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1 Number 1 Primary Health Care and Community Based Rehabilitation: Implications for physical therapy based on a survey of WCPT's Member Organisations and a literature review. Tracy Bury, Project Manager, WCPT
3 Purpose: This paper aims to consider the implications for physical therapy arising from developments in primary health care, with a focus on community-based rehabilitation (CBR). It is intended as a learning resource and to facilitate further debate and development among the World Confederation for Physical Therapy's (WCPT) Member Organisations and the global community of physical therapists. It has been developed as a result of work undertaken by WCPT arising from a motion passed at the 14 th General Meeting of the (WCPT) in May 1999 and ongoing work. This has included: the circulation of a CBR discussion paper, prepared by the Africa region of WCPT, and an accompanying survey on CBR; and a request for information on primary health care. Both of these were distributed to WCPT's Member Organisations in The responses to these consultations have been analyzed and supplemented with a review of the literature covering primary health care, CBR, policy developments, models of health care, rehabilitation, disability and physical therapy. This paper has also been developed at a time that coincides with an international review of CBR policy (see The paper forms part of an overall work programme for WCPT on CBR and primary health care that was approved at the 15 th General Meeting of WCPT in June At the General Meeting two new policy statements were approved, a Declaration of Principle on Primary Health Care and a Position Statement on CBR, along with amendments to the Declaration of Principle on Education. These are designed to further developments in these areas of practice and support patient / client care. They are appended to this paper for ease of reference. This paper is not a WCPT policy document and as such does not state the views of the Confederation; rather it is designed to stimulate further debate. Any views expressed in the paper are those of the author and do not necessarily reflect those of WCPT. Author: Tracy Bury, Project Manager, WCPT Date: Access: Further copies of this paper can be obtained from the WCPT website or from WCPT: Kensington Charity Centre, 4th Floor, Charles House, 375 Kensington High Street, London, W14 8QH Tel: +44 (0) , Fax: +44 (0) Website: This paper should be cited as: World Confederation for Physical Therapy. (2003) Primary Health Care and Community Based Rehabilitation: Implications for physical therapy based on a survey of WCPT's Member Organisations and a literature review. WCPT Briefing Paper 1. WCPT: London. Copyright WCPT 2003
5 Primary Health Care and Community Based Rehabilitation: Implications for physical therapy based on a survey of WCPT's Member Organisations and a literature review. Contents Executive summary The need for rehabilitation Prevalence of disability International policy Disability in a cultural context Society The disability movement Models of disability Human rights Definitions Primary health care Community based rehabilitation Linking primary health care and CBR Health services delivery Introduction Models of rehabilitation Rehabilitation provision Physical therapy provision Assessing local needs and resource analysis Community-based rehabilitation Funding and accountability Organisation CBR personnel Multi-professional and multi-sectoral collaboration Evaluation of CBR Implications for physical therapy Professional autonomy and status Physical therapy roles Pre and post qualifying education of physical therapists Conclusions Acknowledgements References Appendix 1: Selected websites of interest Appendix 2: WCPT's policy statements... 31
7 Page 1 of 33 Primary Health Care and Community Based Rehabilitation: Implications for physical therapy based on a survey of WCPT's Member Organisations and a literature review. Executive summary The number of disabled people is increasing steadily with only a minority receiving accessible and appropriate rehabilitation services. International policy exists to promote primary health care. In addition the protection of the human rights of individuals and the social inclusion of disabled people are embedded in international policy and legislation. How disability and disabled people are viewed affects the extent to which they are integrated into society. The terms primary health care and community-based rehabilitation (CBR) are open to interpretation, although internationally recognised statements / definitions exist. The general concepts and principles involved are generally agreed worldwide but the nature of services referred to by the terms varies internationally. There is a need for a stronger orientation towards rehabilitation in primary health care services, balanced with the current emphasis on health promotion and disease prevention. Health care systems vary worldwide. This requires a flexible, responsive and innovative approach to developing services that are reflective of local needs, environments and available resources. Physical therapy provision is insufficient for the needs of most countries, therefore service delivery models need to be developed that result in the skills and knowledge of physical therapists meeting the needs of a higher proportion of those in need. Physical therapists are able to contribute to CBR programmes through a variety of roles. Multi-professional, inter-agency and cross-sectoral collaboration is vital for the development of CBR and primary health care. The physical therapy profession needs to address the perceived lower status conferred on those who work in the community or rural settings. Physical therapy professional education needs to equip physical therapists with the appropriate knowledge and skills to work in a variety of settings as well as promoting the value of working in these settings. Physical therapists should be aware of the current international review of CBR and ready to assess and act on its implications. WCPT's new Declaration of Principle on primary health care and Position Statement on CBR, as well as the revised Declaration of Principle on education should assist the profession, and therefore client care, in developing these areas of practice.
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9 Page 3 of 33 Primary Health Care and Community Based Rehabilitation: Implications for physical therapy based on a survey of WCPT Member Organisations and a literature review. 1.0 The need for rehabilitation This section gives a brief overview of international policy relevant to rehabilitation, specifically as it relates to primary health care and community-based rehabilitation (CBR). It is not designed to be exhaustive or to provide a detailed critique; rather it is intended to provide contextual information. Readers are referred to the documents referenced for more detailed information. 1.1 Prevalence of disability Depending on how disability is defined there is a large variation in the reported prevalence figures. Estimates of the number of disabled people worldwide vary from 0.2% to 21% (Helander 1999; Thomas and Thomas 2002). The most frequently quoted international figure is 10% of the population (Helander et al. 1989; Leavitt 1995; Thomas and Thomas 2002; World Health Organization 1981). This stems from work undertaken in 1976 based on calculations which included a high proportion of people with slight and potentially reversible disabilities (Helander 1999). A global estimate of moderate and severe disability has been given as 5.5% (Helander 1999). Based on population and survey data it is estimated that 70% of these 5.5% live in the developing countries (Helander 1999). In the developing countries it has been cautiously estimated that there were about 234 million moderately or severely disabled people in 2000 and that this will grow to about 525 million in 2035 (Helander 1999, 2000). Not all of these people would benefit from some form of rehabilitation nor perhaps be prepared to participate. It has been suggested that there are at least 70 million who would benefit now, rising to 149 million in 2035 (Helander 1999, 2000). At present only about 3% of those who need rehabilitation in the developing countries receive any meaningful service (Helander 2000). It is estimated that 10% of children are born with or acquire a disability and of these no more than 10% receive appropriate rehabilitation (according to UNICEF cited in World Health Organization 2001a). 1.2 International policy Health promotion, prevention, rehabilitation and the social integration and equalization of opportunities for people with disabilities have been accepted policy for the United Nations (UN) and World Health Organisation (WHO) for many years, with an increasing focus on primary health care and community services. Focusing on rehabilitation and primary health care, community-based rehabilitation (CBR) is one model of service provision, which WHO has advocated for over a decade (Helander et al. 1989; World Health Organization 1994, 1995a). The participation of people with disabilities, their carers and communities has long been a guiding principle for health care policy development, planning, implementation, monitoring and evaluation (International Labour Organization et al. 2002; International Labour Organization et al. 1994; United Nations 1983, 1989b, 1994; World Health Organization 1976, 1977, 1981, 1995a, 2001c; World Health Organization and UNICEF 1978), even if is not quite a reality worldwide.
