Symbolic sites of belonging and prevention and control of tuberculosis: perceptions and practices of community health workers in Brazil and Ethiopia. / Sítios simbólicos de pertencimento e prevenção e controle da tuberculose: percepções e práticas dos Agentes Comunitários de Saúde no Brasil e na Etiópia.

This article aims to evaluate the contribution of Community DOTS, Directly Observed Treatment Short-Course, for the prevention and control of Tuberculosis actions in primary care in Brazil and Ethiopia, based on the perceptions and practice of the community health care workers. We employed the Symbolic Sites conceptual-methodological framework, accounting for its three types: Black box, Conceptual box, and Toolbox. The contrasting case study involved triangulating and complementing data collection and analysis from semi-structured interviews with community health workers and health professionals, site observation, and document analysis. The results highlight a sense of commitment as an essential value regarding the activities developed by community health workers in both contexts. The main challenges are the insufficient capacity building and supervision (Conceptual box), and the difficulties related to access (Toolbox), expressed in long geographic distances in the Ethiopian case and barriers related to territory violence, mostly drug trafficking, although not explicit, in the Brazilian context. This implies in a continuous effort for the community health workers to adapt their practices, respecting the cultural values (Black box), in order to direct their actions to overcome these challenges.

O objetivo do artigo é avaliar a contribuição do DOTS comunitário, do inglês "Directly Observed Treatment Short-Course", nas ações de prevenção e controle da tuberculose na atenção primária no Brasil e na Etiópia, a partir das percepções e práticas dos agentes comunitários de saúde (ACS). Utilizou-se o referencial conceitual e metodológico dos sítios simbólicos de pertencimento, com suas três tipologias: caixas preta, conceitual e operacional. Empregou-se o estudo de dois casos contrastantes, triangulando e complementando informações advindas de entrevistas semiestruturadas com ACS e profissionais de saúde e também observação participante. Os achados destacam o sentido de comprometimento dos ACS como um valor importante nas ações desenvolvidas em ambos contextos. Os principais desafios são a insuficiência de capacitação e supervisão das ações realizadas (caixa conceitual), assim como as dificuldades de acesso (caixa de ferramentas), expressas em distâncias geográficas no caso etíope e em barreiras relacionadas à violência no território, não explicitadas, no contexto brasileiro. Isto implica em um esforço contínuo dos ACS para adaptar suas práticas, respeitando os valores culturais (caixa preta) que dão sentido e direção às suas ações na superação dos desafios.

Strategic analysis of tuberculosis prevention and control actions in Brazil and Ethiopia: one size fits all?

OBJECTIVES: This study aimed at conducting a strategic analysis of Tuberculosis prevention and control actions in Brazil and Ethiopia, looking at the potential of directly observed treatment short-course strategy (DOTS) and community DOTS in both countries. METHODS: Literature review was conducted using PubMed, Medline-Ovid, EMBASE, and SCIELO databases. The reviewed terms were Tuberculosis, prevention and control and Brazil (or Brasil) or Ethiopia (or Etiopia). Study's eligibility included article's title or abstract in English or Portuguese and comprised the following Tuberculosis policy components: management; care; communication, and social mobilization; training and professional development; epidemiological surveillance, and monitoring and evaluation. The study identified, compared, and analyzed the challenges and recommendations reported in the literature. RESULTS: Although DOTS was not able to address all the difficulties regarding Tuberculosis control and prevention, it contributes to overcome challenges identified in the literature review. Decentralizing DOTS in Ethiopia and implementing DOTS in Brazil were key recommendations to overcome problems of access and treatment default. CONCLUSIONS: DOTS and Community DOTS cannot solve every identified Tuberculosis challenge, but together they complement each other. Both strategies need to be tailored to site's challenges.

Khat and alcohol use and risky sex behaviour among in-school and out-of-school youth in Ethiopia.

