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Disabil Rehabil, 2013; 35(23): 1941–1953

! 2013 Informa UK Ltd. DOI: 10.3109/09638288.2013.770078

REVIEW

Community-based rehabilitation (CBR) monitoring and evaluation

methods and tools: a literature review
Sue Lukersmith1, Sally Hartley1,2,3, Pim Kuipers4, Ros Madden1, Gwynnyth Llewellyn1, and Tinashe Dune1
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1
Australian ICF Disability & Rehabilitation Research Program (AIDARRP), Centre for Disability Research and Policy, University of Sydney, Sydney,
Australia, 2School of Allied Health Professions, University of East Anglia, Norwich, UK, 3The London School of Hygiene and Tropical Medicine,
London, UK, and 4Population and Social Health Research Program, Griffith Health Institute, Griffith University, Brisbane, Australia

Abstract Keywords
Purpose: To identify and analyse tools and methods that have been reported in the literature for CBR Guidelines, CBR matrix,
the monitoring and evaluation of community-based rehabilitation (CBR) programmes. Method: A community-based rehabilitation,
literature review and descriptive analysis were carried out to scope CBR monitoring and evaluation, monitoring
evaluation methods and tools. A search was conducted using PubMed and Google Scholar
databases, hand searches and reference lists. Reports were retrieved, screened and information History
was extracted and analysed against research questions. Results: There were 34 reports which met
the inclusion criteria. Analysis of the 34 reports showed that most reports used demographic and Received 15 January 2012
programme data. A range of methods were used: interviews, focus groups and questionnaires Revised 29 October 2012
For personal use only.

being the most common. Apart from this, no common standardised procedures or tools were Accepted 22 January 2013
identified and there was not a standard approach to the inclusion of people with disabilities or Published online 10 April 2013
other CBR stakeholders. Conclusions: The findings suggest that there would be value in creating
resources such as guidelines, common processes and checklists for monitoring and evaluation of
CBR, to facilitate efficient and comparable practices and more comparable data. This needs to be
done in partnership with people with disabilities, CBR providers, partners and researchers to
ensure that all stakeholders’ needs are understood and met.

ä Implications for Rehabilitation

 While there is broad scope and complexity of CBR programmes, there needs to be
consistency and a valid approach in the monitoring and evaluation methods and tools used
by CBR programmes.
 The principles of CBR and CRPD require that monitoring and evaluation involve people with
disabilities, CBR managers and staff not only as informants but also in the design and
execution of monitoring and evaluation activities.
 The consistent use of appropriate and valid monitoring and evaluation methods and tools will
contribute to developing a stronger evidence base on the efficacy and effectiveness of CBR.

