Archives of Physical Medicine and Rehabilitation journal homepage: www.archives-pmr.org Archives of Physical Medicine and Rehabilitation 2015;96:1606-14
ORIGINAL RESEARCH
Experience of People With Disabilities in Haiti Before and After the 2010 Earthquake: WHODAS 2.0 Documentation Kim Parker, MASc,a James Adderson, CP,a Marc Arseneau, MSc, RN,b Colleen O’Connell, MD, FRCPCc From the aAssistive Technology, Capital District Health Authority, Nova Scotia Rehabilitation Centre, Halifax, Nova Scotia; bTeam Canada Healing Hands, Inuvik, Northwest Territories; and cTeam Canada Healing Hands, Fredericton, New Brunswick, Canada.
Abstract Objective: To describe the functioning and participation of people with disabilities seen in Haiti Team Canada Healing Hands clinics before and after the 2010 earthquake. Design: Cross-sectional survey. Setting: Rehabilitation clinics. Participants: A convenience sample of individuals attending Team Canada Healing Hands clinics (NZ194): individuals who completed the survey before the 2010 earthquake (nZ72) and individuals who completed the survey after the 2010 earthquake (nZ122). Interventions: Not applicable. Main Outcome Measures: The World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). Results: Overall WHODAS 2.0 scores before and after the 2010 earthquake were in the top 10th percentile of population normative data, where higher scores reflect greater disability. A median increase (6.6 points) in disability was reported after the earthquake (Mann-Whitney U, PZ.055). There was a significant increase (Mann-Whitney U, P15% of the participants scored 0 or 100, respectively, on domains.23 Data normality was determined using the Shapiro-Wilk test, and if assumptions were not met, nonparametric statistics were used. Chi-square tests were used to examine differences in the proportion of male and female participants, health problems, or those working or in school before and after the earthquake. To investigate the responsiveness of the WHODAS 2.0 to the impact of a natural disaster, pre- and post- earthquake measures were compared. Independent t tests (Mann-Whitney U, P.007) were used to compare ages and WHODAS 2.0 total and domain scores between pre- and post- earthquake groups. Responsiveness of the WHODAS 2.0 was explored through the calculation of effect size. A 1-way analysis of variance was used to investigate differences in WHODAS 2.0 total scores based on self-reported health problem before and after the earthquake (Kruskal-Wallis). Within each self-reported health problem group, differences in WHODAS 2.0 total scores before and after the earthquake were determined (Mann-Whitney U, P.017). Bonferroni corrections were applied to reduce type I error in interpreting the data. Unless otherwise noted, the level of statistical significance was defined as P.05.
Results A total of 72 surveys from the November 2009 pre-earthquake visit and 122 from the June 2012 post-earthquake visit were completed. Thirty-two surveys were incomplete because of missing WHODAS 2.0 items: 8 before the earthquake and 24 after the earthquake. The pilot implementation of the WHODAS 2.0 before the earthquake indicated that Team Canada Healing Hands staff was willing to help recruit participants and administer the questionnaire. The local clinic community and attending patients were receptive to participation. Some issues with regard to wanting payment for participation were encountered in the first reported pilot implementation, but this was not seen after the earthquake. However, after the earthquake, some participants struggled emotionally with some of the questions relating to the participation domain. Specifically this included the following questions: 6.3 “How much of a problem did you have living with dignity because of the attitudes and actions of others?” 6.4 “How much time did you spend on your health condition, or its consequences?” and 6.5 “How much have you been emotionally affected by your health condition?” A summary of population descriptors is given in table 1. There were no significant differences between respondents before and after the earthquake with respect to self-reported age or sex. www.archives-pmr.org
Disabilities in Haiti Table 1
1609
Population descriptors
Descriptor Sex Male Missing Age (y) Mean SD Median Range Missing People working or in school Self-reported health problem Amputation Stroke SCI Other Assistive devices used Prosthetics Orthotics Cane or crutch Walker Wheelchair
Pre-Earthquake: November 9e13, 2009 (nZ72)
Post-Earthquake: June 5eJuly 9, 2012 (nZ122)
35 (48.6) 4 (5.6)
51 (41.8) 0 (0.0)
47.318.4 49.5 18e91 0 (0.0) 59 (81.9)
48.817.1 51.0 16e80 0 (0.0) 31 (25.4)
19 28 0 25
(26.4) (38.9) (0.0) (34.7)
14 46 20 42
(11.5) (37.7) (16.4) (34.4)
3 3 37 3 9
(4.2) (4.2) (51.4) (4.2) (12.5)
10 7 36 10 42
(8.2) (5.7) (29.5) (8.2) (34.4)
NOTE. Values are n (% within visit) or as otherwise indicated.
