Public Health (PhD)

Permanent URI for this collection

http://etd.aau.edu.et/handle/123456789/76

Browse

Now showing 1 - 20 of 30

Barriers to Access to Modern Contraception
(Addis Ababa University, 1998-02) Tekalegne, Agonafer; Bergevin, Yves (PhD)
Assessment of the Knowledge, Attitude and Practice of Health Care Workers on Universal Precaution in North Wollo Zone, Amhara Region, North Eastern Ethiopia, 2006
(Addis Abeba university, 2007-04) Damte, Mesele; Betre, Mulugeta(PhD)
Background Employing universal precautions means taking precautions with everybody. If precautions are taken with everyone, health care workers do not have to make assumptions about people's lifestyles and risk of infection. Objectives: The main objective of the study was to assess the knowledge, attitude and practices of health care workers on universal precautions and factors in health institutes. Methods: This cross sectional health institution based survey was conducted in North Wollo Zone from January through September 2006. The study has used quantitative and qualitative methods. Statistical significance was determined by computing mean variations using T test and one-way ANOVA methods. Results: - The response rate for quantitative method was 93.4%. The mean knowledge score of health care workers was 2.53 ± (SD 1.17) and 156 (44.4%) of the respondents had greater or equal to the mean score. Seventy-nine (87.8%) of the observed injection practices was found to be unsafe to the health care workers and clients or community. The overall hand hygiene adherence rate was 28.34% ± (SD 27.58%). Correct hand hygiene practice has statistically significant association with availability of water, alcohol, and participating on UP trainings (OR (95% CI) = 6.89(2.66, 17.87), (OR (95% CI) = 3.95(1.46, 10.68), and (OR (95% CI) = 5.84(2.32, 14.72). Also female health care workers better adhere to hand hygiene than male (OR (95% CI) = 0.15(0.06, 0.38). According to the FGD’s result luck of supplies and facilities were the main factors for unsafe practices in health institutes. Conclusion: Considerable proportion of health care workers in North Wollo had lacked proper knowledge, attitude and practice towards universal precautions. Equally health care facilities in North Wollo were not adequately prepared in supplying essential materials to safe practices. Providing training on universal precaution to all health care staff and enhancing sustainable supplies systems are recommended. Key words: universal precaution, health care workers, universal precaution related practice and hand hygiene.
Vitamin A Deficiency in Ethiopia:Magnitude, Distribution and Potential Risk Factors
(Addis Abeba University, 2010-02) Demissie(Phd) Tsegaye; Prof.Ali, Ahmed
Background Based on the high vitamin A deficiency rates indicated in the reports of several pocket level surveys, it can be concluded that vitamin A deficiency is a major public health problem exacerbating child morbidity, mortality and disability in Ethiopia. In order to effectively address the problem, upto-date and comprehensive information is imperative. Objective of the thesis The aim of the research is to provide up-to-date and disaggregated information on the magnitude and determinants of vitamin A deficiency in Ethiopia that are deemed important in the prevention and control efforts. Methods The national survey, the major component of the research, employed cross-sectional study design and multi-stage cluster-sampling approach. A total of 23,148 children were examined for the clinical signs and symptoms of vitamin A deficiency. Blood was collected from 1200 children for serum retinol analysis and a questionnaire addressing most of the potential determinants of vitamin A deficiency was administered to 2552 households. Assessment of risk factors to vitamin A deficiency among primary school children employed a case-control study design and included 97 clinical cases and 194 controls. In addition, analysis of beta carotene contents of fifteen food items, five each from common vegetables, common fruits and common staple foods was done. Results The survey revealed high prevalence rates of vitamin A deficiency across the country. The national bitot’s spot prevalence rate was 1.7% with the highest rates in the Amhara Region (3.2%), followed by the prevalence rates in Afar (2.1%), Oromiya (1.5%), Addis Ababa (1.4%), Harari (1.2%) and Dire Dawa (1.1%). The national maternal night blindness prevalence rate was 1.8% with the high prevalence rates in Tigray (14.1%), Benishangul-Gumuz (5.7%), Afar (1.2%) and Amhara (1.0%). The national weighted prevalence rate of subclinical vitamin A deficiency (<0.7µmole/lt) was 37.7% (95% CI; 35.6%-39.9%), with high prevalence rates in Afar (57.3%) and Oromiya regions (56.0%), moderate prevalence rates in Dire Dawa (48.0%), Amhara (40.7%) and Harari (35.3%) regions and relatively low prevalence rates in Tigray (14.3%) and SNNP (11.3%) regions. Among the under-six children, male children and older children were affected more by clinical vitamin A deficiency than female children and young children (p<0.05). The prevalence of clinical vitamin A deficiency was significantly higher among children from predominantly rural areas compared to that of children from predominantly urban areas (p<0.05). Being from Muslim households (OR = 2.23), belonging to mothers who could not mention at least one fact about vitamin A (OR = 1.80), not receiving vitamin A supplement at least once in the previous year (OR = 1.45), belonging to mothers who have given birth to three or more children (OR=1.46) and being sick in the two weeks preceding the survey (OR=1.42) were found to have been associated with high levels of subclinical vitamin A deficiency among preschool age children. Similarly, being from Muslim households (OR = 7.03), not consuming vegetables three or more times a week (OR=3.04) and being sick in the two weeks preceding the survey (OR=2.04) were associated with high levels of clinical vitamin A deficiency among primary school children. In aggregate, 41.5% of the studied households did not produce/cultivate any of the common vegetables over the year preceding the survey and the proportion was high in Addis Ababa (99.7%), Afar (94.9%), Dire Dawa (94.2%), Tigray (86.4%) and Harari (63.1%) regions. Similarly, 75.5% of studied households did not cultivate/produce any of the common fruits over the year preceding the survey and the proportion was high in Addis Ababa (100%), Dire Dawa (95.3%), Afar (92.9%), Tigray (92.2%), Harari (83.3%) and Oromiya (81.8%) regions. Overall, 38.1% of the children studied did not eat any of the common vegetables over the week preceding the survey and the proportion was high in Afar (85.0%), Tigray (77.6%), Amhara (61.8%) and Addis Ababa (59.3%). Similarly, 36.5% did not eat any of the common fruits over the week preceding the survey, with the highest proportions in Tigray (88.1%) and Afar (83.5%) regions. Over 66% of the children included in the study did not eat meat, close to 53% of the children did not eat eggs and 33.4% of the households included in the study did not use oil over the week preceding the survey. The situation regarding own production of fruits and vegetables was significantly better (p<0.05) in predominantly rural areas whereas market availability and consumption of fruits, meat, egg and oil was significantly better (p<0.05) in predominantly urban areas. High beta carotene content in kale ( 6100.45 µg/100gm) and carrot (5800.09 µg/100gm), moderate amounts in spinach ( 800.12 µg/100gm), mango (500.54 µg/100gm) and papaw (800.86 µg/100gm) and no or negligible amounts in injera, bread and kocho were observed. Conclusions and recommendations Conclusions The study revealed that, albeit the longstanding effort to control and eradicate vitamin A deficiency in Ethiopia, the problem is still prevailing unabated. Although the prevalence of vitamin A deficiency (clinical and subclinical) were higher than the WHO cut off points in all regions, the extent of the problem in Amhara, Afar and Oromiya regions appears to be more serious. Again, although vitamin A deficiency (clinical) was significantly higher in predominantly rural areas compared to predominantly urban areas, prevalence rates in Addis Ababa, Harari and Dire Dawa (predominantly urban areas) were found to constitute a public health concern. The study highlighted the increased risk of Muslim preschool and school children, male and older preschool age children to vitamin A deficiency compared to their respective counterparts. The negative impacts of morbidity, enormous benefits of vitamin A supplementation and the strong positive contributions of maternal awareness to vitamin A status of children were underlined in the study. Moreover, the strong association of vegetable consumption with vitamin A deficiency among primary school students was also underscored. The study, however, showed that the practice of planting/cultivating and consumption of common vegetables and fruits was suboptimal in Ethiopia. Recommendations Policy and strategy related recommendations • Agricultural policies and strategies that facilitate production of fruits, vegetables and livestock products must be developed and implemented. • School health and nutrition policy and strategy to enhance the awareness of the students regarding the importance of vitamin A must be developed. Intervention related recommendations • Continuation and intensification of the ongoing periodic vitamin A supplementation by ensuring universal coverage, its timeliness and safety is recommended. • Strengthening attempts aimed at enhancing the consumption of vegetables, fruits, oil and livestock products are recommended. • Strengthening efforts to improve women’s awareness regarding the importance of vitamin A is recommended. • Priority and attention must be given to Amhara, Afar, Oromiya and Harari regions and Addis Ababa and Dire Dawa city administrations. • Interventions aimed at improving maternal vitamin A nutrition, particularly, postpartum vitamin A supplementation is recommended. Surveillance related recommendations • Mechanisms to monitor vitamin A status must be established. • Conducting serial cross-sectional surveys at national, regional and sub-regional level periodically (e.g. in 5 years interval) using biological indicators is recommended Research related recommendations • The increased risk of Muslim preschool and primary school children to vitamin A deficiency merit an in depth and well designed investigation. • Similarly, the increased risk of male and older preschool age children to clinical vitamin A deficiency requires further in-depth assessments to expound the reasons. • Investigation on the reasons why Ethiopians do not adequately produce and consume vegetables and fruits is recommended.
Assessment of Fertility Desire and Family Planning Utilization Among HIV Positive People Who Are on Antiretroviral Treatment, Asella Hospital, Arsi Zone, Oromia Region, 2011
(Addis Abeba university, 2011-05) Tadesse, Legesse; Belachew, Ayele(PhD)
Back ground:- People who are living with HIV / AIDS may or may not have desire of children and want to use family planning . However, the degree of their desires and how it varies by individual social health and demographic characteristics is not well understood. Objective:-To assess fertility desire and family planning utilization in PLWHA that were on follow up care in Asella Hospital ARV treatment unit. Methods:-A cross-sectional health facility based study design supplemented by qualitative in-depth interview was done from November 1 to December 30 2010. The study was conducted in Asella Hospital, Asella Town, Arsi Zone, Oromia, Ethiopia. The study population was all HIV positive people who had at least one visit to the ART unit and age group 18-49 for female and 18-55 for male. The sample size taken were 384 .Pre tested questionnaire was used to collect the data which was entered using EPI info window 2000 and analyzed by SPSS 15.0 statistical packages. The qualitative study sample taken until enough information was obtained and interview included participants, a health service provider at ART, Family planning and VCT service provider at out patient department. Notes were taken and data were grouped in to thematic area words of the respondents were quoted accordingly. Results:- Seventy-five (29.3%) of the women and 56 (43.3%) of the men, totally Hundred thirty one 131(34.1%) of HIV positive people receiving care In Aella ARV treatment unit. HIV infected women desire children than men counter parts (AOR o.o1,95% CI 0, 0.25) ; PLWHAs those who have one/ no child had more desire for children in the future than those who have two and above (AOR 115, 95% CI 3868.6); single individuals had less need than married counter parts (AOR 0.01, CI 0, 0.96). Family planning utilization of PLWHA before knowing their HIV status was 47.7% but current users were 76.5% during the study period. Current FP usage was less in those who were not in marriage than those who were in marriage at study period and those who were on ART for two years or less (AOR 0.04, 95% CI 0.02, 0.1) , 0.5(0.28, 0.89) respectively
Risky Sexual Practice, Accessibility and Utilization of HIV Service among People With Disabilities in Addis Ababa
(Addis Abeba university, 2011-05) Kumssa, Hanna; Zergaw, Ababi
Background: HIV/AIDS is known to be one of the most catastrophic diseases that have confronted humanity in living memory. Even though there are segments of disadvantaged social groups who are at risk HIV infection due to their lower level of socio economic capacity it is believed that people with disability are more vulnerable to HIV infection. Objective: To assess the risky sexual practices, accessibility and utilization of HIV service among people with disability in Addis Ababa City Administration. Materials and methods: Between September 2010 and April 2011, a cross sectional community based survey was conducted using interviewer administered questionnaire of 417 people with disabilities found from associations of people with disabilities in Addis Ababa City Administration. This was supplemented with focus group discussions with disabilities for access and utilization of HIV services. The findings were described and analyzed using SPSS version 16. Result: Based on the findings, more than half (60%) of study participants were sexually active and a third of them (28.4%) had initiated sex before 18 years. Almost half (48%) of these did not use condoms consistently and 33.6% had multiple sexual partners. Majority (92.8%) have information for existence of HIV services in the country. About 72% of all participants have ever utilized some kind of HIV services ever. Female respondents were nearly 2.5 times more likely to use condoms than males irrespective of type of disabilities [AOR (95%CI) 2.46 (1.28-4.71)]. Those ever married were 2.5 times more likely to use condoms than singles [AOR (95%CI) 2.54(1.49-4.35)]. Visually impaired participants are about 2 times more likely to have multiple sexual partners than those of physically impaired [AOR (95%CI) 1.90(1.02-3.55)]. In addition, those who were singles are 45% less likely to have multiple sexual partners than those of ever married [AOR (95%CI) 0.55(0.31- 0.97)]. Regarding utilization of HIV services, hearing impaired participants were about two times more likely to have utilized any HIV services than those of visual impaired [AOR (95%CI) 2.12(1.13-3.98)]. Conclusions: In general, the findings in this study showed poor access to information, less convenient of facilities and low utilization of HIV service among people with disabilities. Improving access to information on HIV through targeting PWDs, support to HIV service providers in developing disability sensitive communication materials and improving health service delivery systems to take care of disability are recommended
Role of Rural to Urban Migrants and Socio-Cultural Factors including Fertility intentions in the Spread of HIV Risk among Rural areas of Bure Woreda,Northwest,Ethiopia.
