and integrated into the existing CBRB team. artificial legs and hands) and mobility devices (e. He lost his income because he was no longer able to work as a rickshaw-puller and he lost his savings because he needed to pay for his medical care. the President of CBRB says: “We were carrying out CBR for many years but since we started providing quality assistive devices we have become more effective. tricycles. prostheses (e. CBRB started a small orthopaedic workshop to carry out minor repairs of assistive devices. CBR personnel.g. providing rehabilitation services to more than  children and adults with disabilities.BOX Nepal Being able to work again Community Based Rehabilitation Biratnagar (CBRB) is a nongovernmental organization that has been working in the eastern region of Nepal since . provision and repair of assistive devices. One of the people to have benefited from the orthopaedic workshop is Chandeswar. splints). wheelchairs) to people living with disabilities in  districts of eastern Nepal. In . therapists and workshop technicians all work hand-in-hand to enhance the quality of life of people with disabilities. our credibility has gone up and now we have a great acceptance in the community”. Currently it is working in  villages of the Morang District and in Biratnagar Submunicipality. 58 cBr gUIdelInes > 2: health comPonent . as many people with disabilities had to travel to the capital or neighbouring India for repairs. Over time.g. He is a rickshaw-puller who worked hard until he suffered an injury and had his left leg amputated. CBRB now provides quality orthoses (e. Now Chandeswar is back pedalling his rickshaw around the busy streets of Biratnagar and making a reasonable living. braces. Seeing the benefit to people such as Chandeswar.g. calipers. CBRB worked towards establishing a fully equipped orthopaedic workshop.

are reduced. specialized computer software/hardware or motorized wheelchairs). availability within communities and referral mechanisms for specialized devices. to complex. including the types avail- • • • • • able. facilitate access to assistive devices and ensure maintenance. high-technology devices (e. including people with disabilities and their families. People with disabilities and their families are knowledgeable about assistive devices and make informed decisions to access and use them.Goal People with disabilities have access to appropriate assistive devices that are of good quality and enable them to participate in life at home and work and in the community. basic fabrication. walking sticks or adapted cups). Desirable outcomes • CBR personnel are knowledgeable about assistive devices. The role of CBR The role of CBR is to work with people with disabilities and their families to determine their needs for assistive devices. their functionality and suitability for different disabilities.g. low-technology devices (e. People with disabilities and their families are provided with training. financial constraints and centralized service provision.g. Environmental factors are addressed to enable individuals to use their assistive devices in all locations where they are needed. such as inadequate information. education and follow-up to ensure they use and care for their assistive devices appropriately. repair and replacement when necessary. assIstIve devIces 59 . It is helpful to consider this wide variety of assistive devices under different categories. Local people. Key concepts Common types of assistive device Assistive devices range from simple. Barriers preventing access to assistive devices. are able to fabricate basic assistive devices and undertake simple repairs and maintenance.

a person with cerebral palsy may require a wheelchair with trunk/head supports to ensure he/she is able to maintain a good sitting position. orthotics and orthopaedic shoes These are usually custom-made devices which replace. production and distribution of wheelchairs. Positioning devices People with physical impairments often have difficulty maintaining good lying. home maintenance). 60 cBr gUIdelInes > 2: health comPonent .g.Mobility devices Mobility devices assist people to walk or move and may include: • • • • • wheelchairs tricycles crutches walking sticks/canes walking frames/walkers. The following devices can help overcome some of these difficulties: • • • wedges chairs. support or correct body parts. hand/leg splints or callipers orthopaedic shoes. toileting. special seats standing frames. The WHO guidelines on Provision of manual wheelchairs in less resourced settings (35) are a useful reference for those people involved in the design. Mobility devices may have specialized features to accommodate the needs of the user. e. including: • • • • • adapted cutlery and cups shower seats and stools toilet seats and frames commodes dressing sticks. Prosthetics. eating. e.g. They are designed. standing or sitting positions for functional activities and are at risk of developing deformities due to improper positioning. spinal braces.g. dressing. For example. e. corner chairs. There are many examples of these devices. manufactured and fitted in specialized workshops or centres by trained prosthetic/orthotics personnel and include: • • • prostheses.g. artificial legs or hands orthoses. bathing. Daily living devices These devices enable people with disabilities to complete the activities of daily living (e.

