PREVALENCE OF UNDETECTED DEPRESSIVE DISORDERS AMONG PATIENTS ATTENDING PHYSIOTHERAPY AT KNH

By GERALD NGANGA KIHUGA

H58/……………/……………

MMed Psychiatry, University of Nairobi

A Dissertation Submitted in Partial Fulfillment of the Requirements for the Award of Masters in Medicine Degree in Psychiatry in the School of Medicine, University of Nairobi

May 2020

DECLARATION OF ORIGINALITY FORM

DECLARATION

1. I understand what Plagiarism is, and I am aware of the University’s policy in this regard.
2. I declare that this thesis is my original work and has not been submitted elsewhere for examination, the award of a degree, or publication. Where other people’s work or my work has been used, this has appropriately been acknowledged and referenced following the University of Nairobi’s requirements.
3. I have not sought or used the services of any professional agencies to produce this work.
4. I have not allowed and shall not allow anyone to copy my work to pass it off as his/her work.
5. I understand that any false claim in respect of this work shall result in disciplinary action, according to the University’s anti-Plagiarism Policy.

Signature _____________________                    Date ________________________

ABSTRACT

Background: Globally, depression is the leading cause of disability, with Kenya ranking fifth with the highest number of depression cases among African countries. Despite literature showing a strong connection between physical wellbeing and mental health, the screening for depression or other mental health disorders is currently inconsistent, and this greatly reduces their chance of accessing suitable treatment.

Study aim: This study aims to assess the prevalence of depression among patients attending the Physiotherapy clinic at Kenyatta National Hospital.

Methodology: This study will make use of a descriptive cross-sectional design. Population of interest are patients receiving physiotherapy at Kenyatta National Hospital. A sample size of 384 will be sampled using systematic random sampling. Once informed consent is obtained from the participants, they will be given a set of questionnaires that include a researcher designed demographic questionnaire, the Becks Depression inventory, and the Work Injury Degree of Disability Schedule. Data will be analyzed using SPSS version 25, where for continuous data, the means and frequencies will be determined.

In contrast, measures of association will be used to assess significance in categorical data. The hypothesis to be tested will be whether the prevalence of depression among patients attending physiotherapy in KNH is higher than that found in the general population. Results will be presented in tables, pie charts, and narrative form.

TABLE OF CONTENTS

LIST OF TABLES

LIST OF FIGURES

ABBREVIATIONS

BDI – Becks Depression Inventory

DALYS – Disability Life Adjusted Years

DSM 5 – Diagnostic and Statistical Manual of Mental Disorders 5

ICD 10 – International Statistical Classification of Diseases and Related Health Problems

KNH – Kenyatta National Hospital

MMSE- Mini-Mental State Examination

PHQ 9 – Patient Health Questionnaire 9

SES – Socio-economic status

SPSS- Statistical Package for the Social Sciences

WHO – World Health Organization

CHAPTER ONE: INTRODUCTION

1.1  BACKGROUND INFORMATION

World Health Organization (2001) highlights that depression is the most common and costly health problem worldwide. Depressive disorders are more widespread among patients with physical illnesses than persons without. Gautam, S. Jain, Gautam, M, Vahia, and Grover (2017) suggest that one-third of medical inpatients report mild to moderate symptoms of depression. When depression co-exists with other medical or psychiatric symptoms, depressive symptoms are more treatment-resistant than those without other underlying disorders. Therefore, it is clear that depression is positively associated with poor outcomes and, if left untreated, leads to poor prognosis.

Depression is a common psychological disorder. It affects approximately 121 million people globally. WHO states that one of the top twenty leading causes of disability and death in the world is unipolar depression. Unipolar depression is ranked third globally since the year 2004 and ranked eighth in developing countries as a burden of Disability Life Adjusted Years (DALYs) disease. According to a WHO (2004) report, unipolar depression affects about 65.5 million people of all ages globally, with 26.5 million people, in low-income countries such as Kenya. A WHO (2017) report, Kenya was ranked fifth among African countries with high depression cases, with a total of 1.9 million reported depression cases (Oketch, 2017). This emphasizes the dire need for early detection and treatment measures to be established in the effective management of unipolar depression in the healthcare sector in Kenya.

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1.2 PROBLEM STATEMENT

According to WHO (2003), global statistics, major depression is the leading cause of disability. Kenya is ranked fifth with the highest number of depression cases in African by a WHO (2017) report. It is estimated 19.1 million people suffered from depression in 2016. Research has demonstrated that depression is a significant cause of lost productivity and pain caused to individuals and families and, more so, the cost to human life through suicidal attempts and actual suicide. Depression affects all people across the races, socio-economic status, and cultural backgrounds.

Despite the strong connection between physical wellbeing and mental health, screening for depression or other mental health disorders is currently inconsistent. This greatly reduces their chance of accessing suitable treatment. The screening of depression, and consequently, treatment is essential in primary health care and more so for patients are undergoing physiotherapy. This study’s objective is to investigate the prevalence of depression among patients attending the Physiotherapy clinic at Kenyatta National Hospital.

1.3 OBJECTIVES

1.3.1 Broad Objective

The study’s overall objective is to determine the prevalence of depression among patients attending the Physiotherapy clinic at Kenyatta National Hospital.

1.3.2 Specific Objectives

1. To determine the socio-demographic profile of patients attending the Physiotherapy clinic at Kenyatta National Hospital.
2. To determine the prevalence of depression among patients attending the Physiotherapy clinic at Kenyatta National Hospital.

1.4 RESEARCH QUESTION

1. What is the prevalence of depression among patients attending the physiotherapy clinic at KNH?

1.5  HYPOTHESIS

1. H₀: The prevalence of depression among patients attending physiotherapy in KNH is not higher than that found in the general population.
2. H₁: The prevalence of depression among patients attending physiotherapy in KNH is higher than that found in the general population

1.6 RATIONALE AND JUSTIFICATION

One of the main challenges of psychiatric co-morbidity with general medical conditions is adherence (compliance) to treatment to both the medical and mental health. Research indicates the importance of addressing depression, citing it as a public health priority to decrease disease burden and disability, and to enhance the overall health of populations. It is with this in mind that the diagnosis and treatment of depression in patients should be encouraged. Ndetei et al. (2009), in a study to ascertain the incidence of mental disorders in adults in general medical facilities in Kenya, found a high prevalence of psychiatric co-morbidity (the bulk of which was depression), which in no small extent was not diagnosed and therefore not treated.

Physiotherapy outcomes can be unpredictable, and recognizing the predictors that promote success or failure is a crucial goal for management and service design. There is a dearth of information on the prevalence and treatment of mental health disorders among individuals dealing with physical ailments requiring physiotherapy. There have been no studies conducted in this area in Kenya. This study will partially meet this deficit by aligning the prevalence of depression to the disabilities presented at the physiotherapy clinic.

1.7 STUDY SIGNIFICANCE

This study will be beneficial in that it will provide some much-needed local data on the commonality of depression, which will assist in coming up with guidelines on how to manage patients attending physiotherapy with co-morbid depression, as it has been noted that it also affects compliance to treatment. This may be of major importance in forecasting outcomes, adapting treatment strategies, and maximizing patient benefit. Early detection and appropriate management are encouraged in current intervention guidelines on the premise that it’s to improved outcomes, minimizing financial cost to the individual and society (Tahir et al., 2009).

