REHABILITATION IN PRACTICE

A framework for evaluating community-based rehabilitationprogrammes in Chinese communities

EVA YIN-HAN CHUNG1,2,3, TANYA L. PACKER2,3,4 & MATTHEW YAU5

1Professional Development and Research Unit, SAHK, Hong Kong, 2School of Occupational Therapy and Social Work,

Centre for Research into Disability and Society, Curtin University of Technology, Australia, 3Faculty of Health Sciences, Curtin

Health Innovation Research Institute, Curtin University of Technology, Australia, 4School of Occupational Therapy, Dalhousie

University, Halifax, Canada, and 5Discipline of Occupational Therapy, School of Public Health, Tropical Medicine and

Rehabilitation Sciences, James Cook University, Townsville, Australia

Accepted November 2010

AbstractPurpose. The primary aim of this study was to develop an evaluation framework that could effectively describe the quality ofcommunity-based rehabilitation (CBR) practice in Chinese communities.Method. This study adopted a case study approach to build and validate a CBR evaluation framework. Core elements ofCBR programmes were defined from the literature to form an Initial Framework. Domains and elements of the InitialFramework were then verified with examples of CBR programmes cited in published articles. The revised framework wasthen further tested for relevance and appropriateness in the real life context through testing in five Chinese CBRprogrammes.Results. A final framework for evaluating CBR programmes was developed. It consists of 5 domains, 25 categorised coreelements and 72 indicators.Conclusion. A comprehensive CBR evaluation framework was built and initially verified with domains, elements andindicators, and is ready for use in Chinese CBR settings.

Keywords: Community-based rehabilitation, China, evaluation

Introduction

Community-based rehabilitation (CBR) is defined as

‘a strategy within general community development

for rehabilitation, equalisation of opportunities and

social inclusion of all children and adults with

disabilities’ [1]. CBR is a common strategy employed

in different countries to promote inclusion and

participation of people with disabilities [2]. CBR

programmes have been variously described as:

1. Having programmes, usually home-based,

that focus on providing rehabilitation activities

for people with disabilities [3,4].

2. Working with communities to ensure that

people with disabilities are included within the

community [3,5].

3. Addressing the problems of poverty of people

with disabilities and their families, with

income-generating activities or loan schemes

of various types as the way to improve quality

of life of people with disabilities [3,6].

4. Working with the self-help and mutual help

issues among people with disabilities or

disabled peoples’ organisations [3,7].

5. Concentrating upon the inequality of the

position of people with disabilities within

society and advocating for change to the

societal and attitudinal barriers within society

[3,8].

CBR has been evolving for nearly three decades

and its practice varies by context and culture. In

China, CBR programmes first emerged in the 1980s.

Correspondence: Eva YH Chung, PhD, Professional Development and Research Unit, SAHK, 18/F., Pak Fuk Road, North Point, Hong Kong.

Tel: þ852-3965-4024. Fax: þ852-2529-0536. E-mail: eyhchung@yahoo.com.hk

Disability and Rehabilitation, 2011; 33(17–18): 1668–1682

ISSN 0963-8288 print/ISSN 1464-5165 online ª 2011 Informa UK, Ltd.

DOI: 10.3109/09638288.2010.541545

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According to official publications, the Chinese

government has put tremendous effort and resources

into the development of CBR in different parts of

China ever since that time. At the current time, CBR

is included as the Chinese government’s strategy to

promote ‘rehabilitation for all’ in their eleventh five-

year plan – their current five year plan. In 2009, the

Chinese budget for healthcare funding was increased

by 38% (118.1 billion yuan) compared to the budget

of 2008 [9]. Even in Hong Kong, which was a British

colony for 150 years and, since 1997, has been a

Special Administrative Region of China, the re-

sources being invested in CBR services continue to

increase [10]. Most programmes have adopted

Western CBR concepts; however, the uniqueness

of Chinese history and culture has made it difficult to

transfer these Western concepts and practices into

Chinese communities [11]. Hence, many CBR

programmes have had to find ways to succeed and

survive in local communities.

Cost-effectiveness of CBR programmes in China

and Hong Kong needs to be measured and under-

stood to ensure that these resources are justifiable

and wisely spent. It is essential to base cost-

effectiveness studies on quality programmes using

objective ways to measure programme outcomes.

According to Thomas and Thomas [12], however,

there has been little research on either outcomes or

the development of indicators with which to measure

quality or success in CBR. Robust indicators for

CBR have not been developed for either evaluation

or research purposes [5,13] in any culture or context.

Hence, the primary aim of this study was to develop

and validate an evaluation framework able to

examine and describe the quality of CBR practice

in Chinese communities. Such a framework should

permit characterisation and evaluation of each

programme according to its nature [14]. Core

elements of CBR programmes were first defined

from the literature and an Initial Framework drafted.

The framework was next verified using examples of

CBR programmes cited in the published literature.

This was followed by verification in the live context

using a case study approach with five existing CBR

programmes. All three phases are described in this

article. Prior to this, a review of existing literature is

presented.

Literature review

Recent work to delineate an evaluation model has

been carried out by some CBR researchers. Sharma

[15] reviewed 22 articles in order to analyse the

extent to which CBR programmes have been

evaluated over the past 30 years. This study revealed

that a variety of methods have been used in the

evaluation of CBR programmes in different commu-

nities including experimental designs, surveys and

qualitative methods. Qualitative and post-test de-

signs are the most common. The lack of consistency

in outcome measures and the lack of focus on

evaluation have been identified weaknesses in the

past evaluations of CBR programmes.

