Issue 5.2 | August 2001 | Information in this issue may be out of date.
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Training the Trainers in Community-Based Rehabilitation

Queen’s University and the Pan-American Health Organization are collaborating on a project called Community-Based Rehabilitation, designed to aid survivors. The project assists victims with their physical, emotional and financial problems to help them reenter and remain active in their communities.

by John Paterson and Will Boyce, Central America Landmine Survivors Project

Introduction

The geography of a typical city creates difficult mobility for people with physical disabilities.

As reported in the Summer 2000 edition of the Journal of Mine Action, Queen’s University is working with the Pan-American Health Organization (PAHO) and the Mexican government to assist survivors of conflict and those affected by landmines, particularly disabled persons, in the countries of Nicaragua, El Salvador and Honduras. The government of Canada, through the Canadian International Development Agency (CIDA), is funding this four-year (1999–2003) project (known as the Tripartite Project) through the humanitarian relief section of its Landmine Initiative.

People injured by landmines display the consequences at several levels: as impairments, disabilities and handicaps. The obvious physical impairments include amputation, spinal cord injury, blindness and burns, but mental impairments, such as Post Traumatic Stress Syndrome, are equally problematic and often as insidious. Landmine-caused disabilities, on the other hand, are the loss of abilities that are normal for a person of a particular age and developmental stage. These disabilities include problems with self-care, mobility or the performance of regular tasks at work. Landmine-caused handicaps are really the result of society’s inability to accommodate people with disabilities. These handicaps include a lack of recognition for the earning potential of disabled persons, barriers that limit physical accessibility and attitudes that promote social stigma and isolation.

Typical exposure experience by people with disabilities.

For over a decade, Queen’s University has been actively promoting and researching Community Based Rehabilitation (CBR) in developing countries and post-conflict regions of the world. As the Canadian technical contributors to the Tripartite Project, the Central America Land Mine Survivors (CALMS) project at Queen’s University addresses the physical, social and economic problems of landmine survivors and disabled persons through the following three components:

• Integrating Community-Based Rehabilitation into primary health care programs
• Improving access to the training of personnel who provide prosthetic and orthotic devices
• Promoting the economic re-integration of survivors into their communities.

In order to respond to the individual needs of each country, all project activities are determined through an annual planning meeting held in each country, at which people from government ministries (health, education, labor and social security), the NGO community, and people with disabilities are represented. This article focuses on the training aspect of the CBR component, the central theme of the project and the only component in which all three countries are actively involved.

An ex-guerrilla participates in CBR training.

Community-Based Rehabilitation (CBR)

The United Nations has determined that one of the most effective means of improving the lives of people with disabilities is by creating and supporting CBR. CBR is a community-based initiative in which all facets of a person’s life, such as health, physical and emotional needs, educational programs, employment needs, and recreational and social lives are considered.

The term "CBR" is used widely throughout the world yet understood by very few. The concept of CBR includes: a thorough knowledge of how communities operate, an understanding of the range of human needs, an acknowledgement of the impact of a disability on the family and the individual, a belief in an individual’s right to determine his/her own future without society-induced barriers, a basic understanding of impairments and treatments, and the skills to transfer this knowledge to others.

CBR Activities in the First Year of the Project

Parade for official "Day of Disabled," sponsored by the government.

In the first year of the project (1999–2000), over 300 people in landmine-affected regions of El Salvador, Honduras and Nicaragua attended 15 workshops. These workshops focused on three themes: Awareness of Disability, Planning of CBR and Clinical Skills for Under-serviced Communities. The participants included people from the communities at large, representatives

of ex-combatant groups, landmine survivors, people with disabilities, local NGOs and personnel from government ministries of health, education and labor. The facilitators were Spanish-speaking Canadian rehabilitation professionals and representatives from the host country.

