Community‐based Rehabilitation for People With Disabilities in Low‐ and Middle‐income Countries: A Systematic Review

This Campbell systematic review looks at the evidence from different types of community‐ based rehabilitation interventions in low‐ and middle‐income countries, which target different types of physical and mental disabilities. This review summarises findings from 15 studies, six which focus on physical disabilities and nine on mental disabilities. Moderate to high quality evidence shows that community‐ based rehabilitation has a positive impact on people with disabilities. Of six studies focusing on CBR for people with physical disabilities, three showed a beneficial effect of the intervention for stroke on a range of outcomes while one found a smaller effect; one study found a beneficial impact of CBR for arthritis; and one showed a positive impact of CBR for people with chronic obstructive pulmonary disease. The nine studies assessing the impact of CBR for people with mental disabilities showed a beneficial effect on schizophrenia (5 studies), dementia (3 studies) and intellectual disability (1 study). None of the studies that met the review's inclusion criteria included economic evaluations of community‐based rehabilitation. Synopsis/Plain Language Summary COMMUNITY‐BASED REHABILITATION FOR PEOPLE WITH DISABILITIES IN LOW‐ AND MIDDLE‐INCOME COUNTRIES: A SYSTEMATIC REVIEW. Review question We reviewed the evidence about the impact of community‐based rehabilitation on the lives of people with disabilities and their carers in low‐ and middle‐income countries. Background People with disabilities include those who have long‐term physical, mental, intellectual or sensory impairments, which in interaction with various barriers may hinder their full and effective participation in society on an equal basis with others. There are estimated to be over one billion people with disabilities globally and 80% of them live in low‐ and middle‐income countries. They are often excluded from education, health, and employment and other aspects of society leading to an increased risk of poverty. Community‐based rehabilitation interventions are the strategy endorsed by the World Health Organization and other international organisations (e.g. ILO, IDDC) for addressing the needs of this group of people in low‐ and middle‐income countries. These interventions aim to enhance the quality of life of people with disabilities and their carers, by trying to meet their basic needs and ensuring inclusion and participation using predominantly local resources. These interventions are composed of up to five components: health, education, livelihood, social and empowerment. Currently only few people who need them benefit from these interventions, and so it is important to assess the available evidence to identify how to best implement these programmes. Study characteristics The evidence in this review is current to July 2012. This review identified 15 studies that assessed the impact of community‐based rehabilitation on the lives of people with disabilities and their carers in low‐ and middle‐income countries. The studies included in the review used different types of community‐based rehabilitation interventions and targeted different types of physical (stroke, arthritis, chronic obstructive pulmonary disease) and mental disabilities (schizophrenia, dementia, intellectual impairment). Key results Overall, randomised controlled trials suggested a beneficial effect of community‐based rehabilitation interventions in the lives of people with physical disabilities (stroke and chronic obstructive pulmonary disease). Similar results were found for non‐randomised studies for physical disabilities (stroke and arthritis) with the exception of one non‐randomised study on stroke showing community‐based rehabilitation was less favourable than hospital‐based rehabilitation. Overall, randomised controlled trials suggested a modest beneficial effect of community‐based rehabilitation interventions for people with mental disabilities (schizophrenia, dementia, intellectual impairment), and for their carers (dementia). Similar results were found for non‐randomised studies for mental disabilities (schizophrenia). However, the methodological constraints of many of these studies limit the strength of our results. In order to build stronger evidence, future studies will need to adopt better study designs, will need to focus on broader clients group, and to include economic evaluations. RÉADAPTATION À BASE COMMUNAUTAIRE POUR LES PERSONNES HANDICAPÉES DANS LES PAYS À FAIBLE REVENU ET REVENU MOYEN: UNE REVUE SYSTÉMATIQUE Ojectif Nous avions conduit une revue systématique sur l'impact de la