article review addis ababa university

Academy of Educational Leadership Journal (Print ISSN: 1095-6328; Online ISSN: 1528-2643)

Research Article: 2021 Vol: 25 Issue: 2S

Gender and Leadership in Ethiopian Higher Education: Challenges and Opportunities: The Case of Addis Ababa University

Easaw Alemayehu, Addis Ababa University

Citation Information: Alemayehu, E. (2021). Gender and Leadership in Ethiopian Higher Education: Challenges and Opportunities: The Case of Addis Ababa University. Academy of Educational Leadership Journal, 25 (S2), 1-22.

Gender equality has been to the forefront of public debate in recent years. Despite international initiatives for gender equality and fairness in higher education institutions, research done in numerous countries continue to indicate that women are underrepresented in top academic leadership roles. Similarly women are underrepresented in Ethiopian higher education institutions. The goal of this study was to determine the challenges and opportunities faced by women working in leadership position at Addis Ababa University. The research looks at how challenges and opportunities affect women both adversely and favorably. The technique of data collection utilized in this study was a descriptive survey, and the instrument utilized to acquire primary data from sample respondents was a questionnaire and an interview as a primary source of data, and document analysis as a secondary source of data. A total of 100 (one hundred) respondents were chosen for the study from 5 campuses using the purposive sample approach. The year of the survey was 2021. In order to answer the core research questions and meet the study's aims, both quantitative and qualitative data analysis methods were used. As a result, the gathered official reports were recorded, edited, arranged, analyzed, presented, and interpreted in connection to research questions for the study's fulfillment and effective completion. The study's findings show that women's involvement in leadership position at Addis Ababa University is still at an all-time low. Low leadership position engaged by women is due to a variety of barriers. These difficulties were divided into three categories: social issues, organizational/institutional issues, and personal traits. On the other hand, the finding as opportunity showed that women who are in leadership positions are strong decision-makers and dedicated to their universities and careers

Challenges, Gender, Higher Education, and Leadership.

Introduction

Background of the Study

Since the previous four decades, the issue of gender in higher education has piqued the interest of researchers and policymakers. Since then, there has been a focus on reducing gender disparities in education by developing female erudition on par with male erudition. Although there was lobbying and some encouraging scenarios on the issue of gender, gender disparities in higher education persist in many nations throughout the world, Abebayehu A, (1995) especially in Africa (Bunyi, 2004; FAWE, 2002). As a result, the Millennium Development Goals of “eliminating gender disparities in primary and secondary education by 2005 and at all levels by 2015” was not achieved to be met even to the academic year of 2021 let alone 2015.

Leadership, according to Caiazza (2004), is a very gendered word or notion. And leadership continues to be associated with men in a number of cultural contexts. Despite the fact that women hold positions of leadership and responsibility, it is common to presume that the "rightful" leader is a man. Men are more likely than women to be leader in most nations (Caiazza, 2004; Annis, 2008). Although contemporary perspectives in leadership in companies and elsewhere prefer a style that is far distant from stereotype masculine leadership and more in line with patterns that may be described as feminine, leadership is still viewed as a male attribute.

According to Caiazza, 2004, women, particularly in poorer nations, tend to assume less prominent positions in corporate leadership through supportive jobs. The significance of this study stems from the notion that views regarding women in leadership influence women's participation in higher education leadership, and that woman in positions of administration, in turn, engage in policies that benefit women.

Even though previous studies have assessed the situation of gender differences and the status of women in Ethiopia in some characteristics, it is critical to examine, update, and document the situation whenever new data is available, as this will allow for the identification of changes/improvements over time, or the lack thereof, as well as the evaluation of the effects of various relevant policies and programs in the main areas of concern such as women, population, youth, health and education. One of several categories of inequality between men and women is their job situation, that is expressed by pay gap, sexual preference salary inequalities, and women's greater involvement in unpaid labor and higher rates of unemployment (UNFPA, 2004). According to Helegsin, (1990) because women in poor nations have low social status, the activities they conduct are valued less; thus women's poor social status is also maintained by the low value put on their activities Asmamaw, A. T. (2017).

The United Nations "Millennium Development Goals" (UN, 2003) specifically address women's issues, promoting gender equality and women's empowerment, and the UN Division for the Advancement of Women (DAW) (UN, 2005a) promotes gender equality and women's empowerment around the world for sustainable development, peace and security, governance, and human rights. The Women's Policy primarily aims to institutionalize women's political, economic, and social rights by establishing an appropriate structure in government offices and institutions to ensure that public policies and interventions are gender-sensitive and that all Ethiopian men and women benefit equally from development (TGE, 1994). Article 25 of the new constitution, which is consistent with the aforementioned principle, guarantees all people equality before the law and bans any discrimination based on gender. Furthermore, Article 35 reaffirms the ideals of equal access to economic possibilities, including the right to equal pay and property ownership (FDRE, 1995).

The FDRE constitution guarantees women the same rights as males. Numerous provisions in the constitution deal with gender problems and emphasize the importance women are given. Article 35 of the constitution specifies the quality of women and men, recognizes the right to affirmative action for women, and pays particular attention to women in public and private institutions so that they can compete on an equal footing with men in political, social, and economic life (Watts, 2007).

As a result, it's easy to see why studying is necessary. And, the purpose of this study is to evaluate the obstacles and possibilities faced by women in Leadership position at Addis Ababa University five campuses.

Some Theoretical and Conceptual Basis

Gender is studied via a socio-cultural perspective in theory. This is due to the fact that gender stereotypes' strength is not just mental; they also have a flawless tangible actuality. Material reality contributes to the social and economic environment in which they have grown and worked (Collier & Rosaldo, 1981). Thus, gender disparity in the present context refers to the unfair treatment of females as compared to males in education, which is rooted in the way society and its culture works. In this context, gender disparity refers to the unequal treatment of females in education relative to males, which is based in the way society and culture operate Annis, B(2008).

Gender equality has become a major source of concern in recent years. Despite international initiatives for gender equality and fairness in higher education institutions, research in numerous countries demonstrate that women remain underrepresented in senior academic leadership roles. For example, the United Nations' Millennium Development Goals (MDGs), which were created for the period 2000–2015 in eight particular sectors, contained objectives for promoting gender equality and women's empowerment, as well as increased access to education (United Nations New Millennial Goals, 2017). Following that, the United Nations developed 17 Sustainable Development Goals for the years 2016–2030, one of which is to provide “equal access to education, health care, decent job, and representation in political and economic decision-making processes” for women and girls (United Nations Sustainable Development Goals, 2017).

Gender imbalance in leadership in higher education is a global concern since progress toward parity has been slow and unequal, despite the fact that more women are increasingly ascending to leadership positions in higher education (Davidson & Burke, 2004). The idea of gender equality was first recognized in the United Nations Charter in 1945, and then again in the Universal Declaration of Human Rights in 1948, (1948). The Beijing Platform for Action (BPA, 1995) is the most prominent of the important modifications made thus far. According to Oplatka, 2006, the United Nations Fourth World Conference on Women in 1995 highlighted the most important prerequisite for women's empowerment. Women in positions of authority and decision-making are essential for democratic government, and the Beijing Platform for Action highlighted it as one of twelve important areas of concern.

Females are chronically underrepresented in higher education and academic leadership in Ethiopia, notwithstanding the huge development of higher education institutions and initiatives undertaken (Asmamaw, 2017). Regardless of the fact that girls join higher education at a pace of 16.4 percent per year quicker than males, and male yearly average increase is 8.2 percent, at Ethiopian higher education institutions in 2019, 15 percent of academic staff were women and 85 percent were men. Women occupied just 15.4 percent of leadership roles in the 44 government institutions, and there was no female president (MoSHE, 2019). While some universities have employed more women, their share in leadership remains low Women made up less than 5% of deans and 3% of department heads at public institutions. Aside from that, women held just around one-third of board member roles less than one-fourth of vice president positions, and only 9.6% of senior management positions (Habtamu, 2004). This means that women make up lowest share of academic personnel in higher education.

This demonstrates that the national educational objective of filling 20% of senior academic posts (university presidents and vice presidents) by 2015 was not met (ESDP IV, 2010-15). And, Ethiopia's female academic personnel and leaders are still insufficient in comparison to the country's population.

Statement of the Problem

According to statistics, women account for half of the world's population. This rationale should have allowed them to have a large proportion in various leadership levels, allowing them to play a substantial part in a country's economic, social, cultural, and political growth. In most situations, though, the truth is quite different. They are underrepresented in a large number of status updates (Abebayehu, 1995). Women's underrepresentation in leadership and decision- making positions is a global phenomenon. However, there is a clear gap between established and developing regions when it comes to women's educational opportunities. Women account for less than 10% of managers and 3% of business directors in most nations where feminism had the greatest influence, and this issue has drawn the attention of international organizations (Onsong, 2004).

Numerous barriers have been found that impede women from ascending to top leadership roles. Sluder, (2007) considers sociocultural ideas to be the most significant impediment in this respect. These views highlight men's supremacy and women's humiliation. Additional obstacle is the institutional structure that governs gender-based labor division, recruiting, and upward mobility. Spero,(1987) observes that because males control public decision-making bodies, these decision- making bodies mirror masculine ideals. Women's participation in leadership position in general is still low, as we saw in the past.

Women have made considerable headway in Ethiopia in terms of reaching parity in teaching, but they remain vastly under-represented in higher education leadership position (MoE 2014). The presence of a large number of women in managerial positions in Ethiopia would help to improve efforts to promote girls' and women's education. Women must be represented in senior university administration roles in order to speak out about the issues and initiatives that affect women.

Women are one of the most important players in higher education, and they must be empowered in order to make decisions. Women will have the capacity to influence policies and bring about change that will benefit both women and men when they have the skills necessary for decision- making, are widely represented in higher education administration, and are gender sensitive. Women have historically been underrepresented in leadership roles in Ethiopia, particularly in higher education institutions, and little is known about their experiences and problems. Despite the presence of official regulations to address these inequities, such as Ethiopia's "gender policy" and "equal employment opportunity," women remain underrepresented (Asmamaw, 2017). The University system's policy-making bodies appear to be mainly dominated by men. This sparked an interest in learning more about the primary hurdles that women face in higher education leadership roles, as well as how the few women who have succeeded in achieving these positions did so, and what their experiences and struggles were. As a result, the experiences and problems these women confront in leadership roles may be unique to women and so warrant further study. As a result, the primary goal of this research is to evaluate the constraints and possibilities for women in leadership position and decision-making roles at Addis Ababa University, Ethiopia.

As a result, the following basic questions were addressed in this study:

1. What are the challenges hindering women in leadership positions at Addis Ababa university?

1.1. What are the social barriers that affect women’s participation in leadership positions at Addis Ababa University?

1.2. How do respondents view the personal characteristics that Affect Women’s participation in leadership Positions at Addis Ababa University?

1.3. What are the institutional barriers that affect women’s participation in leadership Positions at Addis Ababa University?

2. What are the opportunities do women have leadership positions at Addis Ababa University?.

Objectives of the Study

General Objective

The study's main goal is to evaluate the obstacles and possibilities faced by women working in leadership positions at Addis Ababa University.

Specific Objectives

The specific objectives of the study are:

a. To find out the key obstacles that women face in obtaining leadership positions at Addis Ababa University.

b. To look into the possibilities for increasing women's involvement in leadership positions at Addis Ababa University.

Significance of the Study

The goal of the study was to analyze the problems and possibilities that women face in the leadership position at Addis Ababa University. As a result, the researcher feels that the study's findings may have the following implications:

It will raise awareness among all levels of organizations and their stakeholders about the obstacles that women in leadership position confront and the possibilities that are accessible to them.

It may encourage the relevant bodies to pay more attention to women's participation in decision-making positions at Addis Ababa University.

It may eventually result in a higher proportion of women working in leadership positions at Addis Ababa University.

It will serve as a starting point for those researchers who wish to pursue this issue further.

Scope of the Study

The goal of this study is to determine the obstacles and possibilities that women face when working leadership position at Addis Ababa University. As a result, it evaluates the status of women in executive roles, group leaders, administrators, and vice administrators. It also seeks to highlight the special obstacles that women have in leadership, as well as the potential that women have in the study field.

Definition of Terms

Challenge: Refers to the barriers that may prohibit women from advancing to higher levels of leadership and management in the business world (Strohs, 2008).

Participation: In this study, the term "participation" refers to giving women an equal chance to participate in the leadership and decision-making of various organizations. It entails women's quantitative and qualitative engagement.

Opportunities: This word refers to methods and strategies for increasing women's quantitative and qualitative involvement in leadership positions.

Review of Related Literature

Women and Leadership Position

In the workplace, women have traditionally been denied equal opportunities in terms of education, training, hiring, promotion, and networking. Despite the fact that women are working in greater numbers across the world, various official and non-government surveys, as well as scholarly studies, demonstrate that women are underrepresented in top-level jobs. This phenomenon is known as the "glass ceiling," which refers to "a lower than expected number of females achieving leadership roles at the top levels in companies" (Hogue & Lord, 2007). To recognize the "glass ceiling" is not to deny that substantial progress has been made in terms of women's social position. Women now have greater personal, political, and economic influence than they had previously. In addition, more women are advancing to positions of leadership at all levels, including upper management positions. Women, on the other hand, continue to be fundamentally inferior to many males. One of the indications is women's underrepresentation in high-level leadership roles across a variety of socioeconomic sectors. Women not only hold fewer high-level leadership roles, but they also earn substantially less money and have less authoritative influence even when they do. Males and women with equal education start off with identical salaries, but after 10 years, men make at least 20% more than women. Women have a harder time ascending the corporate ladder (Sluder, 2007).

Female Leadership in Higher Education

Despite the fact that the number of female academic leaders is growing, they are still uncommon (Lie and Malik, 2014). (Fritsch, 2016). Women's overrepresentation in the teaching population and underrepresentation in educational leadership roles have continued to draw scholarly attention in the expanding literature on women and educational leadership. (Grogan & Shakeshaft 2009). The goal of much of this writing is to remind us of the ever-present hurdles that women face when it comes to leadership in education. The growing body of knowledge about educational leadership and women in global contexts demonstrates the importance of political, historical, social, and economic circumstances in women's leadership. Higher education leadership has traditionally been organized in hierarchical systems that have been supported by social formations of bureaucracies informed by liberal political ideas based on individual merit (BlackChen, 2015). These arrangements have typically favored male academics in top educational leadership roles, such as Faculty and Academic Deans, Pro-Vice Chancellors, Departmental Chairpersons, and positions chairing university-wide committees (Shepherd, 2017).

Women in leadership roles do not necessarily have an easy professional path (Eagly and Carli, 2007), and in some situations, they are referred to be "university donkeys" (Mabokela, 2003). Gender disputes in the past have centered on the numerical statistics of women's presence in official leadership posts and the disparities in promotion rates between male and female academics. However, leadership is situational and contextual (Strachan et al. 2010). (Fitzgerald 2006). Some say that more research is needed on how women as a group perceive what helps or hinders their access to leadership roles (Alimo-Metcalfe, 2010).

Much of the research is Western-centric and it is informed by a mainstream epistemology about women in educational leadership roles that has been constructed, classified, and theorized from a white hegemonic perspective (Oplatka, 2006). Fitzgerald (2006) asserts that Western values and leadership practices homogenize, marginalize, and silence women educational leaders from developing countries, and that Indigenous and non-western theories of educational leadership, based on research, are needed to account for and explain Indigenous women's ways of knowing and leading.

Additionally, previous research has revealed why women are seen to be underrepresented in higher education leadership posts (Morley, 2013a). Gendered division of labor, gender prejudice and misrecognition, management and masculinity, selfish companies, and work/life balance difficulties, according to Morley (2013a) The first refers to academia as a zone where people are free of all obligations save those that are related to employment (Lynch, 2010; Morley, 2013a). Women, on the other hand, frequently blur the lines between job and family as primary caregivers for children, the sick, and the old (Runte & Mills, 2004). Women are frequently consigned to “lesser” managerial jobs, such as human resources, quality assurance, and marketing, as a result of these factors, and remain in assistant and/or adjunct positions (Eagly & Carli, 2007). Despite the fact that most nations have a gender imbalance in top-level leadership in higher education (Shepherd, 2017), there are a number of initiatives and programs aimed at reducing these disparities.

Obstacles to Women's Leadership Position Participation

Women educators in both rich and poor nations face comparable hurdles to progress and have similar leadership styles and professional experiences, yet they are vastly different in many ways. Women are unable to get positions because of the cultural and social structures in which they live and work, as well as many parents' unwillingness to send their daughters to higher school. Though after overcoming so many obstacles and being appointed as school principal, they are confronted with issues from their coworkers. In Turkey, female principals reported having trouble dealing with their employees, with the most severe issue they had in their professions being the unwillingness of female instructors to work for female administrators (Sluder, 2007) (Cited by Oplatka, 2006). Women are under-represented in leadership, and several researchers have attempted to highlight the problem and provide various recommendations based on their findings. Aside from that, nations such as Ethiopia have signed several agreements and declared various policies regarding the non-discrimination of women. The Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW) is one of the most important of these because it provides for the elimination of all forms of discrimination against women in the political, social, economic, and cultural fields through a variety of legal and policy interventions. In terms of representation, there has been some progress in recent decades, but it still falls short of what is required and anticipated, particularly in poor nations. Despite Ethiopia's remarkable progress in recent years in promoting and developing women in the workplace, women continue to be underrepresented in higher education leadership position Onsongo, J (2004).

