As part of the occupational therapy course students must complete a minimum of 1000 hours of clinical placement to be eligible for the World Federation of Occupational Therapy (WFOT) accreditation. At the Bangladesh Health Professionals' Institute (BHPI), the training institute attached to CRP, twenty-nine third year students were divided into groups of 6-9 students and rotated around four placement sites. These included neurology in the Postgraduate Hospital in Dhaka, cardiac at the National Institute of Cardiovascular Diseases (NICVD) in Dhaka, Pabna Mental Hospital in the north-west of Bangladesh and Community Based Rehabilitation (CBR) at CRP's subcentre in Gobindapur, Sylhet.

The placements in Gobindapur were supervised by myself (Monique Baxter) for the first three months and then Jane Bourke for the last month. Jane and I are both experienced occupational therapists trained in Australia. The students were given the opportunity to experience working with clients in their own homes. They learned about the everyday difficulties facing people with disabilities in rural Bangladesh. The students were able to put their theoretical knowledge into practice. They taught people how to be more independent in their self care activities like eating, dressing, and going to the toilet. They also advised women how to go about their domestic chores more easily to reduce the likelihood of back pain. In addition, the students had the opportunity to make equipment out of bamboo or mud - just as effective as commercially available assistive devices but inexpensive and easy to make.

Community integration for people with disabilities is greatly impeded by the difficulty in finding a suitable job. Where appropriate the students gained experience in addressing vocational and income generation activities with people with disabilities in the village. An successful example of this is the person who, before being seen by an occupational therapy student, wanted to be thrown in a river to drown. Following advice and encouragement he is now able to contribute to his family's income after 38 years .

My experience of supervising students on placement was an extremely challenging and rewarding experience. The demands on a sole foreign supervisor were many - from coping with different languages (Bangla, Sylheti, English), different interpretaions of the definition of an over crowded bus, and the inability of people in the villages to understand "No I don't want another cup of tea or piece of mishti"! However, the opportunity to make an impact on the lives of people in the villages in Bangladesh far outweighs any inconvience I endured in my time up there. It was also a fantatic opportuntity to appreciate the friendly and helpful staff based at CRP Gobindapur. It is well worth visiting this site to relax in the beautiful surroundings.

One person who received occupational therapy intervention reported he was diagnosed with sciatica 38 years ago and since then lay on his bed. Consequently he developed contractures at his hip and knee limiting his movement greatly, preventing him from walking. When first seen by the student he wanted to be thrown into the river to drown. However, by focusing on his abilities (being very strong in his upper body) the student was able to encourage the man to move from his bed onto a chair. By using this technique of placing chairs in appropriate positions he was able to make it out of his house. The next problem was the steps into the mud walled house. This was overcome by the student and client working together to build steps big enough for a chair to fit on each step so he could get out in the yard. This in turn has enabled him to start weaving baskets in his yard. After being financially dependent on his brother for the past 38 years he can now start working for himself. Showing this man how he could get out of bed has helped him be able to contribute to the finances of his family again after 38 years.

This is only one of many success stories that have occurred from giving the students of occupational therapy the opportunity to experience working with their clients in rural Bangladesh.

Evaluation of student placement at Gobinadpur 2001-2001 - Monique Baxter, Clinical supervisor

It has been approximately four years since occupational therapy students have had the opportunity to have a student clinical placement in a community setting. From November 2001 to March 2002, the 29 third year occupational therapy students have participated in a community based rehabilitation (CBR) placement at the CRP-Gobindapur site. The placement duration was four weeks with groups of students ranging from six to nine students. The placement supervisors were Monique Baxter for the first three months and Jane Bourke for the last month. Both these therapists hold a Bachelor of Occupational therapy from La Trobe University, Australia are experienced in working in a community setting.

The following is an outline of the placement and recommendations for the future.

Community Survey
With each of the four batches of students the first 1-2 weeks was conducting a community survey identifying people with disabilities in the Brahman Bazaar Union, Bromchal Union and parts of the Tilagoan Union and Kulara Union. The students attempted to conduct a house-to-house survey of the villages in these unions. At times they were required to go house-to-house however in many villages a local person voluntarily helped the students to identify where the people with disabilities lived. The information that was collected was: person with disabilities name, name of father/husband, name of village, age, sex, problems, advice/recommendations.

