ABSTRACT
Background: Physical disability due to mobility impairment is a disabling condition that can impede an individual’s ability to function normally by requiring more effort in carrying out basic daily activities. Recent concepts of disability have moved beyond mortality and morbidity so that having a disability is no longer synonymous with having a health problem, as many people with disabilities have been noted to live very healthy lives. The aim of this study was to examine the extent of functionality of people with physical disability in Rivers State. In studying Functional disability, activities of daily living have been shown to be a strong predictor of dependence, extent of functionality and mortality.
Methods: This cross-sectional study was carried out on 179 male and female persons specifically with mobility disability in Rivers State, Nigeria. Sample size was determined using the Fischer formula and a two-stage sampling process using a computerized random-number generator application was used as the sampling method. An interviewer-administered questionnaire was data collection tool. Activities of daily living were measured using the ten-item Barthel Index. Data was analysed using student’s t-test, chi-squared and Pearson’s Correlation tests with p-value set at< 0.05.
Results: The mean age of respondents was 38.49 ± 10.89years. The leading cause of disability was accidents (29.61%). However, (25.14%) of respondents did not know the cause of their disability. More than half (53.07%) of them were paraplegic. By using the Barthel Index, prevalence of functional disability was 1(0.56%). Most of the respondents (77.65%) were independent in mobility. (69.27%) were independent when they climb up and down the staircase. 178(99.44%) could feed themselves. 94.97% were able to use the toilet independently, indicating high functionality.
Conclusion: The findings of this study reveal that the prevalence of functional disability assessed using activities of daily living was low (0.56%) inferring that presence of physical disability does not necessarily connote poor functionality and dependence. The findings of this study will encourage continuous health education and rehabilitative activities with the view to promoting good health and prolonging the life of persons with disability.
Key-words: Physical disability, activities of daily living, functional assessment.
1.INTRODUCTION
It was during the 2006 UN Convention on the Rights of Persons with Disabilities that these group of persons were properly identified and categorized to include those who have long-term physical, mental, intellectual or sensory impairments such that interaction with various barriers may hinder their full and effective participation in society on an equal basis with others (UNCRPD 2006).
The World Health Organisation (WHO) in its 2011 report on disability estimates that one billion people (15%) of the world’s population experience some form of disability and that disability prevalence is higher for developing countries as 80% of persons with disability live in middle and low income countries. Nigeria has a population of over one hundred and seventy million, and an estimated 22-25 million citizens of Nigeria are said to have one or more forms of disability (Eleweke and Ebenso 2016; Haruna 2017).
Physical disability due to mobility impairment is a disabling condition that can impede an individual’s ability to function by increasing difficulty in carrying out basic daily activities and affect quality of life. Recent concepts of disability have moved beyond mortality and morbidity so that having a disability is no longer viewed as with having a health problem, as many people with disabilities live relatively healthy lives.
Activities of daily living (ADL) are routine tasks carried out daily by an individual. They are considered essential to independent living and self-care activities are the most basic and at the core of our daily needs. These basic skills are acquired during primary socialization and typically comprise self-grooming and personal hygiene such as dressing up, toileting, feeding and transferring from one place to the other. Each activity is categorized under “independent,” “needs help” or “dependent”(Mlinac and Feng 2016; Vermeulen et al. 2011).
An individual’s ability in performing Activities of Daily Living is important in determining their physical fitness (Puteh et al. 2015) and ultimately quality of life. In studying ADL, Brach and VanSwearingen were able to show that individual functionality is a strong predictor of long-term institutionalization, dependence on others and mortality (Brach and VanSwearingen 2002).
Functional assessment is a multi-dimensional and often inter-disciplinary diagnostic process, which assesses cognitive and physical functional status of people with disability (Devi 2018; Granger, Albrecht, and Hamilton 1979). It measures severity of disability, level of function and ability to perform work-related tasks on a safe and acceptable way over a defined period of time (Horner 1994).
