Use of the WHO classification assessing the prevalence of diseases, impairments and handicaps in Punjab, Pakistan / Jane Finnstam, Gunnar Grimby & Saeeda Rashid

- 157 - USE OF THE WHO CLASSIFICATION IN ASSESSING THE PREVALENCE OF DISEASES, IMPAIRMENTS AND HANDICAPS IN PUNJAB PROVINCE, PAKISTAN Jane Finnstam.3 Gunnar Grimbya & Saeeda Rashidb The Member States of the World Health Organization have agreed to include rehabilitation in the goal of health for all by the year 2000. Recognizing the great need for rehabilitation in developing countries, with predominantly rural populations having limited ac- cess to rehabilitation facilities, WHO developed a community-based rehabilitation (CBR) programme for integration within national primary health care programmes. According to CBR goals disabled per- sons should be able to look after themselves, move around the house and village, attend school, be employed and carry out household activities, enjoy family life and take part in community activities. The project reviewed here was undertaken as part of a feasibility study concerning this programme's ap- plication in Pakistan. The study was carried out in a village (population 4 521) some 34 km outside Lahore and in a slum area (population 2 342) in the same city. Disabled people were identified by local supervisors in accordance with the CBR manual which contains instructions and guidance on the identification of people requiring training or other rehabilitation measures, and on the conduct of a household survey. Local supervisors used a CBR questionnaire to identify those who had seizures (fits), those with difficulty in hearing, speaking, learning, moving, and seeing, and those with "strange" behaviour. A second questionnaire identi- fied those who could benefit from training or re- habilitation. The validity of the ascertainment proce- dure was established by qualified physicians who carried out a medical survey of the village using the International Classification of Diseases (ICD) and WHO's Classification of Impairments, Disabilities, and Handicaps (ICIDH-excluding the dimension of economic self-sufficiency). • Department of Rehabilitation Medicine, University Hospital, Goteborg, Sweden. b Department of Community Medicine, Lahore, Pakistan. The comparison of prevalence estimates derived from disabilities identified by local supervisors, and those derived from impairments and handicaps assessed by physicians, revealed agreement. In par- ticular, it was found that the disability and handicap elements of the ICIDH were easy to administer and use for qualified staff. This article compares the prevalence rates of the village and the slum area studied. Results The most common diagnoses in the village were eye disorders, diseases of the musculoskeletal system, hearing disorders, and respiratory diseases. Infec- tious diseases such as tuberculosis, malaria, polio- myelitis, and gastrointestinal infections with diar- rhoea were also common. A similar spectrum was found in the urban slum although infectious dis- eases, endocrine disorders, diseases of the digestive system (including diarrhoea), bronchitis, and anae- mia were more common than in the village; on the other hand, no cases of poliomyelitis were found. Most of the people with eye disorders were elderly and had cataracts, which start 10-20 years earlier than in industrialized countries. The younger people in the village with eye disorders usually had eye infections which were badly treated or untreated. Impairments were somewhat more common in the urban slum than in the village, with prevalence figures of 14% and 11%, respectively. The common- est problems were ocular and skeletal impairments, as would be expected from the disease diagnoses. Investigation of disablement (Table 1), using the CBR approach, indicated about the same prevalence of disabilities in the rural area (262/4 521) and in the urban slum (130/2 342) with a significantly lower prevalence of seeing disabilities in the village. In- vestigation of disablement was undertaken through 23 questions about primary and secondary activities TABLE 1. DISABLEMENT IDENTIFIED BY LOCAL SUPERVISORS, COMMUNITY-BASED REHABILITATION STUDY, PUNJAB, PAKISTAN, 1982-1985 TABLEAU 1. INCAPACITES DETERMINEES PAR LES CONTROLEURS LOCAUX, ETUDE SUR LA READAPTATION A. BASE COMMUNAUTAIRE, PENDJAB, PAKISTAN, 1982-1985 Disablement - lncapacites Seeing - Troubles de la vision Moving - Troubles moteurs Speech and hearing - Troubles de !'elocution et de !'audition