Disability and its prevalence and cause in northwestern Ethiopia: evidence from Dabat district of Amhara National Regional State: A community based cross-sectional study

Background Disability is not just a factor of an individual’s physical condition; it develops through human interactions and reects the social fabric of communities. Despite the fact that it directly affects 15% of Ethiopians, understanding and policy-relevant studies on disability and the conditions of persons with disabilities are lacking. The Dabat Demographic and Health Surveillance System part of the response to ll this gap. With signicant drawbacks in the Surveillance System, this study aimed at assessing the prevalence, types and major causes of disability in Dabat district. Method A community-based cross-sectional study design was employed and covered 17,000 households residing in 13 Kebeles of Dabat district. The district is where DHSS collects health data semi-annually; but this study was designed and executed separately in 2018 utilizing robust tools (World Health Organization’s Disability Assessment Schedule (WHODAS 2.0) used to collect comprehensive data on disability in the district. The data was organized and presented using frequencies and percentages in table and gures. Relevant variables were used to construct a logit model that predicts the likelihood of disability whereby P-value < 0.05 was considered as statistically signicant. Results This study found that the overall prevalence of disability in Dabat district was 2.14% [95% CI: 2.03, 2.24]. About 8.3% of households reported at least one member with disability. Visual impairment was the most commonly reported impairment d51%) while 8.19% had multiple impairments. Eighty-three percent of immediate the causes of disability were modiable – specically, illness (36.93%), injury (17.81%), and congenital (10.86%). The aged [AOR=1.0; 95% CI: 1.03, 1.04], those unable to read or write illiterate [AOR=1.57; 1.15,2.14], the unmarried/single [AOR=1.39; 95% CI: 185,2.47] and the separated [AOR=2.78; 95% CI: 4.14,6.19] were more likely to risk disability in the population. Conclusion This study reported an increased likelihood of impairment among those with advanced ages. The proportion of households with PwDs was also high. While most disabilities were visual, there were signicant numbers with mobility impairments and hard of hearing. Most school-age PwDs did not complete secondary education, while employment was signicantly limited. The ndings indicated that most causes of disability were reversible. aging, inaccessibility of health services, etc. that require programmatic at national, regional and local levels. On the other hand, this study indicated that the prevalence of disability increased among


