Children with disabilities in low and middle-income countries have significantly lower primary school enrollment numbers and achievement growth in spite of prevalent inclusive education policies.[1],[2] Adequate hearing and vision are essential prerequisites for healthy learning. Recent research in one district in Ethiopia found that 2.6% of children aged 0-14 years are living with a known disability[3] based on interviews with their caregivers.[4] However, for the 2014/2015 school year, the Government of Ethiopia indicated that only 0.38% of children enrolled in its primary schools are reported to have a disability.[5] 

To help achieve the goals of Education for All and inclusive education as outlined in Ethiopia’s education strategic plans, as well as the objectives of USAID’s education assistance to Ethiopia, RTI International partnered with South African firm HearScreen and UK’s Peekvision for a proof of concept activity implemented under the USAID-funded READ TA project aimed at improving the classroom experience for children with disabilities. 

Conducting hearing screening demo and vision screening tests in Ethiopia (photo credit: Tewodros Worku, RTI) 

Image of child seen from back, with headphones. Assessor person standing behind child, illustrating how to sign, with hand raised, where the child hears the testing sound. Child facing other children sitting on floor.      Image of child seen from front, but with one hand covering her eye. Assessor is sitting in front of child, at some distance, holding a phone facing the child. The child is pointing to the right with the left arm.

READ TA’s assistive technology capacity building initiative (ATCBI) aims to support the systematic implementation of the revised curriculum for reading and writing in Mother Tongue in Ethiopia. Through extensive planning and consultation, regional working groups made up of Regional State Education Bureaus (RSEBs) and Disabled Person’s Organizations (DPO) worked together to design regional assistive technology pilots. The initiative functions as a proof of concept to explore:
•    if and how teachers may adopt technology, specifically locally available smartphones, for instruction in inclusive classrooms; 
•    if provision of phone-based pedagogical support materials and training will promote adoption of inclusive instructional practices; and 
•    if such technology and practices help remove barriers of teacher attitude and self-efficacy in teaching children who are hard of hearing (HOH) or who have low vision (LV).

In December 2016, eleven trained assessor teams traveled to 65 schools in five regions of Ethiopia to screen grade two children in selected classrooms for their vision and hearing levels and interview them about their reading, classroom and schooling experience. Assessors also surveyed teachers about their instructional practices, attitudes, and self-efficacy in teaching children that are HOH or have LV, and observed their classrooms. School principals were asked about the prevalence of disability among their students, inclusive practices implemented by their schools, and resources to support children that are HOH or have LV.  

Among the over 3,700 students screened, 150 children (4%) were identified with some hearing impairment and 211 children (5.6%) with some vision impairment.

Assessors used locally available smartphones loaded with a combined version of the clinically validated hearScreen and Peek screening applications. Assessor teams also used RTI’s open source data collection tool, TangerineTM, to electronically collect interview and observation data from students, teachers, and principals. Participating students were excited about being part of the screening as it allowed them to interact with the assessors’ team using mobile phones. The identified children were referred to the nearest health facility through the school principal for access to medical diagnosis and support.

HearScreen application example screens

Image show hand holding a smartphone with a screen image from the hear screen application, a list of frequencies.    Image show hand holding a smartphone with a screen image from the hear screen application, a frequency indicator.    Image show hand holding a smartphone with a screen image from the hear screen application, testing results from a patient.

PeekVision application example screens

Image show hand holding a smartphone with a screen image from the vision screening application, a tumbling E letter sign.    Image show hand holding a smartphone with a screen image from the vision screening application, a half screen image of a person with the other half screen being blurred.

Initial analysis found that among the over 3,700 students screened, 150 children (4%) were identified with some hearing impairment and 211 children (5.6%) with some vision impairment. These results indicate much higher prevalence rates than previously estimated. These rates are also higher than what teachers were aware of. Before the screening, participating grade 2 teachers reported being aware that 1.8% of their students have a disability. Thus, a significant number of children with these disabilities are not identified and not able to receive accommodation or specialized support, even where willingness, capabilities, or resource may be available.

We felt happy that the screening referral process worked, and the family became aware of the issue and had the chance to seek medical diagnosis and help for their child.

Valid screening options on mobile phones may allow students to get the help they need, as witnessed by a READ TA Special Needs Expert. “During the first day of our school visit, we had identified a child with severe vision impairment,” the expert said. “The following day, when we went to class to interview the child, he was not at school. Later, we were informed that his family went to do a medical eye exam with him. We felt happy that the screening referral process worked, and the family became aware of the issue and had the chance to seek medical diagnosis and help for their child.”

