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Interventions to support employment among
disabled adults in low- and middle-income
countries: a systematic review of the evidence
3ie-LIDC Seminar Series, London
25 March 2015
Janice Tripney, EPPI-Centre, Social Science Research
Unit, UCL Institute of Education, University College London
Contents
1 Contributors
2 Background
3 Methods
4 Findings
5 Discussion
Section 1:
Contributors
Contributors:
– Janice Tripney (UCL Institute of Education)
– Alan Roulstone (University of Leeds)
– Carol Vigurs (UCL Institute of Education)
– Elena Schmidt (Sightsavers International)
– Nina Hogrebe (University of Münster)
– Ruth Stewart (University of Johannesburg)
Section 2:
Background
The problem
• A billion people in the world, 15% of the population, have a disability severe
enough that it limits their participation in family, community and political life.
• 20% of the world’s poorest people are disabled.
• Evidence base demonstrating the relationship between disability and poverty
(disability both cause and consequence of poverty).
• One of the routes into poverty = labour market disadvantage.
• In low- and middle-income countries:
– Up to 80% of people with disabilities of working age can be unemployed, around
twice that for their counterparts in industrialised countries.
– When disabled people do work, they generally do so for longer hours and lower
incomes, have fewer chances of promotion, and are more likely to work in the
informal labour market.
• Disability is not mentioned in any of the 8 MDGs set in 2000.
Action (policy and research)
• Increasing recognition that disability is a key threat to reaching the
MGSs. People with disabilities’ life chances are relevant to all eight of the
MDGs, making it an issue central to reducing poverty.
• Framework for action: The UN Convention on the Rights of Persons with
Disabilities came into force in May 2008. Countries ratifying the Convention
must ensure that international development programmes are inclusive
of, and accessible to people with disabilities.
• World Report on Disability (2011): Produced jointly by WHO and the World Bank, this
report “provides the best available evidence about what works to overcome barriers to health care,
rehabilitation, education, employment, and support services, and to create the environments which
will enable people with disabilities to flourish”.
• Other reviews: – Same topic (some broad, some narrow) but not LMIC;
– Fewer LMIC reviews; mostly non-systematic; although one ongoing Campbell/Cochrane
review focusing on CBR (broad range of outcomes).
This systematic review
Funded by Sightsavers International and 3ie.
Main objectives:
a) To assess the evidence on the effects of interventions on labour
market outcomes for disabled adults in LMICs.
b) To assess if effects are moderated by characteristics of the
participants, interventions, and/or settings.
c) To provide an explanation for the intervention effects by
examining what participants in the included studies reported about
why the interventions did, or did not, work for them.
This presentation = work in progress on this review.
The review is not yet completed. It is registered with the Campbell
Collaboration and will be published in 2015 in the Campbell
Library (where you can find the protocol, see below).
Tripney J, Roulstone A, Vigurs C, Schmidt E, Moore M, Stewart R
(2013) Protocol for a Systematic Review: Interventions to improve
the labour market situation of adults with physical and/or sensory
disabilities in low- and middle-income countries. Campbell
Systematic Reviews.
http://www.campbellcollaboration.org/lib/project/263/
Section 3:
Methods
Selection criteria
• Evaluate the impact of an intervention.
• Investigate outcomes for adults aged 16-65 years with
physical and/or sensory impairments associated with
disability.
• Utilise experimental or quasi-experimental design (including
single-group pre-test/post-test design).
• Examine at least one labour market outcome.
• Published 1 January 1990 to 31 December 2013.
No language or form of publication restrictions applied.
All forms of publication were eligible.
Specific exclusions
Studies focused solely on:
(i) People with mental health conditions and/or intellectual
impairments;
(ii) Those with chronic illnesses that predominate in later life (e.g.,
chronic obstructive pulmonary disease, cancer, stroke, and renal
disease) or HIV/AIDS (on the grounds that these groups have
different rehabilitation needs);
(iii) Persons with minor health problems, such as fractured bones or
hayfever (so evaluations of RTW interventions for employees on
short-term sick leave were outside the scope of the review).
Methods - quick overview
• Registered with Campbell Collaboration.
• Extensive search (10 major bibliographic databases, 32
specialist databases and library catalogues, 59 websites,
6 journals, reference lists, citation checks, search
engines, contact with relevant stakeholders).
• A staged screening of titles/abstracts and then full-texts
(FTS conducted by two independent reviewers).
• Two reviewers independently extracted data and
assessed risk of bias.
• Narrative approach to synthesis.
