1. The DHS Program Pilot of a Household Survey Disability Module 6 OCTOBER 2015

2. Outline Pilot testing of disability questions in Ghana –Context –Questions as piloted –Process –Results/Findings Next steps

3. Context Pilot testing of various new questions/modules, including disability questions modeled on Washington Group Short Set Pilot took place in Ghana in June-July 2015 Disability questions included in Household Questionnaire, all HH members age 5+ eligible 3 processes: –Fieldwork –Fieldworker feedback –Cognitive interviews

4. Disability questions as piloted

5. Fieldwork process Questionnaires in English, Akan, Ga, and Ewe Convenience sample –Targeting HH with women age 15-49 and men age 15-59 Total of 1,177 households Mix of urban and rural Total 5,161 HH members, of which 3,860 were age 5+ and eligible for disability Qs Region No. of clusters No. of HH questionnaires Central 6175 Eastern 6189 Greater Accra 18601 Volta 6212 Total 361,177 Age groupTotal 0-4 years1,301 5-9 years674 10-19 years909 20-39 years1,505 40-59 years684 60+ years88 Total5,161

6. Fieldwork results 4% of total wear glasses/contacts 9% of total have some degree of difficulty seeing Prevalence of both glasses-wearing and difficulty seeing increases with age

7. Fieldwork results 1 - 3% of total experience difficulty in various domains Prevalence of all kinds of difficulty increases with age –Difficulty communicating has the lowest prevalence in all age groups –Little spike: difficulty washing/dressing age 5-9

8. Fieldwork results Washington Group definition of disability: a lot of difficulty or cannot (see, hear, etc.) at all in at least 1 of the 6 domains Excludes those with some difficulty By that definition, overall disability prevalence is 3%; increases with age Most of that 3% has difficulty in only 1 domain (seeing) # of domains Percentage with a lot of difficulty or unable 1 or more3.39% 12.88% 20.31% 30.10% 40.05% 50.03% 6 096.61%

9. Fieldworker feedback process After fieldwork, assembled field staff for debrief/feedback Presentation on basic question design concepts Feedback form – Qs on hearing, remembering/concentrating, walking/climbing steps –Did respondents have trouble with the question? –Did you (the fieldworker) have trouble with the question? –If so, please summarize the problems

10. Fieldworker feedback results Does (NAME) have difficulty hearing even if he/she is using a hearing aid? Would you say (NAME) has no difficulty hearing, some difficulty hearing, a lot of difficulty, or can he/she not hear at all? 16/27 fieldworkers had problems with this question Written feedback: –Lack of familiarity with hearing aids made the question confusing to respondents –Conflation with children not paying attention Percentage of interviewers who found respondents sometimes or often had trouble: Percentage of interviewers who sometimes or often: Understanding the question 44% Had to repeat the question 41% Thinking of/remembering the answer 11% Had to reframe the question 37% Articulating/framing the answer 26% Sensed that respondents gave a desired rather than accurate response 11% Giving the answer 19% Had trouble fitting answers into the categories 19%

11. Fieldworker feedback results Does (NAME) have difficulty remembering or concentrating? Would you say (NAME) has no difficulty remembering or concentrating, some difficulty, a lot of difficulty, or can he/she not remember or concentrate at all? 9/27 fieldworkers had problems with this question Written feedback: –Respondents did not understand the question Percentage of interviewers who found respondents sometimes or often had trouble: Percentage of interviewers who sometimes or often: Understanding the question 19% Had to repeat the question 22% Thinking of/remembering the answer 4% Had to reframe the question 22% Articulating/framing the answer 4% Sensed that respondents gave a desired rather than accurate response 0% Giving the answer 0% Had trouble fitting answers into the categories 0%

12. Fieldworker feedback results Does (NAME) have difficulty walking or climbing steps? Would you say (NAME) has no difficulty walking or climbing steps, some difficulty, a lot of difficulty, or can he/she not walk or climb steps at all? 5/27 fieldworkers had problems with this question Written feedback: –Respondents needed clarification – does the question include getting tired, lack of endurance, and/or laziness? Percentage of interviewers who found respondents sometimes or often had trouble: Percentage of interviewers who sometimes or often: Understanding the question 7% Had to repeat the question 7% Thinking of/remembering the answer 0% Had to reframe the question 7% Articulating/framing the answer 0% Sensed that respondents gave a desired rather than accurate response 0% Giving the answer 4% Had trouble fitting answers into the categories 0%

