Public Health (PhD)

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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
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
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.
Barriers to Access to Modern Contraception
(Addis Ababa University, 1998-02) Tekalegne, Agonafer; Bergevin, Yves (PhD)
Brief Psychological Intervention for Bipolar Disorder in Integrated Care Settings in Rural Ethiopia
(Addis Ababa University, 2021-10) Demissie, Mekdes; Fekadu, Abebaw
Bipolar disorder is a severe mental illness characterized by recurrent manic and depressive or mixed episodes. Bipolar disorder leads to a significant impairment in functioning, considerable stigma and premature mortality. The social disruption caused by acute episodes related to the illness often persists beyond clinical remission. Various factors affect the outcome of bipolar disorder such as distressing life events, substance use, poor coping mechanisms, sleep disturbance and treatment nonadherence. Complementing pharmacotherapy with psychological interventions has been shown to be more effective in preventing or delaying relapse and improving the course and outcome of the disorder compared to pharmacotherapy alone. In LMICs, there is very limited evidence on the adaptation, effectiveness and implementation of such psychological interventions. Furthermore, there is limited understanding of the particular risk factors and coping mechanisms relevant to LMICs that may be addressed with psychological interventions
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.
Childhood Tuberculosis Epidemiology in Urban Central Ethiopia: Death Predictors, Disease Determinants, and Unfavorable Treatment Outcomes
(Addis Ababa University, 2024-06) Adere,Abay Burusie; Addissie,Adamu (MD, MPH, MA, PhD); Salazar-Austin,Nicole(MD); Enqueselassie,Fikre(PhD)
Background: Limited evidence exists on the epidemiology of childhood tuberculosis (TB) in Ethiopia. Even though the TB treatment success rate is one of the most important global metrics for assessing the implementation of the End TB Strategy, little is known about the magnitude and determinants of unfavorable TB treatment outcomes that affect TB treatment success rates among children in Ethiopia. Additionally, despite Ethiopia's high national BCG coverage and studies showing the vaccine's effectiveness against TB meningitis (TBM), the disease remains a persistent problem. Objectives: To describe the epidemiology of drug-susceptible TB and identify predictors of TB death, identify determinants of TB disease, assess the magnitude and predictors of unfavorable TB treatment outcomes, and evaluate the effectiveness of BCG vaccine against TBM among children aged 16 and under in Urban Central Ethiopia. Methods and materials: This study was conducted across healthcare facilities in Addis Ababa, Adama, and Bishoftu from September 25 to June 24, 2022. A retrospective cohort design was used to address the following specific objectives: describing TB epidemiology, identifying predictors of death, and assessing the magnitude and determinants of unfavorable treatment outcomes. Additionally, 1:1 matched case-control and 1:4 unmatched case-control designs were used to identify determinants of TB disease and assess BCG vaccine effectiveness against TBM, respectively. Sample sizes were statistically determined. Thirty-two healthcare facilities—26 in Addis Ababa, three in Bishoftu, and three in Adama—were randomly selected. All children treated for TB at these facilities were included in the descriptive epidemiology and predictors of death analyses, as well as in the study on unfavorable treatment outcomes. In the matched case- control study, cases (children with TB) were randomly selected from treated children identified through TB registries. Controls (children never diagnosed with TB) were sequentially chosen from the same facilities. Data on TB cases were collected through TB record reviews and phone interviews with parents or caregivers. Data on controls were obtained through face-to-face interviews with parents or caregivers. Descriptive epidemiology was presented using relative frequency tables and graphs. Statistical analyses included Cox proportional hazards regression (challenged with extended Cox regression) to compute adjusted hazard ratios (aHR) for death predictors, conditional logistic regression for matched adjusted odds ratios (mORadj) of TB xi disease determinants, log-binomial analysis for risk ratios (aRR) of unfavorable outcomes, and unconditional logistic regression for adjusted odds ratios (aOR) to assess BCG vaccine effectiveness against TBM. This study was approved by the Institutional Review Board of the College of Health Sciences, Addis Ababa University (protocol number: 057/19/SPH). Results: Data from 640 children aged 16 years and under who underwent treatment for TB were analyzed. Among them, 80 (12.5%) were under two years old, and a resurgence occurred starting from around 12 years of age. Most of the enrolled children, 557 (87.0%), had no known household TB contact. Out of 519 children with an identified place of stay, 396 (76.3%) were attending school or daycare before being diagnosed with TB. Thirty-six (5.6%; 95% confidence interval (CI) = 4.0–7.7%) of the 640 children died during the course of TB treatment. Among those who died, nine (25%) were under two years old. Factors such as HIV infection (aHR = 4.2; 95% CI = 1.9–9.3), undernourishment (aHR = 4.2; 95% CI = 2.2–10.48), age below 10 years (aHR = 4.1; 95% CI = 1.7–9.7), and relapsed TB (aHR = 3.7; 95% CI = 1.1–13.1) increased the likelihood of death during TB treatment. Children not vaccinated with BCG at birth or within two weeks of birth (mORadj = 2.11; 95% CI = 1.28–3.48), those who lived with a TB-sick family member (mORadj = 4.28; 95% CI = 1.95–9.39), those who lived with a smoking family member (mORadj = 3.15; 95% CI = 1.07– 9.27), and HIV-infected children (mORadj = 8.71; 95% CI = 1.96–38.66) were more likely to develop TB than their counterparts. A post-estimation analysis indicated that children who were BCG-vaccinated at birth or within two weeks of birth had a lower risk of TB than their unvaccinated counterparts until the age of 15, but there was no difference found between the two groups when they turned 16. Out of 640 children, 42 (6.6%; 95% CI = 4.8–8.8%) had unfavorable TB treatment outcomes, with 31 (73.8%; 95% CI = 58.0–86.1%) occurring after the first two months of treatment initiation. Children under ten years old (aRR = 2.69; 95% CI = 1.56–4.61), those with relapsed TB (aRR = 3.19; 95% CI = 1.79–5.70), undernourished children at TB diagnosis (aRR = 2.68; 95% CI = 1.53–4.71), and HIV-infected children (aRR = 2.62; 95% CI = 1.50–4.59) had a higher risk of unfavorable TB treatment outcomes than their counterparts. However, among children who completed the first two months of TB treatment, relapsed TB was not significantly associated (aRR = 2.81; 95% CI = 0.96–8.22) with unfavorable outcomes, while the remaining xii factors retained significance. No significant association was detected between BCG vaccination and the risk of TBM (aOR = 0.46; 95% CI = 0.11–1.84). Conclusions: Most children contract TB from the community, with morbidity resurging around age 12, possibly due to waning BCG vaccine effectiveness. Despite a pooled global death rate of 0.9% in treated childhood TB patients, the death rate in Urban Central Ethiopia is high. Risk factors for death and unfavorable outcomes include being under 10, suggesting redefining the high-risk age category from 5 to 10 years. BCG vaccination is protective of childhood TB but wanes with age. Second-hand smoking increases childhood TB risk, underscoring the need for public health policies to reduce children's exposure to tobacco smoke. HIV remains a significant morbidity and mortality risk factor, raising concerns about the coverage and efficacy of TB preventive treatments. The rate of unfavorable TB treatment outcomes aligns with the WHO's milestone, staying below 10%, but nearly three-quarters of these outcomes occur during the continuation phase, highlighting the need for extended risk-focused follow-up. Undernutrition persisting into the continuation phase of TB treatment predicts unfavorable outcomes, indicating the need for nutritional interventions throughout both the intensive and continuation phases of childhood TB treatment. BCG was not found to significantly protect against TBM compared to other types of TB combined. Recommendations: Expand TB contact tracing in children to include school communities and maintain universal newborn BCG immunization. Consider legislation against smoking in households with children. Include children under 10 as a high-risk group for TB-related death in TB guidelines. Evaluate the coverage and effectiveness of TB preventive therapy intervention in HIV-infected children. Children under 10, those who are HIV positive, and undernourished children should be carefully assessed, treated, monitored, and provided with necessary support, regardless of the phase of TB treatment they are in. This study recommends conducting larger studies to assess the effectiveness of BCG vaccination against TBM compared to other types of TB
