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[page 40] [Mental Illness 2016; 8:6647]
Disability among attendees
with schizophrenia
in a Nigerian hospital:
further evidence for integrated
rehabilitative treatment
designs
Andrew Toyin Olagunju,1
Dapo Adebowale Adegbaju,2
Richard Uwakwe3
1Department of Psychiatry, College of
Medicine, University of Lagos; 2Federal
Neuropsychiatric Hospital, Yaba, Lagos;
3Faculty of Medicine, Nnamdi Azikiwe
University, Anambra State, Nigeria
Abstract
Evidence-based rehabilitative treatment is
constrained due to limited knowledge about
disability and its related factors among individ-
uals with schizophrenia across West Africa.
This study aims to investigate the pattern of
disability, and the associated factors among
individuals with schizophrenia. One hundred
consecutively recruited consenting partici-
pants were subjected to designed question-
naire to inquire about their demographic and
illness-related variables. This was followed by
the administration of Structured Clinical
Interview for DSM-IV-TR Axis I Disorders and
Brief Psychiatric Rating Scale to confirm the
diagnosis of schizophrenia and rate severity of
symptoms respectively in them. In addition,
the World Health Organisation Disability
Assessment Scale II (WHODAS-II) was used to
assess for disability in all participants.
Different degrees of disability based on WHO-
DAS-II mean score of 27.02±3.49 were noted
among individuals with schizophrenia, and
affectation of domains of disability like self
care, getting along with others, life activities
and participation in the society among others
were observed. In addition, high level of dis-
ability was significantly associated with
younger adults in the age group 18-44 years
(P=0.007), unemployment status (P=0.003),
remittance source of income (P=0.034) and
ethnicity (P=0.017); conversely, less number
of children (P=0.033), less amount spent on
treatment (P<0.001) and lower BPRS score
(P<0.001) correlated negatively with high
level of disability. In spite of clinical stability
following treatment, individuals with schizo-
phrenia were disabled to varied degrees, and
socioeconomic as well as illness-related fac-
tors constituted important correlates.
Integration of rehabilitation along with social
intervention into treatment design to reduce
disability is implied, and further research is
also warranted.
Introduction
Schizophrenia is a chronic debilitating
mental illness with socioeconomic and public
health significance due to the remarkable and
life–long health care needs among those
affected globally. The economic cost of schizo-
phrenic illness is not only linked to the signif-
icant cost of care based on its chronic course,
but also largely due to the indirect cost result-
ing from its disabling effects linked to the loss
of skills needed for productive life in affected
individuals.1As a mental health syndrome, the
symptoms of schizophrenia are sometimes
grouped as positive, negative and other addi-
tional symptoms. The key positive symptoms
include delusion, thought interference or pas-
sivity and hallucination among others.
Whereas, negative symptoms include loss of
the normal level of motivation or drive, loss of
awareness of socially appropriate behaviour,
flattening of mood and difficulty in abstract
reasoning or thinking.2,3 In general, the nega-
tive symptoms are more resistant to treatment,
more disabling and connote poorer prognosis.4
The presentation of disability in schizophre-
nia is such that there may be restriction or lack
of ability to perform an activity in the manner
or within the range considered normal for a
human being. Such disability is specifically
concerned with compound or integrated activi-
ties of the body as a whole (e.g. task, skills and
behaviour), and includes excesses or deficien-
cies of customarily expected activities and
behaviour. For easy assessment of disability in
chronic medical conditions, the International
Classification of Functioning, Disability and
Health (ICF) classified the affected domains
from the perspective of body, individual and
society. The domains for assessment were
done by listing body functions and structure as
well as activity and participation. Since an
individual’s functioning and disability occurs
in a context, the ICF also included a list of
environmental factors.5,6 In relation to disabil-
ity, schizophrenia ranks third after quadriple-
gia and dementia globally,7and research has
shown that negative symptoms contribute
much more to functional disability, poorer
quality of life, and caregivers burden than the
positive symptoms.4,8 A deficit in patients’ abil-
ity to care for themselves and to meet the
expectations of others are the root challenges
faced by people with schizophrenia and con-
nected with disability.9In spite of treatment,
individuals with schizophrenia contend with
significant level of disability based on evidence
from extant literature that are preponderantly
from western populations. For instance,
Harding et al.10 reported in a long term follow-
up of profoundly disabled patients with schizo-
phrenia for 20-25 years after release from the
hospital that they had sixteen years of schizo-
phrenic symptoms and ten years of disability.
