37

The Rapid Assessment of Disability – Informing the Development

of an Instrument to Measure the Effectiveness of Disability
Inclusive Development Through a Qualitative Study in
Bangladesh
Nafisa Lira Huq1*, Tanya Jane Edmonds2, Sally Baker2, Lucy Busjia3, Alexandra Devine2,
Kathy Fotis4, Manjula Marella2, Nicolas Goujon5, Jill Keeffe4

ABSTRACT
Purpose: The Rapid Assessment of Disability (RAD) questionnaire was
developed to provide governments and development agencies with an appropriate
instrument to determine the prevalence of people with disability within their
target populations, and to design and evaluate the effectiveness of disability
inclusive activities in addressing their priorities and needs.
Method: The RAD questionnaire was developed using two conceptual
frameworks: the United Nations Convention on the Rights of Persons with
Disabilities (UNCRPD), and the International Classification of Functioning,
Disability and Health (ICF). Existing instruments were reviewed to inform
the structure and content of the RAD questionnaire. The RAD questionnaire
that was developed for field testing in Bangladesh comprised both a household
questionnaire and a questionnaire for individuals within each household, with
5 sections: 1) Demographic information, 2) Assessment of functioning, 3)
Awareness of rights of people with disability, 4) Well-being and quality of life,
5) Participation in the community.
Prior to field-testing the RAD questionnaire in Bangladesh, a qualitative study
was conducted to ensure the relevance of the questionnaire in the context of a
developing country. In-depth interviews with 9 people with disability and a
focus group of 8 parents of children with disability were conducted in Dhaka,
Bangladesh.

1 Centre for Reproductive Health, International Centre for Diarrhoeal Disease Research, Bangladesh
2 Nossal Institute for Global Health, The University of Melbourne, Australia
3 Melbourne Brain Centre, Royal Melbourne Hospital, Australia
4 Centre for Eye Research Australia, The University of Melbourne, Australia
5 Departement de Medicine Generale, Universite Bordeaux Segalen, France
* Corresponding Author: Nafisa Lira Huq, Assistant Scientist, Centre for Reproductive Health, International Centre
for Diarrhoeal Disease Research, Bangladesh.Email:[email protected]

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Results:Qualitative findings highlighted factors relevant to the lives of people

with disability in Bangladesh, including discrepancies between the awareness
and attainment of rights for people with disability, the wellbeing of people with
disability and their families, as well as numerous barriers to full participation
in their community. While the findings confirmed that the design and content
of the questionnaire reflected all these aspects, some changes were made to the
items in the questionnaire to ensure that it reflected the views of people with
disability from the context of a developing country.
Conclusion and Implications: This qualitative study was an important step
in the development of the RAD questionnaire as it helped to achieve its aim -
namely, to establish the prevalence of disability and to assist in the design and
evaluation of disability inclusive interventions in the setting of a developing
country.
Key words: Questionnaire development, disability, developing countries

INTRODUCTION
Article 32 of the United Nations Convention on the Rights of Persons with
Disabilities (UNCRPD) states that all international development programmes
should be inclusive of people with disability (United Nations, 2006). Despite
this, and a growing body of evidence on the relationship between disability and
poverty, thus far people with disability have not been adequately included in
development activities (Department for International Development (DFID), 2000;
World Health Organisation and the World Bank (WHO & WB) 2011).
In response to the increasing awareness of the need for disability-inclusive
development, several governments and international donors, including the
Australian Agency for International Development (AusAID) and implementing
agencies, have developed policies and made broad commitments to mainstream
disability across their development programmes. However, while programme
implementers increasingly understand why development activities need to be
inclusive of people with disability, there is limited knowledge and experience of
how this is to be done (Noe & Paul, 2006; CBM, 2008). Contributing to this challenge
are factors such as limited internationally comparable data on the prevalence and
trends of disability across and within countries and limited experience of how to
include people with disability and their priorities across the programme cycle of
development activities (Noe & Paul 2006; WHO & WB, 2011).