10 Page 4 of 33 The Alma Ata Declaration on primary health care (World Health Organization and UNICEF 1978) was enthusiastically received as a means by which "Health for All" by the year 2000 (World Health Organization 1977) could be realised. However, it was also met with criticism that it was unrealistic and too idealistic (van der Geest et al. 1990), especially from those who perhaps wanted quick fixes and tangible early results. Internationally there have been different interpretations of what primary health care is, often as a result of political intent, with a large number of varying programmes being developed in the name of primary health care. The hope of primary health care was that it would address the economic reality of health care with an increasing shift to primary disease prevention and health promotion, promoting self-reliance. Community-based health care, by and for the community, encompassing traditional health care combined with basic health services, controlled and financed by the government or private institutions, were seen as the integrated systems by which primary health care could be achieved (World Health Organization and UNICEF 1978). International groups such as the United Nations Children's Fund (UNICEF) and WHO, along with international politicians and health planners, have called for greater self-reliance at the community level with increased attention on prevention. However, this could be considered to impose a top-down expectation that may not be matched with local ownership of the concept of self-reliance (van der Geest et al. 1990; Vanneste 1997). Some consider that self-reliance can appear to equate to people being left to fend for themselves (van der Geest et al. 1990) rather than gaining ownership and a sense of control. In addition, the aspirations of many developing countries for a health care system similar to that of developed countries may risk undermining self-reliance given the criticisms of the medicalisation of health care in western society (van der Geest et al. 1990). Disability incurs both economic and social costs for society which can be reduced by effective rehabilitation and support programmes (Hammerman and Maikowski cited in World Health Organization 1981). Generally, up until now, primary health care efforts have focused on family planning, childhood immunisations, nutrition and AIDS, all of which are important in the prevention of population health problems and disability (van der Geest et al. 1990). While for many communities primary health care initiatives that focus on preventative measures will pay dividends in the long term, the priority needs of the people are more likely to be associated with treatment and rehabilitation where, if services were available, there is the potential for immediate effect. A balance therefore needs to be struck between prevention, health promotion, treatment and rehabilitation. Rehabilitation has historically been seen as a low priority around the world due to a number of factors (Coleridge 1993; Leavitt 1995): Cost-benefit ratio of providing services to those with disabilities Under-estimation of disabled peoples potential to achieve Negative societal attitudes towards disability Discriminatory practices Absence of urgency rehabilitation tends to focus on the chronic, non-communicable diseases or illnesses that do not pose a risk to others Interest of biomedical practitioners focuses on improvement and cure, which is not always feasible or realistic for rehabilitation or the 'Cure or Care' model Public policy is not influenced by those with disabilities as they represent a relatively small marginalised minority. Access to appropriate rehabilitation remains problematical. Where services do exist they are frequently centred on urban institutions (World Health Organization 1981). In addition care is
11 Page 5 of 33 frequently driven by health care professionals rather than people with disabilities, their carers and communities, and therefore fails to address priorities and needs from their point of view. There are many calls to increase the number of health care professionals available to provide services, including physical therapists, recognising the significant shortfalls worldwide. However, there has been limited progress in maximising the potential of that which is available for the benefit of the majority of people in need. The international review of CBR that is currently progressing aims to contribute to the further development of the CBR concept and its implementation, by identifying the basic elements essential for effective CBR, through a review of current CBR practice and experience in a variety of settings (World Health Organization 2003). The full set of background papers can be accessed at The report of the meeting should also be available from this site when available. 2.0 Disability in a cultural context Much has been written that seeks to explore the concept of disability and its meaning for individuals and society. In addition, recent developments including the International Classification of Functioning, Disability and Health, referred to as the ICF (World Health Organization 2001b), are attempting to redress the negative way in which disability has been perceived. Rather than an emphasis on disability the shift is to focus on the abilities of disabled people. This section gives a brief introduction to the cultural context of disability, the influence of the disability movement and different models that exist in the literature. It also highlights the human rights and equalization of opportunities issues associated with disability. Again, this section is not designed to provide a detailed discussion of the issues, but to stimulate readers to think about them and explore the literature more. 2.1 Society disability is defined by culture, and without an awareness of how disability is perceived in the target culture, a disability programme does not stand much chance of being relevant or sustainable. (Coleridge 2000, page 21) Disability does not define people, society does. How disability is viewed often reflects the extent to which society embraces disability and diversity, rather than focusing on how an individual s ability to participate to socially accepted norms might be limited. Therefore what is perceived as a disability in one society or culture may not be viewed as such in another (Gregory 1994). The extent to which the focus is on the rights of the individual, versus the needs of the population or community, will also determine how disability is viewed. While the culture of many developed countries gives predominance to the individual the same cannot be said for many developing countries (Thomas and Thomas 1999; van der Geest et al. 1990). This is not to say that one is right and the other wrong, but that society has influenced how rights are defined and needs identified and met. How acquired (especially accidentinduced) disability is seen in comparison to congenital, disease or illness-induced disability can be quite marked resulting in inequitable access to services and opportunities, and often financial support (Gregory 1994). While few can argue with the ethics of equitable health for all, consideration needs to be given to the ways in which disability is perceived in different societies, in response to a number of cultural variables, along with materialistic and economic issues. For example, different belief systems in some traditional societies give prominence to fate, karma and