Introduction
Using global population estimates, the World Report on Disability
concluded that about 15% of the world’s population lives with
some form of disability [1]. The Report also identified the need to
expand rehabilitation services to people with disabilities in low-
resource, capacity-constrained settings through community-based
rehabilitation (CBR)1. CBR [1] is a community development
1 of people with a disability, current practice, changing under-
Community based rehabilitation (CBR): ‘‘a strategy within general
community development for the rehabilitation, poverty reduction, equal-
ization of opportunities and social inclusion of all people with disabilities.
CBR is implemented through the combined efforts of people with
disabilities themselves, their families and communities, and the relevant
governmental and non-governmental health, education, vocational, social
and other services’’. (WHO/ILO/UNESCO 2004, p. 2).
Address for correspondence: Sue Lukersmith, University of Sydney,
Sydney, Australia. Tel: +61 4011 704 118. E-mail:
sue.lukersmith@sydney.edu.au
13
20
strategy2 currently implemented in over 90 countries throughout
the world to address the needs of people with disabilities and
communities [2]. CBR is relevant for any community where
environmental barriers, economic restrictions, resource and
service limitations restrict opportunities for the participation of
people with disabilities in rehabilitation, community activities,
education, employment and other areas of life [1–3].
Since its introduction in 1970s, the conceptual development
and guiding principles of CBR have been influenced by the needs
standings of CBR and by emerging evidence from the literature.
These influences are reflected in the Joint Position Statement [3]
2
Community development: Community development programmes take
place in the community. The programmes help communities to develop
the skills to identify issues and concerns, make change to improve
conditions and so have some level of local community determination and
control.
 1942 S. Lukersmith et al.
and more recently the CBR matrix and Guidelines [2]. As a
strategy adopted internationally to meet the needs of people with
disabilities, there are important conceptual links to be made
between CBR, the United Nations (UN) Declaration of the
Millennium Development Goals (MDGs) [4] and the UN
Convention on the Rights of Persons with Disabilities (CRPD)
[5]; in particular the CBR Guidelines shares the principles of the
CRPD.
Importantly, the World Report on Disability [1] also
recognised the substantial gaps in the research in CBR. Many
authors have identified the need for a stronger CBR research base
and observed that the existing body of evidence on the effective-
ness and efficacy of CBR is weak [1,6,7]. This critique relates
mainly to the need for robust research and systematic measure-
ment of the key outcomes of CBR [6], more medical rehabilitation
research [8], a participatory focus and involvement of people with
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disabilities [9] and a stronger focus on the psychosocial dimen-
sions of disability [10]. Overall, there is a need for a stronger
research foundation and evidence base for CBR programmes,
which will assist in improving measurement, resource allocation
and information provision [1,6,11,12].
The first step required to establish the effectiveness of CBR is
for programmes to undertake monitoring and evaluation activities
and confirm what the programmes do and what they achieve.
Although often described together, monitoring and evaluation
have different objectives and occur at different levels [13].
Monitoring is used to describe systematic, continuous assessment
of progress to inform managers and other stakeholders. As it is
conducted regularly and is ongoing, there is an internal element.
The purpose is to help identify goals, problem areas, progress
For personal use only.
towards achieving results and to initiate change. It may be
performed at the level of the individual, programme or local
community. The information collected includes inputs and outputs
of the programme and the processes employed. The information
obtained from monitoring can inform and strengthen an evalu-
ation and form an essential basis for establishing efficacy and
effectiveness [13–15].
Evaluation, on the other hand, focuses on the outcomes from a
programme and aims to objectively assess progress and the
achievement of results towards an agreed goal or to answer certain
questions and provide guidance to decision-makers. Evaluation
may have a broader or more general focus than the specific
programme, for example considering policy, systems or national
level implications although it is typically linked to outcomes and
not only outputs. Evaluation is usually conducted on a ‘‘one off’’
basis [13–15]. The desire for objectivity means evaluation often
has an external element and so is typically conducted by people or
organisations external to the programme, including funding
agencies and international researchers.
CBR is not a single, linear or discrete intervention but rather a
complex3 and multi-dimensional approach [2,7,16–19]. There are
multiple elements which can be dependent or interdependent of
each other and which are heavily influenced by resources and
contextual factors. CBR programmes differ in their goals,
structure and activities. The multi-dimensional and complex
nature of CBR makes it difficult to use standard or single element
outcome measures or single intervention research methods such as
randomised controlled trials. As a result, researchers have
3 4
A complex intervention involves a number of components, which may
act both independently and inter-dependently. The components usually
include behaviours, parameters of behaviours (e.g. frequency, timing),
and methods of organising and delivering those behaviours (e.g. type(s) of
practitioner, setting and location) (p. 2 . Campbell et al. [16])
Disabil Rehabil, 2013; 35(23): 1941–1953
proposed diverse research and evaluation approaches for CBR
programmes. These include the following:
 Specific tools and methods such as classification models
[10,20–24], quality of life [25], case studies, focus groups,
and key informant interview methods [26], and a functional
assessment scale [27].
 Development of appropriate indicators for measurement [28].
 Use of participatory methods to develop baseline data and
information systems [29].
 Development of frameworks or the use of existing frame-
works [2,21,30–32].
It is not known if there exist common tools and methods used
by CBR programmes for monitoring and evaluation activities
worldwide, and if so, what these might be.
The purpose of the current study was to identify and analyse
the tools and methods reported in the recent literature for the
evaluation and monitoring of CBR programmes. The study was
guided by the question: ‘‘What does the literature reveal about the
tools and methods that have been used for monitoring and
evaluating CBR programs?’’
Method
Study design
The study comprised a literature review and descriptive analysis
to scope CBR monitoring and evaluation methods and tools [33].
Initial scoping identified two groups of literature which were
potentially informative on monitoring and evaluating CBR. The
first group addressed CBR programmes specifically, and the
second related to community development generally. This review
addressed only the former, whilst recognising the value of both
these sources. Articles related to CBR were identified and
analysed and key information extracted as described below.
Stage 1 – Identifying relevant studies
Three search strategies were performed to locate relevant
documents. The first involved electronic database searches
through PubMed and Google Scholar. The search was limited to
studies in English. As the study aimed to focus on recent