Cornielje et al. [16] were the first to introduce the

use of a classification model to evaluate CBR pro-

grammes. They presented an approach classifying

programmes according to four dimensions: ‘restora-

tion of quality of life’, ‘locus of power’, ‘commitment

to involve others’ and ‘types of response’. They used

these four dimensions to evaluate CBR programmes

using an agreed scoring system to categorise pro-

grammes. Their study provided a starting point for

evaluation of different CBR programmes highlight-

ing the importance of using a scoring system to aid

evaluation. However, more detailed work is needed

to define and describe the criteria used for classifying

programmes [15].

Wirz and Thomas [3] commented that ‘among

evaluations that have been undertaken, there has

been a tendency to describe practice rather than the

effectiveness of practice’ [3, p.163]. They empha-

sised the need for outcome indicators to measure the

effectiveness of CBR programmes. They examined

10 evaluation reports and classified the outcomes of

the programmes into three domains: (1) maximising

potential of people with disabilities, (2) service

delivery and (3) the environment where the person

with disability lives. They used a table format to

outline programme activities and outcomes. They

developed indicators to guide evaluation emphasis-

ing that indicators should be robust, easy to use and

related to the aims of the programmes. They also

recommended that these indicators should be tested

in the field in order to enhance CBR practice [3].

Wirz and Thomas provided good insight into the

development of a framework for programme evalua-

tion and outlined important considerations in the

delineation of an evaluation framework. However,

their postulations have not yet been fully elaborated,

operationalised or validated in practice. Among the

three domains mentioned, they only outlined the

activities, outcomes and indicators for the first

domain. They did not mention in their article how

each domain could be quantified and/or measured.

Kuipers and Quinn [17] adopted a cooperative

approach in a workshop to develop a framework to

guide the evaluation of CBR programmes. They

developed a template comprised of a number of

guiding questions within three domains (the people

domain, the programme domain and the perspective

domain). Velema and Cornielje [18] then developed

a list of evaluation questions and indicators for each

dimension. However, the work of Velema and

CBR framework 1669

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Cornielje presented the same weakness as Wirz and

Thomas [3]; their framework and postulations were

not tested with CBR programmes to investigate

feasibility and applicability. Both Kuipers and Quinn

[17] and Velema and Cornielje [18] suggested the

use of evaluation questions to capture the necessary

information in an evaluation. However, the questions

suggested by both parties appeared to be mostly

broad and open ended questions that lacked quanti-

fication and measurements. Evaluation implies a

sense of comparison within/across programmes with-

in a time frame [18]; and, findings have to be

quantified to allow such comparison.

Following the work on the classification model by

Cornielje et al. [16] and Velema and Cornielje [18],

Finkenflugel et al. [14] reviewed the classification

model using 16 published articles describing rehabi-

litation programmes in the community. They con-

cluded that the classification model could be used to

structure the evaluation of and compare CBR

programmes of a diverse nature by using indicators

within a theoretical framework. Three types of

indicators are outlined in their articles; structure,

process and output indicators. Structure indicators

provide a description of the relevant aspects of the

project area, process indicators are used to describe

the process of a programme and outcome indicators

reflect the results of a programme [14].

Cornielje et al. [19] have continued the develop-

ment of their classification model and developed two

flowcharts that embed the evaluation questions

related to the programme environment and the

rehabilitation process. They introduced the use of

the management information system and emphasised

the role of such monitoring systems in evaluation.

They argued that any monitoring system should be

owned by the stakeholders within the system and

therefore the development of baseline data and

information systems should involve a participatory

process considering the political and cultural realities

of the context. They outlined the steps in the

building of a monitoring and evaluation system as

(1) develop objectives, (2) develop indicators, (3)

establish baseline data and (4) establish targets.

The World Health Organization has been devel-

oping a conceptual framework for CBR [20]. The

WHO recognised that there is no single model of

CBR appropriate for the whole world and they

proposed a ‘CBR Matrix’ or a common framework to

reflect a comprehensive multi-sectoral approach [2].

The CBR matrix consists of five components; health,

education, livelihood, empowerment and social

components. Each component is divided into five

elements and the elements are then sub-divided into

content headings [20]. The matrix suggests a pick

and mix option so that the practitioner can select the

most practical entry point or the next logical step

until a coherent programme of appropriate compo-

nents and elements is formed [20]. This matrix aims

at providing a framework for a coherent CBR

programme. Together with this matrix is the devel-

opment of the CBR guidelines in which a framework

for CBR is provided for making CBR a multi-

sectoral strategy and highlighting best practice in the

field [2]. The guidelines were expected to be

finalised and distributed in 2010 [21], but at this

time have not yet been released.

In summary, there appears to be consensus that a

framework or classification model would be useful to

highlight the unique dimensions of CBR programmes

and to guide programme evaluation. A matrix or

framework with a set of CBR objectives (or elements)

is advocated to enable evaluation of programmes with

a community focus but of a varied nature. Scholars

are recommending that outcomes of CBR pro-

grammes should be grouped into domains to facilitate

systematic collection and processing of data. They

further recommend that use of management strate-

gies, such as information management systems,

should facilitate the development of CBR programme

evaluation. Despite this consensus, proposed frame-

works have not yet been put into practice and they

lack experiential and empirical proof of their feasi-

bility, applicability and effectiveness in the field.

Formulation of an initial CBR framework based

on existing conceptual papers

Delineation of domains

As noted above, different scholars have delineated

broad domains of interest within CBR programmes;

some have also suggested detailed elements and/or

indicators. Formulation of the Initial Framework

first focused on finding consensus on the varying

views at the domain level.

Conceptual papers describing broad domains of

interest were purposefully selected from the literature

available as at March 2007 [22] and are listed in

Table I. Based on the literature, the Initial Frame-

work included four domains: (1) Outcomes of

Service Users, (2) Content and Mode of Service

Delivery, (3) Service Users in Context and (4)

Programme in Context.

