COMMUNITY -BASED REHABILITATION WORKERS OF SOUTH INDIA:
THEIR ATTITUDES AND THEIR EDUCATION

ABSTRACT

This paper describes the attitudes of community based rehabilitation (CBR) workers in southern India towards people with disabilities. It provides a clearer understanding of attitudes and the factors involved in the acquisition of attitudes. Educators and managers are given direction in their quest to design appropriate and effective CBR curricula for the CBR worker.

INTRODUCTION

The community based rehabilitation (CBR) worker of southern India works in one of the most challenging environments in the world. India is ranked 134th out of 174, on the UN Human Development Index. Each year, 3.1 million children die before the age of five, and fifty percent of the rural population lives in poverty (1). Within this developing society, the CBR worker works with one of the most marginalised groups, namely, people with disabilities.

CBR has had a relatively long standing presence in southern India. Regional CBR programmes can trace their beginnings back to the mid-eighties, which is a long period of time for a discipline that was officially recognised only in 1981 (2). Generally, CBR programmes evolved from existing public health care (PHC) programmes in response to the needs of people with disabilities in the community. Initially, workers were re-assigned from community health related tasks to work with people with disabilities, until a separate CBR designation became recognised. It was not until a few years later that unique CBR worker training programmes were developed, of which there are now several in the four southern states of Tamil Nadu, Andhra Pradesh, Karnataka and Kerala. As CBR evolves, the CBR worker's roles and responsibilities have become more clearly defined as a distinct occupation. Presently, most CBR workers must complete a training period before gaining employment. In training for any vocation, acquiring a unique combination of knowledge, skills and attitudes is essential to enable individuals to function in their chosen fields. CBR training has made great strides in developing a CBR worker's skills and knowledge (3), as is evident within the curricula utilised at training programmes throughout southern India. However, the attitude requirements of CBR workers are poorly defined, seldom evident in curricula and rarely taught, despite the fact that attitudes are almost universally recognised to be highly significant to a CBR worker (4, 5). Attitudes are relevant only to the extent that they are believed to determine human behaviour, and most researchers agree that attitudes are one of the key factors that predispose a person to act or behave in a particular manner towards another. Some other behavioural influences include a person's perceived ability to enact the behaviour (self efficacy), their motivation, community social norms, past habits, exposure to persons with disability, personality, fear of punishment or reward (6,7).

This study has adopted the definition of an attitude as "an idea charged with emotion which predisposes a class of action to a particular class of social structures" (6). This definition recognises that attitudes are multi-dimensional, having cognitive, affective and behavioural components, and do not exist in isolation from each other. Rather, they are products of environmental factors, and exist only in relation to a "class of social structures"(6), or referent, which in this case is the person with a disability. This perspective of attitudes supports the belief that attitudes can be influenced and changed through effective educational interventions. Negative attitudes on the part of care givers can present real barriers to the rehabilitation and integration of people with disabilities. As pointed out by Helander in 1994, "Perhaps the most important reason for the difficulties disabled people are facing lies in the negative attitude towards them, an attitude based on ignorance and prejudice" (8). Berry and Dalal stated that "among the main factors affecting disability, probably the most important are the beliefs, attitudes and behaviours surrounding a person with a disability" (9). In the case of the CBR worker, their attitudinal focus is people with disabilities. Therefore, understanding the attitudes of CBR workers towards people with disabilities is critical to the development of effective CBR worker training and evaluation. If the CBR worker is indeed the central figure in the community rehabilitation of people with disabilities, then understanding the attitudes of CBR workers towards people with disabilities not only assists in the selection and education of CBR workers, it also ultimately influences the success of CBR programmes. In southern countries, there are few studies about attitudes towards people with disabilities, especially those using rigorous research methods. A collaborative study between the University of Allahabad, India and the International Centre for Advancement of Community Based Rehabilitation (ICACBR), Queen's University, Canada began the process with the Disability, Attitudes, Beliefs and Behaviours study a few years ago (3, 9).