Background
Disability is part of a human condition that can be experienced by any person at some point in life, temporarily or permanently. As a concept, it has been used to alternatively refer to physical impairments, activity limitations, or participation restrictions. Currently, the WHO-ICF de nition of disability is widely adopted i.e. a person is considered to have a disability if and when his/her activity performances in his/her usual environment are limited in nature, function, or quality . Hence, it includes physical or learning and intellectual disability that cause functional limitations. consistently related to human dignity and inclusion.
The World Health Organization (WHO) and the World Bank (WB) estimated that about 80% of the global 1 billion persons with disabilities (PwDs) currently live in developing countries where rehabilitation services are poor or non-existent. These numbers are increasing -both globally and in developing countries -due to population growth, man-made and natural disasters, war, accidents and aging.
On the other hand, data on the proportion of PwDs in Ethiopia is highly fragmented or sometimes misleading and contradictory. For example, based on the 2007 Population and Housing Census, Ethiopian Central Statistical Authority (2007) reported that there were less than 1 million Ethiopians with disability i.e. 1.2%. Conversely, WHO's World Disability Report (2011) indicates that the national prevalence of disability in Ethiopia is around 17% The in-congruence between the two sources of disability statistics could be explained by the multidimensional of disability that makes its measurement variable. The World Disability Report explains, "Operational measures of disability vary according to the purpose and application of the data, the conception of disability, the aspects of disability examined, the de nitions, question design, reporting sources, data collection methods, and expectations of functioning" (1). In Ethiopia, many are skeptical about the census statistics on disability that could have been affected by "under-reporting, the way the census questions were formulated, lack of disability awareness among enumerators and data managers and use of a narrow de nition of disability" in the census. Others have argued the census gure actually reveals the number of PwDs in Ethiopia has not been identi ed yet.
Despite their inconsistencies and contradictions, literature and statistical reports on disability in Ethiopia identify mobility, visual and hearing impairments as the top-three most prevalent forms of disabilities, in that order. The prevalence and types have also been reported to be similar in North Gondar Administrative Zone of the Amhara National Regional State (ANRS), Ethiopia.
Reliable statistics on disability is a requirement to promote inclusive and sustainable development. It will furnish data on the level of functioning in the population, the need for rehabilitation services and equalization of opportunity by helping identify the barriers to PwDs' inclusion and participation in community affairs. PwDs have the rights to equal opportunities to schooling and employment as well as access to health and other services. In recent years, national and global actors have pushed the issue of disability to the center and front of policies, programming and service provision to ensure the effective inclusion of PwDs in development.
The causes and impacts of disability on people are numerous and complex. In Africa, nonetheless, it is evident that the major causes of disability are communicable diseases, war, accidents, and inadequate prenatal and neonatal health-care services. Studies have also shown that disability is strongly linked to underlying and basic problems of poverty, poor nutrition and restricted access to basic services such as health and schooling. These factors are also relevant to the Ethiopian context where the list of causes/factors include low standard of living, malnutrition, natural and man-made disasters, accidents, infectious and non-infectious diseases, intermittent wars and violence.
Negative attitudes and limited understanding around disability and people with disabilities can contribute to poor mental health and wellbeing, and, lead to societal exclusion across many life domains. But persons with disabilities do not form a homogenous group. Alongside a variety of different types of impairments (e.g. physical, psycho-social, sensory, intellectual, neurological), people with disabilities live in a variety of contexts with different intersecting identities. This may include gender, age, education status, employment and economic status, and, geographical location. How these contexts and different characteristics intersect, lead to very different experiences of disability [15]. In Ethiopia, for instance, about 46% of PwDs are women and they carry the double burden of stereotypes, discrimination and economic challenges associated with their gender and disability. Age is also a factor whereby children with disabilities (CwDs) are less likely to attend schooling or access healthcare services leaving them vulnerable to poverty and poor health that substantially reduce their quality of life [17,18]. As a group, without underplaying these variations within, PwDs are still among the most disadvantaged segment of the society.
With existing and emerging man-made and natural disasters, technological changes and global communications, disability statistics and surveillance are necessary to assess and examine trends on the conditions of PwDs to inform policies and strategies on inclusive and sustainable development as well as programming for delivery of social-and healthcare-services. Speci cally, disability statistics and surveillance furnish empirical and reliable data on needs, priorities, strategies and resources that promote the effectiveness of interventions to meet the challenges of PwDs. By doing so, they will contribute to lling the existing knowledge gap on disability -its magnitude, types, effects, trends, etc. -in Ethiopia at policy, research and programming levels.
Researches have documented the complicated relationship among disability, its social and health outcomes and national and contextual realities; and, the provision of long-term everyday care for PwDs is becoming a major problem on public health policy and programming especially in developing countries where resources, quali ed personnel and rehabilitation centers and services are very limited. It is against this backdrop that University of Gondar (UoG) launched the Dabat Health Surveillance System (DHSS) in 1995 to collect, organized and disseminate regular and up-to-date information on the health conditions of the population (including PwDs) in Dabat district, northwestern Ethiopia. Nonetheless, with the focus of Dabat Research Center being on general health and demography, it only started to collect data on disability recently and even that did not employ robust, internationally-validated disability measurement tools to assess the status of disability in the district. As a result, the Center reports signi cantly low disability prevalence in the district. This study, hence, aimed at assessing the prevalence, types and causes of disability on residents of the Dabat district employing a disability measurement tool containing items from WHO Disability Assessment Schedule (WHODAS 2.0) and the International Classi cation of Functioning, Health and Disability (ICF).

