Cholera remains a significant public health challenge in many developing countries, including Ethiopia. It is an acute diarrheal disease caused by ingesting food or water contaminated with Vibrio cholerae.1–3 Ethiopia is among the 47 countries worldwide that report annual cholera cases, often resulting in fatalities.4 According to the World Health Organization (WHO), cholera affects an estimated 1.3 to 4 million people globally each year, leading to 21,000 to 143,000 deaths.5 Despite progress in expanding access to healthcare and safe water, Ethiopia continues to experience recurrent cholera outbreaks, impacting thousands of people annually.6 Recent surveillance data from the Ethiopian Public Health Institute (EPHI) and regional health bureaus indicate frequent outbreaks in southern Ethiopia, including the Sidama Region, where cholera remains endemic due to seasonal flooding, poor sanitation, and fragile health systems.4,6
Community engagement is widely recognized as essential for effective cholera preparedness and response, particularly in settings with limited institutional capacity. Engagement strategies that emphasize local participation, empowerment, and intersectoral collaboration—alongside consistent communication—have been shown to improve health outcomes and resilience.7–9 For instance, in Bangladesh and Kenya—countries facing similar environmental challenges—community-based cholera control models have successfully involved local leaders and volunteers in case detection, household disinfection, and health messaging, leading to improved outbreak containment and service utilization.10
In Ethiopia, ongoing national efforts focus on training health workers and raising awareness about cholera prevention.11–14 However, these programs often emphasize biomedical responses and fall short of meaningfully incorporating local experiences, knowledge systems, and cultural values.6,13 This disconnect can hinder community ownership and reduce adherence to health measures, as interventions may be perceived as externally imposed or irrelevant.7 When community voices are excluded, trust in public health systems weakens, uptake of interventions declines, and vulnerability to preventable outbreaks increases.8,11
Despite decades of investment, significant gaps remain in fully integrating community perspectives into cholera response frameworks.15 In particular, the limited inclusion of local voices in planning and decision-making contributes to low awareness and engagement in preparedness activities. While health workers are well-trained in treatment protocols, community-level participation in prevention and surveillance remains limited.10 Although Health Extension Workers (HEWs) have helped deliver education and services, the integration of bottom-up perspectives into planning remains insufficient. In addition, there is limited data on how sectors collaborate at regional levels to coordinate community engagement in outbreak response,16 which hampers efficient resource allocation and rapid action during emergencies.17
This study aims to address these challenges by prioritizing community engagement in cholera preparedness and response. Specifically, it focuses on the Health Development Army (HDA) network in the Sidama Region—a community-based structure critical to linking households with the health system. Through in-depth qualitative research, the study explores local perspectives on cholera management and identifies strategies to strengthen engagement and intersectoral collaboration. Findings will provide practical insights for designing inclusive, culturally grounded, and resilient cholera interventions across Ethiopia and comparable settings.
Methods
Study design, setting, and time period
This qualitative study adopted a phenomenological approach to examine community perspectives on participation in public health emergency response efforts for cholera outbreaks. The research was conducted in community settings across Ethiopia, focusing on the experiences of Health Development Army members and other local residents actively engaged in health initiatives. Between June and August 2023, in-depth interviews were conducted to explore participants’ lived experiences with cholera outbreak preparedness and management. Interviews were conducted in either Sidamu Afoo (the local Sidama language) or Amharic, depending on the participant’s preference, and were facilitated by trained bilingual data collectors fluent in both languages. These interviews aimed to capture the complexities of community engagement in public health initiatives, generating rich, descriptive data that reflects on-the-ground realities. The study period was strategically chosen to align with ongoing public health efforts, ensuring that the insights gathered would be both relevant and timely for informing future cholera management strategies.
The Sidama Region, home to over 4.3 million people—most of whom live in rural areas—comprises 36 woredas and more than 500 kebeles. The study was conducted in four purposively selected woredas—Aleta Wondo, Hawassa Zuriya, Dale, and Shebedino—and included eight kebeles identified in consultation with local health authorities. The region’s vulnerability to recurrent cholera outbreaks, often driven by environmental and infrastructural factors, underscores the importance of localized preparedness efforts. It was selected due to its recent establishment as an independent administrative area, necessitating an assessment of its emerging regional public health systems. Additionally, the region’s ongoing outbreak patterns, active healthcare facilities, and engaged community groups involved in outbreak surveillance and management made it a suitable study site. The research team included native Sidama-speaking researchers and field staff who had long-standing relationships with local health authorities and communities, enhancing contextual understanding and trust during data collection. The chosen districts and kebeles provided a range of perspectives within a geographically contained area, facilitating field visits and an in-depth exploration of different response experiences.