These initial workshops met with some success. An El Salvadorian physical therapist found that she gained much more job satisfaction once she viewed her work from a CBR perspective. She no longer views her work as a technician who ameliorates muscle and joint problems, but now she deals with her patients as individuals who have more complex social needs. A doctor in Nicaragua found that using the community as a resource helps him find assistive devices for patients with mobility problems. Although the impact of these initial workshops was clear, a more detailed and sustainable model is needed.

The Training of Trainers (TOT) Model

A participant, who is also a landmine victim, "teaches the trainers." 

Rationale

Upon completing the first year of the project, it became apparent that there were insufficient resources to continue presenting CBR workshops throughout the many landmine-affected communities in all three countries. A new model was required, one that was sustainable and feasible. Therefore, the "Training of Trainers" (TOT) model was adopted in the second year of the project. The TOT model allows project resources to be better used in developing the skills and knowledge of appropriate people within each country. In this way, a cadre of personnel, with a thorough knowledge of CBR and the skills to teach it to others, will remain in the region upon completing the project in 2003. Also, each country, community and village will have the opportunity to adapt CBR to the needs of their communities, rather than simply adopting a Canadian, Asian or Mexican model of CBR. Therefore, CBR does not become another imposed strategy dictated from the North or from centralized government ministries in the capital. The results are beneficial to all: the work loads of the limited number of ministry people are diminished; the need for highly trained medical and rehabilitation professionals in remote regions is decreased; and the community gains recognition and a sense of accomplishment from taking responsibility for CBR.

Goal

The program’s goal is to increase the number of people who are trained to teach other people about CBR.

Objectives

The TOT objectives are:

1. To teach the knowledge, skills and attitudes necessary to train others about CBR

2. To present the theory and teaching skills behind the training of adults in community environments

Strategies and Resources

In keeping with the current best practices of adult education, all workshop participants are expected to take an active role in the learning process and ultimately assume responsibility for their own education. Trainers (from Canada, Mexico and the host country) act as facilitators, guiding the participants through a carefully planned curriculum of activities designed to build on their own skills and knowledge. The TOT training is completed in three separate workshops (levels 1, 2 and 3), each held a few months apart. An integral part of the training directs the participants to plan, design, present and evaluate CBR workshops in their home communities, involving the community and people with disabilities. These participant-lead workshops are held in the periods between the TOT workshops, so that participants may plan and review their work with their fellow TOT colleagues.

The prime resource for the TOT workshops is each participant, who brings his/her own training, expertise, skills and attitudes to the workshops. Participants are expected to use the resources in their own communities, such as landmine survivors, people with disabilities, their organizations and other related community groups. The facilitators act as resource people to encourage each participant to maximize his/her own capabilities. Queen’s University has prepared detailed manuals for each level of the training.

Topics

There are two basic themes within the training: Education and CBR. Table 1 (below) details the topics covered and the level at which each topic is discussed.

Education Levels CBR Levels
Goals and objectives 1,2 Disability principles 1
Educational principles 1 Models of disability 1
Adult education 1,2 Determinants of disability 1,2
Learning styles 1 Prevention of disability 1,2,3
The teacher 1 Models of CBR 1
Teaching strategies 1,2,3 Dimensions of CBR 2
Developing a lesson 1 Attitudes to disability 2
Determining learning needs 1,2 CIDDM 2
Use of resources 1,2,3 Evaluation of community needs 2
Motivational techniques 2 CBR: the three elephants 2
Group Strategies 2 Planning CBR 2
Curriculum development 2,3 Rehabilitation in the community 3
Evaluation 2 Rehabilitation and PHC 3
Alternative methods: theater, etc. 2,3 RBC in post-conflict regions 2,3
Evaluation of workshops 1,2,3 Development of resources 3
Problem solving 2 Referral to specialists 3
Learning in the community 2,3 Strengthening CBR in the community 1,2,3
Multi-dicsiplinary aspects 3 Mental health 3
Evaluation 2,3 Cultural awareness 3
Sustainability 3 Sustainability / Politics 3
Working with people with disabilities and families 3 Table1: Topics covered and levels at which each is discussed.
New learning technologies 3