CHAPTER TWO: LITERATURE REVIEW

2.1 INTRODUCTION

“Depression can be described as an abnormal emotional state characterized by exaggerated feelings of sadness, melancholy, dejection, worthlessness, emptiness, and hopelessness that are inappropriate and out of proportion to reality. The overt presentations, which are extremely variable, ranging from a slight lack of motivation and inability to concentrate to severe physiologic alterations of body functions and may represent symptoms of a variety of mental and physical conditions, a syndrome of related symptoms associated with a particular disease, or a specific mental illness.” (Anderson, Keith, Novrak et al, 2002)

The World Health Organization (1992) International Statistical Classification of Diseases and Related Health Problems (ICD-10) and the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM 5, 2013) classification of mental disorders, offer an operationalized diagnostic criterion of depression. For a diagnosis of major depression, the presence of five or more symptoms (below), must be present and must cause the individual significant distress or impairment in their life:

• either a predominantly depressed mood
• and loss of interest in most activities over at least two weeks and negatively impacts one’s personal, social, and professional life.
• other symptoms include;
  1. diminished concentration,
  2. significant changes in weight or appetite,
  3. fatigue or loss of energy,
  4. loss of clarity of thought or indecisiveness,
  5. psychomotor retardation or agitation,
  6. feelings of excessive guilt, or worthlessness,
  7. insomnia or hypersomnia,
  8. and recurrent thoughts of death.

Depression is common in patients attending physiotherapy clinic, and has been associated with;

• Increased social and economic neglect
• Increased psychosocial and physical disability
• Increased likelihood of unemployment,
• Increased medication used and
• Increased pain intensity.

Depressive symptoms have been recognized as an influential risk factor for problematic response to physiotherapy (Tahir, Zangana, and Ali, 2009).

Intervention guidelines currently encourage early detection for the management of depression.  Appropriate management is based on the evidence that it leads to better outcomes, reduces financial burden to both the individual and society and prevents vulnerability to both depression and the physical illnesses (Borys, Strauss, Altmann, 2015)

Physiotherapy refers to the process in which an individual is helped to restore movement and function when affected by illness, injury, or disability. It can also help to reduce your risk of injury or disease in the future. There are many musculoskeletal injuries that physiotherapy or physical therapy plays an integral part in management. Borys et al. (2015) claim that physical therapy aims to rehabilitate or treat an individual after an operation or injury to allow you to return to your average level of function in the quickest time possible and prevent additional damage and loss of fitness.

2.2 EMPIRICAL LITERATURE

2.2.1 depression

Studies done in Kenya by Aillon, Ndetei, Khasakhala, et al. (2014) have shown that depression is one of the most prevalent mental disorders present in patients attending primary healthcare clinics. Othieno, Okech, Omondi, Makanyengo (2001) found that few referrals were made due to the perceived stigma felt by these patients when they were diagnosed with depression. Aside from perceived stigma by patients upon diagnosis of depression, the poor clinician detection rate of depressive symptoms in patients attending primary health care clinics in Kenya was of major concern. In a study carried out to investigate the prevalence of mental disorders in 2,770 adult patients receiving inpatient and outpatient services from 10 medical facilities of different levels in Kenya, about 1,163 (42%) of the participants had mild to severe symptoms of depression. Only 114 of the 2,770 participants had a hospital record with a working diagnosis of a mental illness, meaning that most of the patients with mental illnesses were undiagnosed (Ndetei,  Khasakhala, Kuria, et al., 2009).

2.2.2 Depression and Medical Issues

WHO (2001; 2003) states that good-quality mental health is essential to individuals, their families, and society. Poor mental health has been recognized as one of the major causes of disability, poor quality of life and reduced productivity.

An individual’s mental health is influenced by a multifaceted interplay of various biological, social, psychological, economic, and environmental factors. Persons affected by mental health disorders have been found to have higher levels of morbidity and mortality, with an increased prevalence of hypertension, cardiovascular disease, diabetes, respiratory disease, and suicide (De Hert, Bobes, Cohen et al., 2011). Gureje, Ademola, and Olley (2008) found a strong association between mental health conditions and reporting multiple pain sites by patients.

Vermeer, Rice, McIntyre et al. (2016), using a retrospective chart review, assessed stroke deficits and lifestyle factors as independent predictors for depressive symptoms in post-stroke patients attending outpatient clinics. In the final analysis, 202 patients were used. Thirty-six percent of patients were found to have mild to severe depressive symptoms. Depressive symptoms were significantly associated with smoking, cognitive impairment, pain, and therapy enrollment. Findings also showed that patients reporting cognitive impairment to be four times more likely to have high scores on the Patient Health Questionnaire (PHQ)-9. This study concluded high levels of depressive symptoms were most common in the chronic phase post-stroke and were partially related to pain, cognition, lifestyle factors, and therapy enrollment.

Azad, Gondal, Abbas, and Shahid (2014), carried out a study that aimed to see the frequency of depression in 110 patients with chronic type-2 diabetes. Depression and anxiety were assessed by the Hospital Anxiety and Depression Scale. Almost 50% of the patients were found to have depression and anxiety in our study with a higher prevalence in women, who are housewives with low education. The duration, treatment, and control of diabetes were found to have little effect on anxiety and depression in this group of patients. These findings suggest a regular screening of this group.

A study by Jema and Assefa (2016), aimed to discover the magnitude of depression and associated factors among patients with chronic kidney disease who received follow-up treatment in the renal units in two hospitals in Ethiopia. A total of 479 patients were recruited, 29.4% were found to have depression. Being a woman, older than 60 years, living alone, poor social support, and having other co-morbid illnesses (hypertension and diabetes) that were associated with depression. This study concluded the need for training health workers and guidelines for those in the renal unit to screen and manage depression.

A world survey done by Moussavi, Chatterji, Verdes, et al. (2007) aimed to explore the effects of depression on overall health status. Sixty countries from all over the world participated with over 245,404 observations made. The findings showed an overall 3.2% one-year prevalence for depressive episode. Participants with one or more chronic physical diseases, between 9.3-23%, had co-morbid depression, which suggested that depression in chronic disease is more prevalent. The survey concluded that depression promotes poorer health outcomes compared with other chronic illnesses.

2.2.3 Depression and Physiotherapy

Literature suggests that depressive disorders are more prevalent in patients with physical illness (MacHale, 2002). Some medical conditions are strongly related to the presence of psychiatric illness than others. Gureje et al. (2008) found a 25% prevalence of depressive illness in patients with diabetes, cardiac or neurological disease. Those in medical inpatient wards are also more likely to have depression than those visiting outpatient clinics

A study by Tahir et al. (2009) aimed to detect the occurrence, severity, and type of depressive disorder among patients receiving care at the physiotherapy clinic and other related factors. 56% of those recruited were found to be depressed, with 27% identified with mild depression, 20.5% moderate, and 8.5% severe depression. Factors associated with depression included being old age, of the female gender, and married. The study recommended the screening of depression in patients attending physiotherapy should be considered.

