DEVELOPMENTAL ARTICLES

REFLECTIONS ON POVERTY AND DISABILITY:
A REVIEW OF LITERATURE

Marlies van Kampen^*, Ingrid M. van Zijverden, Tony Emmett^**

ABSTRACT

This study carried out a review of literature describing the relationship between poverty and disability, in order to establish the evidence base for this relationship. Several authors seem to accept the existence of this link, even without a sound research basis. Articles and books were scrutinized to find out what sources were used in these publications to conclude that there was evidence for a strong relationship between disability and poverty. Peer-reviewed articles were used as much as possible.

It was found that cultural determinants play the greatest role in the process of disability leading to poverty. Monetary factors are also essential determinants when it comes to poverty as a result of disability. The relationship between disability and poverty seems to be a vicious circle. Most of the literature concerning poverty and disability is based on non- rigorous (literature) studies.

Relating disability to poverty and vice versa is a complex matter that needs to consider several interdependent factors that influence this process.

INTRODUCTION

It is widely accepted that poverty and disability are somehow linked. Much has been written about the existence of a two-way relationship between those two issues; poor people have more chance of becoming disabled and disability adds to the risk of poverty (1,2). However, there often seems to be lack of scientific evidence for the statements and conclusions made in most publications. Most of the sources used in the articles appear to be less accredited or even anecdotal. It also appears that most studies done on poverty either do not consider disability as a determinant or result of poverty or use different definitions for both issues, making it impossible to compare international data (3). One article contains a good review of the literature (1) about the relationship, but most of the reviewed sources were studies carried out in Western countries, as there was limited amount of accessible data and information on disability in developing countries (1,3).

The aim of the present literature study is to provide a more rigorous basis for the existence of a relationship between poverty and disability. This report, executed during the first part of 2006 for the South African-Netherlands Research Programme on Alternatives in Development (SANPAD) was prepared as part of a two-year research project on the effects of inclusion policies of the South African government as well as (international) non-governmental organisations (NGOs), on the lives of disabled people in South Africa. This research is a collaborative study of the University of Pretoria as lead investigator, and the University of Amsterdam and University for Applied Health Sciences in Leiden, in The Netherlands, playing a supportive role.

METHOD

Definitions of poverty and development, as well as disability and impairment were searched on the Internet and in various publications. Google Scholar was used to trace articles and books, and some articles were also found in the Royal Library in The Hague. Several terms (poverty, disability, handicap, impairment, discrimination, exclusion, stigma, development etc.) were used to search for articles on the link or definition. Articles used were first scrutinized on sources referring to a possible link between disability and poverty and sources that were seen as reliable. The authors made use of the following list with screening questions in order to scrutinize the articles for their usability in this particular literature study, and their reliability and validity.

• What is the central research problem?
• What type of research instrument was used?
• What type of research design was used?
• What is the relationship between the research problem and the research design?
• What is the methodology of the research?
• Are correct conclusions made? → Internal validity
• Can results/conclusions be generalized? → External validity
• What is the quality of results? → Objectivity

DEFINITIONS

Prior to making any comparisons on existing data on incidence of poverty and disability, it is important to define what is understood by poverty and disability. There are many different definitions used in research studies that focus on disability and poverty. This is one of the reasons why there is so little internationally comparable information on this issue (4). For comparative research, it is essential that every country uses the same definition of poverty and disability and the same method for estimation of occurrence, so that the country can measure any progress and plan its poverty programme accordingly (5).

Defining poverty (and development)

"The way that poverty is conceptualised is inherently about value preferences that vary between individuals, organisations and societies" (6).

The United Nations describes poverty as: 'the denial of opportunities and choices most basic to human development - to lead a long, healthy, creative life and to enjoy a decent standard of living, freedom, dignity, self-esteem and the respect of others' (5).

The World Bank created a more "practical", but simplified monetary indicator to identify poverty using a 'poverty line' of income of less than US$1 a day (7).

In order to define poverty it is important to realize that poverty has a multidimensional nature, and to first consider which factors indicate poverty. In the different definitions that exist, many different factors are being mentioned, which makes it hard to indicate one specific definition as being the best or most accurate one. Mention is also made of two sorts of poverty, namely absolute poverty (measured against the bare minimum necessary to maintain a person's physical efficiency) and relative poverty (measured against the average living standard of a particular society) (8).