Sampling strategy and sample size
Purposive sampling was employed to select key informants capable of providing in-depth insights into the research topic. A maximum variation purposive sampling approach was used to capture diverse perspectives. The study sample comprised Health Development Army (HAD) members actively engaged in community health programs. To be eligible, participants must have served as HDA members in their respective communities for at least one year.
While focusing on HDA members might seem to narrow the scope, this selection was intentional, as they play a pivotal role in community health initiatives and offer valuable insights into local perspectives on cholera management. This aligns with the study’s overarching objective of prioritizing community engagement and ensuring that local voices are incorporated into health decision-making. By specifically interviewing HDA members, the research aims to generate rich qualitative data that captures community-level experiences and challenges, ultimately contributing to a more comprehensive understanding of effective cholera management strategies. This focus will be consistently reflected in the study’s title, abstract, and introduction to maintain coherence throughout.
An initial list of information-rich informants was generated based on the eligibility criteria. Purposive sampling was then applied, with initial participants assisting in identifying additional HDA members with valuable insights. To minimize potential bias introduced by snowball sampling, efforts were made to select participants from different districts and kebeles, ensuring geographic and demographic variation. In total, 30 in-depth interviews were conducted with HDA members. Data collection continued until data saturation was reached, meaning no substantially new themes emerged from additional interviews. Saturation was confirmed through review of field notes and coding summaries maintained during iterative analysis, which documented theme recurrence across transcripts. This determination was based on inductive thematic analysis conducted alongside data collection and preliminary analysis. The recurrence of consistent perspectives across interviews confirmed that saturation had been achieved with a sample of 30 HDA members.
Data collection methods and instruments
Qualitative data were gathered through in-depth, semi-structured interviews using a field interview guide. The guide, developed by AA and SD in local languages, was designed to explore key aspects of community participation in cholera outbreak management. The interview guide covered six thematic areas to explore comprehensive community insights: sociodemographic factors (e.g., “Can you describe your household’s main source of income or your level of education?”), community leadership dynamics (e.g., “Who are the most trusted figures in your community during a health crisis?”), disease awareness (e.g., “What do you know about how cholera is transmitted and prevented?”), preparedness activities (e.g., “What actions has your community taken to prepare for a potential cholera outbreak?”), health service trends (e.g., “How has access to and use of healthcare services changed over time in your area?”), and external support structures (e.g., “Have any external organizations provided assistance during cholera outbreaks, and if so, how?”). These thematic areas and illustrative questions enabled a deeper understanding of the lived experiences, knowledge gaps, and structural factors shaping community engagement in cholera preparedness and response. The interview questions and probes within each theme were carefully structured to elicit comprehensive insights from participants. Each interview lasted approximately 60 minutes, allowing for an in-depth exploration of perspectives aligned with these key areas of inquiry.
With participant consent, digital audio recordings of interviews were securely stored. Additionally, observational field notes were taken during interviews and debriefing sessions. The interview guide and procedures were pre-tested by the research team to ensure clarity and relevance. Based on the pilot testing, minor revisions were made, such as simplifying technical terms and reordering questions to improve narrative flow and comprehension. Efforts were made to match interviewers and participants by gender and language wherever possible, and all interviewers were culturally familiar with the Sidama Region to foster rapport and contextual sensitivity. This refinement process aimed to uphold informed consent principles while optimizing the collection of contextually meaningful qualitative data. Strict data management and security protocols were followed, adhering to established ethical standards to ensure confidentiality and anonymity.