monitoring and evaluation methods and tools, studies were
limited to those published between 1990 and 2011. The search
terms and strings used were PubMed (‘‘community-based
rehabilitation’’ OR ‘‘community based rehabilitation’’ OR
‘‘CBR’’) AND (evidence OR outcome$ OR monitor$ OR
evaluate$)) and Google Scholar (Evidence or evaluation or
outcomes or monitoring) and (‘‘community based rehabilitation’’
or ‘‘community-based rehabilitation’’ or ‘‘CBR’’).
Many CBR monitoring and evaluation reports are in the grey
literature4, in that these reports are not published in peer-reviewed
journals, although may be available from other Internet-based
sources. Google Scholar covers a wider variety of publications
than Web of Science and can retrieve a broader range of
information across science, medicine, education and the social
sciences [34–36]. Google Scholar matches search terms to the
most relevant peer-reviewed articles, books, magazines, disserta-
tions, ERIC documents, newspaper articles, websites, conference
papers, monographs, newsletters and government documents
Grey literature refers to research that is either unpublished or has been
published in non-commercial form. It includes papers, reports, technical
notes or other documents produced and published by governmental
agencies, academic institutions and other groups that are not distributed
or indexed by commercial publishers.
 DOI: 10.3109/09638288.2013.770078
Table 1. Inclusion and exclusion criteria.
Inclusion criteria
Articles written in English
Peer-reviewed journal articles from 1990 to 2011
Grey literature from 1990 to 2011
Reports of programs either from developing or developed countries
Reports from programs that meet all three criteria of CBR drawn from
the CBR Guidelines (page 24) [2] stated below:
1. A program for people with disabilities (adults and/or children)
accessed in their own community
2. Program measures that involved at least one of the following:
rehabilitation, equalisation of opportunity, poverty reduction or
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social inclusion together with a broader focus of community
development
3. Paid or unpaid work performed by a combination of at least two of
any of the following: people with disabilities, families, organisa-
tions and communities, volunteers, health professionals or CBR
(basic or mid-level training) from government, NGOs health
education, vocational and social services (NB: passive recipients
of services are not counted as one of the groups)
The monitoring/evaluation tools and methods, described in sufficient
detail to be able to code the information
which are provided through proprietary databases, including
commercial, open source publishers and established biblio-metric
For personal use only.
sources like Thomson ISI Web of Knowledge as well as intranets
of research institutions [34,36,37]. The precedent of the first 100
results of studies of the Google Scholar search was used for
inclusion in the study [38].
The second search strategy was hand searching to locate
additional grey literature through practitioner contacts, organisa-
tion’s newsletters and CBR Network websites, as well as reports
published in key journals. The newsletters, websites and networks
utilised were the CBR networks from Africa, Malaysia, Nepal,
South Asia, China and Afghanistan, and the Global South to
North Disability network. The key journals which were hand
searched were Asia Pacific Disability Rehabilitation Journal
previous issues 2008–2010, now called the Disability, CBR and
Inclusive Development Journal (from the first issue in 2011) and
Disability and Rehabilitation (2008–2011). The third strategy was
to check the reference lists of reports found through the database
and hand searches for additional reports that are related to the
research question.
Stage 2 – report selection
Following the searches, reports were screened according to the
inclusion and exclusion criteria detailed in Table 1.
Stage 3 – information extraction
In order to understand the context for the use of tools and
methods, some information about the CBR programme was also
extracted. The relevant information from each included report was
extracted and recorded in an Excel spreadsheet. The framework
for the spreadsheet was developed by operationalising the
research question by the following 11 sub-questions:
(1) What populations do the CBR programmes target?
(2) In what country and setting are the tools and methods used?
(3) What is the goal(s) of the CBR programmes that are being
monitored/evaluated?
(4) How does this goal(s) relate to the CBR matrix
components?
CBR monitoring and evaluation methods and tools 1943
Exclusion criteria
Programs not meeting the three stated criteria of CBR
Outreach or outpatient programs provided by (allied) health or
educational professionals, which provide a therapeutic or educational
intervention for the individual based in the home, community facility
or via the Internet or telephone technology and do not have a
community development component to the program (e.g. physiother-
apy provided in the person’s home; tele-rehabilitation for the
family)
Evaluations of training and courses
Literature reviews, systematic reviews (with/without meta-analyses)
which do not consider monitoring and evaluation methods or tools
Articles that deal with general concepts, approaches or opinion on the
monitoring and evaluation of CBR programs
Research studies that are not focused on monitoring and evaluation
Reports of programs did not adequately describe the monitoring/
evaluation tools and methods
(5) What is the reason behind the monitoring and evaluation
activity?
(6) What methods and tools have been used?
(7) How do the tools and methods relate to the CBR matrix
components?
(8) Who used the tools (and methods) and who was the informant?
(9) Is there any pattern to the use of monitoring tools and
methods?
(10) How does the monitoring and evaluation reflect or link to
the CBR principles?
(11) Were people with disabilities and community members
involved in the monitoring and evaluation, and if so, how?
Key topics of information which addressed these questions
were identified and recorded in a spreadsheet. The information
topics and categories relevant to the study questions are
summarised in Table A1.
Data from the reports were extracted and entered onto the
spreadsheet by the first author. The second author assisted with
information from eight studies. Some reports had limited
description of the methods or tools used, such that there were
gaps in explicit information for the aforementioned research sub-
questions. In these circumstances, information was deduced
through related information and descriptors evident in the
report. For example, the report may have described a home visit
and history-taking from which was deduced to mean the tool used
a semi-structured interview, where there were pre-determined
question prompts for the interviewer on key topics. The data
extracted were collated as narrative, categories or numerical
responses in order to synthesise key issues or themes.
Stage 4 – verification of information extraction
The third author conducted a quality check on a random sample of
10% (4) of the studies. This blinded verification of the review
process comprised an independent reading and categorisation of
the information extraction. Through subsequent discussion, any
inconsistencies were resolved in the data extraction process.
For the purposes of the current study, the following operational
definitions were developed:
 1944 S. Lukersmith et al.
 A standard tool refers to one that is published or is readily
available. The standard tool may or may not have reliability
and validity data available.
 A questionnaire is a set of written questions with a choice of
answers.
 An interview is a meeting where the interviewer aims to
obtain statements on opinions, perceptions, attitudes or facts.