The CPRC states in its report on Chronic Poverty, that there is no objective way of defining poverty (6). Many countries have defined their own poverty lines, which would represent the level of income or consumption necessary to meet the minimum requirements, such as clothing, housing and health care. Most countries use the minimum amount of nutritional intake needed in order to measure poverty, but different nutritional norms are used. When every country adopts its own poverty line, it becomes impossible to make cross-country comparisons with regard to poverty, and someone defined as poor in one country, might not be poor according to standards used in other countries (7).

In order to be able to make the cross-country comparisons, the World Bank had introduced an international poverty line (mentioned in the World Development Report, 1990), as being an income of (less than) US$1 a day, expressed in 1985 Purchasing Power Parity (PPP) of dollars and referring to household expenditure per person (6,8). The use of official exchange rates to convert national currency data to US dollars would however not reflect the relative domestic purchasing powers of currencies (7). The PPP reflects how much currency in one country is required to purchase the "same" amount of goods and services as can be bought with one unit of the currency of the base country and is influenced by information about prices and quantities of commodities consumed in third world countries (9).

Not every one agrees with the international poverty line (IPL) as being the right definition for, and tool to identify poverty. Several authors (9,10) report on the deficiencies of the World Bank Poverty Line. The biggest point of criticism is that the IPL only measures poverty in terms of money ('income'). Reddy and Pogge (9) express their criticism with the "money- metric" methodology of the IPL and state that the World Bank "...uses an arbitrary international poverty line that is not adequately anchored in any specification of the real requirements of human beings"(9). Comments are also made about the validity of existing comparative studies. The CRPC states in its 'Global chronic poverty in 2004-2005'-report that: "The validity of cross-country comparisons depends on the accuracy with which these PPP exchange rates are computed, as well as the comparability and reliability of the income or consumption data. Both of these cause serious difficulties. While the currently quoted figures in the 2003 World Development Indicators enable comparisons to be made, there are serious questions about the figures in a number of instances (e.g. Nicaragua, Pakistan, Uganda)"(6).

Reddy and Pogge (9) argue that an IPL should be substantially higher, for a human being to be able to meet the elementary requirements of living (such as food, housing, clothing, etc.), given the example of the United States. The US Department of Agriculture estimates $3.51 per person per day as the lowest cost required to meet minimal nutritional standards in 1999, in the USA. This concerns only food costs. The poverty line of $1 a day would be an underestimation of the numbers living in poverty in the US. Therefore the question whether international comparison can be made based on the IPL, remains critical (9,11).

As shown, analysis at this point is primarily undertaken of money-metric and other quantitative indicators, concerning the research of chronic poverty (12). This appears to be the easiest solution when measuring poverty, for it is convenient to compare figures that already exist, without having to 'translate' someone's feelings, thoughts and experiences as expressed in quality of life studies. It however, remains questionable if only the comparison of money- metric data gives a good reflection of the reality of lives of scores of people living in poverty.

More attention is given by some authors to the fact that poverty is not only a matter of lack of money, but concerns also social exclusion and powerlessness, arguing that national development policies cannot solely be based on generating more income (4,13). More recently, the World Bank has started to describe poverty in terms of material deprivation, low levels of education and health, exposure to vulnerability and risk, and voicelessness and powerlessness. It is good that these issues are now being taken into consideration, but they still lack the precision and comparability that is shown by income/consumption measures. Since the issues mentioned deal with for example the quality of life, it is hard to quantify them in order to make cross-country comparisons (12). The United Nations has defined poverty as the lack of what is basic to human development, similar to what is being described above (13). Basic needs include not only food, water, shelter and clothing, but also access to other assets or services like education, health, credit, participation in political process, security and dignity (12). The UN states in their World Development Report 2004, that measuring human development extends beyond the national income accounting approach. They argue: "Although useful, national income figures fail to reveal the composition of income or the main beneficiaries of economic growth. In some instances, people may value better nutrition and health services, increased access to knowledge, a greater voice and accountability in decision-making, more secure livelihoods, or better working conditions above absolute income gains. However, these human development gains are not clearly reflected in income or economic growth statistics" (13).

It is evident that more research is needed in order to find ways and means to concretise all aspects that should be considered, and to develop indicators and measure them, in order to get a full view and understanding of poverty.

Defining disability

Poverty is not the only issue that is hard to define. Defining disability is also quite a complex issue, considering all the different aspects, values and interpretations (14). When looking at the term throughout the ages, several attitudes towards disability emerge. It evolves from an 'evil spell' in ancient Greece, and a 'jester' or 'representation of poverty' in the Middle Ages, to 'representation of the irrational; that which cannot be assimilated to a norm without undermining it' in the Classical Period (15).