Thus, a clearer picture of the disability associ-
ated with mental disorders may need assess-
ment of the number of previous episodes, aver-
age length of episodes, the average time
between episodes, inter-episode psychosocial
functioning and response to treatment among
others.1The measure of good outcome in the
care of people living with chronic mental ill-
nesses including schizophrenia is shifting
from assessment of remission of symptoms
alone, to include recovery from all dimensions
of impairments. To ensure the foregoing, reha-
bilitation and social measures11 geared
towards addressing impairments to assist re-
integration of individuals with schizophrenia
into a productive socio-economic life have
been advocated for inclusion in mental health
interventions against schizophrenia. In this
light, our study was aimed to expand the
scanty research in the field by investigating
the pattern of disability and associated factors
in stable individuals with schizophrenia so as
to promote evidence-planned rehabilitation,
and recovery into productive life among indi-
viduals with schizophrenia across the West
African region. We postulated that individuals
with schizophrenia would experience varied
degrees of disability, and identifiable socio-
economic along with illness-related factors
would constitute identifiable determinants of
disability.
Mental Illness 2016; volume 8:6647
Correspondence: Andrew Toyin, Olagunju
Department of Psychiatry, College of Medicine,
University of Lagos, PMB 12003, Lagos, Nigeria.
E-mail: aolagunju@unilag.edu.ng,
andyolagus@yahoo.com
Key words: Associated factors; Disability;
Rehabilitation; Schizophrenia; Social interven-
tion.
Contributions: the authors contributed equally.
Conflict of interest: the authors declare no poten-
tial conflict of interest.
Received for publication: 18 June 2016.
Revision received: 14 October 2016.
Accepted for publication: 17 October 2016.
This work is licensed under a Creative Commons
Attribution-NonCommercial 4.0 International
License (CC BY-NC 4.0).
©Copyright A.T. Olagunju et al., 2016
Licensee PAGEPress, Italy
Mental Illness 2016; 8:6647
doi:10.4081/mi.2016.6647
Non commercial use only
[Mental Illness 2016; 8:6647] [page 41]
Materials and Methods
This cross sectional study was carried out at
the outpatient department of a Nigerian hospi-
tal in West Africa. The inclusion criteria were
subjects aged between 18-64 years, duration of
illness and treatment ≥6 months, and those
who gave informed consent. While the exclu-
sion criteria were evidence of obvious head
injury or injury to any part of the nervous sys-
tem and refusal to participate. Consecutive
patients that satisfied the inclusion criteria
were interviewed till the calculated sample
size was obtained. The calculated sample size
was one hundred participants based on Fliess12
formula. Ethical permission was sought and
obtained from the ethical committee of the
hospital by sending the proposal to the com-
mittee before commencement of the study. All
participants gave informed consent, their con-
fidentiality was strictly maintained and volun-
tary refusal or disengagement at any point of
the interview without any negative conse-
quence on their treatment was allowed.
The following instruments were adminis-
tered to all participants:
1. Questionnaire: A designed socio-demo-
graphic and clinical questionnaire inquiring
about socio-demographic data of the partici-
pants including age, sex, ethnicity, religion,
marital status, occupation, educational
level, source of income, income per month,
amount spent on treatment per month, resi-
dential type and living condition. Illness-
related variables were also incorporated into
the questionnaire including duration of the
illness and number of hospitalization.
