- Open Access
Treatments used for malaria in young Ethiopian children: a retrospective study
Malaria Journal volume 17, Article number: 451 (2018)
In Ethiopia, medicinal plants have been used to treat different diseases, including malaria, for many centuries. People living in rural areas are especially noted for their use of medicinal plants as a major component of their health care. This study aimed to study treatment-seeking and prioritize plants/plant recipes as anti-malarials, in Dembia district, one of the malarious districts in Northwest Ethiopia.
Parents of children aged under 5 years who had had a recent episode of fever were interviewed retrospectively about their child’s treatment and self-reported outcome. Treatments and subsequent clinical outcomes were analysed using Fisher’s exact test to elicit whether there were statistically significant correlations between them.
Results and discussion
Of 447 children with malaria-like symptoms, only 30% took the recommended first-line treatment (ACT) (all of whom were cured), and 47% took chloroquine (85% cured). Ninety-nine (22.2%) had used medicinal plants as their first-choice treatment. Allium sativum (Liliaceae), Justicia schimperiana (Acanthaceae), Buddleja polystachya (Scrophulariaceae) and Phytolacca dodecandra (Phytolaccaceae) were the most frequently used. Justicia schimperiana was the one associated with the best clinical outcomes (69% self-reported cure rate). However, the difference in clinical outcomes between the plants was not statistically significant.
In this study, only 30% of children took the recommended first-line treatment. 22% of children with presumed malaria were first treated with herbal medicines. The most commonly used herbal medicine was garlic, but J. schimperiana was associated with the highest reported cure rate of the plants. Further research is warranted to investigate its anti-malarial properties.
Ethiopia has made tremendous progress in reducing incidence and mortality from malaria. There was a rapid scale-up of long-lasting insecticidal nets (LLINs) and artemisinin-based combination therapy (ACT) in 2007, associated with a 73% reduction in malaria admissions and a 62% reduction in malaria deaths in children aged under 5 years . The Health Extension Programme increased coverage of primary health care in Ethiopia to 90% in 2010 . Health extension workers are employed, each of whom is responsible for 500 households. Amongst other tasks, they can conduct rapid diagnostic tests for malaria and administer anti-malarial drugs. This contributed to Ethiopia’s rapid reduction in under 5 mortality, the fastest in East Africa, from 205 deaths per 1000 live births in 1990 to 64 in 2013 .
Because of increasing chloroquine resistance, in 2004 Ethiopia adopted artemether–lumefantrine (AL) as the first-line treatment for Plasmodium falciparum infections. Chloroquine remains the first-line treatment for Plasmodium vivax. Although national treatment guidelines recommend that this should be followed by a 2-week course of primaquine, in practice it is not routinely used because there are no widely available tests for G6PD deficiency. It is only used under the supervision of healthcare providers for patients with limited risk of malaria infection in the future, such as those who are not living in malaria endemic areas. A recent review showed that in Ethiopia, 98.1% of patients with P. falciparum were successfully treated with AL and 94.7% of patients with P. vivax were successfully treated with CQ . However, AL is only effective in 75.1% of patients with P. vivax . Although prevalence of P. falciparum has reduced rapidly since the introduction of AL, prevalence of P. vivax has risen slightly .
Therefore, malaria remains a leading public health problem in Ethiopia. It is estimated that about 75% of the total area of the country and 65% of the population is at risk of infection . In 2016, an estimated 2.6 million malaria cases and 5000 deaths occurred in the country, which was an increase since 2014 . Two-thirds of cases were due to P. falciparum, but Ethiopia is home to the second highest number of cases and mortality due to P. vivax in the world (after India). There is still room for progress: use of insecticide-treated bed nets in children under 5 ranges from 45 to 69% [8, 9]. The biggest gap between practice and policy is that only 41% of children under 5 with fever were taken to a health facility or provider, and only 34% sought care promptly . Furthermore, AL was less than 20% of the anti-malarials received by under-5 s .
One possible explanation for this is the use of herbal medicines. Traditional medicinal plants are an integral part of the variety of cultures in Ethiopia ; up to 80% of the population uses traditional medicine due to the cultural acceptability of healers and local pharmacopeias, the relatively low cost of traditional medicine and difficult access to modern health facilities . People living in rural areas are particularly noted for their use of medicinal plants as a major component of their health care [12,13,14,15]. The hypothesis of the current study was that many people who do not use formal care are using herbal medicines instead. Plants which are traditionally used for the treatment of malaria are a potential source of active lead compounds with new mechanisms of action.