This study investigated the attitudes of CBR workers in southern India, a region with one of the most extensive networks of CBR programmes in the world (10). The study also reports briefly on the state of attitude training in southern India, and provides some suggestions. The study objectives were as follows.

1. To provide an accurate description of the CBR worker. A thorough investigation of CBR workers has never before been undertaken. As CBR workers become more wide-spread throughout the developing world, investigators and practitioners alike require a more detailed profile of the CBR worker's qualities and characteristics. This knowledge could assist in their selection, training and evaluation.
2. To determine the attitudes of CBR workers towards people with disabilities, and to determine the relationships between workers' characteristics and experiences. The attitudes of people who work in rehabilitation can be key contributors to the handicapping environment (11). If the factors responsible for these attitudes are determined, then CBR curriculum planners and educators will be better equipped to select trainees and plan appropriate and effective training programmes.

1. 2. 3. To investigate the teaching of attitudes in CBR training programmes in southern India. In meeting after meeting, CBR trainers and managers have expressed an almost unanimous viewpoint that CBR workers' attitudes are essential to their success. However, concrete evidence of attitude training in CBR workers' curricula, either as an objective, or a strategy, is lacking.

METHOD

The data were gathered from six organisations carrying out CBR programmes and CBR workers' training, from the southern states of India. The organisations were The Rehabilitation of the Disabled, Pondicherry, Seva in Action, Bangalore, The Association of Physically Handicapped, Bangalore, The Training and Research Centre in Rehabilitation, Madanapalle, and the Spastics Society of Tamil Nadu, Madras. Characterising the CBR worker was a challenge. People were included in the sample if they described themselves as CBR workers who were community based and worked with people with disabilities. Sixty one CBR workers were asked to describe their personal characteristics and backgrounds. They also completed the CAB (12), a newly developed instrument to measure attitudes towards people with disabilities. Apart from this, three focus groups were held with the same group of CBR workers following administration of the instruments. Twenty three key informant interviews were conducted with CBR teachers, administrators and community members involved in the implementation, design or support of CBR programmes. The curricula of the training programme, where available, were examined for evidence of attitude teaching. The training in all the locations was observed by the author.

The attitude measuring device, CAB was developed from the Disability Factor Scale (13) and revised specifically for use in India. The CAB has 40 statements about disability or people with disabilities to be answered on a six point Likert scale of agreement. The statements were designed to be multi-dimensional, reflecting the cognitive, affective and behavioural components of attitudes, with the intention of providing a more accurate means of measuring a person's attitudes, and therefore in designing appropriate educational interventions. The statements were revised to reflect the incidence of disabling conditions found in India, and translated into the appropriate south Indian language for each site. All respondents were trained in the use of Likert scales.

RESULTS

1. Describing the CBR worker

Demographics : The 61 CBR workers in this study were primarily female (76.4%), young (mean age 21.6 years, SD 6.1) and married (57%). Seven workers (11%) had a disability. Most had little work experience in CBR or related disability work (mean years of experience 3.3, SD 3.1), and sixty percent had less than 3 years of experience. CBR work requires basic literacy and in this study, all but one worker was fluent in at least English and one Indian language. Almost half of them (49%) knew three or more languages. CBR workers in the villages tended to be younger than their city counterparts, reflecting the need for new recruits to fill vacancies in more remote environments, and the desire of older workers to live in urban environments with better educational and health facilities for their children. Urban workers were better educated than their rural colleagues, again perhaps because of the availability of more educational facilities in cities, which allowed for further studies.

Contact : CBR workers were asked to describe the intensity of contact with people with disabilities. Most (57.4%) reported that their primary contact with people with disabilities was because of work or training course requirements, almost a third (31.1%) reported frequent social contact as acquaintances or neighbours, while only 10% said that they had had close personal contact, either immediate family or a close friend. One person who was a new employee reported no contact at all.