Delineation of elements in each domain

Once the domains had been identified, conceptual

papers describing core elements of CBR were

purposefully selected so that elements could be

‘mapped’ against each domain. Key conceptual

papers were retrieved from journals as at March

1670 E. Y.-H. Chung et al.

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2007. The core elements of CBR programmes

described in the selected papers were categorised

into the four domains. Descriptions of the elements

in the cited literature were extracted and further

translated into indicators for each element. Table II

diagrammatically presents a synthesis of the litera-

ture that reports or describes core elements of CBR

programmes. Results are briefly reviewed below.

Wirz and Thomas [3] examined the activities and

outcomes of 10 evaluation reports of CBR pro-

grammes and derived a set of activities and outcomes

of CBR programmes. The work of Velema et al. and

Velema and Cornielje [16,18] provided a framework

for evaluation by listing evaluation questions for

CBR projects. A Joint Position Paper of the Inter-

national Labour Office, UNESCO and World

Health Organization [1] outlined four essential

elements of CBR programmes that contribute to

sustainability. The WHO also outlined five compo-

nents in their CBR matrix: (1) health, (2) education,

(3) livelihood, (4) social and (5) empowerment

components. Kuipers and Quinn [17] outlined a

template for evaluating community rehabilitation

service. The template was derived at a workshop of

representatives from four specialist rehabilitation

services based in South-East Queensland, Australia.

Similar studies [23,24] describe core elements and

outcomes for CBR programmes. Elements described

by each are summarised in Table II.

Since the proposed framework was expected to be

used in the Chinese context, Chinese literature was

also searched, however, no Chinese frameworks were

found. In view of this, Chinese concepts of health

were reviewed and included. Hwu et al. [25]

provided the most valuable insight. They outlined

six dimensions/concepts of Chinese health (1)

independence; (2) physical functioning; (3) content-

ment in social interaction; (4) zest for life; (5)

serenity and (6) meaning.

Content validity – comparison to published

literature

Once constructed, the Initial Framework was next

tested for validity using examples of CBR pro-

grammes reported in the literature. Content validity

in this study was defined as the process of ensuring

that the framework contained all the elements that

comprehensively describe CBR practice. There are

no statistical indices that can assess content validity

and the determination of content validity is a rather

subjective process [26]. Examples of CBR pro-

grammes in published journals were therefore used

as a comparison against which to verify the compre-

hensiveness of the elements and domains, and thus

constitute a measure of content validity. It is

recognised that this retrospective analysis was limited

to the information reported. Had full details and

records of the programmes been available results

may have demonstrated inclusion of more elements

per programme. However, as the intent was to test

the utility of the framework, rather than the quality of

the programmes this approach was justified.

Method

The process of theory building using a case study

approach, as suggested by Eisenhardt [27], was used

to systematically examine validity of the Initial

Framework. The steps and their application in this

study are explained below.

Selecting cases. Existing descriptions of CBR pro-

grammes were used to verify the Initial Framework.

The inclusion of articles was based on the following

criteria:

1. formal publication in an academic journal;

2. programme described in the article was identi-

fied by the author as a CBR programme and

3. a clear description or evaluation of the pro-

gramme contents and practice.

Thirteen articles describing CBR programmes in

nine countries, published between 1988 and 2004

were found and included in this study [4, 28–39]. Of

these, three were in Chinese communities.

Crafting instruments. Each article was reviewed by

the investigator for (1) programme content,

Table I. The four domains of CBR.

Wirz and

Thomas

(2002)

Cornielje

et al.

(2000)

Velema and

Cornielje

(2003)

Hwu

et al.

(2002)

Kuipers and

Quinn

(2003)

ILO,

UNESCO,

WHO (2004)

WHO

(2004)

Domain One – Outcomes of Service User � � � � � � �Domain Two – Content and

Mode of Service Delivery

� � � � � �

Domain Three – Service Users in Context � � � �Domain Four – Programme in Context � � � �

CBR framework 1671

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(2) outcome(s) and (3) distinctive features of the

programme. Excel spreadsheets were designed to

record findings.

Entering the field and analysing data. Articles were

read and reread; all descriptions of the programmes

were highlighted. Each highlighted description was

then examined and compared to the elements in the

Initial Framework. The indicators of the Initial

Framework were used to operationalise the elements.

The presence or absence of the elements reported in

each article was then tabulated.

Results

Consolidated findings from all 12 programmes are

shown in Table III which also illustrates the elements

present in each CBR programme reviewed. In

Domain One, authors tended to emphasise elements

related to physical and medical rehabilitation of

people with disabilities. The provision of home-

based and centre-based training for improvement of

physical function was common in the programme

descriptions. Another focus in this domain was

education. Most participants of the programmes

described were children with disabilities. Integration

of these children into mainstream or special schools

was frequently emphasised. The three Chinese CBR

programmes mentioned aspects related to the

elements of education, functional independence,

physical change, psychosocial change and participa-

tion in family and community life. However, the

element of economic independence was not de-

scribed in the Chinese programmes. Spiritual change

was not mentioned in any of the articles.

In Domain Two, most authors described efforts to

build networks within the community to facilitate

appropriate referral pathways. They also recognised

the importance of accessible channels to allow people

with disabilities to seek assistance and intervention.

Involvement of families in programmes was a

common characteristic with most articles emphasis-

ing the importance of identification, training and

support for the family trainers. Advocacy was

mentioned in a total of five articles but none of

these were within the Chinese programmes de-

scribed. The element of compliance to relevant

service standards was described in only one

programme.

Table II. Core elements of CBR as reviewed from literature.

Wirz and

Thomas

(2002)

Cornielje

et al.

(2000)

Velema and

Cornielje

(2003)

Hwu

et al.

