The Face of Disability in Nigeria: A Disability Survey in Kogi and Niger States

Abstract

The Leprosy Mission Nigeria conducted a disability survey in Kogi and Niger States of Nigeria in 2005, investigating the demographic characteristics of people with disabilities, including gender, age, religion, marital, educational, occupational, employment and economic status, understanding of disability and health-seeking behaviour. Information was gathered from a convenience sample of participants, across 30 randomly selected towns and villages in the two states. Twelve trained bilingual research assistants were used, to translate the English language questionnaire verbally into the local language of each participant. From the 1093 respondents studied, the most common disabilities involved vision (37%), mobility (32%) or hearing (15%). A third of these were less than 21 years of age and had no occupation, and 72% were Muslim. Over half of them had no education, 20% had primary, 8% secondary, 2% tertiary and 18% had Islamic education. Common occupations were begging (16%), studying (14%), farming (11%) and trading (8%). The majority were unemployed (61%) due to their disability. Over 70% were not able to access disability specific health services and 37% had an assistive device. Services accessed included health - mainstream (90%), traditional (61%) and counselling (58%); and other - rehabilitation (30%), assistive device provision (24%), welfare (22%), special education (15%), vocational training (10%) and economic empowerment (4%). hese results are comparable with findings in other studies. Disability affects a person's ability to participate in education, work, family life and religion, influences health-seeking behaviour and contributes to poverty.

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THE FACE OF DISABILITY IN NIGERIA: A DISABILITY
SURVEY IN KOGI AND NIGER STATES
Natalie Smith*
ABSTRACT
The Leprosy Mission Nigeria conducted a disability survey in Kogi and Niger
States of Nigeria in 2005, investigating the demographic characteristics of
people with disabilities, including gender, age, religion, marital, educational,
occupational, employment and economic status, understanding of disability
and health-seeking behaviour.
Information was gathered from a convenience sample of participants, across 30
randomly selected towns and villages in the two states. Twelve trained bilingual
research assistants were used, to translate the English language questionnaire
verbally into the local language of each participant.
From the 1093 respondents studied, the most common disabilities involved
vision (37%), mobility (32%) or hearing (15%). A third of these were less than
21 years of age and had no occupation, and 72% were Muslim. Over half of them
had no education, 20% had primary, 8% secondary, 2% tertiary and 18% had
Islamic education. Common occupations were begging (16%), studying (14%),
farming (11%) and trading (8%). The majority were unemployed (61%) due
to their disability. Over 70% were not able to access disability specic health
services and 37% had an assistive device. Services accessed included health
- mainstream (90%), traditional (61%) and counselling (58%); and other -
rehabilitation (30%), assistive device provision (24%), welfare (22%), special
education (15%), vocational training (10%) and economic empowerment (4%).
hese results are comparable with ndings in other studies. Disability aects
a person’s ability to participate in education, work, family life and religion,
inuences health-seeking behaviour and contributes to poverty.
Key words: Disability survey, people with disabilities
INTRODUCTION
An estimated 10% of any population is likely to be disabled, and up to one in
ve of the world’s poorest have a disability (1,2). With a population of over
140 million, Nigeria has approximately 14 million people with disabilities (3).
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Disability is both a cause and a consequence of poverty (4,5,6), reducing access
to education, employment, opportunities and resources. Poor people without
disabilities can develop them, due to inadequate nutrition, unclean environments,
disease, inecient health services and poor infrastructure (7,8,9,10). Untreated
and chronic diseases aect increasing numbers of people in developing countries
(11,12), resulting in physical and functional disability (9,10,13,14).
Preventable disease, congenital malformation, birth related incidents, physical
injury and psychological dysfunction all produce disability. In 2004, the infant
mortality rate in Nigeria was 101 deaths per 1000 live births, and the under-5
mortality rate was 197 per 1000 live births (15,16). Most neonatal deaths in
developing countries result from infections, pre-term delivery and asphyxia,
and disabilities for survivors can include cerebral palsy, spina bida, congenital
deformities and encephalitis (9,17,18). At least six preventable diseases of
childhood - measles, poliomyelitis, diphtheria, tetanus, tuberculosis and
whooping cough - can cause visual, auditory, physical and intellectual disability
(4,19,20). Yet in November 2003, when suspicions regarding contamination led
to the temporary cessation of polio vaccinations, Nigeria reported 217 new polio
cases (21,22).