(Addis Ababa University, 2012-03) Semegne, Melesse Tamiru(PhD); Prof.Hailemariam, Damen; Dr.Mitikie, Getnet
Background: The AIDS epidemic is global in its span; a particularly heavy burden has fallen on Sub-Saharan Africa. The consequences of the African AIDS epidemic are growing—not only just in size—but in complexity. These consequences are no longer just biological; increasingly, they are also behavioural, social and cultural. It is well-known that 84% of the population in Ethiopia lives in rural areas relying on the agricultural sector which plays the central role in the country’s economy. However efforts to conduct HIV related studies in rural areas of the country remain extremely patchy. So far, there have been few studies concerning the nature of HIV infection in rural areas resulting in meagre information on how HIV spreads from urban to the rural areas and how local people perceive the epidemic and protect themselves from risk factors. The rural people in Bure Woreda are not an exception. The negative influences of migration, fertility intentions and other socio-cultural factors in the spread of HIV in the Amhara region in general and in the present study area in particular are not known, moreover, overlooked social activities such as leisure activities which may be linked to HIV risk behaviours among the study population of the rural to urban migrants and non-migrants in Bure Woreda, North West Ethiopia require due attention and a thorough investigation. The way in which migration contributes to the spread of HIV risk is complex and not well understood. Previous studies have focused on the destinations of migrants, or, less often, on the areas from which migrants come. In this study exploring both ends of migration routes in atypical rural areas is fundamental for successful interventions Although subsistence agriculture is the major economic activity in Ethiopia; parents want to have large numbers of children for assistance in farming activities as well as economic support during old age. In the rural areas, women’s fertility and HIV infection are not independent of one another. Conditions and behaviours resulting in high levels of fertility are also likely to impact upon womens' likelihood of acquiring HIV. Women and men desire children for their utilitarian–economic, social, and psychological values, whereas fertility is on the decline primarily due to changes in economic development. Different segments of the population are at different stages of this transition with different values attributed to children at each stage. The challenge is will women take measures to prevent HIV infection in themselves and their babies if they perceive themselves at high risk of HIV infection, or will endeavour to fulfill the utilitarian–economic, social, or psychological dictates of childbearing. Objectives: The general objective of this study was to assess and explore the role of rural to urban migrants (potential bridging population) and socio-cultural factors (including high fertility intentions) in the transmission and spread of HIV risk to the rural community of Bure Woreda. Methods: In order to address this general objective, the study assessed factors that affect the sexual behaviours of rural to urban migrants and non-migrants (rural residents) by comparing the link between predisposing, and enabling factors with the sexual risk behaviours among rural to urban migrants and non-migrants and by investigating the leisure activities which are associated with different levels of likelihood to engage in HIV risk behaviours among rural to urban migrants and non-migrants. Moreover other sexual and cultural practices of the rural people in relation to HIV risks including the association of fertility intention (the desire to have children) with HIV risk were investigated. In this study, HIV-related sexual risk behaviours among rural to urban migrants and non-migrants is compared and the role of migration in HIV transmission and socio-cultural practice and norms for the spread of the virus in the rural areas of Bure Woreda is explored. The detailed methodology included two components: The first one was a quantitative cross-sectional study which involved 1,310 men (655 men rural to urban migrants, 655 non- migrants) and 1,380 married women aged 18 to 49 years. The second component was a qualitative study which consisted of 8 focus group discussions and 25 key informant interviews. I) Quantitative study: Radom sampling technique was applied to select the required study units from the rural- urban migrants (road construction sites (Cobble stone), Ethiopian Commodity Exchange (ECX), commercial agricultural farm employees and rural residents from the rural kebeles of Bure Woreda. A total of 2,751 participants, 667 rural men and 1,418 rural married women were drawn from the 23 rural kebeles of Bure Woreda while the remaining 666 rural to urban migrants were taken from Bure and around Bure town. Because the present study had a number of different outcome variables so it was necessary to calculate the respective sample sizes separately with different assumptions. Structured questionnaires were used to collect the quantitative data. The questionnaires were tested prior to collecting the actual data in order to standardize the flow and content of the questions. Accordingly, amendments were made depending on the results of the pre-test that was conducted in the nearby similar areas. Data collection was carried out by twenty diploma holders who were given three-days of intensive training with practical exercises. Four health officers/sanitarians were assigned to supervise the data collection process and the data was analyzed using SPSS version 17 statistical software. The, chi-square test and binary logistic regression were used to see the association of variables. II) Qualitative study: This part of the study was aimed at substantiating and complementing the quantitative study. The selection of participants and formation for focus group discussions (FGD) were facilitated by the community leaders of the respective kebeles under consideration. Four rural kebeles were identified for the 8 FGDs and 25 in-depth interviews. The main data analysis took place on completion of each interview. In this regard, the usual principles guiding qualitative analysis were taken into account and sequences of interrelated steps (reading, coding, displaying, data reduction and interpreting) were employed while analyzing the data. In short, as can be noted from the above explanations, the procedure used to process the raw data for the purposes of classification, summarization and tabulation was thematic content analysis. The basic idea here was to identify the extracts of data that were informative in some way and to sort out the important messages hidden in the mass of each key informant interview and FGD. Results: A total of 2,690 participants (response rate, 97.7 %) responded to the questionnaire on HIV risk behaviours, leisure activities and fertility intention. This study consisted of two groups 655 male rural to urban migrants working in Bure town and rural residents (655 male nonmigrants and 1,380 married women). When the two groups (rural to urban migrants and non-migrants) are compared in terms of practicing sexual risk behaviours i.e. having of multiple sexual partners, practicing sex with commercial sex workers, contracting sexual transmitted infections and practicing premarital sex there is a difference between them. The proportions of rural to urban migrants vs non- migrants who had multiple sexual partners (31.4 % vs 7.4 %), practiced sex with commercial sex workers (22.3% vs 13.3%), contracted sexual transmitted infections (11.7% vs 3.2%) and practiced premarital sex (20.8% vs 14.2 %) were significantly higher in rural to urban migrants than nonmigrants. Among those who had multiple sexual partners, only 12.7 % of rural to urban migrants and 9.8 % of non-migrants reported consistent condom use with sexual partners other than their spouse. In addition, the findings of the study indicated that both migrants and non-migrants were engaged in different leisure activities when they did not have work. The first three leisure activities with the highest rates of participation among migrants were visiting entertainment installments (76.3%), chatting (64.9%), and listening to radio (31.5%). On the other hand, doing chores (71.6%), visiting entertainment installments (30.7%) and chatting (29.2%) were among the activities in which non- migrants were participating most often. The differences noted between the two groups in terms of the types of leisure activities were statistically significant (P=0.001). Multiple logistic regression analysis was also done to explore the association between the eleven leisure activities and each of the five HIV risk behaviours among migrants and nonmigrants. Among migrants, watching TV, reading (including non migrants), chatting, watching videos, wandering on streets (including non-migrants), and visiting entertainment facilities were positively associated with most of the five HIV risk behaviours. Listening to radio for migrants and chatting and doing chores in non migrants were negatively associated with some of the HIV risk behaviours. The association of rural married women to HIV perceived risk, child mortality and desire to have children and the link to HIV risk was assessed. Overall, 32.8 % of subjects expressed desire for future pregnancy, 8.8 % perceived themselves at high risk for HIV infection and 26.7% reported the death of at least one child in the past five years. In multiple logistic regression analysis, reporting at least one child's death (OR=6.92; 95% CI=4.91 to 9.47) was significantly associated with a higher desire higher to become pregnant. Furthermore perceived high risk for HIV infection (OR=2.08; 95% CI= 1.35 to 3.19) was found to be associated with the desire to get pregnant. Being currently married, having no education, being of low parity and having low household expenditure were significantly associated with having the desire for more children. The qualitative part of this study identified a number of social factors and cultural norms and practices that impact on HIV/AIDS. The first category consists of factors that were said to promote the spread of HIV/AIDS such as alcohol drinking and drunkenness. To that effect, all social and cultural functions that involve large gatherings such as holidays and wedding ceremonies, alcohol drinking and dancing were seen to greatly contribute to the spread of HIV/AIDS. The second category is of factors influencing the reduction in the risk of HIV transmission such as promotion of virginity and arranged marriages. Interestingly, some of the main social factors, cultural norms and practices that increase the risk of HIV transmission were seen to also play significant roles in risk reduction; church gatherings, weddings, and burials were singled out as major avenues for promoting positive sexual behaviours while some people use them to engage in risky behaviours. HIV/AIDS and the social and cultural set-up of communities have impacted upon each other. In the context of HIV/AIDS, social and cultural practices play dual roles, on one side enhancing HIV transmission while on the other facilitating reduction in incidence. However, social factors, cultural norms and practices were seen more as facilitators than inhibitors of HIV transmission, while low awareness about HIV/AIDS and lack of supportive services such as VCT and knowledge of condoms remain major limitations to sustain behaviour change. Accessibility to these services is also limited to the majority in the rural areas Conclusions: As both rural to urban migrants and non-migrants are at risk for HIV infection, intervention program targeting both groups are recommended. However, in order to contain the bridging effect on HIV transmission from urban to rural areas particular attention should be given for the rural to urban migrant population. Effective HIV prevention programming must reach and serve populations at risk. This study shows that male migrants are at high risk of HIV due to risky sexual partnerships and low condom use. Additionally, their high mobility and multiple partnerships potentially contribute to the spread of HIV to the rural areas. Sero-prevalence data should be collected to complement behavioural data and enable tailored programming to reach this vulnerable group. Employers should be engaged in HIV prevention for this population. Socially desirable and constructive leisure activities such as listening to the radios among migrants and doing chores and chatting among non-migrants may prevent them from being engaged in HIV risk behaviours while leisure activities such as visiting entertainment installments and watching videos may increase the odds for migrants to be engaged in HIV risk behaviours. However the evidence in this study strongly suggest that migrants who are detached from family and home environment may be exposed to leisure activities possibly associated with HIV risk behaviours. Therefore, given the high mobility of migrants, it is very important to strengthen work place intervention in their destination places High perceived risk of HIV infection was associated with high desire for future pregnancy. Moreover women seem to have a higher desire for a future pregnancy to replacing a dead child that may have lost its life as a result of HIV infection. This finding indicated the crucial role of desire for fertility by a married woman irrespective of the risk for acquiring HIV infection. This implies that there should be further research to address the issue and the utilitarian-economic, social, and psychological values attributed to children by both women and their male sex partners. The involvement of men as partners in childbearing should be explored, as their desire for children may be the primary barrier to protective behavioural change among women. In order to change rural Ethiopian parents’ perception of values of children, child education needs to be compulsory so the cost of raising children will increase and inhibit a further high desire for pregnancy. In the area the prevailing cultural practices and norms encourage large families and discourage the use of condoms. In such settings, there is the need to find appropriate mechanisms that could help increase the use of all types of contraceptives. As contraceptive use increases, it is likely that the use of condoms for AIDS prevention and also for family planning purpose would increase.. According to the qualitative findings some striking characters were noted - these are the mobility of commercial sex workers from large town to small towns such as Bure or adjust rural villages in order to attract a wider or different client base, for adventure and to conceal illnesses which might be associated with HIV/AIDS, drinking alcohol while on ART drugs to pretend as HIV free and involve in sexual activity, desired to be considered as a HIV positive in order to get the support given to PLHI, underline the needs for further investigation due to their possible contribution for sustaining the HIV epidemic. Although there are some prevention activities to fight HIV/AIDS in the rural areas, most of them were inappropriate in terms of convenience in time, place and target groups. For instance, HIV educations are given only in weekends, holidays and around the church areas where most of the young people are not available. The finding has programmatic implications as it misses the young who are vulnerable to HIV infections. The needs and priorities in prevention of HIV/AIDS are two fold: to enable community members to be fully informed about the disease and reduce potentially risky behaviour; and to secure viable rural livelihoods which would reduce the need for people to move into potentially HIV-risky environments.
