d i s a b i l i t y a n d r e h a b i l i t a t i o n , 1999; v o l . 21, n o s . 10± 11, 515± 521

Community-based rehabilitation in Moshupavillage, Botswana

LENA A. NORDHOLM ‹ * andBIRGITTA LUNDGREN-LINDQUIST Œ

‹ Go$ teborg University, Department of Rehabilitation, Box 111, SE40530 Go$ teborg, Sweden

ΠLa Trobe University, School of Occupational Therapy, Bundoora, Victoria 3083, Australia

Summary

This article presents a summary of ® ndings from the`Moshupa Community Based Rehabilitation (CBR) project’ ,which to date have been the subject of three studies: one initialsurvey of disabled people and two follow-up studies. Of the 132disabled people who were identi® ed in the survey, all but threecould be accounted for in the ® rst follow-up. Seventy-sevenwere interviewed about independence of activities of dailyliving, school} jobs and quality of life. A high percentage ofelderly (17% were 65 and over) were alive, and most hadmaintained high levels of ADL skills. Twenty per cent of theadult disabled were working, 10 out of 14 school-aged childrenwere enrolled in schools, and life satisfaction was high. Thesecond follow-up study indicated that personnel, althoughacknowledging the bene® ts of the programme, pointed toseveral remaining problems such as lack of rehabilitationeducation for the personnel. The results are discussed withreference to the CBR programme’s aims, and implicationsdrawn for industrialized countries.

Introduction

In this article we will describe the Botswana

Community-Based Rehabilitation (CBR) project, which

was initiated in 1990 and ® rst described by Lundgren-

Lindquist and Nordholm 1993." A follow-up study on

the impact of CBR was next carried in 1993# and a

second follow-up of a selected group of clients and the

rehabilitation workers and volunteers in 1995.$ Details

of the second follow-up have not previously been

published.

b a c k g r o u n d

In 1976 the member countries of WHO adopted an

approach to rehabilitation called community-based re-

* Author for correspondence.

habilitation.% Rehabilitation is de® ned as `a process

aimed at enabling persons with disabilities to reach and

maintain their optimal physical, sensory, intellectual,

psychiatric and} or social functional levels, thus pro-

viding them with tools to change their lives towards a

higher level of independence’ .& In CBR the emphasis

traditionally placed on an institutional approach has

been shifted to a community-oriented approach. This

approach has been described by Helander as `a strategy

for enhancing the quality of life of disabled people by

improving service delivery, by providing more equitable

opportunities and by promoting and protecting their

human rights. It calls for the full and coordinated

involvement of all levels of society : community ; in-

termediate and national’ .’

At the community level CBR is seen as a component of

community development. It involves mobilization of

local resources, such as the family. The community

should support the families who carry out rehabilitation

at home. It should also provide opportunities for

education, and functional and vocational training, and

ensure that disabled members are not deprived of their

human rights. Self-actualization, self-determination,

social integration and empowerment are key concepts. A

community committee should be set up to provide local

management. ’

At the intermediate level the government should

provide professional support services. The personnel

should train and supervise the community personnel,

provide services and managerial support, and liaise with

referral services. ’

At the national level CBR seeks the involvement of the

government in planning, implementing coordinating,

and evaluating the CBR system. This should be done in

cooperation with communities, the intermediate-level

and the non-governmental sector, including

organizations of disabled people. ’

Disability and Rehabilitation ISSN 0963± 8288 print} ISSN 1464± 5165 online # 1999 Taylor & Francis Ltdhttp:} } www.tandf.co.uk} JNLS } ids.htm

http:} } www.taylorandfrancis.com} JNLS } ids.htm

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CBR may be the best answer for a majority of disabled

people, but it is of greatest importance that a person with

a disability is carefully assessed and given full equal

opportunities for development of his } her full talents. `If

a blind boy is capable of becoming a professor there is

absolutely no reason why he should be encouraged to

take up dairy farming, operating a small shop in a village

or do similar occupations.’ ( Therefore, according to

Advani,( it is necessary to `develop delivery programmes

that are balanced, realistic and are tailored to the needs

not just of the majority but also of a minority which is

talented and capable of making a valuable contribution

to the enrichment of our social, economic and cultural

life’ .