Negative consequences on outcomes and healthcare costs are influenced by poor adherence to treatment. In the area of physiotherapy, little is known about the barriers to treatment. A systematic review of 20 studies by Jack, McLean, Moffett, and Gardiner (2010), showed poor social support, low self-efficacy, low levels of physical activity, anxiety, depression, helplessness, low in-treatment adherence with exercise, increased pain levels during training as well as higher perceived number of barriers to exercise were strongly associated with poor treatment adherence.

Chronic musculoskeletal pain is a frequent and costly health problem which can be challenging to manage. A study carried out by Rahman, Reed, Underwood, Shipley, and Omar (2008) to identify factors influencing the intensity of pain and self-efficacy of patients referred to a chronic pain clinic over five years. Findings from this study suggested that the patients had high pain intensity scores and low self-efficacy. Depressive symptoms and being unemployed were correlated with low self-efficacy, while pain intensity was associated with depressive symptoms, extensive pain, and low levels of education.

Sinyor, D.A.V.I.D, Amato et al. (1986) assessed the impact of post-stroke depression on rehabilitation outcomes. Sixty-four patients presented to a rehabilitation program within weeks of first stroke were recruited. A prevalence of depression of 47% was found in this population and evidenced greater functional impairment at both admission and discharge despite showing similar gains throughout rehabilitation. Depressed patients were found to participate less in the rehabilitation process, indicating an association with a degree of functional impairment, thus influencing the rehabilitation process and outcome.

A study to determine the effect of the psychiatric symptoms of anxiety and depression was carried out in Swansea by Khan, Whittal, Mansol, et al. (2013). One hundred eight women presenting with pelvic floor dysfunction and had been admitted to the six-month physiotherapy program were recruited. Findings showed a strong positive relationship between the severity of the pelvic floor dysfunction and the severity of depression and anxiety symptoms.

George, Coronado, Beneciuk, et al. (2011) carried out a study to assess both the prevalence and effect of depressive symptoms in patients with musculoskeletal pain across different anatomical regions in a sample of 8,304. The prevalence of severe depression was found to be higher in women, as well as in patients who reported chronic pain or prior surgery. At the same time, lower rates were observed in patients older than 65 or with upper- or lower-extremity pain. The severity of depression differed slightly based on the anatomical region experiencing musculoskeletal pain. Depressive symptoms were found to have effects on pain ratings and functional status. The symptoms also showed a consistent negative impact on outcomes, except for those on discharge scores for the cervical anatomical region.

Findings from physiotherapy research suggest that depression is high among patients and that their experience of depressive symptoms influences the effectiveness of the treatment. There are determinants have been identified to influence the susceptibility of one to depressive symptoms in this group. They are factors such as age, gender, severity of the disability/dysfunction, coping strategies, and type of support the patient receives.

2.3 THEORETICAL FRAMEWORK

This study will be guided by Beck’s Cognitive Theory of Depression (Beck, A. T., 2008), which relates depression to ongoing stressful life experiences. The cognitive theory recognizes that traumatic life experiences and their resultant construction of faulty or maladaptive cognitive beliefs as predisposing events to developing stress and depression later on in life.

Beck describes a cognitive triad that explains an individual’s reaction to a stressor. The exposure to negative stimuli causes maladaptive thinking and emotional incongruence leading to a negative self-image of oneself. The triad explains how the physical and psychological aspects of an individual are influenced by their maladaptive thinking patterns when they are experiencing stressful situations.

Beck’s Cognitive Theory of Depression describes the role of stress as a key to activating previously dormant irrational cognitive schemas in an individual. Information processing in depressed people is based on silent cognitive assumptions of how other significant people in their lives treat or view them. For those in physical therapy, the silent assumptions may be derived from their significant others’ behavior and inability to perform as they were previously able to bring about feelings of inadequacy and self-blame.

Depression from the stress of the healing process develops over time with repetitive exposure to the physical therapy process, and the difficulties experienced through the exercise that may be aggravated when the victim’s dormant pre-existing irrational cognitions are re-awakened, and the victim develops negative silent cognitive assumptions based on how they currently view themselves.

2.4 CONCEPTUAL FRAMEWORK

Attending the physiotherapy is the independent variable in this study, while depression is the dependent variable. Mediators shown in the framework may lead to an increase in one’s susceptibility to developing depression. Factors such as age, gender, one’s socio-economic status (SES), the severity/ degree of the disability/dysfunction, number of sessions one has to attend, coping strategies, and social support are the mediating factors we feel may influence the development of depression in patients receiving physiotherapy.

Figure 1: Conceptual framework

CHAPTER THREE: RESEARCH METHODOLOGY

3.1 INTRODUCTION

This chapter describes the methodology that was used to conduct this study. These include: Research paradigm, research design, target population, sample size determination and sampling method, data collection instruments, and procedures. Further, quality assurance procedures and ethical considerations are discussed.

3.2 RESEARCH PARADIGM

Kenyatta National Hospital (KNH) in Nairobi, Kenya, is the largest and oldest referral hospital in East and Central Africa. This government hospital offers a plethora of services, including Physiotherapy services for both inpatients and outpatients.

The specific study site for this study is the physiotherapy clinic, which receives approximately 4000 or more number of patients annually. KNH takes in referral cases mostly from private clinics and government hospitals within the country.

3.3 RESEARCH DESIGN

This study will use a Cross-Sectional Descriptive design.

3.4 TARGET POPULATION

The study’s target population is patients attending physiotherapy at the KNH, and that meet the criteria as outlined below.

3.4.1 Inclusion Criteria

• Patients attending physiotherapy clinic.
• Patients aged 18 years and above.

• Patients who have given consent to participate in the study.

3.4.2 Exclusion Criteria

• Patients who do not give consent/permission to participate in the study.

• Patients with active psychopathology. Mini-Mental Status Examination (MMSE) will be carried out by the researcher to rule out active psychopathology (those with delusions, hallucinations, and lacking insight). Patients with active psychopathology will be excluded as the symptoms may interfere with their ability to give informed consent and fill out the assessments.
• Patients with severe debilitating illness, as shown in the files. These patients may have pain and other symptoms that may be too stressful such that they can not concentrate on the study.

3.5 SAMPLE SIZE AND SAMPLING METHOD

3.5.1 SAMPLE SIZE DETERMINATION

This study will use Cochran’s (1977) sampling formula;

n =  z² p (1-p)

             d²

Where                         n –Estimated sample size

d –The level of precision

p – Proportion of those with the condition of interest

z –Confidence level

Using a confidence interval of 95%, expected prevalence of 50% (in a situation like this where the prevalence is not known) and a level of significance of 5% (0.05),

n = 1.96 x 1.96 x 0.5 x 0.5

0.05 x 0.05

n = 384

3.5.2 SAMPLING METHOD

This study will use systematic random sampling to select participants. During regular clinical visits, the patients are attended to on a first-come, first-serve basis where they are given numbers as they come into the clinic. The numbers show the order in which the patients will be attended to depending on time arrived. The researcher will use this numbering method to select every third patient on the list, that is, patients numbered 3, 6, 9, 12, 15, and so on until the recommended sample size is met.

3.6 STUDY VARIABLES

3.6.1 Independent variables

The predictor in this study is physical disability or injury.

3.6.2 Dependent variables

The dependent variable in this study is depression.