Vision devices Low vision or blindness has a great impact on a person’s ability to carry out important life activities. A range of devices (simple to complex) can be used to maximize participation and independence, including:

• • • • • • •

large print books magnifiers eyeglasses/spectacles white canes braille systems for reading and writing audio devices, e.g. radios, talking books, mobile phones screen readers for computers, e.g. JAWS (Job Access with Speech) is a screen reader programme.

Hearing devices Hearing loss affects a person’s ability to communicate and interact with others; it can impact on many areas of development, e.g. speech and language and restricts educational and employment opportunities, resulting in social discrimination and isolation. Devices include:

• • • • •

hearing aids headphones for listening to the television amplified telephones TTY/TTD (telecommunication devices) visual systems to provide cues, e.g. a light when the doorbell is ringing.

BOX

Papua New Guinea

Top of the class
Anna is a mother who lives in East Sepik province of Papua New Guinea. Her daughter Koris was born deaf. Anna was very determined to send her daughter to school and, through a CBR worker trained by Callan Services for Disabled Persons (a national nongovernmental organization), Anna became aware of a nursery school for deaf children. Before attending this school, Callan Services arranged for the provision of hearing aids; ear mould impressions were taken for Koris and when the hearing aids were ready to be fitted she was sent to an audiologist in Port Moresby. Koris started attending school and also began learning sign language. With the help from assistive devices and with the support of her teachers, Koris soon became one of the top pupils in her class.

assIstIve devIces

61

Communication devices Augmentative and alternative communication devices can assist individuals who have difficulty understanding and producing speech. They are provided to support speech (augmentative), or to compensate for speech (alternative). Devices include:

• • • •

communication boards with pictures, symbols or letters of the alphabet request cards electronic speech output devices computers with specialized equipment and programmes.

Cognitive devices Cognition is the ability to understand and process information. It refers to the mental functions of the brain such as memory, planning and problem-solving. Brain injuries, intellectual impairment, dementia and mental illness are some of the many conditions that may affect an individual’s cognitive ability. The following devices can assist individuals to remember important tasks/events, manage their time and prepare for activities:

• • • • •

lists diaries calendars schedules electronic devices, e.g. mobile phones, pagers, personal organizers.

Selection of assistive devices
Appropriate technology Many types of technology are not suitable for rural/remote areas and low-income countries. However, “appropriate technology” is designed with consideration given to the environmental, cultural, social and economic factors that influence communities and individuals. Appropriate technology meets people’s needs; it uses local skills, tools and materials and is simple, effective, affordable and acceptable to its users. Assistive devices are technologies that must be carefully designed, produced and selected to ensure they meet these criteria.

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BOX

India

Wearing the same shoes
The Assisi Leprosy and CBR programme in Andhra Pradesh, India provided sandals made of black microcellular rubber to people with leprosy who had lost sensation in their feet and were at risk of foot ulcers. It became obvious that many people who were provided with these sandals did not use them. After talking with these people, it was discovered that by wearing the sandals they were subject to social stigma – the black sandals had become easily identifiable in the community as shoes that only people with leprosy wore. As a result the programme decided to use sandals available from the local market, modifying them as necessary to suit the requirements of people with leprosy. People began wearing the footwear as there was little visible difference between their sandals and those that other community members wore.

