Final Answer Book Volume 1 Oct 2011

An Introduction to the Trainers Guide
Dear trainer, This answerbook is a guide, which has been written to help you develop your teaching skills. It suggests how to facilitate students to understand the practical issues they will encounter when working in the field. The rehabilitation therapy handbook and answerbook encourage participatory learning and are designed to be used together to guide your training. If you follow them when planning your lessons, we hope your training style will develop and will help students learn to find out solutions for themselves. The questions and activities in the handbook encourage students to think of their own ideas and to problem solve. Students will have many different ideas and therefore this answerbook does not contain right or wrong answers. It does give suggestions that can be used to guide students to stay focused on the relevant information. Some of the suggestions have been written in an Indian context but we understand that you will be training students from different low income countries. We hope you can be flexible with the answers and adapt your teaching methods, so that they are appropriate for different cultures. We would appreciate your ideas and suggestions so that we can make improvements for the next edition.
How to Use this Guide

Each chapter in this trainers guide matches the same chapter in the handbook. The question/activity and corresponding page number in the handbook is written next to each answer so you can refer back to them. For example: 4.1. HEALTH CARE See page 56 in the handbook (volume 1) This refers to the page of the handbook that the question has been written.
This symbol tells you that there is a question for the students to answer. The question is the same as the question in the handbook. For example: 2. Which aspects of health do you think are not included in box 1? This symbol appears next to an activity, the same way in which it appears in the handbook. For example: 1. Name some of the barriers to communicating with PWD and their families. Trainers Note This is a box which tells you information about the topic that is not specifically asked in the questions and activities. It can also give suggestions about how to facilitate the students to think of appropriate answers. For example:
Trainers note This chapter contains answers to questions that will be answered differently by each student. Some of the examples shown have been written by students themselves and have been used here to suggest the type of answers that are expected.
Further reading in the handbook This note tells you where you can find more information about the topic in the handbook. For example:
Further reading in the handbook (volume 1) See page 383 for the CBR matrix summary
Section 1
Chapter 2
Disability, Development and Community Based Rehabilitation
2.1. WHAT IS DISABILITY? See page 5 in the handbook (volume 1)
Prasads Story Nagamani and Gangappa live in a village in Andhra Pradesh. They are agricultural labourers earning Rs. 50/day. They have three children. Once, their son Prasad had a high fever and they soon realised that he was not able to walk. Doctors called it polio but they did not understand what it meant. They took him to the local medicine man, priests, faith healer and even to the district hospital. All this meant that one of them could not go to work and their income was reduced. They soon got into debt and were unable to continue their effort to help Prasad walk. From then on, the family and neighbours stopped caring for Prasad - they stopped carrying him around or playing with him. He grew up a loner (socially isolated) and had no friends. The children in the neighbourhood would not play with him. They started calling him cripple instead of Prasad. Prasad had food and clothes, but no love from his family and no friends. His family saw him as a burden and believed he was useless. He had a negative image of himself and was depressed. The women of the village told Nagamani that the family was paying for its sins and whatever happens to people is in the hands of God. Prasad was not considered a useful family member because his parents could not imagine him growing up to be like the other children, to look after siblings or animals, to go to school or learn a trade or get married and so on. Prasad may not have been affected by Polio if his parents had access to information about immunisation.
Chapter 2
Disability, Development and Community Based Rehabilitation
1. Why do you think that disabled people are often not referred to by their names but their disabilities?

If the disability can be seen by other people, it is sometimes the first thing that is noticed about that person. Historically (in the past) people were referred to by their disability rather than their name. It is sometimes used as a way to describe a person (especially if the persons name is not known). Most communities do not understand what disability is and what causes it. For example, some communities think that disability is a punishment from God so they do not respect the person. Many people are not aware of the feelings of others. They may not understand that referring to a person by their disability can be de-motivating for them and that they will not participate in daily activities within the community.
2. What do you think of Prasads story? Think about medical and social aspects/issues. MEDICAL:
Because of the muscle weakness in his legs, Prasad is unable to walk or carry out his activities (e.g. his ADL, going to school and playing with other children). Prasads disability is a result of polio, which could have been easily prevented with an appropriate vaccination. SOCIAL: Prasad is not able to carry out his activities, not only because of the muscle weakness in his legs, but also because of: The negative attitude of his family and the community e.g. his family does not see him as being helpful in the house, like their other children. The superstitious beliefs of the community. An inaccessible environment (e.g. school, playing outside). Non-acceptance of the community. The poverty of the family. Prasads parents do not have enough money to give Prasad appropriate care. They also do not have the knowledge about disability and how best to look after him. Poor access to services e.g. medical/therapy services and education.
Experiencing Disability Spend 1 hour temporarily disabled, either with your hands tied, legs tied, blindfolded or not speaking. 1. What have you learnt from this experience? Each persons experience with this activity will be different. This activity helps us gain an understanding of the difficulties that a person with a disability faces. The two key barriers which affect the function of a PWD are:
The environment (the structures in the community e.g. steps, footpaths, public toilets). Other peoples attitudes (shown by their actions and comments). a. easier? b. worse?
What would make it:
These are some thoughts that may be discussed: Activity

Blindfolded
Things that would make it easier

If the surroundings are known very well. If there is someone to guide the person so they know where they are. Tactile tiles and Braille to help with orientation. Voice activated buttons e.g. for lifts, doorways. Someone to help. Adaptations to the environment that would make it easier e.g. a lift or ramp instead of stairs.
Things that would make it worse

People around are not willing to help. If there are no people at all in the surroundings. Obstacles in the environment. Changing the environment without informing the person.
Legs tied together
Environmental obstacles. If people do not help/give space to make it easier. If the people around do not understand why the person cannot walk properly. Environmental obstacles. Negative attitudes of people.
Hands tied together
Someone to help. Adaptations to the environment. Orientation/education for the person to make use of his other abilities.
Not speaking
Someone the person can communicate with through writing things down. This helper could then communicate with other people on the PWDs behalf. Sign language/gesture. The use of pictures for the person to communicate. A sign language interpreter.
If the person that is being communicated with does not understand why they are not speaking. If the person they are trying to communicate with does not know any other communication mode (i.e. if the person cannot read, speak sign language or is visually impaired).
2.2 . BARRIERS
See page 6 in the handbook (volume 1) We are not born with negative feelings or attitudes. Why do we develop them? We form our own views of a situation if we do not understand it fully. These views are often influenced by those around us e.g. our parents, friends and the society we live in. We may have seen negative things in a similar situation in the past and these thoughts and feelings then affect what we think now. We rarely see disabled people in everyday roles like others. Often we see them in unfortunate situations e.g. begging at the railway station and temple. We associate PWD with these roles, rather than in a more positive way. First, list everything you need to live your life in the left box. Next, list everything a PWD needs to live his/her life. YOUR NEEDS
Examples include: Food Shelter Clothes Health care Education Transport Skills Recreation Money The freedom to choose
NEEDS OF PWD
The same as your needs.
Friends and family
2.3 . THE INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY AND
HEALTH (ICF) See page 7 in the handbook (volume 1) 6
Based on what you have learnt from Prasads story, what are the problems with the old classification? a) The definition of disability is limited to being only caused by the impairment. It only considers medical/internal factors (which focus more on the individual) that influence disability. It does not consider the external factors e.g. (negative attitudes and environmental barriers) which affects the activities of PWDs. b) It is based on the negative view of the persons inability.
the questi on above are only ideas and sugge stions. There are many other possib ilities that may not be writte n here but may also be correc t. The trainer can facilita te discus sion amon gst the stude
The old WHO classification (1980): Provision of rehabilitation and equipment.
The ICF (2001): Provision of rehabilitation and equipment, improvement of environmental and attitudinal barriers.
SHANTI AND RANI
Read the case studies about Shanti & Rani. Both are children who were born blind. For each child, complete the empty boxes below.
Shanti Shanti is a little girl who was born blind, in 7 small village in India. When her parents a found out that she was blind, they secretly took Shanti to an orphanage and left her there, because they were frightened that other villagers would look down on them. People in the orphanage did not know how to care for a child with blindness and they were busy with the other children. They kept Shanti alive but did not give her any love or stimulation they picked her up to clean and feed her. Nobody tried to teach her how to feed herself or how to walk and talk. As she grew older, Shanti spent most of her time sitting on the doorstep, rocking herself and poking her eyes. She never spoke and cried when she was hungry. Other children stayed away from her because they were frightened of her.
Body structure and function (impairment)

Blindness. Shanti may have intellectual disability due to lack of stimulation.
Activity limitations
She is unable to do any ADL. She is unable to walk independently. She is unable to talk to express her needs (e.g. needing the toilet, hunger).
Participation restrictions
She does not play with other children. She does not go to school. She has no family/community life.
Rani Rani is also a little girl who is blind. When her parents found out that she was blind, they were also worried about what other villagers would say. BUT Ranis grandmother, who had lost her sight 5 years ago, said: I think we should do everything we can for Rani. Look at me, I am now blind but still have all the feelings and needs that I had when I could see. I can still do most of the things I used to do bring water from the well, grind the rice, milk the goats 8 We must help Rani to learn, just as I have, by sound and touch. I can teach her and we can get advice from the health worker. The family followed the advice of the health worker and gave Rani lots of stimulation in hearing, feeling and smelling and talked to her a lot. Grandmother took Rani everywhere and made her feel and listen to everything. When Rani was 2, her grandmother taught her to feel her way along the fence and walls. By 3, Rani could find her own way to the toilet and the well. When she was 4, the health worker taught the other children how to play with her. When Rani was 6 she started school and other children came for her every day. When villagers saw them walking down the road, it was hard to tell which child was blind.
Body structure & function (impairment)

She is not able to see.
Activity limitations
None Rani can do all of the activities she needs to.
Participation restrictions
None she is able to participate fully within the community.
Shanti and Rani both have the same impairment, but Shanti has many more limitations and restrictions than Rani. WHY? This is due to environmental factors, mainly the attitudes of others and the services given to 9 both girls.
The largest influence is the negative attitude of Shantis parents. This was because they were scared of what others may think and thought more about this than how to care for Shanti. They also did not understand how to care for Shanti, so sent her away.
Ranis grandmother has experience with blindness so she can give better guidance to Rani and her family. Shanti did not have this opportunity, so there was nobody to guide her.
Rani was accepted by her parents and supported by her family but Shanti was immediately admitted to the orphanage so lost the love and affection of her family. The orphanage did not have staff that were trained to help Shanti.
Shantis environment at the orphanage had a big effect on Shantis learning and behaviour. She was not taught how to adapt to her blindness like Rani. This was mainly due to the lack of care and understanding of the staff at the orphanage.
Overall, a lack of understanding and negative attitudes of the family and community had a very negative effect on Shantis quality of life.
2.4 . HOW COMMON IS DISABILITY?
See page 10 of the handbook (volume1)
1. India census 2001 found 2% of the Indian population has a disability this is lower than worldwide figures. Do you think there are less PWD in India? What could be the reasons for the low figure? Families are protective and do not want to declare disabled household members. inadequate training. There is a lack of committed and trained people employed to get the census information. The information about disability is often not a priority. Research has shown that women are less likely to see themselves as disabled than men. The definition of disability may not be correct in the census: Some disabilities may not be counted e.g. mental illness or disability related to old age.
Families and health workers are not able to identify disabilities correctly. This is often due to

2. What is the benefit for the Indian government if the figure is only 2%?
If disability is seen as a smaller problem, helping the problem is less important. In order to make the situation better, the government would have to do many things, such as passing laws and providing more services. This all costs money. 10there are fewer disabled people, the If government can put less money and resources towards services.
3. Do the majority of PWD live in rural or urban areas?
Why? There are more PWD in rural communities. There are many reasons for this. People in these areas are poorer and have less access to health services, education and livelihood opportunities. Most impairments are preventable if people in the community have the right education, access to health services and a hygienic environment.
4. What statistics are available for your region/country?
These are examples of statistics for various countries. Statistics for India
Information from the Census of India 2001.
The information below has been taken from The United Nations Disability Statistics Database Statistics for Yemen 11
Yemen 1994 Census Percentage of persons with disability by age and sex
All areas Total Male Female Urban Total Male Female Rural Total Male Female Total 0.5 0.6 0.5 Total 0.5 0.6 0.5 Total 0.5 0.5 0.5 0-14 0.1 0.2 0.1 0-14 0.2 0.2 0.1 0-14 0.1 0.2 0.1 15-59 0.7 0.8 0.6 15-59 0.6 0.7 0.5 15-59 0.7 0.8 0.6 60+ 3.0 2.6 3.6 60 + 3.0 2.9 3.3 60 + 3.0 2.5 3.6
Statistics for Sri Lanka Sri Lanka 1981 Census Percentage of persons with disability by age and sex
All areas Total Male Female Urban Total Male Female Rural Total Male Female Total 0.5 0.6 0.4 Total 0.4 0.4 0.3 Total 0.5 0.6 0.4 0-14 0.3 0.4 0.3 0-14 0.3 0.3 0.2 0-14 0.3 0.4 0.3 15-59 0.5 0.6 0.4 15-59 0.3 0.4 0.3 15-59 0.5 0.6 0.4 60 + 1.2 1.4 1.0 60 + 1.0 1.2 0.9 60 + 1.2 1.4 1.0
Statistics for Gaza Strip Gaza Strip 12 Survey 1996 Percentage of persons with disability by age and sex
All areas Total Male Female Total 2.1 2.3 1.8 0-14 1.7 1.8 1.6 15-49 1.9 2.4 1.4 50 + 4.4 4.8 4.0
Statistics for Nigeria Nigeria 1991 Census Percentage of persons with disability by age and sex
All areas Total Male Female Urban Total Male Female Rural Total Male Female Total 0.5 0.5 0.5 Total 0.4 0.5 0.4 Total 0.5 0.5 0.5 0-14 0.3 0.3 0.3 0-14 0.3 0.3 0.3 0-14 0.3 0.4 0.3 15-59 0.5 0.6 0.5 15-59 0.5 0.5 0.5 15-59 0.6 0.6 0.6 60 + 1.2 1.3 1.2 60 + 1.2 1.3 1.1 60 + 1.3 1.3 1.2
5. The number of people with a disability is increasing. Why?
Many low and middle income countries need to address longstanding problems such as malnutrition and disease and new problems such as chronic diseases. The rise in chronic diseases (e.g. diabetes, heart disease, cancer) is caused by peoples diet changing to include more sugary and fatty foods.
There is an increase in road accidents due to poor implementation of safety rules. War and violence are increasing. Natural disasters are increasing with climate change.
Medicine and healthcare are improving, which helps to preserve and prolong life and increases the population. As more people grow older, the effects of ageing are seen more often. There is a rise in HIV/AIDS and other infectious diseases (e.g. TB).
2.5 . POVERTY AND DISABILITY
See page 11 in the handbook (volume 1) 13 POVERTY: Lack of money is one factor of poverty, what are some other factors? There are many factors of poverty. Many of these are discussed below:

Living conditions, access to food, health, sanitation and drinking water are often very poor. There is limited access (and control) of resources, basic services and entitlements e.g. education, health and livelihood. People in poverty do not have the ability to choose, make decisions and access information. They do not have enough knowledge, skills and education. They do not have enough access and exposure to accurate information. There is often a low life expectancy of people in poverty. Unequal land distribution (especially in rural areas) makes it difficult for sufficient agriculture. Social factors such as:
-
Gender. There is often higher illiteracy among women as they do not have the same opportunities as men for education and employment. Caste. Children (e.g. child labour).
Many people in poverty are exploited and do not have the ability to change their situation e.g. bonded labour. People in poverty often have low self-confidence and high dependency on other people. This causes them to not feel respected and dignified. Many households in poverty do not have the ability to manage shock e.g. conflict or natural disaster. These often increase the vulnerability to poverty.
See page 12 in the handbook (volume 1) 1. Who are vulnerable groups and why? 14 Every PWD is vulnerable. There are many reasons for this, but an important factor is that there is a stigma around disability as some people believe it is harmful in their traditional beliefs and practices. An example of this is tying up a person with intellectual disability. Another example is, an African belief that you can cure a woman with a physical disability through having sex with her. This can than lead to high infection rates of HIV/AIDS.
As a result of this stigma, people with disabilities:

Often receive less care and food. Are often left out of family activities and interactions. Find it very difficult getting an education and employment. Do not have enough access to health care and rehabilitation services i.e. therapy and rehabilitation devices. The main vulnerable groups of people who are at risk of poverty are:
Children with disabilities: Their parents do not feed or stimulate them as much as nondisabled siblings and they are reliant on their parents to access health and education.
Women with disabilities. There are many reasons for this, some of these include:
They do not have enough access to reproductive health care. They have very little opportunity for marriage. They are more vulnerable to physical, sexual and mental abuse. They do not fulfill the expected and traditional mother role. Deaf and blind women are more at risk of sexual abuse. It is assumed that a deaf woman will not be able to communicate who her violator was. A blind woman is not able to see who her violator is.
Older adults with disabilities: This is because they are very dependent on others for help.
2. What are reasons for exclusion? There are many reasons for exclusion. The main reasons include:
PWD are seen as a low priority within the community. 15
There is poor knowledge about disability, which leads to lower acceptance of a PWD in the community.
There are many attitudinal, physical and environmental barriers for a PWD within the community.
Malnutrition is one cause of higher rates of disability among people living in poverty. Name some other causes:
Dangerous work, mostly caused by poor knowledge about safety measures.
Living in highly populated and unsanitary conditions. These people are more at risk of catching infectious diseases.
Limited access to (quality) medical care. Often, traditional healers are consulted instead, who can be ineffective but are often visited because they are affordable.
Poorly educated people and those who lack basic knowledge e.g. parents who do not immunise their children.
Renukas Story Ramapuram is a typical south Indian village. It is the harvest season with men, women and children working in the paddy fields. At the end of each day, men are paid Rs.15 and women are paid Rs.10 as wages. They also get a fifth of the total yield as their share. Renuka is 26 and her husband, Siddappa, is 30. Both work in the fields all day. They have 3 children- 2 daughters (Rani aged 5 and Lakshmi aged 3) and a son, Nagraju, who is 6 months old. After working in the fields, Renuka,s days work is not over. The evening meal has to 16 be prepared. She sets the fire and prepares the evening meal, while Rani takes care of baby Nagaraju Raju as he is affectionately called. The family eats a simple meal of rice, rasam, and pickle, with Renuka carefully portioning out the rice to her husband and daughters. She always eats her meal after feeding the family. As she eats Renuka watches Rani bottle-feed the baby. Renuka remembers her mother explaining the importance of breast feeding as long as possible. But when her son was 1 month old, her milk dried up. She was frequently ill those days and even for the short while she breast fed him, she could only do it twice a day in the morning before going to work and on returning from work in the evening. When Renuka and Siddappa return home from work one day, they find Raju is ill. Siddappa only knows two remedies - the Kashaya and the fever pills which readily available in the local store. Rani is sent off to buy the pill and the baby is fed the powdered pill. Renuka prays to the village deity, Chenchamma Devi and ties a 25 paisa coin in the piece of yellow cloth as a token and promises to make more offerings at a later date. Renuka sits up all night looking after her sick baby. The next day she leaves for work unwillingly. She has no choice but to go. A day work lost is a whole days wage lost. She finds it difficult to concentrate on her work. While at work, she sees Rani running towards her. She hears with growing fear and anxiety that the baby has severe diarrhoea as well as fever, cold and cough. Renuka rushes to her husband and explains to him that Raju needs to be taken to the Dai (local Midwife) immediately. They both approach the landlord and ask to be excused from work for the rest of the day. The landlord is not very happy and he threatens to cut off their share of the grain if they absent themselves again. They both are too worried to argue and hurry away. Gouramma is the village Dai. Renuka trusts her completely, as most women in the village do. She has brought her daughters to her on many occasions. The Dai`s Kashaya makes no difference to the babys condition. She advises them to take the baby to the doctor in the next village, which is 5km from Ramapuram. Renuka and Siddappa hurry on to the next village on foot, past the primary health centre, which is locked. The doctor in the next village sees his patients in a small room. Nobody in the village knows when or how he started his practice. He is the only `doctor` around and the villagers have accepted him. Rajus turn comes and the doctor decides to treat the stubborn fever and diarrhoea with an injection. Siddappa pays him Rs. 5. Renuka prays for the child. They spend another restless night with the child. By now they are very much worried.should they go to the city hospital? What about expenses?
Siddappa has no option but to approach the landlord for the money. After pleading with him for a long time he gets Rs.100. He decides to return to work. Renuka will have to go alone to the city. Every rupee is important now. She leaves for the city with her son in her arms. She waits for the bus thinking of how she will save Raju, no matter what the cost. She will have to make up for the lost hours of work or she will pay heavily by forfeiting their share of the grain. Renuka stands under the shelter of a tree. She knows that the city hospital will close at 5pm. It is noon already and the bus ride will take 2 hours. The bus comes after a long time. The crowded streets, the noise, the zooming vehicles and pace of life in the city overwhelm Renuka. The hospital is crowded with patients, doctors, nurses, ward boys Renuka is confused. What to do? Where to go? A helpful man directs her to a desk where a person sits with a register. For each name entered he collects a fee of one rupee and gives a registration slip to the patient. Renuka collects the slip of paper and joins the long queue of other mothers and crying babies. After a thorough examination of Raju, the doctor tells Renuka that her son is a victim of polio a crippling disease. How crippling? she wants to ask but no sound comes out of her mouth. Tears well up in her eyes. Too scared to ask the busy doctor, she approaches a nurse who begins to scold her for ignoring the advice of the health worker who came to her village to vaccinate children against dreadful diseases like whooping cough, tetanus and polio. The nurse blames Renuka and says that it is due to her negligence that her son has not been given the polio drops. She also tells Renuka that Raju will never walk normally. Renuka is horrified. She weeps openly now for her son and at her own helplessness. She remembers the day when she carried her baby faithfully to the primary health centre for the polio drops. But she was asked to return the following week, as the duty nurse had not turned up. Each visit meant missing a days work. Renuka and Siddappa are landless workers and therefore answerable to the landlord. And of course they had to think of the money. So the following week she did not return to the health centre, nor the next week Renuka is shocked back to the present. She is angry, upset and confused. But did her neighbours daughter not limp even though the mother never missed a single visit to the primary health centre? Who can change ones fate? She returns to her village determined to call the village Tantrik to invoke the Goddess Chenchamma Devi with her power. Siddappa begins to sell small portions of grain from their store to pay the Tantrik. The tantrik`s mantras and tantras fail to cure Raju. Siddappa quarrels frequently now, he shouts at Renuka for having undergone the family planning operation after Rajus birth. They can never hope to have another son, he complains. Little Rani sees the pain on 17 mother`s face and tries to comfort her her younger sister and baby brother. They have spent a lot of money in the last month over Rajus treatment. Siddappa and Renuka have to struggle to provide even one meal a day to their growing children. Raju is now 16 year old. He stays at home with a thin left leg. At times he sits at the door of the house. He has no friends and has never been to school. The only school is 25 km from the house. Polio has left its mark.
See page 14 in the handbook (volume 1) List the causes for Raju becoming disabled under the following categories: 18 Biological: Factors in the body or health of the child.
Raju suffered from a fever, cold, cough and diarrhoea, which are symptoms of polio. His left leg was paralysed, has become weak and thin and he is not able to walk.
Physical: E.g. earthquakes, floods and famine.
The story suggests that there was poor hygiene inside and outside of the house.
Cultural: E.g. traditional beliefs and practices.

When Raju got a fever, Siddappa gave him kashaya and fever pills, which he bought at the local store. Renuka prays to the village deity Chenchamm Devi. She ties a 25 paisa coin to the piece of yellow cloth as a token and promises to make more offerings (a supersticious belief). Renuka and Siddappa did not take Raju to the hospital immediately, but to the local Dai (village midwife), whom they trust completely. They also return to the village, to call the village Tantrik to invoke the Goddess Chenchamma Devi with her power.
Renuka always eats her meal after feeding the family. There is a difference between the wages of men and women, even though they do the same work. This is known as gender discrimination.
Economic: Factors controlling the purchasing power of the family.
Renuka and Siddappa work in the paddy fields all day. Ranuka earns Rs.10 a day and Siddappa earns Rs.15 and a fifth of the total yield as their share. They can only afford to eat rice, rassam and pickle and the rice is carefully portioned. When Raju was 1 month old, Renukas breast milk dried up because she does not have access to adequate food and nutrition. Although Raju has fever, they cannot take him to the hospital because they have to go to work and earn money. A days work lost is a whole days wage lost. Siddappa only needs to sell small portions of grain from their store to pay the Tantrik. They do not go to the city hospital straight away after Rajus illness because it is expensive and Siddappa has to borrow Rs.100 from the landlord to pay for the trip. Siddappa is unable to come with Ranuka because he has to work, so she has to take Raju alone. Ranuka did not return to the primary health centre as she could not afford to miss another days work. Because of the expenses they have paid for Rajus treatment, Siddappa and Renuka have to struggle to provide even one meal a day for their growing children. 19 Raju did not go to therapy because the family did not have enough money. As a result, he does not interact with his environment, sitting at the door of the house. He has no friends and has never been to school.
Political: Factors outside the control of the family in the system or society, the government set-up.
Siddappa and Renuka do not own their land as it is unevenly distributed in the village. The landlord is dominating the workers and will not pay them if they are not working that day (known as a daily wage). They go to the next village on foot as there is a poor transport service. The primary health centre is locked. There is a poor bus service to the city hospital and the bus takes 2 hours to arrive there. the city
There is poor availability of hospitals in the area and hospital is crowded and closes at 5pm.
The facilities at the hospital are poor. Renuka has to wait in a long line behind many other mothers and crying babies. The doctor is very busy and does not have enough time to discuss Rajus problems fully.
When Renuka visited the primary health centre, to give Raju
polio drops, she was asked
to return the next week as the nurse had not turned up.
Give a % weighting for each cause depending how big a factor it was (total 100%): Each person may have a different opinion for this answer. Biological: 20% Physical: 20% Cultural: 20% Economic: 20% Political: 20%
2.7. HUMAN RIGHTS See page 17 in the handbook (volume 1) 20 In a small group, discuss what you understand by human rights. This answer is very open and different people may have different ideas and opinions. The group may talk about torture, political prisoners, freedom of movement (e.g. to leave your country or travel to different countries). It is important to think about the rights of PWD that are being denied on a daily basis. Examples of these include freedom of movement (e.g. due to access, the family not wanting them to be seen out), equal opportunities and access to education/employment.
The most relevant articles from the UN Convention on the Rights of Persons with Disabilities are listed below. Discuss how they will be useful to you as an RTA/P&O? Summary Table: UN Convention on the Rights of Persons with Disabilities. Article Main Idea Usefulness
Article 6: Women with disabilities Article 7: Children with disabilities
Support growth and empowerment of women with disabilities.
Good for arguing for services for women or the inclusion of women in development programmes, womens groups etc. Good for arguing for childrens services, their consent and right to choose.
Children with disabilities have equal rights and should be consulted in matters concerning them. Buildings, the outdoors, transport, information, communication and services should be accessible. PWD have as much right as everyone else to live in the community and participate in community life. Services should be available to them in the community.
Article 9: Accessibility
Good for arguing for adaptations to hospitals, schools and other public places.
Article 19: Living in the community and being included in the community
Gives a useful argument for justifying CBR programmes. People have community based services as a right.
Article 20: Personal mobility
PWD have a right to mobility training and affordable mobility aids. Staff also need to be trained to carry out this.
Good for discussing rehabilitation service provision, the training of staff and the provision of mobility aids.
Article
Article 24: Education
Main Idea
All children have the right to education. The government needs to ensure it is accessible and local 21 and childs needs are catered for.
Usefulness
Good for arguing that the government must take steps to meet the needs of children with a disability in a local school.
Article 25: Health
Healthcare is equally accessible to Good for arguing for the training of health PWD and their health needs are met professionals in disability issues and access in the local area. to local services for PWD. Countries must provide rehabilitation services as early as possible, to ensure PWD enjoy maximum independence. Services are available close to where the PWD lives. Rehabilitation professionals are trained and the use of assistive devices is promoted. Good for arguing for rehabilitation services provision, the training of physiotherapists, CBR workers and occupational therapists.
Article 26: Habilitation and rehabilitation
What laws exist in your region/country to protect the rights of PWD?
The answer for this question will be different, depending on the country. Examples of laws present in India that protect the PWD are:

Mental Health Act, 1987 Rehabilitation Council of India Act, 1992 The Persons with Disabilities Act, 1995 National Trust Act, 1999
2.10. CBR MATRIX AND THE ROLE OF THE RTA AND P&O TECHNOLOGIST WITHIN IT See page 20 in the handbook (volume 1) 22 What will your role be as an RTA or P&O technician in CBR? This table below suggests the role of both a RTA and a P&O technician in CBR. Much of the information has been guided by the WHO CBR Guidelines (2010). HEALTH
answer s to the questio ns above are only ideas and sugges tions. There are many other possibil ities that may not be written here but may also be correct . The trainer can facilitat e discuss ion among st the student s in
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Key Elements in Matrix

Promotion
The Role of the RTA

Creating awareness in the community about the causes, prevention and consequences of an unhealthy lifestyle and environment. Encourage people with disabilities to actively participate in health promoting activities. Refer to the appropriate health professional as necessary.
The Role of the P&O Technician

Creating awareness in the community about the causes, prevention and consequences of an unhealthy lifestyle and environment. Encouraging people with disabilities to actively participate in health promoting activities. Providing information to PWDs, their families and the community about the importance of prosthetics, orthotics and assistive devices. Ensuring the care, maintenance and simple repairs of these devices. Refer to the appropriate health professional as necessary. Primary prevention:
Prevention
Primary prevention:
Educating the community about healthy behaviours and lifestyles. Ensuring access to health information and services that aim to prevent health conditions. e. g. educating the community about health and nutrition during pregnancy and how to access appropriate maternal health services. Secondary prevention:
Educating PWDs and their families about healthy behaviours and lifestyles. Ensuring access to health information and services that aim to prevent health conditions. Secondary prevention:
Identifying conditions that need medical intervention and referring to the appropriate resources. This leads to earlier detection and treatment of health conditions and aims to lessen their impact on health. e. g. identifying that a client has an infection and referring her to the local health centre.
Identifying conditions that need medical intervention and referring to the appropriate resources. This leads to earlier detection and treatment of health conditions and aims to lessen their impact on health. Tertiary prevention:
Providing prosthetic and orthotic devices which, as part of rehabilitation services, reduce activity limitations and promote independence, participation and inclusion.

Prevention continued
The Role of the RTA

Tertiary prevention:

Educating the service user about the care and maintenance of their prosthesis or orthosis and carrying out repairs as required. Referring people with disabilities to the RTA for rehabilitation therapy.
Providing rehabilitation services which aim to reduce activity limitations and promote independence, participation and inclusion. e.g. teaching a child with cerebral palsy how to walk to the local shop. Referring people with disabilities to the P&O technician for prosthetic and orthotic devices. Identification of the need of referral to appropriate services. Working with community facilitators to ensure people with disabilities can access services which, identify, prevent, minimise and/or correct health conditions
Medical care
Identification of the need of referral to appropriate services. Working with community facilitators and RTAs to ensure PWD can access services which, identify, prevent, minimise and/or correct health conditions and impairments.

Assistive devices
The Role of the RTA

Identifying the need for developmental 24 aids and other aids to improve independence in daily living e.g. toilet chairs, modified spoons and cups. Designing and producing assistive devices. Emphasis is placed on the use of locally available materials. Referring to the P&O technician for the provision of prostheses or orthoses, along with their repair or replacement, as needed.

Identifying the need for prosthetic/orthotic devices and developmental aids that are suitable for the individuals needs. Designing and producing prosthetic and orthotic devices that are suitable for an individuals needs. Referring to the RTA for provision of developmental aids and other aids to improve daily living, as appropriate. Educating people with disabilities and their families about prosthetic and orthotic devices, their care, maintenance, replacement and repair when necessary.
Educating people with disabilities and their families about assistive devices, their care, maintenance, replacement and repair when necessary. Further reading in the handbook (volume 1) See page 383 for the CBR Matrix Summary
EDUCATION
The Role of the RTA
Early childhood care and education
Providing rehabilitation therapy for children with disabilities so that they can access early childhood care and education. Educating parents, health workers and anganwadi workers (pre-school teachers) on child development. Involvement in early identification of developmental delay. Educating parents, health workers and anganawadi workers about how to modify the environment and facilitate therapeutic interventions, e.g. play, to promote child development. Providing assistive devices so that children with disabilities can access early childhood care and education.
Providing prosthetic and orthotic devices, mobility aids and developmental aids to enable children with disabilities to access education.
Referral to community facilitator to facilitate access to inclusive education.

Primary education, secondary and higher education
The Role of the RTA

Providing rehabilitation therapy for 25 children with disabilities so that they can access education. Educating teachers about how to modify the environment and facilitate therapeutic interventions to promote child development. Working with the community facilitator to promote a barrier free environment so that children with disabilities can access inclusive education. Home-based education, educating home tutors about how to modify the environment and facilitate therapeutic interventions, so that child development is promoted. Providing rehabilitation therapy and assistive devices for adults with disabilities. Prescribing mobility aids and referring to the P&O technician for their provision. PWD can then access

Providing prosthetics, orthotics, mobility aids and developmental aids for children with disabilities so that they can access education. Working with the community facilitator to promote a barrier free environment so that children with disabilities can access inclusive education.
Non-formal education
Providing prosthetics, orthotics, mobility aids and developmental aids for children with disabilities so that they can access non-formal education. Providing prosthetic and orthotic devices and mobility aids to enable adults with disabilities to access life-long learning.
Life-long Learning
knowledge and skills needed for employment, adult literacy and other learning that promotes personal development and participation in society. Referral to community facilitator to facilitate access to non-formal education. Providing training of community members in basic therapy interventions e.g. home exercises.
Providing training to PWDs and their families in P&O interventions. E.g. wheelchair and assistive devices repair. Referral to community facilitator to facilitate access to non-formal education.
LIVELIHOOD
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Skills development
The Role of the RTA

Providing rehabilitation therapy for PWDs so that they can access and develop knowledge, attitudes and skills they need for work. E.g. working with a PWD to improve their mobility so that they can access adult training and education. Referral to the community facilitator to facilitate access to skills development training. Providing rehabilitation therapy to PWDs so that they can earn their livelihood through self employment. E.g. working with the PWD to improve their mobility and access to their working environment. Suggesting ideas to PWDs about modifying their environment so that it is more accessible for them. Referral to the community facilitator to facilitate access to self employment. Providing rehabilitation therapy for PWDs so that they can earn their livelihood through waged employment. Creating awareness in the community about disability to encourage employers to increase equal access and treatment in the workplace for PWDs. Providing suggestions to employers about the modification of the environment so that it is accessible for PWDs. Referral to the community facilitator to facilitate access to wage employment if necessary.

Providing prosthetic and orthotic devices and mobility aids to PWDs so that they can access education and skills, attitudes and skills they need for work. Referral to the community facilitator to facilitate access to skills development training.
Selfemployment
Providing prosthetic and orthotic devices and mobility aids for people with disabilities so that they can earn their livelihood through self employment. Referral to the community facilitator to facilitate access to self employment.
Wage employment
Providing prosthetic and orthotic devices and mobility aids for people with disabilities so that they can earn their livelihood through waged employment. Referral to the community facilitator to facilitate access to waged employment if necessary.
Financial services and social protection
Referral to the community facilitator to facilitate access to financial services and/or social protection if necessary.
SOCIAL

Personal Assistance
The Role of the RTA

Educating caregivers about how to include therapy interventions in the care they provide to PWDs. Providing suggestions about how to modify the environment so that it is accessible for PWDs. Referral to the community facilitator to facilitate access to personal assistance if needed. Creating awareness in the community about disability to reduce negative family and community attitudes. Improve integration of disabled people into the community. Referral to the community facilitator to facilitate access to appropriate services, which support a parenting role if needed. Providing rehabilitation therapy for PWDs so that they can participate in cultural and arts activities e.g. working with a PWD to improve his mobility so he can go to the temple. Suggesting modifications of equipment and the environment so it is easier for PWD to participate in culture and arts. Referral to the community facilitator to facilitate access to inclusive cultural and artistic activities if needed. Providing rehabilitation therapy for PWDs so that they can participate both actively and as spectators in recreational, leisure and sporting activities. E.g. working with a PWD to improve her mobility so that she can play games.

Educating caregivers about the appropriate use of prosthetics and orthotics so that they can assist PWDs. Referral to the community facilitator to facilitate access to personal assistance if needed.
Relationship, Marriage and Family
Improving awareness in the community about orthotic and prosthetic devices, in order to help reduce negative family and community attitudes. Referral to the community facilitator to facilitate access to appropriate services, which support a parenting role if needed. Providing orthotics, prosthetics and mobility aids for PWDs so that they can participate in cultural and arts activities. Referral to the community facilitator to facilitate access to inclusive cultural and artistic activities if needed.
Culture and Arts
Sports, Recreation and Leisure
Providing orthotics, prosthetics and mobility aids for PWDs so that they can participate both actively and as spectators in recreational, leisure and sporting activities.
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Sports, Recreation and Leisure continued
The Role of the RTA

Suggesting modifications of equipment and the environment so it is easier for PWD to participate in sports, recreation and leisure. Referral to the community facilitator to facilitate access to inclusive recreational, leisure and sporting activities if needed.

