operationalizing community participation in community-based rehabilitation: exploring the factors

CLINICAL COMMENTARY

Operationalizing community participation in community-basedrehabilitation: Exploring the factors

NICK POLLARD1 & DIKAIOS SAKELLARIOU2

1Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield, UK, and 2Occupational therapist, Petroupoli,

Greece

Accepted December 2006

AbstractPurpose. The purpose of this article is to critically discuss issues that pertain to the operationalization of communityparticipation in community-based rehabilitation (CBR).Method. Data were drawn from an international, questionnaire-based survey of occupational therapists involved in CBRconducted through the World Federation of Occupational Therapists. A search of CINAHL. PsychInfo and Medlinedatabases for articles on CBR was performed and both descriptive articles and analytical ones were included.Results. Although there are guidelines on the nature of CBR these do not always match its application in practice. Activeinvolvement of local communities in CBR projects is often limited, threatening the sustainability of CBR programmes.Furthermore, the failure to acknowledge the sociopolitical underpinnings and the cultural nature of disability is likely tocompromise the nature of disabled people’s involvement in CBR.Conclusions. There is confusion and lack of clarity about the nature of CBR. Educational modules on CBR should be madeavailable to professionals. These should consider the importance of community involvement and context-specific andculture-sensitive programmes in practice.

Keywords: Community-based rehabilitation, disability, community participation

Introduction

In many societies there is some principle of social or

communal obligation to others, but this is frequently

perceived in unidirectional terms as a value which is

extended from those in a position of privilege and

dominance to those who lack something. Countries,

such as the UK which currently have state health and

social care provision, often have political elements

raising an argument against the costs for taxpayers.

The voices of those who lived when access to

healthcare was a matter of privilege are rarely heard.

George Hewins, who died in 1978, recalled numer-

ous abuses of the poor, the aged, the disabled and the

vulnerable in an early 20th-century Britain before the

establishment of state welfare, that sound like a story

from the ‘developing world’ [1]. These conditions

motivated the activities of a whole range of social

philanthropists, among which were those who

pioneered occupational therapy in the UK and

USA [2,3]. However, their class origins suggest that

the power they had to act came from privileges

produced through capital gain, and economic and

political inequality that continue to set limits to

citizenship for members of marginalized groups

[4 – 6]. Whether at the local, social and global level,

the major causes for health disparities and disability

are related to the uneven distribution of resources

(including opportunities), which can lead to lack of

education, limited access to healthcare and poor

housing conditions for people who do not have

access to sufficient income [7 – 10]. As we discuss in

this paper, the responsibility for initiating solutions

to these problems is one which is shared between

health and social care professionals and communities

themselves. In particular, given their concern with a

holistic view of human occupation, occupational

therapists could more effectively develop their role in

Correspondence: Nick Pollard, BA, DipCOT, PGCE, MA, MSc (OT), Senior Lecturer in Occupational Therapy, Sheffield Hallam University, Faculty of

Health and Wellbeing, 11 – 15 Broomhall Road, Sheffield, S10 2BP, UK. E-mail: [email protected]

Disability and Rehabilitation, 2008; 30(1): 62 – 70

ISSN 0963-8288 print/ISSN 1464-5165 online ª 2008 Informa UK Ltd.

DOI: 10.1080/09638280701192980

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the facilitation of such a process with disabled com-

munity members.

Disability is not a problem which can be under-

stood in isolation, it has to be negotiated in the

sociopolitical context where it occurs. The term

disability is used to refer to a number of distinct

realities [11] and conceptualizations which vary

among and within cultural groups [12,13]. Disability

can be thought of as a passive state or a dynamic

process, understood as a natural, inevitable phenom-

enon or as one that is constructed and therefore can

also be deconstructed [14]. Depending on the

approach taken, the focus of rehabilitation pro-

grammes may lie with the individual (often leading

to discriminatory practices) or a more objective

sociopolitical reality. While proponents of the social

model view societal oppression as the origin of

disability [6], many people believe disability and its

origins lie within the physical body. However, it is

not simply a case of either one or the other. An

integrated approach would recognize both the socio-

political parameters of disability and its biomedical

implications [15].

Internationally, the occupational therapy profes-

sion has sought to reclaim its roots by framing recent

concepts such as ‘occupational apartheid’ [16],

‘occupational injustice’ [17] and ‘occupational de-

privation’ [18] as matters of professional concern for

occupational therapists. The authors argue that the

professional preoccupation with these occupational

justice issues remains largely theoretical, rather than

in practice. Occupational therapy has only just begun

to appreciate how the political potential of occupa-

tion can be realised through forms of intervention

that go beyond health and social care to address the

sociopolitical dimensions of disability [19].