CBR programmes have been initiated in many of the

developing countries. However, not all of these are

sustained over a period of time. In countries where a

large proportion of the people live in poverty, govern-

mental priorities may not emphasize the needs of disabled

people. Along with the establishment of CBR pro-

grammes, the need for evaluation has been recognized

and the importance of continuous follow-up

emphasized. ) Several successful evaluation studies have

been carried out, such as Finnstam et al.,* Rottier et al." ! ,

Mariga and McConkey " " and Lagerkvist. " # These studies

suggest that CBR is a feasible and e� cient way of

providing guidance and assistance to the disabled.

p u r p o s e

The major purposes for the three studies carried out

on the Botswana project were :

(1) to identify and describe disabled people in

Moshupa village, in the context of establishing a

CBR programme initially;

(2) to follow up the disabled people in order to study

the impact of the CBR programme at a later date ;

(3) to assess the perceptions of rehabilitation workers

in Moshupa village as to the strengths and

weaknesses of the programme.

b o t s w a n a Ð t h e c o u n t r y a n d i t s p o p u l a t i o n

Botswana lies at the centre of the southern African

plateau. Approximately 84% of the land surface is

covered with sand, which supports a low savanna

vegetation. The population was about 1.3 million in early

1992. There are many diŒerent tribal groups and many

languages and dialects spoken. The most common

language is Setswana, but the o� cial language in English.

The household is the basic unit in each village. One or

more rondavels Ð circular, thatch-roofed clay houses Ð

situated within a compound, surrounded by a fence or

low wall, accommodate the household. The huts are

mainly used as bedrooms. All activities such as cooking,

other household work, repair of utensils or production of

utility products take place outside the huts. All of these

activities are usually performed by the women when they

are not busy in the ® elds, stamping corn, or carrying

water from a distant pipe.

The village Moshupa was chosen as study area. This

village, situated in the south district of Botswana, close

to the desert, has a population of about 11000, and is

fairly typical of a large village in Botswana. It is

governed by a chief and 15 headmen. People have more

than one homestead, such as a cattlepost, a shelter on

their agricultural land and a home in the village. This

pattern of settlement is typical for the country, but

makes it hard to locate people. Health services are

provided by three small health posts. There is no doctor

in the village.

Method

s u r v e y m e t h o d

The ® rst study of the Botswana project was carried out

in 1990 and is described in more detail in Lundgren-

Lindquist and Nordholm. " The initial phase of the

project involved educating and motivating the com-

munity leaders to obtain their support for the project. In

order to identify disabled persons, a door-to-door survey

was conducted. The personnel participating in the survey

were given education about CBR and instructions about

the survey form to be used. The standardized questions

used in the survey included:

(1) Family history (e.g. Were the parents related?

How many children in the family? Birth order of

the disabled person).

(2) Pregnancy and delivery.

(3) History of disability (e.g. At what age was the

disability discovered? What was the perceived

cause of the disability?)

(4) Type of disability.

(5) Type of treatment Ð if any.

(6) Education.

(7) Activities of daily living.

As a result of the survey, 151 disabled persons were

identi® ed. However, su� ciently completed survey forms

were available for 132 individuals, who thus comprised

the study population. Rehabilitation interventions were

proposed for all those concerned, which included

surgery, medical treatment, blind} deaf school referrals,

orthoses, prostheses and technical aids.

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CBR in Moshupa village, Botswana

m e t h o d o f t h e f i r s t f o l l o w - u p s t u d y

In 1993 (3 years after the establishment of the CBR

programme) a follow-up of the 132 disabled persons was

conducted. # When a client had been located, a re-

habilitation assistant conducted the interview in

Swetsana under the guidance of a senior researcher. Each

interview lasted between 30 and 60 minutes. The disabled

person was interviewed whenever possible. In some cases

(for example very young children or persons who were

unable to communicate) a family member, relative or

caregiver answered for the disabled person. The interview

questions included family structure, treatment, activities

of daily living, use of aids, working} schooling, per-

ception of whether life was better} worse } the same as 3

years earlier, quality of life.#

m e t h o d o f t h e s e c o n d f o l l o w - u p s t u d y

Two years later again (in 1995), a second follow-up

study was carried out.$ A small selected sample of 20

clients were interviewed, but the major emphasis in this

study was on the rehabilitation personnel, in order to

ascertain their perceptions of strengths and weaknesses

of the CBR programme in Moshupa. Two persons of the

CBR team and 15 Red Cross volunteers were interviewed

with standardized open-ended questions using an in-

terpreter, who was a member of the Red Cross team.

The questions included CBR training, use of the CBR

manual, visits to disabled persons, perceived strengths

and weaknesses of the CBR programme, suggestions for

improving the CBR programme.