12 Page 6 of 33 divine punishment. These suggest that the person with a disability is not in need of intervention, as the disability is a result of the natural order of life that is not within anyone s control (Coleridge 2000). There are also the differing responsibilities that the individual assumes, depending on their status in a family or community, and the way in which any decisions are made. This is likely to impact on the extent to which the notion of empowerment (allowing, encouraging and facilitating individuals with disabilities and their families to speak and act for themselves) is appropriate or applicable (Lang 1998). In many poor communities disabled people are not seen as a priority for development and investment, an awareness of this and other cultural issues is key to any process designed to integrate disabled people more fully in society (Coleridge 2000). Understanding that culture is the sum of political, economic, social and spiritual aspirations over a period of time is essential to avoid alienation, exclusion and a loss of identity or sense of community. If changing perceptions and thinking about disability is to be stimulated then it needs to be done without undermining people s own sense of identity (Coleridge 2000). 2.2 The disability movement The disability in need of charity and disability in need of treatment perspectives were challenged by the disability movement (disabled people themselves) with the emergence of three key ideas: the social model of disability independent living civil rights movement (Oliver 1999). With the development of these issues has come a greater focus on environmental change for the benefit of a greater number of people, rather than individual based interventions (Oliver 1999). This has posed challenges for health care professionals whose work has been dominated by one-to-one interventions, with Oliver giving the warning in 1983 (Oliver 1983) that professionals must work with disabled people to develop appropriate practice, based on the social model of disability. Consumers initiated the challenge to professionally controlled rehabilitation in North America and other developed nations, which led to the emergence of the Independent Living (IL) movement. In this barriers to access and equality in service provision were principally identified as environmental and attitudinal with particular concern that the professional-client relationship facilitated dependency-inducing features in the person with a disability. In the USA and Canada IL centres developed providing peer counselling, consumer-based research, advocacy and self-help (Lysack and Kaufert 1994). There has perhaps been greater progress with social welfare issues than with rehabilitation in this approach. This might in part be related to the way in which independent living centres (ILCs) were set up by professionals, as opposed to centres for independent living (CILs) which were set up and staffed by disabled people (Oliver 1999). The term independence is one that different stakeholders would agree on, but how it is interpreted varies: Governments see independence as developing self-reliance and reducing the burden on the state Health care professionals focus on the ability of individuals to undertake a range of activities that enable them to be self-caring For disabled people independence is seen in terms of personal autonomy and the ability to take control of their lives (Oliver 1999).
13 Page 7 of 33 One of the debates in the disability movement literature seems to be the issue of power and the answers to two key questions: Who has the right to determine how disabled people should live their lives; and Who has the legitimate right and voice in determining the priorities for the provision of disability services (Lang 1998)? Answers to these vary within different cultural and societal contexts. While the disability movement has been critical of the health care professions the professions have perhaps listened and begun some fundamental changes. Through empowering people with disabilities to be active participants and decision-makers in health care planning, delivery, individual treatment programmes and service evaluation they have acknowledged that people with disabilities are not passive recipients of perceived professional wisdom, knowledge and skills. A partnership model is therefore being progressed by all those involved. These are important developments to take heed of in considering the role of physical therapy in any health services delivery model. 2.3 Models of disability Another key debate concerning disability is the way in which the medical and social models of health have often been presented in opposition, as summarised by Lang (1998) in table 1. Table 1: Models of disability Reprinted with permission from: Lang R. (1998) Guest Editorial: a critique of the disability movement. Asia Pacific Disability Rehabilitation Journal 9(1): page 6 The Medical Model personal tragedy theory personal problem individual treatment medicalisation professional dominance expertise adjustment individual identity prejudice behaviour care control policy adjustment The Social Model social oppression theory social problem social action self-help individual and collective responsibility experience affirmation collective identity discrimination attitudes rights choice politics social changes It would seem that in the context of disability neither model provides a complete approach and that an integrated approach, encompassing elements from both models will best serve to meet the needs of people with disabilities, their carers and communities. This will facilitate participation and contribute to the process to change the social parameters of individual existence (Cole 1999, page 2). This integrated approach does appear to have been recognised by WHO (International Labour Organization et al. 2002; World Health Organization 1998, 2001c); see also the international review of CBR papers at:
14 Page 8 of Human rights Health for all and the equalization of opportunities, along with access to rehabilitation delivered in a culturally and socially sensitive manner, can be seen as basic human rights issues (Cole 1999; United Nations 1983, 1994). Cole argues that the essential human right is the right to progress, achieved through the facility and ability to choose and participate in processes of social change (Cole 1999, page 8 emphasis added). Ensuring that those with disabilities enjoy all aspects of human rights is embedded in international legislation and also widely at a national level. This means that the rights-based approach to disability is subject to law. The approach is designed to " empower disabled persons, and to ensure their active participation in political, economic, social, and cultural life in a way that is respectful and accommodating of their difference" (Office of the High Commissioner for Human Rights 2003, page 2). The extent to which national implementation makes this a practical reality is variable. The human rights approach sees the problems of disability stemming from within society, not the individual. The existing order of society, and the consequent allocation of scarce resources, necessarily engenders inequality, which reflects the power structure of society. This social status quo is ideologically justified, legitimating privilege. And hence any effective analysis of the social position and human rights of persons with disabilities in particular, and disadvantaged people in general, and the resultant questioning of the allocation of resources, will have to address the inadequacies of the extant institutional order. And hence raise questions about the ideological and cultural basis of social life. (Cole 1999, page 13) In the context of international legislation there are a number of United Nations documents setting out international standards on human rights, along with a number of resolutions and declarations. For example see: Universal Declaration of Human Rights (United Nations 1948) International Covenant on Economic, Social and Cultural Rights (United Nations 1966) Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (United Nations 1984) Convention on the Rights of the Child (United Nations 1989a) The Standard Rules on the Equalization of Opportunities for Persons with Disabilities (United Nations 1994) The majority of this legislation does not specifically mention disabled people, except for the Convention on the Rights of the Child and the Standard Rules. There are however, antidiscrimination clauses in place. While all the relevant human rights treaties have significant potential to improve the situation of disabled people it appears that they are under-utilised (Quinn and Degener 2002, cited in Office of the High Commissioner for Human Rights 2003). The core values of individual dignity, autonomy or self-determination, equality and the ethic of solidarity are fundamentals of human rights law that concern disability. To achieve this there is an increased focus on the participation and involvement of disabled people and their representatives, including Disabled People's Organisations (DPOs) in the development and implementation of policies and plans (Office of the High Commissioner for Human Rights 2003).
