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Background Community-based rehabilitation (CBR) programmes have been described as highly effective means of promoting the rights and opportunities of persons with disabilities (PwD). Although CBR is often the main way in which PwD in low-income and middle-income countries access rehabilitation services, there is little literature providing rigorous evaluation of their impact on people's well-being. Methods Data were collected in the Mandya and Ramanagar districts (Karnataka state, India), between December 2009 and May 2010. In total 2540 PwD were interviewed using stratified random sampling: 1919 CBR beneficiaries (who joined the programme between 1997 and 2009) and 621 persons who were living in villages not covered by the programme. We controlled for the systematic differences between people joining and not joining the programme using the propensity score matching method controlling for covariates at individual and village level. We evaluated the impact of the programme on the subgroups of PwD who are disadvantaged on the dimensions of interest: access to pensions, use of aid appliances, access to paid jobs and improvement in personal-practical autonomy after 4 and 7 years of joining the CBR. Results We observed a positive and significant impact of the programme on access to services, rights and opportunities of PwD. The results indicate that compared with the control group access to pensions and allowances, aid appliances, access to paid jobs and personal-practical autonomy increased by 29.7%, 9.4%, 12.3% and 36.2%, respectively, after 7 years. Conclusions The CBR programme analysed has a positive impact on access to services and the well-being of PwD who are particularly deprived on outcomes of interest.
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The Effectiveness of Community based rehabilitation programs: An impact
evaluation of a quasi-randomised trial
Vincenzo Mauro*, Mario Biggeri*, Sunil Deepak**, Jean-Francois Trani°
*Dept. of Economics, University of Florence, **Associazione Italiana Amici di Raoul Follereau
(AIFO), °Brown School of Social Work and Institute of Public Health, Washington University in St
Louis.
Corresponding author: Jean-Francois Trani Assistant professor, Brown School and Institute of
Public Health, Washington University in St. Louis, Campus Box 1196, Goldfarb Hall, Room 243,
One Brookings Drive, St. Louis, MO 63130 [o] 314.935.9277 [c] 314.412.0077 [e]
jtrani@wustl.edu
Keywords: Capability Approach, Community Based Rehabilitation, Disability, Quasi-experiment.
Word count: 3223
ABSTRACT
Background Community based rehabilitation (CBR) programs have been described as highly
effective means of promoting the rights and opportunities of persons with disabilities (PwD).
Although CBR are often the main way in which PwD in low and middle income countries access
rehabilitation services, there is little literature providing rigorous evaluation of their impact on
people’s well-being.
Methods Data was collected in the Mandya and Ramanagar Districts (Karnataka State, India),
between December 2009 and May 2010. 2,540 PwD were interviewed using stratified random
sampling: 1,919 CBR beneficiaries (who joined the program between 1997 and 2009) and 621
persons who were living in villages not covered by the program. We controlled for the systematic
differences between people joining and not joining the program using the propensity score matching
(PSM) method controlling for covariates both at individual and village level. We evaluated the
impact of the program on the subgroups of PwD who are disadvantaged on the dimensions of
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interest: access to pensions, use of aid appliances, access to paid jobs and improvement in personal-
practical autonomy after four and seven years of joining the CBR.
Results We observed a positive and significant impact of the program on access to services, rights
and opportunities of PwD. The results indicate that compared to the control group access to
pensions and allowances, aid appliances, access to paid jobs and personal-practical autonomy
increased by 29.7%, 9.4%, 12.3% and 36.2% respectively after seven years.
Conclusions The CBR program analysed has a positive impact on access to services and the well-
being of PwD that are particularly deprived on outcomes of interest.
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INTRODUCTION
Community based Rehabilitation (CBR) is defined in the 2004 position paper - adopted by World
health Organisation (WHO), International Labour Organisation (ILO) and the United Nations
Educational, Scientific and Cultural Organization (UNESCO)- as “a strategy within general
community development for the rehabilitation, equalization of opportunities and social inclusion of
all people with disabilities” based on a participatory process involving people with disabilities
(PwD), their families, organizations and communities [1]. The new CBR guidelines [2], are based
on the principles of the UN Convention on the Rights of Persons with Disabilities (CRPD) [3], as
well as on empowerment, self-advocacy and sustainability.
The CBR matrix consists of five components: health, education, work, empowerment and social
participation. Each component includes five elements [2]. Each CBR program is supposed to select
components fitting local needs and priorities and considering available resources.
Issues relating to CBR feature twice among the top ten most relevant and challenging priorities (out
of 83) for future research on disability [4]. However, although CBR is considered the most cost-
effective approach for improving the wellbeing of PwD [2-5], and for fostering their participation in
the community and society at large [6, 7], we lack evidence of the impact of CBR programs. This
jeopardises the development and implementation of effective rehabilitation policies and
programmes [7, 8, 9, 10-12]. Sharma (2007) carried out an analysis of evaluation reports of 22 CBR
programmes in 14 countries: she found that studies focused mainly on accessibility, program reach,
identification of needs and specific outcome.
CBR research in low-income countries has recently increased [9]: Alavi and Kuper (2010)
identified 51 studies evaluating the impact of rehabilitation programs in Africa, Asia and Latin
America. But few studies were focusing on the program impact. The type of study design was
quasi-experimental in 19 studies, randomised controlled trials (16) and case-series (14). Only 2
studies had a comparison group, one being the present study.
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Our study contributes to filling this gap by measuring the impact of CBR programs on PwDs that
are particularly deprived on four core dimensions of interest (access to pensions, use of aid
appliances, access to paid jobs and improvement in personal-practical autonomy) after four and
seven years of joining the CBR. The field study is built on a potential outcomes framework [13, 14]
using a large-scale household case-control study.
Our theoretical framework and the outcomes of interest are based on the CBR guidelines [2], the
CRPD [3], and the capability approach [15, 16]. CBR’s strategy “promotes the rights of people with
disabilities to live as equal citizens within the community, to enjoy health and well-being, to
participate fully in educational, social, cultural, religious, economic and political activities” [2, p.4].
As a result, CBR programs aim at expanding capabilities of PwD (capacities and opportunities) and
agency to live a life they value. [17, 18]
METHODS
Study location and population
Our study analyses a CBR program implemented in the Mandya and Ramanagar districts of
Karnataka State, India, with a total population of over 2.2 million people (figure 1). From 1997
onwards, this program reached 2,045 villages and 22,000 PwD. We defined disability following the
form 1 instructions of the WHO CBR Manual [19].
Figure 1. Map of the districts under research (approximately here)
The CBR program is managed by two non-governmental organisations (MOB, Maria Olivia
Bonaldo and SRMAB, Sri Raman Maharishi Academy for Blind) and reached PwD from different
5
age groups and with different types of disabilities in rural, semi urban and urban areas. The
implementation process is carried out by trained community CBR workers supported by a
supervisor and a project coordinator with a high involvement of PwD themselves through Self-Help
Groups (SHGs).
Randomisation
We measured the impact of CBR by comparing PwD in three neighbouring districts (figure 1). The
first two, Mandya and Ramanagar, were covered by the intervention, while the third –Mysore-
housed the control sample. The choice of the Mysore area was due to its extreme similarity with the
intervention areas. Furthermore, the villages in the control area were selected for their proximity
with Mandya district. Two big cities, Bangalore and Mysore, are close to both the treatment and the
control areas. As a result, a similar range of referral services and specialised institutions in health,
education, social welfare and occupation are accessible to participants and controls. In particular,
the two cities provide access to vocational training, specialized health service and technical
appliances. The three districts also have few local services, such as special schools for children with
hearing and speech impairments and a vocational training centre for children with visual
impairment.
