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IS DOING GOOD 'GOOD': PROFESSIONAL MOTIVES VS. COMMUNITY NEEDS

Nick Pollard*, Dikaios Sakellariou**

ABSTRACT

This paper offers a critical discussion of the goodness of fit between professional motives and community needs in the field of community-based rehabilitation (CBR). Data were drawn from the authors' involvement in a survey of occupational therapists involved in CBR and a search of CINAHL, PsychInfo and Medline online databases for related descriptive and analytical articles.

Due to cultural differences and time constraints CBR professionals often are, and remain, 'outsiders' to the community they are working with. The focus of CBR is sometimes uncertain. Professional motives do not always meet community needs and good intentions do not necessarily transpire into sustainable, culturally appropriate action.

The involvement of the community in all stages of programme development and implementation is important both to ensure relevancy and build alliances with the community. CBR needs to be approached and evaluated as a unique area of professional practice.

INTRODUCTION

Community based rehabilitation (CBR) is a concept which first appeared thirty years ago (1). The working definition developed by the International Labor Organisation, the United Nations Educational, Scientific and Cultural Organisation and the World Health Organisation describes CBR as " a strategy within community development for rehabilitation, equalisation of opportunities, and social inclusion of all people with disabilities" (2).

Despite the existence of a definition there remain many difficulties in establishing focus, terms of reference and objectives (1,3,4,5) and this is, at least partly, due to the fact that CBR covers a range of interventions which need to be created with rather than for disabled people and thus calls for accommodation of diverse cultural values.

The effectiveness of CBR services may be compromised if they are not conceptually equipped to match the local cultural and social needs of the people they seek to engage with. The challenge is to conduct evaluations which ensure these needs can be identified and met (6). However, the process of evaluation can be difficult to organise and contain. Caseloads can be extensive, running into thousands; there can be many layers and sites of interaction between and within groups of stakeholders; the infrastructures on which data systems are based can be fragile; the resources available may be stretched to provide practical intervention without the additional demand of research and outcomes evaluation (3). More importantly, community participation is not always considered as an important parameter and it is often not measured in evaluations of CBR programmes. Out of 22 CBR evaluation studies that were included in Sharma's (7) study, only six considered community participation.

The process of finding out what is appropriate and will be effective is one of experimentation and often involves working according to local needs in ways which practitioners' previous education has not anticipated (8,9,10,11). Given the dearth of critical evaluations of CBR programmes it is hard to establish what is the worth and benefit of CBR programmes for the local populations. To what extent are the goals of CBR professionals relevant to the needs of the community? This paper explores the goodness of fit between professional motives and community needs in the field of CBR. After a brief discussion on the focus of CBR and issues related to culture and timeframes, the latter part of the paper deals with the perception of CBR as a process of doing good.

CBR: ESTABLISHING FOCUS

Sakellariou et al (10) found that none of the occupational therapists who participated in their survey, reported negative experiences in connection with their CBR involvement. Literature suggests this is a common issue (12). It is possible that the training and education of CBR professionals such as occupational therapists makes them naturally adaptable to all kinds of circumstances and therefore bound to experience everything positively, but the process of identifying service learning needs suggests that this is not so (6,8). Perhaps, particularly where the practitioners are expatriates or from other regions within a large country, the setting out of objectives is negotiated on an unequal basis. One reason for this may be that the outsiders bring with them the possibility of otherwise unattainable resources, or are understood to have superior knowledge, so that the recipients only partially disclose the issues which are deep in their community in case the aid dries up. Another issue may be that access to funds, and the access of non-governmental organisations (NGO) to disadvantaged populations is also dependent on the communication of positive messages or at least, agreements with policy. Community development operations are a key element of CBR, but are often used as instruments of government policy (13,14). Some governments have expelled foreign NGO workers or taken over their operations (13), and even in some western countries there have been concerns over proposed changes to charity law that appear to demand accord with government policy (15). The dissatisfaction of community members with the person they are working with, because either they have the wrong kind of expertise to meet their needs or does not match their expectations of expertise is not uncommon (11,16). The extent to which these interactions are a mutual learning process may not be understood at first; learning on both sides may be recognised but needs a lot of time to drive a path through the hurdles of miscommunication in order to achieve a common understanding.

The uncertainty of the focus of CBR contributes to this dissonance; are CBR projects being designed and carried out for, or in, or with the community concerned? Furthermore, both the understanding of CBR work and motives for involvement vary . as much amongst the recipients or local participants as amongst the professionals and volunteers. This may influence the stance of the professional and thus affect the scope of the intervention and the way that it engages the community, creating a professional-community dissonance in the perception of needs and solutions (4,17).

