a global and public health issue

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INTRODUCTION
Childhood diarrhoea continues to be a global and public health issue affecting developing and
developed countries with soaring rates of morbidity and mortality (Liu et al, 2012). Diarrhoea
prevalence in population groups vary, but mostly affects children 5 years and under, making it the
second leading cause of childhood mortality, resulting in 1 in 9 deaths globally (Centre for Disease
Control (CDC), 2014). Diarrhoea is defined as the intermittent passage of loose stools daily which
occurs as a result of an intestinal tract infection caused by several viral, bacterial and parasitic
organisms (World Health Organization; WHO, 2017; Nyantekyi et al, 2010). This disease is
contracted through contaminated food//water, improper waste disposal (faecal and solid waste),
rudimentary congested houses and overall poor hygiene of the individual (Woldu, 2016).
Globally, it is estimated that there are about 1.7 billion diarrhoea cases of children under five
resulting in about 760,000 childhood deaths yearly (WHO, 2015). This estimate accounts for onetenth of childhood mortality globally particularly in South Asia and Sub-Saharan Africa (Liu et al,
2012). In Ethiopia, diarrhoea is one of the major cause of water-related disease mortality among
children 5 years and under accounting for 46% of all child deaths (88/1000) in 2014 (Mamo &
Hailu, 2014). Diarrhoea prevalence is worse in Ethiopia than other parts of the world with chances
of death before 5th birthday 30 times greater than in developed countries (WHO, 2015). Several
studies have indicated that childhood diarrhoea prevalence in Ethiopia ranges from 12.2% to
35.6% which was attributed to their living conditions, overall health, absence of safe drinking
water, poor sanitation, nutritional status and hygiene (Teklit, 2015; Tamiso et al, 2014; Azage et
al, 2016).
Afar region has the highest child death rate as it is one of the least developed, poorest and underserviced regions in Ethiopia (Gizaw et al, 2017). Communities in Afar region are nomadic in nature
as they move from one place to another in search of water and pasture (Alebel et al, 2018). These
communities depend mainly on pastoral farming which shows possible risk factors of childhood
diarrhoea apart from the sanitation, water and hygiene-related diseases (Woldu et al, 2016). It is
estimated that 25% of childhood deaths between ages 1 to 4 years and 24% to 30% of all infant
mortality were related to diarrhoea disease in Ethiopia (Ahmet et al, 2014). Likewise in Afar
region, 12.7% of all under-five mortality was attributed to diarrhoea disease (Central Statistical
Agency, 2011); with a yearly death rate of 123/1000 live births, approximately 6500 deaths of
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children 5 years and under (Ethiopian Demographic Health Survey, 2016). Gizaw et al (2017)
highlighted that rural communities in this region suffer from sanitation facilities, hygiene and
water shortage as their main water source comes from wells, rivers, ponds and streams. A
systematic review by Alebel et al (2018) also reported the highest diarrhoea prevalence of 27% in
Afar region compared to other nomadic communities which are attributed to differences in
household and caregivers’ basic behavioural and environmental characteristics.
Several strategies/policies have been put in place to reduce childhood diarrhoea prevalence in
Ethiopia. A recent one is the Health Sector Development Program IV (2010-2015) which was
aimed at reducing the mortality rate from 101/1000 to 68/1000 live births. Despite these
strategies/policies, childhood mortality rate as a result of diarrhoea disease is still high compared
to other countries in Sub-Saharan Africa (Bizanueh et al, 2017). This essay will therefore critically
analyse and evaluate ways in addressing the prevalence of diarrhoea among children 5 years and
under in a highly deprived area of Afar Region in relation to the social determinants of health and
their contribution to inequalities in health. This essay will also critically analyse and evaluate the
need for community-based interventions, communication, community engagement,
empowerment, participation as well as partnership working, using asset-based approach to reduce
the high diarrhoea prevalence in this age group. This essay will further evaluate and analyse ways
by which approaches to community development can be monitored and evaluated when proposing
public health interventions.
SOCIAL DETERMINANTS OF HEALTH AND HEALTH INEQUALITIES
Marmot (2008) highlighted that the state of health of the population, which can be as a result of
social inequalities should not be perceived as a natural occurrence but as a result of multiple
factors. Social determinants of health (SDH) as defined as by Marmot (2008) are conditions that
contribute to the overall physical, mental and social well-being of people at the local, national and
global level. These determinants are situations/circumstances that surround the social,
environmental, economic, cultural, political systems and access to social and health facilities of an
individual (Centre for Disease Control (CDC), 2017; WHO, 2008. These conditions trigger the
cause of ill-health which has prompted the interest of researchers to better explain health outcomes
that surround these determinants (Marmot et al, 2008). Thus while diarrhoea is one of the major
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cause of child mortality, susceptibility is also greatly determined by the environmental, cultural,
social and political factors.