Referral to the community facilitator to facilitate access to inclusive recreational, leisure and sporting activities if needed.
Justice
Referral to the community facilitator to facilitate access to justice if needed.
EMPOWERMENT

Advocacy and communication
The Role of the RTA
Referral to community facilitators to facilitate access to information and communication resources. Community facilitators also ensure that the environment of PWDs provides opportunities and support, which allows effective decision making and expression of their needs and desires. Creating awareness in the community about disability. This helps to reduce negative family and community attitudes and improve integration of disabled people into the community. Referral to the community facilitator to facilitate community involvement in CBR programmes. Improving awareness in the community about orthotic and prosthetic devices, which helps to reduce negative family and community attitudes. Referral to the community facilitator to facilitate community involvement in CBR programmes.
Community mobilisation
Political Participation
Referral to the community facilitator to facilitate increasing skills and knowledge of the political system for disabled people, to enable them to participate in politics. Community facilitators also facilitate access to opportunities for participation. Referral to the community facilitator, as needed, to facilitate involvement of disabled people and the community in self-help groups. These aim to solve common problems, enhance individual strengths and improve quality of life. Referral to the community facilitator, as needed, to facilitate the co-operation between CBR programmes and disabled peoples organisations.
Self-Help groups
Disabled peoples organisations
Look at the matrix on the next page. Colour the areas that you will be involved in, either directly or indirectly. 29
Goal: Inclusive development Inclusive society COMMUNITY BASED REHABILITATION MATRIX
Trainers Note The version of the CBR Matrix printed here is the updated version published in the WHO CBR Guidelines (2010). It has been modified since the publishing of the Rehabilitation Therapy Handbook (2010).
2.11. REHABILITATION SETTINGS See page 22 in the handbook (volume 1) 30 List the strengths and limitations of both institution and community based rehabilitation (IBR and CBR): IBR
STRENGTHS
CBR
The PWD is assessed and treated in his/her own community so it is easy to address the problems that they are experiencing at home. The PWD and their family participate in making decisions about rehabilitation. CBR is more economical for the service user as no travel expenses are needed for intervention. Intervention occurs at an earlier point as the CBR approach focuses on early identification. Due to the above strengths, regular therapy follow up is more likely to be achieved in CBR.
In an institution there are more resources available. E.g. there may be resources to make assistive devices or to use therapy equipment. It is more likely there will be qualified physiotherapists, occupational therapists or P&O staff to provide guidance and support. This gives opportunities to learn and develop skills.
LIMITATIONS
Service users come to the hospital/ rehabilitation centre for treatment. It is difficult to understand their environment and identify problems they may be experiencing in their own homes. Treatment is more likely to follow a medical model. Hospitals and rehabilitation centres are often in cities/large towns. Many service users living in rural areas may live far away and cannot afford transport, treatment or
There are generally less resources in the community. RTAs, P&O technologists and other community personnel often need to work alone in the community. This makes it hard to ask for help from a qualified professional if they are having difficulties. Referrals to other health facilities are often more challenging in rural
intervention. Early identification and intervention are less likely to occur in IBR. In many larger hospitals, service users do not participate as much in the decision making process as in CBR. Decisions are made by the service provider. Due to the above limitations, regular therapy follow up is less likely in IBR.
areas.
Trainers Note Both CBR and IBR are needed for an effective service. Ideally, IBR programmes should have a number of CBR programmes to reach out to more people in the community. The success of a CBR programme depends on a good referral system and support from IBR. If community 31 workers are trained in the early identification and treatment of disabilities but appropriate facilities are not available, then CBR will not be sustainable.
2.12. MEMBERS OF THE REHABILITATION TEAM See page 23 in the handbook (volume 1) What is the role of the rehabilitation therapy assistant?
Carrying out effective rehabilitation at the community level in partnership with other professionals, PWD and carers. Communicating effectively with PWD and their families, carers, the community and other members of the rehabilitation team. Educating PWDs, their families, community members and the CBR team about disability and rehabilitation issues. Carrying out a basic assessment of PWD in order to identify individual functional problems and rehabilitation needs. Setting SMART, functional goals and making treatment plans based on these. Reassessment, evaluation and modification of goals should occur regularly. Working with the rehabilitation team and supporting community staff to implement rehabilitation programmes in the field. Building a network of professionals in the local area so that referrals to the appropriate staff can be made when necessary.
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Chapter 3
Personal and Professional Studies
3.1. COMMUNICATION SKILLS 3.1.5. BARRIERS TO COMMUNICATION See page 28 in the handbook (volume 1)
Trainers note This chapter contains answers to questions that will be answered differently by each student. Some of the examples shown have been written by students themselves and have been used here to suggest the type of answers that are expected. Many of the questions do not have a right or wrong answer and students should be encouraged to explore ideas and their abilities to help their personal and professional development.
1. Name some of the barriers to communicating with PWD and their families. There are many barriers to communication that may be present when communicating with PWD and their families. Students may think of some of these examples:
Language barriers. If the sender and receiver speak different languages, spoken or written information may not be sent or received correctly. If the language used is not clear, it may not be understood.

Poor memory. The sender or receiver may not be able to remember the message sent or received. Cultural barriers. If the sender and receiver have different cultural beliefs there may be a misunderstanding of words/phrases, gestures, body language and facial expressions. Insufficient time. If the sender is in a hurry, they may not give the correct information or make sure that the receiver understands it. If the receiver is in a hurry, they may not take the time to understand the information correctly.
The attitude of the people communicating. E.g. if either person is not interested in communicating, the communication may not be effective.
Poor understanding of the information provided. This can happen for many reasons, such as intellectual disability, dementia, or poor communication skills (as discussed above).
Poor health. The sender or receiver may be unable to communicate properly if he is not well.
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2. What abilities do we need to communicate with PWD and family members? List them. There are many abilities needed to communicate with PWD and their family members. These are some examples that students may think of:
Show respect to PWD and his family members. This can be done in various ways e.g. following the local customs and traditions and using respectful language and gestures. Active listening skills are needed when receiving information. Simple and clear language should be used so that the PWD and their family members can understand the message. It is important to use both verbal and non-verbal communication. Use positive body language and gestures.
3. What abilities do I need to develop to improve my communication skills? This answer will be different depending on different skills and abilities. These are a few examples that students have given:

Knowledge of the problems of society and PWDs. Active listening skills. Maintaining eye contact while communicating, as well as using more non-verbal communication. The ability to speak clearly and in a simple language.
3.2. ACTIVE LISTENING
3.2.6. OPEN AND CLOSED QUESTIONS
34
See page 33 in the handbook (volume 1)
1.
Are the questions below open or closed?
Question A. B. C. D. E. F. G. H. I. J. Where are you from? Is the orthosis helping? How is the orthosis helping? Tell me how this problem affects you on a daily basis? Have you done your exercises? How can I help you? What would you like to achieve in rehabilitation? Do you want to learn to walk? How are you feeling? Would you prefer to wait for an appointment today or come back at a later date?
Open or closed? Closed Closed Open Open Closed Open Open Closed Open Closed
2. What techniques are necessary for active listening skills when you communicate with PWD and families?
Show that you are interested in the PWDs message. When actively listening, using open rather than closed questions encourages the person to express themselves more openly.
Pay attention to what the PWD and his family members are saying. Do not think about what you will say next until the person has finished speaking. Use non-verbal communication such as positive body language, smiles and gestures. Avoid being distracted by other people or things happening in your environment. Be patient, let the PWD finish speaking do not interrupt. Always put the PWD and his family members at ease. Show that you understand using gestures and words. If you do not understand, ask questions and clarify any doubts you may have. Do not pretend that you understand.
3. Self assessment of your active listening skills. 35 An example of a students self assessment is shown below. There is no correct or incorrect answer for this and each person will have different strengths and areas for improvement.
What areas of active listening do you think you are good at? I always smile, introduce myself and ask the name of new service users and her family members. I always try and make the service user and her family feel comfortable so that they are able to share their problems openly. I try and use positive body language and gestures when communicating with people. I try to show interest when listening to people. I ask questions and clarify my doubts when listening to people (if required).
What areas do you need to improve? I get distracted easily if there are many people in my surroundings. I sometimes ask closed questions instead of open questions. I sometimes interrupt while speaker is saying something. I need to improve my knowledge on the issues and rights of the PWDs.
3.3. SELF DEVELOPMENT
3.3.4. WHY WE NEED TO UNDERSTAND OURSELVES
1. Using the chart below, take feedback from others (who know you) about what they think of you in a straightforward way, with no verbal communication.
First, the person who is giving you feedback fills in the column B YES or NO. You cover and do not see it. As a next step, you fill in column A. Now you have a chart which shows what you know you are and what others think you are - some will be the same and some will be different. If you do not agree with what your friend has written, you can ask them why they felt that way. E.g. You feel I often interrupt others. Why is it so? This is an example of the exercise that two students completed to demonstrate how the activity should be completed. Answers will be different for each student.
Are you someone who: 1. Keeps trying until you get success 36 2. Listens carefully to others and takes an active role in a group 3. Often interrupts others 4. Tends to decide in haste 5. Tries to make other feel comfortable 6. Waits for others to say hello first 7. Gets ahead by pushing others in the background No 8. Prefers to be by himself or herself Yes 9. Wants to do what is fun and does not worry about the future 10. Would try to get in the good books of your superior 11. Tells jokes 12. Would take the blame for a co-workers failure 13. Has a high commitment to your work group 14. Believes that most people can be trusted 15. Will let people take undue advantage of you
A Yes Yes No Yes Yes No No No No Yes No No Yes Yes No No No Yes Yes
B Yes Yes Yes Yes Yes No No Yes No Yes Yes No Yes Yes Yes No Yes Yes Yes
16. Is a difficult person to manage 17. Always has something to say 18. Asks others for help 19. Is satisfied with yourself 20. Is much too independent 21. Volunteers to help others 22. Gets upset under pressure 23. Tries to get things done 24. Will work for social welfare even if it means sacrifices for you 25. Wants things done in your own way 26. Makes friends easily 27. Has difficulty in saying NO 28. Is warm and friendly 29. Does things when it is most urgent 30. Does not tell or explain about himself to others 31. Does the minimum necessary 32. Prefers to work with others 33. Cannot keep a secret 34. Manages difficult situations 35. Lacks control of emotions 36. Is serious 37. Is highly result oriented 38. Is willing to consider and accept other's suggestions 39. Supports others 40. Takes personal responsibility for your own performance
No Yes Yes No Yes Yes Yes Yes Yes No No No Yes No Yes No No No Yes Yes Yes
No Yes No Yes Yes Yes Yes No Yes No No No Yes Yes Yes No No No Yes Yes No
3.3.5. THE JOHARI WINDOW See page 38 in the handbook (volume 1)
37
For each aspect of yourself, give an example based on what you have learnt from the last activity. 1. Open self the open part of me, which I know and which I show others. An example of this in the activity above is number 10, would try to get in the good books of your superior.
2. Hidden self the hidden part, which I do not want others to see e.g. anxieties, fears.
An example of this in the activity above is number 22, gets upset under pressure.
3. Blind self the part of me not known to me but is known to others. I am not aware of it but others are. An example of this in the activity above is number 3, often interrupts others.
4. Unknown self there is a part unknown to others and unknown to me also e.g. I do
not know I am capable of a skill and others also do not know. You cannot give an example of this now but you will be able to in the future.
3.3.7. GIVING FEEDBACK Choose one or two areas from the previous activity and plan the steps for your self development. This is an example of the exercise that the same student who completed in activities 1 and 2 to demonstrate how the activity should be completed. Answers will be different for each student. 17. Always has something to say After completing the previous activity I realised that I often want to give my opinion without listening to others. I can sometimes speak without thinking and therefore often say things that are not relevant to the conversation. I did not realise that I do this. I will now think about this in a different way. Before I speak in a group of friends, colleagues, or with my family, I will think about the following things: - I will make sure that other people have finished speaking before I speak. - I will think about what I plan to say and check that it is relevant to the conversation before saying it. I will decide if it is appropriate to give my opinion during the conversation. After considering the above points, it may not be appropriate to share my opinion and I should choose another time.
3.4. LEARNING DIARIES AND STYLES 38
3.4.2. HOW TO WRITE A LEARNING DIARY
See page 40 in the handbook (volume 1) Think of a recent situation where you learnt something and it gave you a feeling
I visited the house of Rajesh, a gentleman who previously had a stroke. When I was carrying out the assessment, I focused on his physical problems and did not assess his environment. He therefore still had difficulties walking around his house. I felt disappointed.
3.4.3. LEARNING DIARY EXAMPLE Think of an experience and what you learned from it. What happened? Describe in detail what happened (Who was there? What was said? What happened?).
I went to a rural community to assess Rajesh, a service user who recently had a stroke. He had weakness in his left upper and lower limbs and spent most of his time on his bed. I assessed his physical problems; his strength, balance, walking ability and transfers in and out of bed. We practiced his bed transfers, which he improved a lot and I gave him some strengthening and balancing exercises. I went back to Rajeshs house the next week, expecting to find him walking around the house. When I arrived, Rajesh was still on his bed and had not left his bedroom. When I asked him what the problem was, he told me that there was a small step between his bedroom and the living area, which he could not use himself. I did not think to ask him about his environment and did not realise that the step was a problem for him.
What went well? (What went well that you did?)

I practiced bed transfers with Rajesh, in which he improved very quickly. I actively listened to him when he told me about his physical problems.
What did not go well? (What did not go well that you did?)
I focused my assessment on Rajeshs physical problems and did not think about the difficulties he may have had in his environment. Rajesh therefore was still unable to walk around his house.
How did you feel?

I felt disappointed that I did not realise the importance of assessing Rajeshs environment and focused on his physical problems.
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What would you do differently?

Next time I assess a PWD, I will think more about the persons environment so that therapy will help him to carry out daily activities that are important to him.
What have you learnt?

I have learnt that a persons environment is just as important as his physical problems. If his difficulties in his environment are not considered, this will limit his ability to become independent.
3.4.4. LEARNING STYLES See page 42 in the handbook (volume 1) Think of something that you have learned. For example: a subject in class, a practical task, how to fix a bike, how to make a poster, how to make a splint etc. It could be anything. Use the space provided to note down your thoughts on the process. There are no wrong or right answers! This is an example of an activity that has been written by a student. What was the thing you wanted to learn? To play cricket Why did you want to learn it? To join in with my friends in the park Did you find the process easy? Why / why not? It was a little difficult as I am not very good at catching a ball and there were lots of rules to remember. I had to practice catching by myself to improve at this.
3.4.5. LEARNING STYLE QUESTIONNAIRE See page 42 in the handbook, volume 1 40 Complete the questionnaire on the next page to see how you learn best. Put a tick next to the answer you most agree with. For example: DOER I am a talker A B OBSERVER I am a listener C D
If you think you are very talkative put a tick under A. If you think you are a little talkative put a tick under B. If you think you are a bit more of a listener put a tick under C. If you think you are very much a listener put a tick under D.
This is an example of a learning style questionnaire that has been written by a student:
DOER I am a talker I like a step-by-step approach when I am doing something. I work at a fast pace I like to try things out to see if they work. I like change I am lively I prefer to do I answer questions I make things up as I go along I am motivated by the result I often interrupt others while talking
OBSERVER I am a listener I first look at the whole picture before I do something I do not rush and hurry things I like to think ideas through before I try them out I like stability I am quiet I prefer to watch I ask questions I plan I am motivated by how you get there rather than the result I like to listen and then give
my opinion Add up your total number of ticks A 2 B 2 C 7 D 0
Circle your highest score. Is it A, B, C or D?
FEELER I do things because they feel right I think about things emotionally I like to have an opinion about things I ask others for help I like experience I accept I feel I take risks I try trial and error I am people orientated I get involved I seek out others I give support Total number of ticks
1 0 2 6
THINKER I do things because they are logical 41 I think about things theoretically I like to have a theoretical reason for things I like to work alone I like ideas I question I think I calculate I plan it out I am result orientated I check for faults I work alone I offer useful criticism
3 7
4 0
Circle your highest score. Is it 1, 2, 3, or 4?
Put your highest letter score here C. Put your highest number score here 3. The two questionnaires are like two different types of approaches.
Feeler................Thinker Doer................Observer
In our approach to life and study we tend to use one approach more often than others. These four styles can be developed. You may use different approaches for different situations.
Transfer your highest score onto the following chart, e.g. your score could be A1 or D3. Which style does this place you in the grid?
FEELER 42
Enthusiastic (jumps in) 2
Imaginative (observes, feels and thinks)
DOER
OBSERVER
C3
Practical (likes to get the job done)
Logical (likes the theory behind the action)
THINKER
Now you know if you are enthusiastic, imaginative, logical or practical (or maybe a bit of all four). Lets see if you agree with what the chart says about you. Tick each answer if you think it applies to you. 43 ENTHUSIASTIC (Feeling plus doing)
1. I enjoy new situations 2. I rush into things 3. I use gut reactions X 4. I ask other peoples opinions and feelings 5. I like risk, change and excitement X 6. I look to the future 7. I can be impulsive 8. I rely heavily on a support network X
IMAGINATIVE (Feeling plus observing)

1. I see lots of different alternatives 2. I like to see a clear picture of the total situation 3. I use my imagination and fantasy 4. I do not hurry X 5. I cannot be pushed until I am ready X 6. I like to listen to other people 7. I like to share ideas with small numbers of people 8. I use my eyes, ears, listen and observe I learn best and am motivated by:
I learn best and am motivated by: 1. Trying new experiences 2. Games, exercises 3. Activities directly related to a future job 4. Working in groups
1. Discussion activities to reflect on experiences 2. Observing others X 3. Having time to prepare 4. Giving and getting feedback I learn least and react against:
I learn least and react against: 1. Standing back and watching others or working on my own 2. Lectures 3. Being too theoretical Number of ticks : 12
1. Being forced into the limelight X 2. Situations that require action with no planning X 3. Being given short notice
Number of ticks : 10
PRACTICAL (Doing plus thinking)

1. I like to solve problems X 2. I like applying theory to practical things 3. I have good detective skills, searching and solving problems X 4. I like to work towards goals 5. I like to be in control of the situation 6. I like to work on my own then get feedback 7. I use factual information, books, theories 8. I learn by testing out things
LOGICAL (Observing plus thinking)

1. I like to understand the theory behind the practice 44 2. I am good at relating different theory topics together 3. I am precise, thorough, careful 4. I am organised 5. I like to follow a plan 6. I react slowly (carefully) 7. I like to work out probabilities 8. I avoid being over emotional X I learn best and am motivated by:
I learn best and am motivated by: 1. A tutor who is the expert on the subject 2. Facing real problems relevant to work X 3. An obvious link between the subject matter and a practical problem 4. Practice and practical issues I learn least and react against: 1. Situations where I cannot see the obvious practical benefit 2. Teachers who seem distant from reality 3. Situations where I cannot use my learning
1. A carefully prepared lesson 2. Understanding the theory behind something 3. Lectures X 4. Theoretical activities I learn least and react against: 1. Doing something without an obvious purpose 2. Situations which emphasise emotions and feelings 3. Unplanned, disorganised lessons
See page 47 in the handbook (volume 1) 1. Which box has the most number of ticks? 45 The logical box has the most number of ticks. I have a logical learning style. 2. What are the advantages and disadvantages of your learning style? The advantages of my learning style are:
I am thorough and careful in my work. I find it easy to link different theoretical subjects I have learnt together. I am organised and follow plans well.
The disadvantages of my learning style are:

