{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,8,21]],"date-time":"2025-08-21T18:36:06Z","timestamp":1755801366154,"version":"3.44.0"},"reference-count":38,"publisher":"Public Library of Science (PLoS)","issue":"8","license":[{"start":{"date-parts":[[2025,8,21]],"date-time":"2025-08-21T00:00:00Z","timestamp":1755734400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100022099","name":"Cerebral Palsy Alliance","doi-asserted-by":"publisher","award":["PG02218\u2014Support CP Trial"],"award-info":[{"award-number":["PG02218\u2014Support CP Trial"]}],"id":[{"id":"10.13039\/501100022099","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>Background<\/jats:title>\n<jats:p>Families of children with Cerebral Palsy (CP) often experience extreme poverty, compounded by limited livelihood opportunities and the added demands of caregiving, which further restrict their ability to earn an income. Targeted livelihood interventions may help improve their economic well-being. This study aimed to assess the cost-effectiveness of livelihood interventions to improve household incomes of ultra-poor families of children with CP in rural Bangladesh.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Method<\/jats:title>\n<jats:p>This was a mixed-methods study utilising a subgroup of a pragmatic, open-label, cluster randomised controlled trial (RCT). This subgroup was part of the \u201cSupporting People in Extreme Poverty with Rehabilitation and Therapy (SUPPORT CP)\u201d trial (ACTRN12619001750178), which was implemented in three rural subdistricts of Sirajganj district, Bangladesh. This RCT involved 251 children across three arms\u2014 integrated microfinance-based livelihood and community-based rehabilitation (IMCBR), community-based rehabilitation (CBR), and care-as-usual. We investigated 80 children with CP whose parents received an IMCBR program as part of the SUPPORT CP trial. Additionally, in-depth interviews were conducted with 21 participants from the IMCBR arm. Descriptive statistics to depict respondent characteristics and the average return on investment (ROI) were calculated to evaluate the most cost-effective livelihood support. Furthermore, thematic analysis was performed with the interview data to explore the advantages and disadvantages of different livelihood products.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Results<\/jats:title>\n<jats:p>The parents\/caregivers of included children with CP were given five forms of livelihood support: Chickens (n\u2009=\u20093, 15 for each), Sewing machine (n\u2009=\u200911, 1 for each), Ghee making utensils (n\u2009=\u20091, 1 for each), Lamb (n\u2009=\u20097, 2 for each), and Goat (n\u2009=\u200959, 2 for each). The average cost of livelihood intervention per family was 65\u2e319 USD. The net return on investment after 12 months was 59.0% for lamb, 70.0% for ghee-making tools, 24.0% for goat, 34.0% for sewing machines, and \u221225.0% for chicken. Lambs proved to be advantageous due to their sustainability, minimal space requirements, and disease resistance.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec004\">\n<jats:title>Conclusions<\/jats:title>\n<jats:p>This study suggests that the provision of lambs as livelihood support is the most effective intervention for empowering ultra-poor families with CP in Bangladesh. This experience can potentially enhance the well-being of ultra-poor families in Bangladesh and other low- and middle-income countries.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pone.0326653","type":"journal-article","created":{"date-parts":[[2025,8,21]],"date-time":"2025-08-21T17:23:23Z","timestamp":1755797003000},"page":"e0326653","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["Cost-effectiveness of livelihood interventions for families of children with cerebral palsy in rural Bangladesh"],"prefix":"10.1371","volume":"20","author":[{"given":"Nuruzzaman","family":"Khan","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5331-9283","authenticated-orcid":true,"given":"Manik Chandra","family":"Das","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mahmudul Hassan","family":"Al