Increasing Awareness of Autism and Other Developmental Disorders Among Rural Ethiopian Community Health Workers: Impact of a Brief Training

Background:  

In Ethiopia basic health services are provided by community health workers (CHWs). Most of the 39,000 currently practicing CHWs have received basic training not encompassing mental health. In 2012 the Ethiopian Ministry of Health started upgrading the training of existing CHWs using the Health Education And Training (HEAT) curriculum, which includes a brief overview of mental health. In 2013 additional training materials, including a DVD with 5 short videos and a Mental Health Pocket Guide, were added to the curriculum of a new cohort of CHWs. This enhanced mental health training (HEAT+) has a particular focus on developmental disorders, including autism.

Objectives:  

To examine the impact of HEAT and HEAT+ training on raising awareness among CHWs about autism and other developmental disorders.

Methods:  

Participants (all females, all working in Ethiopia’s Southern Nations and Nationalities Peoples Region) comprised i) 107 CHWs who had completed the upgrading training using HEAT 16 months prior to the data collection and had since returned to their work place; ii) 101 CHWs who had studied the enhanced (HEAT+) training 4 months prior to the data collection and were still in full-time study; iii) 111 practicing CHWs untrained in mental health (controls). All participants completed a survey that included case vignettes describing intellectual disability and autism, followed by questions on autism characteristics (adapted from the Autism Survey; Stone, 1987). The survey also asked whether and how CHWs used the training in practice.

Results:  

All groups were equally likely to recognise intellectual disability from its case vignette (p>.05). A greater proportion of HEAT+ trained CHWs (28.7%) than untrained CHWs (16.2%) were aware of children in their local community with intellectual disability (p=.03); the HEAT trained and control group did not differ significantly from each other (p>.05).  CHWs trained using the HEAT+ curriculum (64.4%) more often identified autism from the case vignette than HEAT trained (8.4%) and untrained (0.0%) CHWs (both p<.001), while the HEAT cohort performed better than untrained CHWs (p=.002). Using the adapted Autism Survey, HEAT and HEAT+ trained CHWs could identify more symptoms of autism than controls, with the HEAT+ group outperforming the HEAT group (all p<.001). HEAT+ trained CHWs (13.9%) were more likely than controls (5.4%) to know local children with symptoms of autism (p=.04). Most (74.8%) HEAT trained CHWs indicated that they apply the training at least once a month in their job; 97.2% of HEAT trained CHWs had organised one or more mental health awareness raising meetings in their community, compared to 10.8% of controls (p<.001).

Conclusions:  

Brief mental health training for CHWs, particularly the enhanced (HEAT+) training, helped to increase awareness of developmental disorders, including autism. CHWs are the primary source of help for families living in rural Ethiopia and the referral gateway to more specialised services. In addition to case identification and referral, a key responsibility for CHWs is providing health education to their community. Most HEAT trained CHWs indicate they are disseminating their mental health knowledge locally, so the HEAT/HEAT+ training has a potentially wide reach.