Results

d e s c r i p t i o n o f t h e s t u d y p o p u l a t i o n

Age and sex

Of the 132 disabled persons, 47% were female and

53% male. Age was categorized according to WHO’ s

recommendation, and details are presented in table 1 ; as

can be seen from this table, 22% of the disabled were

Table 1 Age distribution of disabled persons (n 5 132)

Age (years) n Percentage

0± 4 10 7.65± 14 19 14.4

15± 24 15 18.925± 44 30 22.745± 64 26 19.765± 74 9 6.8751 13 9.9

Note: Age data not available for 10 persons.

younger than 15 years of age and 17% were over 65

years. The mean age was 38 years.

Family structure

The average family size was 7.62 children; 24% came

from families with 10 or more children; 21% of the

disabled were ® rst-born and 14% were last-born ; 30%

had parents who were related to each other. Parents and

other close relatives cared for the disabled person and in

32% of cases it was single mothers who were caregivers.

Only 2.4% were cared for by people other than relatives.

Disability

Approximately half of the group indicated that their

disability had been recognized in the ® rst year of life, and

46% had some idea of why it had occurred. Disability

was classi® ed according to the CBR manual (table 2). As

can be seen from this table, 65% of the group had

mobility di� culties. Mental retardation was the second

largest group (33%) while seeing, hearing and speech

di� culties were rare. Twenty-one per cent had more than

one disability and are thus listed in several categories in

the table.

Thirty per cent of the disabled persons had parents

who were related to one another; 34% received

treatment. A cross-tabulation of the two variables

schooling and treatment resulted in a signi® cant positive

association (higher percentage of individuals who had

schooling were receiving treatment). "

Activities of daily living (ADL)

Table 3 shows the distribution of disabled persons who

were competent in various ADL activities; this table

shows a high level of competency in these basic ADL

skills.

r e s u l t s o f t h e f o l l o w - u p o f t h e 132 d i s a b l e d

p e r s o n s

Table 4 gives a summary of the results of our attempts

to locate the 132 individuals: 58% of the group were

assessed at the follow-up. Since missing data can

invalidate a study we were concerned about the credi-

bility of our ® ndings. The ® rst strategy was to describe

the group that could not be assessed based on data from

the ® rst survey. These data are presented in table 5,

which shows that 18 persons were deceased and the

majority of the deceased persons were elderly. Of the six

persons in special schools, ® ve were in a school for

speech and hearing education and one in vocational

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Table 2 Distribution of disabled persons according to type of disability used in the CBR manual (n 5 131)

Type of disability n Percentage

Moving di� culties, e.g. CP, polio, stroke 85 65

Seeing di� culties 2 1.5Hearing and speech di� culties 4 3

Learning di� culties, e.g. mental retardation 43 33

Strange behaviour, e.g. mental illness 10 8

Fits, e.g. epilepsy 15 11.5

Note: 28 persons had more than one disability and are thus listed in several categories.

Table 3 Distribution of disabled persons competent in various ADL activities

ADL skill Respondents (n) Frequency Percentage

Walking 117 100 85.5Feed oneself 130 125 96.2Use the lavatory 130 117 90.0Wash oneself 129 97 75.2Dress oneself 123 109 88.6Get up from bed} chair 127 116 91.3Write one’s name 127 45 35.4

Table 4 Results of attempts to locate the 132 disabled persons in the

1993 follow-up study

n Percentage

Assessed disabled persons 77 58

Deceased persons 18 14

At the lands} cattle post 21 16

Special education far from home 6 5

Relocated 7 5

Unknown 3 2

Totals 132 100

training; 21 persons were on their agricultural lands far

away from the village and could not be located due to

time limitations for the follow-up.

The second strategy was to compare the original group

(n 5 132) with the follow-up group (n 5 77) to check on

the representativeness with respect to age and sex and

ADL competency. Statistical tests indicated that, with

respect to these crucial variables, there were no

Table 5 Characteristics of disabled persons who could not be located (n 5 55)

Sex Age (years)

Category n Male Female ! 14 15± 59 " 60

Deceased 18 10 8 0 5 13

Special school 6 5 1 3 3 0

Relocated 7 4 3 2 4 1

At the lands 21 8 13 2 14 5

Unknown 3 1 2 1 1 1

Table 6 Percentages of disabled persons (n 5 77) who were

independent in ADL, 1990 and 1993

ADL activity 1990 (n 5 77) 1993 (n 5 77)

Feeding 96 99

Getting up 95 89

Washing oneself 76 79

Lavatory 91 87

Dressing 90 84

Fetch water‹ 71

Start a ® re‹ 70

‹ Not included in 1990.