Coffee dust exposure and respiratory health among workers in primary coffee processing factories in Ethiopia
(Addis Abeba University, 2019-05) Wakuma, Samson(PhD); Dr.Kumie, Abebe( PhD ); Dr.Deressa, Wakgari; Prof.Moen, Bente E(PhD); Prof.Bratveit, Magne (PhD)
Background: Dust exposure is one of the major risk factors for health in many work places including coffee processing factories. Dust generates at different stages of coffee handling and processing. Excessive exposure to coffee dust can cause respiratory health problems. Coffee workers in Ethiopia are exposed to coffee dust, but the level of exposure and the magnitude of its health effect have not been widely investigated. Objectives: The aims of this study were to assess the level of personal total dust exposure, factors affecting dust exposure, the prevalence of respiratory symptoms and lung function reduction among coffee workers. In addition, assessing microbial contamination of coffee at different stages of both wet and dry method on farm coffee processing was a part of this dissertation. Methods: Comparative cross-sectional studies were conducted in primary coffee processing factories involving 3 regions: Oromia Regional State; Addis Ababa City Administration; and Southern Nations, Nationalities and Peoples’ Region. The study also included a comparative population in 3 water bottling factories, one from each region mentioned above. A total of 360 dust samples were collected from 12 primary coffee processing factories for dust exposure assessment. In addition, 60 total dust samples were collected from the 3 water bottling factories. Dust samplings were collected from breathing zone of workers using 25mm three piece, closed-faced conductive cassettes with a cellulose acetate filter attached to Side Kick Casella pumps with a flow rate of 2 liter/ minute. Observational checklist was used to identify possible determinants for dust exposure. Lung function tests were performed for a total of 420 participants ( 120 male coffee workers, 120 male controls, 60 hand pickers with tables, 60 hand pickers without tables and 60 female controls) using a portable spirometer (SPIRARE 3 sensor model SPS 320). Lung function parameters such as Forced Vital Capacity (FVC), Forced Expiratory Volume in one second (FEV 1 ), the mean forced expiratory flow between 25% and 75% of the FVC (FEF ) and ratio FEV FVC were measured. Prevalence of chronic respiratory symptoms were assessed with an interview, using a standardized questionnaire adopted from the American Thoracic Society. 1/ Coffee cherries each weighing about 25 grams were sampled from each stage of the wet and dry processes for microbial contamination assessment. Standard Plate Count agar was used 25-75% to grow total bacteria and gram stain technique were used to identify gram negative and gram positive bacteria. Data were entered into an electronic database using EpiData version 3.1 and exported to SPSS version 22 for analysis. Missing values and outliers were checked using frequency tabulation, and then were managed accordingly. The results were described as arithmetic mean, standard deviation, geometric mean (GM), and geometric standard deviation (GSD). A one-way analysis of variance was performed to compare the GM of personal total dust exposure level between different job groups and between tasks. Linear mixed effect regression models were developed to identify significant determinants for personal total dust exposure. Independent t-tests were used to compare the mean values for the continuous variables. The Pearson Chi-square test or Fisher’s exact test, if the expected value was less than 5, were used to test the difference between the groups regarding the categorical variables. Poisson regression analysis with a robust variance was used to determine the prevalence ratio of the different respiratory symptoms between the coffee workers and controls. Analysis of covariance and linear regression were used to compare the mean lung function parameters between the coffee workers and controls while adjusting for confounders. Results: The GM dust exposure among machine room workers ranged from 4.09 to 34.40 mg/m 3 , among transport workers from 3.51 to 24.19 mg/m 3 , and among hand pickers from 0.26 to 5.87 mg/m 3 . Overall the GM personal dust exposure was significantly higher (P = 0.001) for the machine room (12.54 mg/m 3 ) and transport workers (12.30 mg/m ) than for the hand pickers (1.08 mg/m 3 ). In these three groups, 84.6%, 84.1%, and 2.6% of the samples exceeded the occupational exposure limit of 5 mg/m 3 respectively. The result also indicated that pouring coffee vigorously from a dropping height was the determinant with the highest impact on personal total dust exposure with 3.2-fold increase compared to gradually pouring coffee from a very short height. Coffee workers had significantly higher prevalence of most of the chronic respiratory symptoms compared with the controls. For most of the chronic respiratory symptoms, hand pickers without tables displayed a significantly higher prevalence ratio than in hand pickers with tables. 3 Male coffee workers in the age groups 28–39 years and ≥40 years, had a significantly lower FVC and FEV compared to the controls in the similar age groups. There were statistical differences in FEF 1 25-75% between hand pickers and controls. In addition, FVC and FEV were significantly lower among hand pickers without tables than among hand pickers with tables. The results also indicated the presence of gram negative bacteria in dried and stored beans from both the wet and dry process. Conclusion: About 84% of the dust samples among machine room and transport workers in primary coffee processing factories were above the occupational exposure limit value for organic dust. Machine and transport workers in primary coffee processing factories had a higher prevalence of chronic respiratory symptoms and lower FVC and FEV than the controls. Pouring coffee beans vigorously from a dropping height, mixing coffee and feeding hopper were the main determinants for increased personal dust exposure level. The dust exposure was related to reduced lung function and higher prevalence of chronic respiratory symptoms among coffee workers. Gram negative bacteria found in dried and stored coffee beans, might release endotoxin which may cause respiratory health problems among coffee production workers. Recommendations: Coffee workers should be provided with efficient respiratory protective device and training on its importance prior to employment and regularly afterwards as necessary. Changing process of pouring coffee beans from vigorously to gradual could reduce personal dust exposure level in the coffee factories. 1 1
Detection and impact of co-morbid mental health conditons in people with epilepsy in rural Ethiopia
(Addis Ababa University, 2023-09) Tsigebrhan,Ruth(PhD); Hanlon,Charlotte(Prof.); Fekadu,Abebaw(Prof.)