Assessment Assistive devices need to be carefully selected and often specially made and fitted to ensure they meet the individual’s needs. Poor selection and design can lead to many problems including frustration, discomfort and the development of secondary conditions. For example, it may be common practice in some countries to distribute donated or second-hand wheelchairs on a large scale. While this may have benefits, it also has the potential to cause harm to users, e.g. the provision of a wheelchair without a cushion to a person with a spinal cord injury may cause a potentially life-threatening pressure area (see Prevention element). Comprehensive assessment is necessary to ensure assistive devices meet the needs of individuals within their homes, schools and work and community environments. A comprehensive assessment might include a medical history, a review of current function, individual goals, an evaluation of existing assistive devices and a physical examination. The approach to assessment should be multidisciplinary where possible and include a wide variety of people, such as people with disabilities, family members, therapists, technicians, teachers and CBR personnel.

assIstIve devIces

63

environments. reorganizing furniture to increase the amount of space for movement. a young woman using a wheelchair must be able to use it to enter/exit her home. a young boy who uses a communication board instead of speech will need to use his board both at home and at school. programmes and services to be usable by all people (2). attitudes and support systems. For example. the purpose and function of assistive devices. willing and able to use this device with him. both with and without disabilities. Adaptations/modifications to the physical environment include installing a ramp where there are steps. CBR personnel need knowledge about: • • the common types of assistive device.Use of assistive devices Barrier-free environments Many people use their assistive devices in different places and it is important to ensure that all environments are barrier-free in order for someone to achieve maximum function and independence.g. CBR volunteers motivated community members to improve the local bridge so that people using wheelchairs as well as others could pass over it comfortably.g. move freely within her home and access important areas (e. referral and education. widening a narrow doorway. e. particularly within the community. schoolteachers and friends are positive. so it is important that family members. Suggested activities Train CBR personnel CBR personnel require training on assistive devices to ensure that they are able to provide accurate information. cBr gUIdelInes > 2: health comPonent 64 . which can also influence a person’s ability to use the device. the bathroom). Universal design means designing products. travel within her community and access her workplace. It is also important to consider other aspects of the environment. it is helpful to consider “universal design” (36). or it may be part of a course on rehabilitation. Training may be specific. For example. When considering environmental modifications. BOX Viet Nam Bridging the community In a village in the Thai Binh district of Viet Nam.

able to use their assistive devices properly and safely and are able to perform repairs and maintenance to ensure long-term use. ensuring accurate information is always available for people with disabilities living in villages. CBR personnel may need to: • • • • • show a family how to build a wooden chair with a strap to enable a child with poor balance to sit upright. teach a child with cerebral palsy. Build capacity of individuals and families CBR personnel need to work closely with people with disabilities and their family members to ensure that they are: • • • • aware of the different types of assistive device and how these can assist individuals to achieve independence and participation. with no speech or coordinated hand movement. BOX Indonesia Information where it’s needed The CBR programme in South Sulawesi. prepared an Assistive Device Resource Sheet listing the main service providers in the province who are able to supply and repair devices. e. to enable access to specialized devices. provide instruction to a blind person on the use of her/his white cane. are available.g. how to use a pictorial communication board using her/his eyes. involved in decision-making regarding the selection and design of assistive devices – providing opportunities for people to see and try assistive devices will assist them to make informed decisions. show a family how to build parallel bars to enable walking practice at home. For example. This resource sheet is distributed to all CBR personnel. particularly for CBR personnel who work in rural/ remote areas. crutches. Indonesia. where specialized devices. e. referral mechanisms. prostheses and hearing aids. able to give feedback to referral services about any difficulties experienced so that adjustments can be made and different options considered.g. assIstIve devIces 65 . the funding options available for people who are unable to afford devices. show a family how to make a simple walking stick for a person recovering from a stroke to assist her/him in walking. Practical training is also essential. to ensure they can produce basic assistive devices and develop the skills and confidence to work directly with individuals who need the devices.• • • • which basic devices can be prepared in the community.

