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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
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]
Keywords: Capability Approach, Community Based Rehabilitation, Disability, Quasi-experiment.
Word count: 3223
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
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.
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.
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]
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
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).
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
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
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)
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
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.
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
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
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.
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.
Table 1 provides the distribution of treated and untreated groups for outcomes of interest. Table 2
reports the average treatment effect (ATT).
Table 1. Randomisation process (approximately here)
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)
St. dev
Pension & allowances
After 4 years
26.8 - 43.6
After 7 years
22.8 - 36.5
Mobility aid and appliance
After 4 years
2.3 - 7.5
After 7 years
1.4 - 7.1
Paid job/work
After 4 years
6.8 - 14.6
After 7 years
7.8 16.7
After 4 years
27.1 43.6
After 7 years
27.9 - 44.5
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)
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
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
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.
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
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 (
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)
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... Although the project was too short (and partly interrupted by the pandemic) to measure sustainable impact, several initial changes were reported. In line with a project from India, we found multidimensional positive impact on the lives of PWD and their families/caretakers [36]. Positive changes were reported in most of the domains of the CBR matrix, i.e., health, livelihood, education, social participation, with the aspect of work inclusion playing a key role. ...
... Positive changes were reported in most of the domains of the CBR matrix, i.e., health, livelihood, education, social participation, with the aspect of work inclusion playing a key role. Although access to employment through CBID programs has been poorly studied [16,36], there is evidence that interventions providing socioeconomic support through self-employment are beneficial on self-esteem, sense of autonomy and empowerment [37]. Labor inclusion can moreover decrease stigma and change attitudes towards PWD. ...
... Labor inclusion can moreover decrease stigma and change attitudes towards PWD. Inequity within the labor sector is mostly caused by negative attitudes towards PWD hampering access to jobs-particularly of women-and not related to productivity or aspects of human capital [36,38,39]. Narratives of participants indicated that changes around self-esteem and empowerment were often achieved. ...
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Background Research on the needs of people with disability is scarce, which promotes inadequate programs. Community Based Inclusive Development interventions aim to promote rights but demand a high level of community participation. This study aimed to identify prioritized needs as well as lessons learned for successful project implementation in different Latin American communities. Methods This study was based on a Community Based Inclusive Development project conducted from 2018 to 2021 led by a Columbian team in Columbia, Brazil and Bolivia. Within a sequential mixed methods design, we first retrospectively analyzed the project baseline data and then conducted Focus Group Discussions, together with ratings of community participation levels. Quantitative descriptive and between group analysis of the baseline survey were used to identify and compare sociodemographic characteristics and prioritized needs of participating communities. We conducted qualitative thematic analysis on Focus Group Discussions, using deductive main categories for triangulation: 1) prioritized needs and 2) lessons learned, with subcategories project impact, facilitators, barriers and community participation. Community participation was assessed via spidergrams. Key findings were compared with triangulation protocols. Results A total of 348 people with disability from 6 urban settings participated in the baseline survey, with a mean age of 37.6 years (SD 23.8). Out of these, 18 participated within the four Focus Group Discussions. Less than half of the survey participants were able to read and calculate (42.0%) and reported knowledge on health care routes (46.0%). Unemployment (87.9%) and inadequate housing (57.8%) were other prioritized needs across countries. Focus Group Discussions revealed needs within health, education, livelihood, social and empowerment domains. Participants highlighted positive project impact in work inclusion, self-esteem and ability for self-advocacy. Facilitators included individual leadership, community networks and previous reputation of participating organizations. Barriers against successful project implementation were inadequate contextualization, lack of resources and on-site support, mostly due to the COVID-19 pandemic. The overall level of community participation was high (mean score 4.0/5) with lower levels in Brazil (3.8/5) and Bolivia (3.2/5). Conclusion People with disability still face significant needs. Community Based Inclusive Development can initiate positive changes, but adequate contextualization and on-site support should be assured.
... 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—are frequently excluded from livelihood opportunities, including employment, social protection, and access to finance. Interventions are therefore needed to improve livelihood outcomes for people with disabilities, such as improving access to financial capital (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 disabilities result in improved livelihood outcomes in low‐ and middle‐income countries (LMIC): acquisition of skills for the workplace, access to the job market, employment in formal and informal sectors, income and earnings from work, access to financial services 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 Global Health, 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 for unpublished grey to ensure maximum coverage of unpublished literature, and reduce the potential for publication bias Selection Criteria We included all studies which reported on impact evaluations of interventions to improve livelihood outcomes for people with disabilities in LMIC. Data Collection and Analysis We used review management software EPPI Reviewer to 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, including for the confidence in study findings appraisal. Data and information were extracted regarding available characteristics of participants, intervention characteristics and control conditions, research design, sample size, risk of bias and outcomes, and results. We found that it was not possible to conduct a meta‐analysis, and generate pooled results or compare effect sizes, given the diversity of designs, methodologies, measures, and rigour across studies in this area. As such, we presented out findings narratively. Main Results Only one of the nine interventions targeted children with disabilities alone, 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 impairment group interventions targeted people with physical impairments alone. The research designs of the studies included one randomised controlled trial, one quasi‐randomised controlled trial (a randomised, posttest only study using propensity score matching (PSM), one case‐control study with PSM, four uncontrolled before and after studies, and three posttest only studies. Our confidence in the overall findings is low to medium on the basis of our appraisal of the studies. Two studies scored medium using our assessment tool, with the remaining eight scoring low on one or more item. All the included studies reported positive impacts on livelihoods outcomes. However, outcomes varied 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 for a variety of programming approaches to improve livelihood outcomes of people with disabilities in LMIC. However, given low confidence in study findings related to methodological limitations in all the included studies, positive findings must be interpreted with caution. Additional rigorous evaluations of livelihoods interventions for people with disabilities in LMIC are needed.