The lists that the students have collected can only been seen as minimum lists of people with disabilities. Initially the people in the village where suspicious of the students, however, over the course of the four weeks when they saw the benefits the students were able to bring about with their selected clients more people identified themselves as having a disability. So if another survey where to be conducted even more people could be identified.

Another limitation of the survey was the students' definition of disability. On repeated occasions the students were reinforced to use the revised IDCHID categorisation of disability looking more at the handicap level and the impact of roles and life expectations and not merely at the disability level focusing on physical problems. This was a difficult to incorporate into the survey for the students for two reasons. The first reason is they had received limited training on the revised model of disability therefore were restricted in transferring the theoretical knowledge to the survey collection. Also having foreign supervisors with limited Bangla, the students could not be corrected each time they described the survey to the people of the village.

The second reason relates to the villagers who were often very busy with harvesting rice or suspicious of the students so were not readily giving the detailed information on the impact their disability has on their life roles and expectations. Taking these limitations into consideration, the students were able to identify at least 100 people with disabilities in each union so this could be seen as a more than adequate basis on building a service for these villages. The results of this survey primarily identified people with physical disabilities (hemiplegia, visual problems, hearing and speaking problems, pain in various parts of the body) and did not identify many people with cognitive or intellectual problems nor those with psychiatric conditions. This could be seen in three ways either there are no people with such conditions in the surveyed community or the students did not include these in their explanation to the people or the villagers did not want these people identified.

Overall despite the limitations of the survey the information collected is still a good starting point for CRP to expand its services to the village level around the Gobindapur site.

Individual client intervention
During the placement weeks 1 and part of 2 were taken up with the survey. The rest of the placement time was spent with the students selecting three clients each and giving them daily therapy in their homes. The students prioritised the clients they selected with regards to:
need and benefit from occupational therapy intervention. The supervisors recommended focusing on clients and/or carers who could report an improvement in function or quality of life after their two weeks of occupational therapy. Some of the people identified in the community survey required medical attention( for treatment of high blood pressure) or other specialist services (leprosy treatment from HEED Bangladesh), so would not benefit from therapy at the present time.

socio-economic status. Those who could afford to travel to the CRP-Gobindapur site to receive therapy were recommended to do so. Many of the students chose to work with very poor people who if they had not been given the chance would not have received any therapy at all.
location. Due to the nature of working in the community a lot of time is spent going from one place to another. It was more time efficient and cost effective for the students to see clients in the same or neighbouring villages so the majority of their time could be spent with the clients.
to expand their experience. The students were recommended to see clients with varying conditions and ages so they could maximise this learning opportunity. As can be expected some students enjoyed the challenge of learning about other conditions.

Overall the students were able to make an impact with some of the people who received therapy. The students provided education on the conditions to the clients and family in an attempt to dispel the myths surrounding the causes of disability. They were also able to provide education on changing the environment to make daily activities easier for the client and/or their carer. This was often as simple as observing the way a client was eating and raising the position of his plate to reduce the need to bend forward which was exacerbating his back pain. Carers were also educated on correct lifting techniques to reduce the possibility of them getting back pain when caring for their relative. The students were also able to put into practice practical skills like hemiplegic dressing techniques to improve their clients level of independence. This in turn will free up the carers time so they can concentrate more on their other daily chores or income generating activities.

Disability awareness programs
As part of the placement the students were to each arrange and conduct disability awareness programs in the villages. There were no constraints on where these could be conducted however the majority of the students chose to conduct the programs in government or BRAC schools. Some creative students chose to run programs in their clients homes educating their client and family and neighbours on the causes and prevention of disability. This appeared the most effective way of getting people in the village thinking and talking about disability as the groups were often smaller and people found it easier to share thoughts and ideas about disability.

As the disability awareness programs were conducted in bangla it was difficult for foreign supervisors to follow all the information that was being presented. With encouragement the students were able to think laterally about how to present the information to the audience, using drama, stories, posters. The information presented is that advised by the Social Welfare Department at CRP and would benefit from being reviewed to ensure the International Classification of Functioning and Disability is being used. Also suggestions on ways to make this information easily understood for age ranges from children to adults requires different presenting styles. A thorough study of the disability awareness programs would be an interesting and valuable topic for a research project.

Benefit for students
The majority of the students on clinical placement reported it was an excellent experience for them to observe village life. Some of the students had not been to a village or inside muddy houses before. The essence of occupational therapy is being able to suggest improvements to the way a person goes about their daily routine. This is near impossible to do if you do not have an understanding of the where and how a person performs their daily activities. For a country like Bangladesh where 85% of the population lives in rural areas, the need for occupational therapy students to understand the daily tasks required of a person living in a village is essential.

