Implementation of disability policy framework in Namibia: A qualitative study.

This article explores some of the implications of a non-governmental organisation (NGO) initiated community-based rehabilitation (CBR) programme, for HIV-related task-shifting programmes which have been recommended by the World Health Organisation (WHO) as an important aspect of HIV prevention, treatment and care programmes. The CBR programme is run by multi-skilled community rehabilitation facilitators (CRFs) in a low income, rural context in KwaZulu-Natal, South Africa, and explicitly recognises the multiple facets of disability. As such, the programme focuses on both the physical and social aspects of living with disabilities. A qualitative approach was used to conduct this study, and semi-structured interviews were conducted with beneficiaries of the programme (n == 35), home and community-based care givers (HCBCs) (n == 13), and managers (n == 2). A focus group discussion was conducted with CRFs (n == 5). We found that the CBR programme successfully delivered rehabilitation services at a community level and that multi-skilled CRFs are an effective means of implementing CBR programmes in low-income rural areas. The developmental focus of the programme created a range of benefits for people with disabilities, including: physical rehabilitation, emotional support and counselling, access to grants, social inclusion and accessing assistive devices. Central to the programme's success was the maintenance of relationships and partnerships at different levels in the community, these included relationships between HCBCs and CRFs, between CRFs and therapists, and between the NGO and the various participants in the programme. However, the NGO struggled to maintain a partnership with the relevant government departments and this had important implications for the programmes sustainability. In conclusion, we argue that this programme's use of multi-skilled mid-level workers who have undergone effective training programmes in CBR demonstrates that a wide range of rehabilitation activities can be effectively undertaken at a community level, and that this programme provides an important example of how the WHO's task-shifting guidelines for HIV treatment, care and prevention can be implemented.

PurposeQualitative participatory methods are needed to measure the effectiveness of the community-based rehabilitation (CBR) program in Namibia. The study explored the experiences of CBR volunteers in evaluating CBR program in Namibia through the use of photovoice. Further the study assessed the strengths and limitations of utilizing photovoice method as an assessment tool for CBR evaluation.Design/methodology/approachThe study employed a qualitative, explorative, descriptive and contextual design. Data was collected through the photovoice method. Two CBR sites and 16 participants who were CBR volunteers were purposively selected. Data was collected and analysis was conducted simultaneously utilizing the photovoice method and themes were determined using WHO CBR matrix.FindingsVarious experiences were elicited regarding participants' experiences in line with the five components of the CBR matrix. Most experiences were reported regarding the health component, and the education component had the least experiences reported. Methodological strength and weaknesses as well as implications for practice are revealed. Further research can explore the benefits of combining photovoice with other data collection methods.Research limitations/implicationsThe use of purposive sampling in selecting both CBR sites and participants limited wider representation of CBR program sites and persons with all disabilities in Namibia, respectively.Originality/valueSustainability of CBR programs depends on community ownership, empowerment and government funding. Photovoice is participatory and hence gives community ownership and empowerment. Evidence from photovoice can enable persons with disabilities to formulate action plans that can advocate their concerns with policymakers and justify more funding for CBR programs.

Introduction: There has not been agreement within the Health Care Services regarding the role of Community Based Rehabilitation (CBR) workers. The training of CBR workers continues although the process was not widely supported and the CBR worker’s function has not been clarified yet CBR programmes are included in the training of students.Aim: The aim is to identify and describe the role of the CBR workers within the Odi District Health Service (DHS) and determine whether they are fulfilling the rehabilitation arid development functions envisaged by the WHO model of CBR programmes.Methodology: Qualitative and quantitative research methods were used. These included a questionnaire; observations of the daily tasks of the CBR workers and interviews with members of the District Health Service (DHS) of the Odi district, clients and CBR workers. Open and axial coding were used in data analyses. Data from the different sources were triangulated to ensure trustworthiness.Results: The skills performed by CBR workers have produced a change in the lifestyle of the disabled people and the initiated projects are benefiting the families of the disabled people within the CBR programme as well as their community. There seems to be a break down of communication between the District Health Manager (DHM) and the supervisor of the CBR workers. A lack of communication within the DHS affects the functions of the CBR workers.Conclusion: It is concluded that, although the tasks of the CBR workers within the Odi DHS are not supported, they produce a positive impact on the quality of life of the disabled within the CBR programme. The CBR workers’ contribution towards community development, although on a small scale, proves that they operate within the World Health Organization’s (WHO) guidelines for CBR.

