South Ethiopia Network of Universities in Public Health II (SENUPH II)

The SENUPH II project represents a network of three universities in southern Ethiopia as well as the University of Bergen. The focus is on public health. Based on history of 20-year collaboration, we aim to strengthen the existing collaboration so to enhance efforts to improve capacity building, research, building independent senior researchers, and collaborate with the Ministry of Health with the relevant health information to improve the health of peoples in southern Ethiopia.

Project’s particular importance

Even if there has been a substantial economic growth in Ethiopia, the country remains among the 20 poorest countries. The population is in a transition with declining fertility, increasing life expectancy, heavy burdens of poverty-related diseases and increasing load of non-communicable diseases. Thus, the country needs evidence-based healthcare to improve health policy and improve the health of the population.

This project focuses on health challenges and priority setting. We believe universities in southern Ethiopia, can produce relevant information for policymakers to enhance public health work. By focusing on infectious diseases, malnutrition and the emerging burden of non-communicable diseases, we aim to build capacity in higher education both at universities and at the Ministry of health.

By the end of the project and through building strong research groups, we expect to have nine independent researchers capable of research leadership, supervising future PhD students, mentoring post docs, that further can develop their institutions when this project ends. Furthermore, we expect to have strengthened two PhD programs that would be sustainable in an Ethiopian context.

Building on a previous joint PhD degree programme between Hawassa University and the University of Bergen, and strengthening research at Dilla and Arba Minch University, we plan through PhD and post doc research, linked to training at the master’s level, strengthen the ownership, capability, and sustainability of the universities and of the Ministry of health to carry out evidence-based healthcare. The teaching, research, and implementation work will be interdisciplinary and integrated and involve disciplines such as epidemiology, medicine, priority setting and health economics, household economy, essential laboratory disciplines for emerging and existing epidemics.

Project goals

Through this six-year project, we aim to strengthen the institutional capacity for teaching, supervision and research by developing teams of researchers consisting of both senior (post docs) and junior researchers (PhD students and PhD holders) and thereby obtaining a critical mass needed for future sustainability of the institution. This will also focus on enhancing leadership capability of researchers so that they become independent researchers.

We shall strengthen research groups on thematic areas such as communicable diseases (malaria, emerging and re-emerging infections, and tuberculosis), nutrition, and priority setting on non-communicable diseases and health economics.

Relevant SDGs in the project

This project will deal with several of the sustainable development goals. The main goal is good health and well-being (SDG3). However, a large proportion of the efforts will be to reduce hunger in an area where chronic malnutrition is highly prevalent (SDG2). Our program will be based on quality teaching (DG4), and gender equality (SDG5).

Partner institutions

In Ethiopia, Hawassa University, Arba Minch University, and Dilla University, and the University of Bergen

History of Yirga Alem Hospital in Southern Ethiopia

Lindtjørn B. The role of a mission organization in building a sustainable government hospital in Southern Ethiopia. Christian Journal for Global Health.7(2):133-46.

This study details the intriguing history of Yirga Alem Hospital in Southern Ethiopia under the aegis of the Norwegian Lutheran Mission since the middle of the last century.

In 1950, the Norwegian Lutheran Mission (NLM) began holistic mission work, including health work in Yirga Alem in Sidama in Southern Ethiopia. The hospital, which had served as a military hospital during the Italian war (1936-41), became a mission hospital. This paper presents some historical developments of a government hospital managed by a mission organization, the story of its medical work, and how the NLM functioned under varying political regimes and societal environments in Southern Ethiopia. At the same time, societal changes occurring in Norway with the weakening of mission organizations and the Norwegian governments policy that influenced external financial support for the hospital are presented and discussed. The key message of the paper is that it is possible under challenging external politics for a mission organization to collaborate with government entities even with difficult regimes. In the area of Yirga Alem Hospital, this was done without compromising the basics of mission, but rather readjusting comparative strategies while ensuring sustainability and local ownership. The uniqueness of this work is that it explores a mission, i.e., the NLM, which developed health work within the context of a nationally owned health service. Moreover, this fruitful collaboration persists until this day and previous missionaries still work to strengthen public health programs that target such major areas as tuberculosis and HIV control, maternal health, childcare, and nutrition.

The paper can be downloaded here:

New and important research from Arba Minch University

Arba Minch University has recently published three important papers. This work comes from the resaearch group on malaria and leishmaniasis. You will find the references with links to fulltext papers below:

Mekuriaw W, Balkew M, Messenger LA, Yewhalaw D, Woyessa A, Massebo F. The effect of ivermectin® on fertility, fecundity and mortality of Anopheles arabiensis fed on treated men in Ethiopia. Malaria Journal. 2019;18(1).

