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Item Role of Rural to Urban Migrants and Socio-Cultural Factors including Fertility intentions in the Spread of HIV Risk among Rural areas of Bure Woreda,Northwest,Ethiopia.(Addis Ababa University, 2012-03) Semegne, Melesse Tamiru(PhD); Prof.Hailemariam, Damen; Dr.Mitikie, GetnetBackground: The AIDS epidemic is global in its span; a particularly heavy burden has fallen on Sub-Saharan Africa. The consequences of the African AIDS epidemic are growing—not only just in size—but in complexity. These consequences are no longer just biological; increasingly, they are also behavioural, social and cultural. It is well-known that 84% of the population in Ethiopia lives in rural areas relying on the agricultural sector which plays the central role in the country’s economy. However efforts to conduct HIV related studies in rural areas of the country remain extremely patchy. So far, there have been few studies concerning the nature of HIV infection in rural areas resulting in meagre information on how HIV spreads from urban to the rural areas and how local people perceive the epidemic and protect themselves from risk factors. The rural people in Bure Woreda are not an exception. The negative influences of migration, fertility intentions and other socio-cultural factors in the spread of HIV in the Amhara region in general and in the present study area in particular are not known, moreover, overlooked social activities such as leisure activities which may be linked to HIV risk behaviours among the study population of the rural to urban migrants and non-migrants in Bure Woreda, North West Ethiopia require due attention and a thorough investigation. The way in which migration contributes to the spread of HIV risk is complex and not well understood. Previous studies have focused on the destinations of migrants, or, less often, on the areas from which migrants come. In this study exploring both ends of migration routes in atypical rural areas is fundamental for successful interventions Although subsistence agriculture is the major economic activity in Ethiopia; parents want to have large numbers of children for assistance in farming activities as well as economic support during old age. In the rural areas, women’s fertility and HIV infection are not independent of one another. Conditions and behaviours resulting in high levels of fertility are also likely to impact upon womens' likelihood of acquiring HIV. Women and men desire children for their utilitarian–economic, social, and psychological values, whereas fertility is on the decline primarily due to changes in economic development. Different segments of the population are at different stages of this transition with different values attributed to children at each stage. The challenge is will women take measures to prevent HIV infection in themselves and their babies if they perceive themselves at high risk of HIV infection, or will endeavour to fulfill the utilitarian–economic, social, or psychological dictates of childbearing. Objectives: The general objective of this study was to assess and explore the role of rural to urban migrants (potential bridging population) and socio-cultural factors (including high fertility intentions) in the transmission and spread of HIV risk to the rural community of Bure Woreda. Methods: In order to address this general objective, the study assessed factors that affect the sexual behaviours of rural to urban migrants and non-migrants (rural residents) by comparing the link between predisposing, and enabling factors with the sexual risk behaviours among rural to urban migrants and non-migrants and by investigating the leisure activities which are associated with different levels of likelihood to engage in HIV risk behaviours among rural to urban migrants and non-migrants. Moreover other sexual and cultural practices of the rural people in relation to HIV risks including the association of fertility intention (the desire to have children) with HIV risk were investigated. In this study, HIV-related sexual risk behaviours among rural to urban migrants and non-migrants is compared and the role of migration in HIV transmission and socio-cultural practice and norms for the spread of the virus in the rural areas of Bure Woreda is explored. The detailed methodology included two components: The first one was a quantitative cross-sectional study which involved 1,310 men (655 men rural to urban migrants, 655 non- migrants) and 1,380 married women aged 18 to 49 years. The second component was a qualitative study which consisted of 8 focus group discussions and 25 key informant interviews. I) Quantitative study: Radom sampling technique was applied to select the required study units from the rural- urban migrants (road construction sites (Cobble stone), Ethiopian Commodity Exchange (ECX), commercial agricultural farm employees and rural residents from the rural kebeles of Bure Woreda. A total of 2,751 participants, 667 rural men and 1,418 rural married women were drawn from the 23 rural kebeles of Bure Woreda while the remaining 666 rural to urban migrants were taken from Bure and around Bure town. Because the present study had a number of different outcome variables so it was necessary to calculate the respective sample sizes separately with different assumptions. Structured questionnaires were used to collect the quantitative data. The questionnaires were tested prior to collecting the actual data in order to standardize the flow and content of the questions. Accordingly, amendments were made depending on the results of the pre-test that was conducted in the nearby similar areas. Data collection was carried out by twenty diploma holders who were given three-days of intensive training with practical exercises. Four health officers/sanitarians were assigned to supervise the data collection process and the data was analyzed using SPSS version 17 statistical software. The, chi-square test and binary logistic regression were used to see the association of variables. II) Qualitative study: This part of the study was aimed at substantiating and complementing the quantitative study. The selection of participants and formation for focus group discussions (FGD) were facilitated by the community leaders of the respective kebeles under consideration. Four rural kebeles were identified for the 8 FGDs and 25 in-depth interviews. The main data analysis took place on completion of each interview. In this regard, the usual principles guiding qualitative analysis were taken into account and sequences of interrelated steps (reading, coding, displaying, data reduction and interpreting) were employed while analyzing the data. In short, as can be noted from the above explanations, the procedure used to process the raw data for the purposes of classification, summarization and tabulation was thematic content analysis. The basic idea here was to identify the extracts of data that were informative in some way and to sort out the important messages hidden in the mass of each key informant interview and FGD. Results: A total of 2,690 participants (response rate, 97.7 %) responded to the questionnaire on HIV risk behaviours, leisure activities and fertility intention. This study consisted of two groups 655 male rural to urban migrants working in Bure town and rural residents (655 male nonmigrants and 1,380 married women). When the two groups (rural to urban migrants and non-migrants) are compared in terms of practicing sexual risk behaviours i.e. having of multiple sexual partners, practicing sex with commercial sex workers, contracting sexual transmitted infections and practicing premarital sex there is a difference between them. The proportions of rural to urban migrants vs non- migrants who had multiple sexual partners (31.4 % vs 7.4 %), practiced sex with commercial sex workers (22.3% vs 13.3%), contracted sexual transmitted infections (11.7% vs 3.2%) and practiced premarital sex (20.8% vs 14.2 %) were significantly higher in rural to urban migrants than nonmigrants. Among those who had multiple sexual partners, only 12.7 % of rural to urban migrants and 9.8 % of non-migrants reported consistent condom use with sexual partners other than their spouse. In addition, the findings of the study indicated that both migrants and non-migrants were engaged in different leisure activities when they did not have work. The first three leisure activities with the highest rates of participation among migrants were visiting entertainment installments (76.3%), chatting (64.9%), and listening to radio (31.5%). On the other hand, doing chores (71.6%), visiting entertainment installments (30.7%) and chatting (29.2%) were among the activities in which non- migrants were participating most often. The differences noted between the two groups in terms of the types of leisure activities were statistically significant (P=0.001). Multiple logistic regression analysis was also done to explore the association between the eleven leisure activities and each of the five HIV risk behaviours among migrants and nonmigrants. Among migrants, watching TV, reading (including non migrants), chatting, watching videos, wandering on streets (including non-migrants), and visiting entertainment facilities were positively associated with most of the five HIV risk behaviours. Listening to radio for migrants and chatting and doing chores in non migrants were negatively associated with some of the HIV risk behaviours. The association of rural married women to HIV perceived risk, child mortality and desire to have children and the link to HIV risk was assessed. Overall, 32.8 % of subjects expressed desire for future pregnancy, 8.8 % perceived themselves at high risk for HIV infection and 26.7% reported the death of at least one child in the past five years. In multiple logistic regression analysis, reporting at least one child's death (OR=6.92; 95% CI=4.91 to 9.47) was significantly associated with a higher desire higher to become pregnant. Furthermore perceived high risk for HIV infection (OR=2.08; 95% CI= 1.35 to 3.19) was found to be associated with the desire to get pregnant. Being currently married, having no education, being of low parity and having low household expenditure were significantly associated with having the desire for more children. The qualitative part of this study identified a number of social factors and cultural norms and practices that impact on HIV/AIDS. The first category consists of factors that were said to promote the spread of HIV/AIDS such as alcohol drinking and drunkenness. To that effect, all social and cultural functions that involve large gatherings such as holidays and wedding ceremonies, alcohol drinking and dancing were seen to greatly contribute to the spread of HIV/AIDS. The second category is of factors influencing the reduction in the risk of HIV transmission such as promotion of virginity and arranged marriages. Interestingly, some of the main social factors, cultural norms and practices that increase the risk of HIV transmission were seen to also play significant roles in risk reduction; church gatherings, weddings, and burials were singled out as major avenues for promoting positive sexual behaviours while some people use them to engage in risky behaviours. HIV/AIDS and the social and cultural set-up of communities have impacted upon each other. In the context of HIV/AIDS, social and cultural practices play dual roles, on one side enhancing HIV transmission while on the other facilitating reduction in incidence. However, social factors, cultural norms and practices were seen more as facilitators than inhibitors of HIV transmission, while low awareness about HIV/AIDS and lack of supportive services such as VCT and knowledge of condoms remain major limitations to sustain behaviour change. Accessibility to these services is also limited to the majority in the rural areas Conclusions: As both rural to urban migrants and non-migrants are at risk for HIV infection, intervention program targeting both groups are recommended. However, in order to contain the bridging effect on HIV transmission from urban to rural areas particular attention should be given for the rural to urban migrant population. Effective HIV prevention programming must reach and serve populations at risk. This study shows that male migrants are at high risk of HIV due to risky sexual partnerships and low condom use. Additionally, their high mobility and multiple partnerships potentially contribute to the spread of HIV to the rural areas. Sero-prevalence data should be collected to complement behavioural data and enable tailored programming to reach this vulnerable group. Employers should be engaged in HIV prevention for this population. Socially desirable and constructive leisure activities such as listening to the radios among migrants and doing chores and chatting among non-migrants may prevent them from being engaged in HIV risk behaviours while leisure activities such as visiting entertainment installments and watching videos may increase the odds for migrants to be engaged in HIV risk behaviours. However the evidence in this study strongly suggest that migrants who are detached from family and home environment may be exposed to leisure activities possibly associated with HIV risk behaviours. Therefore, given the high mobility of migrants, it is very important to strengthen work place intervention in their destination places High perceived risk of HIV infection was associated with high desire for future pregnancy. Moreover women seem to have a higher desire for a future pregnancy to replacing a dead child that may have lost its life as a result of HIV infection. This finding indicated the crucial role of desire for fertility by a married woman irrespective of the risk for acquiring HIV infection. This implies that there should be further research to address the issue and the utilitarian-economic, social, and psychological values attributed to children by both women and their male sex partners. The involvement of men as partners in childbearing should be explored, as their desire for children may be the primary barrier to protective behavioural change among women. In order to change rural Ethiopian parents’ perception of values of children, child education needs to be compulsory so the cost of raising children will increase and inhibit a further high desire for pregnancy. In the area the prevailing cultural practices and norms encourage large families and discourage the use of condoms. In such settings, there is the need to find appropriate mechanisms that could help increase the use of all types of contraceptives. As contraceptive use increases, it is likely that the use of condoms for AIDS prevention and also for family planning purpose would increase.. According to the qualitative findings some striking characters were noted - these are the mobility of commercial sex workers from large town to small towns such as Bure or adjust rural villages in order to attract a wider or different client base, for adventure and to conceal illnesses which might be associated with HIV/AIDS, drinking alcohol while on ART drugs to pretend as HIV free and involve in sexual activity, desired to be considered as a HIV positive in order to get the support given to PLHI, underline the needs for further investigation due to their possible contribution for sustaining the HIV epidemic. Although there are some prevention activities to fight HIV/AIDS in the rural areas, most of them were inappropriate in terms of convenience in time, place and target groups. For instance, HIV educations are given only in weekends, holidays and around the church areas where most of the young people are not available. The finding has programmatic implications as it misses the young who are vulnerable to HIV infections. The needs and priorities in prevention of HIV/AIDS are two fold: to enable community members to be fully informed about the disease and reduce potentially risky behaviour; and to secure viable rural livelihoods which would reduce the need for people to move into potentially HIV-risky environments.Item Brief Psychological Intervention for Bipolar Disorder in Integrated Care Settings in Rural Ethiopia(Addis Ababa University, 2021-10) Demissie, Mekdes; Fekadu, AbebawBipolar 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 interventionsItem Barriers to Access to Modern Contraception(Addis Ababa University, 1998-02) Tekalegne, Agonafer; Bergevin, Yves (PhD)Item 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.Item Role of faith and traditional healing practices in the care of Severe Mental Disorders and impact on patient level outcomes(Addis Ababa University, 2013-06) Belachew, Ayele(PhD); Dr.Fekadu, Abebaw; Dr.Molla, Mitike; Prof.Hailemariam, DamenIntroduction:Mental disorders are common and are associated with severe disability, cost andmortality. The burden of mental disorders in low income countries like Ethiopia is compoundedby thehuge treatment gap, which is over 90% for Severe Mental Disorders (SMD) such as schizophrenia,bipolar disorder and major depressive disorder. The current strategy of the Federal Ministry of Health to narrow the treatment gap focuses onintegration of mental health care into primary care. This agenda of integration has been advocated bythe World Health Organization(WHO), and relies on training primary care staff to provideevidence-based interventions for selected (priority) disorders. However, neither the WHO nor the Ministry ofHealth provided explicit suggestions on how the integration would occur. Although Faith andTraditional Healers (FTHs) are key for the success of such integration, there is no direction on howthey may be engaged or support care provision. Understanding treatment practices, attitudes, cultural factors and explanatory models that influencecommunity utilization of FTHs and the link of these factors with utilization ofbio-medical servicesmay allow development of strategies to support collaboration between the FTHsand the biomedicalsector. It may also improve access to timelybio-medicalcare. Thisproposed study will explore the roleof FTHs in thecare of patients with SMDand the impact on bio-medical service utilization and patientlevel outcomes. Thestudyhypothesizes that most patients with SMDs will use FTHs before accessingbiomedicalcare andthese patientsare likely to have longer duration of untreated psychosis resulting inpoorer clinical, social and economic outcomes. Objectives: the mainobjectiveof the study is to explore the pattern and determinants of the use ofFTHs practices for the care of SMDs, andimpacton patient level outcomes. Methods: four complementary studies will be conducted using a mixedquantitative and qualitativeresearchdesign.o Study Iwill havetwocomponents o The first component will be a cross-sectional communitybased study on 1,500 randomlyselected sample ofcommunity members in Sodo district todetermine community attitudetowards FTHs and describe the prevalence and pattern of use of FTHs by the community. o The second part of the initial cross-sectional survey will describe the profile of FTHs, theirEMs about SMDsas well as define types of use of available service (predominant use) o Study IIwill havetwocomponentso The first component will be toexplore the prevalence, pattern and determinants of use of FTHs among community(Key