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2. Title of Paper (12-25 Words)

Epidemic Acute Watery Diarrhoea (AWD) in Somali region of Ethiopia. The role played by family practices in promoting behavioursthat shape prevention and treatment seeking in the 1st 90 days of intervention.


3. Abstract (Up to 300 Words)

The researcher intends toevaluate the role played by family practices in promoting behaviours (practices, attitudes, beliefs, and social norms) that prevent, risk of cholera/AWD transmission and explores contextual factors that shape treatment-seeking  in the 1st 90 days of interventions.Objectives are based on the role of behaviours of family practices i.e. attitudes, beliefs and social norms as primary factors that influence AWD outbreak; on the basis of its uniqueness in climatic conditions as compared to other areas of the Republic of Ethiopia. The other socio-economic, political and demographic issuesto be considered as factors that enhance the spread of the disease and or support treatment seeking.The study intends to use a triangulation of qualitative and quantitativeapproaches. Data will be collected from the five zones (Jijiga, Jarar, Dollo, Shabelle and Fafan) of Somali region of Ethiopia. Thiswill be a case study selected randomly from the republic of Ethiopia Somali region and sub Saharan Africa. The data analysis willbe done using statistical correlation analysis technique to investigate the relationships between the different variables that came up as important factors in the spread of cholera and prevention. The collected data will be primary andsecondary data. This will be collected using questionnaires, interviews, observations, andset reading of published materialson Acute Watery Diarrhea (AWD).

From the literature, it is clear that public health promotive interventions is a catalyst to avert disease outbreaks (AWD), however, in the sub Saharan countries, this reality is far. Hence, the needfor research that will provide an understanding ofwhat should be done differently to make them a success story especially in countries where the health sector has not achieved the health care universal coverage and are still facing multiple disease outbreaks.


4. Research Objectives (Around 25 Words)

The study aims to evaluate the role played by family practices in promoting behavioursthat shape prevention and treatment seeking in the 1st 90 days of AWD intervention.


5. Identification/Defining Research problem(No word count)

Limited knowledge of good family practices has led to a severe risk of Cholera/AWD that have become a recurrent disease outbreak in most parts of sub-Saharan Africa (WHO 2018). With unpredicted appearance in bordering countries. In Somali region of Ethiopia, it’s believed to have crossed the border (Moyale) from Kenya progressing unabated to the region (UNICEF 2017). Despite prompt medicalintervention, health education and media awareness campaigns, AWD continues tospread impacting community livelihood, employment and services.


The question is what contextual factorsplay a role as drivers, enablers, and motivators?what is the relationship between family practices/behaviours and AWD spread in affected communities?


  1. Despite lots of preventive efforts, why is AWD transmission risk on the rise among adults aged 15-49 yearsin Somali region of Ethiopia?
  2. What are the contextual, behavioural, social, cultural and environmental factors related to prevention and treatment seeking behavioursin rural areas?  
  3. What are the possible solutions to problems faced by Government, NGOs and stakeholders in the provision of AWD interventions services?


6. Thesis Statement/Hypothesis (No word count)

Can the use of a combination of biomedical, behavioural, environmental, and treatment seeking strategies reduce barriers to AWD testing and improve prevention cascadeamong adults aged 15-49 years inthe Somali region of Ethiopia.


7. Literature Review (No word count)




All adults aged 15-49 years inSomali Region of Ethiopia



Use of a combination of biomedical, behavioural, environmental, and home-basedprevention and treatment strategies to encourage routine AWD testing  and readiness at subnational level




Use of Standard Voluntary AWD testing (CTC) and counselling (opt-out) care


Primary outcome:

  • Proportion tested for AWD (15-49) and sustaining good family practices/behaviours


Secondary outcomes:

  • Proportion accessing treatment (CTC), Care, and support
  • Proportion with improved quality of life
  • Proportion with reduced feelings of fear, rejection, and stigma


  1. Search Strategy

The key terms used were: Cholera/AWD outbreak; AWD testing and counselling, Family practices, behaviours, Adults, and Somali region of Ethiopia.The MESH terms identified for these key terms were: AWD, diagnosis, prevention, adults. The following combination was introduced into Google Scholar, PubMed, PubMed Central databases using the Boolean operators AND, OR: [AWD]AND [AWD testing OR AWD family practices OR AWD behaviours OR AWD diagnosis] AND [AWD Counselling] AND [Adults]AND[Somali region of Ethiopia].