Study Area
This paper discusses disability and conditions of PwDs in Dabat district, northwestern Ethiopia -the district covered by DHSS longitudinal study. Dabat town is located 60kms northwest of Gondar city, and it serves as an administrative center of the Dabat district. The district has an estimated population of 168,331 (male/female: 50%) (CSA 2013) that occupy 1,199.15km 2 area. It is administratively organized under 5 urban and 27 rural Kebeles with altitudes ranging between 1000 and 3000 meters above sea level (Dabat Rural Project Statistics, 2015).
The district has 29 health posts, 3 health stations and 2 health centers. UoG established DHSS in 1995 to collect demographic, social and health data in 13 Kebeles (9 rural and 4 urban) of 32 Kebeles of the district. According to the 2014 Re-census Baseline Survey, DHSS collects data on 17,000 households, with 72,000 inhabitants, semi-annually.

Study Design
To identify the prevalence, causes and associated factors of disability at Dabat district, the study used a community-based cross-sectional design. Data analyzed and discussed in this paper are not part of the longitudinal survey conducted by DHSS since 1995 but part of the add-on cross-sectional survey launched in 2016 to speci cally address the gap in the DHSS data on disability. The data contained in this paper are from the eldwork conducted between January and June 2018.

Study Population
This study covers all members and permanent residents of the 17,000 households covered by the DHSS in Dabat district. Data on disability was gathered from household heads residing in 13 Kebeles of the district. The DHSS staff and enumerators collect health and demographic data on well-de ned entities or primary subjects (individuals, households, and residential units) semi-annually (and changes over time) by visiting the 17,000 households and their members.
This study reports and discusses the ndings of a separate cross-sectional study on the same study population, but exclusively focusing on disability and employing robust disability measurement tools to collect household data and assess the prevalence, causes and associated factors of disability vis-à-vis socio-demographic and other relevant dimensions.

Sample size and sampling procedures
Theoretically, this study included all 17,000 households and their members and permanent residents as well as those on the streets in the 13 Kebeles within the Dabat DHSS catchment area. It excluded those who were not-permanent residents (less than 6 months, as per the CSA de nition of 'household members') at the time of data collection.

Data collection: tools and procedure
The household survey employed a structured and pre-tested questionnaire containing items adapted from The World Health Organization Disability Assessment Schedule (WHODAS-2.0) and the International Classi cation of Functioning, Health and Disability (ICF) to re ect local contexts. Respondents were asked to provide information on household members with signs of disability including hard of hearing or total loss, visual impairment or blind, speech impairment, loss of senses or limbs, paralysis, diagnoses insanity, etc. The information gathered on disability through the community survey did not account for mild or moderate type of disability. It was then translated and deployed in its Amharic -language of the local community. With the questionnaire being not validated in Ethiopian context, the researchers relied on their robust researching and programing experiences on disability, inclusion and community rehabilitation in the Dabat district to contextualize and ensure its culture-appropriateness and scienti c validity. Furthermore, it was pre-tested on a population with similar demographic and socioeconomic pro le as the study area, with its outcomes used to review and adapt its framework, organization as well as items sequencing and wording.
WHODAS-2.0 is a standardized and validated tool to assess health and disability status both at individual and community levels, and across cultures. As a generic tool, it effectively assess disability induced limitations on activity and participation both in community and clinical set-up. Furthermore, it has been fruitfully deployed to measure the effectiveness of disability interventions. The survey questionnaire speci cally adapted items from WHODAS-2.0 that measure the six domains of disability: learning and intellectual, mobility, self-care, getting along, life activities and participation.
The questionnaire had also included items from International Classi cation of Functioning, Health and Disability, Children & Youth version (ICF-CY) to assess disability, activity limitations and other outcomes among population under 18 years of age. Survey data were collected by well-trained data collectors and DHSS staffs who administered the questionnaire through face-to-face interview. They visited all 17,000 households in Dabat district and interviewed heads of households to collect the necessary information on all members of the household, including themselves. The use of self-reporting rather than conducting clinical screening on household members to collect data on disability is identi ed as the limitation of this study. Finally, when new cases of disability were identi ed or reported, they were referred and/or linked to local Community-based Rehabilitation (CBR) eldworker.

