What is community-based rehabilitation? A view from experience

This paper argues that unless community-based rehabilitation (CBR) programmes acknowledge the complexities of working in diverse communities with their unique cultural, religious, social and economic conditions, they will not be able to meet the needs of service provision for people in developing countries. An examination of some of the main aspects that form the essential components of CBR, the realities of the manner in which they interact, and the way they should interact is presented from experiences of CBR services initiated by the Spastics Society of Eastern India, in West Bengal, India.Keywords: community-based, unique cultures, integration, demystify, flexible, partnerships, nurture, marganalized, beliefs, challenging     

Preliminary validation of a parental adjustment measure for use with families of disabled children in rural India

Parental adjustment is an important outcome in child disability interventions, as well as an important mediating variable for other child and family outcomes. This is just as true in developing countries using models of community-based rehabilitation. Previous experience with Western instruments indicated that an appropriate new measure was required. A questionnaire containing 34 attitude statements rated on a five point scale was administered to the mothers of 46 children with epilepsy in a treatment programme in rural West Bengal, India. Factor analysis was performed on the dataset. Mothers reported feelings of rejection, low self-esteem and guilt. Four domains were derived from the factor analysis. All these attitudes are consistent with previous Indian studies on childhood disability. These preliminary findings have implications for social support and counselling intervention. Further research is necessary to validate this instrument for field studies of intervention.     

武汉社区康复需求现状：预实验研究

目的实验从机构、康复工作人员及社区居民3个层面对社区康复现状及需求进行调查。方法分别对武汉5家社区卫生服务机构、29名机构内康复工作者及42名社区居民进行社区康复现状及需求调查。结果社区卫生服务机构均缺乏系统康复医疗设备。康复工作人员缺乏系统康复知识及技能,其所提供服务以中医康复为主。超过半数居民首选社区康复服务,而方便快捷及价格适宜等为主要原因。结论研究将为在全国范围内开展社区康复需求现状调查提供依据,从而为建立完善的社区康复护理服务体系提供参考。     

Ageing and intellectual disability in Israel: a study to compare community residence with living at home

The present study was conducted to compare ageing phenomena in people with intellectual disabilities aged 40 years and above living in community residences (n = 29) with those living with their families (n = 31). The goals were to compare the health status between the two types of settings, to compare the health status between the study sample and the general Israeli population of the same age group, and to investigate whether deterioration occurs among the participants in activities of daily living (ADLs), cognitive ability and leisure activity. Health problems had already appeared by 40 years of age among the participants. The most frequent problems were visual impairment (33%), hearing impairments (20%) and heart problems (20%). Dental problems were found in 30%. The community-based residence group displayed more medical problems than people living at home, whereas individuals living at home had more dental problems. The functioning of the participants in the ADL areas was high, with no evident decline reported during the previous 5 years. Concerning leisure time, a decline in functioning in both residential groups was observed, and interestingly, the scores for social life and leisure activities were better for the community-based residential group. There is a need for better dental service provision for people with intellectual disabilities living at home. The data provided in the current study can serve as a preliminary base for the development of geriatric services for older adults with intellectual disabilities in the community and also provide a basis for further comparison with peers in the general population.     

Community-Based Prevention and Chronic Disease Self-Management Programmes

There is considerable merit in undertaking to shift disease patterns at the community level. Typical problems reflect difficulties in the application of community-based prevention programmes, rather than inherent deficiencies in the concept itself. Scientific issues bear as much on successful outcomes as project management and practice considerations. Nonetheless, given their limited success, it can be asked whether advocates of community-based programmes have been carried away with the rhetoric of health promotion, pursuing a romanticised vision of community. In this regard, some of the disappointments that have prevailed in recently published community trials may reflect an intentional avoidance of programmes or activities that serve people on a one-to-one level.The equating of ‘community-based’ with ‘community-wide’ approaches to disease prevention overlooks the fact that social norms are institution-bound as much as they are the product of broader social forces. Future work must address the inward involvement of institutions in changing their own norms, not simply seeking outward cooperation in mass media and community-wide efforts for disease prevention.     