Imam","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Israt","family":"Jahan","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2269-5056","authenticated-orcid":true,"given":"Delwar","family":"Akbar","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mohammad","family":"Muhit","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Nadia","family":"Badwai","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0661-4113","authenticated-orcid":true,"given":"Gulam","family":"Khandaker","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"340","published-online":{"date-parts":[[2025,8,21]]},"reference":[{"key":"pone.0326653.ref001","unstructured":"World Health Organization. Disability. https:\/\/www.who.int\/news-room\/fact-sheets\/detail\/disability-and-health. 2023."},{"issue":"12","key":"pone.0326653.ref002","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0189996","article-title":"Poverty and disability in low- and middle-income countries: A systematic review","volume":"12","author":"LM Banks","year":"2017","journal-title":"PLoS One"},{"key":"pone.0326653.ref003","author":"S Mitra","year":"2021"},{"key":"pone.0326653.ref004","article-title":"Individualized funding interventions to improve health and social care outcomes for people with a disability: A mixed-methods systematic review","volume":"15","author":"P Fleming","year":"2019","journal-title":"Campbell Syst Rev"},{"issue":"5","key":"pone.0326653.ref005","doi-asserted-by":"crossref","first-page":"601","DOI":"10.1111\/dmcn.14013","article-title":"Epidemiology of cerebral palsy in Bangladesh: a population-based surveillance study","volume":"61","author":"G Khandaker","year":"2019","journal-title":"Dev Med Child Neurol"},{"issue":"6","key":"pone.0326653.ref006","doi-asserted-by":"crossref","first-page":"754","DOI":"10.1111\/dmcn.15435","article-title":"Supported-standing interventions for children and young adults with non-ambulant cerebral palsy: A scoping review","volume":"65","author":"LJ McLean","year":"2023","journal-title":"Dev Med Child Neurol"},{"key":"pone.0326653.ref007","article-title":"Supporting People in Extreme Poverty with Rehabilitation and Therapy (SUPPORT CP): A Trial Among Families of Children with Cerebral Palsy in Bangladesh","author":"MH Al Imam","year":"2023","journal-title":"Dev Med Child Neurol"},{"issue":"3","key":"pone.0326653.ref008","article-title":"Effectiveness of interventions for improving livelihood outcomes for people with disabilities in low- and middle-income countries: A systematic review","volume":"18","author":"X Hunt","year":"2022","journal-title":"Campbell Syst Rev"},{"issue":"3","key":"pone.0326653.ref009","doi-asserted-by":"crossref","first-page":"223","DOI":"10.1080\/13600818.2016.1142960","article-title":"Disability and social protection programmes in low- and middle-income countries: a systematic review","volume":"45","author":"LM Banks","year":"2016","journal-title":"Oxford Development Studies"},{"key":"pone.0326653.ref010","volume-title":"The economic costs of exclusion and gains of inclusion of people with disabilities","author":"LM Banks","year":"2014"},{"issue":"10267","key":"pone.0326653.ref011","doi-asserted-by":"crossref","first-page":"2006","DOI":"10.1016\/S0140-6736(20)32340-0","article-title":"Global estimates of the need for rehabilitation based on the Global Burden of Disease study 2019: a systematic analysis for the Global Burden of Disease Study 2019","volume":"396","author":"A Cieza","year":"2021","journal-title":"Lancet"},{"key":"pone.0326653.ref012","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1111\/j.1469-8749.2007.00201.x","article-title":"The definition and classification of cerebral palsy","volume":"49","author":"P Rosenbaum","year":"2007","journal-title":"Dev Med Child Neurol"},{"issue":"3","key":"pone.0326653.ref013","doi-asserted-by":"crossref","first-page":"530","DOI":"10.1542\/peds.2014-0594","article-title":"Changing trends of childhood disability, 2001-2011","volume":"134","author":"AJ Houtrow","year":"2014","journal-title":"Pediatrics"},{"issue":"12","key":"pone.0326653.ref014","doi-asserted-by":"crossref","first-page":"1494","DOI":"10.1111\/dmcn.15346","article-title":"Global