 A focus group is a conversation with a group of people to
seek out their perceptions, opinions or attitudes on particular
topics and which may/may not develop a consensus.
 A structured observation is observations of individuals or
situations using an established set of criteria and a semi-
structured protocol.
Results
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The searches resulted in 241 reports identified through Google
Scholar, 231 through PubMed and 72 through hand and reference
searches. Each group of papers was screened by title and abstract
to select papers meeting the inclusion/exclusion criteria detailed
in Table 1. The search identified a number of studies of CBR in
developed countries. These were excluded if they involved
outpatient treatment or rehabilitation and did not have a
community development component. Potential papers were
retrieved and read. This resulted in further exclusions and the
removal of duplicates. There were a total of 34 CBR monitoring
and evaluation reports identified that met the inclusion criteria.
These reports are detailed in Table A2.
There were 32 reports from low- and middle-income countries
and two reports from high-income countries. Most of the reports
For personal use only.
concerned CBR programmes targeting both children and adults
(20 studies), with 4 targeting only children and 10 specifically
focusing on adults. Almost half of the reports (15) did not identify
the nature of the disabilities or health condition of the programme
participants. Nine programmes targeted people with a specific
health condition (leprosy, cerebral palsy, mental health condition).
Most of the CBR evaluation reports described participants with
impairments broadly related to the International Classification of
Functioning, Disability and Health [39] body functions and
structures in mental, sensory, voice and speech, neurological,
muscular, skeletal, movement, and related activity limitations and
participation restrictions. Table A2 provides details of the
country, disability/health condition of the CBR programme
participants, whether the programme occurred in a rural or
urban setting and the tools and methods used for monitoring and
evaluation.
According to the World Health Organization (WHO) regions,
programmes were located in Africa (12 studies), South-eastern
Asia (10 studies) and Western Pacific (10 studies). Four
programmes had two reports each, with each focusing on a
different aspect of the evaluation or monitoring of the CBR
programme.
The statement of the goal of the CBR programme that was
being monitored or evaluated ranged from no statement (4
reports) to a definitive statement. Some reports explicitly
described goals, for example ‘‘create opportunities for self-
employment, open employment or job placement and jobs in
sheltered workshops (for participant) or relatives of those with
severe disabilities’’ [40]. Other reports provided a broad and
general service goal similar to what might be an organisation’s
mission statement, for example, ‘‘to achieve full integration of
disabled persons in the main streams of society by undertaking
rehabilitation measures at the community levels that use and build
on local resources available in the community’’ [41]. Refer to
Table A2 for further detail on the goals of the CBR programmes
described in each report. Due to the absent or sparse description
Disabil Rehabil, 2013; 35(23): 1941–1953
of programme goals in most instances, it was only possible to
approximately relate the goal to the CBR matrix components
(rather than the sub-categories/elements). The goals in seven of
the programmes in the reports related to only the health
component of the CBR matrix. All other programmes related to
two or more of the CBR matrix components. The most frequently
occurring CBR matrix component was health (25 programmes),
followed by social (21) and then empowerment (21). The two
components less frequently related were livelihood (14) and
education (12).
The reasons for the monitoring and evaluation of the CBR
programmes were extracted from statements in the reports or by
related descriptors. Some reports described multiple reasons for
the monitoring and evaluation. Reasons given for monitoring or
evaluation included measuring individual participant progress
(27), programme change (20), community change (14), a com-
bination of individual participant and community change (12) and
participant satisfaction (5). Reports also described purposes of
measuring impact (16), programme expansion (11) and ensuring
ongoing funding (7).
Of the 34 reports, 8 used qualitative, 4 quantitative and 22 used
mixed methods in monitoring and evaluation. Thirty-three reports
utilised demographic or programme data about the service or
participant – for example age, gender of participant, the frequency
of visits by CBR worker, activities of programmes – and the
nature of the assistance provided, treatment compliance data,
information from policy documents, income data, staff training
and duration of illness. Of the 34 reports, several used a
combination of questionnaires, interviews and focus groups, with
7 using standard tools, 11 using questionnaires, 23 describing
interviews, 12 using focus groups and 6 reports using structured
observations. There were 14 different standard tools but no
measure was found in more than one report.
Following is a summary of the tools used in the reports.
Standard tools or tests
 Translated version of the Attitude Towards Disabled People
(ATDP) Scale [42]
 Adapted version of the Household Form [43]
 Independent Behaviour Assessment Scale (developed and
standardised in Bangladesh) [44]
 Mother Maternal Stress Self-report Questionnaire [44]
 Judson Scale for Maternal Adaptation [44]
 Family Support Scale for Perceived Support [44]
 Positive and Negative Syndrome Scale (PANSS) [45]
 WHO Disability Assessment Schedule (WHODAS) [45]
 Communication Outcome Measuring Tool (COMT) [46]
 WHO – QoL Questionnaire [46]
 WHO Assessment Form (‘‘the ladder’’) for CBR participants
[47]
 Health of the Nation Outcome Scales (HoNOS) [48]
 Social Functioning Scale from the Social and Occupational
Functioning Assessment Scale (SOFAS) [48]
 Indian Disability Evaluation Assessment Scale (IDEAS) [49]
Questionnaires
Most of the questionnaires used were specifically designed for the
particular CBR programme. The questionnaire required either a
verbal response (subject to literacy or language difficulties) or a
written response, typically with specific response options (e.g.
yes/no). One report used a specifically designed quality of life
rating scale (not standardised) [50], another a compliance with
medication questionnaire [45].
 DOI: 10.3109/09638288.2013.770078
Interviews
In the reports, the interviews were usually described as semi-
structured with a list of questions to facilitate and guide the
interview. Examples of the interview topics include family reports
of independence with activities of daily living (ADL), use of aids,
participation in work or school, client’s perception of pre-injury
life, relationships, economic and social interactions, access to
local services, involvement in community activities, description
of ‘‘life story’’, coping and child-rearing strategies, supports
available, perceptions and socio-economic information. Staff
interview topics included their impressions of the programme,
their opinions on factors that influence sustainability, human
resources, organisational setting, social and political environment
and financing.
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Focus groups
In some reports, focus groups had been used to generate a list of
social activities to use as progress indicators and in others a
strengths, weakness, opportunities and threats (SWOT) frame-
work was utilised. One focus group generated locally relevant
social outcomes, developed through a peer-debriefing forum. The
