After months of prevention and response activities by the Government of Ethiopia, the World Health Organization (WHO) and other partners, the acute watery diarrhea (AWD) outbreak in Somali Region is showing signs of decline. Intensified risk communication, effective surveillance, and improvements in water, sanitation and hygiene (WASH) and case management contributed to the decline. 

Engaging communities allowed response teams to understand the power relations, influencers and preferred communication channels in the Somali Region. Clan heads, religious leaders, woreda and kebele administrators, and men generally wield a lot of influence in the communities.

A recent case control study conducted by the Somali Region Health Bureau, the US Centers for Disease Control and Prevention (CDC) and WHO in Jigjiga Town, the region’s capital, found most people in the region relied on information from neighbours and community leaders about AWD much more than radio or television. Knowing with whom and how to share key messages about AWD was essential to curbing the outbreak.

Additionally, the clear and elaborate administrative system in Somali Region, and throughout Ethiopia, is suitable for implementing effective community engagement. Ethiopia is divided into nine regions and two special city administrations. Each region is geographically divided into zones made up of administrative districts known as woredas. Woredas are further divided into kebeles and sub-kebeles which are the smallest administrative units.  

Each woreda has a Social Mobilization Team is supported by a Health Extension worker who cascades key messages and desired preventive behaviours to kebeles and sub-kebeles. Health Extension workers further cascade messages and desired behaviors to households and individuals through the 1-to-5 networks (five persons organized under one leader). 

The joint WHO/UNICEF Risk Communications team working with the Regional Health Bureau, community leaders and local information networks used these structures to share six key messages with communities, households and individuals through leaflets, posters and practical demonstrations in the local Somali language: 

1. Wash your hands before cooking, before eating, and after using the toilet
2. Cook food properly, keep it well and eat it while still hot
3. Boil or chlorinate drinking water to make it safe
4. Always drink safe water
5. Come to the health care facility as soon as possible in case of acute watery diarrhea
6. Start drinking Oral Rehydration Salt (ORS) at home and during travel to the health care facility

When reports of AWD cases increased in four kebeles, the teams intensified community engagement in these localities contributing to a reduction in cases. They also identified some challenges. For example, a high awareness of AWD exists, but this was not adequately matched by taking actions to effectively control the occurrence and recurrence of the disease.

The main reason for low compliance with the WASH messages was shortage of water, particularly in arid rural areas, where people must choose between using their meagre water supply for drinking, food preparation or for sanitary purposes. In Somali Region, as in other places undergoing severe drought, shortage of safe water remains an important factor in AWD prevention and control.

There are knowledge gaps that require direct community engagement regarding the safety of water treatment chemicals, poor eating behaviors and sanitation practices. Some people live in “hard-to-reach” areas, requiring extra effort and different targeting strategies to reach them with AWD messages.

Overall community engagement using individual counselling, house-to-house mobilization, community meetings and use of religious institutions are proving invaluable in mobilizing communities for AWD action. Most importantly, community leaders in the region now appreciate that community engagement is their responsibility and that it has to continue even after AWD comes to an end.

For community engagement activities to bring about lasting change, they need to be complemented with other interventions including the provision of safe water, adequate supply of water treatment tablets and construction of latrines. This requires a multi-sectoral response and coordination between various stakeholders in the health and water management arenas.