Self-help groups can be particularly beneficial when someone has limited access to rehabilitation personnel. Train local artisans It is unrealistic to expect people living in rural areas to travel to specialized centres to have their devices repaired and many people stop using their devices when they experience problems.g. CBR programmes can identify local artisans who are interested in producing them and facilitate training. to teach them how to make simple splints. BOX Mongolia Learning how to make assistive devices In . 66 cBr gUIdelInes > 2: health comPonent . prostheses and wheelchairs. Self-help groups can support individuals to adjust to newly acquired assistive devices. standing frames and basic seating can also be produced by local artisans because they are simple to make using locally available materials. screws or rivets. repair orthoses by replacing straps. the National CBR programme in Mongolia organized a training course for staff working at the National Orthopaedic Laboratory in Ulaan Baatar. Now. whenever a CBR programme starts in a new province of Mongolia. e. Local artisans can be trained to make small repairs to assistive devices such as orthoses. Assistive devices such as walking sticks. walking frames. prevention of secondary complications and how to achieve optimum function. CBR programmes can identify local artisans and facilitate this training in partnership with technicians. seating devices and mobility devices using local materials and appropriate technology.g. educating them on their care and maintenance and can provide advice on self-care. crutches.This health component highlights the fact that self-help groups enable people to share valuable information. two local artisans are identified and trained at the National Orthopaedic Laboratory. e. skills and experiences.

number of visits required for measurements and fittings and time for production. mobile facilities. poverty. toilet chairs. providing transport for small groups of people from rural/remote areas to travel to referral centres. They also created five distribution. ensuring this information is available in an appropriate format and is communicated to people with disabilities and their families. BOX Lebanon Accessing assistive devices The national disabled people’s organization in Lebanon launched a production unit for wheelchairs and other assistive devices such as crutches. administrative procedures.g.g. Set up small-scale workshops When referral services are not available. including referral mechanisms. partnering with referral centres. e. establish a mobile service or regular meeting point in the community for people needing repairs to their devices. e. assisting people to complete relevant administration processes so they can obtain a disability certificate. or barriers such as cost and distance cannot be overcome. distance and centralized service provision. providing home or community-based repair services for people living in rural/remote areas. identifying funding options for people who are unable to afford the costs associated with assistive devices – CBR programmes can facilitate access to existing government or nongovernmental schemes and can raise their own funds and/or empower individual communities to donate resources. assessment procedures. The disabled people’s organization has also ensured an adequate national budget for assistive devices. The production unit and repair workshops employ people with disabilities.Facilitate access to assistive devices Access to assistive devices may be limited by inadequate information. compiling detailed information on each service provider. CBR personnel need to work closely with people with disabilities and their families to facilitate access to assistive devices by: • • • • • • • • identifying existing service providers – local. CBR programmes can now refer people who need assistive devices to these centres to access assistive devices. regional and national – who produce and/or supply a wide range of assistive devices (basic and specialized). e. local authorities and other organizations to discuss ways to decentralize service provision. orthopaedic shoes and specialized seating systems. repair and maintenance workshops around the country to facilitate access to these devices. which in many countries will enable them to access free devices.g. CBR programmes can consider setting up and/or supporting a small 67 assIstIve devIces . walkers. costs and processes. ensuring prior arrangements are made with these centres.

female and disabled – they were all seen as liabilities within their families and communities. are assets to their families and are role models for many people with disabilities. Life has changed for the women since they started their business (Rehabilitation Aids Workshop by Women with Disabilities). Simple devices can be produced by locally trained people. Finding appropriate materials is often a problem and importing materials is very costly. 68 cBr gUIdelInes > 2: health comPonent . India. They are married. In  the  women trained as orthopaedic technicians and were provided with a loan from one of the CBR programmes to open a commercial workshop. BOX India Making a small business work Several CBR programmes in Bangalore. uneducated. have good quality of life and are seen as active contributors to their communities. to the development of social networks and ultimately to empowerment. BOX Guinea-Bissau Finding local solutions Cumura Hospital in Guinea-Bissau has a small workshop for preparing orthoses and two people with disabilities have been trained as orthopaedic technicians to work here. The women are now earning good incomes. This can generate income and lead to their recognition as active contributors to their communities. identified a group of  young women with disabilities. Both the WHO CBR manual (32) and Disabled village children (33) provide information about making assistive devices in the community using local resources. All of these women faced disadvantages and discrimination because they were poor. therefore the technicians try to find local solutions for designs from other workshops. They extended their business by becoming agents for several major companies that manufactured assistive devices and healthcare products and by establishing links with major private hospitals in the city. For example they have started to make a leather and plastic splint for persons with foot-drop. The workshop started making a profit from the second year and by the end of the fourth year they had repaid the whole loan.workshop to meet local needs. People with disabilities can also be trained to make assistive devices.