diŒerences between the follow-up group and the original

sample. Thus, we felt reassured that the follow-up group

did indeed represent the total group. We then proceeded

with the analyses of the follow-up sample (n 5 77). A key

issue was the degree of independence which had been

achieved by the disabled persons. Questions on various

aspects of self-care were posed and compared to answers

in the original survey. Table 6 shows the results, which

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CBR in Moshupa village, Botswana

Table 7 Satisfaction with various aspects of life strati® ed by age (children ! 14 years old excluded)

15± 59 (n 5 47) 60 1 years (n 5 17)

Aspect of

satisfaction n

Percentage

dissatis® ed

Percentage

satis® ed n

Percentage

dissatis® ed

Percentage

satis® ed

Life in general 34 35 65 14 36 64

Work 8 25 75 3 0 100

School 9 11 89 Ð Ð Ð

Leisure activity 14 0 100 2 0 100

Friendships 32 16 84 14 50 50

Self-care 32 9 91 13 39 61

Family 35 9 91 15 20 80

Health 31 26 74 15 47 53

indicate only slight diŒerences between the two

occasions. A generally high level of independence is

evident. The more general question, `Do you take care of

yourself ’ , was answered in the a� rmative by 79%

adding to the general impression that, at least in terms of

personal ADL, the group is mostly independent.

Quality of life for the disabled persons was of great

interest in the follow-up. The data on adults for two

diŒerent age groups are presented in table 7, and show a

high level of satisfaction with the various aspects of life.

However, the elderly are somewhat less satis® ed with

health, self-care ability, friends and family life compared

to the younger age group.

r e s u l t s o f i n t e r v i e w s w i t h p e r s o n n e l

A content analysis of the interview material revealed

the following perceptions of strengths and weaknesses

and ideas for improvement of the programme in

Moshupa:

Strengths:

(1) Knowledge and information about rehabilitation

had reached the majority of the disabled persons.

(2) Awareness about disabilities had increased.

(3) Disabled persons had become more integrated in

the families and in the community. Disabled

persons were no longer hidden.

Remaining problem areas :

(1) Unsatisfactory cooperation between the CBR

team and the Red Cross volunteers.

(2) Lack of transport. The Red Cross jeep was not

always available.

(3) Lack of information about the work of the CBR

team among health-post personnel and school

teachers.

(4) Lack of knowledge among health-post personnel

in being able to diagnose children with disabilities.

As a consequence the referral to the CBR team did

not function well.

The personnel were also interviewed about what

suggestions they had to improve the programme. A

content analysis of these answers yielded the following

suggestions for improvements :

(1) Add two family welfare educators to the CBR

team so that all disabled people will receive regular

home visits.

(2) Let the nurse of the CBR team receive more

education in rehabilitation.

Interviews with 15 Red Cross volunteers (a total of 40

were registered in March 1995) revealed that 10 had

heard about the conception of CBR, but only three

had received training in rehabilitation. Of these 15, eight

were visiting disabled people in their homes. A common

concern among the volunteers (13 of the 15) was the need

for more training for themselves in terms of courses in

rehabilitation. One volunteer wanted a more suitable

place for the training of disabled persons and one

expressed the need for more technical aids.

Discussion

The prevalence of disability as de® ned by the door-to-

door survey in Moshupa was 1.37%. Since about 7± 10%

of disabled persons can be expected in the population," #

the current survey showed too low an estimate. One

reason for this may be that the pattern of settlement

(very spread out and several homesteads per family) has

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contributed to the di� culty in identifying the disabled.

Another reason may be the greater ease with which a

mildly retarded individual is integrated in a rural

community.

Since children are overrepresented in the age dis-

tribution of developing countries (approximately 50%),

the ® nding that only 22% of the disabled were children

is surprising. Similarly surprising is the large proportion

of elderly disabled (10% were 75 years old or above).

The large average family size was expected and is

comparable with previous studies. * In countries where

birth control is not practised, and where children provide

valuable work on the land, and support for the parents

in their old age, women have many children. In this

society the mother is the centre of the family, since in

many cases the father is working away from home.

Women do most work on the land and in the family.

Women may choose not to marry, so as to keep the right

to their own property, wages, etc. ; women predominated

as caregivers, and single mothers were the largest group.

To be cared for in one’ s own home by a loving family

which can provide support and guidance has been

recognized as a major advantage of the CBR pro-

gramme. " $

The follow-up study produced several encouraging

results. First, many of the old disabled people were still

alive; 17% were 65 years or older. Given the generally

lower level of life expectancy for disabled persons, " % this

® nding was surprising. However, it must be noted that

the elderly people in our sample had not been born

disabled, but were suŒering from age-related functional

loss, e.g. loss of sight, hearing or mobility, and were thus

more similar to a `normal ’ old-age population.