Section 4:
Findings
Total records screened on
title and abstract after
duplicates removed
Electronic search: N = 20,417
Full text reports retrieved
and screened
Electronic search: N = 347
Non-electronic search: N = 132
TOTAL = 479
Included in the review
13 studies (in 12 study reports)
Excluded on title and
abstract
Publication date: N =
404
Study design: N =
17,599
Population: N = 855
Not LMIC: N = 940
Outcomes: N = 272
TOTAL: N = 20,070
Excluded on full text
Publication date: N = 10
Study design: N = 146
Population: N = 47
Not LMIC: N = 214
Outcomes: N = 43
Intervention type: N = 4
Unavailable: N=3
TOTAL: N = 467
Figure 1: Size of the literature reviewed
Descriptive analysis
• Few studies
• Poor methodological quality
• Heterogeneous
13 studies (in 12 reports) published between 1992
and 2012.
All ranked high risk of bias.
Heterogeneous in terms of:
• Geographical setting
• Study design/methods
• Type of intervention
• Target group
• Outcomes
9 countries in Asia, Africa and
Latin America were represented
in Asia, Africa and Latin America: Counties in xx were represented.
Bangladesh (3 studies)
Brazil (2 studies)
China (1 study)
India (3 studies)
Kenya (1 study)
Nigeria (1 study)
Philippines (1 study)
Vietnam (1 study)
Zimbabwe (1 study)
Different methodologies to
construct the counterfactual
• 5 studies - concurrent comparison group (some
used statistical techniques control for bias)
• 1 study - regression estimation methods applied
to pre-test/post-test data
• 7 studies - single-group pre-test/post-test design,
with no statistical controls
14 interventions (in 13 studies)
• Treatment & therapy (n=4)
• Assistive devices and accommodations
(n=2)
• Occupational rehabilitation services (n=4)
• Financial services (n=1)
• Community-based rehabilitation (n=3)
14 interventions (in 13 studies)
• 12 were multi-component programmes.
• All were specifically targeted at disabled
people.
• 8 aimed to improve employment outcomes.
• NGOs were the most common source of
funding.
• Designed & implemented on different scales.
Target group (of reviewed
interventions)
• Physical impairments (7 interventions,
majority targeted at specific impairments)
• Visual impairments (3 interventions)
• Any type of impairment (4 interventions)
Outcomes
• All studies measured labour market
outcomes.
• Four studies measured additional
outcomes: health-related (n=4); social
(n=4); and empowerment-related (n=1).
Outcomes / target group Interventions for persons with physical impairments (n=7)
Interventions for persons with visual impairments (n=3)
Interventions for persons with any type of impairment (n=4)
Motivation to work
1 study
Professional social skills
1 study
Paid employment 6 studies 1 study 4 studies
Self-employment 2 studies
Hours worked 1 study
Income 2 studies 1 study
Synthesis of results
• The research was heterogeneous, making
overall synthesis of results challenging.
• Our approach was to group by outcomes,
to address a number of sub-questions.
Objective (a): To assess the
evidence on the effects of
interventions on labour market
outcomes for disabled adults in
LMICs.
(a.1) What effects do
interventions to support
disabled persons have on paid
employment?
Paid employmentStudy Country Design Intervention Target
group
Direction
of effect
Guarino et al.
(2007)
Brazil QED Lower limb
prosthesis
Physical
impairment
+
Momin (2004) Bangladesh QED Occupational
rehabilitation
programme
Physical
impairment
+
Hansen et al.
(2007)
Bangladesh QED(SGPPT) Occupational
rehabilitation
programme
Physical
impairment
+
Metts & Olsen
(1995)
Kenya QED(SGPPT) Disabled Persons
Loan SchemePhysical
impairment
+
Shore &
Juillerat (2012)
India
VietnamQED(SGPPT) Wheelchair Physical
impairment
+
Tang et al.
(2011)
China QED(SGPPT) Occupational
rehabilitation
programme
Physical
impairment
+
Paid employment (cont.)Study Country Design Intervention Target
group
Direction
of effect
Finger et al.
(2012)
India QED Cataract outreach
programme
Visual
impairment
+
Biggeri at al.
(2012)
India QED Community-based
rehabilitation (CBR)
Any type of
impairment
+
Lagerkvist
(1992)
Philippines QED(SGPPT) CBR Any type of
impairment
+
Lagerkvist
(1992)
Zimbabwe QED(SGPPT) CBR Any type of
impairment
+
Nuri et al.
(2012)
Bangladesh QED(SGPPT) Occupational
rehabilitation
programme
Any type of
impairment
+
(a.2) What effects do
interventions to support
disabled persons have on self-
employment?