uk/Documents/publications/disabilitypovertydevelopment. assIstIve devIces 69 . accessed 30 May 2010).pdf.Network and collaborate In some countries it may not be feasible to establish services that provide a wide range of assistive devices. Geneva.pdf. Becker H.who. Office of the United Nations High Commissioner for Human Rights/World Health Organization. school. The determinants of health. United Nations Economic and Social Commission for Asia and the Pacific/UNDP/ADB. CBR programmes need to develop strong links with international and national nongovernmental organizations who are often active in producing and providing assistive devices with a view to the development of sustainable service provision. 10. Geneva.int/governance/eb/who_ constitution_en. where they are likely to be cheaper and easier to access than importing them from high-income countries. 2005. 8.asp. United Nations – DESA/OHCHR/IPU. 7. 31). Health systems. World Health Organization. Geneva. Disability.pdf. or small populations.gov.org/Documents/Publications/ Factsheet31. But many assistive devices will be available in neighbouring countries. accessed 30 May 2010). References 1. 2008 (www.pdf. Access to basic services for the poor: The importance of good governance (Asia Pacific MDG Study Series). Address barriers in the environment Very often there are barriers in the home. 2. Convention on the Rights of Persons with Disabilities. 2006 (www. 3. Constitution of the World Health Organization. 5. Bangkok. poverty and development. 4. accessed 30 March 2010).who. The right to health (Fact Sheet No.unescap.org/Documents/Publications/training14en. In addition.int/whr/2008/whr08_en. communities and local authorities to identify and address them.org/pdd/prs/ProjectActivities/Ongoing/gg/access-to-basic-services. accessed 30 May 2010).who. accessed 30 May 2010). 2010 (www. Geneva. 2000 (www. From exclusion to equality: realizing the rights of persons with disabilities. Geneva. World health report 2008: primary health care – now more than ever.who. accessed 30 May 2010). accessed 30 May 2010). New York. 6. London. work or community environments that make it difficult for people to use their assistive devices.int/topics/health_systems/en/.ohchr.un. family members. 9.pdf. World Health Organization. dfid. World Health Organization. 2007 (www.ohchr. 2006 (www. 2007 (www. Measuring health among people with disabilities. Geneva. Department for International Development. CBR personnel require practical knowledge regarding these barriers so they can work with individuals.int/hia/evidence/ doh/en/. 29(1S):70S–77S. Community Health. This may be due to government priorities. CBR programmes need to determine what resources are available in neighbouring countries and collaborate with these countries where possible.org/ disabilities/. United Nations. accessed 30 May 2010). limited resources. 2010 (www. 2008 (www. accessed 30 May 2010).

