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TRAINING OF TRAINERS (TOT) PROGRAMME ON INTELLECTUAL DISABILITY FOR CBR WORKERS

Jayanthi Narayan*, P. Sudhakara Reddy**

ABSTRACT

Community Based Rehabilitation (CBR) for persons with intellectual disability is focused more on training in independent living skills when compared to other disabilities, where provision of assistive devices and supports are of prime importance. This requires equipping the CBR workers with skills in training the person with intellectual disability and the family. The present study aimed at training middle level functionaries in an existing CBR programme of Andhra Pradesh State Government in India, using a CBR manual prepared exclusively for this purpose. A ToT package was prepared along with the manual for this purpose. A pre and post test were conducted. A follow up workshop was carried out after 3 months to see the efficacy of the training programme. Site visit and impact and process evaluation were carried out during the follow up workshop and it was found that the training programme was effective in providing knowledge, skills and competencies to the participants.

INTRODUCTION

Intellectual Disability, commonly and legally known as "mental retardation" in India, is a condition requiring special attention in terms of reaching out with services for such persons in various corners of the country. The major difference between community based rehabilitation (CBR) for persons with mental retardation and other disabilities is that the former need appropriate training during the various stages of life for independent living while the latter require suitable aids and appliances, assistive devices and appropriate guidance so that they may function in society with minimal support. To focus on training for persons with mental retardation, the trainers should be well equipped with knowledge, skills and competencies. As rightly noted by Cook et al (1), CBR is not a 'band aid' solution, but rather a solutuion that provides long lasting effects, which is further endorsed by Thomas (2), stating, 'regardless of what is 'politically correct', CBR today is understood by most stakeholders in the disability sector, as a strategy to promote inclusion, rights and equal opportunities for the persons with disabilities.'

Recognising this need, a training programme was organised by Indira Kranthi Patham(IKP), a project of the state government of Andhra Pradesh in India. The main objective of this project is to enable rural poor people to improve their livelihoods and quality of lives through their own organisations. The project is implemented by Society for Elimination of Rural Poverty (SERP), Department of Rural Development, Government of Andhra Pradesh (3). SERP is an autonomous body that implements the project through District Rural Development Agencies (DRDA) at the district level. Disability rehabilitation is one of the major components of this project. As noted rightly in the IDDC position paper on CBR (4), a CBR programme needs to be closely linked to general development goals such as poverty alleviation and other millennium development goals. The IKP aims precisely at this goal.

Most CBR programmes focus on areas of health, such as provision of aids and appliances, physiotherapy, surgery and medicines, and on education and income generation programmes for persons with disabilities with minimum focus on mental retardation. (5). There is an urgent need to provide an appropriate programme through CBR with focus on skill training for persons with mental retardation. Imparting technical training to already existing functionaries in the CBR system, is one way of reaching out to this group.

METHOD

Participants

In the State of Andhra Pradesh, every district is divided into Mandals, with each Mandal having roughly 50,000 population, 10,000 households and 25 to 35 villages. In the project IKP, every Mandal has one Community Coordinator (CC-D) for activities related to disabilities (CC-D). It is the responsibility of the CC-Ds in the IKP project to enable and empower persons with disabilities, by helping them to build their Self Help Groups (SHG) at village level, form federations of those SHGs at Mandal level and develop strong linkages with other institutions for the poor. The CC-Ds are supported by the Community Development Workers (CDWs) at the grass root level to give intensive facilitation support to persons with disability, their families and their institutions. The work carried out by the CC-Ds is monitored by the federation of persons with disability, i.e Mandal Vikalangula Samakhya at the Mandal level. They are supported by District Project Managers anchoring the disability programme at District level and State Project Manager(SPM) at the State level.

There were 25 participants for the study including 23 CC-Ds and 2 CDWs from different districts of Andhra Pradesh. Thirteen of them were women. All the CC.Ds had a Masters Degree or a post graduation, while the CDWs had completed intermediate education. Among the participants 4 had a motor disability and 2 were parents of children with disability. In addition to the postgraduate qualification, four of the CC-Ds had special education training, or Orientation and Mobility training. All the participants except one, had worked in IKP for 3 years and more.

Tools/Materials

The manual prepared with the support of Health and Behaviour Unit, WHO, Regional office for South East Asia, New Delhi was used in the current training programme (6). The manual contains general information on mental retardation, characteristics of persons with mental retardation, identification, early intervention, activities for children of an older age group, adolescents and adults. The manual covers activities of daily living, functional academics, domestic and occupational skills and recreational skills. It also includes details on resource mobilisation and tips for trainers. To train the trainers of grass root level functionaries, the manual has a Training of the Trainers (ToT) package, which contains information on trainer competencies, and day-wise training schedule of contents to be covered to prepare the trainers. The ToT along with the training manual was used to train the trainers in the project carried out by IKP.

In addition, basic skill training booklets on mental retardation, adapted material for daily living activities such as clothing, shoes, spoons, glasses and tooth brush and other materials described in the CBR manual which also formed the training tools. Live demonstrations with the help of persons with mental retardation with their or their guardian's consent, were also carried out.