focus group composition included mixed or single stakeholders
(e.g. gender, district versus village, people with disabilities).
Structured observation
Examples of information sought include living situation, ability to
perform ADL, neuro-developmental assessment, neurological
examination, measurement of anthropometrics (weight, height),
For personal use only.
rating of the level of disability, observation of health professional
on technical skill, interpersonal quality (interaction) and structural
quality (management), and impressions of demeanor, coping
skills and body language.
The authors of some of the monitoring and evaluation reports
identified the limitations of the tools used for monitoring and
evaluation of CBR programmes. These include concerns about
accuracy when using interpreters and translations (e.g. vocabulary
in a language to translate abstract concepts), limitations in literacy
level of informants where written questionnaires are used, the
potential for bias in response recording, bias where interviewees
had been nominated (e.g. supportive neighbour), the influence of
pre-existing relationships between the interviewer and informant
(e.g. CBR worker as interviewer of parent), potential relationship
issues between participants in the same focus group (e.g. worker
and supervisor) and time constraints which limited the number of
interviews, focus groups and questionnaires.
The reports described a range of people who collected the
demographic or programme data for monitoring or evaluation
purposes. Of the studies, 13 relied on a programme community
worker or health professional, 2 used a programme manager, 16
an external person located in the same country and 17 an external
person from another country. In several instances, multiple people
were involved in administering the tools to collect the data. In
seven cases the administration of the tools was performed solely
by an external person from another country with/without a
translator (whether a translator was/was not used was not always
reported).
Not all reports provided details of the informants involved in
focus groups or interviews or with whom the tools were used. The
sample size was often not reported or not well described.
Examples of the informants include CBR programme participant,
people with disabilities and members of Disabled Person’s
Organisations (DPOs), family or relatives, caregivers, general
public, ex-clients, neighbours of CBR participants, CBR workers
at all levels (village, district, regional, provincial), volunteers,
CBR monitoring and evaluation methods and tools 1945
coordinators, supervisors and managers, village or religious
leaders and other stakeholders such as temporary international
staff, administrators, general community or development workers
and service providers (e.g. teachers). There were 13 reports which
used a single stakeholder group as informants (e.g. participant or
family), 3 used two stakeholder groups (e.g. CBR worker,
participant) and 16 used 3 or more groups of stakeholders (e.g.
participant, neighbour, CBR worker, regional coordinator).
It was difficult to locate information in the reports which
specifically aligned the tools used, to the recently published CBR
matrix. One report evaluated a programme where activities are
related to health; however, the tools appeared to more appropri-
ately align with the CBR matrix components of empowerment and
social. In a number of other reports, the programme goals could
be seen to reflect a particular CBR matrix component, yet there
was a disparity in the type of monitoring and evaluation tools
used. For example, one report described the goal of the
programme to be the provision of rehabilitation which would
relate to the health component of the CBR matrix, yet the tool
used appeared to be aligned to the empowerment component.
Discussion
The current study reports on the methods and tools used in the
monitoring and evaluation of CBR programmes. In order to
understand the context for the use of tools and methods, broad
information about the programme was extracted.
In terms of the CBR programme context, while many low- and
middle-income countries were represented in the reports,
countries from the WHO regions of Eastern Mediterranean,
Europe and the Americas were under-represented. The CBR
programmes were typically set in rural areas, or across both rural
and urban areas. There was no discernible pattern in the age,
range of disabilities or health conditions of the programme
participant population.
Generally, information on the CBR programme goals was
limited although it appeared that many of the CBR programmes
targeted a few CBR matrix components (health, social and
empowerment). CBR programmes described in the reports were
typically generalist and provided support for children and adults
with disabilities, rather than for a single or specific health
condition. The variations across programmes, population, country
and goals make the descriptions and comparisons between
programme challenging.
The findings from this descriptive literature review indicate
there are several reasons for conducting monitoring and evalu-
ation activities. These include investigating change and progress
for programme participants or the community and identifying the
strengths and possible weaknesses in a programme so that
changes could be made. Other reports are better described as
exploratory with a broad range of activities which aimed to
provide information on progress and outcomes. Recognising that
sustainability, and specifically economic sustainability, is a key
concern of CBR programmes [2], the current study also identified
these issues in monitoring and evaluation reports. It is noteworthy
that only seven reports included financial information or funding
as one of the reasons for the evaluation. CBR programmes would
benefit from clearly articulating programme goals, activities and
the anticipated measureable outcomes, so that monitoring can be a
targeted and pre-determined process.
Another area for further consideration is highlighted by the
finding that only 5 of the 34 studies considered programme
participant satisfaction as an aspect of the monitoring or
evaluation. People with disabilities and their families are in a
prime position to identify questions, concerns, strategies and
solutions which may be relevant to monitoring and evaluation.
 1946 S. Lukersmith et al.
Furthermore, Article 32 of the CRPD requires that people with
disabilities should be consulted on services and supports in which
they are involved. Seeking out programme participants’ satisfac-
tion is also indicative of providing opportunities for empowering
people with disabilities, another of the CBR principles [2].
The current study sought to discern whether there was any
pattern in the monitoring and evaluation tools and methods used
for CBR programmes. There were some broad similarities in non-
standard tools used and how CBR programmes were monitored or
evaluated. First, most reports used mixed methodologies with
quantitative and qualitative research methods. Second, the
description of the CBR programme’s goals and activity was
generally limited. Third, all but one report [51] sought demo-
graphic or other data about individual participants of the
programme and less frequently about the staff. Information
about the community was generally not part of the information
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gathered by the monitoring or evaluation tools and methods,
although sometimes mentioned in the programme or setting
description. Finally, the most common methods used were
qualitative tools, predominantly interviews, followed by focus
groups and then questionnaires.
Interviews, focus groups and questionnaires are often labour-
intensive and time-consuming to conduct and analyse, a point
noted by some of the authors of the reports included in this study.