19. 2003–2004 (www. accessed 30 May 2010). 1978 (www.html. World Health Organization Regional Office for the Western Pacific. 2009 (www. accessed 30 May 2010).un. 20.int/whr/2002/en/. Regional framework for health promotion 2002–2005.pdf. accessed 30 May 2010).unescap.int/hpr/ NPH/docs/ottawa_charter_hp. Smith RD. promoting healthy life. Washington. Geneva. Journal of Lifestyle Medicine. The Standard Rules for the Equalization of Opportunities of Persons with Disabilities. 15. 18. World Health Organization.pdf. 26. 1997. American Journal of Health Promotion. 2002 (www. United Nations.int/disabilities/publications/cbr/en/index. 17.who. World health report 2002: reducing risks. World Health Organization. 282). who. United Nations Educational. 6–12 September 1978. Health Promotion International. Geneva. Ottawa Charter for Health Promotion. Water and sanitation for people with disabilities and other vulnerable groups: designing services to improve accessibility. Macmillan Education.htm. poverty reduction and social inclusion of people with disabilities (Joint position paper 2004). 2(5):409–420. DC. Jones H. 22. Health promotion for people with disabilities: Implications for empowering the person and promoting disability-friendly environments. World Health Organization. The Surgeon General’s call to action to improve the health and wellness of people with disabilities.int/publications/pub_9290810328.int/mediacentre/factsheets/fs282/en/index. USSR.oxfordjournals. International Labour Organization. Alma Ata. Declaration of Alma Ata: International Conference on Primary Health Care. 25. Harrison T. 14. accessed 30 May 2010).asp.html. Water Engineering and Development Centre. Hubley J. Scientific and Cultural Organization.org/esa/socdev/enable/dissre00. 2005. accessed 30 May 2010). CBR: A strategy for rehabilitation. accessed 30 May 2010). World Health Organization. Health promotion glossary. 2005. Office of the Surgeon General. Geneva. United Nations. accessed 30 May 2010). 2000. accessed 30 May 2010). 15(1):79–86 (http://heapro. Manila. 21.who.int/publications/almaata_ declaration_en. Patrick DL. 2004 (www.htm. 13. 23. 2009 (www. accessed 30 May 2010). Understanding community-based rehabilitation. 29(1S):12S–19S. Rimmer JH. 2nd ed. Promoting the health of people with physical disabilities: a discussion of the financing and organization of public health services in Australia. Oxford. New York.un. accessed 30 May 2010). Section V – Rights of special groups with disabilities.who. accessed 30 May 2010).who. Visual impairment and blindness (Fact Sheet No.11. accessed 30 May 2010). United Nations Economic and Social Commission for Asia and the Pacific. equalization of opportunities. and World Health Organization. United States Department of Health and Human Services. 1993 (www. Loughborough.org/cgi/content/abstract/15/1/79. 2008. Geneva.pdf. Rethinking prevention for people with disabilities Part 1: a conceptual model for promoting health. 2002 (www. 2005 (www. 11(4):257–260. Reed B.org/esa/socdev/enable/discom500. Rowland JL. 2004. International Norms & Standards Related to Disability.wpro.who. World Health Organization.htm. 24. Communicating health: an action guide to health education and health promotion. 16.gov/library/disabilities/calltoaction/index. 1998 (www. who. Bangkok.int/hpr/NPH/docs/ hp_glossary_en.surgeongeneral. New York. Geneva.html. 27. 1986 (www. Geneva. 70 cBr gUIdelInes > 2: health comPonent . 12. Health promotion for persons with disabilities: what does the literature reveal? Family Community Health.org/esid/psis/disability/decade/publications/ cbr.