Pareyn M, Van den Bosch E, Girma N, van Houtte N, Van Dongen S, Van der Auwera G, et al. Ecology and seasonality of sandflies and potential reservoirs of cutaneous leishmaniasis in Ochollo, a hotspot in southern Ethiopia. PLoS Negl Trop Dis. 2019;13(8):e0007667

Pareyn M, Kochora A, Van Rooy L, Eligo N, Vanden Broecke B, Girma N, et al. Feeding behavior and activity of Phlebotomus pedifer and potential reservoir hosts of Leishmania aethiopica in southwestern Ethiopia. PLoS Negl Trop Dis. 2020;14(3):e0007947.

New article: Few pregnant women seek health care in Gedeo in southern Ethiopia

Borde MT, Loha E, Johansson KA, Lindtjorn B (2019) Utilisation of health services fails to meet the needs of pregnancy-related illnesses in rural southern Ethiopia: A prospective cohort study. PLoS ONE 14(12): e0215195.

Although maternal survival has improved in the last decades, evidence on illnesses and the use of health services during pregnancy remains scarce. Therefore, we aimed to assess the incidence and risk factors for illnesses among pregnant women and measure the use of health services. A prospective cohort study was conducted in three kebeles in rural southern Ethiopia among 794 pregnant women from May 2017 to July 2018. Each woman was followed every two weeks at home. Poisson and survival regression models were used for analysis. The incidence rate of episodes of illnesses was 93 per 100 pregnant-woman-weeks (95%CI: 90.6, 94.2), with an average of eight episodes of illnesses per woman. Anaemia accounted for 22% (177 of 794 women), and hypertension 3% (21 women of 794 women). However, utilization of health services for any illness episodes was only 8% (95%CI: 7.6%, 8.9%). The main reasons for not using health services were that the women thought the illness would heal by itself, women thought the illness was not serious, women could not afford to visit the health institutions, or women lacked confidence in the health institutions. The risk factors for illnesses are having many previous pregnancies in life time (ARR = 1.42; 95%CI = 1.02, 1.96), having history of stillbirth (ARR = 1.30; 95%CI = 1.03, 1.64), having history of abortion (AHR = 1.06; 95%CI = 1.02, 1.11), and walking more than 60 minutes to access the nearest hospital (AHR = 1.08; 95%CI = 1.03, 1.14). The risk factors for low use of health services are also having history of abortion (AHR = 2.50; 95%CI = 1.00, 6.01) and walking more than 60 minutes to access the nearest hospital (AHR = 1.91; 95%CI = 1.00, 3.63). Rural Ethiopian pregnant women experience a high burden of illness during pregnancy. Unfortunately, very few of these women utilize health services.

New article: Can we measure household Food Insecurity?

Kabalo, Bereket Yohannes, Seifu Hagos Gebreyesus, Eskindir Loha, and Bernt Lindtjørn. “Performance of an Adapted Household Food Insecurity Access Scale in Measuring Seasonality in Household Food Insecurity in Rural Ethiopia: A Cohort Analysis.” BMC Nutrition 5, no. 1 (2019/11/20 2019): 54.

Background  Seasonality poses a considerable food security challenge in Ethiopia. Yet, measuring seasonal variations in food insecurity, particularly the dimension of food access, lacks an adequately validated tool. We therefore evaluated the performance of an adapted Household Food Insecurity Access Scale (HFIAS) to estimate seasonal variations in food insecurity (FI) among subsistence villagers in Ethiopia.

Methods  We employed a cohort study design using a panel of four repeated measurements taken in June, September, and December in the year 2017, and in March 2018. The study recruited 473 villagers from the drought-affected Wolaita area in southwest Ethiopia. The performance of the HFIAS was evaluated via internal consistency (Chronbach’s alpha values) and criterion validation techniques. The set of criteria include: parallelism between affirmative responses to FI questions and wealth strata; dose-response relationship between FI and dietary intake; and also FI severity and household wealth status.

Results  This study revealed that the HFIAS had satisfactory performance in four repeated measurements. The likelihood of affirmative responses to questions about FI decreased with ascending wealth quintiles. We observed an inverse dose-response relationship between FI and wealth status, and between FI and household dietary diversity.

Conclusions  The HFIAS showed an acceptable potential for measuring seasonal variations in FI in the study area. Our findings complement efforts to evaluate the scale’s applicability in various settings, in order to promote cross-culture monitoring and comparisons. However, it required a careful adaption for contextual and cultural sensitivities.

Reducing poverty

Intervention studies, and especially randomised controlled trials, has been in the health tool box for many years. In medicine, we usually examine one intervention and look at one outcome. About 20 years ago, economists, furthermore, began to use these powerful methods.