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The Rapid Assessment of Disability (RAD) questionnaire aims to address these

challenges. The intention is that it can help monitor a population’s progress
towards achieving the disability inclusive goals of the UNCRPD. The RAD
questionnaire has been designed to establish baseline data on disability prevalence
and its impact on people’s lives, and to support the design, implementation and
evaluation of disability inclusive development activities in low and middle income
countries. The RAD questionnaire was developed for 3 age groups – one each for
children aged 0-4 years and 5-17 years, and one for adults. This paper describes
the development of the adult version (≥18 years) of the RAD questionnaire, with
a focus on findings from the qualitative interviews and a focus group conducted
to align the relevance of the RAD to people with disability in the context of a
developing country.

METHOD
The conceptual frameworks guiding the development of the RAD are the
UNCRPD and the International Classification of Functioning, Disability and
Health (ICF), which was developed by WHO (2001). In line with the principles
in Article 3 of the UNCRPD, the research was designed to be inclusive of people
with disability at all stages of the process, including representation from Disabled
Persons’ Organisations (DPOs) on advisory committees (UN,2006) along with
academics and experts in disability inclusion. Drawing on these frameworks and
the expertise of advisory committee members, the research team identified major
domains which would potentially meet the objectives of the RAD. These domains
included: 1) socio-economic factors; 2) assessment of functioning to determine
prevalence of disability; 3) wellbeing and quality of life; 4) awareness of the
rights of people with disability; and 5) barriers and facilitators to participation of
people with disability in their community. Ethics approval was obtained from
the University of Melbourne Human Research Ethics Committee (Australia), the
Royal Victorian Eye and Ear Hospital Human Research and Ethics Committee
(Australia) and the Ethical Review Committee at ICDDR, B (the research partner
in Bangladesh).
The next step was a review of existing disability-related questionnaires to identify
existing measures of disability and the lived experience of disability (Goujon et
al, 2013). The UNCRPD and literature from the development sector such as the
World Health Organisation’s Community Based Rehabilitation framework were
also reviewed to help identify sectors and services relevant to disability inclusive

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development (e.g. education, health, water and sanitation) and potential barriers
to access for people with disability (e.g. environmental, attitudinal and legal
barriers) (UN, 2006; WHO, 2010).
Individual items from the identified instruments were grouped under the
main ICF domains that provided the best conceptual fit for the item, i.e. body
structure and functions; activity limitation and participation restriction; and
environmental/contextual factors. These groups of items were then assessed for
content concordance with the five RAD domains identified by the research team
and re-grouped under the relevant RAD domains. As there was considerable
overlap in the content of a number of items grouped under each domain, the
research team used sets of items that best covered the objectives of the RAD;
this also helped to maintain the integrity of the existing instruments. It was also
important to ensure that the RAD questionnaire was not heavily focussed on
health conditions and was relevant to development initiatives seeking to address
the participation of people with disability.
Gaps in the ability of existing instruments to measure important factors relevant
to disability inclusive development included measuring awareness of the rights
of people with disability and measuring participation in aspects of community
life and the barriers to this participation. Workshops, involving the research
team, people with disability and experts in the field, were conducted to generate
new items to address the gaps. These new items were then grouped under the
relevant RAD domains.
Revisions were made to items from existing instruments and to newly generated
items so as to ensure: 1) consistency in structure and language of all items; and
2) items were phrased using positive terminology to avoid the potential for any
negative psycho-social impact on questionnaire respondents.
Proxy versions of items were developed for those who were unable to provide
responses. The household questionnaire contained 15 items adapted from the
World Bank’s Demographic and Health Surveys (DHS) Wealth Index (Grosh
& Glewwe, 2000; Falkingham & Namazie, 2002; Rutstein & Johnson, 2004; ICF
International, 2011). Household characteristics used to estimate a wealth index
included source of water, having electricity, sanitation facility, roof, wall and floor
materials, plus asset indicators including durable goods and ownership of the
house, land and cattle.