The classical way of identifying medicinal plants for further research is through ethnobotanical studies. Yet conventional ethnobotanical studies rarely involve clinicians. They could and should provide much more clinical information if the ultimate goal is to know which one, among numerous treatments for a given ailment, has the best effects. Although identification of the plants is usually of a good standard, definition of the diseases which they treat is not. There is rarely sufficient questioning about the observed patient status and progress, perceived efficacy and limitations of the remedies, and whether these are indeed the ‘treatment of choice’. Many plants are ‘supposed’ to be good for one disease or another, but are not actually the preferred treatment used in everyday life. The ‘Retrospective Treatment Outcome Study’ (RTO) was designed circumvent these problems . This adds two essential elements to the ethnobotanical method: clinical information and statistical analysis. Clinical information is collected retrospectively on the presentation and progress of a defined disease episode. This approach has proved to work well in Mali , and has then been used in other places.
Aims and objectives
This study aimed to measure the frequency of use of different treatments, and associated outcomes, in children under 5 years of age with a recent episode of fever (identified by the parents as uncomplicated malaria) in a rural district of Ethiopia.
Dembia is a rural district in Northwest Ethiopia, covering a total area of 127,000 km2 (Fig. 1). The altitude of the district ranges from 1750 to 2100 m above sea level. It lies next to the largest lake in Ethiopia (Lake Tana) which contributes to the high and rising level of malaria in the area . Following the rainy season, the incidence of malaria peaks from the end of September to the middle of December. There were 12,221 malaria cases in the district in the year 2012, and this rose to 22,166 in 2016 . Within the district there are 5 urban kebeles and 40 rural kebeles (a kebele is the smallest administration unit, which is equivalent to a village). According to demographic data of the district, Aberjeha, Chenker and Tezeba were the most malarious kebeles with populations of 10,490, 6520 and 6213, respectively, and with incidence rates of 7.7%, 7.0% and 6.6%, respectively (Dembia District Health Office Demographic Data, 2012). These were selected for the study. The proportion of under five children was estimated to be 14% (3251) of the total population.
The sample size for the study was determined using the formula for a single population proportion. It was estimated that 50% of the population would be using plants, and required a 95% level of confidence. Therefore, sample size was determined as follows:
In order to allow for an estimated 15–17% non-response, the final sample size was increased to 451. The selection of respondents was performed in order to ensure that they were representative of the whole population, with a corresponding proportion of houses to be randomly visited until the desired sample size was reached.
Data collection process
During the peak malaria season, from November to December 2013, the parents of children aged under 5 years who had had symptoms of uncomplicated malaria (mainly fever) within the previous 2 months were interviewed. Data was collected using a structured and pre-tested questionnaire which was developed by Graz et al.  and subsequently modified, in order to elicit relevant symptoms, treatments and self-reported outcomes. Specimens of the reported anti-malarial plants were collected and identified by Mr. Abiyu Enyew (Botanist), Department of Biology, College of Natural Sciences, University of Gondar, to correspond the local name to the scientific name and deposited at herbarium unit, Department of Biology.
Data were coded, checked for completeness and consistency, entered using EPI-INFO™7 statistical software and then exported to SPSS version 20 for further analysis. Descriptive statistics of the collected data (list of plants/recipes used, frequency of children used, mode of preparation and treatment outcome, form of the treatment) was done. Statistical correlation with reported clinical recovery was also computed using Fisher’s exact test.
Permissions and ethical clearance
The study was carried out after getting permission from the ethical review board of the University of Gondar (R/C/S/V/P/05/239/2013). Then a letter of permission was obtained from the district health office and local administrator, and the individual household heads were invited to give written informed consent before the interview. Confidentiality was respected by keeping the privacy of the respondents while filling the questionnaire. Seriously ill children were advised to visit a health facility. Any personally identifiable information (such as names, addresses) was not entered into the database.
Socio-demographic characteristics of respondents
Among 451 patients who were approached for the study, 4 either did not complete the interview or were not willing to be included in the study. Finally, 447 were included, resulting in a response rate of 99.1%. 52.1% were girls and half of them (50.3%) were aged between 1 and 3 years. The mean age was found to be 34 months, with a range between 7 months and 5 years.
Treatment providers and treatment choices
Over three-quarters of respondents (75.6%) had sought treatment from a nurse, health extension worker, doctor or pharmacist, mostly (50.1%) from a nurse (Table 1). For those who took herbal medicines, more were provided by a family member (13.5%) than by a traditional healer (8.5%).
