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Rehabilitation models in India

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In the previous post we learned about Networking Lobbying and Advocacy in the field of Social Work The basic understanding of the various rehabilitation models used in India is introduced in this post. The reader will learn the post at the conclusion of this article:

  • Learn enough about the concept and meaning of rehabilitation.
  • Recognize the many types of rehabilitation models and
  • Discover the results of rehabilitation.

Contents

  1. Introduction
  2. Rehabilitation
  3. Community based rehabilitation (cbr)
  4. Institution Based Rehabilitation
  5. Rehabilitation measures and outcomes

Introduction

According to the WHO, a billion individuals, or 15% of the population, have a severe disability that limits their family, community, and political engagement. 80% of these billion people reside in low- and middle-income countries, where health and social services are restricted. Disabled people are hit harder. Disability is a public health problem, especially in India. The situation will worsen when non-communicable diseases become more common and life expectancy rises. Rehabilitation procedures should be targeted according to the disabled's needs with community participation. In India, most disabled people live in rural areas, where accessibility, availability, and cost-effectiveness are key challenges. Villagers and small-town residents lack access to hospitals and schools. They learned from their parents and older relatives. Families and neighbours helped those with physical or mental disabilities. A blind person may be led around by a child. Grandmother taught a disabled youngster to talk at home. Family members created a wooden crutch for a lame individual. One neighbour learned to sign with deaf folks. Disabled people found work in the fields or at home. Mentally disabled people got easy-to-learn jobs. People with disabilities who couldn't work turned to fortunetelling, massage, or music. When disabled persons lacked family and income, they begged for food and shelter from villagers and townspeople. Disability was difficult even with everyone's aid. They couldn't do some things. Girls and women may obtain less food than men. They had trouble finding a spouse. Even if others assisted, they may be harsh. They reported a strange'spirit' made them incapacitated. They made the best of it. They learned how to navigate their hamlet or small town and interact with others. Even if it wasn't great, they had a spot there. People with disabilities sometimes consulted a religious leader or a healer. Healer or religious leader may reside nearby or far away. Their family may have debated whether to take them to a healer or religious leader. Prehistoric societies had rehabilitative models. These rehabilitation approaches helped people adjust to and live with disability. Social workers who create change among persons must be knowledgeable about rehabilitation approaches available to people with disabilities for inclusion and mainstreaming.

Rehabilitation:

The goal of rehabilitation for people with disabilities is to help them achieve and maintain their highest levels of physical, sensory, intellectual, psychological, and social functioning. People with disabilities receive the resources they need via rehabilitation to achieve independence and self-determination. Rehabilitation is defined by the United Nations as "any actions aimed at lessening the impact of a person's handicap and enabling them to attain independence, social integration, a higher quality of life, and self actualization." Rehabilitation should be provided as a process in which all participants are actively and intimately involved rather than as a product to be supplied.

Rehab is "a set of measures that assist individuals who experience, or are expected to experience, disability to attain and sustain optimal functioning in interaction with their environments," according to the World Report on Disability. There is a difference between rehabilitation, which helps people who have lost function to achieve maximum functioning, and habilitation, which attempts to enable those who develop disabilities congenitally or early in life to develop maximal functioning (Sweedish Disability Policy, 2010). Both forms of intervention are referred to as "rehabilitation." Despite the broad definition of rehabilitation, not all matters relating to disability can be covered by the term. Rehabilitation aims to enhance a person's capacity for self-care through changes in eating and drinking. Making adjustments to the patient's environment, such installing a toilet railing, is another aspect of rehabilitation.

Rehabilitative services lessen the effects of a variety of medical illnesses. Acute or initial rehabilitation, which is required from the moment a health condition is recognised through the post-acute and maintenance phases, can entail one or more interventions performed by an individual or a team of rehabilitation specialists over a set period of time.

The process of rehabilitation entails identifying a person's requirements and difficulties, connecting those issues to important aspects of that person and their surroundings, formulating rehabilitation goals, organising and carrying out the necessary interventions, and evaluating the results. The development of knowledge and skills for self-help, care, management, and decision-making in people with disabilities depends on education. When partners in rehabilitation, people with disabilities and their families enjoy greater health and functioning (Llewellyn et. al., 2010).

Community based rehabilitation (cbr):

The rehabilitation, equalisation of possibilities, and social inclusion of all people with disabilities are goals of this comprehensive community development concept. The main goal of CBR is to raise the standard of living for underprivileged groups like disabled people. Equality, social justice, solidarity, integration, and dignity are important CBR principles.

CBR does not treat individuals with disabilities as passive recipients of care or just concentrate on their physical or medical needs. It is not a center's outreach. It is not based on the requirements of an organisation or a group of experts, and it is not distinct from services for other people.