Significant differences were noted in the number of individuals who indicated that they were working or in school in 2009 (81.9%) as compared with those who indicated that they were working or in school in 2012 (25.4%). Generally, main selfreported health problems were the same between visits, with the exception of 16.4% of the study population in 2012 having an SCI
compared to none reported in the 2009 study population. Of those surveyed in 2012, 31 (25.4%) identified having their health problem before the earthquake, 25 (20.5%) indicated their health problem was due to the earthquake, and 2 (1.6%) had missing or unclear responses. Figure 1 provides the WHODAS 2.0 total and domain scores. There was a median increase (6.6 points) in disability scores after the earthquake (Mann-Whitney U, PZ.055) with a moderate effect size of .35. Table 2 provides missing data, floor and ceiling counts for WHODAS 2.0 domain scores, and individual questions. No participant had a WHODAS 2.0 total score of 0, indicating no difficulty due to their health condition. Similarly, no participant had a WHODAS 2.0 total score of 100. There were missing WHODAS 2.0 data for 11% of the sample before the earthquake and for 20% of the sample after the earthquake. The domain with the most missing data before the earthquake was getting along with people, whereas after the earthquake the increase in missing data was due to the life activities domain, with 20% of the postearthquake sample not answering any questions in the life activities domain. Of those not answering any of the questions in the life activities domain after the earthquake, half were people with SCI. Domain scores that significantly increased after the earthquake were related to mobility, life activities, and participation domains. Floor effects were present before and after the earthquake for understanding and communicating and getting along with people domains. Floor effects that were present only before the earthquake were for getting around and self-care domains. Ceiling effects were noted with 15.3% before the earthquake and 22.1% after the earthquake, indicating extreme difficulty in the life activities domain. WHODAS 2.0 scores did not differ significantly between health problem groups after the earthquake (fig 2). WHODAS 2.0 scores were significantly different between health problem groups before the earthquake (Kruskal-Wallis, PZ.023), with the greatest differences noted between individuals with amputations and those
Fig 1 Median WHODAS 2.0 total and domain scores. )Post-earthquake values were significantly different from pre-earthquake values (P
ORIGINAL RESEARCH
Experience of People With Disabilities in Haiti Before and After the 2010 Earthquake: WHODAS 2.0 Documentation Kim Parker, MASc,a James Adderson, CP,a Marc Arseneau, MSc, RN,b Colleen O’Connell, MD, FRCPCc From the aAssistive Technology, Capital District Health Authority, Nova Scotia Rehabilitation Centre, Halifax, Nova Scotia; bTeam Canada Healing Hands, Inuvik, Northwest Territories; and cTeam Canada Healing Hands, Fredericton, New Brunswick, Canada.
Abstract Objective: To describe the functioning and participation of people with disabilities seen in Haiti Team Canada Healing Hands clinics before and after the 2010 earthquake. Design: Cross-sectional survey. Setting: Rehabilitation clinics. Participants: A convenience sample of individuals attending Team Canada Healing Hands clinics (NZ194): individuals who completed the survey before the 2010 earthquake (nZ72) and individuals who completed the survey after the 2010 earthquake (nZ122). Interventions: Not applicable. Main Outcome Measures: The World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). Results: Overall WHODAS 2.0 scores before and after the 2010 earthquake were in the top 10th percentile of population normative data, where higher scores reflect greater disability. A median increase (6.6 points) in disability was reported after the earthquake (Mann-Whitney U, PZ.055). There was a significant increase (Mann-Whitney U, P15% of the participants scored 0 or 100, respectively, on domains.23 Data normality was determined using the Shapiro-Wilk test, and if assumptions were not met, nonparametric statistics were used. Chi-square tests were used to examine differences in the proportion of male and female participants, health problems, or those working or in school before and after the earthquake. To investigate the responsiveness of the WHODAS 2.0 to the impact of a natural disaster, pre- and post- earthquake measures were compared. Independent t tests (Mann-Whitney U, P.007) were used to compare ages and WHODAS 2.0 total and domain scores between pre- and post- earthquake groups. Responsiveness of the WHODAS 2.0 was explored through the calculation of effect size. A 1-way analysis of variance was used to investigate differences in WHODAS 2.0 total scores based on self-reported health problem before and after the earthquake (Kruskal-Wallis). Within each self-reported health problem group, differences in WHODAS 2.0 total scores before and after the earthquake were determined (Mann-Whitney U, P.017). Bonferroni corrections were applied to reduce type I error in interpreting the data. Unless otherwise noted, the level of statistical significance was defined as P.05.