Intimate Partner Violence against Women in West Ethiopia: Magnitude, Associated Factors, Health Effects, and Community Perceptions.
(Addis Ababa University, 2012-10) Garoma, Sileshi (Phd); Fantahun, Mesganaw(MD, MPH, PhD); Dr.Worku, Alemayehu(BSc, MSc, PhD)
Background Intimate partner violence against women is a psychological, physical, and sexual abuse directed towards spouses. Globally it is the most pervasive yet underestimated human rights violation. Intimate partner violence against women is known to undermine the physical, mental and reproductive well-being of women and children. Since much of this is hidden inside the home, it is difficult to document it and work towards its prevention. Empirical data are needed to take appropriate measures in curbing the problem. Objective The overall aim is to assess the magnitude, associated factors and adverse health effects of intimate partner violence against women, and explore the community’s perception towards such violence in East Wollega Zone, West Ethiopia. Methods Community-based cross-sectional and case-control studies were conducted from January to June, 2011 using standard World Health Organization multi-country study questionnaire. To assess the magnitude, associated factors, and adverse health effects of intimate partner violence against women, a sample of 1540 ever married/cohabiting women aged 15-49 years was randomly selected from urban and rural settings of the study area. To examine the association between intimate partner violence against women and under-five deaths, a sample of 858 biological mothers aged 15-49 years (286 cases and 572 controls) was included. Cases were biological mothers of the under-five deceased within two years preceding the survey, whereas controls were biological mothers of live under-five matched by age and sex of the child as well as area of residence. Data were double-entered into Epi DATA and analyzed using SPSS version 19 and STATA 11 and principally analyzed using logistic regression models. Online databases were searched from the earliest entry to December 2010 for systematic review and meta-analysis to assess the effect of intimate partner violence against women on under-five mortality. On the final search, 11 studies from developing countries were inputted into Metaesy add-in for MS Excel version 1.0.4 software for meta-analysis. Random effect model using DerSimonian and Laird's (DL) estimator was used to calculate the pooled estimates of the studies. In addition, a total of 12 focus group discussions involving 55 men and 60 women were conducted from December, 2011 to January, 2012 to explore the perceptions of the community towards intimate partner violence against women. Discussants were purposively selected from the study area. The analyses followed the procedure for qualitative thematic content analysis. Results Lifetime and current (last 12 months) prevalence of intimate partner violence against women showed 76.5%; 95% CI, 74.4 to 78.6% and 72.5%; 95% CI, 70.3 to 74.7%, respectively. The joint occurrences of psychological, physical, and sexual violence were 56.9%. The patterns of the three forms of violence are similar across the time periods. Rural residents (AOR, 0.58; 95% CI, 0.34 to 0.98), literates (AOR, 0.65; 95% CI, 0.48 to 0.88), and women autonomy (AOR, 0.46; 95% CI, 0.27 to 0.76) were at decreased likelihood to have lifetime intimate partner violence against women. Yet, older women were nearly four times (AOR, 3.36; 95% CI, 1.27 to 8.89) more likely to report the incident. On the other hand, marriage by abduction (AOR, 3.71; 95% CI, 1.01 to 13.63), male polygamy (AOR, 3.79; 95% CI, 1.64 to 8.73), spousal alcoholic consumption (AOR, 1.98; 95% CI, 1.21 to 3.22), spousal hostility (AOR, 3.96; 95% CI, 2.52 to 6.20), and previous witnesses of parental violence (AOR, 2.00; 95% CI, 1.54 to 2.56) were factors associated with an increased likelihood of intimate partner violence against women. Nearly two-thirds (64.1%) of physically abused women had injuries to their body parts. The vast majority (93.3%) experienced symptom of mental distress. Sixty four percent of the abused women compared to 41.7% of the non-abused ever had symptom of sexually transmitted infections. Furthermore, 16% and 7.2% of the abused women had unintended pregnancy and termination of pregnancy, respectively while only 11.3% and 4.8% of the non-abused had the same respectively. On the other hand, 82.2% of the cases and 68.6% of the controls ever experienced at least an incident of intimate partner violence against them while 61.9% and 50.9% of the respective groups had ever experienced all forms of intimate partner violence. Intimate partner violence against women is independently associated with symptoms of mental distress, sexually transmitted infections, unintended pregnancy and termination of pregnancy. Mothers who have ever experienced controlling behavior in marriage were more than four times (AOR, 4.27; 95% CI, 0.97 to 18.89) as likely as mothers who did not to have under-five mortality. In addition, mothers who experienced two forms of violence at the same time were more than two times (AOR, 2.24; 95% CI, 1.31 to 3.85) as likely as mothers who did not to have under-five mortality. Ever experiences of the three forms of maternal intimate partner violence were more than two and half times (AOR, 2.55; 95% CI, 1.66 to 3.92) as likely to have the same. Similar effect was observed in meta-analysis, with the mean effect size, 0.23; 95% CI, 0.16 to 0.32 is significantly different from zero and the value of pooled Odds Ratio, 1.34; 95% CI, 1.12 to1.46). In focus group discussions, most of the discussants confirmed that the community has divergent views on the acceptance of intimate partner violence against women. The act is acceptable in circumstances of practicing extra marital sexual affairs and suspected sexual infidelity. Most discussants perceived that the majority of women in their area tolerate the incident due to traditional beliefs, norms and attitudes of the community and very few, including victims, defend themselves against violent husbands/partners. Biased arbitration is marked by excluding women from reconciliatory local elders. The suggested measures by the community to stop or reduce violence against women targeted provision of education for individuals, family, community, and society. Conclusion In their lifetime, three out of four women experienced at least an incident of intimate partner violence against them. In the study area, various socio-demographic and behavioral factors are associated with intimate partner violence against women. Moreover, intimate partner violence against women negatively affects the physical, mental and sexual/reproductive health of women. Further, it is independently associated with under-five mortality. Measures suggested by the community to stop or prevent the act were focused on provision of education about women’s right to individuals, family, community, and society. Recommendations There are needs for an urgent attention at all levels including policymakers, stakeholders and professionals to alleviate the situation. Involving men in maternal and child health programs could be one strategy to address the issue of intimate partner violence against women. Moreover, efforts to dispel myths, misconceptions and beliefs of the community should be strengthened. Finally, extensive national studies are encouraged to address the issues of intimate partner violence against women and under-five mortality.
Role of faith and traditional healing practices in the care of Severe Mental Disorders and impact on patient level outcomes
(Addis Ababa University, 2013-06) Belachew, Ayele(PhD); Dr.Fekadu, Abebaw; Dr.Molla, Mitike; Prof.Hailemariam, Damen
Introduction:Mental disorders are common and are associated with severe disability, cost andmortality. The burden of mental disorders in low income countries like Ethiopia is compoundedby thehuge treatment gap, which is over 90% for Severe Mental Disorders (SMD) such as schizophrenia,bipolar disorder and major depressive disorder. The current strategy of the Federal Ministry of Health to narrow the treatment gap focuses onintegration of mental health care into primary care. This agenda of integration has been advocated bythe World Health Organization(WHO), and relies on training primary care staff to provideevidence-based interventions for selected (priority) disorders. However, neither the WHO nor the Ministry ofHealth provided explicit suggestions on how the integration would occur. Although Faith andTraditional Healers (FTHs) are key for the success of such integration, there is no direction on howthey may be engaged or support care provision. Understanding treatment practices, attitudes, cultural factors and explanatory models that influencecommunity utilization of FTHs and the link of these factors with utilization ofbio-medical servicesmay allow development of strategies to support collaboration between the FTHsand the biomedicalsector. It may also improve access to timelybio-medicalcare. Thisproposed study will explore the roleof FTHs in thecare of patients with SMDand the impact on bio-medical service utilization and patientlevel outcomes. Thestudyhypothesizes that most patients with SMDs will use FTHs before accessingbiomedicalcare andthese patientsare likely to have longer duration of untreated psychosis resulting inpoorer clinical, social and economic outcomes. Objectives: the mainobjectiveof the study is to explore the pattern and determinants of the use ofFTHs practices for the care of SMDs, andimpacton patient level outcomes. Methods: four complementary studies will be conducted using a mixedquantitative and qualitativeresearchdesign.o Study Iwill havetwocomponents o The first component will be a cross-sectional communitybased study on 1,500 randomlyselected sample ofcommunity members in Sodo district todetermine community attitudetowards FTHs and describe the prevalence and pattern of use of FTHs by the community. o The second part of the initial cross-sectional survey will describe the profile of FTHs, theirEMs about SMDsas well as define types of use of available service (predominant use) o Study IIwill havetwocomponentso The first component will be toexplore the prevalence, pattern and determinants of use of FTHs among community(Key informant) identifiedpersons with SMD, completed usingall available information(Butajira Case Detection MethodBCDM); o The second component to determine baseline clinical, social and economic profiles in thethree groups ofpatients with SMDbasedontheir level of service utilization: predominantlyFTH users, Predominantly Boimedical service users and those who use both sercvices o study IIIwill be a follow up of participants in study II to examine short-term (six months) patientlevel outcomes (clinical, social and economic) and pathways in care in relation to baseline FTH use pattern; ando study IVwill examine, on purposivelyselected sample of FTHs and BMPs,behavioraldeterminantof collaboration between FTHs and BMPs (beliefs, attitudes, subjective norms and perceivedbehavioral control as well as intention towards collaboration) and the changes in thesedeterminants. Assessments:A set of assessment tools will be used to establish diagnosis, symptomatic and functionalstate as well as costs. Qualitative assessment will consist of face-to-face interview using semistructured questionnaire, Focus Group Discussions, In-depth interviewand observations using guidesand checklists. Quantitative datawill be entered in epiData version 3 and analyzed using SPSS version17 and STATA 8.Thematic content analysis will be used for qualitative data. Ethical consideration: Ethical approval will be sought from the Scientific Committee of theDepartment of Psychiatry and theInstitutional Review Board of the College of Health Sciences, AddisAbaba University. Official permission will be secured from the Sodo district health office andhealthinstitutions.Every selected respondent will be briefed about the purpose of the study and informedwritten consentwill be soughtfromeach participant. All papers, computers, external hard drives, andUSB memory sticks containing data will be password protected and kept in secure (locked) locations toensure confidentiality of information. Expected outcome:The results of the study would provide more objective determination of the impactof FTHs utilization on patient level outcomes.The findings would allow development of possiblemodels of broader collaboration and interventions to improve access to quality mental healthcare andhence improve the mental health status of people with SMDs. Budget:Part of the cost for the study will be covered by aPRIME fellowship to the candidate. But thestudy will be nested within the larger PRIME (‘PRogramme for Improving Mental health carE) project. Research plan:The research proposal will be submitted inMarch2013 for ethical approval and datacollection is expected to begin in May2013.The whole research work will be finalized in early 2015.