2. Structured Clinical Interview for DSM-IV-TR
Axis I Disorders (SCID):13 This is a semi-
structured interview for making major DSM-
IV-TR axis I diagnosis. The SCID-P version
was used in this study and only the module
on schizophrenia was used. This instrument
detects lifetime prevalence and current
episode (one-month). Scoring is from 0-3. A
score of zero denotes inadequate informa-
tion, one denotes absence, two denotes sub-
threshold and three denotes threshold. The
instructment enjoys good validity property
in this context and has been well used in
Nigeria.14
3. Brief Psychiatric Rating Scale (BPRS):15
This is an 18-item scale that measures psy-
chotic and non-psychotic symptoms in major
psychiatric illness especially schizophrenia.
The 18 items are scored on a seven-point
scale, (1= not present, 7= extremely
severe). The scale assesses tension, emo-
tional withdrawal, mannerisms, motor retar-
dation, and uncooperativeness, conceptual
disorganization, thought content, anxiety,
guilt feelings, grandiosity, depressive mood,
hostility, somatic concerns, hallucinatory
behaviour, suspiciousness, blunted affect,
excitement and disorientation. The BRS has
been used extensively in Nigeria.16,17
4. World Health Organisation Disability
Assessment Scale II (WHODAS-II):18 The 36-
item interviewer-administered version of
WHODAS-II was used in this study. It meas-
ures the difficulty the individual has had
with performing particular daily activities
over a period of 30 days. It consists of 36
Likert formatted questions, divided into six
domains and scored as 1=none, 2=mild,
3=moderate, 4=severe, 5=extreme. The
total maximum score of 180 is converted to
0-100 with higher scores depicting more dis-
ability. It is of note that this instrument has
been used in previous research works in
this context.19,20
The researchers had training in the use of
the instruments before commencement of the
study. Data were analysed using the Statistical
Package for Social Sciences, seventeenth edi-
tion (SPSS-17).21 Additional information on
study population, sampling and procedure
were described in earlier works.19 For analyses,
participants were dichotomised such that
those scoring above the mean score on WHO-
DAS-II18 were regarded as reporting high level
of disability, and those below mean score as
not.
Article
Table 1. Distribution socio-demographic profile of participants.
Variables N %
Age group
18-44 years 75 75
45-64 years 25 25
Sex
Male 45 45
Female 55 55
Marital Status
Single 65 65
Married 36 36
Seperated 6 6
Divorced 3 3
No of Children
None 56 56
One 18 18
Two 13 13
Three 4 4
>Three 9 9
Education Status
None 2 2
Primary Uncompleted 2 2
Primary Completed 13 13
Secondary Uncompleted 8 8
Secondary Completed 55 55
Tertiary Uncompleted 4 4
Tertiary Completed 16 16
Employment Status
Employed 45 45
Unemployed 55 55
Religion
Christianity 73 73
Islam 27 27
Ethnicity
Yoruba 77 77
Ibo 7 7
Edo 5 5
Urhobo 2 2
Others 9 9
Source of income
Salary 18 18
Personal Business 27 27
Remittance 55 55
Total 100 100%
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Results
Socio-demographic profile of par-
ticipants
Majority of the study participants, consist-
ing of three-fourths (75%) belonged to the age
group 18-44 years, while 55% were females.
Similar proportions of the participants were
single (55%) and had no children (56%). A lit-
tle above half of the participants, made up of
55% each completed secondary school and
were unemployed. The largest proportions of
the participants were Christians (73%) and
belonged to the Yoruba ethnic group (77%).
Fifty-five participants relied on remittance,
while the remaining earned money from their
jobs (Table 1).