(2002)

Kuipers and

Quinn

(2003)

ILO,

UNESCO,

WHO (2004)

WHO

(2004)

Domain One

Functional independence � � � � � �Education � � �Economic independence � � � �Participation in family & community life � � � � � �Physical status � � � �Psychosocial status � � � �Spiritual status �

Domain Two

Advocacy � � � � �Networking � � �Involvement of PWD’s family/relative � � � �Involvement of neighbours/community members � �CBR manager and programme management � � � �CBR workers � �Compliance to relevant service standards �Ethical practices �

Domain Three

Leadership role in the community � �Ownership of programme � �Locus of power � � �

Domain Four

Community support & recognition �Continuous growth & development �National/government level support � � �Multi-sectoral collaboration � � � �

�¼Presence of elements as reported by each author.

The review of literature used for development of the Initial Framework ended in March 2007.

1672 E. Y.-H. Chung et al.

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CBR framework 1673

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In Domain Three, most programmes described

the involvement of people with disabilities and their

relatives in self-help and mutual help activities.

Social gatherings and opportunities to share experi-

ences were frequently described. Taking a leadership

role in the community was mentioned by one Hong

Kong programme which had adopted the self-

management approach for the people with rheuma-

toid arthritis. Autonomy of service users in the

programme was mentioned in the article describing

the Vietnamese programme.

In Domain Four, training of local supervisors was

frequently described. In the initiation of pro-

grammes, it was regarded as important to provide

training prior to launching services. Many pro-

grammes translated the WHO manuals and used

them as a training guide for their workers. Besides

continuous growth and development, collaboration

and support among different sectors was commonly

described in programmes. Five articles mentioned

aspects that corresponded with the element of

community support and recognition and three

mentioned national/governmental level support.

In summary, the most commonly reported items

in the first domain were the elements related to the

‘physical dimension’, ‘education’ and ‘participation

in community life’. In Domain Two, the most

commonly reported elements were ‘networking’

and ‘involvement of relatives and families of people

with disabilities’. ‘Ownership in the programme’ was

reported most in Domain Three and ‘continuous

growth and development’ was the most common

element in Domain Four. Although, no articles

described activities corresponding to the spiritual

dimension or ethical practice elements, these ele-

ments were not removed from the framework as

these elements were considered essential in some of

the conceptual papers. Further verification of the

non-reported elements was delayed until the later

phase of this study. No descriptions resulted in the

need to add elements.

In conclusion, an Initial Framework with four

domains was built from the review of seven

conceptual papers. The framework was validated

through comparison to 13 CBR programme exam-

ples cited in literature setting the stage for the second

validity study undertaken in the real life context of

existing CBR programmes.

Content validity – comparison to existing

programmes in Chinese communities

This study also adopted the case study approach in

order to test the framework in real life settings. The

intent was to specifically test the framework within a

Chinese context. A multiple, embedded case study

design added reliability to findings and offered a

thorough understanding of cases in the study [40].

The embedded case study design allowed the

investigator to study the programmes through the

pre-selected categories of descriptions; the different

domains, elements and indicators in the frame-

work [41].

Methods

Selecting cases. Five CBR programmes in Hong

Kong or China were purposefully selected to inform

an understanding of the research problem and

central phenomenon in the study [42]. As stated in

the introductory part of this article, CBR pro-

grammes have been variously described as: (1)

having programmes, usually home-based, that focus

on providing rehabilitation activities for people with

disabilities [3,4]; (2) working with communities to

ensure that people with disabilities are included

within the community [3,5]; (3) addressing the

problems of poverty of people with disabilities and

their families, with income-generating activities or

loan schemes of various types as the way to improve

quality of life of people with disabilities [3,6]; (4)

working with the self-help and mutual help issues

among people with disabilities or disabled peoples’

organisations [3,7] and (5) concentrating upon the

inequality of the position of people with disabilities

within society and advocating for change to the

societal and attitudinal barriers within society [3,8].

Since the understanding of CBR varies and not all

programmes in practice have all of the above

characteristics, programmes that had at least three

of the above were eligible for inclusion in this study.

Five additional inclusion criteria were applied: (1)

CBR programmes carried out in Hong Kong or in

Mainland China; (2) target service users were

Chinese people with disabilities; (3) programmes

had been operating for 2 years or more; (4)

programmes were formally registered in the local

community and (5) programmes having autonomy in

their budget management, staff management and

administration.

Ethics approval was gained from Curtin University

Human Research Ethics Committee (Reference

Number HR 68/2007) [22]. Programmes were

recruited via networking by the investigator or

appropriate agencies. Letters of invitation, including

a description of the research process, were forwarded

to potential programmes. Upon consent, pro-

grammes were then contacted by the researcher.

Programme users and workers were identified by

programme managers. Voluntary, informed consent

was obtained from all participants prior to their

participation. Each participant received an informa-

1674 E. Y.-H. Chung et al.

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tion sheet and provided written consent. Participants

were informed that they could withdraw their

participation without prejudice.

Crafting instrument and protocols. Multiple data

collection methods were used to collect data in the

selected programmes. Developed to ensure consis-

tency of data collection procedures across pro-

grammes, the Case Study Protocol included an

overview of the research project, field procedures,

case study questions and a guide for the case study

report. The use of the Protocol standardised the data

collection procedures and enhanced the validity and

reliability of the case study [40]. Data were collected

through interviews, observations, reading of pro-

gramme documentation, home visits and guided by a

‘Template for Data Collection’ based on the

domains, elements and indicators of the Initial

Framework. An ‘Indicator Summary Template’ was

also designed using Microsoft Access to tabulate the

huge volume of data recorded with respective to each

element and domain. The template provided a matrix

that combined data collected from different sources.