Both at the time of the initial survey and at the follow-

up, the disabled persons had great competency in ADL

skills. There was no noticeable change between these two

occasions, but possibly the CBR programme has con-

tributed to the maintenance of competencies. In the

follow-up study two instrumental ADL activities were

added (fetching water and starting a ® re). In a rural

community these are important tasks of independent

living, which 70% of the group did manage. Many

clients lived in three-generation households and the

average number of the family group was seven persons.

This probably implies that the disabled person who

cannot manage ADL would receive help from family

members. By contrast, in industrialized countries many

persons live alone (36%) and face the threat of isolation

and loneliness." &

The CBR programme for children had promoted

integration into normal schools for physically disabled

children and referrals to special schools for those with

hearing and seeing disabilities. The follow-up study

showed that these recommendations had been followed

to a large extent. These result corroborate several

previous studies which have emphasized the bene® ts of

CBR to children. " # , " ’

The CBR programme for adults had attempted to ® nd

jobs for the adult disabled. Several other studies have

examined the proportion of disabled people in work as a

measure of CBR." # We found that 20% were working

despite di� culties about ® nding jobs in a rural area such

as Moshupa. Examples of employment were farming,

cattle, work in small shops or in the only petrol station.

Quality of life was a major concern in this study. With

a dichotomized (satis® ed vs dissatis® ed) scale we com-

pared older people (60 and over) with younger persons

(15± 59). Although the groups expressed similar levels of

satisfaction with life in general, older people were less

satis® ed with the aspects of friends, self-care, and health.

These results are understandable since dissatisfaction

with life among elderly people is often correlated with

disease, loneliness, widowhood, or ® nancial di� culties." (

The ® nding that older people were less satis® ed than

younger ones was further supported by answers to the

question : `How is your life today compared to three

years ago? ’ While a majority (60%) of younger persons

judged it better, and only 16% judged it worse, 80% of

the older people found it worse and only 7% better. This

® nding is probably correlated to opportunities for work

and involvement in community life, in which younger

people are likely to be engaged.

Comparisons between men and women yielded only

one signi® cant result. A greater proportion of males were

satis® ed with friends. This may re¯ ect a cultural pattern

in rural South Africa where women do most of the work

on ® elds and around the home and men can often be seen

sitting around with other men. " )

Most of the data in the present project are quantitative

except for the interviews with personnel. Although there

are obvious di� culties with carrying out interviews with

the help of interpreters, the need for qualitative data of

good quality is obvious. This point was made by

Finken¯ ugel et al.," * who emphasized the need for

process-oriented data and development of qualitative

research in CBR.

When evaluating the CBR programme in Botswana it

is obvious that it has indeed been a component of

community development in the spirit of the WHO

approach. The programme has many volunteers who,

despite insu� cient training, still try to ful® l the goals of

CBR to the best of their ability. Most volunteers

expressed the need for more training in CBR, thus

substantiating the view elaborated by Hale and Wallner# !

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CBR in Moshupa village, Botswana

that CBR workers need to be trained in greater numbers

to provide acceptable standards of service. Clients cannot

be left without some continued support such as home

visits. If rehabilitation workers do not provide such

services for at least some minimum of time after the

initiation of the CBR programme, the programme is not

likely to survive. The Rehabilitation Committee also has

an important function. In Moshupa village a Rehabili-

tation Committee has been formed, which works for self-

determination and social integration of disabled people.

The committee has organized fund-raising and social

events in the village.

While the government at the national level has

recognized its responsibility for the disabled in the

National Development Plan, there are as yet insu� cient

support structures at the intermediate level. Support

personnel such as physiotherapists and occupational

therapists are needed to advise, train and supervise

rehabilitation personnel. The role of physiotherapists in

this context has been discussed by Kay et al.# " They point

out that physiotherapists are currently under-utilized,

and suggest that physiotherapists achieve an elevated

and more independent role in areas of management,

assessment and treatment. This proposed role within the

medical domain should include out-reach and edu-

cational programmes at the local level. A similar role

would be equally appropriate to other categories of

rehabilitation workers such as occupational therapists.

Finally, we would like to suggest that CBR has

important implications not only for developing

countries, but also for the rest of the world. Many

industrialized countries are experiencing great strain on

® nancial resources for health care, and governments are

cutting back funds. This, in association with an ageing

population and the increasing demands on health care

for the aged, may give impetus to establishment of more

CBR programmes in the near future.

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