"We need to confirm at least from two or three": Healthcare workers' discretion as gatekeepers in the context of the Ethiopian abortion law.

INTRODUCTION: Women's access to legal and safe abortion is a vital means to reduce unsafe abortion, which in turn is known to reduce maternal morbidity and mortality. In 2005, Ethiopia enacted a relatively permissive abortion legislation. However, there is evidence that access to abortion care services may be challenging and controversial even if progressive abortion laws are in place. This article examines women's access to abortion services from the perspective of healthcare workers in a rural setting in Ethiopia. Drawing on Lipsky's theory of street-level bureaucrats, the article discusses healthcare workers' discretion and the substantial authority they hold as gatekeepers to safe abortion services. METHODS: The study draws upon a qualitative, interpretative methodological approach, with in-depth semi-structured interviews with healthcare workers as the key method of data generation. The data was analyzed and interpreted thematically. Healthcare workers' perspectives were examined with reference to the national abortion legislation and guidelines. RESULTS: The findings reveal that healthcare workers make decisions on behalf of the women who seek abortion, and they involve parents and partners in abortion-related decision-making processes. Moreover, they assess the social context of the pregnancy such as the marital and economic statuses of the abortion-seeking women in ways that restrict women's access to legally-endorsed abortion services. CONCLUSIONS: Healthcare workers' practices in this rural area were found to challenge the basic provisions laid out in Ethiopia's abortion legislation. Their negative discretion of the legislation contributes to the substantial barriers Ethiopian abortion-seeking women face in gaining access to legal abortion services, despite the presence of a progressive legal framework and guidelines.

Less known but greatly feared: Cervical cancer in Ethiopia community awareness.

To improve a community's awareness and attitude towards cervical cancer, strong evidence is needed to inform contextually appropriate policies. This study aims to explore community awareness about cervical cancer from the perspective of women, men and health extension workers (HEWs). The research was conducted from May to July 2021 in Jimma, Ethiopia. A total of 23 in-depth interviews were conducted. The study included married and unmarried women (15-19 and 25-29 years old), men of similar ages (married and unmarried), and HEWs. Furthermore, eight separate focus group discussions (FGDs) were conducted with both men and women. Thematic analysis was used to draw findings from the interviews and FGDs. Community awareness about cervical cancer was very limited. However, people who knew of it believed that cancer is fatal. A few participants were aware of cervical cancer through its symptoms, but most people did not know it by name and had never heard about HPV as the cause of cervical cancer. There was little understanding of HPV risk, transmission factors, prevention, vaccination, screening, or treatment. Participants considered their participation in this study as their first chance to learn about the disease. HEWs had limited knowledge about HPV and cervical cancer. Study participants demonstrated favorable attitudes towards HPV vaccination, cervical screening, and treatment after they received basic information about cervical cancer from the data collectors. Participants and HEWs strongly suggested awareness creation programs for the wider community members, including active involvement of men and HEWs in cervical cancer interventions. There is a critical information gap regarding cervical cancer, its cause and risk factors, HPV transmission, cervical screening, and treatment programs. Limited community awareness leads to poor uptake of cervical screening in the few settings where it is available. Therefore, community awareness programs about HPV, cervical cancer, and available services should improve the community's awareness of cervical cancer and HPV.

Carers' and health workers' perspectives on malnutrition in infants aged under six months in rural Ethiopia: A qualitative study.