13. Process of cognitive interviews Separate from fieldwork Field teams and implementing agency staff identified participants 2-person teams, 1 interviewer and 1 note-taker First administered the questionnaire, then asked scripted follow-up questions to identify problems understanding, being able to answer, and formulating answers to the questions Administered in Akan and English, notes taken in English CharacteristicWomenMenTotal Language English 628 Akan 516 Residence Urban 9312 Rural 202 Education None 000 Low 404 High 7310 Total 11314

14. Process of cognitive interviews QTextProbes 12 Does (NAME) wear glasses or contacts? What does ‘contacts’ mean to you? When you answered this question, did you think only about medicated glasses, or did you think also about glasses for fashion? 13 Does (NAME) have difficulty seeing even if he/she is wearing glasses or contact lenses? What kinds of things did you think about when I asked you if members of your household have ‘difficulty seeing’? When you think about ‘difficulty seeing’, does this include people who just wear glasses for reading? When you think about ‘difficulty seeing’, does this include people who wear glasses just at night? 14 Does (NAME) have difficulty seeing? 15 Does (NAME) have difficulty hearing even if he/she is using a hearing aid? What kinds of things did you think about when I asked you if members of your household have ‘difficulty hearing’? What kinds of things did you think about when I said “hearing aid”? Have you ever seen a hearing aid? 16Does (NAME) have difficulty communicating using his/her usual language, for example understanding or being understood? What kinds of things did you think about when I asked you if members of your household have ‘difficulty communicating using his or her usual language’? How did you arrive at the answer to this question?

15. Process of cognitive interviews QTextProbes 17 Does (NAME) have difficulty remembering or concentrating? What kinds of things did you think about when I asked you if members of your household have ‘difficulty remembering’? What kinds of things did you think about when I asked you if members of your household have ‘difficulty concentrating’? Were you uncertain about how to respond to the question? 18 Does (NAME) have difficulty walking or climbing steps? What kinds of things did you think about when I asked you if members of your household have ‘difficulty walking or climbing steps’? Did you understand this question to include temporary difficulties, like a broken leg, or just permanent conditions? 19 Does (NAME) have difficulty washing all over or dressing? What kinds of things did you think about when I asked you if members of your household have difficulty ‘washing all over’? What kinds of people would you say do have difficulty washing all over or dressing? 12 – 19 Repetition of response categories for each question Was it helpful for me to repeat the response categories each time I asked you one of these questions?

16. Results of cognitive interviews Does (NAME) wear glasses or contacts? –“Contacts” was a confusing term for most respondents –Respondents thought of medicated/prescription glasses Does (NAME) have difficulty seeing? –Most respondents did not include people who wear glasses just for reading in their conception of people who have difficulty seeing Does (NAME) have difficulty hearing? –Most respondents had not seen a hearing aid and had difficulty understanding the concept

17. Results of cognitive interviews Does (NAME) have difficulty communicating? –Respondents did not have a perfectly common understanding of “difficulty communicating” –Some conflated it with speaking another language (including a sign language) Does (NAME) have difficulty remembering or concentrating? –This was challenging for respondents to explain –Some gave examples of ordinary forgetfulness or children deliberately forgetting chores

18. Results of cognitive interviews Does (NAME) have difficulty walking or climbing steps? –Most respondents would have included temporary difficulties like a broken leg Does (NAME) have difficulty washing all over or dressing? –Some respondents with young children included them in this question; upon probing, they said the difficulty was due to the child’s age and was expected to pass as the child got older Repetition of response categories –Mixed opinions

19. Next steps Reviewed pilot results –Some minor revisions to questionnaire –More issues identified to be dealt with during fieldworker training Suggested revisions submitted to USAID –Seeing screening question: change “contacts” to “contact lenses”, add phrase “to help them see” –Add screening question for hearing aids –Remove question-like phrasing of 1 st sentence for all questions Does (NAME) have difficulty seeing? -> I would like to know if (NAME) has difficulty seeing. Would you say (NAME) has… Will be available as optional module for DHS surveys