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RESULTS
The draft RAD questionnaire consisted of two questionnaires: a household
questionnaire to assess household demographics and socio-economic status
- to investigate associations with poverty, for example - and an individual
questionnaire to collect data across five sections:
1. Demographics – comprising 25 items including age, gender, nationality,
ethnicity, religion, marital status, education (if not completed, the reasons why),
literacy, occupation or reasons for not being employed. Individuals are also asked
about health conditions, including the type and cause, and self-perceived impact
on daily living as well as information on any assistive devices used.
2. Assessment of Functioning - The purpose of this section is to identify people
experiencing prolonged (6 months) functional limitations as a proxy for risk of
disability. From a total of 18 items, 11 items address difficulties in functioning
in 6 domains: vision, hearing, communication, mobility, gross and fine motor,
and cognitive. Six items address difficulties in psycho-social functioning, and a
final item asks whether a person has difficulty interacting with others due to
appearance. In accordance with the ICF, items ask participants to report on their
own perception of functioning when using assistive devices available to them
(e.g. seeing, even if wearing glasses) (WHO,2002; UN, 2006).Participants are
asked about difficulties in each domain to which they respond ‘yes’ or ‘no’. If
the response is ‘yes’, they are then asked “how often” with choices being ‘some’,
‘most’ or ‘all the time’. Those who respond ‘most’ or ‘all the time’, and matched
controls for age and gender would then continue with the other 3 sections. Items
are drawn from a number of existing questionnaires (Table 1).

Table 1: Assessment of Functioning

Item
Source
WHO
Rapid Assessment of Disability
WCG ALS/PRS DAS II PS ICF K6
In the last 6 months have you had
difficulties…
… seeing, even if wearing glasses?   
… hearing, even if wearing aid(s)?   
… moving around inside your home,
even if using assistive device(s)?   

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… moving around outside your

home, even if using assistive
device(s)?  
… using your hands and fingers
(e.g. pickup up small objects or
closing containers) even if using
assistive device(s)?  
… with self-care (e.g. washing
yourself, dressing, eating food)
even if using assistive devices?    
… concentrating on an important
task or activity?    
… remembering to do things that
are important to you (e.g. keeping
appointments, paying loans)?   
… learning how to do new things
(e.g. something you have never
done before)?   
… understanding others (e.g. when
people communicate with you)?  
… communicating (for example,
understanding others or others
understanding you)?   
… interacting with others in
the community due to your
appearance (e.g. some people have New Question
skin problems, or look different to
other people)?  
In the last 6 months have you felt…
… so sad that nothing could cheer
you up? 

… nervous? 
… restless? 
… hopeless? 
… like everything is hard to do? 
… worthless? 
WCG - Washington City Group; ALS/PRS - Activity Limitation Scale/Participation Restriction Scale; WHO
DAS II - WHO Disability Assessment Schedule; PS – Participation Scale; ICF - International Classification
of Functioning, Disability and Health; K6 – Kessler 6.

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3. Awareness of the Rights of people with disability - The purpose of section 3 is

to obtain information about the awareness of the rights of people with disability.
Sixteen items informed by the UNCRPD were generated by the research team,
in consultation with the advisory committee, to obtain information about the
awareness of the rights of people with disability (UN, 2006).

Table 2: RAD Section 2 - Awareness of Rights items

Item source
Rapid Assessment of Disability
UNCRPD

Do you think you are entitled to… Articles 9 and 21

….access the information needed in your everyday life?
Yes
No
… live in a safe home environment? Articles 16, 19 and 23
... go to school/study? Article 24
…work? Article 27
…access to health care? Article 25
... access to assistive devices or personal equipment that you need? Articles 20 and 26
… get protection from the police if needed? Article 13
… get legal support to tell your side of the story? Article 12
… look after your personal care (e.g. washing yourself, dressing, etc)? Article 19
… initiate and maintain relationships? Article 23
… participate in decision making which affects you? Article 21
… participate in decision making which affects your family? Article 23
… participate in decision making which affects your community? Article 19
… be treated as equally as everyone else? Preamble
… get married? Article 23
… have children? Article 23

4. Wellbeing and Quality of life – The purpose of section 4 is to assess individuals’

perceptions of their wellbeing, including quality of life. Twenty items for the
wellbeing section were sourced and selected from existing questionnaires (Table
3) to assess these perceptions.

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Table 3: RAD Section 3 -Wellbeing

Item source
WHO WHO
Rapid Assessment of Disability QOL PS ALS/PRS WCG DAS II
In the last 6 months, how often…  
… have you been satisfied with your
health?
Never
Sometimes
Most of the time
All of the time
   
… have you been satisfied with your sleep?     
… have you been satisfied with yourself? 
… have you been satisfied with your sex
life/intimate relationships? 
… have you been confident to try to learn
new things?     
… have you enjoyed life?     
… have you felt respected in the
community?     
… has your opinion counted in family
discussions?     
… have you been comfortable with your
bodily appearance?     
… have you felt your life has been
meaningful?     
… have you felt safe in your daily life?     
… have you been able to maintain family
relationships?    
…have you been able to make new friends?     
… have you been able to maintain
friendships?     
… have you been able to deal with people
you don’t know?     
… have you been able to deal with persons
of authority?     
…have you been able to take care of
yourself as much as you would have liked?     