... 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. ...
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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.
... Gainful employment can have a significant positive impact on feelings of worth, ability, and self-determination for individuals with disabilities, as well as increasing their social and civic interaction (Morgon Banks and Polack, 2014;Heymann et al., 2014;Lamicchane, 2015;Burns and Oswald, 2014). A quasi-randomized control trial in India found that community-based rehabilitation (CBR) programmes significantly improved the well-being and access to services of people with disabilities (Mauro et al., 2014). Compared to the control group, access to pensions and allowances, aid appliances, access to paid jobs and personalpractical autonomy for the people with disabilities involved in the CBR programmes increased by 29.7 per cent, 9.4 per cent, 12.3 per cent and 36.2 per cent respectively after seven years (Mauro et al., 2014). ...
... A quasi-randomized control trial in India found that community-based rehabilitation (CBR) programmes significantly improved the well-being and access to services of people with disabilities (Mauro et al., 2014). Compared to the control group, access to pensions and allowances, aid appliances, access to paid jobs and personalpractical autonomy for the people with disabilities involved in the CBR programmes increased by 29.7 per cent, 9.4 per cent, 12.3 per cent and 36.2 per cent respectively after seven years (Mauro et al., 2014). A randomized control trial in China found that people with schizophrenia who received individualized family-based interventions worked 2.6 months more per year than those who did not receive the treatment (Morgon Banks and Polack, 2014). ...
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The growing disconnect between the improving macro-economic indicators and the growing descent into poverty of over 170 million Nigerians is clearly anindicative of the fact that economic growth in Nigeria is non-inclusive as the country may have only attained what is known as growth without development. Using a purely descriptive and analytical methodology, this paper shows that inclusive growth is the growth that generates employment opportunities and reduces the depth and severity of the incidence of poverty. However, people with disability have in many cases been denied of job opportunities in Nigeria. This paper argues that the country cannot have inclusive growth unless disability is made an integral part of her growth. Considering that the economic inclusion of people with disabilities is a cross-cutting issue, successful results require complementary activities in multiple sectors. However, inclusion of people with disabilities in work/employment can lead to greater economic self-sufficiency. Though it should not be promoted as the only option for economic inclusion, self-employment can be a good alternative, especially in a country like Nigeria where there is a general dearth of opportunities for formal sector jobs. In that regard, this paper suggests that microfinance institutions should extend credit and other financial services for self-employment of people with disabilities. Better still, specialized microfinance should be established for people with disabilities to provide supporting or complementary services.
... Fokus penelitian ini menggunakan proses pemberdayaan model EPE (Engagement-Participation-Empowerment) oleh Steiner dan Farmer (2017) dalam (Sofiah & Sunarti, 2018) (Mauro et al., 2014) di beberapa wilayah India, pelaksanaan program rehabilitasi bagi penyandang disabilitas menggunakan CBR (Community Based Rehabilitation) yang menjadi cikal bakal lahirnya program rehabilitasi melalui SWP menunjukkan dampak yang signifikan dalam meningkatkan kemandirian aktivitas kehidupan seharihari, partisipasi dalam keluarga serta masyarakat. Hal ini berkontribusi untuk mengurangi sikap stigmatisasi terhadap penyandang disabilitas dan menjadi upaya mempromosikan model pemberdayaan yang sesuai untuk penyandang disabilitas dan hak asasi manusia. ...
Balai Besar Rehabilitasi Sosial Penyandang Disabilitas Intelektual (BBRSPDI) Kartini di Temanggung bekerjasama dengan Dinas Sosial Kabupaten Magetan mengadakan program rehabilitasi sosial non-institusional bagi penyandang disabilitas intelektual, berfokus pada kegiatan ekonomi produktif untuk mencapai kemandirian serta mewujudkan lingkungan yang inklusif. Penelitian ini bertujuan untuk mendeskripsikan proses rehabilitasi sosial bagi penyandang disabilitas intelektual melalui SWP Baskara di Desa Gebyog. Fokus dalam penelitian ini menggunakan teori pemberdayaan model EPE (Engagement-Participation-Empowerment), terdiri dari empat tahap pemberdayaan yaitu (i) eksogen, (ii) eksogen dengan endogen, (iii) endogen dengan eksogen dan (iv) endogen. Data diperoleh melalui wawancara, observasi dan studi dokumentasi dari data sekunder yang berkaitan dengan topik penelitian. Analisis data dilakukan secara deskriptif kualitatif. Hasil penelitian menunjukkan, pelaksanaan rehabilitasi melalui SWP Baskara memberikan dampak positif bagi penyandang disabilitas intelektual / penerima manfaat di Desa Gebyog, baik dari segi sosial maupun ekonomi. Saran dari penelitian ini adalah perlunya pengembangan batik ciprat baik dari sisi produk maupun pemasaran guna meningkatkan daya saing. Selain itu, peningkatan aksesibilitas bagi penyandang disabilitas intelektual / penerima manfaat yang tinggal diluar Desa Gebyog juga penting dilakukan agar mereka rutin mengikuti kegiatan di SWP Baskara.