Functional Assessment has been an invaluable activity in rehabilitation medicine since after World War ll. In its most practical form, Functional Assessment is used to set rehabilitation goals, develop and decide on specific therapeutic interventions and monitor clinical improvement and other changes.
Globally, there are different standardized Functional Assessment tools in use but whatever tool is being used, whether adapted or adopted, should be easy to apply and correctly interpreted. It should also be culturally suitable and aim to provide valid, reliable and reproducible results. One study in Northern Nigeria (Abdullahi, Aminu and Abba 2015) researched into developing an ADL scale suitable for religious adherents with disability that must carry out daily prayers and ablutions requiring complex transfers in standing and sitting positions. Functional assessment tools are packaged in the form of self-report or caregiver/healthcare worker administered questionnaire focussing on specific interests according to the client’s needs and challenges. The commonly available tools, many of which have been in use for decades, evaluate Activities of Daily Living, Aerobic capacity, Balance evaluation, Cognition, Community re-integration, Pain syndrome assessment, Palliative care assessment, Stroke and Traumatic brain injury (Mahoney and Barthel 1965).
This present research focused on assessing daily routine activities often referred to as basic activities of daily living (BADL). It is important to differentiate between Basic ADL and Instrumental ADL (IADL). The latter evaluates more complex activities relating to independent living in the society such as managing finances, keeping appointments and maintaining households. IADL is invaluable in assessing cognitive decline such as is seen in early dementia, whereas for BADL, reduction in scores begins to manifest in late dementia stages (Cahn-Weiner et al. 2007). BADL is more essential for survival than IADL which deals more with independent and responsible functioning in the community.
In evaluating ADL, standardized tools commonly employed include Barthel Index, Functional Independence Measure, Patient-Specific Function Scale, Canadian Occupational Performance Measure and Lawton’s Instrumental Activities of daily living.
How and who measures disability differs depending on the purpose, setting and the resources available. Self-report is one way of measuring it. It may involve an individual involuntarily expressing a difficulty with bodily functions (e.g. seeing, concentrating etc) and/or physical activities (e.g. moving around, self-care etc) (Mitra and Sambamoorthi 2014).
For the purpose of measuring disability in this study, the Barthel Index was the tool of choice. Reliability of Barthel Index has been a subject of many studies. Wylie and White (1964) and Wylie (1967)(Wylie 1967) were among the earliest to assess this tool. In their study, they compared the results they obtained with the Barthel Index with that of other measures of disability that use such data as demographic factors, progress over time, length of stay and final clinical state on discharge. The Barthel Index was found to be valid both at a particular point in time and as a measure of improvement over time.
Collin and Wade in 1988 compared inter-rater reliability with the reliability of self-report by the disabled person. Their finding indicated that the Barthel Index was a reliable and useful measurement tool. Similarly, some studies have rated the Index as a gold standard because it has been widely validated and found reliable in many disability studies (Eakin 1989). However, Jacelon et al (1986) had a different view. They identified some drawbacks in the use of the Barthel Index especially when used among persons with cognitive impairment. Further to this, they also reported that the Barthel Index is generally not reliable for use with people who have changes in their mental status and those with communication deficits. The other downside to the use of the Barthel Index which is also commonly seen with other tools is differences in scoring due largely to varying levels of skills and perception between observers.
A study on variations in disability in eight low and middle-income countries showed that irrespective of the country assessment was undertaken, it recognized increasing levels of impairment in basic activities of daily living with increasing age and with the female gender. Gomez and colleagues compiled a prevalence of functional disability in basic activities of daily living (BADL) that varied from 13% in China to 54% in India (Gomez-Olive et al. 2017). A Taiwan study identified bowel, bladder control and feeding as commonly dysfunctional ADL (Hu et al. 2012).
Paucity in the availability of robust data about disability in developing countries like Nigeria also pose limits for evidence-based advocacy on disability issues, resulting therefore in a knowledge gap.
This study aimed to conduct a functional assessment of activities of daily living (ADL) among people with physical disability in Rivers State, Nigeria using the Barthel Index.