As shown in Fig. 2, from the total of 447 children with malaria, the commonest treatment was chloroquine (47%) followed by ACT (30%), usually artemether + lumefantrine. Ninety-nine (22.2%) were found to use medicinal plants alone for treatment of the illness as a first choice while 12 and 3 were found to use medicinal plants as a second and third alternative, respectively. Holy water was also reported to be used by three respondents as the first choice. Twelve plant species were mentioned and identified as treatments for malaria. Allium sativum (Liliaceae) was the most frequently reported plant (Table 2).
Treatments used and associated outcomes
According to their parents, all children who were treated with ACT were cured while 84.6% and 15.4% of children treated with CQ were cured and improved, respectively (p < 0.001). Of the herbal treatments, garlic was the most commonly used, but Justicia schimperiana was associated with the highest proportion of patients who said they were “cured” (69%). Although this seemed to be higher than the reported cure rate for all other medicinal plants (53%), the difference was not statistically significant (Fisher’s exact test statistic = 0.284).
Most patients used leaves (41.9%) followed by roots (17.1%). The oral route was the most frequent form of administration (92.8%) whereas decoctions were the most common preparation. Respondents were also asked about the unit of measurement for medicinal preparations and the majority of them used teaspoons and coffee cups for liquid preparations such as decoctions. Water was the most widely used solvent and honey was commonly used as sweetening agent to mask unpleasant tastes.
Summary of findings and comparison with the literature
It was found that much higher rates of treatment-seeking from formal health workers than reported in other sources. In spite of this, only a minority of children with malaria were treated with ACT, confirming results of other studies . Chloroquine was the commonest treatment, used in almost half of all cases. This is more frequent than would be expected, given that P. vivax is estimated to cause less than one-third of malaria cases in Ethiopia . This may in part be because CQ can be obtained from drug shops at a relatively cheap price ACT are only available from official health centres.
Although there are a few reports of CQ resistant P. vivax in Ethiopia [19,20,21,22], CQ is still recommended for the treatment of P. vivax malaria in Ethiopia  and is still effective in 94.7% of cases . The lower reported “cure” rate in this study (reported by parents) could imply that chloroquine was being used for cases of falciparum malaria (some of which are resistant to chloroquine), and that some of the children may have had a disease other than malaria.
The use of herbal medicine was lower than expected. This may partly be due to the expansion of the Health Extension Programme (HEP) at the household level which increased treatment-seeking for malaria in some areas  although in this study, only 12.5% of respondents received treatment from a Health extension worker.
None of the plants were associated with a very high reported “cure” rate, unlike studies in some other African countries . However almost all parents reported that their children had “improved”. Previous ethnobotanical studies have shown that several plants reported here are used elsewhere for the management of malaria and malaria-like symptoms (Table 3).
The anti-malarial activity of several of these plant extracts has been assessed in rodent models in vivo (Table 4). Ajoene, a compound isolated from Allium sativum, was found to prevent the development of parasitaemia in mice infected with Plasmodium berghei and substantially improved the anti-malarial activity of chloroquine . However the most promising plant was J. schimperiana. Although not the most commonly used, it was associated with the highest reported cure rates in this study. Its root extract has been tested against P. falciparum in vitro and was not very active (IC50 = 71 mcg/ml for the methanolic extract) . However, aqueous leaf extracts (which more closely resemble the traditional preparation) suppressed growth of P. berghei in mice in the 4-day suppressive test by 41%, and the methanol leaf extract suppressed parasitaemia by 65% . Although Clerodendrum myricoides and Zehneria scabra also had good anti-malarial activity in mouse models, they were not widely used, possibly because they are widely regarded as poisonous .
Strengths and limitations of the study
This was a community-based study conducted in one of the most malarious areas of Ethiopia. There was a very high response rate so the results are likely representative of the population in this area, and it could be confident in the prevalence of use of the different treatments. Voucher specimens of plants were collected and identified by a botanist.
The first limitation of this study is that patients were not asked whether they had been tested before receiving the treatment. With hindsight, it would have been useful to know the proportion of patients tested, and the proportion with P. falciparum or P. vivax. As the survey was retrospective, it is likely that some patients were not tested, and some may not actually have had malaria. Secondly, parents may not have been aware of the qualifications of the person they saw and may have said she was a ‘nurse’ when in fact she may have not been qualified. Thirdly, the data on outcomes is based on self-reporting by parents of the children. It seems that the question which discriminated best between treatments was whether a patient was ‘cured’, since almost all patients claimed to have at least “improved”. Therefore, the % of patients ‘cured’ on each treatment was compared. This approach seems to be valid, because 100% of patients claim to have been ‘cured’ after taking an ACT (to which there is no documented resistance in Ethiopia) compared to 84.6% who took chloroquine, against which there is some resistance.