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…have you been able to take care of your

household?     
… have you been living in the same
conditions as for the rest of your
household?     
… have you had the opportunity to help
other people (e.g. neighbours, friends,
relatives)?     
WHO QOL – The World Health Organisation Quality of Life – BREF; PS – Participation Scale; ALS/PRS
- Activity Limitation Scale/Participation Restriction Scale; WCG - Washington City Group; WHO DAS II –
World Health Organisation Disability Assessment Schedule

5. Participation in the Community - The objective of section 5 is to understand

participation of people with disability in aspects of public and community life,
and to identify and prioritise barriers to participation across several domains.
Items were informed by the UNCRPD, the ICF checklist, and the CBR framework
(WHO, 2001; UN, 2008; WHO, 2010) and existing questionnaires (Table 4).
Participants are asked if they have been able to access each of the domains “as
much as they would like” to which the responses are ‘yes’ or ‘no’. If the response
is “no” they are then asked the reasons, and if more than one is given they are
asked to specify which barrier has limited them the most.

Table 4: Access to the Community

Item source
WHO
Rapid Assessment of
DAS ALS/ WHO
Disability
ICF CBR UNCRPD II PRS QOL PS
In the last 6 months, how
often…
…has the information that
you needed been readily
available?
….has the layout of places in
the community made it easy
for you to access them?
….have you been able to use
transport needed in your
everyday life?
… have you been able to
participate at school as much
as you would like?    
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… have you been able to

participate in work activities
as much as you would have
liked?    
… have you been able to
access health care as much
as you needed?   
… have you been able to
participate in community
decision making as much as
you would have liked?    
… have you been able to
access assistive devices that
you needed?  
... have you been able to access
rehabilitation services?  
…have you been able to
live in a suitable home
environment as much as you
would like?
… have you had access to
safe drinking water? 
… have you been prepared
New question generated by research team
in case of a natural disaster?
… have you been able to
New question generated by research team
gain police assistance?
… have you been able to gain
legal assistance as much as
you needed?  
… have you been able to
participate in recreational
activities?     
… have you been able to
participate in religious
activities as much as you
would have liked?    
ICF - International Classification of Functioning, Disability and Health; CBR – WHO Community-based
rehabilitation: CBR guidelines; UNCRPD – United Nations Convention on the Rights of Persons with
Disabilities; WHO DAS II – World Health Organisation Disability Assessment Schedule; ALS/PRS -
Activity Limitation Scale/Participation Restriction Scale; WHO QOL – The World Health Organisation
Quality of Life – BREF; PS – Participation Scale.

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Section 5 – Response categories (example structure, this structure applied to all domains)
In the last 6 months,
…have you attended any school?
Yes
No
If yes,
… have you been able to participate at school as much as you would have liked?

Never
Some of the time
Most of the time
All of the time
Which of the following barriers have hindered your participation at school?
Lack of learning materials in suitable format
Physical access to school
Not being included in school activities by teachers
Not being included in school activities by fellow students
Cost of attending school
Other (please specify)
Which of the following barriers affected you the most?
Lack of learning materials in suitable format
Physical access to school
Not being included in school activities by teachers
Not being included in school activities by fellow students
Cost of attending school
Other (please specify)

Prior to finalising the RAD questionnaires for field testing in Bangladesh, a small
qualitative study including in-depth semi-structured interviews with people
with disability and a focus group with parents of children with disability were
conducted. This was undertaken to ensure that the RAD questionnaire was
applicable to people with disability living in low and middle income countries.
The interviews and focus group were conducted in May 2010 by the Bangladeshi
research team at ICDDR, B in collaboration with the Centre for Disability in
Development (CDD), at 2 sites in Bangladesh - Tongi, an urban area in Dhaka,
and Narshingdi, a rural district in the Dhaka division.
Interview and focus group participants were purposively recruited through the
network of CDD. Two female and two male Field Research Officers of ICDDR,
B with previous work experience in qualitative methods and fluency in English
and Bangla were trained to conduct the interviews and focus group. Potential