3.7  RESEARCH INSTRUMENTS

3.7.1 Researcher designed questionnaire

The respondents will complete their information in a researcher designed questionnaire. The social demographic questionnaire will gather participant information such as age, religion, marital status, socio-economic status. The clinical information questions will include; injury, time since injury, age of the respondent at the time of the accident,

3.7.2 Beck’s Depression Inventory (BDI-II)

The BDI-II is a 21 item self-report instrument for measuring the presence and severity of depression in adults. The respondent will be required to select one of four options ranging from 0-3, with increasing scores reflecting higher severity of a given symptom of depression. The BDI-II is a paper and pencil test. It can be self-21 administered or examiner administered. Due to its brevity, ease of administration, scoring, congruence with the DSM-IV, and strong psychometric characteristics, the BDI-II is deemed the most appropriate test for depression. The cutoffs are represented as follows: 0–10: minimal depression; 11-16 mild depression; 17–30 moderate depression; 31–40 severe depression; and>40 extreme depression.

3.7.3 Work Injury Degree of Disability Schedule

 Used to assess the degree of disability. Work injuries are divided into three classes:

• Temporary incapacity,
• Permanent incapacity and
• Fatal injury leading to the death of a worker.

All the tools will be clinician-administered, to allow for maximum participation of participants and reduce the possibility of missing values.

3.8 DATA COLLECTION PROCEDURES

3.8.1 RECRUITMENT AND CONSENTING PROCEDURES

The study participants will be recruited by the researcher from the Physiotherapy clinic waiting room. This will be done during regular clinic hours. Screening will be done individually to determine whether they meet the inclusion criteria.

The recruited patient will then be given the informed consent document, which will have details of the study. As the patient reads through the document, he/she will be allowed to ask any questions regarding the survey. Ethical considerations will be emphasized, including voluntariness, where the patient has the right to accept, withdraw, or even refuse to participate. Once all the questions have been addressed, and the participant has understood his/her role in the study, they will sign the consent statement.

3.8.2 DATA COLLECTION PROCEDURES

Once informed consent has been given, the participant will be shown to a secluded room where there is no disturbance and where seats are placed a meter apart to prevent Corona virus transmission. The participant will then be given the study questionnaire to fill. The questionnaire filling will take approximately 30-45minutes. The participants will be thanked on successfully filling the questionnaire.

Figure 2: Participant recruitment, consenting and data collection flow chart

3.9 QUALITY ASSURANCE PROCEDURES

Emphasis will ensure that study participants fully understand the questions being asked and what the study was about.

All research materials, including informed consent and assent forms, questionnaires and results will be kept in a locked safe. Soft copies in the computer devices will be password protected. The room will be locked, and the researcher will be the only one to access the room even after, or during the time of destroying the hard copies of data, no one will have access to the data.

3.10 ETHICAL CONSIDERATION

This study will be presented at the Department of Psychiatry before proceeding to the University of Nairobi/ Kenyatta National Hospital ethics research committee for approval to carry out the study. Once the ethical committee grants authorization to carry out the study, the researcher will seek written authority and clearance from the officer in charge at the physiotherapy clinic.

Once all the approvals have been given, the researcher will sample as previously explained and will approach the participants at the physiotherapy clinic. The researcher will explain the study’s purpose to the approached participants, and they will be allowed to ask for clarification if need be. They will be informed that participation is voluntary, and the information collected is for the study alone. Those who refuse to participate or withdraw at any stage will not be penalized, and their withdrawal will not influence the services they seek at the institution.

Participants that meet the inclusion criteria and are willing to participate will be included in the study. The study will not be discriminated against any political affiliations, gender, race, sexual orientation, or physical disabilities. Proper explanation of the study process, objectives, and purpose of the study will be given to all eligible patients, and they will be offered a chance to participate without coercion.

Participants will be assured that the data will be kept confidential and will only be used for research purposes. The researcher will maintain the anonymity of the participants. There will be no personal identifiers on the questionnaires, and this will ensure that no participant can be traced. Secure serial code will be used for questionnaires to identify participants as an alternative to names, and they will be kept in a secure password protected locked safe.

3.10.1 COMPENSATION FOR PARTICIPANTS

Participants will not receive any compensation for participating in the study as they will be involved during regular clinic visits hence will not incur any extra expenses on their part.

3.10.2 POTENTIAL STUDY RISKS

There is no physical harm expected from this study. However, if the researcher notices any psychological distress in a participant, he will review and refer severe and extreme cases for further follow-up at the Mental Health department at the KNH. Minimal and mild cases will be addressed by the counselor within the physiotherapy clinic.

3.10.3 POTENTIAL BENEFITS TO STUDY PARTICIPANTS

The participants will understand the tenets of emotional wellbeing and get to know where they stand as they attend to the questions in the BDI. The data from the study will also help the patients, and the clinicians better understand the association between physiotherapy and depression, which can improve their management.

3.11 DATA MANAGEMENTS AND STATISTICAL ANALYSIS

Data will be cleaned by reviewing the questionnaires at the end of the data collection daily. Data entry will be done using MS Excel and later uploaded into SPSS version 25 for analysis.

Data analysis will be done using SPSS version 25. The type of disability and age data, which will be continuous data, will be analyzed in the form of means and frequencies. The categorical data from BDI and socio-demographic data apart from age will also be analyzed using means and rates. Results will be presented in tables and narratives (See dummy tables below):

Table 1: Types of disability

Table 2: Prevalence of depression

Table 3: Association of demographic factors and depression

3.12 STUDY LIMITATIONS

The following study limitations are anticipated:

1. The study will rely on participants’ self-reported information, and there may be no way to ascertain the accuracy of the information. Scores may be minimized or exaggerated on the self-report questionnaires.
2. The findings of this study cannot be generalized to other smaller hospitals as KNH is a major referral hospital.

CHAPTER FOUR:

 DISSEMINATION OF STUDY FINDINGS

The study results will be presented to the Department of Psychiatry and the Department of Mental Health and Physiotherapy at KNH through a formal meeting where a copy of the same will be provided. To help improve the type of care of patients attending the physiotherapy is given to help enhance their healing process. The results will also be disseminated in workshops and conferences as well as in academic peer-reviewed journals.

STUDY TIMELINE

STUDY BUDGET

REFERENCES

Aillon, J. L., Ndetei, D. M., Khasakhala, L., Ngari, W. N., Achola, H. O., Akinyi, S., & Ribero, S. (2014). Prevalence, types, and co-morbidity of mental disorders in a Kenyan primary health center. Social psychiatry and psychiatric epidemiology, 49(8), 1257-1268.

Anderson D. M., Keith J., Norvak P.D., et al., (2002) Mosby’s Medical, Nursing & Allied Health Dictionary. 6th edition, page 501. Mosby, Inc.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

Armiya, A. Y., Gyang, B. A., Maigida, K., & Goar, S. G. (2017). Co-morbid physical illness among depressed prisoners in a Nigerian prison population. Journal of Forensic Sciences and Criminal Investigation, 4(2), 1-4.

Azad, N., Gondal, M., Abbas, N., & Shahid, A. (2014). Frequency of depression Journal of Psychiatry Aillon, J. L., Ndetei, D. M., Khasakhala, L., Ngari, and anxiety in patients attending a diabetes clinic. Journal of Ayub Medical College Abbottabad, 26(3), 323-327.

Beck, A. T. (2008). The evolution of the cognitive model of depression and its neurobiological correlates. American, 165(8), 969-977.

