Community Based Rehabilitation

Introduction
Rehabilitation is an important and essential part of comprehensive nursing . It is ideally starts at
the moment a patient enters in the health care system. However rehabilitation programme may take
place in the special units of health care organization or independent center in the community.
Basic Concept of community based rehabilitation
1.Health concept
2.Disability concept
Health Concept - Health is a valuable resource that enables people to lead individually ,socially and
economically productive lives, providing them with the freedom to work, learn and engage activity in
family and community life.
Disability concept - Disability is an “umbrella term for impairments, activity limitations or participation
restriction “ which result from the interaction between the person with a health condition and
environment factors ( e.g. the physical environment ,attitudes) , and personal factors (e.g. age or gender. )
Definition
According to WHO
Community based rehabilitation is a strategy within general community development for the
rehabilitation ,equalization of opportunities and social inclusion of all people with disabilities.
Community based rehabilitation is implemented through the combined efforts of the people with
disabilities themselves, their families, organizations and communities and the relevant governmental and
non-governmental health, education, vocational, social and other services.”

CBR is a strategy within general community development for the rehabilitation ,equalization of
opportunities ,reduction poverty and social inclusion of the people with disabilities

Community based rehabilitation is a systematized approach with in general community development

where by person with disabilities are enabled to live a fulfilling life within their own community
Global Statistics .

 Approximately 10% of the world’s population lives with a disability

 People with disabilities constitute the world’s largest minority.
 No rehabilitation service are available to people with disabilities in 62 countries.
 Only 5-15% of people with disabilities can access assistive devices in the developing.
 An estimated 15-20% of the world’s poorest people are disable.
 Children with disabilities are much less likely to attend school than others.
 An 80% of people with disabilities live in developing countries.

Origin of the CBR

  The declaration of ALMA-Ata in 1987 was the first international declaration advocating
primary health care as the main strategy for achieving the WHO “s goal of “Health for all “ . This
strategy was enhance the quality of life for people with disabilities through community initiatives.
 Other UN agencies such as the international Labour Organization (ILO) united Nations
Educational, scientific and Cultural organization and united Nations Children’s Fund became involved,
recognizing the need for a multisectoral approach .
 In 2003 an International consultation to review CBR for a number of key recommendations on
service delivery methods.

Evolution of concepts in CBR

 Disability and Rehabilitation -The social model of disability has increased the awareness that
environmental barriers ( attitudinal, physical and institutional to participate impede the functioning of
PWDs as equal. Professionalize person can make informed decisions to enable them to lead a fulfilling
life.

 Human rights - CBR promotes the right of PWDs to live as equal citizen with in the community, to
enjoy health and well being and to participate fully in educational ,social cultural , religious, economic
and political activities
.
 Poverty - There is a strong correlation between disability and poverty. Poverty leads to increased
disability in turn leads to increased poverty. So eradicate severe poverty and hunger.

Features Of CBR
 Removal of physical and attitudinal barriers in the community toward disabled.
 Ensuring opportunities for disabled to participate in school, work ,leisure, social and potential
activities within the community.
 Caring for the family of disabled person by community groups.
 Providing local job training for disabled person and facilities for disabled children in school at
their own village or community.
 Assisting disabled in transportation, loans and income generating activities.
 Tanning of community person , community worker for intervention in the rehabilitation
services.
 Maximum community participation in the care of disabled within the community.
 Supporting the referral services.

Mainstreaming and inclusion

Mainstreaming and inclusion is seen as an effective way.

 To include person with disability

 To give equal opportunities
 To provide a non –discriminative environment for their growth and development

Objectives of CBR
 To ensure that PWDs person are able to maximize their physical and mental abilities.
  To access regular services and facilities and to become active contributors to the community and
society.
 To activate communities to promote and protect the human rights of PWDs through changes
within the community, for example by moving barriers to participation.
 Apply evidence-based practice.
 To scaling up CBR programme.
 multisectoral collaboration in CBR programme.
 To reduce the social stigma in a effective way.
 To find out the actual hidden factors
 Reduce mortality and morbidity.

