Community Based Rehabilitation(CBR) Matrix

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Original Editor - Redisha Jakibanjar Top Contributors - Redisha Jakibanjar, Kim Jackson and Naomi O'Reilly

What is CBR matrix ?

CBR matrix is a framework established in 2004 to create a uniformity in CBR programmes. CBR matrix highlights the different sectors and elements of community to create a CBR strategy.

CBR matrix has five key components which is further divided into 5 elements. The CBR personnel can pick and choose any element or component from the matrix which planning the programme. The matrix should not be viewed as a sequential.

Components of CBR

The five components of CBR matrix are: health, education, livelihood, social and empowerment. The following table shows the elements of the matrix along with the components:

Health	Education	Livelihood	Social	Empowermeent
Promotion	Early childhood	Skills development	Personnel assistance	Advocacy and communication
Prevention	Primary	Self-employment	Relationships, marriage and family	Community mobilization
Medical care	Secondary and higher	Wage employment	Culture and arts	Political participation
Rehabilitation	Non- formal	Financial support	Recreation, leisure and sports	Self-help groups
Assistive devices	Lifelong learning	Social protection	Justice	Disabled people's organization

Health

Health is one of the most important component of CBR matrix.The main aim of CBR is to help People with disabilities (PWDs) achieve their highest attainable standard of health by addressing the five elements of the health(promotion, prevention, medical care, rehabilitation and assistive devices). CBR personnel also has to work with family members along with the individual to help them to get proper access to health services and ensure that all the aspects of the health are well addressed.

The desirable outcomes for the health are:

• PWDs and their family members are active participant for achieving sound health and have increased knowledge about the health and health care system.
• Every health personnel is aware about the right of PWDs toward health and there is no any discrimination based on disability, gender and many other factors.
• Both PWDs and their family members have close and easy access to health care services in their community in reasonable price.
• Health and rehabilitation interventions enable PWDs to become active participants in family and community life.
• There is improved collaboration across all development sectors, including education, livelihood and social sectors, to achieve good health for PWDs.

There are various determinants of health and one should also be aware about the health care provision of the their nation. Besides the disability they are having, PWDs have different barriers to the health-care services. Few of them are:

• Lack of proper policies and legislation, difficulty implementing the policies and discrimination while providing the service.
• Limited income of family and economic barriers.
• Lack of access to transportation and buildings due to geographical and physical barriers.
• Difficulty with communication among health professionals and access to information.
• Poor attitudes of health workers about PWDs and lack of knowledge, understanding and skills to manage health issues for PWDs.
• Lack of knowledge among PWDs about their rights and health issues and available health services.

The five elements of the health are described below.

Health promotion

Health promotion of the matrix focuses on the importance of health promotion for PWDs. It guides the CBR programmes to focus on facilitating the access to health promotion activities and implementing basic activities wherever necessary. Health promotion changes the wide range of determinants of health and involves many sectors and not just the health sectors.

The goal of health promotion is to recognize the health potential of PWDs and their families and empower them to enhance/maintain the existing levels of health.

Some of the desirable outcomes of health promotional activities are:

• Health promotional information provided to PWDs, their family members and members of the general community are same.
• Health promotion materials and programmes incorporate the special needs of PWDs.
• PWDs and their families have proper knowledge, skills and support to help them to achieve good level of health.
• People related to health care system have improved awareness about the general and specific health needs of PWDs and respond to the issues through relevant health promotional activities.
• Supportive environment is created by the community for PWDs to get enrolled in the activities which enhance their health.
• CBR programmes value good health and undertake health-promoting activities in the workplace for their staff.

There are various areas for action which can be used to help develop and implement health promotional strategies. The areas of health promotional activities are listed below:

1. Build healthy public policy
2. Create supportive environments
3. Strengthen community actions
4. Develop personnel skills
5. Reorient health services

Health prevention

There are three level of health prevention: Primary, secondary and tertiary.

Primary health prevention

Primary health prevention focuses primarily on prevention. It is directed at avoidance and using interventions like immunization, nutrition, changing behaviors, providing safe water supplies, sanitation and good living that prevent health conditions form occurring.

Secondary health prevention

Secondary health prevention focuses on early detection and early treatment of health conditions. Some of the examples are: early detection of breast cancer using mammograms, eye examinations, multidrug treatment of leprosy to prevent disease progression and appropriate handling of fractured bone to promote proper healing and prevention of deformity.

Tertiary health prevention

Tertiary health prevention focuses on limiting and reversing the impact of already existing health conditions and impairments. It includes rehabilitation services and interventions that aim to prevent activity limitations.

The main goal of health prevention is to prevent PWDs from developing health conditions related or unrelated to their impairments that affect their quality of life.