Two thirds of the world’s 278 million individuals with hearing impairments live
in developing countries (23), where the prevalence rates for bilateral hearing
impairment at birth range from 2-4 per 1,000 live births (24). In sub-Saharan
Africa, which includes Nigeria, higher rates of diseases that may aect hearing
(eg. malnutrition, chronic otitis media, and meningitis) exist (25,26), and access
to immunisation against measles, mumps and rubella - causes of childhood
deafness - is impeded by poverty (13). Deaf people tend to be marginalised, live
in isolation, and cannot hear public health messages (25).
In Nigeria, mental illness is highly stigmatised (27) and symptoms are hidden
or denied. Nigeria has fewer than 100 psychiatrists for its population and less
than 1% of suerers have access to psychiatric support or treatment (27). A
recent national survey of 5,000 randomly selected participants, found 23% had
experienced a psychiatric episode but only 8% received any treatment (28).
METHOD
The Leprosy Mission Nigeria (TLMN), implemented this survey as a component
of a health systems research program conducted by the Koninklk Instituut voor
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de Tropen (KIT) in The Netherlands. TLMN provided the funding, vehicles,
materials and equipment. Ethics approval was obtained through KIT. Prior to
survey commencement, wrien consent and approval to conduct the survey
were obtained from the two State Ministries of Health and Social Welfare, the ten
Local Government Area (LGA) Authorities, and the community and religious
leaders in the selected towns.
Kogi and Niger are two of eight states where TLMN assists in 21 and 25 LGAs
respectively. The survey included people with disabilities from urban and rural
areas who resided in ten LGAs (ve from each state) – the two LGAs containing
state capitals and four other randomly selected LGAs per state. In the randomly
selected LGAs, the main town was selected, along with two other randomly
selected villages, resulting in 30 towns and villages.
A questionnaire in English was used to collect information from the participants,
as English is Nigeria’s national language. Bilingual research assistants were
used, to interpret the questions to each participant unable to speak English.
The term “disability” was used, rather than “impairment”, because words
describing disability existed in all the languages. The 29 item survey contained
26 quantitative questions about personal, socio-demographic and disability-
related information, and three qualitative, open-ended questions about the non-
use of health services and factors that would make community participation
easier or harder.
A total of 12 research assistants (six per state) were recruited from among the
Tuberculosis and Leprosy Supervisors who were local government employees. The
criteria for their selection were their experience as health workers, understanding
of disability issues and bilingual skills. Research assistants were trained for ve
days, which included interview techniques, the use of data collection tools (for
reliability and validity), implementation of the survey pre-test and nalisation of
data collection materials and logistics.
Announcements were made in each town and village, two weeks before survey
commencement. Village elders, town criers and leaders of disabled people’s
organisations gathered people with disabilities at a central meeting place on the
survey days. In the towns, people with disabilities were interviewed on a ‘rst
come, rst serve’ basis, as there were too many to survey. In villages with fewer
people with disabilities, snowball or chain sampling was used to nd respondents
who were house-bound.
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There was no payment for participation, which may have inuenced the decision
of some to participate. A signature or equivalent consent was gained from each
participant or the carer, aer explanation about the purpose of the survey, use of
the material gathered and condentiality of the information collected.
Data collection occurred over a period of four weeks in 2005. Pairs of research
assistants spent two days each, in their allocated towns and villages, conducting
interviews and cross-checking the accuracy of questionnaire completion. The
questionnaires were numbered serially according to state and town, and contained
information identifying the research assistant and the person who transferred
the data to the Epi Info 2003 database. Accuracy of data entry was checked by
the double entry of 8% (87) randomly selected questionnaires. This revealed the
majority of computer entry errors, which were primarily made on more complex
data questions, and were easily corrected.
A number of statistical tests were used to analyse the quantitative data. These
included frequencies of all the variables, stratication by gender and state, and
cross tabling of variables. Relative risk and risk dierence calculations were used
to identify associations between variables. The 95% condence intervals were
calculated for every relative risk and risk dierence.
The three qualitative questions collectively produced 38 dierent reasons for not
using health services, and 120 dierent factors that inuenced participation or
non-participation in the community. These responses were summarised into 9
and 14 thematic categories respectively, which were cross tabulated with other
relevant variables.
There were a number of limitations in the survey, resulting from questionnaire
formation, sampling methods, interview techniques and data processing. The
interpretation of questionnaires into the dierent languages increased the
possibility of misinterpretation and loss of key information. Flaws in questionnaire
development (eg. not using WHO age groupings) meant results were not
comparable with other population data. The study sample was not representative
of the populations of the two states, as participants were conveniently selected
in each village. Survey advertising may have been too brief. Sampling diered
between larger and smaller towns. Participation in the survey was voluntary
and with no payment. Interviews were conducted on working days, excluding
those unable to leave their places of employment to participate. Other restrictions
to participation included cultural and religious practices, which may have
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inuenced the number of women ‘allowed’ to participate in the survey, transport
costs to get to the interview, type and severity of disability, and the need to rely
on others to communicate.