Data analysis
Data were entered into the Household Registration System (v-2.1) and the survey data was entered into and analyzed using STATA (v. 12) software. Descriptive statistics -means, percentages, standard deviation, etc. -were employed to describe the characteristics of the study population. Table and gures were used to present aggregated and disaggregated, as appropriate, data. Binary logistic regression was tted to test and identify factors signi cantly associated with disability. The bivariate analysis was carried out, and variables with p-values of <0.2 were entered into the multivariable logistic regression model. The crude odds ratio (COR) and nally, a Logistic regression models were constructed on predictors of disability among the study population. The adjusted odds ratios with the corresponding 95% Con dence Interval (CI) were used to show the strength of association between independent variables (age, sex, place of residence, religious a liation, educational attainment, occupation marital status) and disability. A P value of <0.05 was considered statistically signi cant.

Results
Respondents' Socio-demographic characteristics: As Table 1 Table 2 and Figure 1 reveal, the prevalence of disability increased with increase in age, and reached the highest level among persons of 65 and above years old (10.18%). Conversely, the prevalence of disability declined with increase in educational status. For instance, the highest proportion of disability -971 (63.2%%) -was recorded among those who cannot read and write, and the difference is stark when we compare it to those with Grade 11/12 (0.72%) and Grade 12 + (0.98%) education (Table 3).
More than 8% of households had a member with disability (1411 in 17,000 households).  Figure 2).
On the other hand, only 253 (16.5%) PwDs attended any form of formal education. In fact, as educational level increases, the proportion of PwDs who attended higher grade-levels fell signi cantly with less than 1% completing secondary education (Table 3).
The survey identi ed the most frequent causes of disability as illness (36.93%), followed by accidents (17.81%), unknown (11.57%), congenital (10.86%) and ageing (5.2%). In other words, more than 83% of the reported immediate causes of impairments could have been prevented from causing functional limitations if they were identi ed and treated early (Table 5 and Figure 4).
Factors associated with disability: Multivariate logistic regression model was constructed to predict the occurrence of disability in the study population from data on respondents' age, educational attainment and marital status.  (Table 6).

Discussion
This study found that though the general prevalence of disability was 2.14%, it signi cantly affects older people in the community. The proportion of households with members with disability i.e. 8.3% was high when compared to previous studies on the study area. As questionable they were in reliability, representativeness or timeliness, CSA and Chala reported 1.82% and 1.09%, respectively, disability prevalence for Dabat district, which were signi cantly lower than the 2.14% reported in this study. However, 2.14% is still signi cantly lower than an estimated 17.6% national disability prevalence rate in Ethiopia that WHO and WB (2011) reported.
There are several possible explanations why different sources provide different reports on the prevalence of disability. For one, WB and WHO conceptualize disability broadly and include various factors and types, such as chronic illnesses as well as moderate and minor impairments, within the rubric of 'disability.' However, limited resources for rehabilitation services and supporting PwDs in developing countries may have dictated a narrower operationalization of disability. In other words, pragmatic conceptualization of disability would set realistic expectations and recommendations for policy formulation and social work practice. For another, this study relied on responses household heads provided to estimate the prevalence of disability in the district. By its design, the quality of data could be affected by respondents' lack of knowledge on the nature and degree of one's and household members' disability, and negative attitude towards disability and PwDs, among other. Hence, lack of understanding on disability, stigma attached to disability in the district and respondents' inability to identify all types and degrees of disability may have lowered reports on disability in the study area.
In terms of type of disability, this study reported similar results as the same team's previous study in Dabat district. Both studies found that visual impairment affects the highest proportion of PwDs; but while the current study found that mobility and hearing impairments are second and third in the number of people they affect, their relative proportion was reversed three years earlier.
A small fraction of PwDs attended formal education; and more importantly, with advance in educational level, their progression to higher grades decreases signi cantly. This result was consistent with the Handicap International report that indicated a small fraction (3%) of the estimated 2.4 to 4.8 million school-age CwDs went to school. CwDs' low school attendance and participation are due to underlaying reasons that include stigma against CwDs, school inaccessibly, rigid teaching practice, poorly trained teachers to accommodate children with special needs and lack of adaptive hearing resources. Another study in South Africa documented how PwDs and their families live with stigma and social exclusion that affect their personal development and community participation. Other studies also report CwDs are less likely to attend schooling and access health care, and they are more vulnerable to poverty which may result in substantial decline in their quality of life.
This study reported that the majority of disabilities were due to modi able illnesses, injuries, etc.; and the causes and impacts of disability are multifaceted. Concurrent to these ndings, studies have documented that the majority of disabilities in Africa result from illness, injury, and accidents -causes that are preventable. In Ethiopia, diseases like measles, poliomyelitis, etc. as well as accidents and injuries cause illnesses to many people that -if identi ed and treated early or on time -may not necessarily amount to serious functional and activity limitations. Most disabilities and their causes can be linked to poverty, and restricted access to basic services. As this study reported, most PwDs were poor -both in urban and rural areas -and a signi cant majority of them were involved in small-scale farming with strained livelihoods. Besides, inadequate health care services were also signi cant contributors to the disability problem on the continent, which is the same in the Dabat district.
Disability causes serious bad health outcomes, and the provision of long-term care for PwDs in resource limited settings is a major public health problem. Disability is especially a concern for developing countries where prevention approach and health service services are inadequate or very scarce. Moreover, stigma and stereotypes limit educational and employment opportunities for PwDs thereby creating dependency and exclusion for PwDs and this study underlines these facts.
When it comes to women with disabilities, they carry the double burden of stigma and discrimination and economic problem due to their gender-roles and disability. Disability and poverty exacerbate their socioeconomic wellbeing and their general quality of life.