informant) identifiedpersons with SMD, completed usingall available information(Butajira Case Detection MethodBCDM); o The second component to determine baseline clinical, social and economic profiles in thethree groups ofpatients with SMDbasedontheir level of service utilization: predominantlyFTH users, Predominantly Boimedical service users and those who use both sercvices o study IIIwill be a follow up of participants in study II to examine short-term (six months) patientlevel outcomes (clinical, social and economic) and pathways in care in relation to baseline FTH use pattern; ando study IVwill examine, on purposivelyselected sample of FTHs and BMPs,behavioraldeterminantof collaboration between FTHs and BMPs (beliefs, attitudes, subjective norms and perceivedbehavioral control as well as intention towards collaboration) and the changes in thesedeterminants. Assessments:A set of assessment tools will be used to establish diagnosis, symptomatic and functionalstate as well as costs. Qualitative assessment will consist of face-to-face interview using semistructured questionnaire, Focus Group Discussions, In-depth interviewand observations using guidesand checklists. Quantitative datawill be entered in epiData version 3 and analyzed using SPSS version17 and STATA 8.Thematic content analysis will be used for qualitative data. Ethical consideration: Ethical approval will be sought from the Scientific Committee of theDepartment of Psychiatry and theInstitutional Review Board of the College of Health Sciences, AddisAbaba University. Official permission will be secured from the Sodo district health office andhealthinstitutions.Every selected respondent will be briefed about the purpose of the study and informedwritten consentwill be soughtfromeach participant. All papers, computers, external hard drives, andUSB memory sticks containing data will be password protected and kept in secure (locked) locations toensure confidentiality of information. Expected outcome:The results of the study would provide more objective determination of the impactof FTHs utilization on patient level outcomes.The findings would allow development of possiblemodels of broader collaboration and interventions to improve access to quality mental healthcare andhence improve the mental health status of people with SMDs. Budget:Part of the cost for the study will be covered by aPRIME fellowship to the candidate. But thestudy will be nested within the larger PRIME (‘PRogramme for Improving Mental health carE) project. Research plan:The research proposal will be submitted inMarch2013 for ethical approval and datacollection is expected to begin in May2013.The whole research work will be finalized in early 2015.Item Occupational Exposure to Inhalable Cotton Dust, Endotoxin and Health Problems Associated with Workers of Ethiopian Integrated Textile Industry(Addis Abeba University, 2021-07) Zele, Yifokire Tefera (Phd); Dr. Kumie, Abera (PhD); Prof.Moen, Bente E. (PhD); Prof.Bratveit, Magne(PhD)Background: Exposure to workplace hazards is a significant risk to workers' health in the textile and garment. Objective measurement of personal inhalable dust and endotoxin level and the effects of exposure to workers' health in this sector was not adequately investigated in Ethiopia. Objectives: This study aimed to measure personal inhalable cotton dust and endotoxin concentration, examine lung function capacity, and analyze registered diseases and injuries of workers in the integrated textile factories of Ethiopia. Methods and materials: Three independent studies were conducted to achieve the stated objectives. Personal inhalable cotton dust and endotoxin level, cross-shift lung function status with chronic respiratory symptoms and registered diseases and injuries are outcomes of the three studies. The overall study objectives were crafted within the framework of the three levels of occupational exposure: external exposure consider (inhalable dust and endotoxin), internal exposure (cross-shift lung function) and effect (diseases and injuries). An institution-based crosssectional and comparative cross-sectional design was employed. The study settings were at three industrial zones in two regions of the country: Amhara Regional State and Tigray Regional State. The study involved three integrated textile factories (Factory 1, Factory 2 and Factory 3) and two soft drinks and water bottling factories as comparison groups. In the first study, ninety-six (96) repeated air samples were collected from sixty-four (64) workers’ breathing zone to analyze the personal inhalable cotton dust and endotoxin exposure levels. The samples were collected from seven work sections or seven similar exposure groups (SEG) from an integrated textile at Factory 1. The seven work sections are Carding, Open-end, Ring frame, Preparatory, Fabric making, Batching and Sewing found in the four production departments (spinning, waving, finishing and garment). Dust samplings were performed for a shift using a conductive plastic inhalable conical sampler mounted with a 37mm glass-fibre filter. The pump operated at a flow rate of 3.5 l. min -1 . The Time Weighted Average cotton dust level was determined by gravimetrical analysis and reported in mg.m -3 . Endotoxin was extracted from the cotton dust samples and analyzed using a quantitative kinetic chromogenic Limulus Amebocytes Lysate test and reported as EU. m In the second study, cross-shift lung function tests and chronic respiratory symptoms assessment were performed among 306 workers from an integrated textile Factory 1 and 156 non-cotton exposed workers. The lung function test was conducted before and after the work shift using a portable spirometer (SPIRARE 3 sensor model SPS 320) for the parameters: Forced Expiratory Volume in one second (FEV 1 ) and Forced Vital Capacity (FVC). Moreover, the prevalence of chronic respiratory symptoms was assessed through a face-to-face interview using a standardized questionnaire adopted from the American Thoracic Society. In the third study, a one-year registration of diseases and injuries of 7,992 workers were collected from the three integrated textile factories (Factory 1, Factory 2 and Factory 3). Data were retrieved from both the registration of factory clinics and human resources. Each worker has a chart/card in the clinic, labelled with the name and unique worker's identification number, similar to the one used in the human resource department database. All clinical consultations of workers during March 2016 to February 2017 were extracted from the health archives of the factory’s clinic. Exposure measurement, lung function and registered diseases data were entered into a Micro Soft Office excel template, whereas the data of the respiratory symptoms were entered using epidemiological information package (Epi-Info) version 7.1. All types of data were exported to SPSS for analysis. Missing values, incomplete recording, outliers and inconsistent records were checked and managed accordingly. The exposure assessment was described by the arithmetic mean, standard deviation, geometric mean (GM), and geometric standard deviation (GSD). The cross-shift change in FEV 1 (∆FEV 1 ) and FVC (∆FVC) was calculated by subtracting the after-shift value from the before-shift value. The Global Lung Initiative Quanjer GLI-2012 multi-ethnic reference value for the African American ethnicity was used to estimate the predicted value and the proportion of subjects with FEV 1 and FVC below the Lower Limit Normal (LLN). Prevalence, percentage and proportion were used to describe the respiratory symptoms and the registered disease conditions as categorical variables. The independent t-test was performed to analyze exposure differences between work sections and to compare the cross-shift difference FEV 1 and FVC among the textile and non-cotton exposed workers. A paired-samples t-test was performed to compare the pre- and post-shift difference of lung function parameters. The correlation between inhalable dust and endotoxin concentrations was analyzed using Pearson's correlation test. Analysis of Variance (ANOVA) was also performed to compare the GM of personal inhalable dust, endotoxin exposure level, and endotoxin ratio to dust between departments and work sections. The Pearson Chi-square test or Fisher's exact test, if the expected value was less than 5, was used to testing the difference between the groups regarding the categorical variables. Logistic regression analysis was used two times in the study by adjusting confounding variables: 1) to compare the chronic respiratory symptoms between the integrated textile workers and control and 2) to identify work and personal factors associated with the registered work-related diseases and injuries. Furthermore, the amount of reduced cross-shift lung function capacity among the integrated textile workers was estimated using multiple linear regressions. Results: In the external exposure measurement, the overall Geometric Mean (Geometric Standard Deviation) of cotton dust and endotoxin level was 0.75 mg·m −3 (2.6) and 831 EU· m (5.4), respectively. The highest dust and endotoxin concentrations were observed in the carding section found in spinning department (1.34 mg· m −3 ) and (6,381 EU· m −3 ), respectively; while the lowest cotton dust (0.46 mg· m −3 ) and endotoxin levels (76 EU· m −3 ) were found in the garment department. There was a moderate linear relationship between personal inhalable dust and endotoxin exposure (r = 0.45, p < 0.001). In the internal exposure assessment, the cross-shift lung function reduction among textile workers (123 mL for FEV 1 and 129 mL for FVC) was significantly higher than the control group (14 mL for FEV 1 