A study carried out by Miherete et al (2014) to identify the determinants of childhood diarrhoea
among children under 5 years in North West Ethiopia concluded that childhood morbidity is
influenced by the interactions of environmental, behavioural and socio-economic factors which
can only be by understanding how these factors interact and relate. A similar study by Asfaha et
al (2018) in Medebay Zana District identified various factors like maternal educational status,
source of income, type of kitchen floor, exclusive breastfeeding and complementary practices,
toilet facilities, solid and domestic waste disposal and source of drinking water as determinants of
diarrhoea. These studies also correspond to research by Bitew et al (2017) on childhood diarrhoea
among the nomadic community which shows hand-washing practices after toilet, personal and
environmental hygiene, source of drinking water and water source shared with livestock as the
leading cause of this disease among these communities
Inequalities in health is still a major issue between and within countries which can be measured by
life expectancy, socioeconomic factors, gender, health status, ethnic group or mortality rates
(Gaskin et al., 2013). Skaftun et al. (2014) highlighted that key health services and health outcomes
are not evenly distributed across various population sub-groups in low and middle-income
countries. This is evident in children from households who are socio-economically deprived with
higher death rates and low coverage of major services than children from affluent households
(Barros et al., 2015). Majority of child-related deaths can be easily treated or prevented which
Kinney et al (2010) considers being unnecessary and unfair, provided they had access to key health
services. Health inequality, therefore, is defined as the disparity in the status of health or
inequitable distribution of health determinants across various population groups (WHO, 2003).
The disparity in health statuses such as access to health care, morbidity status and life expectancy
is usually unjust as a result of the social and economic situation of an individual but can be
modified by appropriate public health interventions (Hay & Peet, 2014).
Social inequality is also an issue as there is a connection between health inequality and social
inequality like gender bias and good housing. Blackburn (2008) suggested that if these inequalities
are tackled, individuals treated and regarded as same, putting in mind that equality is attainable, it
can be greatly reduced. Health inequalities as suggested by Beeston et al, (2015) can be addressed
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by implementing public health policies and intervention aimed at targeting the main causes of
economic and social inequalities, then behavioural change interventions (WHO, 2014). For
instance, choice-based and individual policies focus on knowledge and information that can be
benefitted by people with higher socio-economic status but people with lower socioeconomic
status feel the greater impact of policies that focuses on behaviours as a result of environmental
changes (Dinno et al., 2009). Backholer et al. (2014) also suggested that inequalities and reducing
the gap between population groups can only be tackled by directing approaches focusing on poor
people, thereby reducing the differences in health disparities in population groups. This not only
narrows the gap between rich and poor but also the socio-economic gradient between underdeveloped, developing and developed countries.
PRINCIPLES AND APPROACHES TO COMMUNITY DEVELOPMENT
In order to tackle health inequalities, community development needs to be adopted at the
elementary level. From a geographical point of view, community as defined by Garkovich (2011)
as people who socially interact, live in the same neighbourhood and share a common interest. A
community can be made up of people with the same ethnicity, age group, race, shared religious
belief/affinity, occupation, sexual preferences and health needs (NICE, 2016). For the purpose of
this essay, the community will be considered to be a group of people living within a geographic
area. Community development, however, is defined as the collective identification of various
issues by community members to help solve and provide solutions towards the identified
problems/issues (Kenny, 2010). Community development aims at equity advocacy, the right to
freedom of expression without encroaching on people’s freedom and their ability to meet their
basic needs (Mackereth, 2006).
Community development relies on approaches that bring communities together based on their
mutual knowledge and skills to tackle issues pertaining to the identified health issue (Daily &Barr,
2008; Quinn & Knifton, 2012). This approach can also be used to tackle inequalities affecting the
deprived communities (SCDC, 2016). An individual’s health as implied by the social model of
health is not only affected by the disease but wider determinants like social position and living
conditions within their communities (Gaskin et al, 2013). With a mutual agreement with major
stakeholders, community development can be planned towards a fundamental change and
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improved the community’s quality of life. Capacity building is also essential of community
development as it allows communities to develop a sense of togetherness and actively engaging in
changes geared towards their communities (Green &Haines, 2015).
