Functional difficulty among children and adolescents aged 5-17 years in Ethiopia: Multilevel analysis of the nationally representative 2024-2025 DHS

Background: Population-based data on functional difficulty among school-age children in Ethiopia are scarce. The 2024-2025 Ethiopia Demographic and Health Survey (EDHS) included, for the first time, the UNICEF/Washington Group Child Functioning Module (CFM) for children aged 5-17 years. We estimated the prevalence and domain distribution of functional difficulty and associated factors in Ethiopia. Methods: We analysed cross-sectional EDHS data from 11,122 children aged 5-17 years (weighted n = 10,726) and 4,739 mothers. Functional difficulty was defined as "a lot of difficulty" or "cannot do at all" in any of 11 domains, or daily anxiety or depression. We estimated design-based prevalence and fitted multilevel logistic regression models (children within mothers within clusters) for any, non-affective and affective difficulty. Interviewer effects were examined with random-intercept models and within-cluster comparisons. Results: Overall, 9.5% (95% CI 8.1-11.1) of children had functional difficulty. Daily depression (6.8%) and anxiety (6.6%) dominated, and 70.3% of affected children had only affective difficulty. Difficulty in at least one non-affective domain affected 2.8% (2.2-3.7), with each domain at 0.5-1.4%. Prevalence ranged from 1.5% in Southwest Regional State, Ethiopia, to 16.5% in Oromia Regional State. In adjusted models, children not attending school had higher odds of non-affective difficulty (AOR 2.82, 95% CI 2.01-3.96), and girls had lower odds (AOR 0.63, 0.48-0.84). Outcomes clustered strongly within families (sibling correlation 67.7%) and clusters (ICC 20.9%). Six of 163 interviewers (7.9% of the weighted sample) contributed 58.2% of weighted cases of daily anxiety or depression; in the same clusters they recorded daily symptoms for 56.4% of children, against 2.1% for other interviewers. Excluding 11 statistically outlying interviewers reduced the prevalence of any difficulty to 4.6% (3.6-5.8) and of daily anxiety or depression to 3.3%. The associations with school non-attendance and sex were unchanged. Conclusions: Functional difficulties across the sensory, physical, cognitive, and affective domains, including anxiety or depression, affect about 2-3% of Ethiopian children aged 5-17 years and are strongly associated with being out of school. Appropriate interventions and resource allocation should be considered.