A questionnaire was developed for pre and post test of the participants. The questionnaire was close-ended having multiple choice questions, predominantly on information on mental retardation. The one difference in the pre and post test questions was the open-ended question at the end of the questionnaire. In the pretest, participants were asked to list their expectations from the training programme, while in the post test, they were asked to list any new learning through the programme and their suggestions for future programmes.

Procedure

On the first day, after introduction of the training programme, all the participants were given a pretest. The first day was devoted to content coverage on trainer competencies, resource mobilisation, team building and leadership skills. On the second day, various aspects including general information on mental retardation, identification, early intervention, and training of older children including activities for daily living and functional academics, were covered. On the third day, adolescence and adulthood related skills including domestic and occupational skills, were covered. On both the days, relevant motor, social and language skills and recreational skills were discussed. In addition, adaptations of material or environment, to compensate for the limited intellectual ability of the target group was focused. Live demonstrations, group and individual exercises and lecture discussions were the methods used for training. All the way through the training programme, emphasis was laid on teaching 'from concrete to abstract', moving from 'easy to difficult' subtasks. On the third day, post test was carried out. The total training was carried out by a qualified, and competent special educator in the area of mental retardation with the logistical support provided by another qualified special educator. On the third day, the participants were asked to provide their feed back.

After three months, a follow up workshop was conducted for three days by the same trainer to find out the impact of the training programme in terms of application in the respective villages. On the first day, a site visit and meeting with the stakeholders were carried out. On the second day, the participants presented and discussed their activities related to mental retardation, which they had carried out for 3 months. On the third day, the gaps found in the training programme were filled and an action plan was drawn for the future.

RESULTS AND DISCUSSION

Training programme

The analysis of pre and post test showed a mean gain of 15% with a mean of 70% in pretest and 85% in the post test. The individual gain ranged from zero (in two participants) to 6 points out of 15 points in one participant. Four participants had gained 5 points out of 15. Three had lost one point each in the post test. In the post test five participants had all 15 correct answers while none had all correct responses in the pretest. The high pretest mean scores could have been because the participants were already in the field, with access to information about mental retardation and their knowledge in the area was good. The gain was found to be in the skill areas. This suggests that the pre and post test should have an adequate number of questions to check on the skill areas, whereas the questionnaire used had more on knowledge. This was further confirmed by the analysis of responses for open ended questions.

Analysis of their responses for the open ended questions revealed that 20 participants needed information on working with parents and families of persons with mental retardation and the community, while 17 required information on how to train persons with mental retardation on daily living skills. Fourteen participants asked for specific information on rehabilitation and 13 asked for information on how to train the grass root level workers.

In the response of post test, it was noted that 23 participants had expressed confidence in training persons with mental retardation as well as their families. This was also noticed when they had hands-on exposure during the training sessions. They had mentioned that they would carry out the training programme in their mandal for family members, community, Anganwadi workers, CDWs and CBR workers. Sixteen participants had expressed that they learnt how to teach children with mental by using the strategy of 'easy to difficult' with concrete examples and minor adaptations in the environment or material. Eleven participants were confident about identification, early intervention and home based training of persons with mental retardation, while 9 expressed that they learnt about trainer competency and leadership skills. For future programmes, the suggestions included: increase in the number of days of training, more detailed coverage on training children with profound mental retardation, more input on sexuality and more use of local language while training.

During the concluding session, most of the participants expressed that though they were familiar with the concept of mental retardation, they were not aware that persons with mental retardation could be trained to lead an independent life and that with training those with severe mental retardation could look after themselves for their basic needs. They expressed confidence in implementing the training programme in their respective mandals. These responses further endorse the fact that though the participants had knowledge on mental retardation (as revealed through high pretest scores), they were not aware of skills required to train.

Follow up workshop

During the follow up workshop, the feedback after 3 months revealed the skills of trainers in terms of training persons with mental retardation as well as the trainee group at grass root level. During the programme, both process and impact evaluation were carried out. Process evaluation included collecting information on the number of training programmes carried out for various target population by the CC-Ds, number of new cases identified and programmes planned, new programmes initiated as a result of the training programme and any other note worthy development. Impact evaluation was carried out through site visit and interaction and discussion with the group. Each participant narrated case specific experiences, which reflected the competencies gained by them and the further needs.

On the analysis of the periodic report sent by the CC-Ds, it was noted that 16 out of the 26 participants had responded.

Process evaluation

Sixteen out of 26 CC-Ds sent their reports. All of them had conducted training programmes for parents and CDWs. Eight of them had conducted training programmes for other CCs in their area and 5 had conducted training programmes for others including school teachers, and members of Mandal Mahila Samakhya and Mandal Vikalang Samakhya. All of them had carried out programming for persons with mental retardation, which included identification of new cases, functional assessment and programming for identified cases including individual programme planning and implementing the training programme through parents. Three had difficulty in training children with profound mental retardation and those with cerebral palsy. Two expressed difficulty in toilet training and 2 expressed that parents of children with profound mental retardation and those who are non ambulatory, have difficulty in attending parent group training programme.

