ORIGINAL ARTICLES

EVALUATION OF A PILOT COMMUNITY BASED REHABILITATION TRAINING PROGRAMME IN EAST TIMOR

Jane Shamrock^*

ABSTRACT

The first Community Based Rehabilitation (CBR) training programme in East Timor was held in Dili between March 2006 and August 2007 based on the Community Approaches to Handicap in Development (CAHD) model. This article presents the results of an evaluation of the training by studying the impact of the CBR training on the trainees. The evaluation was completed by (a) investigating how the trainee CBR workers experienced their training period, (b) describing the work of the 12 active CBR workers and (c) commenting on the value of the CAHD toolkit as a basis for the CBR training.

The evaluation found that CBR workers were providing a variety of CBR interventions with some errors occurring because of insufficient skills in assessment, problem solving, monitoring and evaluation. The CAHD toolkit was found to be a useful framework for the training programme with changes needed in response to the needs of the trainees.

INTRODUCTION

The first CBR training programme in East Timor was developed by Australian therapists and was planned for one week a month over a year, starting in March 2006. The training was based on the CAHD toolkit (1). The training programme was interrupted by a period of civil unrest which began in May 2006, during this time Timorese began fleeing Dili and the expatriate trainers were evacuated.

The training recommenced in October 2006, continuing into 2007 with further disruptions from periods of unrest. Certificates of participation were finally presented to those who attended the last module in August 2007.

Learning Objectives of the Training

The overall learning objectives of the East Timor CBR training programme based on the CAHD toolkit were:

1. Participants will develop an understanding of the need for equal opportunities in development and the importance of advocacy where disability and disadvantage are evident.
2. Participants will be able to make a realistic needs assessment where disability is a major issue.
3. Participants will develop intervention skills to introduce appropriate change.
4. Participants will develop skills in communication to be able to carry out successful interventions.
5. Participants will develop skills in monitoring and evaluating the results of CBR activities.

METHOD

A. During the Training

Data were collected at the beginning of the training to assess the skills and experience of the new trainees.

During and at the end of the training (2006 - 2007), trainees were asked for feed-back relating to the course, the venue, the translation and personal issues that impacted on their involvement in the training programme. Trainers were asked to fill out a sheet to reflect on their teaching experiences at the end of individual classes. Competencies were developed for each module and participants and trainer/mentors were asked to record trainees' skill acquisition.

Following the break in the training programme caused by the civil unrest in mid-2006, trainees were asked about their CBR activities during that time.

B. After the Training

During April 2008, a three week visit was made to East Timor where semi-structured interviews were carried out with eleven of the CBR workers, two programme managers and one manager/mentor.

• Three brief field visits were made to see programmes in action; sound recordings were made and backed up by field notes.
• Trainees were asked a series of open questions and particular lines of enquiry were followed through where appropriate.
• Verbatim responses were typed into a table format and coded according to content. The data were then collated using the "sort" function in Microsoft Word. Broad categories were identified and the larger categories were coded further and sorted again; in this way themes were identified.

Ethical considerations

Each respondent was informed that the purpose of the interview was to generate a report to be made available to those involved in planning future training of CBR workers in East Timor. Individuals were assured of privacy and offered the right to decline to be involved in the evaluation process, however, no trainee declined to be interviewed.

Respondents were assured that they would not be named or identified. This was particularly important as at least two trainees believed that a place in the next training could be jeopardised if the "wrong" answers were given.

RESULTS

A. Results from the Training Period

The Trainees

Twenty-five trainees started the training, 19 male and 7 female. The ages of those starting the programme ranged from 19 to 38 years, with several older trainees joining the programme as the training progressed. The trainees came from 11 of the 13 districts of East Timor. Table 1 shows the previous employment of the trainees who started the training in March 2006. Of the 30 trainees, 54% had been previously employed and 46% were newly employed to start the CBR training.

