The impact of rehabilitative services in the lives of adults and children with disabilities, in low-income and middle-income countries: an assessment of the quality of the evidence

"Otherwise … he will be a beggar": a focus group study to understand the Perspectives of physiotherapists about measuring rehabilitation outcomes and impact in low-resource and conflict-affected settings

PURPOSE

Rehabilitation outcomes are important for patients, professionals and policy makers. Most outcome measures (OMs) were developed for "Western" contexts and may be inadequate for low-resource and conflict settings, where the ability to demonstrate impact would be critical to strengthening the sector. This study aims to understand perspectives of physiotherapists from challenging environments regarding current practices, value, barriers, and facilitators of measuring rehabilitation outcomes.

MATERIALS & METHODS

Focus group discussions were held in English with 35 physiotherapists from 18 countries. Audio recordings were transcribed verbatim, anonymised, and analysed using reflexive thematic analysis.

RESULTS

Four themes emerged illustrating the levels at which outcomes and measures were discussed: User (patients, families), provider (physiotherapists, rehabilitation workers), application (OMs), and structure (management, health system). Participants discussed diversity in current practices and patient populations, utility of OMs and a neglected rehabilitation sector lacking investment. Barriers to progressing outcome measurement included lacking patient health literacy, rehabilitation provider training, valid OMs, and leadership. Participants suggested improved patient involvement, routine outcome measurement by using, developing, or adapting simple, context- and stakeholder-relevant OMs, and support from management.

CONCLUSIONS

These insights illustrate the need of and provide robust recommendations for context-adapted development of rehabilitation outcome measurement in various challenging contexts.

The impact of a community based rehabilitation program in Afghanistan: a longitudinal analysis using propensity score matching and difference in difference analysis

BACKGROUND

The 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.

METHODS

We 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.

RESULTS

Three 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]).

CONCLUSIONS

Our 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 REGISTRATION

ISRCTN, ISRCTN50214054 . Registered August 5th 2020 - retrospectively registered.

A systematic review of physical rehabilitation interventions for stroke in low and lower-middle income countries

Purpose: Approximately 70% of strokes occur in low and middle income countries, yet the effectiveness of physical rehabilitation in these contexts remains undetermined. This systematic review identifies and summarises the current evidence supporting physical rehabilitation interventions post-stroke in low and lower-middle income countries.Methods: Five databases were comprehensively searched (April 2017) for randomised controlled trials, clinical controlled trials, and cohort studies testing rehabilitation interventions post-stroke in these countries. The Effective Public Health Practice Project Tool assessed quality of included studies.Results: Sixty-two studies (2115 participants) were included. Interventions addressed upper limb (n = 26), lower limb (n = 22), and other (n = 14) outcomes. Seven studies were rated as strong in quality, 16 moderate and 39 rated as weak. Overall, in addition to usual care, physical rehabilitation interventions improved outcomes for stroke survivors. Best evidence synthesis provides level I (b) evidence supporting constraint induced movement therapy and mirror therapy to improve upper limb functional outcomes. Level I (b) evidence supports multimodal interventions that include lower limb motor imagery to improve gait parameters. Level II (b) evidence supports sit-to-stand training to improve balance outcomes.Conclusions: Exercise-based and brain training interventions improved functional outcomes post-stroke in low and lower-middle income countries. Further high-quality studies including participation outcomes are required.Implications for RehabilitationLow-cost physical rehabilitation interventions requiring minimal resources can improve functional outcomes after stroke in low and lower-middle income countries.Exercise-based interventions can improve upper limb, lower limb, gait, and balance outcomes after stroke.Brain training paradigms such as mirror therapy and motor imagery, when included in therapy packages, can improve upper limb and gait outcomes.The proven efficacy for rehabilitation interventions in improving stroke outcomes in low and lower-middle income countries supports the need to strengthen the rehabilitation workforce in this context.

Mental health service provision in low and middle-income countries: recent developments

PURPOSE OF REVIEW

The study discusses key issues and concepts of how to provide basic mental health services for people with mental disorders in low and middle-income countries (LAMICs).

RECENT FINDINGS

In the last years a considerable gap between mental healthcare needs and available services in LAMICs has been documented. The transformation of hospital-based to community-based mental health and the building of accessible services in low-resource settings require mental health training of primary care providers, task-sharing/task-shifting models, involvement of families and peers and basic models of community rehabilitation. Several international initiatives have been set up to increase the evidence base and test the feasibility, acceptability, and effectiveness of these approaches which are not new but which have been implemented in only a small amount of LAMICs. A combination of interventions on different levels (governance, legislation, providers, and community) is necessary.

SUMMARY

It remains to be shown how the recent global mental health movement, beyond increasing international financial resources, will be helpful in finding locally and culturally sensitive solutions to reduce the mental health gap in LAMICs. Although concepts of a well designed mix of services are available, solutions to reduce implementation barriers must be local, and implementation strategies may vary considerably and still lack a sufficient evidence base.

A scoping review of 10 years of published literature on community-based rehabilitation

PURPOSE

To identify the characteristics of peer-reviewed literature on community-based rehabilitation (CBR) in low- and middle-income countries published in English from 2003 to 2012.

METHODS

This scoping review involved a systematic search of electronic databases using specific keyword/subject heading combinations. Journal articles were included if they were published in English, used "CBR" as related to rehabilitation with persons with disabilities and not limited to high-income countries (HICs). Data were charted according to both pre-determined and emergent categories. A subset of articles was charted by two reviewers to ensure reliability of variables.

RESULTS

A total of 114 articles were included. Fifty-two articles presented empirical research and 49 were published in one of two journals. The articles represented CBR activity in 26 specific countries, although only two of these were in Europe and only one was in the Americas. Authors were predominantly affiliated at universities and in HICs.

CONCLUSIONS

This scoping review identified and characterized a large pool of literature on CBR, facilitating its incorporation into research and practice. Future research should examine the engagement of persons with disabilities in creating CBR literature, and analysis of literature in languages other than English. Implications for Rehabilitation Community-based rehabilitation (CBR) has been promoted as a rehabilitation strategy of choice in low- and middle-income countries (LMICs), but it has been critiqued for lack of an evidence base. A large number (114) of peer-reviewed articles were published on CBR between 2003 and 2012. Just under half of these articles (45%) presented empirical research, indicating that the evidence base for CBR is growing but will benefit from continued, rigorous inquiry. Furthermore, researchers from LMICs appear to be largely under-represented in published CBR research, flagging the need to support LMIC partners to share their CBR research in peer-reviewed journals.