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, P<.001) in WHODAS 2.0 scores related to mobility (18.8 points), life activities (30 points),
and participation (16.7 points) domains after the earthquake.
Conclusions: Persons in Haiti with a disability attending Team Canada Healing Hands clinics reported a low level of functioning. The increase in
WHODAS 2.0 scores related to mobility, life activities, and participation domains suggests that the 2010 earthquake had a negative impact on
functioning of this population and provides additional information on the responsiveness of the WHODAS 2.0 in limited resource settings. Future
work can include using WHODAS 2.0 to monitor the impact of rehabilitation service and advocacy initiatives in Haiti and similar locations.
Archives of Physical Medicine and Rehabilitation 2015;96:1606-14
ª 2015 by the American Congress of Rehabilitation Medicine

In 2011 the Pan American Health Organization reported that
there were an estimated 800,000 individuals with disabilities in
Haitidw10% of the total population.1 Haiti is considered to be
one of the poorest countries in the world, where 80% of the
population lives on less than US$2 per day.2 Before 2000, ac-
cess to rehabilitation services in Haiti was limited, with little to
no support from the government in providing access or stan-
dardized training to therapists or prosthetic and orthotic
Presented in part to Canadian Association for Prosthetics and Orthotics, August 4e7, 2010,
Quebec City, Quebec, Canada.
Disclosures: none.
technicians. Access to assistive devices such as prosthetics,
orthotics, and wheelchairs remains inadequate, with consider-
able unmet need. To address limited access to rehabilitation,
various nongovernmental organizations have emerged to pro-
vide rehabilitation services in Haiti, including Healing Hands
for Haiti International Foundation and Team Canada Healing
Hands. Healing Hands for Haiti International Foundation
established an outpatient rehabilitation and training clinic, Kay
Kapab Clinic, in Port-au-Prince, Haiti. Team Canada Healing
Hands has partnered with Healing Hands for Haiti International
Foundation at the Kay Kapab Clinic, with a focus on
providing rehabilitation services including education, training,