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participants were approached by the FROs and provided with information

about the study. Written consent was obtained from them and they were assured
of confidentiality. Efforts were made to ensure equal representation of male
and female participants from rural and urban settings, with various types of
impairments (vision, hearing, physical and communication impairments and
people with mental illness).
All participants were 18 years of age or older.
Participants in interviews and the focus group were asked a series of open-ended
questions focussing on perception of rights of people with disability, wellbeing
and quality of life, and barriers and facilitators to participation in the community,
such as education, health services and livelihoods. Guidelines for the semi-
structured interviews and focus group were initially developed by the research
team in English and translated into Bangla. The interviews and focus group were
audio recorded, transcribed in Bangla and translated into English. Members of
the research team then analysed the transcripts to identify individual statements
describing a single element of lived-in experience of people with disability. These
statements were entered into Microsoft Excel (Version 2003, Microsoft Corp.) and
coded according to the main topic, using open coding. Individual statements
were mapped onto questionnaire item(s) that best captured the meaning of
each statement to determine if or how well that theme was addressed by the
questionnaire. This helped to identify items that were potentially redundant or
irrelevant, and those that needed to be included in the case of themes that may
have been missed or were under-represented. The research team then discussed
the implications of the findings for the RAD questionnaire, and revised it
accordingly.
In all, 9 people with disability took part in qualitative interviews and 8 parents
of children with disability participated in a focus group. Interviews took
approximately 45 minutes and the focus group lasted for approximately 1.5 hours.
The average age of the 9 interview participants was 26.6 years (range 22- 40 years)
with more male participants (n=6, Sex Ratio=2) available for interviews. Only 1
participant reported having received any education. Five of the 9 participants
reported no occupation (Table 5). The participants for the focus group were
parents of children with disability (n=8), the majority of whom were mothers.
Their children were between 3 and 8 years of age, and experienced a range of
disabilities.

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Table 5: Demographics of Interview Participants

Variable N=9
Age in years
Average (range) 26.8 (22-40)
Gender
Male 6
Female 3
Marital status
Married 4 (3 male, 1 female)

Setting
Urban 4
Rural 5
Education
No education 5
Primary 1
Not known 3
Occupation
No occupation 5
Farmer 2
Beggar 1
Ironing shop 1
Type of impairment
Vision 2
Hearing 2
Physical 2
Psycho-social 2
Intellectual 1

Findings from the qualitative interviews and focus group are presented under
the relevant sections of the RAD questionnaire. Many of the findings however
were cross-cutting and have significance across all sections. (Note: As described
in Methods, the qualitative study did not explore self-assessment of functional
limitation, which is assessed in Section 2. Therefore, these results are presented
across Sections 3, 4 and 5 of the RAD.)
Section 3: Awareness of the rights of people with disability - The findings
indicate that a number of participants were aware of the rights of people with
disability, particularly in terms of education, marriage, livelihood and ability to
live as equal members in the community. However, a discrepancy was highlighted
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between participants’ awareness of their rights and their ability to exercise these
rights, particularly with reference to education. For example, one participant
observed that while everyone has the right to education, her daughter was denied
this right through the actions of teachers. Many violations of the rights of people
and children with disability, including the right to a safe living environment and
to be treated on an equal basis with others, were also voiced.
The right to marry, for men and women with disability, was a strong concern
identified among the participants. Due to the lack of livelihood opportunities,
men with disability were seen to be dependent on their families, thereby reducing
their prospects of making a good marriage. For women, concerns ranged from the
expectation that women with disability require a large dowry, often not affordable
by their families, and the fear that girls with disability would experience violence
after marriage.
Findings also suggest that their marriage prospects are reduced further by
persistent fears and perceptions in society that people with disability might
produce offspring with disability. Fears regarding marriage also related to
broader parental anxiety regarding their child’s future after the passing away of
the parents and marriage of siblings (Table 6).

Table 6: Sample of responses relevant to the RAD Section 3 – Awareness of

rights of people with disability
Item domain Sample responses Source
Right to live as “We disabled persons want that we can lead our Male interview
part of society life in a suitable manner. We do not want to beg, participant with physical
we want to live like other people in the society in impairment
an equitable manner, so no one can ignore us.
This is the main right of people with disabilities.”