The findings of our study should have significant policy implications for policymakers at national, state and local government levels and for disability advocates. Furthermore, it will help in the design and implementation of interventions for people with disability in Rivers State, Nigeria.
2.MATERIALS AND METHODS
Ethical clearance was obtained from the Ethics Committee of the University of Port Harcourt. Participants were all given written and verbal information explaining the study objectives and procedure. Afterwards, those who were selected to participate were asked to sign a written Informed Consent form. Anonymity and confidentiality were ensured as no names were taken during the interview.
Cross-sectional descriptive study design was used. The study population for this research was made up of male and female people with mobility disability aged 18 years and above in Rivers State. Children (0-17 years) were excluded as this age group is normally largely dependent on family and others for care and support. Also excluded were persons with mobility disability who also had cognitive and speech impairment.
The sample size was determined using the Fischer formula which gave a sample size of 179 and a two-stage sampling process using a computerized random number generator application was used as the sampling method. Study tool was an interviewer-administered semi-structured questionnaire which was a self-report on questions and tasks mentioned in the questionnaire. The questionnaire ensured that all aspects of the aims of the study were appropriately researched.
Descriptive statistics was used to analyze data which were expressed as frequencies, percentages, means and standard deviations. Inferential statistics was employed to assess the relationship between socio-demographic variables and activities of daily living using student t-test and Pearson’s Correlation test. Significance was set at P <0.05. The proportion of persons with functional disability through the activities of daily living scores was also determined.
Functional Disability using activities of daily living (ADL) was assessed using the ten-item Barthel index, which assesses an individual’s level of independence. It is a weighted scale assessing 10 items of ADL, viz; personal care, bowel, bladder continence and movement.
The chosen scale for this study scored out of 20 with possible score range from 0 – 20. The respondent’s scores were summed for each item after rating by the level of assistance needed with each task. Lower scores indicated increased functional disability. For this study, the operational definition of functional disability being present was a score ≤10, meaning the respondent is needing help in one or more of the activities of daily living and categorized ‘dependent’, while a score >10 means absence of functional disability, where the respondent is said to be ‘independent’.
The activities of daily living covered by the Barthel Index are generally representative of the overall functional abilities of disabled people. The index also seems to accurately reflect ranges in functional abilities to a certain level of sensitivity (Wade and Collin 1988). The sections in the index cover most of the functional activities of daily living and provide a baseline for more in-depth assessment by the healthcare team. The Index allows professionals, disabled persons and their carers to assess progress over a period of time. It is adaptable in that any member of the healthcare team or non-professional carer can be trained to score. The findings of the Index are easily communicated, either in writing or verbally to others (Wade and Collin 1988). It also provides some information for clinical audit purposes and projections for care.
2.1 STUDY LIMITATIONS
First, the results of this study should be evaluated in view of the limitation that the sample population only included people with physical disabilities who were mobility impaired, and so may not be generalized to the entire population of people with disability. Second, self-reporting by persons with disabilities themselves which may depend on self-perceived ability may not provide an objective or accurate account of the individual’s status. Therefore, a mixed-method including Actual Performance Observation may likely yield a better result. Third, mobility disability will limit an individual’s social environment thereby reducing their inclusiveness in scientific research.
resulted in higher incidence of physical and psychological trauma in the region to the extent that Medicines Sans Frontiers had to establish a free trauma hospital in the area.
Majority of the study subjects (46.37%) had formal education up to secondary school level. This is similar to Zheng et al who had 52% of people with physical disability completing at least secondary school, unlike many studies that reported a high level of illiteracy with most of their respondents either not in school or stopping at primary school (Eide and Ingstad 2013). 25.70% of our respondents reached tertiary level of education. 1.68% of the respondents were professional (one was a lawyer, the other two lecturers with Phds). Our report has shown that despite discrimination, poor accessibility and the barriers to non-inclusive education, people with disability will go to school and also excel if given the correct social environment. Compared to non-disabled counterparts, level of literacy and education is still low. This is a trend seen across four African countries – Namibia, Zambia, Zimbabwe and Malawi – where the highest educational attainment was mostly primary school level (Eide and Ingstad 2013). The WHO identified people who have low income, out of work, or have low educational qualifications to be at an increased risk of any form of disability. Another assessment found children from poorer households to have a significantly higher risk of disability (WHO 2011).