The lessons learned from this initial screening and data collection can help inform follow-on activities. For instance, one key lesson related to the logistical challenges of conducting hearing screenings in a school setting. It was difficult to find a private place to conduct the screenings, given the level of background noise constantly present at schools. This required assessors to move children several times and to repeat screenings for the same child, and may have caused some children to fail the screening test. To mitigate this challenge, the data collection team used the principal’s office or at times even their vehicle to conduct the hearing test.

For the vision screening, a key lesson learned was that some children found it difficult to indicate the direction of the test item, which was a ‘tumbling E’. It was observed that, at times, some children consistently pointed to the opposite direction. To mitigate this challenge, the assessors repeated instructions and took the time to practice with the children how to focus and to clearly indicate the direction of the test items. Another important lesson related to keeping the tester-testee distance to exactly 2 meters, as prescribed by the screening protocol. It was found good practice to use a 2-meter string and chalk to draw a half circle to indicate where both tester and testee should stand. 

An important lesson learned is that educators do not share common concepts about inclusive education and disability.

Generally, an important lesson learned is that educators do not share common concepts about inclusive education and disability. Terms and definitions adopted for the study and instruments need to be carefully clarified as part of the initial study briefing, consent procedures, and when introducing the questionnaires to maximize comparability of results between participants.

The RTI and HearScreen team also worked to harmonize data outputs from both the screening apps and the Tangerine data collection platform to facilitate variable merging and analysis by RTI statisticians. In the coming weeks, data from the baseline will be analyzed further and reports developed to share the findings. 

The regional working groups will in parallel implement and monitor the proof of concept intervention they designed. For this purpose, RTI Special Needs advisors worked with local experts to develop a revised version of the grade 2 teacher guides developed under READ TA in seven mother tongue languages. This revised version of the teacher guides integrates explicit guidance to better accommodate children that are HOH or have LV in general education classrooms, while all students continue to use the same textbook. Audio files, embedded into the electronic versions of the lessons plans accessible to the teachers on the phones they received as part of the study, will complement the student textbooks for further instructional support. Teacher training started in February 2017. The activity will be implemented and monitored through April 2017, at which point an endline data collection will be conducted. 

The READ TA team hopes that this effort between the participating educators, MOE staff at central and regional levels, DPO representatives, HearScreen, PeakVision, and RTI International will increase understanding of how the revised curriculum can benefit a wider range of children learning to read and write in Mother Tongue.

For questions or comments about this activity, please don’t hesitate to contact Carmen Strigel, Director, Technologies for Education and Training, at RTI International: cstrigel@rti.org

See also:

USAID's Guide for Promoting Gender Equality and Inclusiveness in Teaching and Learning Materials (here)

Read TA ICT Baseline Assessment Report in Colleges of Teacher Education (here)

Footnotes:

1 For this article, inclusive education is understood as an approach that “seeks to address the learning needs of all children, youth and adults with a specific focus on those who are vulnerable to marginalisation and exclusion” (UNESCO, 2003), with an emphasis on children with disabilities.
2 UNESCO. (2016). Global education monitoring report 2016. Education for people and planet: Creating sustainable futures for all. Paris: UNESCO. Retrieved from http://unesdoc.unesco.org/images/0024/002457/245752e.pdf; World Health Organization. (2011). World report on disability. Geneva: WHO. Retrieved from http://www.who.int/disabilities/world_report/2011/en/
3 For this article, disabilities are defined as “long-term physical, mental, intellectual or sensory impairments which, in interaction with various barriers, may hinder [individuals’] full and effective participation in society on an equal basis with others” (United Nations, 2006).
4 Geda, B., Berhane, Y., Assefa, N., & Worku, A. (2016). In rural eastern Ethiopia hearing loss is the most frequent disability during childhood: A community based survey. Plos ONE, 11(5), 1-12. doi:10.1371/journal.pone.0152791
5 Ethiopia Ministry of Education. (2016). Education statistics 2007 E. C. (2014/15). Addis Ababa. Retrieved from http://www.moe.gov.et/statistics

About the Expert

Carmen Strigel is the Director of the Technology for Education & Training team at RTI International. Her technical work focuses on building capacity, fostering stakeholder collaboration, and facilitating information-based decision-making and policy reforms. Carmen’s passion lies in teacher professional development and pedagogic integration of technology – including as assistive technology. At RTI she led the development of Tangerine®, open source software facilitating electronic data collection, continuous student assessment, and program monitoring. Tangerine is now being used by over 40 organizations in over 60 countries around the world. Carmen also drives CurrentMobileTM, RTI’s work in using a “serious games” approach to assessing employability skills of youth.