  1. Literature search

Suitable peer-reviewed qualitative and quantitative studies published in English from Ethiopia, Somali region of Ethiopia, East Africa, and Sub-Saharan Africa, Asia, describing and reporting on role of family practices that shape AWD prevention and treatment seekingfor adults (15-49 years) were searched from PubMed, PubMed Central, Global Health (from CDC Global official site), and Google Scholar databases. All articles were sorted by relevance, filtered for Humans, full text, and publication date of 1970 (More than 40 years after its resurgence in Africa) to 2018. Furthermore, additional studies were sorted from both the reference and related citation lists next to the PubMed summary list. Official WHO, CDC, UNICEF, UNHCR, UHI and UNAIDS sites, and National Government Agency sites and reports were equally searched. However, one of the national reports included was in Ethiopia due to its high relevance. 2,640 peer-reviewed articles and reports were identified for further screening.

  1. Sorting out citations

Criteria for inclusion or exclusion from the study will be:

  1. Inclusion Criteria

Studies were included, if they reported data on any of the conditions and outcomes enumerated in the PICO e.g. proportion of target population (adults 15-49), family practices (persons tested for AWD), willing to participate, proportion linking to Cholera Treatment Center (CTC), Somali region of Ethiopia adults, barriers and facilitators to AWD testing and treatment seeking. Descriptive, observational, prospective, and systematic reviews were eligible.

  1. Exclusion Criteria

Excluded were studies and case reports exclusive to AWD, Infant settings, or patients testing and reporting for diseases other than AWD, unwilling to participate, and duplicated articles.

Intervention group

Participants will receive health education and sensitization based on the use of a combination of biomedical, behavioural, environmental, and home-based testing strategies. The first educational session will be delivered after collection of baseline data. The impact of the intervention on the study outcome variables will be evaluated at 12 months.

  1. Acute Watery Diarrhea/ Cholera:-

Drought, famine and cholera/AWD (Acute Watery Diarrhoea) outbreaks have become recurrent in the Horn of Africa (WHO 2017). Somali region of Ethiopia is no exception. Drought naturally contribute to trigger increases in epidemics such as AWD and measles, some of which are cross-border outbreaks (UNHCR 2017). AWD remains a significant public health problem in many parts of Somali region of Ethiopia, where they can spread quickly unless an outbreak is stopped. This underpins the international partners evidence on humanitarian responses to AWD in Ethiopia, in terms of necessary cross district and/or cross border co-ordination, as well as the human and financial resources needed (Fisseha, 2016; Oxfam GB, 2017; UNICEF, 2017a; OCHA Somalia, 2018).  WHO (2017a; 2017b; 2018; Fisseha, 2016), UNICEF (2017a, 2017b; Beauregard, 2017) and Oxfam (2017) have assessed their own AWD responses in Ethiopia and neighboring countries. In developing countries, up to 50 per cent of cases die from dehydration and kidney failure, if not adequately rehydrated. Infection without symptoms or with only mild diarrhea also occurs, particularly in children (UNICEF 2016).

AWD outbreaks in Somali region are often cyclical and  manmade causing substantial morbidity and mortality(UNICEF 2016). While there are some contextual and environmental factors involved, such as decreased rainfall and decreased vegetation cover, the conflict and poor family practices is the main driver of the outbreaks (UNICEF 2017). This can be complex with limited water access, latrine use and food handling practices for AWD prevention and treatment seeking.Outbreaks of diarrheal disease, including AWD/cholera, further worsen the situation of ongoing drought and conflict (US Department of State Humanitarian Information Unit (HIU 2017).This can be as a short outbreak and protracted epidemic. The transmission of the causative bacteria is usually through the fecal-oral route of contaminated food and or water caused by poor sanitation practices (UNICEF 2017).