I find it difficult to do something unless it has a clear purpose. I do not work well if a situation is unplanned and disorganised. I do not learn well if I need to empathise with emotions and feelings.
These are some thoughts about how I can improve in other styles: Practical: I can experiment more to see if something works.
I can try and think about practical issues when a theoretical topic is being discussed.
Enthusiastic:
I can follow my gut feelings more. I can try out new experiences and become involved in activities in which I need to be more active.
Imaginative:

I can watch other people doing things more. I can ask more questions and think in a more creative way.
3.5. ETHICS See page 48 in the handbook (volume 1) Write down an example of your own46 code of ethics (a principle that you stick to). E.g. stand up for elderly people, no sex before marriage, respect elders, do not steal from others Some examples of ethical codes that a student may have are:
Never speaking badly about someone when they are not there. Never taking advantage of another person based on their race, sex or religion. Always looking after family members. Not interrupting people when they are speaking. Never harming another person either physically or verbally. CASE STUDY
As part of your job, you are doing your final checkout for an orthosis/ prosthesis. The service user says it is rubbing in the groin area. They are of the opposite sex and around the same age as you. You feel very uncomfortable about doing this. Look at the code of ethics and think about your own personal code of ethics.
1. What are the ethical issues? This situation may result in the following code of ethics being broken, if it is not dealt with correctly:
In the Code of Ethics (See code of ethics 3,4 and 5 on page 48 in the handbook, volume 1)
3. Have respect for PWD and their families at all times (whatever the caste, religion, language, socio-economic status of the person). 4. Provide services in a professional manner which focuses on the need of the PWD and his family. Financial, commercial and personal interests will be secondary. 5. Respect a PWDs privacy. Using an example of a students code of ethics above
Never taking advantage of another person based on their race, sex or religion. A health professional is providing a service to the service user and is in a position of influence. If the P&O checks the groin area and they are alone with the service user, it may seem like they are taking advantage of this position.
2. How will you deal with the situation?
47 It is best to ask another member of staff, who is the same sex as the service user, to carry out the assessment. If it is not possible to find a trained professional, then another member of staff (of the same sex as the service user) should be present during the assessment. Try and make sure that the service users family members are present so that she feels more comfortable.
3.6. TRAINING SKILLS
3.6.3. WHAT ARE THE DIFFERENT TRAINING METHODS?
See page 52 of the handbook (volume 1)
1. Name some training aids (teaching materials) you can use to help you when training people: Training aids can be used to teach many different people that you may come across in your work. These people include services users and their families, community workers and teachers. Examples of teaching aids you can use include:
Pictures and diagrams Models or samples e.g. of assistive devices Books Electronic equipment e.g. television or computer Instructions written in Braille Gesture and demonstration Poems/rhymes Written instructions in the persons mother tongue (local language)
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4.1. HEALTH CARE 4.1.3. HEALTH CARE SERVICES See page 56 of the handbook (volume 1)
Trainers Note This chapter discusses many health issues, services and facilities that are available in the local community. For many of the questions, the answers will be different, depending on the resources in the local area. The answers written here are either described generally, or give an example related to local communities in South India. This is to Discuss which factors of health are being addressed by the aims on the debate openly 1. demonstrate the way in which the question should be answered but students need to discuss andprevious and relate the discuss which community. page. Thenanswers to their owndimensions (aspects) of health might be affected if these
issues are not addressed. This table shows possible examples of factors and dimensions that may be affected by the aims. Many different examples are possible and should be discussed. Aim in 1978 WHO congress
Education about health problems and methods of preventing and controlling them
Factors of health that may be affected

Behavioural and Health Services
Aspects of health that may be affected if issues are not addressed

Physical and mental People in the community will have a high risk of disease, leading to disability. This is caused by factors such as: An unhealthy lifestyle Poor awareness about the prevention of diseases and the local availability of medical facilities. These factors will cause a high incidence of disability (physical and mental), which in turn will have an effect on the following aspects: Social Emotional
This can be demonstrated in the following examples: Education about activities with harmful health consequences. e.g. smoking. Education about health-promoting activities. e.g. vaccination programs. Education about how or when to access medical care. Vocationa l
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Aim in 1978 WHO congress Education about health problems and methods of preventing and controlling them continued Factors of health that may be affected Aspects of health that may be affected if issues are not addressed Physical and mental If health care is not affordable and people are not aware of the available facilities, the community will not be able to access the appropriate services. As a result, they will not be able to prevent and treat diseases, which may increase the incidence of disability. Again, this will have an effect on the following aspects: Social Emotional Physical and mental People in the community will use traditional methods of health care which are often ineffective at treating diseases.
Socio-economic
Some countries provide free healthcare which removes the barrier of cost for those who are unable to afford healthcare. Education about services and their availability will allow people who may not have known about them to access these.
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Socio-cultural
Health behaviours are often culturally determined e.g. the use of traditional, but ineffective treatments. Education can help change these socio-cultural factors.
Aging
Social People in the community may neglect the elderly as they may not understand the importance of addressing their health needs.
Education about common conditions seen in older adults and their prevention and management. e. g. awareness programmes about osteoporosis/diabetes and how they may be prevented with an appropriate diet. Promotion of food supply and proper nutrition Behavioural and Health Services Education about proper nutrition and a balanced diet. Socio-economic Provision of nutritious food at an affordable price.
Physical and mental People will not eat a balanced diet, which increases malnutrition. Malnutrition is one cause of higher rates of disability among people living in poverty. As above, this will have an effect on the following aspects:
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Socio-cultural
Education about how to include Vocationa

nutritious food in the local diet.
Social Emotional
Aim in 1978 WHO congress

An adequate supply of safe water and basic sanitation
Factors of health that may be affected 50

Behavioural and Health Services Education about hygiene, water and food borne diseases along with clean living conditions. Socio-economic Provision of access to clean water and the resources to get it.

Physical and mental Contaminated water and an unhygienic environment will result in high incidence of disease. This can increase the rate of disability, which will have an effect on the following: Social Emotional Vocational Physical and mental Conditions will not be detected before they have an impact on maternal/child health. The community will not have adequate knowledge of maternal and child health care and family planning. These factors will cause a high incidence of disability, which in turn will have an effect on the following aspects: Social Emotional Vocational
Maternal & child health care, including family planning
Biological and Health Services Ante-natal monitoring aims in early detection of conditions before they impact upon maternal/child health. Behavioural Education about the importance of maternal/child health care and family planning. Education about the importance of proper nutrition and a balanced diet during pregnancy. Socio-cultural Awareness programmes in the community to promote womens and child health. These could specifically address socio-cultural barriers e.g. in some cultures in India, food is given to the children and husband first at mealtimes. The mother eats after the family. If there is no food left, she must wait until the next meal.
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Aim in 1978 WHO congress

Immunisation against infectious diseases Prevention and control of endemic (common) diseases Appropriate treatment of common diseases and injuries Provision of essential drugs
Factors of health that may be affected

Behavioural and Health 51 Services Education about the importance of immunisation, prevention of common diseases and appropriate treatment. Education about the availability of appropriate health services within the community. Biological and Health Services Medical services aim to prevent, control and treat diseases before they impact upon a persons health. Health services aim to provide essential drugs for people in the community. Socio-cultural Education can create awareness in the community about effective medical treatments and discourage the use of traditional and ineffective treatments. Socio-economic Some countries provide free or affordable healthcare so that appropriate treatment is accessible to those with a low income.

Physical and mental People in the community will have a high risk of disease, leading to disability. This is caused by factors such as: An unhealthy lifestyle. Insufficient awareness of the prevention of disease and locally available medical facilities.
Insufficient medical services and supply of essential drugs in the community.
These factors will cause a high incidence of disability, which in turn will have an effect on the following aspects: Social Emotional Vocational
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2. Which aspects of health do you think are not included in box 1? Health does not only mean physical wellbeing. There are many other factors that affect a persons health, such as: Education Livelihood Empowerment Family well being and health
See page 57 in the handbook (volume 1) 1. Are there any core health services in your country or community? 52 These are core services provided by the government or national agencies. They will vary depending on the area you are living. Examples in Karnataka (South India) include: Primary health centres in the community. Government hospitals in cities and towns. Vaccination programmes. Sanitation programmes. Training of community workers. Awareness programmes about child health care and family planning. Epidemiological data collection.
2. Does your community have any other agencies involved in health care delivery? Dispensaries (private health care centres). Non-governmental organisations. Other health services include traditional or community healers. Rehabilitation centres. Insurance schemes (medical insurance provided by private agencies). Voluntary health agencies.
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Specialised government services e.g. Blind Control Society, Voluntary Counselling and Testing Centres (VCTC) (for HIV and sexually transmitted diseases [STDs]) and mental health services.
3. Which important health services does your community lack? Examples of the services lacking in a rural district in South India are:

Adequately trained health professionals in rural communities. E.g. in an area of 50-60,000 people, there is one doctor. The basic infrastructure of the primary health centres e.g. no facilities for hospital admission. Inadequate medical equipment and resources in the health centres. Insufficient provision of essential drugs. Inadequate mental health services. Inadequate diagnostic services.
4. Discuss how health and welfare is achieved in your community In the above example, the following services are provided by a local non-governmental organisation. 53
The facilitation of community participation (men, women, young people, elders and community organisations) in the following services:
Education about specific health issues and general community awareness programmes. Training community health workers to address the basic needs of the community. Advocacy and lobbying. When the community does not receive adequate healthcare, they inform the government and fight for services. Health check-ups, followed by assessment and referral to the appropriate resources. 5. Map out what health services are available within your community This is an example of a map of local health services in an urban slum in South India.
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6. Draw a diagram of a patient's journey from home to hospital and all the people they might meet along the way 54 This is an example of a diagram of a patients journey from home to hospital.
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There are many obstacles that a person may face on her journey between home and hospital when she has an illness. Examples of these include: Leave from work means loss of income (daily wages). Lack of awareness of local services. Lack of transport to access the service. Large distances between service facilities. Lack of money to spend on travel and services.
All of these factors result in the person having a longer and more difficult journey between home and hospital.
4.2. KEEPING HEALTHY
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4.2.2. NUTRITION See page 61 in the handbook (volume 1) 1. Find out which food groups common foods in your diet belong to. This answer depends on the community in which you live. This is an example of food eaten in rural areas in South India.

Carbohydrates. Examples of these are chapatti, rice, pongal, idli, dosa, and potato. Proteins. Examples of these are dal, beans, channa, egg, fish, meat. Fruits and vegetables. Examples of these are papaya, banana, coconut, green leaves and tomatoes. Sugary or fatty foods. Examples of these laddu, poori, bhaggi and samosa. Dairy products. Examples of these are milk, curd and cheese.
Food that is typically eaten throughout a day may include: Breakfast - Idli, sambar (made with dal and vegetables) and tea. Lunch - Rice, dal, (seasonal and affordable) vegetables and curd. Evening Coffee/tea. Dinner Chapatti, dal and (seasonal and affordable) vegetables. 2. Is your diet balanced? If it is not, think how you would need to alter it to make it balanced. The diet in question 1 is not balanced. This diet contains a lot of carbohydrates. Although vegetables are eaten often, there is a lack of variety as they can be expensive. In Indian food, they are often cooked for long periods, which can cause them to lose their nutritional value. Fruit could be added to ensure a greater variety of nutrients. Dal is a source of protein, however, adding fish, meat or eggs to the diet would provide a more substantial source. Fish and meat are sometimes expensive in South India (depending on location) but eggs are commonly available. Dairy products like milk and curd should also be added to the diet along with a small amount of sugary or fatty foods.
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Trainers Note
It is important that throughout every day, food is eaten from each of the 5 food groups.
The table below includes a few examples of foods that are eaten in India. Students may think of other foods that are eaten in their community.
Compile be found by the of common foods in your community, their calorific 3. information cana simple list students going to the shop and reading the information available on The content, food (a good activity to and their nutrient (vitamin and mineral) content. packets of their food group do for homework).
Sometimes all of the information described in the question is not available on packets of food e.g. some food companies do not provide information about56 vitamin and mineral content and only basic information such as calories, carbohydrates, protein and fat are provided. The purpose of the question is for the students to gain a basic understanding of a healthy diet. Aim for the students to understand that the diet should include a balance of food groups, as discussed on page 59 in the handbook (volume 1). Encourage the students to find out about the vitamin and mineral content of foods if possible (the most important ones being vitamin A, C, D [This is in some foods. Sunshine is also important], calcium, iron and protein). It is important for the students to gain an understanding of what happens if these vitamins and minerals are not present in the diet e.g. protein energy malnutrition.
These are examples of basic information that can be found in India on many food packets. Some food packets may give information about the following vitamins and minerals. For example:
Energy per 100g (kcals) 152.89 148 219 255 62 344 Protein( g) per 100g 4.99 6.0 8.0 9.20 4.1 6.7 Fat (g) per 100g 1.29 6.2 11 1.70 3.1 0.5 Cholesterol (mg) per 100g 0.0 Information not available 7 0.0 8 Not a sufficient source Carbohydrate (g) per 100g 30.33 17.1 22.0 50.0 4.4 77
Food Item Idli Rajma massala Dal makhani Bread Curd Rice (uncooked)
Food Group Carbohydrate Protein Protein Carbohydrate Dairy Carbohydrate
Further reading in the handbook (volume 1) See page 59 for more information about the ideal composition of a healthy diet 57
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Food Item
Dal makhani Curd Rice Moong dal (uncooked)
Iron (mg)
per 100g 2 Information not available Not a sufficient source 3.9
Vitamin C (mg)
per 100g Information not available Information not available Not a sufficient source 0.0
Vitamin A (mg)
per 100g 0.12 0.075 Not a sufficient source 0.05
Calcium (mg)
per 100g 79 183 Not a sufficient source 75
4. Devise a nutritious meal for an 18 month old child A nutritious meal for an 18 month old child should include all the food groups, in the correct proportions. This is an example of a nutritious evening meal that can be given to an 18 month old child in South India.

1 small cup of rice (carbohydrates) or half a chapatti (carbohydrates). 1 large spoonful of dal (protein). Half a boiled egg (protein). 2 pieces of papaya, or any locally available fruit (fruit and vegetables). 1 small spoonful of curd (dairy) with a small spoonful of sugar (sugary or fatty foods).
4.2.3. LIFESTYLE See page 63 in the handbook (volume 1) In small groups: 1. Discuss and choose the three most important lifestyle messages for the health of your community. Three examples of lifestyle messages that may be important for a rural community in South India are:
Access to timely healthcare. This does not happen because of lack of knowledge of available services in the community, lack of transport and money. Womens health. Women are not appropriately educated about womens health such as menstruation, infections, anaemia and maternal health. Smoking and drinking. Often men spend their income on these activities rather than providing for their family. Alcohol related abuse is also common.
2. For one of these issues, compile a list of who, within the community, does this issue affect and how?
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An example that has been chosen here for discussion is womens health. This issue affects women of all ages. Pregnant women
Often there is a lack of awareness of available maternal health services and the importance of regular health checks during pregnancy. Many women in the rural areas are in poverty and cannot afford to access the appropriate services. Most health problems during pregnancy are related to inadequate nutrition e.g. anaemia. Children with disabilities are often born into a family with these issues and the children, husband and other family members are strongly affected. Teenage girls
There is a lack of sex education and awareness of issues such as puberty, menstruation and young pregnancy. This is especially common if she does not go to school and has an early 58 marriage. Elderly women
These women are often unable to work because of age and poor health. She is reliant on her family for her food and income. In many communities, older womens health needs are not seen as important and are not addressed (due to poverty and lack of awareness). 3. What resources exist within your community that address this issue and how does your community access them? This is an example of the womens health services existing in a rural district in South India.
Primary health centres and local government hospitals provide womens and childrens healthcare but these are not enough to meet the communitys needs. The government provides the specialist service Voluntary Counseling and Testing Centres (VCTC) for HIV and STD patients. Currently there are limited awareness programmes being run on this topic in the community and many women do not have knowledge of the available services. 4. What other resources are needed and who might be responsible for developing or setting them up?
Relating to the example in questions 2 and 3: Adequately trained womens health professionals in the rural communities.
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Infrastructure to provide primary health centres for maternal and womens health. Adequate medical equipment and resources in health centres for womens needs. Essential drugs needed for maternal care and womens health. Awareness programmes in the community about womens issues.
The government is responsible for setting up and developing these services. Community support is also needed so that the government understands community needs and how best to meet them.
4.3 . WOMENS HEALTH
See page 64 in the handbook (volume 1) 1. Think of a typical man and woman59 your community. Make a list of all the in work/chores each of them do during the day, from waking to going to sleep. This is an example of the work/chores that a typical man or woman often does in rural South India. Activities will be different in other communities. TIME 5.00 am 6.30 am 7.30 am MEN Get up and have coffee/Tea WOMEN Wake up and clean the home Prepare coffee/tea Prepare breakfast Get the children ready for school Prepare and organise food for their children Have breakfast and go to work e.g. in the field/workshop 8.30 am 9 am 10 am 11 am Sometimes take the children to school Serve the children/husband/other family members breakfast Take the children to school Eat breakfast Cleaning utensils and clothes Prepare lunch
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12 pm 2 pm 3 pm 3.30 pm 4.30 pm 6 pm 10 pm Have lunch and go to work e.g. in the field/workshop Go for household work e.g.to the farm Serve the children/husband/other family members lunch Eat lunch Pick up the children from school Household chores Prepare dinner Serve the children/husband/other family members lunch Eat dinner Clean utensils and go to sleep
Eat dinner and go to sleep
11 pm
2. Think about how these cultural differences between men and women might impact upon womens health.
There is an inequality between the expectations and activities of women compared to men. She is expected to look after the home, the children and sometimes she is also expected to 60 work. In the example above, the woman always eats her food after the family has eaten. There may not be enough food to go round and then she does not receive enough nutrition. Men are expected to go to work but generally do not help with household chores and it is common that women do not get enough support with these.
Women are at risk of developing problems physically, mentally and socially due to these cultural differences.
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Physical: Problems may include weakness, anaemia, menstruation problems, maternal deaths (if pregnant) and diabetes. Mental: The stresses and demands on women are great, which may put her more at risk of depression and anxiety (especially if she is not treated well by her husband). Social: Women generally have a lower status in society and are more at risk of mistreatment and violence.
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3. What access do women have to healthcare resources in your community? In South India, womens health and maternal care are inadequate in rural areas and some urban slums. Medical services are less accessible and act less favorably towards women who have already been marginalised by poverty and discrimination. 4.3.3. POST-NATAL CARE (CARE AFTER DELIVERY) See page 68 in the handbook (volume 1) In small work groups: 61
1. Discuss and prioritise the key message in womens health Some key messages in womens health are: Poverty Many women are not able to earn an income and are reliant on money from their husband and family. They have no control over the money they receive and this is often very little. Poverty is a large cause of malnutrition and inability to access womens medical services. The low status of women in society Women are seen as less important than men and often fewer services are provided for their needs, especially in rural areas. They have little power over their lives and their health and are often unaware about their health needs, especially during pregnancy. Inequality
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Women receive less food than men, which causes problems with development and may affect childbirth. Other physical problems discussed on page 62 (in the answer book) are common for this reason. Violence This is common against women and can cause physical injuries, disabilities, mental health problems and even death. Often women do not speak out if they are a victim of violence and there are inadequate facilities available to support their needs. Maternal health problems During pregnancy, women often do not receive regular check-ups and family planning advice. There are many reasons for this (see question 2 on page 64 in the answerbook), mainly inadequate services and the lack of awareness, empowerment or money to access the services that are available. Anaemia This is a large health problem in pregnancy in low income countries. This is mainly because of inadequate education and nutrition among pregnant women.
2. Discuss some of the reasons why mothers in your community might not come for ante-natal check-ups. There are many reasons why a mother may not come for anti-natal check-ups. The reasons will 62 be different for each individual. Some common reasons may include:
Poverty she may not have enough money for travel expenses. The low status of women her health may not be seen as important by the family. E.g. if she needs to look after other children or carry out work at home, an anti-natal check-up may not be seen as a priority. Lack of awareness she may not understand the importance of attending (e.g. if older family members also did not attend), or where the facilities are.
Further reading in the handbook (volume 1) See page 66 for information about anaemia.
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Fear she may not understand what will happen at the check up and is anxious about attending. Insufficient family support e.g. if her family do not encourage her to go or do not come with her or help her with her chores, this makes it more difficult for her to attend. 3. Think about ways you might be able to communicate the importance of ante-natal checks and the messages of a healthy pregnancy to the mothers in your community. Some examples of these include:
Awareness programmes on maternal health, nutrition and a balanced diet. Video shows in the community on ante-natal health check-ups and their importance. The use of a maternal health guide who speaks the local language. She can discuss issues in a womens group/self-help group. Display posters in community centres, primary health centres and local doctors. Health camps (organised in the community to provide various services e.g. general health checks).
4.4. CHILD HEALTH See page 69 in the handbook (volume 1) 63 1. Despite the immunisation schedule, a number of children in India are still not immunised. There are many reasons for this, can you think of some?

