TRAINING OF CBR PERSONNEL :CURRENT ISSUES-FUTURE TRENDS

This paper reviews the main trends that have taken place in training persons for CBR work in the past twenty years. It stresses the relevance of the Canadian manpower model to CBR and the logical approach to training generated. New trends for the near future are outlined and a need for more research is seen as crucial to future developments.

INTRODUCTION
There is now a wide variety of community based rehabilitation (CBR) programmes around the world that are well established and have a wide range of experience. Within this range there are a number of interpretations of what CBR is or should be which include envisaging it as a community health model, as in the original World Health Organisation (WHO) model, an outreach rehabilitation programme, community development, the fight for human rights or a combination of these (1). In reviewing the recent literature covering CBR work I was surprised to find very little on training issues. There does not seem to be much new in this field.

At this point, it is worthwhile to remind ourselves of the radical shift that took place in training approaches in the disability field in the 1970s. Neufeldt (2) lucidly outlined some of the developments that occurred on which much of what we now do in CBR is based. Prior to that time, the "medical" or "disciplinary" model held sway, as no doubt it still does in many programmes. This model was characterised by training based on knowledge, theory and data with very little attention being paid to the needs of people with disabilities, to attitudes or personality and much less emphasis on skills. Different disciplines were hierarchically organised, with those with the most training, namely doctors, at the top. In 1971 the Canadian National Institute on Mental Retardation published a report of a study in Canada on manpower needs which revolutionised the approach to personnel preparation. Many organisations and programmes have subsequently adopted this approach, though they may not know its origins and if one analyses human service programmes of different kinds in third world countries, the structure of the Canadian Manpower Model can often be seen. Some of the key features of the development of this model (2) are given below.

1. It was found that 80% of trained personnel could be in the category of front line personnel, who at the time of the study, were mostly untrained.
2. Training would be based on the functional tasks required of or performed by these persons.
3. Training focussed on skills and attitudes as well as knowledge.
4. A modular curriculum approach could be used which would be very flexible according to the needs of different groups of personnel and the need for changes in content over time.

Four levels of personnel were defined. Levels 1 and 2 were at the front-line level, Level 3 were managers and professionals, and Level 4 were programme directors or leaders. In Canada, a career ladder was proposed (which has not been as well implemented as envisioned) in which personnel could move from the front-line (aide/assistant) level up into professional categories with further training. Community college training of the front-line level was widely established and national and regional advisory councils were set up to guide the programme.

Developments in the CBR field necessitated a manpower and personnel structure. WHO proposed a "Mid Level Rehabilitation Worker" to manage CBR programmes, which was part of a 4 tier structure similar to the Canadian manpower model. This concept is critical to the design and content of training, as the latter will depend on the responsibilities and tasks of the different categories of workers in the programme.

SOME OF THE CURRENT PRACTICES

Levels of personnel
Reading reports and articles about CBR programmes indicates that many programmes use the manpower model though the proportions of the different categories may vary, with some programmes having a much higher percentage of professional or supervisory staff, while others may have very few. The latter situation is often found in government programmes, where CBR has been imposed on existing generic programmes and efforts are made to keep costs down (3). Non-governmental organisation (NGO) projects tend to have more professionals and thus are more expensive.

3D Projects, one of the earlier CBR programmes (4), deliberately adopted this model from the inception of the programme, the four levels of staff being community rehabilitation workers (CRWs), supervisors (recruited from the most competent CRWs), co-ordinators (professional teachers, therapists, nurses, etc.) and the programme director. Training has been a combination of short courses of 3-4 weeks of pre-service training, followed by planned modules of in-service over a year or so to provide all the skills needed by the CRWs. Content is designed according to the needs of the clientele.

Community workers
Generally, community workers are either recruited from the local community from people with limited levels of education, whether they be paid workers or volunteers. In some programmes, volunteers may be persons with higher levels of education such as teachers or nurses. Pre-service training varies from two weeks in the WHO model to 3-4 weeks or several months. Training should be based on task analysis of the work to be done by the personnel but this may not always be the case. Typical curricula of these courses have been described by several authors (5, 6, 7, 8) and there are many others that have not been published. The content will depend to a great extent on the scope and coverage of the programme, for example, which disability groups will be served and which age groups, as well as the philosophy and emphasis of the programme. Some programmes place greater emphasis on community mobilisation and participation, while others emphasise the transfer of daily living, mobility, language, social, and developmental skills. Some programmes such as the Guyana CBR programme (7) trains almost exclusively from video packages while others train in the acquisition of skill in the different techniques used in the programme, such as the use of specific tests or checklists. In the Canadian manpower model, this category would make up about 65-70% of the workforce. Training should always be conducted at the site of the CBR programme so that the facilities and clients are incorporated as much as possible.

Supervisors
This category can be approximately 15-20% of the personnel in a programme. Usually they are recruited from the community workers who have shown competence, responsibility and have earned the respect of people with disabilities and their colleagues. Their promotion is facilitated by further training in more specialised rehabilitation knowledge and skills and/or supervisory and management skills, depending on what supervisory role they are to take. Training may be conducted on site or by sending personnel to another programme where they can get the skills desired. This will often depend on how many persons are to be trained. In some cases it may be on-the-job training.