AWD are communicable and contagious water borne disease caused by pathogens Vibro choleri (WHO 2016). The bacteria contaminates drinking water, uncooked seafood and other foods. The symptoms are frequent passing of watery diarrhea, colored like rice water, uncontrollable vomiting, body weakness, dehydration circulatory collapse and shock. Many infections are associated with milder diarrhea or have no symptoms at all. If left untreated, 25-50% of severe cholera cases can be fatal (CDC 2016). It kills within short time, if patients are not rehydrated and given adequate mineral and liquid balance needed in human body. The risk increases at epidemic proportions in regions with poor water and sanitation facilities, lack of health facilities, poverty-stricken areas, overcrowding, drought, conflicts, insecurity, and uncontrolled areas of water sources.

In 2016, WHO and its partners, acknowledged the continued public health threat posed by the disease; the enduring problems of lack of access to clean water and adequate sanitation; and the absence of any long-term impact on cholera incidence through perennial responses to major outbreaks. Con?icts, mass urbanization, climate change, and growing competition for water resources may, in fact, contribute to further increases in the AWD burden (WHO 2016).

7.2 AWD spread in the region (Kenya and Ethiopia)

From late 2014 to end of 2015, AWD outbreak has seized 30 of the 47 counties of Kenya causing close to 7000 cases of morbidity and over 100 deaths. The outbreak occurred in light of the El Niño floods which created favourable conditions for the spread of the causative bacteria. After spreading in Kenya for over a year, the disease moved to Ethiopia.

In Ethiopia, AWD was first reported in districts of Oromia and Ethiopian Somali close to the Ethio-Kenyan border (Moyale) in February 2016. Thereafter, it continued spreading east and north reaching many parts of the country including the capital city and the northern parts of the country and Somali region of Ethiopia remain the hardest hit due to several reasons.  Despite an ongoing effort to contain the outbreak, it continued spreading to large areas of the country affecting a large number of people; its course remained protracted and kept many people at risk.

TheCholera/AWD risks factors that propagated the spread of the disease are:

  1. Water, Sanitation and family practices: Insufficient WASH access, population density, poor awareness about the disease and way of life. Violence prevents people from accessing adequate water sources, displaces them to settlements with poor water and sanitation and hinders them reaching health care centres. In addition, in a drought, water becomes scarce and pathogens accumulate in stagnant waters, and people and cattle are pushed to use these contaminated waters, sharply increasing the risk of a cholera/AWD epidemic.


  1. Demographic and social factors: Demographic explosion especially in big cities-associated with poverty and disordered urbanization is a key factor in the occurrence of the outbreak. Big gatherings (pilgrimages and celebrations), communal eating practices, that favour overcrowding and lack of hygiene practices at family level are risk factors that exacerbate the outbreak.


  1. Climatic condition (Famine, drought): AWD outbreak is known to occurs in humid and intertropical zones during rainy seasons. Flooding during rainy seasons can favor the emergence or the upsurge of AWD outbreak. Although the causative bacteria are more delicate in the atmospheric environment than in its aquatic environment, it can survive well for days on fruits and vegetables. Ecosystem changes due to global warming, environmental pollution, drought, deforestation leading to floods and other climatic disasters are the reason for the upsurge of AWD outbreak.


7.3 Gaps in Knowledge and how this will inform my Research Project

Following an extensive search strategy, 19 nineteen review studies were identified that noted interventions that encourage AWD testing and treatment seeking strategies,role played by family practices in promoting behaviours that shape prevention and treatment seeking in the 1st 90 days of AWD interventionwhile 15of the included studies out of 19 presented evidence of PICO as an outcome. Most of the identified studies did not focus on promoting awareness strategies but rather coping structural mechanisms and behavioural risk reduction interventions. Most studies were systematic reviews not clinical trials in health facilities that provide AWD and nutrition services. The studies were mostly conducted in Asia, the USA and Haiti where the real context is widely different from that of Somali region of Ethiopia. 