The students also reported that this placement was the first time they were incorporating aspects of environmental modification and adapting an activity to improve someone's independence. They reported on previous placements they were only using "clinical skills" concentrating primarily on the physical aspect of therapy. There are limitations to incorporating functional activities in a clinical or hospital setting, however since the aim of occupational therapy is to improve function this should always be first and foremost in the mind of the therapist.

Taking these two points in mind of giving the students the opportunity to experience village life, and focus their therapy on functional activities, the CBR placement is an invaluable learning experience for them. To promote further learning and consolidation of skills a community occupational therapy placement in second year would be most beneficial. This could focus on assessing and providing intervention for someone in their home environment, thereby getting the students to concentrate on the person, the activity they are performing, and the environment in which the activity is being performed. Then in third year the CBR placement could have more of a focus on integrating people with disabilities into their community and addressing these barriers. For example, continuing to conduct disability awareness campaigns, prevention campaigns (road safety, back care education programs), or looking at the physical environment of the villages that may be hindering integration.

Benefit for CRP
If one of the aims of the placement was to promote the services of CRP Savar and Gobinapur then it was well achieved. The students were continually talking about CRP and the services available from the Gobindapur site. The statistics of the physiotherapy and CBR departments would show the benefit of the number of clients seen and the number of disability awareness programs conducted. So overall CRP has benefited greatly from having students surveying and providing intervention for the people in villages around Gobindpur.

Benefit for foreign occupational therapy supervisors
The opportunity of supervising students on the CBR placement was a great personal and professional challenge that I was lucky to have. I found it more satisfying teaching students in a small group and putting the theory we had covered about in class into practice. I felt very privileged to be able to provide a service to the people living in the villages and hope in some way this has made a lasting positive impact on their lives.

Also from a professional point of view, as mentioned previously, for an occupational therapist to work effectively in any setting they need to understand the culture and lifestyle of the clients they are working with. I was fortunate to learn about village life in Bangladesh while working on the female ward with Lakmi Gomes and while doing home visits with Salam from social welfare. At the time I did not appreciate all I learned from these experiences however found while on placement I had already learned a lot about the way people with diabilities live in villages. So I would encourage all foreign therapist and therapy teachers to take the opportunity to experience rural life in Bangladesh.

I would also like to add that it was at times very difficult being the only foreigner at Gobindapur. Added to this having to supervise of 6-7 students, where english is not their first language. This ratio for the community setting is not ideal. One supervisor for this many students was a time management challenge with the only solution for the supervisor working 12 hours per day and on weekends. The students would only have a supervisor with them one out of every 3 or 4 days as the pairs of students were all working in different villages. Input to the stronger students was often sacrificed for the weaker students due to lack of time and energy of the supervisor.

This should in no way discourage conducting this placement again as the benefits far outweigh the disadvantages. However smaller placement size would be much more beneficial for the students and the supervisor. Another difficulty for the supervisors was being the only foreigner in the area. It was not easy to contact other teachers or friends in Savar for support professionally or emotionally. However again this should not discourage foreigner supervisors from taking up the challenge, but I would strongly recommend that a weeks break in Savar between placement groups would be beneficial for the foreign supervisor to relax and regain some energy. This in turn would ensure the level of input for all the groups of students is consistent and reduce the likelihood of supervisors burning out after one group.

Future placements
One of the aims of this placement was to identify areas of service that the occupational therapy department and students could provide at the CRP Gobindapur site in the future. As mentioned previously this is a perfect setting for students to be able to put into practice the theory they have learned in the class room, with a focus on improving a clients functioning in daily living activities. I cannot stress enough the benefit the students would get from having this opportunity in second year placement learning about occupational therapy in the community, and then in third year placement learning about occupational therapy in community based rehabilitation. A lot of the placement was spent consolidating basic second year knowledge, for example hemiplegic dressing techniques, writing objectives, positioning a stroke patient.

This should in no way should de-value the skills the students learn in the clinical or hospital settings, however having a community placement for both second and third year will facilitate greater learning as it is the clients' "real environment". When students are learning, the more realistic the environment the more they can understand the areas occupational therapy intervention, and then with experience adapt it to the clinic setting.