0003-9993/15/$36 - see front matter ª 2015 by the American Congress of Rehabilitation Medicine
http://dx.doi.org/10.1016/j.apmr.2015.05.008
Disabilities in Haiti
care, and support in the development of sustainable rehabili-
tation programs.
On January 12, 2010, there was a devastating earthquake off
the coast of Haiti near the capital, Port-au-Prince. Because of the
earthquake, there were w300,000 injuries, 150 spinal cord injuries
(SCIs), and 1200 to 1500 amputations.3-6 A recent population-
based survey of disability in the Port-au-Prince region of Haiti
estimated the prevalence of disability to be 4.1%, with less than
half of those disabled receiving medical rehabilitation. The most
common disability domains were difficulties with vision, mobility,
and cognition.7 In addition to the increase in demand for services
to address the physical needs of people injured, there was a noted
increase in demand for psychosocial support services.8
At the start of this study in 2009, relatively little had been
published about the experiences of people with disabilities in
Haiti. In 2001, Healing Hands for Haiti International Foundation
interviewed 164 people with amputations throughout Haiti and
found only 25% had a prosthetic limb. Many reported lack of
access and cost as the primary barriers to receiving prosthetic
care.9 A similar survey of 140 individuals who had lower limb
amputations was completed after the 2010 earthquake. By using
the Trinity Amputation and Prosthesis Experience Scales, they
found that amputees reported better adjustment functionally than
psychosocially.10
Measurement of functioning and disability with a tool that
captures a range of health issues is important for documenting not
only the impact of health care initiatives but all local policy and
infrastructure that are important influences on the experience of
having a disability. The World Health Organization (WHO)’s In-
ternational Classification of Functioning, Disability and Health
provides a framework to describe and classify health and disability
with respect to body functions and structure, activities, and
participation in the context of their environmental and personal
factors.11 Based on the conceptual basis of the International
Classification of Functioning, Disability and Health, the WHO
developed a cross-cultural questionnaire to measure function and
disabilitydthe World Health Organization Disability Assessment
Schedule 2.0 (WHODAS 2.0).12 The WHODAS 2.0 was devel-
oped to correspond directly to the International Classification of
Functioning, Disability and Health’s activities and participation
framework dimensions, key outcomes for rehabilitation programs,
and services.
The objectives of this study were developed in 2 phases. Phase
1 occurred before the 2010 earthquake. At this time, members of
Team Canada Healing Hands sought to obtain a more thorough
picture of the functioning and participation of people with dis-
abilities receiving rehabilitation care services at Team Canada
Healing Hands clinics in Haiti. As such, the WHODAS 2.0 was
identified as the most culturally appropriate measure of function
and disability for the pilot implementation. The pilot study would
indicate the feasibility of administering the WHODAS 2.0 and
provide initial benchmark measures of disability previously not
available that could be used to monitor future service, training,
and advocacy initiatives. The primary objective of this study was
to describe the functioning and participation of individuals with
List of abbreviations:
SCI spinal cord injury
WHO World Health Organization
WHODAS 2.0 World Health Organization Disability Assessment
Schedule 2.0
www.archives-pmr.org
1607
disabilities attending rehabilitation clinics in Haiti through the
pilot implementation of the WHODAS 2.0 questionnaire.
As a result of the 2010 earthquake, a second phase (phase 2) of
the study was developed. Team Canada Healing Hands members
sought to investigate whether changes in functioning and partici-
pation of individuals with disabilities had occurred since the 2010
earthquake and to reestablish disability measures for service and
advocacy initiatives. A second administration of the WHODAS
2.0 would also provide an opportunity to investigate the respon-
siveness of the questionnaire to a natural disaster. The damage to
the local infrastructure and loss of services would likely result in
more difficulties encountered in functioning and participation of
individuals with disabilities. A second objective of this study was
to investigate whether individuals attending Team Canada Healing
Hands clinics reported an increased difficulty in functioning and
participation since the 2010 earthquake.
Methods
Study design and participants
A cross-sectional survey was conducted during 2 time periods,
November 9 to 13, 2009 (phase 1), and June 5 to July 9, 2012
(phase 2), before and after the 2010 earthquake. Participants older
than 16 years who attended Team Canada Healing Hands reha-
bilitation clinics and clinics held by affiliated partners and Team
Canada Healing Hands staff during these 2 time periods were
recruited. Participants were required to understand Haitian Creole,
French, or English; to follow verbal instructions; and to be over
the self-reported age of 16.
Individuals who attended a Team Canada Healing Hands clinic
were approached by the attending clinician to seek consent to
participate. The study was verbally explained by the clinician, and a
letter of information about the study was supplied. If the individual
was interested in participating, they were introduced to a member
of Team Canada Healing Hands or staff/volunteers affiliated with
Team Canada Healing Hands who had been trained to administer
the survey. Informed consent was given by the participant, agreeing
to answer survey questions in a face-to-face interview. No identi-