15 Page 9 of 33 To focus on how services are delivered and by whom risks failing to integrate the person with a disability in society. It fails to address the barriers to participation, so that while they might receive appropriate equipment and improve their mobility they may, for example, still be refused a job. Whereas an approach that recognises the rights of disabled people and puts in place comprehensive integrated policies and strategies to address these is more likely to fulfil these human rights. Providing rehabilitation and equipment would be only one part of this (Stubbs 2002). Specifically in relation to CBR, the revised draft international position statement on CBR (International Labour Organization et al. 2002) now places CBR within a human rights framework with reference to the International Covenant on Economic, Social and Cultural Rights and the United Nation's Standard Rules. 3.0 Definitions This section outlines the differences in how the terms primary health care and CBR are used and interpreted. This is evident in the literature and in the responses WCPT received to its survey of Member Organisations concerning CBR. 3.1 Primary health care The Alma Ata definition of primary health care is the one to which governments have pledged their allegiance and it is this which has shaped the development of national policies. "Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part both of the country's health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process." (World Health Organization and UNICEF 1978) Primary health care focuses on: maximum use of local resources, including traditional healers and trained community health workers participation of the individual and the community affordable and accessible care integration of prevention, promotion, treatment and rehabilitation coordination between the health care sector and other aspects of society, such as housing and education (Leavitt 1995; World Health Organization and UNICEF 1978). Prevention is usually referred to as primary, secondary or tertiary and is not limited to that which takes place in primary care settings. Primary prevention consists of measures to prevent diseases, injuries, or conditions that can result in impairments or disabilities (World Health Organization 1995a). For example, health
16 Page 10 of 33 education, immunization, maternal child health services, and safety promotion. It forms a major component of primary health care. Secondary prevention consists of early intervention in the treatment of diseases, injuries, or conditions to prevent development of impairments. Treatment of diseases (eg Tuberculosis) and injuries (eg fractures) may prevent impairments and hence disabilities. Treatment of this type is usually initiated by the referral services, but follow-up is provided within the primary health care system (World Health Organization 1995a) Tertiary prevention includes measures to limit or reduce impairments or disabilities, for example, surgery to correct joint deformities. Treatment is likely to reduce impairment and may also reduce or eliminate the disabilities that can result from such impairments. It also includes the treatment of disabilities and therefore rehabilitation (World Health Organization 1995a). This classification of prevention is in need of updating given developments with the ICF (World Health Organization 2001b) and the focus on maximising abilities. Rehabilitation personnel, including physical and occupational therapists and mid-level rehabilitation workers, have been identified as being well placed to facilitate the prevention of tertiary disability, whereas physicians and nurses are perhaps more familiar with primary and secondary prevention (World Health Organization 1995a). However, physical therapists have a valuable contribution to make across all levels of prevention. To only see their role at the tertiary level poses the risk of increasing the number of individuals with this level of disability requiring this type of care, rather than seeking to prevent them with earlier intervention. Rehabilitation, in some instances, has been seen as a service delivered by health care professionals, a key domain of therapists. However, as O'Toole stated: Rehabilitation can no longer be seen as a product to be dispensed; rather, rehabilitation should be offered as a process in which all participants are actively and closely involved. (O'Toole 1995, page 313) The recent publication of Innovative Care for Chronic Conditions: Building Blocks for Action (World Health Organization 2002) goes some way towards redressing the imbalance in service delivery that has evolved with many primary health care initiatives. This places greater emphasis on the need for health services to meet the needs arising from chronic conditions, much of which could be met in the community. This needs to be balanced with the needs for primary prevention a key driver in primary health care, as described earlier. Another view of primary health care that emerges from WCPT's consultation is the extent to which it equates to first contact practitioner status. For example, that patients / clients do not need a medical referral to receive care from a physical therapist but can consult them directly. In this instance that care can be provided in acute, primary and community settings. In the context of this paper primary health care is seen to reflect international policy and therefore services that are provided in the community.
17 Page 11 of Community based rehabilitation Community Based Rehabilitation (CBR) has been defined by the International Labour Organization, the United Nations Educational, Scientific and Cultural Organization and the World Health Organization in a Draft Joint Position Paper (International Labour Organization et al. 2002) as follows: Community-based rehabilitation is a strategy within community development for the rehabilitation, equalization of opportunities and social integration of all people with disabilities. CBR is implemented through the combined efforts of disabled people themselves, their families and communities, and the appropriate health, education, vocational and social services. CBR was designed as a model by which cost-effective community / home-based rehabilitation could be provided in developing countries (Helander et al. 1989). As defined it was not seen to equate to all rehabilitation that takes place outside an institutional setting, although it is easy to see how the term can be interpreted as such, and this is reflected in the feedback from WCPT Member Organisations. CBR, as internationally defined, is very much client-centric as opposed to profession-centric. In trying to clarify what CBR is and to draw a distinction with any care that takes place in a community environment there are a few key points. CBR is not: An approach that only focuses on the physical or medical needs of a person About delivering care to disabled people as passive recipients Only outreach from a centre Rehabilitation training in isolation An approach which is determined by the needs of an institution or groups of professionals Segregated and separate from services for other people (Stubbs 2002). Conversely CBR involves: Partnerships with disabled people, both adults and children, their families and carers Capacity building of disabled people and their families, in the context of their community and culture An holistic approach encompassing physical, social, employment, educational, economic and other needs Promoting the social inclusion of disabled people in existing mainstream services A system based in the community, using district and national level services for referral (Stubbs 2002; Vanneste 2001). CBR has been described on the basis of component features such as: provision of functional rehabilitation services creating a positive attitude towards people with disabilities the creation of micro and macro income-generation vocational training the prevention of the causes of disabilities (United Nations Economic and Social Commission for Asia and the Pacific 1997). It has also been described on the basis of philosophical or ideological thinking (Vanneste 1997).