Essential Components of CBR programme

CBR vary a great deal for implementing this programme ,but they have some elements in common that
contribute to the sustainability of their CBR programmes . Theses are-

1. Cover all types of PWDs who need rehabilitation services .

2.Multisectoral approach including social integration intervention health,education and economic
programmes .
3.The programme should have access to or generate a good and effective referral system.
4.Full integration of the PEDs into his/her community.
5.The programme have gender and disability focus and balance.
6.Community and well trained community members as service providers.
7.It should have strike a balance between provision of service delivery and empowering the PWDs ,family
and community through regular transfer of skills
8. It has facilitate the formation and strengthening of the disabled people ‘s movement to ensure that the
rights of the PWDs are not denied through advocacy at local, state and national level.
9.The presence of motivated community workers
10. National level support through policies, co-ordination and resource allocation.

Support for CBR

 Support from the social sector – Example : disability pensions, technical aids and adaptations, vocational
training and co-ordination of referrals for individuals who needs services from other sector.
 Support from the health sector – Primary health care is the key to attaining health for all. It also address
the main health problems in the community ,providing promotive, preventative, curative and rehabilitative
services. Early identification of impairements and providing basic intervention. Referrals to specialized
services e.g. physical ,occupational and speech therapies.
 Support from the Educational sector – Adapting the content of the curriculum and method of teaching .
Ensuring the classrooms ,facilities and educational materials are accessible.
 Support from the Employment sector – Collaboration with the employment and labour sector. Productive
and decent work in a conductive environment.
 Support from the NGOs sector- CBR is often initiated by a stimulus from ministries or NGOs.
 Support from the Media – All CBR stakeholders should work closely with the media to identify priorities
and to provide relevant information.
 Support from the policies, Laws. –Equal employment opportunities through national polices and
legislation.

Principles of CBR

Inclusion – inclusion means placing disability issues and people with disability in the mainstream of activities.

Participation – It depends on the participation and support of people with disabilities ,family members and
local communities .and also active contributor to the CBD programme from policy-making to implement and
evaluation.

Empowerment- Local people and specially people with disabilities and their families may make the
programme decisions and control the resources. Results are seen in restored dignity and self-confidence.

Equity- CBR focusing the equally of opportunities and rights equal citizenship. Raising awareness addresses
attitudes and beheviour with in the community .
.
Self-Advocacy - Self advocacy is a collective notion, not an individualistic one. It means mobilizing,
organizing, representing and creating space for interaction and demands.

Facilitation -CBR requires multisectoral collaboration to support the community and to address the individual
needs ,with the ultimate aim of an inclusive society.

Partnerships –CBR depends upon on effective partnerships with the community based organizations,
,government organization and other organized groups.

Sustainability- CBR activity must be able to continue beyond the initial interventions,and be independent of
the initiating agency.

Steps of CBR
1. Identification of person requiring rehabilitation services.
2. Assessment of disabilities and various need for rehabilitation of identified person.
3. Provide the basic services through PHC such as drugs, dressing , materials protective foot wear,
counselling and training in self care.
4. Introduce or escort the person to village health committee along with his or her problems.
5. Refer to secondary or tertiary care centers.
6. Facilitating the accessibility to socioeconomic rehabilitation services.
7. Review meeting by all stakeholders, to discuss programme
8. Co-ordination with the social welfare department and working jointly.

Challenges of CBR
1.Lack of understanding of concept.
2 Rapid turn over of civil servants , finance, and prioritization.
3 Acceptancr of CBR as a valid intervention.
4 Poor Management and disorganized planning of CBR
5 Lack of communication.
6 Lack of co-ordination between the government and NGO’s.
7 Social welfare department often has a weak structure at community level.

Role of CBR

1. The role of CBR is to identify health promotion activities at a local, regional and national level and work
with stakeholders.
2. Ensure access and inclusion for people with disabilities and their family members.
3. Maintain the good health and encourage the diabled person to actively participate in health promoting
actions.
4. Health care personnel have improved awareness about the general and specified health needs of people
with disabilities and respond to these through relevant health promotion actions.
5. Participate in primary prevention activities. e.g. immunization programme to reduce the risk of developing
additional impairments.
6. CBR personnel are knowledge about medical care services and able to facilitate referrals for people with
disabilities and their families for general or specialized medical care needs.
7. People with disabilities can access medical and surgical care to minimize or correct impairments and
discuss with them about treatment options, make informed decisions and manage their health conditions.
8. Increased awareness regarding respect their rights and dignity and provide quality of services.
9. People with disabilities and their family members understand the role and purpose of rehabilitation and
receive accurate information about the services available with in the health sector.
10. CBR is to work to determined their needs for assistive devices like walking sticks ,wheelchairs ,
prostheses etc, and ensure maintenance , repair and replacement when necessary.