In order for community development to be effective, beliefs that frame the dynamics of the
community should be informed using the social research approach (Garkovich, 2011).
Furthermore, community health needs assessment is also an appropriate intervention for
community development as it helps the community in identifying their needs, providing a sense of
ownership, and finding solutions to strengthen the capacity of the community (Robison & Fear,
2011). It is important to note that leadership is a common issue in community development as it
involves an effective corporation of various individuals who normally do not work together due to
lack of interest (CHEX, 2009). Kirk (2009) therefore suggested that coordination and interaction
among community members and key stakeholders are crucial in overcoming leadership issues.
AN ASSET-BASED APPROACH TO COMMUNITY DEVELOPMENT
Conventional public health approaches have been criticized on their efficacy as they focus on
reducing the population’s relationship with the disease risk factors, thus leading to a shortfall of
health promotion and policy-based strategies (Brooks & Kendal, 2013. For instance, good water
supply, sanitation and improved personal hygiene campaigns have been said to reduce diarrhoea
prevalence among children 5years and under but attempt to tackle the health issue and reduce
inequalities has resulted in widening inequities within communities as some communities are
favoured over another (Nierderdeppe et al., 2008). Semalegne et al. (2015) also highlighted that
some approaches focus on promoting dependence on external sources usually the government
which has resulted to formulating policies that are deficiency-oriented (Deficit-based approach)
and discouraging capacity building.
Recently, advocates have put forward a more suitable approach which focuses on empowering
communities to be responsible and sustain their health and well-being rather than focusing on ways
to tackle any health issue and reducing the burden of the disease (Morgan & Ziglo, 2007). This
approach is known as the Asset-Based Approach which is also in accordance with the WHO
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Ottawa Charter (1986) health promotion awareness that advocates individuals having control over
their quality of life and tackling their health issue. Asset-Based Approach also focuses on
communities’ positive aspects, boosts their self-esteem and reduce dependence on the government
and other professional services. Though the Assed-Based Community Development (ABCD)
approach is favoured over the Deficit-Based approach as it empowers the individuals/communities
with a sense of ownership and their ability to cope and work towards sustaining their health and
well-being (Morgan & Aleman-Diaz, 2016). Freidli (2013) also critiqued this approach as it might
result in the power imbalance between the communities and the public services which can also be
limiting by globalization and capitalism (Ennis & West, 2010).
As a public health practitioner, the ABCD approach will be adopted as a public health intervention
to map out the abilities and assets of the communities and what they have to offer. This approach
will help to empower and inspire community members based on their skills and successful in
dealing with certain health issues. The public health practitioner will also note to include all
community members as NICE (2016) highlighted that this promotes information exchange and
social networking. Also, empowering the community through the capacity building has been
stressed by the Scottish Government (2015) to be effective in health promotion as it increases their
access to resources, skills and knowledge.
In relation of Afar region, the ABCD approach will be used as a public health intervention to
communicate effectively with mothers with children under 5 years on safe hand-washing
techniques, good personal hygiene and sanitation, proper health education on maternal and child
health, proper faecal and solid waste disposal, safe source of water, intensified family planning
and proper breastfeeding (Asfaha et al., 2018; Woldu et al., 2016). This approach will also need to
identify the community’s health assets i.e. intervention/tool useful in promoting health and
reducing inequalities. Furthermore, an evidence-based community health centre will be established
to help educate the mothers frequently on practising these interventions through fun and engaging
health awareness/activities, group discussion sessions which will help to build communities’
abilities and capacities.
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COMMUNITY
PARTICIPATION
AND
COMMUNICATION
IN
HEALTH
PROMOTION
The success of any intervention mainly relies on meeting the needs of the community and also
solving the problem at that point in time through community engagement and participation with
the recognition that their point of views is valid. According to Corcoran (2013), he highlighted
that health promotion aims to improve health and well-being thereby reducing health inequalities
through community capacity building, communication, participation and empowerment. As
communication is an essential tool in health promotion, one of the most used models in guiding
this is the Health Belief Model. This model is the most suitable health promotion model in risky
health-related behaviours like diarrhoea, characterized by cultural and socio-economic factors.
Also, the theory of planned behaviour is another model predicts a person’s behaviour based on
their attitude towards a supposed action (Kasprzyk & Montano, 2015). With the help of these two
models, it may help in identifying the behavioural factors influencing the prevalence of diarrhoea
in this age group and also help in guiding an effective intervention.