Entering the field. Detailed examination of each

programme was undertaken during a 4-day field

visit. The first author, who is fluent in English,

Mandarin and Cantonese, visited the selected

programmes and examined the objectives and

activities of each programme. She read publications,

service materials and any available programme

reports. Interviews with the programme manager,

CBR workers and service users (in the form of visits

to participant’s home or activity programmes) were

carried out in each programme using a semi-

structured interview. The following was noted in

the process: (1) the objectives of the programme; (2)

the description of activities carried out in the

programme; (3) any stated outcomes and indicators

to describe practice and (4) reasons for the objec-

tives, activities and outcomes for the programme.

Analysing data.

1. All interviews were transcribed. Observations

and findings from the document review were

recorded in the Template for Data Collection.

The analysis of all transcripts and documents

was done in the original language (i.e.,

Chinese) by the primary author with input

from the second author. The second author

provided methodological support and pro-

vided an international perspective where

needed. The third author provided a perspec-

tive from the Chinese side.

2. Two types of data analysis were carried out.

Within-case analysis – combining all sources

of data for each programme; across case

analysis – aggregating data from all pro-

grammes to determine the occurrence of

elements and domains across programmes;

Presence, absence and the most common CBR

elements in the four domains were identified and

tabulated. Data (for example programme objectives

and activities) reported by programmes that could

not be matched to indicators in the Initial Frame-

work were considered as potential new items for

addition to the Framework. To be considered as a

new item, it had to have appeared in any of the

programmes with a clear description of its process

and outcomes by the programme manager, workers

and/or users. As noted, analysis to this point was

conducted in the original language. Once presence

and/or absence of items were determined and a list of

potentially new items was completed, they were

translated to English. All potential items in the

Framework were then examined and edited by the

research team. During the editing process, all data

collected were thoroughly examined by the research

team with regard to organisation, grouping and

wording of domains, elements and indicators in the

Framework. The team reviewed all the items in the

Revised Framework to check whether the descrip-

tions were all clear and relevant. The rationale for

and the nature of change in the Initial Framework

were recorded in written format. Consensus was

reached regarding all modifications in the frame-

work.

Results

Nine programmes were approached with seven

programmes responding positively for this study.

Five programmes among the seven met the selection

criteria for inclusion. The profile of each programme

can be seen in the within-case analysis (see Table

IV). The across case analysis demonstrated that all

elements in the Initial Framework were present in at

least one of the five programmes (see Table IV). Two

items, not originally included in the Initial Frame-

work emerged from the analysis: (1) early interven-

tion and (2) programme sustainability. The

indicators for ‘early intervention’ found in the data

were (1) service user identified in early stage of

illness; and (2) service user received early interven-

tion or treatment. The indicators for ‘sustainability of

programme’ were (1) stable financial resources for

the continuing existence of the programme in the

community; (2) stable human resources for continu-

ing existence of programme in the community and

(3) continuous entry of new service users into the

programme. The frequency of data matching the

CBR framework 1675

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indicators of these new elements (as shown in Table

V) demonstrated the prominence of these elements

in the studied CBR programmes.

The new items were placed into the framework

and all domains, elements and their respective

indicators were again reviewed by the research team.

Renaming of domains, changing of wording and

reorganisation of the elements in the framework was

undertaken. Consequently, five rather than four

domains emerged: (1) Participant Outcomes, (2)

CBR Programme Content, (3) Participant Govern-

ance/Empowerment, (4) Community Ownership

and (5) Programme Operation and Development.

Three original elements, ‘ethical practice’, ‘compli-

ance to relevant service standards’ and the ‘contin-

uous growth and development’, were moved to the

new, fifth Domain. This domain included all

elements related to programme operation, service

management, quality assurance, programme sustain-

ability and continuous development. This domain

was recognised as different from the other four

domains. Although universal to all rehabilitation

programmes regardless of their nature, it was

considered an essential domain in the framework.

Table IV. Programme summary table.

Framework elements

Programme

1 2 3 4 5

Domain One

1.1 Functional independence � � � �1.2 Education � � � �1.3 Economic independence � � � �1.4 Participation in family and community life � � � � �1.5 Physical dimension (Chinese sense) � � � � �1.6 Psychosocial dimension (Chinese sense) � � � � �1.7 Spiritual dimension (Chinese Sense) � � �

Domain Two

2.1 Advocacy � � � � �2.2 Networking � � � � �2.3 Involvement of relatives and families of PWD � � � � �2.4 Involvement of neighbours/community Members � � �2.5 CBR manager and management issue � � � � �2.6 CBR workers � � � �2.7 Compliance to relevant service standards � �2.8 Ethical practices �

Domain Three

3.1 Leadership role in the community � �3.2 Ownership in the programme � � �3.3 Locus of power � � �

Domain Four

4.1 Community support and recognition � � � � �4.2 Continuous growth and development � � �4.3 National/government level support � �4.4 Collaboration and support among different sectors � � � �

�¼Presence of element.

Table V. Programme summary table for the added items and their respective indicators.

Added Elements and Indicators

Programme

1 2 3 4 5

Early detection and intervention

User identified in early stage of illness � � � �User received early intervention for treatment � � � �

Sustainability of programme

With stable financial resource for the continuing existence of the programme in the community � � � � �With stable human resource for the continuing existence of the programme in the community � � �With continuous entry of new service users into the

Programme � � � �

�¼ Presence of elements.

1676 E. Y.-H. Chung et al.

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The two newly added elements were added to the

framework. ‘Early detection and intervention’ was

put in Domain One and ‘Sustainability of pro-

gramme’ was in Domain Five. With the revised

domains, elements and indicators, the Revised

Framework was confirmed and is shown in Table VI.