Health behaviours, risk-taking and conceptual changes among schoolchildren aged 7 to 19 years in semi-rural Sweden

Background This study covers a broad age group (7–19 years) and includes a wide range of themes. The aim is to describe how various behaviours, complaints and conceptual changes come into play and to discuss the factors that might support or hamper the happiness and well‐being of growing children and adolescents. We also discuss the implications of our findings for future prevention programmes. Methods This cross‐sectional study included all schoolchildren in a semi‐rural district in Sweden (2181 pupils). A structured classroom questionnaire was used but the children were also given the opportunity to describe in their own words what was important for their happiness and well‐being. Results Mean response rate was 85%. Most changes in behaviour occurred between 11 and 14 years of age. Girls had a more rapid process of change than boys. Both girls and boys experienced stress in their relations with peers, parents and teachers. Gender differences in emotional support were prominent. Regardless of age and sex, all schoolchildren asked for a richer choice of leisure time activities, a place where they could meet with friends and caring teachers, parents and adults in the surrounding community. Conclusions Adolescence was perceived as a risky and problematic period not only by adults but also by the adolescents themselves. However, the perceived risks and the worries differed. While the adults mainly worried about the early onset of smoking and drug use, the schoolchildren worried about their social situation and their personal relationships. After decades of preventive programmes in Swedish schools, only modest results are seen. To be effective, future preventive programmes probably have to focus more on the conceptual world of the growing child.     

The International Classification of Impairments, Disabilities, and Handicaps (ICIDH): its use in rehabilitation

This article intends to show possibilities and examples of actual use of ICIDH in rehabilitation. Most of the examples concern the use of the classification at the individual level (patient profile, assessment of patient needs, evaluation of treatment, discharge status). Some can serve at meso level: aggregated data (statistics) for evaluation of treatment at institutional level, determination of numbers of staff required. A few other examples concern the use of the ICIDH at macro level in rehabilitation: national policy, education and training of professionals, community-based rehabilitation programmes. Special attention is given to examples of ICIDH use in rehabilitation of special groups such as children, the mentally retarded, cancer patients, elderly people, geriatric patients.     

‘What works here doesn’t work there’: The significance of local context for a sustainable and replicable asset‐based community intervention aimed at promoting social interaction in later life

Interventions that harness local assets to benefit a community are increasingly being promoted to improve health and well‐being. In practice, we know little about how local contexts or reliance on local resources affect the sustainability and scalability of asset‐based community developments. This qualitative case study documents the development and implementation of a novel asset‐based community development project. Based in a large mainly rural county in North East England with relatively high levels of socioeconomic deprivation, the project aimed to prevent social isolation among older people, using a range of food‐related activities. Twenty‐one semi‐structured interviews were conducted with service users, volunteers, project partners, project development workers and senior staff. Interviews explored the project's design and implementation process, outcomes for participants and the wider community, and project sustainability and scalability. Thematic analysis of the data identified four factors likely to be important for creating sustainable and replicable asset‐based community projects. These factors are (a) recognising and harnessing assets among local people who may be otherwise marginalised due to age, geographical isolation and/or socioeconomic deprivation; (b) identifying assets that can be provided by local businesses; (c) genuine project co‐production to develop activities that meet local needs and inspire enthusiasm among all stakeholders; and (d) ongoing organisational support to meet the challenges to sustainability that exist in socioeconomically deprived areas. We conclude that successful asset‐based community projects require extensive community input and learning captured from existing programmes can facilitate the replicability of programmes in other community contexts.     