Background:Research evidence from around the world indicates high levels of co-morbid mental conditions among people with epilepsy (PWE) compared to the general population. Nevertheless, there is very limited evidence regarding the detection or impact of co-morbid mental health conditions in PWE from low-income country settings. Therefore, the main aim of this PhD thesis was to investigate the detection, impact and lived experience of co-morbid mental health conditions in PWE in a rural Ethiopian setting. Specific objectives were to:  To synthesis evidence examining the association of co-morbid mental health conditions in people with epilepsy with quality of life or functioning in LAMICs.  Evaluate the performance of primary health care workers (PHC) in identification of co-morbid mental health conditions in PWE attending PHC.  Examine the association of co-morbid mental health conditions with quality of life, functioning and seizure control.  Explored the experiences of mental ill-health in the contexts of the lives of PWE. Methods:First, a systematic review and meta- analysis (Study 1) was conducted to examine the evidence on the association between co-morbid mental health conditions and quality of life and functioning of PWE in low- and middle-income countries. We searched five main databases from their dates of inception to January 2022. Cohen‟s d was calculated from the mean difference in quality-of-life score between people with epilepsy who did and did not have a co-morbid depression or anxiety condition. Second, a prospective cohort of people with epilepsy was carried out in four districts of south-central Ethiopia. PWE were ascertained in the community, refererred and recruited at the PHC facility after diagnostic confirmation of convulsive seizures. Co-morbid common mental disorder (CMD) symptoms (depression, anxiety and somatic symptoms) and risky substance use (exposures) were measured using the culturally validated Self Report Questionnaire (SRQ-20) and Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), respectively. Clinician-diagnosed co-morbid mental disorders were measured using a standardised, semi-structured clinical interview (Operational Criteria for Research; OPCRIT+) administered by mental health professionals. The main outcome, quality of life (QoL) was measured at baseline and 6 months using the Quality of Life in Epilepsy questionnaire (QOLIE-10P). Functional disability was measured using the 12-item World Health Organization Disability Assessment Schedule (WHODAS-2). Seizure frequency was measured at baseline and during the follow-up period (6 months). Study 2: The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of PHC worker diagnosis against the reference standard clinical diagnosis was calculated. Logistic regression was used to examine the factors associated with misdiagnosis of clinically diagnosed co-morbid mental disorder by PHC workers. Study 3: Univariate analysis followed by multiple linear regression modelling was used to cross-sectionally examine the association between clinically diagnosed co-morbid mental disorder (primary exposure) and quality of life, adjusting for potential confounding factors identified a priori. Study 4: Multivariable linear regression was employed to evaluate whether co-morbid CMD symptoms predicted a change in QoL and functional disability after adjusting for baseline levels and pre-defined potential confounders. Structural equation modelling (SEM) was employed to examine direct and indirect pathways linking co-morbid CMD symptoms with QoL or functional disability. Study 5: A qualitative study using a phenomenological approach was employed, comprising in-depth individual interviews with PWE. Thematic analysis was used, supported by OpenCode software. Results:Study 1: The search strategy identified a total of 2,101 articles, from which 33 full text articles were included in the review. A large standardized mean effect size (ES) in quality of life score was found (pooled effect size (ES) -1.16, 95% confidence interval (CI) -1.70, -0.63) between those participants with co-morbid depression compared to non-depressed participants (meta-analysis of 19 studies). There was significant heterogeneity between studies (I2= 97.6%, p<0.001). The median ES (IQR) was -1.20 (-1.40, (-0.64)). An intermediate standard effect size for anxiety on quality of life was also observed (pooled ES - 0.64, 95% CI -1.14, -0.13). There was only one study reporting on functioning in relation to co-morbid mental health conditions. Study 2: The prevalence of clinically diagnosed co-morbid mental disorders was 13.9% (95% CI 9.6%, 18.2%). PHC workers identified 6.3% of clinic attendees as having a mental health condition (95%CI 3.2%, 9.4%). The sensitivity and specificity of PHC worker diagnosis against the clinical standardised reference diagnosis were 21.1% and 96.1%, respectively. Against the reference diagnosis, the optimum cut-off for SRQ-20 (CMD symptom scale) was 9 or above, which identified 41.5% of attendees as „probable CMD‟, 95% CI 35.2%, 47.8%. In those diagnosed with co-morbid mental disorders by PHC workers, only 6 (40%) had SRQ-20 score of 9 or above. When a combination of both diagnostic methods (SRQ-20 score ≥9 and PHC diagnosis of depression) was compared with the standardised reference diagnosis of depression, sensitivity increased to 78.9% (95% (CI) 73.4, 84.4%) with specificity of 59.7% (95% CI 53.2, 66.2%). Only older age was significantly associated with misdiagnosis of co-morbid mental disorders by PHC (adjusted odds ratio, 95% CI= 1.06, 1.02 to 1.11). Study 3 - Comorbid mental disorders were associated with poorer quality of life (Adjusted (Adj.) β -13.27; 95% CI -23.28, -3.26) and greater disability (multiplier of WHODAS-2 score 1.62; 95% CI 1.05, 2.50) after adjusting for hypothesised confounding factors. Low or very low relative wealth (Adj. β -12.57, 95% CI -19.94, -5.20), higher seizure frequency (Adj.β coef. -1.92, 95% CI -2.83, -1.02), and poor to intermediate social support (Adj. β coef. -9.66, 95% CI -16.51, -2.81) were associated independently with decreased quality of life. Higher seizure frequency (multiplier of WHODAS-2 score 1.11; 95% CI 1.04, 1.19) was associated independently with functional disability. Study 4: In the multivariable regression model, neither CMD symptoms (β coef= -0.37, 95%CI -1.30, +0.55) nor moderate to high risk of alcohol use (β= -0.70, 95% CI -9.20, +7.81) were significantly associated with change in QoL, and there was no effect modification by treatment engagement. Frequent seizures were associated with a negative change in QoL. In SEM, QoL at 6 months was significantly predicted by seizure frequency. The summative effect of CMD on QoL was significant (B= -0.27, 95%CI -0.48, -0.056), although direct and indirect associations were non-significant. Change in functional disability was not associated with baseline CMD symptoms (β coef.