Ethiopian Women in Leadership Positions

Ethiopia is a patriarchal culture where women are seen as second-class citizens (Haregewoin & Emebet, 2003). There is a cultural foundation for the idea that women are docile, obedient, patient, and tolerant of tedious work and violence (Hirut, 2004). Ethiopian women, like those in many other African countries, have a poor social position. Various studies have revealed that women in underdeveloped nations in general, and Ethiopia in particular, have a low status (Almaz, 1991; Hirut, 2004). They have been denied equitable access to education, training, and meaningful work prospects, and their participation in policy development and decision-making has been negligible. Clearly, women play an important role in the community by overseeing all societal activities.

The FDRE administration has implemented numerous boosting tools to encourage equal involvement of women in every topic of the nation's decision-making positions, the most promising and binding of which is the FDRE constitution, which has ever existed in the country's history. Despite some attempts, women's involvement in leadership and decision- making positions remains low in comparison to their male counterparts. This can be seen in a variety of ways. For example, the proportion of women in the parliament, which is entitled to be the nation's highest policy-making body, though it may appear to be increasing from time to time, it is still negligible, according to information obtained from the International Parliament Union (IPU). In the 2005 national election, women accounted for 21.3 percent of the vote, while in the 2 010 national election, they accounted for 152 (27.8%) of the total 547 seats held by HPR members, compared to Rwanda (56.3 percent) and South Africa (44.5 percent).

A Male-Dominated Culture

The rules of masculine culture are identical with the traditional rules and perceptions of business and administration. The administration domain is dominated by patriarchal and hierarchical structures (Alvesson & Willmott, 2003). Women have traditionally served as spouses in men's family life domains, where males have traditionally dominated due to their capacity to generate wealth. Women's dominance in the home has spilled over into other social arenas, including the workplace, where they are not permitted to plant their feet firmly from the start. Having women in the same cohort causes discomfort and necessitates changes that many males are unwilling to undertake.

The exclusion of women from the social informal networking of males, such as golf excursions and sports activities, is another commonly highlighted concern, which is not unconnected to the comfort element. Professional contacts are frequently developed and information regarding training opportunities, job openings, critical tasks, and fellowships is regularly shared at informal social events in the business sector. Excluding oneself from these informal networking events might result in missed chances, which can be essential to one's professional progress (Kanter, 1993).

Stereotypical Judgment and Assumptions Based on Gender

According to Harding, 2004, Traditional gender-based judgments and assumptions, which have resulted in cultural and societal preconceptions about what roles are and are not suitable for women, are among the most significant and subtle hurdles women confront. Women have traditionally been thought to be less physically and psychologically suited than males to operate in the public arena of a society dominated by men.

Prejudice against female leaders stems from an inconsistency between expectations about women (feminine qualities such as compassionate, emotional, and supporting) and expectations about leaders (masculine characteristics such as being ambitious, powerful, and competitive) (Eagly & Carli , 2003a). Women who do take on leadership responsibilities must frequently battle preconceived beliefs about how their job should be done or what traits are required for leadership roles, which have been shaped by decades of male supremacy in a field. This can put women in a catch-22 situation, as Kathleen Jamieson (1995) pointed out.

In principle, women in the workplace are supposed to be competitive and harsh, but not too competitive or aggressive, lest they be labeled ball busters. Women in the business sector, on the other hand, are supposed to be feminine enough to be attractive and kind. But not excessively feminine, should their look and conduct be interpreted as improper or as a sign of weakness.

Research Design and Methodology

Design of the Study

The research design is a descriptive survey. Descriptive survey research aims to describe behaviors and collect people's perceptions, opinions, attitudes, and beliefs about a current leadership position issue. The primary approach for gathering such data or information from people was to conduct a survey. It would also attempt to assess the challenges and opportunities faced by women seeking positions in leadership positions. The number or percentage of people who reported each response was then used to summarize the descriptions. As a result, it detailed what the truth is and what is truly happening in the study area's present practices and conditions. It gives you a greater knowledge of a study topic or subject than each research method on its own. As a result, a mixed method strategy was adopted for this study as a research technique that involves gathering, analyzing, and integrating (or mixing) quantitative and qualitative research (and data) in a single study.

Data Source

Primary and secondary data were employed to achieve the study's goal. Sample respondents were recruited by selecting from the whole study population from five campuses (Sedist Kilo campus, Faculity of Business and Economics Campus, Arat Kilo Campus, Lideta Campus, Debrezeyit Veterinary School Campus) team leaders and experts who operate in selected organizational campuses, and key informants from administration positions who work at Addis Ababa university branches provided primary data. Women's affairs office reports and other recorded sources from Ministry of education administration were the primary sources for secondary data.

Sampling Design

Study Population: The sample would be chosen from the study population, which is a collection of components. As a result, the study's 100 (one hundred) participants were Addis Ababa University`s, team leaders, experts, supervisors, administrators, and vice administrators, all of whom are permanent employees at Addis Ababa university at five campuses.

Sample size: A total of 100 (one hundred) people were chosen from the general target population to participate in this study using the purposive sampling approach. The sample size was chosen because as the sample size grows, the research's dependability grows, and it can better reflect the reality of women's participation in leadership and public decision-making in Addis Ababa University.

Sampling Techniques: Simple random sampling and availability sampling procedures were used to choose sample responders from the whole population. Simple random sampling procedures were employed to reduce bias and to help generalize data obtained from sample respondents. Furthermore, availability sampling was employed as a strategy, and significant informants included women's leaders at the five branches of the university. The researcher used this strategy to include such leadership bodies in order to provide meaningful data regarding the obstacles and opportunities of women participation in leadership position and decision-making.

Method of Data Collection: The researcher combined primary and secondary data in order to complete this study. The technique of data collection utilized in this study was a descriptive survey, and the data collecting tools utilized to acquire primary data from sample respondents were a questionnaire, an interview, and document analysis.

Questionnaire: There are both closed and open-ended versions in the questionnaire. This makes it simple to get a huge amount of data from a big number of responders in a short amount of time and at a low cost. Furthermore, all of the participants were literate since they are working in the higher educational institution. As a result, people may read and react to the questionnaire more freely, expressing their thoughts on the subject, and it allows respondents to provide information without fear of reprisal.

Interview: A semi-structured interview was conducted with key informants such as faculty heads, department heads and top administrators at Addis Ababa university five different branches in order to obtain detailed information from the informants about the overall current context of the challenges and opportunities for women in leadership positions.

Document Analysis: Annual abstracts, women affairs office reports, various publications in the areas of administration, management & leadership, involvement of women in leadership positions and internet web sites were all reviewed to gather information.

Method of Data Analysis

In order to answer the core research questions and meet the study's aims, both quantitative and qualitative data analysis methods were used. As a result, the obtained data were recorded, edited, organized, analyzed, presented, and interpreted in connection to research questions for the study's implementation and effective completion. For data acquired using surveys, descriptive statistical tools such as tables, figures, percentages, and means were utilized, whereas for data obtained through interview and document analysis, descriptive statistical techniques such as description of finding were employed.

Ethical Consideration

The sort of agreement that the researcher made with his or her study participants is referred to as research ethics. All research studies had ethical implications, and all researchers must be aware of and respond to the ethical concerns relevant to their investigations. As a result, respondents were urged to participate voluntarily. Responding to interviews and completing surveys took a lot of time and effort. As a result, the researcher will inform the respondents about the study's goals and relevance before allowing them to exercise their right to voluntary participation. They were given assurances that the information they provided would be kept private. To do this, the researcher eliminated data that required respondents' names to be identified. Furthermore, an opening introduction letter was presented on the first page of the questionnaire, seeking the respondents' help in providing the essential information for the study.

Result Analysis, Presentation and Interpretation

This part examines data collected from primary and secondary sources using closed and open- ended surveys, interviews, and document analysis. The data was presented in tables, charts, and graphs, and then evaluated and interpreted in connection to the core research questions and the key study objectives previously mentioned. The information gathered was kept as the respondents' characteristics, problems that women face in leadership position, and the opportunities or techniques that Addis Ababa University is using to increase women's participation in leadership position.

To accomplish all of this, a total of 100 questionnaires were issued to respectable respondents, with 94 (98%) of them being correctly filled out and returned to the researcher, as well as interview questions asked of important informants and utilized for discussion in accordance with the goals.

Characteristic of the Respondents

Individual respondents' personal characteristics are included in this part, including sex, age, and educational qualification, service years, current position, and marital status. Tables and graphs were used to illustrate demographic data for officers (Faculity heads, department heads , and administrators) who took part in closed and open-ended surveys.

According to the characteristics of respondents by sex, 61 (65%) of the total number of respondents were male, while the remaining 33 (35%) were female, as shown in Table 1 . In terms of age and years of service, 58 (61.7%) of respondents are between the ages of 21 and 30, while 49 (52.1%) are between the ages of 6 and 10. This data clearly demonstrated that the majority of total respondents had at least five years of work experience, implying that they are able to offer enough and appropriate knowledge regarding the present status and issues affecting women's involvement in leadership positions at Addis Ababa University.

According to the educational qualifications of respondents, there were no respondents with a certificate or less, 4 (4.25 percent) of them had a diploma, 30 (31.91%) of them had a BA/BSC, and the remaining 39 (41.48%) had an MA/MSC, 21(22.34 %) had PhD degree. Despite the fact that education is the most important factor in females' participation in leadership positions, the questionnaire and interview results show that only a few women have had the opportunity to succeed in educational leadership positions.

According to the above Table 2 , the marital status of respondents is 31 (33%) and 18 (19%) married men and females, respectively, and 30 (32%) and 14 (15%) single men and females, respectively. According to the data above, more married women worked in higher education leadership positions, and marriage provides expertise in family management as well as the potential to lead.

Challenges of Women’s Participation in Leadership Positions at Addis Ababa University

According to the researchers, there are a number of barriers that prevent people in higher education leadership positions from progressing to higher-level positions. These various challenges or factors are divided into three categories. They looked at things like societal hurdles, institutional/organizational impediments, and personal traits to see if they might succeed.

Social Barriers That Affect Women’s Participation in Leadership Positions at Addis Ababa University.

Many factors, according to the researcher, can influence women's participation in leadership roles. Some of these social elements were provided to the respondents via a questionnaire, and their level of agreement is described below. When assessing rating scale answers, strongly disagree and disagree are combined as a negative answer, while strongly agree and agree are combined as a positive answer.

As shown in Table 3 , 45 (47.9%) and 4 (4.3%) of respondents felt that girls and boys had progressed in gendered role socialization, respectively. In contrast, 10 (10.6 percent) and 24 (25.5 percent) of respondents said they were uncertain and disagreed with the same viewpoint, respectively. The growth of women's childhood was another social element of their involvement in leadership positions, as half of the respondents agreed, and the mean 3.07 suggested. Item two showed that 38 (38.3%) and 15 (16%) of respondents agreed and strongly agreed with the concept that women lack the capacity and abilities to be leaders, respectively. On the other hand, 14 (14.9%) and 21 (22.3%) of respondents said they were uncertain and disagreed, respectively. Because the majority of respondents agreed and the mean of the question are 3.3, it indicates that people's attitudes haven't changed, making it difficult for women to work in educational leadership position.

They believe women lack the competence and skill to lead, and they are less accepting of their participation in leadership positions.

As shown in items three and four, 44 (46.8%) and 18 (19.1%) of respondents from item three agreed and strongly agreed with the idea that patriarchal and male-dominated culture affects women's participation in leadership position, respectively, whereas 21 (22.3%) and 9 (9.6%) of them responded undecided and disagreed.

Furthermore, according to linked item four, 48 (51.1%) and 19 (20.2%) of respondents agreed and strongly agreed with the premise that most people believe males retain decision- making power. On the other hand, 13 (13.8 percent) and 9 (9.6%) of them said they disagreed and were unsure, respectively.

Item five revealed that 38 (40.4 percent) and 31 (33 percent) of respondents agreed and strongly agreed that having too many job and family responsibilities hinders women's involvement in higher education leadership positions.

As seen in item one of the preceding Table 4 , 34 (36.2%) and 18 (19.1%) of respondents disagreed and strongly disagreed with the idea that women are reluctant/unwilling to accept responsibility. On the other hand, 25 (26.6 percent) and 13 (13 8 percent) of respondents agreed and were unsure about the same point of view, respectively. The majority of respondents disagreed with the notion that women are hesitant or unable to embrace responsibilities. As a result, it signified that women's involvement in higher education leadership positions is not greatly influenced by their reluctance or unwillingness.

Item two revealed that 47 (50 percent) and 28 (29.8 percent) of respondents agreed and strongly agreed with the view that women can make strong decisions and be devoted to the university and their careers. It found that the majority of respondents agreed, with a mean of 4.02 indicating that women can make strong decisions and are devoted to the university and their careers. This viewpoint is backed by the interview questions, which show that when women lead, they are powerful and devoted, and they have the capacity to create dictions and conduct activities better than males. According to the findings, women's dedication and decision-making ability is not a barrier to their involvement in higher education leadership positions and professional advancement.

Regarding item three, 33 (35.1 percent) and 23 (24.5 percent ) of respondents disagreed strongly agreed and with the thought that women lack confidence to be leaders respectively, whereas 12 (12.8 percent ) and 19 (20.2 percent ) of respondents were unsure and disagreed with this view.

Concerning item five, it was discovered that 44 (46.8 percent) of respondents agreed with the thought that women lack inspiration from their partners, whereas 20 (21.3 percent) and 18 (19.1 percent) of respondents were unsure and disagreed with the same notion, respectively.

Institutional Barriers that Affect Women’s Participation in leadership Positions at Addis

According to the researchers' findings in the review literature, there are several barriers to women's involvement in higher education leadership positions. Organizational and institutional considerations are among the obstacles that prevent them from pursuing a career in higher education leadership.

As stated in item one of the above Table 5 , 29 (30.9 percent ) and 12 (12.8 percent ) of the respondents disagreed and strongly disagreed with the opinion that organizations lack policies to encourage women's professional advancement. On the other hand, 23 (23.5 percent) of respondents said they were uncertain or agreed.

It was discovered that half of the respondents did not agree with the premise that universities lacked policies to encourage women's career advancement, while the other half were opposed or neutral to the concept that higher education institution lacked rules and a support structure.

Regarding question two, 37 (39.3 percent) of respondents agreed that the lack of openness is a selection criterion for higher education leadership position. On the other hand, 20 (21.3 percent) of them said they were uncertain or disagreed. It suggested that half of the respondents agreed with the proposal, and the mean 3.07 showed that the leadership position selection criteria are opaque.

Opportunities that Enhance Women’s Participation in Leadership Position at Addis Ababa University

Experts and scholars proposed a variety of approaches that may be used to alleviate or at least mitigate the consequences of the hurdles, as well as boost women's desire to work in leadership roles. Some of these metrics were given to questionnaire respondents, and their level of agreement is reported below.

As the majority of respondents agreed and the mean 3.33 male hierarchies are more likely to promote men for leadership posts and they promoted quicker than women, it is a problem for women's involvement owing to males' negative impression of female leaders. The majority of governmental and nonprofit organizations and institutions have a problem with unfavorable views about women leaders and a lack of trust in women leadership; as a result, every organization has a problem allocating leadership positions.

Item 5 revealed that 43 (45.7 percent) and 10 (10.6 percent) of respondents agreed and strongly agreed that there is a lack of encouragement and support for women's engagement from colleagues in the university. On the other hand, 21 (22.3%) and 16 (17%) of respondents said they disagreed and were uncertain, respectively. The majority of respondents agreed on all of the issues, and the mean of 3.36 demonstrated that lack of encouragement and support from colleagues for women's engagement in the university is one of the obstacles women face, and it has an impact on their desire to work in leadership position.

Table 5 shows that 50 (53.2 percent) and 12 (12.8 percent) of respondents agreed and strongly agreed with the idea that the university recruitment guide line had special treatment for women applicants during the selection process, while 14 (14.9 percent) and 9 (9.6 percent) of respondents disagreed, strongly disagreed, and were undecided about the same idea.

It was shown that the university guideline preferential treatment for women applicants during selection time is one option that promotes their involvement in higher education leadership positions, as the majority of respondents agreed and the mean 3.45 stated.

In response to item two in Table 6 , 45 (47.9%) and 14 (14.9%) of respondents agreed that the education office should provide capacity building/training to encourage women to pursue positions in higher education leadership. On the other hand, 22 (23 percent) and 7 (7.4%) of them said they disagree and are uncertain about the same issue, respectively.

Item three revealed that 51 (54.3%) and 12 (12.8%) of respondents agreed and strongly agreed that Addis Ababa University should include women members in committees for recruitment, training, and development of individuals. On the other hand, 16 (17%) and 14 (14%), respectively, of the respondents said they were uncertain and disagreed with the same viewpoint. The presence of women representatives in the committee during recruitment, training, and development of persons provides a chance for women to improve their participation in leadership positions, as the majority of respondents agreed and the mean 3.65 indicated.

Concerning item four, 44 (46.8%) and 6 (6.4%) of respondents agreed with the notion of separate quotas to compute among women themselves and male competitors, respectively, whereas 19 (20.2%), 15 (16%), and 10 (10.6%) of them responded unsure, disagree, and strongly disagree with the same notion.

Concerning question five, 38 (40.4%) and 20 (21.3%) of respondents agreed and strongly agreed that women have more experience with family management and have more opportunities for higher education leadership jobs than males. On the other side, 18 (19.1%) and 12 (12.8%) of them said they were uncertain and disagreed with the same viewpoint, respectively. This suggested that the majority of respondents thought that women's expertise with family management provides them with a greater opportunity for leadership tasks than males. As a result, this is another chance to increase women's participation in higher education leadership roles.

This section contains a summary of the findings, as well as a conclusion.

Summary of the Findings

The study's strategic goal was to evaluate women's difficulties and potential in leadershippositions at Addis Ababa University five campuses.