Lack of belief in the importance of immunisation and how it works in disease prevention. Lack of awareness about facilities where immunisation takes place. Ineffective implementation of immunisation programmes resulting in some members of the community not accessing services. Lack of trained health professionals and community workers.
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Many people cannot afford to travel to health centres for immunisation.
2. Think about your communitys beliefs about vaccines. Is there a good vaccination programme? This is an example of communities in South India, who have received input from a local nongovernmental organisation (NGO).
Prior to input from the NGO, many people did not believe that vaccines were important and did not understand how they helped prevent disease. Understanding has improved and parents are aware of the importance of vaccinations in urban slums, due to the NGO organised programmes. This is less true in rural communities, where access to and awareness of vaccination programmes is more difficult. Vaccination programmes have also been aided by the government, which has improved awareness. More facilities have become available in primary health centres and anganwadis (school that young children attend before primary education). 3. How might vaccination uptake be improved for your community?
Some examples include: Awareness programmes. Gaining the support of community leaders and local panchayats to help improve awareness. Providing regular monitoring and follow-up in anganawadis, primary health centres and government hospitals.
E.g. are t
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65 65
Chapter 5
Assessment Principles and Intervention Planning
5.6. INVOLVING THE FAMILY WITH INTERVENTION PLANNING See page 85 in the handbook (volume 1) Why is it important to involve the family with intervention planning? Family members play a very important role in intervention planning because:

They understand what abilities the person has and what problems she faces in her day to day life. They can speak on her behalf if she is unable to communicate. If family members are involved, they will understand the reasons for the goals and interventions that have been suggested and will be more likely to: Give the person encouragement to do activities and exercises (and help if needed). Remove barriers to achieve goals at home. Include the PWD in family and social activities.
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Section 2
Chapter 6
Anatomy and Physiology
6.1. BODY PARTS See page 88 in the handbook (volume 1) Label the body parts by putting a letter in each box:
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6.2. POSITIONS OF THE HUMAN BODY See page 89 in the handbook (volume 1) Terms of position and direction all relate to the anatomical position (shown in the picture). Label the boxes and arrows by putting a letter in each box.
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See page 90 in the handbook (volume 1) 1. Why do you need to know the names of body parts and positions of the human body? Body part names are used by everyone, so that it is clear which part of the body is being talked about. It is important to know the names of body parts, so when different parts of the body are discussed with service users, families, and health professionals (people working in health care), it is clear which part of the body is being referred to. Positions of the body (e.g. prone lying, long sitting) are mainly used by people working in health care e.g. doctors, P&Os and therapists. This language is the clearest way to describe positions when discussing the care of service users, so that there is no confusion. Understanding of the normal parts and positions of the body is needed to identify when there is a problem, what it is and how to describe it.
Here are two examples which show the importance of knowing the parts and position of the body:
Normal Position
Sitting
Abnormal Position
Body Parts involved in the Position

Buttocks, hips, thighs, knees, legs, ankles and feet. Hips, thighs, knees, legs, ankles and feet.
Potential Cause of Abnormal Position

Cerebral palsy (CP)
W- sitting
Walking
Waddling gait
Muscular dystrophy
2. Will you use these words when talking to service users? Explain your answer. No, these terms are difficult for the service user and her family to understand. To help them understand it is always better to explain to them in their own mother tongue (if possible), using simple language. You should never use medical terms and technical words with service users or families, unless they ask you to.
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6.5. FOOD AND NUTRITION See page 93 in the handbook (volume 1) 1. In your region, what types of foods do people eat? Which food groups may some people be missing and why? This answer will be different in different communities and countries. Examples of foods that are often eaten in South India are:

Rice and dhal. These are the main ingredients. Wheat and ragi are also used for cooking. Coconut is used in small quantities.
The food groups that some people may be missing include: Proteins. Large amounts of these can be found in meat and eggs. Often meat is expensive and many people do not buy it. Fruit and vegetables. These are used in lots of South Indian dishes but they are often seasonal and (especially in rural areas) there is not much variety. Many vitamins and minerals may be lacking in the diet because of this. Foods containing dairy products. Curd is eaten a little and milk is drunk mainly in tea and coffee. Some people may not be eating/drinking enough of these.
2. What problems could be caused by a diet that: a. Does not include all the food groups? This table explains some conditions that may occur if essential vitamins and food groups are not included in the diet: Deficiency
Iron Vitamin C Calcium and Vitamin D Protein Vitamin A
Problems that may occur

Thinness of the blood (known as anaemia). This can cause tiredness and weakness. Bleeding gums, tiredness and pain in the muscles and joints of the legs and feet. Dry skin and swelling of the hands and feet is also common. Weak and underdeveloped bones. Bone deformities. Swelling in the arms, legs and face. Wasted muscles. Sore and pale skin (known as Kwashiorkor). Night blindness, dry eyes and eventual blindness if not treated.
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b. Does not have enough nutrition? Not having enough nutrition in the diet causes malnutrition. The problems that may occur as a result of this are:
Reduced normal growth and development. Impaired intellectual and social development. More frequent illness. If a pregnant woman is malnourished, Further reading in the handbook (volume 1) there is a higher risk that the baby will be born with Cerebral Palsy (CP) or See page 59 for more information about malnutrition. intellectual disability (ID). Loss of body weight. Tiredness. Dizziness.
3. If you identify that a service user has a poor diet, what do you think you could do?

Explain the importance of eating a balanced diet and how it helps to prevent health problems. It is important to tell them how to do this using locally available food that is not expensive to buy. If it is a community wide problem, an awareness programme can be conducted on health and nutrition.
Give a friend a glass of water and some rice: a. When they are lying down b. When they are sitting up Was it easy or difficult to swallow? Why? a. When lying down swallowing is more difficult. There are a few reasons for this:

The windpipe (trachea) is open and not protected by the epiglottis, so it is possible for food to enter the lungs when it is swallowed, which can cause coughing or choking. The muscles that are involved in swallowing are not in an effective position, which makes it more difficult for the food to pass from the mouth to the oesophagus.
b. In sitting it is easier to swallow. The reasons for this are:
The epiglottis closes across the trachea when food is being swallowed, preventing food entering the lungs.
The muscles that are involved in swallowing are in a more effective position so work better and the food passes easily from the mouth to the oesophagus.
6.6. RESPIRATORY SYSTEM See page 94 in the handbook (volume 1) 1. Why do we need oxygen and food? Oxygen and food are both needed to create energy. All systems of the body need energy e.g:

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To clean waste products out of the body. To fuel the body's muscles. To strengthen the bodys immune system. To keep the heart pumping and healthy. To stimulate the lungs to breathe.
2. What stops food and drink from entering the wind pipe? The epiglottis closes over the wind pipe (trachea) when swallowing. 3. What can happen if it does? Sometimes, when food or liquid enter a persons windpipe, coughing or throat clearing cannot remove it. Food or liquid that stays in the windpipe may enter the lungs and create the chance for harmful bacteria to grow. A serious infection (aspiration pneumonia) can result. This can be fatal (i.e. it can cause death).
6.7. CIRCULATORY SYSTEM: HEART, BLOOD VESSELS AND BLOOD See page 96 in the handbook (volume 1) 72 1. What will happen to our brain if we do not have enough oxygen in our blood? The brain will be damaged if it does not get enough oxygen. Brain cells are very sensitive to low oxygen levels. Some brain cells actually start dying less than 5 minutes after their oxygen supply disappears. As a result, lack of oxygen to the brain can rapidly cause death or severe brain damage.
2. Name some situations when the brain may not get enough oxygen Examples of situations when the brain may not get enough oxygen are: Choking Drowning Suffocation Smoke inhalation (this can cause lung damage)
6.8. URINARY SYSTEM See page 97 in the handbook (volume 1) 73 1. Amina is at her friends house and she needs to go to the toilet. What is she going to do? The structure of the toilet is not accessible for Amina. She cannot use it independently and may feel uncomfortable asking for help. For this reason, she may avoid using the toilet at her friends house and wait until she returns home. 2. Amina sometimes solves this problem by not drinking enough water. Why is it very important that she does not do this? Less water in her bloodstream causes her urine to become more concentrated. This increases her chance of getting a urinary infection. She also has a greater chance of becoming dehydrated. 3. How could you make it easier for her to use the toilet? It is important to educate Amina about the problems she could have if she avoids going to the toilet. These are a few suggestions of what Amina could do, depending on the situation: Using an incontinence pad (a pad that is used by people who are unable to control their urination) is one way Amina can manage the situation independently. This can be made at home (e.g. using old clothes) or purchased from a local store.
She could discuss her difficulties with her friend and the family and ask for their assistance. She could use a bed pan or portable toilet chair. Aminas friends family may be able to help her by modifying the toilet to make it easier for her or Amina may be able to use another toilet in a more suitable place.
6.9. SKIN See page 98 in the handbook (volume 1) 74 1. If your nerves (sensation) are damaged, what kind of problems would you have?

Numbness or insensitivity to pain, temperature or touch. Tingling, burning, or prickling feelings. Sharp pains or cramps. Extreme sensitivity to touch (even light touch).
2. What condition could cause your nerves to be damaged? Examples of some conditions are:
Diabetic neuropathy Peripheral nerve injury Leprosy (Hansens disease)
3. Why is it so painful when you get a superficial burn? A superficial burn involves only the top layer of skin, which is full of sensory nerve endings. Burns affecting deeper skin may hurt sometimes but are less painful than superficial burns.
The skin is red and dry and usually painful. The burned area may also swell which causes pressure on pain nerve endings. Any movement of the area will cause stretching of the skin and this increases the pain. 4. Why is it important to prevent infection if you get a wound? It is important to prevent infection because it can prevent the wound from healing properly. Infection is caused by bacteria entering the wound and can lead to sepsis (infection of the bloodstream). It can lead to amputation or death if it is not treated.
5. If a service user has a wound and it becomes infected, what should you do? The service user should go to the nearest health centre for appropriate treatment of an infected 75 wound. If they are not able to get to a health centre straight away, you can help by keeping the wound clean. Wound care involves:

Rinsing the wound with clean water. Putting antiseptics such as Dettol or Savlon on the wound to help remove bacteria. Covering the wound with gauze, cotton, bandages or adhesive plasters so that dirt and dust do not get inside it.
6.10. THE SKELETAL SYSTEM AND THE JOINTS 6.10.1. OVERVIEW OF THE SKELETON See page 99 in the handbook (volume 1) 76
Label the arrows with the correct bones to label the skeleton
6.10.2. BONY LANDMARKS See page 100 in the handbook (volume 1) 77 Label the skeletons with the following bony landmarks:
6.10.3. OVERVIEW OF BONE See page 101 in the handbook (volume 1) 78 1. When does bone need to grow?
In children as they develop and grow to their adult height. After a fracture the broken parts grow and then join back together.
Bone cells are constantly changing and laying down new bone, which is a lifelong process. 2. How does it grow? Bone is a living material. Bones are made of calcium which is laid down by cells. As children grow, special cells at the end of bones add new calcium to the growing bone. Children have layers of these cells in the shape of plates at the ends of their bones. These are called growth plates (in the epiphysis), and they close up when children reach their full adult height. 3. Bone needs calcium to grow - what foods are good sources of calcium? There are many foods which are a good source of calcium. Some of these include:

Milk and products made from milk, such as cheese and yoghurt. A vegetarian diet is one of the richest and most beneficial sources of calcium. Vegetables such as turnip greens, mustard greens, cabbage, broccoli and spinach are good sources of calcium.
6.10.7.THE SPINE AND SPINAL CURVES See page 109 in the handbook (volume 1) 1. Name the three normal spinal curves The cervical (lordosis), thoracic (kyphosis) and lumbar (lordosis) curves.
2. Some conditions can affect the spinal curves and cause spinal deformities. Give two examples of conditions that can affect the spinal curves and the deformities that can result: 79 a. Polio can cause a scoliosis. b. Tuberculosis can cause a larger than normal thoracic kyphosis.
3. For the examples you have given, explain WHY the spinal deformities happen. Polio: Scoliosis occurs because of paralysis of the muscles in the trunk of the affected side. It also happens because of limb shortening. Tuberculosis: Excessive thoracic kyphosis occurs because infection causes the vertebrae to collapse.
6.11. THE MUSCULAR SYSTEM

6.11.1.
THE STRUCTURE OF SKELETAL MUSCLE
See page 111 in the handbook (volume 1) 1. In order to work, a muscle needs a message from the brain and energy to contract. Where does the energy come from? The energy comes from food and oxygen. 2. What would happen to the size of your skeletal muscles if: a. You exercise every day? The size of muscle belly would increase. b. You have an accident and your legs become paralysed? There would be a decrease in muscle mass, called muscle wasting.
6.11.2.TYPES OF MUSCLE CONTRACTION See page 112 in the handbook (volume 1) Could you still bend your elbow joint if80 elbow extensors did not relax? Tick the the correct box and explain your answer:
NO Because the elbow extensors are pulling the elbow in the opposite direction, the elbow cannot flex.
6.12.3. THE SPINAL CORD See page 121 in the handbook (volume 1) 1. If you fall out of a tree and damage your spine at a lumbar level, what parts of your body could be affected? The lower limbs will be affected. Bladder and bowel control may also be affected. The severity of the injury depends on whether or not it is a complete or incomplete spinal cord injury (SCI). If it is complete, there will be no movement or feeling in the lower limbs below the level of injury. If it is an incomplete SCI there will be some movement and sensation below the level of injury. The term used to describe a spinal cord injury which affects the lower limbs is paraplegia.
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Chapter 7
Child Development and Developmental Delay
7.2. WHAT ARE DEVELOPMENTAL MILESTONES? See page 124 of the handbook (volume 1) What is voluntary movement? Give an example: It is a purposeful goal directed movement. An example of this is writing. What is involuntary movement? Give an example: Movement without a purpose is called involuntary movement. An example of this is a tremor. When a small baby holds your finger, is he trying to tell you not to go away, or is it a reflex? No he is not trying to tell you not to go away. This is called a grasp reflex.
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CASE STUDY: NINA Nina is 3 years old and has cerebral palsy. She still has trouble holding up her head or sitting without falling over. However, her mother is sure she is almost ready to walk. Several times each day she holds Nina in a standing position and moves her forward, so that her feet take stiff, jerky steps on tip toe. Her mother does not know that this stepping reflex is normally seen in young babies. It means that in some ways Ninas development is still at the level of a 1 to 3 month old baby. She is not ready to walk. Making her step will only keep the early reflex active, which she needs to lose in order to walk properly. We must help Ninas mother realise that Nina needs help with other important development steps before she will be ready to learn to walk. To help her develop further, her mother will need to work out what developmental stage Nina is at. She can then decide what skills to start to build on to the ones she has now, in the same order in which a normal child develops. Imagine you are working in Nina's village. You help her mother to work out what developmental stages Nina is at. Draw circles on the two development charts on pages 128 to 131, using the information below (you should photocopy them before you draw on them, so you can use them for all your assessments):

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Nina has trouble holding her head up. Nina sits with her back supported or by using her hands. Nina needs help to roll from her tummy to her back. Nina can pick up her toys and play with them using both hands. Nina likes looking at her brother's school books and her father's newspaper. Nina knows if a visitor is coming as she can hear the dog barking. Nina listens to her father telling her mother about his work. Nina can say some words but people find it difficult to understand her. She normally gives up and points to what she wants.
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These are the reasons for the suggested answers on the child development charts. For some of the activities that Nina does, development is achieved in more than one area e.g. hearing and attention and interest. The following is a guide only and students may have different suggestions for some of the activities.
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Ninas Current Ability

Nina has trouble holding her head up.
Type of Development
Physical development; head and trunk control.
Development Level Circled on the Chart

Holds head up briefly.
Skill that Training Needs to Focus on

Holds head up high and well.
Reason
Nina can hold hear head up sometimes but finds this difficult. More practice is needed so she can hold her head up high and well. The highest level of development that Nina has achieved is sitting with hand support. The next skill she needs to develop is to be able to sit without support. Nina needs more practice to be able to roll from her tummy to her back independently.
Nina sits with her back supported or by using her hands.
Physical development; sitting.
Sits with hand support.
Begins to sit without support.
Nina needs help to roll from her tummy to her back. Nina can pick up her toys and play with them using both hands.
Physical development; rolling.
There is nothing appropriate to circle on the chart.
Rolls belly to back.
Physical development; arm and hand control.
Passes objects from one hand to the other.
Grasps with thumb and forefinger.
Nina shows that she has enough arm and hand control to pass objects from one hand to the other. She needs to improve her arm and hand control further by practicing grasping with her thumb and forefinger.
Mental and social development; play.
Plays with simple objects.
Begins to enjoy first social games (peek-aboo).
Nina can play with toys, which suggest she can play with simple objects. She needs to develop her play skills by practicing social games.
Ninas Current Ability