Treatment-related variables among
participants
The mean age of participants was
37.35(±9.48) years, and mean illness duration
was 9.90(±6.75) years. Majority of the partici-
pants (91%) earned less than 20,000 (~$127)
monthly given the background of an average
income of 18,000 (~$114) monthly set as the
national minimum wage.22 More participants
(85%) spent less than 2,000 (~$13) on med-
ications and those that spent less than 1000
(~$6.3) monthly were more (58%). Thirty-
three participants each were living with their
parents and spouse/children respectively.
Majority of the participants (81%) lived in
homes with more than one room. Similar pro-
portions of participants reported illness dura-
tion ranging 1-10 years (58%) and previous
hospital admission (57%) (Table 2).
Pattern of disability among partici-
pants
The mean score for participants on WHO-
DAS-II18 was 27.02(±3.49), and the scores
ranged from 21.11-40.00. This mean score was
used to dichotomize participants into those
above and below average WHODAS-II18 score.
The most affected domain with respect to dis-
ability among participants was participation in
the society, while the least impairment was
seen in the domain on self-care. Life activities
were more impaired in participants compared
to getting along with others (Table 3).
Relationship between socio-demo-
graphic attributes and WHODAS-II
Following dichotomization, 57% of partici-
pants scored below the mean score (27.02) on
WHODAS-II.18 Participants within the age
group 18-44 years (P=0.007), that were unem-
ployed (P<0.001), relying on remittance
(P=0.034) and belonging to the Yoruba ethnic
group (P=0.017) were more likely to report
scores above the mean score on WHODAS-II18.
Whereas participants with no children
(P=0.033) were significantly over-represented
among those that scored below the mean
score. The participants who scored above and
below the mean score on WHODAS-II18 were
not significantly different with respect to edu-
cational status (P=0.438), gender (P=0.508),
religion (P=0.861) and marital status
(P=0.128) (Table 4).
Relationship between treatments
related variables and WHODAS-II
Participants that spent less than 2000
(~$127) on medications were more likely to
score below the mean score on WHODAS-II18
compared to those that scored above the mean
score (P<0.001). However, the living condition
Article
Table 2. Treatment related variables among participants.
Variables N %
Income per month
<10,000 58 58
10,000-20,000 33 33
20,001-30,000 5 5
30,001-40,000 1 1
40,001-50,000 3 3
Amount spent on treatment
<1000 58 58
1001-2000 27 27
2001-3000 8 8
3001-4000 5 5
4001-5000 1 1
>5000 1 1
Living conditions
Alone 16 16
With spouse 4 4
Spouse and Children 32 32
Children 3 3
Parents 36 36
Other relatives 7 7
Friends 2 2
Residential type
One room 19 19
Room and Parlour 42 42
Two Bedroom Flat 28 28
Three Bedroom Flat 11 11
Illness duration
1-10 years 58 58
11-20 years 36 36
>20 years 6 6
No of Hospitalization
None 43 43
One 28 28
Two 22 22
Three 5 5
Four 2 2
Age (Years) 37.35±9.48
Illness duration (Years) 9.90±6.75
Illness range (Years) 01-37
Table 3. Summary statistics of WHODAS of participants.
WHODAS Mean SD Range
Overall 27.02 3.49 21.11-40.00
Domain 1: Understanding and communication 3.42 0.351
Domain 2: Getting around 3.27 0.44
Domain 3: Self-care 2.23 0.05
Domain 4: Getting along with others 4.46 1.16
Domain 5: Life activities 5.15 0.82
Domain 6: Participation in the society 8.48 1.85
[page 42] [Mental Illness 2016; 8:6647]
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[Mental Illness 2016; 8:6647] [page 43]
(P=0.406), residential type (P=0.755), income
per month (P=0.258), duration of illness
(P=0.834), and number of hospitalization
(P=0.867) were not significantly different
between participants with scores above or below
the mean score on WHODAS-II18 (Table 5).