There are time demands when the use of interviews, focus groups
and questionnaires are used as monitoring tools. Cost implications
(e.g. salaries, transport), particularly when used routinely, needed
for ongoing monitoring warrant consideration. However, a
particular strength of the interviews, focus groups and question-
naires is the rich and detailed information, which is often difficult
For personal use only.
to obtain using other methods.
Of further interest is the fact that there was no common
standard tool or common structured observation in the reports
reviewed. Across the 14 standard measures used, no single
standard measure or structured observation was noted in more
than one report.
The analysis undertaken for this study has identified some key
principles which should be considered when selecting tools for
CBR programme monitoring and evaluation.
 The identification of anticipated outcomes arising from the
programme is critical to selecting the appropriate measure-
ment tool(s).
 The programme constructs such as the CBR programme goal
need to be clear and explicit. The programme goals and
activities should be specific, realistic with measurable
outcomes over time. If these are absent, it is difficult to
monitor progress or evaluate effectiveness. It would be
appropriate if the programme goal(s) related to the recently
released CBR matrix. Frameworks such as the CBR matrix
and CBR Guidelines [2] and potentially the ICF [39] provide
a structure and common language to describe the programme
goal(s). In monitoring and evaluation activities, it could be
expected that there would be content alignment between
programme goals, the reason for monitoring and evaluation
and the methods and tools used.
 Standard measures or tools (e.g. neurological examination)
and structured observations may require a level of knowledge
or skill which is not available within CBR programme
resources. The results from this study suggest that in
approximately half of the studies, administration of the
tools was completed by an external international party/
parties. The use of external international parties in ongoing
monitoring activities clearly has implications for cost,
continuity and sustainability.
 The monitoring and evaluation tools and methods need
to be valid for the specific population with whom they
Disabil Rehabil, 2013; 35(23): 1941–1953
will be used. There may be the potential to develop local
semi-structured observation tools of environmental and
personal factors with checklists of identified outcomes
recorded (e.g. accessible toilet).
 There were several studies which involved DPOs as inform-
ants in focus groups. People with disabilities were key
informants for demographic, historical and functioning data,
yet their feedback on, and their satisfaction with, the
programme was infrequently reported. Despite the participa-
tory objectives of CBR [2], few monitoring and evaluation
reports described the active involvement of people with
disabilities in the design, implementation, analysis or
reporting. It seems that people with disabilities were largely
limited to being data informants. Although one or more of
the external evaluators and local programme workers/man-
agers who led the monitoring or evaluation may have been
people with disabilities (although not identified as such), the
lack of explicit leadership by people with disabilities or
DPOs in the reviewed reports appears inconsistent with CBR
ideals [52]. This review suggests that greater participation
and collaboration with people with disabilities [9] should be
a key dimension of future monitoring and evaluation of CBR
programmes.
Limitations
There are a number of limitations in the current study. Resource
constraints allowed for a thorough but not a systematic search of
the literature for CBR monitoring and evaluation reports. Within
these resources, quality appraisal of reports was not included in
the aims of this study. Further, this study examined only the recent
literature relating specifically to the monitoring and evaluation of
CBR programmes excluding reports on general community
development. The information gaps in the reports limited the
data available on some topics. None of the reports analysed in this
study directly linked their methodology or purpose with the CBR
principles, a not unexpected finding as all but two studies were
published before the principles were articulated and released in
the CBR Guidelines [2].
Future research
The themes identified in this article have highlighted some key
messages to be considered in future research involving CBR
monitoring and evaluation. Given the participatory requirement of
Article 32 of the UN CRPD, future monitoring and evaluation
activities should involve people with disabilities not only as
informants but also in the monitoring and evaluation design and
execution. Similarly, future research could carefully consider the
balance of other stakeholders involved in monitoring and evalu-
ation – notably CBR managers and staff and international
researchers. Immediate attention needs to be given to developing
appropriate frameworks for monitoring and evaluation that
accommodate the multi-dimensional and complex nature of the
CBR programmes, heterogeneity of target groups and contextual
factors. Examination of the literature on monitoring and evalu-
ation of community development projects could also potentially
inform practice on CBR monitoring and evaluation activities.
Conclusion
This study highlights the variation in the activities and context of
CBR programmes. It shows that a variety of tools and methods
have been used by CBR programmes for monitoring and
evaluation purposes and confirms the complexity and heterogen-
eity of CBR programmes worldwide. The monitoring and
evaluation tools and methods have been reported in
 DOI: 10.3109/09638288.2013.770078
varying levels of detail and show an absence of internal
consistency between the stages of the evaluation and external
consistency across the studies reported. The lack of detail
and consistency make systematic measurement of CBR pro-
gramme outcomes difficult and point to a need for more rigorous
and compatible monitoring and evaluation practices to be
developed, trialled and evaluated.
A consistent approach adopted by CBR programmes in
monitoring activities will provide better information to CBR
programme managers and workers. It would also enable external
personnel and agencies to collect data within one or more
programmes over time and across programmes and thereby
facilitate the development of a stronger evidence base on the
efficacy and effectiveness of CBR. There would be value in
creating resources such as tools and guidelines to help build CBR
programme capacity for monitoring and evaluation activities and
Disabil Rehabil Downloaded from informahealthcare.com by Memorial University of Newfoundland on 07/31/14
to facilitate efficient and comparable practices. This needs to be
done in partnership with people with disabilities, CBR pro-
gramme partners and researchers. It is envisaged that documents
such as the CRPD [5], the CBR matrix and Guidelines [2] and the
ICF [39] could help provide a conceptual and structural frame-
work to this process.
Acknowledgements
We thank our CBR project partners: Bounlanh Phayboun and the team at
Co-operative Orthotic and Prosthetic Enterprise (COPE); Bounpheng
Phetsouvanh and the team at Centre for Medical Rehabilitation (CMR)
CBR Project Laos; Nguyen Viet Nhan and the team at the Office of
Genetic Counselling and Disabled Children (OGCDC), Vietnam, and
Penafrancia Ching, College of Allied Medical Professionals (CAMP),
For personal use only.
Philippines.
Declaration of interest
The authors report no declarations of interest.
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 DOI: 10.3109/09638288.2013.770078 CBR monitoring and evaluation methods and tools 1949
Appendix