Nina likes looking at her brothers school books and her fathers newspaper. Nina knows if a visitor is coming as she can hear the dog barking.
Type of Development
Physical development; seeing.
Development Level Circled on the Chart

Looks at small things/pictures.
Skill that Training Needs to Focus on

See small shapes clearly at 6 metres.
Reason
Nina likes looking at the books and newspaper, which is an indication of the development of her sight. She needs to develop her ability to see small shapes clearly, further away.
Physical development; hearing.
Turns head to sounds.
Responds to mothers voice.
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This suggests that Ninas hearing is developing as she is able to hear the dog barking. Although she can hear, she has not yet learnt to respond. She needs to learn how to respond to her mothers voice.
See page 126 in the handbook (volume 1) Can you now make some goals and an intervention plan for Nina? These are some examples of goals that could be made for Nina: Goal
To be able to hold her head up independently (whilst in the prone position) whilst playing with her toys for 5 minutes in 4 months To be able to roll from the prone to supine position independently in 3 months To be able to sit unsupported whilst she eats her breakfast (with her mothers help for feeding) in 5 months.
Intervention plan
Positioning e.g. using a prone board, if available or pillows on the floor. These can be used for play and her toys can be placed above her head to encourage Nina to look up.
Place her favorite toy on one side and encourage her to roll over and reach it (with assistance initially). Sitting balance training e.g. sit with one hand support and progress to sitting without support. This can be done while keeping Ninas attention with toys or her brothers school books. The corner of the house is a supportive environment and can be used to practice this.
To be able to use 10 simple, single words clearly, when prompted, in 6 months.
Teach her simple words such as ma, pa, then 2 syllable words like mama and papa. Gradually increase the number of words and teach the words that are used in everyday activities e.g. eating, drinking and toileting.
Trainers Note These are just examples of goals that could be written for Nina. Trainers and students may think of different goals, which are also relevant. When thinking of new goals, it is important to make sure that they are specific to Nina and that they are SMART.
Further reading in the handbook (volume 1) See page 84 for more information about SMART goals
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See page 127 in the handbook (volume 1) Nina's mental development is around age 2 years. Using the diagrams below to help you, discuss what you think are the causes for Nina's delayed mental development.
It is not clear exactly how cerebral palsy (CP) has affected Ninas brain, but we can discuss the different factors that may have contributed to her mental delay. Ninas delayed mental development could be caused by: Conditions inside the head: Cerebral palsy (CP) may have caused damage to Ninas brain. Ninas brain may also be small, or not complete. Conditions outside the head
Ninas physical disability makes it harder and slower for her to develop the use of her mind. She has no independent head control and has difficulty sitting independently.
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This makes it difficult for her to see what is happening around her, interact with people and explore her environment. Because of this, Ninas brain is not being used fully (as she does not have enough stimulation). This is more likely to be the main cause for her mental delay. The reason for this is that her mental delay is not very much, compared to her severely delayed motor development. This motor delay may be enough to cause some mental delay. Assess a normal child and a child with developmental delay. Make circles on the physical and social/mental charts for each child.
Discuss what you think you might do to help the child with developmental delay to progress (use the box on page 132 to write notes).
Please see page 86-9 of the answerbook, for an example of an assessment of a child using the development charts.
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E.g. are t
8.4. AXIS AND PLANE See page 135 in the handbook (volume 1) Open an umbrella and describe the planes and axes. When an umbrella is opened, the fabric in its open form represents the planes. The central rod connecting the upper part with the handle represents the axis.
The axis and planes are always perpendicular (at 90 degrees) to each other and an open umbrella shows all the planes and axis when held in different directions e.g. facing the front, facing the sides and facing the top.
2. Which body movements can you see in each of the three planes?
a) Frontal plane: Abduction and adduction. b) Sagittal plane: Flexion and extension. c) Horizontal or transverse plane: Pronation and supination.
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8.5. FORCE, WEIGHT AND APPLICATIONS OF FORCES See page 136 in the handbook (volume 1) 1. Take a rope and in two teams, pull from each side. Which side moves and why? For example, the magnitude (amount) of force applied by the two boys in the picture is more than the force applied by the girl. The girl moves towards the boys.
2. For each of the pictures below, which direction will the square move in?
The square will move up with a net force of 400N
The square will move down with a net force of 200N
The square will move to the left with a net force of 20N
[1200 800 = 400]
[50 50 = 0. 0 + 20 = 20] [800 600 = 200]
8.6. NEWTONS LAWS See page 138 in the handbook (volume 1) 94
Explain what is happening in the pictures above and why? Here are the examples of Newtons third law
1. The car travelling at low speed hits the tree. There is only a little
damage done by this accident to the car. The force applied to the tree is small (action) and the reaction force applied back onto the car (reaction) is equally small.
S l o w c a r h i t s t r e e
2. The car travelling at high speed hits the tree. There is a lot of damage done by this accident. The force applied by the car to the tree (action) is high and the force applied by the tree to the car (reaction) is equally high. Large damage is caused due to the impact.
F a s t c a r h i t s t r e e
3. The flower falling from the tree onto the
The force applied by the flower to the head the force produced by the head to the equally small. These small forces mean the
F l o w e r f a l l s o n
ladys head is light. (action) is small and flower (reaction) is head is not injured.
t h e h e a d
Coconut falls on the head
4. The coconut is falling from the tree onto the persons head. The coconut, being heavy, causes a large force when it hits the head (action) and the force produced by the head (reaction) is equally large. This causes larger damage due to the impact. The head is injured and the person is unconscious so is taken to the hospital.
8.7. GRAVITY See page 140 in the handbook (volume 1) 95 Locate the centre of gravity in these pictures.
Lying supine: The centre of gravity is at the level of the 2nd sacral vertebra.
Standing: The man in the picture on the right looks like hes had a stroke affecting his right side. His centre of gravity has moved to the left because he is weight bearing more on his left side. It falls between the base of support, closer to the left foot.
Standing on one leg: The centre of gravity has moved upwards and towards the left side of the body. The weight bearing line passes through the left foot.
See page 143 in the handbook (volume 1) 1. Which is more stable and why? A wooden block OR an iron block of same size and shape. An iron block is more stable because iron is heavier than wood. 8.8. LEVERS See page 144 in the handbook (volume 1) 96 1. For each of the pictures below label: fulcrum, weight, effort and name which class of lever it is. Nodding the head:
The neck extensors act as an effort (E), the atlanto occipital joint as a fulcrum (F) and the front part of the face acts as weight/load (W). This is a first class lever.
Raising the heel: The metatarso-phalangeal joints (joint between the phalanges and metatarsals) are the fulcrum (F). The upwards pull of the Tendo-Achilles (TA), acts as the effort (E ) to raise the heel and the weight of the body directed downwards, acts as the load/weight (W), which is being raised. This is a second class lever system.
Lifting the bucket: The insertion of biceps in front of the elbow joint, acts as the effort (E) and the elbow joint acts as the fulcrum (F). The weight the hand (the bucket) and the gravity acting on the forearm acts the load/weight (W). This is a third class lever system. in as
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Chapter 9
Gait
9.4. FEATURES OF GAIT AFFECTING THE MOVEMENT OF THE CENTRE OF GRAVITY (CG) 9.4.1. KNEE FLEXION DURING STANCE PHASE See page 148 in the handbook (volume 1) Ask a friend to walk without flexing his/her right knee. What do you observe about the vertical displacement of his/her CG? The centre of gravity is displaced upwards.
9.4.4. WIDTH OF WALKING BASE Ask a friend to walk with their legs close together and then wide apart. What do you observe about the lateral displacement of the CG? There is more lateral displacement of the CG when the legs are wide apart.
9.5. THE ROLE OF THE MUSCLES See page 149 in the handbook (volume 1) Name the main lower limb muscle groups that are working in the: A. Stance phase: The body is maintained upright by anti-gravity muscles.
Hip extensors control and keep the hip straight when the body weight is taken by the leg. Knee extensors keep the knee straight.
Ankle dorsiflexors assist with heel strike at the beginning of the stance phase. Ankle plantarflexors assist with heel off and toe off at the end of the stance phase.
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B. Swing phase: Muscles move the leg forward ahead of the rest of the body.

Ankle plantarflexors - push the leg forwards at the beginning of the swing phase. Ankle dorsiflexors - help the foot clear the floor from acceleration to deceleration. Hip flexors - pull the leg forward. Knee flexors (hamstrings) - slow the leg down in deceleration, ready for landing.
9.6. RANGE OF MOVEMENT NEEDED FOR GAIT Which forces have the most significant influence on movements of the body during normal walking?
1. The contraction of muscles. 2. The weight of the body (caused by gravity). 3. Ground reaction force (the force that passes from the ground to
the body, when the body is in contact with it).
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Section 3
Chapter 10
Post Polio Residual Paralysis
10.6. SECONDARY PROBLEMS 10.6.1. CHANGES IN MUSCLE LENGTH See page 155 in the handbook (volume 1) 1. If the knee extensors are weak, what will be the position of the knee joint? Knee flexion. There is a muscle imbalance of the knee extensors and flexors. The flexors are stronger and so will become shorter, pulling the knee into flexion. 2. If the dorsiflexors are weak, what will be the position of the ankle joint? Plantarflexion. If the dorsiflexors are weak the ankle joint is held in plantar flexion. The dorsiflexors become long and the plantar flexors become short.
3. If the hip extensors are weak, what will be the position of the hip joint? Hip flexion. As the hip extensors are weak, they will become long. The flexors are strong and will become short. The hip will stay in a flexed position unless the hip extensors are strengthened.
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10.10. THERAPY INTERVENTION See page 160 in the handbook (volume 1) CASE STUDIES: RAJU AND ABDUL 1. For the following case studies, what therapy interventions could you use? 2. Explain why you would choose each intervention. Raju has severe paralysis in his legs and hips. He has contractures in his hips, knees, and feet. He cannot stand up and crawls to get around his house, using his arms, which are very strong. He finds it difficult to use the toilet as he is unable to squat. He would like to go to school and visit his friends but he has no way of getting around outside. Therapy interventions and reasons:
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Abdul walks with the help of a stick. He has paralysis mainly in his right leg and foot. Because of weak thigh muscles, he locks his knee backward in order to bear weight on it. This has become more extreme as the cords behind the knee stretch. The foot is very unstable and flops to one side, causing him pain. The weaker leg looks shorter and for walking is much shorter because of the bent-back knee and bent-over foot. He is not able to walk very far and it is becoming more and more difficult to walk to Problem list Therapy Intervention Reason school.
Difficulty moving Therapy interventions around, so he is unable to go to school or visit his friends.
and reasons: (please see next page) elbow crutches with his KAFO
(depending on the severity of his contractures). If these are not suitable then providing him with a selfpropelling wheel chair is another option. If Raju uses a wheelchair and his house is big enough for him to use it inside, adapt the house to make it wheelchair accessible. Discuss with the school about adaptations to make the school accessible for Raju.
Raju could try using a pair of
To enable inclusion within his community and for him to be able to go to school.
Difficulty using the toilet
Toilet modification e.g. a commode over the toilet and hand rails in the bathroom. Toilet transfer practice. If he is using a wheelchair, he can practice transferring between his wheelchair and the commode. Good positioning. Raju could sit in long sitting to maintain the length and prevent further shortening of his knee flexors. Lying in prone maintains the length of his hip flexors. If he is able to (if his contractures are not too severe), Raju could use a standing frame.
To help Raju to be able to use the toilet independently
Contractures
The use of splinting, positioning or a standing frame prevents the worsening of contractures and deformities.
Splinting could be used. A KAFO will maintain the length of his plantarflexors and knee flexors (as long as his function is not reduced).
There are many additional benefits of Raju using a standing frame. It allows weight bearing through his legs (this helps to make his bones strong) and improves his digestion and respiratory function. He can use it to maintain a good position in the classroom, when he goes to school.
Problem List
Difficulty walking to school
Therapy Intervention
Reason
Abdul can be given a KAFO, He can walk for longer distances with an which will support his right orthosis. ankle and knee joint when 102 he is walking. Abduls weak muscles can be strengthened through functional exercises (e.g. standing up from a chair strengthens the quadriceps). Note: paralysed muscles cannot be strengthened. Strengthening weak knee extensors. A KAFO for his right leg. Strengthening knee extensors will reduce Rajus genu recurarvatum. Stronger leg muscles will help Abdul walk more easily.
Muscle weakness
Genu recurarvatum (back knee)
Stronger knee extensors can reduce hyperextension of the knee. A KAFO will provide the support needed for more efficient walking. Provides support, good stability and easy weight bearing during walking which prevents injury. Prevents further joint deformities developing. Reduces pain caused by instability and deformity.
Unstable foot
A KAFO.
Limb length discrepancy
Add a heel raise within the KAFO.
To reduce the difference in leg length. This will help to reduce abnormal stresses put on the joints during weight bearing (this happens when the leg lengths are different). A KAFO provides support during walking and reduces abnormal stresses placed on the muscles and joints in the foot.
Pain in the right foot
This should reduce as the KAFO will provide good support.
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Further reading in the handbook (volume 2) See page 107 for more information about home adaptations. See page 111 for more information about developmental aids.
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E.g. are
11.3. WHAT ARE TIGHTNESS, CONTRACTURE AND DEFORMITY? See page 164 in the handbook (volume 1) 1. A 12 year old boy has spasticity of the muscles in the left side of his trunk, which have pulled his trunk to the left side. The muscles have stayed in a shortened position for a long time which has caused a deformity called scoliosis. . Because of spasticity, the muscles on the left side were in a shortened position, which led to tightness. It was left untreated for a long period of time, so it became a contracture and then a deformity.
2. A 70 year old lady has been treated for a fracture of her forearm. She is able to move the elbow joint through some range of movement herself and the therapist can stretch it to achieve full range of motion. Does the lady have tightness or a contracture of the elbow joint? The lady has tightness in the muscles of the elbow joint. Some active range of movement is achieved by the lady herself and the remaining range of movement is achieved by stretching. Full range of motion is achieved, so it is tightness.
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Chapter 12
Amputation
12.7. ASSESSMENT See page 172 in the handbook (volume 1) Why does an amputee need to be able to do all the things listed above, in order to benefit from a prosthesis? For this question, the points listed above will be discussed one by one. Does the amputee want to walk?
It is very important to know his desire to walk. If the amputee does not want to walk, and he is happy using a wheelchair for his mobility, prosthetic rehabilitation will not be beneficial. It is likely the amputee will not use the prosthesis. It will also be using money and resources that could be used for a person who would benefit more from a prosthesis.
Will it be possible for him/her to walk? He/she must be able to: Transfer independently Dress independently Have manual dexterity (fine finger control) to put limb on
Asking these questions will also help to decide whether an amputee will require a prosthesis or a wheelchair. An amputees ability to transfer to and from a wheelchair, dress and put his limb on independently can tell us if a prosthesis will be suitable and safe for the amputee to use. - Be fit enough to stand and walk with prosthesis (older people with other problems such as high B.P, heart disease, osteoarthritis etc. may not be able to). If the amputee is not fit enough to stand and walk with a prosthesis (and it is not likely that he could do this with further rehabilitation), then a wheelchair may be more suitable. If an amputee is not safe when he is walking, or he finds it very difficult, a wheelchair is a more positive option.
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Will prosthetic rehabilitation improve the amputees quality of life?
In order for a prosthesis to be beneficial, it should improve his quality of life. Giving an amputee a prosthesis and providing rehabilitation for walking needs a lot of time, effort and money. A prosthesis should only be given if it will bring about a positive change and increase independence in daily functions (ADL).
Trainers Note Some Extra Considerations These are some important points to consider when thinking about how well an amputee will manage with a prosthesis: Older adults Older adults often have other problems than can make using a prosthesis difficult. In those who have had a transfemoral amputation due to a non-traumatic cause, rehabilitation with a prosthesis may be slower and there may be less potential for success. Family support It is very important to involve his family, so that they can help him to use his prosthesis correctly and support him during therapy. If he does not have continuous encouragement he may not use his prosthesis. Cognitive function It is useful to assess the amputees ability to understand and remember instructions, when deciding if a prosthesis is appropriate. If his cognitive impairment is mild, this could be managed by involving family members or giving him an instruction leaflet in his own language. If his cognitive impairment is severe, he may not be able to participate well in rehabilitation and so a wheelchair may be a more suitable way of improving his independence.
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12.8. REHABILITATION AIMS AND THERAPY INTERVENTION See page 173 in the handbook (volume 1)
A. CARE OF THE STUMP

A Trainers Note about Bandaging Bandaging of the stump can help control oedema, particularly if the cause of amputation is trauma. The bandaging needs to be applied effectively and re-applied regularly. It is the surgeons job to shape the stump appropriately during surgery and this should not be attempted by bandaging. Be careful when bandaging the stump of a diabetic amputee because it may cause wound breakdown and damage to the blood supply, particularly if it is applied tightly.
Further reading in the handbook (volume 1) See page 380 for more information about diabetes.
B. PREVENTION OF CONTRACTURES See page 175 in the handbook (volume 1) Place a tick or a cross by each picture, according to whether it is good or a bad position: Transfemoral amputee The muscle groups that commonly become tight are the hip flexors and adductors. If the stump is not kept in the correct position and if these muscle groups are not stretched regularly, then contractures will develop. If contractures develop, prosthetic rehabilitation is less likely to be successful.
These two pictures show bad positions. The picture on the left encourages flexion, which may lead to contracture of the hip flexors. In the picture on the right, the amputee should have a pillow to prevent the stump going in adduction.
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This position is good for stretching the hip flexors to prevent contractures.
This is a bad position because it encourages flexion of the hip, which may lead to contracture of the hip flexors. If he has loss of sensation, he could develop a wound in his stump because he is putting pressure through it whilst resting on the crutch.
This position is good because the hip is in neutral and contractures of the hip flexors are less likely to develop.
Transtibial amputee
The muscle groups that commonly become tight are the hip flexors, adductors and knee flexors (hamstrings).
In this picture, the hip and knee are in a neutral position, so contractures of the hip and knee flexors are less likely to develop.
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H. MANAGEMENT OF COMPLICATIONS See page 180 in the handbook (volume 1) 1. Why do you think amputees often get osteoarthritis? There are many reasons that amputees often get osteoarthritis. Some of the most common reasons are:

Overuse of the joints of the non-affected limb. These need to take more weight/stress to compensate for the amputated limb. Gait abnormalities and asymmetrical loading (one side is different to the other) in both lower limbs and the lumbar spine. The differences in loading can put stress on parts of the joints that do not have enough support. If it more difficult for an amputee to move around and keep active and this can cause a greater chance of gaining weight. An increase in weight can put the joints of the non-affected limb at a higher risk of developing osteoarthritis. As amputees are generally less active, the strength of the muscles protecting the weight bearing joints on the non affected limb are likely to be weaker and do not provide as much support. This increases the chance of extra stress and strain on the joints and therefore increases the risk of developing arthritis.
2. Which joints are most often affected and why? The knee joint is most commonly affected, followed by the hip, ankle and foot in the unaffected limb. This is due to overuse. If a walking aid is used, the lumbar spine, shoulders, wrists and hands are more likely to develop osteoarthritis. The reason for this is that when using a walking aid, these joints take extra weight.
Chapters 13 to 18 do not have any questions or activities, therefore answers have not been provided.
19.2. CAUSES OF SCI See page 268 in the handbook (volume 1) 110
1. Name some causes of SCI? These are the most common causes of SCI: 1. Accidents that cause injury to the spine, such as:
Falling from a height e.g. from a tree or a house. Diving in shallow water. Fighting with bullets and knives. Other trauma such as war and landmines. Road traffic accidents (RTAs) e.g. a four-wheeler or bike accident.
2. Fractures of the vertebrae. This occurs very often in osteoporosis.
Further reading in the handbook (volume 1) See page 373 for more information about osteoporosis. See page 375 for more information about TB spine.
3. Disease/disabling conditions e.g. TB spine and spina bifida.
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2. If a person has had a SCI, what kind of problems could they have? If a person has had a SCI, the following problems may occur, depending on the level of injury.
Muscle weakness or paralysis in the legs and/or arms.
Loss of sensation (feeling).
Loss of bladder and bowel control which can lead to a urine infection if he does not drink enough water, or if he does not go to the toilet regularly. Constipation can also occur.
The above 3 problems can cause pressure sores.