... 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.
... 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. ...
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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.
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The purpose of this study was to review Community-Based Rehabilitation (CBR) as a strategy recognized internationally to address barriers of access to equal opportunities and improvement of quality of life (QOL) for people with disabilities. The study also sought to interrogate how CBR be localized in Kenya to meet the sociocultural, health, education and economic needs of young people with visual impairment. When CBR was first developed in the 1980s, it was centered on providing access to community-level health and therapy. The World Health Organization (WHO) saw CBR as a strategy to increase access to rehabilitation services at community level for people with disabilities. However, the CBR approach has evolved into a much broader, multisectoral approach to inclusivity at community level in supporting and increasing development (WHO, 2017). Young people with disabilities in Kenya are generally not accessed equal opportunities and work participation in the community. They are marginalized owing to cultural biases and severity of disabilities which interact with such factors as gender, age and poverty.
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.
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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
Background: The prevalence of disability in India has been estimated at 1.8%; however, factors affecting the employment of persons with disability (PWD) in India have not been examined.Methods: Using nationally representative data from the National Sample Survey Organization, this paper examines factors that affect the impact of disability in terms of employment for persons with disability.Results: The extent of disability (represented by the person’s ability to perform self care activities) was lower for those from rural areas and of lower socioeconomic status. Disabled men were more likely to be employed than women (p<0.001), as were rurally resident persons with disability who were likely to be employed than their urban counterparts (p=0.009). Individuals at a lower level of monthly expenditure (suggesting a lower socio-economic status) were more likely to change or lose work due to disability but were less likely to be unemployed or unable to work due to disability.Conclusions: The data suggests that PWD have variable employment status. The data provide important information for formulating and strengthening targeted strategies to empower them.
Community-based rehabilitation (CBR) has grown and evolved over the last three decades, from being a service delivery approach for persons with disabilities living in rural areas in developing countries, to a world-wide accepted strategy and movement, based on inclusive community development principles. This article traces the origins and current understanding of CBR, goes on to discuss some of debates around the concept of CBR, and introduces the WHO CBR Guidelines. The Guidelines provide a structure for CBR planners and practitioners, based on a synthesis of CBR experiences from different regions of the world, and are an attempt to build on existing field level practice. The Guidelines demonstrate how CBR can be a useful strategy to achieve the goal of inclusive development for persons with disabilities. The Guidelines also provide a much needed framework for monitoring and evaluating CBR projects, with the increasing calls from around the world for strengthening the evidence base for CBR.
Problems involving causal inference have dogged at the heels of statistics since its earliest days. Correlation does not imply causation, and yet causal conclusions drawn from a carefully designed experiment are often valid. What can a statistical model say about causation? This question is addressed by using a particular model for causal inference (Holland and Rubin 1983; Rubin 1974) to critique the discussions of other writers on causation and causal inference. These include selected philosophers, medical researchers, statisticians, econometricians, and proponents of causal modeling.
In the AIDS Clinical Trial Group randomized trial 002 comparing the effect of high-dose versus low-dose 3-azido-3-deoxythymidine (AZT) on the survival of acquired immunodeficiency syndrome (AIDS) patients, the median survival in the low-dose arm exceeded that in the high-dose arm. But subjects in the low-dose AZT arm received significantly more prophylaxis therapy for pneumocystis carinii pneumonia (PCP), a nonrandomized treatment, than those in the high-dose AZT arm. Thus the improved median survival in the low-dose arm might represent either the benefits associated with avoiding the toxicity of high-dose AZT therapy or the benefits of receiving prophylaxis therapy. The authors use structural nested failure time (SNFT) models to estimate the survival curves that would have been observed if the PCP prophylaxis experience in the high-dose and low-dose treatment arms had been similar. Our simplest models relate a subject's observed time of death and observed prophylaxis therapy to the time that the subject would have died if prophylaxis therapy had been withheld. Conditional on certain assumptions and our model, we infer that survival in the low-dose arm would have still exceeded that in the high-dose arm even if the two arms had been given identical amounts of prophylaxis. Under the same assumptions, we also find the data are consistent with continuous prophylaxis therapy increasing survival by 16% or decreasing survival by 18% at the 95% confidence level (p = .85).