Data analysis
Verbatim transcription of the interview recordings enabled a thematic analysis of the qualitative data. Two research team members, AA and SD independently conducted the analysis using an inductive open-coding approach. The data were managed and coded manually without the use of qualitative software such as NVivo or Atlas.ti. To ensure consistency and reliability, the researchers held regular meetings to cross-check coding schemas and refine the analytical framework. After establishing initial codes, an interpretive thematic analysis was conducted to identify key themes and patterns within the data. For example, initial codes such as “trusted leaders,” “household-level hygiene,” and “external support gaps” were grouped into broader categories like ‘community leadership dynamics’ and ‘barriers to preparedness,’ which evolved into final themes used in reporting. Representative participant quotes were integrated into narrative accounts to illustrate findings in a compelling yet confidential manner. Several measures were implemented to ensure the trustworthiness and rigor of the analysis. Purposive sampling enhanced the credibility of the identified themes, while regular researcher debriefings fostered reflexivity and dependability by critically examining the analytic process and mitigating potential bias. These rigorous procedures strengthened the depth and reliability of insights drawn from community perspectives.
Ethical considerations
This qualitative study received ethical approval from the Institutional Review Board of St. Paulo’s Millennium Medical College (reference number PM 23/71, dated 26/7/2022). Participants provided voluntary informed written consent after being fully briefed on the study’s objectives, procedures, potential risks and benefits, confidentiality measures, and their right to participate freely. For participants with low literacy, information sheets were read aloud in their preferred language, and understanding was confirmed verbally before obtaining signed consent.
To protect participant identity, all identifying information was removed from transcripts and replaced with coded identifiers. Hardcopy data files were securely stored in locked cabinets, while electronic files were encrypted, and password protected. Results were reported in an aggregated and anonymous manner to further ensure confidentiality. There were no foreseeable risks to participation beyond potential mild discomfort. However, participants had the right to decline any question or withdraw at any time. The study’s potential benefits, aimed at informing improvements in cholera management programs and policies, outweighed any minor risks. Throughout the research process, all ethical guidelines were strictly followed to safeguard participants’ well-being, autonomy, privacy, and overall welfare.
Result
The sociodemographic characteristics of the 30 HDA members who participated in the study highlight several key trends. The majority were female (57%), while males comprised 43% of the sample. Age distribution showed that most participants were between 30–35 years (33%) and 36–40 years (27%). All participants identified as Sidama, reflecting the ethnic homogeneity of the group.
Regarding education, more than half had completed high school (57%), while 36.6% had attained elementary education, and a small proportion (7%) held a diploma. Work experience among HDA members was evenly distributed across different categories: 1–3 years (27%), 4–6 years (23%), 7–9 years (27%), and 10–15 years (23%). These distributions are summarized as follows: 17 were female and 13 males; 10 participants were aged 30–35, 8 were aged 36–40; 17 completed high school, 11 completed elementary school, and 2 held a diploma. These findings offer a clear demographic profile of the study participants, providing context for their perspectives on cholera management. A detailed breakdown of these characteristics is presented in Table 1
Themes
The study identified six key themes related to community engagement in cholera response. The first theme, Illuminating Socioeconomic Context, revealed that households primarily rely on smallholder agriculture and casual labor, highlighting significant economic vulnerabilities that affect health outcomes. The second theme, Influential Leadership Dynamics, demonstrated the critical role of respected community figures in shaping health decisions and fostering collaboration with health workers to enhance community mobilization. The third theme, Gaps in Cholera Awareness, indicated that while there is basic awareness of cholera symptoms, substantial knowledge gaps persist regarding its transmission and prevention measures. The fourth theme, Understanding Indigenous Prevention Efforts, showed that community-led initiatives focus on hygiene and environmental cleanliness, but face challenges related to mobilization and inconsistent support. The fifth theme, Drivers of Healthcare Access Evolution, noted improvements in health-seeking behaviors, although barriers to accessing healthcare services remain. Finally, the sixth theme, Optimizing External Stakeholder Engagement, highlighted a lack of support from external partners, which limits the effectiveness of cholera response efforts and underscores the need for strategic collaborations to bolster community resilience.