Now, this year’s Nobel prize in economics gives an outstanding recognition to Abhijit Banerjee, Indian born professor at Massachusetts Institute of Technology, to Esther Duflo, a French born professor also at MIT, and to Michael Kremer, professor at Harvard University.

Their great achievements are that they introduced randomised controlled trials to obtaining reliable answers about the best ways to fight poverty. They divided the question of reducing poverty into smaller and more manageable, questions – for example, the most effective interventions for improving educational outcomes or child health. They show by doing so, questions are generally best answered via carefully designed experiments among the people who are, for the most part, affected.

In the research that we do, we frequently find that poverty is an underlying cause of a health problem, as can be seen by for example malnutrition. Now, the challenge is to identify smaller steps that could reduce poverty and subsequently malnutrition using their novel concept of breaking the problems into tinier and manageable proportions.

I hope that development agencies and governments, in collaboration with universities, will use such tools to improve their work.

New article: Spatiotemporal clustering of malaria in southern-central Ethiopia: A community-based cohort study

Solomon T, Loha E, Deressa W, Gari T, Lindtjørn B (2019) Spatiotemporal clustering of malaria in southern-central Ethiopia: A community-based cohort study. PLoS ONE 14(9): e0222986.

Introduction  Understanding the spatiotemporal clustering of malaria transmission would help target interventions in settings of low malaria transmission. The aim of this study was to assess whether malaria infections were clustered in areas with long-lasting insecticidal nets (LLINs) alone, indoor residual spraying (IRS) alone, or a combination of LLINs and IRS interventions, and to determine the risk factors for the observed malaria clustering in southern-central Ethiopia.

Methods   A cohort of 34,548 individuals residing in 6,071 households was followed for 121 weeks, from October 2014 to January 2017. Both active and passive case detection mechanisms were used to identify clinical malaria episodes, and there were no geographic heterogeneity in data collection methods. Using SaTScan software v 9.4.4, a discrete Poisson model was used to identify high rates of spatial, temporal, and spatiotemporal malaria clustering. A multilevel logistic regression model was fitted to identify predictors of spatial malaria clustering.

Results   The overall incidence of malaria was 16.5 per 1,000 person-year observations. Spatial, temporal, and spatiotemporal clustering of malaria was detected in all types of malaria infection (P. falciparum, P. vivax, or mixed). Spatial clustering was identified in all study arms: for LLIN + IRS arm, a most likely cluster size of 169 cases in 305 households [relative risk (RR) = 4.54, P<0.001]; for LLIN alone arm a cluster size of 88 cases in 103 households (RR = 5.58, P<0.001); for IRS alone arm a cluster size of 58 cases in 50 households (RR = 7.15, P<0.001), and for control arm a cluster size of 147 cases in 377 households (RR = 2.78, P<0.001). Living 1 km closer to potential vector breeding sites increased the odds of being in spatial clusters by 41.32 fold (adjusted OR = 41.32, 95% CI = 3.79–138.89).

Conclusions   The risk of malaria infection varied significantly between kebeles, within kebeles, and even among households in areas targeted for different types of malaria control interventions in low malaria transmission setting. The results of this study can be used in planning and implementation of malaria control strategies at micro-geographic scale.


New and important publication from the Arba Minch group

Mulchandani R, Massebo F, Bocho F, Jeffries CL, Walker T, Messenger LA. A community-level investigation following a yellow fever virus outbreak in South Omo Zone, South-West Ethiopia. PeerJ. 2019;7. doi: 10.7717/peerj.6466.


Despite the availability of a highly effective vaccine, yellow fever virus (YFV) remains an important public health problem across Africa and South America due to its high case-fatality rate. This study investigated the historical epidemiology and contemporary entomological and social determinants of a YFV outbreak in South Omo Zone (SOZ), Ethiopia.


A YFV outbreak occurred in SOZ, Ethiopia in 2012–2014. Historical epidemiological data were retrieved from the SOZ Health Department and analyzed. Entomological sampling was undertaken in 2017, including mosquito species identification and molecular screening for arboviruses to understand mosquito habitat distribution, and finally current knowledge, attitudes and preventative practices within the affected communities were assessed.


From October 2012 to March 2014, 165 suspected cases and 62 deaths were reported, principally in rural areas of South Ari region (83.6%). The majority of patients were 15–44 years old (75.8%) and most case deaths were males (76%). Between June and August 2017, 688 containers were sampled across 180 households to identify key breeding sites for Aedesmosquitoes. Ensete ventricosum (“false banana”) and clay pots outside the home were the most productive natural and artificial breeding sites, respectively. Entomological risk indices classified most sites as “high risk” for future outbreaks under current World Health Organization criteria. Adult mosquitoes in houses were identified as members of the Aedes simpsonicomplex but no YFV or other arboviruses were detected by PCR. The majority of community members had heard of YFV, however few activities were undertaken to actively reduce mosquito breeding sites.