Nature of work : Three quarters of the sample (74%) worked in villages, while the reminder were based in cities, although sometimes working in outlying urban regions. When asked to describe their primary responsibilities, most CBR workers stated that it was to work with children with disabilities and their families. Integrating children into schools was also a major priority. Only a few worked with adults, usually in vocational training and income generation programmes. Most worked with people with physical disabilities, who often demonstrated accompanying intellectual impairments. Few CBR workers focused on people exclusively with intellectual disabilities, and even fewer on those with visual challenges. One respondent worked with alcoholics. The responsibilities of the CBR workers included dispersing knowledge about disability, raising awareness in the community, counselling families and people with disabilities, assessing needs, referring people to other services, providing direct rehabilitation treatment, supporting families, making simplified technical devices, empowering individuals and groups, changing attitudes and teaching mobility skills. Some CBR workers were involved in innovative strategies not commonly thought to be a part of CBR. For example, local youth were given leadership training in the hope that they would assume influential positions in their communities in adulthood and promote inclusion of people with disabilities. Families with disabled children were assisted in obtaining loans to run small businesses, thereby not only increasing their income, but also raising their esteem in the community. Local politicians and business people were encouraged to make their communities more accessible for those with physical disabilities.

CBR workers in this sample dealt with day-to-day stresses that affected their ability to function. A previously receptive family, with whom a CBR worker had visited several times, suddenly became unfriendly and asked the worker to stay away. Apparently the family was scorned by neighbours who questioned why they would allow the CBR worker, who was a woman of lower caste, into their higher caste home. A worker in Tamil Nadu was torn with the knowledge that many of the families in the communities she served still practised infanticide with female new-borns. Some CBR workers faced false expectations from the community as they were perceived as providing a conduit to government funding. Or they were viewed with suspicion and hostility as possible government informants placed to gather data on village practices. It was not abnormal for parents to request the CBR workers to remove their disabled child to an institution because they found it too difficult to cope.

Qualities of the CBR Worker : The key informant and focus groups generated an ambitious list of the necessary qualities of CBR workers. They must be aware of their own motivation, have good self esteem, treat others as equals, be facilitators and motivators, be patient and empathetic listeners, be respectful of different classes and cultures, have excellent communication skills, be team players, and above al1, believe in the rights and dignity of the individual, whether disabled or not. In the context of these challenging requirements and social conditions, the CBR worker needs to be a therapist, teacher, social worker, politician and vocational counsellor, as well as having the boundless energy and resourcefulness to work independently.

Education : This sample was very well educated. Eighty percent had obtained their secondary graduation, and eighteen percent were college or university educated, usually in social work, orthotics or speech therapy. Only 2 workers were not educated beyond primary school. The mean number of years of school attended was 12.7 years (SD 2.6). There were several models of CBR training found in this region, which could be categorised as either 'formal' or 'informal'. The formal training programmes consisted of separate educational facilities dedicated to the training of the workers. These facilities employed specialist teachers, taught a prescribed curriculum and required students to be resident on a full-time basis for 3 to 16 months. Often, potential CBR workers were sponsored by a local employer to attend one of these formal training courses, otherwise they attained their skills from work experience only, having worked with people with disabilities in some other field. The informal training programmes were more of the 'on-the-job' variety, which were on-going educational programmes for staff already employed by a community agency. For example, one day in a week could be dedicated to training on an aspect of CBR, with senior staff or visiting lecturers acting as instructors. In this sample, 13% had no training in CBR, but some within the group had related education in community development or orthotics. Over half ( 52.56%) were currently enrolled in, or had completed a formal CBR training programme, and (34%) were involved in, or had completed an informal model of CBR education.