Villages and PwD were sampled in all areas following a one-stage cluster sample design, using the
villages as first-stage units. Three variables were chosen for stratification: the geographical area
(using sub-districts as strata), the size of the village and the year the CBR program was introduced
(for areas covered by the program only). In selected villages of the intervention areas, all PwD
participating in the CBR program were interviewed. In control areas, all PwD were interviewed.
PwD were identified using existing data in participating villages and a 9 items screening tool [20]
tool in control areas. Our final dataset consisted of 2,540 respondents including 1,919 participants
in 237 villages and 621 controls in 28 villages not yet covered. The average response rate was
91.8%.
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A comparison between respondents and non-respondents showed no significant differences with
respect to the available characteristics. We therefore assumed that unobserved data are missing
completely at random and the estimated effects are unbiased [21]. The PSM methodology
corroborates this assumption: our results remained unbiased under the less restrictive hypothesis
that missingness and the unit’s characteristics are conditionally independent given a set of variables.
Figure 2. Randomisation process (approximately here)
Procedures
The present trial is the first component of a larger study composed of: (i) an emancipatory research
focusing on the mapping of barriers faced by PwD in the communities, their strategies for
overcoming these barriers and the role played by the CBR program; and (ii) a participatory research
to provide in-depth understandings of the key issues identified in the quantitative and emancipatory
researches and elaborate recommendation to improve the program. Therefore, this research program
is compliant with article 30 of the CRPD.
The study benefitted from the input of an Advisory and Scientific committee (composed of
academics, PwD representative of Disabled Peoples Organizations in Mandya and Ramanagara,
experts from AIFO, local NGOs and social worker representatives). The theoretical framework and
survey instruments were elaborated following eight months of desk research, several in depth
interviews and various focus group discussions. The study instrument is composed of four sections
including socio-demographic characteristics, activity limitations, a participation scale, and objective
and subjective dimensions of quality of life. Ethical clearances were obtained from both UCL and
AIFO.
7
A two weeks training programme for a team of 5 supervisors and 35 enumerators covered
theoretical, practical and ethical issues, including a brief pilot survey, during November 2009. The
survey was administered between December 2009 and May 2010.
Variables
Selected outcomes of interest were identified based on specific CBR activities made available to
participants.[2] We focused on three objective outcomes (i.e., access to pension and allowances,
access to mobility and assistive device, and access to paid job) and one subjective outcome based
on self-perceived personal practical autonomy.
These outcomes reflect two of the CBR matrix components: livelihoods, health and rehabilitation.
They constitute required additional resources linked to disability – what Sen called the “conversion
handicap” [17]. PwD need more resources but also face social and environmental barriers that can
directly or indirectly influence the conversion of personal resources into the freedom to leading
lives they value.[18, 20]
The outcomes selected explore the contribution of the CBR to expanded functionings and
capabilities for participants. The opportunity to have a paid job is central to PwD as it provides
financial autonomy as well as family and community recognition, enhancing social inclusion and
self-esteem [11, 23]. Access to pensions and allowances similarly advances autonomy and social
recognition. Access to aid appliances is central to increase autonomy for people with mobility
restriction. The perceived impact of the CBR on individual autonomy is a good indicator of self-
esteem and well-being.[11]
Statistical analysis
8
The framework to identify causal effects is based on potential outcomes. This framework is rooted
in the statistical work on randomized experiment by Fisher [21] and Neyman [22], later extended by
Rubin [14, 23] and others to quasi-randomized studies and other forms of inference. This approach
known as “Rubin’s Causal Model” considers causal inference as a problem of missing data: the
explicit mathematical modelling of the assignment mechanism aims at revealing the observed data
[24]. We can reasonably assume that participants and control villages have similar characteristics as
shown above. We tested both treatment and control groups for the various cofounding factors and
tests always show that we cannot reject the hypothesis of equality of mean between groups for any
of these variables. This confirms the similarity between the two groups for each covariate included
in the P-score model (data not shown). Yet, participants and controls were not assigned randomly to
both arms of the quasi-experiment and therefore straightforward comparison between units may
introduce a selection bias [25-27]. PSM was used to address this bias, building treatment and
control groups with balanced pre-treatment covariates [13].
The impact of the program on all outcome variables is calculated over two periods of time, after 4
and 7 years of treatment respectively, in order to capture both short and medium-term effects. The
covariates included in the models estimating the propensity score are both at individual and village
level. There are seven main individual covariates: age, gender, education, household size, type of
disability, level of disability and level of wealth. Since caste and religion often play a significant
role in determining access to different services in India, we have included them in our analysis but
with some limitations because of their sensitive nature. For ethical reasons, and to avoid non-
response bias, the scientific advisory committee decided not to ask this information to the control
group. Nonetheless, in order to better understand the dynamics underlying these variables, caste and
religion were introduced as covariates in a comparison among PwD joining the program at different
times, measuring a two-year effect of the CBR. These results didn’t seem to be affected by the
9
introduction of these covariates, suggesting no caste or religion-based discrimination in accessing
CBR programs.
There are five main village-level covariates in the model: size of the village, presence of a hospital,
presence of a middle school, distance from a main road, and quality/type of the road that leads to
the village.
Moreover, in order to reduce information bias linked to self-reported measure of personal practical
autonomy and to take into account adaptive preferences, we added a covariate based on a personal
score using a vignette [28]
The PSM approach allowed the identification of a control group of PwD unexposed to the program
that matched the intervention group on any characteristics that would influence the outcomes of
interest to avoid the introduction of a selection bias into the resulting program effect estimate. The
main drawback of PSM is that it can only take into account observed covariates. Latent factors that
affect assignment to treatment cannot be accounted for in the matching procedure. The risk of
selection bias arises at individual level (i.e. PwD in villages covered by the program may decide not
to join it). We argue that the village-level assignment mechanism can be considered random. In
order to gather information about the individual-level assignment mechanism, we performed a
complete census of the PwD in 17 randomly selected villages in order to identify PwD who did not
join the program. A statistical analysis of this subgroup of “never-taker” units (i.e. units who do not
receive the treatment even if they can) showed significant differences between those and treated
units in three key variables: level of wealth, age and severity of disability. Results show that
wealthier, older people experiencing milder disability are less likely to join the program, while the
caste registered non-significant differences (data not shown). These three variables are included in
the model estimating the propensity score, guaranteeing that the treated and control groups are
balanced with respect to these key characteristics, and implicitly supporting the unconfoundedness
assumption, that remains not directly testable.
10
We restricted our analyses to the subgroup of deprived PwD to obtain even more robust results.
This approach has two important advantages. First, it allows a straightforward interpretation of the
results. Considering the outcome as a binary variable (e.g. 0=deprived, 1=not deprived) allows
interpreting the results as the share of both participants and controls meeting the outcome.
The second advantage is that before being treated the two groups are perfectly balanced with
respect of the outcome variable (that equals 0 for all the units). For example, when analysing the
effect of the CBR program on getting a pension, we compared groups of treated and control units
who did not have a pension at the starting point. If the propensity score unconfoundedness
assumption holds, this leads to a setting that can be considered experimental. This approach also
presents some drawbacks -the main one being the impossibility of measuring the effect of the
program on PwD’s capacity to keep a pension that they already secured.
