Comparing Beliefs, Attitudes and Social Distance of Community Health Extension Workers Towards Children with Autism in Ethiopia: Impact of Brief Training through the Health Education and Training (HEAT) Programme

Background: Improving access to health care for people with autism in Ethiopia is highly dependent on the awareness and attitudes of frontline community-based health extension workers (HEWs). The Ethiopian Federal Ministry of Health is upgrading the skills of HEWs through the Health Education And Training (HEAT) programme in collaboration with The Open University UK, AMREF and UNICEF. HEAT includes a brief overview of child mental health and developmental disorders.

Objectives: To compare beliefs and attitudes towards, and preferred level of social distance from, children with autism in HEWs who have and have not received HEAT training.

Methods: HEWs were selected randomly from two groups: (i) those who had received HEAT mental health training and (ii) those not trained. Beliefs, attitudes and preferred social distance in relation to children with autism were measured using questions from the World Psychiatric Association Stigma Toolkit. Social distance refers to the level of distance favoured by one societal group towards another. 

Results: A total of 374 HEWs were included in the analyses, 108 had received HEAT training and 266 had not been trained. Across both groups of HEWs, stigmatising beliefs and attitudes were high. HEWs who had been trained in HEAT were less likely to endorse positive outcomes for children with autism, for example, that they could play with other children, make their parents proud or get married. The trained HEWs were also more likely to consider people with autism to be a public nuisance and did not differ from the untrained HEWs in their endorsement of other negative stereotypes such as dangerousness.

Despite these stigmatising beliefs, HEWs with HEAT training were less likely to favour social distance from children with autism and their families. After adjusting for age, educational level and religious affiliation, HEWs with HEAT training were less likely to be afraid to have a conversation with a child with autism (adjusted odds ratio (aOR): 0.52 (95% confidence interval (CI) 0.31, 0.86)), to report that they would not be able to maintain a friendship with the parent of a child with autism (aOR 0.57; 95%CI 0.33, 1.00) or to be ashamed to be seen out in the street taking care of a child with autism (aOR 0.22; 95%CI 0.06, 0.73). None of the trained HEWs supported chaining up children with autism, compared to 4.5% of non-trained HEWs.

Conclusions: Even brief training was associated with a decreased tendency, by HEWs, to favour social distance towards children with autism. This is likely to have an important positive impact on HEWs’ willingness to provide care. However, training did not lead to more positive beliefs about outcomes for children with autism. In this rural Ethiopian context those children with autism who are recognised by HEWs are likely to be severely affected. As the HEWs gain an initial awareness of autism through training they may, therefore, begin to reflect on the associated problems. This may explain the apparent paradox of increased negative expectations. Future HEW training may benefit from increased focus on the potential positive outcomes of autism.