and 12 mL for FVC) at p < 0.001. The prevalence of chronic respiratory symptoms was significantly higher among textile workers (54 %) than the controls (28 %). Breathlessness was the most prevalent chronic respiratory symptom with the highest adjusted odds ratio of 9.4 (95 %; CI: 4.4–20.3). The prevalence of respiratory diseases was highest (34 %), followed by musculoskeletal disorders (29 %), gastrointestinal infection (21 %), peptic ulcer (19 %) and injury (17 %); the injury was the leading cause of sick leave. About 69 %, 65 % and 60 % of textile, garment and support workers, respectively, were diagnosed with a disease in one year. In the effect measurement, 27,320 consultations for different disease diagnoses were made by 5,276 (66 %) workers; claimed 16,993 workdays lost due to sick leave annually. Work-related and personal factors were associated with diseases and injuries; textile department, females, older and workers with low educational status had a significantly higher risk for most diseases than the support, male, young and workers with higher educational level. Conclusions: We found a high level of personal inhalable dust and endotoxin in external exposure from workplaces. Eleven percent of the dust samples were higher than the Workplace Exposure Limit set by the Health and Safety Executives (HSE) of the United Kingdom and 89 % higher than the Dutch experts' recommendation for endotoxin exposure. A lower level of inhalable dust exposure does not guarantee safe exposure to endotoxin in work sections. The textile workers had a higher level of cross-shift lung function reduction in the internal exposure, which could be related to external exposure. The prevalence of chronic respiratory symptoms was also higher among textile factory workers compared to control. Majorities of the workers were diagnosed with different types of diseases and injuries as an effect. The textile and garment production workers had a higher risk of acquiring diseases than the support process workers, indicating that some diseases might have resulted from the external exposure and development of internal exposure at the workplace. Thus, factory clinics seem to be an essential source of evidence to understand the burden of occupational diseases and injuries. Further, the study showed the link between exposure and effect. Recommendations: A comprehensive workplace hazard exposure assessment and worker's health protection program in the integrated textile factories should be strengthened. The occupational health and safety programs should be prioritized and focused on addressing the specific gaps and needs of high-risk workers. Besides, factory management, occupational health and safety practitioners, policy and regulatory bodies should be part of the program. Further research is required to assess exposure measurement to other hazards, including cotton dust and endotoxin, by tracking workers' exposure profiles to estimate cumulative exposure and relationship to disease outcome. The occupational diseases and injuries study may be extended to compare the results with the general population using a standard and similar diagnosis tool, the International Classification of Diseases (ICD) code. .Item Vitamin A Deficiency in Ethiopia:Magnitude, Distribution and Potential Risk Factors(Addis Abeba University, 2010-02) Demissie(Phd) Tsegaye; Prof.Ali, AhmedBackground Based on the high vitamin A deficiency rates indicated in the reports of several pocket level surveys, it can be concluded that vitamin A deficiency is a major public health problem exacerbating child morbidity, mortality and disability in Ethiopia. In order to effectively address the problem, upto-date and comprehensive information is imperative. Objective of the thesis The aim of the research is to provide up-to-date and disaggregated information on the magnitude and determinants of vitamin A deficiency in Ethiopia that are deemed important in the prevention and control efforts. Methods The national survey, the major component of the research, employed cross-sectional study design and multi-stage cluster-sampling approach. A total of 23,148 children were examined for the clinical signs and symptoms of vitamin A deficiency. Blood was collected from 1200 children for serum retinol analysis and a questionnaire addressing most of the potential determinants of vitamin A deficiency was administered to 2552 households. Assessment of risk factors to vitamin A deficiency among primary school children employed a case-control study design and included 97 clinical cases and 194 controls. In addition, analysis of beta carotene contents of fifteen food items, five each from common vegetables, common fruits and common staple foods was done. Results The survey revealed high prevalence rates of vitamin A deficiency across the country. The national bitot’s spot prevalence rate was 1.7% with the highest rates in the Amhara Region (3.2%), followed by the prevalence rates in Afar (2.1%), Oromiya (1.5%), Addis Ababa (1.4%), Harari (1.2%) and Dire Dawa (1.1%). The national maternal night blindness prevalence rate was 1.8% with the high prevalence rates in Tigray (14.1%), Benishangul-Gumuz (5.7%), Afar (1.2%) and Amhara (1.0%). The national weighted prevalence rate of subclinical vitamin A deficiency (<0.7µmole/lt) was 37.7% (95% CI; 35.6%-39.9%), with high prevalence rates in Afar (57.3%) and Oromiya regions (56.0%), moderate prevalence rates in Dire Dawa (48.0%), Amhara (40.7%) and Harari (35.3%) regions and relatively low prevalence rates in Tigray (14.3%) and SNNP (11.3%) regions. Among the under-six children, male children and older children were affected more by clinical vitamin A deficiency than female children and young children (p<0.05). The prevalence of clinical vitamin A deficiency was significantly higher among children from predominantly rural areas compared to that of children from predominantly urban areas (p<0.05). Being from Muslim households (OR = 2.23), belonging to mothers who could not mention at least one fact about vitamin A (OR = 1.80), not receiving vitamin A supplement at least once in the previous year (OR = 1.45), belonging to mothers who have given birth to three or more children (OR=1.46) and being sick in the two weeks preceding the survey (OR=1.42) were found to have been associated with high levels of subclinical vitamin A deficiency among preschool age children. Similarly, being from Muslim households (OR = 7.03), not consuming vegetables three or more times a week (OR=3.04) and being sick in the two weeks preceding the survey (OR=2.04) were associated with high levels of clinical vitamin A deficiency among primary school children. In aggregate, 41.5% of the studied households did not produce/cultivate any of the common vegetables over the year preceding the survey and the proportion was high in Addis Ababa (99.7%), Afar (94.9%), Dire Dawa (94.2%), Tigray (86.4%) and Harari (63.1%) regions. Similarly, 75.5% of studied households did not cultivate/produce any of the common fruits over the year preceding the survey and the proportion was high in Addis Ababa (100%), Dire Dawa (95.3%), Afar (92.9%), Tigray (92.2%), Harari (83.3%) and Oromiya (81.8%) regions. Overall, 38.1% of the children studied did not eat any of the common vegetables over the week preceding the survey and the proportion was high in Afar (85.0%), Tigray (77.6%), Amhara (61.8%) and Addis Ababa (59.3%). Similarly, 36.5% did not eat any of the common fruits over the week preceding the survey, with the highest proportions in Tigray (88.1%) and Afar (83.5%) regions. Over 66% of the children included in the study did not eat meat, close to 53% of the children did not eat eggs and 33.4% of the households included in the study did not use oil over the week preceding the survey. The situation regarding own production of fruits and vegetables was significantly better (p<0.05) in predominantly rural areas whereas market availability and consumption of fruits, meat, egg and oil was significantly better (p<0.05) in predominantly urban areas. High beta carotene content in kale ( 6100.45 µg/100gm) and carrot (5800.09 µg/100gm), moderate amounts in spinach ( 800.12 µg/100gm), mango (500.54 µg/100gm) and papaw (800.86 µg/100gm) and no or negligible amounts in injera, bread and kocho were observed. Conclusions and recommendations Conclusions The study revealed that, albeit the longstanding effort to control and eradicate vitamin A deficiency in Ethiopia, the problem is still prevailing unabated. Although the prevalence of vitamin A deficiency (clinical and subclinical) were higher than the WHO cut off points in all regions, the extent of the problem in Amhara, Afar and Oromiya regions appears to be more serious. Again, although vitamin A deficiency (clinical) was significantly higher in predominantly rural areas compared to predominantly urban areas, prevalence rates in Addis Ababa, Harari and Dire Dawa (predominantly urban areas) were found to constitute a public health concern. The study highlighted the increased risk of Muslim preschool and school children, male and older preschool age children to vitamin A deficiency compared to their respective counterparts. The negative impacts of morbidity, enormous benefits of vitamin A supplementation and the strong positive contributions of maternal awareness to vitamin A status of children were underlined in the study. Moreover, the strong association of vegetable consumption with vitamin A deficiency among primary school students was also underscored. The study, however, showed that the practice of planting/cultivating and consumption of common vegetables and fruits was suboptimal in Ethiopia. Recommendations Policy and strategy