Discussion

At the time this article was written, the TOT process was still in progress, and a full evaluation of its impact remained to be completed. Early impressions and feedback from the participants have yielded some interesting findings. Participants have been consistently encouraged and motivated by the interactive approach of the workshops. It is a style of teaching to which most people in Central America are not accustomed, and yet they readily accommodate the approach with enthusiasm and typical cultural exuberance. Participants are less comfortable with the sense of openness and self-criticism that is encouraged during the workshops. Perhaps this is to be expected in a society recently torn apart through internecine conflicts and one in which conformity is expected. Nonetheless, as future trainers of trainers, they are encouraged to develop skills of self-evaluation and critical thinking.

Since the beginning of the CALMS project, dealing with the predominantly medical focus of the activities has been a challenge. The concept of CBR has always been to promote the rehabilitation of disabled people in an integrated and holistic manner, in which the individual is viewed as a person, not just a patient, mother, client, worker or student. Because the CALMS project is administered in the countries by the various ministries of health, it is difficult for the integrated approach to CBR to take hold. The participants and facilitators are predominantly from a health background, which promotes the image of disability as a purely medical problem, contrary to the predominant view of disabled activists who view disability as a social issue. On the other hand, the health/medical systems are the best-developed services within each country and are often linked to other ministries (education, labor, etc.), therefore allowing the project easy access to people in the remote regions most affected by landmines.

Another early finding is that the participants arriving at the workshops are stressed and tired, and they tend to belong to an already very busy and active segment of their communities. Participating in the TOT workshops places an additional demand upon their already limited time and resources. This raises the question of the long-term sustainability of the TOT approach: how can a country with limited capacity find the resources to support and promote CBR activities and CBR trainers? With the exception of Honduras’ Functional Therapy graduates, none of the TOT participants will graduate from the TOT workshops with the exclusive responsibility of being a CBR trainer of trainers. These issues are currently being discussed with the national ministries of health and education.

Trainees performing a disability simulation in the community.

There are several other issues and questions to be resolved over the next few years:

• How will TOT graduates be certified?
• How will this training become recognized with the country?
• Is there an existing administrative structure in place within the country and the community enabling these newly trained people to function?
• Are graduates expected to take on CBR training responsibility as part of their other jobs? How do they cope? How are they supported?
• How is the involvement of people with disabilities assured?
• How do we evaluate the impact of these workshops?
• How do we support the need to create Spanish-language resources in CBR?

Future Considerations

With two years remaining in the CALMS project, using the available time and resources to the maximum benefit of the people and in particular, the landmine survivors of Central America, becomes essential. The following options are being considered and are under negotiation with the project partners:

• To train as many people as possible through the continuation of the TOT courses throughout the region
• To conduct specialist courses in areas such as adaptive devices for remote regions, dealing with children, school integration and mental health issues
• To set up a regional training center for CBR
• To integrate the CBR component with the economic and prosthetic components of the project
• To train higher-level personnel
• To integrate CBR within present systems in each country.

Conclusion

The people of Central America have not only a rich and detailed history but one fraught with internal conflict and external political and economic subjugation as well. Although trainers are familiar with other models of CBR used in Asia or Africa, they are anxious to develop working models of CBR for Central Americans. The TOT approach promotes this process by encouraging participants to become active in developing and implementing CBR in their own communities. The fundamental plan is for these newly trained individuals to become a core of innovative and talented members of their societies, people who will oversee and champion a Central American CBR model that helps people with disabilities and landmine victims become full members of society.

*All photos and table courtesy of Central America Landmine Survivors Project.

Contact Information

Central America Landmine Survivors Project
Social Program Evaluation Group
McArthur Hall
West Campus, Queen’s University
Kingston, Ontario, Canada
K7L 3N6

Tel:( 613) 533-6498
Fax: (613) 533-6761
E-mail: calms@post.queensu.ca
Website: http://calms.queensu.ca