PROTOCOL: Community‐Based Rehabilitation for People with Disabilities in Low‐ and Middle‐Income Countries

Background: 
\nCommunity Based Rehabilitation (CBR) is the strategy promoted by the World Health Organization (WHO) and other United Nations (UN) agencies as an effective way to improve the lives and wellbeing of people with disabilities in underserved regions. During the last decade CBR has undergone major reconceptualization, and is now a multi-sectorial approach, as reflected in the new CBR guidelines. Evaluation of Community-based Rehabilitation (CBR) is considered important for developing good practice. However, evaluations remain scarce and as a consequence very little is known about how CBR benefits persons with disabilities and their families. Consensus is lacking about appropriate evaluation methods in CBR.
\nLeading international frameworks such as the United Nations Convention on the Rights of Persons with Disabilities (CRPD) and the WHO CBR Guidelines have participation as one of the core principles in their human rights based approach to disability, including participation in programme evaluation. The WHO CBR Guidelines strongly recommend the application of participatory evaluation (PE) approaches in CBR. However, while there are many models of PE in mainstream development, it is unclear which may be appropriate for use in CBR.
\nThe aim of this research is to identify, field test, adapt and assess an existing model of Participatory Evaluation (PE) in a real world environment. This thesis, rather than researching the impact of CBR on people with disabilities, focuses on the evaluation process itself and the variables that affect changes in stakeholders thinking and behavior as a result of engagement in the evaluation.
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\nMethodology
\nThere were two research components:
\n1. Selection of PE model to be adapted to CBR:
\nThree steps were taken to provide background for an expert group to select one model for field-testing: 
\nAn online survey of current evaluation capacities and practices within CBR programmes internationally; 
\nA systematic review of PE models used in international development; 
\nA Delphi study with CBR experts to derive criteria for good PE models for CBR.
\nThe expert group used the research findings and selected Outcome Mapping (OM) as PE model to be implemented and field-tested in a CBR programme in Jamaica.
\n2. Field testing of the PE model in a Jamaican CBR programme: This research component consisted of three main elements:
\nThe implementation and adaptation of PE (OM) in a Jamaican CBR Programme;
\nInterviews and focus groups collecting narratives about the evaluation process from stakeholders were undertaken to explore the usability of the adapted PE model in this programme. Changes in “process use”, i.e. how the stakeholders in the evaluation learned from and acted upon their involvement in the PE processes, were explored; 
\nThe participatory development of a framework that participants felt could guide PE in CBR, one that can be locally adapted to different situations.
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\nConclusion: 
\nThe evaluation participants felt there were significant limitations of the OM approach in their setting and therefore proposed a substantially modified model. They favored a more fluid PE framework, which was flexible, adaptive and iterative, rather than a rigid approach, and one that focused on creating a safe space for sharing, learning and taking action. The thesis concludes with a call for more critical and bottom-up approaches of evaluation that move away from control-oriented approaches towards a more experimental and adaptive problem and process-orientated mindset of evaluative thinking.

BackgroundIrrespective of the severity, survival of a stroke has become commonplace, but many experience long-term physical, cognitive, and emotional difficulties, with walking difficulties being a frequent challenge. The community-based model of gait training is an innovative and holistic approach to neurorehabilitation that focuses on restoring mobility and enhancing the overall quality of life of stroke survivors.AimsTo assess the impact of community-based stroke rehabilitation programs from existing literatures.ObjectivesTo identify community-based stroke rehabilitation programs that are effective in improving function in stroke survivors.MethodsWe conducted a scoping review of peer-reviewed articles to understand the impact of the community-based rehabilitation model of mobility training after stroke. We searched five different databases: PsycINFO, PubMed, CINAHL complete, Embase, and SCOPUS using topic-specific keywords. Only studies published in the English language from 2013 to 2023 were included.ResultsThirty-five articles met the inclusion criteria. Mobility training using either a treadmill or overground surfaces improved mobility. Orthotics use improved gait and balance among stroke survivors. Adapted video games for rehabilitation improved gait speed, balance, and mobility while the use of transcutaneous electrical nerve stimulation (TENS) aided functional recovery. The use of music or sound incorporated with exercises improved mobility, gait speed, and balance. Engaging in group exercises improved walking capacity, balance, walking speed, cardiovascular function, and community integration.ConclusionSome community-based rehabilitation programs are effective in improving the physical and social recovery of stroke survivors. This concept can be considered when planning a recovery program for stroke survivors who do not have the ability to access a hospital rehabilitation setting.

