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Module 23

Models of Rehabilitation

Component IA

Role Name Affiliation

Principal Investigator Dr. Geeta Balakrishnan Principal,

College of Social Work,
Nirmala Niketan, Mumbai.
Paper Coordinator Dr. P. Saleel Kumar School of Social Work,
Marian College Kuttikkanam, Kerala.
Content Writer Ms. Easter Subha Jasmine Secretary / Principal,
CREST, Tamil Nadu.
Content Reviewer Dr. Cherian P. Kurien Professor & Director,
School of Social Work,
Marian College Kuttikkanam, Kerala.
Language Editor Dr. Ruble Raj Professor & Director,
School of Social Work,
Marian College Kuttikkanam, Kerala.

Component IB

Description of Module

Subject Name Social Work Education

Paper Name Social Work in the Field of Disability
Module Name Models of Rehabilitation
Module ID SWE/SWFD/23
Pre Requisites Passion to learn about various models of
rehabilitation and desire to improve upon the
rehabilitation process of persons with disabilities.
Objectives To develop adequate knowledge about the meaning
and definition of rehabilitation.
To understand the various models of rehabilitation
and
To learn the outcome of rehabilitation.
Key words Community Based Rehabilitation, Institution Based
Rehabilitation, Models of Rehabilitation, Persons
with Disabilities

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Quadrant 1

1. Introduction:

According to World Health Organisation, a billion people in the world, 15% of the population, have a
disability severe enough that it limits their participation in family, community and political life. Eighty
percent of those billion people live in low and middle-income countries, where often access to basic
health and social services is limited for all citizens. However, the impact on persons with disabilities is
more profound.

Disability is an important public health problem especially in developing countries like India. The
problem will increase in future because of increase in trend of non-communicable diseases and change in
age structure with an increase in life expectancy. The issues are different in developed and developing
countries, and rehabilitation measures should be targeted according the needs of the disabled with
community participation. In India, a majority of the disabled resides in rural areas where accessibility,
availability, and utilization of rehabilitation services and its cost-effectiveness are the major issues to be
considered.

In general, the people living in villages and small towns lack access to basic facilities such as hospitals or
schools. Whatever they needed to learn, they learnt from their mothers and fathers and older family
members. Whenever people had a physical or mental disability, their families and neighbours tried to help
them. For example, a child might lead a blind person around the village. Grandmother spent extra time at
home teaching a child with a mental disability to talk. The men in the family made a wooden crutch to
help a lame person walk. One of the neighbours learnt to talk with deaf people who make signs using their
hands.

Persons with disabilities found some work to do in the fields or at home that suited their abilities. People
with mental disabilities were given jobs that they could learn easily. People whose disability stopped
them from doing ordinary work found something else to do, like fortune telling or massage or music.
When people with disabilities had no family to help them, and could not earn enough to live on, they
begged food and shelter from other people in the village or town.

Even if everyone helped, it was still a hard life for people with disabilities. There were things that they
wanted to do, but could not do. They might get less to eat than other people, especially if they were a girl

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or woman. There were problems about finding a wife or husband for them. And even if other people
helped, they might also sometimes tease them or be cruel. Sometimes they said they had a strange 'spirit'
in them, which made them disabled. But they made the best they could make out of their life. They learnt
how to find their way around, and how to deal with other people in their village or small town. They had a
place there, even if it was not a very good place.

People with Disabilities sometimes went to a religious leader who said prayers for them or they might go
to a person who was skilled at healing. The healer or religious leader might live in the same village, or in
another place, far away. Perhaps their family argued among themselves, whether they should spend time
and money taking them on a journey to see a skilled healer or a well known religious leader.

Models of rehabilitation began to be established even in the pre-historic societies. These rehabilitation
models enabled people to make adjustment to their disabilities and lead life in the mainstream.

Social Workers engaged in creating change among the individuals are expected to ensure knowledge
about different models of rehabilitation available to those individuals living with disabilities for their
inclusion and mainstreaming. This module introduces the basic understanding regarding various models
of rehabilitation in India.

At the end of this module, the learner will:

 Develop adequate knowledge about the meaning and definition of rehabilitation.
 Understand the various models of rehabilitation and
 Learn the outcome of rehabilitation.

2. Rehabilitation:

Rehabilitation of people with disabilities is a process aimed at enabling them to reach and maintain their
optimal physical, sensory, intellectual, psychological and social functional levels. Rehabilitation provides
disabled people with the tools they need to attain independence and self-determination.