Seizures - Convulsions Strange behaviour - Anomalies du comportement Learning - Troubles de l'apprentissage Other - Autres Multiple - lncapacites multiples • Significant difference (p < 0.05) - Difference significative (p < 0,05). Wld hlth statist. quart., 42 ( 1989) Rural (262 cases/cas) Number % of population Nombre % de la population 88 55 46 22 11 0 25 15 1.95 1.22 1.02 0.49 0.24 0 0.55 0.33 Urban slum - Urbain pauvre ( 130 cases/cas) Number % of population Nombre % de la population 23 18 26 14 3 2 32 12 o.98· 0.77 1.11 0.60 0.13 0.09 1.37" 0.51 - 158 - of daily living (ADL), asked by the local supervisors and later by occupational therapists in an evaluation group. It was felt that the use of ICIDH would not have yielded more information. The prevalence of handicap, according to ICIDH specifications, was 6.0% and 4.5% in the village and urban slum re- spectively, i.e. it was lower than that for impair- ments. The most common handicaps (Fig. 1) related to mobility, occupation, and social integration; for all aspects, more severe degrees were recorded overall in the village than in the urban slum. This did not systematically apply for all age groups or for all causes, and was more striking for rheumatism, pul- monary diseas~, and eye disorders (Fig. 2). Table 2 shows the broad categories of disease responsible for handicap, the most frequent being eye disorders and respiratory and mental diseases and, in the village, disorders of the musculoskeletal system. Po- liomyelitis and epilepsy usually give rise to hand- icap; handicaps linked to diseases of the eye and of the genitourinary and musculoskeletal systems were more frequent in the village than in the urban slum. FIG.1 OVERALL DISTRIBUTION OF SUBJECTS FOR FIVE DIMENSIONS OF THE WHO CLASSIFICATION OF HANDICAPS, AS PERCENTAGES• Orientation DISTRIBUTION GENERALE DES SUJETS SUR CINO AXES DE LA CLASSIFICATION OMS DES DESAVANTAGES, EN POURCENTAGES• % 80 % 80 Physical independence lndependance physique Mobility - Mobilite Occupational - Occupations 60 •1• Social integration - Integration sociale • Rural O Urban slum - Urbain pauvre 0 0123456789 Source: Reference (3) - Reference (3). '/. 6 a 0: no handicap; 4+: severe handicaps - 0: pas de d0savantage; 4+: dE:savantages prononces. "!. 60 Note: Please note scale differences - Nater les differences d'echelle . TABLE 2. DIAGNOSES IN PERSONS WITH HANDICAP,• COMMUNITY-BASED REHABILITATION STUDY, PUNJAB, PAKISTAN, 1982-1985 TABLEAU 2. DIAGNOSTICS POSES CHEZ DES HANDICAPES,8 ETUDE SUR LA READAPTATION A BASE COMMUNAUTAIRE, PENDJAB, PAKISTAN, 1982-1985 Rural Urban slum - Urbain pauvre (313 cases/cas) (102 cases/cas) Disease type - Type de maladie Number % of population Number % of population Nombre % de la population Nombre % de la population Tuberculosis - Tuberculose 13 0.27 5 0.21 Poliomyelitis - Poliomyelite 14 0.31 0 ob Other infections - Autres infections 10 0.22 4 0.17 Endocrine - Endocrinopathie 7 0.15 1 0.04 Blood - Affections du sang 4 0.09 6 0.26 Mental - Troubles mentaux 29 0.66 17 0.73 Epilepsy - Epilepsie 8 0.18 2 0.09b Nervous system, other - Autres affections du systeme nerveux 14 0.31 6 0.26 Eye - Affections de l'ceil 104 2.21 23 0.98b Ear - Affections de l'oreille 22 0.49 8 0.34 Circulatory - Troubles circulatoires 12 0.27 5 0.21 Respiratory (excluding tuberculosis) - Affections respiratoires (a !'exclusion de la tuberculose) 30 0.69 23 1.07 Digestive - Troubles de la digestion 16 0.35 8 0.34 Genitourinary - Affections genitourinaires 12 0.27 0 ob Skin - Afffections dermatologiques 6 0.13 2 0.09b Musculoskeletal - Affections osteomusculaires 52 1.13 7 0.30 Congenital anomalies - Anomalies congenitales 6 0.17 4 0.17 Injuries - Traumatismes 10 0.22 4 0.17 a Only conditions with a duration of one month or more are taken into account - II n'est tenu compte que des affections d'une duree egale au sup0rieure a un mois. b Significant difference (p < 0.05) - Difference significative (p < 0,05). Wld hlth statist. quart., 42 ( 19891 - 159 - FIG.2 DISTRIBUTION OF SUBJECTS FOR FIVE DIMENSIONS OF THE WHO CLASSIFICATION OF HANDICAP AS PERCENTAGES, ACCORDING TO ETIOLOGICAL DISORDER• DISTRIBUTION DES SUJETS SUR CINQ AXES DE LA CLASSIFICATION OMS DES DESAVANTAGES EN POURCENTAGES, D'APRES LES FACTEURS ETIOLOGIQUES• % A. LUNG DISORDERS - TROUBLES PULMONAIRES Orientation 100~-------------, 80 60 40 20 a 2 3 4 5 6 8 9 % Social integration - Integration sociale 100 80 60 40 20 % a 23456789 8. EYE DISORDERS - TROUBLES OCULAIRES Orientation 100...