= -0.03, 95% CI-0.48,+0.54) or with moderate to high risk of alcohol use (β coef.= -1.31, 95% CI -5.89, 3.26) and there was no evidence of effect modification by treatment engagement. However, in the SEM model, functional disability at 6 months was predicted by both baseline CMD symptoms (B=0.24, 95% CI 0.06, 0.41) and seizure frequency (B=0.67, 95% CI 0.46, 0.87) independently. Study 5: Twenty-two PWE were interviewed (8 women, 14 men). The following themes were identified: expression of ill-health; the essence of emotions; the emotional burden of epilepsy and aspirations and mitigating impacts. Participants reported multiple bodily (e.g. fatigue) and emotional (e.g. irritability, sadness) experiences which were tied up with their experience of epilepsy and not separable into physical vs. mental health. Emotions were considered inherently concerning, with emotional imbalance spoken of as a cause or trigger for seizures. These emotional burdens resulted in difficulties fulfilling occupational and social life obligations, in turn exacerbating the stigma-related experienced from others. Conclusion:In this rural Ethiopian setting, comorbid mental disorders were associated with functional imairemnt and poor quality of life of people with epilepsy. Co-morbid CMD symptoms and seizure frequency in PWE independently predicted functional disability. The association between CMD symptoms and quality of life was less conclusive. Routine detection of co- morbid mental disorder by PHC workers was very low. Combining clinical judgement with use of a screening scale holds promise but needs further evaluation. People living with epilepsy in this rural Ethiopian setting experience various emotional, financial, occupational and interpersonal problems which are crucially interwoven with one another and with the experience of epilepsy. A people-centred approach to supporting recovery of PWE requires consideration of mental health alongside physical health, as well as interventions outside the health system to address poverty and stigma
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.
Diabetes Mellitus among Pregnant Mothers and Its Effect on Maternal and Birth Outcome in Wolaita Zone, Southern Ethiopia
(Addis Abeba University, 2019-06) Wolka, Eskinder(PHD); Dr. Deressa, Wakgari; Dr.Reja, Ahmed
Background: Currently, diabetes mellitus (DM) is considered as one of the top health problems of the World. The World Health Organization (WHO) estimated that, globally, hyperglycemia is the third highest risk factor for premature mortality, next to high blood pressure and tobacco use. World estimate of 8.8% (415 million) adults aged 20-79 affected by DM in 2015 with little gender difference and in the same year the estimate of hyperglycemia in pregnancy in Africa was 10.5% affecting 3.3 million live births. Its burden is increasing and the largest increase will take place in low and middle-income countries. The magnitude of diabetes is nearly equal among both sexes but it uniquely affects women through its impact during pregnancy. Today as many as 60 million women of reproductive age have type 2 diabetes and gestational diabetes mellitus (GDM), affects up to 15% of pregnant women worldwide. Poorly controlled diabetes is important cause of maternal and fetal complications among pregnant mothers. Early identification, close monitoring and management of diabetes mellitus among pregnant women can meaningfully improve pregnancy and birth outcome. In Ethiopia, although diabetes mellitus is recognized as one of the major non-communicable diseases, the burden among pregnant women and its effect on pregnancy and birth outcomes are not well researched. Objective: To assess the magnitude of DM and its effect on maternal and birth outcomes among pregnant mothers in Wolaita Zone, Southern Ethiopia Methods: This study has been undertaken in Wolaita Zone, Southern Ethiopia. Institution-based retrospective document review with a cross-sectional design, cross-sectional study and retrospective cohort study designs were employed respectively to determine magnitude of preexisting diabetes, prevalence of GDM and effect of diabetes on pregnancy and birth outcome among mothers receiving maternity services in selected health facilities in Wolaita Zone. Qualitative study was done to explore detection and management modalities of GDM. The study took place from August 2017 to June 2018. The study populations were pregnant mothers and health care providers. Data were collected by document review or data extraction, interviewing of pregnant women by structured questionnaire, and in-depth interview of health professionals engaged in maternity care. Oral glucose tolerance test was performed and GDM was diagnosed based on WHO criteria. Data were entered in to Epi Info version 7 and analysis was done by STATA version 14. Descriptive statistics was computed and data were presented using figures and tables. Chi-square and corresponding p-value were determined to assess the association between dependent and independent variables for the first objective. Binary logistic regression was applied to show the association of independent variables with dependent variables. Thematic analysis approach was used to analyze qualitative data using NVIVO version 12. The study was approved by Institutional Review Board of College of Health Sciences, Addis Ababa University. Results: Magnitude of pre-existing DM among mothers receiving maternity care within one year period was 2.8% 95% CI (1.5, 4.2). The magnitudes among urban and rural residents were 3.3% and 1.4% respectively. Pre-existing diabetes mellitus was significantly associated with family history of diabetes (Chi square 24.8, P-value, 0.001). Previous history of spontaneous abortion (aOR: 5.3; 95%CI: 1.6-17.4 ) and fetal macrosomia (aOR: 3.9; 95%CI: 1.2-13.1 ), were identified to be significantly associated with pre-existing diabetes. Prevalence of GDM was 4.2% (95% CI, 2.5, 6.2) with mean post glucose load level of 160.1 mg/dl (6.3) and 15(4%) among urban residents and 7(4.9%) among rural residents. The proportion of GDM increases with increase in number of pregnancies. Previous history of spontaneous abortion (aOR: 3.5; 95%CI: 1.7-14.6 ) and family history of type II diabetes (aOR: 4.3; 95%CI: 1.3-8.7 ) were significantly associated with GDM. Mothers with DM were 2.9 times more likely to be delivered by caesarean section than nondiabetic mothers (aRR: 2.9, 95%CI: 1.3-6.2) and the risk of pre-term delivery is 2.5 times higher among mothers with DM, (aRR: 2.5, 95% CI: 1.1-6.2). Screening of women for GDM was done by selective screening within 24-28 weeks of gestational age. The