Purpose: To examine community perspectives regarding the strengths, weaknesses, opportunities, and threats of a community-based rehabilitation (CBR) program in Toledo District, Belize.Method: A participatory approach was implemented using the CBR Matrix as a conceptual framework. Semi-structured interviews were conducted with CBR community partners and program participants living in Toledo District. Respondents were recruited until thematic saturation was achieved (i.e., no new themes were identified from subsequent interviews). Interviews were recorded and transcribed verbatim. Recurring themes were identified using thematic content analysis.Results: Eight CBR community partners and 11 program participants completed interviews. Key strengths of the program included engaging CBR program participants as partners in the decision-making process and raising disability awareness. Key weaknesses of the program included lack of a vocational training program and lack of a systematic approach to identify people with disabilities (PWD) or risk factors for disease and disability.Conclusions: This participatory evaluation provided PWD, their families, and the community the opportunity to express their needs and priorities regarding CBR. Key recommendations included: (1) developing vocational training programs for PWD; (2) expanding collaborations with craftspeople and other community partners throughout Toledo District; (3) continuing the disability awareness program in schools and the broader community; and (4) strengthening community outreach and data collection.Implications for RehabilitationPersons with disabilities, their families, and community partners should play an active role in the development, implementation, and evaluation of CBR programs to ensure program goals align with community priorities.The CBR evaluation process should strive to include diverse perspectives that represent the most marginalized populations (e.g., individuals with significant disabilities living in geographically remote areas).The CBR matrix can provide a comprehensive and flexible framework with which to examine community perspectives regarding the strengths, weaknesses, opportunities, and threats of CBR programs.

This case study examines local resources of disabled people at the individual and social levels in a rural area. The research was conducted in the model administrative division of the national community-based rehabilitation (CBR) programme in Sri Lanka. In this division, the programme began in 1998, and international volunteers started support activities in 2007. The author applied action research after commencing work as a social worker in the local government office in February 2013. Data were based on social work practice in the field level: assessment, planning, implementing and monitoring. This study used data from semi-structured interviews with disabled people, interviews with a social services officer, documents relevant to CBR, and the author's field notes. Data were analyzed with qualitative procedure. The findings suggest that living conditions of disabled people have improved through the development of community workshops and other local resources since 2009. Using interview data, the study reveals individual level elements at each stage: infancy, school age, after school age, turning points and after participation. The significant elements are meeting with a key person and being linked to local resources, developing social support network, and increasing income. The analysis also indicates that the division's CBR programme encounters the challenges: the right to receive education, information sharing and networking, the variety of local resources, sustainable activities, empowerment and leadership, and capacity building. Finally, we discuss implications of these findings and show a new action plan based on the results.

BackgroundThe 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.MethodsWe 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.ResultsThree 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]).ConclusionsOur 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 registrationISRCTN, ISRCTN50214054. Registered August 5th 2020 - retrospectively registered

Today there are Community-based Rehabilitation (CBR) programmes in a large number of countries. In many countries, the CBR approach is a part of the national rehabilitation services. However, there is a lack of reliable data about persons with disabilities who benefit from CBR and the kind of benefits they receive. This article reviews the disability data collection systems and presents some case studies to understand the influence of operational factors on data collection in the CBR programmes. The review shows that most CBR programmes use a variable number of broad functional categories to collect information about persons with disabilities, combined occasionally with more specific diagnostic categories. This categorisation is influenced by local contexts and operational factors, including the limitations of human and material resources available for its implementation, making it difficult to have comparable CBR data. Therefore, any strategies to strengthen the data collection in CBR programmes must take these operational factors into account.

BackgroundThis study examined community-based rehabilitation (CBR) practice in China on the basis of the development of an evaluation system using current evidence in a real context.MethodsA multiple embedded case study design was used to interpret both quantitative and qualitative data. In Part 1, a thematic analysis was conducted to identify the different levels of evidence available in CBR programs in China. Identified themes were then associated with the literature to form a system to code, categorise, and rank the obtained evidence. In Part 2, CBR practice was examined in 12 CBR programs by using the developed evaluation system with the CBR matrix and CBR framework.ResultsSix themes under three categorised levels of evidence for demonstrating quality of practice were found. An evaluation system of program practice, based on existing standards to define levels of evidence, was created and used with the CBR matrix and CBR framework to evaluate the quality of practice in 12 CBR programs. The results of a within-case analysis revealed the strengths and areas for improvement in each program. An across-case analysis by using identified correlations revealed the characteristics of CBR practice in China, as demonstrated in the interaction of core CBR components. The content elements of CBR programs were significantly correlated with health outcomes, social development, education, and empowerment. Empowerment was significantly correlated with participant governance and community ownership.ConclusionThe proposed evaluation system, as developed in a real context, is feasible for monitoring and identifying the strengths of and areas for improvement in CBR programs. This study described the characteristics and interaction of different CBR components in CBR practice in China and is pertinent for enhancing the evidence-based practices and quality of CBR programs in China.