2.CBR Worker Attitudes

The attitude measurement instrument, the CAB, yielded a mean score of 132.39 (SD 14.89), the maximum possible score being 216. By dividing the total score by the number of statements (36), a mean score per statement was determined at 3.73 (SD .43), suggesting that this sample had a mildly positive attitude towards people with disabilities. When the CAB statements were grouped by type of disability some interesting trends were noticed, as shown in Table 1.

Statements about sensory disabilities elicited the lowest score (3.34), which is unusual considering that visual problems are the most common disability in India (10). In the author's experience, Indians with visual impairments were segregated into specialised schools and vocational centres. Perhaps this is due to the lack of environmental adaptations for blind persons, making independent living very difficult. Their exclusion may have encouraged negative stereotypes, leading to more negative attitudes. Attitudes towards people with physical disabilities were most positive (3.95), perhaps because most clients of CBR workers belong to this group and fewer misconceptions are held about their capabilities. Scores for the non-visible disability group were in the middle range (3.65), which may be indicative of an ambivalent attitude of CBR workers towards people with heart disease, epilepsy and cancer. These latter conditions are much less significant to the overall health problems of India, which faces more pressing problems such as cholera, malaria, malnutrition, and leprosy (10). Attitude scores were also compared between the five sites used in this study. There were no significant differences measured between the locations (at p>.05), despite widely differing curricula.

3. What characteristics influence attitudes?

Statistical comparisons were made between the workers' attitude scores on the CAB and characteristics such as age, gender, marital status, presence of a disability, type of work environment (urban or village), degree of contact with people with disabilities, amount of work experience, and their education. Neither contact with people with disabilities nor the work experience variables were significant to the CBR worker's attitude scores. Age, gender, marital status, and presence of a disability were also not correlated to CBR workers' attitudes.

As this study focused on the role of education in determining attitudes, a delineation was made between the overall years of education from primary level upwards that a worker had attained, and the of training exclusively in CBR. Linear regression analysis, as shown in Table 2 indicated that overall years of schooling was highly significant (p=.0060) in influencing CBR workers' attitude scores. The amount of education in CBR was not found to be significant (p = 0.259 and 0.270).

DISCUSSION

The attitudes of CBR workers towards people with disabilities were not affected by age, gender, marital status, presence of a disability, CBR work experience, and contact with a person with a disability. Their attitudes are slightly more positive towards those with physical disabilities and more negative towards people with a visual impairment. The only significant influence on attitudes was the overall years of school attended, but not the amount of CBR education. It is curious that the number of years of education have more influence on attitudes towards people with disabilities than specifically designed CBR education. Indian schools are not believed to include attitude training about people with disabilities, and few students are exposed to disabled children through integration. Perhaps the amount of education can be associated with social class, economic status, parental background, and caste. Subsequently, people with more education would have increased access to television, movies, travel, and literature, all of which are factors that could influence their attitudes towards people with disabilities.

Although CBR education would be expected to have an influence on attitudes, this was not observed, perhaps because none of the CBR training sites included concrete, detailed objectives for the acquisition of attitudes in their curricula. However there was a strong sense of support for attitude training. The predominant strategies for attitude training, as observed and as stated by CBR educators, were the mentoring role of CBR educators and the CBR workers' field experiences. Therefore, any influence that CBR education programmes may have had on forming attitudes was unintentional.

So what influences the development of a CBR worker's attitudes? The majority of CBR experts interviewed felt that CBR students arrived with their attitudes firmly in place. Two of the CBR sites visited conducted their own attitude pre-screening of candidates, acknowledging that other factors pre-date the influence of CBR education. These could be the student's primary education, family upbringing, community awareness programmes, or the mainstreaming of disabled children in the schools. Research has illustrated that educational interventions can improve attitudes, but that these gains are not always sustained (14). As Dalal (15) states, "attitudes and beliefs about disability are only now beginning to change in India, and slowly". Dalal goes on to argue that well designed educational interventions, among other strategies, could have a significant impact on changing attitudes in India. This does not preclude the fact that the attitudes of CBR workers could be positively influenced through the application of concrete, outcome-measured strategies within CBR educational programmes.