Assessment of Effect of Access to Free Health Care on Early Childhood Mortality, Controlled Quasi Experimental Study of Butajira Birth Cohorts from 2002-2008, South Central Ethiopia
(Addis Abeba university, 2014-06) Abay, Mebrahtu; Mekonnen, Wubegzier(PhD)
Background: Mortality in African children is unacceptably high. Providing free health care to young children has been hypothesized to improve access to health care and lead to better health outcomes. However, there have been only few methodologically robust studies testing this hypothesis. This study examined the impact of free healthcare provided to a birth cohort of children born from March, 2005 to June, 2006 in Butajira DSA (Demographic Surveillance Area) through the C-MaMiE project (Child outcomes in relation to Maternal Mental health in Ethiopia), in comparison to three cohorts of user fee children (children born within 2.5 years before and after the intervention and parallel with the intervention). Objective: The aim of this study was to assess the impact of making health care services free at the point of use upon under-fives mortality. Methods: This controlled quasi-experimental study compared intervention cohort, children born in Butajira from March, 2005 to June, 2006 and received free health care provided by the C-MaMiE project, from pre-birth (pregnancy) to 12 months, and from 24 to 60 months, and three comparison cohorts of children born in the same geographical area (2.5 years before, during and after the intervention). The crude and adjusted under-five mortality in the intervention cohort versus the comparison cohorts was evaluated using Cox regression model. Result: Incidence of under-five mortality was 15.7 (12.3-20.0), 98.7 (88.3-110.3), 41.2 (35.2- 48.2) and 39.3 (33.5-46.1) per 1000 person-years of observation children provided free, user fee before intervention, user fee during intervention and user fee after intervention health care services, respectively. The risk of under-five mortality among user fee children (before, during and after the intervention) were 5.87 (4.47-7.72), 2.45 (1.84-3.28), and 2.72 (2.03-3.66) times higher than those provided freely, respectively. Maternal death (AHR=2.10; 95% CI; 1.36- 3.23), rural residence (AHR=0.56; 95% CI; 0.44-0.72) and death of elder child (AHR=1.28; 95% CI; 1.01-1.61) were also found to be independent predictors of under-five mortality. Conclusion and recommendation: There was a slow decrement of early childhood mortality in the study area and was relatively high among user fee children, even compared to the after arm comparison cohort whereby lower mortality is expected, and health policy makers should give more emphasis on abolition of user fee health care services as it is one of the methods which significantly reduce under five mortality
Development assistance for health: Trend and effects on health outcomes in Ethiopia and Sub-Saharan Africa
(Addis Ababa Universty, 2016-06) Gutema, Keneni; Haile Mariam, Damen (Professor)
Background: For decades, health targeted aid in the form of development assistance for health has been an important source of financing health sectors in developing countries. Health sectors in Sub Saharan countries in general and Ethiopia in particular, are even more heavily reliant upon donors. Consequently, a more audible donors support to health sectors was seen during the last four decades, consistent with the donor's response to the global goal of Alma-Ata declaration of “health for all by the year 2000” through primary health care in 1978. Ever since, a massive surge of development assistance for health has followed the out gone of the 2015 United Nations Millennium Declaration Goals in which three out of the eight goals were directly related to health. In spite of the long history of health targeted aid, with an ever increasing volumes, there is an increasing controversy on the extent to which health targeted aid is producing the intended health outcomes in the recipient countries. Despite the vast empirical literatures considering the effect of foreign development aid on economic growth of the recipient countries, systematic evidence that health sector targeted aid improves health outcomes is relatively scarce. The main contribution of this study is, therefore, to present a comprehensive country level, and cross-country evidences on the effect of development assistance for health on health outcomes. Objectives: The overall objective of this study was to analyze the effect of development assistance for health on health outcomes in Ethiopia, and in Sub Saharan Africa. Methods: For the Ethiopian (country level) study, a dynamic time series data analytic approach was employed. A retrospective sample of 36-year observations from 1978 to 2013 was analyzed using an econometric technique - vector error correction model. Beside including time dependency between the variables of interest and allowing for stochastic trends, the model provides valuable information on the existence of long-run and short-run relationships among the variables under study. Furthermore, to estimate the co-integrating relations and the other parameters in the model, the standard procedure of Johansen’s approach was used. While development assistance for health expenditure was used as an explanatory variable of interest, life expectancy at birth was used as a dependent variable for the fact that it has long been used with or without mortality measures as health status indicators in the literatures.In the Sub Saharan Africa (cross-country level) study, a dynamic panel data analytic approach was employed using fixed effect, random effect, and the first difference-generalized method of moments estimators in the period confined to the year 1995-2013 over the cross section of 43 SSA countries. While development assistance for health expenditure was used as an explanatory variable of interest here again, infant mortality rate was used for health status measure done for its advantage over other mortality measures in cross-country studies. Results: In Ethiopia, the immediate one and two prior year of development assistance for health was shown to have a significant positive effect on life expectancy at birth. Other things being equal, an increase of development assistance for health expenditure per capita by 1% leads to an improvement in life expectancy at birth by about 0.026 years (P=0.000) in the immediate year following the period, and 0.008 years following the immediate prior two years period (P= 0.025). Similarly, in Sub-Saharan Africa, development assistance for health was found to have a strong negative effect on the reduction of infant mortality rate. The estimates of the study result indicated that during the covered period of study, in the region, a 1% increase in development assistance for health expenditure, which is far less than 10 cents per capita at the mean level, saves the life of two infants per 1000 live births (P=0.000). Conclusion: Contrary to the views of health aid skeptics, this study indicates strong favorable effect of development assistance for health sector in improving health status of people in Sub Saharan Africa in general and the Ethiopia in particular. Recommendations: The policy implication of the current findings is that development assistance for health sector should continue as an interim necessity means. However, domestic health financing system should also be sought, as the targeted countries cannot rely upon external resources continuously for improving the health status of the population. At the same time, the current development assistance stakeholders assumption of targeting facility based primary health care provision should be augmented by a more strong parallel strategy of improving socioeconomic status of the population that promotes sustainable improvement of health status in the targeted countries.
Physician workforce situation and health system’s response in Ethiopia: a mixed-methods study
(Addis Ababa Universty, 2017-12) Assefa, Tsion; H/Mariam, Damen (Professor,MD, MPH, PhD)
Background: Shortages and imbalances in physician workforce distribution between urban and rural and among the different regions in Ethiopia are enormous. However, with the recent rapid expansion in medical education training, by adopting the so called “flooding strategy”, it is expected that the country can make progress in physician workforce supply. Nevertheless, the effectiveness of the intended strategy also relies on a lot of interrelated factors. Factors such as accessibility, composition and turnover of the medical education workforce; the role of medical instruction in influencing the medical students’ attitudes and career choices; and also the level of preparation and cooperation made in the system when such strategy is implemented. Objective: This research aimed to investigate physician workforce (distribution, attrition and associated factors), medical students’ career choice and intention (to work in rural/remote locations and to leave abroad), and to discover the health system response and its consequences which have been made to overcome the physician workforce shortages in Ethiopia. Methods: The study employed a mixed-methods study design (organizational survey, medical students’ survey, and qualitative study design by adopting a grounded theory approach). A longitudinal medical education and physician workforce data sets of about six years (between September 2009 and June 2015) were retrospectively collected from seven government owned medical schools, and five regional and two city administration health bureaus to examine the physician workforce distribution in and turnover from the public health sector and the medical schools. In measuring the medical education workforce turnover, the study employed the concepts of survival analysis with a Cox Proportional Hazards Model. However, the study opted to use Poisson Regression Model hence the data collected from regional health bureau and city administrations failed to satisfy the Cox’s Proportional Hazards Model assumptions. For medical student survey, 959 medical students who pursue their medical education in six government owned higher learning institutions of Ethiopia were involved through self-administered questionnaire to examine the medical students’ career choice and intention to work in rural and remote locations, and also regarding moving abroad. The qualitative study was employed to discover perspectives and viewpoints on the health system response and its consequences by involving 43 purposefully selected respondents from government, academics, and private settings. Each interview was transcribed verbatim, coded and xv analyzed using the grounded theory research approach and presented in a narrative form. Finally, the relationships between the main categories were illustrated using figures. Results: In the public health care settings, the majority of the medical doctors were males (80.5%), young (born after the year 1985 (50.9%), work experience of less than three years (57%), and were general practitioners (84.2%). A decreased incidence of turnover was observed among physicians born between 1975 and 1985 compared to those born after 1985. However, increased rate of turnover was found among females, physicians working in district and general hospitals, and in Amhara Region. Similarly, in the academic health care settings, a total of 6,670.5 physician-years observation was analyzed. About 15.7% of the observations were completed and the remaining 84.3% were censored. In this setting, lower risk of turnover was observed among those who were born before 1975 and with those high academic rank (associate professors and above). The risk of turnover was also lower among those working in Mekelle and Gondar universities but the reverse was observed among those working in Jimma University. Regarding medical students’ career choices, (70.1%) of the medical students wanted to practice in clinical care settings. However, only a small proportion of them showed interest to work in rural and remote areas (21% in zonal and 8.7% in district/small towns). On the contrary, most of them had the intention to leave abroad for both economic and non-economic reasons. For the majority of them internal medicine was the first specialty of choice followed by surgery. However, students showed little interest in obstetrics and gynecology, as well as in pediatrics and child health as their first specialty of choices. In addition, medical students’ attitudes towards their institution in preparing them to work in rural and remote areas, to pursue their career within the country and to specialize in medical disciplines in which there are shortages in the country were very low. In the qualitative study, almost all participants agreed that physician migration (emigration and out-migration) has contributed to skilled human resource shortage in the country. The most frequently cited reasons were both financial and non-financial. The latter one includes lack of recognition, not valuing expertise, and incompetent leadership and management as well as external factors which include opportunities and value shift. xvi In relation to massive admission and production, two distinct types of preparation were identified; preparation that needs to be made in the medical schools and in the system, though at the time of the study, both were not sufficiently addressed. As a result, there were potential consequences at the present. These were related to clinical service delivery, patient right and privacy, medical education workforce, and quality of medical education. In the future, it was anticipated to affect the graduates, the system, as well as the community in the short and long term consequences of physician workforce flooding. Besides, in relation to HRH preparation and utilization, lack of cooperation, strategic planning and capacity, and system continuity were also identified as underlying and basic problems of the system, respectively. Conclusion: Overall, young and less experienced physicians make up significant proportions of the public and academic physician workforce of the country, which is a signal for the presence of substantial improvement in supply. However, without retention efforts, skilled turnover will result in a “system of ever-green hands (Ac16)”; a system staffed with junior physician workforce. In addition, shortage, lack of composition and diversity, and low satisfaction of the medical education workforce can hinder the quality of medical education, which failed to influence the medical students’ attitudes to prefer to work in rural and remote locations including their career choices. Moreover, across the settings, economic and non-economic reasons were the main reasons of turnover as well as the reasons behind the medical students’ intention to move. Furthermore, massive admission has negative impact on the quality of medical education, patient care and satisfaction, and also on the medical workforce at the present with its additional consequences on the medical graduates, system and the community at large in the long run. Hence, the flooding is not only limited to issues to do with what currently has been observed but also rooted in the underlying (strategy, planning, and capacity) and basic (functional continuity of the system) problems of the health system. Recommendations: Therefore, there is a need to revisit the flooding strategy in such a way as to minimize the consequences of massive medical students’ admission and physician workforce production along with working on the other dimensions of the problem.