18 Page 12 of 33 Helander (1999) has identified a number of key principles relating to CBR. They are; equality, social justice, solidarity, integration and dignity. These can be seen to relate to the principles embedded in human rights legislation. 3.3 Linking primary health care and CBR As one aspect of its broad remit, CBR is a means of delivering health services in the primary health care setting and therefore the two are intrinsically linked. CBR is not an approach that only focuses on the physical or mental needs of a person and as such extends beyond the healthcare domain. However, it is also viewed by some nations as encompassing all care that takes place in the community, more analogous with the wider concept of primary health care. CBR is not the only means by which rehabilitation services can be delivered in primary health care settings. Both CBR and primary health care focus on the needs of individuals and the wider population. It is important though to understand that rehabilitation in the context of CBR extends beyond a purely medical interpretation as discussed in sections 3.2 and Health services delivery WHO s declaration of Health for all by the year 2000 (World Health Organization 1977) still remains a long way off. In 1995 the World Health Assembly (resolution WHA 48.8) urged WHO and its member states to take coordinated action to reform health care, acknowledging that fundamental change was required in approaches to health care delivery, the use of human resources and their education and training (World Health Organization 1995b). This section discusses some of the wider health service delivery issues and focuses on rehabilitation. 4.1 Introduction Differences in health status and health care systems, including rehabilitation, are significant from one country to another. However, they are most marked when comparing the developing countries with those that are developed. While the socio-economic differences are acknowledged the continually widening economic gap is seen to be the principal influencing factor (Leavitt 1995). Even though the economic resources required to provide a level of service that even goes some way to closing the gap between met and unmet need seems far from reach, as Kay et al said Developing nations can ill-afford the expense of the morbidity that a failure to rehabilitate causes. (1994, page 77). That said, levels of morbidity tend to be higher in poorer communities and, depending on the local health care system, this means that they end up paying more when they can ill-afford to do so (Werner 1996). Within countries there are usually a number of referral levels (figure 1). Starting with community level services there is then access to district services, where district is defined as the area covered by the first-referral level hospital and also the most peripheral unit of local government and administration with comprehensive powers and responsibilities. It is seen to exist at the interface between community planning and development and central government planning and development (World Health Organization 1989, 1994). There is then a secondreferral level to provincial / regional / state services. These services, as well as providing a greater level of expertise, also provide education and supervision of rehabilitation workers at the district level. Some special schools and vocational training centres may also be located in these areas. The third level of referral is referred to as central or national services. Examples include specialty or teaching hospitals in large urban areas (World Health Organization 1989, 1994).
19 Page 13 of 33 Figure 1: Referral Levels This description of services may be more recognisable in developing countries but all countries have an analogous system of increasing complexity, specialisation and multisectoral collaboration. 4.2 Models of rehabilitation Institution-based rehabilitation and outpatient services are models recognisable to most health care professionals and the ones that have historically influenced education provision. These services have been driven and developed by health care professionals. Health care reforms are seeing an increasing emphasis on service user involvement in shaping future models of health service delivery. However, this remains a relatively new concept and one in development itself. In most countries institution-based rehabilitation is urban-based, making it relatively inaccessible and expensive to access, especially in poorer communities. How disability has been perceived has influenced health care service provision, including rehabilitation. The disability movement and the development of the social model of health (see section 2) have been influential in affecting change in recent years. With a focus on community settings rather than institution-based centres, CBR is one model of providing rehabilitation, which is explored further in section 5 of this paper. There are a number of different models of CBR that have been developed in response to local needs and a number of other programmes of interventions which share some common goals, but have fundamental differences. One such programme is that referred to as out-reach. These programmes are run by health care workers e.g. physical therapists, at a local level to provide complex professional care which directly addresses patients pathology, impairments, and / or disabilities (Kay et al. 1994; World Health Organization 1994). Such services are controlled from an institution and there may be a mismatch between what the people need and what the institution can provide (Stubbs 2002). CBR is not the only model in which community participation is emphasised. The development of the Independent Living (IL) movement, described in section 2.2, is another. While their origin is different they both developed as a response to criticisms of the traditional rehabilitation model that was dependent on highly trained health care professionals. The essential difference between CBR and IL is that the CBR model is one of
20 Page 14 of 33 partnership between the community and service providers, whereas control is seen as essentially being with disabled consumers in the IL model (Lysack and Kaufert 1994). In contrast to the IL movement it is often health care professionals who speak out in support of CBR and raise its profile, whereas in IL it is principally consumer driven (Lysack and Kaufert 1994). How well this is then translated through implementation is another matter. 4.3 Rehabilitation provision In 1995 O Toole suggested that institution-based rehabilitation was helping no more than 2% of those in need (O'Toole 1995). There is however an increasing shift away from delivering health services managed from institutional care facilities to primary health services, centred on the needs of the local community and delivered in the community. This is a focus in both developed and developing countries. Institutions are not redundant but are becoming increasingly focused on the provision of specialist services. The way in which it is developing varies from country to country with the differing funding and infrastructure systems, as well as the different social and cultural environments. A recent evaluation of the implementation of the UN Standard Rules on the Equalization of Opportunities for Persons with Disabilities (World Health Organization 2001d) found that almost 30% of countries responding did not provide national rehabilitation programmes. It also found that physical therapists and other allied health professionals are rarely available at a local or district level, being predominantly available at the national level. CBR workers were not reported as being present in developed countries. Physical therapists and other professional health care workers were seen as specialists and often only accessible at national centres, which are impractical and costly to consult. The problems of providing programmes of treatment and rehabilitation, beyond one consultation, are further magnified. The survey (World Health Organization 2001d) found that primary health care has become the focus of delivering services to villages and poor urban areas. Forty-four countries reported providing community-based rehabilitation in these settings. However, estimates suggest that almost 50% of countries are only providing rehabilitation for 20% or less of the population. Where rehabilitation services are provided they appear to focus on mobility problems and less so on other needs. Primary health care and CBR were both reported as mechanisms by which rehabilitation is delivered. While there has been progress in involving people with disabilities through CBR or as teachers, instructors and counsellors, they are less likely to be involved in the design, organisation or evaluation of rehabilitation programmes. The survey (World Health Organization 2001d) also investigated the inclusion of disability issues in the training curriculum of health care professionals. Concern was expressed at the number of countries where this was not provided for doctors, nurses and primary health care workers. On the contrary, physical therapy performs well in this area, with only 7 countries reporting that it is not a component. However, this should still be rectified. While the survey found that children are generally well provided for the needs of adults and the elderly are not well catered for despite the significant risks of disability associated with age and socio-economic and political circumstances (World Health Organization 2001d). Some rehabilitation services focus on a defined client group, such as those with multiple sclerosis, often reflecting financial backing from a Non Governmental Organisation (NGO), or a particular type of functional limitation, such as visual, in isolated settings. What such programmes need to ensure is that they provide for physical, sensory, mental, spiritual, emotional and social needs, taking a holistic approach.
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Unfortunately, most email clients will not show forms in emails. That's why it is not a good practice to add forms into your emails.

subset: commoncrawl


text:
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Peekier doesn't store cookies, doesn't save your IP address or any other information, doesn't save search keywords, and doesn't aggregate any information for its own use or to sell to marketeers. Your personal information remains yours alone and is not shared with others.