participants also mentioned that they made diagnosis of GDM based on WHO criteria. Health care providers use dietary modification, exercise and drug treatment to treat GDM. Participants confirmed that lack of standard guidelines and protocols, lack of attention of mid-level workers to screen GDM, inadequate trained health care providers, shortage of supplies and equipment and late antenatal care visits were barriers to detection and management of GDM. Conclusions and Recommendations: The magnitude of pre-existing DM is almost the same as that of International Diabetes Federation estimate to Ethiopia. Family history of diabetes is found to be associated with pre-existing DM. Pre-existing diabetes is associated with increased risk of abortion and fetal macrosomia. The prevalence of GDM is higher compared to other studies conducted in the country. Diabetes mellitus among pregnant mothers is associated with increased risk of pre-term birth and caesarean section delivery. Commonly reported challenges to detect GDM among mothers were lack of standard guidelines and protocols, lack of trained health care providers, shortage of supplies and equipment and late antenatal care visits. Strengthening screening, care and prevention strategies for gestational diabetes mellitus are important to improve maternal and child health. Early detection and management of diabetes mellitus should be one of the key activities to improve maternal and child mortality and morbidity. Policy makers and health care leadership need to address challenges for detection and management of GDM, by strengthening the health care system by availing standard guidelines and protocols, providing on job training for mid-level health care providers, fulfilling supplies and consumables and working on early antenatal visits of pregnant mothers. National large scale study is important to estimate the burden of DM among pregnant mothers and its effect on maternal and birth outcomes at national level.
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.
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.
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.
Household air Pollution and its health Effects among Under-Five children in Wolaita Sodo, Ethiopia.
(Addis Abeba University, 2019-07) Admasie, Amha(PhD); Kumie, Abera(PhD, Associate Prof.); Worku, Alemayehu(PhD, Prof.)
Background: Household air pollution is among the top ranked global public health concern particularly in developing nations, like Africa. Eighty percent of the population of sub-Saharan Africa and 90% of the Ethiopian population use biomass fuels for cooking. It is linked to many health problems including acute respiratory infection in children. The cause of this health problems is attributable to many factors including household air pollution. Acute respiratory infection is the most common illnesses in childhood, comprising as many as 50% of all illnesses in children less than 5 years old in the world. Household air pollution is still a big problem in developing countries. In Ethiopia, pneumonia alone contributed to 27% of all illness and 18% of all deaths to under-five children. Exposure assessment on indoor air pollution, specifically linked to acute respiratory infection is limited in Ethiopia. Objective: To assess household air pollution and its health effects among under-five age children in Wolaita Sodo town, Ethiopia. Methods: A community-based unmatched case-control and cross-sectional study design were used in the study. Census has been conducted prior to the actual data collection to specify sampling frame. One thousand one hundred forty-four (1144) children with cases to controls ratio of 1:3 (i.e. 286 cases and 858 controls) aged 0-59 months paired with their mothers were participated in the study. Cases are defined as a child who fulfilled the world health organization criteria of acute respiratory infection (i.e. a child who suffered from cough, followed by rapid breathing in the two weeks that preceded the survey date), while controls are a child who is free of any complaints of respiratory illnesses in the two weeks that preceded the survey date. In an eleven Kebele (the smallest administrative structure/unit of the government) in the town, six Kebeles were selected randomly. Sample sizes were distributed based on probability proportional to size of the households in each Kebele. Census of all children in the selected Kebeles were conducted to set the sampling frame. Based on the sampling frame, cases and controls of acute respiratory infection in a child were identified using case definition of acute respiratory infection by interviewing their mothers. The mother of a child was interviewed about her child health history for assessment of cases and controls. For exposure assessment, a sub sample of 110 kitchens and 66 were involved to determine the level of particulate matter (PM 2.5 ) and carbon monoxide pollution respectively from biomass fuel XII using a monitoring equipment designed by the University of California, Berkeley Particle Monitor (UCB-PM) and HOBO CO data logger, respectively. Data were managed and analyzed using Epi Info and SPSS version 21. Exposure data were managed using UCB Monitor Manager software (Version 2.1.3) and BoxCar Pro software (Version 4.3) software. Descriptive statistics, Odds ratio, Chi-squired tests, Unconditional logistic regression, Linear regression, ANOVA, Pearson's correlation coefficient and Eta-test were employed. Results: The study was conducted with the response rate of 99.65%. The mean age of the children was 24.15 (SD=14.98) months, while the age group between 12-23 months was accounted to 330 (28.86%). More than three-fourth of children lived in households that used mainly polluting fuel for cooking, biomass fuel 1001 (87.5%), while the rest only 143 (12.5%) of the households used mixed type of fuel energy, such as biomass, electricity, biogas and liquefied petroleum gas. About 712 (62.23%) of households had a kitchen separated from the main house, while 351 (30.68%) of the households had kitchen inside the living house. About 417 (58.5%) of the kitchen had no chimney, 666 (93.54%) didn’t open windows during the cooking time. The prevalence of acute respiratory infection in under-five children were 10.1% (95% CI 9.5, 10.8). Biomass fuel users for cooking (AOR=2.08, 95% CI 1.03-4.22), poorly ventilated houses (AOR=4.31, 95% CI 2.60-7.15), less than 2 years of child birth interval (AOR=1.40, 95% CI 1.021.91), large family size, (AOR=1.85, 95% CI 1.30-2.61), petty trade job of mother (AOR=0.50, 95% CI 0.31-0.81) were significant risk factors of acute respiratory infection in under five children. A 24 hour Geometric mean concentration of PM 2.5 in all monitored households were 413.27 µg/m 3 . The arithmetic mean 772.03 