Association of BPRS scores with
WHODAS-II scores
The mean score for participants on the
BPRS15 was 25.84 (±4.45), and the scores
ranged from 19-41. BPRS15 score was signifi-
cantly higher in participants with scores above
the mean score on WHODAS-II18 than those
that scored below the mean (t=-6.085,
P<0.001).
Discussion and Conclusions
Clinical stabilization of individuals with
schizophrenia is considered a cardinal goal in
most treatment models.1However, given the
level of psychosocial impairments frequently
seen in people with schizophrenia despite
treatment, the evaluation of illness with
respect to functioning outcome among affect-
ed individuals is germane. Particularly
because such assessment can provide the evi-
dence needed to develop informed and compre-
hensive psychosocial management of schizo-
phrenia targeted towards ameliorating the dis-
ability suffered by the affected population. In
this light, our study report some important
findings that include varied levels of disability
among individuals with schizophrenia, com-
prising affections in domains that assessed
self-care, getting along with others, life activi-
ties and participation in the society among
others. Further, high level of disability was
more likely to be linked with the young adults
in the age group 18-44 years, unemployment
status, remittance source of income and
Yoruba ethnic group; while participants who
spent less on treatment, had less number of
children, and had lower BPRS15 score were less
likely to report high level of disability.
In this study, it is not surprising that gender
was not observed to be associated with disabil-
ity, especially because approximately equal
male: female ratio was observed, and this was
also similar to the gender ratio fielded in other
works on schizophrenia.23,24 With regards to
ethnicity, most participants were not only
found to be of Yoruba extraction in agreement
Article
Table 4. Association between socio-demographic profile and WHODAS-II.
Variables Below WHODAS, mean n (%) Above WHODAS, mean n (%) Total (%) TOS P-value
Age group
18-44 years 37 (37) 38 (38) 75 (75) 2.756 0.007
45-64 years 20 (20) 5 (5) 25 (25)
Sex
Male 24 (24) 21 (21) 45 (45) -0.665 0.508
Female 33 (33) 22 (22) 55 (55)
Marital Status 1.537 0.128
Single 25 (25) 30 (30) 55 (55)
Married 26 (26) 10 (10) 36 (36)
Seperated 5 (5) 1 (1) 6 (6)
Divorced 1 (1) 2 (2) 3 (3)
No of Children 2.158 0.033
None 26 (26) 30 (30) 56 (56)
One 11 (11) 7 (7) 18 (18)
Two 11 (11) 2 (2) 13 (13)
Three 3 (3) 1 (1) 4 (4)
>Three 6 (6) 3 (3) 9 (9)
Education Status -0.779 0.438
None 1 (1) 1 (1) 2 (2)
Primary Uncompleted 2 (2) 0 (0) 2 (2)
Primary Completed 7 (7) 6 (6) 13(13)
Secondary Uncompleted 4 (4) 4 (4) 8 (8)
Secondary Completed 35 (35) 20 (20) 55 (55)
Tertiary Uncompleted 0 (0) 4 (4) 4 (4)
Tertiary Completed 8 (8) 8 (8) 16 (16)
Employment Status -3.095 0.003
Employed 33 (33) 12 (12) 45 (45)
Unemployed 24 (24) 31 (31) 55 (55)
Religion 0.176 0.861
Christianity 42 (42) 31 (31) 73 (73)
Islam 15 (15) 12 (12) 27 (27)
Ethnicity 2.420 0.017
Yoruba 49 (49) 28 (28) 77 (77)
Ibo 3 (3) 4 (4) 7 (7)
Edo 2 (2) 3 (3) 5 (5)
Urhobo 0 (0) 2 (2) 2 (2)
Others 3 (3) 6 (6) 9 (9)
Source of income 2.14 0.034
Salary 12 (12) 6 (6) 18 (18)
Personal Business 20 (20) 7 (7) 27 (27)
Remittance 25 (25) 30 (30) 55 (55)
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[page 44] [Mental Illness 2016; 8:6647]
with other studies done in similar location,19
but participants of the Yoruba ethnic group
were more likely to report high level of disabil-
ity. While this finding may seems to reflect the
location of the study site in Yoruba land, it also
brings to fore the potential negative effects of
socio-cultural interpretations and schemas of
schizophrenia that pervade delayed treatment,
social exclusion and stigma among the
Yorubas. For example, the attribution of super-
natural causation, and connotation of schizo-