Programme managers
Programme managers have a wide variety of backgrounds. Since CBR is not yet recognised as an academic professional discipline, university or degree training courses for "CBR therapists" or professionals do not yet exist though no doubt they are in the planning stages in some countries, such as India where the demand is rapidly increasing. CBR programme managers and professionals are recruited from a wide variety of disciplines including therapists, social workers, educators, nurses, psychologists and others depending on the emphasis of the particular CBR programme. Within any one programme, depending on the size, there may be many coming from different backgrounds making up a multidisciplinary team. In some countries, such as in Africa, many such staff are expatriates.

There seems to be a wide variety of training options here. One of the mainstays for many years has been the course in CBR at the Institute of Child Health in London. Some CBR programmes run regular training courses of 3 weeks to 3 months to nine months at specific times of the year, depending on the demand and size of the host programme. These are often open to persons from other programmes or countries and have become established international courses. The content varies in emphasis from technical, management issues, community development, theoretical and training subject material. It would probably be very helpful to have an inventory of these international courses, so that CBR programme directors can find the most appropriate and relevant courses that best meet the needs of their staff.

Other personnel
In addition to training for in-house staff, some CBR programmes conduct training for other groups of persons within their communities. This is usually to facilitate changes in community attitudes and inclusion of people with disabilities in generic programmes. Target groups for community level training include parents, groups of people with disabilities, community groups, teachers, health care workers, the police, the judiciary and others. Where efforts are to be made to have CBR shifted from being provided by NGOs to government agencies, this strategy is essential

Style of training
As mentioned at the beginning, with the gradual shift in approaches to personnel structure, there have also been considerable changes in training styles. Among these are emphases on hands-on training in practical skills, participatory training, the collaborative learning approach (9), use of video (10) and communicating by satellite. Hopefully the lecture format has almost disappeared from training courses for levels 1 and 2 workers, though it is still extensively practised in professional training programmes.

THE PROBLEMS AND CONSTRAINTS

As a relatively new field and because it is largely confined so far to third world countries, there are many problems and constraints many of which may be due to lack of resources and of investment in infrastructure, research and evaluation

Lack of standardisation
Is there a need for standardisation? Because of the wide diversity of programmes, which are often established to meet specifically local needs, there is a wide range of quality in staffing and performance. However the main justification for CBR is that it should reach many more disabled persons than would be possible through traditional institutional rehabilitation programmes. Also the proponents of the community development model see the rehabilitation content being secondary to the need for attitude change and inclusion, so the technical aspects may be less important and less in need of standardisation. However, it would probably be desirable to have a minimum basic training content for all CBR programmes.

Lack of recognition and accreditation
This issue relates directly to standardisation. For there to be recognition of a particular category of worker, acceptance for the need for such a worker has to be well established and accreditation will be dependent on an acceptable standard of training. This seems to have happened so far in only a very few countries. However, if we wish CBR to have adequate coverage and be sustainable, this will be a necessary step.

Lack of a career ladder
Again because of the lack of recognition of CBR personnel, there is often no career path in which people can move up and get promotion. If they do, it may well be out of the CBR programme. Since the work is rarely paid well, this leads to frustration and burn out.

Availability of appropriate trainers
This can be a major constraint to the content and quality of training. In many countries in Africa, local professionals do not exist and outsiders have to be brought in, often for only short periods of time to cover the training only and with no follow up. Thus there is no continuing support for the community workers, something which has long been recognised as essential. In Guyana, this has been overcome to some extent by the CBR programme conducting much of its training by video.

Turnover
All the above constraints may tend to result in rapid turnover. This is also augmented by the use of volunteers. Although some programmes have been sustained for 10 years and more on volunteers, in countries like Philippines, Guyana and Sri Lanka, there has to be frequent training, and these programmes are probably the exception rather than the rule.

OTHER ISSUES

In his thoughtful paper on personnel training issues, Neufeldt (2) cited a number of developments and changes which may affect future patterns. Though some of these may be more relevant in more developed countries, they are worth re-stating here.

Information technology revolution
It is clear that electronic technology has already had a profound effect, even in some less developed countries, though it is hard to see it being useful to community level workers in the poorer countries of Asia and Africa. For persons living in far flung places, video and email can bridge the gap for updating knowledge and skills. However, a very important component of the effectiveness of rehabilitation personnel is the element of personality and attitudes which has to be dealt with by interactive exchange and face-to-face contact.

Economic restructuring
While the serious effects of economic re-structuring and the financial crises of many governments are leading to devastating cutbacks in human services of all kinds, it may be that this will force some programmes to be more cost effective and thus de-professionalise rehabilitation, where it exists. CBR may be seen as a reasonable alternative instead of just a "make-do".