‘Occupational justice’, ‘occupational deprivation’

and ‘occupational apartheid’ are terms which are

rarely heard outside the occupational therapy profes-

sion. Each of these terms refers to the principle that

occupation is an essential part of human experience.

Therefore access to meaningful occupation, defined

as the means to engage in the human activities

through which individuals maintain their sense of

purpose and identity, is a right. Whereas ‘occupa-

tional justice’ refers to the right to this access,

‘occupational deprivation’ refers to situations where

the opportunities for meaningful occupation are

limited. ‘Occupational apartheid’, however, is a term

used to indicate situations where occupational

exclusions arise through systematic processes of

oppression.

An occupational justice perspective views disabling

situations, such of access to resources and opportu-

nities, not as natural, inevitable events but as the

products of individuals and societies. Injustice

occurs whether or not the restrictions in access are

intentional [16,17]. Disabling situations limit indi-

vidual access to opportunities and resources, and so

reduce, sometimes drastically, the occupational

choices open to people. Dwyer [9] argues that to

produce sustainable social change people need to

explore the political origins of the observed injus-

tices. As Kronenberg and Pollard [16] would say, we

need to identify the actors, study their conduct and

explore the political landscape in order to acquire a

thorough understanding of the injustice situation and

design appropriate action for establishing occupa-

tional justice.

One approach to tackle disabling situations is

community-based rehabilitation (CBR). According

to the most recent definition agreed upon by the

International Labor Organization, the United

Nations Educational, Scientific and Cultural Orga-

nization and the World Health Organization: ‘‘CBR

is a strategy within community development for

rehabilitation, equalization of opportunities, and

social inclusion of all people with disabilities. CBR

is implemented through the combined efforts of

people with disabilities themselves, their families,

organizations and communities, and the relevant

governmental and non-governmental health, educa-

tion, vocational, social and other services. The major

objectives of CBR are: (a) to ensure that people with

disabilities are able to maximize their physical and

mental abilities, to access regular services and oppor-

tunities and to become active, contributing members

to the community and society at large and (b) to

activate communities to promote and protect the

human rights of people with disabilities through

changes within the community, for example, by

removing barriers to participation’’ [20, p. 2].

CBR is a strategic approach to tackle the under-

lying causes and the effects of disability. CBR

addresses the needs of people where disabling

situations combine with limited healthcare availabil-

ity, restricted infrastructure, scarce resources and/or

marginalization and lack of recognition of commu-

nity needs [21,22]. Medical rehabilitation is there-

fore only one of the aspects of CBR and serves as a

means to allow greater community involvement and

opportunities for engagement in occupation for

disabled people [23,24]. The aim of CBR is to

empower people with disabilities to be full and

valued members of their community [25,26]. Ideally,

CBR is based on the joint efforts of various

stakeholders, among whom are the community itself,

healthcare professionals, family members and first

and foremost the disabled people themselves

[25,27].

In practice, the urgency of the rehabilitation needs

of people facing disabling situations can often be

used to dismiss concerns for full citizenship rights.

Dwyer [9] argues that addressing immediate needs

Operationalizing community participation in community-based rehabilitation 63

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may be a short-term strategy. In the long run it is

important that knowledge and power are shared and

that the focus is concentrated on the persons facing

disabling situations through community develop-

ment strategies that are beneficial to the whole com-

munity [28 – 30]. As Edmonds and Peat [31, p. 276]

stated ‘CBR is much more than the transfer into the

community setting of ‘‘conventional’’ rehabilitation

strategies’.

CBR calls for the active involvement of disabled

people and their communities in the rehabilitation

process. This is seen as a necessary means of meeting

the shortfall between the resources available to

provide professional staff and sustainable culturally

relevant services and the requirements of disabled

people themselves [32]. Although CBR is practiced

in many countries, only 2% of the world disabled

population has access to such services and the

number of individual service providers has not been

quantified [21]. CBR is often merely interpreted as

medical rehabilitation that takes place in the com-

munity (where the community is only the place of the

intervention) or as voluntary work in developing

countries (we use the terms developing country and

developed country as a convention, due to lack of more

accurate and non-hierarchical terminology) that do

not have an extended healthcare infrastructure nor

the necessary human resources to provide healthcare

services [21]. This confusion can endanger the

sustainability as well as the effectiveness of many

CBR programmes and is perhaps one of the factors

why health policies in developed countries have been

reluctant to include CBR as a valuable and cost-

effective strategy to address health disparities and

disability.