Depression this is very common as SCI dramatically changes a persons life and it can be
very difficult to accept.
Spasticity may develop in the legs and/or arms, which can lead to muscle tightness.
Contractures can develop if this is not managed properly.
Paralysis of the chest muscles, if the injury is in the cervical region. This will cause breathing
problems, which may put him at risk of developing a chest infection.
All these six problems will result in mobility and functional problems, which may hinder his day to day activities. If the injury is complete, it is likely he will need a wheelchair for his mobility as there will be no movement or sensation below the level of the injury.
If the injury is incomplete, there will be some movement and sensation below the level of the injury.
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Further reading in the handbook (volume 1) See page 163 for more information about contractures. See page 279 for more information about pressure sores.
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20.5. WHERE DO PRESSURE SORES DEVELOP?
Mark the areas of the body where pressure sores are most likely to occur for people who use wheelchairs.
Pressure sores generally develop on areas of the body where bones can be felt. In these places, there is less protection from soft tissue and more pressure is felt.
The common areas of the body where pressure sores develop for people who use wheelchairs are marked below:
The foot has been shown here as it is at risk of being knocked on the footrests of the wheelchair.
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Chapter 21
Intellectual Disability
21.2. CAUSES OF INTELLECTUAL DISABILITY See page 289 in the handbook (volume 1) For each of the case studies below, does the child have an Intellectual Disability (ID) or not? Explain your answer. 1. MANSURI is 3 years old and he was born deaf. He does not come when he is called, gets angry when he is not understood and cries a lot. He looks at people when they talk to him, but cannot answer them. He makes noises but cannot speak. Mansuri shows no signs of ID. He does not come when he is called because he cannot hear the person calling him. He is able to understand that someone is speaking to him if he can see their face and the gestures they are making. He cannot answer a person because he has not learnt how to communicate using speech. In order to speak, he needs to hear what sounds he is making and he cannot do this because of hearing impairment. It is likely that Mansuri gets angry and cries a lot because he finds it difficult that he cannot communicate with other people. 2. RAMU is 10 years old and can talk normally and do simple things around the house. When he goes out, he gets easily lost and cannot find his way home. If he goes to the shop, he will forget what he is supposed to buy and sometimes leaves money on the counter. Ramu does show signs of mild ID. He is able to go out (a community/social activity) but requires assistance as he cannot remember his way home. This may be because his concentration is not very good or that he cannot understand where he is in his environment. Ramus short term memory may also be impaired. This may be the reason he cannot find his way home or complete tasks such as buying something from the shop.
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3. SHAKU is 6 years old and has poor vision. When she was younger she had difficulty in feeding and dressing herself, but can do most of this herself now. Sometimes she forgets to do all her buttons up and brush her hair. She turns when she hears sounds and speaks using sentences. In that way, she is the same as her older brother when he was that age. Shaku does not have ID. She shows signs that she can learn well as she has learnt to feed and dress herself with only a little help. She may forget to do all her buttons up or brush her hair because she cannot see them (so has nothing to remind her that she hasnt done these tasks). Her hearing and speech are not affected and in all other ways her development is normal.
4. SHAJAAN is 2 years old. Her mother says she is a very good baby because she is no trouble and is always happy. She does not speak, cannot sit without support and does not play with toys. Her mother knows she can see and hear as she smiles at her and turns her head when there is a noise outside. Shajaan does show signs of ID. Her communication and social skills are less developed than other children of her age. A child would normally have learnt to use single, simple words when they are around 1 year old. Shajaan shows no signs of hearing impairment so hearing is not the reason that she has not yet learnt to speak. Being unable to sit without support and being unable to play are other signs that Shajaans learning is slow. A child normally learns to do these when they are 6 months old. Her mother knows she can see which tells us that impaired vision is not a reason for her slow learning.
Further reading in the handbook (volume 1) See page 301 for more information about communication problems
See page 298 in the handbook (volume 1) 116 TRUE/FALSE QUIZ: Explain your answers in the space provided Facts about ID
It is a waste of time helping a person with an ID. It takes too much time and the person cannot be cured.
True or false
FALSE
Explanation
It is very important to help a person with ID. It is true that it takes a lot of time to help someone with ID and that there is no cure, but everyone is able to learn to some extent. Even people with severe ID can become semiindependent if they are given the right training, care and supervision. ID is a delay in mental development; it is not a mental illness. Every child who has an ID can be affected differently.
ID is a kind of mental illness. All children with ID are similar. Children with ID can be slow in their physical, social and mental development. ID can be caused by a pregnant woman being frightened or shocked. All children who have behaviour
FALSE
FALSE
TRUE
This is because they find it harder to understand and learn. Some or all of these abilities can be affected.
FALSE
The main causes during pregnancy are lack of nutrition, taking certain medicines, abuse of alcohol or the pregnant woman being under age 16 or over the age of 40.
FALSE
Children may have behaviour problems for lots of reasons (e.g. traumatic brain injury) other than ID.
problems have some form of ID. Malnutrition can cause ID. Some children with ID have epilepsy too. ID can be cured by getting married. TRUE If a pregnant woman does not get enough nutrients during pregnancy, this can cause ID in her child. More than one area of the brain can be affected, which means that the child may also have epilepsy. This should be managed by medicines from the doctor. There is no cure for ID.
TRUE
FALSE
Facts about ID
You can tell from looking at 117 someones features that he has an ID. Parents are doing the right thing when they stop their children playing with children who have an ID. All children with speech problems have an ID.
True or false
FALSE
Explanation
If the ID is caused by Downs syndrome, it is possible to tell from the persons features. Often a person with an ID can look the same as you or I.
FALSE
Parents are doing the wrong thing if they stop their children playing with children with ID. Children with ID have the right to be treated equally. It is important they play with other children as this gives them stimulation and helps them to learn. Not all children with speech problems have ID. They may have a hearing impairment which makes it difficult for them to learn to speak, or a condition that affects the muscles they use to speak (e.g. cerebral palsy).
FALSE
The most common cause of ID is it being inherited from the mother.
FALSE
The most common causes of ID are: Brain damage (this has many causes). Downs syndrome caused by a fault in the chromosomes. The risk of the child getting this increases if the mother is less than 20 or over 35 years.
22.2. HOW A CHILD LEARNS THE SKILLS NEEDED FOR COMMUNICATION 118 See page 304 in the handbook (volume 1)
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Think about the skills needed for communication and how a child learns these skills (shown in the diagram on page 304). What disabilities could affect learning these skills and why? by getting a response
If a child has hearing or visual impairment, he may not be able to hear or see a response from another person when he receives it. by experiencing language in meaningful situations
Hearing impairment will limit his ability to hear the language. If a child has intellectual disability he may not understand the meaning of the language. If a child has visual impairment, he may hear and understand the language but not be able to see the situation it is spoken in. by hearing words spoken and seeing what they refer to
A child with visual impairment will not be able to see what the words are referring to. A child with hearing impairment will not be able to hear the words spoken. If a child has intellectual disability, she may not be able to link the word spoken and the situation it refers to. She may not remember what the word was and in which situation it was said. A child with multiple disabilities will find it very difficult to learn to communicate in this way. by repeating words often in different meaningful situations
A child with hearing impairment will not hear the words spoken and she will not be able to hear what words she is saying herself. A child with a physical disability which affects oro-motor function (e.g. CP), may not be able to form words clearly. If a child has intellectual disability, she may not be able to repeat the correct word in the correct meaningful situation. A child with visual impairment will not have seen the situation and so may not be able to understand when to repeat the word. by enjoying communicating
Because of the difficulties that children with disabilities face when learning to communicate, some children may not enjoy communicating. These children need lots of encouragement to try and improve their communication skills. We must try and make it fun and enjoyable for them.
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by having someone to communicate with
A child with hearing, visual, physical or intellectual disabilities may find it difficult communicating with her family, friends and the community. A child with a physical disability may not be able to move herself to situations where there are other people around and may be left behind or forgotten. She may then miss out on opportunities to communicate. If the people around her are finding it difficult communicating, they may not be patient when she is learning. If she does not have anyone to communicate with, she will not be able to practice and learn new communication skills.
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23.2. CAUSES, PREVENTION AND MEDICAL MANAGEMENT OF BLINDNESS AND LOW VISION See page 327 in the handbook (volume 1) 1. Can you name some foods that are rich in vitamin A? There are many foods that are rich in vitamin A. Some of these include: Milk Curd, cheese and butter Eggs Colourful fruits and vegetables Fish Liver
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Chapter 24
Multiple Disability
24.1. WHAT IS MULTIPLE DISABILITY? See page 333 in the handbook (volume 1) Imagine you are a parent of a child with multiple disabilities. How do you think you might feel? There are many different feelings that a parent may have. Some of these include:

It is likely a parent will feel stressed and tired as looking after a child with multiple disability is very difficult. They may be worried about the future. How will they earn a living if they are busy caring for him? Who will look after him if they are not there for him? They may feel unsupported and frustrated if there is nobody there to help them. They may feel guilty and may think they have made a mistake in the past and that is why this has happened to them. They may feel that God has punished them.
Would you blame the parents for neglecting their child? YES/NO There is not a single correct answer for this as each situation is different. Some important considerations are:

The parents are not aware of the available health and education services for a disabled child. The parents may feel the pressures brought about by poverty. It may be necessary that both parents go to work, in order to provide for the rest of the family (which may be very large). This means they have no option but to leave her at home. Some areas may have poor health programmes set up by the government and basic healthcare is not available. The community may have a negative attitude or different spiritual beliefs about disabilities and this can affect the parents view of her. If there is a lack of support from the community, it makes it a lot harder to look after a child with multiple disabilities.
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There may be a poor understanding of disability by the health professionals that visit her and they do not advise the parents correctly. The parents may not know how to care for her. Often when parents are educated they do not neglect their children. In a rural area it is often a long way to basic health facilities and the family may not be able to access them e.g. because of travel expenses.
When considering these factors, the answer may be NO. What could you do to help them?
Educate the family about the available services, facilities, and provisions of government and non-government organisations for a PWD. Refer them to these services if appropriate. Create a positive attitude and awareness within the family and community towards disability by running an awareness programme. Teach his parents how to involve him in the community by taking him to functions and modifying the environment to one in which he feels more comfortable. Introduce the PWDs family to other families with children with disabilities, to support and motivate them. Give a clear explanation to the family about his disability. This improves their understanding and does not raise false hopes or expectations about his potential for improvement. Refer him to, or contact, other health professionals such as doctors, physiotherapists, occupational therapists and speech therapists if required. Increase his independence in ADLs. This could be done by providing assistive devices and developmental aids and by providing adaptations to his home, so that he has better access to his surroundings. It is important to involve the family in these interventions so that they understand the benefits and will take an active role in his therapy.
The answers to the question s above are only ideas and suggesti ons. There are many other possibilit ies that may not be written here but may also be correct. The trainer can facilitate discussio n amongst the students in small groups.
Speak to the CBR facilitator who can help to organise a volunteer from the community to give
support for the family. E.g. the volunteer can stay in the house and look after him while his mother can go to the shops or visit friends.
25.5. FRACTURE HEALING See page 336 in the handbook (volume 1) Fractures normally take between one and three months to heal. What factors affect the healing time of a fracture? The most common factors that affect fracture healing are: 125 The age of the patient. Fractures heal faster in children compared to adults because the
layer surrounding the bones (the periosteum), is thicker in children. Hence, there is a greater blood supply to the bone which causes faster healing. In older adults, the bone mass is less which delays healing.
The type of bone. Flat and spongy bone unites (heals) faster than long and compact bone. The type of fracture. E.g. Spiral fractures heal faster than compound fractures. If the bone
has a spiral fracture, larger surfaces of the bone are in contact with each other. A compound fracture is made of smaller pieces so smaller surfaces of the bone are in contact with each other. poorer the result. Mild injury of the bone will heal easily, whereas severe injuries with large soft tissue damage heal poorly.
The degree of trauma. The greater the injury to the bone and surrounding soft tissues, the
Systemic Diseases. Diseases like osteoporosis and diabetes will delay healing. The location of the fracture. Upper limb bones heal faster than lower limb bones.
Trainers Note Not all fractures need reduction. This is because either there is no displacement, or the displacement is minimal and the bone is still able to heal in the correct position.
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25.6. MEDICAL MANAGEMENT 25.6.2. IMMOBILISATION See page 338 in the handbook (volume 1) 1. Why is reduction of the bone important? What could happen if it is not done? Reduction is done for many reasons. It is important because: It ensures the correct position of the bone or joint. It encourages fracture healing. It reduces pain around the fracture site. It prevents mal-union (when the bone heals in the wrong position). It prevents deformity.
If reduction is not done, it may lead to:
Pain, which may be permanent. Delayed or non-union of the fracture. Mal-union, which may lead to deformity or shortening of the limb. Infection (if the fracture is open).
2. Why is immobilisation important? What could happen if the bone is not immobilised? Immobilisation is important to ensure that the fracture fragments are in the correct position so that the bone can start healing. If the bones are not immobilised, the following problems may occur:

The bone fragments may not heal in the correct position because they are moving. This may lead to mal-union. The bone may not be able to heal fully, causing delayed or nonunion. Pain can occur when the fracture moves. This improves with immobilisation.
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26.3. WHAT CAUSES MENTAL ILLNESS? See page 341 in the handbook (volume 1) In a group, discuss what kind of things do you think cause mental illness?
Trainers Note It is important that the students understand the difference between brain damage (where the brain has suffered some injury and is unable to instruct the body normally) and mental illness (where the emotions or mood of a person is changed or not as expected). Not all mental illness is a result of brain damage but many forms of brain damage also cause mental illness. The causes of mental illness can then be explored by the students.
Insight An important component of treating mental illness depends on whether an individual has insight. If
someone shows no insight about their emotional state or behaviour, then they need to be seen and treated by a psychiatrist.
However, if they understand that they feel upset, down, anxious or are behaving inappropriately e.g. drinking too much or getting angry easily, but cannot seem to help themselves, then they show insight. They may respond to simple supportive understanding and practical help.
Emotional upset or mental illness, can be a result of a chemical imbalance, or can be caused by external stresses affecting a person. Stress is the pressure that individuals feel when dealing with problems occurring throughout life.
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Chemical imbalance During pregnancy or postnatal period. Sometimes
Stresses
Examples of causes include: Being disabled or physical ill health. Being a victim of domestic violence or bullying. Poverty, loss of job or income. Loss of loved one.
after childbirth, the new mother gets mild depression. This can occasionally develop into a more severe and lasting illness. Substance misuse. Drugs and alcohol have an immediate mood changing effect on the brain but can also cause brain damage from long term use. Organic brain disease (e.g. dementia, injury or infection such as meningitis). This can cause temporary or permanent changes or damage in the brain.
Trainers Note It is important to help the students to understand the difference between singular traumatic events and repetitive and longstanding stress i.e. a persistently difficult situation with no relief. Encourage the students to determine whether the mental illness is due to a chemical upset or stress. There may not be a single cause, but components of both. An example of this might be post natal depression, where the pregnancy has caused a chemical imbalance, but the mother feels that the stress of looking after the child is making the problem worse.
26.4. STRESS, ANXIETY AND DEPRESSION 26.4.3. WHAT IS ANXIETY? See page 343 in the handbook (volume 1) 1. Think of some situations that might cause a person to be stressed:
Trainers Note Some people may be unable to cope with some of the situations described in the table above and text below and may develop mental illness. There are also people who may be able to cope for some or most of the time, but do not develop mental illness. Persistent stress without relief can lead to mental illness. Every person and their ability to cope with a situation will be different and may be different on different occasions Ask the students to provide examples of someone they know with mental illness. Encourage the students to identify if there are singular or persistent stresses. There may not be one stress, but many or a single event may have persisted causing ongoing stress. Equally, not being able to cope tends to result in non-coping behaviours, e.g. ignoring the problem, drinking or getting angry, make the situation worse.
There are many situations that may cause a person to feel stressed. Here are a few examples:
130 Loss of a loved one or family member (known as bereavement). A mother may have to look after her disabled child and many other children without support at home. A child with disability needs a lot of care and attention and this can be difficult for her to manage on her own. A traumatic accident or significant injury. Difficult or demanding work, long hours. If a person loses her job, it can be very worrying as there will be less money and no regular income for the family. A sudden change in life situation or difficult life event e.g. pregnancy, retirement or marital breakdown. A PWD or their family may be upset when they are excluded by the community. They may not be able to access education, work or social activities and do not have many opportunities to make friends. A person may become stressed if they have a lot of pressure at work and they are not able to manage this. It can be very difficult to work every day and also come home and look after children. A severe, life threatening or terminal illness. Suffering ongoing domestic violence or being bullied. Having too many children to look after and other home stresses.
2. Think about a situation that happened to you that made you feel stressed. How did you feel? In a group, discuss your experiences and make a list of the symptoms of stress, divided into three areas: IN YOUR MIND E.g. feeling anxious IN YOUR BODY headache IN YOUR BEHAVIOUR restlessness
Here are two examples of situations that a person may have experienced. Students may have very different examples that have come from personal experience. Situation: Umesh is having trouble at work. His boss is often blaming him for things that are not his fault and is not giving him enough breaks during the day. He no longer looks forward to going to work and becomes nervous when his boss is around. IN YOUR MIND Feeling nervous IN YOUR BODY Palpitations in the chest IN YOUR BEHAVIOUR Not sleeping enough
Feeling criticised
Sweatiness Situation: Geetanjali is a young girl who has a sister with disability. Her mother has recently passed away. Her mother used to take care of her sister while her father was at work. Now Geetanjali has to stop going to 131 school and look after her sister.
IN YOUR MIND Feeling upset and worried Feeling angry family/sister Feeling sad alone Feeling scared sleeping/eating
IN YOUR BODY Body aches Tired Crying
IN YOUR BEHAVIOUR Not socialising with friends Fighting with Spending time Not
These are some other examples of symptoms of depression: In Behaviour In the Body In the Mind Feeling sad Not being able to
concentrate
Running away from or not dealing with problems Getting into fights or arguments Crying or being very weepy Cutting wrists or inflicting self harm Trying to kill oneself Becoming more isolated or losing friends Becoming withdrawn Not speaking Becoming agitated and worried about irrational things Becoming fixed with difficult behaviours and finding it difficult to change Not eating enough or eating too much Not sleeping enough or sleeping too much
Tiredness Aches and pains, e.g. headaches Changes in bowel habits loose stools Getting very tense Sweatiness Palpitations Muscles tightness Existing illnesses becoming worse e.g. eczema or bowel problems Any physical symptom can be caused by stress - there is often a repeating pattern Weight loss or weight gain Feeling agitated, fidgety, slowed down or lethargic
Having poor memory Not enjoying doing usual