fying information (eg, name, address, and identification numbers)
was collected. Ethical approval for this study was obtained from the
Research Ethics Board of the Capital District Health Authority and
was approved by the Director of Operations of Healing Hands for
Haiti International Foundation in Haiti.
Measures
The primary outcome measure was the WHODAS 2.0. The
WHODAS 2.0 has been shown to be a reliable and valid measure
of function and disability across different health conditions, cul-
tures, ages, and sexes.13 Research suggests that the WHODAS 2.0
has acceptable internal consistency, reliability, validity; is
responsive to change; and differentiates between people with high
and low levels of SCI impairment.13-18 The WHODAS 2.0 in-
cludes 6 domains related to an individual’s activity and partici-
pation. These 6 domains include understanding and
communicating, mobility, self-care, getting along with people, life
activities, and participation. A score is generated from an in-
dividual’s self-report on the difficulty he/she has experienced in
performing the task. Domain and total scores can range from 0 to
1608
100, reflecting no difficulty to extreme difficulty due to the health
condition. Reliability and validity studies on the WHODAS 2.0
report total scores for the general population to be below 10,
whereas scores for people with physical disabilities are closer to
30. Interviewer-administered, self-administered, and proxy ver-
sions are available in a short (12-item) and long (36-item) format
in various languages on the WHO website. This study used the 36-
item WHODAS 2.0 in both French and English. WHODAS 2.0
scores were calculated using an item response theoryebased
scoring and a simple approach to missing data.12
In addition, the survey included questions on respondents’ age,
sex, health problem, and/or cause of disability, and assistive de-
vices used. On the basis of their measures of self-reported health
problem and/or cause of disability, participants were considered
belonging to 1 of the 4 groups: (1) health problems due to an
amputation (upper and/or lower limbs); (2) stroke; (3) SCI; and (4)
other. “Other” included a range of other health problems such as
broken bones, muscle weakness, and missing or unclear responses.
Procedures
During phase 1 of the study, researchers with Team Canada
Healing Hands visited Haiti from November 9 to 13, 2009. All
2009 surveys were conducted at the Kay Kapab Clinic, a Team
Canada Healing Hands outpatient rehabilitation clinic located in
Port-au-Prince. Individuals attending Team Canada Healing
Hands clinics during this time period were potentially referred
from other hospitals, were physician referrals from community
practice, or simply attended the clinic because of word-of-mouth
publicity. Individuals with typical health problems seen in Team
Canada Healing Hands clinics included people who had a stroke
or presented with amputations or musculoskeletal injuries. Phase 2
(after the earthquake), a second administration of the WHODAS
2.0, was conducted at the Kay Kapab Clinic, other Team Canada
Healing Hands partner sites in Port-au-Prince established in
response to the earthquake, and a partner site in the Cap-Haitian
region between June 5 and July 9, 2012. Individuals were referred
through the same pathways as in 2009, except referrals from
nongovernmental organizations providing health services after the
earthquake. Services provided during both visits included reha-
bilitation assessment and recommendations that involved services
such as physiotherapy and provision of assistive devices including
prosthetics, orthotics, and wheelchairs.
All interviews were administered by members of Team Canada
Healing Hands and a translator or by Team Canada Healing Hands
staff. Team Canada Healing Hands staff members assisting with
the administration of the survey were trained by research team
members in the research protocol for approaching and recruiting
potential participants and in the administration of the survey,
including the WHODAS 2.0 questionnaire. WHODAS 2.0 training
materials were reviewed by research team members along with
Team Canada Healing Hands staff.12,19 Team Canada Healing
Hands staff observed research team members administering initial
surveys followed by administering the survey themselves to the
participants, while research team members providing any
needed support.
In 2009, the English or Canadian French self-administered
version of the WHODAS 2.0 was used.20-22 Owing to issues with
literacy, research team members used the self-administered
version in an interview style, reading the questions to partici-
pants in French or Haitian Creole. Based on the 2009 pilot
experience, the interviewer-administered version of the WHODAS
K. Parker et al
2.0 was used in 2012.12 In addition to the demographic informa-
tion obtained after the earthquake, 1 question was added to the
survey to determine whether the participant’s health problems
were due to the earthquake. Completed surveys were kept in a
secure location in Haiti within a facility secured by Team Canada
Healing Hands. After the completion of the study visit, all surveys
were returned to Nova Scotia Rehabilitation Centre and results
were entered into an electronic database.
Statistical analysis
Statistical analyses were performed using SPSS version 20
(2011).a Descriptive statistics (cross tabulations, means  SDs,
medians, ranges) were performed on all data. A floor or ceiling
effect was considered present if >15% of the participants scored
0 or 100, respectively, on domains.23 Data normality was deter-
mined 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 con-
sequences?” 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.
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Disabilities in Haiti 1609