Safeguards and well established processes are required so that one can be " good at being good" (18). Complaint handling, codes of conduct, audit procedures, even accreditation by appropriate bodies are among the processes that can be implemented to ensure accountability, relevance of projects and adherence to humanitarian and professional mandates over any personal motivation [18,19]. Personal motivation is not necessarily negative, nor does it clash with professional ethics to acknowledge that engagement in CBR work may serve individual interests as well as altruistic purposes. However, it is a factor that needs to be explored in relation to the professional's perceived role within a CBR programme, and as a component of the initial motivation that drives individuals to seek a career in a caring profession (20,21). Wanting to travel and experience something new, to offer help, to respond to spiritual callings, to improve one's resume, or to undo the wrongs of the colonial past of their country are among the reasons professionals decide to volunteer or work in CBR, but they may be the wrong reasons unless they are accompanied by a stronger commitment to social change (11).

Misunderstandings and misinterpretations are often inevitable. The situations in which CBR interventions are applied are often unstable and very few of the world's disabled or disadvantaged population are likely to have encountered any form of service provision (1,3,22). Similarly, very few of the professionals involved in CBR are likely to have received training to assist them in the community development role called for by CBR, or to have been exposed to the realities of extreme poverty, exclusion and lack of recourses and access to services faced by the communities they work with, a point made by several respondents in Sakellariou et al's study of professional involvement in CBR (10). Furthermore, conceptualisations of diversity and how it impacts on people's participation can sometimes be vague (23). With so many uncertainties about the form of CBR interventions, it is sometimes difficult to determine the extent to which they actually involve communities in decision making and developing local strategies (3,10). Failure to involve communities might undermine their sense of ownership of the CBR programme and have adverse effects on its success and eventual sustainability.

Enabling community participation might be complicated by the fact that CBR programmes often involve many stakeholders: professionals, non-governmental and state sector organisations, disabled people, and non-disabled community members being among the main actors, often overlaid with nuances dependent on cultural factors. The resources available can be sparse, and the region the programme covers can sometimes be considerable, with difficulties in communication and logistics due to geography and infrastructure. In these circumstances it can become difficult to define accountability; who is to be held accountable for what and to whom? Even notions of 'accountability' may be very difficult to determine given the complex interplay of cultures. Dorman's (13) review of post-colonial African politics, for example, makes it very clear that Western conceptions may be irrelevant to local needs and there may be significant problems in trying to reconcile these with the demands of Western organisations. The terms of engagement need to be understood as a process by all parties, especially since the changes they produce can have unforeseen consequences for sustainability (12). On the one hand, if the main goal of CBR interventions is to engage community members in a process of community development through capacity building, skill transfer, emancipation, empowerment, or other culturally appropriate means, then professionals need to be held accountable to the community, thus ensuring their involvement responds to locally identified needs (24). On the other hand the community needs to be enabled in developing realistic, achievable and appropriate objectives with those involved in the intervention.

CONSIDERING CULTURE

Culture refers to one's way of being in the world, learned through behaviours, scripts and beliefs that are shared among members of a community, or people who share a common identity (25). It influences values and understanding of the world. CBR professionals often do not share the same culture with the community they are working with. Professional approaches and ethical considerations may come into conflict with the demands of local cultures, as for example when a Western emphasis on independence or integration is not desired by the community (26). In many communities cultural practices surrounding disability differ from the concept of disability used by professionals (27). The meanings ascribed to disability differ depending on the context. CBR specialists often arrive from a privileged position by virtue of access to education and have to work across indigenous, racial and social class divides. Consequently, there may be a climate of suspicion, and professionals may have to prove their good intentions by passing a series of assessments - for example local people may gauge their attitudes through their reactions to the theft of equipment which may later be returned. This is one of the processes by which both parties recognise and establish a common language and learn to work together. However, the onus is very much on the CBR professional. If a member of the community is offended, or a breach of trust is committed, all the work of negotiation may be undone and the professional excluded (19).

Negotiating the admission of non community members into the community with which they are to work has to be done in a delicate way, or else it may prove impossible to work with people later on (27). On the other hand, gains can be made if something seems to work despite the scepticism with which the CBR specialist may be met, or if the outsider (as an anthropologist perhaps) represents a mouthpiece for the marginality of a community.

CONSIDERING TIME ISSUES

The duration of the intervention is an important parameter that should not be overlooked and rigorous priority setting is necessary to establish realistic goals to work towards within specific time frames. It may be that through the level of resources available and because of the delicate process of negotiating differences a short term project is all that is possible. In such cases enabling access to the intervention may be more significant than trying to maintain sustainability (1). Pressured for time and resources some interventions concentrate on biomedical and short term psychosocial interventions rather than more loosely structured and longer term social approaches directed towards community developments, empowerment and capacity building.