The only downside I see with Peekier is that the search results are derived from Bing, so you tend to not receive as many relative "hits" and you do not have as many options for searches as you would get from Google's Advanced Search or even from DuckDuckGo. Still, Peekier is a true alternative to Google.
You can check it out at https://peekier.com.


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2561 Fishing Lures, Hooks, Mini Tackle Boxes - Full Manifest
Great for flea markets and bait shops!
All items come in generic plastic packaging. You will receive the units exactly as pictured. The open units are for picture purposes only.
Auction is for 2561 units. Some items come packed together. Each item is counted as 1 individual unit. Please see manifest.
This auction is fully manifested, please view the manifest for more information.
Please view the additional pictures by clicking the "View all photos" tab.
For an explanation on the various condition codes used on Liquidation.com please Click Here


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Kelly TAN"Probing inhibitory circuits of the VTA with pharmacological and optogenetic tools"13 avr. 2012 à 13:30 (Magendie)
Abstract :
Dopamine (DA) neurons of the ventral tegmental area (VTA) project to several target regions in the mesocorticolimbic system. Their activity is controlled by excitatory and inhibitory afferents. In my presentation, I will focus on the GABA inputs that arise mainly from GABA interneurons and from the rostro-medial tegmentum, a small nucleus located dorsally to the VTA. I will examine how positive modulators of GABAA receptor transmission (i.e. benzodiazepines, BDZs) and direct manipulations (optogenetic tools) of VTA GABA neuron activity impact on circuit function and behavior.
We observed that the BDZ midazolam (MDZ) decreased the firing rate of GABA neurons, but increased DA neuron firing in vivo. I will provide evidence that MDZ causes a disinhibition of DA neurons that depends on α1-containing GABAA receptors, which are expressed on GABA but not DA neurons. As a consequence mice preferred a MDZ-containing drinking solution over a solution without MDZ, when given a choice.
Conversely, an aversive stimulus (e.g. footshock) transiently increased the firing rate of GABA neurons, leading to a transient inhibition of DA neurons. A selective optogenetic activation of VTA GABA neurons with channelrhodopsin 2 mimicked these responses and caused place aversion. The observation that this behavior could be reproduced by direct inhibition of DA neurons using halorhodopsin 3 confirms the determinant role of DA neurons.
To conclude, the bidirectional modulation of VTA GABA neuron activity, most likely by increasing or decreasing DA levels in targets of the VTA, drives opposite behaviors.
Selected publications
Claire L. Padgett, Arnaud L. Lalive, Kelly R. Tan, Miho Terunuma, Michaelanne B. Munoz, Menelas N. Pangalos, Jose Martinez-Hernandez, Masahiko Watanabe, Stephen J. Moss, Rafael Lujan, Christian Lüscher and Paul A. Slesinger. Methamphetamine-Evoked Depression of GABA(B) Receptor Signaling in GABA Neurons of the VTA. Neuron. 2012 Mar 8;73(5):978-89.
Arnaud L. Lalive, Uwe Rudolph, Christian Lüscher, Kelly R. Tan. Is there a way to curb benzodiazepine addiction? Swiss Med Wkly. 2011 Oct 19;141:w13277.
Tan KR, Rudolph U, Lüscher C. Hooked on benzodiazepines: GABAA receptor subtypes and addiction Trends Neurosci. 2011 Apr;34(4):188-97. Epub 2011 Feb 25. Review.
Kelly R. Tan, Matthew Brown, Gwenaël Labouèbe, Cédric Yvon, Cyril Creton, Jean-Marc Fritschy, Uwe Rudolph & Christian Lüscher. Neural bases for addictive properties of benzodiazepines. Nature 463, 469-474. Epub 2010 Feb 11.
Scientific focus :
After obtaining my PhD at the University of Bern, I joined the laboratory of Prof. C. Lüscher to complete a postdoctoral fellow. I am focusing on the effects of Benzodiazepines on the GABAergic transmission in the Ventral Tegmental Area. I am using patch-clamp electrophysiological techniques in midbrain acute slices as well as confocal imaging.


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Oh how I just live for the thrift... or as I'd like to call it 'the treasure hunt.' You can wake me up for a good flea market at all times! I have to admit, I am picky... most flea markets I find to be boring, or even disappointing. But fortunately, a véry good fleamarket is held montly in my town. I am so happy with the beautiful goodies I found the other day at the Vechtsebanen flea market in Utrecht. I hardly ever find so many pretty things in one day! Do you? Let me run you through the treasures I brought home.
|A gorgeous never used leather bag (much prettier irl) and belt; 15,-
|I always fall for these antique fashion prints; 7.50 (for the set)
|A pretty 30s blouse (another family heriloom the seller told me); 3,-
|Paper dolls to dress up (Barbie's precursor!); 3,-


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I never thought I'd be opening my own daycare to solve the problem of what to do with my daughter while I went back to school. Never mind the fact I never thought I'd have a daughter in the first place, or even go back to school.
I guess I'm like a lot of women; I grew up believing I had to be practical, get a good job, have a career. Other women struggled before me, right? So I earned a degree in engineering and went to work in the mining industry, moving to financial services after that.
I never questioned why I was doing it; I was fulfilling requirements, doing my duty. I paid rent, bought food, travelled. Yet, while I was enjoying some of it, there was something missing. I felt as if it wasn't quite right, and I was waiting for something to happen.
So there I was, working in the risk analysis department of a third-party payment processing company, when a friend asked what I really wanted to do with my life, and I got to thinking. I had talked about music over the years, and I even considered pursuing it, but it wasn't practical. For some reason, this time I reevaluated the idea, and I decided to take it seriously – no more waiting.
Going back to school was a shock to say the least. But, I discovered that I really loved music theory and was able to play well enough to pass auditions; I even got a scholarship in my first year. Music was like second nature to me. I loved what I was doing. I felt ecstatic, exhilarated, fulfilled.
Then I got pregnant.
I had always said I would never have kids – it was a certainty. I had other plans with my life. No kids for me. I don't know what changed, but suddenly I felt like maybe I could have a kid, and maybe I wanted one. So I started to think about it, to imagine and feel it, and that was that. The man I was seeing talked about it, and we gave it a try, and to our surprise, it worked – I got pregnant. Things didn't work out with the man, but we had a beautiful daughter together who is now the light of our lives.
Going to school with a newborn was a lot to deal with. My professors allowed me to bring her to class, which I did from the time she was two months until she was about five months. At that point I needed a daycare.