réadaptation à base communautaire sur la vie des personnes handicapées et de leurs familles dans les pays à faible revenu et revenu moyen. Contexte Les personnes handicapées sont des personnes qui ont des déficiences physiques, mentales, intellectuelles ou sensorielles à long terme, dont leur environnement peut constituer un obstacle à leur pleine et effective participation dans la société. On estime que plus d'un milliard de la population mondiale présente un handicap, dont 80% vivant dans des pays à faible revenu et revenu moyen. Les personnes handicapées sont souvent exclues du système éducatif, de la santé, de l'emploi et d'autres aspects de la société, conduisant à un risque d'appauvrissement accru. La réadaptation à base communautaire est une stratégie approuvée par l'Organisation Mondiale de la Santé et d'autres organisations internationales (telles que OIT, IDDC) pour répondre aux besoins des personnes handicapées et de leurs familles dans les pays à faible revenu et à revenu moyen. Ces interventions visent à améliorer la qualité de vie des personnes handicapées et de leurs familles, satisfaire leurs besoins de base et favoriser l'inclusion et la participation, principalement par l'utilisation de ressources locales. Ces interventions sont composées de cinq composantes: santé, éducation, moyens de subsistance, social et autonomisation. Actuellement, dans les pays a faible revenu et revenu moyen, seulement une faible proportion des personnes qui pourraient bénéficier de la réadaptation à base communautaire ont accès a ces interventions, et il est donc important d'évaluer la littérature disponible pour identifier comment mettre en œuvre au mieux ces programmes. Characteristiques des éudes Les études de cette révue systématique arrivent jusqu'à Juillet 2012. Cette revue systématique a identifié 15 études qui ont évalué l'impact de la réadaptation à base communautaire sur la vie des personnes handicapées et de leurs familles dans les pays à faible revenu et revenu moyen. Les études inclues dans la revue systématique utilisent différents types d'interventions de réadaptation à base communautaire et s'adressent à différents types de handicaps physiques (accident vasculaire cérébral, arthrite, broncho‐pneumopathie chronique obstructive) et mentaux (schizophrénie, démence, déficience intellectuelle). Résultats principaux Dans l'ensemble, les essais contrôlés randomisés suggèrent un effet bénéfique des interventions de réadaptation à base communautaire dans la vie des personnes handicapées physiques (accident vasculaire cérébral et broncho‐pneumopathie chronique obstructive). Des résultats similaires ont été trouvés pour les études non randomisées pour le handicap physique (accident vasculaire cérébral et arthrite), à l'exception d'une étude non randomisée sur les accidents vasculaires cérébraux démontrant que la réadaptation a base communautaire est moins efficace que la réadaptation en milieu hospitalier. Dans l'ensemble, les essais contrôlés randomisés ont suggéré un effet bénéfique modeste des interventions de réadaptation à base communautaire sur les personnes ayant un handicap mental (schizophrénie, démence, déficience intellectuelle), et sur leurs familles (démence). Des résultats similaires ont été trouvés pour les études non randomisées pour le handicap mental (schizophrénie). Cependant, les contraintes méthodologiques de plusieurs de ces études limitent la robustesse de nos résultats. Afin d'établir des preuves plus solides, les futures études devront adopter de meilleures méthodologies, étudier un nombre de cas plus large, et inclure des évaluations économiques. REHABILITACIÓN BASADA EN LA COMUNIDAD PARA LAS PERSONAS CON DISCAPACIDAD EN LOS PAÍSES DE BAJO Y MEDIO INGRESO: UNA REVISIÓN SISTEMÁTICA Ojetivo Se revisó la evidencia sobre el impacto de la rehabilitación basada en la comunidad en la vida de las personas con discapacidad y de sus cuidadores en países de bajo y medio ingreso. Contexto Las personas con discapacidad incluyen a aquellas que tienen deficiencias físicas, mentales, intelectuales o sensoriales a largo plazo que, al interactuar con diversas barreras, pueden ver impedida su participación plena y efectiva en la sociedad. Se estima que más de mil millones de personas viven en el mundo con alguna forma de discapacidad y 80% de ellos viven en países de bajo y medio ingreso. A menudo son excluidos de la educación, de la salud, del empleo y de otros aspectos de la sociedad, y esto conduce a un mayor riesgo de pobreza. Las intervenciones de rehabilitación basada en la comunidad son la estrategia aprobada por la Organización Mundial de la Salud y otras organizaciones internacionales (por ejemplo, OIT, IDDC) para hacer frente a las