The United Nations defines rehabilitation as ‘Rehabilitation includes all measures aimed at reducing the
impact of disability for an individual, enabling him or her to achieve independence, social integration, a
better quality of life and self actualization’. Rehabilitation can no longer be seen as a product to be

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dispensed, rather rehabilitation should be offered as a process in which all participants are actively and
closely involved.

The World Report on Disability, defines rehabilitation as “a set of measures that assist individuals who
experience, or are likely to experience, disability to achieve and maintain optimal functioning in
interaction with their environments”. A distinction is sometimes made between habilitation, which aims
to help those who acquire disabilities congenitally or early in life to develop maximal functioning; and
rehabilitation, where those who have experienced a loss in function are assisted to regain maximal
functioning (Sweedish Disability Policy, 2010). The term “rehabilitation” covers both types of
intervention. Although the concept of rehabilitation is broad, not everything to do with disability can be
included in the term. Rehabilitation targets improvements in individual functioning, by improving a
person’s ability to eat and drink independently. Rehabilitation also includes making changes to the
individual’s environment for example, by installing a toilet handrail.

Rehabilitation reduces the impact of a broad range of health conditions. Typically rehabilitation occurs
for a specific period of time, but can involve single or multiple interventions delivered by an individual or
a team of rehabilitation workers, and can be needed from the acute or initial phase immediately following
recognition of a health condition through to post-acute and maintenance phases.

Rehabilitation involves identification of a person’s problems and needs, relating the problems to relevant
factors of the person and the environment, defining rehabilitation goals, planning and implementing the
measures, and assessing the effects. Educating people with disabilities is essential for developing
knowledge and skills for self-help, care, management and decision making. People with disabilities and
their families experience better health and functioning when they are partners in rehabilitation (Llewellyn
et. al., 2010).

3. COMMUNITY BASED REHABILITATION (CBR):

It is a strategy within general community development for the rehabilitation, equalization of opportunities
and social inclusion of all people with disabilities. The primary objective of CBR is the improvement of
the quality of life of people with disability / marginalized persons. Key principles relating to CBR are
equality, social justice, solidarity, integration and dignity.

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CBR is not an approach that only focuses on the physical or medical needs of a person or delivering care
to disabled people as passive recipients. It is not outreach from a centre. It is not determined by the needs
of an institution or groups of professionals, neither is it segregated and separate from services for other
people.

Conversely CBR involves partnerships with disabled people, both, adults and children, their families and
careers. It involves capacity building of disabled people and their families, in the context of their
community and culture. It is a holistic approach encompassing physical, social, employment, educational,
economic and other needs. It promotes the social inclusion of disabled people in existing mainstream
services. It is a system based in the community, using district and national level services.

Disability often requires life-long management, therefore, activities aimed at enabling people with
disability should be community based as much as possible. Sustainability is the ability of project or
program to continue to address needs as long as needs exist. The most basic rehabilitation activities can
be carried out in the person’s own community. A multi-sectoral / multidisciplinary concept of CBR is to
be adopted. This concept emphasizes working with and through the community. In response to this
conceptual change, CBR is now defined as a community development program that has seven different
components:

3.1. Creation of a positive attitude towards people with disabilities

3.2. Provision of rehabilitation services
3.3. Provision of education and training opportunities
3.4. Creation of micro and macro income-generation opportunities
3.5. Provision of long term care facilities
3.6. Prevention of causes of disabilities
3.7. Monitoring and Evaluation.

The core values of individual dignity, autonomy or self-determination, equality and the ethic of solidarity
are fundamentals of human rights law that concern disability. To achieve this there is an increased focus
on the participation and involvement of disabled people and their representatives.

Community based rehabilitation is fully consonant with the concept of Primary Health Care. This
approach promotes awareness, self reliance and responsibility for rehabilitation within the community. It

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builds on manpower resources in the community, including the disabled themselves, their families and
other community members. CBR encourages the use of simple methods and techniques that are
acceptable, affordable, effective and appropriate to the local setting.

CBR is implemented through the combined efforts of disabled people themselves, their families and
communities, and the appropriate health, education, vocational and social services. CBR program must be
flexible so that it can operate at the local level and within the context of local conditions.

In initial phase of CBR process it is important to identify and understand the current situation and map
services, then to identify with all those concerned what gaps exist and what is required. Only then
consideration by all relevant parties is given to what health service provision is most appropriate. This
needs to take account of feasibility, accessibility and acceptability issues. None of this can be done
without consideration of resource constraints, financial, facilities / equipment, education, transport, and
manpower, including level of skills and competency required to deliver what is necessary.