The frequency of the occurrence of indicators in

the Revised Framework is presented in Table VII to

show the prevalence of items. All indicators were

found in the data of the five programmes. In Domain

One (Participant Outcomes), ‘changed in physical

functioning’ and ‘participant identified in early stages

of illness’ were found to be most common. In

Domain Two (CBR Programme Content), the most

commonly reported items were ‘enhanced family

members’ level of knowledge, coping skills and

techniques’ and ‘worked with community to raise

awareness about the need for and benefits of the

CBR programmes’. In Domain Three (Participant

Governance/Empowerment), ‘people with disabil-

ities (or their family members) participated in

planning, execution and monitoring of interventions

in the programme’ was reported most commonly.

For the Domains Four (Community Ownership) and

Five (Programme Operation and Development), the

most commonly reported items were ‘programme is

known by local community’ and ‘programme showed

a clear organizational framework’, respectively.

Discussion

The process of framework building

This research study is significant in the development

of CBR as it has developed and validated a frame-

work to examine, describe and compare different

Chinese CBR programmes. The framework informs

practitioners, researchers, policy makers and funding

bodies of the core components of CBR programmes

and provides multiple indicators that can be used for

programme evaluation. As suggested by the litera-

ture, there is no single set of indicators to monitor

and evaluate the outcomes of CBR practice due to its

complex nature, hence, a descriptive framework with

multiple indicators to guide evaluation is regarded by

researchers and programme providers as more

valuable than a rigid monitoring system [3,18]. With

the understanding of the essential components of

CBR programmes and the desired outcomes, this

practical evaluation model can be used by research-

ers, service provider and workers while still con-

sidering and respecting the unique context of

individual programmes.

The Initial Framework was built from a synthesis

of the seven conceptual papers regarding CBR

programme evaluation. The use of a taxonomy

embedding the various dimensions (or elements) of

CBR into composite domains enables a simple, but

comprehensive description of a CBR programme

proving useful insight for funders, managers and

workers. Unlike the CBR matrix developed by the

WHO, the framework designed here is not intended

for a quick ‘pick and mix’ according to the preference

of the users. Rather, it aims to identify the core

elements and domains to be included in a CBR

programme. A best practice programme should

demonstrate the presence of some elements in all

domains. The presence of more elements in a

programme indicates the likelihood of achievement

of more successful outcomes by a programme.

The Initial Framework, built on the thinking of

international and Chinese scholars was validated

using 13 international programmes cited in journal

articles. As shown from the tabulated findings, most

elements of the framework could be found in the

pool of selected programmes, warranting further

validation in the real life context of existing CBR

programmes in Chinese communities.

Findings in the final validation study mirrored that

of the first – most elements in the Initial Framework

were present in the five Chinese programmes.

However, two additional elements were identified

and added ensuring its completeness and relevance

in the Chinese context.

The added elements were ‘early detection and

intervention’ and ‘sustainability of the programme’.

Since CBR is usually incorporated into the primary

health care system in China [12], it is obvious that

CBR programmes have a definite role in the early

detection of and intervention for people with

disabilities. Most Chinese CBR programmes tended

to use a door-to-door survey as the initial step in

setting up of the programmes [39]. With a door-to-

door survey, the CBR programmes easily located

people with various kinds of illness and/or disabilities

isolated at home. Necessary interventions could then

be offered. One of the main target populations in the

five CBR programmes recruited in this study was

children with disabilities. Program staff actively

identified those children in the early stages of illness

(or disability) and offered immediate interventions.

The second added element related to the ‘sustain-

ability of the programme’. Some of the programmes

recruited in this phase were funded and organised by

foreign agencies. They employed expatriate staff to

set up programmes in the local community with the

hope that the programme would become sustainable

in the community. Once established, the expatriate

funder expected to invest resources to develop CBR

programmes in other regions. The pre-requisites for

sustainability were regarded as a well-established

system and adequate resources. However, similar to

some of the programmes cited in the CBR literature,

CBR framework 1677

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Table VI. The revised framework.

Core elements Outcome indicator

Domain One – Focus on Participant Outcomes

1.1 Functional

independence

1.1.1 Changed in functional status

1.1.2 Changed in health status

1.2 Education 1.2.1 Changed in educational level

1.2.2 Acquired general/specific skills or knowledge

1.3 Economic

independence

1.3.1 Changed in participation in productive activities

1.3.2 Changed in economic status

1.4 Participation in

family and

community life

1.4.1 Changed in use of the community services and facilities

1.4.2 Changed in frequency and quality of engaging in meaningful activities in various systems

(such as marriage, friendship)