Since the promulgation and implementation of a new anti-drug law in 2008, the Chinese central government has encouraged local governments to carry out community-based drug rehabilitation programmes. This study explores the association between community-based drug rehabilitation programmes and drug users' physical and mental health. This study collected data between October 2018 and February 2019 from a community-based rehabilitation programme in a community in Foshan Municipality in Guangdong Province of China. A total of 162 drug users participating in a community-based drug rehabilitation program were selected to complete a self-administered and anonymous questionnaire. A cover letter interpreting the purpose of the study and a self-administered questionnaire was provided to the drug users. Ethics approval for this study was obtained from the Academic Committee of School of Public Administration, JiNan University, Guangzhou, China. All participants gave verbal informed consent. Four multiple linear regression models were used to explain social services that influence drug users' physical and mental health. The findings show that the number of service items provided by the social service organization was significantly associated with physical and mental health among drug users. Particularly, the employment assistance service influenced the drug user's physical and mental health status significantly.

Purpose: This paper proposes practice guidelines to evaluate community-based rehabilitation (CBR) programs.Method: These were developed through a rigorous three-phase research process including a literature review on good practices in CBR program evaluation, a field study during which a South Africa CBR program was evaluated, and a Delphi study to generate consensus among a highly credible panel of CBR experts from a wide range of backgrounds and geographical areas.Results: The 10 guidelines developed are summarized into a practice model highlighting key features of sound CBR program evaluation. They strongly indicate that sound CBR evaluations are those that give a voice and as much control as possible to the most affected groups, embrace the challenge of diversity, and foster use of evaluation processes and findings through a rigorous, collaborative and empowering approach.Conclusions: The practice guidelines should facilitate CBR evaluation decisions in respect to facilitating an evaluation process, using frameworks and designing methods.Implications for rehabilitationTen practice guidelines provide guidance to facilitate sound community-based rehabilitation (CBR) program evaluation decisions. Key indications of good practice include:• being as participatory and empowering as possible;• ensuring that all, including the most affected, have a real opportunity to share their thoughts;• highly considering mixed methods and participatory tools;• adapting to fit evaluation context, local culture and language(s);• defining evaluation questions and reporting findings using shared CBR language when possible, which the framework offered may facilitate.

BackgroundCommunity based rehabilitation (CBR) aims to promote the inclusion and participation of people with disabilities, particularly in low- and middle-income countries (LMICs). Yet people with psychosocial disabilities are often excluded from CBR programmes. The restrictive inclusion criteria used by previous reviews make it difficult to identify promising examples that could otherwise help to inform the uptake of CBR for people with psychosocial disabilities. We aim to address this gap using gold standard methods for the review and synthesis of grey literature on CBR for people with psychosocial disabilities in LMICs.MethodsOur search strategy was developed in consultation with an expert advisory group and covered seven grey literature databases, two customised Google Advanced searches, 34 targeted websites and four key reports. A single reviewer screened the search results and extracted relevant data using a standardised format based on the World Health Organisation’s CBR matrix. The included programmes were then checked by a second reviewer with experience in CBR to ensure they met the review’s criteria. A narrative synthesis with summative content analysis was performed to synthesise the findings.ResultsThe 23 CBR programmes identified for inclusion spanned 19 countries and were mostly located in either rural areas or urban areas where a large proportion of the population was living in poverty. 13 were classified as livelihood programmes, eight as empowerment programmes, seven as social programmes, seven as health programmes and four as education programmes. Only two addressed all five of these components. 12 of the included programmes reported challenges to implementation, with stigma and lack of resources emerging as two of the most prominent themes.ConclusionThis grey literature review identified several CBR programmes and synthesised key learning that would have otherwise been missed by a more traditional review of the published literature. However, as evaluation by implementing organisations is not always conducted to a high standard, the quality of this evidence is generally poor. A flexible monitoring and evaluation framework for CBR programmes could help to reduce heterogeneity in terms of the quality and content of reporting.

Background: 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 implementing the WHO CBR matrix in the context of Afghanistan is having a positive impact on those dimensions. Methods: 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 and difference in difference analysis, we estimated the impact of the CBR on various outcomes of interest, namely mobility, activities of daily living, communication, participation in social and community life, emotional well-being. Findings: There were statistically significant differences between participants and controls on all outcomes between baseline and endline, with impact ranging from the highest impact on emotional well-being (1.02, 95%CI 0.04-2.00) and the lowest impact on activities of daily living (0.08, CI 0.03-0.13). Interpretation: Our study indicates that a CBR program may provide positive rehabilitation outcomes for persons with disabilities even in a conflict context such as Afghanistan. It contributes to address the longstanding question whether CBR can actually improve overall well-being of all participants with disabilities, whatever their impairment and individual characteristics and whatever the component of the CBR matrix considered. Funding Statement: The funding source had no role in the conception and the design of the study, the data collection process, the data analysis, in the writing of the manuscript or the decision to submit it for publication. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication. Declaration of Interests: None. Ethical Approval Statement: The present study was approved by the Human Research Protection Office of Washington University in St Louis (IRB ID #:201206117) and by the Institutional Review Board of the Ministry of Public Health of Afghanistan. All human studies have been approved by the appropriate ethics committee and have therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.