Impact of a community-based comprehensive primary healthcare programme on infant and child mortality in Bolivia

Community-based comprehensive primary healthcare programmes are a widely-promoted strategy for improving child survival in less-developed countries, but limited documentation exists concerning their effectiveness in actually reducing child mortality. This study examined the impact of a community-based comprehensive primary healthcare programme on child survival in Bolivia. Mortality rates from two intervention areas where Andean Rural Health Care (ARHC) had been conducting child-survival activities for 5-9 years were compared with those from two geographically-adjacent comparison areas that lacked such activities and that were virtually identical to the intervention areas in socioeconomic characteristics. Vital events were registered at the time of regular visit to all homes. In the comparison areas, limited services were available which reached only a small percentage of the population, while in the intervention areas, prenatal care, immunizations, growth monitoring, nutrition rehabilitation, and acute curative services were readily available to the entire population. In 1992-1993, the annual rates of mortality of children, aged less than five years, were 205.5 per 1,000 and 98.5 per 1,000 in the comparison and intervention areas respectively. The absolute difference in mortality of 107.0 deaths per 1,000 (95% confidence interval [CI], 72.7-141.3 per 1,000) represented 52.1% (95% CI, 35.2-68.8%) lower mortality of children aged less than five years in the intervention areas compared to the control communities. These results suggest that the provision of community-based, integrated health services can significantly improve child survival in poor countries. Better-designed and larger field trials of community-based comprehensive primary healthcare programmes in multiple regions of the world are needed to provide a stronger scientific basis for developing this approach further in developing countries.     

Training for health care in developing countries: the work of the Tropical Health and Education Trust

The Tropical Health and Education Trust (THET) was established to strengthen medical education and training for health care in developing countries. The Trust responds to requests from training institutions with a wide range of activities and programmes. Projects to meet specific needs are planned in outline with the Deans or Directors of institutions, as a basis for a long-term link with a similar institution in the United Kingdom. These links are now the preferred method for meeting requests to develop skills, strengthen services and promote staff development. However, funding is always necessary for their support. THET has promoted students' community-based training by enabling students in a team-training programme in Ethiopia to make interventions in primary health care. A prize for the best students' community, clinical or laboratory projects in six African countries encourages enquiry by the students, promotes independent learning, and relates academic work to problems in health care. Work with Ministries of Health includes a continuing medical education programme for rural medical officers in Uganda, courses in basic and life-saving surgery for Ethiopian health and medical officers, and a programme to update the skills of laboratory technologists in rural hospitals in Ghana. The range of projects that THET supports is wide because the needs, defined by those who are working in, and responsible for, training in the health service are diverse.     

Benefits and challenges of providing transitional rehabilitation services to people with spinal cord injury from regional, rural and remote locations

OBJECTIVE: To identify the factors influencing participation and outline the benefits and challenges of providing transitional rehabilitation for people with spinal cord injury (SCI) from rural and regional locations. DESIGN: Grounded Theory analysis of service records and policy documents. SETTING: One transitional rehabilitation service for people with SCI. PARTICIPANTS: Service records of 40 individuals with SCI from non-metropolitan locations who participated in transitional rehabilitation and 29 individuals with SCI who declined transitional rehabilitation over a two-year period. Interventions: Home-based transitional rehabilitation programs offered by a multidisciplinary team including physiotherapy, occupational therapy, nursing and social work. MEASURES: Participation was measured using the percentage of people from non-metropolitan locations who decline transitional rehabilitation. The benefits and challenges of transitional rehabilitation were identified using open, axial and selective coding of service records. RESULTS: People with SCI from non-metropolitan areas were underrepresented among transitional rehabilitation participants, with 69% of those declining transitional rehabilitation coming from regional or rural areas. The study identified five functions of transitional rehabilitation that presented both benefits and challenges of this model in assisting people from non-metropolitan locations. These included: (1) the identification, education, coordination and funding of local care providers; (2) family involvement in rehabilitation; (3) contact with social and community supports; (4) specialist support to problem-solve discharge needs; and (5) skill acquisition and transfer in a community environment. CONCLUSIONS: The transitional rehabilitation model offers many advantages over traditional hospital-based rehabilitation but still faces challenges in offering an equitable model for people with SCI from non-metropolitan locations.     

