Disability and the Majority World
Towards a Global Disability Studies
The 1st International Conference
Impact of Community-Based Rehabilitation (CBR) programs
in Mandya district (Karnataka, India)
Jean-Francois Trani, Vincenzo Mauro
Mario Biggeri, Jayanth Kumar, Parthipan Ramasami, Jayanth Kumar, Parul
Bakhshi, Sunil Deepak and Ramesh Gariyappa
Background: disabilities and CBR
 Disability: different models and different strategies
 Initial view of CBR linked with Primary Health Care
cheaper, simpler, community level interventions
 Relevance for WHO strategy in countries such as India
 Side-effects – empowerment, organizations of persons
with disabilities, advocacy, laws, leisure, sports
 CBR Matrix (WHO et al. 2010) Capability Approach
(Sen, 1999)
Advantages of CBR Programmes
 CBR programmes are considered fundamental to
improve the wellbeing of people with disabilities, and for
fostering their participation in the community and society
at large (Cornielje, 2009; Sharma, 2007).
 CBR programmes are also considered to be the most
cost-effective approach to improve the wellbeing of
people with disabilities, in comparison with care in
hospitals or rehabilitation centres (Mitchell, 1999).
Evidence?
 little literature providing knowledge-based evaluation of
the impact of CBR programmes on the well-being of
people with disabilities
 tendency to concentrate limited resources on the
implementation of CBR rather than on research and
evaluation about it
 No universally agreed criteria for the evaluation of CBR
programmes (Finkenfugel, Cornielje and Velema, 2007;
Alavi and Kuper, 2010).
 NB: Very little research available on the effective
participation of people with disabilities, families and
communities in CBR.
Limited literature
 Alavi and Kuper (2010) identify a total of 51 studies
evaluating the impact of rehabilitation for people with
disabilities in Africa, Asia and Latin America (only two of
these studies evaluating CBR programmes or services
used a comparison group)
 Worldwide survey of researches and methods: literature
is limited especially from an overall impact point of view.
(WHO et al. 2010)
Table 9.1. Re-framing the disability models through the capability approach for policy implementation - the data information matrix
CAPABILITIES INFORMATIONAL SPACE
Individual conversion
factors
Means
(commodities,
Achieved
resources,
functionings
Agency
Choices
technology)
Are you able
Do you have
Are you now Is…. Important to change
Are you
enough money
enjoying….?/sc to have for
willing to
your….?/
to buy
1) Life and physical health
ore^
you?/score*
have…?/ 0/1 drugs?/0/1 **
score~
Examples of
dimensions/capabilies
and functionings
Capabilities
relevance for
the group
Household/family level
conversion factors
Community Level
Personal
Impediment
Means
(commodities,
resources,
technology)
Means
(commodities,
resources,
Community
technology) Impediment
Family
Impediment
0/1 **
0/1 **
0/1 **
0/1 **
State/Regional level
Means
(commodities,
resources,
technology)
State/ Regiona
Impediment
0/1 **
0/1 **
0/1 **
2) Love and care
score^
score*
score~
0/1
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
3) Mental well-being
score^
score*
score~
0/1
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
4) Bodily integrity and
safety
score^
score*
score~
0/1
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
5) Social relations
6) Participation /
information
score^
score*
score~
0/1
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
score^
score*
score~
0/1
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
7) Education
score^
score*
score~
0/1
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
7a Learning to know
score^
score*
score~
0/1
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
7b Learning to be
7c Learning to live
together
score^
score*
score~
0/1
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
score^
score*
score~
0/1
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
7d Learning to do
score^
score*
score~
0/1
0/1 **
Do you have
books to learn at
school? 0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
8) Freedom from economic
and non-economic
exploitation
score^
score*
score~
0/1
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
9) Shelter and environment
score^
score*
score~
0/1
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
10) Leisure activities
score^
score*
score~
0/1
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
11) Respect
score^
score*
score~
0/1
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
12) Religion and identity
score^
score*
score~
0/1
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
13) Time autonomy and
undertake projects
score^
score*
score~
0/1
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
14) Mobility
score^
score*
score~
0/1
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
Others dimensions
score^
score*
score~
0/1
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
0/1 **
Note that for relevant dimensions it is fundamental to dettail them in sub-dimensions. * score is given on a scale of measurement of importance of each capability dimension for the respondent ^ score is given on a scale of measurement of achieveme
functionings for each capability dimension for the respondent ~ score is given on a scale of measurement of the level of sgency to change the achievement functionings for each capability dimension for the respondent Note: ‘Internal’ factors, such as person
characteristics (e.g. physical conditions, sex, skills, talents, intelligence, sensitivity, interaction attitude), convert resources (or commodities) into individual functionings. The conversion is also related to ‘external’ factors such as social characteristics (e.g. publ
policies, institutions, legal rules, traditions, social norms, discriminating practices, gender roles, societal hierarchies, power relations, public goods) and environmental endowments (e.g. infrastructure, country, public infrastructure, climate, pollution).
CBR programmes in Mandya and Ramanagar districts
- Karnataka State, India – AIFO
The CBR project managed by SRMAB (Sri Raman
Maharishi Academy for Blind) called Malavalli Project was
initiated in 1997 in 25 villages, now about 1300 villages
spread over 5 taluks (sub-districts) with around 11,000
persons with disabilities belonging to all the different groups
of disabilities.