The counterfactual outcome of each unit treated is calculated via a kernel-weighted average of the
outcome of all non-treated units, using the distance between units to estimate the weights. This
method has been found to produce more robust results compared to a one-to-one matching method,
especially when the number of potential controls is lower than the number of treated unit, as it is the
case in our study [29]. In order to test the sensitivity of the results to the matching algorithm, the
results were recalculated via a nearest-neighbour method obtaining similar estimated effects.
RESULTS
Table 1 provides the distribution of treated and untreated groups for outcomes of interest. Table 2
reports the average treatment effect (ATT).
11
Table 1. Randomisation process (approximately here)
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Table 2. Impact evaluation: access to selected dimensions (approximately here)
Note: Kernel Matching method
Figure 3 shows the impact of the CBR program on outcomes of interest at time 0 (before the CBR
started) and after 4 and 7 years (Figure 3).
Figure 3. Results of the outcomes analysed after 4 and 7 years (approximately here)
Outcomes
Treated
%
Improv.
Control
%
Improv.
N.
treated
N.
controls
Effect
%
Confidence
Interval
95%
St. dev
p-value
Pension & allowances
After 4 years
42.80
10.33
314
230
35.2
26.8 - 43.6
0.035
<0.001
After 7 years
67.15
38.38
314
230
29.7
22.8 - 36.5
0.046
<0.001
Mobility aid and appliance
After 4 years
6.81
1.85
637
379
4.9
2.3 - 7.5
0.012
<0.001
After 7 years
9.43
5.80
637
379
4.2
1.4 - 7.1
0.015
<0.005
Paid job/work
After 4 years
9.15
0.00
263
148
10.7
6.8 - 14.6
0.018
<0.001
After 7 years
14.34
1.43
263
148
12.3
7.8 16.7
0.019
<0.001
Personal/practical
autonomy
After 4 years
40.29
7.83
265
115
35.4
27.1 43.6
0.041
<0.001
After 7 years
43.40
11.30
265
115
36.2
27.9 - 44.5
0.043
<0.001
12
The CBR program had a positive impact on all outcomes of interest. The effect on access to
pension/allowances was already significant after 4 years (35.2%), and remained robust after 7 years.
We found that people in the control areas obtained pension or allowance after a longer time period.
The impact on getting a paid job was positive and significant both after 4 and 7 years. We observed
a greater effect after 7 years, suggesting a long lasting impact. We also found a small but significant
impact of the program on obtaining mobility and aid appliances after 4 years. This effect was twice
higher after 7 years. Results reported in table 1 also show that treated PwD, who initially had little
or no personal autonomy in daily life activities such as keeping oneself clean and tidy benefited
from an increased probability of being able to look after themselves (35% after 7 years)
DISCUSSION
Our study is the first attempt to evaluate the impact of CBR programs using a quasi-randomised
trial. Our results showed that low-cost community driven CBR programs can improve various
aspects of the livelihoods and well-being of PwD by having a positive impact on access to public
pension schemes and allowances, paid jobs, mobility aid and appliances and perceived levels of
autonomy in daily life activities. Results also established the long lasting effect of the CBR
program: it remained significant after 7 years.
The outcomes of interest were identified based on the CBR guidelines [2] the UN CRPD and the
capability approach literature [16-18]. Literature shows that access to pension and allowances is
essential to fight poverty and promote agency of PwD [30]. Having a job has been showed to foster
social inclusion and quality of life of PwD [31]. Assistive devices are instrumental in removing
barriers in the environment and expand the capabilities set [17]. Many PwD depend on disability
13
equipment such as wheelchairs and ramps to enable them to participate in daily life and contribute
to productive activities [2] .
The increase of personal practical autonomies of PwD is one of the main relevant action/objective
of CBR workers and has a deep impact on the self-esteem and relational capacities of PwD [2].
Our study shares limitations of the propensity score matching approach. This includes the
fundamental and non-directly testable assumption -often referred to as “unconfoundedness”-
according to which adjusting for differences in observable characteristics linked to the outcome
removes biases in the comparison between treated and control units, thus allowing for causal
interpretation of the results [13].
What is already known
Existing CBR studies have been focusing on accessibility, importance of the program, identification
of needs and specific outcomes using only post-test or pre-post tests evaluation designs [6, 7, 32].
Very few investigated the impact of CBR programs using randomised control trial or quasi-
experimental design and had a limited sample size. Most evaluations were even exclusively
descriptive. Others made inference from qualitative interviews of a small sample of PwD [7, 24].
None explored access to employment [7].
What this study adds
Our study shows the overall effect of a multipronged program for PwD in Karnataka State using the
CBR matrix which has been recently recommended as the reference framework for CBR evaluation
[2]. The CBR program evaluated here has many components and must be interpreted as an overall
effect of joining the program for a PwD. Nonetheless, the qualitative and emancipatory researches
that complement our study underline that the range of circumstances in which CBR has successfully
improved the quality of life of PwD indicates that CBR workers possess a range of skills and
expertise beyond medical proficiency [33]. The most significant impact was detected in increased
14
autonomy in daily life activities, which is the primary tenet of CBR. This has implication for a
better participation in family and community matters. This contributes to reducing stigmatising
attitudes towards PwD and promoting empowerment in line with the social model of disability and
the human rights framework [34-36]. Similar findings apply to Botswana, Ghana, the Philippines,
Zimbabwe, South Africa and Vietnam [37-40]. Another major finding is that the CBR program has
been promoting access to employment, which is an essential aspect of social integration and
changing attitudes towards PwD, particularly those with mental illness related disabilities such as
schizophrenia, bipolar disorders and severe depression. [41]. In fact, research in India has shown
that employment level disparity between PwD and non-disabled people is not explained by a major
difference in productivity and human capital but most probably by negative attitudes resulting in
discrimination in access to jobs [42] particularly for women [43].
Policy implication
There are several policy implications of our results. First, our study, inclusive of all types of
disability, and using validated instruments can be applied in other low-income settings to measure
the impact of CBR programs in the various domains of the CBR matrix – health, livelihoods,
employment, education, social participation and empowerment. Second, results show that CBR
programs are particularly effective in a context such as India where laws, regulations and public
policies addressing disability and mental health exist. Previous research has shown the lack of
knowledge PwD have of their rights in India [44]. PwD, particularly those with mental disability,
are also reluctant to claim their rights as they might face public stigma linked to public disclosure of
their status [45]. CBR workers were trained to navigate the Indian legal and administrative system
to promote information and inclusion of CBR participants in public services (education,
rehabilitation and health notably) as well as defend their rights (for instance to free transportation)
and protect them against prejudice [31]. In summary, our paper shows that a CBR program can set
in motion virtuous interactions in the communities through social empowerment, fostering new
opportunities for those who are discriminated against and lobbying efficiently for PwD’ rights.
15
Acknowledgement
We wish to thank participants in this study and their family who took the time to respond to our
survey. We also thank the team of data collectors and supervisors for their patience and efforts in
learning how to carry out the survey and for their outstanding work in the field. We thank AIFO
India in Bangalore, and the two partner organizations (SRMAB and MOB) in Mandya district for
the high level of commitment to the research project and for their continuous logistical support. We
have been privileged to receive help, comments and suggestions from a large number of people. For
this reason we would like to express our gratitude to Parul Bakhshi, Deveraj Basavaraj, Paolo
Battistelli, Marco Bellucci, Cristina Devecchi, Srinivas Gowda, Giampiero Griffo, Nora Groce,
Renato Libanora, Aron Martin, Fabrizia Mealli, Francesca Ortali, Enrico Pupulin and Enrico Testi.
"Competing Interest: None to declare."