Strengths and Limitations
The study aimed at exploring factors and the prevalence of disability and its deleterious impacts in low resource setting i.e. Dabat district, Northwestern Ethiopia. Large size samples were drawn to collect representative empirical data about the population. Literature review revealed that there is dearth of scienti c, empirical information to understand the trend and changes on the prevalence and magnitude of disability and its effects in Ethiopia. It has also established the evident fact that there is low community and governmental attention on disability and the empowerment of PwDs in developing countries such as Ethiopia. Therefore, by identifying contributing factors to disability and its prevalence and impacts on peoples' lives in northwest Ethiopia, this study will promote disability awareness and inclusive society as well as inform the agenda for disability research, policy and practice in the district and beyond.

Conclusion
This study found the proportion of reported disability per household to be high. Vision and mobility disability were the most frequently observed types of disability, and most immediate causes of disability were modi able. This conclusion, however, does not apply to underlying structural factors to disability such as poverty, aging, inaccessibility of health services, etc. that require programmatic interventions at national, regional and local levels. On the other hand, this study indicated that the prevalence of disability increased among the ageing-groups. As educational level increase, the proportion of PwDs attending school decreases, and most PwDs do not complete secondary education. Similarly, a small proportion of PwDs were government employees, and the majority were engaged in farming.
Early intervention and appropriate medication will prevent the burden of disability. To this end, appropriate attention should be given to improve quality of healthcare facilities and services to reduce the burden of disability on families, communities and the health care system. Moreover, community awareness creation and enhancing inclusive education will improve education opportunity for PwDs. With improve in educational level and skills, PwDs will be able to nd and/or create jobs thereby promoting their independence and better quality of life. Health Sciences -were submitted to Dabat District Administrator. Letter of information describing the purpose and objectives of the study, and written informed consent was obtained from the study participant (household head), and consent forms were given or read to study participants prior to the commencement of the interview. Participants were granted the right to terminate their participation in the study at any point if and when they chose to.
Once in the eld, researchers and DHSS staff put their maximum efforts in assuring all ethical and scienti c standards are maintained. Participants' privacy and con dentiality were respected during and after interviews. Once data was collected, each questionnaire was coded, and personal identi ers were removed to maintain anonymity and con dentiality of participants. All data was entered and saved on a computer with a strong password which was only accessible by the research team. Participants who reported disability or were found ill during data collection were either linked to UoG-CBR eldworkers or health centers for better care.       Types of disability among PwDs in Dabat district (Source: Survey 2018)