The CBR project managed by MOB (Maria Olivia Bonaldo)
called Mandya Project was initiated in 1998 in 4 villages, now
1200 villages spread over 4 sub-districts and reaches about
9,000 persons with disabilities.
Sampling design
Two-stage Cluster Sampling:
 First stage units: Villages
 Second stage units: PwD within the selected village
Sampling scheme
This design allows to collect more information: data are
readily available
Drawback of Cluster Sampling: generally it is less efficient
if the clusters are not similar + cluster effect.
Solution: using available information to stratify the villages
and improve efficiency
The more information available, the better the sampling
scheme.
Sampling scheme
3 variables chosen for stratification of first stage
units:
Size of the Village (more/less than 1,000 units)
Geographical position
Year the CBR started
Sampling scheme
Total: 9x2x10=180
25 non-empty strata
Sample size
CBR areas
= treated villages
Statistical Framework
A useful statistical framework for Causal Inference
is the one based on Potential Outcomes.
Based on the work on randomized experiments by
Fisher (1918 and later) and Neyman (1923), extended
by Rubin (1974 and later) and subsequently by others
to apply to non-randomized studies and other forms
of inference.
This perspective is called “Rubin’s Causal Model”
(RCM, Holland, 1986)
Statistical Framework
We assume that people joining and not joining the program can
be systematically different, but that we can control for this effect
using a set of variables available for both groups. This assumption
(namely “unconfoundedness”) requires that all variables
(covariates) that could influence both outcome and the probability
of participating in the CBR are observed.
Rosenbaum and Rubin (1983) developed the “propensity score”
methodology. The propensity score is defined as the probability of
a unit (e.g., a PwD) being assigned to a treatment (e.g. be part of
the CBR program)
the conditional probability, for a PwD, of joining the program
Outcomes
The outcome variables analyzed are related to four (out of five) CBR
matrix components and to the related capabilities:
Health
- Do you have or have you received any mobility aid or an appliance?
Livelihood
- Do you have a job/work for which you earn money?
- Do you receive any pension or allowance?
Social
- Does your family consider your views in taking decisions?
Empowerment and dignity
- Can you express your views and participate in the family decisions?
Some results..
Health: Do you have or have you received any mobility aid or an
appliance?
In the propensity score analysis we selected only the large subgroup of
people who declared in 2002 not to have any mobility aid or an appliance
After 2 years
After 4 years
N. treated
N. controlled
Effect
St. dev
t
870
138
0.061
0.019
3.145
N. treated
N.
controlled
Effect
St. dev
t
870
379
0.054
0.011
4.826
CBR programme has a significant effect (after four years as well as after two
years) on reducing the negative impact of impairment and functionings
Some results..
Livelihood: Do you have a job/work for which you earn money?
N. treated
N.
controlled
Effect
St. dev
t
326
63
0.022
0.032
0.706
CBR programme doesn’t have a significant effect on employment after two
years of implementation
N. treated
N.
controlled
Effect
St. dev
t
326
135
0.128
0.019
6.886
Yet, after 4 years CBR has a high impact on the opportunity of people with
disabilities to find a job/work (for those who had not it four years before)
Some results..
Livelihood: Do you receive any pension or allowance?
N.
N. treated controlled
457
60
Effect
St. dev
t
-0.008
0.101
-0.075
Propensity score analysis propensity shows an impact of the CBR
programmes very close to zero after two years
N. treated
N.
controlled
Effect
St. dev
t
487
272
0.328
0.029
11.272
After 4 years, the propensity score matching that confirms a 32% difference
(p<0.001)
Some results..
Social participation: Does your family consider your views in
taking decisions?
N. treated
N.
controlled
Effect
St. dev
t
953
139
0.047
0.015
3.128
After 2 years, We observed better results for people with disabilities
participating in the CBR programme: in almost 5% of cases, they improve their
capacity to express opinions and take decisions, while this is observed in only
1% of the control group.
N. treated
N.
controlled
Effect
St. dev
t
953
304
0.068
0.012
5.616
After 4 years, capacity to express opinions and take decisions improve by 7%
(did not change significantly for control)
Some results..
Empowerment and dignity: Can you express your views and
participate in the community decisions?
N. treated
N.
controlled
Effect
St. dev
t
953
131
0.042
0.013
3.181
After 2 years, participating in the CBR programme has a positive effect on the
possibility to express one’s view.
N. treated
N.
controlled
Effect
St. dev
t
953
304
0.057
0.013
4.282
After 4 years, participating in the CBR programme has a even higher positive
effect on the possibility to express one’s view.
Conclusions
There are still no universally agreed criteria for the
evaluation of CBR programmes (Finkenfugel et al., 2007)
Evaluation through a technique based:
• methodologically on propensity score matching
• and theoretically both on the capability approach and
CBR matrix (health, education, work, empowerment and
social participation).
Conclusions
Our results show that CBR programs have an overall
positive and significant impact on the health, livelihood,
social participation and empowerment of participants with
disabilities, especially after four years of CBR activities.
In a capability approach perspective, this signifies an
increase in opportunities for people with disabilities to
conduct the life they value which includes dignity, respect
and social participation.
Further research
More components analyzed (education, etc.)
Impact evaluation of indirect effects
Sensitivity analysis
Continuous (non-binary) treatment
Thanks for your attention !
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