Contributorship statement
The study was elaborated by VM, JFT and MB. The analysis were carried out by VM. The first
draft has been written by VM, MB and JFT. All authors collaborated and agreed to the final draft.
Funding: This work was supported by AIFO/Italy, SMHF/Japan, FIRAH/France and
DAHW/Germany.
Ethical approval was obtained from both UCL and AIFO.
Licence for Publication
The Corresponding Author has the right to grant on behalf of all authors and does grant on behalf of
all authors, an exclusive licence (or non exclusive for government employees) on a worldwide basis
to the BMJ Publishing Group Ltd to permit this article (if accepted) to be published in JECH and
any other BMJPGL products and sublicences such use and exploit all subsidiary rights, as set out in
our licence (http://group.bmj.com/products/journals/instructions-for-authors/licence-forms).
16
Figure 1. Map of the districts under research (approximately here)
Figure 2. Randomisation process (approximately here)
Figure 3. Results of the outcomes analysed after 4 and 7 years (approximately here)
17
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... One programme, conducted with individuals without disabilities, aimed to remove social and attitudinal barriers to access for people with disabilities . Finally, four interventions aimed to improve livelihoods by improving access to rehabilitation Mauro et al., 2014), or assistive technology . ...
... In the domain 'access to the job market', two studies examined outcomes to do with the capacity of people with disabilities to engage in job searching , and three physical and social barriers to employment . Most outcomes fell into the category of 'employment in formal and informal sector', with six studies examining entrepreneurship and informal sector participation as well as waged employment and formal sector participation Mauro et al., 2014;. Four interventions used outcomes related to 'income and earnings from work' Mauro et al., 2014). ...
... Most outcomes fell into the category of 'employment in formal and informal sector', with six studies examining entrepreneurship and informal sector participation as well as waged employment and formal sector participation Mauro et al., 2014;. Four interventions used outcomes related to 'income and earnings from work' Mauro et al., 2014). Finally, one study used the outcome of access to formal and informal social protection . ...
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Background:People with disabilities—more than a billion people worldwide—arefrequently excluded from livelihood opportunities, including employment, socialprotection, and access to finance. Interventions are therefore needed to improvelivelihood outcomes for people with disabilities, such as improving access to financialcapital (e.g., social protection), human capital (e.g., health and education/training),social capital (e.g., support) or physical capital (e.g., accessible buildings). However,evidence is lacking as to which approaches should be promoted.Objectives:This review examines whether interventions for people with disabilitiesresult in improved livelihood outcomes in low‐and middle‐income countries (LMIC):acquisition of skills for the workplace, access to the job market, employment informal and informal sectors, income and earnings from work, access to financialservices such as grants and loans, and/or access to social protection programmes.Search Methods:The search, up to date as of February 2020, comprised of:(1) an electronic search of databases (MEDLINE, Embase, PsychINFO, CAB GlobalHealth, ERIC, PubMED and CINAHL),(2) screening of all included studies in the instances where reviews were identified,(3) screening reference lists and citations of identified recent papers and reviews, and(4) An electronic search of a range of organisational websites and databases(including ILO, R4D, UNESCO and WHO) using the keyword search forunpublished grey to ensure maximum coverage of unpublished literature, andreduce the potential for publication biasSelection Criteria:We included all studies which reported on impact evaluations ofinterventions to improve livelihood outcomes for people with disabilities in LMIC.Data Collection and Analysis:We used review management software EPPI Reviewerto screen the search results. A total of 10 studies were identified as meeting the inclusion criteria. We searched for errata for our included publications and found none.Two review authors independently extracted the data from each study report, includingfor the confidence in study findings appraisal. Data and information were extractedregarding available characteristics of participants, intervention characteristics and controlconditions, research design, sample size, risk of bias and outcomes, and results. Wefound that it was not possible to conduct a meta‐analysis, and generate pooled results orcompare effect sizes, given the diversity of designs, methodologies, measures, and rigouracross studies in this area. As such, we presented out findings narratively.Main Results:Only one of the nine interventions targeted children with disabilitiesalone, and only two included a mix of age groups (children and adults with disabilities.Most of the interventions targeted adults with disabilities only. Most single impairmentgroup interventions targeted people with physical impairments alone. The researchdesigns of the studies included one randomised controlled trial, one quasi‐randomisedcontrolled trial (a randomised, posttest only study using propensity score matching(PSM), one case‐control study with PSM, four uncontrolled before and after studies, andthree posttest only studies. Our confidence in the overall findings is low to medium onthe basis of our appraisal of the studies. Two studies scored medium using ourassessment tool, with the remaining eight scoring low on one or more item. All theincluded studies reported positive impacts on livelihoods outcomes. However, outcomesvaried substantially by study, as did the methods used to establish intervention impact,and the quality and reporting of findings.Authors' Conclusions:The findings of this review suggest that it may be possible fora variety of programming approaches to improve livelihood outcomes of people withdisabilities in LMIC. However, given low confidence in study findings related tomethodological limitations in all the included studies, positive findings must beinterpreted with caution. Additional rigorous evaluations of livelihoods interventionsfor people with disabilities in LMIC are needed.1|PLAIN LANGUAGE SUMMARY1.1|Livelihood interventions appear to improveoutcomes for people with disabilitiesA range of programming approaches reported improvements inlivelihood outcomes for people with disabilities in low‐and middle‐income countries (LMICs). However, confidence in study findings islow, due to methodological limitations in the research.1.2|What is this review about?More than one billion people have some form of disability. Peoplewith disabilities are frequently excluded from livelihood opportuni-ties, including employment, social protection and access to bankingand loans. Among people with disabilities over the age of 15, 36% areemployed, compared to 60% for people without disabilities.Livelihood interventions are therefore needed for people withdisabilities. These include interventions aiming to improve access tofinancial capital (e.g., social protection), human capital (e.g., healthand education/training), social capital (e.g., support) and physicalcapital (e.g., accessible buildings).What is the aim of this review?This review examines whether interventions for people withdisabilities in LMICs result in improved livelihood outcomes,including acquisition of skills for the workplace, access to thejob market, employment in formal and informal sectors,income and earnings from work, access to financial servicessuch as grants and loans, and access to social protectionprogrammes.
... Many studies focus on a small sample of CBR participants and provide qualitative information on existing barriers and challenges to participation. Many quantitative studies evaluate the health component of CBR [35], a lot less education, less access to assistive devices [36,37], nutrition [38], immunization [39], livelihoods [40] and social inclusion [41], and almost no empowerment [34]. The existing research does not look usually at various disabilities but instead focus on one condition or type of disability [42]. ...
... The existing research does not look usually at various disabilities but instead focus on one condition or type of disability [42]. Few studies focus on service delivery outcomes and the improvement in wellbeing [27,36]. Limited research investigates CBR impact in Low Income Countries. ...
... Studies have mostly investigated the access to healthcare services for persons with disabilities [7,[47][48][49][50]. They rarely assessed the access to services for participants in a CBR program [36]. Similarly, the perceived satisfaction of persons with disabilities with services received is rarely emphasized. ...