Occupational therapy interns at CRP Gobindapur
Another aim of this placement was to identify what occupational therapy interns could offer to the services already provided at Gobindapur. The following are suggestions that have been identified by foreign supervisors coming in for a short period of time. Some may not be practical or are already being carried out, however due to communication difficulties this information has not been made evident to the supervisors.

The physiotherapy assistant and interns provide a service at the site, and visit surrounding thana health complexes. Since there already seems to be much blurring of roles between occupational therapy and physiotherapy at Savar, in Gobindapur occupational therapy interns can really demonstrate all they have to offer. I would strongly encourage the occupational therapy department to continue to provide services to people in their home. The home environment is an ideal setting to demonstrate the unique aspects of occupational therapy providing intervention for the client focusing on the person and their physical, cognitive and psychological abilities, the activity they are performing and the environment they are performing the activity in. The names of perspective clients on the community survey could be the starting point.

In CBR occupational therapy cannot only provide individual intervention but can also look at bigger community issues. The students have already conducted an assignment on analysing the environment of the bazaars. Through talking with both abled and disabled people they have come up with recommendations on how to improve the physical access for people using the bazaar. With an intern at CRP Gobinadpur they could actually go to the chairman or bazaar committee and offer their services to conduct an audit and provide practical suggestions on how to improve access for everyone.

The intern could also contact the owners' association of the transport used there and provide disability awareness campaigns and road safety campaigns. These types of transport could also approached to advertise positive messages of disability, for example having messages painted inside the tempos about road safety.

Once a more established occupational therapy service was established the intern could give education to the CBR workers of the surrounding unions for appropriate occupational therapy referrals. Logistically providing a service to people in their home could be difficult, however if a bicycle or motorbike was available for their use it would facilitate better service coverage. There are many solutions on how to provide services to the villages around Gobindupur, one group of students suggested a tent set up in a field when the harvest season is over or using someones house to provide therapy services to a larger number of people. However I would recommend this with much caution as the services provided should not compromise quality of individual service for providing a below average service to a large quantity of people.

Occupational therapy interns should also develop an education program on the benefits of therapy. This is required to educate the community about the new professions of occupational therapy and physiotherapy, and inform people in the villages that medication will not in all cases improve their disability. The use of medication is reinforced by the amount of advertising material provided by drug companies. It was often ironic that the students were encouraging people to receive therapy at CRP Gobindapur and writing the details on paper with a drug company logo on it! If therapy could be promoted in any way, pamphlets, posters, during education programs then people may receive intervention from appropriate therapists and reduce the likelihood of further deformity.

Other education programs could be conducted on back care education, arthritis education, stroke education.

As the CRP Gobindapur site is so removed from Savar working there as an intern there could be seen as a "holiday" as some physiotherapy interns referred to it. To ensure that the services of occupational therapy in CBR where effective, adequate supervision should be provided for the interns. One of the students suggested the intern time should be two months.

With the amount of diploma interns available in May 2002, two occupational therapy interns could be placed in Gobindapur for two months. Another project that the interns could do at CRP Gobindapur would be to evaluate the services provided from the student placement. The interns could visit the clients who received individual intervention during the student placement period and find out if the recommendations provided to them were continued. If it the suggestions were not continued identify the reasons.

Research topics for B.Sc. (Hons) students
Some suggestions of areas that include researched could be the effectiveness of disability awareness programs, analysing community attitudes toward people with disabilities. Conducting the ground work for any of the above suggestions for interns could also be appropriate research topics.

Student evaluation on placement and Dhaka University
Due to the structure of the affiliation with Bangladesh Health Professional Institute (BHPI) and Dhaka University, student placements have been included in a exam subject therefore a summative (number) mark must be allocated. Evaluating the students on the placement was difficult enough given the number of students in each group. Added to this the pressure of producing a percentage mark, takes away the constructive suggestions provided by the supervising therapist.

The evaluation form needs to be improved with regards to weighting of assessed areas. In addition there is a certain amount of repetition. Another way to ensure consistent scoring for each student and between the different supervisors is to provide training in how to use the form. This was a suggestion that was not followed through which is disappointing and created much tension for myself when it came to evaluation time.

To improve the evaluation of students on clinical placement I would strongly recommend a different evaluation form, and replace the summative marks with an overall pass or fail mark. I appreciate this would be difficult with Dhaka University however feel it is a better way to evaluate students on clinical placement.