The desired outcome of CBR programme are:

• PWDs and their families have proper information and services aimed at health prevention.
• PWDs and their families adopt the healthy behavior and lifestyle to reduce the risk of developing health problems.
• PWDs are included and participate in primary prevention activities, e.g. immunization programmes, to reduce their risk of developing additional health conditions or impairments.
• All community members participate in primary prevention activities, e.g. immunization programmes, to reduce their risk of developing health conditions or impairments which can lead to disability.
• CBR programmes collaborate with the health and other sectors, e.g. education, to address health issues and provide support and assistance for prevention activities.

Medical care

The goal of this element is to provide proper access to medical care both general and specialized based on their individual needs. The desired outcome of the CBR program are:

• CBR personnel have adequate knowledge about medical care services and referral for general or specialized medical care.
• PWDs and their families have access to services(screening and diagnostic) that focuses on early identification of health conditions and impairments.
• Establishment of inclusive medical care service and have improved access for PWDs.
• PWDs have access to surgical care for impairment correction and minimization.
• PWDs and their families develop self-management skills whereby they are able to ask questions, discuss treatment options, make informed decisions about medical care and manage their health conditions.
• Medical care personnel have increased awareness regarding the medical needs of PWDs, respect their rights and dignity and provide quality services.

There are three types of medical care: primary, secondary and tertiary.

Primary medical care

Primary level of care is the basic health care provided at the community level and is usually provided through health centers or clinics. Primary medical care includes treatments for acute conditions (e.g. infections) and routine management of chronic conditions(e.g. leprosy, epilepsy, tuberculosis, diabetes).

Secondary level of medical care

This type of care is provided by large clinics or hospitals which are usually present at the district level. Primary health care provides an important link to secondary care through referral mechanisms.

Tertiary level of medical care

This is highly specialized medical care which is provided by specialized medical professionals in association with nurses and paramedical staff and involves the use of specialized technology. These services are provided by large hospitals in major cities at the national or regional level. Medical care provided at the tertiary level might include brain surgery, cancer care or orthopaedic surgery.

Rehabilitation

The goal of CBR is to provide access to PWDs to rehabilitation services for uplifting their overall well-being, inclusion and participation.

The desirable outcome of CBR programme are:

• PWDs receive individualized assessments and are involved in the decision making for interventions provided in rehabilitation.
• PWDs and their family members are aware about the role and purpose of rehabilitation and receive accurate information about the services available within the health sector.
• PWDs are referred to specialized rehabilitation services and are provided with follow-up to ensure that these services are received and meet their needs.
• Basic rehabilitation services are available at the community level.
• All the required materials are available for CBR personnel, PWDs and families to support rehabilitation activities.
• Appropriate training, education and support are received to enable them to undertake rehabilitation activities.

Assistive devices

The main goal of CBR program is to provide access to PWDs for appropriate assistive devices that are of good quality and enable them to participate in social and personnel life. The desirable outcome of the CBR programme are:

• CBR personnel have proper knowledge about the types of assistive devices available, functionality and suitability according to the disability and referral mechanisms for specialized devices.

• PWDs and their families are aware about the types and function of the assistive devices and make informed decisions to access and use them.
• PWDs and their families are provided with training, education and follow-up to make sure that they use and care for their assistive devices appropriately.
• Local people, including PWDs and their families, are able to fabricate basic assistive devices and undertake simple repairs and maintenance.
• Barriers preventing access to assistive devices, such as inadequate information, financial constraints and centralized service provision, are reduced.
• Environmental factors are addressed to enable individuals to use their assistive devices in all locations where they are needed.

Education

Education starts from the birth and is broad than the schooling. Every human have right to education and PWDs should not be excluded from this. The main goal of CBR program is to provide PWDs access to education and lifelong learning, leading to fulfilment of potential, a sense of dignity and self-worth, and effective participation in society. The desirable outcome of the CBR program are:

• All PWDs have access to learn and all the needed resources are available.
• Inclusive education system is implemented in local schools so that children with disability can also play alongside their friends.
• Local schools have process access to trained teachers, supportive environment, good links with families and community and resources to maintain proper hygiene and welcoming environment.
• PWDs are involved in education as a role models, decision makers and contributors.
• Home environments are favorable and encouraging for learning.
• Communities are aware that PWDs have right to learn and provide support and encouragement.
• There is good collaboration between the health, education, social and other sectors.
• There is systematic advocacy at all levels to make national policies comprehensive to facilitate inclusive education

The five elements of education are described below:

Early childhood care and education

Early childhood is the period from birth to eight years and early childhood care and education is the main seed for the inclusive society as children with and without disability get to play and learn together. The main goal of CBR program is that all children with disabilities have the best possible start in life and are supported throughout their development in inclusive learning environments.