OBJECTIVES: Supporting small and nutritionally at-risk (potentially malnourished) infants under six months is a global health priority, albeit with a weak evidence-base. To inform policy and research in this area, we aimed to assess the perceptions and understanding of infant malnutrition and its management among carers, communities, and healthcare workers in rural Ethiopia. METHODS: We conducted in-depth and key-informant interviews, from May-August 2020 in Jimma Zone and Deder District, Ethiopia. We used purposive sampling to recruit the participants. Interviews were transcribed into Amharic or Afaan Oromo and then translated into English. Atlas ti-7 was used to support data analysis. Findings were narrated based on the different themes arising from the interviews. RESULTS: Carers/community members and healthcare workers reported on five different themes: 1) Perceptions about health and well-being: an 'ideal infant' slept well, fed well, was active and looked 'fat'; 2)Perceptions of feeding: overall knowledge of key recommendations like exclusive breastfeeding was good but practices were suboptimal, notably a cultural practice to give water to young infants; 3)Awareness about malnutrition: a key limitation was knowledge of exactly how to identify small and nutritionally at-risk infants; 4) Reasons for malnutrition: levels of understanding varied and included feeding problems and caregiver's work pressures resulting in the premature introduction of complementary feeds; 5) Perceptions about identification & treatment: carers prefer treatment close to home but were concerned about the quality of community-based services. CONCLUSION: To succeed, research projects that investigate programes that manage small and nutritionally at-risk infants under six months should understand and be responsive to the culture and context in which they operate. They should build on community strengths and tackle misunderstandings and barriers. Interventions beyond just focusing on knowledge and attitude of the carers and health workers are necessary to tackle the challenges around infants under 6 months of age at risk of malnutrition. Moreover, stakeholders beyond the health sector should also be involved in order to support the infants under 6 months and their mothers as some of the key reasons behind the at-risk infants are just beyond the capacity of the health sector or health system. Our list of themes could be used to inform infant nutrition work not just in Ethiopia but also in many others.

Implementation research on management of sick young infants with possible serious bacterial infection when referral is not possible in Jimma Zone, Ethiopia: Challenges and solutions.

INTRODUCTION: Of 2.5 million newborn deaths each year, serious neonatal infections are a leading cause of neonatal death for which inpatient treatment is recommended. However, manysick newborns in sub-Saharan Africa and south Asia do not have access to inpatientcare. A World Health Organization (WHO) guideline recommends simplified antibiotic treatment atan outpatient level for young infants up to two months of age with possible serious bacterial infection (PSBI), when referral is not feasible.We implemented this guidelinein Ethiopia to increase coverage of treatment and to learn about potential facilitating factors and barriers for implementation. METHODS: We conducted implementation research in two districts (Tiro Afata and Gera) in Jimma Zone, Ethiopia, to learn about the feasibility of implementing the WHO PSBI guideline within a programme setting using the existing health care structure. We conducted orientation meetings and policy dialogue with key stakeholders and trained health extension workers and health centre staff to identify and manage sick young infants with PSBI signs at a primary health care unit. We established a Technical Support Unit (TSU) to facilitate programme learning, built health workers' capacity and provided support for quality control, monitoring and data collection.We sensitized the community to appropriate care-seeking and supported the health care system in implementation. The research team collected data using structured case recording forms. RESULTS: From September 2016 to August 2017, 6185 live births and 601 sick young infants 0-59 days of age with signs of PSBI were identified. Assuming that 25% of births were missed (total births 7731) and 10% of births had an episode of PSBI in the first two months of life, the coverage of appropriate treatment for PSBI was 77.7% (601/773). Of 601 infants with PSBI, fast breathing only (pneumonia) was recorded in 432 (71.9%) infants 7-59 days of age; signs of clinical severe infection (CSI) in 155 (25.8%) and critical illnessin 14 (2.3%). Of the 432 pneumonia cases who received oral amoxicillin treatment without referral, 419 (97.0%) were successfully treated without any deaths. Of 169 sick young infants with either CSI or critical illness, only 110 were referred to a hospital; 83 did not accept referral advice and received outpatient injectable gentamicin plus oral amoxicillin treatment either at a health post or health centre. Additionally, 59 infants who should have been referred, but were not received injectable gentamicin plus oral amoxicillin outpatient treatment. Of infants with CSI, 129 (82.2%) were successfully treated as outpatients, while two died (1.3%). Of 14 infants with critical illness, the caregivers of five accepted referral to a hospital, and nine were treated with simplified antibiotics on an outpatient basis. Two of 14 (14.3%) infants with critical illness died within 14 days of initial presentation. CONCLUSION: In settings where referral to a hospital is not feasible, young infants with PSBI can be treated on an outpatient basis at either a health post or health centre, which can contribute to saving many lives. Scaling-up will require health system strengthening including community mobilization. REGISTRATION: Trial is registered on Australian New Zealand Clinical Trials registry (ANZCTR) ACTRN12617001373369.