Contrarily, CBR incorporates collaborations with families, employers, and disabled persons of all ages, including adults and children. In the context of their society and culture, it involves enhancing the capacity of persons with disabilities and their family. It is a wholistic strategy that takes into account needs for the body, the community, employment, education, and other factors. It encourages the social integration of people with disabilities into current mainstream programmes. It is a community-based structure that makes use of district- and federal-level services.

Disability frequently necessitates lifelong management; as a result, community-based activities focused at helping individuals with disabilities should be prioritised. The capacity of a project or programme to continue meeting demands as long as those needs persist is known as sustainability. The most fundamental rehabilitation procedures can be carried out in the patient's neighbourhood. CBR should be viewed from a multi-sectoral, multidisciplinary perspective. This idea places a focus on collaborating with and through the community. This conceptual shift has led to the definition of CBR as a community development programme with seven distinct components: 
  1. Creation of a positive attitude towards people with disabilities 
  2. Provision of rehabilitation services 
  3. Provision of education and training opportunities 
  4. Creation of micro and macro income-generation opportunities 
  5. Provision of long term care facilities 
  6. Prevention of causes of disabilities 
  7. Monitoring and Evaluation
Disability-related human rights law is based on the fundamental principles of individual dignity, autonomy or self-determination, equality, and the ethic of solidarity. The engagement and involvement of individuals with disabilities and their representatives is being given more attention in order to accomplish this. The idea of primary health care is completely consistent with community-based rehabilitation. This strategy encourages community members to be informed, self-sufficient, and responsible for rehabilitation. It draws on the community's human resources, including the disabled individuals themselves, their families, and other community members. CBR promotes the adoption of straightforward strategies and tactics that are accepted, inexpensive, efficient, and suitable for the local environment.

The implementation of CBR involves the collaborative efforts of disabled persons, their families, and communities, as well as the necessary social, health, and educational programmes. The CBR programme needs to be adaptable so that it can function locally and in light of regional circumstances. In the early stages of the CBR process, it's critical to recognise and comprehend the current condition, map the services, and then determine with everyone involved what gaps there are and what is needed. The best way to provide health services is only then taken into account by all pertinent stakeholders. Issues of acceptability, accessibility, and feasibility must be considered. None of this is possible without taking into account available resources, including money, facilities and equipment, education, transportation, and labour, as well as the level of skills and competency required to provide what is required.

The CBR people could be community service providers who are on the ground level. Gross root workers are organised and supported by supervisors or medicosocial workers. They could also be specialists, such as doctors, physiotherapists, vocational trainers, and counsellors, to whom the community can make recommendations.

The key to CBR implementation is the CBR workforce. They frequently have the most communication with the family. They can represent local health services staff members on behalf of people with disabilities and their families. On behalf of professionals, provide liaison and continuity of care in the community, such as ongoing oversight of home-based programmes. Assume leadership roles in community projects to eliminate the structural and social barriers that cause exclusion. If a service user has a disability themselves, act as a role model for them. Doctors, nurses, physical therapists, occupational therapists, counsellors, support workers, orthotists/prosthetists, and technicians are just a few of the specialists who may be involved in the third level of service delivery. The decentralisation of responsibility and resources, both human and financial, to community level groups is the fundamental tenet of the multi-sectoral approach to CBR. Governmental and nongovernmental institutional and outreach agencies must support neighbourhood projects and groups in this strategy.

The useful initiatives for CBR can be:
  • 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 

Institution Based Rehabilitation:

Excellent services for addressing the difficulties of a specific impaired person are provided through institutional rehabilitation, which is frequently only accessible to a small number of people at a very expensive cost. Additionally, the efforts made in institutions are frequently out of step with the demands that the disabled person perceives, falling short of their expectations. The community is not involved in the rehabilitation process in an institutional programme. As a result, it could be challenging for the impaired person to assimilate into their community once they return home.

The foundation of rehabilitation services in developed countries has been institutional services, such as medical and vocational rehabilitation centres, residential homes, special schools with therapy and nursing care, sheltered workshops, and day centres, to name a few of the most notable. To varying degrees, these institutional services have been supported by financial and material benefits, counselling, and other support services in the community. Access to support services, however, can vary greatly for disabled persons who live at home, as well as for their families and friends who live or work with them. Despite accumulating evidence of the shortcomings of many such institutions, many people—particularly those with serious mental disabilities—remain in long-term residential care (Thomas, 1982).

Because they lack the trained professionals, facilities, resources, and funding necessary to provide effective psychological, social, educational, and vocational rehabilitation, as well as the ability to reach only a small portion of the population in need, rehabilitation services developed in this way are frequently limited to providing very basic care. Governments face the same issues with limited resources, and while they racially desegregate services and offer some financial support to rehabilitation institutions in the private sector, they are unable to afford to build or finance institutions for all the disabled who require long-term care or rehabilitation.

