"Disability Grading" is helpful to look at things form a GENERAL PUBLIC HEALTH perspective …

Leprosy Mailing List – March 1st, 2012 

Ref.:    "Disability Grading" is helpful to look at things form a GENERAL PUBLIC HEALTH perspective …

From:  L Lehman, Brazil

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Dear Salvatore,

Thank you for the posting of the results from the Disability Survey from Prof Cairns Smith - well done.

It highlights the areas of confusion and inconsistencies.  It shows us how to focus training and where we must monitor as new people come into health services.  I must personally say that the publication from Brandsma in 2003 of his "Proposed Grading" created confusion in several countries and health services I visited.  They thought it was an "Official W.H.O. Grading " that was supposed to be changed.  Brandsma's Proposal in Leprosy Review in 2003 is not acceptable by all but, could lead to further discussions as pointed out in this survey.

It might be worthwhile to discuss the PURPOSE of the Grading.  Many try to use it beyond its capabilities and Ebenso and Ebenso addressed this in their article in Leprosy Review a few years ago.  I do not believe it can substitute for doing a good clinical examination and documentation of the impairments found on the face, eyes, hands, feet and body.  It too does not look at the WHOLE person and the effects of the disease on their ability to do activities or participate socially - that is one of the reasons the SALSA and P-scale were developed and later an instrument to measure stigma.  

This "Disability Grading" is helpful to look at things from a GENERAL PUBLIC HEALTH perspective (providing it is done correctly and all are using the SAME criteria).  It can give us an idea of the following:

1. Early Diagnosis and if Health education is helping people identify and seek treatment early;

2. QUALITY of Treatment/Care.  Determine if New cases have been MANAGED adequately.  (In addition to multi-drug therapy (MDT), Completion of a cohort analysis comparing the Grades at Beginning and end of MDT Treatment gives one a better idea of quality of care).

I found when at the end of treatment the Grade was worse it usually was related to:

a. people not managing reactions well;

b. not doing adequate self-care education which included Grade 0 with reactions, Grade 1 & 2;

c. not having or using adequate protective footwear for those feet at RISK.  

The COHORT analysis of the grades at beginning and end of treatment may be one of the best QUALITY Indicators we could use on a more global level.  We do it for multibacillary and paucibacillary MDT completion rates, why can this not be considered?   I found when I did it with individual health services, it opened their eyes to areas in their management and care that needed attention.  

Another issue needing further discussion is the labeling of persons as "Disabled" based on the Grading.  This could be addressed at another time. 

Thank you again for this excellent work!

Linda Lehman