Combining Cornerstone Interventions to Prevent Diarrhea: Ethiopia lessons

Background: Diarrhea accounts for over 100,000 child deaths in Ethiopia annually. Prevention is the best first-line strategy based on several key hygiene and sanitation practices coupled with optimal feeding practices. When prevention fails, effective use of increasing ORT and feeding will decrease diarrhea-related deaths. The Government of Ethiopia undertook an ambitious Health Extension Program in 2003, placing a new cadre of two paid women health extension workers (HEW) in every village, focused on health promotion. An action-based community mobilization effort was developed to maximize this new program's potential to change household health practices.

Design and Evaluation Methods: USAID-funded Essential Services for Health in Ethiopia (ESHE) project supported the creation of a cadre of over 21,000 volunteer Community Health Workers (vCHW) living in 52 districts of southern region serving 6 million people. Volunteers were trained to help HEW reach their preventive health goals. A combination of child health topics including several diarrhea-prevention cornerstone interventions was included in the package: latrines, optimal breastfeeding and complementary feeding, oral rehydration therapy, hand-washing after defecation and before preparing food, diarrhea danger signs, and appropriate care-seeking.

A quasi-experimental design was used to evaluate the project using cross-sectional household surveys at baseline in 2003/04 and end-line in 2008 including 900 households in intervention areas and 900 households.

Results/Outcome: End-line results demonstrated highly significant increases in a set of key indicators across diarrhea prevention and treatment. Pit latrines increased from 35% to 82%; exclusive breastfeeding increased from 58% to 76%; timely complementary feeding increased from 61% to 83%; ORS increased from 21% to 36%; women increased fluids and breast-feeding to children with diarrhea from 6% to 40%. Two-week incidence of diarrhea decreased from 25% to 15%. ESHE supported zones demonstrated significant step-wise increases beyond overall regional improvements.

Conclusions: World-wide trends of diarrhea prevention and treatment rates are slipping. Ethiopia offers important lessons on how to scale-up traditional cornerstones.. Investing in community health workers is paying off in Ethiopia. Other countries short on trained human resources for health should consider Ethiopia's Health Extension Program and the companion volunteer CHW program to reach their MDGs.