Article
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The United Nations Convention on the Rights of Persons with Disabilities (UNCRPD), ratified in 2006, states that the achievement of equal rights, empowerment, and social inclusion of people with disabilities requires comprehensive rehabilitation services involving educational, social, economic, and medical interventions, all dimensions of the World Health Organization Community based rehabilitation (CBR) matrix. CBR programs aim at achieving those goals. In the present study, we investigated whether a large scale CBR program is improving access to multiple services (namely physical therapy, assistive technology, education, employment, advocacy, and community awareness) and providing satisfactions (by measuring the reduction in unmet needs) of Afghans with disabilities. We enrolled in the study 1861 newly recruited CBR participants with disabilities from 169 villages between July 2012 and December 2013, and 1132 controls screened with disabilities randomly selected with a two-stage process within 6000 households from 100 villages in the same provinces as the CBR but outside its catchment area. Using propensity score matching (PSM) and difference in difference analysis, we estimated the differences in accessing services. There were statistically significant differences between participants and controls on the access of available services between the baseline and endline. Using PSM we also found that needs were more often met among CBR participants compared to the controls. Our study indicates that a CBR program may be an effective way to provide services for persons with disabilities even in a conflict context such as Afghanistan. It contributes to addressing the longstanding question whether CBR can actually improve the rehabilitation of persons with disabilities.
... However, there is also a call for the inclusion of quantitative indicators in order to capture the progress made by people participating in CBR programs [7]. Moreover, CBR has a positive and significant impact on access to services, rights, and opportunities of people with disabilities [8], and has demonstrated its efficacy in low-and middleincome countries [9]. However, the methodological constraints of many of these studies limit the strength of their results. ...
Article
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Community-based rehabilitation (CBR) is a multi-sectorial community strategy for guaranteeing that people with disabilities enjoy the same rights and opportunities as all other community members. CBR is organized in a five-component matrix—namely, health, education, social, livelihood, and empowerment. To measure the effectiveness of CBR, the World Health Organization (WHO) has developed standardized indicators. The objective of the present study is to translate and validate the CBR indicators (CBR-Is), providing preliminary evidence of their use for disability in Italy. After obtaining permission from the WHO, the CBR-Is followed a process of translation and cross-cultural adaptation according to international guidelines. An examination of internal consistency and reliability was than performed. The intra-rater reliability was estimated using the Intraclass Correlation Coefficient with a 95% confidence interval. In order to measures the differences between people with and without disabilities, an independent sample t-test was used for quantitative indicators. The Italian version of the CBR-Is (IT-CBR-Is) was administered to 234 people. The internal consistency showed a good value, with a Cronbach’s alpha coefficient of 0.862, and the intra-rater reliability analysis showed solid values for each domain (range: 0.723–0.882). Statistically significant differences between people with and without disabilities were found for each domain of the CBR matrix—namely, health, social, education, livelihood, and empowerment. The IT-CBR-Is are consistent and reliable measures when used to investigate disability in a community-based inclusive development perspective. National stakeholders can now have specific indicators to implement services and actions for people with disabilities.
... Our study shows that the CBR program had a significant positive impact on several outcomes of interest promoted by the WHO, namely individual mobility, activities of daily living, communication skills, emotional wellbeing, social participation and employment. Our findings suggest that CBR programs can improve livelihoods and wellbeing of persons with disabilities in LMICs [8,13,20,37]. Yet, existing studies present multiple limitations -small sample size, inadequate sample methodology, mostly observational or qualitative approaches, recall bias in the only existing quasi experiment and lack of accounting for confounding factors in regression analysis [8,38]. Our study follows and interviews a large group of CBR participants and a random group of controls multiple times over a period of 3 years. ...
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Background The 2006 United Nations Convention on the Rights of Persons with Disabilities states that the achievement of equal rights, empowerment and social inclusion of people with disabilities requires comprehensive rehabilitation services encompassing all components of the World Health Organization Community based rehabilitation (CBR) matrix: health, education, livelihood, social and empowerment. CBR programs specifically aim to deliver such comprehensive interventions. In the present study, we investigate the impact of a CBR program in Afghanistan on all these components. Methods We enrolled 1861 newly recruited CBR participants with disabilities in the study, from 169 villages between July 2012 and December 2013 as well as 1132 controls with disabilities randomly selected through a two-stage process within 6000 households from 100 villages in the same provinces but outside the catchment area of the CBR program. We interviewed them again after one (midline) and two (end-line) years in the study. Using propensity score matching and difference in difference analysis, we estimated the impact of the CBR on outcomes of interest, namely mobility, activities of daily living, communication, participation in social and community life, emotional well-being and employment. Results Three years on average into the CBR program, participants showed a significant and close to medium effect size reduction in emotional (Cohen’s d = − 0.48, 95%CI[− 0.58--0.38]), and social participation challenges (Cohen’s d = − 0.45, 95%CI[− 0.53−− 0.36]); small to medium effect size reduction in unemployment (Cohen’s d = − 0.21, 95%CI[− 0.33--0.10]), activities of daily living (Cohen’s d = − 0.26, 95%CI[− 0.35--0.18]), mobility (Cohen’s d = − 0.36, 95%CI[− 0.44--.29]) and communication challenges (Cohen’s d = − 0.38, 95%CI[− 0.46--0.3]). Conclusions Our study indicates that a CBR program may provide positive rehabilitation outcomes for persons with disabilities even in a conflict context, and improve overall well-being of all participants with disabilities, whatever their impairment, individual characteristics and the CBR matrix components considered. Trial registration ISRCTN, ISRCTN50214054 . Registered August 5th 2020 - retrospectively registered
... El sistema sanitario chileno (Becerril-Montekio, Reyes & Manuel, 2011) en las últimas décadas, ha orientado sus esfuerzos a fortalecer el primer nivel de atención en salud (García-Huidobro, 2010), con un fuerte enfoque hacia la rehabilitación basada en la comunidad (RBC) (Ase & Burijovich, 2009;WHO, 2004). La RBC representa una estrategia exitosa para la plena inclusión social de personas en situación de discapacidad (PeSD) y sus familias, observando buenos resultados en países de bajos y medianos ingresos (Stefanovics, Filho, Rosenheck & Scivoletto, 2014;Van Dort, Wilson & Coyle, 2014) donde se destacan mejoras en el acceso a servicios y en el bienestar de las PeSD (Mauro, Biggeri, Deepak & Trani, 2014). La RBC se organiza a partir de 5 pilares que permiten entender y abordar con visión integradora la situación vital de un individuo: educación, trabajo, salud, participación social y empoderamiento (Ministerio de Salud y Protección Social, 2014;WHO, 2004), todo, con el fin de aportar a incrementar los niveles de calidad de vida y las oportunidades de participación e inclusión en términos sociales (WHO, 2012). ...
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Introducción: La Rehabilitación Basada en la Comunidad (RBC) representa un nuevo ámbito de trabajo para fonoaudiólogos(as) en Chile. En la región de Valparaíso co-existen organizaciones no gubernamentales (ONG) y otras instituciones donde la RBC constituye un marco de acción para el quehacer profesional. A la fecha y desde la fonoaudiología, no se ha descrito el manejo teórico-práctico de los profesionales que se desempeñan en este ámbito. Objetivo: El objetivo de esta investigación fue describir el conocimiento que poseen los fonoaudiólogos respecto a la estrategia RBC y cómo estos saberes se ajustan a su práctica profesional. Método: estudio convergente paralelo a partir de un estudio observacional-descriptivo, de corte transversal, complementado con un diagnóstico participativo. Resultados: un 22% de los informantes comunica que las instituciones donde trabajan adscriben a la RBC, el 78% cuenta con contratos inferiores a 12 horas semanales y 83% considera que su jornada no le permite realizar acciones atingentes a la estrategia. Un 50% define de forma adecuada la RBC y el 88% acierta al identificar los pilares de la misma. Un 75% de los consultados refiere el ser agente de salud como eje central de su labor y un 25% comunica que sus responsabilidades han de centrarse en la ejecución de talleres comunitarios. Los profesionales observan a la comunidad como un otro al cual asisten sanitariamente y declaran la necesidad de transitar hacia un paradigma donde domine la promoción y la prevención. Conclusiones: El conocimiento de la RBC por parte de fonoaudiólogos participantes del estudio, es aún intuitivo no existiendo coherencia entre los saberes teóricos y prácticos declarados. Es necesario fortalecer la formación a nivel de pre y posgrado, con objeto de alinear la práctica fonoaudiológica con las recomendaciones internacionales de la RBC.