Reflections From Trainers During The Training Period

At times, during the training period trainers were asked to reflect on various aspects of their teaching sessions. The main findings can be summarised as follows:

What went well

• Practical sessions with persons with disabilities.
• Case studies.
• Problem solving real situations.
• Revision sessions where trainees could demonstrate their new knowledge.
• Discussion of East Timorese cultural beliefs or discussion about problems of language and understanding of words in different parts of East Timor stimulated lively discussion.
• The active teaching methods offered in the CAHD training manual were usually appreciated. These included discussion, games, role-play, activities with large sheets of paper, small and large group activities, debates and didactic sessions.

What could have been better

• Trainees often needed more time than was initially allowed in the teaching plan.
• At times trainers needed to be better prepared for their session and explanations needed to be clearer.
• The translator needed to understand the subject.
• Complex material was more difficult to teach in the afternoon when trainees and trainers were tired.
• Trainers needed to have a fall-back plan to manage frequent power failures.

B. Results from the Interviews May 2008

Thirty trainees passed through the CBR training programme; 25 started the training, 21 finished the programme and 12 were working as CBR workers at the time of the evaluation. Their locations at the time of interview are outlined in Table 2.

Evaluation of the Learning Objectives

1. Development and advocacy

Most respondents spoke of the importance of explaining the rights of persons with disabilities firstly to village leaders, then to family and neighbours."There is discrimination in East Timor, we need to explain to friends or family" (respondent U).

One respondent noted a change over the time he had been involved in CBR. "Before people did not understand, now attitudes change. Before, the person was in the back of the house" (respondent O).

Three of the respondents expressed a passion for their work. One respondent reported taking an informal opportunity to speak to a member of parliament to explain the needs of persons with disabilities. Another said that she was respectfully known as "handicap mother" in one of the villages that she regularly visited. One CBR worker was exceptionally zealous in her attempts to improve the lot of a woman with a disability. "I was together with the lady for three days because the family didn't care for her. The family closed her in the kitchen... I explained to the family and the community and gave her training to stand up" (respondent N).

One trainee described how before the CBR training, she and her family were afraid of persons with disabilities and would not speak about disability for fear of becoming disabled themselves. Since completing the CBR training, this respondent had taken time to explain to her family that disability cannot be caught like other diseases.

The CAHD toolkit encourages persons with disabilities to undertake CBR training to be able to be effective as an advocate for disadvantaged persons with disabilities. Three persons with disabilities participated in the training. At the end of the training, one was working as a therapy assistant, one had returned to his district to take up other activities and one could not be traced.

Several trainees expressed problems with village or family attitudes to persons with disabilities. One respondent explained "the mother wants to get rid of the children and leave them at Taibesse school because this is the place for this child. But we explained this is life and you have to take care, this is your responsibility" (respondent L).

2. Assessment

Respondents made assessments by discussion with families. For example, "I do an assessment and prioritise problems, I talk to the family and decide what to do based on that" (respondent I).

Several problems were noted in descriptions of the assessment process. These included:

• Inaccurate assessment of needs: two instances were reported where promises were made to persons with disabilities to entice them to come to ASSERT (the rehabilitation service at Dili) for assessment: "He was promised a plastic support {i.e. foot splint} and when we did a thorough assessment he has a spinal cord injury and he should have a wheelchair, this is not good assessment!" (respondent S").
• Difficulties prioritising needs: two managers expressed concern that the CBR workers' assessments focussed only on disability when the more basic need of malnutrition was being overlooked.
• The amount of time needed to really get to understand the needs of people in remote areas:"We need to take time to get to know them, the culture is different, we need to know the culture and the language" (respondent L).
• Need for further training in assessment: one of the trainers interviewed was concerned at the lack of time spent on assessment during the training programme: "we taught them how to set objective goals.....but we didn't follow up enough on that" (trainer K).
• Limited educational background: "{the CBR} worker has only had pre-secondary education" (trainer K).
• Lack of ability for creative problem solving: "they don't get this whole problem-solving thing...... I see it in our programme, they {the adults} don't even know how to do a simple child's puzzle!" (trainer K).

3. Interventions for change

Most CBR workers interviewed felt appreciated by the families that they were involved with. For example "she said.. you want to take care of my child and to help me...we can make them smile and give us thanks" (respondent L).