BACKGROUND: Khat (an evergreen plant with amphetamine-like properties) and alcohol are widely consumed among the youth of Ethiopia. However, their relationship to risky sexual behaviour is not well described. This study was conducted to describe the magnitude of risky sexual behaviour (unprotected sex and early initiation of sexual activity) and its association with Khat and alcohol consumption in Ethiopian youths. METHODS: A probabilistic national sample of 20,434 in-school and out-of-school youths aged between 15 and 24 years of age was selected and interviewed regarding their sexual behavior and substance use. RESULTS: Over 20% of out-of-school youth had unprotected sex during the 12-month period prior to interview compared to 1.4% of in-school youth. Daily Khat intake was also associated with unprotected sex: adjusted OR (95% CI) = 2.26 (1.92, 2.67). There was a significant and linear association between alcohol intake and unprotected sex, with those using alcohol daily having a three fold increased odds compared to those not using it: adj. OR (95% CI) = 3.05 (2.38, 3.91). Use of substances other than Khat was not associated with unprotected sex, but was associated with initiation of sexual activity: adj. OR (95% CI) = 2.54 (1.84, 3.51). CONCLUSION: A substantial proportion of out-of-school youth engage in risky sex. The use of Khat and alcohol and other substances is significantly and independently associated with risky sexual behaviour among Ethiopian youths.

The Role of Empowerment in the Association between a Woman's Educational Status and Infant Mortality in Ethiopia: Secondary Analysis of Demographic and Health Surveys.

BACKGROUND: Socioeconomic status at national, sub-national, household, and individual levels explains a significant portion of variation in infant mortality. Women's education is among the major determinants of infant mortality. The mechanism through which a woman's own educational status, over her husband's as well as household characteristics, influences infant mortality has not been well studied in developing countries. The objective of this study was to explore the role of woman's empowerment and household wealth in the association between a woman's educational status and infant mortality. METHODS: The association between a woman's educational status and infant death, and the role of woman's empowerment and household wealth in this relationship, were examined among married women in Ethiopia through a secondary, serial cross-sectional analysis utilizing data on birth history of married women from three rounds of the Ethiopian Demographic and Health Survey. Univariate, bivariate, and multivariate analyses were conducted to examine the association between woman's education and infant death, and the possible mediation or moderation roles of woman empowerment and household wealth. RESULTS: Female education and empowerment were inversely associated with infant death. The results indicated mediation by empowerment in the education-infant death association, and effect modification by household wealth. Both empowerment and education had strongest inverse association with infant death among women from the richest households. CONCLUSION: The findings suggest an important role of female empowerment in the education-infant death relation, and the complexity of these factors according to household wealth. Woman empowerment programs may prove effective as a shorter term intervention in reducing infant mortality.

Sítios simbólicos de pertencimento e prevenção e controle da tuberculose: percepções e práticas dos Agentes Comunitários de Saúde no Brasil e na Etiópia / Symbolic sites of belonging and prevention and control of tuberculosis: perceptions and practices of community health workers in Brazil and Ethiopia

Resumo O objetivo do artigo é avaliar a contribuição do DOTS comunitário, do inglês "Directly Observed Treatment Short-Course", nas ações de prevenção e controle da tuberculose na atenção primária no Brasil e na Etiópia, a partir das percepções e práticas dos agentes comunitários de saúde (ACS). Utilizou-se o referencial conceitual e metodológico dos sítios simbólicos de pertencimento, com suas três tipologias: caixas preta, conceitual e operacional. Empregou-se o estudo de dois casos contrastantes, triangulando e complementando informações advindas de entrevistas semiestruturadas com ACS e profissionais de saúde e também observação participante. Os achados destacam o sentido de comprometimento dos ACS como um valor importante nas ações desenvolvidas em ambos contextos. Os principais desafios são a insuficiência de capacitação e supervisão das ações realizadas (caixa conceitual), assim como as dificuldades de acesso (caixa de ferramentas), expressas em distâncias geográficas no caso etíope e em barreiras relacionadas à violência no território, não explicitadas, no contexto brasileiro. Isto implica em um esforço contínuo dos ACS para adaptar suas práticas, respeitando os valores culturais (caixa preta) que dão sentido e direção às suas ações na superação dos desafios.