Lastly, because herbal medicine was less frequently used than predicted, the sample size was too small to be able to find statistically significant differences in outcomes between patients who had taken different herbal remedies. Sample size calculation was based on an estimation of 50% of patients having taken herbal medicines. If that had been the case, this sample would have included twice as many patients who had taken herbals, which would have increased the statistical power to find differences in outcomes between subgroups—for example those who had taken J. schimperiana versus those who had taken Allium sativum.
Implications for policy, practice and research
Further investigations are needed to understand why the majority of children with malaria in Ethiopia receive CQ rather than AL, although the majority of malaria cases are reported to be caused by P. falciparum rather than P. vivax. Since most of the anti-malarial medicines were provided by health workers, a qualitative study of health workers would help to understand this. Factors to explore would include availability of AL and use of diagnostic tests or microscopy to distinguish between malaria species.
Justicia schimperiana may have the potential to be a candidate for the development of efficacious and safe anti-malarial phytomedicines and/or compounds, using a ‘reverse pharmacology’ model . It would be useful to further investigate the way in which it is prepared and used, and to isolate the active phytochemical(s).
In the most malarious villages of Dembia district, Ethiopia, only 30% of children with presumed malaria took the recommended first-line treatment (artemether–lumefantrine), while 47% took chloroquine and 22% were treated with herbal medicines as the first-line treatment. The most commonly used herbal medicine was garlic, but J. schimperiana was associated with the highest proportion of patients who said they were ‘cured’ (69%). Further research is warranted to understand reasons for the low use of AL, and to investigate the anti-malarial properties of J. schimperiana.
Retrospective Treatment Outcomes
Statistical Packages for Social Sciences
Otten M, Aregawi M, Were W, Karema C, Medin A, Bekele W, et al. Initial evidence of reduction of malaria cases and deaths in Rwanda and Ethiopia due to rapid scale-up of malaria prevention and treatment. Malar J. 2009;8:14.
Banteyerga H. Ethiopia’s health extension program: improving health through community involvement. MEDICC Rev. 2011;13(3):46–9.
Ruducha J, Mann C, Singh NS, Gemebo TD, Tessema NS, Baschieri A, et al. How Ethiopia achieved millennium development goal 4 through multisectoral interventions: a countdown to 2015 case study. Lancet Glob Health. 2017;5:e1142–51.
Gebreyohannes EA, Bhagavathula AS, Seid MA, Tegegn HG. Anti-malarial treatment outcomes in Ethiopia: a systematic review and meta-analysis. Malar J. 2017;16:269.
Tesfa H, Bayih AG, Zeleke AJ. A 17-year trend analysis of malaria at Adi Arkay, north Gondar zone, Northwest Ethiopia. Malar J. 2018;17:155.
Alemu A, Abebe G, Tsegaye W, Golassa L. Climatic variables and malaria transmission dynamics in Jimma town, South West Ethiopia. Parasit Vectors. 2011;4:30.
WHO. World malaria report 2017. Geneva: World Health Organization; 2018.
UNICEF. The State of the World’s Children 2017. New York: UNICEF; 2017.
Birhanu Z, Yihdego YYE, Yewhalaw D. Caretakers’ understanding of malaria, use of insecticide treated net and care seeking-behavior for febrile illness of their children in Ethiopia. BMC Infect Dis. 2017;17:629.
Pankhurst R. An historical examination of traditional Ethiopian medicine and surgery. Ethiopian Med J. 1965;3:157–72.
Kassaye KD, Amberbir A, Getachew B, Mussema Y. A historical overview of traditional medicine practices and policy in Ethiopia. Ethiop J Health Dev. 2006;20:127–34.
Endale A, Berhanu Z, Berhane A, Tsega B. Ethnobotanical study of antimalarial plants in Denbia District, North Gondar, Amhara Region, Northwest Ethiopia. In: 6th multilateral initiative on malaria conference; Durban, South Africa. 2013. p. 305.
Paulos B, Fenta TG, Bisrat D, Asres K. Health seeking behavior and use of medicinal plants among the Hamer ethnic group, South Omo zone, southwestern Ethiopia. J Ethnobiol Ethnomed. 2016;12:44.