Theme 1: Illuminating socioeconomic context
The in-depth insights provided a nuanced understanding of respondents’ social and economic realities. The dominant livelihoods revolved around smallholder agriculture and casual wage labor, highlighting the economic vulnerability faced by most households. “Most of us survive by farming small plots of land. If the rain fails, everything becomes difficult,” one participant explained, reflecting the heavy dependence on unpredictable agricultural conditions. Many relied on cultivating cash crops such as khat for subsistence, underscoring the precarious balance between survival and sustainability. As another informant stated, “Khat is not what we prefer to grow, but it helps us get money quickly when there is no food at home.” Respondents with lower levels of education or less stable income sources more frequently reported difficulty accessing hygiene materials or paying for transport to health facilities, indicating a link between economic hardship and reduced health-seeking behavior. Despite ethnic and religious diversity within the local population, participants frequently emphasized the long-standing inter-communal harmony and mutual understanding that defined social relations. “Even though we come from different religions, we help each other when someone is sick or during funerals,” shared one community member, highlighting the strength of social ties. While sustaining livelihoods required intensive labor, social cohesion within communities remained strong and served as a critical asset in collective health initiatives. These trends were most pronounced among women respondents aged 30–40, who often balanced household caregiving with seasonal agricultural labor. These findings offer a detailed portrayal of residents’ lived experiences, helping to inform and tailor more effective intervention strategies that align with both their socio-economic challenges and communal strengths.
Theme 2: Influential leadership dynamics
Informants emphasized the significant influence of key community figures, such as respected elders, religious leaders, and elected administrators, in shaping local decision-making. Their authority stemmed from their esteemed roles and responsibilities within society. As one participant noted, “The key community leaders who influence health decision-making are elderly people, religious leaders, women leaders, kebele administrators, HEWs, and Edir committees.” Despite their influence, these leaders worked in collaboration with frontline health workers to coordinate prevention efforts and align programs with public health objectives. These partnerships were crucial, as certain cultural traditions supported prevention initiatives. For example, the community’s emphasis on proper toilet facilities naturally aligned with public health goals. Another informant highlighted this by stating, “Elderly people, religious leaders, and community leaders are highly influential in making decisions regarding general health. These individuals have responsibilities in the community.” Leaders often hold influence by virtue of age, moral standing, or elected position, and their selection frequently follows customary norms or local elections overseen by community assemblies. By actively engaging both formal and informal leaders, health interventions were strengthened, fostering greater community engagement. These findings highlight the importance of strategically involving respected gatekeepers to mobilize communities. Coordinating efforts with influential figures such as elders and religious leaders can enhance prevention and response efforts by driving widespread participation and support.
Theme 3: Gaps in cholera awareness
While most community members had a basic awareness of cholera’s symptoms through health outreach efforts, informants highlighted significant gaps in understanding other critical aspects of the disease. As one participant noted, “The majority know cholera as a deadly disease characterized by symptoms such as diarrhea and vomiting.” This initial knowledge was largely acquired from local health personnel. Another informant explained, "For most respondents, their source of information was HEWs and health professionals working in the district."
However, respondents lacked a comprehensive understanding of cholera’s specific characteristics, modes of transmission, and key prevention measures—areas that health development teams emphasized as essential. “Respondents are not well aware of the detailed features of cholera and the symptoms that should be recognized by health development teams”. For instance, one participant remarked, ''I thought cholera causes fever like malaria. I didn’t know vomiting and watery diarrhea are signs to worry about,'" reflecting confusion between common febrile illnesses and cholera’s distinct symptom profile. These knowledge gaps were more frequently noted among participants with limited formal education, reinforcing the need to tailor communication strategies by literacy level. Compared to similar studies in Somali and Gambella regions, where community awareness of transmission routes was also limited, the knowledge deficits observed here appear consistent with national patterns in underserved rural areas.
These findings underscore the need for targeted awareness campaigns focused on transmission dynamics and risk-related behaviors. Strengthening community understanding could enhance local ownership of cholera preparedness efforts, fostering proactive prevention. By optimizing outreach strategies, public health stakeholders can build community capacity to recognize, respond to, and mitigate cholera’s spread, creating more sustainable and effective disease control efforts.
Theme 4: Understanding indigenous prevention efforts
Informants described that ongoing community-led prevention efforts focused on environmental cleanliness, hygiene promotion, and sanitation initiatives. These activities formed the backbone of cholera prevention strategies. One participant explained, “Keeping the environment clean, preventing open defecation, maintaining handwashing, personal hygiene, sanitation, and constructing toilet facilities are key efforts.” The initiatives primarily emphasized behaviors such as proper handwashing, consistent toilet use, and the elimination of open defecation. As another informant noted, “Preventing open defecation, keeping handwashing, personal hygiene, and sanitation are essential prevention measures.” Additionally, awareness-raising efforts played a crucial role in reinforcing these grassroots actions. “Awareness creation is a key activity in cholera preparedness and prevention within communities,” one respondent stated.