Putting aside financial limitations, the idea of institutions catering only to the needs of disabled persons goes against the spirit of integration. The service is segregated by its very nature, and the actual task of integration can only start in earnest when rehabilitation in this environment comes to an end. The most important factors for the successful integration of people with disabilities are not the acute medical phase of rehabilitation (which may involve hospitalisation), but rather long-term therapy, accommodations, education, vocational training, and employment. Opportunities for recreation, self-fulfillment, and social interaction are also necessary. The dilemma of whether to pursue a long-term institutional care plan or a community- or home-based rehabilitation strategy becomes critical if we are concerned with life quality rather than just life quantity. This is where rehabilitation ultimately succeeds or fails. Long-term institutional care is now largely viewed negatively in industrialised countries, and families who "put away" their mentally disabled kid, for example, would feel quite bad about doing so. The hazards of institutionalisation are highlighted in studies by Miller and Gwynne (1974), Shearer (1981), and many others. These concerns include the development of reliance, boredom and underachievement, low self-esteem, stigmatisation, and loneliness. In addition to improving their openness to families and the society at large by reducing their status as "total institutions" in Goffman's definition, institutions may be "humanised," becoming more like a home in terms of scale, routine, and regulation, in order to decrease these issues (Goffman, 1961). However, despite the apparent success of some such developments in both hospitals and long-term residential homes for disabled people, such changes, particularly when they involve a genuine shift in power to disabled residents themselves, tend to be resisted by both immediate care staff and the administrative hierarchy (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).

Because it isolates the disabled from their families, communities, and regular homes, centralised institutional care is likely to fall short in the long run as a rehabilitation method for independence and societal integration. The growth of knowledge of the disabled person's needs and of her or his capacity to contribute to society is hampered by transferring responsibility for the impaired person from the family and the community. The family instead learns to live without the impaired people and to take on whatever roles or tasks they may have undertaken. This has nothing to do with reducing cultural anxieties and ideas about disability or creating a climate of acceptance for the disabled person's return. The likelihood that disabled persons will learn to adapt to their typical, typically rural, surroundings is likewise decreased when they are removed from the family, both culturally and practically. In contrast to a contemporary, urban institution, daily activities and those associated with productive work are considerably different in an impoverished rural context. In summary, long-term institutional care is likely the poorest approach to fostering the integration of the disabled into society. Of course, it is also prohibitively expensive as a rehabilitation technique intended to assist all disabled people in a developing nation. It is improper for this reason as well. Existing institutions typically have a chronic lack of resources, qualified staff, and equipment. They are also likely to have extensive wait lists for admission and a subpar staff-rehabilitee ratio. When follow-up services are subpar, it is difficult to discharge patients, which exacerbates these issues. Most institutions' urban settings also tend to divert resources away from rural areas, which contributes to their relative underdevelopment.

Rehabilitation measures and outcomes:

Rehabilitation strategies focus on bodily structures and functions, participation in activities, contextual conditions, and individual factors. They use the following general outcomes to help a person achieve and sustain optimal performance in connection with their environment:
  • 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 advantages and alterations in a person's functioning over time that can be attributed to a single factor or collection of factors (Finch, et. al., 2002). The degree of an individual's impairment has always been the main focus of rehabilitation outcome measurements. More recently, individual activity and participation outcomes have been added to outcomes measurement (Scherer, 2005; Scherer, et. al., 2005). The performance of the person is evaluated in terms of communication, mobility, self-care, education, work and employment, and quality of life in measurements of activity and participation outcomes. Program results for participation and activity can also be measured. People who stay in or return to their home or community, independent living rates, return-to-work rates, and the amount of time spent engaging in leisure and recreational activities are a few examples. Changes in resource usage, such as a reduction in the number of hours needed each week for support and assistance services, can also be used to gauge the success of rehabilitation programmes (Turner Stokes, et. al., 2005).

Summary

Some form of community-based or community-oriented rehabilitation seems to be the only feasible strategy 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 full community acceptance. Centralized institutional care fails to educate the community and adds psychological stress and seclusion to already stressed people while rehabilitating them for a different environment. Community-based rehabilitation is part of rural development, which promotes cash, materials, services, jobs, and human potential. It provides disabled people actual integration, not isolated rehabilitation. Different countries and districts need a strategy that meets their objectives in a culturally acceptable, practically and economically feasible way. More developing countries should experiment with and increase community rehabilitation programmes as part of national rehabilitation policies. The potential benefits reach well beyond the immediate needs of disabled persons, enriching and developing the entire community. They include both humanitarian and economic factors.
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