µg/m 3 (837.39) with 95% CI 613.04, 931.01. The 24 hour measurement of mean concentration of carbon monoxide in all monitored households were 14.26 mg/m 3 (SD=10.06). Type of fuel use, type of stoves (improved/traditional) and duration of time spent in cooking had significant differences on the level of particulate matter and Carbon monoxide. Conclusions: The prevalence of acute respiratory infection is still a public health concern given the high level of household air pollution. Biomass fuel sources and poor house ventilation had a significant association on acquiring of acute respiratory infection. Mother’s unemployment, higher family size, child birth interval of less than 2 years, biomass fuel use for cooking, living a poor ventilated house and carrying child while cooking were risk factors of acute respiratory infection among children. The geometric mean concentration of particulate matter and carbon monoxide were much more exceeded the World Health Organization Air Quality Guideline values. Recommendations: Promotion and distribution of improved cooking stoves, introducing better house design, promote a separate kitchen, to incorporate a sufficient number of windows and rooms in the house are sustainable solutions. Health education and promotion on the preventive measures of acute respiratory infection, the risk of biomass fuel combustion and engaging or carry child in the back while cooking and the importance of house ventilation should be delivered. Sustainable urban electrification (clean energy supply) is highly recommended solution to solve the cooking fuel related health problems.
Husbands’ involvement and women’s utilization of maternal health care in Sidama zone,Southern Ethiopia.
(Addis Abeba University, 2019-03) T/Silasie, Wondwosen (PhD); 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 ANCvisit (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.
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.
Hypertensive disorders of pregnancy and its effect on birth outcomes among mothers in public hospitals of Tigray, North Ethiopia.
(Addis Abeba University, 2019-05) Kahsay, Hailemariam Berhe (PhD); Enqusellasie, Fikre(PhD); Mekonnen, Wubegzier(PhD)
Background: over half a million women die each year from pregnancy related causes signifying that complications of pregnancy and childbirth are the leading cause of death amongst women of reproductive ages. Hypertensive disorders of pregnancy are the second direct cause of maternal death only next to hemorrhage which accounts 14% of all maternal mortality globally and 16 % in subSaharan African countries. In Ethiopia 11% of all maternal deaths and 16% of direct maternal deaths are due to this obstetric complication. There is paucity of study looking into the pattern and distribution, the risk factors and the maternal and perinatal outcomes of hypertensive disorders of pregnancy. Moreover, little is known why hypertensive disorders of pregnancy are not early detected and managed to prevent the serious consequences of the disorders. Objective: the aim of this study was to assess hypertensive disorders of pregnancy and its effect on birth outcomes Methods: The study was conducted in public hospitals of Tigray, Ethiopia. Cross-sectional, matched case control, cohort and descriptive qualitative designs were applied for objectives one, two, three and four respectively. For the retrospective record review, all records of women diagnosed with hypotensive disorders of pregnancy from September 2012 to August 2017 (with calculated sample size of 746) were considered while for the case control study a total of 330 (cases=110 and controls=220) matched by parity were included. In addition, a total of 374 (exposed/with hypertensive disorders=187, non-exposed/without hypertensive disorders=187) were included in the follow up study. In the qualitative study, for documenting barriers, health professionals, health care leaders and women with a history of hypertensive disorder of pregnancy were included. Cases were pregnant women attending maternal health services with a diagnosis of hypertensive disorders of pregnancy by an obstetrician while controls were pregnant women attending maternal health services without hypertensive disorders of pregnancy. In the cohort study, exposed group were women diagnosed with any of the hypertensive disorders of pregnancy after 20 weeks of gestation by an obstetrician while non-exposed group were women free from any of the hypertensive disorders of pregnancy. Case-control incidence density sampling was used to identify cases and controls. For the cohort study, women diagnosed with hypertensive disorders of pregnancy with their nonhypertensive pairs were enrolled after 20 weeks of gestation and followed until the first 7 days postpartum. In both designs (case-control and cohort) the sample size was distributed to each selected hospitals according to the case load. For the qualitative study, a total of 22 in-depth interviews were conducted and the sample size was guided by the level of information saturation Data entry for the quantitative study was done into Epi-Info software and it was analysed using STATA 14 software. Descriptive statistics was computed and data were summarized in frequencies, proportions and means. Binary logistic regression was used to calibrate the association of different variables with the dependent variable for the quantitative study. For the case control study conditional logistic regression model was applied and Odds ratio was generated. Besides, relative risk was generated from a binary logistric regression for the cohort study. P-value less than 0.05 were considered significant in all analysis. For the qualitative study, recorded data were transcribed verbatim and translated to English. The transcript was exported to Atlas ti.7 software for qualitative data analysis which was followed by developing a categorization scheme to reduce the data and make it more manageable. Transcripts were read for several times and the primary codes were extracted. Then, the related codes were put in one group/category. Finally, based on similarity and content, the subcategories were used to make the main categories or themes. Thus, thematic content analysis was used to generate the main themes of the study. The overall findings were presented using figures, tables and texts. Ethical clearance was obtained from Institutional Review Board (IRB) of Addis Ababa University College of Health Sciences. Cooperation letter was written from the Regional Health Bureau and permission was requested from study facilities. Individual written informed consent was also sought from respondents at the time of data collection. Results: A total of 45,329 mothers were admitted to deliver in the selected public hospitals of Tigray during the five years study period (September 2012 to August 2017). Out of the total deliveries, 1347 (3%) women were diagnosed for one of the hypertensive disorders of pregnancy. The overall magnitude showed an increasing trend over the review period ranging from 1. 