Epidemiological study on community acquired pneumonia among hospital treated adults in Tigray, Ethiopia.
(2017-12) Berhe, Haftu; Enqueselassie, Fikre (PhD,Professor)
Background: - Lower respiratory tract infections are a leading cause of mortality worldwide, causing 1.6 million deaths annually in adults. Excluding tuberculosis they are the third most common cause of death worldwide and the most common cause of death in low-income countries. Community acquired pneumonia is responsible for a large proportion of these deaths. Globally, it is the leading cause of death from an infectious disease and the sixth leading cause of death overall. Studies in different settings of the world, attest to the fact that community acquired pneumonia has a substantial clinical and economic burden. Despite its high morbidity and mortality globally and specifically in Ethiopia, community acquired pneumonia is not adequately researched. Objective:-The aim of this study was to assess the epidemiology of community acquired pneumonia among hospital treated adults in Tigray, Ethiopia. Methods:-The study was conducted in Tigray Region, north Ethiopia. A retrospective patient record review and case control study designs were used. The source population for the case control study design were both men and women aged 18 years and above who have been attending their treatment in all zonal hospitals and Ayder Tertiary Hospital. Charts of all types of pneumonia patients treated from July, 2013 to July, 2015 in all zonal hospitals of Tigray and Ayder Tertiary Hospital were the source population for the retrospective record review. In this study cases were patients of community acquired pneumonia who had been on treatment and fulfilled the definition for community acquired pneumonia, while controls were clients who came for some other purposes to the hospitals but without community acquired pneumonia. To assess the magnitude of community acquired pneumonia all medical records from the selected hospitals of the period 2013 to 2015 were retrieved and the cost estimation was made from the records of the period 2014 to 2015.The sample size for the case control study was calculated using two proportion formula with a case to control ration of 1 to 2.To collect the data semistructured interviewer-administrated questionnaire and check list were adapted from different literatures .Once the data were collected, it was entered into Epi info 2002 and exported to SPSS Version 20 statistical program for analysis. Ethical clearance was obtained from Institutional Review Board of the Addis Ababa University College of Health Sciences. Letter of agreement XIV was secured from the Regional Health Bureau. Individual written informed consent was solicited from the respondents at the time of data collection and examination. Finally measures of central tendency & proportion were calculated. The association between the exposure and outcome variables were also determined using bivariate and multivariable analysis. Data for cost was analyzed using descriptive statistics, numerical summary measures, and simple linear regression analysis. The method of cost estimation employed, included a bottom-up approach in order to estimate direct patient side medical cost, whereas the indirect cost was calculated using a human capital approach. Results: During the study period, there were 36,005 patients of all types of pneumonia with 5877 cases of community acquired pneumonia, making the magnitude of community acquired pneumonia to be 16%, with proportions for males (16%) and females (17%). The proportion of admitted patients due to community acquired pneumonia was 9.8%, with a mean admission length of 6 (+5.59) days. History of contact with pets, working in dusty environment, history of pulmonary tuberculosis, history of pneumonia, having contact with people who had respiratory infection, history of respiratory infection, history of tonsillectomy, history of upper airway problem, age and educational status had significant association with community acquired pneumonia in the bivariate logistic regression analysis, while working in dusty environment [OR (95% CI);2(1.1,4.1)], history of respiratory infection [OR (95% CI); 2.3(1.5,5.7) ], contact with people who had respiratory infection [OR (95% CI);2.5(1.2,5.3)] and previous history of pneumonia confirmed by radiograph [OR (95% CI); 39(19.4,78,6)] were significantly associated in the multivariate analysis. The total amount of money incurred over the study year was 319,056.52 Ethiopian Birr ($15,193.2). The direct medical expenditure was 242889.60 Eth.B ($11,566.20) and the cost of lost working days by the patients due to community acquired pneumonia was 76166.92 Ethiopian Birr ($3627). From the cost of direct medical expense, 47.6 % was used for medication, 18% for imaging (X-ray), 15% for laboratory, 16% for bed and 3% for registration. XV Conclusion: The study revealed that the magnitude of community acquired pneumonia in the study area was 16% and most prevalent among younger population. Working in dusty environment, having history of pneumonia, history of respiratory infection and having contact with people who had respiratory infections are the risk factors of community acquired pneumonia confirmed in this study. The cost of illness among adult patients of community acquired pneumonia in the study area was substantially high. Of the total cost incurred, 76 % was due to direct medical expense and 24 % for the lost working days. Hence, appropriate prevention strategies should be designed and implemented so that the magnitude of community acquired pneumonia would be minimized and terminally the treatment cost incur by the community acquired pneumonia will be reduced. Besides, Treatment guideline has to be developed and proper management should be offered to prevent the re-occurrences of previous pneumonia and other respiratory infections as a result the development of community acquired pneumonia would be minimized. Moreover, safety measures like personal protective equipments should be used when there is contact with patients having respiratory tract infections. More so, further prospective studies should be conducted to estimate the magnitude and comprehensive costs of community acquired pneumonia. Larger studies are also needed to assess the effect of some risk factors in the general population.
Challenges of tuberculosis control in South west Ethiopia: treatment delays, cost, and outcomes Abyot Asres Shetano
(Addis Ababa Universty, 2018-04) Asres, Abyot(Phd); Deressa, Wakgari (Phd, Associate Professor)
Background: Tuberculosis (TB) is among the major public health problems over the world. Thus, global efforts have been designed to combat three distinct, but overlapping humanitarian, public health, and economic burdens posed by the TB illness. Timely case detection and treatment of cases have been a focus and priority in the prevention and control of TB. However, long delays to initiate anti-TB treatment have been reported for which evidences on predictors of the delay and impact of the delayed treatment on outcomes are limited. Elimination of catastrophic costs posed by TB illness to patients and households has taken attention in the latest end TB strategy. On the other hand, evidences on magnitude and drivers of patient cost across continuum of TB care are scarce in Ethiopian setting. Treatment regimens play a vital role in reducing time delays to treatment and cost spent across continuum of TB care, and improving outcomes. Nonetheless, evidences on the interdependence among delays, patient cost of care and outcomes in the era of shortened treatment regimen is scanty in Ethiopian setting. Objectives: The aims of the dissertation were 1) to compare outcomes of six and eight-month TB treatment regimen, 2) to determine time delays to initiate anti-TB treatment and its predictors, 3) to assess pre-and post-diagnosis patient costs for TB care and 4) to examine association between delayed anti-TB treatment initiation and treatment outcome. Methods: A blend of cross-sectional and longitudinal studies were conducted among 735 TB cases on treatment and 790 patient records from 14 public health facilities of Bench Maji, Kaffa and Sheka zones in Southwest Ethiopia. The cases were selected using multistage cluster sampling technique. Both primary and secondary data were gathered and/or extracted using structured questionnaire from January 2015 through June 2016. For comparison of outcomes across the six and eight month regimen, patient clinical profiles and outcomes were extracted from unit TB register of cases registered during 2008 through 2014. Data for the cases on treatment were collected at two points; 1) at enrollment when patients‟ sociodemographics, careseeking practices, direct and indirect costs of TB care seeking were collected and 2) at the end of treatment when treatment practices, patient cost of TB treatment and outcomes were inquired. The data were entered in to Epi-Data and processed on SPSS version 21 and STATA version 13. Since the cost data were right skewed, analysis was made on natural logarithm and reported in corresponding antilog. Bivariate and multiple logistic, linear, and log-binomial regression models were fitted to identify predictors of delays, cost, and outcome. In all the statistical tests, necessary assumptions were checked and significance judged at p<0.05. x Results: The overall treatment success among cases registered during 2008 through 2014 was 88 % ( 85.3% vs 90.6%, p=0.02 among those treated for eight months with 2ERHZ/6HE and six months with 2ERHZ/4RH regimens, respectively). Thus, 4RH continuation phase treatment adjusted Odds Ratio [aOR=0.55,95% CI;(0.34,0.89)], weight gain at the end of second month treatment [aOR=0.28, 95% CI; (0.11, 0.72)] predicted lower odds of unsuccessful outcome. On the other hand, age [aOR=1.02,95%CI; (1.001,1.022)], rural residence [aOR=2.1,95%CI;(1.18,3.75)] and HIV co-infection [aOR=2.39,95%CI;(1.12,5.07)] independently predicted higher odds of unsuccessful outcome. TB patients had spent a median [inter-quartile range (IQR)] of 55(32-100) days to initiate anti- TB treatment since onset of illness (total delay). Similarly a median (IQR) of 25(15-36) and 22(9-48) days had been elapsed respectively to initiate care seeking (patient delay) and anti-TB treatment since first consultation (provider delay). Thus 54.6% of the total delay was attributed to provider (health system) and the rest to the patient. Prior self-treatment (aOR: 1.72, 95% confidence interval [CI]:1.07-2.75), HIV co-infection (aOR: 1.80, 95% CI: 1.05-3.10) and extra pulmonary TB (aOR: 1.54, 95% CI: 1.03-2.29) independently predicted higher odds of patient delay. On the other hand, initial visits to health posts or private clinics (aOR: 1.42, 95% CI: 1.01, 2.0) and delayed to seek care (aOR: 1.81, 95% CI: 1.33-2.50) significantly predicted higher odds of provider delay. Since onset of illness, TB patients totally incurred mean [(standard deviation (+SD)] of US$244.71(+0.1) for care seeking and treatment. Thus mean (+SD) US$108.0(+0.1) and US$117.0(+0.1) were respectively incurred during pre-diagnosis and post-diagnosis periods. Mean (+SD) out of pocket patient expenditures during pre-and post-diagnosis were US$21.46(0.16) and US$43.80(+0.1) respectively. Total indirect and pre-diagnosis costs constitute 70.6% and 53.6% of the total cost respectively. Patient delay (adjusted coefficient (βadj)= 0.004, p<0.001), provider delay (βadj =0.004,p<0.001), number of visited healthcare facilities (βadj =0.17,p<0.001) and diagnosis at private facilities (βadj=0.16,p=0.02) independently predicted increased pre-diagnosis cost. Similarly, rural residence (βadj=0.27,p<0.001), hospitalization (βadj=0.91,p<0.001), patient delay (βadj=0.002,p<0.001) and provider delay (βadj =0.002,p<0.001) predicted increased post-diagnosis costs. The overall treatment success among the prospectively enrolled cases was 89.7% (86.7% vs. 92.6%, p=0.01) respectively among those initiated anti-TB treatment beyond and within 55days xi of onset of illness). Accordingly, treatment initiation beyond 55days of onset [Adjusted Relative Risk (aRR)=1.92, 95%CI:1.30, 2.81),treatment center being hospital (aRR=3.73, 95%CI:2.23, 6.25), and HIV co-infection (aRR=2.18, 95%CI: 1.47, 3.25) independently predicted higher risk of unsuccessful treatment outcome. In contrast, weight gain at the end of second month treatment (aRR=0.40, 95%CI: 0.19, 0.83) predicted lower risk of unsuccessful outcome. Conclusions: The switch of continuation phase TB treatment regimen from 6EH to 4RH has brought significantly higher treatment success that verified applicability of the regimen change in resource constrained and high burden countries. TB cases in the study area elapsed too long time to initiate care seeking and treatment. The delays are attributed to the patient, disease and health system related factors. Throughout the care seeking and treatment pathways, TB cases incurred substantial direct and indirect cost for TB care despite the “free TB service”. The delay to initiate anti-TB treatment was significantly associated with increased patient costs and risk of unsuccessful outcome. Patient and health system attributes predicted both costs incurred across continuum of TB care and treatment outcome. Recommendations Promotion of early care seeking for TB through community level awareness creation; involving both formal and informal providers can minimize patient delays. Moreover, improving diagnostic and case-holding efficiencies of both private and public healthcare facilities can reduce delays to treatment and risk of unfavorable outcomes. On the other hand, adoption of patient centered TB care, reimbursement mechanisms of costs and scale up of the national community and social insurance schemes to the study area can reduce the financial burden on patients. Finally, further studies are required to explore reasons for patient and provider delays using qualitative designs, costs of TB care, and its impacts on household and health system.