things
Wanting to hurt oneself Wanting to kill oneself Feeling isolated Feeling helpless Feeling worthless Finding it difficult coping
with everyday activities
Being very angry
Depression & anxiety have many symptoms that are the same, but symptoms of anxiety are more likely to involve agitation. These are some more examples of symptoms of both depression and anxiety: Fear 132 Chest pains The desire to run away Over-reactive behaviours e.g. becoming very angry or suddenly crying Being so scared it is difficult to do things Agitation Palpitations Sweatiness Difficulty breathing
3. Think about some service users and their family members/carers you have seen recently did any of them seem stressed? If so, what were the signs of stress? What was causing them to be stressed? These are a few examples of the situations that may have been seen. Students may have very different examples that have come from personal experience.
Example 1: Geetha Geetha starts crying during her therapy session. She was recently told by her doctor that she will need to use a wheelchair for her mobility. She appears quite withdrawn and does not engage with therapy. She says that she feels very tired and does not feel like it today. This is a very big change in her life and she finds it very difficult to cope with. She is very upset at the thought of needing help with her daily activities and not being able to walk very far.
Geetha seems stressed. The signs of stress (depression) that she is showing are withdrawn behaviour, tiredness, lethargy and loss of enjoyment in her therapy. It is likely she is stressed because she is finding it difficult to accept that she will need to use a wheelchair.
Example 2: Nagaraj
Nagaraj takes his son, who has CP, for his therapy session. Nagaraj becomes quite agitated during the session and keeps asking why his son is not getting better at walking. He appears quite tense. He is very worried about his son. He does not fully understand what is wrong with him and the people in his village tell him that his family is paying for its sins. Nagaraj does not earn very much money. He cannot afford to pay for his sons medical expenses and to feed the rest of his family. He cannot sleep very well at night and feels very restless during the day. Nagaraj seems stressed (anxiety). The signs he is anxious are his
agitation and tension, feeling restless during the day and not sleeping enough at night. He is anxious about being able to care for his son and having enough money to provide for his family. Example 3: Rahul
Rahul is a diabetic amputee. After his amputation one year ago, his family were very supportive and helped him with his ADL. His wife Arthi used to help him get in and out of his wheelchair and helped him when he was 133 bathing. Over the last few months, Rahul has become more independent with his ADL and his transfers. To improve his independence, Arthi has been encouraging Rahul to do more for himself so that he can get more practice. She has started helping him less. Rahul is upset about this and feels that Arthi has become unsupportive. He has stopped doing his exercises that the RTA taught him and has been sleeping a lot more. He no longer enjoys spending time with Arthi and has stopped going to the local temple, which he normally enjoys. Rahul seems stressed. He has lost enjoyment in his normal pleasures (going to the temple and spending time with Arthi) and is sleeping too much, which are signs that he is depressed. He may be feeling stressed because he thinks that Arthi does not care about him anymore as she has been helping him less. These thoughts make him feel very sad.
26.6. MANAGEMENT OF MENTAL ILLNESS See page 345 and 347 in the handbook (volume 1)
CASE STUDY: SWETHA Swetha is a mother of three children. Pretti is four years old and has multiple disability, she is dependent for all her ADL and is also blind and deaf. Swetha has been caring for her on her own since she was born.
Over a few months Swethas family noticed that Swetha does not smile or laugh any more. She has stopped caring for herself and for Pretti both their clothes are dirty, their hair not brushed and she has stopped doing the therapy and playing with Pretti, as the RTA taught her.
Swethas other two children, who are seven and nine, come home from school each day to find Swetha in bed or watching TV and so they do the household chores and make the food for the family. They do not have time to do their homework and are tired when they go to school.
1.
Discuss how Swethas mental illness is affecting her husband and other two children. What do you think could happen if Swetha does not get some help?
Swethas other two children are helping her do the household chores because Swetha now cannot manage to do anything. This is very 134 difficult for them and they are unable to carry out their schoolwork and help out at home. As a result of this, their education is being neglected. Swethas husband comes home after a tiring day at work and finds the house not looked after as usual by Swetha. He may think that Swetha has decided she does not want to work in the house and does not understand that her behaviour is caused by depression. Swethas husband appears frustrated and angry at Swetha. These are signs that he is stressed. If Swetha does not get help, her family will have two family members who need looking after. They may not be able to give Pretti the full time care that she needs. They may also feel stressed carrying out their normal activities (e.g. work and school) as well as caring for Swetha and Pretti. This is a very difficult situation for Swethas family to manage.
Trainers Note
Some Simple Management Tools for Mental Illness
Support Talking to others e.g. friends or family, discussing feelings and explaining how the situation makes an individual feel is very important. It helps reduce isolation and improves the understanding of the persons burden and worries. Seeking help This can be done from people with experience, e.g. an RTA or other health agencies, who understand how difficult things are and may be able to provide practical solutions to some difficulties. They may be able to explain why some things are happening as a result of stress e.g. getting angry or crying. Sharing workload So that the entire burden is not on one individual, the workload can be shared within the family. This can help ensure that there is some relief from stress, even if it is for a short time.
It important for people with stressful lives to use these tools before a crisis develops rather than waiting for one to happen. Ask the students to explore how these tools might help in each of the situations above. Are there any other simple measures which might be useful? Sometimes thinking about people who, despite apparently stressful lives, seem to manage and remain positive, is helpful.
2. You visit Swetha and observe that she is showing signs of depression, probably because of the stress of having a child with multiple disability. How can you help as a RTA?
Swetha may find it helpful to talk about her worries, to help identify what she needs. Encourage her to share her feelings with her family too, so they can understand what life is like for her and they can share with her how135 feel. It is important to listen to what Swetha they has to say and show her that her feelings are understandable.
It is also important to explain to Swetha & her family how depression can make people behave, and that it is not Swethas fault she is behaving in this way. Explain the symptoms of depression and why she may be suffering from this.
Encourage Swetha and her family to think of practical solutions that may help her complete, both her household tasks and caring for Pretti. This will help Swetha feel less stressed and more supported. The family should try to share out the burdens as much as possible.
Teach the family and Swetha to recognise early signs of increasing stress, to support each other and prevent the situation becoming worse. Encourage them to seek help early.
Swethas case could be discussed with the CBR team to see if there are any other resources that are available to help. e. g. if there is a community group, or a volunteer who could help Swetha look after the children. This would give her time to rest or go shopping.
If these simple measures are Swetha may psychologist, prescribe some help Swetha feel
support not enough, need to see a who may medication to better.
27.2. COMMON PROBLEMS OF OLDER PEOPLE See page 350 in the handbook (volume 1) 136
For each problem, write down how it could affect rehabilitation and suggest some possible solutions.
Problem Example:
How it Affects Rehabilitation Does not remember some advice given or exercises that have been taught.
Possible Solutions Ask the person to repeat back what you have told her.
A. Poor memory Write it down for her.
Give advice and teach exercises with another family member present.
Draw pictures of exercises.
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B. Dementia (no memory and/or changed behaviour)
She gets confused with too many instructions.
Keep instructions functional and simple.
She is easily distracted and finds it difficult engaging with therapy.
Keep therapy sessions short and with a purpose. Try to fit therapy into her normal daily routine and activities.
She often forgets an instruction as soon as it was given.
Use demonstration and pictures.
Repeat the instructions as often as needed.
Be patient.
C. Poor vision
She may not be able to see demonstrations of exercises that are taught to her.
Ask her to demonstrate the exercises so that it is clear that she has understood them.
Write or draw exercises in large letters. She may need to use Braille if her vision is very poor.
She may trip over or walk into objects.
Guide her around the environment if she is in unfamiliar surroundings.
Problem
How it Affects Rehabilitation
Possible Solutions
D. Poor hearing
She may not be able to hear instructions given when exercises are taught to her. She may appear to have heard instructions but actually she did not. She may have felt uncomfortable asking for them to be repeated. She may need to use a hearing aid during therapy.
Demonstrate all exercises.
Write the exercises and instructions down for her.
Ask her to demonstrate the exercises. If it is not clear if she heard them correctly, ask her to repeat them. Make sure she is wearing her hearing aid. If she does not have one, refer her to the local health centre or hospital for an assessment for a hearing aid. Split the therapy into shorter sessions and allow rest periods in between each session.
E. Poor stamina
She may not be able to walk or exercise for long periods.
She may become short of breath during therapy.
Do not wait until she becomes very breathless before resting. Let her rest regularly before her breathlessness becomes uncomfortable.
Ask her to say how she is feeling throughout the therapy.
To increase her stamina, she needs to be challenged but the therapy time or distance she walks should be increased gradually.
F. Increased risk of falling
She may have poor confidence and be anxious about walking or she may have poor insight and take unnecessary risks when walking.
Give her lots of reassurance.
Assess her balance and teach her some balance exercises.
After a fall, she may have pain and reduced mobility.
Check her home environment.
She may also have osteoporosis which means she has a high risk of breaking a bone (a fracture).
Check her footwear and ensure that it is well fitting.
If she has fallen, she may have a fracture. If it appears she has a fracture, she will need to go to the doctor.
If she has osteoporosis, advise her on how to keep her bones strong through a healthy diet and regular weight bearing exercise.
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Problem G. Mobility problems e.g. joint pain or weakness
How it Affects Rehabilitation Other conditions such as arthritis or osteoporosis may make it painful or difficult for her to exercise or walk far during therapy.
Possible Solutions Make sure that she is not in pain before therapy as it will be uncomfortable to exercise.
Her other mobility problems may cause her progress with therapy to be very slow or limited.
Think about her other mobility problems and how they may affect progress with therapy.
You will need to consider these problems when setting goals with the person and her family.
She may think she is not improving if her (and her familys) expectations and goals are not realistic.
An orthotic intervention or mobility aid
may help her.
H. Less bladder and/or bowel control
Sometimes bladder and/or bowel control can be more difficult during movement. This may make the person not want to participate in therapy.
Advise her to use an incontinence pad. These can be bought or made at home out of old clothes.
Advise her not to sit in soiled or wet clothes to prevent her from getting pressure sores.
She may have urinated or passed stools without knowing or may feel uncomfortable about telling her family. If she also has problems with her mobility and stays in the same position for a long time, she is at risk of getting pressure sores.
Check her skin for pressure sores, particularly around the sacrum. Advise her family to do this regularly.
Advise her on the importance of eating and drinking regularly to prevent malnutrition and dehydration.
She may be scared to drink/eat in case this makes it more difficult to control her bladder and/or bowels. This will put her at risk of malnutrition and dehydration.
Problem I. Medicine side effects, e.g. tiredness or dizziness
How it Affects Rehabilitation She may become dizzy when standing up.
Possible Solutions Advise her to stand up more slowly and make sure she has some furniture or aid to support her if she often feels dizzy.
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She may be taking too many different kinds of medication.
If she becomes dizzy during therapy, advise her to sit or lie down until she feels better.
Advise her to go to the doctor to check her medication.
Further reading in the handbook (volume 1) See page 373 for more information about osteoporosis and page 353 for more information about arthritis.
28.8. THERAPY INTERVENTION
140
1. Why might someone with OA or RA have muscle imbalance?
Pain and decreased ROM in a joint often cause some muscle groups to become weaker. Muscles that straighten a joint (extensors) are more commonly affected. These become weak and so, the joint often remains slightly bent. The joint rests in a bent position and the flexors become stronger. This can lead to a contracture and then deformity if is not managed properly
For example:
In a knee joint with OA or RA, the muscles that extend the knee (quadriceps) are often weak because of lack of use and pain when fully extending the knee.
The knee is therefore often kept in a slightly bent position and the knee flexors (hamstrings) become shorter and stronger. This is a muscle imbalance.
141
142
E.g. are
29.4. PREVENTION OF BURNS See page 360 in the handbook (volume 1) 1. Within your work, what risks are there of you burning yourself or a service user? How can you reduce the risks? At work, an RTA/P&O or service user is at risk of becoming burnt in many ways. Most of the risks are present when in a service users home. In rural communities, many daily tasks are done on the floor, which increases the risk of a burn. Some of the main risks are discussed below: Open fires A service user or any of their family members may be cooking on an open fire. If the house has lots of objects/items inside, these can become close to the fire and set alight. If the open fire is outside, the wind may blow and blow the fire onto surrounding objects.
Electrical equipment If any electrical equipment has been left on for a long time e.g. an electric heater or fan, then it becomes very hot and it can catch fire. The risk of fire increases if it is covered by items such as clothing. If the equipment is broken it may cause a spark and could start a fire. Equipment may be broken if it makes a strange noise, sparks fly when it is on, or if there is a burning smell. If the electrical equipment is touched in the wrong place e.g. inside it or the hot part of it, it is possible to get an electrical burn.
Flammable substances
These can catch fire very easily if they come into contact with a spark. Examples of these are fuel for vehicles or for cooking.
143
Gas
This is often used in cooking stoves and is dangerous if it is not turned off properly, or if it is leaking. It can cause an explosion if it comes into contact with a spark. It is possible to smell gas and so it is easy to tell if it is in the air.
Candles and lamps These are a fire risk if they are left without anyone watching them. Many families use these, particularly during a pooja or if there is a power cut. Kerosene, the fuel used for lamps, is highly flammable.
Cigarettes/beedis/hookahs If these are not put out properly after use, they can start a fire.
Steam burns These can occur if a person comes into close contact with steam e.g. if a service user accidentally places their arm over a boiling kettle.
These are ways that an RTA/P&O can reduce the risk of burns to themselves and service users. Service users and their families can also be given this advice:
Make sure that all electrical equipment is uncovered and switched off if not in use. Do not touch parts of equipment if it is not known what they are. Make sure that any electrical equipment in your surroundings is working properly. If you see any broken equipment, tell the person that they should not use it. If you see any flammable substances that are leaking or not stored properly, inform the dangers to the owner. If there is a gas leak, immediately let lots of air into the room and find the source of the leak. Warn people in the surroundings that they should stay away from the area until it has cleared. Ensure no-one is using anything flammable such as a cigarette or fire lighter. Make sure candles and lamps are put out properly after use and that no objects can fall onto them. Ensure that any service users or their families put out their cigarettes, beedis or hookahs properly, especially if there any additional fire hazards as discussed above. Keeps arms and legs clear of any steam during cooking. Hands can be protected by using a cloth or gloves when handling hot items.
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2. What education could you give PWD to reduce the risk of burns within the home? The main groups of people that are more at risk of being injured by burns within the home are: Children, with or without disabilities Adults with disabilities
A PWD is more at risk of burns within the home. If the person has mobility problems, they will not be able to move away from a hazard very quickly (a hazard is a situation that may put the PWD at risk). They may have other disabilities, such as blindness or deafness and they may not be able to see or hear hazards as well. There are many ways in which a PWD and their family can be educated about reducing the risk of burns within the home. These are a few examples:

Explain the risks of the factors discussed in question 1. Keep hazards e.g. lamps, boiling water, electrical equipment, stoves etc. at a higher level, where children cannot reach them. Keep flammable substances (e.g. kerosene for the stove) away from candles, beedis and other items that may set them alight. After having a pooja, make sure that candles and lamps are put out. Be aware of what small children are doing as they can easily play with dangerous items and cause a fire hazard.
answe rs to the questi ons above are only ideas and sugge stions. There are many other possib ilities that may not be writte n here but may also be correc t. The traine r can facilit ate discus sion amon gst the stude nts in small
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E.g. are t

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An Introduction to the Trainers Guide

How to Use this Guide

What would make it:

These are some thoughts that may be discussed: Activity

Things that would make it easier

Things that would make it worse

Legs tied together

Hands tied together

Friends and family

2.3 . THE INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY AND

HEALTH (ICF) See page 7 in the handbook (volume 1) 6

The old WHO classification (1980): Provision of rehabilitation and equipment.

SHANTI AND RANI

Body structure and function (impairment)

Body structure & function (impairment)

2.4 . HOW COMMON IS DISABILITY?

See page 10 of the handbook (volume1)

Information from the Census of India 2001.

5. The number of people with a disability is increasing. Why?

2.5 . POVERTY AND DISABILITY

As a result of this stigma, people with disabilities:

PWD are seen as a low priority within the community. 15

Dangerous work, mostly caused by poor knowledge about safety measures.

Physical: E.g. earthquakes, floods and famine.

Cultural: E.g. traditional beliefs and practices.

Economic: Factors controlling the purchasing power of the family.

When Renuka visited the primary health centre, to give Raju

polio drops, she was asked

Article 6: Women with disabilities Article 7: Children with disabilities

Support growth and empowerment of women with disabilities.

Article 20: Personal mobility

Article 25: Health

Article 26: Habilitation and rehabilitation

What laws exist in your region/country to protect the rights of PWD?

Key Elements in Matrix

The Role of the RTA

The Role of the P&O Technician

Key Elements in Matrix

The Role of the RTA

The Role of the P&O Technician

Key Elements in Matrix

The Role of the RTA

The Role of the P&O Technician

Key Elements in Matrix

The Role of the RTA

The Role of the P&O Technician

Early childhood care and education

Referral to community facilitator to facilitate access to inclusive education.

Key Elements in Matrix

The Role of the RTA

The Role of the P&O Technician

Key Elements in Matrix

The Role of the RTA

The Role of the P&O Technician

Financial services and social protection

Key Elements in Matrix

The Role of the RTA

The Role of the P&O Technician

Relationship, Marriage and Family

Culture and Arts

Sports, Recreation and Leisure

Key Elements in Matrix

The Role of the RTA