The research summary and conclusions were based on the following fundamental questions.

1.3. What are the institutional (organizational) barriers that affect women’s participation in leadership Positions at Addis Ababa University?

2. What are the opportunities do women have leadership positions at Addis Ababa University?

A descriptive survey was used, incorporating both a quantitative and qualitative approach. Purposive sampling procedures were used to pick 104 samples from 10 higher education leadership officials and executives. Respected respondents were given 104 questionnaires, and 98 percent of them were filled out and returned correctly.

The data gathered through surveys from primary and secondary sources was presented in tables, figures, and charts, then evaluated using descriptive statistics such as percentage, frequency, and mean, and quantitatively and qualitatively evaluated in connection to the study objectives.

Respondents' characteristics were characterized in terms of sex, service years, ages, educational attainment, and marital status. According to the data, 68 percent of respondents were males and 32 percent were females, indicating that women's participation is low.

Women's current standing is still low, with 72.4% of respondents agreeing that women are underrepresented in higher education leadership positions. Only 25% of females participated in the poll in the chosen location, according to the results. According to the majority of respondents (75.5%), even if there are a large number of female employees in higher educational professions, women's participation in leadership positions is limited when compared to leadership positions engaged by men. At the same time, their participation is usually restricted to the middle, and they are seldom seen in higher positions. According to 81 percent of respondents, women's participation in higher education leadership positions is rising with time when compared to the past, although it is still low when compared to males today.

Females' childhood development was a social factor in their participation in leadership positions, as 52 percent of respondents agreed and the interview supported that females' development process was not free of demoralizing situations and that they did not use selective motivational words to motivate them. As a result, their engagement in higher education leadership position is influenced by their childhood development. The patriarchal and male- dominated society is a fundamental role in women's involvement, according to the majority of respondents (70 percent), and most people still believe males have decision-making authority. Furthermore, many people believe that women lack the competence and talent to lead, and therefore are less accepting of their participation in higher education leadership roles.

The majority of respondents (85%) agreed that women are more responsible for home and family issues than their male counterparts, and that having too many work and family responsibilities, as well as a lack of support from their families or spouses, are the major barriers to their participation in higher education leadership positions.

The majority of respondents (77.6%) agreed that societal attitudes influence women's desire to work in higher education leadership position. This is due to a lack of encouragement and support from family and coworkers; societal attitudes toward women leaders, which believe that women lack confidence and ability to lead; a lack of community respect; a lack of income to teach themselves; biological and religious factors, as well as sexual harassment, are some of the challenges that limit women's interest in higher education leadership positions.

Concerning the idea that organizations lack policies to support women's career advancement, half of the respondents disagreed, while the other halves were opposed and neutral. However, the organizations/institutions interviewed lacked policies and support systems, and they did not provide a good work environment to empower and make fertile for women higher education leadership positions.

As many as 66 percent of them felt that men's unfavorable attitudes of women was preventing them from pursuing careers in leadership. Men are more likely to be promoted to executive positions in male hierarchies, and they are promoted quicker than women; hence, women's involvement is a difficulty.

The majority of respondents (56.5 percent) agreed that a lack of professional networking system, a lack of role models in higher education institutions, a lack of mentors, and a lack of support from colleagues in the organization are additional challenges that affect women's motivation to pursue positions in higher education institutions like Addis Ababa University. Similarly, 61.7 percent of respondents believed that institutional and organizational culture, as well as a lack of encouragement and support in the workplace, have an impact on women's involvement in leadership roles. The open-ended question response that the organizations need a framework to inspire women leaders supports this view.

According to the data, 80 percent of respondents felt that women are strong decision- makers and dedicated to their universities and careers. According to the findings, women's dedication and decision-making skills is barely a barrier to their involvement in higher education leadership jobs and their career advancement, and women's unwillingness to participate in higher education leadership roles is not a significant factor.

Conclusions

This study looked at the barriers to participation that women encounter, as well as the possibilities that encourage them to pursue careers in higher education leadership. The conclusions were successful based on the findings. Women's participation in higher education leadership roles is still at an all-time low. Women's decreased involvement is due to a variety of factors. Some of the barriers to women's involvement in leadership roles include social factors, organizational/institutional factors, and personal qualities, which are classified as social factors, organizational/institutional factors, and personal characteristics. Women's engagement is influenced by a variety of societal variables. An influential aspect is the early growth process, which was not free of depressing experiences and did not employ selective motivational phrases. Another element influencing their involvement is patriarchal and male-dominated culture: because most people believe that males have more decision-making authority and that women lack the capacity and talent to lead, women's acceptability in higher education leadership roles is lower.

Furthermore, women are more responsible for home and family concerns than males, and too much work and family conflict, as well as a lack of support from their families or husbands, are the biggest obstacles to their involvement in higher education leadership jobs. At the same time, society's attitude has an impact on women's desire to work in university leadership. This is due to a lack of encouragement and support from family and coworkers; society's attitude toward women leaders, which they believe is related to a lack of confidence and competence to lead; a lack of community respect; and a lack of funds to educate themselves, the hurdles that restrict women's interest in leadership roles are biological and religious reasons, as well as sexual harassment.

Organizational issues such as males’ unfavorable perceptions of women influence women’s engagement in leadership. This meant that males in the male hierarchy were more likely to be promoted to leadership positions, and that they were promoted quicker than women. As a result, most universities struggle to allocate leadership, and lack of transparency is a selection factor for higher education leadership roles. Similarly, there is a dearth of a professional networking structure and a role model in business; women's aspirations to work in higher education leadership roles are further hampered by a lack of mentors and a supportive environment from colleagues. It may be concluded that institutions/universities lack real encouragement and support, as well as a framework to motivate women leaders, and as a result, their involvement is hampered by this culture.

Personal traits of women who are reluctant or hesitant to assume responsibility have little bearing on their involvement, but the disadvantage of women leaders is that they lack the strength to defend themselves and have less acceptances of society. Women, on the other hand, are capable of making strong decisions and being devoted to the company and their professional growth, as well as having the confidence and competence to lead and participate in higher education leadership position. As a result, it was claimed that this is a contributing component that is being exploited as a chance for their involvement in university leadership post.

Some opportunities or tactics for increasing women's involvement in higher education leadership positions were mentioned. Rather than prioritizing women's engagement, the only way to increase their engagement is to provide capacity development, raise awareness, and provide long and short-term training. Role model families, expertise with family management, assigning a representative during recruitment and selection for training and development of persons, and women's leadership styles are all examples of possibilities that might help them participate more fully.

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The Impact of Training and Development on Employee Performance and Effectiveness: A Case Study of District Five Administration Office, Bole Sub-City, Addis Ababa, Ethiopia, (03), pp.188-202 Marginality as a Root Cause of Poverty: Identifying Marginality Hotspots in Ethiopia, (78), pp.420-435. Developmental State of Ethiopia: Reflections on the Benefits Obtained and the Costs Incurred, (14), No.2 Leskaj, E. (2017). The challenges faced by the strategic management of public organizations. Administratie si Management Public, (29), pp.151-161.

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Challenges and coping mechanisms of parents of children with attention deficit hyperactivity disorder in Addis Ababa, Ethiopia: a qualitative study

• Wongelawit Mesfin 1 &
• Kassahun Habtamu 1  

BMC Psychology volume  12 , Article number:  354 ( 2024 ) Cite this article

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Metrics details

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder that has manifestations of inattention, hyperactivity, and impulsivity. It affects every facet of a child’s life, including one’s own emotions, family and school life, and social interaction. The few available studies on ADHD conducted in Ethiopia focus on teachers’ awareness and the prevalence of ADHD. None of these studies has taken into account parents of children who have ADHD. The present study, therefore, aimed to find out the challenges and coping mechanisms of parents who have children with ADHD.

A phenomenological qualitative study was conducted to explore the experiences of parents who have children with ADHD. The study was carried out in Addis Ababa, the capital city of Ethiopia. Fourteen parents and two healthcare providers were involved in the study. Participants were selected using a purposive sampling technique. In-depth interviews were conducted with parents of children with ADHD ( n  = 8) and healthcare providers ( n  = 2). One focus group discussion (FGD), consisting of six members, was also conducted with parents. A topic guide for conducting the interviews and FGD was developed. Interviews and the FGD were audio-recorded. The data were transcribed verbatim, translated into English, and then analyzed using a thematic analysis approach.

With regard to challenges of parents of children with ADHD, three themes emerged: social challenges, economic challenges and psychological challenges. Stigma is found to be the most common challenge. Other challenges included worry about the child’s future, lack of social support, strained relationships with others, impact on their job, and marital conflict. Concerning coping mechanisms, two themes emerged: Inward and outward means of coping. The inward means of coping included prayer and developing an optimistic mindset whereas the outward means were family support, healthcare providers’ guidance, and social avoidance.

Conclusions

The study found that parents of children with ADHD experience several aspects of psychological, social, and economic challenges. Support from healthcare professionals, family members, and the community at large is found to be useful for parents to cope with these challenges. Future research should focus on evaluating interventions that would help parents with ADHD cope with the challenges they experience.

Peer Review reports

Introduction

The Diagnostic and Statistical Manual of Mental Disorders (DSM) defines attention deficit hyperactivity disorder (ADHD) as a neurodevelopmental disorder characterized by inattention, disorganization, and/or hyperactivity-impulsivity [ 1 ]. Inattention and disorganization entail inability to stay on task, seemingly not to listen, and losing materials, at levels that are inconsistent with age or developmental level [ 2 ]. Hyperactivity-impulsivity, on the other hand, refers to over-activity, fidgeting, inability to stay seated, intruding into other people’s activities, and inability to wait- symptoms that are excessive for age or developmental level [ 3 ]. These symptoms have to present prior to age 12 years, have also been present in two settings (at home and school) and they interfere with, or reduce the quality of social, academic, or occupational functioning [ 1 ]. ADHD is believed to occur in all cultures in about 5% of children and about 2.5% of adults [ 4 ]. The prevalence of ADHD worldwide is estimated to be around 6 in 100 children and adolescents and 3 in 100 adults [ 5 , 6 ].

According to the World Health Organization (WHO), there are three categories of ADHD [ 7 ]. The first is the predominately inattentive type. In this category are those children with poor attention who may forget time and again, are easily distracted, sidetracked from a task, appear not to be listening, are messy, take time to initiate doing things and lose their possessions regularly. The second category is the predominately hyperactive/impulsive type. Children with hyperactivity may often be restless, fidgety, full of energy or “always on the go”, loud, continuously chattering, unable to stay seated (in the classroom, workplace, etc.), running about or climbing in inappropriate places and unable to play or do leisure activities quietly. Children with symptoms of impulsivity may often do things without thinking, have difficulty waiting for their turn in games or a queue, interrupt people in conversation, blurt out answers before the question is finished, look intrusive and start using other people’s things without permission [ 8 ]. The third one, which is the combined type, has symptoms from both the inattentive and the hyperactive/impulsive types.

ADHD has an impact on the different aspects of a child’s life, such as poor peer relationships, and low self-esteem [ 9 ]. Children with ADHD show significant academic underachievement and educational problems [ 10 , 11 , 12 ]. For instance, they score significantly lower on reading and arithmetic tests than controls [ 13 ].

ADHD is commonly associated with elevated levels of parenting stress because the parents’ perceptions of the demands of their role as parents exceed their resources to cope with them [ 14 ]. Stress from parenting is a set of processes that starts off from efforts to adapt to calls of parenthood and results in unwanted psychological and physiological responses [ 15 ]. Apart from higher emotional impact, impaired family activities, less parental warmth, and higher parental depression and anxiety, parents of children diagnosed with ADHD reported higher stress [ 16 ]. A study has shown that the children’s problems affect the parenting stress more than parenting stress affects the children’s problems [ 17 ]. For instance, a study showed that South African parents experienced difficulties such as negative emotions, economic problems, inadequate social support, stigma, and extra care giving responsibilities [ 18 ]. Tanzanian parents experienced difficulties in handling children whose level of functioning was impaired due to abnormal and disruptive behaviour such as not being able to follow parental instructions [ 19 ]. They are also faced with psychological problems due to caring demands exacerbated by a lack of support and stigma from the community, disruptions in family functioning and social interactions among family members.

Parents need coping mechanisms to deal with the challenges they are facing in raising a child with ADHD. Folkman & Lazarus [ 20 ] explained coping as an individual’s continuous effort in thoughts and actions to manage specific external or internal demands appraised to be challenging and overwhelming to the individual. In addition, coping is considered highly contextual, in that its effectiveness is determined by the ability to change over time and across different conditions. There is no previous study on the coping mechanisms of parents who have children with ADHD in Ethiopia. Nevertheless, a study on mothers of autistic children found that religion, experience sharing, and social support are the most commonly used coping mechanisms [ 21 ]. A similar study on parents of children with intellectual disability showed that religion (praying, fasting, and attending church ceremonies), experience sharing with like parents and maintaining smooth relations with their children’s teachers are their coping mechanisms [ 22 ].

Few studies have been conducted on the prevalence, risk and protective factors and impact of ADHD in the Ethiopian context [ 23 , 24 , 25 ]. Nevertheless, to the best of our knowledge, there are no studies done on the challenges and coping mechanisms of parents of children with ADHD in the Ethiopian context. This study, therefore, aimed to explore the challenges and coping mechanisms of parents of children with ADHD.

Study design

A phenomenological qualitative study was conducted. A qualitative approach was more suitable for this study as it seeks to acquire an in-depth understanding of the experiences of parents with ADHD through exploration instead of measurement [ 26 ]. According to Draper [ 27 ], qualitative research investigates a phenomenon considering the context of people’s everyday lives and also attempts to understand and explain the world from participants’ points of view. Green & Thorogood [ 28 ] concur by stating that the focus of qualitative research is to find explanations for questions such as “what”, “how” or “why” of an occurrence.

This study intended to assess the challenges parents of children with ADHD face and the coping mechanisms they use. Data were gathered by using in-depth and key informant interviews and focus group discussion. In doing so, the study gave participants the freedom to articulate their experiences with their own words rather than choosing words from a predetermined list. The study also adopted Bronfenbrenner’s Ecological Model as its theoretical framework [ 29 ].

Study setting

The study was conducted at St. Paul Hospital, located in Addis Ababa, the capital city of Ethiopia. The present site of the hospital building was constructed in 1968/69 and could admit 400 inpatients and 300 outpatients. St. Paul’s Hospital opened a medical college during the Ethiopian Millennium celebration in 2007 after serving the nation as a hospital for six decades. Afterward, it was renamed St. Paul’s Hospital Millennium Medical Collage (SPHMMC) by the Ministry of Health of Ethiopia. At present, it has more than 2,500 clinical, academic and administrative staff. While the inpatient capacity is 700 beds, more than 2,000 outpatient and emergency clients visit the health facility every day. St. Paul Hospital has a vision of becoming a medical university with a prestigious academic and research center, and one of the most sought- after medical care providers [ 30 ].

The Child and Adolescent Psychiatry Department of the hospital launched its service around 8 years ago. It provides services to children and adolescents who have different types of psychiatric conditions such as depression, autism spectrum disorder, ADHD, intellectual disability, substance use disorder, oppositional defiant disorder, and conduct disorder. On average, around ten patients pay a visit to the department daily. Service users will have their follow-ups until age 18 years in the Department and then will get transferred to the Adult Psychiatry Department. There are two resident psychiatrists, one senior psychiatrist, two psychologists and two nurses who are providing services in the Department.

Participants

Purposive sampling was used to select participants in the study. This was carried out until saturation was reached. Parents who have children with diagnosed ADHD and healthcare providers who are providing treatment to children with ADHD participated in the study. Participants had to meet the following inclusion criteria to be included in the study: being a parent to a child with a diagnosis of ADHD, ability to communicate fluently in Amharic, and willingness to participate in the study. As for the healthcare providers, the study included the two of them who were on duty during the study. The target population of this study was parents of children who have ADHD at St. Paul Hospital and health care professionals who were providing services to these children and their parents. The nurse provided the information on whether parents had children with ADHD or not. Then, parents were asked for their oral consent to participate in the study.

There is no formula to acquire a sample size in qualitative research. Rather, most scholars agree on the concept of data saturation to reach to sample size. Englander [ 31 ] argued that sample size in qualitative research is often determined on the basis of theoretical saturation (the point in data collection when new data no longer bring additional insights to the research questions). Sandelowski [ 32 ] suggested that the assessment of the sample size’s appropriateness becomes a “matter of judgment”, depending on the milestones retained in the attention field by the researcher.

Creswell [ 33 ] recommended interviews with up to 10 people in phenomenological research so this study planned to interview two healthcare professionals and eight parents who have a child with ADHD. Regarding the focus group discussion, Johnson & Christensen [ 34 ] suggested that focus groups usually contain 6–12 persons. Krueger [ 35 ] suggested 6–9 focus group members and groups with more than 12 participants tend to limit each person’s opportunity to share insights and observations while focus groups with less than 6 participants make it difficult to sustain a discussion. One focus group discussion was conducted comprising six parents who have a child with ADHD.

Methods and procedures of data collection

In-depth and key informant interviews and focus group discussion (FGD) were used as methods of data collection. Both interviews and FGD gave the participants the autonomy to express their experiences in raising children with ADHD. In-depth interviews and FGD were conducted with parents of children with ADHD. Healthcare professionals who diagnose and provide treatment to children with ADHD at St. Paul Hospital were also interviewed. Triangulation is of vital significance in qualitative research in terms of data collection method and data source. Having different respondents for the interview and FGD enriched the information gathered. The sequence for the data collection was from individual interviews with parents to focus group discussion with parents and then to individual interviews with healthcare providers. The major reason for this sequence was that in-depth interview with parents was the primary method of data collection and it was easier to make the interview with parents iterative than the interview with healthcare providers as well as the FGD with parents. In addition, the interview with parents shaped both the FGD and the interview with healthcare providers.