The CBR personnel may be CBR workers are gross root workers delivering services in a community.
They may be supervisors or medico social workers who organize and support gross root workers. They
also may be professionals such as surgeon, physiotherapist, vocational trainers, counselors to whom
referrals can be made from the community.

CBR workers are the key in the implementation of CBR. They are usually the main person in contact with
the family. They are able to act as local advocates on behalf of people with disabilities and their families
with the health services personnel. Provide liaison and continuity of care in the community on behalf of
professionals for example, the continued supervision of home based programs. Act as directors of
community initiatives to remove social and physical barriers that affect exclusion. Provide a positive role
model for service users if they themselves have a disability. Professionals involved at the third level of
service provision can be included, but are not limited to doctors, nurses, physical therapists, occupational
therapists, counselors, support staff, orthotists / prosthetists and technicians. The basic concept inherent in
the multi-sectoral approach to CBR is the decentralization of responsibility and resources, both human
and financial, to community level organizations. In this approach governmental and nongovernmental
institutional and outreach services must support community initiatives and organizations.

The useful initiatives for CBR can be:

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 Social counseling
 Training in mobility and daily living skills
 Providing or facilitating access to loans
 Community awareness raising
 Providing or facilitating vocational training or apprenticeships
 Facilitating information for local self-help groups, parents groups and
 Disabled People’s Organizations (DPOs)
 Facilitating contacts with different authorities
 Facilitating school enrolment (school fees and contacts with teachers)

Components of CBR program:

 Prevention of cause of disability

 Provision of care facilities.
 Creating a positive attitude towards people with disabilities.
 Provision of functional rehabilitation services.
 Empowerment, provision of education and training opportunities.
 Creation of micro & macro income generation opportunities.
 Management or monitoring and evaluation of CBR projects

4. Institution Based Rehabilitation:

Institutional rehabilitation provides excellent services to address the problems of individual disabled
person and is often available only for a small number at a very high cost. Moreover, the endeavor in an
institution, is often out of context to the felt needs of the disabled person, and thus falls short of their
expectations. In an institutional rehabilitation program, the community is not linked with the process.
Hence, when the disabled person returns home, it may become difficult for them to integrate into their
community.

Institutional services, including medical and vocational rehabilitation centres, residential homes, special
schools with therapy and nursing care, sheltered workshops and day centres, to name the most salient,
have formed the backbone of rehabilitation services in developed countries, supported to differing degrees
by financial and material benefits, counselling and other support services in the community. However, for

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disabled people living at home, and for their families and friends living or working with them, access to
support services may vary enormously. Many people, particularly those severely mentally handicapped,
remain in long term residential care despite mounting evidence of the inadequacies of many such
institutions (Thomas, 1982).

Rehabilitation services developed in this way are often unable to do more than provide a very basic care
service, with little effective psychological, social, educational or vocational rehabilitation, as they lack
experienced and skilled personnel, facilities, equipment and money to do so, and they can in any case
reach only a small proportion of the population in need. Governments face the same problems of scarce
resources, and, although they racially desegregate services and provide some economic support to
rehabilitation institutions in the private sector, they cannot afford to build or finance rehabilitation
institutions for all the disabled in need of rehabilitation or long term care.

Economic constraints aside, the very concept of institutions caring solely for disabled people contradicts
the aim of integration. The very nature of the service is one of segregation, and the real work of
integration can only seriously begin at the point where rehabilitation, in this context, ends. It is not the
acute medical phase of rehabilitation (which may entail hospitalisation), but long term therapy,
accommodation, education, vocational training and employment that are the most critical for the
successful integration of people with disabilities. In addition opportunities for social contacts and
relationships, recreation and self-fulfilment are needed. If we are concerned about quality and not merely
the quantity of life, then it is here ultimately that rehabilitation really succeeds or fails, and it is here that
the questions of long term institutional care or a community or home-based rehabilitation strategy become
crucial.

In developed countries long term institutional care is now widely seen in a very negative light, and
families who 'put away' their mentally handicapped child, for example, may feel very guilty about doing
so. Studies such as that by Miller and Gwynne (1974), Shearer (1981), and many others, highlight the
risks of institutionalisation, including the creation of dependency, boredom and under-achievement, low
self-esteem, stigmatisation and loneliness. These problems may be lessened by a 'humanising' of
institutions, making them more like a home in terms of scale, routine and regulation, and also by
increasing their openness to families and the community at large by making them less than 'total
institutions' in Goffman's sense (Goffman, 1961). But such changes, particularly when they involve a

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genuine shift of power to disabled residents themselves, tend to be resisted by both immediate care staff,
and the administrative hierarchy, despite the evident success of some such developments in both hospitals
and long term residential homes for disabled people (Thomas, 1982).