Rehabilitation Services in India.

A large number of Govt. departments, NGOs, institution are functioning for disabled for their
rehabilitation and care. Some of them are enlisted here.
 Ministry of social justice and empowerment.
 Ministry of Health and Family Welfare ,Human Resources Development.
 Rehabilitation Council of India.
 Occupational Therapy School (Mumbai,Nagpur)
 All India Institute of Physical Medicine and Rehabilitation ( Mumbai, CMC Vellore)
 National Institute for the Orthopedically Handicapped, Kolkata.
 Regional and district Rehabilitation Centers.I

Common framework of CBR

The matrix consists of five key components .These are The Health, Education, Livelihood, Social and
Empowerment components.
CBR Martix

Community Based Rehabilitation

Health Empowerment
Education Livelihood Social

Early child hood Skills Relationship & Social

Promotion
development development family Mobilization

Self
Prevention Primary Personal Political
Employment
Assistance participation

Secondary and Wages Culture

Medical care Communication
Higher Employment Religion and
arts

Financial Leisure
Rehabilitation Non-Formal
Services Recreation Self-help group
&sports

Disabled
Social Access to people
Assistive devices Life-long learning
protection justice organization
 Human rights of mentally ill person

Introduction
Mental illness is maladjustment in living. It produces a disharmony in the person’s ability to meet
human needs comfortability or effectively and function with in a culture. A mentally ill person
loses his ability to respond according to the expectations he has for himself and the demands that
society has for him.

Evolution of concept
The Mental Health Care Act, 2017 has defined mental illness as a substantial disorder of
thinking ,mood, perception, orientation or memory that grossly impairs judgement, behavior,
capacity to recognize reality or ability to meet the ordinary demands of life.
Chapter VIII of mental health Act 1987 contains a very novel and explicit provision of protection
of human rights. Universal Declaration of Human Rights in Article 24(1) explicitly mentions,”
Everyone has the right to a standard of living adequate for the health and well-being of himself and
his family, including food ,clothing, housing and medical care and necessary social services.”

Rights under Mental Health Care Act,2017

The mental Health Care Act, 2017 has been looked upon as a historical intervention in the field of medical
health care. It has been termed as a “pro-right” document for the mentally ill person.
 Right to appropriate treatment and related services in the setting that is supportive and least restrictive
to person freedom.
 The right to an individualized written treatment or service plan, right to periodic review and revision of
the plan based on treatment need.
 The right consistent with one’s capabilities to participate in and receive a responsible explanation of the
care and treatment process.
 The right to refuse treatment except in a emergency situation or as permitted by law.
 The right not to participate in experimentation in the absence of informed voluntary written consent.
 The right to human treatment environment that affords reasonable protection from harm and
appropriate privacy.
 The right to confidentiality of medical record.
 The right to access to medical record except information received from third patients under promise of
confidentiality and when access will be detrimental to patients health.
 The right access to use of telephone, personal mail and visit
 The right to spend a sum money for their own expenses.
 The right to hold civil service status.
 The right to manage and dispose of property and execute wills. .
 The right to live in a community with his family.It may restricted if there is a risk of herm to the
child .
 The right to protection from cruel, inhuman and degrading treatment in any health establishment.
 The right to equality and no discrimination on the basis of gender ,sex ,religion ,cultural cast and social
beliefs.
  The right to information - the person has also the right to know all the facets of the treatment for
which he has admitted..

Nurses Implications for protecting rights

One of the responsibilities of the nurse to guide the clients and their relatives in matters about to their
rights and protect the clients from any mistreatment.
 To protect patient’s rights, the nurse should be aware of these rights in the first place.
 She should ensure that ward procedures and policies should not violate patient’s rights.
 Discussing theses rights with the mental health team and including these rights in nursing care plan is
all part of her responsibilities in protecting the patient’s rights.

Conclusion
The mental health act ,2017 has provide various rights to such people. Moreover there are various other
laws also which lays down various rights and disabilities of a person with mental illnesss. The law
changes to keep pace with the demands of society and so can be seen in the field of mental health care.
Sub- Community Health Nursing –II

Community Based Rehabilitation

And
Human Rights Of Mentally ill Person
Submitted To Submitted By
Mrs. Sangita Roy Rita Naskar
Senior Faculty M.Sc Nursing
Final
Year Student
C.O.N.M.C.H. C.O.N.M.C.H.