The range of interventions were usually simple, such as issuing a wheelchair, providing walking aids or other equipment, referrals for specialist services, teaching the person with disability to walk, giving exercise sessions, training a family member to help the person with disability with exercises and making a ramp to improve access to the home of a person with disability and counselling.

At times the interventions were based on advice given by others such as therapists at ASSERT or an expatriate therapist. Generally there were several weekly visits as time had to be taken to meet with local leaders, communities and families. Some interventions took several months with regular visits.

Some CBR workers worked in isolation, making decisions alone about what help to provide to families. At times help was sought from community organisations such as the church or the school. CBR workers at times organised trips to Dili to visit ASSERT for expert help or specialist advice. Usually the trips resulted in the person with disability and family receiving extra support, equipment, therapy or service.

During the field trip in May 2008, three community income-generating projects were seen. In one village a group met regularly to plan for a chicken raising programme. Accommodation was being prepared for the chickens, the local vet had volunteered to provide support and recipients had been identified. Another person with disability received support and US$500 from an NGO (non-government organisation) to set up a small shop. In another community effort, a respondent was involved in a project where community members removed stones on a pathway to allow easier access for a wheelchair (respondent L).

Some difficulties were found with interventions such as:

• Advice that did not work out: one income-generating project experienced difficulties when the CBR workers advised planting a crop which subsequently failed.
• Not considering the whole picture: One manager qutoed the complaints of a disabled person who had been given a wheelchair which was too large for the family home. "She {the client} said, I don't want this wheelchair, where in my house will I put this wheelchair, this wheelchair doesn't fit me" (respondent S).
• Difficulties dealing with attitudes of families: "Parents say that the child can't do anything because he is disabled" (respondent I).
• Difficulties dealing with attitudes of the person with disability: "Often the person with the disability is passive" (respondent C).
• Not enough skill base: "I need training about wheelchairs and nutrition and how to involve the community and the disabled person" (respondent T).
• The need for technical support in the field: respondent C believed that the technical support available to CBR workers was insufficient. "The most important thing that we need in the field is technical advice".
• Lack of appreciation of the CBR workers' efforts for some other reason. A client "was given a stick by the church but he won't use it. When I go to have a meeting with the family to explain how D could have a better future, the wife says that she doesn't want the equipment. That's because some time in the past something happened so now they don't want the equipment".
• Misunderstanding the limitations of CBR. Following the death of a client a CBR worker was asked for a coffin and candles for the client's funeral (respondent I).

4. Communication skills

The CBR workers saw communication as important and most were confident of their abilities to communicate with persons with disabilities and stakeholders. "I talk with the family, and the community, it's important that the community understands. CBR must integrate with the community and the families' ideas" (respondent C). Respondent G explained that he has "good relations with the community, hospital, community leaders, no problem. They are happy to help with disability".

Specific communication skills have been used by CBR workers, such as how to get along with a child and the family of a child. "I give toys to play with and I speak to the father and the mother" (respondent U). Most respondents also stressed the importance of talking to the local leaders and gaining their support before becoming involved in the lives of village people, especially in remote areas where the level of education is poor. "People only know what the local leader knows" (respondent A).

One respondent saw her role as counsellor and educator as well as therapist. "Counselling includes the family and is very important. Family education is very important" (respondent L).

CBR workers at times, could not convince families to participate in therapy. "Families are lazy and won't do therapy even when I explain to them" (respondent D).

One respondent joked that his problems in the field came from difficulties explaining the meaning of CBR. He revised the meaning of the acronym to "Confusion Based Reality" (respondent C).

5. Monitoring and evaluating CBR programmes

Most respondents said that they recorded the number of clients they saw and/or kept notes on the type of disability or the type of service, either daily, weekly or monthly. One CBR worker made a monthly report to his NGO, whilst another made notes in the client's file when something changed.

Most CBR workers returned to check on the success of their interventions. "I do evaluation and follow-up whether it's good or not, so we can be satisfied with the wheelchair" (respondent I).

