Modelo de simulación HEC-HMS

6.1 Introduction to discussion

This is a study of impairment and disability in a relatively privileged section of Saudi society. Even though care was taken to include all grades in the original sampling frame, the residents of the military academy (KAMA) enjoy better amenities compared to individuals in similar circumstances in the general population. Like parents everywhere, the Saudi parents of children with disability were seeking explanations and ways to rehabilitate their affected children.

This study has attempted to understand the feelings and anxieties of parents and how they have moved from recognition through reactions to acceptance and to coping. Each individual parent is unique, and each family's background is also unique. The same is also true about the affected children. These families' experiences are now discussed against the background of other studies.

This chapter is organised similarly to the Results into five sections, viz. Recognition, Reactions, Acceptance, Coping and Role of Services.

6 .2 Recognition of the impairment

6.2.1 Defining recognition (see also Literature Review section 2.3)

It may be useful to distinguish recognition by the family and that by the health services. The present study has shown the important role of the family in recognising that "something is wrong" and "slow progress" in a child. This "family surveillance" is an important first step in

recognition. Only when "family recognition” has occurred will a child begin to be accepted for what he or she is able to do. Otherwise the child may be seen as a failure in not doing things that are expected. Family recognition determines service utilisation, because families will not initiate service use until they have recognised the impairment, particularly after a home delivery. Tw o thirds (2 0 /3 1 ) of the children were born at home. Presence of any congenital disability will depend upon the recognition of abnormal appearance or behaviour. The delay in diagnosis ranged from birth to 13 years, for example, Down's syndrome diagnosed at the age of 4 years. Late diagnosis increases the shock of discovering an impairment in a child.

Recognition by the services (medical, social, educational or occupational) requires provision of key diagnostic procedures which will ensure an accurate assessment of the impairment and disability if present. Service recognition is also a form of labelling. In the present study even in those born in hospital, there was a measure of delay, but in general recognition of abnormality was early. Obvious impairments such as most cases of Down's syndrome and congenital rubella were diagnosed at birth. But hemiplegia and cerebral palsy took as long as 1 year to be confirmed. The more common an impairment, the greater are the chances of it being recognised (Hirst and Cooke, 1988). All services are limited by family recognition. Although some (surveillance) services precede family recognition, only when families also recognise the impairment can the services (traditional and modern) begin to help.

6 .2 .2 Prevalence rates

Some information on the size of the problem of disability internationally is shown in the introduction, section 1.2 and in the literature review section 2 .1 . Prevalence rates of some of the impairments in the present study are described in the results. In the cultural setting of Saudi Arabia the methods used in this study for obtaining an assessment of prevalence are practical and acceptable and as accurate as is possible.

6 .2 .2 .1 Overall prevalence of disability

In industrial countries, a number of large-scale surveys indicate that about 10% of the population has some disability. In developing countries, some 1 00 studies, including surveys and official population counts, have been done. It is difficult to compare the results of the various studies because different methods were used. Nevertheless, it appears reasonable to conclude that 7 - 1 0 % of the population in developing countries have a disability, which is less than in industrialised countries, but probably only because of under-reporting and lack of recognition of problems such as developmental delay (see literature review section 2 .1 ). Numerically there are far more people with disabilities in the developing world because of large populations (see introduction section 1.2).

6 .2 .2 .2 Types and prevalence of disability

Some comparative data is summarised below for minor impairments, poliomyelitis and road traffic accidents and for epilepsy, developmental delay and cerebral palsy.

