2.1.- LA ECONOMÍA DEL DESARROLLO Y LA TEORÍA DE LAS ETAPAS

The demographics for the sample were shown to match others reported for PLWHIV in South Africa. The validity and reliability of the HDQ was determined for this sample which differed in terms of demographic factors and medical history from other samples of PLWHIV on which the HDQ had been validated.

90 The findings in the factor analysis indicate that the construct validity HDQ may be affected by these differences and support the importance of establishing validity of assessment tolls on different populations.

For assessments to be valid they should provide scores that have the same meaning across different populations. They must be evaluated for differences in scoring and for factors that may differ from the original population on which the assessment was developed. While the language and self-report nature of the questionnaire was accommodated in this study to make the test accessible to participants by training research assistants to assist with administration of the test, other factors appear to have played a role in structure of the assessment which may affect interpretation and identification of disability in different domains on the HDQ. Thus before recommending the HDQ as a valid test for South African PLWHIV, particularly in light of 0 scores for some domains on the severity scale, further investigation into participants’ perceptions of the presence and severity of their disability as well as the episodic nature of their disability needs to be completed.

The HDQ appears to measure the construct of disability in PLWHIV as defined by O’Brien et al. (2014) and shown in the confirmatory factor analysis and convergent and divergent correlation studies. The levels of disability assessed by the HDQ were also associated with known group factors in the South African sample indicating that the assessment is responsive to mils, moderate and severe disability levels (O’Brien et al., 2014).

Based on the measurement of the construct of disability the internal consistency was established for the HDQ. The deficiency which may be related to the high Cronbach’s alpha scores for this aspect, however, may bring the relevance of all items into question.

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CHAPTER 6: CONCLUSION

6.1 CONCLUSION

The aim of this study was to determine the validity of an assessment instrument, the HDQ for a sample of PLWHIV in South Africa. The HDQ had been researched in developed countries by O’Brien, et al. (2015) but not in South Africa and many other low resource countries where the presentation of HIV differs in a low resourced health system and economy (Stats SA, 2015). The selection of a convenient sample of 498 participants in clinics in Johannesburg resulted in a sample that differed in gender, age, length of time on ART, the number of concurrent health conditions and employment rates from those used to test the validity of the HDQ previously.

The HDQ validity was tested using factor analysis, convergent and divergent validity as well as whether known group hypotheses were supported by the levels of disability assessed in the South African sample.

The principal component analysis results supported those found previously for the HDQ except for the domains related to activity limitations or difficulty with day to day activities where items loaded in the domain related to participation restrictions or challenges with social and community inclusion. Some items related to participation restrictions also loaded into the domain or uncertainty. These differences may have been related to the known group variables such as employment status and the number of concurrent health conditions that differ between this sample and that assessed by O’Brien et al. (2014) when she validated the HDQ in Canada (O’Brien et al., 2014).

Confirmatory factor analysis in this study indicated an acceptable goodness of fit for the framework used for identifying the construct of disability in the South African sample. The maximum likelihood ratio also confirmed that the factors loaded on one construct – that of disability. Therefore, the HDQ can be accepted as a tool which measures disability in PLWHIV in the South African sample. This was confirmed by the convergence to scores on a reference assessment instrument which assesses activity limitations and participation restrictions, the WHODAS 2. Divergent validity from assessment MOS-SSS indicated that the

92 HDQ assessed disability and not social support. It can therefore be accepted that the HDQ is a valid assessment instrument for the overall evaluation of disability according to the Episodic Framework developed by O’Brien et al. (2008) in PLWHIV in South Africa.

The HDQ was also found to be assessing different levels of disability when these were compared to known group variables related to HIV. Although there were more female participants in this study, this did not affect the level of disability. Other known factors such as the number of concurrent health conditions and shorter time on ART was congruent with the lower presence and severity of disability found in the South African sample. The level of severity and presence of disability was also significantly different in PLWHIV who were employed and unemployed, confirming the validity of the test to identify higher levels of disability in those who are no longer able to work.

When the domains and episodic nature of disability were considered some differences were found between those reported previously in the HDQ in developed countries and those found for the sample of PLWHIV in South Africa. The principal component factor loading structure of the HDQ was found to fit the six domains of the HDQ with the exception of Domain 5; difficulties with day to day activities which loaded with Domain 6 Challenges in social inclusion. These two domains can be considered to assess occupational performance related to participation restrictions and this finding may reflect those found for the episodic nature of disability.

These findings may be related to the effects of living in low resourced circumstances where participants encounter difficulties in accessing health care and coping with a chronic illness may be affected by socioeconomic or social circumstances. The validity of the HDQ in assessing participation restrictions in a low resourced country as well as the added burden placed on those living with HIV in a developing country such as South Africa needs further investigation.

The research study did consider the validity of the first HIV specific disability instrument for use in South Africa. In addition, the study contributed to the known literature related to the socio-demographic profile of those individuals and also the effect of this profile on disability in those living with HIV in Gauteng Province.

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