Effect of quality antenatal care service on the continuum of maternal and newborn health care services; a follow up study at public health facilities of Bahir-dar city administration; North West Ethiopia
(Addis Ababa Universty, 2018-05) Ejigu, Tadese; Fanthahun, Misganaw (Professor)
Background: In Ethiopia, more than 62 % of pregnant women attend antenatal care (ANC) at least once and it is an opportunity for reaching pregnant women with a number of interventions that may be vital to their health and the well-being of their infants. However data on the extent to which providers utilize these opportunities remain limited especially in developing countries. Ethiopia is one of the countries that experiences relatively high ANC coverage and high maternal and neonatal mortality. This paradox urges the need to investigate the linkage between ANC service quality and continuum of maternal and newborn health care services. Objective: To assess the effect of antenatal care service quality on the continuum of maternal and newborn health care services at public health facilities of Bahir Dar City Administration. Method: A facility based prospective follow up study was conducted among 970 first ANC visit pregnant women with gestational age ≤16weeks selected by systematic sampling technique (k=3). Women were followed from their first ANC visit till six weeks after delivery. Longitudinal data on the quality of ANC service was collected through structured observation checklist during consultation with ANC providers during each of the four ANC visits. ANC service was considered as acceptable quality if women received ≥75th percentile of the essential ANC services. Exit interview just after their fourth ANC visit was carried out to assess the satisfaction of pregnant women on ANC services they received and another exit interview was also conducted at 6 weeks after birth when women come to immunize their child to assess the essential newborn care practices that their babies received from a provider and/or woman; and whether or not they started to use postpartum modern family planning. If a woman does not come to the health facility for immunization, the data collectors traced her based on the address registered during her first ANC visit. For the assessment of health facility delivery, postpartum modern family planning use and essential newborn care practices, completed data were obtained from 823 women where as for the assessment of birth weight, it was obtained from 718 women since those women who gave birth at home and those who deliver a premature or still birth baby were excluded due to the fact that data on birth weight could not be obtained and as it might be affected by the underlying conditions respectively. XVI Generalized Estimating Equation (GEE) was carried out to control cluster effect among women who received ANC in the same facility. The model fitness was checked by observing the difference of the -2 log likelihood ratio between the null model and the model with independent variables; linear regression assumptions were also checked by graphical and/or statistical methods accordingly. In addition, Multi co linearity diagnosis was also carried out using variance inflation factor (VIF). Based on Hosmer and Lemeshow applied logistic regression guide a p-value <0.2 was considered to select eligible variables for multivariable regression analyses and p-value <0.05 was considered to identify statistically significant predictor variables for the outcome of interest. Results: Among 823 pregnant women who completed follow up, only about one-fourth (27.6%) (95% CI =24.5%, 30.5%) received acceptable quality ANC services. The odds of giving birth at health facility among pregnant women who received acceptable ANC service quality was about 3.38 times higher than pregnant women who received un acceptable quality ANC service (AOR=3.38, 95% CI: 1.67, 6.83). Being urban dweller (AOR = 9.91, 95% CI: 2.52, 38.91), being younger age (AOR = 3.69, 95% CI: 1.44, 9.49); Secondary school and above educational status of pregnant women (AOR = 6.83, 95% CI; 3.33, 13.97) were also positively associated with Health facility delivery. However, primary school educational status of women has no significant difference in the use of institutional delivery compared to those women who cannot read and write. The magnitude of low birth weight (<2500grams) among 718 babies delivered at the health facility was 7.8% (95%CI= 6.0%, 9.7%) with 1.4% versus 10.5% among those who received acceptable and not acceptable ANC services quality respectively (P-value<0.001); frequency of maternal nutritional advice (β= 0.147, 95%CI= 0.11, 0.19), iron-folic acid supplementation (β= - 0.358, 95%CI= -0.476,-0.240), tetanus toxoid vaccination (β= 0.609, 95%CI= 0.316, 0.903), maternal educational status (β= 0.079, 95%CI= 0.06, 0.10) and parity (β= -0.174, 95%CI= 0.24, 0.11) were determinants for birth weight. About 22.7% of pregnant women were counseled about postpartum family planning at least once during their four ANC visits. The magnitude of postpartum modern family planning use within 6 weeks after delivery among the study women was 157 (19.1%) with 95%CI (16.4%, 21.9%). The odds of postpartum modern family planning use within 6 weeks after birth among women who XVII were counseled about postpartum family planning at their third or fourth visit was 3.5 times higher compared to those who were not counselled at any of their visits (AOR=3.5; 95% CI:2.19,5.49). Being satisfied with ANC services received (AOR= 4.12; 95% CI: 2.55, 6.66), counseling on birth preparedness and complication readiness plan (AOR= 2.2; 95% CI: 1.32, 3.55), Being counselled on breast feeding (AOR= 1.8; 95% CI: 1.15, 2.82) and post natal care use (AOR= 13.5; 95% CI: 8.24, 22.07) had also significant positive effect on postpartum modern family planning use. The composite index for good essential newborn care practice was only 13.7%, with 95% CI (11.3%, 16.2%). About 24.7% versus 9.6% women who received acceptable and un acceptable ANC service quality had good essential newborn care practices (X2=31.668, p<0.000). ANC service quality (AOR= 2.31, 95% CI=1.47, 3.65), PNC use (AOR= 1.69, 95% CI=1.03, 2.79), parity (AOR= 0.43 95% CI=0.27, 0.69) and age (AOR=3.94 95% CI=1.12, 13.91) of the women were predictors for essential newborn care practice (ENBC) practice Conclusion and recommendation: The quality of ANC service was low and adherence to essential contents of ANC services was also heterogeneous. ANC service quality ensures normal birth weight outcome Majority of the post partum women were at risk for closely spaced pregnancy; the risk increases among those who were not counselled on FP Good ENBC practice was significantly low; mainly due to problem related to clean cord care Quality of ANC service matters continuum of maternal and newborn health care services more than frequency of visit. Therefore Maternal and newborn health programme managers and health providers need to ensure continuity of care through maintaining the quality of ANC service by integrating maternal and newborn health care services and through strengthening referral linkages between community health workers (like health extension workers and health development armies) and primary level of care for maternal and newborn care services. In addition, the local authorities at each level of health sector or the nongovernmental organizations working to improve maternal and newborn health need to provide training for ANC providers and equip the necessary supplies for the provision of quality ANC service.
The role of genetic and environmental factors in the etiology of or ofacial clefts in the Ethiopian population
(Addis Ababa Universty, 2018-05) Eshete, Mekonen; Deressa, Wakgari (MPH, PhD)
Background: Orofacial clefts (OFCs) are the commonest craniofacial birth defects with a worldwide birth prevalence of 1/700 live birth. It varies from 1/2500 to 1/500 births depending on the geographic origin, racial and ethnic backgrounds, and socioeconomic status. The incidence of this anomaly in Ethiopia is not known and the etiology has never been studied. We investigated the contribution of previously reported candidate genes and chromosomal loci to the risk of non-syndromic orofacial clefts (NSOFCs) in the Ethiopian population, which is important for improving the management and prevention. It is also of paramount importance in parental counseling and intervention. We investigated the role of environmental factors in the occurrence of NSOFCs in the Ethiopian population. The quality of life of children affected and their parents was also assessed. Objectives: The main objective of this study was to investigate the role of genetic and environmental factors in the etiology of NSOFCs in the Ethiopian Population Methods: We assessed the epidemiology, etiology and quality of life of those affected and the perception of their parents. The epidemiology of OFCs was assessed using the Ethiopian 2007 sensus retrived from the Federal Ministry of Health (EFMH) and the Smile Train (ST) databases. The data was collected from June 2007 to December 2013. ST is a charity organization, which supports cleft care in Ethiopia. We used data collected from November 2012 to January 2016 on maternal and child demographic data, maternal illness, medication, lifestyle and exposures. Saliva samples collected from the participants (Cases, Case mothers, controls and Control Mothers) for analysis using Oragne saliva collection kits and sponges. The collected saliva samples were sent to University of Iowa, USA for DNA processing. We collaborated with similar projects in Ghana and Nigeria to perform the genetics part of this investigation. We selected &genotyped 48 single-nucleotide polymorphisms (SNPs) on 701 non-syndromic cleft lip and or palate (NSCL/P)&163 non-syndromic cleft palate only (NSCPO) cases, 1070 unaffected relatives &1078 unrelated controls. The association of these SNPs with NSOFCs in Asian and European population was confirmed through Genome-wide xiv association (GWAS)& candidate gene (CG) studies. We conducted association analyses for each population using the cleft-type cohorts described above, and a meta-analysis of the three subpopulations The role of environmental factors in the etiology of NSOFCS was assessed using the data collected on maternal demographic data, maternal illness, maternal medication use, lifestyle and exposure before and during pregnancy. We interviewed 359 mothers of children born with NSOFCs and 401 mothers of children born without any congeneital anomaly. We assessed the oral health related quality of life (OHRQoL) of children born with NSOFCS &the perception of their parents using the child oral health impact profile (COHIP) questionnaire. In this study 41 children born with NSOFCs and treated from December 2008 to December 2016 and equal number of parents participated. Results: We determined the incidence/prevalence of OFCs in Ethiopia using the ST database, which was collected from June 2007-December 2013. During this time 18,073 patients with cleft lip and or palate (CL/P) were operated, out of the total operated patients with OFCs 8,232 are under seven years old. The total number of live births during this period was 18,811,316. This gives an incidence of 44/100,000 live births of orofacial clefts in Ethiopia. The prevalence was estimated using the total number of Cleft patients operated from June 2007 to December 2013 (N=18,073) as a numerator and the total number of population (N= 88,703,914) in 2013 as a denominator. It is estimated to be 20/100,000 populations. We confiremed that SNPS, which were found to be associated withn the occurrence of NSOFCs in European population, were found to be associated with the occurrence of NSOFCs in our study populations. In the Ethiopian subpopulation PAX7 (rs742071, P = 0.005574,OR=1.329 and 95%CI 1.087-1.626), IRF6 (rs642961, P =0.01508;OR= 1.442; 95% CI 1.072-1.94), DYSF (rs2303596, P = 0.00231;OR= 0.6854; 95%CI 0.5371-0.8747), 8q24 (rs987525, P =0.000782; OR= 1.413; 95%CI 1.154-1.73), were found to be Nominally associated with the occurrence of NSCL/P. SNPS in NTN1 (rs8081823, P xv = 0.03251; OR=0.4905, 95% CI 0.216-1.114) were also found to be nominally associated with NSCPO in the Ethiopian population. The role of maternal environmental factors and diseases in the occurrence of NSOFCs was assessed and revealed that mothers who lived outside Addis Ababa during their pregnancy time had a higher risk of delivering a child with NSOFCs and mothers who gave history of threatened abortion and Bronchial Asthma were having a higher risk of delivering a child with NSOFCs. Mothers who had exposure to diagnostic X-Ray were also at higher risk of having a child with NSOFCs No significant differences were found for overall and subscales COHIP scores between the patients and their parents. The maximum overall score parents obtained on the COHIP was 186 and the patients was 190. The mean overall score of the patients and parents was 155. This indicates good OHRQoL of children born with NSOFCs. Conclusion and recommendations: The prevalence 20/100,000 populations found in this study are lower than the previous studies done in many parts of Africa including the study done in Addis Ababa. Loci, which contributed to the occurrence of NSOFCs in European and Asian population, were found to contribute to the occurrence of NSOFCs in sub-Saharan populations (Ethiopia, Ghana and Nigeria). We found out that the affected children who received multidisciplinary cleft care had good OHRQoL and the responses of the affected children and their parents did not differ. We recommend community based prospective study to find out the true incidence of OFCs. We also recommend conducting a prospective case control study to better understand the contribution of environmental factors and the gene environment interaction in the occurrence of birth defects in general and OFCs in particular. Finally, we recommend that the child oral health impact profile (COHIP) questionnaire should be modified to fit the cultural beliefs of various populations and society around the world.