compared to none reported in the 2009 study population. Of those

Table 1 Population descriptors
surveyed in 2012, 31 (25.4%) identified having their health
Pre-Earthquake: Post-Earthquake: problem before the earthquake, 25 (20.5%) indicated their health
November 9e13, June 5eJuly 9, problem was due to the earthquake, and 2 (1.6%) had missing or
Descriptor 2009 (nZ72) 2012 (nZ122) unclear responses.
Sex Figure 1 provides the WHODAS 2.0 total and domain scores.
Male 35 (48.6) 51 (41.8) There was a median increase (6.6 points) in disability scores after
Missing 4 (5.6) 0 (0.0) the earthquake (Mann-Whitney U, PZ.055) with a moderate ef-
Age (y) fect size of .35. Table 2 provides missing data, floor and ceiling
Mean  SD 47.318.4 48.817.1 counts for WHODAS 2.0 domain scores, and individual questions.
Median 49.5 51.0 No participant had a WHODAS 2.0 total score of 0, indicating no
Range 18e91 16e80 difficulty due to their health condition. Similarly, no participant
Missing 0 (0.0) 0 (0.0) had a WHODAS 2.0 total score of 100. There were missing
People working or 59 (81.9) 31 (25.4) WHODAS 2.0 data for 11% of the sample before the earthquake
in school and for 20% of the sample after the earthquake. The domain with
Self-reported health the most missing data before the earthquake was getting along
problem with people, whereas after the earthquake the increase in missing
Amputation 19 (26.4) 14 (11.5) data was due to the life activities domain, with 20% of the post-
Stroke 28 (38.9) 46 (37.7) earthquake sample not answering any questions in the life activ-
SCI 0 (0.0) 20 (16.4) ities domain. Of those not answering any of the questions in the
Other 25 (34.7) 42 (34.4) life activities domain after the earthquake, half were people
Assistive devices used with SCI.
Prosthetics 3 (4.2) 10 (8.2) Domain scores that significantly increased after the earthquake
Orthotics 3 (4.2) 7 (5.7) were related to mobility, life activities, and participation domains.
Cane or crutch 37 (51.4) 36 (29.5) Floor effects were present before and after the earthquake for
Walker 3 (4.2) 10 (8.2) understanding and communicating and getting along with people
Wheelchair 9 (12.5) 42 (34.4) domains. Floor effects that were present only before the earth-
quake were for getting around and self-care domains. Ceiling
NOTE. Values are n (% within visit) or as otherwise indicated.
effects were noted with 15.3% before the earthquake and 22.1%
after the earthquake, indicating extreme difficulty in the life ac-
Significant differences were noted in the number of individuals tivities domain.
who indicated that they were working or in school in 2009 WHODAS 2.0 scores did not differ significantly between
(81.9%) as compared with those who indicated that they were health problem groups after the earthquake (fig 2). WHODAS 2.0
working or in school in 2012 (25.4%). Generally, main self- scores were significantly different between health problem groups
reported health problems were the same between visits, with the before the earthquake (Kruskal-Wallis, PZ.023), with the greatest
exception of 16.4% of the study population in 2012 having an SCI 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<.007).
The possible range for WHODAS 2.0 total and domain scores was 0 to 100.