Borys, C., Lutz, J., Strauss, B., & Altmann, U. (2015). Effectiveness of a multimodal therapy for patients with chronic low back pain regarding pre-admission healthcare utilization. PloS one, 10(11).

De Hert, M., Correll, C. U., Bobes, J., Cetkovich‐Bakmas, M. A. R. C. E. L. O., Cohen, D. A. N., Asai, I., … & Newcomer, J. W. (2011). Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications, and disparities in health care. World Psychiatry, 10(1), 52-77.

Gautam, S., Jain, A., Gautam, M., Vahia, V. N., & Grover, S. (2017). Clinical practice guidelines for the management of depression. Indian journal of psychiatry, 59(Suppl 1), S34.

George, S. Z., Coronado, R. A., Beneciuk, J. M., Valencia, C., Werneke, M. W., & Hart, D. L. (2011). Depressive symptoms, anatomical region, and clinical outcomes for patients seeking outpatient physical therapy for musculoskeletal pain. Physical therapy, 91(3), 358-372.

Gureje, O., Ademola, A., & Olley, B. O. (2008). Depression and disability: comparisons with common physical conditions in the Ibadan study of aging. Journal of the American Geriatrics Society, 56(11), 2033-2038.

Gureje, O., Von Korff, M., Kola, L., Demyttenaere, K., He, Y., Posada-Villa, J., … & Iwata, N. (2008). The relation between various pains and mental disorders: results from the World Mental Health Surveys. PAIN®, 135(1-2), 82-91.

Haggman, S., Maher, C. G., & Refshauge, K. M. (2004). Screening for symptoms of depression by physical therapists managing low back pain. Physical therapy, 84(12), 1157-1166.

Jack, K., McLean, S. M., Moffett, J. K., & Gardiner, E. (2010). Barriers to treatment adherence in physiotherapy outpatient clinics: a systematic review. Manual therapy, 15(3), 220-228.

Jema, H., & Assefa, A. (2016). Technical Efficiency of Smallholder Wheat Production in Soro District of Hadiya Zone, Southern Ethiopia (Doctoral dissertation, Haramaya University).

Khan, Z. A., Whittal, C., Mansol, S., Osborne, L. A., Reed, P., & Emery, S. (2013). Effect of depression and anxiety on the success of pelvic floor muscle training for pelvic floor dysfunction. Journal of obstetrics and gynecology, 33(7), 710-714.

MacHale, S. (2002). Managing depression in physical illness. Advances in psychiatric treatment, 8(4), 297-305.

Macharia, L. M. (2013). The Prevalence Of Depression Among Patients With Burns Admitted At Kenyatta National Hospital. Unpublished Bachelor of Psychology Thesis, College of Health Sciences, School of Medicine, Department of Psychiatry, University of Nairobi.

Moussavi, S., Chatterji, S., Verdes, E., Tandon, A., Patel, V., & Ustun, B. (2007). Depression, chronic diseases, and decrements in health: results from the World Health Surveys. The Lancet, 370(9590), 851-858.

Ndetei, D. M., Khasakhala, L. I., Kuria, M. W., Mutiso, V. N., Ongecha-Owuor, F. A., & Kokonya, D. A. (2009). The prevalence of mental disorders in adults in different level general medical facilities in Kenya: a cross-sectional study. Annals of general psychiatry, 8(1), 1.

Oketch, A. (2017). WHO report reveals 2m Kenyans are depressed. Daily Nation. http://www.nation.co.ke/news/report-reveals-2m-Kenyans-depressed/1056-3828982-134wls7/.

Othieno, C. J., Okech, V. A., Omondi, J. A., & Makanyengo, M. A. (2001). How Kenyan physicians treat psychiatric disorders. East African medical journal, 78(4), 204-207.

Rahman, A., Reed, E., Underwood, M., Shipley, M. E., & Omar, R. Z. (2008). Factors affecting self-efficacy and pain intensity in patients with chronic musculoskeletal pain seen in a specialist rheumatology pain clinic. Rheumatology, 47(12), 1803-1808.

Sinyor, D. A. V. I. D., Amato, P. H. Y. L. L. I. S., Kaloupek, D. G., Becker, R. U. B. I. N., Goldenberg, M. A. R. V. I. N., & Coopersmith, H. E. N. R. Y. (1986). Post-stroke depression: relationships to functional impairment, coping strategies, and rehabilitation outcome. Stroke, 17(6), 1102-1107.

Tahir, D. H., Zangana, J. M., & Ali, S. K. (2009). Depression among Patients Attending Physiotherapy Clinics in Erbil City. Zanco Journal of Medical Sciences, 13(2), 22-27.

Vermeer, J., Rice, D., McIntyre, A., Viana, R., Macaluso, S., & Teasell, R. (2017). Correlates of depressive symptoms in individuals attending outpatient stroke clinics. Disability and Rehabilitation, 39(1), 43-49.

1268. N., Achola, H. O., Akinyi, S., & Ribero, S. (2014). Prevalence, types, and co-morbidity of mental disorders in a Kenyan primary health center. Social psychiatry and psychiatric epidemiology, 49(8), 1257-1268.

World Health Organization. (1992). International statistical classification of diseases and related health problems: ICD-10.

World Health Organization. (2001). Mental health: a call for action by world health ministers. Ministerial round tables 2001.http://www.who.int/mental_health/advocacy/en/Call_for_Action_MoH_Intro.pdf.

World Health Organization. (2003). Investing in mental health. World Health Organization.http://www.who.int/mental_health/advocacy/en/Call_for_Action_MoH_Intro.pdf.

World Health Organization. (2008). The global burden of disease: 2004 update. World Health Organization.

World Health Organization. (2017). Depression and other common mental disorders: global health estimates (No. WHO/MSD/MER/2017.2). World Health Organization.

                                                         LIST OF APPENDICES

Appendix 1: Participant information sheet and consent form – English version

CONSENT EXPLANATION

Prevalence of Undetected Depressive Disorders among Patients Attending Physiotherapy at KNH

Principle Investigator: Dr. Gelrald Nganga, University of Nairobi

Co-investigators:  Dr. Muthoni Mathai and Dr. John Mburu, University of Nairobi

My name is Dr. Gerald Ngángá, a Masters in Psychiatry student at the University of Nairobi. I am doing a study entitled Prevalence of undetected depressive disorders among patients attending physiotherapy at KNH as part of my master’s degree program. My supervisors are Dr. Muthoni Mathai and Dr. John Mburu from the Department of Psychiatry, Faculty of Medicine, College of Health Sciences, University of Nairobi.

The study’s purpose is to assess the level of depression, otherwise known as low mood distress among patients attending physiotherapy at KNH. This document explains further what your role could be in this study and allows you to agree (consent) or disagree to participate in the study. In either case, you shall still be attended to in the clinic as usual.

Once you consent to participate in the study, you will be given a questionnaire that will ask you questions regarding your feelings and accompanying mood over six weeks. Answering the questionnaire may take you 30 – 45 minutes and will involve only paper and pencil tests

Benefits of this study: There is no direct benefit for participation in this study. However, the study results will help gather information that will enable better screening and management of people with depression in Kenya following physical disability/injury. You will not incur any costs by participating in the study.