Maternal near miss: incidence, causes, factors and adverse perinatal outcomes in Addis Ababa
(Addis Ababa Universty, 2018-05) Firdawek, Ewnetu; Worku, Alemayehu (Professor, PhD)
Background: A maternal near-miss event or severe acute maternal morbidity is defined by the World Health Organization as „a woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy‟. Since maternal mortality is a rare event in each health facility, it is important to study maternal nearmiss as a complement to evaluate and improve the quality of obstetric care. Studies addressing the incidence, causes, factors and adverse perinatal outcomes of maternal near-miss are rare in Ethiopia. Thus, the findings of the current study are important to provide a reliable evidence for policy makers, programmers and health practitioners. Objectives: The study aimed to assess the incidence, causes, factors and adverse perinatal outcomes of maternal near-miss. Methods: The study was conducted in five selected public hospitals of Addis Ababa, Ethiopia from May 1, 2015 to April 30, 2016. The hospitals were selected based on the number of deliveries they managed per year. In addition, presence of an Intensive Care Unit, maternity ward, blood transfusion service and availability of cesarean section delivery were considered in the selection of hospitals. A mix of methods was used to address the objectives of the study. A facility-based cross-sectional study was used to determine the incidence and causes of maternal near miss (Objective I). All maternal near-miss cases admitted to the selected hospitals during the study period were prospectively recruited. Maternal near-miss was ascertained using the World Health Organization criteria. A nested case-control design was used for identifying factors associated with maternal near-miss (Objective II). All women who developed maternal near-miss during the study period were included as cases, and those who delivered without any complications within the same day of the near-miss event were enrolled as controls. A total of three controls matched for age and study area were selected for each maternal near-miss case. A prospective cohort study design was used to examine adverse perinatal outcomes of maternal near-miss (Objective III). Women who were admitted to the participating hospitals during the study period and developed maternal near-miss according to the World Health Organization criteria were included as exposed group. Women who delivered without any complications were enrolled as non-exposed group. We followed a total of 828 women admitted for delivery or treatment of pregnancy-related complications along with their singleton newborn babies. The xiv main outcomes of interest were adverse perinatal outcomes and defined with a composite measure. Participants were interviewed by well-trained data collectors using pre-tested questionnaire. Medical records were also reviewed to abstract relevant information. In order to review the participants‟ record, permission was obtained from the participants and administrators of each participating hospital. Univariate analysis was performed to know the underlying and contributing causes of maternal near-miss. The number of maternal near-miss cases over one year per 1000 live births occurring during the same year was calculated to determine the incidence of maternal near-miss. Bivariate and multivariable conditional logistic regressions were performed to identify factors associated with maternal near-miss. Multivariable logistic regressions were also performed to determine the adjusted risk of adverse perinatal outcomes. Stata version 13 was used for the analysis. Results: During a one-year period, a total of 238 maternal near-miss cases and 29,697 live births were reported in the hospitals included in the study, which produced a total maternal near-miss incidence ratio of 8.01 per 1000 live births (95% CI; 7.06 – 9.09). The underlying causes of the majority of maternal near-miss cases were hypertensive disorders and obstetric hemorrhage. Anemia was the major contributing cause reported for maternal near-miss. Most of the maternal near-miss cases occurred before the women‟s arrival at the participating hospitals. The main factors associated with maternal near-miss were: history of chronic hypertension (AOR=10.79, 95% CI; 5.15 – 22.64), rural residence (AOR=10.68, 95% CI; 4.60 – 24.78), history of stillbirth (AOR=6.06, 95% CI; 2.09 – 17.49), no antenatal care attendance (AOR=5.58, 95% CI; 1.82 – 17.05) and history of anemia (AOR=5.16, 95% CI; 2.81 – 9.47). After adjusting for potential confounders, women with maternal near-miss condition had more than five-fold increased odds of adverse perinatal outcomes compared to women without maternal near-miss (AOR=5.69: 95% CI; 3.69 – 8.76). Other risk factors that were independently associated with adverse perinatal outcomes included: rural residence (AOR=2.16: 95% CI; 1.03 – 4.53), history of prior stillbirth (AOR=2.39; 95% CI; 1.12 – 5.10) and primary educational level (AOR=1.89: 95% CI; 1.07 – 3.34). Conclusions and recommendations: The majority of maternal near-miss cases have already occurred on the women‟s arrival at the participating hospitals, implying the need to focus on existing pre-hospital barriers. However, near-miss cases that develop during hospitalization can xv help to measure the quality of obstetric care provided within the health facilities. Efforts made towards improvement in the management of life-threatening obstetric complications could reduce the occurrence of maternal near-miss problems that occur during hospitalization. There is a need for appropriate interventions in order to improve the identified factors of maternal nearmiss. The factors can be modified through a better access to medical and maternity care, scaling up of antenatal care in rural areas, improve in infrastructure to fulfill referral chain from primary level to secondary and tertiary health care level, and, health education to pregnant women. Presence of maternal near-miss in women is an independent risk factor for adverse perinatal outcomes. Hence, interventions rendered at improvement in maternal health can lead to an improvement in perinatal outcomes. The follow-up time used by the World Health Organization to define maternal near-miss has duration of 42 days postpartum. However, because of logistic and feasibility concerns, our follow-up time was limited to only the length of the hospital stay. This might have caused us to underestimate the magnitude of maternal near-miss and hindered us not to investigate the occurrence of other events such as maternal deaths occurred after maternal discharge.
Spatial variations and associated factors of food insecurity and child under nutrition in east Gojjam zone, Ethiopia: a multilevel mixed effects model.
(Addis Ababa Universty, 2018-10) Aderaw, Zewdie (PhD); Ali, Ahmed (Professor)
Background: - Child undernutrition remains a major public health challenge. The magnitude of the problem varies based on geographical location. In Ethiopia, spatial analysis studies were done based on coarse spatial resolutions. To be more efficient in targeting interventions geographically, spatial analysis using micro level spatial resolution is recommended. Accordingly, different studies were done to identify factors associated with food insecurity and child undernutrition, but most of them ignore either the individual or community level factors. Hence, identification of spatial variations and individual and contextual level determinant factors of food insecurity and child undernutrition in XVI | P a g e relation to the agroecosystem is essential to deliver targeted, efficient and sustainable solutions to the problems. Objectives: - This study determined spatial variations of food insecurity and child undernutrition. The study also identified the role of individual and community level factors of food insecurity and child undernutrition using multilevel mixed effects regression analysis in East Gojjam Zone, Ethiopia. Methods: - An agroecosystem linked to community based comparative cross sectional survey was conducted among 3108 households with children aged 6-59 months. Multistage cluster random sampling technique was used to select study participants. Data were collected on household geographical location, socio-demographic characteristics, child and maternal anthropometry and on potential individual and community level determinant factors. Collected data were entered using Epi info version 3.5 and exported to World Health Organization (WHO) Anthro to determine child nutritional status. SaTScan software was used to determine spatial variations of food insecurity and child undernutrition using SaTScan Bernoulli model. To identify the most likely clusters using SaTScan software, the Log Likelihood Ratio (LLR) at 95% Confidence Interval (CI) and P value less than 0.05 as the level of significance were considered. To identify determinant factors of food insecurity and child undernutrition, multilevel mixed effects ordinal regression and multilevel mixed effects linear regression analyses were used, respectively. The results of fixed effects were shown as an adjusted odd ratio (AORs) for the multilevel mixed effects ordinal regression and regression coefficients for the multilevel mixed effects linear regression. The results of random effects were presented as variance and the intra-class correlation coefficient (ICC) was calculated to estimate unexplained variance attributable to cluster level. Results: - The overall prevalence of household food insecurity was 65.3% (95% CI: 63.5, 67.00). The highest prevalence of food insecurity was observed from the lowlands of the Abay Valley (70.6%, 95% CI: 66.9, 74.2). Followed by the hilly and mountainous highland areas of Choke Mountain (69.8%, 95% CI: 65.9, 73.3). Similarly, sample clusters taken from hilly and mountainous highland areas (LLR: 11.64; P<0.01) and low lands of the Abay Valley (LLR: 8.23; P<0.05) were identified as the most likely primary and secondary clusters, respectively. XVII | P a g e The prevalence of stunting 39.0% (95% CI: 37.32, 40.75), 18.7% (95% CI: 17.32, 20.0) underweight, and 12.22% (95% CI: 11.12, 13.42) wasting were observed in the study area. The highest prevalence of wasting (15.9%; 95% CI: 13.5, 18.8) was observed from hilly and mountainous highlands. The highest prevalence of child stunting (42.4%; 95% CI: 38.5, 46. 6) and underweight (22.9%; 95% CI: 19.7, 26.3)) were observed from the lowlands of Abay Valley. SaTScan spatial analysis indicated that sample clusters taken from the hilly and mountainous highlands were the most likely primary cluster for child wasting (LLR: 13.0, p < 0.01) and underweight (LLR: 23.16, p < 0.001). Also, primary cluster for child stunting was identified from lowlands of Abay Valley (LLR: 10.78, p<0.05). After adjusting for both individual and community level determinant factors, 1.5% (p<0.001) of the variance of food insecurity was attributable to the cluster level. Similarly, after adjusting for all potential determinant factors, 2.4% (p<0.001) of the child weight for height Z score and 1.4% (p<0.001) of the child height for age Z score variance were due to cluster level. From level one factors, in the final model, household head being male, marital status being in union, higher parental education, women’s participation in household decision making, having additional income sources, better crop production in the survey year and application of chemical fertilizer have a positive influence in mitigating household food insecurity. From community level determinant factors, households being from hilly and mountainous highlands and lowlands of the Abay Valley were more severely household food insecure compared to midland plain areas. Households with better farmland size showed less severe household food insecurity in the study area. In the study, from level one factors, the number of under five children, antenatal (ANC) follow up, breast feeding initiation time, household dietary diversity, mother nutritional status, household food insecurity and diarrheal morbidity were associated with weight for height Z score. From level two factors, agroecosystem characteristics, proper household refuse disposal practice, agroecosystem characteristics and proper latrine utilization were significantly associated with child weight for height Z score. From level one factors, child age in months, child gender, the number of under-five children in the household, child immunization status, breastfeeding initiation time, mother nutritional status, child diarrheal morbidity, household level water treatment practice and household dietary diversity showed a statistical significant association with child height for age Z score. From level two factors, agroecosystem characteristics, proper household refuse disposal practice and proper latrine utilization were significantly associated with child height-for-age Z score. XVIII | P a g e Conclusions: - The prevalence of food insecurity and child undernutrition were public health concerns in the study area. Spatial variations of household food insecurity and child undernutrition were observed across the agroecosystems. Households from the lowlands of Abay Valley and hilly and mountainous highland areas were more vulnerable to food insecurity and child undernutrition compared to midland areas. The SaTScan cluster level spatial analysis identified statistical significant hotspot clusters for food insecurity, childhood stunting, underweight and wasting. The multilevel mixed effects analysis indicated that the heterogeneity of food insecurity, childhood stunting and wasting were observed after adjusting to potential individual and community level determinant factors. Both individual and community level factors played a significant role in determining food insecurity and child undernutrition (stunting and wasting). An agroecosystem characteristic was one of the community level factors affecting household food insecurity and child undernutrition. Recommendations: - The spatial variation of food insecurity and child undernutrition based on agroecosystem characteristics should be fully understood by program implementers and policy makers during planning, resource allocation and community mobilization in the study area. Water, sanitation and hygiene interventions are important in the study area. Further study on spatiotemporal variations of food insecurity and child undernutrition at different time is recommended. Also, food insecurity and child undernutrition intervention strategies and plans designed using aggregated or macro level evidence may not indicate the true picture of spatial distribution of the problem at lower government administrative units. So, program level planning may take into account agroecosystem based micro level variations to allocate resources. Policy and intervention strategies aiming at mitigating food insecurity and child undernutrition should address the effects of lower and community level determinant factors using the integration of individual/household level and geographical targeting.