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 1610
Table 2 Floor, ceiling, and missing data for WHODAS 2.0 domain scores and individual questions
Pre-Earthquake Post-Earthquake
Domain Question Floor Ceiling Missing Floor Ceiling Missing
1: Understanding and communicating 22 (30.6) 0 (0.0) 3 (4.2) 20 (16.4) 0 (0.0) 3 (2.5)
1.1 Concentrating on doing something for ten minutes? 29 (40.3) 6 (8.3) 2 (2.8) 59 (48.4) 2 (1.6) 3 (2.5)
1.2 Remembering to do important things? 29 (40.3) 3 (4.2) 1 (1.4) 53 (43.4) 1 (0.8) 3 (2.5)
1.3 Analysing and finding solutions to problems in day-to-day life? 27 (37.5) 4 (5.6) 2 (2.8) 40 (32.8) 8 (6.6) 3 (2.5)
1.4 Learning a new task, for example, learning how to get to a new place? 28 (38.9) 4 (5.6) 3 (4.2) 76 (62.3) 3 (2.4) 3 (2.5)
1.5 Generally understanding what people say? 30 (41.7) 0 (0.0) 4 (5.6) 99 (81.1) 0 (0.0) 3 (2.5)
1.6 Starting and maintaining a conversation? 31 (43.1) 0 (0.0) 2 (2.8) 78 (63.9) 0 (0.0) 3 (2.5)
2: Getting around 15 (20.8) 3 (4.2) 1 (1.4) 8 (6.6) 13 (10.7) 3 (2.5)
2.1 Standing for long periods such as 30 minutes? 22 (30.5) 15 (20.8) 3 (4.2) 19 (15.6) 52 (42.6) 3 (2.5)
2.2 Standing up from sitting down? 24 (33.3) 10 (13.9) 3 (4.2) 25 (20.5) 42 (34.4) 3 (2.5)
2.3 Moving around inside your home? 25 (34.7) 7 (9.7) 3 (4.2) 36 (29.5) 36 (29.5) 3 (2.5)
2.4 Getting out of your home? 23 (31.9) 10 (13.9) 3 (4.2) 19 (15.6) 29 (23.8) 3 (2.5)
2.5 Walking a long distance such as a kilometre [or equivalent]? 19 (26.4) 27 (37.5) 1 (1.4) 17 (13.9) 59 (48.4) 6 (4.9)
3: Self-care 14 (19.4) 3 (4.2) 1 (1.4) 14 (11.5) 5 (4.1) 3 (2.5)
3.1 Washing your whole body? 21 (29.2) 21 (29.2) 3 (4.2) 34 (27.9) 39 (32.0) 3 (2.5)
3.2 Getting dressed? 22 (30.5) 13 (18.0) 1 (1.4) 34 (27.9) 13 (10.6) 3 (2.5)
3.3 Eating? 34 (47.2) 3 (4.2) 1 (1.4) 78 (63.9) 8 (6.5) 3 (2.5)
3.4 Staying by yourself for a few days? 21 (29.2) 20 (27.8) 2 (2.8) 26 (21.3) 70 (59.0) 14 (11.5)
4: Getting along with people 20 (27.8) 0 (0.0) 5 (6.9) 35 (28.7) 0 (0.0) 3 (2.5)
4.1 Dealing with people you do not know? 34 (47.2) 1 (1.4) 3 (4.2) 76 (62.3) 14 (11.5) 3 (2.5)
4.2 Maintaining a friendship? 35 (48.6) 1 (1.4) 5 (6.9) 98 (80.3) 6 (4.9) 3 (2.5)
4.3 Getting along with people who are close to you? 38 (52.8) 1 (1.4) 2 (2.8) 69 (56.5) 10 (8.2) 3 (2.5)
4.4 Making new friends? 42 (58.3) 0 (0.0) 4 (5.6) 89 (73.0) 3 (2.4) 3 (2.5)
4.5 Sexual activities? 48 (66.7) 8 (11.1) 9 (12.5) 82 (67.2) 13 (10.6) 8 (6.6)
5(1): Life activities 9 (12.5) 11 (15.3) 2 (2.8) 1 (0.8) 27 (22.1) 25 (20.5)
5.1 Taking care of your household responsibilities? 24 (33.3) 17 (23.6) 2 (2.8) 6 (4.9) 46 (37.7) 24 (19.7)
5.2 Doing most important household tasks well? 23 (31.9) 18 (25.0) 3 (4.2) 9 (7.4) 51 (41.8) 24 (19.7)
5.3 Getting all the household work done that you needed to do? 20 (27.8) 17 (23.6) 2 (2.8) 8 (6.5) 40 (32.8) 26 (21.3)
5.4 Getting your household work done as quickly as needed? 10 (13.9) 20 (27.8) 2 (2.8) 4 (3.3) 62 (50.8) 25 (20.5)
5(2): Life activities for those in work/school 17 (28.8) 19 (32.2) 0 (0.0) 1 (3.2) 1 (3.2) 0 (0.0)
5.5 Your day-to-day work/school? 25 (42.4) 24 (40.7) 0 (0.0) 4 (12.9) 7 (22.6) 0 (0.0)
5.6 Doing your most important work/school tasks well? 26 (44.1) 23 (39.0) 1 (1.7) 8 (25.8) 1 (3.2) 0 (0.0)
5.7 Getting all the work done that you need to do? 25 (42.4) 21 (35.6) 0 (0.0) 10 (32.2) 4 (12.9) 0 (0.0)
5.8 Getting your work done as quickly as needed? 23 (39.0) 21 (35.6) 1 (1.7) 1 (3.2) 3 (9.7) 0 (0.0)
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6: Participation in society 0 (0.0) 0 (0.0) 1 (1.4) 0 (0.0) 1 (0.8) 5 (4.1)