Many of our respondents were either into business (50.28%) or unemployed (29.05%). Business bordered on small businesses either selling or using vocational skills acquired to open small businesses. Mitra et al in studying several low-income countries, found disability to be significantly associated with higher levels of multi-dimensional poverty (Mitra, Posarac and Vick 2013). People at the lower socio-economic ladder are more likely to be disabled, and those with disabilities are less likely to be employed and generally earn less even when employed (WHO 2011).
A high percentage of our respondents turned out to be single (53.07%) and still lived at home with their family (71.51%) or alone (20.11%), indicating that living alone for people with disability in Rivers State is not a common practice. It can also be inferred that disability is a common reason for single marital status. Most people with physical disability will live at home until they marry or have a meaningful source of livelihood. Married respondents were (39.11%) of total respondents. It is reassuring to know that persons with disability can still have a stable and reasonable family life.
A large proportion (29.61%) of the respondents indicated that an accident was the cause of their disability, although our study did not distinguish between the types of accidents. Evans et al., in a 5-year follow-up of young persons with disability following major physical trauma, identified accidents as a common and important cause of long-term disability. Accidents are unplanned, so the victim is usually unprepared, unprotected and likely to be left with injuries and trauma which sometimes result in disability. A report from this part of the country by Ohakwe et al. showed that the incidence of road traffic accidents are on the increase, especially during the rainy season. Rivers State is located in the Mangrove rain forest with heavy rains most months of the year. This may be a contributing factor to the high proportion of people with disabilities due to road traffic accidents in this locality (Al Ju’beh 2015).
The next leading cause of disability which is very striking in this study was the response “I don’t know” (25.15%) or a fourth of the respondents did not know what had caused their disability, majorly because they were not properly diagnosed. Some were able to describe events or circumstances that led up to onset of disability as told by their parents but many had no idea of the cause or the reason for which they were mobility impaired. This is very unlike what was reported in studies especially outside Africa where most people with physical disability are easily knowledgeable of the cause of their disability. This could be indicative of poor health-seeking behaviour. It has been noted that poor service provision and stigma may result in lower disclosure rates (Amosun, Nyante, and Wiredu 2013).
The big question here is ‘do they truly not know or is this response a pointer to attitudinal barriers they face. In Nigeria, the traditional setting view disability as a curse, a curse from God or from their ancestors so persons with disability are commonly discriminated against even within their family. The implication is that this negative attitude denies them rights to their due dignity and ability to be open and freely express themselves.
To probe the cause of disability, more than a quarter of the respondents blamed ‘spiritual’ forces behind their disability state. They also had a strong belief that disability could also be resolved likewise (16.20%). While for some it was polio, whether self-diagnosed or hospital confirmed. Our study revealed that for many people with physical disability, the cause of disability was largely unknown, especially if the disability was not caused by an obvious event. Another reason many were unable to say the cause of disability in our study could also be due to time of onset of disability (57.54%) of our respondents had onset of disability at childhood or at birth.
The proportion of disability attributed to non-communicable diseases in our study is low 5.53%. The WHO in its 2011 report stated that global increase in diabetes, cardiovascular diseases, mental disorders, cancer, and respiratory illnesses will have a profound effect on disability worldwide, but most especially in developing regions. Large increases in non-communicable disease-related disabilities have also been predicted for the developing regions due largely to population ageing, reduction in infectious conditions, lower fertility, and changing lifestyles related to tobacco, alcohol, diet, and physical activity (WHO 2011).