A recent international survey of 59 occupational

therapists active in CBR that was carried out as part

of the project plan on CBR developed by the World

Federation of Occupational Therapists (WFOT)

revealed a polyphony in regard to the understanding

of the concept of CBR and its operationalization in

practice. The methods and the results of this survey

are detailed elsewhere [33,34]. This paper draws

from the results of this survey and critically discusses

central concepts of the CBR process with the aim to

initiate a discussion on issues that impact on com-

munity involvement in CBR.

Community participation in CBR

Community participation is an important aspect of

CBR [32,35] that is often inadequately understood

and misapplied. Several authors [25,32,36] argue

that involvement of community members in all

aspects of program design and implementation is

vital for developing a sense of ownership of the

programme, which can positively influence its

sustainability. Community members need to be

actively involved in the CBR process, including

planning and decision taking, and not passively

taking part [32,37]. However, it has been observed

that the participation of disabled community mem-

bers in CBR is limited, being largely restricted to

them being recipients of care [26,29]. In one of the

few studies that specifically explored the perspective

of disabled people regarding CBR, it appeared that

disabled people often have limited involvement in the

programmes [22]. Limited participation of disabled

people in programmes designed for them has also

been observed in initiatives both in developing [38]

and developed countries [39].

In accordance with the literature, the majority of

responses received by the WFOT team [33] did not

mention involvement of persons with disabilities and

the communities in which they live. Figure 1 shows

the number of disabled people involved in any way in

CBR programmes, as reported by the surveyed local

and expatriate professionals.

Active involvement by people with disabilities was

reported in only seven out of 66 programmes for

Figure 1. Participation of disabled people in CBR programmes.

64 N. Pollard & D. Sakellariou

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which information was received. This presents a

significant problem, since active participation in

decision-making appears to be strongly related to

empowerment [40]. CBR programmes might fail to

take local values, attitudes and needs into account if

community members can often only express their

opinion but the power to take decisions is held by

expatriate staff who can be ignorant of the socio-

cultural context they are working in [26]. Figure 2

shows a tendency for the short-term involvement

by expatriate occupational therapists in CBR

programmes.

Under these circumstances expatriate therapists

may bring their own values and a sense of their own

moral superiority into the programme and expect the

local population to accommodate them [12,41].

Although several authors have indicated the impor-

tance of cultural relevance when designing and

implementing CBR programmes [29,42,43] most

of the expatriate participants in the WFOT survey

reported brief involvement in CBR. It is possible that

they did not have time to acquire a deep under-

standing of the local context or the negative

ramifications of this lack for programme design,

implementation and effectiveness.

The Program of Rehabilitation Organised by the

Disabled Youth of Western Mexico (Programa de

Rehabilitacion Organizado por Jovenes Incapacita-

dos de Mexico Occidental [PROJIMO]) project in

Mexico [44], briefly described by Rapp [45],

exemplifies active community involvement in CBR

and ownership of the programme by the local

community with the aim to maximize the potential

of local communities and of people facing disabling

situations. It is a community based rehabilitation and

education programme run by and for the disabled

people. It does consciousness-raising with non

disabled people and school children and focuses on

the strengths of disabled persons as members of the

community. Unfortunately, as observed by Finken-

flugel [25] programmes like PROJIMO are still the

exception in CBR. In many CBR programmes the

involvement of local communities is limited with the

consequence that health and social care professionals

can actually end up delivering care and thus per-

petuate dependency, disablement and disempower-

ment. The lack of (the chance of) reciprocity, i.e., an

interaction where all parties act both as recipients

and as givers, is central in the construction of stigma

and social exclusion [46] and if CBR programmes

are to foster empowerment and self-determination,

people with disabilities and their communities need

to be respected and enabled to assume decision

making roles [47].

This issue has of course many parameters.

Simmond, an occupational therapist, aptly describes

how being an expatriate professional from a devel-

oped country can produce unrealistic expectations in

local professionals, for example having the expertise

to perform the functions of a doctor [48]. Misunder-

standings can arise because the involvement of

expatriate expertise in the project may have been

facilitated by false assumptions on either side. On the

other hand, excessive deference to foreign expertise

can further act to perpetuate reliance on external

help rather than the development of local skills

[22,38]. The therapists need to practice caution

when they operate outside their cultural context. The

authors believe CBR involvement should be con-

sidered as a rewarding learning experience from all

sides involved. As physiotherapists Kay and Dunlea-

vy [49, p. 117] suggest: ‘have we considered the

possibility that therapists from developing countries

may be able to reciprocate by teaching physical

therapists from the USA?’.