... Moreover, Mauro et al. (2014) state that PWDs are to receive physiotherapy in addition to physical rehabilitation from the rehabilitation centers. Furthermore, rehabilitation centers provide appropriate active and passive exercises such as balance and coordination exercises, electric stimulation and pop correction (JICA, 2002). ...
Article
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The purpose of this article is to explain the practice, challenges and future prospects of community-based rehabilitation (CBR) in Gedeo zone, a district of nearly one million inhabitants in the south of Ethiopia. The study used a mixed methods design. The quantitative part of the study involved 138 parents and care givers selected by convenient sampling technique. In addition, a total of 22 (seven female and 15 male) research participants were purposively selected from various categories: one head of zone labor and social affairs, three heads of district labor and social affairs, three representatives of associations of PWDs, 11 parents, two CBR heads, and two CBR social workers. Questionnaires and interviews were used as tools of data collection. The data were analyzed using both descriptive and thematic analysis. The finding indicated that there was no well-established CBR service provision for PWDs in Gedeo zone to ensure full participation and successful adjustment in the community. The article also revealed that a lack of trained manpower, following the charity model of CBR, and a failure to understand the modern essence of CBR were some of the major challenges that hindered the implementation of CBR service in Gedeo zone. Based on the findings, we recommend the establishment of rehabilitation centers in combination with community services in various districts of the zone. CBR requires centers with skilled staff, able to empower local people in the community to develop inclusive structures. Furthermore, we suggest that the practice of CBR in Gedeo zone should empower CBR workers in community-based inclusive development.
... El sistema sanitario chileno (Becerril-Montekio, Reyes & Manuel, 2011) en las últimas décadas, ha orientado sus esfuerzos a fortalecer el primer nivel de atención en salud (García-Huidobro, 2010), con un fuerte enfoque hacia la rehabilitación basada en la comunidad (RBC) (Ase & Burijovich, 2009;WHO, 2004). La RBC representa una estrategia exitosa para la plena inclusión social de personas en situación de discapacidad (PeSD) y sus familias, observando buenos resultados en países de bajos y medianos ingresos (Stefanovics, Filho, Rosenheck & Scivoletto, 2014;Van Dort, Wilson & Coyle, 2014) donde se destacan mejoras en el acceso a servicios y en el bienestar de las PeSD (Mauro, Biggeri, Deepak & Trani, 2014). La RBC se organiza a partir de 5 pilares que permiten entender y abordar con visión integradora la situación vital de un individuo: educación, trabajo, salud, participación social y empoderamiento (Ministerio de Salud y Protección Social, 2014;WHO, 2004), todo, con el fin de aportar a incrementar los niveles de calidad de vida y las oportunidades de participación e inclusión en términos sociales (WHO, 2012). ...
Article
Full-text available
La Rehabilitación Basada en la Comunidad (RBC) representa un nuevo ámbito de trabajo para fonoaudiólogos(as) en Chile. En la región de Valparaíso co-existen organizaciones no gubernamentales (ONG) y otras instituciones donde la RBC constituye un marco de acción para el quehacer profesional. A la fecha y desde la fonoaudiología, no se ha descrito el manejo teórico-práctico de los profesionales que se desempeñan en este sector. El objetivo de esta investigación fue describir el conocimiento que poseen los fonoaudiólogos respecto a la estrategia RBC y cómo estos saberes se ajustan a su práctica profesional. Investigación convergente paralela a partir de un estudio observacional-descriptivo, de corte transversal, complementado con un diagnóstico participativo. Un 22% de los informantes comunica que las instituciones donde trabajan adscriben a la RBC, el 78% cuenta con contratos inferiores a 12 horas semanales y 83% considera que su jornada no le permite realizar acciones atingentes a la estrategia. Un 50% define de forma adecuada la RBC y el 88% acierta al identificar los pilares de la misma. Un 75% de los consultados refiere el ser agente de salud como eje central de su labor y un 25% comunica que sus responsabilidades han de centrarse en la ejecución de talleres comunitarios. Los profesionales observan a la comunidad como un otro al cual asisten sanitariamente y declaran la necesidad de transitar hacia un paradigma donde domine la promoción y la prevención. El conocimiento de la RBC por parte de fonoaudiólogos participantes del estudio, es aún intuitivo no existiendo coherencia entre los saberes teóricos y prácticos declarados. Es necesario fortalecer la formación a nivel de pre y posgrado, con objeto de alinear la práctica fonoaudiológica con las recomendaciones internacionales de la RBC.
Chapter
People living with disabilities are often stigmatized and excluded from Nigeria’s social, economic, and political affairs. The health system has no social program designed to improve their quality of life and no designated department within the Federal Ministry of Health to address medical rehabilitation issues at the national level. In describing the debacle, one analyst called individuals with disabilities “visible but invisible people.” This chapter discusses the types and causes of disabilities, including the dimensions, scope, and burden of disability in Nigeria. It also analyses the challenges of living with disabilities and relevant protection laws in the country. Lastly, this chapter offers recommendations for a national disability strategy and action plan to address barriers in buildings and roads, including learning accommodation for children and adults with disabilities.
Article
Community Based Rehabilitation (CBR) represents a new field of work for Speech and Language Pathologists (SLPs) in Chile. In the fifth region of Valparaíso-Chile, non-governmental organizations (NGOs) and other institutions coexist and the CBR represents a framework of action for professional work. To date and from SLP, the theoretical-practical management of professionals working in this field has not been described. The objective of this research was to describe the knowledge that SLPs have regarding the CBR strategy and how this knowledge fits their professional practice. Parallel convergent study based on a cross-sectional observational-descriptive study, complemented by a participatory diagnosis. Twenty-two percent of the informants reported that the institutions where they work are aligned with CBR, 78% have contracts of less than 12 hours per week and 83% consider that their workday does not allow them to carry out actions related to the strategy. Fifty percent adequately defines the CBR and 88% can identify the pillars of it. Seventy-five percent of those consulted refer to being a health agent as the central axis of their work and 25% report that their responsibilities should focus on the execution of community workshops. The professionals observe the community as “another” to which they healthily assist and declare the need to move towards a paradigm where promotion and prevention dominate. The knowledge of the CBR by SLPs is still intuitive and there is no coherence between the theoretical and practical knowledge declared. It is necessary to strengthen pre and postgraduate training, in order to align the SLPs practice with the international guidelines of the CBR.