One respondent noted that he needed more training in report writing: "I can manage many things, like exercises, like how to talk to the people but writing the report is the difficult thing for me" (respondent G).

Other Findings from the Interviews

Gaps in the training programme

The CBR workers interviewed were asked what they felt had been left out of their training programme, in the light of their subsequent experiences. All workers contributed comments which included the following needs:

• More information about causes of disability.
• More information about equipment.
• Improved skills in management and report writing.
• How to conduct self-help groups.
• How to conduct vocational groups.
• More information about different diseases.
• More information about nutrition.

Other problems were also identified in the training program. These included:

• The training period was too long.
• A better translator was needed.
• Some of the trainees were identified as not being really interested in disabled people, "we....need to choose participants in the next training who work with handicapped people and who are interested in handicapped people... some come to the course because they... like the per diem or to get a job with lots of money" (respondent S ).

Effect of the crisis on the training

There was a range of comments about the effect of the crisis period. These included: "We had to keep stopping because of the crisis, it was difficult to think but we continued and we tried hard even though we were afraid" (respondent S). "The crisis was not a problem, it was only in Dili" (respondent A) and "we couldn't find the patients, some ran away and some went to the IDP (internally displaced persons) camps" (respondent L), "we were afraid that it would happen again and we were afraid that we would lose the training" (respondent E). Trainer B noted "..... individuals whose personalities had changed, whose concentration had changed, whose enthusiasm had been curbed, who were pessimistic rather than excited, who were flat rather than supportive, trainers as well as participants".

One respondent said that he still does not bring the reference book, "Disabled Village Children"(2) to Dili for fear that it may be lost.

Barriers to present work

CBR workers were asked about the barriers in their present work to see if present barriers related to the training programme. Many of the barriers related to general difficulties of working in East Timor, such as large work loads, poor logistical support or remoteness of many of the communities. More specific barriers included:

• Families' fears that their disabled child may cause problems if he/she goes to school.
• Discrimination against persons with disabilities in communities.
• Need for specialised transport for persons with disabilities.
• Need for technical supervision.
• Lack of specialist services such as speech therapy.
• Need for more support from managers.
• Families not engaging in the CBR activities being offered.
• An unexpected barrier was described: "People in Oecusse thought that we would sell their information, that we would take their name and address to get money" (respondent L).

A creative approach

CBR workers were constantly being faced with unique situations that called for a creative response. Two notable instances were found of creative problem solving.

One CBR worker taught a disabled child and all his siblings to write, before the family would allow the child to go to school. She also taught him to cook so that he could help his family. In another instance, the same CBR worker convinced the local priest to make the church more accessible for disabled parishioners. The same respondent also reported making parallel bars at a family home to facilitate the exercise programme. Another respondent described how she managed to convince a client to give up smoking, to the delight of the client's wife.

CBR workers, especially older people, may have found a creative problem-solving approach difficult to take up, especially if he/she had previously been of lower status: "before ninetynine {the year 1999 when the Indonesian occupation ended} the CBR worker was paired with someone who was a nurse who was trained to do rehab, the CBR worker just tagged along and didn't have to make any decisions" (respondent K).

The managers' and trainers' viewpoints

Four people, who were either managers or trainers at the time of the training, were asked for comments on the CBR training programme and subsequent CBR activities. They all reported that some CBR workers were now doing good work and a few still needed significant support to carry out their CBR tasks. "I think most of them are trying hard, but they need good support, they should be getting more training" (respondent S).

All spoke of the need to build on the basic skills given in the training programme. This included: support in developing problem solving skills, support in accurately identifying and prioritising needs, skills in record keeping and monitoring activities, good backup with provision of phones, vehicles and other resources needed to carry out their service. One manager suggested, "regular workshop refresher meetings of the CBR workers across the country to support and share information. Mutual support is very important" (respondent S).

Manager M commented on the importance of cultural relevance and noted that, "we need to consult with various organisations to give some input to see if the material is relevant to East Timor, otherwise we just try to adapt to East Timor but it's not right for East Timor, for the conditions in East Timor, because of the experience, knowledge, culture, economics and everything."