1. Types and prevalence of disability: minor impairments, poliomyelitis and RTAs

i) Minor impairments

The total child disability rate in 0 -1 5 year olds was found to be 3 .9 % for minor impairments in the present study. When severe impairment in children is included the child disability rate in 0 -1 5 year olds is 4 .3 % of the total population. This compares with an under 15 rate of disability in the UK (surveyed in 1 9 8 5 -1 9 8 6 ) of a slightly lower 3 .2 % of the total population (WHO, 1990) and with an Ethiopian study in 1981 showing a much lower 0 -1 5 rate of 0 .2 % probably due to extensive under-reporting (WHO, 1990). In Bangladesh amongst 2 -9 year olds screened with the rapid ten questions method 8 .2 % screened positive for disability (Zaman et

al, 1 9 9 0 ). In Jamaica a prevalence of all types and levels of disability of 9 .3 % in children aged 2-9 was found, and serious disability at 2 .5 % of the child population (Paul et al, 1992).

For minor impairments, the current study found a prevalence rate in the child population of 6.1 % (9 .6 % in 6-15; 2 .3 % in under 5) for minor visual impairment, 4 .8 % (6 .8 % in 6 -1 5 and 2 .6 % in under 5) for minor hearing impairment and 4 .4 % for minor learning difficulties in children 6 -1 5 years old.

Comparison with other studies is limited because of reporting of disability type lacking analysis by age group (e.g. Rodriguez, 1989; WHO, 1990). For all age groups a prevalence rate in the whole population of Spain of 2 .4 % is reported for vision problems; and 2 .6 % for hearing compared with the finding in the current study of 1.8% for seeing (when the child cases are expressed as a percentage of the total population); 1.4% for hearing (see Table 5 .1 ).

In Jamaica (Paul et al, 1992) prevalence of hearing problem (all types) was found to be 0 .9 % of the child population (2-9 years) lower than in the present study, and 1 .1 % (of 2-9 year olds) for vision problems, again lower than the present study.

ii) Poliomyelitis (3 cases: Salman, Fawzia, Wadha)

Poliomyelitis still poses a serious public health problem in Saudi Arabia despite regular vaccination campaigns, though there is a lack of information on the extent of paralytic poliomyelitis. Poliomyelitis is also endemic in neighbouring countries. The incidence of this disease is frequent in the first years of life, demonstrating the importance of early vaccination (Serenius, 1988).

population in KAMA). This is much higher than the EMRO reported rates of 3 per 1 0 0 ,0 0 0 population in 1 9 8 6 and 1 per 1 0 0 ,0 0 0 in 1 9 8 8 (Robertson et al, 1 9 9 0 ). It has been estimated that during 1 9 8 6 , 1987 and 1 9 8 8 , there were 2 0 0 ,0 0 0 cases of paralytic poliomyelitis in the world. These are mostly children who belong to the 7 8 0 million people living in absolute poverty where polio vaccination is not available. With the current level of polio immunisation coverage it is estimated that 3 6 0 ,0 0 0 cases of paralytic poliomyelitis were prevented in 1988. The incidence of poliomyelitis in unimmunised infants is expected to be 5 per 1 0 0 0 (Robertson et al, 1 9 9 0 ).

iii) Road traffic accidents (RTA)

Mohammed's tetraplegia had been caused by a road accident. 3 0 % of hospital beds in Saudi Arabia are occupied by people injured in car accidents (Ministry of Health, 1981; unpublished data). It is well established that seat belts reduce mortality and morbidity among children. Data are presented for 4 1 3 children injured severely in motor vehicle crashes to require hospitalization. Of the unrestrained children 4 .5 % died, compared with 2 .4 % of the belted children. Unrestrained children had a higher proportion of injuries in anatomical regions, were more severely injured, stayed longer in hospital, and were 15% more likely than belted children to have impairments (Osberg and Discala, 1992). Little evidence exists on the social and medical costs of this disability arising from RTAs, which may be prolonged or permanent.

2. Types and prevalence of disability: epilepsy, developmental delay and cerebral palsy

iv)

Epilepsy

The prevalence of epilepsy in the population is said to range from 3 .5 per 1 0 0 0 in the industrial world to 1 5 -5 0 per 1 0 0 0 in the developing world (WHO, 1 9 8 7 , 1 9 90). The present study found a rate of 0 .7 per 1 000 when expressing the child cases as a proportion of the total