related recommendations • Agricultural policies and strategies that facilitate production of fruits, vegetables and livestock products must be developed and implemented. • School health and nutrition policy and strategy to enhance the awareness of the students regarding the importance of vitamin A must be developed. Intervention related recommendations • Continuation and intensification of the ongoing periodic vitamin A supplementation by ensuring universal coverage, its timeliness and safety is recommended. • Strengthening attempts aimed at enhancing the consumption of vegetables, fruits, oil and livestock products are recommended. • Strengthening efforts to improve women’s awareness regarding the importance of vitamin A is recommended. • Priority and attention must be given to Amhara, Afar, Oromiya and Harari regions and Addis Ababa and Dire Dawa city administrations. • Interventions aimed at improving maternal vitamin A nutrition, particularly, postpartum vitamin A supplementation is recommended. Surveillance related recommendations • Mechanisms to monitor vitamin A status must be established. • Conducting serial cross-sectional surveys at national, regional and sub-regional level periodically (e.g. in 5 years interval) using biological indicators is recommended Research related recommendations • The increased risk of Muslim preschool and primary school children to vitamin A deficiency merit an in depth and well designed investigation. • Similarly, the increased risk of male and older preschool age children to clinical vitamin A deficiency requires further in-depth assessments to expound the reasons. • Investigation on the reasons why Ethiopians do not adequately produce and consume vegetables and fruits is recommended.Item Patient and Diagnosis Delays and Survival among Women with Breast Cancer in Addis Ababa, Ethiopia: A Follow-up Study(Addis Abeba University, 2021-05) Abraha, Alem Gebremariam(PhD); Prof. Worku, Alemayehu (PhD); Dr.Addissie, Adamu (PhD); Dr.Assefa, Mathewos(MD, Oncologist); Dr. Jemal, Ahmedin(PhD)Background: Breast cancer is a leading cancer among women in Ethiopia. It accounts for onethird of all newly diagnosed female cancers. Most women with breast cancer in Ethiopia are diagnosed with late-stage disease, do not receive high-quality care, and face a poor prognosis. Locally relevant information on the extent of delayed diagnosis, reasons for late diagnosis, care, and determinants of survival among women with breast cancer is essential to guide clinical practices and public health policy. However, little is known about the extent and reasons for patient interval (from date of symptom recognition to the first consultation of health care providers), diagnosis interval (from consultation to diagnosis), and treatment initiation interval (from diagnosis to treatment initiation). Moreover, evidence on the relationship between patient delay (> 90 days)/diagnosis delay (> 30 days) and stage at diagnosis, and its effect on survival among women with breast cancer in Ethiopia is limited. Objectives: To determine the magnitude of delays (patient and diagnosis delay) as well as stage at diagnosis and its effects on the survival of women with breast cancer in Addis Ababa. Methods: The study employed mixed-methods (a cross-sectional study, a qualitative study, and a prospective cohort study). A cohort of 441 women newly diagnosed with breast cancer between 1 st of January 2017 to 30 th of June 2018 in Addis Ababa were recruited for the quantitative phase of the study, and followed prospectively for two years. Data were collected at different points in time, as a cross-sectional study (Paper I and III) and prospective cohort study design (Paper IV) to address the quantitative study objectives. During recruitment, data on the participants' socio-demographic characteristics, date of first symptom recognition, and medical consultation after recognizing symptoms were collected using a structured interviewer-administered questionnaire. The date of diagnosis was taken from the patient's pathology report. One year after the recruitment, medical data, such as stage at diagnosis, date of diagnosis, histologic tumor type, date of receipt of treatment, and type were captured using a data extraction tool from the study participants’ medical charts. Finally, at about two years following diagnosis, data related to survival status were obtained using both face-toface interviews and telephone interviews. Also, medical charts were reviewed to update the treatment status of the study participants. We have conducted a univariable descriptive analysis to describe each variable. Multivariable Poisson regression with a robust variance model was used to determine the factors associated with patient/diagnosis delay and stage at diagnosis. Also, Kaplan-Meier and multivariable Cox regressions were used to determine the overall survival rate and factors contributing to the overall survival of women with breast cancer, respectively. All statistical tests were assessed for significance at p-value < 0.05. The qualitative study (Paper II) was conducted to explore the patients’, family members’, and health care providers’ perspective on late diagnosis of breast cancer. It was employed among purposively selected 23 in-depth interviewees. Each of the audio recordings was transcribed verbatim, coded, and analyzed using thematic analysis. Results: The magnitude of patient (>90 days) and diagnostic delays (>30 days) was 35.7%, 95% CI (31.1%, 40.3%) and 69.1%, 95% CI (64.6%, 73.3%), respectively. Patient delay was significantly higher among women who used traditional medicine before consultation (adjusted prevalence ratio [aPR] =2.13, 95% CI (1.68, 2.71). Diagnosis delay was significantly higher among women whose first consultation was at health centers (aPR=1.19, 95% CI [1.02, 1.39]) and those visited ≥ 4 facilities before confirmation (aPR=1.24, 95% CI [1.10, 1.40]) but lower among women who recognized progression of symptoms before consultation (aPR=0.73, 95% CI (0.60, 0.90). The qualitative study revealed that pre-diagnostic awareness about breast cancer risk, causes, initial symptoms, early detection methods, and treatment was low. Disregarding the clinical importance of the first symptom or seeking care from traditional healers were noted as common practices among women with breast cancer that contributed to late diagnoses. Also, lack of awareness, and misperception about breast cancer treatment and its outcomes, competing priorities, financial insecurity, fear of diagnosis of cancer, and weak health systems (e.g., delay in referral and long waiting period for consultation) were identified as important causes of late diagnosis of women with breast cancer. The median (interquartile range [IQR]) tumor size at diagnosis was 4 (3 to 6) centimeters. Sixtyfour percent of the women (95% CI [59.5%, 68.8%]) were diagnosed at advanced-stages (44% stage III and 20% stage IV) of their disease. The prevalence of advanced-stage disease was significantly higher among women who used traditional medicine before diagnostic confirmation (aPR=1.29, 95% CI [1.10, 1.52]), and in those who waited for > 6 months before diagnosis (aPR=1.35, 95% CI [1.12, 1.63]). On the contrary, it was lower among women who had ever practiced breast self-examination before symptom recognition (aPR=0.77, 95% CI [0.63, 0.96]). The median total interval (symptom recognition to first treatment initiation) was 7 (IQR: 2.7 to 15.7) months. One-fifth of the women started first treatment after one year of first symptom(s) recognition. Adjuvant chemotherapy initiation was delayed (>90 days) in 30% of patients. Only 31.4% (n=137) of the women had received radiotherapy, 64.2% (n=88) of which was adjuvant radiation. Adjuvant radiation initiation was delayed (>90 days) in 56.1% of the women. The overall survival rate at year one was 88.3% (95% CI [84.9%, 91.0%]), and 75.2% (95% CI [70.7%, 79.0%]) at year two. Women diagnosed at stage I had a two-year survival of 100% in contrast to 26.7% at stage IV. The risk of death was significantly higher among women who had a symptom interval of >3 months (adjusted hazard ratio [aHR] = 1.87, 95% CI [1.15, 3.03]) and diagnosed with advanced-stages (aHR=3.32, 95% CI [1.81, 6.10]) but lower among those who had surgical (aHR=0.23, 95% CI [0.15, 0.35]) and hormonal therapy (aHR=0.26, 95% CI [0.17, 0.40]). Conclusions: Substantial proportions of women with breast cancer in Addis Ababa have experienced patient and diagnostic delays that contribute to the high proportion of advancedstage breast cancer, and low breast cancer survival rates. The factors identified that contribute to delayed diagnosis and advanced-stage diagnosis are modifiable. These include poor awareness about breast cancer, using traditional and spiritual remedies, downplaying the clinical importance of the first breast cancer symptoms, health care providers' limited provision of clinical breast examination and delayed referral of women for diagnosis with suggestive of breast cancer symptoms, and longer navigation process to get diagnosis. Once diagnosed, significant number of women experienced delay to adjuvant chemo-and radiotherapy initiation. Recommendations: Breast health awareness campaigns that mitigate misconceptions and improve awareness about breast cancer both in the community and frontline health care providers are essential. Interventions to enhance early detection and prompt referral following consultation, and decrease waiting time between symptom recognition and breast cancer diagnosis are needed to improve early-stage diagnosis and survival rate of women with breast cancer. Also, the expansion of cancer diagnostic and treatment centers is necessary to shorten the diagnosis and treatment delays.Item 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.Item Metabolic Syndrome: Epidemiology and Sociocultural Contexts, among People Living with HIV, in Gedeo Zone, Southern Ethiopia.