We developed a topic guide for the interviews and the focus group discussion (Supplementary Material 1 ). The questions within the topic guide we used for parents focused on finding out parents’ reactions to the first diagnosis of their child, the change after diagnosis, their positive experiences, the challenges they face and their coping mechanisms. For the healthcare providers, the questions focused on finding out about parents’ reactions to the first diagnosis of their children, the challenges of parents and the support given by the healthcare providers. For each guiding question, planned probes were included.

Interviews involve a one-to-one in-depth discussion where the researcher adopts the role of an “investigator.” This implies the researcher asks questions, controls the dynamics of the discussion, or engages in dialogue with a specific individual at a time [ 36 ]. According to Nyumba [ 36 ] in a focus group discussion, researchers adopt the role of a “facilitator” or a “moderator.” In this setting, the researcher facilitates or moderates a group discussion between participants and not between the researcher and the participants. The study was conducted in a naturalistic setting of the out-patient of the Department of Child and Adolescent Psychiatry at St. Paul’s Hospital. Both the interviews and focus group discussion were conducted in Amharic and electronically recorded. This allowed the researcher to refer to the data gathered anytime and also avoid recall bias. In-depth interviews with parents lasted between 30 and 50 min, whereas the FGD took 90 min. The key informant interview with one of the healthcare providers lasted 45 min and with the other 60 min.

Data analysis

Data were transcribed verbatim and then translated into English. We followed the following four steps in analyzing the data: (a) familiarization with the data, (b) generating initial codes and searching for themes, (c) reviewing themes, and (d) naming themes [ 28 ].

In the course of getting familiar with the data, we listened to the audio recordings several times and transcribed the recordings into text format. Then meticulous reading of the transcripts was carried out with the aim of spotting keywords or phrases describing the experiences of the informants. Labeling and organizing the relevant pieces enabled the coding to be achieved which subsequently helped in identifying key themes. The formation and naming of these key themes were a result of the grouping of related themes. Then the subthemes were formed.

Ethical considerations

We confirm that the study was conducted in accordance with the Declaration of Helsinki. Ethical approval for the study was obtained from the Research Ethics Committee of the School of Psychology, Addis Ababa University, and the Ethics Committee of St. Paul’s Hospital Millennium Medical College. The study was carried out in a manner that was transparent to all the participants. All the participants in the study were well informed of the aim of the study. Only those who gave their oral informed consent to participate in the study were included. The participants were assured that the data gathered would only be used for research purpose. In addition, they were reassured that the use of the voice recording was solely for the research.

Assurance of confidentiality was attained by giving pseudonyms to participants. At the end of the interview, all participants were debriefed. Finally, the researcher offered the chance of getting the findings of the research to the participants.

The socio-demographic characteristics of the interview and FGD participants are presented in Table  1 .

The in-depth interview participants were eight in number and all were biological parents. Seven mothers and a father participated in the interview. All were married, except one (who was divorced), in terms of marital status. The age of the parents who participated in the interview ranged from 27 to 48 years. Concerning their religion, two of them were Muslims, two of them were Orthodox Christians and the rest four were Protestants. With regards to educational level, one was not able to read and write, two were seventh graders, three were tenth graders, one was eleventh grader and one had a BA degree. When it comes to occupation, five of them were stay at home mothers, one a cleaner, one tea and coffee vendor and one a pastor. Respondents of the focus group discussion were six biological parents. The group consisted of four mothers and two fathers, with age ranging from thirty to sixty. When it comes to marital status, there was one single parent, four married and one cohabiting with a partner. Four of them were orthodox Christians whereas the other two were Protestant or Muslim. Regarding their educational level, two of them had first degree, one had diploma, two of them completed 12th grade and one was a tenth grader. Concerning their occupation, the two degree holders both were teachers, one self-employed and three of them were stay-at home mothers.

Concerning the socio-demographic characteristics of health care professionals, one was a female General Practitioner and the other was a male third-year Psychiatry resident. Both were single. In terms of religion, one was Muslim and the other Protestant.

The major themes along with their sub-themes that emerged from the data are presented in Table  2 .

Parents’ reaction to their children’s diagnosis

For the question about their reaction when the healthcare provider first informed them about their children’s diagnosis, parents responded that they reacted with a range of feelings. There was no ‘right’ way to feel to come to terms with the diagnosis and move on with everyday life. The healthy thing to do was to recognize and validate these feelings. Some accepted it, some were shocked and confused and others were engulfed with different feelings. Apart from those who accepted it easily, we had observed other parents responding with sadness and teary eyes or even sobbing.

Parents’ acceptance of their children’s diagnosis is a way of melding the condition in their lives without engaging in any intrapersonal conflict. Intrapersonal conflict was a fight within oneself with one’s thoughts and values. The intrapersonal conflict for parents like these might be in the form of self-blame, guilt, blaming others, becoming mad at God, or taking the incident as a punishment from God. Easy acceptance of their children’s diagnosis was possible for some parents because of the prior information they got from different sources.

While we were living in Saudi Arabia, I had seen TV programs that enabled me to have a clue concerning children’s mental health. So accepting it was not that much of a trouble to me. (INTV, Fatuma) As a teacher, I knew the behaviour of children. I had noticed something wasn’t right when it came to the behaviour of my son. I couldn’t understand why he didn’t have the motivation and the patience to study. I searched over the internet and finally took him for an assessment. (FGD, Afework)

Shock and confusion

Hearing the unexpected news yielded two predominant emotions: shock and confusion. Shock was a reaction to a surprising and unpleasant incident while confusion was a state where one feels disoriented, cannot think clearly and is unable to make a decision. Two of the interviewed mothers had the following to say:

My daughter was on Thyroxine tablets that were prescribed to her by doctors in Saudi Arabia. Back then I was told that my daughter’s behaviour was a result of the side effect of this medication. But when we came to Ethiopia, she was diagnosed with ADHD. As I had accepted what the doctors from Saudi Arabia said about the behaviour of my daughter, finding out she had a mental health condition was shocking. The two different opinions of the doctors made me confused. Why the doctors did come up with two different diagnoses? (INTV, Sifan) I didn’t expect my daughter would be diagnosed with a mental health condition so it was shocking news for me. I raised my daughter alone and struggled to support us. God knew what I was going through and had helped my problems come to pass. So, when this happened I was confused why God allowed another problem to happen to me. I had seen no hope until my daughter started taking the medication. (INTV, Tirunesh)

Emotional ambivalence

Some of the parents reported that they experienced emotional ambivalence (a state where one has a mixture of emotions that might contradict each other). These included anxiety, hopelessness, depression, guilt, self-blame, denial, shame, self-doubt, sadness and blame. Anxiety arises from the feeling of uncertainty and fear about what the future holds for their children. Blaming others, guilt and self-blame were effects of the search for possible causes of the disorder. Parents moved down memory lane to dig out what they should have done. Anxiety, fear and insecurity could lead to denial about the incident. Feelings of shame arise when parents think about what society might say about their child’s diagnosis. Parents also might doubt themselves about their competence as a parent.

The news about the diagnosis erupted mixed emotions in other parents which included denial, anxiety, sadness, hopelessness, shame and self-blame. One mother whose son had epilepsy explained the assurance they had in prayer for the spiritual healing of their son. Not seeing any progress made her sought professional help. He was not only diagnosed with epilepsy but also with ADHD. What she had felt was anxiety, hopelessness, confusion, shame and self-blame. This was what another sobbing mother had to say:

My son had swallowed a coin and we took him to the hospital. X-ray images were taken thrice. I blame myself for not refusing when the medical practitioners did that. So I believe the exposure to the X-ray that day caused my son’s ADHD. I felt as though I’d failed so I blamed myself for that . In addition, I had shame, denial and guilt. (FGD, Mesert)

A father had also the following to share:

As our neighbors told us, my son had fallen several times when he was very little and we believe that his ADHD was a result of it. A teacher was complaining about my son’s behaviour to his mother. His mother told the teacher that he had started holy water treatment for his behaviour. The principal of the school overheard their conversation and later on warned us that he must get assessed by a professional. As the school is an international school, she also wanted a medical certificate after his assessment in order for them to support him afterwards. I had felt shame and sadness. (FGD, Workneh)

The two healthcare professionals described what the reactions of parents were when they were first told about the diagnosis of their children. The resident psychiatrist reported that most parents got confused, shocked, and exhibited denial.

The general practitioner shared her observation as:

Most of the parents did not have a clue about ADHD and often were perplexed and assumed ADHD was as a full-blown psychosis. Moreover, parents wrestled with self-blame if something had happened in the past which they might think had caused their child’s disorder. This included a fall of the child that took place during the early years, instances during their pregnancy, etc. (INTV, GP)

Parental change after diagnosis

Parents reported that they experienced a change in themselves after they knew about the diagnosis of their children. These included an increased understanding of ADHD and better care provision.

Awareness about ADHD

For some of the parents, the change after the diagnosis of the child was an increased understanding about the condition not only for themselves but also for the ones that were close to them. Two parents shared the changes that took place with them as follows:

I thought my son’s condition was associated with supernatural evil manifestation and that was the reason why we chose prayer prior to getting him professionally evaluated. Our perspective has shifted after his diagnosis. (INTV, Deraretu) The first time I heard about ADHD was in the psychiatrist’s office during my son’s assessment. When I go home, I shared the information with my wife. Later on, I told my elder sister about it as she sometimes looked after him. (INTV, Haile)

Knowing about their children’s condition has enabled some parents to become better caregiver to their children. One parent described it as:

I not only give him unique attention to his needs but also strive for his emotional well-being. I am always more watchful when relatives come to visit us so that they don’t call him “naughty” or something else. Whenever I had to go pay a visit to a relative, I wanted to take my other kids along and leave my son home. On the one hand, I feel like I am protecting him from harsh comments. On the other hand I knew this would make him feel lonely. In the end, I refrained from doing this and went by myself. (INTV, Tayitu)

Another parent added:

I came to know that physical exercise helps with concentration. I always encourage my son to do regular physical exercises. (FGD, Afework)

Positive experiences while parenting a child with ADHD

Even though their situation was unfortunate and dubious, parents gained some sort of positive experience in the upbringing of their children with ADHD. These included knowledge, advocacy, and inspiration.

For most of the parents, their knowledge of ADHD increased after the diagnosis. Moreover, they shared what they knew with the ones they believed should know about their children’s condition as described in the quotations below.

A teacher had called my son stupid which had been informed to the director. As the teachers didn’t have a clue about ADHD, I made a brief explanation about his condition to all of them. (INT, Haile) Fellow teachers used to tell me to support my son academically as if I was negligent towards this. I tutored a lot of children and enabled them to be high achievers academically. I knew my son had a good potential but the perspective of others differed about it. I shared what I knew about the condition with a heavy heart knowing it was not a one-time incident. I wish people were aware of ADHD. (FGD, Afework)

Becoming an advocate for children with ADHD was another positive experience gained for most of the parents. Parents have become advocates with the intention creating a supportive environment for their children. The quotation below supports this narration.

If I see children who have similar behaviour as my son’s, the first thing that comes to mind is his condition (ADHD). Whenever I take a taxi and observe a hyperactive child, I try to play with them and defend them if any negative comment is forwarded. (INTV, Kedija)

Another parent claimed that he not only became an advocate for children with ADHD but also for mental health in general.

During a discussion about mental health, I made sure people dropped any myths they might have about ADHD and other mental health issues. Even the ones we considered worst like schizophrenia can be managed with medication and normal life can be attained. (FGD, Workneh)

Inspiration

Some of the parents wanted to share their experiences with other similar parents and also get encouraged by other parents who have children with other neurodevelopmental disorders. A parent highlighted her positive experience in terms of knowledge of ADHD, inspiration, and advocacy as follows.

While waiting for my son’s turn at the hospital, I always engage in a conversation with other parents. If the parents have a newly diagnosed child, I tell them their journey might be challenging but it’s manageable. I told them how I managed my son’s epilepsy and ADHD. If their child has autism or another condition, it’s my turn to learn from their strength. (FGD, Mesert)

Challenges of parents of children with ADHD

The study found that parents of children with ADHD experienced psychological, social, and economic challenges. More specifically, these included worry about the future of the child, stigma, lack of social support, strained relationship with others, impact on their job, marital conflict, teachers’ lack of knowledge on ADHD, and having anxiety and depression symptoms.

Social challenges

Social challenges were those challenges originating from society and have negative consequences on the individual. Stigma was found to be one of the major social challenges for the majority of the parents. This included a negative, biased and unfair belief about ADHD. An excuse for laziness, way out of trouble, wrongly disciplined, and judgment on parents were some of the aspects of stigmata associated with ADHD.

Less social support from relatives and neighbors and a low level of knowledge of teachers take up the next level of challenges. The less social support from relatives and neighbors might be the result of stigma. Strained relationships and marital conflict are the challenges that stood out for a few parents in addition to other social challenges. Due to the stigma and social avoidance, some parents had strained relationships with members of their community. Others had conflicts with their partners regarding the diagnosis and treatment of their child’s ADHD.

A parent stated her experience as:

I face different setbacks but the one that hurts me most is my marital conflict. My husband doesn’t seem to care about my son who has ADHD. Ever since my son’s diagnosis, he isolated himself from anything connected to my son’s condition. In regards to my son’s school, the school administration informed me that my son wasn’t up to the criteria set for kids with autism and therefore had to leave the school. I took the case to the Ministry of Education. So I carry the entire burden by myself. (FGD, Muluemebet)

Another mother added:

I have a similar story. My mother-in-law believes that my son’s condition is brought by evil spirits and the remedy is in the hands of a shaman. As she has inflicted this idea in my husband’s head, a fight arises whenever my son’s condition is raised. One day my son was late to come home. But when he returned, his father locked the door and started beating him up. He opened the door to let him out on the arrival of the police. Even though I had explained to my sisters about my son’s condition, they suggested I should look for a detention facility for children like him. Due to my son’s condition, I no longer work and am a housewife. I sometimes get judged about my son by individuals from my church’s congregation. (FGD, Mesert)

Economic challenges

Economic challenges were those challenges that put economic turmoil on an individual due to mental health conditions. Quitting job to take care of their children with ADHD was the challenge to many of the parents. As taking care of children with ADHD demands a lot of patience, parents especially mothers fear other caregivers might lose their temper and hurt their children, and, therefore, quit their job to look after these children. Few parents reported the stress they had because of their socioeconomic status and others terminated their children’s follow-up due to financial strain. Overall, parents of children with ADHD described the impact on jobs and expenses associated with the child’s illness.

Spending extra time on school-related activities, such as helping the child to do homework and assignments was found to be difficult and frustrating not only for the child but also for the parent as well. A parent stated that her life is always nothing but stress. This parent carries the burden of being a single mother, divorced, financially constrained, and a daughter with a mental health condition who always worries about the actions of her landlord and stigma.

My husband abandoned me the minute our daughter had her first seizure. She no longer has seizures but I have never heard from him. Because of her behaviour, I got to relocate and met new landlords frequently. As I am the sole breadwinner, the financial constraint is enormous. With the earnings I get from selling tea and coffee, meeting my needs of living expenses coupled with my daughter’s follow-up is so nerve-racking. Moreover not knowing her condition, people always judge me for not raising a well-behaved child. (INTV, Tirunesh)

Psychological challenges

Psychological challenges as a result of being a parent of children with ADHD which included stress, anxiety, sadness, loneliness, helplessness, hopelessness, and depression were frequently aired in the interviews and FGD. Most of the parents worried about their child’s future. Parents worried a lot about who would have the patience to take care of these children when they were no longer alive. A mother claimed she had been depressed for some time until recently. This mother felt helplessness and had no happiness in life.

Here is what two mothers had to say about the psychological challenges of parents of children with ADHD.

I was in a queue waiting for a taxi with my daughter. She wanted to play around but I refused to let her go because I feared a car might hit her. She knelt, started crying and would not stand up. One guy interfered and asked me why she was crying. He was so suspicious that I abducted someone else’s child. An ugly scene was created which later involved the police. I explained her condition to them and the case was solved. I was humiliated. Another issue that I face constantly is with my daughter’s handwriting. Her teachers said that her handwriting is below her peers. Her teachers not only complain about her behaviour but also her handwriting. This deeply made me sad and angry. (FGD, Sifan) I constantly worry a lot about my son. I always beg my son not to go out of our compound but boredom seems the rationale for him to do so. Some boys have got sexually molested near where we live. My prior warnings and advice I gave him didn’t seem to work as I had to tell him time and time again. (FGD, Mesert)

The first author witnessed one of the parents who participated in the interview throwing the appointment card on the nurse’s desk and shouting at her which later ended up in crying. The interviewer calmed her down and she said she was so stressed out. According to her, nurses in the other department mistreated her and people were judging her. She later apologized to the nurse for the way she behaved.

When it comes to the challenges that parents of children with ADHD faced, the resident explained that they faced stigma, hopelessness, and depression.