Till recently, disability used to be seen primarily as a medical condition, with the problem located within the individual (16). Though disability indeed results from physical or mental impairment (being the medical part), it also concerns social and health implications, which is the reason for disability activists to have changed the emphasis from disability as a medical condition to disability referring to socially imposed restrictions, that is, the system of social constraints that are imposed on those with impairments by discriminatory practices of society (17). This 'social model of disability' draws a clear distinction between impairments and disability (18,19).

A more recent definition that is increasingly being accepted and used is stated in the International Classification of Functioning, Disability and Health (known as ICF), a modified version of the International Classification of Impairment, Disability and Handicap (ICIDH) (20, 21).

Although the ICF is a health and health-related classification, it is also used by other sectors such as insurance, social security, labour, education, economics, social policy and general legislation development, and environmental modification. It has been accepted by the World Bank and many other key development organisations and it seems to have become the gold standard for understanding and measuring the extent of disability. DPI (Disabled Peoples' International) are utilising it and the United Nations have also accepted it as one of the social classifications. The ICF incorporates the Standard Rules on the Equalization of Opportunities for Persons with Disabilities. Thus it appears that the ICF provides an appropriate instrument for the implementation of stated international human rights mandates as well as national legislation (21,22,23). However, in one of the publications of disability KaR there is some criticism on the ICF definition. The authors state that the ICF represents little more than medical model thinking clothed in social model language, particularly as many professionals continue to pay little attention to environmental impacts and focus instead on impairments (22, 24).

Despite the criticism, the ICF is becoming more accepted as a global and universal tool. The World Health Organisation argues: "The ICF was developed and refined through a 10 year process involving over 65 Member States, which lead to a broad-based consensus about the terminology and classification, and used more commonly in several countries. Extensive field testing provided for cross-cultural comparability making the ICF a truly international standard for functioning and disability classification" (25).

Models of disability

Several models of disability exist that describe the way people may think about disability. Those ideas on disability can differ from person to person and may be influenced by their belief systems, or culture.

Medical model

In this model, disabled people are defined by their impairment and medical/technical solutions offered to alleviate their condition. Disabled people are seen as 'ill' or 'sick' in this model and are expected to be 'cured' or 'normalised'. Medical professionals are seen as 'disability experts'. According to this model, the disabled person is the one with the problem, and interventions are provided for the person to be rehabilitated, or to find a way to deal with the problem. This model concerns an individualistic approach that does not consider social barriers (4, 26).

Charity model

This model is condemned by critics as disabling, because disability is seen as a personal disaster, disabled people are seen as tragic victims to be pitied and helped by charity in order to survive. Those who manage to be happy and achieve their goals despite their disability, are seen as brave. Disabled people are expected to be humble and grateful for what they receive and need charity in order to survive. There is no question of recognition of equal rights or the role that discrimination plays (4, 26).

Social model

This model is based on rights. It considers disability as the social consequence of having an impairment. The inequities faced by disabled people can only be overcome if society becomes inclusive. If the problem lies with society and the environment, then society and environment have to change. In this model, disability is not seen as something invoking pity or in need of cure. It implies that the lives of disabled people will improve when attitudinal, physical and institutional barriers are removed. Equality for disabled people is seen in the same light as equality for other under-represented groups (4).

Religious model

In a Western Judea-Christian society, the roots of understanding bodily difference have been grounded in Biblical references, the consequent responses and impacts of the Christian church, and the effect of the enlightenment project underpinning the modern era. These embodied states were seen as the result of evil spirits, the devil, witchcraft or God's displeasure. Alternatively, such people were also signified as reflecting the "suffering Christ", and were often perceived to be of angelic or beyond-human status, to be a blessing for others.

Therefore, themes which embrace notions of sin or sanctity, impurity and wholeness, undesirability and weakness, care and compassion, healing and burden have formed the dominant bases of Western conceptualisations of and responses to, groups of people who in a contemporary context, are described as disabled. In the past, various labels have been used for such people. These include crippled, lame, blind, dumb, deaf, mad, feeble, idiot, imbecile, and moron (26).

Most (science-based) writings relate to the Christian Religion. Other religions, for example traditional African religions or Islam also have certain visions of disability, which might be quite similar to the (historical) Christian beliefs. However, searching for a 'religious model' resulted primarily in the (historical) Christian view, which is the reason that only the Christian vision is mentioned in this article. Further research should be done before mentioning views of other religions based on scientific research.