(Addis Abeba University, 2021-04) Bune, Girma Tenkolu (Phd); Prof. Worku, Alemayehu (MSc, PhD); Dr. Kumie, Abera (Ph.D.)Background: following an intensive global operation of antiretroviral therapy (ART), the worldwide morbidity and mortality from infectious diseases have occupied a backseat. Instead, a non-communicable diseases (NCDs) risk marker called metabolic syndrome (MS) has emerged. MS is risk factors for cardiovascular disease that has public health issue, which places social, economic, and disease conditions on the community within the geographical region of subSaharan Africa, including Ethiopia. Litreatures have shown that human immunodeficiency virus (HIV) infected patients on ART have a 2-fold risk of dying from MS. There are no such studies in Gedeo zone, southern Ethiopia; hence the need for this study to fill this gap. Objective: To assess the epidemiology and the socio-cultural contexts of metabolic syndrome among people living with HIV (PLHIVs), in the Gedeo Zone, Southern Ethiopia. Methods: This dissertation was conducted in the randomly selected two hospitals and health centers. A mixed approach was used to address the objectives of this dissertation. To estimate and compare the magnitude of overall MS among the two comparative groups, a comparative cross-sectional design was employed among the randomly chosen PLHIVs from two hospitals and two health centers, exist in the Gedeo zone, southern-Ethiopia (Paper I). The data collection for this study was run beginning from December 29 th , 2017 up to January 22 nd − 2019, using the WHO steep tool. Ultimately, the completed data was entered into Epidata (V-3.1) and exported to SPSS (V− 22) for analysis. The revised Adult Treatment Panel three (ATP III) criterion was used to define the overall MS and its corresponding traits. The mean, standard deviations, and proportions were used as a descriptive summary. Categorical data and the proportion of overall MS in the two groups were compared using binary logistic regression, and results were reported statistically significant at a p-value is less than 5%. To identify predictors of metabolic syndrome among PLHIVs (Paper-II), a health institution-based unmatched case-control study was conducted. All HIV-infected adult persons who are receiving routine care in the randomly selected two hospitals and two health centers of the Gedeo zone were involved in the study, from December 29 th, 2017 to January 22nd, 2019. The PLHIVs diagnosed with overall MS using ATP III criteria were considered as a case, and those subjects free of it in the survey were enrolled as controls. Binary logistic regression was employed to identify predictors of MS. In the crude analysis, all variables significant at (P<0.1) were included in a multivariable logistic regression model, using the enter method to arrive at the final model. In which, the adjusted odds ratio (AOR) with 95% CI, was estimated to assess the presence and strength of associations, and was determined statistical significance at a p-value < 0.05. To understand the role of sociocultural contexts in forming individual PLHIVs' behavior towards lifestyle-related MS risks, a deductive descriptive phenomenological approach, using the PEN-3 model as a theoretical basis and the knowledge, attitude, and practices (KAP) as a conceptual framework were used. Adult PLHIVs were chosen purposefully from Dilla University referral hospital and Wonago health center and were involved in the discussion. The data collection was enhanced with a focus group discussion (FGDs) and an in-depth interview method, starting from February 1 st to 30 th 2018. Finally, the primary data produced from the discussions were handled and analyzed iteratively, by using Atlas. ti (Version.7.5.7) and SPSS (Version.22) software. Result: a total of 633 (n=422, ART exposed and n=211, ART naïve) PLHIVs were involved in the first paper, with a response rate of 92.1%. MS was diagnosed in (22.0%, 95% CI: 19.0-25.4) of PLHIVs. It was slightly higher in the ART-exposed (22.5%, 95% CI: 18.7-26.8) than ART naïve (20.9%, 95% CI: 15.2-27.1) group. However, the observed differences were not statistically significant(P>0.05). In paper two, a total of 633 (139 cases and 494 controls) PLHIVs were included. The multivariable analysis result found that age (AOR=1.09, 95% CI (1.05-1.12)); educational status being completed secondary school (AOR=0.22, 95% CI (0.020.42)); occupational status being of students (AOR=0.11,95% CI (0.24-0.51); wealth index being in the middle quintile (AOR=0.22, 95%CI (0.06-0.79)); ART status exposed to ART (AOR=3.07, 95%CI(1.37-6.89)); total physical activity state being physically active (AOR=0.36, 95%CI (0.16-0.79)), and engaged in low levels physical activity (AOR=3.83 , 95%CI(1.4610.05)) were the factors significantly associated with MS. Furthermore, the result from the third paper revealed that a total of 32 male and female respondents were involved in the discussion. More than half, 68.8 %(22) of the subjects were found within the age range of (35-44) years, with a mean age of 36.96 (+8.94) years-old. The getting hold of MS risk associated health knowledge of a person encompasses multiple sources. Family, the spouse's children, sisters, and brothers; the government structure, mainly the health care structures; the social systems, principally, the religious organization, the social calls 'Idir', were primary role player in educating the PLHIVs. Conclusions and recommendations: Paper one demonstrated that the magnitude of overall MS was higher among PLHIVs in the Gedeo zone; with a relatively higher magnitude seen in the ART-exposed than ART naïve groups. However, the observed differences were not statistically significant. Implicated that at the time of implementation of the entire test and treatment policy in those vulnerable target groups, a routine screening program of MS will be a vibrant action. While education, occupation, wealth index, antiretroviral therapy status, total physical activity, and lower physical activity levels were concluded by the second paper as modifiable predictors of metabolic syndrome, age was found as a non-modifiable independent risk of metabolic syndrome. This suggested that there is a need for an ongoing effort to realize an integrated care plan that addresses the routine care, along with the regular screening and management programs of the risks associated with MS and its traits in these subjects. The sociocultural contexts dictate the PLHIVs' to have inadequate knowledge concerning risk factors and methods for preventing MS. And, this, in turn, contributed to form an unfavorable attitude and inadequate practices. The finding indicates the significance of the adoption of the healthy living practices associated awareness creation program, which targets the PLHIVs to bring behavior change that eventually enable them for the better prevention and control of MS and its long term consequences.Item 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.Item 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.Item 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, WakgariBackground: 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.Item 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 1Item 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, AhmedBackground: 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.Item 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.Item The Spatial Epidemiology of Tuberculosis in Gurage Zone, Southern Ethiopia.(Addis Ababa University, 2018-12) Tadesse, Sebsibe; Enqueselassie, Fikre(PHD); Hagos, Seifu (PHD)Background: The global distribution of tuberculosis is skewed heavily toward low-and-middle income countries, which accounted for about 87% of all estimated incident cases. Ethiopia is a low-income country in east Africa that remains highly afflicted by tuberculosis, with varying degrees of magnitudes across settings. However, there is a dearth of studies clarifying about the spatial epidemiology of the disease in Ethiopia. Lack of such information may contribute to the partial effectiveness of tuberculosis control programs. Objectives: The specific objectives of this study were: 1) to detect spatial and space-time clustering of tuberculosis, 2) to estimate spatial risk of tuberculosis distribution using limited spatial datasets, and 3) to identify ecological factors affecting spatial distribution of tuberculosis in Gurage Zone, Southern Ethiopia. Methods: The study data were obtained from different sources. Specific objectives 1 and 3 included a total of 15,805 tuberculosis patients diagnosed at health facilities in Gurage Zone during 2007 to 2016, whereas specific objective 2 included 1,601 patients diagnosed in 2016. The geo-location and population data were obtained from the Central Statistical Agency of Ethiopia (specific objectives 1-3). The altitude data were extracted from global digital elevation model v2 (specific objective 2). The normalized difference vegetation index data were derived from the moderate resolution imaging spectroradiometer imagery, and the temperature and rainfall data were obtained from the Meteorological Agency of Ethiopia (specific objective 3). The global Moran’s I, Kulldorff’s scan and Getis-Ord statistics were used to analyze purely spatial and space-time clustering of tuberculosis (specific objective 1). The geostatistical kriging approach was applied to estimate the spatial risk