6.1 How much of a problem did you have in joining in community activities 32 (44.4) 16 (22.2) 2 (2.8) 13 (10.6) 64 (52.4) 3 (2.5)
(for example, festivities, religious or other activities) in the same way as

K. Parker et al
anyone else can?
(continued on next page)
Disabilities in Haiti 1611

who had a stroke. No significant differences were found on

24 (19.7)
5 (4.1)

3 (2.5)

1 (0.8)

3 (2.5)

5 (4.1)

6 (4.9)

3 (2.5)
examining WHODAS 2.0 scores by health problem before and
Missing after the earthquake. The most notable difference found was in
people with amputations who had a nonsignificant median in-
crease of 15.1 in disability score after the earthquake.
Post-Earthquake

39 (32.0)

26 (21.3)

31 (25.4)

41 (33.6)

81 (66.4)

45 (36.9)

77 (63.1)

0 (0.0)
Discussion
Ceiling

The primary objective of this study was to describe the func-

tioning and participation of individuals with disabilities attending
rehabilitation clinics in Haiti through the pilot implementation of
the WHODAS 2.0 questionnaire. A second objective of this study
43 (35.2)

was to investigate whether individuals attending clinics reported

11 (9.0)

4 (3.3)

6 (4.9)

4 (3.3)

6 (4.9)

6 (4.9)

0 (0.0)
an increased difficulty in functioning and participation since the
Floor

2010 earthquake. Overall WHODAS 2.0 scores of Haitians with

disabilities attending Team Canada Healing Hands clinics were in
the top 10th percentile of population normative data, which were
8 (11.1) 10% greater than published typical data for people with physical
disabilities. This suggests that our surveyed population reports
Missing
2 (2.8)

4 (5.6)

2 (2.8)

2 (2.8)

1 (1.4)

1 (1.4)

1 (1.4)

greater difficulty in functioning and participation both before and

after the earthquake as compared to population normative data.12
Median WHODAS 2.0 scores after the earthquake were 6.6 points
higher than those before the earthquake, with significantly more
difficulties encountered in the mobility, life activities, and
Pre-Earthquake

12 (16.7)

10 (13.9)

34 (47.2)

30 (41.7)

48 (66.7)

22 (30.5)

22 (30.5)

participation domains after the earthquake.

0 (0.0)
Ceiling

Conducting the survey within Team Canada Healing Hands

clinics is feasible as indicated by the willingness of Team Canada
Healing Hands staff to assist with participant recruitment, survey
administration, and the obtained completed surveys. The emotional
response to some WHODAS 2.0 questions that was noted only after
25 (34.7)

40 (55.5)

10 (13.9)

12 (16.7)

16 (22.2)

25 (34.7)

the earthquake likely reflects the impact of the earthquake on their

0 (0.0)

0 (0.0)

emotional well-being; this finding was also supported by reports of

Floor

an increase in demand for mental health support after the earth-

quake.8 Few studies have used the WHODAS 2.0 to measure the
functioning of people with physical disabilities in limited resource
environments or after natural disasters. A 2001 study of individuals
with traumatic SCI living in Kabul and Herat, Afghanistan, found
6.6 How much has your health been a drain on the financial resources of
6.3 How much of a problem did you have living with dignity because of the
6.2 How much of a problem did you have because of barriers or hindrances

6.8 How much of a problem did you have in doing things by yourself for
6.7 How much of a problem did your family have because of your health

that the WHODAS 2.0 mean score of 55.7 placed them in the top
0.5% of the greatest reported difficulty in functioning and partici-
6.4 How much time did you spend on your health condition, or its

6.5 How much have you been emotionally affected by your health

pation, indicating greater disability, as compared to population

normative data.24 In our study, participants with SCI generally
report similar levels of disability and function. In comparison, data
from a more resourced setting based on individuals living with SCI
had median WHODAS 2.0 scores ranging from 27 to 32, which
were close to typical values obtained for people with physical
disabilities. This lower disability score is likely a reflection of both
the environment and the ability to adjust to the injury.17,18 In
comparison, individuals with recent lower limb amputations in a
resourced setting had 12-item WHODAS 2.0 scores placing them
attitudes and actions of others?

in the top 5th percentile for disability normative scores.25 Our

NOTE. Values are n (% within visit).

sampled population with amputations reported much lower

in the world around you?