In many developing countries it is commonly believed that institutions can provide better services than
can home care, because they have specialist staff, specialised facilities and equipment, special education
or vocational training on the premises and so on, facilities that are scarce or non-existent in the rural
areas, and in most urban areas too. Institutional care may be sought also because it removes the burden of
responsibility and the stigma of disability from the family. Particularly among less educated, poor, rural
families, disability can be an intolerable economic burden to the family, and the cause of severe social
and family problems because of the widespread stigma attached to disability and suspicion as to its causes
(WHO, 1984).

In the long run, centralised institutional care is likely to fail as a rehabilitation strategy for independence
and integration of the disabled into their society precisely because it separates the disabled from the
family, community and normal home environment. By removing responsibility for the disabled person
from the family and the community, the development of understanding of the disabled person's needs and
of her/his capacity to contribute to society is inhibited. It does nothing to reduce cultural fears and beliefs
about disability, nor to create a climate of acceptance for the disabled person's return - quite the contrary,
the family learns to live without the disabled persons, and to take over any roles or tasks they might have
performed. Removal from the family also reduces the chances of the disabled people themselves learning
to cope with their normal, usually rural, environment, both in a cultural and a practical sense. Activities of
daily living and those related to productive work are very different in a poor rural setting compared with a
modern, urban institution. In short, long term institutional care is probably the worst possible strategy for
promoting integration of the disabled into their communities. It is also, of course, prohibitively expensive
as a rehabilitation strategy aiming to reach all the disabled in a developing country. For this reason also it
is inappropriate. Existing institutions generally suffer from a chronic shortage of funds, skilled personnel
and equipment, and are likely to have a poor staff-rehabilitee ratio and long waiting lists for admission.
These problems are exacerbated by the difficulty of discharging people when follow up services are poor.
The urban setting of most institutions also skews resources away from rural areas, thus contributing to
their comparative underdevelopment.

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5. Rehabilitation measures and outcomes:

Rehabilitation measures target body functions and structures, activities and participation, environmental
factors, and personal factors. They contribute to a person achieving and maintaining optimal functioning
in interaction with their environment, using the following broad outcomes:
 Prevention of the loss of function
 Slowing the rate of loss of function
 Improvement or restoration of function
 Compensation for lost function
 Maintenance of current function.

Rehabilitation outcomes are the benefits and changes in the functioning of an individual over time that are
attributable to a single measure or set of measures (Finch, et. al., 2002). Traditionally, rehabilitation
outcome measures have focused on the individual’s impairment level. More recently, outcomes
measurement has been extended to include individual activity and participation outcomes (Scherer, 2005;
Scherer, et. al., 2005). Measurements of activity and participation outcomes assess the individual’s
performance across a range of areas including communication, mobility, self-care, education, work and
employment, and quality of life. Activity and participation outcomes may also be measured for
programmes. Examples include the number of people who remain in or return to their home or
community, independent living rates, return-to-work rates, and hours spent in leisure and recreational
pursuits. Rehabilitation outcomes may also be measured through changes in resource use for example,
reducing the hours needed each week for support and assistance services (Turner Stokes, et. al., 2005).

6. Summary:

It would seem that some form of community based or community orientated rehabilitation is the only
feasible strategy to attempt to meet both the immediate physical needs of disabled people, and the long
term goal of community conscientisation about health care, prevention of impairments, rehabilitation of
the disabled and their full acceptance into the community. Centralised institutional care fails to educate
the community, and imposes further psychological stress and isolation on already stressed people, whilst
rehabilitating them to cope with an environment different from their own. In the wider context,
community based rehabilitation can be seen as part of the general aim of rural development, whereby
resources of cash, materials, services, jobs, and, crucially, human potential are promoted in the rural

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areas. For people with disabilities it offers the possibility of real integration, and not the segregated
rehabilitation of the institution. Different countries and districts need a strategy appropriate to their
particular constraints and demands, and one that can be developed with flexibility to meet their particular
needs in ways that are culturally acceptable and practically and economically feasible.