necesidades de este grupo de personas en países menos desarrollados. Estas intervenciones tienen como objetivo mejorar la calidad de vida de las personas con discapacidad y sus cuidadores, satisfacer sus necesidades básicas y garantizar su inclusión y participación utilizando principalmente recursos locales. Estas intervenciones consisten de cinco componentes claves: salud, educación, subsistencia, social y fortalecimiento. Actualmente, de las personas que necesitan este tipo de intervenciones, sólo pocas se benefician de ellas, por lo que es importante evaluar la evidencia disponible para identificar cómo mejorar su implementación. Características de los estudios La evidencia en esta revisión sistemática está actualizada a Julio 2012. Esta revisión sistemática identificó 15 estudios que evaluaron el impacto de la rehabilitación basada en la comunidad en la vida de las personas con discapacidad y de sus cuidadores en países de bajo y medio ingreso. Los estudios incluidos en la revisión sistemática analizan diferentes tipos de intervenciones de rehabilitación basada en la comunidad y se dirigen a diferentes tipos de discapacidad física (accidente cerebrovascular, artritis, enfermedad pulmonar obstructiva crónica) y mental (esquizofrenia, demencia, deficiencia intelectual). Resultados principales En general, los ensayos clínicos aleatorios sugieren un efecto positivo de las intervenciones de rehabilitación basada en la comunidad en la vida de las personas con discapacidad física (accidente cerebrovascular y enfermedad pulmonar obstructiva crónica). Se encuentran resultados similares para los estudios no aleatorios para discapacidad física (accidente cerebrovascular y artritis) con la excepción de un estudio no aleatorio que muestra que la rehabilitación basada en la comunidad por las personas que sobreviven a un accidente cerebrovascular tiene un efecto positivo menor que la rehabilitación en el hospital. En general, los ensayos clínicos aleatorios sugieren un efecto positivo modesto de las intervenciones de rehabilitación basada en la comunidad en la vida de las personas con discapacidad mental (esquizofrenia, demencia, deficiencia intelectual), y en la vida de sus cuidadores (demencia). Se encontraron resultados similares para los estudios no aleatorios por las personas con discapacidad mental (esquizofrenia). Sin embargo, las limitaciones metodológicas de muchos de estos estudios limitan la fuerza de nuestros resultados. Con el fin de construir una evidencia más robusta, los estudios futuros necesitarán adoptar mejores diseños de estudio, analizar grupos de estudio más amplios e incluir evaluaciones económicas. Executive Summary/Abstract BACKGROUND Recent estimates suggest that there are over one billion people with disabilities in the world and 80% of them live in low‐ and middle‐income countries. Community‐based rehabilitation (CBR) is the strategy endorsed by the WHO and other international organisations (ILO, IDDC and others) to promote the inclusion of people with disabilities, particularly in low‐ and middle‐income countries. The coverage of CBR is currently very low, and the evidence‐base for its effectiveness needs to be assessed in consideration of scaling up of this intervention. OBJECTIVES To assess the effectiveness and cost‐effectiveness of CBR for people with physical and mental disabilities in low‐ and middle‐income countries, and/or their family, their carers, and their community. SEARCH METHODS The search for studies was not restricted by language or publication status. Searches were limited to studies published after 1976. We searched 23 electronic databases: AIM, CAB Abstract, CENTRAL, CINHAL Plus, Cochrane Database of Systematic Reviews, DARE (The Cochrane Library), EconLit, EMBASE, ERIC, Global Health, HTA Database, IBSS, IMEMR, IMSEAR, LILACS, MEDLINE, NHSEED, PAIS International, PsycINFO, The Campbell Collaboration Library of Systematic Reviews, Web of Science, WHOLIS, and WPRIM. We also searched relevant websites, contacted authors, screened the reference lists and tracked citations of included studies. The latest search for trials was in July 2012. SELECTION CRITERIA Controlled studies evaluating the impact of CBR offered to people with physical or mental disabilities and/or their family, their carers, and their community in low‐and middle‐income countries. The following study designs were eligible: randomised controlled trials, non‐randomised controlled trials, controlled before‐after studies, controlled interrupted time series studies, and economic studies. We excluded studies where CBR intervention took place only in health facilities or schools. DATA COLLECTION AND ANALYSIS Pairs of authors independently screened the