WHODAS 2.0 scores before the earthquake, indicating fewer dif-

relaxation or pleasure?

ficulties encountered in functioning and participation. This

you or your family?

WHODAS 2.0 total score

discrepancy may be due to cultural differences in function and

Table 2 (continued )

consequences?

participation expectations.
Domain Question

It is not clear whether a 6.6-point increase in WHODAS 2.0

condition?

problems?

score after the earthquake, with a moderate effect size of .38, is a

meaningful change. To provide some context, WHODAS 2.0 ef-
fect sizes have ranged from .44 to 1.07 in studies investigating
interventions in populations with back pain, schizophrenia, oste-
oarthritis, and alcohol dependence.12,13 The WHODAS 2.0 total

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1612
Fig 2 Median WHODAS 2.0 scores by self-reported health diagnosis. No self-reported SCI was surveyed before the earthquake. The possible
range for WHODAS 2.0 total scores was 0 to 100.
score has been shown to be able to distinguish between individuals
with higher and lower impairment level SCIs, with disability score
differences ranging from 6.6 to 13.6.17,18 The measured increase
in WHODAS 2.0 disability score suggests that the earthquake had
some impact on the reported disability level. The item response
theoryebased scoring of the WHODAS 2.0 results in different
weighting of some questionnaire items, which may have
contributed to the lack of significant differences between visits. A
likely result of the earthquake was the significant decrease in the
percentage of the population working or in school because of the
damage of the local infrastructure and reflected in the increased
levels of difficulty in life activities and participation domains. This
may have implications for the poverty experienced by people with
disabilities in Haiti and subsequently reflected in increased
disability scores.
Changes in WHODAS 2.0 scores may also be a reflection of
the difference in rehabilitation case mix seen in Team Canada
Healing Hands clinics before and after the earthquake. Self-
reported health problems were generally the same between visits.
The exception was observed in 16.4% of the study population with
SCI in 2012 as compared with 0% of the study population in 2009.
Our study included 20 individuals with SCI, an estimated 7% of
Haitians with SCI due to the earthquake. This is a population that
was not typically seen in the rehabilitation setting before the
earthquake. One possible reason for this is thought to be the result
of low survival rates for people who initially survived severe SCIs,
which is consistent with other underresourced settings. The in-
ternational response to the 2010 earthquake resulted in an increase
in survival for people with SCI.4 This population may be over-
represented because surveys were conducted 1 day at a clinic with
a focus on SCI management, the Cap-Haitian region clinic. In-
dividuals with amputations are likely underrepresented in the post-
earthquake study population. After the earthquake, the population
K. Parker et al
with amputations typically seen in Team Canada Healing Hands
clinics were, at the time, being referred to a temporary physical
rehabilitation center. This was a partner clinic, but one of many
partner clinics surveyed after the earthquake in Port-au-Prince.
Levels of disability and function remained essentially the same
across health problems before and after the earthquake. The only
group to indicate increased WHODAS 2.0 scores after the earth-
quake was individuals with amputations, which may be a reflec-
tion of different levels of amputation in the population surveyed
before and after the earthquake. This, in addition to the inclusion
of people with SCI who reported the second highest WHODAS
2.0 scores, may have influenced the overall increase in median
WHODAS 2.0 score after the earthquake. The increased number
of individuals with injuries, specifically people with SCI not
previously seen before the earthquake, and the influx of aid after
the earthquake have led to twice as many wheelchairs being used
by the population sampled. This highlights the need to address the
appropriate provision of wheelchairs and wheelchair skills
training.26 The WHO has developed guidelines for wheelchair
provision in less-resourced settings, and it has been recommended
that these guidelines be implemented in Haiti.27 This also high-
lights a need to help advocate for greater inclusion of people with
disabilities and to plan accordingly in the infrastructure rebuilding
and health care service program delivery.
It is interesting to note the increase of missing data in the post-
earthquake visit. This seems to be due to the difficulty in
answering questions in the life activities domain after the earth-
quake. It may be due to the fact that many are still residing in
temporary housing, so the concept of household tasks has changed
and is not relevant to their current situation. This is also likely