of tuberculosis distribution (specific objective 2). The spatial panel data analysis was used to estimate the effects of ecological factors on spatial distribution of tuberculosis prevalence rate (specific objective 3). Results: The prevalence of tuberculosis varied from 70.4 to 155.3 cases per 100,000 population in the Gurage Zone during 2007 to 2016. Eleven purely spatial clusters (relative risk: 1.36–14.52, P-value < 0.001) and three space-time clusters (relative risk: 1.46–2.01, P-value < 0.001) for high occurrence of tuberculosis were detected. The clusters were mainly concentrated in border areas of the zone. The predictive accuracies of ordinary cokriging models have improved with the inclusion of anisotropy, altitude and latitude covariates, the change in detrending pattern from local to global, and the increase in size of spatial dataset (mean-standardized error = 0, rootxi mean-square-standardized error = 1, and average-standard error ≈ root-mean-square error). The spatial risk of tuberculosis was estimated to be higher (i.e., tuberculosis prevalence rate > 100 cases per 100,000 population) at western, northwest, southwest and southeast parts of the study area, and crossed between high and low at west-central parts. The tuberculosis prevalence rate observed in a given kebele was determined by both tuberculosis prevalence rate (spatial autoregressive coefficient = 0.83) and unobserved factors (spatial autocorrelation coefficient = - 0.70) in the neighboring kebeles. By controlling the spatial effects, a 1°C rise in temperature was associated with an increase in the number of tuberculosis prevalence rate by 0.72, and a 1 person per square kilometer increase in population density was related to an increase in the number of tuberculosis prevalence rate by 1.19. Conclusions: The spatial and space-time clusters for high occurrence of tuberculosis were mainly concentrated at border areas of the Gurage Zone. The prevalence rate of tuberculosis in a given kebele was determined by both the prevalence rate of tuberculosis and other unobserved factors in its neighboring kebeles in the zone, indicating sustained transmission of the disease within the communities. The spatial risk of tuberculosis distribution between kebeles in the zone was partly explained by spatial variations in temperature, population density, altitude, and latitude. The geostatistical kriging approach can be applied to estimate the spatial risk of tuberculosis distribution in data limited settings. Recommendations: Tuberculosis control programs should consider the cooperation of neighboring kebeles in the design and implementation of tuberculosis prevention and control strategies to interrupt the chain of disease transmission between the communities. Moreover, the designing of locally effective tuberculosis prevention and control strategies should consider spatial locations with higher temperature and population density. Further research is required to evaluate the effectiveness of geographically targeting tuberculosis prevention and control interventions using the inputs from spatial epidemiological methods.Item Physician workforce situation and health system’s response in Ethiopia: a mixed-methods study(Addis Ababa Universty, 2017-12) Assefa, Tsion; H/Mariam, Damen (Professor,MD, MPH, PhD)Background: Shortages and imbalances in physician workforce distribution between urban and rural and among the different regions in Ethiopia are enormous. However, with the recent rapid expansion in medical education training, by adopting the so called “flooding strategy”, it is expected that the country can make progress in physician workforce supply. Nevertheless, the effectiveness of the intended strategy also relies on a lot of interrelated factors. Factors such as accessibility, composition and turnover of the medical education workforce; the role of medical instruction in influencing the medical students’ attitudes and career choices; and also the level of preparation and cooperation made in the system when such strategy is implemented. Objective: This research aimed to investigate physician workforce (distribution, attrition and associated factors), medical students’ career choice and intention (to work in rural/remote locations and to leave abroad), and to discover the health system response and its consequences which have been made to overcome the physician workforce shortages in Ethiopia. Methods: The study employed a mixed-methods study design (organizational survey, medical students’ survey, and qualitative study design by adopting a grounded theory approach). A longitudinal medical education and physician workforce data sets of about six years (between September 2009 and June 2015) were retrospectively collected from seven government owned medical schools, and five regional and two city administration health bureaus to examine the physician workforce distribution in and turnover from the public health sector and the medical schools. In measuring the medical education workforce turnover, the study employed the concepts of survival analysis with a Cox Proportional Hazards Model. However, the study opted to use Poisson Regression Model hence the data collected from regional health bureau and city administrations failed to satisfy the Cox’s Proportional Hazards Model assumptions. For medical student survey, 959 medical students who pursue their medical education in six government owned higher learning institutions of Ethiopia were involved through self-administered questionnaire to examine the medical students’ career choice and intention to work in rural and remote locations, and also regarding moving abroad. The qualitative study was employed to discover perspectives and viewpoints on the health system response and its consequences by involving 43 purposefully selected respondents from government, academics, and private settings. Each interview was transcribed verbatim, coded and xv analyzed using the grounded theory research approach and presented in a narrative form. Finally, the relationships between the main categories were illustrated using figures. Results: In the public health care settings, the majority of the medical doctors were males (80.5%), young (born after the year 1985 (50.9%), work experience of less than three years (57%), and were general practitioners (84.2%). A decreased incidence of turnover was observed among physicians born between 1975 and 1985 compared to those born after 1985. However, increased rate of turnover was found among females, physicians working in district and general hospitals, and in Amhara Region. Similarly, in the academic health care settings, a total of 6,670.5 physician-years observation was analyzed. About 15.7% of the observations were completed and the remaining 84.3% were censored. In this setting, lower risk of turnover was observed among those who were born before 1975 and with those high academic rank (associate professors and above). The risk of turnover was also lower among those working in Mekelle and Gondar universities but the reverse was observed among those working in Jimma University. Regarding medical students’ career choices, (70.1%) of the medical students wanted to practice in clinical care settings. However, only a small proportion of them showed interest to work in rural and remote areas (21% in zonal and 8.7% in district/small towns). On the contrary, most of them had the intention to leave abroad for both economic and non-economic reasons. For the majority of them internal medicine was the first specialty of choice followed by surgery. However, students showed little interest in obstetrics and gynecology, as well as in pediatrics and child health as their first specialty of choices. In addition, medical students’ attitudes towards their institution in preparing them to work in rural and remote areas, to pursue their career within the country and to specialize in medical disciplines in which there are shortages in the country were very low. In the qualitative study, almost all participants agreed that physician migration (emigration and out-migration) has contributed to skilled human resource shortage in the country. The most frequently cited reasons were both financial and non-financial. The latter one includes lack of recognition, not valuing expertise, and incompetent leadership and management as well as external factors which include opportunities and value shift. xvi In relation to massive admission and production, two distinct types of preparation were identified; preparation that needs to be made in the medical schools and in the system, though at the time of the study, both were not sufficiently addressed. As a result, there were potential consequences at the present. These were related to clinical service delivery, patient right and privacy, medical education workforce, and quality of medical education. In the future, it was anticipated to affect the graduates, the system, as well as the community in the short and long term consequences of physician workforce flooding. Besides, in relation to HRH preparation and utilization, lack of cooperation, strategic planning and capacity, and system continuity were also identified as underlying and basic problems of the system, respectively. Conclusion: Overall, young and less experienced physicians make up significant proportions of the public and academic physician workforce of the country, which is a signal for the presence of substantial improvement in supply. However, without retention efforts, skilled turnover will result in a “system of ever-green hands (Ac16)”; a system staffed with junior physician workforce. In addition, shortage, lack of composition and diversity, and low satisfaction of the medical education workforce can hinder the quality of medical education, which failed to influence the medical students’ attitudes to prefer to work in rural and remote locations including their career choices. Moreover, across the settings, economic and non-economic reasons were the main reasons of turnover as well as the reasons behind the medical students’ intention to move. Furthermore, massive admission has negative impact on the quality of medical education, patient care and satisfaction, and also on the medical workforce at the present with its additional consequences on the medical graduates, system and the community at large in the long run. Hence, the flooding is not only limited to issues to do with what currently has been observed but also rooted in the underlying (strategy, planning, and capacity) and basic (functional continuity of the system) problems of the health system. Recommendations: Therefore, there is a need to revisit the flooding strategy in such a way as to minimize the consequences of massive medical students’ admission and physician workforce production along with working on the other dimensions of the problem.Item Spatial variations and associated factors of food insecurity and child under nutrition in east Gojjam zone, Ethiopia: a multilevel mixed effects model.