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The objectives of this Campbell systematic review were: • 1) To describe the range and diversity of interventions available for addressing the low labour market participation of adults with physical and/or sensory disabilities in developing country contexts. • 2) To systematically identify, assess, and synthesise the evidence on the effects of interventions on labour market outcomes for disabled adults in low‐ and middleincome countries. As part of this, to critically analyse the evidence along the causal chain framework, linking interventions with intermediate outcomes and final impacts, and document the level/strength of evidence on potential pathways of impact using the framework. • 3) To assess if effects are moderated by characteristics of the participants, interventions, and/or settings. • 4) To provide an explanation for the intervention effects by examining what participants in the included studies reported about why the interventions did, or did not, work for them. A total of 14 studies met the eligibility criteria. Publication dates of included studies ranged between 1992 and 2012, with six studies published in the four‐year period 2010‐2013. A key finding of this review is the overall scarcity of robust evidence, as indicated by the relatively few studies that met the inclusion criteria. Although the evidence in general showed positive results, we need to be wary of drawing strong inferences from the findings of this body of literature. Not only is the number of impact evaluations limited, but most used designs in which conclusively attributing causality is not possible. Our assessment of the evidence does not allow us to develop practical suggestions on what interventions are likely to work, for whom, and when. Clearly, there is an urgent need for investment in high quality impact evaluations of interventions to support people with disabilities in accessing the labour market in low‐ and middle income settings. To build the evidence base further, it is therefore important that many more of the interventions currently in existence in low‐ and middle‐income countries are rigorously evaluated, and the results are reported and disseminated widely. The methodological inconsistencies and weaknesses of the current evidence base, and specific knowledge gaps, suggest a number of future research priorities. Executive Summary BACKGROUND Disability is a development issue, with widespread poverty, inequality and violation of human rights. Recent estimates suggest that more than one billion people are living with some form of disability. Persons with disabilities are over‐represented among the world's poor, and significant labour market disadvantage helps maintain the link between poverty and disability in many country contexts. The costs of disability are particularly acute in low‐ and middle‐income countries (those with gross national income per capita of less than $12,616), where up to 80% of people with disabilities of working age can be unemployed, around twice that for their counterparts in high‐income countries. When people with disabilities do work, they generally do so for longer hours and lower incomes, have fewer chances of promotion, are more likely to work in the informal labour market, and are at greater risk of becoming unemployed for longer periods. The barriers faced by people with disabilities globally in accessing and sustaining paid work is a profound social challenge. There is now growing recognition of employment as a key factor in the process of empowerment and inclusion into society, and the role of interventions to improve labour market outcomes for disabled people is receiving increased international attention. It is therefore both vital and timely to increase understanding of the impacts of available programmes, in order to ensure that they are effective in delivering positive outcomes for people with disabilities and provide value for money. Although several reviews have attempted to summarise the existing research in this area, there are a number of substantive and methodological limitations to these reviews. Thus, there is a need to systematically examine the evidence base to provide an overview of the types of interventions being used to improve employment outcomes, to identify those that are effective and ineffective, and to identify areas in which more research needs to be conducted. OBJECTIVES • To describe the range and diversity of interventions available for addressing the low labour market participation of adults with physical and/or sensory disabilities in developing country contexts. • To systematically identify, assess, and synthesise the evidence on the effects of interventions on labour market outcomes for disabled adults in low‐ and middle‐income countries. As part of this, to critically analyse the evidence along the causal chain framework, linking interventions with intermediate outcomes and final impacts, and document the level/strength of evidence on potential pathways of impact using the framework. • To assess if effects are moderated by characteristics of the participants, interventions, and/or settings. • To provide an explanation for the intervention effects by examining what participants in the included studies reported about why the interventions did, or did not, work for them. SELECTION CRITERIA To be included in the review, studies were required to meet several eligibility criteria. First, studies must have evaluated an intervention with the means to improve the labour market situation of adults with disabilities. Such interventions could take the form of a device, policy, programme, strategy, or other type of action. Second, studies must have investigated outcomes for adults aged 16‐65 years with physical and/or sensory impairments associated with disability. Third, the study setting must have been a low‐or middle‐income country (LMIC). Fourth, studies must have utilised one of the following: (a) randomised experimental design, (b) rigorous quasi‐experimental design that used robust methods for removing biases due to non‐random assignment of treatment, or (c) quasi‐experimental design that used less rigorous methods for constructing the counterfactual, including uncontrolled studies. Fifth, studies must have reported at least one quantitative employment‐related outcome variable. Sixth, the date of publication or reporting of the study must have been within the period 1 January 1990 to 31 December 2013. Finally, no language or form of publication restrictions was applied. SEARCH STRATEGY A systematic and comprehensive search was used to locate both published and unpublished studies. Ten major bibliographic databases were electronically searched, along with 32 specialist databases and library catalogues, and 59 websites of relevant organisations. Six journals were manually searched and search engines used. The reference lists of previous reviews and included studies were examined, and forward citation checking exercises were conducted. Finally, information was requested from authors of included studies and other relevant stakeholders. DATA COLLECTION AND ANALYSIS Each study was subject to a rigorous process of data extraction and quality assessment, conducted independently by pairs of reviewers using a coding tool specifically designed for this review. Descriptive analysis was undertaken to examine and describe data related to the characteristics of the included studies and interventions. The findings from the included studies were combined descriptively using a narrative approach to synthesis. RESULTS The literature search yielded a total of 20,417 potentially relevant reports, 479 of which were retrieved for full‐text screening. A total of 14 studies met the eligibility criteria. Publication dates of included studies ranged between 1992 and 2012, with six studies published in the four‐year period 2010‐2013. Studies were conducted in nine different LMICs in Asia, Africa and Latin America: Bangladesh (three studies); Brazil (two studies); China (one study); India (four studies); Kenya (one study); Nigeria (one study); Philippines (one study); Vietnam (one study) and Zimbabwe (one study). The majority of studies examined outcomes for adults with physical impairments. There was variation in sample sizes. One study had a sample size greater than 500 participants, the sample size was between 251 and 500 in three studies, and the remaining ten studies had a sample size of less than 250. Different methodologies were employed to construct the counterfactual and evaluate the impacts of the interventions. The majority were uncontrolled before‐and‐after studies. One quasi‐experiment (ex‐post) utilised propensity score matching techniques and one study applied logistic regression to pre‐test/post‐test data. The remaining studies used a non‐equivalent groups design. All 14 studies were assessed as high risk of bias. The 14 studies examined 15 different interventions grouped as follows: treatment & therapy (four interventions); assistive devices and accommodations (two interventions); occupational rehabilitation services (four interventions); financial services (one intervention); and community‐based rehabilitation (four interventions). Thirteen were multi‐component programmes. All 15 interventions were targeted at people with disabilities, with some designed for people with a specific impairment or diagnosis. Six interventions targeted persons with specific types of physical impairment, and a further two interventions were available to adults with any type of physical impairment. Three interventions were targeted at persons with visual impairments. Finally, four interventions were available to persons with any/multiple impairments. Non‐governmental organisations (NGOs) were the most common source of funding. The main aim of eight interventions was to improve employment prospects for persons with disabilities. The other interventions sought improvements in a wider range of outcomes. The interventions were designed and implemented on different scales, with the majority available over a large geographical area, such as one or more districts, provinces or regions. Information about duration of the interventions was often not reported, but typically they were available for periods of less than six months. All 14 studies measured relevant labour market outcomes and assessed the following impacts: motivation to work (one study); professional social skills (one study); employment participation (12 studies); self‐employment (two studies); income (four studies) and hours worked (one study). Five studies measured additional outcomes: health‐related outcome (four studies); social outcomes (five studies); and empowerment‐related outcome (one study). Several studies relied solely on self‐reported outcome data. The majority of study reports did not provide clear