Some studies presented in media newsletters and blogs were excluded because of limited credibility of source and missed out approaches that lead to promoting good family practices for AWD services. In general, most gaps that have been identified with the studies are that they did not discuss further, intervention strategies but rather mentioned them broadly. Most of the studies/reviews conducted  were outside Somali region of Ethiopia a gap that indicated  limited study ofAWD on family practices in this setting. With this background, there is need for more studies to assess the role played by family practices in promoting behaviours that shape prevention and treatment seeking in the 1st 90 days of AWD intervention.


8.Research Methodology(No word count)

The study methodology will use a triangulation approach that will combine both qualitative and quantitative approaches with more emphasis on qualitative research.This approach will allow flexibility in all aspects of the research process and to determine the nature of the problem. Data will be collected from the five zones ((Jijiga, Jarar, Dollo, Shabelle and Fafan) of Somali region of Ethiopia. Thesampling technique for research subjects will be randomly sampling selected from the affected zones. The data analysis will be done using correlation analysis technique. The collected data will be primary and secondary data and the data will be collected using questionnaires, interviews, observations, and set reading of published research material including both present and historical information on disease outbreaks, mainly Acute Watery Diarrhea (AWD) sometimes known as Cholera.


8.1. Research design

Study Design

Type of study

A cluster sampling will be designed (qualitative , quantitative, comparative, and analytical in nature) to assess the role played by family practices in promoting behaviours that shape prevention and treatment seeking using a combination of health education strategies (intervention) on AWD testing and sustaining good family practices among adults aged 15-49 years in five (5) communities. This will be compared to Standard care seeking (control) in five (5) communities all in the Somali region of Ethiopia.The study will involve evaluating the outcome of a combination of biomedical, behavioural, environmental, and home-based testing interventions on the primary outcome, barriers related to AWD testing and secondary outcomes, as proportions stated in the objectives. The data will then provide basis for drawing inferences and possible generalization of results among adults aged 15-49 years. A baseline population-based survey will be conducted for sampling and baseline data purposes. There will be random assignment of clusters (communities/zones) instead of individuals in order to avoid possible contamination between intervention and control groups.


Choice of design

This study design has been chosen for the following reasons: it is best for evaluating either prevention/treatment or other specific interventions, it allows for research to be conducted with a reduced economy. The cost of interviewing every household or individual within the group would be very limiting. Cluster sampling reduces variability and offers the advantages of random sampling and stratified sampling. Makes blinding more likely and minimizes both selection and information bias as well as facilitates statistical analysis.Cluster sampling however may result in biased samples and have a greater tendency towards sampling error. This will be minimized by choosing a fair (unbiased) sample by way of simple random sampling of clusters. The sample will be large enough and a representation of the target population (adults 15-49 years).A Cluster sampling is a sampling method where populations are placed into separate groups. A random sample of these groups is then selected to represent a specific population. This is because the intervention in question (family practices that influence routinebehaviour changes on AWD) directed to groups than individuals. Thus, the study requires cluster randomisation of geographical areas which will serve to minimise contamination risk (through exchange of information) between the intervention. This will involve interviewing study subjects 15-49 years in the affected communities of the five zones to complete at least 250 interviews (50 in each of the five zones) with members of the Somali communities. This will adopt semi-structured interviewing; participant observation and available published literature. I intend to work with local community-based organisation to support data collection. Provide training for the data collectors on the tools to be use and this will overcome the barriers of language.


8.2. Sampling technique

A  multi-stage random sampling technique will be used. The primary sampling unit (PSU) will be the sub-divisions. The sub-divisions will be enlisted and numbered 1-34. A simple computer-random generator (Stat Trek’s Random Number Generator) will be used to generate different random numbers. This will serve in the random selection of sub-divisions. In the second stage, 1 community per sub-division (PSU) will be randomly selected based on the generated random numbers to constitute the study area. It is intended that the 5 communities will have similar population sizes and natural characteristics. This will ensure that every element in a sample framehas an equal chance of being incorporated into the sample.


8.3. Data Collection
The method for data collection will be by use of structured interviews, questionnaires, telephone survey and examination of CTC and home records of the study participants. Data collection at baseline and home testing will be done by research assistants in a quiet, comfortable, private, and confidential area of the home. They will do repeated home visits before the intervention to create a relationship and gain the confidence of participants. Data collection tools will be developed according to National Norms and Standards for Cholera/AWD research adapted from WHO guidelines. Five research team members will be trained on data collection process and assigned in the five zones. Throughout the study duration, monitoring and evaluation data will be collected.