Democratisation
The trend towards the acceptance of human rights of various minorities and disadvantaged groups, including people with disabilities, has already had an effect on the responsibilities and training of personnel in the disability field. Nevertheless, a lot more still needs to be done. The concepts of choice by consumers, equality of opportunity and consumer control are becoming more widely accepted as necessary and staff have to be aware of these and practise accordingly. At the community worker level they will need to be less directive and more facilitatory while at the management and professional level, they will have to be better listeners and more democratic organisers.

Environment
We are becoming more aware of the need to conserve our environment and this has a direct effect on quality of life, which should have positive implications for people with disabilities. Human development is seen as part of enhancement of the environment and this may facilitate the availability of resources for training.

Ageing
While the demographic changes in population structure are already being felt most profoundly in more developed countries, the implications for third world countries are clear and immediate. Many of our programmes tend to focus more on children as opposed to adults but this will have to change as many more disabilities accompanying accidents, trauma and the ageing process become more common. Perhaps we will also have to look towards using older people more as field and family workers.

Multiculturalism
The last decade has seen an immense increase in population movements between developing countries in times of war and crisis and from less to more developed countries. In the former case, the implication for rehabilitation is in the increase in numbers and types of disability in the migrants who are homeless, have few possessions and have been injured or damaged by their experiences. In the latter case, there may be a shift in the pattern of disability in the new migrant groups and adaptations to different cultural backgrounds will have to be made by staff.

OTHER TRENDS

In our third world countries we perhaps need to re emphasise a few more points relevant to issues of training personnel for CBR

Movement towards better acceptance of CBR
While there are still many constraints and inadequacies in the way we practice CBR, we have to accept that it is, so far, the best solution to reaching the large numbers of people with disabilities in need. At least three elements need to be incorporated into CBR strategies, namely, community integration and involvement, human rights and rehabilitation assistance. Without these three, CBR will not achieve the desired goals. There is a danger that some programmes focus too much on one of these elements and exclude the others. Training at all levels needs therefore to incorporate all these. This along with efforts suggested earlier to standardise and accredit training programmes may help us to achieve better acceptance of CBR. CBR also has to gain the confidence and enthusiastic support of people with disabilities themselves. Although some programmes are run by people with disabilities, a clear central role for them in a directive or giving capacity, as opposed to a recipient one, needs to be made more transparent.

More research
Inherent in the present status of CBR as a second rate form of rehabilitation, is the paucity of research in the practice of and training for CBR. There must be very few universities in third world countries that carry out research in CBR if they do any rehabilitation research at all. Access to research results is poor and only journals like the Asia Pacific Disability Rehabilitation Journal give any consistent exposure to relevant research findings or issues. A glance at the contents of even this journal, shows that there is not much research on CBR topics. We need to have more information validating different approaches, techniques, practices, attitudes, the overcoming of barriers to successful implementation of programmes, training methodologies and many others. More investment is needed in this field.

REFERENCES

1. Thorburn MJ Roles and relationships of community based rehabilitation. In Beyond Basic Care. Special Education and Community Rehabilitation in Low Income Countries. Eds Brown RI, Baine D and Neufeldt AH. 1996 126-150. Captus Press, York University Campus, 4700 Keele Street, N York, Ont Canada M3J 1P3.
2. Neufeldt AH Major trends in rehabilitation and implications for staff training. Journal of Practical Approaches to Developmental Handicaps 1992; 16: 5-10.
3. Vanneste G. CBR in Africa: a critical review of the emerging scene. Asia Pacific Disability Rehabilitation Journal 1997; 8: 34 37.
4. Thorburn MJ A community approach to helping disabled children in Jamaica. International Journal of Mental Health 1991 20. 61-76.
5. Thorburn MJ. Training community workers for early detection, assessment and intervention. In Thorburn, MJ, Marfo, K (Eds) Practical Approaches to Childhood Disability in Developing Countries, 3D Projects, Jamaic,: 1990: 125-140
6. Thorburn MJ. Training community workers in a simplified approach to early detection, assessment and intervention. Journal of Practical Approaches to Developmental Handicaps 1992; 16: 24-29.
7. O'Toole B, McConkey R, Maison Halls G "Hopeful Steps" and "Community Action on Disability", Training manuals of the Guyana CBR Programme. CBR Resource Centre, Guyana, 1995.
8. Mendis P. Education of personnel: the key to successful community based rehabilitation. In O'Toole B, McConkey R (Eds) Innovations in Developing Countries, Chorley, UK: Lisieux Hall, 1995: 211-226
9. Levitt S. The collaborative learning approach in community based rehabilitation. In Leavitt RL (Ed). Cross Cultural rehabilitation: An International Perspective. London, Edinburgh and Philadelphia, WB Saunders, 1999: 151-161.
10. McConkey R. Using video as a teaching aid. In Thorburn MJ, Marfo K (Eds) Practical Approaches to Childhood Disability in Developing Countries. 3D Projects, Jamaica, 1990: 141-159.

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ASIA PACIFIC DISABILITY REHABILITATION JOURNAL Vol. 11 @ No. 1 @ 2000

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