4% in 2013 to 4% in 2017 which gives average percentage increase of 31% per annum.The change over the five years period was checked for its significance using chi-square trend analysis and it was found to be significant (X 2 = 153, p≤0.001). Multivariable analysis on the relationship between hypertensive disorders of pregnancy and different covariates revealed that rural residence (AOR = 3.7, 95% CI; 1.9, 7.1), less amount of fruits consumption (OR =5.1, 95% CI;2.4, 11.15), being overweight (pre-pregnancy BMI>25 Kg/m2) (AOR= 5.5 95% CI; 1.12, 27.6), gestational diabetes mellitus (AOR = 5.4, 95%CI; 1.1, 27.0) and multiple pregnancy (AOR= 4.2 95%CI; 1.3, 13.3) were independent predictors of hypertensive disorders of pregnancy. Moreover, the study showed higher risk of having pregnancies complicated by maternal and perinatal adverse outcomes. Thirty six (20.2%) of hypertensive women and 19(10.7%) of normotensive women undergone cesarean section delivery. Preterm birth (RR=1.8; 95%CI, 1.5, 2.2), stillbirth (RR=1.6; 95%CI, 1.3, 2.02), low birth weight (RR=1.9; 95%CI, 1.6, 2.3), early neonatal death (RR=1.7; 95%CI, 1.3, 2.3), perinatal death (aRR=2.6, 95%CI; 1.2, 5.7) and cesarean section delivery(RR=1.7; 95%CI, 1.02, 2.9) were significantly higher among women with hypertensive disorders of pregnancy Furthermore, the qualitative study showed that knowledge deficit and traditional believes towards hypertensive disorders of pregnancy, delayed referral and provision of incomplete pre-referral treatments in the lower level health care facilities, failure to implement antenatal follow up as per the recommendation; scarcity and interruption in the supply of resources; and lack of mentorship programs to make professionals competent were claimed for the late detection and management of hypertensive disorders of pregnancy. Conclusion: Hypertensive disorder of pregnancy in Tigray is found to be 3% and it showed an increasing trend. Rural residence, less fruit consumption, multiple pregnancy, presence of gestational diabetes mellitus and pre-pregnancy overweight were identified as independent risk factors in the current study. Besides, women with hypertensive disorders in pregnancy were at significantly higher risk of having pregnancies complicated by maternal and perinatal adverse outcomes. A significant risk of cesarean section delivery, preterm birth, perinatal death, stillbirth and low birth weight delivery were reported among women with hypertensive disorders of pregnancy. Moreover, poor awareness of mothers and community misconceptions towards hypertensive disorders of pregnancy, multiple referrals before reaching the final functional health care facility, less focus on the quality of antenatal care, scarcity of resources and limited capacity building programs were reported as barriers for early detection and management of hypertensive disorders of pregnancy. Therefore, health care managers and administrators at different level of the health care system should give due emphasis to hypertensive disorders of pregnancy as it is one of the top causes of maternal and perinatal mortality and its magnitude is increasing from time to time. Health institutions should have strong strategies of screening, counselling, follow-up and referral linkage of mothers in the antenatal clinic and maternity wards by availing necessary materials and designing strong supportive supervision/ mentorship programs.
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.
Malaria Elimination in Ethiopia: Relevance of advanced Molecular/Diagnostic Tools in Epidemiological Studies
(Addis Abeba University, 2019-11) Bahita, Ashenafi Assefa(Phd); Ahmed, Ahmed Ali; Dr. Deressa, Wakgari
Background: Malaria is still among the major diseases of public health importance in Ethiopia. Ethiopia presents a diversified ecological situation, resulting in a highly variable eco-epidemiology of malaria. Following the scale-up of antimalarial interventions in the past two decades, malaria burden has significantly declined leading to the National Malaria Control Program (NMCP) in Ethiopia to reembark on a strategy for step by step nationwide malaria elimination. Learning from the failed malaria elimination endeavors of the 1960s, achieving such an ambitious target, given the complicated eco-epidemiology of malaria in Ethiopia may require several inputs and evidences. Measures of malaria burden and transmission dynamics using conventional diagnostic methods [microscopy and Rapid Diagnostic tests (RDTs)] may be incomplete, particularly, in low and seasonal transmission settings, where few infections are detected. Unlike most parts of Africa, P. falciparum and P. vivax co-exist in Ethiopia. Malaria elimination requires determining the actual burden, distribution as well as detection and cleaning of all forms of malaria infection. The knowledge gap in the occurrence, prevalence and distribution of Glucose-6-Phosphate Dehydrogenase (G6PD) deficiency has been a limiting factor for radical cure of relapsing malaria and transmission interruption. The group of drugs within 8-aminoquinolines, such as Primaquine and Tafenaquine, are the only available treatment of relapsing malaria. Eight-aminoquinolines can induce severe hemolysis in G6PD deficient individuals. The study used advanced tools to investigate the epidemiological risk factors relevant for malaria elimination. Objective: This study used serology and molecular methods to describe the malaria (Plasmodium spp) burden and distribution, as well as to determine G6PD deficiency prevalence and allelic types, in order to produce reliable evidence for malaria elimination in Ethiopia. Methodology: Dried blood spot (DBS) samples collected in 2011 and 2015 as part of the national household Malaria Indicator Surveys (MIS) were used. The Ethiopian Malaria Indicator Surveys (EMISs) utilized a multi-stage cross sectional surveys representating the various malaria epidemiological settings in Ethiopia. EMIS-2015 samples were investigated using bead-based multiplex assays for IgG antibodies for six Plasmodium spp antigens: four human malaria species-specific merozoite surface protein 1 19kD antigens (MSP-1) and apical membrane antigen 1 (AMA-1) for P. falciparum and P. vivax. Seroprevalence was estimated by age group, elevation, and administrative regions. Seroconversion rates were estimated using a reversible catalytic model fitted with maximum likelihood method. Sub samples of EMIS-2015 from three administrative regions (Amhara, Tigray and Benishangul Gumuz