The desired outcome of the CBR program are:

• All children have an increased chance of survival and good health.
• All the children are developed to their maximum potential in physical, social, language and cognitive skills.
• Inclusive and welcoming environment for all children to access formal and non-formal early childhood education.
• Children with disabilities and the people who assist them are part of the family and community and have appropriate support.
• Children learn to play together, accept the differences between them and help each other.
• The impact of impairments is reduced and compensated for.
• Children with disabilities make a smooth transition to primary schooling together with their peers.

Primary education

Primary education usually begins from age of six or seven years old and continues into the early teens. Achieving universal primary education is the second of the Millennium Development Goals. So, the goal of CBR program is to create a welcoming, inclusive primary education system in local schools within the community.

The desirable outcome of the CBR program are:

• The whole community is working to develop inclusive primary education.
• Families create supportive and positive environment for inclusive primary education.
• Every children with disability complete a quality primary education.
• All the assistive devices, interventions and other necessary assistance are provided so that children with disability can participate in inclusive education.
• Proper assessment and identification of issues related to access within school environment is done and those are addressed.
• Teachers who educate children with disabilities are confident and are made to feel supported.
• Every activity should be child-focused and inclusive like: Curricula, examination and assessment systems, teaching approaches and extracurricular activities (e.g. sports, music, clubs).
• Appropriate Local and specialist resources for education are provided and they are fully and appropriately utilized.
• Disabled children from poor families attend primary school.
• To ensure national policies promote inclusive primary education, needed partnerships are created with stakeholders and proper advocacy at all level is also done.

Secondary and higher education

The main role of CBR program is to facilitate the inclusive education, increase participation of disabled children and work with the local authorities and school to create accessible environment and flexible curriculum.The desirable outcome of the CBR program are:

• Increased enrolment, retention and completion in secondary and higher education by students with disabilities.
• Government grants, scholarships and other sources of funding are provided to students with disabilities and parents and communities have knowledge and skills to access these kind of support.
• Communities support lobbying groups and campaigns for equal access to education.
• Families and communities encourage their children, including children with disabilities, to pursue secondary and higher education.
• Secondary and higher education programmes are accessible and inclusive in terms of environment, teaching methods, curricula, extracurricular activities (e.g. sports, recreation, music) and assessment and examination systems.
• Secondary schools learn about diversity and inclusion from the experiences of people with disabilities, and develop skills needed for an inclusive society.
• Specialist resources and support are used correctly to enhance the inclusion of students with disabilities.
• Transitions between secondary/higher education programmes and into adult life are well supported and career guidance is accessible and inclusive.

Non-formal education

The main goal of CBR program is to develop knowledge and skill in PWDs and improve their quality of life(QOL). PWDs should get access to educational opportunities that suit their own need and interest in inclusive setting.

The desirable outcome of the CBR program are:

• PWDs participate in non-formal education programmes and learn skills that contribute to their better living conditions.
• PWDs actively participate in planning and execution of non-formal education.
• PWDs, family members, disabled people’s organizations and parents’ associations play vital role in decision-making and implementing non-formal education programmes.
• Home-based learning is available either as a supplement to formal schooling, or in preparation for formal schooling, or as an alternative to formal schooling.
• Students with disabilities and non-disabled students interact together and develop friendships which help to strengthen the social cohesion.

Lifelong learning

The main goal of lifelong learning is to provide access to PWDs for lifelong learning opportunities and variety of learning experiences. The opportunity of lifelong learning will help to prevent social exclusion, marginalization and unemployment of PWDs.

The desirable outcome of CBR program are:

• Favorable environment is created during formal schooling to Youth with disabilities for learning skills and are helped in their transition to the world of work through vocational and careers guidance and peer counselling services.
• Adults with disabilities have access to appropriate, flexible and effective learning opportunities throughout life, for example adult literacy through open schools and higher education through distance learning.
• Individuals and groups who have special needs, such as youth and adults with significant and multiple impairments as well as their caregivers and family members, have access to ongoing learning opportunities.
• Education related to life skills and survival needs including knowledge about reproductive health, sexuality and HIV/AIDS are provided to youths and adults with disabilities.
• Every educational institute in community promote social inclusion of youth and adults with disabilities by providing lifelong opportunities.

Livelihood

The goal of CBR program on livelihood is that PWDs gain a livelihood, can easily access social protection measures and are able to contribute to their families and communities economically.

Related links

• https://www.euro.who.int/__data/assets/pdf_file/0004/129532/Ottawa_Charter.pdf