The general practitioner added:

ADHD affects every aspect of the lives of these parents. The significant challenge that parents face is at the school where these children go to. Unless they have comorbid conditions, children with ADHD go to regular schools and are bombarded by the harsh criticisms and judgments of their teachers who lack knowledge about ADHD. In addition, managing the child’s behaviour daily, stress, concern about the future of the child, impact on their job and marital conflict were other challenges that parents faced. Upon discovering heredity as being one possible etiology of ADHD, most couples argued over who passed it on to the child and mothers ended up taking the blame mostly. Some couples don’t reach an agreement on whether to continue with the follow-up or not. This mostly resulted in the discontinuation of the treatment. Some fathers also expressed feelings of doubt about the mother’s competence as a parent. Sometimes the diagnosis of the child involves not only the parents but also in-laws. (INTV, GP)

Some parents whose children had become teens explained another psychological challenge as:

My son used to take his medication properly. The doctors had increased the dosage of his medication. I was the one who gave him the medication every night. By the time he became a teen, he started refusing to take his medication and going for follow-ups. My wife and I couldn’t force him to continue and we are waiting on him to start again. The journey takes a different lain when children with ADHD become adolescents. (FGD, Afework) My son doesn’t want to go to the hospital now. The different mental conditions of the children he saw at the hospital tormented him emotionally. By the time he became a teen, he claimed he wasn’t as mentally ill as the others and did not see the point of going to the hospital. As the medication had made a huge difference for him, I did not want him to stop taking it. So I usually go to the hospital without him for the prescription. I usually inform the doctors about his status and any change in his behaviour if any and they adjust the dosage accordingly. I wanted to have more kids but changed my mind after his diagnosis. (INTV, Menen)

Coping mechanisms of parents of children with ADHD

Parents reported different types of coping mechanisms they use to deal with the challenges they face when raising children with ADHD. Parents used a combination of different coping mechanisms which could be broadly grouped into two: inward means and outward means.

Inward means

The inward means were the mechanisms that the parents perform to come up with a positive outlook. These included prayer and the state of being an optimist. Prayer decreased stress, gave a sense of relief, improved self-esteem, and increased spirituality. Due to challenges like isolation and stigma, prayer was a way to connect to their Creator where parents feel their worries and fears are heard without judgment and validation for what they go through. Being optimist during difficult times helped with handling stress and boosted resilience.

Prayer was practiced as the first coping mechanism by almost all parents. Being optimistic was another coping mechanism for other parents. Below are what three parents had to say about their use of inward coping mechanisms:

I observed my daughter grasping something faster than her siblings and knew she had potential. So I believe that Allah has created her for a bigger purpose in life. I pray and lean on Him to help her be what He wants her to be. (FGD, Sifan) With a lot of challenges that are going on in my life, prayer is the one thing that calms me down. As my elder sisters are living within the same compound, we have daily prayer. I pray about my son a lot. I believe God has a bigger purpose in my son’s life. (FGD, Mesert) I don’t know what I would do without prayer. Being a single mom with a mentally ill child, facing financial constrain, and living in a hypercritical society is so exhausting. When I pray to God for my provision, He miraculously makes it available. (INTV, Tirunesh) Even though I am faced with different challenges, I am trying to see the bright side of life. Whenever I take my child for a checkup, I get a chance to observe other mothers who have children with autism or other disorders. My challenges mean little when compared with theirs. This makes me grateful and hopeful. (FGD, Sifan)

Outward means

The outward means referred to coping mechanisms that parents get from their environment. These coping mechanisms included family support, healthcare providers’ guidance, and social avoidance. Every appointment gave a chance to the parents to get little information. Few but very close individuals knew about their child’s condition and give support to these parents. Others use avoiding social gatherings and interactions as a coping mechanism. In fear of the stigma, these parents had decided to meet up with only those who knew their child’s condition. Some even did not have friends that they can talk to.

Some parents reported that guidance from healthcare providers was one of the most useful coping mechanisms. Healthcare providers’ guidance in combination with other coping mechanisms was used by many parents. Some parents also used family support as a coping mechanism.

I haven’t told anyone about my son’s condition except my sister who is supportive of me. I don’t allow my son to go out and play with kids from the neighborhood for fear of being called names and getting bullied. I had observed a few kids who exhibited similar behaviour as my son and I believed their parents kept their conditions undisclosed. I therefore did the same thing and kept it a secret. My son had a seizure in the beginning and people had compassion for such illness not for his ADHD. Due to this, I prefer my son’s seizure over his ADHD. I wish people would stop being judgmental towards any illness. (INTV, Tayitu)

A mother expressed how the assistance she got from the health care providers became one of her coping mechanisms as

In the beginning, my husband and I were so much focused on prayer as a solution to our child’s problem. But after a while, the continuous aid from the healthcare providers became one of our coping means. (INTV, Deraretu)

A mother used social avoidance as a coping mechanism and expressed it as

I take him [the child with ADHD] anywhere I go like grocery shopping and other places he shouldn’t supposed to go like funerals. I have avoided meeting up with my friends. My parents’ place is a safe haven for my son and me. I am longing to see a support group with whom I can talk freely without being judged. (INTV, Fatuma)

The study shows that the reaction of parents during and after the diagnosis of their children varies from simple acceptance to a mixture of different emotions. Some of the parents noticed deviant behaviour in their children and got their children assessed due to their doubt and later on accepted their child’s diagnosis easily. Due to prior knowledge they have had on ADHD, these parents accepted the diagnosis easily as it gave them relief regarding their doubt. This finding is similar to other studies done on ASD diagnosis in a way that parental suspicion of a child’s developmental problems leads to getting an early diagnosis and coping more with the diagnosis than those not suspicious [ 37 , 38 ]. A study by Dosreis et al. [ 39 ] had a similar finding on parents of children with ADHD that acceptance was achieved by 38% of parents as their main concern was trying to find an explanation for the difficult behaviour of their children.

For parents whose children have been diagnosed with mental illness, resolution is a fundamental part of the process en route to acceptance [ 40 , 41 ]. According to Pianta and Marvin [ 42 ], resolution can be taken as accepting the diagnosis and integrating it into one’s life while refusing to accept self-blame. Milshtein et al. [ 40 ] argued resolution is a perception of complying and acknowledging the diagnosis and its inference. For parents of children with ASD, acceptance and normalization are very important to give the best possible life to their children [ 21 ].

Upon finding out about their child’s diagnosis, the majority of participants flaunted their reactions with a variety of emotions which include hopelessness, confusion, shame, guilt, self-blame, confusion, anxiety and denial. This is consistent with the findings of other previous studies done on the commonly experienced emotions about a child’s mental health diagnosis which include helplessness, devastation, sadness, loneliness, guilt, anxiety, and grief [ 43 , 44 ]. Parents of children with mental illness go through a feeling of loneliness, misunderstanding, stigma and rejection, grief and self-blame, cynicism, unhappiness, guilt, and anxiety [ 44 ]. In congruence with other studies [ 40 , 41 ], the findings of this study showed no relationship between the reactions of parents to diagnosis and parental demography. Fathers and mothers of children with ADHD reacted similarly.

The positive experiences parents gain while raising children with ADHD include knowledge, advocacy, and inspiration. Consistent with our study, Ustilaite and Cvetkova [ 45 ] revealed that parents of children with disabilities gained a range of positive experiences like inner parental growth, family relationships, finding new spiritual and material resources and feelings such as love, emotional bond with the child, and child as a source of joy and happiness.

Parents who are involved in this study experience different types of psychological, social, and economic challenges while raising children with ADHD. From these, parents’ concern for the future well-being of children and stigma from the community stood out. Social challenges include stigma, limited social interaction, marital conflict, strained relationships, teachers’ lack of knowledge of ADHD, and low social support. According to Sirey and colleagues [ 46 ], stigma is a socially formulated observable fact that encompasses stereotyping, labeling, segregation, loss of status, and nepotism which are allowed to take place in social circumstances by individuals with power. A “culture of suspicion”, about mental health treatment particularly if it involves a child, has been created by the stigmatizing convictions towards people with mental health conditions [ 47 ].

The finding that some parents have challenges in their social interaction and have strained relationships is similar to a previous study [ 48 ] which found that children’s ADHD has negatively influenced parents’ social lives and forced them to have frictions in their relationships. Other similar studies have revealed that parents had feelings of isolation from their friends and families, due to other adults being intolerant of their children’s behaviour [ 18 , 49 ]. In regards to marital conflict, this study has similar findings to other studies [ 18 , 50 ] which found that it is a result of unlike opinions among parents on the diagnosis and treatment of their child. Other studies revealed that it might be caused by troubles with a child’s behavior [ 51 ]. In a study conducted by Wymbs et al. [ 52 ] parents who had a child with ADHD were not only more likely to divorce but also had a shorter latency to divorce than parents of children without ADHD.

Ambikile and Outwater [ 53 ] found that the challenges of Tanzanian parents who have children with mental disorders including ADHD were insufficient children’s social services, stigma, childcare strain, lack of public awareness of mental illness, absence of social support, and troubles with social life. As per the different studies conducted in Ethiopia [ 54 , 55 ], a large number of teachers lack knowledge on ADHD. This negatively impacts the parents and that is what the present study identified as one of the challenges for the parents.

A study carried out in Ethiopia on parents of children with ASD revealed that parents have a social burden [ 56 ]. Other similar studies [ 57 , 58 ] found that the challenges of parents of children with ASD were marital conflict, time-consuming, lack of social support, stigma, the severity of the child’s behaviour, child’s inability to understand feelings and needs, inadequate service (school and treatment), and lack of self-care. In another study, separation from a partner, family/societal reactions, and social isolation are the challenges of parents who have children with intellectual disability [ 59 ].

The study found that parents of children with ADHD experience severe economic challenges and this is consistent with findings of previous studies. For instance, Fridman et al. [ 60 ] found that parents of children with ADHD are likely to quit their jobs to take care of their children. Kvist et al. [ 61 ] also concluded that having a child with ADHD will decrease the labor supply of parents. This is likely to put parents to severe economic strain. Studies conducted in Ethiopia [ 62 , 63 ] found that parents of children with neurodevelopmental disorders experience such economic challenges as financial difficulty, lack of education and training, lack of financial support and employment opportunities.

Parents of children with ADHD also experience several psychological challenges. The current study revealed that what constantly worries parents is that who, in a highly stigmatized society, would have the patience to take care of their children in their absence. Cheung & Theule [ 64 ] and Durukan et al. [ 65 ] found a higher prevalence of depression and anxiety than parents of children without ADHD. This was similar to the experiences of some of the respondents in the present study. The present finding is in line with the study by Deault [ 66 ] that parents of children with ADHD have stress on which the children might play a role. In addition, Minichil et al. [ 67 ] found out that parents of children with mental health conditions can go through depression due to low social support which is also prevailing in this study. In another study, parents of children with ADHD reported that they experience greater levels of parenting stress than parents of children with autism [ 68 ] or with serious conditions such as Epilepsy [ 69 ]. Another study revealed that the distress is related to isolation, stigma, and frustration due to the lack of support [80].

Studies conducted in Ethiopia [ 65 , 66 , 67 ] found that the psychological challenges of parents of children with ASD were stress, concern about the child’s future, and psychological burden. According to Negash [ 59 ] uncertainty about the future, emotional disturbance, and spiritual crises were the challenges of parents who have children with intellectual disability. Tanzanian parents who have children with mental disorders including ADHD experience stress, sadness, bitterness and concern about the present as well as the future life of their children [ 53 ]. Three-fourths of parents in Nepal who have children with intellectual disability suffer from severe stress to clinically significant stress caused by their children’s disorder [ 70 ].

The present study adopted the Bronfenbrenner’s Ecological Model as its theoretical model. This theory describes the existence of multifaceted levels of the environment with an effect on the development of a child [ 29 ]. The theory demonstrates the development of a child within a system, the interaction between the systems, and the influences they have on each other and the child. According to the views of the theory, a complex system of relationships affected by multiple levels of the surrounding environment is where a child develops. When we compare the ecological model with all the challenges parents of children with ADHD are going through, here are some of our observations. At the microsystem level, it was found that the low level of knowledge the teachers have about ADHD has an impact on the parents. The reaction of some church members about the behaviour of a child with ADHD and the humiliation it has on the parents exhibit the bi-directional influence of the microsystems. At the exosystem, what was observed were the interactions of the parents with their neighbors, with friends of the parents, with their in-laws and relatives, and the way our mass media wrongly portrays mental health. At the macrosystem level, it was observed how these parents were affected by the stigma that exists about mental health. At the chronosystem level, the experience of some parents going through divorce, separation and an incident where a mother was forced to relocate from place to place due to her child’s condition was encountered. In addition, as explained by the ecological theory, the child will lack the means to explore other parts of the environment if the interaction in the immediate microsystem breaks down. The absence of acceptance in the child/parent (child/other significant adult) relations will make the children look for attention in an improper place. These inadequacies appear during adolescence as anti-social behaviour, absence of directing oneself and self-control [ 29 ]. This was somehow partially evident with the two parents who have teens with ADHD.

For the majority of the parents, adaptive strategies like religion, optimism, guidance from professionals and family support are used as coping mechanisms. Almost all of the parents use prayer as a coping strategy. Parents reported that they feel less stressed and believe that better days will come after praying. Healthcare providers’ guidance is also another coping mechanism that most parents use to deal with their challenges. The support from family members also played a role as a coping strategy. Research has revealed that religion is used to going through unpleasant experiences and trying to make meaning out of them and finally coming up with an optimistic outlook [ 71 ]. A Tanzanian study found that support from professionals, spiritual help from traditional healers and religious leaders, and assistance in child care from other family members were the coping mechanisms used by parents who have children with mental disorders including ADHD [ 53 ]. For parents of children with ASD, trying to make meaning out of the situation, support groups, being optimistic and religiosity were used as coping mechanisms [ 56 ]. Another similar study found that religion, social support, increased knowledge of autism, acceptance and cherishing little progress are the coping mechanisms for parents who have children with ASD [ 58 ].

Parents in the present study use optimism as a coping mechanism and this is consistent with the finding of a study by Oelofsen and Richardson [ 72 ] which revealed that parents of children with ADHD used an optimistic belief of having control over the situation, high sense of coherence and support as coping strategies. Parents from Hong Kong use acceptance, problem-centered coping methods and situational-based acts as their coping strategies [ 73 ]. A Nepalese study revealed that coping strategies used by Nepalese parents who have children with intellectual disability were acceptance, societal support, positive reinterpretation and growth, planning, inhibition of competing actions and use of emotional social support [ 70 ]. A similar study in Ethiopia found that spiritual beliefs, hope (better future) and relationships with other similar parents were the coping mechanisms of parents of children with intellectual disability [ 59 ].

Other parents use maladaptive coping strategies like social avoidance as a coping mechanism for the challenges they face. Avoidance coping strategies take place when stressful circumstances, experiences, or complicated opinions and feelings are averted to use as a coping strategy. This study is in line with one study that revealed that mothers who have children with ADHD use avoidance as one of their coping strategies [ 74 ].

Strengths and limitations

We substantiated the views of parents who have children with ADHD by interviewing healthcare providers who are providing treatment to children with ADHD. We also used different methods of data collection (i.e. in-depth interviews and FGD) for triangulation purpose. Nevertheless, the findings of this study need to be interpreted taking several limitations into account. This is a qualitative study and generalizability of the findings of the study to other populations and study setting would not be possible. The participants were recruited from one government hospital and those who are attending private health centers might have different experiences. All respondents are from Addis Ababa and their experiences might be different from those living in the rural areas where the stigma is believed to be higher. In addition, the majority of the participants of the study are mothers and the experiences reported in the study may not represent fathers who have children with ADHD.

Parents of children with ADHD experience various psychological, social and economic challenges. Support from healthcare professionals, family members and society at large plays a role for parents to cope with these challenges. Knowledge about ADHD prior to the diagnosis of the child has helped parents to easily accept the condition. Easy acceptance of the diagnosis reduces the psychological challenges of the parents. By creating awareness to society, most of the challenges of parents who have children with ADHD can be minimized.

The concerned government body has to consider the financial constraints parents are facing and facilitate further medication subsidies not only for children with ADHD but also for children with other neurodevelopmental disorders. This will encourage parents who intend to discontinue their children’s follow-up because of financial constraints to reconsider their intention. Healthcare facilities diagnosing and treating children with ADHD need to see the desperate need to facilitate for the parents to set up a support group where they would be able to exchange their experiences with like parents which in turn serve as a coping mechanism.

Policymakers need to observe the lack of teachers’ awareness about ADHD and the skill to handle children with ADHD as one of the challenges for parents of children with ADHD and work to design strategy to provide training that would equip teachers with the necessary knowledge in dealing with students with ADHD. As per the narratives of some of the parents, they are in constant brawls with their children who just became adolescents over their refusal to take medication. This can be an area for further study. Another focus for future research can be evaluating interventions that would help parents with ADHD cope with the challenges they experience. Quantitative studies that would estimate the burden and associated factors of parents who have children with ADHD are also warranted.

Data availability

The data used for this analysis will become available through the first author at any time from now up on reasonable request.

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Attention Deficit Hyperactivity Disorder

American Psychological Association

Autism Spectrum Disorder

Diagnostic and Statistical Manual of Mental Disorders

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We are enormously thankful to the parents as well as the healthcare professionals who participated in this study.

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W.M. and K.H. conceived and designed the study. W.M. did recruitment of the participants and led the data collection process. W.M. did the data analysis in close consultation with K.H. W.M. produced the first draft of the manuscript. K.H. supported in the interpretation of data and significantly contributed in the writing of the manuscript. Both authors approved the final manuscript to be submitted for publication.

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Mesfin, W., Habtamu, K. Challenges and coping mechanisms of parents of children with attention deficit hyperactivity disorder in Addis Ababa, Ethiopia: a qualitative study. BMC Psychol 12 , 354 (2024). https://doi.org/10.1186/s40359-024-01828-0

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Vibrio cholerae O1 and Escherichia coli O157:H7 from drinking water and wastewater in Addis Ababa, Ethiopia

• Helina Mogessie 1 ,
• Mengistu Legesse 1 ,
• Aklilu Feleke Hailu 1 ,
• Tilahun Teklehaymanot 1 ,
• Haile Alemayehu 1 ,
• Rajiha Abubeker 2 &
• Mogessie Ashenafi 3  

BMC Microbiology volume  24 , Article number:  219 ( 2024 ) Cite this article

Metrics details

In Addis Ababa, Ethiopia, open ditches along innner roads in residential areas serve to convey domestic wastewater and rainwater away from residences. Contamination of drinking water by wastewater through faulty distribution lines could expose households to waterborne illnesses. This prompted the study to assess the microbiological safety of wastewater and drinking water in Addis Ababa, identify the pathogens therein, and determine their antibiotic resistance patterns.