The food multimix concept: new innovative approach to meeting nutritional challenges in Sub-Saharan Africa

Food insecurity, chronic hunger, starvation and malnutrition continue to affect millions of individuals throughout the developing world, especially Sub-Saharan Africa. Various initiatives by African governments and International Agencies such as the UN, the industrial nations, the International Monetary Fund, the World Bank and the World Trade Organisation to boost economic development, have failed to provide the much-needed solution to these challenges. The impact of these economic shifts and the failures of structural adjustment programmes on the nutritional well-being and health of the most vulnerable members of poor communities cannot be over-emphasised. The use of ad hoc measures as an adjunct to community-based rural integrated projects have provided little success and will be unsustainable unless they are linked to harnessing available local resources. The present paper therefore focuses on exploring alternative ways of harnessing the scant agricultural resources by employing a scientific approach to food-related problem-solving. The food multimix (FMM) concept offers a scientific contribution alongside other attempts currently in use by the World Food Programme, WHO and FAO to meet the food insecurity challenges that confront most of the developing world in the twenty-first century. It is an innovative approach that makes better use of traditional food sources as a tool for meeting community nutritional needs. The FMM concept employs a food-based approach using traditional methods of food preparation and locally-available, cheap and affordable staples (fruits, pulses, vegetables and legumes) in the formulation of nutrient-enriched multimixes. Developed recipes can provide > or =40% of the daily nutritional requirements of vulnerable groups, including patients with HIV/AIDS and children undergoing nutrition rehabilitation. The FMM approach can also be used as a medium- to long-term adjunct to community-based rural integration projects aimed at health improvement and economic empowerment in Sub-Saharan Africa.     

Occupational therapy in rural India

India is called the land of villages. In 1951, 82.7% of the Indian population lived in rural areas. Sanskritisation and urbanisation have changed the pattern. It is expected that by the year 2020 this percentage would come down to 55%. These villagers are relocating in urban slums. Thus from the rehabilitation point of view both problems pose challenges. An Indian village community is a political, economic and cultural unit. At the urban slum area at Malwani and in small villages near Juchandra, community rehabilitation programmes were found to be most pragmatic. Community education and preventive occupational therapy are found to be essential steps in rural rehabilitation. Therapists have to work on ‘disability, attitude and beliefs’ and change the behaviour to deal with the grass root (basic) causes. It is felt that for longer sustainment, community-based rehabilitation should originate within the community. Heath professionals must recognise the capabilities of individuals within the support structure of the family and community, while helping individuals to improve the quality of their lives.     

Toes that look like toes: Cambodian children's perspectives on prosthetic legs

When designing assistive devices for people with disabilities in developing countries, product developers tend to prioritize economic and technical requirements, ignoring aesthetic and cultural issues. This can result in devices that create or reinforce social barriers, creating negative impacts on users' self-esteem and sense of well-being. To understand the social implications of using prosthetic legs for Cambodian children, a pilot research study was conducted in Phnom Penh and surrounding provinces. I used innovative research methods to help children share their perspectives. The objective was to help product designers develop improved assistive devices that not only increase mobility for child prosthesis users but also support the sociocultural integration of these children and their families. A philosophical hermeneutics research approach was used to seek the views of three children. The findings are useful for nongovernmental organizations and product developers that focus on the needs of impoverished children in rural, predominantly Buddhist communities.     

Measles in developing countries. Part II. The predicted impact of mass vaccination

A mathematical model is developed to mimic the transmission dynamics of the measles virus in communities in the developing world with high population growth rates and high case fatality rates. The model is used to compare the impacts of different mass vaccination programmes upon morbidity and mortality arising from infection by measles virus. Analyses identify three conclusions of practical significance to the design of optimal vaccination programmes. First, there is no single optimum age at which to vaccinate children for all urban and rural communities in developing countries. For a given community the best age at which to vaccinate depends critically on the age distribution of cases of infection prior to the introduction of control measures. Second, numerical studies predict that the introduction of mass vaccination will induce a temporary phase of very low incidence of infection before the system settles to a new pattern of recurrent epidemics. Mass vaccination acts to lengthen the inter-epidemic period in the post-vaccination period when compared with that prevailing prior to control. Third, numerical simulations suggest that two-phase and two-stage vaccination programmes are of less benefit than one-stage programmes (achieving comparable coverage) aimed at young children. The paper ends with a discussion of the needs for: improved programmes of data collection; monitoring of the impact of current vaccination programmes; and the development of models that take account of viral transmission dynamics, host demography and economic factors.     