regions) were screened by Microscopy, RDTs and nested Polymerase Chain Reaction (nPCR) for malaria parasites and results were compared to determine prevalence of subpatent infections. A randomly selected subset of samples from EMIS2011 were genotyped by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) technique and three common G6PD genotype variants: G6PD*A (A376G), G6PD*A- (G202A) and Mediterranean (C563T) were investigated. Data were analysed using Stata 13 (College Station, USA). Serology data were generated from a multiplex instrument as Mean Floruescent Intensity minus background (MFI-bg). To dichotomize seropositivity, log-transformed MFI-bg values were fitted to a two-component Finite Mixture Model (FMM) by the FMM procedure with normal distribution and maximum likelihood estimation outputs. A seropositivity cutoff value was determined by the mean MFI-bg value of the first (assumed seronegative) component plus three standard deviations. Plasmodium falciparum and P. vivax seropositivity were defined as being positive for either or both MSP-1 and AMA-1 antigens. Species specific MSP-1 antigens were used for P. malariae and P. ovale seropositivity. EMISs sampling weights were used to ensure the representativeness of the samples tested to the study population. Adjustments were made by region, elevation, and age group. Linear and multiple logistic regression models with 95% confidence intervals (CI) were employed to determine the association of risk factors with Plasmodium spp infection. Differences in distributions were evaluated using Chi square (χ2) test with P value < 0.05 considered significant. Spatial analysis and geographical mapping were done using QGIS and ArcGIS softwares. Main Findings: National seroprevalence for antibodies to P. falciparum was 32.1% (95% CI: 29.8-34.4) and 25.0% (95% CI: 22.7-27.3) for P. vivax. Estimated seroprevalence for P. malariae and P. ovale were 8.6% (95% CI: 7.6-9.7) and 3.1% (95% CI: 2.5-3.8), respectively. Seroprevalence estimates were significantly higher at lower elevations (<2000 m) compared to higher elevations (2000-2500 m), for P. falciparum [Adjusted Odds Ratio (aOR) 4.4 (95% CI: 2.7 -7.0), p<0.01].], although evidence was weak for P. vivax [aOR 1.5 (95% CI: 0.9-2.3), p>0.05]]. Among administrative regions, P. falciparum seroprevalence ranged from 11.0% (95% CI: 8.8-13.7) in the Somali to 65.0% (95% CI: 58.0-71.4) in Gambela Region. Seroprevalence for P. vivax ranged from 4.0% (95% CI: 2.66.2) in the Somali to 36.7% (95% CI: 30.0-44.1) in Amhara Region. Models fitted to measure seroconversion rates showed variation nationally and by elevation, region, antigen type and within species. Malaria DNA screening using nPCR from three regions (Amhara, Tigray and Benishangul Gumuz) detected 3.3% (95% CI: 2.7-4.1) positive cases. P. falciparum accounted for 3.1% (95% CI: .53.8), P. vivax 0.4% (95% CI: 0.2-0.7), mixed (P. falciparum and P. vivax) 0.1% (95% CI: 0.0-0.4), mixed (P. falciparum and P. malariae) 0.1% (95% CI: 0.0-0.3). nPCR detected nearly three-fold more positives compared to microscopy. Sixty one percent of the nPCR positive cases were from Benishangul Gumuz Region. The G6PD genotyping study showed the more severe G6PD deficiency allelic types, G202A (A-) and C563T (Mediterranean), to be absent in the current study. A national prevalence of 8.1% G6PD*A (A376G) mutation variants was observed with regional variation, with highest prevalence observed in Tigray Region (13.7%) to none in Harari. Of the G6PD*A (A376G), 31% were hemizygous males and 62.1% and 6.8% were heterozygous and homozygous females, respectively. Conclusion and Recommendations: The current study used multiplex serology and serological markers to report the malaria exposure burden and transmission intensity of the four human malaria species. The study documented heterogeneity in malaria burden and transmission over different elevations, administrative regions, and age groups. Malaria exposure was by far higher compared to the active infection reported by microscopy and RDTs. P. falciparum sero prevalence increases with decreasing elevation, whereas P. vivax slightly increases with elevation in the study setting up to 2,500 m; showing P. vivax is more prevalent in highlands compared to P. falciparum. Variation was observed on the spatial distribution and dynamics of transmission over the regions. The northwestern part of the country is carrying the largest burden of malaria compared to the east. Among the regions, Gambela and Benishangul-Gumuz had the highest burden of malaria transmission. The current study documented the presence of P. malariae and P. ovale in all administrative regions. Given that P. ovale possesses a hypnozoite stage, its control and elimination requires programmatic attention. The seroprevalence results may be used as baseline data for the future malaria elimination efforts and may help the NMPCP in tailoring intervention approaches. The current study documented a considerable proportion of subpatent Plasmodium spp infections undetected by microscopy. Such subpatent infections are potentially infective to mosquitoes, contributing for malaria transmission in addition to their debilitating chronic effect on the individuals affected. Efficient malaria elimination efforts have to address the impact of subpatent infection on transmission and health. In this study, the more severe variants G6PD *A- (G202A) and Mediterranean (C563T) mutations were not observed. The G6PD *A (A376G) mutation observed is a mild variant resulting in close to normal (85%) enzyme activity of a non-deficient person, without significant clinical manifestations of G6PD deficiency related hemolysis. This study investigated three of the most important and potentially expected mutation types in the study area among the hundreds of known G6PD variants worldwide. Although the study cannot definitively conclude the absence of any clinically important G6PD deficiency, it suggests a low risk of hemolysis, and confirms the utility of the recently adopted Primaquine treatment without prior G6PD testing. The risks and benefits of Primaquine radical cure without G6PD testing may need to be further assessed in Ethiopia as the P. vivax and P. ovale case management is evolving and may incorporate higher dose and shorter course regimens of Primaquine and Tafenoquine. In summary, the current work used advanced serological and molecular diagnostic tools to produce evidence to the epidemiological factors that may be relevant for malaria elimination. It also emphasized the need for assessing and introducing advanced diagnostic techniques, such as PCR and multiplex serology to provide releable evidences required towards malaria elimination in Ethiopia.

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