Abstract This article aims to evaluate the contribution of Community DOTS, Directly Observed Treatment Short-Course, for the prevention and control of Tuberculosis actions in primary care in Brazil and Ethiopia, based on the perceptions and practice of the community health care workers. We employed the Symbolic Sites conceptual-methodological framework, accounting for its three types: Black box, Conceptual box, and Toolbox. The contrasting case study involved triangulating and complementing data collection and analysis from semi-structured interviews with community health workers and health professionals, site observation, and document analysis. The results highlight a sense of commitment as an essential value regarding the activities developed by community health workers in both contexts. The main challenges are the insufficient capacity building and supervision (Conceptual box), and the difficulties related to access (Toolbox), expressed in long geographic distances in the Ethiopian case and barriers related to territory violence, mostly drug trafficking, although not explicit, in the Brazilian context. This implies in a continuous effort for the community health workers to adapt their practices, respecting the cultural values (Black box), in order to direct their actions to overcome these challenges.

Outpatient therapeutic feeding program outcomes and determinants in treatment of severe acute malnutrition in tigray, northern ethiopia: a retrospective cohort study.

BACKGROUND: Outpatient Therapeutic feeding Program (OTP) brings the services for management of Severe Acute Malnutrition (SAM) closer to the community by making services available at decentralized treatment points within the primary health care settings, through the use of ready-to-use therapeutic foods, community outreach and mobilization. Little is known about the program outcomes. This study revealed the levels of program outcome indictors and determinant factors to recovery rate. METHODS: A retrospective cohort study was conducted on 628 children who had been managed for SAM under OTP from April/2008 to January/2012. The children were selected using systematic random sampling from 12 health posts and 4 health centers. The study relied on information of demographic characteristics, anthropometries, Plumpy'Nut, medical problems and routine medications intakes. The results were estimated using Kaplan-Meier survival curves, log-rank test and Cox-regression. RESULTS: The recovery, defaulter, mortality and weight gain rates were 61.78%, 13.85%, 3.02% and 5.23 gm/kg/day, respectively. Routine medications were administered partially and children with medical problems were managed inappropriately under the program. As a child consumed one more sachet of Plumpy'Nut, the recovery rate from SAM increased by 4% (HR = 1.04, 95%-CI = 1.03, 1.05, P<0.001). The adjusted hazard ratios to recovery of children with diarrhea, appetite loss with Plumpy'Nut and failure to gain weight were 2.20 (HR = 2.20, 95%-CI = 1.31, 3.41, P = 0.001), 4.49 (HR = 1.74, 95%-CI = 1.07, 2.83, P = 0.046) and 3.88 (HR = 1.95, 95%-CI = 1.17, 3.23, P<0.001), respectively. Children who took amoxicillin and de-worming had 95% (HR = 1.95, 95%-CI = 1.17, 3.23) and 74% (HR = 1.74, 95%-CI = 1.07, 2.83) more probability to recover from SAM as compared to those who didn't take them. CONCLUSIONS: The OTP was partially successful. Management of children with comorbidities under the program and partial administration of routine drugs were major threats for the program effectiveness. The stakeholders should focus on creating the capacity of the OTP providers on proper management of SAM to achieve fully effective program.

Beyond indicators: advances in global HIV monitoring and evaluation during the PEPFAR era.

Monitoring and evaluation (M&E) is fundamental to global HIV program implementation and has been a cornerstone of the President's Emergency Plan for AIDS Relief (PEPFAR). Rapid results were crucial to demonstrating feasibility and scalability of HIV care and treatment services early in PEPFAR. When national HIV M&E systems were nascent, the rapid influx of funds and the emergency expansion of HIV services contributed to the development of uncoordinated "parallel" information systems to serve donor demands for information. Close collaboration of PEPFAR with multilateral and national partners improved harmonization of indicators, standards, methods, tools, and reports. Concurrent PEPFAR investments in surveillance, surveys, program monitoring, health information systems, and human capacity development began to show signs of progress toward sustainable country-owned systems. Awareness of the need for and usefulness of data increased, far beyond discussions of indicators and reporting. Emphasis has turned toward ensuring the quality of data and using available data to improve the quality of care. Assessing progress toward an AIDS-free generation requires that the global community can measure the reduction of new HIV infections in children and adults and monitor the coverage, quality, and outcomes of highly efficacious interventions in combination. Building national M&E systems requires sustained efforts over long periods of time with effective leadership and coordination. PEPFAR, in close collaboration with its global and national partners, is well positioned to transform the successes and challenges associated with early rapid scale-up into future opportunities for sustainable, cost-effective, country-owned programs and systems.