Table A1. Information topics and categories relevant to study questions.

Information topics Categories (where relevant)

Reference
Reason for monitoring or evaluation
Disabil Rehabil Downloaded from informahealthcare.com by Memorial University of Newfoundland on 07/31/14
Year of publication, author, title
Monitoring
To change the program
To develop a training program
To monitor the individual program participant’s progress
To monitor changes in the community, e.g. attitudes
To monitor participant satisfaction
Evaluation
For funding information, e.g. to determine costs and funding needs
In preparation of expansion to other regions
To determine the impact

Study methodology Quantitative

Qualitative
Mixed – both qualitative and quantitative
Tools used Demographic or program data, e.g. frequency of service, number of people attending
Standard tools or tests
Questionnaire
Interview (individual)
Focus group
Informed observation, e.g. observation of performance of an individual, structured
observation such as physical screening
Tool Description
Source of the information Who was the tool administered to
Tool administration Who administered the tool
CBR program – internal program community worker or health professional: internal
manager/administrator
External – external person to the CBR program but from the same country (in-country),
For personal use only.

external person from another country (international)

Sample size How many people were involved in providing data?
Country Name
Setting Rural
Urban
Coverage Regional
National
CBR program participants target Children
Adults
Both children and adults
Impairment or health condition of CBR program Description
participants
Goal of CBR program Description
Goal of CBR program linked to CBR matrix Health, education, livelihood, social, empowerment
components
Tools linked with CBR matrix Yes, no, not known
To which of the CBR principles does the monitoring Dignity and autonomy
or evaluation study link Non-discrimination
Inclusion society
Acceptance
Equality of opportunity
Accessibility
Gender equality
Respect for children’s rights and capacity
Empowerment
Sustainability
Stated study limitations Description
Comment on whether people with disabilities were Description
involved, and if so, how?
Study conclusions Description
Other comments General impressions and comments
Additional study limitations identified
 Disabil Rehabil Downloaded from informahealthcare.com by Memorial University of Newfoundland on 07/31/14
For personal use only.

Table A2. Monitoring and evaluation reports: population group, setting, goals, tools and methods.
1950

Disabilities or health condition of Goal of CBR program as described

No. Author and year Country CBR program participants Program setting in the paper Tools and methods used
1 Lagerkvist [53] Philippines and Range – moving difficulties, Not known Enhance activities of daily living Interview
Zimbabwe seeing difficulties, hearing and and participation Structured observation
speech difficulties, difficulties
with learning, strange behav-
iour, fits
S. Lukersmith et al.

2 Thorburn [54] Jamaica Range – learning, motor, speech, Rural Early intervention for child Interview
hearing, visual, multiple development
problems
3 Gershon & Srinivasan [40] India Leprosy Urban Create opportunities for self- Interview
employment, open employment
or job placement and jobs in
sheltered workshops (for par-
ticipant) or relatives of those
with severe disabilities
4 Mitchell et al. [42] China Not specified Urban Community attitude towards Interview
people with disability
5 Jagannathan et al. [55] India Leprosy Rural Training for a trade for employ- Nil (demographic, program data
ment, provision of start-up only
funds
6 Dolan et al. [56] South Africa Range – mental retardation and Rural Create a receptive and supportive Interview
learning difficulty, cerebral environment for disabled
palsy, mental illness, stroke, people, passing therapeutic
blindness and poor vision, skills directly to the family and
amputation, spinal disorder, educating the community
epilepsy, hearing difficulty,
communication difficulty,
polio, arthritis, heart disease,
albinism, club feet
7 Lundgren-Lindquist & Nordholm Botswana Not specified Rural No description Questionnaire
[50] Interview
Focus group
8 Bischoff et al. [43] Jamaica Not specified Rural No description Questionnaire
Interview
9 Hill et al. [51] Solomon Islands Range – amputees, polio but may Not known Rehabilitation and preventative Questionnaire
include others health Structured observation
10 Valdez & Mitchell [57] Philippines Not specified Urban and rural Rehabilitation, preventative health, Questionnaire
recreation and leisure, referral Structured observation
to other services (vocational,
education, prosthetics and orth-
otics, specialist services),
medication

(continued )
Disabil Rehabil, 2013; 35(23): 1941–1953
 Disabil Rehabil Downloaded from informahealthcare.com by Memorial University of Newfoundland on 07/31/14
For personal use only.