The problem is that the waiting lists for Montreal daycares are notorious. You actually have to go on these lists before you're pregnant if you want a space. I put my name on a few, but it's been nine months and they still haven't called.
I'm on the McGill daycare waiting list too, but only since April 2008. There's been no response there either, but maybe that's because they also don't accept children less than 18 months old. So, again, I have to wait longer than I'd like, even if a space becomes available now.
Quitting school was not an option, although I did think about it. Then I realized that even if I went back to work I'd still need a daycare. It quickly became obvious that daycare was indispensible regardless of what I chose. It was then that I decided to open my own.
That was now my plan. I had gone from a steady job to going back to school, then having a baby, becoming a single mom, and opening a daycare. People questioned it; they thought I was getting in too deep, doing too many things at once. And I'll admit, it does feel like it sometimes.
The hardest part was learning the business and figuring out how to present myself to people in an acceptable manner. I studied the Montessori method to get a more specified idea of what I wanted to do, and I received my certificate after three months. This gave me a structure to stick to as much as it gave one to the kids.
Let's face it, I never imagined I would be designing a Montessori curriculum based around music, for a roomful of hungry little minds and hearts in my own daycare. But it works. I'm fortunate to have great staff, and they enjoy working with me in part because of the environment I've created. Caring for children has allowed me to discover many things about myself. For instance, I care deeply about the correctness of everything, but if I allow myself to relax a bit on that, I find that I enjoy children a lot more. I also think that they find their true selves by engaging in the activities that I've set up for them.
Because of this I'm still in school. There are still a few spaces to fill in my daycare, but it's catching on. It's all working out in ways I couldn't have predicted. Montessori was the right choice. I'm seeing results in my daughter's growth, as well as in the kids who come to me.
I took a chance and chose from the heart. It was a challenge, but it was worth it. Now all I want to know is what's next?
Kelly is a U3 Music Theory student. She can be reached at firstname.lastname@example.com.


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Many people want to start a business at home, but they do not know the proper steps. Is this your situation? Then continue reading! The following article will teach you how to successfully run a home business.
Track your business-related mileage expenses, as you will be able to deduct all or a portion of them. Travel expenses, regardless of their distance or frequency, are completely deductible for you. However, you need to be able to prove that that the travel is necessary for your business.
Be prepared to describe your business in a nutshell. If your business purpose can be summarized well in only a few sentences, it can impress prospective clients. This statement also provides you with a ready-made base for a slogan, as it will already cover the important points of your business.
Make it a point to keep current and repeat customers satisfied with your business. If your customers are happy, you will generate a lot of return sales. Keep those customers happy, and they will return.
If you are out of stock in a particular item, be sure to let your clients know about it. Customers do not like to wait, and you will seriously upset them if the items they ordered won't be arriving for several days. Be up front about items that aren't in stock, so that customers can choose a different product and save the wait time.
Your family should avolid interrupting you when you're working at home. Too many interruptions can hinder your ability to work, so always let loved ones know when you will be working as well as when you will be finished. Tell them about the need for privacy and that privacy will help you finish sooner. It's important that you have proper supervision for your children and you are available if there is an emergency.
Now you should be armed with the knowledge necessary to get down to business. Remember all of the things this article has taught you and apply these things to your business. You are going to find success if you use the knowledge you've attained.


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Walt Disney Co: Disney Stock is a Screaming Bargain
Major Upside in Disney Stock?
When a company is delivering double-digit earnings growth, you'd think that investors would be cheering for it. But that's not the case for Walt Disney Co (NYSE:DIS) stock. Despite posting solid results, Disney stock tumbled 6.6% year-to-date.
If a company is growing but its stock price is declining, it must mean that the stock was too expensive to start with, right?
That's not the case either. At $98.08 apiece, Disney stock is trading at 17 times its earnings, which is lower than the entertainment industry's average price-earnings (P/E) ratio of 19 times.
What's more is that if you take a look at Disney stock's financials, you'd see that the company is actually firing on all cylinders.
Disney's fiscal 2016 ended on October 1, 2016. For the year, revenue increased six percent year-over-year to $55.6 billion. Earnings came in at $5.73 per share, a 17% improvement from the $4.90 per share earned in its fiscal 2015. (Source: "The Walt Disney Company Reports Fourth Quarter and Full Year Earnings for Fiscal 2016," Walt Disney Co, November 10, 2016.)
Segment-wise, Studio Entertainment was the best-performing one. It brought in 28% more revenue this year, while its operating income surged by an even more impressive 37%.
But this shouldn't really come as a surprise, given that Disney had quite a few box office hits in this period, including Star Wars: The Force Awakens, Zootopia, The Jungle Book, Finding Dory, and Captain America: Civil War. Notably, Star Wars: The Force Awakens surpassed Avatar to become the highest grossing film of all time in the U.S. just 20 days after its release.
Other segments weren't bad either. "Parks and Resorts" revenue increased by five percent year-over-year, while segment operating income increased by nine percent. "Consumer Products & Interactive Media" had a three-percent decline in revenue, but segment operating income actually increased by four percent.
And then we have "Media Networks," the favorite segment of Disney stock bears. They argue that, because consumers are moving from cable television to on-demand video streaming, Disney's Media Networks—including ESPN, ABC, and the Disney Channel—will have no future.
So, did the segment have a catastrophic year? Not really. In Disney's fiscal 2016, Media Networks revenue actually grew two percent year-over-year, while operating income from the segment remained unchanged.
The bears do have a point. But rather than slowly becoming irrelevant, Disney is taking a proactive approach.
The company is acquiring a 33% stake in video streaming company BAMTech. You might not have heard of this company before, but it plays an important role in today's video streaming industry. BAMTech is behind the streaming services for HBO Now, the National Hockey League, Major League Baseball, and the WWE Network. (Source: "The Walt Disney Company Acquires Minority Stake in BAMTech," Walt Disney Co, August 9, 2016.)
At the same time, don't forget that Disney also owns 30% of Hulu, LLC. While Hulu is not as popular as Netflix, Inc. (NASDAQ:NFLX), its near-12-million subscriber base is nothing to sneeze at.
The Bottom Line on Disney Stock
Bottom line: the company is far from over. Cord-cutting is still a concern, but Disney also has stakes in the online video streaming industry. These stakes might not be enough to cause Disney stock to shoot through the roof, but they could ensure that the company remains relevant when more consumers embrace on-demand video streaming.
