DISCUSSION LED BY :

Elizabeth Henley and Robyn Twible
Faculty of Health Sciences, University of Sydney, East Street, P.O Box 170, Lidcombe NSW, Australia
Fax : 0061-2-9351-9197

Physiotherapy and occupational therapy are two health disciplines which specifically focus on providing functional rehabilitation for people with disabilities. Both professions complement each other in their knowledge and skills and in their approaches to management of disability. However, the key to successful provision of services by these professions is in the ability of the practitioners to use a good clinical reasoning or problem solving approach to management of disability and to be client and family focused in the provision of therapy.
In persons with chronic disabilities it is highly desirable that the person with the disability has access to the knowledge and skills of a good occupational therapist and physiotherapist at some stage of their lifetime, preferably as early as possible after the detection of the disability. In this way, relevant therapy can be instituted as soon as possible.
In countries such as India, where 85% of the population live in rural and remote areas of the country, access to such specialist services is a luxury rather than a right. Consequently, there is significant value in training mid-level workers to provide basic home-based therapy on a day-to-day basis. It is our contention that such training requires a basic understanding of the principles of anatomy, physiology and pathology of disabilities; more importantly the workers need significant training in using a functional approach to assessment and management of disabilities, with particular emphasis on problem solving, documentation, realistic goal setting and understanding simple progression of rehabilitation programs for common disabilities which they encounter. After training, these workers continue to need access to 'expert' therapists who act as consultants to the mid-level workers. These 'experts' can provide advice on a regular basis and review complex cases, meanwhile contributing to the continuing education of the mid-level worker.
Since 1995, faculty from The University of Sydney have collaborated with ActionAid India and other non-government agencies to provide final year physiotherapy and occupational therapy students, who act as an 'expert' technical resource for the teaching and training of community based rehabilitation workers(CBRW's) and other village health workers in selected CBR projects throughout South India.
In our experience there are several distinct principles that must be adopted in providing training to mid-level health workers:

1. An adult learning approach to presentation of materials must be used rather than the traditional pedagogical approach.
2. Interactive or experiential learning is much more successful and promotes thinking and reasoning rather than passive learning.
3. A functional approach to assessment and intervention is essential, rather than the traditional 'medical model' approach to diagnosis and treatment. A functional approach is more meaningful to the client and care-givers and provides greater motivation to improve, as the clients can see that the interventions affect their ability to perform normal activities of daily living.
4. Theoretical sessions must be interspersed with practical sessions whereby participants can practice their skills and implementation of knowledge on each other, before exposure to clients with disabilities.
5. Fieldwork practice sessions are essential, from the very beginning of any training programme, so that participants can put into practice what they have learned in the 'classroom'.
6. Regular review of knowledge and skills, with concurrent feedback is highly recommended.
7. The level and complexity of knowledge and skills presentation must be tailored to the needs and educational standards of the participants.
8. Documentation is essential. It provides an objective baseline assessment for the functional status of the client, from which realistic, measurable treatment goals can established. Therapists can therefore evaluate efficacy of interventions and progression of therapy. It is essential that measurable outcomes are introduced. Such documentation can also be of value to CBR co-ordinators, in that they can measure the effectiveness of their CBR programs; they can also discover deficits in CBRW's knowledge and abilities, thereby knowing where continuing education needs to be provided.

General discussion followed the presentation by the authors. Much discussion was generated around the issue of whether CBRWs should be multi-skilled in all areas of CBR or whether there is value in training different types of mid-level workers; that is, therapy workers, community workers, etc. It is the contention of the authors that no one system is appropriate for all CBR programmes. It may be appropriate, for example, to have 'therapy workers in projects that have a large number of clients or a large area of coverage and where there is significant community development work to be done. In another project it may be more appropriate for the CBRW to incorporate all areas of community based rehabilitation - therapy, community involvement, income generation, etc. If the former scenario is adopted it is essential for the lines of communication to be firmly established so that all workers are focusing on a common goal - that is, that the person with a disability is given maximum opportunity to become an active and equal member of the community

TRAINING MANUALS FOR USE IN COMMUNITY BASED REHABILITATION

1. Portage Guide to Early Education (PGEE): Low cost home based training for mentally retarded children between birth and six years.
2. Distance Training Package (DTP) (Bangladesh) : Training materials for the parents of mentally retarded children to be used at home.
3. Zimcare Trust Training Packages (Zimbabwe) : Packages for training of mentally retarded children.
4. WHO Training Manual (WHO) : For all disabilities, for community workers.
5. Disabled Village Children : Manual for Health Workers, Rehabilitation Workers and Families. (Mexico) : For all disabilities.
6. Simple Aids for Daily Living (AHRTAG-LONDON).

Dr. Maya Thomas & Dr. M J Thomas
J-124, Ushas Apts, 16th Main, 4th Block, Jayanagar, Bangalore - 560 011, India
Tel and fax : 91-80-6633762
Email : thomasmaya@hotmail.com

Printed at :
National Printing Press
580, K.R. Garden, Koramangala, Bangalore - 560 095 Tel : 080-5710658

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