Results Vibrio cholerae

O1, mainly Hikojima serotype, was isolated from 23 wastewater and 16 drinking water samples. Similarly, 19 wastewater and 10 drinking water samples yielded Escherichia coli O157:H7. V. cholerae O1 were 100% resistant to the penicillins (Amoxacillin and Ampicillin), and 51–82% were resistant to the cephalosporins. About 44% of the V. cholerae O1 isolates in this study were Extended Spectrum Beta-Lactamase (ESBL) producers. Moreover, 26% were resistant to Meropenem. Peperacillin/Tazobactam was the only effective β-lactam antibiotic against V. cholerae O1. V. cholerae O1 isolates showed 37 different patterns of multiple resistance ranging from a minimum of three to a maximum of ten antimicrobials. Of the E. coli O157:H7 isolates, 71% were ESBL producers. About 96% were resistant to Ampicillin. Amikacin and Gentamicin were very effective against E. coli O157:H7 isolates. The isolates from wastewater and drinking water showed multiple antibiotic resistance against three to eight antibiotic drugs.

Conclusions

Open ditches for wastewater conveyance along innner roads in residence areas and underground faulty municipal water distribution lines could be possible sources for V. cholerae O1 and E. coli O157:H7 infections to surrounding households and for dissemination of multiple drug resistance in humans and, potentially, the environment.

Peer Review reports

Water is the dominant component of living organisms and consumption of water is a basic requirement for survival. Access to safe drinking water is essential for human health and well being. Therefore, drinking water must be free from disease-causing organisms and poisonous chemicals. One of the Sustainable Development Goals, ‘Goal Six’, aims at ensuring availability and sustainable management of water and sanitation for all by 2030” [ 1 ]. To achieve the goal, water supply systems should be constructed or improved so that safe piped water at point-of-use is provided to consumers. Thus, a safe sanitation system should be designed and used to separate human excreta from human contact at all steps of the sanitation service chain [ 2 ].

In Addis Ababa and other cities in Ethiopia, households secure drinking water from treated municipality lines. Drinking water, however, is not sterile and low levels of microorganisms may persist in the treated water [ 3 ]. However, there were reports that drinking water at point-of-use was more contaminated than at the source in many developing countries, including Ethiopia [ 4 , 5 , 6 , 7 ]. Even worse, the prevalence of diarrheagenic bacteria was more frequent in water at point-of-use than in the public domain source water in a low-income community [ 8 ]. These findings are thus indicative of faulty drinking water distribution lines.

In Addis Ababa, it is common to see open ditches, serving as sewers, along innner roads in residential areas, to convey wastewater and rainwater away from residences. Open-ditch sewers are often blocked throughout the distribution line, and result in stagnant wastewater close to residences. This would eventually sink into the soil surrounding old, and possibly corroded and perforated, underground water distribution lines. It is reported that microorganisms in the surrounding could be sucked into drinking water distribution system by negative pressure [ 9 ], causing contaminant to pass into water distribution system as proved experimentally by Fontanazza et al. [ 10 ]. According to a study in Arbaminch, Ethiopa, faulty distribution lines could lead to the infiltration of bacterial contaminants into drinking water [ 5 ].

Several authors have isolated various pathogens from drinking water. A review by Kristanti et al. [ 11 ]. showed that pathogenic bacteria, viruses, protozoan parasites, and parasitic worms were isolated from drinking water from different parts of the world.

Isolation of Vibrio cholerae ( V. cholerae ) from environmental samples such as drinking water or sewer systems were reported from Nepal [ 12 ], Bangladesh [ 13 ], Uganda [ 14 , 15 ] and Azerbaijan [ 16 ]. Vibrio cholerae causes cholera, manifested as life-threatening voluminous and watery diarrhea and vomiting. Outbreaks of cholera in different sub-cities of Addis Ababa have been reported at different times [ 17 , 18 , 19 , 20 ]. Although the pathogen was isolated from stool specimen, none of the studies, however, isolated V. cholerae from environmental samples, except one which reported the isolation of the pathogen from two holy water samples consumed [ 20 ].

Similarly, it has been long reported that Escherichia coli ( E. coli) O157:H7 has been isolated from drinking water samples in different countries [ 21 , 22 , 23 ]. E. coli O157:H7 typically causes acute bloody diarrhea, which may lead to hemolytic-uremic syndrome. In Ethiopia, several reports indicate the isolation of E. coli O157:H7 only from meat and milk from cattle [ 24 , 25 , 26 , 27 ].

Various studies reported the antimicrobial sensitivity patterns of V. cholerae [ 28 , 29 , 30 ] or E. coli O157:H7 [ 31 , 32 ]. Multiple drug resistance was detected in a considerable proportion of isolates belonging to both species [ 33 ].

The aims of this study were, therefore, (a) to isolate V. cholerae and E. coli O157:H7 from drinking water at point-of-use and wastewater in open ditches found along innner roads in residential areas in Addis Ketema and Akaki/Kality sub-cities in Addis Ababa, Ethiopia, and (b) to determine the antimicrobial resistance levels of the isolates (c) to detect Extended Spectrum Beta-Lactamase (ESBL) producing and Carbapenem resistant V. cholerae and E. coli O157:H7 .

Materials and methods

Study area and study period.

A Cross sectional study was conducted in three woredas each of Addis Ketema and Akaki/Kality sub-cities to isolate V. cholerae and E. coli O157:H7 from drinking water and wastewater samples. Sample size was determined using simple population proportion formula.

Where: n  = sample size; Zα = risk expresses in z-score; p = expected prevalence (14%, based on 2019 Cholera outbreak); q = 1-p; d = absolute precision.

Considering a 10% non-responsive rate, the final sample size was taken as 206.

A total of 206 environmental water samples were aseptically collected from drinking water at point-of-use and surface sewerage from May to July 2023. These samples were collected from six different woredas within two sub cities in Addis Ababa (Fig.  1 ). A woreda is the smallest administrative unit in Addis Ababa. The sub cities were Addis Ketema sub city and Akaki Kality sub city. Three woredas each were selected from the two sub-cities: Woreda Three, Seven and Eight from Addis Ketema and Woreda Six, Seven and Eight were from Akaki Kality sub cities.

Map showing the study woredas in Addis Ketema and Akaki/Kality sub-cities, Addis Ababa

The study sub-cities and woredas were selected purposively based on their high incidence of cholera cases in the 2019 outbreak in Addis Ababa. The simple population proportion formula was used to determine the sample size and a total of 206 samples consisting of drinking water ( n  = 97) and wastewater ( n  = 108) were considered for this study. Study households were selected following the systematic random sampling method. Sewage samples were collected from open sewage ditches close to selected households.

All drinking water samples were collected from point-of-use taps found in a total of 97 households from all study woredas each of the two study sub-cities. A volume of 250 mL of drinking water samples was aseptically collected using 500-ml sterile narrow-necked screw capped bottle. Similarly, 250 mLof wastewater samples were aseptically collected from 108 open ditch sewer sites found along innner roads in residential areas in both sub-cities. Collected samples were immediately transported to the laboratory in an icebox. Samples were processed within two hours of collection.

Isolation of V. cholerae and E. coli O157:H7

A volume of 100 of a well-mixed sample was filtered through a 0.22-µm pore size polycarbonate filter (diameter 45 mm). The filter was placed in a 50 mL falcon tube containing 12 mL of sterile Phosphate-Buffered Saline (PBS) (OXOID) and vortexed vigorously for 5 min to suspend the attached bacteria into the saline solution.

To isolate V. cholerae , an aliquot of one mL of PBS suspension was added to an enrichment flask containing 25-ml Alkaline Peptone Water (APW) and incubated at 30-35 o C for 18–24 h [ 34 ].

Surface growth from APW was streaked on pre-dried plates of Thiosulfate Citrate Bile salts Sucrose (TCBS) agar (OXOID) and incubated at 30-35 o C for 18–24 h. All yellow colonies that fermented sucrose in TCBS agar were sub-cultured on Trypton Soy (TSY) Agar (OXOID). For cell morphology, wet mounts were examined microscopically at 40x using oil immersion. Colonies from TSY agar were also subjected to oxidase and string tests for Vibrio cholearae. Curved rods that had positive oxidase and string tests were presumptively considered as V. cholerae [ 34 ]. For serological confirmation, colonies were suspended in 0.5 mL physiological saline on a glass slide and gently mixed with a drop of antiserum for somatic O antigens by tilting the glass slide back and forth for one minute. Agglutination indicated a positive serological reaction. Serogroup O1 was similarly serotyped using type antisera.

To isolate E. coli O157:H7, 25 mL of the membrane filtered suspension was added to Phosphate Buffered Saline (PBS) and was incubated at 32 ºC for 18–24 h. The growth was directly streaked on pre-dried plates of Sorbitol MacConkey (SMAC) agar [ 35 ] and incubated at 32 ºC for 18–24 h. Non-sorbitol fermenting colorless colonies were further subjected for confirmation using E. coli O157:H7 Latex agglutination Test [ 36 ].

Antimicrobial susceptibility testing for V. cholerae O1 and E. coli O157:H7 isolates

Antimicrobial susceptibility for V. cholerae and E. coli O157:H7 was determined by Kirby-Bauer disc diffusion method on Mueller-Hinton agar plates with commercially available antibiotic discs (OXOID) The 0.5 MacFarland was maintained using a 0.85% saline suspension of fresh colony from TSA agar and by measuring it using an OXOID MacFarland spectrometer.

V. cholerae Isolates were tested against 13 antimicrobial drugs consisting of amoxycillin (AML, 30 µg), azithromycin (AZM, 15 µg), ampicillin (AMP, 10 µg), peperacilin pazobactam (TZP, 110 µg), trimethoprim/sulphamethoxazole (STX, 25 µg), meropenem (MEM, 10 µg), cefoxitin (FOX, 10 µg), tetracycline (TE, 30 µg), ciprofloxacin (CIP, 5 µg), nalidixic acid (NA, 30 µg), ceftriaxone (CRO, 30 µg), ceftazidime (CAZ, 30 µg), ceftazidime/clavulanic acid (CAZ/CLA, 30/10 µg). After an overnight incubation of Mueller-Hinton agar, the inhibition zone of each antibiotic was measured [ 37 ].

E. coli O157:H7 isolates were also tested against 12 antimicrobial drugs consisting of ampicillin sulbactam (SAM 20 µg), amoxcillin clavulanic acid (AMC 30 µg), azithromycin (AZM, 15 µg), ampicillin (AMP, 10 µg), amikacin (AK, 30 µg), gentamicin (CN, 10 µg), trimethoprim/ sulphamethoxazole (SXT, 25 µg), imipenem (IPM, 10 µg), tetracycline (TET, 30 µg), ciprofloxacin (CIP, 5 µg), ceftriaxone (CRO, 30 µg), nitrofurantoin (F 300, µg). After an overnight incubation of Mueller-Hinton agar, the inhibition zone of each antibiotic was measured [ 38 ]. E. coli ATCC 25,922 strain was used as a positive control.

In both susceptibility tests a known positive control, and a blank disc were included. After an overnight incubation of Mueller-Hinton agar, the inhibition zone of each antibiotic was measured and recorded. For interpretation, the ‘Intermediate’ values were considered as ‘Sensitive’.

The multiple antibiotic resistance index (MARI) was calculated and interpreted according to Krumperman [ 39 ] using the formula: a / b , where ‘ a ’ represented the number of antibiotics to which an isolate was resistant, and ‘b ’ represented the total number of antibiotics tested.

Determination of extended spectrum β-lactamase (ESBL) production and carbapenem resistance

Extended Spectrum Beta Lactamase (ESBL) producing V. cholerae and E. coli O157:H7 isolates was determined by using a double disk synergy test (DDST) [ 40 ]. Ceftazidime and Ceftazidime Clavulanic acid discs were employed and an inhibition zone diameter difference of ≥  5 mm between the two drugs was considered as indication of ESBL production.

To detect Carbapenem Resistance among V. cholerae and E. coli O157: H7 resistance against Meropenem and Imipenem were checked, respectively. After an overnight incubation of Mueller-Hinton agar, the inhibition zone of both antibiotics was measured and recorded. The recorded size of inhibition zone was then changed into Sensitive (S), Intermediate (I) and Resistant (R) as per CLSI-M100. Resistance against the drugs were considered ar Carbapenem Resistance.

Results and discussion

A total of 206 samples were collected from Addis Ketema (132) and Akaki/Kality (74) sub-cities. Of these, 97 (47.1%) were drinking water samples collected from point-of-use taps and 109 (52.9%) were wastewater samples from open sewers. V. cholerae O1 was isolated from 18 samples from Addis Ketema and 21 samples from Akaki/Kality sub-cities. Of the positive samples, 16 were drinking water samples and 23 were those from wastewater (Table  1 ). V.cholerae O1 isolates were dominated by Hikojima type (Table  1 ). Similar to the findings of this study, Ferdous et al. [ 7 ] detected V. cholerae in 10% of point-of-drinking water samples in a low-income urban community in Bangladesh. Similarly, the most frequently isolated V. cholerae O1 serotype from the sewage of Katmandu Valley, Nepal, was the Hikojima strain [ 12 ]. In a recent cholera outbreak in Addis Ababa, the responsible serotype belonged to the Ogawa type [ 18 ]. A review on cholera in Sub-Saharan Africa showed that Ogawa and Inaba serotypes were predominant [ 41 ]. V. cholerae O1 serotypes isolated from Kisumu county, Kenya were dominantly Inaba types followed by Ogawa [ 42 ]. According to Jubyda et al. [ 43 ], serotypes of V. cholerae O1 strains differed temporally in predominance in Bangladesh.

A total of 28 strains of E. coli O157:H7 were isolated from the total samples of wastewater and drinking water in this study. The pathogen was encountered only in one samples of drinking water and seven samples of wastewater found in two woredas of Addis Ketema sub-city. Nine drinking water and 12 wastewater samples in Akaki/Kality sub-city, however, yielded E. coli O157:H7 (Table  1 ). Other authors also reported the isolation of E. coli O157:H7 from drinking water in Bangladesh [ 44 ] and in USA and Canada [ 45 ]. Schets et al. [ 22 ] isolated E. coli O157:H7 from 2.7% of samples in the Netherlands that otherwise met the drinking water standards. Momba et al. [ 44 ] reported that about 26% of their drinking water samples were positive for E. coli O157 in South Africa. Olsen et al. [ 21 ] reported that a large outbreak of E. coli O157:H7 infection which occurred in Wyoming, USA, was significantly associated with drinking municipal water. In fact, several outbreaks due to E. coli O157:H7 were strongly linked to the consumption of drinking water [ 46 ].

Wastewater would seep into the surrounding soil, eventually finding its way into drinking water through faulty water distribution lines. Interruptions of drinking water supply in Addis Ababa occur frequently. Resumption of supply would create negative pressures that would result in a suction effect inside the pipe, and pathogens in the surrounding would be sucked into the system through pipe leaks as observed by Collins and Boxall [ 9 ]. According to Ameya et al. [ 5 ]. , incorrect cross-connection with sewer lines, interconnection with toilets, pipe corrosion, and pipe breakage could lead to the infiltration of bacterial contaminants into water distribution lines. For this reason, Rashid et al. [ 47 ] recommended the use of chlorine tablets at point-of-use tabs to effectively inactivate V. cholerae from drinking water in households.

The contamination of drinking water by sewage was reported by Kwesiga et al. [ 14 ] in Western Uganda, which resulted in prolonged community-wide cholera outbreak. Shah et al. [ 48 ] found ten leakages in the drinking water pipelines of the affected areas during a cholera epidemic, caused by V. cholerae in Lalpur town, India. El-Leithy et al. [ 49 ] isolated E. coli O157:H7 from wastewater. Outbreaks of hemorrhagic colitis were linked to wastewater containing E. coli O157:H7 [ 50 ].

(Table  1 )

Our V. cholerae O1 isolates exhibited different levels of resistance to the β-lactam antibiotics considered in this study: 100% resistance to two penicillins (Amoxicillin and Ampicillin), 51–82% resistance to the cephalosporins. About 44% of the isolates in this study were ESBL producers. Moreover, 23% were resistant to the only carbapenem, Meropenem, tested in this study and, possibly, could be carbapenemase producing strains. According to Goh [ 51 ], carbapenem-resistant Vibrio isolates have been identified in all continents and once carbapenem resistance is acquired among Vibrio isolates, the resistance genes may disseminate to other bacteria through mobile genetic elements and rapidly amplify the development of carbapenem resistance. Peperacillin/Tazobactam was the only effective β-lactam antibiotic against V. cholerae O1 in this study, because of its Tazobactam component, a β-lactamase inhibitor. (Table  2 ).

Resistance to the Cephalosporins, Ciprofloxacin, Tetracycline and the Carbapenem (Meropenem) was much higher than that reported in other studies [ 28 , 29 , 30 , 41 ].the V. cholera O1 strains in this study were, however, less resistant (69%) to Trimethprim Sulphamethoxazole than those of Garbern et al. [ 28 ] and Awuor et al. [ 42 ] which showed  ≥  99% resistance to the drug. Previous isolates of V. cholera O1 from Addis Ababa were sensitive to Tetracycline and Trimethprim/Sulphamethoxazole [ 18 ], whereas between 64% and 69% of the isolates in this study, respectively, were resistant to the two drugs.