Generally, it appears that different religions have inconsistent approaches to disability, as well as different people within each religion, ranging from acceptance of people with disabilities as a gift from god(s) and therefore special, to rejection of those with disabilities as a punishment from god(s). While this varies by religion and family, attitudes can also vary by the type of disability (27).

Devlieger et al have expounded further on different models and the dimensions in which they differ from each other (28).

RELATING POVERTY AND DISABILITY

'The analysis of the relationship between disability and economic status should be interpreted as an association and not necessarily a cause or consequence' (29).

Having reflected on the definitions of both poverty and disability and all the different aspects that should be taken into consideration, an analysis is made of publications referring to the possible link between the two issues.

Several authors mention social exclusion or isolation as a result of disability. A research from sub-Saharan Africa (30) showed the effect of stigma on people with epilepsy. Women with epilepsy were considered as poor wives by the community, for they were not able to cook or take care of the children and in polygamous regions, would therefore not be likely to become first wives. This has its consequences, because unmarried females are particularly vulnerable to sexual exploitation, physical abuse, and extreme poverty (30). This study indicates an indirect link between disability and poverty, where disability leads to stigma, and therefore to exclusion, which subsequently can cause poverty. Stigma seems to be the linking determinant in this case. The example shows that social values of a community appear to be crucial when it comes to disability as a cause of poverty, for stigma and exclusion can only exist because of the notions of the people. Yeo argues that it depends on the society and culture how someone with an impairment feels. In most societies people with impairments are excluded and, according to Yeo, this is what disables them (4,11).

In Uganda, a study focused on the issues of disability and poverty. One of the conclusions of this study was that disabled people face various forms of exclusion, isolation and neglect and this condemns them to perpetual (chronic) poverty. Another conclusion is that different categories of disabled people have different needs and are affected differently by poverty, which supports the statement that social values are very important when it comes to considering who is disabled (19).

Another example concerning disability and social exclusion is the birth of a disabled child in most of the developing countries. This is often seen as a tragedy, a curse or witchcraft (considering the religious model). In developing countries children are supposed to take care of their parents and family in the future. When a disabled child is born, or a child gets disabled, he/she needs more care than a child who is healthy and moreover, he/she will not be able to fulfil assigned tasks in the future. Parents often think it is God's will to have a disabled child and sometimes they refuse to give the child treatment, because of this reason. Other factors like shame, ignorance and lack of monetary means to invest in the child also play a part. Most likely the child will not be sent to school, for which parents have several reasons. First, they would think their child will not be able to manage, even when the child has only a physical impairment. Second, they might think it is not worth their money. School is expensive and they might rather spend their money on the healthy siblings. Subsequently the child will be excluded from 'normal' social life. In the future, the child will therefore not be able to find a job and thus support his/her parents, because of the lack of education (4,19).

A study of eleven household surveys done in nine developing countries confirms the earlier statement with regard to education, arguing that youth with disabilities are less likely to start school, and have lower transition rates in some countries, which results in lower education levels (29).

Somehow, there seems to be a vicious cycle. Several articles illustrate this. One of them is about the barriers to care in (rural) Zambia. Health care is an expensive service that many people in Zambia cannot afford (31). The few people who are able to pay for the transportation and medical fees (most rural economies rely on a bartering system, so the expenses exceed most people's monetary abilities) can be referred to a medical centre with imaging capabilities and neurological expertise. Most people with complaints will not immediately consult a physician, most of the times due to lack of money. For example, people with headaches caused by mass lesions are often seen by the physician when visual loss has already occurred, or seizures become manifest along with progressive neurological deficits. Delayed evaluation (in this case due to financial issues) often results in advanced disease, no longer amenable to treatment.

The symptoms and consequences of neurological disease will make a person socially and economically vulnerable, which in itself limits their access to care even more (31). This case study shows that poverty may lead to delayed evaluation by a physician and therefore may cause disability. This disability may exclude people socially and economically, which makes them poorer and gives them even less access to care, which in turn may aggravate their disability.

A study done in Cambodia shows that poor people lack access to basic health care which means that simple infections, illnesses and injuries could result in permanent disability because they go untreated or are mistreated (32). All informants who became disabled later in life indicated that they became poorer after they were disabled, and most said they had become much poorer. This might be explained by the fact that disability can have an impact on a person's ability to work and earn a living. It can be illustrated by a case study about a woman who had rice fields and several animals. After carrying a heavy bag, she had a back injury; the doctor gave her an injection, which paralyzed her. She was not able to carry out her work anymore, so she had to rent out her land and sell her animals. The only income she then had was by renting the land. Another reason for this woman becoming poorer is that she was not able to come out of her house to meet and see other people (32). Being poor is seen as a multidimensional concept.