information about the timing of outcome measurement. Only one study examined longer‐term outcomes, evaluating impacts after two and four years of participants entering the programme. In all 14 studies, the direction of effect was positive for the outcome variables measured. Five studies reported results of tests for statistical significance and indicated study findings were significant. Effects on motivation to work. One study measured this outcome. It investigated two interventions for visually impaired students. Effects on professional social skills. One study measured this outcome. It assessed a programme for persons with any type of physical impairment. Effects on paid employment. Twelve studies measured this outcome. Of these, seven studies evaluated different types of support for persons with physical disabilities, with five designed for people with a specific diagnosis or impairment. One study investigated an intervention for the visually impaired. The remaining four studies in this category evaluated interventions that were open to individuals with any/multiple types of impairments. Effects on self‐employment. Two studies measured this outcome. Both studies evaluated interventions available to persons with any type of physical impairment. Effects on income. Four studies measured this outcome. Of these, three studies evaluated interventions designed for persons with physical disabilities. The remaining study focused on an intervention for the visually impaired. Effects on hours worked. One study measured this outcome. It evaluated a programme for persons with any type of physical impairment. Seven of the 14 included studies explored variation in treatment effects. The variables considered were gender (three studies), participants' size of business (one study), impairment severity (one study), type of intervention (one study), and duration of follow‐up (two studies). Four of the seven studies tested whether results were statistically significant. Overall, these seven studies were not sufficiently similar to detect meaningful differences in outcomes. Two studies investigating occupational rehabilitation services reported participants' observations, experiences and views about why the intervention they received had worked for them. The following factors were cited: general health & well‐being; cooperation in the family/community; motivation; attitudes in the workplace; attitudes in the community; and appropriateness of the training. Three studies reported participants' observations, experiences and views about why the intervention they received had not worked for them. Two examined occupational rehabilitation services and the other evaluated the provision of free wheelchairs. The following barriers to the success of the interventions were cited: discriminatory attitudes of prospective employers; attitudes of family members and/or wider community; health and well‐being; physical inaccessibility (workplace and/or broader environment); lack of ‘start‐up’ funds for self‐employment; shortcomings of the training (i.e., mismatch between it and participant's skills, abilities and financial resources); lack of education and skills; and motivation. AUTHORS' CONCLUSIONS A key finding of this review is the overall scarcity of robust evidence, as indicated by the relatively few studies that met the inclusion criteria. Although the evidence in general showed positive results, we need to be wary of drawing strong inferences from the findings of this body of literature. Not only is the number of impact evaluations limited, but most used designs in which conclusively attributing causality is not possible. Our assessment of the evidence does not allow us to develop practical suggestions on what interventions are likely to work, for whom, and when. Clearly, there is an urgent need for investment in high quality impact evaluations of interventions to support people with disabilities in accessing the labour market in low‐ and middle‐income settings. To build the evidence base further, it is therefore important that many more of the interventions currently in existence in low‐ and middle‐income countries are rigorously evaluated, and the results are reported and disseminated widely. The methodological inconsistencies and weaknesses of the current evidence base, and specific knowledge gaps, suggest a number of future research priorities.
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A wide variety of very different and complementary approaches are taken in developing countries, such as India, to adequately respond to the needs of persons with disabilities. CBR programmes are considered fundamental for improving the well-being of persons with disabilities, and for fostering their participation in the community and society at large (Cornielje, 2009; Sharma, 2007). CBR programmes are also considered, in theory, to be the most cost effective approach to improving the well-being of persons with disabilities, in comparison with care in hospitals or rehabilitation centres (Mitchell, 1999). The original CBR strategy was to promote the use of effective locally developed technologies to prevent disability, and transfer knowledge and skills about disability and rehabilitation to persons with disabilities, their families and the community at large (WHO, 1976). However, more than three decades later, there is little literature providing evaluations of the impact of CBR programmes on the well-being of persons with disabilities. This can partially be explained by a tendency to concentrate resources on the implementation of CBR rather than on research and evaluation. Within the CBR literature which does exist, there are many identified gaps that pertain to the substantive issues this research seeks to address. Firstly, there are still no universally agreed criteria for the evaluation of CBR programmes (Cornielje, Velema, and Finkenfugel, 2008). Secondly, there is little research available on the effective participation of persons with disabilities, families and communities in CBR. There is therefore little evidence to address the criticism that many CBR programmes are managed using a “top-down” approach, and do not effectively engage with persons with disabilities or their organizations. Our research project aims to contribute towards filling this gap, using an original methodology — capabilities based on a potential outcomes framework — based on different measurement tools which explore various facets of the programmes’ impact. This project is timely as the WHO is collecting information about CBR in order to test their new version of the Community Based Rehabilitation manual (published at the end of 2010). This information will also address the need for more knowledge about how to effectively ensure equal opportunities for persons with disabilities, as emphasized by the UN Convention of the Rights of Persons with Disabilities (2006). In particular, our research assesses the impact of the CBR approach on the lives of persons with disabilities and their communities in two CBR projects covering the Mandya district and neighbouring areas of Ramanagaram district in South Karnataka State in India. The overall Research Initiative called S-PARK/CBR (Samagama Participatory Action Research and Knowledge in Community Based Rehabilitation) is organized in three main phases, which are partly consecutive and partly parallel: Phase 1: Quantitative research based on a large-scale survey of persons with disabilities and some key stakeholders in the areas covered by CBR and in control areas. The present volume reports on this phase of research. Phase 2: Emancipatory research focusing on the mapping of different barriers faced by persons with disabilities in the communities, their strategies for overcoming these barriers and the part played by the CBR programme. This research is conducted by representatives of persons with disabilities from Mandya district with support from a scientific advisory group. Phase 3: Participatory research for in-depth understanding of key issues emerging from the first two phases of the research through the introduction of emancipatory research approach in routine CBR activities of the two projects. Main conclusions In particular, this volume focusing on Phase 1 presents the three main paths that were investigated during the large-scale survey and their main conclusions. The research obtained relevant results for the literature, and these are detailed in the following chapters of this volume. Firstly, the research aimed to understand and measure the overall role and impact of CBR in improving the quality of life of persons with different types of impairments, as well as different demographic, social and economic backgrounds. Quality of life is determined in the capability approach framework by the freedom of people to do and to be what they value (Sen, 1999). Therefore, we investigated the effectiveness of CBR programmes in improving the control that persons with disabilities have over their daily lives, participating in different aspects of community life (i.e. combating stigma and prejudice), and accessing various services, over the five domains of the CBR matrix (health, education, livelihood, social and empowerment). Furthermore, we examined to what extent persons with disabilities involved in the CBR programmes are improving their socio-economic conditions, and therefore escaping from multidimensional poverty (Sen, 1992). We found that the CBR programmes have rather a positive impact on the well-being of persons with disabilities in the examined district in most areas of intervention: health, education, livelihoods (including opportunity for employment), disability rights, and social participation. It is also relevant to notice that the findings show that participation in CBR has an impact in terms of changing mentalities and fighting prejudice and exclusion. Secondly, we investigated the factors which constitute barriers to access CBR activities and support. The research should highlight whether the CBR programmes are completely inclusive of all groups of individuals with disabilities. The results on the CBR coverage are very relevant since they disentangle the question of inclusion and access to CBR activities. Almost 60% of persons with disability are part of CBR. Furthermore the persons who are not part of CBR are less poor, have more mild disabilities and are older. Thirdly we tried to capture spillover effects of CBR – i.e. if in the area of CBR activities there is an effect on the well-being of other persons from the community, such as the caregivers, and on the community social environment through the heads of villages, social workers and teachers. We found evidence of spillover effects in the community of the area of CBR both at village level and for individuals such as the caregivers
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