RESULTS
The study interviewed 1093 people with disabilities. The majority of these (68%)
responded themselves. Others who spoke on behalf of the person with the
disability included the carer (27%), head of household (3%) or some other relative
(2%).
Respondents selected their disability from nine denitions provided in the
questionnaire which included the following impairments - visual, hearing,
communication, body movement, mobility, daily life inability, intellectual /
developmental, learning and mental / emotional. Those who selected a single
impairment made up 61% of the sample. The other 39% selected from between
two and seven of the disability options. The least frequently mentioned disabilities
were intellectual (5%), learning (4%), psychiatric (2%) and unspecied others
(3%).
This survey found that 37% had visual, 30% had mobility, 15% had hearing and
9% had mental or learning disabilities. There were 673 men (62%) and 420 women
(38%). Their ages ranged from zero to above 80 years, and a third were 20 years
or younger. Muslims comprised 72%, Christians 26% and Animists 2% of the
sample population; and 51% were married, 3% divorced, 6% widowed, and 40%
unmarried.
Both Muslim and Animistic cultures allow polygamy in Nigeria. In this study,
those with two to four wives totalled 13% of married men. Almost 38% had one
to ve children, 17% had between six to ten children, and 4% had from 11 to 25
children. Of those married, 92 (8.4%) had a spouse with a disability, and 23 (2%)
had a child with a disability.
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Table 1. Education, Occupation and Income of People with Disabilities
Variables Kogi Niger All
Male Female Male Female
N = 337 100% N = 206 100% N = 336 100% N = 214 100% N = 1093 100%
Education
None 171 50.7 116 56.3 123 36.6 133 62.1 543 49.8
(no schooling)
Islamic 29 8.6 1 0.5 114 33.9 51 23.9 195 17.8
(primary - sec)
Nursery 3 0.9 3 1.5 5 1.5 2 0.9 13 1.2
(pre-Grade 1)
Primary 85 25.2 55 26.7 48 14.3 18 8.4 206 18.9
(Grades 1-6)
Secondary 33 9.8 23 11.2 23 6.8 8 3.7 87 7.9
(Grades 7-12)
Tertiary 7 2.1 6 2.8 9 2.7 1 0.5 23 2.1
(University)
Vocational Training 7 2.1 2 1 4 1.2 0 0 13 1.2
(Aged 15+)
School for 2 0.6 0 0 7 2.1 1 0.5 10 0.9
Handicapped
(primary - sec)
Other 0 0 0 0 3 0.9 0 0 3 0.2
(not specied)
Occupation
None 104 30.9 69 33.5 90 26.7 74 34.6 337 30.9
Begging 52 15.4 8 3.9 78 23.2 40 18.7 178 16.3
Student 47 13.8 38 18.4 43 12.8 20 9.3 148 13.6
Farming 66 19.6 10 4.9 39 11.6 1 0.5 116 10.7
Pey Trading 5 1.5 34 16.5 12 3.6 34 15.9 85 7.7
Civil Service 31 9.2 11 5.3 24 7.1 4 1.9 70 6.5
Housewife 0 0 23 11.2 0 0 28 13.1 51 4.6
Other 8 2.4 5 2.4 16 4.8 7 3.3 36 3.3
(not specied)
Business 6 1.8 5 2.4 20 6 2 0.9 33 3
Tailoring 3 0.9 3 1.5 3 0.9 2 0.9 11 1
Carpenter 8 2.4 0 0 1 0.3 0 0 9 0.8
Labourer 1 0.3 0 0 5 1.5 2 0.9 8 0.7
Mechanic 5 1.5 0 0 2 0.6 0 0 7 0.6
Blacksmith 1 0.3 0 0 3 0.9 0 0 4 0.3
Average Monthly Income (Naira – N)
Nothing (N 0) 125 37.1 101 49 104 31 86 40.2 416 38
N 1 – 2,000 73 21.6 52 25.2 78 23.3 80 37.4 283 26
N 2,001 – 5,000 75 22.2 37 17.8 67 19.7 32 14.9 211 19.4
N 5,001 – 8,000 35 10.4 9 4.5 32 9.5 6 2.7 82 7.5
N 8,001 – 10,000 8 2.4 2 1 20 6 1 0.5 31 2.8
N 10,001 – 15,000 9 2.7 2 1 14 4.2 4 1.9 29 2.6
N 15,001 – 20,000 1 0.3 2 1 11 3.3 1 0.5 15 1.3
N 20,001 + 11 3.3 1 0.5 10 3 4 1.9 26 2.4
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Almost 50% of the sample had no education. The most common forms of schooling
were either primary (19%) or Islamic education (18%). Across the states, 12% of
males and 6% of females aended primary school, and 10% of the population
surveyed reached secondary or tertiary levels.