The CAHD tool-kit

The CAHD tool-kit provided the trainers with a firm structure on which to base the training programme. The range of teaching methods ensured that therapists acting as trainers had a range of presentation styles to engage their students.

However, adjustments were frequently being made " "on the run". These changes were needed to address issues such as educational levels, cultural issues, the sequence in which information was presented, the trainees' fatigue levels and their ability to concentrate under difficult circumstances.

SUMMARY AND CONCLUSION

Some of the trainees who completed all, or part of the training have moved on to become CBR workers and are making a difference in the lives of persons with disabilities.

The CBR workers all demonstrated awareness of human rights and were prepared to discuss this with those involved in the lives of persons with disabilities.

CBR workers were initiating mostly successful interventions which were generally appreciated by the recipients. Some mistakes have occurred from lack of knowledge, lack of problemsolving skills and/or difficulty explaining the scope of CBR which had raised unrealistic expectations in recipients. There would likely have been fewer mistakes if all the therapist/mentors had been able to support the trainees for the full training period as originally planned. CBR workers and the managers interviewed agreed that trainees needed on-going support such as regular get.togethers for skill sharing, or training in identified areas to make their interventions more effective (3).

Monitoring and evaluation were not widely considered in the CBR workers' service. Monitoring and evaluation require a good understanding of client needs as well as good record-keeping. There is a risk that if managers and CBR workers do not understand these issues, the impact of CBR programmes will be lost (4,5).

CBR must be relevant to match East Timorese perceptions of disability and relevant to the lived experiences of persons with disabilities (6). The CAHD tool-kit, while providing a very useful basis for the training programme would benefit from revision to make it more appropriate to the East Timorese culture and individuals' education levels. Basic information from a complete needs assessment in the recipient villages, as well as a sound assessment of trainees education levels would help ensure that teaching is relevant and within the abilities of the trainees.

Logistical support from the NGOs was identified as lacking by some CBR workers. Better logistical support would help remind the CBR workers that their work in remote areas is appreciated and would make their service more effective. This support should include suitable transport, time out for training sessions and readily available advice such as nutrition or agricultural information.

In conclusion, although this evaluation does not compare the CBR workers' statements against experiences of the recipients of CBR, the evidence available indicates that the CBR workers' views gave a useful picture of CBR's small start in East Timor. The CBR services were beginning to penetrate areas where previously no support was available for persons with disabilities, their lives were being positively affected and community attitudes were beginning to change.

^*5 Colsak Close,
Palmwoods, Qld 4555
Australia
Email: jane_dili@yahoo.com.au

ACKNOWLEDGEMENT

The research was carried out with staff from the following organisations based in East Timor: 1. The Leprosy Mission International (TLMI), Dili , 2. Katilosa, Dili, 3.ASSERT, Dili, 4. Klibur Domin, Tibar, 5. Maryknoll clinic, Aileu. The CBR training programme was an exciting but difficult time for all involved and the courage of all those who returned to the training modules again and again despite their fears is acknowledged.

REFERENCES

1. CAHD Toolkit (CD ROM) available from Centre for Disability in Development Bangladesh. http://www.cdd.org.bd/index.php 2001
2. Werner D. Disabled Village Children. A Guide For Community Health Workers, Rehabilitation Workers, And Families. Hibernian Press 1993.
3. Understanding Community Approaches to Handicap in Development (CAHD) Published by Handicap International 14, Avenue Berthelot, 69361 Lyon Cedex 07, France 2001.
4. Chelimsky, E. and Shadish, W. (eds) Evaluation for the 21st Century. A Handbook, Sage, Thousand Oaks 1997.
5. Rubin, F. A Basic Guide to Evaluation for Development Workers, Oxfam, Oxford (1995).
6. Finkenflugel H Empowered to Differ, Stakeholders' Influence in Community-Based Rehabilitation - CBR Pilot. PhD Thesis. University of Rotterdam (http://dare.ubvu.vu.nl/handle/1871/10205) 2004.