In the following paragraphs we will explore some

issues that are of importance in the operationaliza-

tion of community participation in CBR.

Figure 2. Local/expatriate professionals and involvement in CBR.


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Conceptualization of CBR

As an umbrella term, CBR can be used to encompass

everything from a paternalistic to a dialectical model

of service provision with its orientation ranging from

biomedical to sociopolitical [29,50]. Among the

issues that compound this indeterminacy are the

following:

. CBR is applied in a variety of circumstances –

attached to hospital structures, primary

healthcare, other social agencies and non-

governmental organizations or local sponta-

neous action in lieu of anything else.

. There appears to be a lack of dedicated educa-

tion modules that address CBR for occupa-

tional therapists and other health professions

for professional registration qualifications. This

situation might be slowly changing, for exam-

ple CBR is being incorporated in some occupa-

tional therapy curricula, as evidenced by

Hunt [51].

CBR is often seen through a medical rehabilitation

perspective. The reasons for this might be traced back

not only to professionals’ limited knowledge about

CBR but also to pressures on time and opportunities

to become familiar with different cultural contexts. It

takes time to build up connections with communities

and understand the nature of their problems

and develop appropriate cultural insights [12,52].

Professional literature which reflects the experiences

of non western cultures is not often available in the

dominant lingua franca, English, or if it is, reflects a

western perspective [53,54]. Knowledge, experience

and the conditions for open-mindedness are pre-

requisites to navigating the community successfully

and establishing good relationships with the people in

it, and the negotiation of programmes that are

responsive to participants’ needs, but often profes-

sionals are working in isolation [12,55]. While the

community should have control of the programme,

its means and its outcomes this may be difficult where

community cohesion is weakened by local circum-

stances. Nor should community empowerment over-

ride professional expertise [21].

These issues can produce complex pressures.

Sometimes professionals feel a need to respond

immediately and swiftly to disability and related

injustices. It can be necessary for the success of CBR

programmes and their acceptance by local commu-

nities that positive effects can be quickly recognized

[9,36], but this might explain an over-emphasis on

medically defined outcomes indicated in some

programmes. Quickly achieved outcomes may not

address the underlying contributory elements of

disability such as poverty. Instead a focus on short

term gains may unintentionally help to perpetuate

it and encourage dependence on external aid.

Moreover, medical rehabilitation alone often fails to

recognize some of the social complexities around

experiences of disability, such as the impact of

multiple marginalizations arising from the other

minority or cultural groups to which disabled people

may also belong. In addition to difficulties which are

due to lack of disability awareness they may

experience many other problems along with other

members of these groups [56].

Both the contextual and conceptual aspects of

CBR influence the length and nature of involvement

of disabled people. For example, short term involve-

ment may often be necessarily focused on medical

rehabilitation and direct service provision, but this,

as already explored, can sometimes jeopardise the

sustainability of the programme because under these

conditions it is difficult to establish active community

involvement and the development of local structures.

Capacity building strategies generally call for a more

long-term commitment and greater involvement of

community members. The WFOT survey [33]

indicated that expatriate staff members often work

for a very limited time in CBR. This may compro-

mise the effectiveness and broader understanding of

the nature of commitment because their experiences

of CBR, when written up for future professionals

seeking to involve themselves in similar work, tend to

be descriptive rather than analytical [57]. Thus it is

likely that the need for and the evaluation of

sustainability will not be well understood. Indeed

such professional literature may contribute to an

impression of the developing world as disaster prone,

of people being grateful for help they are unable to

generate themselves, of a world of problems which

are only distantly connected to global inequalities,

and which can be happily resolved through what is in

effect the combination of a working holiday with

western altruism, as suggested by Miles [26].

Disability

An effective response to situations of disability first

requires a frame of reference which can be applied

across different contexts. Whether a certain situation

will be recognized as a disability depends largely on

the cultural context. People become disabled to the

extent that they cannot participate in the activities

they are expected to within their community [13].

Thus their ability to fulfil the requirements for

community membership is compromised. Disability

is therefore context-related. Consequently it is

important to collaborate with the greater community

and explore their attitudes towards disability,

and to enable disabled people to identify their own

needs.