Occupation referred to the type of job held by most participants, regardless of
whether it was salaried, self-generated income, or unpaid. Of the sample, 31%
said they had no occupation, and another 34% had an occupation with no formal
or regular income. This included beggars (16%), students (14%) housewives (5%),
and seasonal farmers (11%). Women were less likely to have an occupation than
men, in both states.
Employment referred to earning an income. The majority (61%) of people
with disabilities interviewed were either not working (55%) or were currently
unemployed (6%). In both states, a higher percentage of women (66%) than men
(48%) had never worked in paid employment. Of those who did work, 32% were
self-employed. The majority currently unemployed blamed disability for their
lack of work (43%). The rest were either retired (29%), made redundant (14%) or
were accident victims (8%). The vast majority of those unemployed were men.
Participants’ economic status was determined by their average monthly income.
The majority of respondents (38%) said they had zero income each month. Another
26% reported 2,000 Naira (N) or less (US$15), 19% earned between N 2,001-5,000,
7% earned between N 5,001-8,000 and the remaining 9% of people with disabilities
earned over N 8,000 (US$38) as their average monthly income. Food was the
rst item purchased by the 677 participants with an income. The second priority
was either clothing (36%), education (7%), health and rehabilitation (4.6%) or a
personal carer (4.3%).
The participants’ understanding of their disability, including age of onset and
beliefs about its cause, was also surveyed. Almost a quarter (23%) did not know
the cause of their disability. Over 50% could give a logical reason for their
disability - disease and sickness (44%), pregnancy and birth (6%), ageing (1%),
accident (13%) and unspecied other causes (3%). A number of people believed
in a supernatural cause for their disability (10%) including sin, a curse by God,
witchcra and a result of eating certain foods.
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Table 2. Health Services Used
Variables Kogi Niger All
Male Female Male Female
N % 1093 N % 1093 N % 1093 N % 1093 N % 1093
General Health
Services 325 29.7 197 18 298 27.2 169 15.4 989 90.5
Counselling for
Parent / Family 237 21.7 134 12.2 270 24.7 180 16.4 821 75
Traditional /
Faith Healer 206 18.8 123 11.2 180 16.5 160 14.6 669 61.2
Counselling for PWD 215 19.7 124 11.3 157 14.3 133 12.1 629 57.5
Basic Amenities /
Infrastructure 302 27.6 183 16.7 11 1 18 1.6 514 47
Medical Rehab. 126 11.5 70 6.4 91 8.3 45 4.1 332 30.3
Assistive Device
Provision 134 12.2 50 4.6 60 5.5 16 1.5 260 23.8
Welfare Services 74 6.7 45 4.1 84 7.7 28 2.6 231 22
Special Education 72 6.6 48 4.4 35 3.2 13 1.2 168 15.4
Vocational Training 59 5.4 25 2.3 17 1.6 9 0.8 110 10
Economic
Empowerment 15 1.4 8 0.7 14 1.3 6 0.5 43 3.9
The most common services accessed were general health (90%), traditional
healers (60%), counselling (57%) and basic amenities and infrastructure (eg. water,
electricity, roads) which facilitate beer access to health (50%). Respondents in
Kogi state accessed and used health services and basic amenities up to three and
ten times more than those in Niger state.
The least-used health services included medical rehabilitation (30%), assistive
devices (24%), welfare services (22%), special education (15%), vocational
training (10%) and economic empowerment (4%). For all services (except for
basic amenities), the percentage of women using services was lower than men.
The most common reasons given for not using services apart from traditional
healers, were ignorance about the service or its high cost. Almost 63% of
participants reported not having an assistive device, and another 19% could
only obtain a locally made walking stick (used as a cane by many with visual
disabilities). Eye glasses were obtained by 6%, and crutches by 3% of participants.