Results A total of 72 surveys from the November 2009 pre-earthquake visit and 122 from the June 2012 post-earthquake visit were completed. Thirty-two surveys were incomplete because of missing WHODAS 2.0 items: 8 before the earthquake and 24 after the earthquake. The pilot implementation of the WHODAS 2.0 before the earthquake indicated that Team Canada Healing Hands staff was willing to help recruit participants and administer the questionnaire. The local clinic community and attending patients were receptive to participation. Some issues with regard to wanting payment for participation were encountered in the first reported pilot implementation, but this was not seen after the earthquake. However, after the earthquake, some participants struggled emotionally with some of the questions relating to the participation domain. Specifically this included the following questions: 6.3 “How much of a problem did you have living with dignity because of the attitudes and actions of others?” 6.4 “How much time did you spend on your health condition, or its consequences?” and 6.5 “How much have you been emotionally affected by your health condition?” A summary of population descriptors is given in table 1. There were no significant differences between respondents before and after the earthquake with respect to self-reported age or sex. www.archives-pmr.org
Disabilities in Haiti Table 1
1609
Population descriptors
Descriptor Sex Male Missing Age (y) Mean SD Median Range Missing People working or in school Self-reported health problem Amputation Stroke SCI Other Assistive devices used Prosthetics Orthotics Cane or crutch Walker Wheelchair
Pre-Earthquake: November 9e13, 2009 (nZ72)
Post-Earthquake: June 5eJuly 9, 2012 (nZ122)
35 (48.6) 4 (5.6)
51 (41.8) 0 (0.0)
47.318.4 49.5 18e91 0 (0.0) 59 (81.9)
48.817.1 51.0 16e80 0 (0.0) 31 (25.4)
19 28 0 25
(26.4) (38.9) (0.0) (34.7)
14 46 20 42
(11.5) (37.7) (16.4) (34.4)
3 3 37 3 9
(4.2) (4.2) (51.4) (4.2) (12.5)
10 7 36 10 42
(8.2) (5.7) (29.5) (8.2) (34.4)
NOTE. Values are n (% within visit) or as otherwise indicated.
Significant differences were noted in the number of individuals who indicated that they were working or in school in 2009 (81.9%) as compared with those who indicated that they were working or in school in 2012 (25.4%). Generally, main selfreported health problems were the same between visits, with the exception of 16.4% of the study population in 2012 having an SCI
compared to none reported in the 2009 study population. Of those surveyed in 2012, 31 (25.4%) identified having their health problem before the earthquake, 25 (20.5%) indicated their health problem was due to the earthquake, and 2 (1.6%) had missing or unclear responses. Figure 1 provides the WHODAS 2.0 total and domain scores. There was a median increase (6.6 points) in disability scores after the earthquake (Mann-Whitney U, PZ.055) with a moderate effect size of .35. Table 2 provides missing data, floor and ceiling counts for WHODAS 2.0 domain scores, and individual questions. No participant had a WHODAS 2.0 total score of 0, indicating no difficulty due to their health condition. Similarly, no participant had a WHODAS 2.0 total score of 100. There were missing WHODAS 2.0 data for 11% of the sample before the earthquake and for 20% of the sample after the earthquake. The domain with the most missing data before the earthquake was getting along with people, whereas after the earthquake the increase in missing data was due to the life activities domain, with 20% of the postearthquake sample not answering any questions in the life activities domain. Of those not answering any of the questions in the life activities domain after the earthquake, half were people with SCI. Domain scores that significantly increased after the earthquake were related to mobility, life activities, and participation domains. Floor effects were present before and after the earthquake for understanding and communicating and getting along with people domains. Floor effects that were present only before the earthquake were for getting around and self-care domains. Ceiling effects were noted with 15.3% before the earthquake and 22.1% after the earthquake, indicating extreme difficulty in the life activities domain. WHODAS 2.0 scores did not differ significantly between health problem groups after the earthquake (fig 2). WHODAS 2.0 scores were significantly different between health problem groups before the earthquake (Kruskal-Wallis, PZ.023), with the greatest differences noted between individuals with amputations and those
Fig 1 Median WHODAS 2.0 total and domain scores. )Post-earthquake values were significantly different from pre-earthquake values (P