Study results highlight the potential role vector control could play in mitigating local disease transmission and emphasize the urgent need to strengthen disease surveillance systems and in-country laboratory capacity to facilitate more rapid responses to future YFV outbreaks.


Reducing stillbirths in Ethiopia

Lindtjorn B, Mitike D, Zidda Z, Yaya Y. Reducing stillbirths in Ethiopia: Results of an intervention programme. PLoS One. 2018;13(5):e0197708. Epub 2018/05/31. doi: 10.1371/journal.pone.0197708. PubMed PMID: 29847607.

Previous studies from South Ethiopia have shown that interventions that focus on intrapartum care substantially reduce maternal mortality and there is a need to operationalize health packages that could reduce stillbirths. The aim of this paper is to evaluate if a programme that aimed to improve maternal health, and mainly focusing on strengthening intrapartum care, also would reduce the number of stillbirths, and to estimate if there are other indicators that explains high stillbirth rates. Our study used a “continuum of care” approach and focussed on providing essential antenatal and obstetric services in communities through health extension workers, at antenatal and health facility services. In this follow up study, which includes the same 38.312 births registered by community health workers, shows that interventions focusing on improved intrapartum care can also reduce stillbirths (by 46%; from 14.5 to 7.8 per 1000 births). Other risk factors for stillbirths are mainly related to complications during delivery and illnesses during pregnancy. We show that focusing on Comprehensive Emergency Obstetric Care and antenatal services reduces stillbirths. However, the study also underlines that illnesses during pregnancy and complications during delivery still represent the main risk factors for stillbirths. This indicates that obstetric care need still to be strengthened, should include the continuum of care from home to the health facility, make care accessible to all, and reduce delays.


Intended and non-intended use of bed nets for malaria protection

Doda Z, Solomon T, Loha E, Gari T and Lindtjørn B. A qualitative study of use of long-lasting insecticidal nets (LLINs) for intended and unintended purposes in Adami Tullu, East Shewa Zone, Ethiopia. Malaria Journal 2018;17:69


Background  Malaria poses a significant public health threat globally, across Africa and in Ethiopia. The use of long-lasting insecticidal nets (LLINs) is currently a proven prevention mechanism. Evidence is building on what happens to LLINs following mass distribution campaigns, with mixed results from different studies, some reporting very low use for intended purposes, others an encouraging level of using for intended purposes. In Ethiopia, between 2005 and 2015, about 64 million LLINs were distributed through periodic mass campaigns with the aims to achieve 100% coverage and 80% utilization. However, studies from rural Ethiopia showed variable LLINs coverage and utilization rate. The MalTrial Project, a collaborative venture between Hawassa University, Ethiopia and NROAID, Norway, has started a trial project in 2014 in Adami Tullu District of central Ethiopia. Quantitative surveys have established evidence on LLINs ownership and utilization, but the behavioural, sociocultural and socioeconomic dynamics of why LLINs’ use for intended purposes is low or why they are employed for other purposes remained elusive. The present qualitative study, building on the quantitative findings and framework, therefore, attempted to fill gaps in these areas using qualitative methods in selected localities of the district.

Methods  The study employed 7 focus groups, 16 individual interviews and observation to undertake data collection in January 2017. The data were analysed using NVivo Version 11 (QSR International) to transcribe, code and identify themes using thematic analysis approach.

Results  The study found out that certain households were more likely to use nets for intended needs in proper ways; a range of factors, notably socio-cultural and poverty, highly influence users’ ideas about the right ways and decisions to use and care for the nets; knowledge gaps and wrong perception exist regarding the purposes and life cycle of the nets; LLINs are employed for repurposed uses once they are considered non-viable, old, or lose their physical integrity; existence of misuse was acknowledged and understood as wrong; and values about gender roles further shape uses, misuses and repurposed use of the nets.

Conclusions  Behavioural, socio-cultural, economic and ecological conditions coupled with deficiencies in perceived bed net design and distribution policies; weak education, communication and social support structures were important in understanding and accounting for why a low level of intended use and a rampant misuse and repurposed use in Adami Tullu community of Ethiopia. A major nexus to address in order to improve intended use of LLINs lies, first and foremost, in economic poverty and socio-cultural factors that underlie much of the misuse and repurposed use of the nets.

Keywords  LLINs Malaria; Intended uses; Misuses; Repurposed uses; Collateral benefits of LLINs