Community participation and engagement is also essential in any health promotion strategy as it
brings the efforts and resources of community members together to actively and directly be
involved inappropriate health service development (Nikkah &Redzuan, 2009). This can only be
achieved through effective communication which is an essential public health initiative in carrying
out any public health intervention (Savio & George, 2013). It should also be noted that Health
Literacy has been identified by several authors as one of the risk factors of diarrhoea prevalence
among children 5years and under (Mihrete e al., 2014; Wasihun et al., 2018; Asfaha et al., 2018).
Health literacy is important in health promotion as it helps individuals to understand and use
information based on their social and cognitive skills. The public health practitioner will ensure
that information is effectively communicated in the most understandable way so that they emulate
the proposed intervention in their daily lives.
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PARTNERSHIP WORKING IN PUBLIC HEALTH
Glasby & Dickinson (2008) stated that collaboration and coordination with people in local,
national and international agencies are crucial in tackling health inequalities. Petch et al (2013)
defined partnership as integrating and working together of two or more organizations with a
common interest to promote service delivery. Partnership working is essential in health promotion
and also a way of addressing the inequalities in health (WHO, 2014; CDC, 2017). Del Fabbro et
al, (2016) highlighted the role of partnership is useful in health promotion as it provides insights
for policy makers, health practitioners and scholars on planning, funding and program evaluation.
Partnership working can be challenging in tackling issues like childhood diarrhoea as it
encompasses a various level of approaches, transcending various organizational and professional
boundaries (Hunter & Perkins, 2012).
A study on public health partnership by Hunter & Perkins (2012) concluded that successful
partnership involves setting out clear targets and motives, outlining responsibilities and accessing
performances based on monitoring and evaluation. Likewise, the availability of resources and
long-term services as well as a number of staff has been said to contribute to the improvement of
services users (Petch et al, 2013). The need for partnership has also been stressed by Peckham
(2007) as some health issues may be designed by some agencies, be repetitive or derailing from
intended activities. It is also important to note that barriers like leadership, cost-effectiveness and
resistance to help from local governments may exist during the partnership.
In order to tackle childhood diarrhoea, partnership working approach will be used with local
communities to promote good sanitation and personal hygiene as well as proper hand-washing
practices. The local health centres will be partnered with to promote these practices and conduct
frequent awareness of the risk factors of this disease. Finally, the partnership will also be formed
with professional health bodies, charitable citizens and non-governmental organizations in
providing clean water supply that is suitable for drinking and public toilet facilities in the
community.
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MONITORING AND EVALUATION
The success of any intervention is measured through monitoring and evaluation to examine the
effectiveness of the intervention in meeting the desired outcome (Katz, 2010). Monitoring and
evaluation are useful tools as it allows the researcher to gain insightful knowledge about previous
and present interventions to help in processing future interventions (Rosenow & Galvin, 2013). It
is important to note complex health and well-being interventions like this can be difficult to
evaluate as communities do not easily adapt to culture-oriented interventions. This should,
therefore, take into account the main objectives of the community in respect to their perspective,
opinions and views.
The LEAP framework designed by the Scottish Government will be adopted ad it focuses on
community empowerment by improving their health and well-being. This framework is suitable
for community development interventions that are asset-based (Hashagen & Paxton, 2007). LEAP
framework is on the basis of understanding health improvement principles and evaluating the
achievement of community development objectives (Scottish Community Development Centre,
SCDC, 2007). As a public health practitioner, this approach will, therefore, be used to monitor and
evaluate the progress of the adapted intervention.
CONCLUSION
The prevalence of diarrhoea among children 5years and under is a public health challenge in
developing countries with considerably high rates in deprived areas with major health inequalities
such as illiteracy, low socio-economic status, lack of basic household facilities and low sanitation
and personal hygiene. Past interventions have focused on ways to reduce the risk factors associated
with diarrhoea which has proven to be ineffective as several factors determining individual’s health
outcome. To tackle the high childhood diarrhoea rates in Afar Region, the ABCD approach will
be appropriate as it builds positive relationship sustained through capacity building, individual
empowerment and better social capacity of the community through networking. Partnership with
local health centres, charitable citizens and non-governmental organizations in providing basic
household facilities as well as creating public health awareness. Monitoring and evaluation will be
done using the LEAP framework to ensure continuity.
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