8.4. Data Analysis

Data collected will be analysed using the STATA statistical software for analytic/inferential statistics to estimate pattern and strength of associations amongvariables, test hypotheses.Descriptive statistics will summarize important features of numerical data. Data analysis and results reporting will be done according to the Extension of CONSORT statement to cluster trials that is; using the modified checklist to the standard CONSORT list. Data analysis will be done using the adjusted cluster-level intention- to- treat population to compare intervention and control arms at follow-up (3 months after implementation of the intervention). Continuous data will be expressed as mean, standard deviation if normally distributed or as median if not. For categorical data will be summarised as proportions.

Two stage analyses will be performed using cluster levels approaches. A summary measure of the proportion of  Testing for AWD for each cluster will be estimated for the primary outcome using a Chi- square test. Random effect regression and generalised estimating equations approaches of binary outcomes (individual and cluster levels) with adjustment for covariates taken into consideration. The major covariates to be balanced with this method at baseline include: age, sex, marital status, socioeconomic status, and distance to health facility. The analysis will be done with the STATA Software Package.All individual level data will be used and intra cluster correlation accounted for in order to increase the analysisstatistical power. The clustering effect will be accounted for by the use of the chi-squared or F-tests both of which are divided by the design effect. Adjusted odds ratio (OR) and relative risk (RR) will be calculated at 95% confidence interval (for precision) as well as P-values for the different outcome variables.This data will further be interpreted and quantified.


9. Time schedule
















 Protocol development and submission















Ethical clearance















Acquire funds/resources















Recruitment and training of project executors and data collectors















Designing and testing of Education materials, questionnaire, clinical forms















Recruitment of participants and baseline data collection






























Data collection















Evaluation of intervention  implementation















Data entry and cleaning















Data processing and analysis















Report writing and Feedback















Report Dissemination































10. Expected Output
The study intends to produce quarterly reports with a written thesis at the end of the study.
Publish in a reputable journal including Texila American University (TAU) the results of the study and present the study findings in international conferences and or universities within Africa and beyond. as the study subject is of high interest to partners working in the areas of public health.


11. Societal and Scientific relevance
The social relevance in terms of family practices, risks, enablers and or behaviours will be highlighted strongly. The scientific aspects of the study will be categorised and its relevance to the society.

12. Ethical Considerations
The fact that this work will involve legal adult participants implies limited ethical issues but the due ethical requirement process will be followed including confidentiality rights. In any research I do, I am always keen to respect the perspectives of my participants and encourage open, and healthy discussion to make the research experience an enjoyable and meaningful one for all concerned; as such my research orientations are participatory ones, with a leaning towards focus group discussion, and interviews to encourage personal expression within a respectful social context. All information obtained from participants will be kept confidential by use of codes (initials not names) and their privacy highly ensured. Data collection tools and consent forms will be developed using national norms and standards for health research. I intend to provide feedback to key stakeholders during and after completion of the study. Data collection tools and consent forms will be developed using national norms and standards for health research. These will be pre-tested, reviewed, and validated by the research team. Co-investigators will train 5 of the research team members on data collection. Control clusters will receive information brochures about standard CTC care at baseline. After following and outcome analysis, evaluation will be done of the efficiency/benefits of the intervention and intervention offered to control arms if successful. Study results will be used to inform policy makers and to contribute to Cholera/AWD research literature



13. References (max. 1 page)


Aden, A.; Omar, M. and others (1997) 'Excess female mortality in rural Somalia – Is

inequality in the household a risk factor?', Social Science and Medicine, 44.5: 709–15.


Beauregard, R. (2017). Adapting Response Efforts to Stop the Spread of Acute Watery

Diarrhoea. 4 May 2017. UNICEF Ethiopia. https://unicefethiopia.org/2017/05/04/adaptingresponse-efforts-to-stop-the-spread-of-acute-watery-diarrhoea/


Carruth, L. (2011) The aftermath of aid: Medical insecurity in the northern Somali Region of

Ethiopia. The University Of Arizona.


