WHO 9789241548052 - Health - Eng

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 classication: 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 specic 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 Ins 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 classication: 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 specic 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 Ins 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 enoyment
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 enoyment 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 enoy-
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 ve 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
0X 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 speclc health-care needs.
The maor 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 ldentlcatlon 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 dened as the absence of dlsease and lllness. However, as
dened 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 lnrmlty (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.
0X 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 mothers 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 rst 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 Khurshldas
famlly obtaln a dlsablllty certlcate for her, whlch enabled access to a wlde range of servlces.
The programme also asslsted Khurshldas mother to access treatment for tuberculosls.
Satyabhama contlnues to work wlth Khurshlda and ls now teachlng her slgn language. |t wlll
be a long ourney 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 persons 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 llfes 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-condence.

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 obectlve set by wHO durlng the l978 prlmary health
care conference ln Alma-Ata. Thlrty years later, communltles globally have yet to achleve
thls obectlve 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 speclc 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 rst
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
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 nd 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 preudlced 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 nd 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 peoples organlzatlons (DPOs) are actlve partlclpants ln the plannlng and
strengthenlng of health-care and rehabllltatlon servlces.
0X 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 dont worry, nothlng speclal or we wlll tell you
later. Nobody really told me anythlng | ust 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 condence and became very dependent on others.
After olnlng a C8P programme | slowly galned condence 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-condence and have also helped to ralse the
prole of dlsablllty by educatlng medlcal professlonals.
Paklstan Paklstan
The courage to overcome barriers
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, lnurles) 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 ldentlcatlon, 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 benet 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. artlclal 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 modled, 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 ust the health sector.
l2 cBr gUIdelInes > 2: health comPonent
0X 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 subect 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 womens 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 chllds 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
speclc 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 speclc
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.
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 lnury, for example, may not be consldered a good candldate for health pro-
motlon as her/hls health has already been anected by lnury.
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 ve 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 enoyable 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 enoyable.
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 peoples 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:

actlvely partlclpatlng ln health promotlon campalgns and assoclated events, ralslng
the prole 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 speclc 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
condent 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 speclc health needs, e.g. groups of people wlth splnal
cord lnurles, 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.
0X S
wlth the support of a C8P programme ln Pledecuesta, Colombla, a group of people wlth
splnal cord lnurles 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 lnury 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
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 speclc 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):
0X 6
C8P programmes can work wlth dlsabled peoples 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 speclc 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, lms and puppet shows.
0X 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 enoylng belng together as a larger
famlly or group of frlends. The C8P programme also
collaborates wlth the local Paralymplcs commlttee,
parents organlzatlons and dlsabled peoples
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,
ob 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, preudlce 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 lnury 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
slgnlcant role ln pro-
motlng and support-
lng preventlve health
care for people wlth
dlsabllltles.
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 persons health and determlne the llkellhood of lnury, 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 declency: 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 persons control, others, e.g. llfe-
style and physlcal and soclal envlronments can be altered, potentlally malntalnlng and
lmprovlng health status. The health sector can play a slgnlcant 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
0X 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 lnury 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, Anltas 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 tted Anlta wlth a
prosthesls and a good palr of shoes to ensure her left foot was protected from lnury. 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 Anltas condence lmproved, untll she was able to walk
lndependently wlth her prosthesls and return to household tasks and work ln the elds.
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). |n these sltuatlons, speclal facllltles or modlcatlons 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, olnt 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.
0X 10
Handlcap |nternatlonal supported the establlshment of a Splnal Cord |nury 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 ust 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 nd 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).
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.
0X 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 ldentled 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
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 speclc
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.
0X 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).
0X 13
The Sanlvlnl 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 ve 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. Sanlvlnl
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
beneted 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 overoyed 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 speclc 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:

nd 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.
0X 14
|n some vlllages of north-west Mongolla, many women have hlp dlslocatlon. when these
women become pregnant, they nd 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.
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 lnury. C8P programmes
can play a role ln lnury preventlon ln thelr communltles by:

ldentlfylng the maor causes of lnury 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 lnurles 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 lnurles ln the home and communlty, e.g. to prevent lnurles
durlng blg festlvals:

provldlng suggestlons for famllles about how to prevent lnurles ln the home, e.g.
watchlng chlldren when they are near water or open res, 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 obects:

provldlng educatlon for employers and workers about how to prevent lnurles 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 lnurles or splna blda (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 olnlng self-help groups:

ensure that any asslstlve devlces provlded to people wlth dlsabllltles do not create
rlsks for secondary condltlons, e.g. that prostheses t properly and do not cause red
marks whlch can lead to pressure sores.
medIcal care 33
Medical care
Introduction
Medlcal care can be dened as the ldentlcatlon, 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 speclcally because of thelr dlsabllltles, lncludlng early ldentlcatlon and
lnterventlon as approprlate: and provldlng servlces as close as posslble to peoples 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.
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 didnt 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). Adnans
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
couldnt 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.
Adnans 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 ldentlcatlon 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.
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
0X 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 ve 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 benets 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.
0X 17
Patrlck, from Kyenyoo 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 nally | 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 Salvadoreo Para La Riabilitacin de Invlidos, 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
(Asociacin de Personas con Lesin Medular de El Salvador).
Strength in numbers
E l S alvador
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 ldentled, 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 ldentlcatlon of communl-
cable or noncommunlcable dlseases,
e.g. tuberculosls, leprosy, larlasls, 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 benet from surgery.
medIcal care 4l
0X 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.
0X 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 slgnlcant 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 ldentlcatlon and treatment of
chlldren wlth clubfoot.
Local doctors, theraplsts and rehabllltatlon eld 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 ldentled 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 benets 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 benets 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.
0X 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:

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 olntly wlth communlty health programmes to ensure that people wlth dlsablll-
tles can access the benets of these programmes.
0X 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 persons 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).
0X 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 APDKs 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 rst C8P programme ln thelr Mombasa branch ln :ooz. Slnce zooo,
they have extended these programmes to the maor 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 nanclal 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 publlcprlvate 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 publicprivate 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 lnury 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.
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 olnt
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/lnury) 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 maor 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.
0X 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 condence 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 condence. She was soon able to manage her own dally
actlvltles, whlch lncluded cooklng for her famlly, an actlvlty she really enoyed. 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 condent about the future.
Lis journey to independence
Chlna Chlna
Rehabilitation plans
Pehabllltatlon plans need to be person-centred, goal-orlented and reallstlc. when devel-
oplng a plan, a persons preferences, age, gender, socloeconomlc status and home
envlronment need to be consldered. Pehabllltatlon ls often a long ourney, 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,
adustments wlll need to be made to the rehabllltatlon plans to ensure the actlvltles
contlnue to be approprlate and relevant.
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
persons 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 adusted 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
lndlvlduals 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 benets 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 beneted from the same or slmllar servlces.

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. nanclal, 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 nanclal constralnts and ensure that a wlde range of
optlons are lnvestlgated lncludlng government and/or nongovernmental organlzatlon
schemes, bank loans and communlty support.
0X 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 maor 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 ldentled 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 chllds 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 enoyable 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.
0X 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 lndlvlduals level of lndependence ln dally
llvlng skllls, e.g. moblllty, communlcatlon, bathlng, tolletlng, dresslng, eatlng, drlnklng,
cooklng, housework. |nterventlons are dependent on a persons 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 speclc technlques used
to address lmpalrments, e.g. muscle weakness, poor
balance and muscle tlghtness, whlch lmpact a per-
sons ablllty to carry out actlvltles: thls mlght lnclude
strengthenlng, stretchlng and tness programmes.
0X 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 Shlrleys 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 Shlrleys
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. Shlrleys 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 peoples organlzatlon.
Learning to view life diferently
Guyana Guyana
Facilitate environmental modifcations
Lnvlronmental modlcatlons may be necessary to lmprove the functlonal lndependence
of a person wlth a dlsablllty. C8P personnel may facllltate envlronmental modlcatlons 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. modlcatlon of
the school envlronment, publlc bulldlngs or work places (see Asslstlve devlces element).
0X 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 x 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 modlcatlon ensured thls
grandmothers 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.
0X 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 peoples 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.

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 speclc centres for people
wlth dlsabllltles.
0X 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 speclc 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 benet 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 5l5% 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 benets of asslstlve devlces are also belng
recognlzed for older people as a health promotlon and preventlon strategy.
0X 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. artlclal 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 beneted from the orthopaedlc workshop ls Chandeswar.
He ls a rlckshaw-puller who worked hard untll he sunered an lnury 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
ldentled by the C8P8 team worklng ln hls vlllage, who tted
hlm wlth a below-knee prosthesls and provlded rehabllltatlon
to ensure he was able to walk well wlth hls artlclal 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 benet 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
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, nan-
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.
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 tted ln speclallzed workshops or centres by
tralned prosthetlc/orthotlcs personnel and lnclude:

prostheses, e.g. artlclal 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 persons 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

magnlers

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 persons 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

amplled telephones

TT/TTD (telecommunlcatlon devlces)

vlsual systems to provlde cues, e.g. a llght when the doorbell ls rlnglng.
0X 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 tted 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
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 lnurles,
lntellectual lmpalrment, dementla and mental lllness are some of the many condltlons
that may anect an lndlvlduals 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 peoples 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.
0X 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 subect to soclal stlgma the black sandals had become
easlly ldentlable 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 tted to
ensure they meet the lndlvlduals 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 benets, 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 lnury 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.
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/modlcatlons 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 persons
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 modlcatlons, 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.
0X 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
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 speclc, 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:

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 condence 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.
0X 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 its 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
adustments can be made and dlnerent optlons consldered.
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-
eclal when someone has llmlted access to rehabllltatlon personnel. Self-help groups
can support lndlvlduals to adust 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.
0X 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 ldentled and tralned at the Natlonal Orthopaedlc
Laboratory.
Learning how to make assistive devices
Mongolla Mongolla
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 peoples 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
peoples 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
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.
0X 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 nd 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.
0X 39
Several C8P programmes ln 8angalore, |ndla, ldentled 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 prot 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 maor companles that
manufactured asslstlve devlces and health-
care products and by establlshlng llnks
wlth maor 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
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.
References
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constltutlon_en.pdf, accessed 30 May 20l0).
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dlsabllltles/, accessed 30 March 20l0).
3. 8ecker H. Measurlng health among people wlth dlsabllltles. Community Health, 2005, 29(lS):70S77S.
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May 20l0).
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World Health Organization
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ENGLISH
ISBN 978 92 4 154805 2
CBR MATRIX
HEALTH EDUCATION LIVELIHOOD SOCIAL EMPOWERMENT
Skills
development
Social
protection
Disabled
peoples
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

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