search results by titles/abstracts and then by full‐text, independently assessed the risk of bias, and independently extracted data. We presented standardised mean differences (SMDs) and 95% confidence intervals (CI) for continuous data and risk ratios and 95% CI for dichotomous data. We undertook meta‐analysis only on outcomes extracted from studies for which the disabilities, research designs and outcome measures were agreed to be sufficiently consistent to allow pooling of data. Meta‐analysis was not performed on other outcomes because the outcomes extracted from studies did not measured the same construct, the intervention was not directed at the same disability condition, or the research designs were not similar. This decision about pooling was made post‐hoc and differs from the protocol. RESULTS We included 15 studies: 10 randomised controlled studies, two non‐randomised controlled studies, two controlled before‐after studies, and one interrupted time series study. The primary focus of 14 of the interventions was on the health component of the CBR matrix, one focused on the education component, and few included other components. Of the 15 studies, six focused on physical disabilities (stroke, arthritis, chronic obstructive pulmonary disease) and nine on mental disabilities (schizophrenia, dementia, intellectual impairment). Most of the interventions targeted both people with disabilities and their carers, although most of the studies evaluated the effect of the intervention on the person with disabilities only. Only one study focused on children as the beneficiaries of CBR. There were eight studies from East Asia and Pacific, two from South Asia, two from Europe and Central Asia, one from the Sub‐Saharan Africa, one from Latin America & the Caribbean, and one from the Middle East and North Africa. The heterogeneity between studies in terms of disabilities, research designs and outcomes meant that the review relies on a narrative summary of the studies and meta‐analysis was only conducted with the three studies on dementia, and only for a limited set of outcomes on users and carers. Among the six studies focusing on CBR for people with physical disabilities, two randomised controlled trials and one controlled before‐after study showed a beneficial effect of the intervention for stroke on a range of outcomes while one non‐randomised controlled trial found a less beneficial effect; one interrupted time series study found a beneficial impact of CBR for arthritis; and one non‐randomised controlled trial showed a positive impact of CBR for people with chronic obstructive pulmonary disease. The nine studies assessing the impact of CBR for people with mental disabilities showed a beneficial effect, including: three randomised controlled trials, one non‐randomised controlled trial, and one controlled before‐after study on CBR for schizophrenia; three randomised controlled trials on CBR for dementia; one randomised controlled trial on CBR for intellectual disability. The dementia trials were under‐powered to show a significant result, but when pooling data from the three studies, meta‐analyses suggested the intervention improved carers' clinical status (SMD=‐0.37, 95% CI=‐1.06‐0.32) and carers' physical quality of life (SMD=0.51, 95% CI=0.09‐0.94) and carers' social quality of life (SMD=0.54, 95% CI=0.12‐5.97). However, they also suggested the intervention did not improve clinical status (SMD=0.09, 95% CI=‐0.47‐0.28) and quality of life (SMD=0.22, 95% CI=‐0.33‐0.77) of people with disabilities, carers' burden (SMD=‐0.85, 95% CI=‐1.24‐0.45), carers' distress (SMD=‐0.16, 95% CI=‐0.54‐0.22), carers' psychological quality of life (SMD=0.11, 95% CI=‐0.31‐0.53), or carers' environmental quality of life (SMD=0.07, 95% CI=‐0.35‐0.49). No economic evaluations meeting the inclusion criteria were found. Methodological concerns were raised about the quality of the studies. AUTHORS' CONCLUSIONS The evidence on the effectiveness of CBR for people with disabilities in low‐ and middle‐income countries suggests that CBR may be effective in improving the clinical outcomes and enhancing functioning and quality of life of the person with disabilities and his/her carer. However the heterogeneity of the interventions and scarcity of good‐quality evidence means that we should interpret these findings with caution. More well‐designed and reported randomised controlled trials are needed to build a stronger evidence‐base. These studies need to be sufficiently powered, and focus on all different components of the CBR matrix and not only the health component. Furthermore, evidence is needed on a broader client groups including children, and economic evidence must be collected.