A great threat to any individual’s independence is functional decline which often leads to functional limitations and loss of several prior abilities. Due to the strong association between ageing, disability and functioning, many researchers have focused studies for disability using activities of daily living on the elderly population, especially those with physical disability and as a result they all reported a high prevalence of functional disability. In contrast, this study reported a low prevalence of functional disability (0.56%). This can be explained by the younger study population when compared to the elderly study population in many other studies (Abdulraheem, Oladipo, and Amodu 2011; Murtagh and Hubert 2004). Our result was similar to an Indian study by Kuvalekar et al (Kuvalekar et al. 2015) among young persons with physical disability. The Indian study obtained a very low prevalence of functional disability. They noted that majority of persons with disability in their study were not dependent on others for their daily activities indicating high daily functionality. Age is understandably linked to increasing difficulties in functioning. As populations age, the prevalence of disability will increase (WHO 2011). Globally, disability prevalence is estimated to be 12% for working-age adults and 39% and more among the elderly (Mitra and Sambamoorthi 2014). Disability, while more common later in life, can occur at any age. The Global Burden of Disease estimates childhood disability prevalence to be 95 million (5.1%), of whom 13 million (0.7%) present with severe disability (WHO 2011).
Our finding indicates that physical disability due to mobility impairment does not translate to an inability to function. Many people with disabilities live healthy, normal lives. Most of our respondents have self-care, which supports their high score on the Barthel Index. Having a disability is said not to be synonymous with having a health problem. This lends credence to the disability paradox that asserts that people with disability remain very tenacious people who struggle and survive well in very difficult conditions. In this study, male respondents had a statistically significant higher proportion of activities of daily living score compared to female respondents. This result is similar to that of Murtagh and Hubert (Murtagh, Kirsten Naumann, and Helen B. Hubert, 2004; Mitra and Sambamoorthi 2014; WHO 2011) who noted that women are more likely to report limitation, need more assistance, and have a greater degree of disability than males. This report was corroborated by Mitra and Sambamoorthi as they analysed data from several countries which showed that globally, women have a higher prevalence of disability than men (Mitra and Sambamoorthi 2014; WHO 2011). A number of possible explanations have been advanced for this. First, the accepted differential mortality rate among sexes in many countries with males having shorter life expectancy to the extent that the males that survive are younger, fitter and less disabled than the females. Also, anatomically, women have a leaner muscle mass throughout life and may be more likely to suffer from impaired physical function in later life due to weakening musculoskeletal system with the passage of time. Another possible explanation is that the female anatomy is able to endure a higher and longer burden of frailty before total system failure hence a longer life expectancy. (Hubbard RE, Rockwood K. 2011).
The male gender is naturally more active, outgoing and more resilient. Culturally, our study society is more accepting of disability states in males than in females. This attitude enables males to handle disability with less effort and more dignity. In our study, educational level, marital status, occupation did not show statistically significant association with activities of daily living.
5. CONCLUSION
This study provides insight into the extent of functionality of people with physical disability in our locality. In assessing activities of daily living, the prevalence of functional disability was low (0.56%), even when persons with severe disabilities such as paraplegics (53%) were among the study participants and also in comparison to data from a global survey which suggested that disability prevalence stands at 12% among working-age adults and 39% among the elderly (Mitra and Sambamoorthi 2014).
Our result inferred that physical disability does not automatically connote loss of everyday functioning. Majority of our respondents had self-care, which confirmed the recorded high level of independence among them. There is still need for well planned, sustainable health promotion strategies aimed at maintaining their health and functioning. Also, this study will by no means raise awareness of the importance of attaining good functionality, which will translate to good quality of life of people with disability in our country, especially with the growing prevalence of non-communicable diseases such as strokes, cancer, and heart disease, communal conflicts and road traffic accidents.
FINANCIAL SUPPORT AND SPONSORSHIP
The study was self-supported.
AUTHOR’S CONTRIBUTION
ANE and OIN designed and carried out the study, OIN supervised, both conducted literature search and wrote-up the manuscript.
CONFLICT OF INTEREST
None declared.
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