The quickly achieved outcomes from such interventions do not always translate to long-living strategies, but they are sometimes necessary as part of the process of establishing a working relationship. For example, in the social practices which accompany military interventions, forces may offer medical treatments and aid to the local population as a means of establishing good will. The sustainability of future interventions may depend on these measures, and though pressing needs cannot be ignored once they have been identified, they need to be prioritised and approached systematically (28). It is worth exploring whether opportunities for longer term developments can be incorporated into approaches aiming to address immediate needs, e.g. discussions which identify long term strategic issues for later follow up, or resources that might be developed later on, so that there is a process which can be applied in short term work, but which looks to the future. Addressing some immediate needs, as for example wheelchair provision and maintenance, access to hospitals, the provision of orthotic equipment might also serve to gain entree in the community, who might resent an invasion of " empty-handed" professionals (29,30).

These challenges can prove to be the fulcrum of the interaction, the point at which the people involved recognise what really has to be done, if anything is to be done at all. They can also be the opportunity for the negotiation of a shared task, where the practitioner has to be taught by the community to be enabled to act for and with them. The way in which a practitioner can act as a bridge to the resources that are needed may be more significant than the possession of lofty expertise (31).

IS DOING " GOOD" GOOD?

The notion of " good" can be interpreted in various ways, each of them valid from a particular vantage point. Doing " good" can actually be bad where there are disagreements between community and professional perceptions of needs and the appropriate avenues to address them. A common understanding needs to be reached, which entails the asking of a number of questions, such as: Is poverty bad? If yes, is it the effects of poverty or poverty itself that needs to be eradicated? What are the limits to inclusion? What are the limits to empowerment? These are all philosophical problems which relate to the sustainability and the contexts for CBR intervention. Resorting to simplistic moral judgments, pertaining for example to ideas of human agency and individual responsibility, can only add to the confusion regarding the scope of CBR. These issues are multifactorial and complex.

Based on a Western, middle-class vantage point it is assumed that these issues are 'problems', but to what extent are they problems for other people? A simplistic response might be that the sacrifice of Western standards of living may seem like one measure to address them, but the consequences for a global economy may be catastrophic. Lack of food, clean water, and restricted access to physical places is, however, a significant problem for many of the world's population and demands a sustained approach.

CBR operates in a changing and negotiable framework of cultural and socioeconomic and political sensitivities. It can take the form of a paternalistic practice, a vehicle for benevolence and satisfaction of personal needs of the professionals involved in it. Such attitudes are objectionable and can be detrimental to the aim of empowering disabled people (32). On the other hand, contributions in CBR by religious organisations and people motivated by personal callings cannot be easily dismissed as perpetuating disablement and dependence. Motivation for engagement in CBR can be on the basis of moral responsibility, whether it is about righting the wrongs of a colonial past, or simply doing things for and with other people if this is connected with a desire for social change. As Pande and Dalal (12) argue, CBR interventions inherently assume a need for social change and are formed with a programme in mind for the communities they are intended to reach. These communities are therefore already the objects of discrimination, since it has been determined by the agency supporting the programme that they lack the means of empowerment, are impoverished, and so on. They have been assessed negatively, rather than in terms of their assets. However, this may not equate with the way the communities see themselves, and making such assumptions may be detrimental to the negotiations which secure the progress of intervention.

In her assessment of what it is to be 'good', Kazez (33) concludes that it is for individuals to do what it is reasonable to do, but in making choices about what seems the best thing to do an individual also makes choices for others. A choice of action sets a precedent for others to follow, or determines the choices available to others. Thus, while involvement in CBR needs to be grounded in professional responsibility to ensure that guidelines for proper engagement with the field are maintained, making the choice to engage in it may lead to a series of assumptions. A perception of the need for social change suggests that a 'service' is being provided for a group of 'victims', and the provision of an intervention can lead to the interpretation that it is a service that can offer resources to people who see themselves as victims. On the other hand, as Pande and Dalal (12) found, if CBR is able to achieve the object of disabled people gaining a sense of empowerment, this can present challenges to other powerful groups in the community who need to be involved as political allies for further community objectives to be met. It also needs to be ensured that it is not only the most powerful community members who have access to CBR (27,34).

In their description of a CBR programme that failed due to misunderstandings and misinterpretations, Pande and Dalal (12) note that " before one intends to modify the psychological structures of others through any programme, examining one's own motivations is perhaps imperative" . In their description of a CBR initiative Mukherjee and Samanta (35) illustrate how good intentions alone are not enough to make a programme work, or even affect some positive change in the community. Failure to consider individual needs and strengths, physical terrain, educational and maintenance issues led disabled people to discard the wheelchairs they were given.