“These children have rights to live in society.” Focus group participant,

parent of male child
with disability

Right to education “She has rights to go to school but the teachers Focus group
stopped her from going to school.” participant, mother
of female child with
intellectual disability

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Right to live “Another family has an intellectually disabled Focus group participant,
in a safe home child; she is always kept on the dirt floor, mother of female
environment, and neglected. Her father says ‘I will be happy if she interview participant,
right to be treated dies.” intellectual disability
in the same way as
others

Male interview
“Disabled (persons) have number of problems, participant with vision
they are ignored in the society, they are ignored by impairment
relatives, they are ignored by their brothers and
sisters, they are ignored by the mother as well.
They feel ashamed to recognise us as their near
relative.”
Right to marry “There is another problem we are facing Focus group participant,
regarding the marriage of our sons and parent of a child with
daughters, other people declines to make marital disability
relationship in our family because of the disabled
son. Because they apprehend that they (family
members without disability) may also give birth
to a disabled baby.”

The findings confirmed that collecting data about awareness of participants’

rights across all areas of life such as the right to a safe living environment,
education and, in particular, right to marry, were important themes. However,
the right to live in society as an equal member was a theme which was added,
as it had not been included in this section of the questionnaire. Further, after
analysing the results of Section 4 on well-being, it was decided to add an
item on the “right to Government social welfare services” as this emerged as
an important theme. The phrasing of questions was also amended after the
qualitative study, as the Bangladesh research team raised concerns that there
were leading questions.

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Table 7: RAD Section 3 – Changes to the Awareness of Rights section after

the qualitative study
Section 3 Changes
Are you aware of the rights of people with a Structure and response category
disability? changed for all items (not directly
Yes because of qualitative findings)
No
I am going to ask you what rights you think people
with disabilities should have. Right to…
…access Government social welfare services? Item added post qualitative study
… live as part of society? Item added post qualitative study

Section 4: Wellbeing and Quality of life - When asked about themes relevant to
the wellbeing and quality of life of people with disability, a number of participants
expressed positive experiences of living with disability and acceptance in the
community. However, several responses indicated that people with disability
felt they were perceived as a burden on society, the government and, in some
instances, their own families. The ability to live independently also arose as a
common theme, with respondents expressing their reliance on others for day-
to-day activities such as crossing the road and going to work. Communicating
with others was also a function that required support from others and this was
reported as impacting on both the wellbeing of individuals and their families.
Participants often highlighted the importance of family, consistent with the
centrality of family in the Bangladeshi culture. Parents of children with disability
expressed great concern about the wellbeing of their children due to the stigma
and discrimination they experienced. Parents discussed the ‘disabling world’ in
which children with disability are unnecessarily segregated and mistreated. For
instance, some parents described experiences of derogatory language being used
in the playground towards their children with psycho-social disability (Table 8).
Findings also indicated that parents felt having a child with a disability increased
the levels of anxiety in their lives. One mother said she had difficulty participating
in activities outside the home, including work, because she could not leave her
child alone, thereby impacting on the family’s income which caused stress. Other
families reported difficulty in providing the support required to educate their
child with disability, especially if they had several other children.

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Table 8: Sample of responses relevant to the RAD Section 4 – Wellbeing

Item domain Sample responses Source
General well- “Though I have no eyesight, I do not feel any Male interview participant
being problem. Maybe I cannot earn my bread on my with vision impairment
own; if I go somewhere, being blind, if ten people
do not help me, at least one man will help me.”
Respected by “They (people with disability) are a burden for Male interview participant
community their society…they are a burden for you and for the with physical impairment
government as well.”
“They addressed him as ‘Mad' and beat him. If our Focus group participant,
children go to play with other children they mimic mother of a male child with a
our children.” disability
Importance of “Every family member loves her and no one uses Focus group participant,
family rough words with her. When guests come to our mother of a child with
house some families hide this kind of disabled disability
person but we do not. We allow her to mix with
others and stay with guests.”
Parental “Now I am alive so I can take care of him, but Focus group participant,
concern when I will die what will happen to him?” mother of a child with
disability

The findings confirmed that questions in the Wellbeing section of the RAD
largely covered experiences likely to impact on people living with disability
and their families, by addressing themes which the study participants identified
as key areas of wellbeing such as self-perception of health, enjoyment in life
and respect in the community. An item asking how often a person received the
help needed to complete daily life activities, and an item asking if the main
person helping them was a member of their family, were added (Table 9).
These additions reflect that the capacity of the family to support individuals
with disability and the ability to live independently arose as important themes
throughout the qualitative study.