A Chinese study analyses the relationship between poverty and Tuberculosis (TB) (33). Poverty appears to be a key risk factor for TB. This disease has two epidemic profiles; one endemic form, of which the incidence rates vary, depending on access to care, food and hygiene of the population and an epidemic form, within the population at risk: prisoners, people in institutions etc. (34). Poor people are specifically vulnerable when it comes to the endemic form. In this example poor people seem to delay consultation, not only because of the cost of the TB-care, but also because the lack of knowledge of TB and fear of social isolation or stigma (33).

Another disease that is strongly related to poverty is malaria (35). Poverty can keep people from using available methods of cure and control (such as mosquito nets) (36). This can lead to disease in children, whereby cerebral meningitis is a specific threat leading to neurological disorders such as cerebral palsy or even death.

Poverty also appears to be a high risk factor for unintentional injuries, resulting in disability. Research conducted in Vietnam, shows that poverty increases the chances of injuries at home (specifically in children and elderly people), at work (specifically in adults between 15- 59 years) and for "other" injuries (37). In this study, it is stated that poor adults are at a greater risk of injuries at work, because people living under harsh economic conditions are willing, or forced, to accept jobs that expose them to extremely high risks or unsafe conditions. Their housing and traffic environments are also often very risky (38, 39).

Research done in Cambodia also showed that poor people appear to be forced to use less safe methods of transport and to work in risky environments (32).

Poverty appears to have its effect on nutrition and thus health and related disability. Booysen and Burger state that there is increasing evidence that poor nutrition in childhood is associated with both short-term and long-term adverse consequences such as poorer immune status, higher incidence of caries and poorer cognitive function and learning ability (40).

HIV/Aids has also been described as a disease of poverty, in close relation with Tuberculosis (41). A research on HIV-infected women in India showed that social position can be a key cause of HIV/Aids in women. Low economic status (due to circumstances or the loss of a primary wage earner) causes vulnerability, which increases the risk of becoming subject to sexual violence and forced prostitution. These are both major contributing factors for HIV- infection (42). After contracting the disease, the women experienced less socioeconomic, spiritual and family support. The worsening of the physical symptoms, emotional and mental anguish forces them into isolation, that negatively affects their mental health (42). People with HIV/ Aids also have compromised immune systems that cause them to be easily infected with the TB virus, developing active TB. This has caused an exacerbation of the TB-epidemic (41, 43).

One third of the increase in the number of TB cases internationally in the past five years has been ascribed to HIV. Diagnosis of TB is likely to be equated with HIV. This can result in discrimination, which can be the reason for people to refrain from consultation (41).

Social exclusion can be considered as a form or consequence of discrimination that comes with social values concerning impairment. It has appeared to be the essential link between disability and poverty.

Articles on research done in high income countries also claim that disability leads to discrimination. In the United States for example, it appears that many people with disabilities experience problems with finding employment (44).

Research done in South Africa showed double discrimination of black wheelchair-bound adults during the Apartheid era. It was found that these people lived in poverty and isolation. A small percentage found employment or had received some form of financial compensation for their injury or disability grants (45).

DISCUSSION

Though many articles consider the possible link between poverty and disability, it is not always very clear where and how they got their (scientific) evidence. In order to make a well-founded analysis of the relationship between poverty and disability, the authors had to scrutinize the references and track the primary sources of all articles. In several articles 'visions' were given about the possible link, but most of the ones read by the authors seem to have not been based on scientific research, considering the sources used.

Eventually, the authors searched for articles that did not necessarily look for a link between the two issues, but considered one aspect (for example epilepsy, when it concerns disability) and the issues related to that one aspect (for example poverty). This means that only those articles were studied that really considered the detailed aspects of research methodology instead of giving general viewpoints without providing at least some basis for validity checks.

One general problem encountered was the fact that several different definitions were used for poverty and disability. This made it hard to compare the different results and conclusions of the various studies. The authors decided to only analyse those articles that used similar definitions.