---------------, 80 60 40 20 a 2 5 6 8 9 % Social integration - Integration sociale 50 40 30 20 10 a 23456789 C. RHEUMATIC DISORDERS - TROUBLES RHUMATISMAUX % Orientation 100...----------------, 80 60 40 20 a ............ ---...... ~--~Jl--~1---...... ~-...-~----< a 2 4 6 8 9 % Social integration - Integration sociale 100 80 60 40 20 a 2 456789 Occupational - Occupations % 100...--------------, 80 60 40 20 a 2 3 6 8 9 % Mobility - Mobilite 100...--...,....,-----------, 80 60 40 20 a 2 3 4 5 6 7 8 9 % Occupational - Occupations so...--------------~ 40 30 20 10 a 2 4 6 7 8 9 % Mobility - Mobilite so...---------------~ 40 30 20 10 a 2 3 4 5 6 8 9 % Occupational - Occupations so~-------------~ 40 30 20 10 a 2 3 4 9 % Mobility - Mobilite so~-------------~ 40 30 20 10 a 2 3 4 6 7 8 9 % Physical independence - lndependance physique 100 80 60 40 20 a 4 6 7 8 9 • Aural (n = 221 O Urban slum - Urbain pauvre (n = 211 WH089747 % Physical independence - lndependance physique 100 80 60 40 20 a 2 3 4 5 6 8 9 • Aural (n = 1041 O Urban slum - Urbain pauvre (n = 23) WH089748 % Physical independence - lndependance physique 100 80 60 40 20 a 23456789 • Aural (n = 521 O Urban slum - Urbain pauvre (n = 71 WHOB9749 a See details under Fig. 1. There is not necessarily an absolute correspondence between each disorder and each handicap, hence some discordance in the number of patients in Figs. 1 & 2 - Vair details sous la figure 1. La correspondance n'est pas necessairement absolue entre chaque cause et chaque desavantage, d'ol.l de possibles discordances dans le nombre de patients des figures 1 & 2. Note: Please note scale differences - Nater les differences d'echelle. Wld hlth statist. quart., 42 (1989) 160 - Discussion This study is a first attempt to derive rough preva- lence estimates for diseases, impairments and hand- icaps in the area. Poliomyelitis was not found in the slum area, immunization having been introduced there earlier (in the village, it was started only during the period of the project). The prevalence of several groups of diseases was higher in the urban slum than in the village, although some conditions may have been underestimated. Mental diseases, for example, are not easily recognized in their milder forms, either by the local population or physicians. Within these limitations, more negative factors may be affecting health status in the slum area. Thus the higher frequency of infectious and respiratory dis- eases could be due to environmental factors. In both study areas, diseases of the eye and ocular impairments were most common, though they were more likely to give rise to handicap in the village; the same was true of musculoskeletal disorders. In general, impairments resulted in handicap in somewhat less than half the cases, though the de- gree of handicap was generally greater in the village. Acknowledgement The study on which this article is based was suppor- ted by WHO, and part of the statistical analysis was supported by a grant from the Coordinating Board of the Swedish Research Council. BIBLIOGRAPHY- BIBLIOGRAPHIE 1. HELANDER, E. ET AL. Training disabled people in the community-a manual on community-based re- habilitation for developing countries. Geneva, World Health Organization, 1983. (A cooperative programme for the United Nations Decade of Disabled Persons). 2. FINNSTAM, J. ET AL Evaluation of community-based rehabilitation in Punjab, Pakistan-I. Use of the WHO manual "Training disabled people in the community". International disability studies, 10 (2): 54-58 (1988). 3. GRIMBY, G. ET AL Evaluation of community-based rehabilitation in Punjab, Pakistan-II. The preva- lence of diseases, impairments, and handicaps. International disability studies, 10 (2): 59-60 (1988). 4. WORLD HEALTH ORGANIZATION. Manual of the inter- national statistical classification of diseases, in- juries and causes of death. Ninth Revision. Geneva, WHO, 1977. ORGANISATION MONDIALE DE LA SANTE. Manuel de la classification statistique internationale des mala- dies, traumatismes et causes de deces. Neuvieme revision. Geneve, OMS, 1977. 5. WORLD HEALTH ORGANIZATION. International Classifi- cation of Impairments, Disabilities, and Hand- icaps-a manual of classification relating to the consequences of disease. Geneva, WHO, 1980. ORGANISATION MONDIALE DE LA SANTE. Classification internationale des handicaps: deficiences, inca- pacites et desavantages - un manuel de classifi- cation des consequences des maladies. Paris, CTNERHI-INSERM, 1988. W/d hlth statist. quart., 42 (19891