The remaining 9% accessed an assortment of other devices. For the 30% (N = 352)
of interviewees with mobility disabilities, 73 pieces of equipment were reported -
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38 crutches, 11 walking frames, 10 wheelchairs, 8 special pairs of shoes, 3 calipers,
2 articial limbs, and 1 tricycle.
The three most common areas that assist respondents to participate in their
communities were their acceptance and integration (22%), government assistance
(13%), and assistive devices (12%). The three most common factors that make
participation in the community harder were no support for integration (19%),
lack of government assistance (18%), and having a disability (16%).
DISCUSSION
The more vulnerable amongst people with disabilities include ethnic minorities,
the aged, women, children, refugees and the displaced (21,29). Most are concerned
with survival from ‘hand to mouth’, in an ongoing disability-poverty cycle
(4,8,30,31). Disabled women are more likely to be uneducated, lack access to health
services, and be victims of discrimination and abuse (30). This survey revealed
similar relationships for women, with lower levels of education, occupation,
employment and nances than men. Women with intellectual disabilities were
more disadvantaged than others.
A weakness of the survey was that the disability categories were ambiguous,
with some being impairment and others being function oriented. This caused
some confusion when respondents self-selected their disability categories. Some
questions were complex and numerous, making survey completion dicult.
Wiman estimated that of all disabilities in a developing country, 40% were
mobility, 30% were mental or learning, 15% were visual and 10% were hearing
and speech (16). In contrast, this survey found that 37% had visual, 30% had
mobility, 15% had hearing and 9% had mental or learning disabilities.
In Nigeria, arranged marriages are common, and a person with disability oen
faces stigma and discrimination in this process. The survey revealed that people
with psychiatric, intellectual, communication and movement disabilities, were
more likely to be unmarried. The cultural practice of polygamy also brings
additional responsibilities and stress for men with disabilities, who must treat
each of their wives equally. In the survey, those with more than one wife most
commonly had visual disabilities and were more likely to have an occupation, be
employed and have a higher income.
Access to education is an equal right for all children, breaks down barriers
and facilitates social integration (30). Exclusion from education aects life
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opportunities, access to training, employment and income generation, prevents
the achievement of economic and social independence and increases vulnerability
to poverty. In this survey, 50% of participants had access to education in Nigeria
where primary education is free.
Occupational empowerment and employment are other key factors that promote
inclusion. In Nigeria, 70% of the population earn below US $1 a day (15, 32).
With 64% of the survey population earning approximately US $15 per month,
and another 20% earning between US $15 - $38 per month, the majority of people
with disabilities fall within this low socio-economic grouping. The 16% earning
more than US $38 a month comprised primarily people with visual disabilities.
Similarly Olusanya found that disabled people with vocational training earned
less than US $35 a month (9).
In the study, 90% of people with disabilities reported access to mainstream health
systems and 61% to traditional healers. The quality of both these services is
questionable, as in 2000, WHO ranked Nigeria’s health care system performance
as 187 out of 191 worldwide (30). Spending income on health or a carer were low
priorities for participants. This reects a level of ignorance about health status,
limited education, inadequate health information provision, lack of legislation to
enhance access to services (16) and diering religious and cultural aitudes to
health.
Assistive devices like hearing aids, wheelchairs, hand-powered tricycles, walking
frames, articial limbs, calipers, specialised footwear, back braces and neck
collars, were noticeably lacking. In the survey, 76% reported no access to such
equipment. This highlights the signicant lack of basic equipment necessary to
improve the quality of life of people with disabilities.
CONCLUSION
The most common disabilities aected vision, mobility and hearing. Less
than 30% received primary, secondary or tertiary education. Most were living
in poverty with minimal income and resources. Begging was the commonest
occupation, and 84% earned less than US $38 a month. Over 70% were unable to
access disability specic health services, and 37% reported having an assistive
device. The results of this survey are comparative with the ndings of other
literature and studies on the relationships between disability, developing
countries and poverty, identifying signicant relationships between type of
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disability, gender, age, education, occupation, employment and economic
status.
*Address for Correspondence
Country Leader,
The Leprosy Mission,
Timor Leste
E-mail: nataliesmith.tlm@gmail.com
ACKNOWLEDGEMENT
The author wishes to acknowledge the work of her co-researchers and colleagues
in The Leprosy Mission Nigeria at the time - Mike Idah and Hannah Fashona -
who were equal members of the research team, and who helped with the training,
logistical management and coordination of the research assistants. The author
also wishes to acknowledge her Master’s Thesis Supervisor from Melbourne
University’s Public Health Program, Heather Dawson, whose wisdom and sound
advice guided the development of this research paper.
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