Women participants, especially those aged 30–45, were more likely to describe detailed hygiene practices and cite participation in environmental sanitation campaigns, reflecting their central role in household health responsibilities.
However, challenges such as weak community mobilization, inconsistent external support, and financial constraints have hindered the full optimization of these efforts. Strengthening community-led prevention requires sustained cross-sector investments and strategic support. These findings highlight both the strengths of existing initiatives and the persistent barriers limiting their impact. Targeted interventions can enhance local capacities, enabling communities to take a more active role in public health preparedness. By reinforcing community-led resilience through tailored support, populations can become better equipped to protect their health and well-being.
Theme 5: Drivers of healthcare access evolution
Informants observed a significant improvement in health-seeking behaviors within the community, marking a shift away from the socio-cultural and economic barriers that previously hindered access to healthcare. One informant noted, “The health-seeking behaviors of the community are much better compared to previous times,” indicating a growing engagement with health services.
Key factors driving this improvement included increased enrollment in Community-Based Health Insurance (CBHI) and strengthened grassroots outreach efforts. As one participant explained, “The reason for the improved health-seeking behavior is HEWs’ intervention, the strengthening of the health system, and increased community awareness.” Community members also recognized the benefits of seeking timely treatment, with another informant stating*, “The perceived benefit of getting treatment, along with the availability and engagement of HDA, has encouraged care-seeking.”
*Participants with secondary education were more likely to report improved trust in health services and regular CBHI enrollment, suggesting education-related differences in access and utilization.
However, persistent barriers such as long distances to healthcare facilities and financial constraints continue to limit access, necessitating targeted investments to further improve service availability. These findings highlight areas where strategic interventions could alleviate remaining challenges and enhance universal healthcare access. Sustained efforts to reinforce both health infrastructure and demand generation will be essential for optimizing community participation. By providing nuanced insights into the evolving patterns of healthcare utilization, this study identifies priority areas for strengthening local health systems. Addressing these gaps through targeted actions can help overcome persistent constraints, fostering greater population-wide responsiveness and long-term public health gains.
Theme 6: Optimizing external stakeholder engagement
While frontline health staff provided meaningful guidance to communities, informants consistently highlighted the lack of additional technical and material support from external partners to complement local efforts. As one participant stated, “Yes, we receive awareness and different support from HEWs, but there are no other benefits received from them.” Beyond outreach efforts by health facility workers, no other organizations were actively involved in aiding. Another informant confirmed, “There is no other benefit received from them,” while others noted, “No NGO or other stakeholders support the HDA.” The absence of external support limited opportunities for regular retraining, monitoring, logistical provision, and technical advising—elements that could have strengthened the community’s ability to respond effectively to cholera outbreaks. Informants suggested that this gap weakened preparedness efforts and underutilized community contributions. These findings present actionable recommendations for external actors aiming to enhance grassroots initiatives. Strategic partnerships that include periodic skill-building, needs assessments, and resource mobilization tailored to local contexts can improve two-way accountability. By fostering synergistic collaborations, external stakeholders can shift from viewing affected populations as passive recipients to recognizing them as active contributors in public health preparedness and response.
Discussion
The study identifies several critical findings that, while seemingly obvious, reveal deeper insights into the socio-economic context and health dynamics of the community. First, the precarious economic situation—characterized by reliance on traditional farming and cash crops like khat and enset—underscores the urgent need for innovative agricultural practices and diversification strategies to enhance resilience against resource scarcity exacerbated by population growth. These socio-economic constraints are not only economic but have direct health implications, particularly for access to water, sanitation, and preventive care. Second, the influential role of community leaders—including elders, religious figures, and local administrators—illuminates an opportunity to harness their authority to foster community ownership and trust in public health initiatives. Engaging these leaders can significantly enhance health messaging effectiveness, leading to greater community participation in preventive measures. Third, the considerable knowledge gaps regarding cholera transmission and prevention indicate a critical need for tailored health education strategies, which could empower the community to take proactive measures against outbreaks. This serve as a reminder that awareness alone is insufficient without actionable knowledge. Lastly, the barriers to effective preparedness, such as weak social mobilization and inconsistent support, underscore the necessity for targeted investments in community engagement and infrastructure.