reflected in the increased ceiling effect in the life activities domain
after the earthquake. This may be especially true for participants
with SCI, half of which were unable to answer any questions in
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Disabilities in Haiti
this domain. Because of this, half the participants with SCI did not
contribute to the WHODAS 2.0 total score, which may account for
lack of significant increase in total disability score after the
earthquake. This has important implications in the use of the
WHODAS 2.0 in the assessment of catastrophic events. This may
require reframing the concept of home and household tasks to
reflect the new living situation. Another option would be to
exclude the life activities domain, which has been done when
using the WHODAS 2.0 in long-term care facilities where in-
dividuals do not have household tasks to perform.28 It is recom-
mended that future studies using the WHODAS 2.0 after
catastrophic events use a mixed methods approach and obtain
qualitative perspectives as well.
Study limitations
As this was the first reported pilot implementation of the
WHODAS 2.0 in Haiti, there are several potential limitations.
First, there should be caution in interpreting study results because
the WHODAS 2.0 has not been validated specifically in Haiti, but
has been evaluated in other low-income countries and shown to
be culturally sensitive. We were unable to obtain a methodo-
logically appropriate translation (panel of experts, forward and
backward translation, and testing) of the survey into Haitian
Creole, and subsequently French and English versions had to be
used, relying on local Haitian research team members to provide
Haitian Creole translation. Second, different WHODAS 2.0 in-
strument versions and training materials were used, which may
account for some differences in the obtained results, although
WHODAS 2.0 domain-specific questions remained the same
between visits. Third, Team Canada Healing Hands clinics
operate in minimally resourced conditions and local staff were
used to recruit and conduct study interviews. Because of the
impact of the 2010 earthquake, a structured study design was not
feasible. Although we encouraged data collectors to capture in-
formation on the number of patients approached, it was not
consistently recorded and subsequently we cannot calculate a
formal response rate. Nor was a formal sampling frame available
to indicate the total population with disabilities; thus, we cannot
determine the representativeness of our convenience sample.
Despite this limitation, the study used local clinic staff to
administer the survey, which was highly regarded by the local
clinic community and attending patients. The post-earthquake
sample was drawn from a larger geographical area and occurred
over a greater duration of time, which may have biased the
sample obtained. Individuals attending Team Canada Healing
Hands clinics before and after the earthquake were primarily
from an urban, upper-middle socioeconomic population, as these
were the individuals who had the ability (transportation) to ac-
cess services. Subsequently, rural and lower-income populations
were underrepresented in this study.
Conclusions
To our knowledge, this is the first study to explore the experience
of people with disabilities in Haiti, as measured using the
WHODAS 2.0. The increase in WHODAS 2.0 score related to
mobility, life activities, and participation domains suggests that
the 2010 earthquake had a negative impact on functioning, while
also providing additional information on the responsiveness of the
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1613
WHODAS 2.0 in limited resource settings. Moreover, this study
highlights the limitation in activities and participation experienced
by people with disabilities in Haiti before the earthquake and
suggests that Team Canada Healing Hands and other nongovern-
mental organizations have an opportunity in partnership with the
Haitian community to help advocate for greater inclusion of
people with disabilities. Future work can include using WHODAS
2.0 to monitor the impact of rehabilitation service and advocacy
initiatives in Haiti and similar locations.
Supplier
a. IBM Corp.
Keywords
Activities of daily living; Earthquakes; Haiti; Outcome assessment
(health care); Rehabilitation; Social participation
Corresponding author
James Adderson, CP, Assistive Technology, Capital District
Health Authority, Nova Scotia Rehabilitation Centre Site, 1341
Summer St, Halifax, NS, Canada B3H 4K4. E-mail address:
james.adderson@nshealth.ca.
Acknowledgments
We thank Riche Zamor, PhD, Executive Director of Healing
Hands for Haiti, for supporting the participation of local Haitian
staff in this project and Mary Halpine, MD, for providing research
site lead in 2012. We also thank Yasmine Edouard, Lesly Danger,
Herold Lojuste, and Louis-Charles Gimps, for assisting in the
administration of the survey in Haiti.
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