Monitoring the scale-up of antiretroviral therapy programmes: methods to estimate coverage

This paper reviews the data sources and methods used to estimate the number of people on, and coverage of, antiretroviral therapy (ART) programmes in low- and middle-income countries and to monitor the progress towards the "3 by 5" target set by WHO and UNAIDS. We include a review of the data sources used to estimate the coverage of ART programmes as well as the efforts made to avoid double counting and over-reporting. The methods used to estimate the number of people in need of ART are described and expanded with estimates of treatment needs for children, both for ART and for cotrimoxazole prophylaxis. An estimated 6.5 million people were in need of treatment in low- and middle-income countries by the end of 2004, including 660,000 children under age 15 years. The mid-2005 estimate of 970,000 people receiving ART in low- and middle-income countries (with an uncertainty range 840,000-1,100,000) corresponds to a coverage of 15% of people in need of treatment.     

Pilot survey of the prevalence of neurologic disorders in the Parsi community of Bombay

There is a paucity of trained neurologists in developing countries. We designed a questionnaire to rapidly screen a community of 851 people (Parsis living in a colony in Bombay, India) for possible neurologic diseases. This questionnaire was pretested and found to have a sensitivity of 100 percent for detecting epilepsy, febrile seizures (only in children), completed stroke, peripheral neuropathy, movement disorders, cerebral palsy, mental retardation, and severe dementia. The screening questionnaire was administered by trained lay health workers. One hundred and sixty-three people were identified by this questionnaire as possibly having neurologic disease. Neurologists later examined these 163 people and found that 80 of them actually suffered from at least one of the neurologic diseases of interest (positive predictive value = 48 percent). The most common neurologic disorders were peripheral neuropathy (32 cases), essential tremor (13 cases), stroke (12 cases), Parkinson's disease (six cases), and epilepsy (four cases).     

Psychosocial outcomes of bone marrow transplant for individuals affected by Mucopolysaccharidosis I Hurler Disease: patient social competency

Aim To explore the frequency with which children and young people participate in social activities with peers, when they are affected by Mucopolysaccharidosis I Hurler Disease (MPS IH) post bone marrow transplant (BMT). This was investigated in relation to patient age, and in comparison with a normative sample. Patient withdrawal, adaptive and social skills are also described in terms of patient age and in comparison with a normative sample. Method Forty‐four individuals affected by MPS IH post BMT participated in this investigation. Their ages ranged from 16 months to 25 years. Semi‐structured interviews with patients' mothers were utilized, which included the Behaviour Assessment System for Children and a socialization questionnaire. Normative data for the socialization questionnaire were collected from 46 mothers of children not affected by chronic illness or disability. Results A one‐way anova revealed that children not affected by disability or chronic illness (mean = 20.63) participated overall in social activities more frequently than children aged under 12 years (mean = 14.87) and over 12 years (mean = 13.25) who were affected by MPS IH post BMT (F = 21.01, P < 0.001). Young people aged 12 years and over affected by this condition were found to participate in social activities the least. A pattern also emerged, which indicated greater withdrawal and less well‐developed adaptive and social skills for MPS IH patients aged 2.5–5 years and 12 years and over, but scores were within the normal range for those aged 6–11 years. Conclusion These data illustrate a lack of social competency and a tendency towards inhibition and withdrawal in this patient group, particularly among the very young children and the adolescents and young adults. Further research is needed to explore these issues longitudinally and to examine the role played by the family, and indeed disability, in the quality and quantity of social interaction experienced by these individuals.