The Future of CBR Education in southern India

There is a groundswell of interest in, and support for, CBR training in southern India. A loosely organised but highly dedicated group of CBR educators and managers has formed the "South India Training Network", and conduct occasional meetings to improve the training of CBR workers, Several meetings have focused on attitudes in the curriculum. A multi-focused and broadly encompassing conference on CBR training was held in Madras, and the central Ministry of Education is developing enthusiasm for the education of CBR workers. Several of the CBR training programmes in the region are in the process of reassessing their goals.

The following statements could be used to initiate discussions for designing CBR curricula for the next century.

• Goals and objectives for attitudes must be established within CBR curricula, on an equal basis with skill and knowledge aspects.
• New models of training should be studied, developed and adopted. These models, while acknowledging their roots in medical practice, should move beyond the "bare-foot doctor' approach and investigate community and empowerment models. Disability must become the major focus, with developmental input from all stakeholders.
• These new curricula could begin with a study of disability in the community. At present, most curricula in the region focus on studying the etiology and rehabilitation of people with various types of impairments (physical, intellectual, etc.). While the study of handicapping conditions is an important part of CBR training, educators and managers must remember that the uniqueness of a CBR worker is firmly based upon the first word in their title, that is, community.
• A commitment must be made to train CBR teachers in the techniques and strategies of teaching attitudes. Most CBR educators in southern India emerge from a medically based training and need to have the opportunity to learn from related disciplines such as social work, education or even business.
• Managers and teachers of CBR programmes should resist efforts of the central government ministries of education to formalise CBR curricula within sanctioned educational institutions. India is too large and regionally diverse to permit such a uniform strategy. Indeed the strength and effectiveness of the present CBR programmes in southern India are largely due to their proximity to the communities in which they serve. They are, indeed, community based. Nevertheless, a centralised presence that provides resources for training and responds to requests for support, would be highly desirable.
• Linkages and loose associations between groups dedicated to CBR training should be facilitated and supported. Many organisations work in isolation from one another, and opportunities to network and co-operate are hindered by distance and lack of funds to travel. Electronic links are becoming more common, but are no substitute for face to face consultation and education.

CONCLUSION

The challenge of conducting attitude research in India must be acknowledged. The CAB represents an initial step in the process and was not intended as a gold standard instrument. At times, language proved to be a more serious issue than anticipated because CBR administrators overestimated the English ability of the CBR workers. It is critically important to be aware of, and attempt to minimise, cultural differences such as wealth discrepancies, caste barriers and social desirability. Time usage is of tantamount importance. Future research could include more extensive questioning to discern sources of attitudinal development such as caste, spiritual beliefs, social and economic status, educational details, and family background.

This study focused on only one attitude referent, that is, people with disabilities. As CBR evolves from its medically-based roots to a more educational and community development focus, so too will the attitudes of CBR workers evolve. Their attitudes encompass other referents, such as attitudes towards styles of community participation, learning practices, and even political involvement. There is much room for innovative study which may serve to enhance the practice of CBR, and ultimately the well-being of people with disabilities. As with any discipline, a CBR worker must have a specific set of knowledge and skills that enables her or him to function in a demanding environment. Attitude is an essential, assumed, and sometimes overlooked element that allows the CBR worker to maintain their commitment, integrity and vision.

ACKNOWLEDGEMENTS

The author is very grateful to the trainers, managers and CBR workers at the sites visited throughout south India. Thanks to Drs Maya Thomas, Will Boyce and Margaret Jamieson for their advice and tutelage, to Actionaid India for tactical and moral support, to the International Centre for the Advancement of CBR, Queen's University, and the Canadian International Development Agency for funding.

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Title:
ASIA PACIFIC DISABILITY REHABILITATION JOURNAL Vol. 10 @ No. 1 @ 2000

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