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The importance of poverty in the construction of

disability should also be recognized [31,39]. In both

developing and developed countries poverty and

disability appear to be engaged in a dialectical

relationship; disabled people are excluded from

access to education and employment and so they

cannot escape poverty and must depend on social

welfare, where available, family or community

support or begging. Moreover, poverty contributes

to higher incidence of disability, due to malnutrition,

limited access to healthcare and higher exposure to

risk factors such as hazardous work environments

[13,38,58]. This two-way link needs to be recognized

and the perspectives of disabled people need to be

actively sought so that they inform the scopes of the

programme.

Voluntarism

CBR programmers frequently depend on voluntar-

ism for a large component of the human resources

they require. Its importance should not be under-

estimated [59,60]. The low cost and the possibility of

a two-way flow of information (between the volun-

teer and the community) make it a useful recruit-

ment option for CBR programmes. The time limited

commitment and the prospect of training in CBR

approaches is often attractive to recruits.

However, these same issues can adversely affect

the sustainability of CBR projects [35]. Many

professionals cannot afford to volunteer on a long-

term basis. Short-term involvement might mean

limited insight into the needs of a community and

thus professionals might resort to medical rehabilita-

tion approaches that are less time-consuming and

bring faster results. These approaches though greatly

limit the involvement of the community, which

becomes more of a passive beneficiary of the pro-

gramme than an active collaborator.

Furthermore, the involvement of the professional

in CBR may stem from a range of motives [22].

Some individuals might choose to volunteer in anti-

cipation of a paying job later on but leave if

employment in the field is not possible [22,25].

Other therapists may be motivated by charitable

reactions or because they recognize the sociopolitical

barriers faced by their clients, factors which are likely

to influence the character of their involvement. In

agreement with relevant literature [61], many of the

respondents of the WFOT survey mentioned a desire

to help persons with disabilities and their commu-

nities as the major motive for their involvement in

CBR. While this is certainly positive and perhaps a

prerequisite to getting involved in CBR, it should

always go along with professional responsibility and

political awareness. Without the guidelines of a pro-

fessional ethos and the knowledge acquired through

familiarity with the local political context, personal

ethos alone might lead therapists to a charity -style

attitude, which can be problematic and potentially

patronizing and development-thwarting, leading to

the perpetuation of dependence [22,38,39]. As

Coleridge [12, p. 25] noted ‘charity, despite its good

intentions, does not promote change; it perpetuates

the status quo of inequality’.

Funding

External funding can be important and especially

necessary in the initial stages of CBR programmes

[26,29]. However there are many issues connected

with it which introduce risks:

. There is the risk of perpetuating dependency,

which might compromise programme sustain-

ability; unless projects can develop their own

means of support they are likely to be discon-

tinued when funding is no longer available.

. Local communities in receipt of external

funding can be disempowered by it. It makes

them accountable to people out of the com-

munity for every decision they take and any

programs they implement. This can mean that

the priorities of the programme are determined

by agendas external to the community.

This is a twofold process; the takers get used to

taking and the givers get used to giving while the

chasm between the two gets bigger. Thibeault

[42,43] drawing from her extensive experience in

the field of CBR, stressed the need to incorporate

action for local capacity building rather than relying

on financial aid.

Discussion

The CBR process is complex and difficult, fraught

with the immediate and longer-term ethical issues of

human need, often without the benefit of a clear

historical process for guidance. Acting in the belief

that they are working for good, expatriate workers

may fail to appreciate these issues. The fear that the

aid might dry up early or that the aid workers might

lose their jobs or sense of purpose may also distract

them. Those who are expatriates or who are not from

the same class or culture as those with whom they are

working may not recognize how CBR has the

potential to create as many dilemmas and problems

as it is intended to resolve [26]. Some of these were

highlighted by the WFOT survey [33]:

. Is CBR connected with the processes of demo-

cratization (through spreading education, po-

verty alleviation, measures which affect


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infrastructure and administration, co-operation)

and a genuine effort towards the promotion of

human rights, or is it a band-aid approach?

. Are the people employed in CBR hoping to

effect sustainable improvements or do they con-

sider their interventions as a band aid approach

that might, having gained entry, spread through

local influence?

. If it is a band-aid approach is it being accepted

and employed by local or national governments

as a means of pacifying both local and inter-

national political demands for more significant

and sustainable reform?

. If it is perceived by chronically disadvantaged

people as immediate help in the short term but

‘gesture politics’ in the long term this may en-

gender a cynicism which could hamper future

interventions and the acceptance of initiatives

for future projects.