London. World Health Organization.who. accessed 30 May 2010). Okune J (eds. Hesperian Foundation. Disabled village children. accessed 30 May 2010).pdf. 32. 3(3):29–42 (www. Mobility International.int/mental_health/resources/mentalhealth_ PHC_2008. World Health Organization. Assistive devices/technologies. accessed 30 May 2010). Geneva. Building an inclusive development community: a manual on including people with disabilities in international development programmes.who. 1996 (www. int/disabilities/publications/care/en/.). Geneva. Integrating mental health into primary care: a global perspective. 2007 (www. Hartley S.int/disabilities/publications/cbr/training/en/index.hesperian. World Health Organization. CA.who. 33. CA. accessed 30 May 2010). World Health Organization. 31. 2003. CBR: inclusive policy development and implementation. Heinicke-Motsch K. Promoting independence following a spinal cord injury: a manual for mid-level rehabilitation workers.who. World Health Organization.int/disabilities/publications/care/en/.who. Recognizing and responding to the health disparities of people with disabilities.23). World Health Organization.int/mediacentre/factsheets/ fs999/en/index. Californian Journal of Health Promotion. Albrecht GL et al. pdf. 2010 (www. Berkeley. Berkeley. CA. Disability. accessed 30 May 2010). accessed 30 May 2010). OR. accessed 30 May 2010). Let’s communicate: a handbook for people working with children with communication difficulties. accessed 30 May 2010). eds. Geneva. 2008 (www. Berkeley.int/disabilities/ technology/en/. 2009 (www. Guideline for the prevention of deformities in polio. who.who. Vol. Thousand Oaks.php. 29.pdf. University College London Centre for International Child Health. 1997 (www. World Health Organization.. Encyclopedia of disability.pdf. World Health Organization.edu/cjhp/3/3/29–42-drum. accessed 30 May 2010). 35. Geneva. 1989 (www.php. management and rehabilitation (World Health Assembly Resolution 58.who. 2004 (www. Recommended reading A health handbook for women with disabilities.hesperian. Helping children who are blind.28. Geneva. CA.who.who. Helping children who are deaf. Geneva.org/publications_ download.hesperian. accessed 30 May 2010).html. World Health Organization. accessed 30 May 2010). 2008 (www. Werner D. accessed 30 May 2010). 34. Promoting independence following a stroke: a guide for therapists and professionals working in primary health care. Hesperian Foundation. 2005 (www. Sygall S (eds.). Eugene. including prevention. Training in the community for people with disabilities.php.int/disabilities/publications/care/en/.html. org/publications_download. Drum CD et al. Berkeley. Sage Publications. 2008.hesperian. 2009 (www. 1999 (www. 2006.). accessed 30 May 2010). CBR as part of community development: a poverty reduction strategy. Hesperian Foundation. Hesperian Foundation. 30. 2006. Geneva. World Health Organization/World Organization of Family Doctors (Wonca).int/disabilities/publications/technology/English%20Wheelchair%20 Guidelines%20(EN%20for%20the%20web). 2000 (www. Hartley S (ed.org/publications_ download. Geneva. accessed 30 May 2010). assIstIve devIces 71 . Guidelines on the provision of manual wheelchairs in less resourced settings. 2.php. Norwich. University of East Anglia. 2005. 1990 (www.org/ publications_download_DVC. CA.int/disabilities/WHA5823_resolution_ en. Geneva. Epilepsy fact sheet.csuchico.int/disabilities/publications/care/en/. Geneva. accessed 30 May 2010).

php. World Health Organization.who.int/disabilities/ publications/care/en/. Geneva. who. Rehabilitation for persons with traumatic brain injuries.org/publications_ download. 2004 (www. 1996 (www.int/disabilities/publications/care/en/. 1992 (www. 1993 (www.Promoting the development of infants and young children with spina bifida and hydrocephalus: a guide for mid-level rehabilitation workers.pdf.int/disabilities/publications/care/en/. WHO/International Society for Prosthetics and Orthotics (ISPO). accessed 30 May 2010). Geneva.int/disabilities/technology/po_services_cbr. Promoting the development of young children with cerebral palsy: a guide for mid-level rehabilitation workers. accessed 30 May 2010). 2003 (www.who. CA. accessed 30 May 2010). accessed 30 May 2010). Geneva. World Health Organization. Where there is no doctor. accessed 30 May 2010). Berkeley. 72 cBr gUIdelInes > 2: health comPonent . Hesperian Foundation. who.hesperian. Geneva. World Health Organization. The relationship between prosthetics and orthotics services and community based rehabilitation (CBR): a joint ISPO/WHO statement.

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marriage and family Community mobilization Medical care Secondary and higher Wage employment Culture and arts Political participation Rehabilitation Non-formal Financial services Recreation.ENGLISH CBR MATRIX HEALTH EDUCATION LIVELIHOOD SOCIAL EMPOWERMENT Promotion Early childhood Skills development Personal assistance Advocacy and communication Prevention Primary Selfemployment Relationships. leisure and sports Self-help groups Assistive devices Lifelong learning Social protection Justice Disabled people’s organizations ISBN 978 92 4 154805 2 World Health Organization Avenue Appia 20 1211 Geneva 27 Switzerland Telephone: + 41 22 791 21 11 Facsimile (fax): + 41 22 791 31 11 .

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