Disabilities or health condition of Goal of CBR program as described

No. Author and year Country CBR program participants Program setting in the paper Tools and methods used

11 Nordholm & Lundgren-Lindquist Botswana Not specified Rural Rehabilitation and awareness of Interview
[58] disability
12 Lopez et al. [59] Philippines Not specified Rural Rehabilitation, inclusion and com- Interview
munity awareness Focus group
DOI: 10.3109/09638288.2013.770078

13 McConachie et al. [44] Bangladesh Cerebral palsy Rural and urban Rehabilitation (activities of daily Standard tool
living, communication, Structured observation
physical)
14 Evans et al. [60] India Range of disabilities – cerebral Urban Medical rehabilitation and primary Questionnaire
palsy, polio, leaning difficulty, health care Interview
communication difficulty, epi- Structured observation
lepsy, seeing difficulty
15 Sharma & Deepak [61] Vietnam Not specified Rural Training of a nucleus of trainers, Interview
transfer of knowledge from Focus group
rehabilitation workers to people
with disabilities and their
families, promotion of multi-
sectoral approach, use of
appropriate technology,
improving referral services,
promoting the integration of
children, enhancing role of
organisations for human rights,
promoting economic self
sufficiency
16 World Health Organization Ghana, Guyana Refers to a range of people with Rural Improve the quality of life of Interview
(WHO) [62] and Nepal disabilities persons with disabilities Focus group
17 Chatterjee et al. [45] India Schizophrenia Rural Provide community-based care for Standard tool
people with schizophrenia Questionnaire
18 Hartley [46] Kenya Communication problems Rural Improve the communication of the Standard tool
children, and quality of life Focus group
19 Kuipers et al. [63] Australia Refers to a range of people with Rural Provide assistance with day-to-day Questionnaire
disabilities, and others who had practical issues and maintain Interview
short term needs broad focus, e.g. transport, Focus group
meals, respite, information, help
in negotiating a service maze,
raising community awareness,
home help, assistance with child
care, independence training,
advocacy
CBR monitoring and evaluation methods and tools

(continued )
1951
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For personal use only.

Table A2. Continued

1952

Disabilities or health condition of Goal of CBR program as described

No. Author and year Country CBR program participants Program setting in the paper Tools and methods used

20 Grut et al. [64] Eritrea Refers to a range of people with Rural and urban Contribute to equal rights and full Interview
disabilities participation of people with Focus group
disabilities – change negative
attitudes, mobilise community
resources, provide equal access
S. Lukersmith et al.

and opportunities, play advo-

cacy role
21 Krokeide [65] Eritrea Refers to a range of people with Rural and urban Provide loans to initiate income- Interview
disabilities generating activities to alleviate
unemployment, impoverish-
ment and dependence of people
with disabilities, to enhance
self-confidence and social
acceptance by enabling earning
own income, make CBR inte-
grated part of community
development, enable people
with disabilities to qualify for
other credit programmes and
strategies
22 Claussen et al. [41] Uganda Refers to a range of people with Rural and urban Achieve full integration of dis- Interview
disabilities abled persons in the main Focus group
streams of society by under-
taking rehabilitation measures
at the community levels that use
and build on local resources
available in the community
23 Eide [47] Palestine Not specified Rural and urban Assist individual and their family, Questionnaire
stimulate and mobilise the Interview
community and promote the
community to organise
themselves
24 Zaino et al. [66] China Cerebral palsy Urban Provide appropriate rehabilitation Interview
and education programmes, Structured observation
improve overall competence of
the rehabilitation and education,
empower the parents to be
organised to obtain support and
services, develop hospital and
rehabilitation personnel skills,
develop and distribute informa-
tional material for parents and
community to raise awareness

(continued )
Disabil Rehabil, 2013; 35(23): 1941–1953
 Disabil Rehabil Downloaded from informahealthcare.com by Memorial University of Newfoundland on 07/31/14
For personal use only.

Disabilities or health condition of Goal of CBR program as described

No. Author and year Country CBR program participants Program setting in the paper Tools and methods used

25 Barbato et al. [48] Italy Mental illness who were con- Urban Enhance social functioning, social Standard tool
sidered treatment failures by inclusion and well-being of
psychiatric professionals people with mental illness
26 Ebenso et al. [67] Nigeria Leprosy Rural and urban Economic empowerment, restor- Standard tool
ation of social status, improve- Interview
DOI: 10.3109/09638288.2013.770078

ment of quality of life, Focus group

restoration of dignity, promo-
tion of acceptance and inclu-
sion, access to basic amenities
27 Bualar & Ahmad [68] Thailand People with physical disabilities – Rural Medical (health and rehabilitation) Interview
half-paralysis, joint defects, loss
of limbs and arms, post-polio
conditions, rheumatism, spinal
injury
28 Chatterjee et al. [49] India Mental health – specifically Rural Rehabilitation for adults with Standard tool
psychotic disorders psychotic, medications, psycho- Questionnaire
education Interview
Focus group
29 Dhungana & Kusakabe [69] Nepal Range of disabilities – sensory, Urban Vocational training, credit and job Interview
physical acquired/congenital placements, advocacy, raising
awareness and visibility of
issues
30 Kim [70] Korea Range of disabilities – mainly Rural and urban No description, appears to be Focus group
physical and sensory advocacy, raising awareness
31 Ebenso et al. [71] Nigeria Leprosy but then the program Rural and urban Social and economic rehabilita- Focus group
expanded to include all people tion, promotion of empower-
with disabilities ment and self-help groups,
individual programmes, cap-
acity building of CBR staff
32 Kumaran [72] India Loco-motor disabilities (primarily Rural Poverty alleviation Questionnaire
polio), hearing impairment,
intellectual disabilities, visual
impairment
33 Mijnarends et al. [73] Vietnam Refers to a range of people with Rural One programme, health access and Questionnaire
disabilities medical rehabilitation; the Interview
second, comprehensive CBR: Focus group
inclusive education, social and
economic support, empower-
ment training
CBR monitoring and evaluation methods and tools

34 Adeoye et al. [74] Uganda Not specified Rural No description – appears to be Interview
rehabilitation, social, commu- Focus group
nity awareness
1953