Suleman S, Beyene Tufa T, Kebebe D, Belew S, Mekonnen Y, Gashe F, et al. Treatment of malaria and related symptoms using traditional herbal medicine in Ethiopia. J Ethnopharmacol. 2018;213:262–79.
Ragunathan M, Weldegerima B. Medico ethno botany: a study on the Amhara ethnic group of Gondar district of north Gondar zone Ethiopia. J Natural Remedies. 2007;7:200–6.
Graz B, Diallo D, Falquet J, Willcox M, Giani S. Screening of traditional herbal medicine: first, do a retrospective study, with correlation between diverse treatments used and reported patient outcome. J Ethnopharmacol. 2005;101:338–9.
Willcox M, Graz B, Falquet J, Diakite C, Giani S, Diallo D. A “reverse pharmacology” approach for developing an anti-malarial phytomedicine. Malar J. 2011;10(Suppl 1):S8.
Agegnehu F, Shimeka A, Berihun F, Tamir M. Determinants of malaria infection in Dembia district, Northwest Ethiopia: a case-control study. BMC Public Health. 2018;18:480.
Yohannes AM, Teklehaimanot A, Bergqvist Y, Ringwald P. Confirmed vivax resistance to chloroquine and effectiveness of artemether-lumefantrine for the treatment of vivax malaria in Ethiopia. Am J Trop Med Hyg. 2011;84:137–40.
Teka H, Petros B, Yamuah L, Tesfaye G, Elhassan I, Muchohi S, et al. Chloroquine-resistant Plasmodium vivax malaria in Debre Zeit, Ethiopia. Malar J. 2008;7:220.
Schunk M, Kumma WP, Miranda IB, Osman ME, Roewer S, Alano A, et al. High prevalence of drug-resistance mutations in Plasmodium falciparum and Plasmodium vivax in southern Ethiopia. Malar J. 2006;5:54.
Ketema T, Bacha K, Birhanu T, Petros B. Chloroquine-resistant Plasmodium vivax malaria in Serbo town, Jimma zone, south-west Ethiopia. Malar J. 2009;8:177.
Drug Administration and Control Authority of Ethiopia. Standard treatment guideline for general hospitals. Addis Ababa: Drug Administration and Control Authority of Ethiopia; 2010.
Bilal NK, Herbst CH, Zhao F, Soucat A, Lemiere C. Health extension workers in Ethiopia: improved access and coverage for the rural poor. In: Chuhan-Pole P, Angwafo M, editors. Yes africa can: success stories from a dynamic continent. Washington, DC: World Bank; 2011.
Perez HA, De la Rosa M, Apitz R. In vivo activity of ajoene against rodent malaria. Antimicrob Agents Chemother. 1994;38:337–9.
Bogale M, Petros B. Evaluation of the antimalarial activity of some Ethiopian traditional medicinal plants against Plasmodium falciparium in vitro. Ethiop J Sci. 1996;2:233–43.
Abdela J, Engidawork E, Shibeshi W. In vivo antimalarial activity of solvent fractions of the leaves of Justicia schimperiana Hochst. Ex Nees against Plasmodium berghei in mice. Ethiop Pharm J. 2014;30:95–108.
Neuwinger HD. African ethnobotany: poisons and drugs. London: Chapman & Hall; 1996.
Aminuddin RDG, Subhan Khan A. Treatment of malaria through herbal drugs from Orissa, India. Fitoterapia. 1993;64:545–8.
Shankar D, Venugopal S. Understanding of malaria in Ayurveda and strategies for local production of herbal anti-malarials. In: First international meeting of the research initiative on traditional antimalarials 1999; Moshi, Tanzania.
Berhanu A, Asfaw Z, Kelbessa E. Ethnobotany of plants used as insecticides, repellents and antimalarial agents in Jabitehnan district, West Gojjam. Ethiop J Sci. 2006;29:87–92.
Odugbemi TO, Akinsulire RO, Aibinu IE, Fabeku PO. Medicinal plants useful for malaria therapy in Okeigbo, Ondo state, Southwest Nigeria. Afr J Trad Complement Altern Med. 2007;4:191–8.
Abera B. Medicinal plants used in traditional medicine by Oromo people, Ghimbi District, Southwest Ethiopia. J Ethnobiol Ethnomed. 2014;10:40.
Meragiaw MM, Asfaw Z. Review of antimalarial, pesticidal and repellent plants in the Ethiopian traditional herbal medicine. J Herbal Sci. 2014;3:21–45.