prevalence of cerebral palsy: A systematic analysis","volume":"64","author":"S McIntyre","year":"2022","journal-title":"Dev Med Child Neurol"},{"issue":"5","key":"pone.0326653.ref015","doi-asserted-by":"crossref","first-page":"601","DOI":"10.1111\/dmcn.14013","article-title":"Epidemiology of cerebral palsy in Bangladesh: a population-based surveillance study","volume":"61","author":"G Khandaker","year":"2019","journal-title":"Dev Med Child Neurol"},{"issue":"4","key":"pone.0326653.ref016","doi-asserted-by":"crossref","first-page":"1597","DOI":"10.3390\/jcm12041597","article-title":"Associated Impairments among Children with Cerebral Palsy in Rural Bangladesh-Findings from the Bangladesh Cerebral Palsy Register","volume":"12","author":"A Narayan","year":"2023","journal-title":"J Clin Med"},{"issue":"12","key":"pone.0326653.ref017","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0189996","article-title":"Poverty and disability in low- and middle-income countries: A systematic review","volume":"12","author":"LM Banks","year":"2017","journal-title":"PLoS One"},{"issue":"2","key":"pone.0326653.ref018","doi-asserted-by":"crossref","first-page":"154","DOI":"10.32725\/kont.2022.019","article-title":"Factors influencing the quality of life of parents raising a child with a disability","volume":"24","author":"K Moln\u00e1rov\u00e1 Letovancov\u00e1","year":"2022","journal-title":"Kontakt"},{"issue":"2","key":"pone.0326653.ref019","doi-asserted-by":"crossref","first-page":"264","DOI":"10.3390\/brainsci12020264","article-title":"A Social Business Model of Early Intervention and Rehabilitation for People with Disability in Rural Bangladesh","volume":"12","author":"MH Al Imam","year":"2022","journal-title":"Brain Sci"},{"issue":"4","key":"pone.0326653.ref020","doi-asserted-by":"crossref","first-page":"641","DOI":"10.1111\/j.1468-0009.2007.00504.x","article-title":"Labor market work and home care\u2019s unpaid caregivers: a systematic review of labor force participation rates, predictors of labor market withdrawal, and hours of work","volume":"85","author":"MB Lilly","year":"2007","journal-title":"Milbank Q"},{"issue":"12","key":"pone.0326653.ref021","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0261148","article-title":"Supporting Ultra Poor People with Rehabilitation and Therapy among families of children with Cerebral Palsy in rural Bangladesh (SUPPORT CP): Protocol of a randomised controlled trial","volume":"16","author":"MH Al Imam","year":"2021","journal-title":"PLoS One"},{"issue":"6","key":"pone.0326653.ref022","doi-asserted-by":"crossref","first-page":"773","DOI":"10.1111\/dmcn.15445","article-title":"SUpporting People in extreme POverty with Rehabilitation and Therapy (SUPPORT CP): A trial among families of children with cerebral palsy in Bangladesh","volume":"65","author":"MH Al Imam","year":"2023","journal-title":"Dev Med Child Neurol"},{"key":"pone.0326653.ref023","unstructured":"Valavanidis A. World Bank Report: Extreme Poverty is Rising Again. From 660 million people (8.5% world population) in 2019 to 733 million in 2022. 2023."},{"issue":"2","key":"pone.0326653.ref024","doi-asserted-by":"crossref","first-page":"108","DOI":"10.1017\/S1466252320000146","article-title":"Evaluating farm-level livestock interventions in low-income countries: a scoping review of what works, how, and why","volume":"21","author":"JF Lindahl","year":"2020","journal-title":"Anim Health Res Rev"},{"issue":"3","key":"pone.0326653.ref025","doi-asserted-by":"crossref","first-page":"249","DOI":"10.1177\/0264619607079805","article-title":"Emotional intelligence and goal setting\u2014an investigation into interventions to increase motivation to work among visually impaired students in Nigeria","volume":"25","author":"MS Eniola","year":"2007","journal-title":"British J Visual Impairment"},{"issue":"1","key":"pone.0326653.ref026","doi-asserted-by":"crossref","first-page":"44","DOI":"10.1080\/19439342.2015.1064986","article-title":"Wheels of fortune: the economic impacts of wheelchair provision in Ethiopia","volume":"8","author":"J