. Those local people who invest in projects might

later be exposed and oppressed or isolated for

the temporary advantages that they may have

gained once external intervention ceases.

These issues and uncertainties require further

investigation. Few of the programmes described in

the WFOT survey were long term, and those were

generally run by people working in their own

country, particularly Colombia and South Africa.

Colombia and South Africa are large countries. In

them it may be possible to work in areas at some

distance from home both in class and culture terms,

producing a geographical and a regional/cultural

dislocation across race, culture and language. Many

countries in the ‘developing world’ such as those of

southern Africa had colonial histories of imposed

regional boundaries and borders, and a correspond-

ing legacy of infrastructure, which did not respect

indigenous cultures [62]. These are often sources or

elements in local conflict, or require accommoda-

tions to be made in order to recognize rights and

enable access across linguistic, political, economic

and cultural divisions as well as those of topography

so as to enable active involvement of the community

in the CBR programmes.

The conditions which are often dealt with through

CBR have evolved and hardened or consolidated

over generations. The problem of measuring out-

comes is one which can only be seen in the context of

local perceptions of effectiveness given the area

specific and sometimes individual nature of the

intervention being offered. It can also be difficult to

determine the success of small teams attempting to

co-ordinate projects involving national populations

(e.g., the refugees from conflict in Uganda).

Dorman’s [62] account of political developments

in southern African states is one example of how

unifying approaches have to take into account

cultural differences and varying local needs. Part of

her account explores how the roles of Non Govern-

mental Organizations (NGOs) have sometimes

enabled them to use previous involvement in the

struggle for development as political capital toward

the articulation of peoples’ rights against govern-

ments, such as that of Zimbabwe, which itself claims

to express the peoples’ will. On the other hand,

despite the considerable humanitarian needs in areas

like Eritrea or Sierra Leone, NGOs have been forced

to hand over their operations to government-

sponsored organizations [38]. Often NGOs are

under pressure to conform to host governments’

expectations.

These environments are therefore full of po-

tential difficulty for therapists who are working

outside the social and cultural environments with

which they were familiar. The consequences may be

no more than a few elementary misunder-

standings, but it is possible that naivety and good

intentions might actually produce damaging

effects not only for the working relationships of the

individuals directly concerned, but other workers

too. Thibeault [43] has, for example, illustrated

the need for a strict political and social neutrality

from the outset in involvement in a project in

the Lebanon. Anything else would have com-

promised the ability of the project to meet its

objectives.

Many of the participants in the WFOT survey

referred to a lack of education in CBR approaches

and occupational therapy applications, but it is clear

that there are changes taking place in course cur-

ricula. There is evidence that courses have developed

modules or other components which offer CBR

experiences [51].

This paper sought to illuminate some issues of

vital importance for the operationalization of CBR.

CBR efforts cannot be sustainable or effective

without full community participation. Despite the

efforts of various governments’ policies, for example

Brazil [63] and South Africa [64] to develop

strategies at national and local level, the success of

community participation is, inevitably, variable.

Some of these interventions have been precipitated

through a shift in occupational therapists’ profes-

sional focus from working with individuals to work-

ing with communities [65,66]. CBR is not a quick fix

option for the needs of disabled people and their

communities [67]. Though some of the respondents

in the WFOT survey [33] may have felt that they

were able to achieve positive results during a visit to

another country in a few weeks or months, the

authors wonder what the user-led evaluation of these

projects might reveal with regard to sustainable

outcomes.


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In this article we have only outlined a few of the

areas through which CBR projects can enhance

community participation. These include:

. An appreciation of the political context of dis-

ability in relation to individuals, communities

and governments;

. Incorporation of CBR modules into profes-

sional education;

. Enhancing cultural awareness in the design of

CBR programmes;

. Planning for medium and long-term outcomes

in the evaluation of CBR programmes.

The relationship between the sociopolitical envir-

onment and disability is not only an economic one,

but an intergenerational one, requiring long term

engagement, a historical cultural perspective and

approaches that are locally sustainable.

Acknowledgements

The impetus for this paper was given through the

authors’ participation in the team of the WFOT-

CBR data collection subproject, which also included

Hetty Fransen, Lena Haglund, Frank Kronenberg,

Marilyn Pattison and Kit Sinclair. We also wish to

thank the colleagues from around the world who

contributed to the discussion on the nature of CBR.

Part of this paper was presented at the 14th Congress

of the World Federation of Occupational Therapists,

23 – 27 July 2006, Sydney, Australia.

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operationalizing community participation in community-based rehabilitation: exploring the factors

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