(Addis Ababa Universty, 2018-10) Aderaw, Zewdie (PhD); Ali, Ahmed (Professor)Background: - Child undernutrition remains a major public health challenge. The magnitude of the problem varies based on geographical location. In Ethiopia, spatial analysis studies were done based on coarse spatial resolutions. To be more efficient in targeting interventions geographically, spatial analysis using micro level spatial resolution is recommended. Accordingly, different studies were done to identify factors associated with food insecurity and child undernutrition, but most of them ignore either the individual or community level factors. Hence, identification of spatial variations and individual and contextual level determinant factors of food insecurity and child undernutrition in XVI | P a g e relation to the agroecosystem is essential to deliver targeted, efficient and sustainable solutions to the problems. Objectives: - This study determined spatial variations of food insecurity and child undernutrition. The study also identified the role of individual and community level factors of food insecurity and child undernutrition using multilevel mixed effects regression analysis in East Gojjam Zone, Ethiopia. Methods: - An agroecosystem linked to community based comparative cross sectional survey was conducted among 3108 households with children aged 6-59 months. Multistage cluster random sampling technique was used to select study participants. Data were collected on household geographical location, socio-demographic characteristics, child and maternal anthropometry and on potential individual and community level determinant factors. Collected data were entered using Epi info version 3.5 and exported to World Health Organization (WHO) Anthro to determine child nutritional status. SaTScan software was used to determine spatial variations of food insecurity and child undernutrition using SaTScan Bernoulli model. To identify the most likely clusters using SaTScan software, the Log Likelihood Ratio (LLR) at 95% Confidence Interval (CI) and P value less than 0.05 as the level of significance were considered. To identify determinant factors of food insecurity and child undernutrition, multilevel mixed effects ordinal regression and multilevel mixed effects linear regression analyses were used, respectively. The results of fixed effects were shown as an adjusted odd ratio (AORs) for the multilevel mixed effects ordinal regression and regression coefficients for the multilevel mixed effects linear regression. The results of random effects were presented as variance and the intra-class correlation coefficient (ICC) was calculated to estimate unexplained variance attributable to cluster level. Results: - The overall prevalence of household food insecurity was 65.3% (95% CI: 63.5, 67.00). The highest prevalence of food insecurity was observed from the lowlands of the Abay Valley (70.6%, 95% CI: 66.9, 74.2). Followed by the hilly and mountainous highland areas of Choke Mountain (69.8%, 95% CI: 65.9, 73.3). Similarly, sample clusters taken from hilly and mountainous highland areas (LLR: 11.64; P<0.01) and low lands of the Abay Valley (LLR: 8.23; P<0.05) were identified as the most likely primary and secondary clusters, respectively. XVII | P a g e The prevalence of stunting 39.0% (95% CI: 37.32, 40.75), 18.7% (95% CI: 17.32, 20.0) underweight, and 12.22% (95% CI: 11.12, 13.42) wasting were observed in the study area. The highest prevalence of wasting (15.9%; 95% CI: 13.5, 18.8) was observed from hilly and mountainous highlands. The highest prevalence of child stunting (42.4%; 95% CI: 38.5, 46. 6) and underweight (22.9%; 95% CI: 19.7, 26.3)) were observed from the lowlands of Abay Valley. SaTScan spatial analysis indicated that sample clusters taken from the hilly and mountainous highlands were the most likely primary cluster for child wasting (LLR: 13.0, p < 0.01) and underweight (LLR: 23.16, p < 0.001). Also, primary cluster for child stunting was identified from lowlands of Abay Valley (LLR: 10.78, p<0.05). After adjusting for both individual and community level determinant factors, 1.5% (p<0.001) of the variance of food insecurity was attributable to the cluster level. Similarly, after adjusting for all potential determinant factors, 2.4% (p<0.001) of the child weight for height Z score and 1.4% (p<0.001) of the child height for age Z score variance were due to cluster level. From level one factors, in the final model, household head being male, marital status being in union, higher parental education, women’s participation in household decision making, having additional income sources, better crop production in the survey year and application of chemical fertilizer have a positive influence in mitigating household food insecurity. From community level determinant factors, households being from hilly and mountainous highlands and lowlands of the Abay Valley were more severely household food insecure compared to midland plain areas. Households with better farmland size showed less severe household food insecurity in the study area. In the study, from level one factors, the number of under five children, antenatal (ANC) follow up, breast feeding initiation time, household dietary diversity, mother nutritional status, household food insecurity and diarrheal morbidity were associated with weight for height Z score. From level two factors, agroecosystem characteristics, proper household refuse disposal practice, agroecosystem characteristics and proper latrine utilization were significantly associated with child weight for height Z score. From level one factors, child age in months, child gender, the number of under-five children in the household, child immunization status, breastfeeding initiation time, mother nutritional status, child diarrheal morbidity, household level water treatment practice and household dietary diversity showed a statistical significant association with child height for age Z score. From level two factors, agroecosystem characteristics, proper household refuse disposal practice and proper latrine utilization were significantly associated with child height-for-age Z score. XVIII | P a g e Conclusions: - The prevalence of food insecurity and child undernutrition were public health concerns in the study area. Spatial variations of household food insecurity and child undernutrition were observed across the agroecosystems. Households from the lowlands of Abay Valley and hilly and mountainous highland areas were more vulnerable to food insecurity and child undernutrition compared to midland areas. The SaTScan cluster level spatial analysis identified statistical significant hotspot clusters for food insecurity, childhood stunting, underweight and wasting. The multilevel mixed effects analysis indicated that the heterogeneity of food insecurity, childhood stunting and wasting were observed after adjusting to potential individual and community level determinant factors. Both individual and community level factors played a significant role in determining food insecurity and child undernutrition (stunting and wasting). An agroecosystem characteristic was one of the community level factors affecting household food insecurity and child undernutrition. Recommendations: - The spatial variation of food insecurity and child undernutrition based on agroecosystem characteristics should be fully understood by program implementers and policy makers during planning, resource allocation and community mobilization in the study area. Water, sanitation and hygiene interventions are important in the study area. Further study on spatiotemporal variations of food insecurity and child undernutrition at different time is recommended. Also, food insecurity and child undernutrition intervention strategies and plans designed using aggregated or macro level evidence may not indicate the true picture of spatial distribution of the problem at lower government administrative units. So, program level planning may take into account agroecosystem based micro level variations to allocate resources. Policy and intervention strategies aiming at mitigating food insecurity and child undernutrition should address the effects of lower and community level determinant factors using the integration of individual/household level and geographical targeting.Item 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.