Risk perceptions and attitudinal responses to COVID-19 pandemic: an online survey in Ethiopia.

BACKGROUND: Effective risk communication is one of the critical strategies in the response to COVID-19. This study examined risk perceptions and attitudinal responses to COVID-19 among the educated section of the society in Ethiopia. METHODS: An internet-based survey was conducted from April 22 to May 04, 2020, in Ethiopia. A questionnaire addressing the perception of health threat-combination of perceived vulnerability (PV) and perceived seriousness (PS), and perceived efficacy-combinations of perceived response efficacy (PRE), perceived self-efficacy (PSE), and perceived collective efficacy (PCE). The data were analyzed using SPSS 21.0. Descriptive statistics were computed after the standardization of the scores. The scores for overall efficacy and threat were split by median value and response classifications were generated through threat by efficacy interactions. For statistical significance, 95% CI and p-value < 0.05 were used. RESULTS: A total of 929 respondents submitted their responses. Eight hundred and twenty-eight (89.1%) of the respondents were male and 753 (81.1%) were Christian. The perceived threat to COVID-19 was generally low (median = 58.3). The median score for overall efficacy, PRE, and PSE were 79.8, 87.5, and 80.0, respectively. However, the median value (66.7) for PCE was relatively low. Perceived threat significantly varied by age, education, occupation, and place of residence (p < 0.05). Perceived efficacy significantly differed by gender, residence, and use of some sources of information (p < 0.05). In terms of response to COVID-19, 290 (31.2%), 239 (25.7%), 175 (18.8%) and 225 (24.2%) of the respondents were in the responsive, pro-active, avoidant, and indifferent attitudinal categories, respectively. The avoidant and indifferent groups constituted a fear control response (mal-adaptive motivation towards COVID-19 protective behavior) whereas responsive and pro-active categories formed a danger control response (self-protective motivation). These responses varied significantly by residence, region, religion, and sources of information (p < 0.05). CONCLUSIONS: Understanding people's perceived health threat and efficacy is a critical step toward creating risk communication campaigns. Hence, this study provided an insight that has the potential to inform the COVID-19 risk communication campaigns targeting the educated section of the society, by ensuring a balanced combination of threat appeals and efficacy messages for improved self-protective responses.

Parents' Knowledge of Danger Signs and Health Seeking Behavior in Newborn and Young Infant Illness in Tiro Afeta District, Southwest Ethiopia: A Community-based Study.

BACKGROUND: Neonatal mortality rates in Ethiopia are among the highest in the world. Reducing neonatal and young infant mortality highly relies on early recognition of symptoms and appropriate care-seeking behavior of parents/care givers. The main aim of this study was to assess the knowledge of danger signs and health seeking behavior of parents/care givers in newborn and young infant illness in Southwest Ethiopia. METHODS: A community-based cross-sectional study was conducted using cluster sampling technique to get 422 samples of parents/care givers who had infants of less than 6 month old. Data was collected through face-to-face interviews using structured questionnaire. Logistic regression was used to identify factors affecting care seeking behavior and knowledge of parents/care givers on newborn and young infant illness. RESULT: Care seeking behavior for newborn and young infant illness was high (83%), the major factor associated with care seeking behavior being place of delivery. Only less than half of the respondents had adequate knowledge of symptoms of illness of newborns and young infants. The major factors associated with knowledge of parents/care givers were maternal education and paternal education. CONCLUSIONS: To improve the knowledge of parents/care givers about newborn and young infant illness, counseling about the major symptoms of newborn and young infant illness should be intensified.