The Impact of a Community Based Rehabilitation Program in Afghanistan: A Longitudinal Analysis Using Propensity Score Matching and Difference in Difference Analysis

Abstract

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.