The findings of this study illuminate critical aspects of the socio-economic context and health dynamics within the community, revealing challenges that extend beyond surface-level observations. The precarious economic situation, characterized by heavy reliance on traditional farming and cash crops such as khat and enset, underscores the urgent need for adaptive agricultural practices and diversification strategies. This aligns with previous research indicating that economic hardship in Ethiopia is driven by inflation and stagnant livelihood practices, demonstrating that the sustainability of local economies is increasingly threatened by rapid population growth and land shortages.18,19 In contrast, other studies have highlighted successful interventions in similar contexts, where innovative agricultural practices have led to improved food security and resilience.14 Thus, this study advocates for the adoption of such practices, emphasizing that without diversification, communities may remain vulnerable to both economic and health crises. However, while participants emphasized the authority and trust held by community leaders, the study did not uncover detailed mechanisms for how formal collaboration between these actors and the health system could be structured. To address this gap, practical frameworks such as participatory action research (PAR) and community advisory boards (CABs) should be explored to ensure sustained and structured involvement.
Structured coordination could be achieved through community health forums co-led by Health Extension Workers (HEWs) and respected local figures, regular joint planning sessions between kebele-level health teams and traditional leadership councils or establishing formal community advisory boards that embed these actors into the public health decision-making cycle. Although our interviews did not yield concrete models for such integration, participants repeatedly emphasized the trust and reach of these leaders—suggesting that formalizing their roles could increase compliance, facilitate rumor management, and bolster public confidence in cholera interventions. Integrating community representatives into outbreak response teams may also facilitate real-time adaptation of strategies during health crises. Future research and programmatic work should therefore focus on co-designing leadership engagement strategies with communities to ensure they are both culturally embedded and operationally feasible.
Furthermore, the influential role of community leaders—comprising elders, religious figures, and local administrators—presents a significant opportunity to enhance health initiatives. Their established authority and social standing can be leveraged to foster community ownership and improve trust in public health messaging. This finding is consistent with literature that emphasizes the importance of local leadership in health promotion.20 Engaging local leaders is not merely advantageous, but essential for mobilizing community resources and participation in preventive health measures. Research indicates that when community leaders, such as elders and local administrators, are actively involved in health initiatives, there is a significant increase in community buy-in and participation in health programs. This engagement fosters trust and enhances the effectiveness of health messaging, leading to better health outcomes.21 In practical terms, this can be achieved by formally integrating these leaders into health planning structures, such as community health steering committees or outbreak preparedness task forces at the kebele level. Additionally, involving them in co-delivery of health education sessions, where messages are jointly communicated by a health worker and a religious or traditional leader, can increase perceived legitimacy and cultural resonance. Leaders can also play a central role in rumor management and risk communication by serving as trusted sources of accurate information during outbreak situations. Regular consultation meetings between health teams and community leadership councils can help align strategies with local norms and ensure early identification of barriers. Such mechanisms go beyond symbolic inclusion and establish a shared responsibility for public health, thereby strengthening the link between formal systems and community structures. In contrast, studies from other regions have shown that a lack of engagement with local leaders can result in ineffective health interventions and low community buy-in, as communities may feel disconnected from initiatives that do not consider their local context or leadership structures.22 Importantly, gender equity must be addressed in these structures, as women—despite playing frontline caregiving roles—are often excluded from formal leadership. Inclusion of women-led groups or rotating leadership models can promote fairer representation.
Finally, this study identifies critical gaps in the community’s understanding of cholera transmission and prevention, emphasizing the need for tailored health education strategies. While awareness of cholera symptoms exists, the lack of knowledge regarding its etiology and transmission routes presents a significant barrier to effective prevention. This finding contrasts with other research that indicates successful community health initiatives often include comprehensive educational components that address knowledge gaps.6 The necessity for such educational initiatives cannot be overstated, as empowering the community with actionable knowledge can lead to significant reductions in disease incidence. Co-facilitation of health sessions by HEWs and local leaders may increase message credibility, while use of community dialogues or peer-led forums can help surface and correct local misconceptions. Additionally, the identified barriers to effective preparedness—such as weak social mobilization and inconsistent support—highlight the need for targeted investments in community engagement and infrastructure. Addressing these challenges, as seen in successful case studies from different regions, can develop robust cholera management strategies that not only mitigate immediate health risks but also promote long-term resilience within the community.23,24
Limitations
This study has several limitations. The relatively small sample size of key informants may restrict the generalizability of the findings beyond the immediate study context. A larger and more diverse sample could capture a broader range of perspectives. Additionally, as a qualitative study, it does not assess statistical significance; incorporating mixed methods with quantitative components could provide deeper insights into community engagement. Furthermore, self-reported recall data may be subject to biases that quantitative methods could help mitigate. Lastly, the study’s focus on a single regional setting may not fully capture variations that exist in other contexts. To mitigate these limitations, future research should apply triangulation approaches including household surveys, social network analysis, and participatory ranking techniques to validate findings and enhance representativeness across diverse demographic groups. Furthermore, although all participants self-identified as Sidama, this does not reflect the broader ethnic diversity of the region. The study areas were selected based on public health relevance and accessibility, which may have limited representation. Future studies should intentionally include participants from all ethnic groups residing in the region to enhance inclusivity and reduce the risk of selection bias.
