Executive Summary This executive summary provides an overview of the needs assessment designed to advance the understanding the need for occupational therapy (OT) services in Ethiopia. The needs assessment was informed by a review of literature, an environmental scan, and stakeholder engagement.
Background Rehabilitation services are services directed at facilitating the optimal functioning and community participation of people who experience, or are at risk for experiencing disability. Comprehensive rehabilitation services address a wide range of factors that influence disability and comprise a variety of health professions, including the profession of occupational therapy.

The University of Gondar, a national pioneer in developing physiotherapy education in the country, introduced a B.Sc. level physiotherapy-training program in 2002, and launched the first Master of Science in Physiotherapy program in 2010. The university aspires to maintain its regional and national leadership in rehabilitation science and practice.

Global estimates indicate that nearly 17.6 million people are affected by disability in Ethiopia. (4) The few studies that have been published on the prevalence of disability in Ethiopia show overall disability rates ranging from 1.82% to 3.8% (5,6). These findings are likely conservative estimates, considering the fact that they do not include the full range of disabilities. Prevalence of the specific disabilities were 17%-47% for walking-related disabilities and 28%-39% for vision-related disabilities. (5 -7)

Rationale for the establishment of the Bachelor of Science degree in Occupational Therapy
Multiple factors have led to the proposal for the Bachelor of Science degree in Occupational Therapy at the University of Gondar. The health sector in Ethiopia is among one of the sectors that demands an immediate and drastic expansion with diversification in trained human power. Occupational therapy is an internationally recognized, evidence-based profession with distinct foundational knowledge and skills related to disability, inclusion and community participation. Occupational therapy focuses directly on enabling people with disabilities to achieve and maintain their optimum function and participation in important community roles and reducing the burden on families and communities. However, in Ethiopia, none of the institutions of higher education have established OT training programs despite the prevalence and a huge numbers of people living with disability (PLWD).

The World Federation of Occupational Therapists define occupation as “ the everyday activities that people do as individuals, in families and with communities to occupy time and bring meaning and purpose to life. Occupations include things people “need to, want to and are expected to do” (8). The curriculum of the undergraduate OT program will be designed to produce competent and internationally recognized occupational therapists who will work with people with a wide range of health conditions experiencing significant disability their families and communities to enable these people to successfully engage and participate fully in their daily activities and in their communities.

Objectives of the needs assessment: Overall, the objectives of the needs assessment were to: 1) understand the activity and participation context for people with disabilities and people vulnerable to disabilities in Ethiopia; and 2) understand how occupational therapy as a profession might support presently unmet service needs related to disability in Ethiopia.

The specific objectives of the needs assessment for an occupational therapy education program were to:

1. Explore the current rehabilitation practice context in Ethiopia, including the current formal and informal education of rehabilitation service providers.
2. Assess present facilitators and challenges to activity and participation for people with disabilities and people vulnerable to disabilities in Ethiopia.
3. Identify present unmet rehabilitation needs of people with disabilities, family members of people with disabilities, and people vulnerable to disabilities in Ethiopia.
4. Explore curricular content, process, and structure that is pertinent to an undergraduate occupational therapy education program in Ethiopia.
5. Identify the potential health and social sectors for practice for future occupational therapists in Ethiopia.

Methods
Several groups of stakeholders were consulted to inform this needs assessment: current health service providers; health system employees in non-clinical roles; people with lived experience of disability and their families and; post-secondary educators with experience teaching students with disabilities. The needs assessment included surveys and semi-structured interviews to gather a range of perspectives.

Study Design
A cross-sectional descriptive study design was used and included participants recruited using convenience sampling methods. For the quantitative surveys, health service providers and individuals who were affiliated with organizations that may hire occupational therapists in the future were recruited. Qualitative interviews included individuals who had information to share about the disability-related supports and services in Ethiopia.

University of Gondar and Queen’s University institutional ethics review boards approved the needs assessment protocol. All volunteer stakeholders were included after the informed consent process was completed. Quantitative and qualitative data were collected by trained data collectors. Once designed and translated from English into Amharic, all data collection instruments were pilot-tested before implementation. The semi-structured interviews were audio-recorded, transcribed and translated into English before analysis.

Data Analysis
Quantitative data analyses from the two surveys were primarily descriptive in nature, and included frequencies, mean and standard deviation statistics.
The process for the analysis of interview data involved both independent review, line-by-line coding in pairs, and refining of the thematic coding structure by the full analysis team.

Results
Survey I Results – Health service providers
Twenty-eight health service provider stakeholders from Gondar (28.57%), Addis Ababa (25%), Dire Dawa and Jimma (10.7% each), Bahir Dar, Dessie, and Mekelle (7.14% each), and Gefersa (3.57%) responded to the first survey. Seventy-one percent were men and 61% were between 30 and 39 years old.

Practice Setting and Training
Most Survey 1 respondents practiced in a hospital setting (n=20), and the majority treated patients with musculoskeletal issues (n=19) followed by patients with neurological conditions (n=16). Twelve departments were represented in the survey, and of these, nearly 29% of the respondents were from a physiotherapy department. Almost 29% reported that they did not have any disability-related training, while others reported to have had a range of trainings such as workshops, certificates and as part and parcel of their professional career training.

Knowledge of OT
The majority of respondents reported that they had little or no knowledge of the OT profession (57%), of the daily work of OTs (75%) and of the training of OT’s (80%) While the respondents were more positive about their personal knowledge and expertise in disability related issues and practice) (57% agree or strongly agree), the survey indicated that a significant minority (28-39%) reported they did not have high levels of knowledge and expertise.