Evaluation of essential drugs availability and wastage rate in Public health facilities in Sheka zone, Ethiopia, 2018.
(Addis Ababa Universty, 2018-10) Belete, Tseatsa; Desalegne, Alemayehu (Professor)
Background: Medicine improves the quality of life and increases the improved the longevity of human beings as it helps to fights against several diseases. Access to essential medicines is the fundamental right of every person. Therefore, the World Health Organization (WHO) demarcates the list of essential medicines (EMs), as medicines that ―satisfy the priority health-care needs of the population. Objective: To evaluate the logistics management system and to estimate the availability of essential drug and wastage rate in public health facilities in Sheka Zone. Methodology: The qualitative method was carried out. The study conducted on facility based retrospective evaluation of availability of essential drugs in the previous one year and evaluate the current availability status. The study analyzed using a thematic content analysis approach. Result: According to this study also found wide variations in availability of essential drugs at the time survey were 53.33%. Based on the store keepers response, majority 96(49.2%) of the HCFs stocked out some essential drugs, while 115(59 %) of the HCs Bin card updated within 30 days. On the other hand revenue lost due to expire of the drug in each health was varying and total 1,343,974ETB was notrevolving drug funds that can potentially affect the availability of essential drugsinthepublichealthfacilityinthestudyarea. Conclussions. Preparing written policies or guidelines regarding selection, forecasting and procurement of essential drugs was not given attention. A major problem uniform to all the HCs was not found regarding selection of essential drugs though each HC had its own problem in the selection of essential drugs. The strength of DTC determined the effectiveness of the selection practice in majority of the HCs. Generally, inadequate supply of essential drugs in PFSA affected the logistics of essential drugs with respecttomaintainingthesystemandavailabilityofessentialdrugs. Work plan: This study conducted from February to Jun 2018.
The Spatial Epidemiology of Tuberculosis in Gurage Zone, Southern Ethiopia.
(Addis Ababa University, 2018-12) Tadesse, Sebsibe; Enqueselassie, Fikre(PHD); Hagos, Seifu (PHD)
Background: The global distribution of tuberculosis is skewed heavily toward low-and-middle income countries, which accounted for about 87% of all estimated incident cases. Ethiopia is a low-income country in east Africa that remains highly afflicted by tuberculosis, with varying degrees of magnitudes across settings. However, there is a dearth of studies clarifying about the spatial epidemiology of the disease in Ethiopia. Lack of such information may contribute to the partial effectiveness of tuberculosis control programs. Objectives: The specific objectives of this study were: 1) to detect spatial and space-time clustering of tuberculosis, 2) to estimate spatial risk of tuberculosis distribution using limited spatial datasets, and 3) to identify ecological factors affecting spatial distribution of tuberculosis in Gurage Zone, Southern Ethiopia. Methods: The study data were obtained from different sources. Specific objectives 1 and 3 included a total of 15,805 tuberculosis patients diagnosed at health facilities in Gurage Zone during 2007 to 2016, whereas specific objective 2 included 1,601 patients diagnosed in 2016. The geo-location and population data were obtained from the Central Statistical Agency of Ethiopia (specific objectives 1-3). The altitude data were extracted from global digital elevation model v2 (specific objective 2). The normalized difference vegetation index data were derived from the moderate resolution imaging spectroradiometer imagery, and the temperature and rainfall data were obtained from the Meteorological Agency of Ethiopia (specific objective 3). The global Moran’s I, Kulldorff’s scan and Getis-Ord statistics were used to analyze purely spatial and space-time clustering of tuberculosis (specific objective 1). The geostatistical kriging approach was applied to estimate the spatial risk of tuberculosis distribution (specific objective 2). The spatial panel data analysis was used to estimate the effects of ecological factors on spatial distribution of tuberculosis prevalence rate (specific objective 3). Results: The prevalence of tuberculosis varied from 70.4 to 155.3 cases per 100,000 population in the Gurage Zone during 2007 to 2016. Eleven purely spatial clusters (relative risk: 1.36–14.52, P-value < 0.001) and three space-time clusters (relative risk: 1.46–2.01, P-value < 0.001) for high occurrence of tuberculosis were detected. The clusters were mainly concentrated in border areas of the zone. The predictive accuracies of ordinary cokriging models have improved with the inclusion of anisotropy, altitude and latitude covariates, the change in detrending pattern from local to global, and the increase in size of spatial dataset (mean-standardized error = 0, rootxi mean-square-standardized error = 1, and average-standard error ≈ root-mean-square error). The spatial risk of tuberculosis was estimated to be higher (i.e., tuberculosis prevalence rate > 100 cases per 100,000 population) at western, northwest, southwest and southeast parts of the study area, and crossed between high and low at west-central parts. The tuberculosis prevalence rate observed in a given kebele was determined by both tuberculosis prevalence rate (spatial autoregressive coefficient = 0.83) and unobserved factors (spatial autocorrelation coefficient = - 0.70) in the neighboring kebeles. By controlling the spatial effects, a 1°C rise in temperature was associated with an increase in the number of tuberculosis prevalence rate by 0.72, and a 1 person per square kilometer increase in population density was related to an increase in the number of tuberculosis prevalence rate by 1.19. Conclusions: The spatial and space-time clusters for high occurrence of tuberculosis were mainly concentrated at border areas of the Gurage Zone. The prevalence rate of tuberculosis in a given kebele was determined by both the prevalence rate of tuberculosis and other unobserved factors in its neighboring kebeles in the zone, indicating sustained transmission of the disease within the communities. The spatial risk of tuberculosis distribution between kebeles in the zone was partly explained by spatial variations in temperature, population density, altitude, and latitude. The geostatistical kriging approach can be applied to estimate the spatial risk of tuberculosis distribution in data limited settings. Recommendations: Tuberculosis control programs should consider the cooperation of neighboring kebeles in the design and implementation of tuberculosis prevention and control strategies to interrupt the chain of disease transmission between the communities. Moreover, the designing of locally effective tuberculosis prevention and control strategies should consider spatial locations with higher temperature and population density. Further research is required to evaluate the effectiveness of geographically targeting tuberculosis prevention and control interventions using the inputs from spatial epidemiological methods.
Husband’s involvement and women’s utilization of maternal healthcare in sideman zone southern Ethiopia.
(Addis Abeba University, 2019-03) Kidane, Wondwosen T/silasle(Ph.D.); Dr. Deressa, Wakgari (MPH, PHD)
Background: Husband involvement is an important intervention for improving maternal health, and is considered as a crucial step in scaling up women’s use of prenatal care. The idea of men’s involvement in reproductive health was first emerged at Cairo’s conference in 1994. Nevertheless, to implement this idea into practice several challenges have been faced. Even today, emphasis has not been given to the concept of men involvement in maternal health in most developing countries. Until recently, there is limited evidence of husbands’ involvement and its contribution for women’s use of skilled maternity care in Ethiopia, a country with low coverage of maternal health care but with high maternal and neonatal mortality. Therefore, there is a need to generate contextual evidence for policy formulation, designing and implementing programs that remove barriers and to promote husbands’ involvement in maternal health care. Objectives: The aims of this study were to assess the magnitude and determinants of husbands’ involvement in maternal health care, and to examine its association with women’s utilization of skilled birth attendants and postnatal care services in Sidama zone, Southern Ethiopia. Methods: The study used mixed research methods. The quantitative methods employed both cross-sectional and follow-up study designs. Data were collected from sample of 1318 men and 709 antenatal women using interview questionnaires from December 2014 to January 2015 and June 01 to November 30, 2015, respectively. The data were analyzed using SPSS ver.20. A descriptive statistics: univariate and bivariate analyses, and inferential statistics: a chi-square test, and binary logistic regression analyses with the corresponding odds ratios, 95% confidence intervals (CI), and p-values were computed. The qualitative method was also employed to explore contextual evidences on barriers to husbands’ involvement in maternal health care. The data were collected using open-ended questions and analyzed thematically using ATLAS.ti software. Before data collection, ethical clearance was assured at every steps of the data collection process. Results: Husbands’ involvement during antenatal care (ANC), skilled delivery care, and postnatal care (PNC), in this study, were 19.9%, 42.7%, and 11.8%, respectively. In the multivariate analysis, offering an invitation letter [adjusted odds ratio (aOR) 6.1, 95% CI: 4.0, 9.1], having <3 under five (U5) year children (aOR=3.3, 95% CI: 2.1, 5.1), and early initiation of ANC visit (aOR 3.0, 95% CI: 1.3, 7.0) were significantly associated with husbands’ involvement during ANC visits. In addition to early initiation of ANC visits and having <3 U5 year children, place of residence (aOR 4.8, 95% CI: 2.4, 9.4) and husbands’ involvement in the preceded ANC visit (aOR 2.1, 95% CI: 1.3, 3.4) were found to be a significant predictors of husbands involvement during delivery care. Similarly, having <3 U5 year children (aOR 3.8, 95% CI: 1.5, 9.5), offering invitation letter to husbands (aOR 3.3, 95% CI: 1.3, 8.0), husbands’ involvement in the preceded ANC visit and couples’ communication were also found to be a significant predictors of husbands’ involvement during PNC services. Respondents in the qualitative study further reported the existed social norms, men’s lack of awareness about when and how to involve, health staffs’ and women’s attitudes towards men’s involvement, and absence of guidelines were the main reasons for un-involvement of husbands in their wives’ maternal health care. In the multivariate analysis of the cohort study, women whose husbands involved at least for one ANC visit were 6.27 times and 7.45 times more likely to receive skilled birth attendants and PNC services, respectively, compared to women attended ANC alone, [aOR: 6.27; 95% CI: 4.2, 9.3; and aOR 7.45; 95% CI: 4.18, 13.3]. Conclusions and recommendations: The proportion of husbands’ involvement in maternal health care in the study areas was lower than the proportion reported from other African countries. Offering an invitation letter to husbands, number of U5 year children alive during the recent pregnancy, husbands’ involvement in the preceding ANC, couple’s communications, initiation of ANC visit and place of residence were found to be significant predictors of husbands’ involvement in maternity care. The observed associations between husbands’ involvement during ANC visit and women’s utilization of skilled birth attendants during birth and PNC services were strong and significant. This implies that woman’s utilization of skilled birth attendants’ and PNC services can be improved by involving their husbands in at least one ANC visit. Therefore, to bring a behavioral change and communication at community and facility levels, a contextual based awareness creation programs that focused on husbands’ involvement during maternal health care need to be launched; secondly, a national guideline on husbands’ involvement in maternity care, at each level of health facilities, need to be prepared and executed.

Browse

Browsing Public Health (PhD) by Issue Date

Results Per Page

Sort Options