Risk of the study: The risk is that due to individual varying appraisal of similar circumstances, you may find specific questions distressing. If you are located in need of further medical intervention, you will be referred to the appropriate clinic in KNH.

Voluntarism: Your agreement to enroll in the study is voluntary, and you may withdraw from the study at any time. There is no penalty or loss of benefit in which you are otherwise entitled due to refusal to participate in the study.

Confidentiality: All the information obtained from this study will be regarded with utmost confidentiality and privacy. Your name will not be recorded anywhere in the research or the resulting publications.

After you read the explanation, please feel free to ask any questions that will allow you to understand clearly the nature of the study. Thank you for participating in this research study.

CONTACTS:                                                                 

Researcher: Dr. Gerald Ng’ang’a Telephone No. 0777260665

Supervisors: Dr. Muthoni Mathai Telephone No: 0727 329904

Dr. John Mburu Telephone No: 0733-918-774

You can also get in touch with the secretary/chairperson, Kenyatta National Hospital-University of Nairobi Ethics and Research Committee on telephone no. 2726300 Ext 44102 or email uonknh_erc@uonbi.ac.ke.

CONSENT STATEMENT

Participant Statement

I, the undersigned, do hereby volunteer to participate in this research study. The nature and purpose have been fully explained to me by Dr. Gerald Ng’ang’a, and he has answered the questions I had. I understand that all the information given/obtained will be treated with utmost confidentiality and used for this study only.

Participant Signature/Thumb stamp ______________________       Date __________________

Researchers Statement

I have fully explained the study purpose and participant roles to the respondents as well as clarified any concerns they had.  I believe the participant has understood the study and what it entails and is willing to freely participate in the study

Researchers Signature/Thumb stamp ______________________     Date __________________

Appendix 2: Participant information sheet and consent form – Swahili version

MAELEZO YA IDHINI

Kuenea kwa shida ya Unyogovu isiyoweza kutengwa kati ya Wagonjwa Kuhudhuria Tiba ya Viungo huko KNH

Mpelelezi wa kanuni: Dk Gelrald Nganga, Chuo Kikuu cha Nairobi

Wachunguzi wa ushirikiano: Dk. Muthoni Mathai na Dk John Mburu, Chuo Kikuu cha Nairobi

Jina langu ni Dk Gerald Ngángá, mwanafunzi wa Masters katika Psychiatry katika Chuo Kikuu cha Nairobi. Ninafanya utafiti uitwao Utangulizi wa shida za huzuni ambazo hazijaonekana kati ya wagonjwa wanaohudhuria mazoezi ya mwili kwa KNH kama sehemu ya mpango wa digrii ya bwana. Wasimamizi wangu ni Dk Muthoni Mathai na Dk John Mburu kutoka Idara ya Saikolojia, Kitivo cha Tiba, Chuo cha Sayansi ya Afya, Chuo Kikuu cha Nairobi.

Madhumuni ya utafiti huo ni kutathmini kiwango cha unyogovu kingine kinachojulikana kama dhiki ya chini ya mhemko kati ya wagonjwa wanaohudhuria mazoezi ya mwili kwa KNH. Hati hii inaelezea zaidi juu ya nini jukumu lako katika utafiti huu na inakupa fursa ya kukubaliana (ridhaa) au kutokubali kushiriki katika utafiti. Kwa vyovyote vile, bado utahudhuriwa katika kliniki kama kawaida.

Mara tu ukikubali kushiriki kwenye utafiti, utapewa dodoso ambalo litakuuliza maswali kuhusu hisia zako na mhemko unaofuatia kwa muda wa wiki 6. Kujibu dodoso kunaweza kukuchukua dakika 30 – 45 na kutahusisha tu majaribio ya karatasi na penseli.

Faida za utafiti huu: Hakuna faida ya moja kwa moja kwa kushiriki katika utafiti huu. Walakini, matokeo ya utafiti huo yatasaidia katika kukusanya habari ambayo itawezesha uchunguzi bora na usimamizi wa watu walio na unyogovu nchini Kenya kufuatia ulemavu / jeraha la mwili. Hauwezi kupata gharama yoyote kwa kushiriki katika utafiti.

Hatari ya utafiti: Hatari ni kwamba kwa sababu ya tathmini tofauti za hali zinazofanana, unaweza kupata maswali kadhaa yanayokusumbua. Ikiwa unapatikana katika uhitaji wa uingiliaji zaidi wa matibabu, utapelekwa kliniki inayofaa katika KNH.

Kujitolea: Makubaliano yako ya kujiandikisha katika masomo ni ya hiari na unaweza kujiondoa kutoka kwa masomo wakati wowote. Hakuna adhabu au upotezaji wa faida ambayo una haki nyingine kwa sababu ya kukataa kushiriki katika utafiti.

Usiri: Habari yote inayopatikana kutoka kwa utafiti huu itazingatiwa kwa usiri na usiri wa karibu sana. Jina lako halitarekodiwa mahali popote kwenye utafiti au kwenye machapisho yanayosababisha.

Baada ya kusoma maelezo tafadhali jisikie huru kuuliza maswali yoyote ambayo yatakuruhusu kuelewa wazi aina ya masomo. Asante kwa kushiriki katika utafiti huu.

MAWASILIANO:             

Mtafiti: Dk. Gerald Ng’angkuru Simu Namba 0777260665

Wasimamizi: Dk. Muthoni Mathai Simu No: 0727 329904

Dk John Mburu Namba ya simu: 0733-918-774

Unaweza pia kuwasiliana na katibu / mwenyekiti, Hospitali ya Kitaifa ya Maadili ya Kenya ya Chuo Kikuu cha Maadili na Utafiti wa Nairobi kwa simu no. 2726300 Ext 44102 au barua pepe uonknh_erc@uonbi.ac.ke.

TAARIFA YA IDHINI

Taarifa ya Mshiriki

Mimi waliowekwa chini ninajitolea kushiriki katika utafiti huu. Asili na kusudi nimeelezewa kikamilifu na Dr Gerald Ng’angisiza na amejibu maswali ambayo nilikuwa nayo. Ninaelewa kuwa habari yote iliyopewa / iliyopatikana itatibiwa kwa usiri wa nje na itatumika kwa utafiti huu tu.

Ishara ya Mshiriki / muhuri wa Thumb ______________________Tarehe __________________

Taarifa ya Watafiti

Nimeelezea kikamilifu madhumuni ya utafiti na jukumu la mshiriki kwa waliohojiwa na pia nimeelezea wasiwasi wowote ambao walikuwa nao. Naamini mshiriki ameelewa utafiti na nini inajumuisha na yuko tayari kushiriki katika utafiti kwa uhuru

Watafiti Saini / muhuri wa Thumb ______________________ Tarehe __________________

Appendix 3: Researcher designed socio-demographic – English version

Age……….. In what year were you born? Year ………………………..

Marital status

Religion

Christian ……… Muslim ……… Other (specify) ………………………………………

Level of Education

For completion of college education:

Socio-economic Status

1. Occupation:

1. Income Range per Month:

Type of injury

Appendix 4: Researcher Designed Socio-demographic – Swahili version

Umri: ………

Ulizaliwa mwaka gani? Mwaka ………………………

Hali ya ndoa

Dini:

Mkristo ……… Muislamu ……… Ingine (Fafanua) ………………………………………

Masomo

Kwa walio maliza masomo ya vyuo:

Hadhi ya kiuchumi na kijamii

1. Kazi:

1. Mapato kwa Mwezi:

Aina ya jeraha

Appendix 5: Becks Depression Inventory – English version

Please use one tick (✔) in each response that applies to you to indicate your answer.