1.4.3 Changed in frequency of participating in cultural/religious activities

1.4.4 Changed in inclusion status

1.5 Physical change 1.5.1 Changed in physical functions

1.5.2 Changed in mobility

1.6 Psychosocial change 1.6.1 Changed in cognitive-behavioural functions

1.6.2 Changed in attitude and motivation

1.6.3 Changed in social skills

1.6.4 Changed in social relationships

1.7 Spiritual change 1.7.1 Changed in sense of serenity

1.7.2 Changed in sense of meaning

1.7.3 Changed in sense of zest for life

1.8 Early detection and

intervention

1.8.1 Participants identified in early stage of illness

1.8.2 Participants received early intervention for treatment

Domain Two – CBR Related Programme Content

2.1 Advocacy 2.1.1 Promoted change of people with disabilities in their participation in various systems

2.1.2 Reduced discriminatory barriers and practices

2.1.3 Changed the law and legislation regarding people with disabilities, policies and disability

2.1.4 Promoted a barrier-free environment for people with disabilities

2.2 2.2 Networking 2.2.1 Provided proper channels for people with disabilities

2.2.2 Carried out networking activities to make proper referrals or service matching

2.2.3 Established profile of networking

2.2.4 Linked with other services or programmes

2.3 Involvement of

relatives and

families of people

with disabilities

2.3.1 Involved families of people with disabilities in programme

2.3.2 Showed positive attitudes towards family members of people with disabilities

2.3.3 Enhanced family members’ level of knowledge, coping skills and techniques to help the

person with disabilities

2.3.4 Provided benefit to family members

2.3.5 Showed satisfaction with programme by family members of people with disabilities

2.4 Involvement of neighbours/community members

2.4.1 Involved community members (volunteers) in programme

2.5 CBR manager 2.5.1 Works with community to raise awareness about the need for and benefits of the CBR

programme

2.6 CBR workers 2.6.1 Liaise between the people with disabilities and services in the community

2.6.2 Worked as support person to advocate participation and inclusion

Domain Three – Participant Empowerment/Governance

3.1 Leadership role in

the community

3.1.1 People with disabilities(or their family members) participated in leadership training

activities

3.1.2 People with disabilities(or their family members) assumed leadership roles in the

community and in appropriate context

3.2 Self-help and mutual

help

3.2.1 People with disabilities(or their family members) participated in self-help activities/

networks

3.3 Autonomy in

Programme

3.3.1 People with disabilities(or their family members) had their voices heard by the programme

3.3.2 People with disabilities(or their family members) participated in planning, execution and

monitoring of interventions in programme

Domain Four – Community Ownership

4.1 Community support

and recognition

4.1.1 Programme is known by local community

4.1.2 Programme is satisfied by local community

4.1.3 Programme is granted political support in the local community

4.1.4 Programme is granted financial/material support in local community

4.1.5 Programme is owned by the local community

(continued)

1678 E. Y.-H. Chung et al.

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Table VI. (Continued).

Core elements Outcome indicator

4.2 National/

Government level

support

4.2.1 Programme is linked to government services

4.2.2 Programme is coordinated by local/central government

4.2.3 Programme is allocated adequate resources from the government

4.3 Collaboration and

support among

different sectors

4.3.1 Programme is collaborated horizontally with related sectors

4.3.2 Programme is collaborated vertically between sectors of different levels (national level,

intermediate level, community level)

4.3.3 Programme is collaborated between various referral services

Domain Five – Programme Operation and Development

5.1 Compliance to

relevant service

standards

5.1.1 Programme identified relevant standards pertaining to service

5.1.2 Programme complied with relevant service standards

5.2 Ethical practices 5.2.1 Programme identified areas of ethical practice that were relevant to service

5.2.2 Programme promoted ethical practice

5.3 Management Issues 5.3.1 Programme showed a clear organisational framework

5.3.2 Programme showed a documented structure in management of human and financial

resources

5.4 Sustainability 5.4.1 With stable financial resource for the continuing existence of programme in the community

5.4.2 With stable human resource for the continuing existence of programme in the community

5.4.3 With continuous entry of new service users into the programme (to demonstrate a need for

such a programme to be sustained in the community).

5.5 5.5 Continuous

growth and

development

5.5.1 Provided staff training activities to promote continuous development

5.5.2 Carried out research activities for programme development

5.5.3 Provided training/materials/reference to staff and to community

5.5.4 Showed new ideas in programme development

Table VII. Checking relevance of indicators in the revised framework.

Indicators Total

1.1.1 Changed in functional status 4

1.1.2 Changed in health status 2

1.2.1 Changed in educational level 3

1.2.2 Acquired general/specific skills or knowledge 2

1.3.1 Changed in participation in productive activities 4

1.3.2 Changed in participation in economic status 3

1.4.1 Changed in use of the community services and facilities 2

1.4.2 Changed in frequency and quality of engaging in meaningful activities in various systems 4

1.4.3 Changed in frequency of participating in cultural/religious activities 3

1.4.4 Changed in inclusion status 1

1.5.1 Changed in physical functioning 5

1.5.2 Changed in mobility 3

1.5.3 Changed in general physique 1

1.6.1 Changed in cognitive-behavioural functions 2

1.6.2 Changed in attitude and motivation 4

1.6.3 Changed in social skills 2

1.6.4 Changed in social relationships 2

1.7.1 Changed in sense of serenity 2

1.7.2 Changed in sense of meaning 2

1.7.3 Changed in sense of zest for life 1

1.8.1 Participant identified in early stages of illness 5

1.8.2 Participant received early intervention for treatment 3

2.1.1 Promoted change for people with disabilities in their participation in various systems 4

2.1.2 Reduced discriminatory barriers and practices 4

2.1.3 Changed the law and legislation regarding people with disabilities, policies and disability 4

2.1.4 Promoted a barrier-free environment for people with disabilities 2

2.2.1 Provided proper channels for people with disabilities 4

2.2.2 Carried out networking activities to make proper referrals or service matching 3

2.2.3 Established profile of networking 1

2.2.4 Linked with other services or programmes 4

2.3.1 Involved families of people with disabilities in programme 5

(continued)

CBR framework 1679

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even the programmes in which local staff had

gradually taken over the management role in the

programme tended to rely heavily on financial

resources from a foreign agency.

Interestingly, two elements included in the Initial

Framework (spiritual status and ethical practice)

based on the conceptual papers were not found in

any of the programmes reported in the literature.

These elements were, however, found in the pro-

grammes who participated in the second validation

study. Both represent somewhat elusive constructs

and authors reporting on programmes may have

lacked tangible ways to measure or report on these

elements. Their inclusion in the framework, together

with potential indicators, may provide a mechanism

for programmes to more easily evaluate and report

existence and/or absence of outcomes related to

these elements.

The final reorganisation of the framework resulted

in elements being assigned to five, rather than four

domains. It is believed that CBR programmes can be

described in a comprehensive way using these five

domains as they include the five principles of CBR as

stated by the WHO, namely, (1) inclusion, (2)

participation, (3) empowerment, (4) self-advocacy

and (5) sustainability [20]. Inclusion is reflected by

the element Advocacy of Domain Two, participation

can be reflected by elements Education, Economic

Independence, Participation in family and commu-

nity life and Leadership Role in the Community.