What's more important is that going forward, Disney has its own growth drivers. Parks and Resorts could be a catalyst with its newly opened Shanghai Disney Resort in China, and the ongoing Star Wars extension to its existing theme parks. In Studio Entertainment, upcoming movies like Rogue One: A Star Wars Story, Beauty and the Beast, and Guardians of the Galaxy Vol. 2 are almost guaranteed to become box office hits.
There are companies with better outlooks than Disney. But at today's price, Disney stock's value is too hard to ignore.
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PetPeePee is growing! We're hitting the road this fall to introduce new customers and pet stores to the PetPeePee Products and Services.
Because we're hitting the road, our blog posts will be a little spaced out. Enjoy our older posts and our posts from the road as we meet new pet lovers like you!
Thank you for your support and if you have a local pet store near you, be sure to let us know to stop by.


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TheAlternativePress.com (TAP), New Jersey's all online hyperlocal daily newspaper met with its new Advisory Board members on March 21 to thank them for their service. Members were welcomed by Lou LaSalle, Vice President at Barnabus Health, and a member of The Alternative Press' Advisory Board of Directors. LaSalle spoke about how valuable TAP is to the communities it serves.
TheAlternativePress.com serves sixteen communities in New Jersey by providing objective, daily, in-depth hyperlocal news and information, covering everything from town council meetings to high school sports and everything in between.
According to TAP founder and New Providence resident Michael Shapiro "Some of our Advisory Board members have been with us since TAP's early days in late October 2008. They and our new board members help TAP in many ways, but I believe their most important job is to provide feedback from the community they serve that enables TheAlternativePress.com to continue to best serve the residents of our towns." He further explains, "People rely on TAP to provide in-depth coverage that is factual and community-friendly. Our board members advise us on ways to improve what we do."
The complete list of Advisory Board members follows. The board is comprised of community leaders and members of local government, and they have diverse backgrounds and interests, which enable TAP to serve communities' best interests fairly and impartially.
Berkeley Heights: Chair: Dr. Donald DeFabio
Members: Tom Barton, Lynn Falanga, Bob McManus, Ciro Scalera, Dr. Patrick Smith, Stephen Yellin
Livingston: Chair: Michael McMane
Members: Mark Annett, Paul Ewing, Joyce Gore, Daniel Katzeff
Madison: Chair: Ken Toumey
Carla Brady, Barbara DeMar, Louisa DeRose, Arleen J. Gaetani, Barry Kroll, John Morris, Diane Werner
Maplewood/South Orange: Rene Clawson, Adam Loehner, Naoma Welk
Millburn/Short Hills: Chair: Steven Brisgel
Members: Jennifer Duckworth, Lisa Hackett, Rhoda Harris, Abby Kalan, Deborah Lerner, Shayne Miller, Walter Pardo, Linda Seelbach, David Stone
New Providence: Chair: Jim Madden
Members: Kevin Carroll, Gary Kapner, Susan Peterson, Tzu Lin Toner, Jimmy Vardas, Penny Vigilante, Sherry Zabel
Summit: Sandy Bloom, Amy Cairns Harrison, Jean Crichton, Lori Dahl, Dr. Marian Glenn, Diane Klaif, Darrell Johnson
The Chathams: Al Brown, Carolyn Cherry, Jim Lonergan, Nelson Vaughan
Westfield: Jay Biss, Beth Brenner, Millicent Brody, David Burns, Charlie Bowman, Bonnie Cohen, Lee Corcoran, Sherry Cronin, Chris Devine, Ginny Leiz, Eric Levine, Suzy Minken, Steve Needle, Carolyn Shane, Darielle Walsh, Stacy Weinman
West Orange: Megan Brill; Michelle Cadeau, Cynthia Cumming, Denise Esposito, Tekeste Ghebremicael, Susan McCartney, Joel Rinsky, Matthew Schwartz, Heidi Sussman
Garden State Green: Leonard Berkowitz, Jennifer Duckworth
According to Amy Cairns Harrison, member of the Summit Advisory Board, "I find the news and information provided by The Alternative Press to be a reliable source of up-to-date information about my town and the surrounding area. No matter what a persons' particular interest may be, it is readily available on TAP via computer, smartphone or tablet. As chair of Summit's Environmental Commission, I appreciate that TAP is environmentally-friendly, it uses no paper and there is no damage done to the environment to distribute it. Furthermore, TAP supports local businesses by providing them a low-cost and sometimes no-cost way to promote themselves and provide expert advice, and not have to compete with regional or national advertisers. The Alternative Press is locally-owned and operated by like-minded residents."
The Alternative Press was founded in 2008 and is the first all-online newspaper to receive accreditation by the New Jersey Press Association.


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Customers Also Viewed
One of Santa Ema's best wines year in and year out. Woodsy and dark on the nose, with boysenberry jam and shoe-polish aromas. It's tannic and powerful for sure, with flavors of ripe tomato, graphite, black plum, herbs and even salt. A rugged, briny tasting finish confirms the inherent rustic character of Carignan.
Shipping & Returns
We ship with Canada Post ExpressPost or Priority within British Columbia only. If you are not at home when Canada Post attempts delivery of your package, you will receive a door hanger to notify you that your package can be picked up at the postal outlet indicated on the card. Unfortunately, we are not legally allowed to ship outside of the province and packages delivered by Canada Post cannot be left on the doorstep. Packages must be received by a recipient over 19 years of age.
Within Downtown Vancouver - 1-2 business days
Outside Downtown Vancouver - 2 business days
Read the full shipping terms by clicking here.


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Photography by Kaylin Chen
Kaylin is currently a Senior at The Ohio State University studying Marketing. She sees traveling as an opportunity to connect with others and to connect with herself. She uses photography as a medium to capture the beauty in life that people often overlook.
Instagram Username: Kay___Chen
(All of these were taken on Kaylin's trip to Burma in October.)


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Back in May of this year the kids had an Art Show at the church where they had been taking lessons alllllllll year...It was so great to see all the work they had done. They love their teacher and enjoyed being with their friends each week (Anthony and Makenzie) Sister Kim and I were pleased at how much they had been taught in this class. What a great year!
Sunday, June 17, 2007
Calling all Artist!!!!!!!!!!
Posted by Just the 4 of Us at Sunday, June 17, 2007
1 comment:
- Journey to Lilly! said...
Michelle, this was really a great class! The kids loved it & it was always a special treat to visit with you!
- June 17, 2007 at 9:18 PM
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