(Table  2 )

Our E. coli O157:H7 isolates showed varying levels of resistance to the nine antibiotic classes used in the study. About 71% were ESBL producing isolates (Table  3 ). Resistance to the β-lactam antibiotic Ampicillin was 96%. High degree of resistance of E. coli O157:H7 to Ampicillin was also reported by various authors [ 31 , 32 ]. Resistance to Amoxycillin/Clavulanic acid and Ambicillin/Sulbactam was relatively lower (33% and 64%, respectively). Higher degree of resistance was, however, observed to Amoxicillin/Clavulanic Acid in other studies [ 25 , 32 ], Both Aminoglycosides (Amikacin and Gentamicin) were very effective against the isolates in this study. Similar low resistance to Gentamicin was also reported by Hamid et al. [ 52 ] and Heydari et al. [ 53 ].

However, about 9% and 86% resistance to Gentamicin were reported Heydari et al. [ 52 ] and Haile et al. [ 25 ], respectively. Resistance to the Carbapenem (imipenem) and Cephalosporin (Ceftriaxone) is building up (29% and 18%, respectively) (Table  3 ) resulting in 28.6% of Carbapenem resistance. Yandag et al. [ 54 ] and Heyderi et al. [ 51 ] detected no resistance against Imipenem. Resistance to Ceftriaxone by isolates from water sources in Nigeria was 100% [ 32 ] whereas Haile et al. [ 25 ] reported no resistance to the drug. Unlike the isolates in this study, those of Tula et al. [ 32 ] showed complete resistance (100%) to Trimethoprim/sulphamethoxazole, Ampicillin, Amoxicillin/Clavulanic Acid and nalidixic acid.

Multi-drug resistance (MDR) patterns of V. cholerae O1 and E. coli O157:H7 isolates

Our 39 V. cholera O1 isolates showed 37 different patterns of multiple antibiotic resistance against three to ten drugs. According to Jubyda et al. [ 43 ], V. cholerae strains differed in their antibiotic resistance pattern with a majority (97%) being multi-drug resistant to up to eleven of the eighteen antibiotics tested. This extreme drug resistant strain carried resistance-related genes that code for extended-spectrum β -lactamases [ 43 ]. The MAR index ranged from 0.3 to 0.8. Index values greater than 0.2 indicate that the origin of an isolate is a source where antibiotics are used to a great degree and/or in large amounts [ 39 ]. This would mean that, in the study areas considered in this study, antibiotics are accumulated in wastewater and, eventually in drinking water contaminated therewith. Igere et al. [ 55 ], determined the MDR of V. cholerae against 31 antibiotics and observed 33 MDR patterns consisting of nine to 23 drugs, with MAR index ranging from 0.03 to 0.5. Agboola et al. [ 56 ] isolated V, cholerae from hospital wastewater which showed multiple resistance against five to eight different antibiotic drugs with MAR index ranging from 0.4 to 0.6.

Although we noted 37 different patterns of multiple antibiotic resistance in V, cholerae O1 isolates, there were few repeating segments within the patterns. The most frequently appearing segments were AML/AMP/AZM (48.7%); CRO/CAZ/NA (38.5%); AML/AMP/AZM/SXT (30.7%); CAZ/CRO/NA/TE (23.1%); and AML/AMP/AZM/FOX/SXT (23.1%). The single V.cholerae O1 isolate from drinking water collected from Addis Ketema sub-city was not multiple drug resistant. Those from drinking water collected from Akaki/Kality sub-city, however, showed a higher magnitude of multiple drug resistance, mostly resistance to six to nine drugs (Table  4 ). This indicates that drinking water in distribution lines in Akaki/Kality sub-city is more prone to contamination from environmental sources.

About 89% of the E. coli O157:H7 isolates from wastewater and drinking water showed MDR against three to eight antibiotic drugs. Resistance to up to 12 drugs was reported by Tula et al. [ 32 ]. Lower proportions (31–68%) of MDR E. coli O157:H7 isolates were reported by various authors [ 24 , 25 , 32 , 50 ]. Four each of the isolates in this study were resistant to four and five drugs. Most patterns (89%) were different from one another. Five were resistant to three drugs, and the most frequent pattern was AMP/SAM/SXT.

The presence of V. cholerae O1 and E. coli O157:H7 in drinking water samples (Table  4 ) exposes residents of the study areas to recurring disease that could be fatal, particularly to vulnerable members of households. Moreover, multiple antibiotic-resistant pathogens, when introduced to the human gut, would result in further conjugal transfer of plasmids, that carry antibiotic resistance genes, to the normal gut microbiota. The gut would, thus, be a permanent source of MDR microorganisms to the individual and the environment [ 57 ]. According to Ceccarelli et al. [ 58 ], enteric pathogens release β-lactam resistant genes to the environment and V. cholerae has the ability to acquire new genetic information therefrom through horizontal gene transfer mechanisms.

An E. coli O157:H7 isolate from drinking water samples was multiple drug resistant to eight drugs. More than half were resistant only to three drugs. AMC/AMP/SAM and AMP/SAM/SXT appeared more frequently than the other patterns. Multiple antibiotic resistance index of the E. coli O157:H7 strains isolated from wastewater and drinking water ranged from 0.3 to 0.8. The MAR index of isolates from drinking water ranged between 0.2 and 0.7 (Table  4 ). Different multiple antibiotic resistance indices were reported for E. coli O157:H7: 0.2 to 0.7 [ 59 ] and 0.6 to 1.0 [ 60 ].

Similarly, the V. cholerae O1 isolates from drinking water samples collected from Addis Ketema sub-city manifested MDR against three to seven antibiotic drugs (MARI, 0.2-0.05). However, those isolates from samples collected from Akaki/Kality sub-city showed MDR against five to nine drugs (MARI, 0.4, 0.8) (Table  4 ). This indicates that drinking water in Akaki/Kality sub-city is more contaminated with MDR V. cholerae O1 strains than that in Addis Ketema sub-city.

The MAR pattern as well as the indices of all V. cholerae O1 and E. coli O157:H7 isolates, including those from wastewater samples, are given in annex 1 and 2 .

Previous cholera outbreaks were reported from all sub-cities at different times. This study addressed only a few woredas in only two sub-cities. It has, however, shown that open ditches for wastewater conveyance along innner roads in residence areas and underground faulty municipal water distribution lines could be major sources for V. cholerae O1 and E. coli O157:H7 infections to surrounding households. The isolation of both pathogens, particularly from point-of-use drinking water taps, makes the quality of municipal drinking water in the city questionable. Thus, consumers may be advised to treat drinking water immediately after collection from point-of-use taps by boiling or adding other treatment chemicals before consumption or storage. On the other hand, it is crucial to manage open sewer ditches by communities and occasionally check the integrity of drinking water distribution lines by the responsible government bodies to achieve the ‘Multi-sectorial Cholera Elimination Plan, Ethiopia 2021–2028’, which targets to end cholera by 2030 as part of the Global Roadmap [ 61 ].

Data availability

Data is provided within the manuscript or supplementary information files.

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Acknowledgements

The authors acknowledge the assistance of Dr. Girmay Medhin in statistical analysis of the data. The first author acknowledges the financial assistance by Dr. M.M.A. (Pittsburg, USA). The technical assistance from the laboratory staff of the Microbiology laboratory at ALIPB is acknowledged.

This article is part of a Ph.D. dissertation by the first author. Partial financial support was obtained from Addis Ababa University. Most expenses associated with field visits, procurement of most culture media and payment for technical assistance were borne by the first author. The authors did not receive any other funding.

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Helina Mogessie, Mengistu Legesse, Aklilu Feleke Hailu, Tilahun Teklehaymanot & Haile Alemayehu

Ethiopian Public Health Institute, Bacteriology Directorate, Addis Ababa, Ethiopia

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Center for Food Security Studies, College of Development Studies, Addis Ababa University, Addis Ababa, Ethiopia

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H.M.: Conceptualization, Methodology, Data Collection, Investigation, Analysis, Writing – Original Draft. M.L.: Conceptualization, Supervision, Review & Editing. A.F.: Review & Editing. T.T.: Conceptualization, Supervision, Review & Editing. H.A.: Methodology. R.A. Methodology. M.A. Conceptualization, Methodology, Analysis, Supervision, Writing, Review & Editing.

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Mogessie, H., Legesse, M., Hailu, A.F. et al. Vibrio cholerae O1 and Escherichia coli O157:H7 from drinking water and wastewater in Addis Ababa, Ethiopia. BMC Microbiol 24 , 219 (2024). https://doi.org/10.1186/s12866-024-03302-8

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Assessment of occupational exposure to lead among workers engaged in a city bus garage in Addis Ababa, Ethiopia: a comparative cross-sectional study

• Merihatsidik Tesema Abebe 1 ,
• Abera Kumie 2   na1 ,
• Samson Wakuma Ayana 2   na1 ,
• Teshome Assefa 3 &
• Wossenyeleh Ambaw 4  

Journal of Occupational Medicine and Toxicology volume  19 , Article number:  26 ( 2024 ) Cite this article

Metrics details

Lead is one of the most nonessential toxic heavy metal agents found in automotive garages. The occupational exposure of garage workers to lead commonly poses acute and chronic health risks that can be prevented. In Ethiopia, there have been limited studies on lead exposure among garage workers, who overemphasize exposure to lead. This study aimed to assess occupational blood lead levels and associated factors in garage workers using a cross-sectional comparative design.

A comparative cross-sectional study design was used to compare the occupational blood lead levels of 36 randomly selected garage workers and 34 office workers who were matched by age and sex. Blood specimens were collected by trained medical laboratory experts. The collected blood samples were tested in a certified laboratory using a microwave plasma atomic emission spectrometry (MP-AES) device at a wavelength of 405.78 nm. Excel and SPSS Version 26 were used for data management and analysis, respectively.

The mean (SD) age of the exposed group was 39.0 (7.5) years, whereas the mean age of the unexposed group was 38.0 (6.1) years. The occupational mean (SD) blood-lead-level in the exposed groups was 29.7 (12.2) µg/dl, compared to 14.8 (9.9) µg/dl among the unexposed groups. The mean blood-lead level among the exposed workers was significantly different from that among the unexposed workers ( P  < 0.01). Of all the study participants, only 22.2% of the exposed groups had blood lead levels higher than the World Health Organization’s recommended limit of 40 µg/dl. The main significant predictors of occupational blood-lead-level exposure among workers were extra working hours, service years, and having a previous (prior) employment history in a garage. The occupations of the two groups did not significantly differ in terms of blood-lead levels ( p  > 0.05).

Conclusions

The BLL of the Garage workers was significantly greater than that of the Non-Garage workers. Hence, it is advised that garage management should encourage workers to use exposure prevention methods, such as washing their hands before eating and taking showers after the completion of work, by providing regular occupational safety training.

Introduction

Around the world, from small to large garage sites, most garage workers are occupationally exposed to heavy metals. One of the most nonessential and harmful types of heavy metals for public health concerns that is still found in occupational work and the environment is lead. Lead is commonly observed as an occupational hazard for workers who are working in painting, welding, battery maintenance, mechanics, and electricity [ 1 , 2 ]. Garage workers are more exposed to lead than non-garage workers. However, millions of people are exposed to lead through inhalation, ingestion, and skin contact pathways that occur in workplaces and in the environment [ 1 , 3 ]. Exposure to lead particles poses significant health problems for workers and affects the reproductive health system, leading to conditions such as memory impairment, kidney failure, intestinal and lung cancer, central nervous system disorders, anaemia, hypertension, and other conditions [ 4 , 5 ]. The 2019 Institute for Health Metrics and Evaluation (IHME) estimation report indicated that lead exposure caused 900,000 deaths annually and 21.7 million years of loss of health (also known as DALYs) due to its long-term impact on health [ 6 , 7 ]. Given this burden, limited effective occupational health treatments exist for 20–50% of workers in industrialized countries and 5–10% of workers in developing countries [ 8 ]. However, more people die each year from occupational diseases and injuries than from malaria, with nearly 2 million deaths worldwide each year. Most workers are susceptible to lead exposure due to environmental and occupational exposure, in addition to a lack of safety training and awareness, the inability to use personal protective equipment (PPE), and spending more time at work [ 9 ]. Hence, to prevent inhalation or ingestion of occupational lead among garage workers, PPE, hygiene and sanitation practices, ventilation, and regular checkups are necessary and available to reduce the transmission of occupational lead dust, fumes, and other particulate matter in the workplace.

Studies around the world indicated that automotive workers in developed countries checked their blood lead levels regularly, while garage workers who were working in developing countries, including Ethiopia, did not test their blood lead levels due to ineffective regular provisions to monitor the exposure regularly [ 10 , 11 ]. It was also observed that the garage workers did not use PPE or safety measures while they were working. The probability of garage workers being exposed to lead is greater than that of non-garage workers [ 1 , 5 , 12 ]. According to a previous study conducted in Khyber, Pakistan, the mean measured blood lead level in exposed groups was 65.3 ± 41.9 µg/dl, whereas in the non-exposed groups, it was 21.7 ± 17.6 µg/dl [ 1 ]. Consequently, the BLL is a biomarker of blood, hair, urine, teeth, or other body parts [ 1 , 5 , 13 , 14 ].

In Addis Ababa, Ethiopia, there is only one large Anbessa city bus service enterprise that provides transport services in and around the city of Addis Ababa. Four bus garage sites are located in four different sub-cities of Addis Ababa. Occupational lead exposure studies have been conducted among garage workers at these sites. Some studies on the occupational lead exposure of automotive workers conducted in Jimma and Harer, Ethiopia, did not include workers working at Anbessa city bus service enterprise (ACBSE) garage sites [ 5 , 12 ]. In Jimma town, the mean blood lead level (BLL) of automotive garage workers was 19.75 ± 4.46 µg/dl, which was significantly greater than that of non-exposed workers (mean blood lead level 10.73 ± 2.22 µg/dl). However, the study did not divide the garage workers into groups of workers working mechanistically, painters, welders, or electricians. A study conducted in Harar, Ethiopia, in 2018 measured the blood pressure and hematological parameters of the garage workers, which did not indicate the exposure of lead levels in the blood. In another study that was conducted in Addis Ababa, Ethiopia, only urinary δ-ALA levels and not lead exposure levels were measured in the blood of lead acid battery repair workers [ 15 ]. Since exposure lead levels in the blood have a half-life of 40 to 120 days but remain in bones for a long time, constituting, on average, 95% of the body’s total lead burden, measuring blood lead levels is typically a valid indicator of lead exposure in the workplace [ 16 ].

Thus, the purpose of this study was to assess the exposure of blood lead levels and their associated factors in Anbessa city bus service (ACBSE) garage workers in Addis Ababa, Ethiopia, by comparing them with non-exposed groups from non-garage sites.

Materials and methods

Study area and period.

The study was carried out in Addis Ababa, Ethiopia, among garage workers at four Anbessa City Bus Service Enterprise (ACBSE) garage sites by comparing them to non-garage workers from March to September 2023. The Enterprise is one of the oldest and largest modern public services in the city. It has approximately 590 garage workers. The Enterprise was established 80 years ago, during Emperor Haile Selassie’s reign. Currently, it has four standard garage sites at Yeka, Gulelle, Nefas Silk, and Akaki-Kality Sub-cities of Addis Ababa (Fig.  1 ).

Study area of the anbessa bus city service enterprise garage sites in four sub-cities of Addis Ababa, Ethiopia

Study design and study subjects

A comparative cross-sectional study of Anbessa City bus service enterprise garage workers and non-garage workers who are working at the Ethiopia Public Health Institute (EPHI) as office workers was conducted. Blood samples were taken from 36 occupationally exposed garage workers (31 males and 5 females) and 34 occupationally unexposed office workers (28 males and 6 females) for blood lead level analysis.

Inclusion and exclusion criteria

Garage workers involved in one of the following job positions—mechanics, electricians, welders, or painters—had at least one year of work experience in garage work. Workers with a previous history of chronic cases, such as diabetes or hypertension, and those who were following their health status in hospitals and rotating from one job position to another were excluded. The unexposed groups were randomly selected as a comparison group if they did not have any previously intended occupational lead exposure history and had approximately matched demographic characteristics, particularly age and sex, as exposed groups.

Sample size

The sample size was calculated using a double-mean-standard deviation comparison formula.

According to a previous study, the mean ± SD was 0.42 ± 0.13 µmol/L in the exposed groups, and the mean ± SD was 0.32 ± 0.07 µmol/L in the unexposed groups [ 17 ]. The open Epi version 3 software calculator was used to estimate the sample size with a specified significance level (0.05) and power (95%) for both the exposed and non-exposed groups. In the first calculation, we obtained n 1  = 29 and n 2  = 29 sample sizes. By adding a 15% nonresponse rate, the calculated sample sizes were n 1  = 34 and n 2  = 34. However, using the approximate proportional allocation technique of the 34 calculated sample sizes to the total population size, 36 garage workers were occupationally exposed for this study.

Selection of exposed groups

Before sampling the participants at the garage sites, a preliminary assessment was conducted to check the functionality of the Anbessa City Bus Service Enterprise garage sites and the availability of workers. At that time, 590 occupational garage workers were working at four sites in the Anbessa City Bus Service Enterprise (ACBSE). Of these 590 garage workers, only 530 fulfilled the inclusion criteria and were used for the sampling frame. However, the proportional allocation method was conducted based on the 34 calculated sample sizes for each occupational job position (mechanics, electricians, painters, and welders) of the garage workers, and 36 sampled garage workers were selected randomly (Table  1 ).