Despite its limitations, this study demonstrates several strengths. The use of in-depth interviews facilitated a detailed exploration of nuanced socio-cultural factors, yielding rich contextual insights that other methodologies may overlook. Purposive sampling ensured that participants directly involved in health programs contributed valuable perspectives. Reflexivity was addressed through the use of trained local facilitators not affiliated with local health governance, helping to reduce social desirability bias. By identifying both strengths and challenges, the study provides actionable insights for improving cholera preparedness efforts and building on existing community engagement successes.
Recommendations for policy
The findings of this study yield several important policy recommendations. Strengthening preparedness initiatives and enhancing leadership capacities through targeted training and skills development can significantly bolster community resilience. In the short term (0–6 months), the Ministry of Health and Regional Health Bureaus should lead training and mentorship programs for Health Extension Workers (HEWs), Health Development Army (HDA) members, and community leaders. Establishing collaborative networks among community leaders, HDA, and health teams can improve coordination and streamline guidance delivery. This can be implemented in the medium term (6–12 months) through woreda-level forums supported by kebele administrations. Expanding stakeholder support through regular monitoring, resource allocation, and technical assistance will help build long-term local capacity. In the long term (12–24 months), development partners and multi-sectoral ministries (e.g., Health, Water, and Education) should jointly invest in WASH infrastructure, poverty alleviation strategies, and emergency preparedness systems. Additionally, addressing the socioeconomic drivers of cholera risk, such as poverty, through multi-sectoral strategies can further mitigate vulnerabilities. Investments in infrastructure, transportation, and healthcare accessibility are essential to improving service utilization and overall outbreak response. To guide national efforts, academic institutions and national research bodies should lead mixed-methods research integrating qualitative inquiry with population-level surveys and geospatial mapping to evaluate implementation progress and identify scalable models.
Conclusions
In conclusion, while this study faced limitations due to its qualitative design and focus on a single regional context, it provides valuable insights for strengthening cholera control through community-driven approaches. By identifying the influential roles of community leaders, knowledge gaps in disease understanding, and challenges in preparedness implementation, the study offers a framework for understanding the socio-cultural factors that shape local response capacities. Addressing these gaps through targeted strategies—such as collaborative training networks, infrastructure development, and enhanced stakeholder coordination—can bolster community resilience and strengthen partnerships between local populations and public health authorities. The findings suggest that leveraging these community assets can lead to more effective and sustainable cholera prevention efforts. Future research should employ large-scale mixed-methods designs focused on vulnerable and underrepresented populations—including women, youth, and persons with disabilities—using household-level surveys, participatory observation, and network analysis to better understand local health dynamics and equity gaps. Overall, this study highlights both strengths and areas for improvement, offering practical guidance for policymakers seeking to enhance community participation in public health initiatives. By integrating these insights with broader structural investments, decision-makers can foster more inclusive and locally informed approaches to population health security.
Ethics approval and consent to participate
Informed consent was obtained.
Availability of data and material
All data analyzed during this study are included with in the manuscript.
Funding
No funding was obtained for this study
Author Contributions
AA & MS originated the research idea. AA, SDS, SM & MS contributed to the data synthesis and writing the manuscript. All authors have read and approved the manuscript.
Competing interests
The authors declare that they have no competing interests
Corresponding authors:
Name: Aschalew Abayneh Workineh
Institution: Ethiopian Public Health Institute
Address: Addis Ababa
Country: Ethiopia
Email addresses: aschalewaw07@gmail.com