1.

• I do not feel sad.

1          I feel sad

2          I am sad all the time, and I can’t snap out of it.

3          I am so sad and unhappy that I can’t stand it.

2.

• I am not particularly discouraged about the future.

1          I feel discouraged about the future.

2          I feel I have nothing to look forward to.

3          I feel the future is hopeless and that things cannot improve.

3.

• I do not feel like a failure.
• I feel I have failed more than the average person.
• As I look back on my life, all I can see is a lot of failures.

3          I feel I am a complete failure as a person.

4.

• I get as much satisfaction out of things as I used to.

1          I don’t enjoy things the way I used to.

2          I don’t get real satisfaction out of anything anymore.

3          I am dissatisfied or bored with everything.

5.

• I don’t feel particularly guilty.
• I feel guilty for a good part of the time.

2          I feel quite guilty most of the time.

3          I feel guilty all of the time.

6.

• I don’t feel I am being punished.

1          I feel I may be punished.

2          I expect to be punished.

3          I feel I am being punished.

7.

• I don’t feel disappointed in myself.
• I am disappointed in myself.
• I am disgusted with myself.
• I hate myself.

8.

• I don’t feel I am any worse than anybody else.
• I am critical of myself for my weaknesses or mistakes.
• I blame myself all the time for my faults.
• I blame myself for everything wrong that happens.

9.

• I don’t have any thoughts of killing myself.
• I have thoughts of killing myself, but I would not carry them out.
• I would like to kill myself.
• I would kill myself if I had the chance.

10.

• I don’t cry any more than usual.
• I cry more now than I used to.
• I cry all the time now.
• I used to be able to cry, but now I can’t cry even though I want to.

11.

• I am no more irritated by things than I ever was.
• I am slightly more irritated now than usual.
• I am quite annoyed or irritated a good deal of the time.
• I feel irritated all the time.

12.

• I have not lost interest in other people.
• I am less interested in other people than I used to be.
• I have lost most of my interest in other people.
• I have lost all of my interest in other people.

13.

• I make decisions about as well as I ever could.
• I put off making decisions more than I used to.
• I have greater difficulty in making decisions more than I used to.
• I can’t make decisions at all anymore.

14.

• I don’t feel that I look any worse than I used to.
• I am worried that I am looking old or unattractive.
• I feel there are permanent changes in my appearance that make me look unattractive.
• I believe that I look ugly.

15.

• I can work about as well as before.
• It takes an extra effort to get started at doing something.
• I have to push myself very hard to do anything.
• I can’t do any work at all.

16.

• I can sleep as well as usual.
• I don’t sleep as well as I used to.
• I wake up 1-2 hours earlier than usual and find it hard to get back to sleep.
• I wake up several hours earlier than I used to and cannot get back to sleep.

17.

• I don’t get more tired than usual.
• I get tired more quickly than I used to.
• I get tired of doing almost anything.
• I am too tired to do anything.

18.

• My appetite is no worse than usual.
• My appetite is not as good as it used to be.
• My appetite is much worse now.
• I have no appetite at all anymore.

19.

• I haven’t lost much weight, if any, lately.
• I have lost more than five pounds.
• I have lost more than ten pounds.
• I have lost more than fifteen pounds.

20.

• I am no more worried about my health than usual.

1          I am worried about physical problems like aches, pains, upset stomach, or constipation.

• I am anxious about physical problems, and it’s hard to think of much else.
• I am so worried about my physical problems that I cannot think of anything else.

21.

• I have not noticed any recent change in my interest in sex.
• I am less interested in sex than I used to be.
• I have almost no interest in sex.
• I have lost interest in sex completely.

Appendix 6: Becks Depression Inventory – Swahili version

Tafadhali tumia tiki moja (✔) katika kila jibu ambalo linatumika kwako kuonyesha jibu lako.

1.

0 Sijihisi mwenye huzuni.

1 Najihisi mwenye huzuni

2 Mimi niko na  huzuni wakati wote na siwezi kuiondoa.

3 Mimi niko na huzuni sana na kwamba siwezi kusimama.

2.

0 Mimi sijakata tamaa kuhusu siku zijazo.

1 Nimekata tamaa kuhusu siku zijazo.

2 Ninahisi kuwa hakuna kitu cha kutarajia.

3 Najisikia siku zijazo haiko na matumaini na mambo hayawezi kuboresha.

3.

0 Sijihisi kama kushindwa.

1 Ninahisi nimeshindwa zaidi kuliko mtu wa wastani.

2 Ninapoangalia nyuma juu ya maisha yangu, yote ninayoyaona ni kushindwa mengi.

3 Ninahisi kuwa ni kushindwa kabisa kama mtu.

4.

0 Niridhishwa sana na mambo kama kitambo.

1 Siridhishwi na mambo kama kitambo.

2 Sijihisi kuridhishwa na chochote tena.

3 Sipendenzwi na lolote.

5.

0 Sina hisia za hatia

1 Niko na hisia za hatia muda kwa muda.

2 Nina hisia za hatia mara kwa mara.

3 Nina hisia za hatia wakati wote.

6.

0 Sijihisi kama ninaadhibiwa.

1 Ninahisi nitaadhimbiwa.

2 Natarajia kuadhibiwa.

3 Nahisi kama naadhibiwa.

7.

0 Sina hisia za kukata tamaa.

1 Nina hisia za kukata tamaa.

2 Nimevunjika moyo na mimi mwenyewe.

3 najichukia mwenyewe.

8.

0 Sijihisi mmbaya zaidi kuliko mtu mwingine yeyote.

1 Mimi ninajijitenga mwenyewe kwa udhaifu wangu au makosa yangu.

2 Ninajihukumu wakati wote kwa makosa yangu.

3 Ninajihukumu mwenyewe kwa kila kitu kibaya kinachotokea.

9.

0 Sina mawazo yoyote ya kuua mwenyewe.

1 Nina mawazo ya kujiua, lakini siwezi kuyachukua.

2 Ningependa kujiua.

3 Ningependa kujiua ikiwa nilipata nafasi.

10.

0 Silii zaidi kuliko kawaida.

1 Nalia zaidi sasa kuliko nilivyokuwa.

2 Mimi nalia wakati wote sasa.

3 Nilikuwa na uwezo wa kulia, lakini sasa siwezi kulia hata kama nataka.

11.

0 Mimi sina hasira zaidi kwa vitu kuliko nilivyokuwa.

1 Mimi nikasirika zaidi sasa kuliko kawaida.

2 Napata hisia za hasira mara kwa mara.

3 Najisikia hasira wakati wote.

12.

0 Sijapoteza riba kwa watu wengine.

1 Mimi niko na nia kidogo kwa watu wengine kuliko nilivyokuwa.

2 Nimepoteza maslahi yangu kwa watu wengine.

3 Nimepoteza maslahi yangu kwa watu wengine.

13.