Only two survey respondents indicated knowledge of any OTs working in Ethiopia (one at ALERT Hospital and the other at St. Georges Beer PLC), while only three people had ever worked with an occupational therapist.

Client Experiences of rehabilitation services
Respondents indicated that there were gaps between the current rehabilitation services required and services available. They indicated that the people currently served in rehabilitation face significant challenges in their daily activities; have inquired about additional rehabilitation modalities; and have expressed concerns about returning to activities they used to do.

Most respondents reported that clients are currently not provided with evidence-based interventions to increase personal capacities, to enable their activity and community participation or to address the environmental factors that influence activities and participation. They indicated that people with disabilities are not offered rehabilitation services in all settings where they engage in daily activities and that training in self-advocacy skills and self awareness is currently limited in rehabilitation settings.

Support for OT profession
Everyone who responded to the survey said they would support the establishment of an OT program in Ethiopia and offered a variety of potential forms of support including employing, mentoring, collaborating with, and recommending the employment of new graduates.

Survey II Results – Non-clinical health services
Twenty-two stakeholders working in non-clinical roles participated in Survey 2. They were predominantly male and ranged in ages from 29 to above 60. Their roles varied in nature (i.e., directors, administrators, team leaders and advisors). Participants represented different healthcare (n=10), governmental (n=6), non-governmental (n=3), and educational (n=2) organizations from the capital, Addis Ababa (n=12), Assela, Bahir dar, Burayu (Oromia), Dessie, Dire Dawa, Jimma, and Mekelle.

Practice Setting and Training
Respondents worked for organizations that, as a group, served people from across the lifespan in age, and living with a wide range of health conditions.
Disability-related training among this group of stakeholders was limited with 40% reporting no specific training.

Overall respondents reported very low levels of expertise and knowledge of disability-related issues and practice and even lower levels of knowledge about occupational therapy.
Perceptions of current health and rehabilitation system
Overall these non-clinical stakeholders perceived that the current capacity of rehabilitation services to address the needs of people with disabilities, in practice and in policy, was very limited.
Support for introduction of Occupational Therapists in Ethiopia

Twenty of 22 respondents supported the establishment of the occupational therapy profession in Ethiopia. Types of support suggested included: hiring graduates and advocating for or providing funding for individuals to access occupational therapy services once established. Occupational therapy was also described as making a contribution to disability prevention, particularly where individuals are supported in living healthy lifestyles, and also disability advocacy and education.

Results of Qualitative Interviews
A total of 44 people from across all stakeholder groups (health service providers, non-clinical health service providers, and people with disabilities) participated in the semi-structured interviews, focusing on their experiences and perceptions of living with disability.
The three overarching themes that emerged included: 1) the nature of healthcare and support services experienced by participants; 2) healthcare systems gaps; 3) the potential role of occupational therapy.
Theme 1: The nature of the healthcare and other Support Services Experienced by Participants
Services received to address the experience of disability were largely biomedical in nature, directed to reducing impairments of body structures or functions.
Services received that focused on daily living activities and community participation were limited and primarily described as directed to supporting school involvement and included Braille books, computer training and tutors.
Theme 2: Emerging Evidence of Healthcare System Gaps
Participants noted the importance of increasing attention to supporting individuals in living and engaging in their communities. Community follow-up is a rarely received service and providers have little knowledge of how the people they serve fare in their community environments.
Families are described as carrying a heavy burden, often as the sole care provider and supporter of their family members with disabilities. For both the individual with disability and their families their community life situations are characterized as desperate with experiences of depression, social exclusion and discrimination.
In this context of limitations and burden, without access to relevant services and supports, acceptance of disability and the establishment of positive identities and hope for the future are compromised.
Theme 3: Potential Role of Occupational Therapy
Participants described the potential role of occupational therapy as contributing to the functioning and emotional well-being of individuals with disability. They believed this could enable their success with everyday tasks and their community participation in important social roles such as work.

The interviews provided information about a number of factors that will need to be considered in advancing rehabilitation services in Ethiopia. These include the urban/rural differences, widespread poverty, the physical inaccessibility of many local contexts, and the high levels of stigma related to disability in the country.

Conclusions
The needs assessment provided useful insight on the need to expand rehabilitation services in Ethiopia and to include a broader range of rehabilitation professions; particularly in relation to the need to address issues related to (1) functioning in daily activities and (2) community participation in important social roles and activities. These issues are a central focus of the knowledge base and work of occupational therapists. The needs assessment suggested that a range of stakeholders in the country support the idea of introducing occupational therapy in Ethiopia and would be willing to support the practice of OTs in their practice settings.

Future Actions
1. Occupational therapy would be a valuable addition to current health and rehabilitation workforce in Ethiopia to help address the many challenges faced by people with disabilities. It is recommended that higher education institutions, and specifically the University of Gondar, commence preparation of qualified occupational therapy professionals.
2. The training of occupational therapists at the Bachelor degree program level is recommended. This level of training is aligned with the minimal standards for education of occupational therapists identified by the World Federation of Occupational Therapists.
3. The Bachelor degree program in occupational therapy is recommended to advance the understanding of disability and disability related concepts, particularly as they are experienced in the Ethiopian context.
4. Consideration should be given to the design of advanced training of occupational therapists at the Master’s level in the future, to support the advancement of the profession and ensure future career opportunities.

 

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