Study Country Design Intervention Target
group
Direction
of effect
Metts &
Olsen (1995)
Kenya QEDSGPPT Disabled
Persons Loan
Scheme
Physical
impairments
+
Momin
(2004)
Bangladesh QED Occupational
rehabilitation
programme
Physical
impairments
+
Self-employment
(a.3) What effects do
interventions to support
disabled persons have on
income?
Study Country Design Interventio
n
Target
group
Direction
of effect
Shore &
Juillerart
(2012)
India
Vietnam
QEDSGPPT Wheelchair Physical
impairments
+
Metts &
Olsen (1995)
Kenya QEDSGPPT Disabled
Persons
Loan
Scheme
Physical
impairments
+
Finger et al.
(2012)
India QED Cataract
outreach
scheme
Visual
impairments
+
Income
(a.4) What effects do
interventions to support
disabled persons have on
number of hours worked?
Study Country Design Interventio
n
Target
group
Direction
of effect
Metts &
Olsen
(1995)
Kenya QEDSGPPT Disabled
Persons Loan
Scheme
Physical
impairments
+
Number of hours worked
(a.5) What effects do
interventions to support
disabled persons have on
motivation to work?
Study Country Design Intervention Target
group
Direction
of effect
Eniola &
Adebiyi
(2007)
Nigeria ED- 2 therapeutic
programmes
Visual
impairments
+
Motivation to work
(a.6) What effects do
interventions to support
disabled persons have on
professional social skills?
Study Country Design Intervention Target
group
Direction
of effect
Pereia-
Guizzo et al.
(2012)
Brazil QED Therapeutic
professional
skills
programme
Physical
impairments
+
Professional social skills
Objective (b): To examine
variability in treatment effects
(e.g., by gender, type of
intervention).
• Seven of the 13 included studies explored between-study
variation in treatment effects.
• The variables considered were gender (three studies),
size of business (one study), type of intervention (one
study), severity of injury (one study), and programme
duration (two studies).
• Four of the six studies tested whether results were
statistically significant.
Objective (c): To provide an
explanation for the intervention
effects.
What were participants’ observations, experiences and views
about why the intervention they received had worked for them?
(2 studies)
• General health & well-being (1 study)
• Cooperation in the family/community (1 study)
• Motivation (1 study)
• Attitudes in the workplace (1 study)
• Attitudes in the community (1 study)
• Appropriateness of the training (1 study)
What were participants’ observations, experiences and views
about why the intervention they received had not worked for
them? (3 studies)
Discriminatory attitudes of prospective employers (1 study)
Attitudes of family members and/or wider community (2 studies)
Health and well-being (1 study)
Physical inaccessibility (workplace and/or broader environment) (2
studies)
Lack of ‘start-up’ funds for self-employment (1 study)
Shortcomings of the training (i.e., mismatch between it and
participant’s skills, abilities and financial resources) (1 study)
Lack of education and skills (1 study)
Motivation (1 study)
Section 5:
Discussion
• The evidence in general showed positive results, but needs to be
treated with a great deal of caution.
• It is not possible to draw conclusions about the effectiveness of
the reviewed interventions, nor who is likely to benefit and who
will not. This aligns with earlier reviews of the LMIC literature, but
contrasts with the evidence base pertaining to many aspects of
vocational rehabilitation in high-income countries.
• The main value of this review, therefore, lies in mapping the
terrain.
• ??? On the whole, little evidence of programmes “changing
the environment” (most still based on medical model?)
Gaps in terms of programmesThe review found:
No evaluations of ‘mainstream’ interventions (all the reviewed
interventions were targeted at disabled persons).
No evaluations of interventions solely for the hearing impaired.
No evaluations of many other types of interventions with the potential to
improve labour market outcomes, including micro-finance programmes,
vouchers to facilitate access to education and training, employer
subsidies, tax breaks, advocacy campaigns, legislation and regulations,
adaptations in the workplace (physical and non-physical), tailored
transport schemes, assistive devices for the visually impaired, ……
Are these types of intervention implemented in LMICs and there are no
impact evaluations, or do they just not exist?
Gaps in terms of impact
evaluations
One example = CBR programmes
• CBR initiated by WHO in 1978 and actively promoted.
• Yet for the 24-year period (1990-2013), our review identified only
three impact evaluations (two published in 1992 and one in
2012).
• Personal observation that evaluations of CBR tend to focus on
processes (how many people are covered by the programme,
etc.) rather than impacts.
Group discussion.....
Thanks for listening.
For further information,
please contact:
Jan Tripney
