Impact of Community Based Rehabilitation Interventions in Five Districts of North West Bangladesh

Abstract

Community-based rehabilitation (CBR) is an approach to rehabilitation and disability services first advocated to the world by the World Health Organization (WHO) in the late 1970’s as an approach for low- and middle-income countries. Originally conceptualized from a medical model, CBR has evolved considerably and is more commonly practiced as a biopsychosocial intervention. The flexible, multi-sectoral nature of CBR which is often applied using different approaches adapted for diverse contexts makes comparative research challenging. Evidence for the impact of CBR is limited. Several literature reviews covering the period prior to 2002 have reported few studies and commented on the lack of quality evidence. The current study reviewed the literature from 2002 to 2017 and found that the trend is continuing with very few quality studies demonstrating the impact of CBR from the perspective of the end user. The author’s literature review used conventional quantitative criteria to assess rigour including the use of a control group, collecting baseline and follow-up data sets, and statistical significance. While some evidence for the impact of CBR was found in the health domain of the CBR matrix, evidence in other domains was very limited. The aim of this study was to assess the impact of two CBR interventions in North West Bangladesh which were managed by The Leprosy Mission. Both interventions were based on the establishment of self-help groups and emphasised social and economic aspects of CBR. Capacity development, transfer of capital via seed capital, and self-advocacy were the primary activities. The study was designed to be methodologically rigorous while not interfering with the intervention or the CBR groups. The study was designed to include samples of 500 people in each of two intervention groups and to have an additional 500 people in each of the two paired control groups, giving a total sample of 2000 people. Individuals in the control group were selected as part of a “pipeline” of individuals who would qualify to be group members in the future. All participants took part in assessments at the beginning of the study and two years later. They provided information to calculate per capita income and completed the short version of the World Health Organization Quality of Life assessment (WHOQOL-BREF). People with a disability completed the Participation Scale (P-Scale), and those that had leprosy-related disabilities also completed the Screening of Activity Limitation and Safety Assessment (SALSA) scale. Additional demographic and socio-demographic information was collected as per routine practice in such interventions. Baseline data comprising demographic, sociodemographic and outcome assessment scores were compared between each paired intervention/control cohort to assess any statistically significant differences. Differences were analysed using chi-square and Wilcoxon rank sum test. Any statistically significant differences were paired with the variable to indicate if a person was in the intervention or control cohort in a type two analysis of variance. If the potential confounder was found to explain the change in scores (pre vs post) the variable was retained for further analysis. A backwards stepwise multiple linear regression was utilised to assess the change in each of the four domains of the WHOQOL-BREF, per capita income, P-Scale and SALSA, making a total of seven outcomes indicators for each of the paired cohorts. Finally, a quantile regression was then performed for each of the final formulae to visually assess the effect of the formula on multiple quantiles, and not merely the 50th quantile as reported by the linear regression. Cohort 1, which was a new CBR intervention in a new geographic region, reported statistically significant improvements across all seven outcomes. Cohort 3, which consisted of new CBR groups in a geographic region with existing CBR groups, saw statistically significant improvements in per capita income, and the social and environment domains of the WHOQOL-BREF. The changes reported in ten out of fourteen outcome indicators provide significant evidence for the impact of CBR in this intervention. The use of standardised assessments provides evidence that the impact of CBR can be more effectively measured, and suggests that noteworthy CBR interventions can be identified and emulated. This study utilised a rigorous approach and provided substantial evidence for the impact of CBR. While these outcomes cannot be claimed as evidence for all CBR interventions, they provide strong indications on which to plan future research and practice.