0 Ninafanya maamuzi kuhusu vile vile nilivyoweza.

1 Ninaacha kufanya maamuzi zaidi kuliko niliyokuwa nayo.

2 Nina shida kubwa katika kufanya maamuzi zaidi kuliko niliyokuwa nayo.

3 Siwezi kufanya maamuzi wakati wote.

14.

0 Sijihisi kuwa ninaonekana kuwa mbaya zaidi kuliko nilivyokuwa.

1 Nina wasiwasi kwamba mimi ni kuangalia zamani au kushindwa.

2 Ninahisi kuna mabadiliko ya kudumu katika muonekano wangu ambayo yanafanya nipate kuangalia kuwa haifai

3 Ninaamini kwamba ninaonekana kuwa mbaya.

15.

0 Ninaweza kufanya kazi kama vile kabla.

1 Inachukua juhudi zaidi ili kuanza kuanza kufanya kitu.

2 Ninahitaji kujisukuma sana kufanya kitu chochote.

3 Siwezi kufanya kazi yoyote wakati wote.

16.

0 Ninaweza kulala kama kawaida.

1 Silali kama nilivyokua nikilala.

2 Ninaamka masaa 1-2 mapema kuliko kawaida na ni vigumu kurudi kulala.

3 Ninaamka masaa kadhaa mapema kuliko nilivyokuwa na siwezi kurudi kulala.

17.

0 Sijihisi mchovu zaidi kuliko kawaida.

1 Najihisi mchovu zaidi kuliko nilivyokuwa.

2 Najihisi mchovu nikifanya karibu kila kitu.

3 nimechoka sana kufanya chochote.

18.

0 Nia yangu si mbaya kuliko kawaida.

1 Njaa yangu si nzuri kama ilivyokuwa.

2 Mlo wangu ni mbaya zaidi sasa.

3 Sina hamu ya yote tena.

19.

0 Sijawahi kupoteza uzito, kama ipo, hivi karibuni.

1 Nimepoteza zaidi ya paundi tano.

2 Nimepoteza zaidi ya paundi kumi.

3 Nimepoteza paundi zaidi ya kumi na tano.

20.

0 Mimi sio wasiwasi juu ya afya yangu kuliko kawaida.

1 Mimi nina wasiwasi kuhusu matatizo ya kimwili kama maumivu, maumivu, tumbo, au kuvimbiwa.

2 Nina wasiwasi sana juu ya matatizo ya kimwili na ni vigumu kufikiria mambo mengine.

3 Mimi nina wasiwasi juu ya matatizo yangu ya kimwili kwamba siwezi kufikiria kitu kingine chochote.

21.

0 Sijaona mabadiliko yoyote ya hivi karibuni kwa nia ya ngono.

1 Mimi siko nia ya ngono kuliko nilivyokuwa.

2 Sina karibu nia ya ngono.

3 Nimepoteza maslahi ya ngono kabisa.

APPENDIX 7: WORK INJURY SCHEDULE

(S.30)

FIRST SCHEDULE

DEGREE OF DISABLEMENT

Minimum degree of disablement (percentage).

1. DEATH

Death as result of accident…………………………………………………….. 100

1. INJURY (GENERAL)
   1. Loss of hand and foot above site of

symes amputation                        …………………………………. 100

2. Injury resulting in the employee being

permanently bed-ridden…………………………………………….. 100

NOTE: The loss of the thumb and four

fingers of one hand is equivalent to the loss of a hand.

1. INJURY TO UPPER LIMB

1. Loss of both hands or loss of both arms

at higher sites…………………………………………………………. 100

2. Loss of remaining arm by one-armed workman………….. 100
3. Loss at shoulder or below shoulder with stump

of less than 20 centimeters from the tip of acromion…..          ..      70

4. Loss from 11 centimeters below the tip of the acromion to

Less than 20 centimeters from the tip of olecranon…………….. 68

5. Loss from 11 centimeters below tip of olecranon………………. 65

6. Loss of hand at wrist…………………………………………………….. 60

7. Loss of four fingers and thumb on one hand………………….. 60

8. Loss of four fingers on one hand………………………………….. 40

9. Loss of thumb:-

both phalanges………………………………………………….. 25

one phalanx……………………………………………………….. 10

10. Loss of index finger:-

three phalanges…………………………………………………. 25

two phalanges………………………………………………….. 10

one phalanx……………………………………………………….. 4

tip and nail, no bone…………………………             2

11. Loss of ring finger:-

three phalanges………………………………..          6

two phalanges…………………………………          4

one phalanx……………………………………          2

tip and nail, no bone………………………….           1

12. Loss of little finger:-

three phalanges………………………………..           6

two phalanges………………………………….          4

one phalanx…………………………………….          2

tip and nail, no bone……………………………         1

13. Loss of metacarpals:-

three phalanges…………………………………          6

two phalanges…………………………………..         4

one phalanx…………………………………….          2

tip and nail, no bone……………………………          1

14. Loss of metacarpals:-

first or second (additional)……………………..         3

third, fourth, or fifty (additional)……………….        2

NOTE: In the case of a right-handed employee, an injury to the left arm or hand and, in the case of a left-handed employee, to the right arm or hand, may in the discretion of the Director be rated at ninety per centum of the above percentages.

Where there are two or more injuries, the sum of the percentages for such injuries may be increased at the discretion of the Director.

1. INJURY TO LOWER LIMB Minimum degree of disablement (percentage)

one foot…………………………………………………………….. 25

two feet…………………………………………………………….. 70

8. Loss of foot at tarsometatarsal joint………………………………………………. 25
9. Loss of all toes of both feet proximal to the proximal inter-

phalangeal joint……………………………………………….              25

10. Loss of all toes of both feet distal to the proximal inter-

Phalangeal joint………………………………………………              15

11. Loss of all toes of one foot proximal to the proximal inter-

phalangeal joint…………………………………………                      15

12. Loss of all toes of one foot distal to the proximal inter-

phalangeal joint………………………………………………………………………… 10

13. Loss of great toe:-

both phalanges………………………………………………………………………….. 5

one phalanx…………………………………………………………………………….. 2

14. Loss of toe other than great if more than one toe lost, each………………… 1
15. Ankylosis in optimum position:-

hip…………………………………………………………………. 50

knee………………………………………………… 25

ankle………………………………………………………………. 15

1. INJURY TO EYES Minimum degree of disablement (percentage).

1. Total loss of sight……………………………………………………………….. 100
2. Loss of remaining eye by one-eyed employee…………………………. 100
3. Loss of one eye, other being normal………………………………………. 30

4. Total loss of vision of one eye, other being normal ……30

5. Another degree of defective vision based on the visual defect as measured after correction with glasses:

When the best visual                            other eye       Minimum assessment acuity is in one eye                                                                           (percentage).

6. For this Schedule, a one-eyed employee means an employee who has no sight in one

1. INJURY – LOSS OF HEARING Minimum degree of disablement (percentage).

1. total loss of hearing – both ears –           –            50
2. total loss of hearing – one ear- –            –            7

1. GENERAL

Except where otherwise expressly provided, the following conditions shall apply to all assessments in this Schedule-

• Total permanent loss of use of limb shall be treated as loss of limb.

• When there are two or more injuries, the sum of percentages for such injures may be

• The Director shall prescribe the compensation criteria for Musculoskeletal disorders and occupational injuries not elsewhere