It seems to be clear for most people that there is a link between poverty and disability. The authors however found that many articles were based on assumptions about the link (without reference to evidence) or just based on anecdotal information. Most of the articles had references whose sources were mostly not referring to scientifically sound research. In many articles the same arguments were used in order to prove the link; possibly because similar - not primary - sources were used in these articles. This somehow implied high quality because there is at least consistency in the explanation of these sources. However, when scrutinizing for validity and reliability, there sometimes was little of either. Many articles appeared to have been based on not well-founded statements by other researchers.

Several of the articles by World Bank and UN, found during this research, were also - partly - based on anecdotal information. Probably other authors also take the "evidence" from such global organisations for granted and do not take a critical view of the reports coming from these bodies.

Some other articles studied seem to have been based on scientific evidence, but some of articles belonging to the primary resources could not be located by the authors. Subsequently the authors were not able to verify the level of evidence of these articles and see whether these were based on primary resources, or again only based on opinion.

Elwan stated in her 'review of the literature' that she was not able to find articles in which a research study was conducted in developing countries. Miles (3) refers to his own bibliography, where a lot of articles are mentioned. The authors of the present study tried to track those articles, in order to use them for this study. Unfortunately, it was indeed very hard to trace the full text articles (through means of internet), mostly because of the year in which these articles were published, and some of them not being formally published. The authors did not have the means (funds and time) to trace the original and primary sources and therefore do acknowledge that there are limitations to this literature study.

The authors have tried in this study to make use of mostly primary resources. These resources, however, concern local studies most of the times. There is of course the doubt if it is possible and correct to generalise the results of local research studies, in order to provide evidence for the link between poverty and disability at a global level. Cultures differ from one to the other. Attitudes towards people with disability may vary from country to country and even within countries. In most countries attitudes result from cultural, traditional and social values that are prevalent in the community. It may very well be that the linking determinants in the relationship between poverty and disability may differ between countries as well.

Not all the references used in this literature study were checked for validity and reliability by using the probing list for screening. This was due to time constraints and difficulty in tracing the primary references. However, the authors tried to scrutinize the articles and their references as much as possible. The reliability may therefore be compromised to some extent.

CONCLUSION

The question whether disability leads to poverty seems culture-related and depends strongly on social values that exist in society. Being disabled also often means being stigmatized (which may lead to exclusion). Subsequently stigma or exclusion makes people more vulnerable towards poverty. Therefore there is a strong indication that disability can indeed lead to poverty. It proves an indirect link, because it only seems to lead to poverty when there is some level of discrimination or social exclusion in the community. This relationship does not only concern developing countries, but can also be seen in developed countries.

Poverty can also lead to disability indirectly, for example, because of poor nutrition. It appears that poor people tend to delay consultation (and have lack of access to health care), when they are ill. This delay (caused by monetary factors, such as inability to pay for transport) can cause exacerbation of disease and therefore, disability. Thus disability can result in more poverty, for the above mentioned reasons (stigma).

Solutions to break the vicious circle of disability and poverty may need to look more into the linking determinants or aggravating factors and thus should largely focus on reduction of stigma, combating discriminatory practices and empowering disabled people. Strategies and interventions to counteract the linking determinants should therefore be those that operate from a social- or human-rights model of disability.

^*Address for correspondence
Enablement, Langenhorst 36
2402PX Alphen aan den Rijn
The Netherlands
E-mail:marliesvankampen@yahoo.com

^**Centre for Augmentative and Alternative Communitcation
University of Pretoria
Cnr of Lynwood and Roper Streets
Pretoria 0002
Gauteng, South Africa
E-mail:emmett@iafrica.com

ACKNOWLEDGEMENT

This study was carried out at University of Applied Health Sciences Leiden, Leiden, the Netherlands. The authors wish to give a special thanks to Huib Cornielje (senior lecturer at the University for Applied Sciences in Leiden,) the supervisor of this project, who was always willing to help during the research, and whose encouragement helped in developing this article. The authors would also like to thank the SANPAD "crew" in South Africa (Tony, Erna and Alecia in particular) and The Netherlands (Ria, Marlies and Huib) who offered them the opportunity to do this research and present its findings in April 2006 at a seminar in Leiden.

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DOES COMMUNITY BASED REHABILITATION REALLY WORK? COMMUNITY BASED REHABILITATION AND PARTICIPATION OF DISABLED PEOPLE

Author: Kenji Kuno

Published by: Institut Sosial Malaysia, Ministry of Women, Family and Community Development, KM 10, Jalan Sungai Besi, Sungai Besi, 57100 Kuala Lumpur, Malaysia.

email:info@ism.gov.my

ISBN 978-983-42685-4-1