Table 9: RAD Section 4 – Wellbeing section - changes post qualitative study

Section 4 Changes

In the last 6 months, how often……

… have you been satisfied with your intimate Changed from “sex life/intimate
relationships? relationships”

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… did you get the help you needed to complete daily New questions
life activities?
Is the main person helping you a member of your
family?
Yes
No

Section 5: Participation in the community - Participants were asked to discuss

access to a range of domains related to participation in community life, such
as education, health services and livelihood, in order to capture barriers and
facilitators to their participation. Findings are reported under the relevant
domains.
Education – This was the most commonly discussed domain by all participants,
revealing a strong desire for improved participation in schooling. The main
barriers to education included negative attitudes from teachers and students, as
well as institutional barriers. While one mother stated that her child was restricted
from attending mainstream school, another wished there were specific training
centres for these children. Other participants reported barriers to education
including fees, especially when the family has other children to educate, cost of
transport and physical access to schools.
Livelihood – While several respondents reported involvement in various
livelihood areas including business and handicrafts, others reported many
barriers to accessing meaningful and paid employment, leading to feelings of
sorrow and worthlessness. Some parents felt that despite their family members
with disability wanting to work, they had not been given the opportunity to
develop skills to participate in the work market or to self-manage their finances.
Some respondents also reported not applying for work as they felt they would be
rejected because of their disability.
Health services – Participants generally reported positive attitudes and good
treatment by health professionals, yet barriers to services were still evident,
with the cost of treatment reported as the major barrier. Some participants
reported that due to unaffordable services, healthcare that could have improved
their condition was forgone. Participants also expressed their need for assistive
devices such as hearing aids, to improve their quality of life. Several barriers to
accessing devices were discussed. Assistive device services are inaccessible to
people living in rural areas of Bangladesh due to the distance from a major city
where the services are located, cost of services and apparent selection bias by
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providers. Participants reported that very few NGOs that are accessible to people
with disability in remote areas offer assistive devices as part of their programmes.
Social welfare services - While some participants were aware of services provided
to people with disability by the Government and NGOs, they reported barriers to
accessing those services. Rural participants perceived that only people living in
urban areas could receive such support. The need to bribe officials to gain access
to government services was also mentioned as a barrier.
Religious activities - Participants also highlighted the importance of religion
in the Bangladeshi culture and discussed participation in religious activities.
While one participant described the local temple as welcoming towards the child
with disability, others reported experiences where negative attitudes of religious
leaders and attendees had prevented participation in religious activities.

Table 10: Sample of responses relevant to RAD - Participation in the Community

Item
Sample response Source
domain
Access to “General schools don’t admit our disabled children. I think Focus group participant,
education if our children will go to general school, they would learn mother of a child with
many things with other students.” disability
“She gets pleasure when she goes to school but she can't Focus group participant,
go. Teachers are neglecting her. Students laugh at her. They mother of a child with a
said, why have you sent her to school?” disability
Access to “I am a blind man, I cannot work, if I could work and earn Male interview
livelihood money, I would have not been neglected by the people.” participant with vision
impairment
Access “My child needs an operation, then he will talk. I need 1500 Focus group participant,
to health taka for the operation. I can’t manage the money so I can’t mother of a child with
services do the operation.” disability
Access “I know that the government helps the disabled persons Male interview
to social a lot but we have not received any sort of help from the participant with physical
welfare government.” impairment
services
“There is a social welfare office in this area…There is a peon Male interview
(office attendant) in the office, he is very corrupt man. I participant with hearing
could not reach to the officer by passing the peon.” impairment

Access to “Once he went to mosque but the religious leader said to go Focus group participant,
religious out. He also said if my son goes to mosque then everybody’s father of a male child
activities prayer will be spoilt. I don’t know whether his prayer was with a disability
accepted or not by Allah.”