Asnake S, Teklehaymanot T, Hymete A, Erko B, Giday M. Survey of medicinal plants used to treat malaria by Sidama people of Boricha District, Sidama Zone, South Region of Ethiopia. Evid Based Complement Alternat Med. 2016;2016:9.
Kenea O, Tekie H. Ethnobotanical survey of plants traditionally used for malaria prevention and treatment in selected resettlement and indigenous villages in Sasiga District, Western Ethiopia. J Biol Agric Healthc. 2015;5:1–9.
Lall Dev K. Indigenous drugs of India. Calcutta: Thacker, Spink & Co.; 1896.
Suleman S, Mekonnen Z, Tilahun G, Chatterjee S. Utilization of traditional antimalarial ethnophytotherapeutic remedies among Assendabo inhabitants in (South-West) Ethiopia. Curr Drug Ther. 2009;4:78–91.
Yirga G, Zeraburk S. Ethnobotanical study of traditional medicinal plants in Gindeberet District, Western Ethiopia. Mediterr J Soc Sci. 2011;2:49–54.
Coe FG, Anderson GJ. Ethnobotany of the Garífuna of Eastern Nicaragua. Econ Bot. 1996;50(1):71–107.
Lebbie AR, Guries RP. Ethnobotanical value and conservation of sacred groves of the Kpaa Mende in Sierra Leone. Econ Bot. 1995;49:297–308.
Singh VK, Ali ZA. Folk medicines in primary health care: common plants used for the treatment of fevers in India. Fitoterapia. 1994;65:68–74.
Vongo R. The role of traditional medicine on antimalarials in Zambia. In: First international meeting of the research initiative on traditional antimalarials; 1999; Moshi, Tanzania.
Petros Z, Melaku D. In vivo anti-plasmodial activity of Adhatoda schimperiana leaf extract in mice. Pharmacol OnLine. 2012;3:95–103.
Coppi A, Cabinian M, Mirelman D, Sinnis P. Antimalarial activity of allicin, a biologically active compound from garlic cloves. Antimicrob Agents Chemother. 2006;50:1731–7.
Muluye AB, Melese E, Adinew GM. Antimalarial activity of 80% methanolic extract of Brassica nigra (L.) Koch. (Brassicaceae) seeds against Plasmodium berghei infection in mice. BMC Comp Alt Med. 2015;15:367.
Adinew G. Antimalarial activity of methanolic extract of Phytolacca dodecandra leaves against Plasmodium berghei infected Swiss albino mice. Int J Pharmacol Clin Sci. 2014;3:39–43.
Tesfaye W, Endalkachew A. In vivo antimalarial activity of the crude extract and solvent fractions of the leaves of Zehneria scabra (Cucurbitaceae) against Plasmodium berghei in mice. J Med Plant Res. 2014;8:1230–6.
Deressa T, Mekonnen Y, Animut A. In vivo anti-malarial activities of Clerodendrum myricoides, Dodonea angustifolia and Aloe debrana against Plasmodium berghei. Ethiop J Health Dev. 2010;24:25–9.
AEG coordinated the overall work and designed the protocol. TK and HS involved in protocol development and manuscript writing. MW and BG designed the protocol and manuscript writing. All authors read and approved the final manuscript.
We are very grateful to the University of Gondar for sponsoring this study and Community Health Association-Geneva for financial support. Training on the RTO methodology was provided by the MUTHI project (EU-FP7 grant agreement no. 266005). We also want to extend our gratitude to data collectors; Mr. Gashaw Sisay, Mr. Baraki Huluf, Ms. Leknesh Belay, Mr. Lakachew Molla, Ms. Elsa Abuhay and Ms. Bosena Lakew. Mr. Zemene Demelash is also highly acknowledged for his contribution in data entry and clearance. We wish to thank the study participants and local leaders, without whose open and keen collaboration the study would not have been possible.
The authors declare that they have no competing interests.
Availability of data and materials
Almost all the materials and data of our study are included in the manuscript, a few of the material and data will be available to other researchers upon request.
Consent for publication
Letter of permission was obtained from the district health office and local administrator, and the individual household heads were invited to give written informed consent before the interview. Moreover, participants of the study have consented to their photograph being taken for publication, if necessary.
Ethics approval and consent to participate
Ethical approval was secured from the Institutional Review Board of the University of Gondar (R/C/S/V/P/05/239/2013), prior to starting of the study.
This project was funded by Community Health Association-Geneva.
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