Grider","year":"2015","journal-title":"J Development Effectiveness"},{"issue":"1","key":"pone.0326653.ref027","first-page":"63","article-title":"Vocational reintegration of people with spinal cord lesion in Bangladesh: an observational study based on a vocational training project at CRP","volume":"18","author":"CH Hansen","year":"2007","journal-title":"Asia Pacific Disability Rehabilitation Journal"},{"issue":"18","key":"pone.0326653.ref028","doi-asserted-by":"crossref","first-page":"1508","DOI":"10.3109\/09638288.2013.823244","article-title":"Do community-based rehabilitation programmes promote the participation of persons with disabilities? A case control study from Mandya District, in India","volume":"36","author":"M Biggeri","year":"2014","journal-title":"Disabil Rehabil"},{"issue":"3","key":"pone.0326653.ref029","doi-asserted-by":"crossref","first-page":"76","DOI":"10.5463\/dcid.v23i3.81","article-title":"Impact Assessment of a Vocational Training Program for Persons with Disabilities in Bangladesh","volume":"23","author":"MstRP Nuri","year":"2012","journal-title":"DCID"},{"key":"pone.0326653.ref030","doi-asserted-by":"crossref","first-page":"185","DOI":"10.1590\/1982-02752017000100018","article-title":"Effects of an intervention on the participation of people with disability in the workplace","volume":"34","author":"LO Vilela","year":"2017","journal-title":"Estudos de Psicologia (Campinas)"},{"issue":"2","key":"pone.0326653.ref031","doi-asserted-by":"crossref","first-page":"265","DOI":"10.1590\/S0102-79722012000200008","article-title":"Evaluation of a professional social skills program for unemployed people with physical disability","volume":"25","author":"S Pereira-Guizzo C de","year":"2012","journal-title":"Psicol Reflex Crit"},{"issue":"9","key":"pone.0326653.ref032","doi-asserted-by":"crossref","DOI":"10.12659\/MSM.883348","article-title":"The impact of a low cost wheelchair on the quality of life of the disabled in the developing world","volume":"18","author":"S Shore","year":"2012","journal-title":"Med Sci Monit"},{"issue":"6","key":"pone.0326653.ref033","doi-asserted-by":"crossref","DOI":"10.5014\/ajot.2017.024802","article-title":"Integrated Supported Employment for People With Schizophrenia in Mainland China: A Randomized Controlled Trial","volume":"71","author":"GF Zhang","year":"2017","journal-title":"Am J Occup Ther"},{"key":"pone.0326653.ref034","author":"S Salami","year":"2000"},{"key":"pone.0326653.ref035","author":"A Fahey","year":"2015"},{"issue":"4","key":"pone.0326653.ref036","doi-asserted-by":"crossref","first-page":"649","DOI":"10.5455\/javar.2022.i634","article-title":"Environmental adaptability, morphometric features with reproductive and productive potentialities of indigenous sheep in Bangladesh","volume":"9","author":"MRH Rakib","year":"2022","journal-title":"J Adv Vet Anim Res"},{"issue":"7","key":"pone.0326653.ref037","doi-asserted-by":"crossref","first-page":"932","DOI":"10.5455\/OVJ.2023.v13.i7.13","article-title":"Productive performance of lambs born in different seasons of the year","volume":"13","author":"BC Heinzen","year":"2023","journal-title":"Open Vet J"},{"issue":"3","key":"pone.0326653.ref038","doi-asserted-by":"crossref","first-page":"1071","DOI":"10.1007\/s10902-020-00264-2","article-title":"The Bigger the Better? Business Size and Small-Business Owners\u2019 Subjective Well-Being","volume":"22","author":"F Fors Connolly","year":"2020","journal-title":"J Happiness Stud"}],"container-title":["PLOS One"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0326653","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,8,21]],"date-time":"2025-08-21T17:23:28Z","timestamp":1755797008000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0326653"}},"subtitle":[],"editor":[{"given":"Najmul","family":"Hasan","sequence":"first","affiliation":[],"role":[{"role":"editor","vocabulary":"crossref"}]}],"short-title":[],"issued":{"date-parts":[[2025,8,21]]},"references-count":38,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2025,8,21]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0326653","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,8,21]]}}}