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The findings confirmed that the design of Section 5 of the RAD questionnaire
largely included community domains such as education, healthcare and,
religious activities, which appear to be important for people with disability in
Bangladesh (Table 4). However, as a result of the qualitative study, new domains
including “Government social welfare” and “Disabled Persons’ Organisations”
(DPO) services were added, reflecting their importance to participation in the
community for people with disabilities.
The qualitative findings also confirmed that most types of barriers to participation
mentioned by the participants had been included in the RAD questionnaire,
including lack of accessible information about available services, physical access,
and negative attitudes of teachers, families and service providers. New barriers
such as ‘difficulty getting to and from facilities’ such as schools or health centres
and the ‘financial cost of accessing services’, which is further accentuated by the
need to bribe officials, were included in the RAD questionnaire because they
emerged repeatedly as issues for participants. These barriers were added as
standard response categories across all domains. Finally, given the importance
of family support for people with disability as displayed throughout all sections
of the study, an additional barrier, ‘family has difficulty assisting you’, was also
added as a standard response category.

Table 11: RAD Section 5 – Additions to Participation in Community after the

qualitative study

Which of the following have limited Additional response categories (in bold) added to
your participation in school? all domains
Which of these has limited your
participation in school activities the
most?

Lack of information about school

Lack of learning materials
Physical access to school
Negative attitudes towards me at school
Cost
Difficulty getting to school from home
Difficulty for my family to help me
Other (please specify)

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… have you accessed Government social New item added

welfare services as much as you needed?

… have you accessed Disabled Persons' New item added

Organisations as much as you would
have liked?

DISCUSSION
The RAD combines the measurement of prevalence of functional limitations in
populations and the assessment of the impact of disability, using the social model
of disability, to reflect the true experience of disability as an interaction between
a person and the environment. The qualitative study provided a valuable
opportunity to consult with people with disability, ensuring that their views
were reflected in the RAD questionnaire. Moreover, this component of the RAD
project yielded valuable insights into the quality of life and barriers to access and
participation in the community for people with disability in Bangladesh.
The qualitative findings confirmed that the themes that emerged during
interviews and at the focus group had been largely addressed in the rights and
wellbeing sections of the RAD questionnaire. In particular, the need for a question
regarding the right of people with disability to get married was also confirmed,
as marriage is very important in the Bangladeshi culture.
In terms of participation in the community, the qualitative findings confirmed
that the design of the questionnaire, based on the ICF and UNCRPD, appeared
to largely reflect the domains of community life that were important for people
with disability in Bangladesh. For instance, as consistently described in the
literature, without access to appropriate education, people with disability have
fewer opportunities to find meaningful employment. This reduces their ability
to access economic resources and live independently (USAID, 2009; WHO &
WB, 2011). However, the qualitative findings also identified access to social
welfare and DPO services to be important domains for participants, and these
were added to the questionnaire. Difficulty in accessing public transportation is
reported in the literature as excluding people with disability from services such as
education and healthcare (Grewal et al 2002; WHO & WB, 2011). Cost, ability of
the family to assist, and difficulty in getting to services were constantly reported
by participants as barriers to participation, and were subsequently included in
the questionnaire as response options.

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These changes were made to the questionnaire for field testing in Bangladesh to
evaluate the psychometric properties of the RAD. Following this, the RAD will
be tested in Fiji for cross-cultural relevance.

CONCLUSION
While the qualitative findings confirmed that the design of the RAD questionnaire
did include the themes and priorities of people with disability, some items
were modified or added to better reflect the needs of people with disability in
Bangladesh. Therefore, this qualitative study was critical in the development
of the questionnaire and can help it to achieve its purpose of assisting in the
design and evaluation of disability inclusive development interventions.
As an appropriate tool for development organisations, it is hoped the RAD
questionnaire will ultimately contribute to the evidence in relation to disability
and development, and promote inclusion of people with disability in the setting
of developing countries.

Acknowledgement
The research project was funded by the Australian Agency for International
Development through the Australian Development Research Awards. The
research is a collaboration between the University of Melbourne’s Nossal Institute
for Global Health and the Centre for Eye Research Australia (CERA). CERA
receives Operational Infrastructure Support from the Victorian Government.
In-country collaborators include International Centre for Diarrhoeal Disease
Research, Bangladesh (ICDDR, B). Gratitude is expressed to the Centre for
Disability in Development for their collaboration during this study. The authors
are especially grateful to the many people who participated in the study, as
their involvement made this stage of the development of the RAD questionnaire
possible.

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