Lee, Nicole

Public Health



Ethiopia - Evaluation of the effectiveness of integrated Population-Health-Environment interventions for improving reproductive, maternal and child health, and promoting family planning, reforestation, wetlands, and rural livelihoods in rural Ethiopia

With only 17% of its population urbanized as of 2010, an estimated population of over 84 million people in 2011, and a total fertility rate of 4.8 children per woman, Ethiopia faces serious challenges related to reproductive, maternal and child health, deforestation, loss of wetlands, encroachment of human populations on zones of high biodiversity such as national parks, and limited options for income generation in rural areas. Climate change and growing population pressures on the environment, including overgrazing and deforestation, threaten livelihoods and heighten the risk of food insecurity. Increasingly, communities and professionals in different sectors view population, health, and environmental issues as closely linked within a dynamic system. Interventions that integrate issues of human and ecosystem wellbeing, referred to as Population, Health, and Environment (PHE) interventions, seek to improve outcomes across a variety of development sectors. Non-governmental organizations (NGOs) pursuing a PHE approach work with regional governments to integrate the responsibilities of local-level, sector-specific government employees such as Health Extension Workers (HEWs) and Agricultural Development Agents (ADAs). These NGOs also work directly with communities to develop interventions that address the needs not met by government programs. Few close examinations of individual components of PHE interventions have been carried out due to the nascent and multi-sector nature of the approach in Ethiopia. The proposed internship will represent the third year of collaboration between Dr. Peter Winch in the Department of International Health and the PHE Ethiopia Consortium http://www.phe-ethiopia.org and its member organizations to 1) evaluate the effectiveness of PHE interventions, 2) identify lessons learned and best practices from existing PHE programs, and 3) build capacity of local universities and non-governmental organizations in monitoring and evaluation. In 2012-2013, two master's students conducted a qualitative process evaluation of PHE programs in Tigray and Oromo Regions. In 2013-2014, one master's student is developing a package of instruments for quantitative assessment of the impact of these integrated programs. This effort involves developing measurement tools for food insecurity, livelihoods, understanding of PHE concepts, and adoption of practices to promote health and family planning and protect the environment. This plan of work is innovative, and helps to build the evidence base for actions to help rural communities adapt to climate change in low-income countries. This evidence base is urgently needed, as new sources of funding such as the Green Climate Fund (http://gcfund.net/home.html) become available to support adaption to climate change in low-income countries. A stronger evidence base is needed to help direct funding to activities that are most effective. In this third year of the collaboration with PHE Ethiopia consortium, the intern (s) will carry out a qualitative process evaluation of a PHE Ethiopia member organization with innovative activities that have not yet been documented, and assist with large-scale application of the tools for quantitative assessment of the effect of PHE interventions developed by the master's student in the second year of the collaboration.

Global Health Mentor: Peter Winch, MD
Director, Social and Behavioral Interventions Program

My initial feelings upon arriving in Addis Ababa were excitement about being in a new country and marvel that it appeared so modern. Soon, I felt overwhelmed from trying to navigate a city where English is not widely spoken and orientation is around landmarks instead of named roads. Generally, most people were extremely helpful and eased the transition.

In October 2014 I engaged with a local organization called Hiwot Ethiopia, a local charity focused on working with children and youth. When I first met with the management team, I explained to them that I had research and evaluation experience and expressed interest in learning more about reproductive health programming. I also did some background research on adolescent sexual and reproductive health issues in the Amhara region. I spent some time creating a more streamlined conceptual framework and creating a progress brief for one of their main projects.

As this engagement was limited by time, I must acknowledge the possibility of overcoming these challenges had I stayed longer. The challenges I experienced were concentrated around two areas: limited data and communication. English was my first language and I spoke no Amharic. Hiwot Ethiopia staff spoke both Amharic and English. Oftentimes there were obstructions in communication where one party did not fully understand the meaning of what the other party was saying. The staff were very encouraging in trying to teach me bits of Amharic during my stay, and I really appreciated being able to practice with them.

Although I am a graduate student in international public health at one of the preeminent institutions in the world, I struggled with acknowledging my own expertise. Who was I to impose my Western ideas on them? I constantly reflected on why I felt “this” wasn’t right or “that” could be done better. Sometimes that dreaded phrase came into mind – “cultural barriers” – but I believe that it was actually a learning experience into how small, local NGOs operate.

This experience created a strong interest to explore beliefs and practices around child marriage as a platform for population health environment issues. It strengthened my desire to work in global health in the future. Although my time there wasn’t perfect, I learned to stand up for my needs and pursue a path that is right for me no matter what someone else thinks. I have skills and ideas, that if applied in the right environment, can be a catalyst for real change.

All in all, I enjoyed my time with Hiwot Ethiopia and was grateful for the opportunity to work with them, even in the short time that I had. I actually like that Addis Ababa has its own identity and the food was mostly wonderful. I got to see the city from Entoto Hills and I think I semi-mastered the mini-bus system. I also met some of the most kind, intelligent, and entrepreneurial people while in Addis Ababa and look forward to meeting them again one day.


Photo Captions:

1. Addis Ababa from Entoto Hills
2. Lunchtime at the Hiwot office, always a social event
2. Enjoying coffee with a local entrepreneur and other interns I met in Addis


Yukari C. Manabe, MD

Associate Director of Global Health Research and Innovation

Noreen Hynes, MD MPH

Director, Geographic Medicine Center of the Division of Infectious Diseases

Robert Bollinger Jr., MD MPH

Director, Johns Hopkins Center for Clinical Global Health Education (CCGHE); Associate Director, Johns Hopkins Center for Global...

Stefan Baral, MD MPH,MBA,MSc

Director, Key Populations Program

Caitlin Kennedy, PhD MPH,BA

Co-Director, MPH concentration in Social and Behavioral Sciences in Public Health; Associate Director, Center for Qualitative...

Joanne Katz, ScD MS,BSc

Associate Chair, Director of Academic Programs

May 2020




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