phrenia as a form of punishment or spell may
lead to stigma, delayed treatment presenta-
tion, poor response to treatment due to
chronicity and high degree of disability.25,26
Such corollary and compounding impacts of
cultural schemas in schizophrenia have been
elucidated among populations in other con-
texts including Asia, South Americans, and
people of colour in the west among others.25
Expectedly, high level of disability correlated
positively with unemployment. Particularly
because schizophrenia has been linked with
notable loss of social and employable skills in
several previous studies elsewhere.27-29 It is
also possible that social exclusion and the dis-
abling effects of schizophrenia are possible
explanations for the high unemployment rate
on one hand, while unemployment state may
also be disabling among the participants in a
vicious circle. In this light, the high unemploy-
ment rate may be linked to loss of job due to
stigma, absenteeism and functional impair-
ment among others following schizophrenic
illness. For instance, Perkins and Renaldi29
reported that there was decrease in employ-
ment rates among individuals with schizo-
phrenia to whom employment discrimination
is likely to be most acute as well as greater in
relation to other mental disorders. Generally,
people with psychiatric disorders have been
frequently discriminated against by entrepre-
neurs as a result of dwindling performance,
stereotypic belief, stigmatization and perva-
sive negative attitudes among others.30 More
than half of the participants with schizophre-
nia in this study relied on remittance from rel-
atives for their monetary needs. This monetary
dependence may be related to the high unem-
ployment rate or having to engage in low pay-
ing jobs in accordance with previous observa-
tions,29,31 that reported a decrease in employ-
ment, particularly the high paying jobs
amongst patients with mental disorders, with
schizophrenia being most affected. In relation
to age and the number of children, participants
in the age group 18-44 years were more likely
to report high level of disability, while those
who had less number of children were less
likely to report high degree of disability. These
finding are possibly a reflection of the negative
interference of the illness factors with respect
to early onset and chronic longitudinal course
on important socio-economic and reproductive
roles. Importantly, these findings seem to also
mirror the disproportionately disabling affec-
tions in participation in the society and life
activities that were reported. The age bracket,
18-44 years represents the significant period
for productive life activities, acquisition of psy-
chosocial skills, social interactions and
engagements. Thus, the disabling impacts of
Article
Table 5. Association between treatment related variables and WHODAS-II.
Variables Below WHODAS, mean n (%) Above WHODAS, mean n (%) Total (%) TOS P-value
Income per month
<10,000 29 (29) 29 (29) 58 (58) 1.138 0.258
10,000-20,000 22( 22) 11 (11) 33 (33)
20,001-30,000 4 (4) 1 (1) 5 (5)
30,001-40,000 0 (0) 1 (1) 1 (1)
40,001-50,000 2 (2) 1 (1) 3 (3)
Amount spent on treatment
<1000 40 (40) 18 (18) 58 (58) -3.908 <0.001
1001-2000 14 (14) 13 (13) 27 (27)
2001-3000 3 (3) 5 (5) 8 (8)
3001-4000 0 (0) 5 (5) 5 (5)
4001-5000 0 (0) 1 (1) 1 (1)
>5000 0 (0) 1 (1) 1 (1)
Living conditions
Alone 7 (7) 9 (9) 16 (16) 0.835 0.406
With spouse 3 (3) 1 (1) 4 (4)
Spouse and Children 23 (23) 9 (9) 32 (32)
Children 2 (2) 1 (1) 3 (3)
Parents 19 (19) 17 (17) 36 (36)
Other relatives 3 (3) 4 (4) 7 (7)
Friends 0 (0) 2 (2) 2 (2)
Residential type
One room 10 (10) 9 (9) 19 (19) 0.312 0.755
Room and Parlour 23 (23) 19 (19) 42 (42)
Two Bedroom Flat 20 (20) 8 (8) 28 (28)
Three Bedroom Flat 4 (4) 7 (7) 11 (11)
Illness duration
1-10 years 32(32) 26(26) 58(58) 0.211 0.834
11-20 years 22 (22) 14 (14) 36 (36)
>20 years 3 (3) 3 (3) 6 (6)
No of Hospitalisation