Impact evaluation

This was done through listening to reports of each participant. All CC-Ds were convinced that persons with mental retardation could be trained. Each one expressed that before the training workshop, their role was restricted to identification, certification and informing them about the benefits and helping them to receive the benefits. After the training, they had gained competencies and were able to see the progress in the individuals with mental retardation. During the site visit to a Mandal on the first day, the parents revealed that they had seen specific progress in some areas. One of the mothers said "My daughter is 23 years and I did not know how to train her in bathing and dressing. I was doing everything for her. Now within a month I could get her to do both because of the training". Other parents expressed details of specific progress seen in some of the areas such as shopping skills, self feeding, and money concept.

During the interaction with the group on the second day, it was noted that all had conducted training in activities for daily living. Nine participants had worked with adults and they expressed that their training tips to parents were helpful and that the person with intellectual disability once trained learnt faster. Adaptations and modifications suggested for training in activities for daily living(ADLs) proved effective in most of the cases. The training manual prepared with the help of WHO which was a support material for the trainers, was reported to be a good reference material for carrying out the training programme.

Three trainers took the support of special teachers for carrying out the training programme, as they did not feel totally confident. Two reported that they needed further support in working with persons with profound mental retardation and/or with cerebral palsy and 4 expressed the need for support in training very small babies with developmental delays. It was noted that documentation of each case work was not carried out systematically.

On the third day, considering the difficulties expressed by the participants, training tips were provided, assessment, programming and documenting was demonstrated. Following the demonstration, the participants carried out a similar exercise with persons with mental retardation under supervision and reported confidence in carrying out the task in their regions.

Future plans of participants

It was decided collectively that:

  • Participants would take up activities including sensitising village leaders and women groups, educating the pre-school workers and school teachers on mental retardation, and forming parents groups. 2008
  • Feed back from the participants would be taken every month in writing and after 3 months one more workshop would be conducted for further action.
  • Training of Area project managers (APM) and District Project Managers (DPM) would be planned so that they are equipped to supervise the CCs and CDWs.
  • The local language version of the manual would be made available to field workers, middle level functionaries, parents and other concerned persons.

CONCLUSION

In conclusion, it can be said that a 3 day training programme using a simple training manual and a ToT for field workers with post graduate qualification and field experience of about 3 years, will help in providing knowledge in the area of training persons with mental retardation and their families. It will make them confident in training grass root level workers, family and community. A follow up workshop is essential to ensure efficacy of the training programme and to fill the gaps if any. In addition, similar training may be carried out in a few more structured CBR programmes where there are middle level functionaries with similar qualifications and experience, to ensure generalisability of the training programme. However, context specific differences should be considered and accommodated. This will help in reaching out to persons with mental retardation with appropriate services in the absence of special schools or other training facility especially in rural areas.

*Address for correspondence
Special Education Consultant
2/c, Anugraha Apts, 157/7, Staff Road
Secunderabad 500009, A.P. India
Email:jnarayans@yahoo.com

**State Project Manager - Disability Programme
Indira Kranthi Patham
Society for Elimination of Rural Poverty
Govt. of Andhra Pradesh, Hyderabad, India

REFERENCES

  1. Cook A, Lucy B, Edward N, Lee E, McDiarmed N, Pope M, Sov E. Aunique community development programme, Action Aid disability News Vol.15, Nov. pp 36. 2005.
  2. Thomas M.Editorial,Asia Pacific Disability Rehabilitation Journal 2007, 18(1).
  3. Annual Report. Department of rural development, Govt. of Andhra Pradesh. 2005, pp 3.
  4. IDDC position paper (2002), International disability development consortium, IDDC CBR Task group meeting,www.iddc.org.uk. accessed on 23.12.2004.
  5. Manian S, Nikhilesh, Abraham C.Evaluation findings of CRDA-CBR,Action Aid Disability News, 1996; 7(2).pp 60.
  6. Narayan J.Intellectual disability . A manual for CBR workers (Draft), New Delhi: Health and behaviour unit, Department of Sustainable Development and Healthy Environment, WHO, 2003.

PUBLICATIONS ON DISABILITYAND REHABILITATION AVAILABLE ON AIFO WEBSITE

  1. Twenty Years of Community-based Rehabilitation in Guyana - An Impact Assessment, by S. Deepak, AIFO, Italy, October 2007: can be downloaded from http://www.aifo.it/english/resources/online/books/cbr/GuyanaCBR-impact_assessment-final07.pdf (file size around 1 MB, in PDF format)
  2. Training Manual on Human Rights of Persons with Disabilities - The participation of organisations of persons with disabilities and their families in the process of ratifying, monitoring and implementing the UN Convention on the rights of persons with disabilities, by G. Griffo & F. Ortali, AIFO - Mongolia, September 2007: can be downloaded from http://www.aifo.it/english/resources/online/books/cbr/ manual_human_rights-disability-eng07.pdf (file size around 600 KB, in PDF format).

Dr. Sunil Deepak Head,
Medical Support Office
AIFO, Italy