Elements of Domain Three reflect the principle of

empowerment and self-advocacy. Sustainability of

programmes can be found in Domain Five. This also

suggests that this framework is compatible with the

CBR concepts and WHO principles and CBR

matrix.

Table VII. (Continued).

Indicators Total

2.3.2 Showed positive attitudes towards family members of people with disabilities 4

2.3.3 Enhanced family members’ level of knowledge, coping skills and techniques to help the person with disabilities 5

2.3.4 Provided benefit to family members 2

2.3.5 Showed satisfaction with programme by family members of people with disabilities 2

2.4.1 Involved community members (volunteers) in programme 4

2.5.1 Worked with community to raise awareness about the need for and benefits of the CBR programme 5

2.6.1 Liaised between people with disabilities and services in the community 3

2.6.2 Worked as support person to advocate participation and inclusion 4

3.1.1 People with disabilities (or their family members) participated in leadership training activities 2

3.1.2 People with disabilities (or their family members) assumed leadership roles in community and in appropriate

context

2

3.2.1 People with disabilities(or their family members) participated in self-help activities/networks 3

3.3.1 People with disabilities(or their family members) had their voices heard by the programme 3

3.3.2 People with disabilities(or their family members) participated in planning, execution and monitoring of

interventions in the programme

4

4.1.1 Programme is known by local community 5

4.1.2 Programme is satisfied by local community 2

4.1.3 Programme is granted political support in the local community 1

4.1.4 Programme is granted financial/material support in local community 2

4.1.5 Programme is owned by the local community 1

4.2.1 Programme is linked to government services 2

4.2.2 Programme is coordinated by local/central government 1

4.2.3 Programme is allocated adequate resources from the government 1

4.3.1 Programme is collaborated horizontally with related sectors 3

4.3.2 Programme is collaborated vertically between sectors of different levels (national level, intermediate level,

community level)

2

4.3.3 Programme is collaborated between various referral services 2

5.1.1 Programme identified relevant standards pertaining to services 2

5.1.2 Programme complied with relevant service standards 2

5.2.1 Programme identified areas of ethical practice that were relevant to services 1

5.2.2 Programme promoted ethical practice 1

5.3.1 Programme showed a clear organisational framework 5

5.3.2 Programme showed a documented structure in management of human and financial resources 1

5.4.1 With stable financial resource for the continuing existence of the programme in community 2

5.4.2 With stable human resource for the continuing existence of the programme in community 2

5.4.3 With continuous entry of new service users into the programme. 4

5.5.1 Provided staff training activities to promote continuous development 3

5.5.2 Carried out research activities for programme development 1

5.5.3 Provided training/materials/reference to staff and to community 1

5.5.4 Showed new ideas in programme development 1

1680 E. Y.-H. Chung et al.

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Strengths and weaknesses

One of the strengths of the framework is its strong

foundation built on evidence both from the academic

literature and existing practice. Use of case study

methodology enabled verification of the theoretical

framework with empirical evidence. Evidence shown

in the literature and in real life is regarded as

complementary and this enhanced the internal

validity of the framework. Traditional methods to

test the validity of this framework were not feasible as

no gold standard exists in the Chinese CBR field, in

fact in any branch of CBR. Neither was the

traditional use of an expert panel to check content

and face validity possible. No recognised scholars in

the field of CBR with specific expertise in Chinese

communities could be identified. It is therefore not

surprising that among the many published journal

articles, no single author has frequently and con-

sistently published work within Chinese CBR prac-

tice. However, through the case study method, the

accuracy and relevance of the elements and indica-

tors were checked against evidence collected in

existing CBR programmes.

All data collected during the field visits were coded

and analysed in Chinese as two of the research team

members were from Chinese background. The whole

team was familiar with both Chinese CBR practice

and the Chinese culture. This further enhanced the

validity of the framework as Chinese CBR practice

was viewed from a Chinese perspective that appre-

ciated the unique characteristics in Chinese commu-

nities. Use of the original language transcripts also

reduced translation error or bias.

There were some weaknesses identified in this

process. Since the five programmes were purpose-

fully sampled to explore Chinese CBR practice, it is

possible additional unidentified items may exist and

need to be added to the framework. The inclusion of

more Chinese CBR programmes of a diverse nature

may enhance the inclusiveness of the data.

Upon building of the framework, missing elements

in the framework were identified through verification

in real life settings and the domains, elements and

indicators in the framework were reviewed and

revised. The framework outlined the essential

elements of CBR programmes and these elements

can also be regarded as the elements of a best

practice programme. However, this framework is not

yet sufficient for programme evaluation. Elements of

the framework need to be quantifiable so that best

practice can be measured and documented. Pro-

gramme evaluation is a way of systematically gather-

ing information with the aim of comparing the

situation of a programme to an agreed standard, to

preset objectives, to the situation at an earlier period

or to the situation found in other programmes [17].

Programme evaluation is useful as it helps to

measure and promote quality of service provided.

Conclusion

In conclusion, an Initial Framework with four

domains was built from the review of seven

conceptual papers. The framework was verified with

the CBR programme examples cited in literature and

the content validity of the framework was prelimina-

rily confirmed. The framework was then verified

using a case study approach with five Chinese CBR

programmes. This led to the final framework with

five domains, 25 categorised core elements and 72

indicators. However, using this framework to mea-

sure and document the performance of individual

programmes requires further quantification and

elaboration of items. Measurement scales and

performance standards are required in order to

discriminate best practice. Nevertheless, the pro-

posed Chinese CBR framework does not only

provide a guide for CBR service development and

evaluation in Chinese contexts, but also a direction

for further research.

Declaration of interest: The authors report no

conflicts of interest. The authors alone are respon-

sible for the content and writing of the paper.

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