Crooks, A. T. and Hailegiorgis, A. B. (2014) 'An agent-based modelling approach applied to

the spread of cholera', Environmental Modelling and Software, 62: 164–77.


Food Security Analysis Unit. (2007). Somali Knowledge Attitude and Practices Study

(KAPS). Infant and Young Child Feeding and Health Seeking Practices. Nairobi: FSAU and



Maxwell, D. and Fitzpatrick, M. (2012). The 2011 Somalia famine: Context, causes, and

complications. Global Food Security, 1(1), 5-12.


Fisseha, B. (2016). Ethiopia - Response for Acute Watery Diarrhea outbreak in Moyale town.
WHO Ethiopia. http://www.afro.who.int/news/ethiopia-response-acute-watery-diarrhea-outbreakmoyale-town


Government of Ethiopia/OCHA (2017). Ethiopia: Humanitarian Response Situation Report No. 16 (November 2017). 30 November 2017.https://reliefweb.int/sites/reliefweb.int/files/resources/situation_report_no.16_november_2017_-


Haileamlak, A. (2016). Why is the Acute Watery Diarrhea in Ethiopia Attaining Extended Course? Ethiopian Journal of Health Science, 26(5), 408.

HIU (2017). Horn of Africa: Populations Impacted by Hunger and Disease (14 Sep 2017). US
Department of State- Humanitarian Information Unit.https://reliefweb.int/report/yemen/hornafrica-populations-impacted-hunger-and-disease-14-sep-2017


IFRC (2017). Emergency Plan of Action (EPoA) Somalia: Response to Acute WateryDiarrhoea (AWD)/Cholera Outbreaks. 24 April 2017. International Federation of Red Cross and RedCrescent Societies.https://reliefweb.int/sites/reliefweb.int/files/resources/MDRSO006Dref.pdf

Reaching nomadic pastoralists who are dispersed, highly mobile and at high risk of contracting AWD due to thelack of access to safe water and sanitation also need to be considered (Government of Ethiopia/OCHA, 2017: 9).

Kiros, B. (2016). Volunteers Blast Hygiene Message to Halt Acute Watery Diarrhea. 3
November 2016. UNICEF Ethiopia.https://unicefethiopia.org/2016/11/03/volunteers-blast-hygienemessage-to-halt-acute-watery-diarrhea/

Oxfam GB (2017). YEMEN: CATASTROPHIC CHOLERA CRISIS. Oxfam Briefing Note. 16
August 2017. ISBN 978-1-78748-036-0. Oxfam International.

UNICEF (2017a). ETHIOPIA Humanitarian Situation Report #18 – Reporting Period 6 November– 5 December 2017.

UNICEF (2017b). UNICEF’s preventive plan to mitigate the risk of Acute Water Diarrhoea (AWD)and Cholera among Rohingya Refugees.


WHO (2017). Community engagement contributes to control of acute watery diarrhea in

Ethiopia’s Somali region. WHO Regional Office for Africa.


WHO Ethiopia (2017a). Looking out for Acute Watery Diarrhoea in Somali region: A day in thelife of a World Health Organization (WHO) surveillance officer in Ethiopia’s Somali region.http://www.afro.who.int/news/looking-out-acute-watery-diarrhoea-somali-region-day-life-world-healthorganization-who


WHO Ethiopia (2017b). WHO’s support to the response of the acute watery diarrhoea outbreakin Ethiopia’s Somali Region. July 2017. http://www.afro.who.int/news/whos-support-responseacute-watery-diarrhoea-outbreak-ethiopias-somali-region

Tull, K. (2017). Humanitarian interventions in Ethiopia responding to acute watery diarrhoea. K4D Helpdesk Report. Brighton, UK: Institute of Development Studies.



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1. RESEARCH PROPOSAL FORMAT 2. Title of Paper (12-25 Words) Epidemic Acute Watery Diarrhoea (AWD) in Somali region of Ethiopia and the role played by family practices in promoting behaviours that shapes prevention and treatment

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