Strategies need to be context specific. Needs as well as actions have to be negotiated between all stakeholders. Failure to do so might lead to failure to affect any sustainable change to the community. It also needs to be recognised and respected that some community members will not want to be involved in a CBR project. For example in interventions which follow on from disasters or conflicts, engagement in narrative processes which are intended to enable a community to tell its story might mean reliving strong and overwhelming memories of trauma. Often, people react to such events by separating themselves from these events and attempting to get on with their lives as quietly as possible (36).

The silence may also stem from scepticism about telling one's life stories to strangers with solutions to problems they have not experienced. Here, intervention might be perceived as a prurient professional game rather than a real service responding to real needs. The profile of the westerner or the western educated professional can often override the efforts of the community who may feel that, whatever happens through the project, it will be presented as an achievement by the professional. People in experiences of disability rarely get to tell their own tale without it being mediated and shaped by others to suit presentation to an audience, and, often in the case of CBR, a Western audience. After all, this is part of the process of supporting engagement by disseminating evidence based practice, meeting funders' requirements and of obtaining funding for further intervention. These issues have the potential to considerably distort the context of CBR provision, and need to be explored in order to enable the fair representation of community members in all stages of CBR. For these reasons CBR, despite any aims it may have for empowerment and facilitating, can never be a process in which the various actors are equal. CBR is not the product of an equal world, and while it is not the purpose of intervention to perpetuate inequity it is quite possible for the resources which have been provided or developed to remain in the hands of the more powerful groups in the community despite all good intentions (12).

MOVING FORWARD

Community based rehabilitation has a great potential to fulfil. Professionals need to form partnerships with the people they work with, the community members and negotiate goals and process with them, in order to ensure ethical, appropriate and effective interventions. Issues of culture and timeframes, as well as the motives of the professionals need to be acknowledged and addressed where necessary.

The purpose of CBR should not be to imitate institution-based health care services but to address the sociopolitical environment as the major underpinning causes of health disparities. This can best be achieved through community development actions that aim for inclusion, empowerment and the elimination of poverty. The forms these actions can take may not always be consistent with widely held ideas in the West; for example communities of disabled people may seek to preserve their separateness from the society around them because it feels safer and also provides visibility which might in turn, translate into power.

If CBR is a distinct area of professional practice, then it needs to be introduced as such in relevant educational curricula (eg, occupational therapy, physiotherapy), or through continuing education opportunities. It needs a theory base linked to an identifiable practice base, and in order to gain a wider role in community development effort it needs to be demonstrably applicable in a range of contexts outside of situations of charity or benevolence (37). Professionals need to develop a moving viewpoint perspective that will enable them to acknowledge the needs of the communities they are working with before considering how they can intervene (38,39). The consequences of this are that it becomes a political practice, because it is a theory for the structuring of community interventions and is therefore directed to social change (12, 27). Once this purpose is clear and formerly disadvantaged communities begin to exercise their new power, they can be seen as a threat to the powerful groups who uphold the status quo. Such groups may use legislation or forceful measures to intimidate or close down new organisations, or else take them over for their own advantage (12,13,40). While some projects may limit their scope for action in order to avoid being perceived as a threat, this can mean that development must be slow paced and low key, in order to balance being sustainable with being acceptable.

CONCLUSION

CBR is a strategy that has a great potential to fulfil not least because as yet it has touched very few of the world's population of impoverished and disabled communities (1). CBR can enable people experiencing disabling situations to live in dignity and gain access to the resources they need in order to improve, restore or maintain their well being, but it may also have the effect of generating more resources for those who already have the power to deprive others. For CBR to work positively, its interventions need to be negotiated with the community, not predetermined paternalistically by an external professional group (3,18,27,32,38) and appropriate evaluation measures need to be established (7). Of course, there are limits to what can be realistically expected by a CBR intervention, especially in cases where short term involvement is all that can be achieved, but establishing a common ground of understanding between the community and the CBR workers is a prerequisite and its importance cannot be overstressed.

*Address for correspondence
Senior Lecturer in Occupational Therapy
Sheffield Hallam University
Faculty of Health and Wellbeing
Room 203 Mundella House
34 Collegiate Cresecent
Sheffield, S10 2BP, U.K. Email: N.Pollard@shu.ac.uk

**Lecturer, Department of
Occupational Therapy
Cardiff University, Tu Dewi Sant
Heath Park Campus, Cardiff CF14 4XN, U.K.
Email: sakellarioud@cardiff.ac.uk

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