It is to be hoped that more developing countries will experiment with and expand community
rehabilitation services, and incorporate this type of strategy as the cornerstone of national policies on
rehabilitation. The potential benefits extend far beyond the immediate needs of disabled people, into the
enrichment and development of the general community itself, and can be identified as incorporating both
humanitarian and economic considerations.

In this electronic text, overview about models of rehabilitation is briefly described covering the whole
panorama from the definition of rehabilitation, through the various types of rehabilitation, and the
outcome of such rehabilitation. In the subsequent modules detailed information about management of
voluntary organisation in the field of disabilities is provided in order to develop better sight to the learner
on the management of NGO’s for promoting rights based inclusion among the persons with disabilities.

This electronic text is supported with electronic tutorial that consists of multimedia through use of
innovative techniques and this intends to give the learner a quick and easy understanding about the lesson
delivered through this module. Besides glossary of terms, web resources and bibliography relating to this
e-content is provided. Self simulation for assessment and evaluation is also provided to support the
effective utility of this content by the learner. This helps the learner to quickly evaluate the understanding
developed by the learner regarding the contents discussed in the module. The learner is encouraged to
expand on this for achieving comprehensive knowledge base on this content.

Bibliography

Thomas D (1982) The Experience of Handicap, Methuen, London

WHO (1984) "Rehabilitation For All", in World Health Magazine, May 1984, WHO, Geneva.

Miller EJ and Gwynne G V (1974) A Life Apart, Tavistock, London.

Shearer A (1981) Disability - Whose Handicap? Blackwell, Oxford.

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Goffman E (1961) Asylums, Penguin Books, Middlesex.

Swedish disability policy: services and care for people with functional impairments: habilitation,
rehabilitation, and technical aids [Article No. 2006–114–24]. Stockholm, Socialstyrelsen, The National
Board of Health and Welfare, 2006 ([Link]
[Link]/Lists/Artikelkatalog/Attachments/9548/2006-114-24_200611424.pdf, accessed 11 May
2010).

Llewellyn G et al. Development and psychometric properties of the Family Life Interview. Journal of
Applied Research in Intellectual Disabilities, 2010,23:52-62. doi:10.1111/j.1468-3148.2009.00545.x

Learning disabilities and young children: identification and intervention [Fact sheet]. New York, National
Joint Committee on Learning Disabilities, 2006
([Link]
Identification_and_Intervention?theme=print, accessed 2 May 2010).

Storbeck C, Pittman P. Early intervention in South Africa: moving beyond hearing screening.
International Journal of Audiology, 2008, 47:Suppl 1S36-S43. doi:10.1080/14992020802294040
PMID:18781512

Beswick AD et al. Complex interventions to improve physical function and maintain independent living
in elderly people: a systematic review and meta-analysis. Lancet, 2008,371:725-735. doi:10.1016/S0140-
6736(08)60342-6 PMID:18313501

Velema JP, Ebenso B, Fuzikawa PL. Evidence for the effectiveness of rehabilitation-in-the-community
programmes. Leprosy Review, 2008,79:65-82. PMID:18540238

Norris G et al. Addressing Aboriginal mental health issues on the Tiwi Islands. Australasian Psychiatry:
bulletin of Royal Australian and New Zealand College of Psychiatrists, 2007,15:310-314.
doi:10.1080/10398560701441687 PMID:17612884

Mola E, De Bonis JA, Giancane R. Integrating patient empowerment as an essential characteristic of the
discipline of general practice/family medicine. The European Journal of General Practice, 2008,14:89-94.
doi:10.1080/13814780802423463 PMID:18821139.

Finch E et al. Physical rehabilitation outcome measures: a guide to enhanced clinical decision-making,
2nd editon. Hamilton, Ontario, Canadian Physiotherapy Association, 2002.

Scherer MJ. Assessing the benefits of using assistive technologies and other supports for thinking,
remembering and learning. Disability and Rehabilitation, 2005,27:731-739.
doi:10.1080/09638280400014816 PMID:16096225

SWE/SWFD/MR/M23 by Dr. P. SALEEL KUMAR

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Scherer MJ et al. Predictors of assistive technology use: the importance of personal and psychosocial
factors. Disability and Rehabilitation, 2005,27:1321-1331. doi:10.1080/09638280500164800
PMID:16298935

Turner-Stokes L et al. Evidence-based guidelines for clinical management of traumatic brain injury:
British national guidelines. London, British Society of Rehabilitation Medicine Publications Unit, Royal
College of Physicians, 2005.

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