None 23 (23) 20 (20) 43 (43) 0.168 0.867
One 16 (16) 12 (12) 28 (28)
Two 15 (15) 7 (7) 22 (22)
Three 3 (3) 2 (2) 5 (5)
Four 0 (1) 2 (0) 2 (2)
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[Mental Illness 2016; 8:6647] [page 45]
schizophrenia and deficits in skills needed for
meaningful and productive activities to satisfy
economic responsibilities as well as fulfill
social roles are likely to more noticeable and
reported in the young adults and those with
more children.
In a similar trend, the severity of symptoms
as indicated by increasing BPRS15 scores in
participants correlated positively with higher
level of disability. Specifically, BPRS15 score
was significantly higher in participants that
scored above WHODAS-II18 mean score com-
pared to those that scored below the mean
score on WHODAS-II18. As it is, this finding
underscores the positive role of symptom con-
trol in full recovery of individuals with schizo-
phrenic illness from associated disability.19,31
It is noteworthy that a little above one-third of
individuals with schizophrenia affirmed living
with their parents in agreement with the find-
ing of Jabelensky et al.32 This finding exempli-
fies the important role of extended family sup-
port system in the care of those with chronic
illnesses in this part of the world. Illness dura-
tion ranged from 1-37years in this study in
contrast to a study among 18-64 year old popu-
lation,33 where the reported range of illness
duration was more than the one fielded in our
study. The mean illness duration was 9.9years,
which is also lower than 15.04 years reported
by Carr et al.34 in Australia. A plausible expla-
nation for this finding is that illness might
have been detected late here due to cultural
and religious beliefs. However, duration of ill-
ness was not found to have significant correla-
tion with disability in contrast to the report of
Alli35 that noted a significant positive correla-
tion of disability with duration of illness.
A number of limitations were identified in
this study. For example, this is a hospital-
based study done at a location with over-repre-
sentation of participants from the Yoruba eth-
nic extraction. Thus, the results obtained may
not be representative of the general popula-
tion, and extrapolation to other contexts needs
be done cautiously, despite the study convey-
ing important lessons that may be potentially
relevant to other contexts and ethnic groups.
Further, the cross-sectional design indicates
that correlates of disability do not imply
causality. Disability was assessed by subjects’
verbal self-report, thus several factors may
affect patient’s motivation to correctly identify
or disclose disability as defined in the present
study. In this regard, use of performance meas-
ures would more objectively clarify disability.
Lastly, elements of bias could have been intro-
duced into the study as a result of non-random
selection of participants and inability to blind
the investigator.
Overall, further studies are needed to
address the limitations identified in this study
by using more robust sample size and prospec-
tive study design with control for confounders.
In addition, more studies are needed to ascer-
tain the causes of disability in schizophrenia.
This will pave way for proactive, preventive
and interventional (treatment) approaches
towards reduction of disability in the popula-
tion affected with schizophrenia. Although not
specifically investigated in this study, an inte-
grated recovery orientation rehabilitation with
social intervention may possibly reduce dis-
ability in patients with schizophrenia.36 Such
intervention could include initiating greater
collaboration between hospitals and communi-
ty occupational therapists that could assist in
improving the social disability that individuals
with schizophrenia do encounter in daily liv-
ing.
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