Selection of unexposed groups

Unexposed groups were selected from among office workers who were working at the Ethiopian Public Health Institute in Addis Ababa, Ethiopia, for comparison purposes. The comparison group was considered to not have a history of chronic cases of lead exposure and was matched for age and sex as garage workers. According to the Institute’s human resources record, some of the office workers were working as supportive staff, and others were health professionals. From these lists, those who fulfilled the inclusion criteria were identified as the unexposed group. The EPHI has a total of 500 health professionals and 300 supportive staff members. However, of all office workers, only 300 health professionals and 200 supportive staff members fulfilled the inclusion criteria and were used for the sampling frame. With a proportional allocation technique of the 34 calculated sample sizes for each occupational job position, 34 unexposed groups were randomly selected for this study (Table  1 ).

Reagents and laboratory glassware

Five series of analytical standard solutions of lead were prepared—20 (µg/dl), 40 (µg/dl), 60 (µg/dl), 80 (µg/dl), and 100 (µg/dl)—by serially diluting a 1000 mg/L commercial stock calibration standard solution of lead. All chemicals and reagents used in the laboratory were of analytical grade.

Blood sample collection

Four-milliliter venous blood samples were collected from each of the 36 occupationally exposed workers and from each of the 34 occupationally unexposed workers using Pb-free, separate labelled vacationer tubes containing 7.2 mg of K2EDTA by trained medical laboratory professionals. To reduce the contamination of samples, the enterprise clinics and other safety materials were used as blood collection sites. The properly collected samples were transported to the EPHI laboratory using a cold box, stored at 4 °C and preserved at -20 °C until the digestion time of analysis.

Sample preparation

After accurate measurement, a 2 ml portion of each whole-blood sample was transferred to a digestion beaker, and 10 ml of a freshly prepared mixture of concentrated nitric acid and hydrogen peroxide (HNO 3 (70%) and H 2 O 2 (30%) (6:4 v/v)) was added, and the mixture was allowed to stand for 10 min. The beakers were covered with a watch glass and then heated at 110 °C for 1–2 h. The digests were again treated with a few mixtures of HNO 3 and H 2 O 2 while increasing the hotplate temperature to approximately 250 °C until digestion or a clear solution was obtained. The excess acid mixture was evaporated until the clear solution remained approximately semidry. Then, we cooled and filtered each clear solution and transferred it to a volumetric flask (100 ml) by diluting it to the mark with deionized water. At the same time, blanks (without samples) were prepared in triplicate using deionized water. Finally, each prepared clear solution was stored and refrigerated at -4 °C until laboratory analysis. The procedures for sample preparation were based on the National Institute of Standards and Technology (NIOSH) fourth edition Manual for Analytical Methods (NMAM) on Method 8005 Issue 2 (1994) and validated published literature [ 1 , 18 , 19 ].

Blood lead level analysis

After the instrument parameters were optimized, the lead levels in the blood of the study subjects were measured by microwave plasma atomic emission spectroscopy (MP-AES) with an Agilent Model 4210 spectrophotometer at 405.781 nm. The low detection limit (BDL) of the instrument for reading the sample was at or above the 0.1 µg/dl detection limit. At this level, the instrument cannot read the sample. The calibration curve of the instrument was generated by running five series of standard solutions of lead. Triplicate samples were analysed, and the average results for each measured sample were taken. A recovery test was performed on four prepared blood samples by selecting randomly from the spiked and unspiked samples with a known sample solution. Then, 99.6% of the average percentage recovery was obtained within the recovery range (80–110%) of the samples [ 1 , 20 ]. In addition to the EPHI-accredited laboratory, another cross-checking Ethiopian Food and Drug Authority (FDA) laboratory was used to check the accuracy and precision of each sample result.

Data collection on exposure factors

In addition to measuring the occupational blood lead level exposures of the study participants, data on socio-demographic factors, behavioural factors, and occupational factors of respondents were collected using an interviewer-administered pretested questionnaire. The questionnaire was designed to provide information on factors associated with the measured occupational blood lead levels by preparing it in English and translating it to a local language for those who do not understand English. The questionnaire was back-translated to English for consistency checking.

Statistical processing and analysis of data

All the data were cleaned and managed in Excel and analysed using the Statistical Package for Social Science (IBM SPSS, Chicago, America) (SPSS version 26) software. Descriptive statistics were used to display the demographic, behavioral, and occupational characteristics in the form of frequencies, means, and percentages. An independent t test was used to compare the statistically significant differences between the exposed and unexposed groups in terms of occupational exposure to blood lead. One-way ANOVA was used to investigate the variation in blood lead levels with specific occupational job positions (mechanics, electricians, welders, and painters) of the study participants, such as workers.

Variables were selected for multiple linear regressions by first conducting a simple linear regression of the dependent variable (BLL) with each independent variable (service years, age, extra working hours, and other independent variables). Then, we selected only variables that had a p value less than 0.2 for multiple linear regression analysis. Multiple linear regression analysis was used to determine the effect of independent factors on the occupational blood lead level of the study participants by considering a p value < 0.05 to indicate statistical significance. However, before applying the regression method, all assumptions for linear and multiple regressions were checked. Diagnostics for multicollinearity among the independent variables were performed using the variance inflation factor. Independent variables with variance inflation factor values > 10 were considered indicative of multicollinearity and removed from the multiple linear regressions.

Socio-demographic characteristics of the study participants

A total of 70 respondents (36 garage workers and 34 office workers) were available for the data analysis. The socio-demographic characteristics of the respondents are presented in Table  2 . The mean age of the exposed group was 39.0 ± 7.5 years, ranging from 27 to 50 years, compared with that of the unexposed group; the mean age was 38.0 ± 6.1 years, with a range of 28 to 49 years. Among the study participants, 86.1% and 82.4% were males in the exposed and unexposed groups, respectively. There were more (80.6% and 79.5%) married than single (19.4% and 23.5%) individuals in the exposed and unexposed groups, respectively. The majority (58.3%) of the exposed groups had diplomas compared to the majority (85.3%) of the unexposed groups who had degrees and above. According to Ethiopian Birr, the majority (72.2%) of the exposed group and 91.2% of the unexposed group were paid a monthly income above 6,000 .

Behavioural characteristics of exposed groups

Regarding PPE users, 17 (47.2%) participants in the exposed group did not use any type of personal protective equipment, as they reported. Of all the exposed groups who were working in garage sites, only 14 (38.9%) were not aware of lead exposure, while 22 (61.1%) of the exposed groups were aware of lead exposure. There were 14 (38.9%) participants in the exposed group who had received safety training. Among the exposed individuals in this study who used exposure prevention methods such as washing their hands before eating and taking showers after the completion of work, 21 (58.3%) were exposed. In terms of addiction habits (drinking alcohol), 15 (41.7%) of the exposed groups were dependent on consuming alcohol during work and after-work activities. According to the overall reporting of the study participants, 24 (66.7%) of the exposed groups did not follow occupational health and safety rules and regulations (safety practices) in the workplace. Of all participants in this study, approximately 31 (86.1%) of the exposed groups had a previous (prior) history of employment at other garage sites (Table  3 ).

Occupational job positions of the study participants

The higher and lower mean blood lead levels per occupational job position of the exposed groups were 35.5 ± 8.3 µg/dl and 24.1 ± 10.7 µg/dl, respectively. However, according to one-way ANOVA, there were no statistically significant differences ( p  > 0.05) in the mean blood lead levels per occupational job position among the mechanics, electricians, welders, or painters among the study participants (Table  4 ).

Comparison of blood lead levels among the study participants

According to the independent sample t test, there was a significant difference between the exposed and unexposed groups (t (68) = 5.6, p  < 0.001), with the mean blood lead level in the exposed group (M = 29.7, SD = 12.2, median = 27.5, and range = 6–52.5) µg/dl being greater than that in the unexposed group (M = 14.8, SD = 9.9, median = 15, and range = BDL-32.5) µg/dl). The magnitude of the two groups’ mean difference (mean difference = 14.9, 95% CI: 9.6 to 20.2) was statistically significant (Table  5 ).

According to the one-way ANOVA, there were highly significant differences in the normal, acceptable, and dangerous blood lead levels among the exposed groups ( p  < 0.001). The mean blood lead levels of the exposed groups in the normal (5.6%) and dangerous (22.2%) BLL category ranges were 6.8 ± 1.1 and 46.9 ± 3.9 µg/dl, respectively, whereas in the normal (332.4%) and acceptable (67.6%) ranges of BLL, the mean blood lead levels of the unexposed groups were 3.3 ± 3 and 20.3 ± 6.7 µg/dl, respectively, with a highly significant difference ( P  < 0.001) between the normal and acceptable ranges of the unexposed groups (Table  6 ).

Factors associated with the blood lead level of the study participants

According to multiple linear regression analysis, the combined significant effects on the blood lead level of the exposed groups according to the general model summary result were R 2  = 0.856, adjusted R 2  = 0.798, F [ 10 , 25 ] = 14.87, p  < 0.001. However, some predictors, such as extra working hours, service years, and previous (prior) employment in a garage, had a statistically significant effect on the increase in lead exposure. The mean blood lead levels of the exposed groups during extra working hours, service years, and previous (prior) employment in a garage increased by 3.8 µg/dl, 0.8 µg/dl, and 7.6 µg/dl, respectively, but other predictors had no direct impact on lead exposure (Table  7 ).

A few studies on occupational exposure to blood lead levels among automotive garage workers were carried out previously in Jimma and Harar, Ethiopia [ 5 , 12 ]. However, the blood lead levels of Anbessa City Bus Service Enterprise garage workers in Addis Ababa, Ethiopia, have not been studied previously. Hence, the results obtained in this study showed that the mean blood lead level (29.7 ± 12.2) 𝜇 g/dl in the exposed group was significantly greater than the mean blood lead level (14.8 ± 9.9) 𝜇 g/dl in the unexposed group ( p  < 0.001). These findings were similar to those of studies conducted in Pakistan and Nearby Addis Ababa-Adama Highway; however, these results were greater than those of studies conducted in Jimma, Ethiopia, for both exposed and unexposed groups [ 1 , 5 , 21 ]. The possible difference in this study could be due to differences in sample size, additional working hours, workload, lack of occupational safety training, and the nature of the working environment.

The World Health Organization (WHO) recommended that the health-based maximum individual biological action levels of male and female workers be 40 µg/dl and 30 µg/dl, respectively [ 22 ]. However, this study revealed that 22.2% of the exposed groups had blood lead levels that exceeded the maximum recommended blood lead level limit by the WHO, but this percentage did not exceed that of the unexposed group [ 22 ]. The World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) also recommended that the blood lead level standard limit of the general population be 10 µg/dl [ 22 , 23 , 24 ]. However, when we compared the blood lead levels of the study participants from the general population, 34 (94.4%) of the exposed and 23 (67.6%) of the unexposed groups of BLLs were above the general population’s BLL recommendation limit [ 22 , 23 ]. The Occupational Safety and Health Administration (OSHA) and other agencies categorized the blood lead levels of workers into three stages: <10 µg/dl, 10–40 µg/dl, and > 40 µg/dl were considered normal, acceptable, and dangerous, respectively [ 25 , 26 ]. However, when we compared both exposed and unexposed groups to OSHA and other agencies, 26 (72.2%) and 2 (5.1%) exposed and 23 (67.6%) and 13 (17.8%) unexposed groups were found to be in acceptable and normal ranges, respectively, but the maximum recommended blood lead level limit was 40 µg/dl [ 22 , 27 ]. Compared with the National Institute for Occupational Safety and Health (NIOSH) standards, blood lead levels exceeded the recommended standard blood lead level limit of 5 µg/dl for approximately 57 (81.4%) of all study participants [ 28 , 29 ]. However, the average blood lead levels (29.7 ± 12.2 µg/dl) of the exposed group and (14.8 ± 9.9 µg/dl) of the unexposed group were less than those of the OSHA (40 µg/dl), the European Union Scientific Committee on Occupational Exposure (30 µg/dl), the American Conference of Governmental Industrial Hygienists (30 µg/dl), and the WHO (40 and 30 µg/dl) recommended blood lead level limits for males and females, respectively [ 22 , 30 ]. This indicates that in Ethiopia, there are no well-known blood lead level standard limits for occupational workers since Ethiopia follows the WHO and International Labour Organization (ILO) occupational and safety guidelines. In our study, statistically significant differences were not found between the occupational job positions of the exposed groups. A similar study conducted in Pakistan and Jimma, Ethiopia, did not find a statistically significant difference in occupational job positions [ 1 , 31 ]. A possible explanation is that most automotive workers who were engaged in different occupational job positions in garages were affected by homogeneous lead exposure levels.

The main predictors of blood lead levels were analysed using multiple linear regressions. However, extra working hours, service years, and previous (prior) employment in a garage were the main statistically significant predictors and had 79.8% combined significant effects on the blood lead level of the exposed groups. A similar study reported that in Nigeria, the operation time was associated with a significant increase in blood lead levels according to automobile mechanics [ 9 ]. Similarly, studies conducted in Jimma, Ethiopia, and Iran have shown that exposure to blood lead has a direct relationship with additional working hours [ 2 , 31 ]. This could be explained by the fact that extra working hours and a long duration of service were important factors in occupational lead exposure. As a result, workers who have been working in garages for long periods/years might be affected by acute and chronic health risks. This indicated that extra working hours and service years of exposed groups positively increased the exposure of blood lead levels of workers. In a similar study conducted in Nigeria, Harar, and Jimma, Ethiopia, long service years for automotive workers had adverse health effects on lead exposure [ 5 , 9 , 12 ]. However, in other studies that were conducted on the Addis Ababa-Adama Highway and Iran, service years had no direct significant effect on blood lead levels [ 21 , 32 , 33 ]. This difference might be due to the presence of lead exposures that can come from different environmental media (air, water, and soil) and the duration of work hours. Thus, non-garage workers and garage workers may be exposed to lead through the air they breathe, the water they drink, the foods they eat, and the surface materials they contact. The other significant variable that affected the blood lead level was a previous (prior) history of employment at other garage sites. Several studies have shown that garage workers are usually more affected by lead exposure than non-garage workers are [ 5 , 12 , 17 , 34 ]. The production and recycling of lead-acid batteries, paints, soldering, and electronic wastes were greater at the garage sites than at the non-growth sites. As a result, most garage workers in devolving counties are currently exposed to lead and have experienced short- and long-term adverse health effects.

In this study, there was a significantly greater mean blood lead level in the garage workers than in the non-garage workers. Blood lead levels exceeded the blood lead limits recommended by the WHO and OSHA (40 µg/dl) for approximately 22.2% of the exposed groups. Extra working hours (more than 8 h per day), a long duration of service and prior employment at garage sites were found to be the main significant predictors of elevated blood lead levels among garage workers. Thus, workers who are working in garage sites require more attention to safety training and preventive mechanisms to reduce exposure to lead and improve the hygiene practices of workers in each working department. Finally, regular checkups and longitudinal studies at the national level with large sample sizes are highly recommended.

Data availability

All the data analysed during this study are included in this article. The data that support the findings of this study are also available from the corresponding author, and the data are available at any time to the journal when a reasonable request is needed.

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Acknowledgements

I would like to thank Abera Kumie (PhD) and Samson Wakuma (PhD) for their moral support and continuous advice on this research. My appreciation and thanks also go to the School of Public Health, Addis Ababa University, for providing ethical clearance for this study. Finally, I would like to extend my thanks to Anbessa City Bus Service Enterprise as well as the data collectors, supervisors, study participants, and Ethiopian Public Health Institute and Ethiopian Food and Drug Authority (FDA) for all their cooperation and permission to perform this research.

No particular funds were available for this research; however, the Environmental and Occupational Health Department of the School of Public Health, Addis Ababa University, and the NORAD project supported this research for data collection and analysis.

Author information

Abera Kumie and Samson Wakuma Ayana contributed equally to this work.

Authors and Affiliations

Department of Public Health Emergency Management Center, Ethiopian Public Health Institute, Addis Ababa, Ethiopia

Merihatsidik Tesema Abebe

Department of Preventive Medicine, School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia

Abera Kumie & Samson Wakuma Ayana

Department of Health Nutrition, Ethiopian Public Health Institute, Addis Ababa, Ethiopia

Teshome Assefa

Department of Food Science, Ethiopian Food and Drug Authority, Addis Ababa, Ethiopia

Wossenyeleh Ambaw

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The first author contributed to the study design, data collection, data analysis, interpretations of the results, and manuscript preparation. The second authors contributed to the study design, continuous comments on data collection and analysis, and manuscript review. The third and fourth authors contributed to laboratory testing and analysis, and the authors participated in the conception or design of the study; the acquisition, analysis, or interpretation of data for the work; and the drafting of the work or critical revision of the manuscript for important intellectual content. However, all the authors have read and approved the final version of the manuscript.

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Correspondence to Merihatsidik Tesema Abebe .

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The study was conducted according to the guidelines of the Declaration of Helsinki ethical principles for medical research involving human subjects [ 35 ], and ethical approval was obtained from the Ethical Review Board Committee of Addis Ababa University, School of Public Health (Ref. No.: SPH/154/23). After providing informed consent from each participant, trained and experienced medical laboratory experts collected blood samples using safe and disposable materials.

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Abebe, M.T., Kumie, A., Ayana, S.W. et al. Assessment of occupational exposure to lead among workers engaged in a city bus garage in Addis Ababa, Ethiopia: a comparative cross-sectional study. J Occup Med Toxicol 19 , 26 (2024). https://doi.org/10.1186/s12995-024-00422-9

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DOI : https://doi.org/10.1186/s12995-024-00422-9

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