Increasing Autism Awareness Among Rural Community-Based Health Extension Workers in Ethiopia: The Health Education and Training+ (HEAT+) Project

Background: In rural Ethiopia basic health services are provided by 39,000 community-based health extension workers (HEWs) serving a population of 73 million. Most HEWs only received basic health training not encompassing mental health. Recently a first cohort of HEWs upgraded their training using the Health Education And Training (HEAT) programme developed by The Open University UK in collaboration with the Ethiopian Federal Ministry of Health (FMoH), UNICEF and AMREF. HEAT provided HEWs with training in mental health and childhood developmental problems for the first time, although specific autism training was limited.  

Objectives:  i) Compare knowledge regarding autism and general mental health in HEWs who completed HEAT training and HEWs who were not yet trained; ii) identify remaining gaps in the knowledge of HEAT-trained HEWs.

Methods: Participants included 108 HEWs who had recently completed the HEAT upgrading programme and 266 HEWs who were not yet trained. All HEWs were female; both groups had similar age (mean 25.78 vs. 25.82 years), work experience length (mean 74 vs. 70 months) and distribution of religious affiliations. Both groups completed a survey including an autism case vignette, followed by questions on autism characteristics, its causes and possible treatments (adapted from the Autism Survey; Stone, 1987). The survey also asked general feedback on the HEAT materials (from those already trained) and the importance of mental health and childhood developmental problems.

Results: HEAT-trained HEWs were less likely than non-trained HEWs to attribute autism to a curse, to think that autism is contagious, can be cured by spiritual or traditional treatments, or that autism symptoms can improve by beating the child (all p<.01). However, the majority of HEWs in both groups thought children with autism are deliberately disobedient (69% vs. 75%; p>.05) and that autism can be caused by unloving parents (72% vs. 69%; p>.05). HEAT-trained participants were more likely to regard mental health (p=.003) and childhood developmental problems (p=.007) as very important. The majority (69%) of HEAT-trained HEWs indicated that they apply the training at least once a month in their job; since finishing the training 36% of them had organised one or more mental health awareness raising meetings in their community. Yet, most (74%) HEAT-trained participants indicated they would like more training on childhood developmental disorders.

Conclusions: HEAT-trained HEWs were less likely to have incorrect beliefs about the causes and treatment of autism and were more aware of the importance of mental health and childhood developmental disorders. However, there were also important gaps in their knowledge and participants indicated they would benefit from more training. Following these findings our team produced five videos teaching HEWs how to interview mothers of children with autism or intellectual disability, in order to improve early detection, supportive counselling and problem solving. Additionally, a ‘Mental Health Pocket Guide’ was produced, endorsed by the FMoH, with dedicated sections on autism and intellectual disability. The effectiveness of these enhanced training materials will be evaluated in a follow-up assessment. All training materials are freely available, allowing for the HEAT model to be applied elsewhere.