The effect of single low-dose primaquine treatment for uncomplicated Plasmodium falciparum malaria on haemoglobin levels in Ethiopia: a longitudinal cohort study.

BACKGROUND: To interrupt residual malaria transmission and achieve successful elimination of Plasmodium falciparum in low-transmission settings, the World Health Organization (WHO) recommends the administration of a single dose of 0.25 mg/kg (or 15 mg/kg for adults) primaquine (PQ) combined with artemisinin-based combination therapy (ACT), without glucose-6-phosphate dehydrogenase (G6PD) testing. However, due to the risk of haemolysis in patients with G6PD deficiency (G6PDd), PQ use is uncommon. Thus, this study aimed to assess the safety of a single low dose of PQ administered to patients with G6PD deficiency. METHODS: An observational cohort study was conducted with patients treated for uncomplicated P. falciparum malaria with either single-dose PQ (0.25 mg/kg) (SLD PQ) + ACT or ACT alone. Microscopy-confirmed uncomplicated P. falciparum malaria patients visiting public health facilities in Arjo Didessa, Southwest Ethiopia, were enrolled in the study from September 2019 to November 2022. Patients with uncomplicated P. falciparum malaria were followed up for 28 days through clinical and laboratory diagnosis, such as measurements of G6PD levels and haemoglobin (Hb) concentrations. G6PD levels were measured by a quantiative CareSTART™ POCT S1 biosensor machine. Patient interviews were also conducted, and the type and frequency of clinical complaints were recorded. Hb data were taken on days (D) 7, 14, 21, and 28 following treatment with SLD-PQ + ACT or ACT alone. RESULTS: A total of 249 patients with uncomplicated P. falciparum malaria were enrolled in this study. Of these, 83 (33.3%) patients received ACT alone, and 166 (66.7%) received ACT combined with SLD-PQ treatment. The median age of the patients was 20 (IQR 28-15) years. G6PD deficiency was found in 17 (6.8%) patients, 14 males and 3 females. There were 6 (7.2%) and 11 (6.6%) phenotypic G6PD-deficient patients in the ACT alone and ACT + SLD-PQ arms, respectively. The mean Hb levels in patients treated with ACT + SLD-PQ were reduced by an average of 0.45 g/dl (95% CI = 0.39 to 0.52) in the posttreatment phase (D7) compared to a reduction of 0.30 g/dl (95% CI = 0.14 to - 0.47) in patients treated with ACT alone (P = 0.157). A greater mean Hb reduction was observed on day 7 in the G6PDd ACT + SLD-PQ group (- 0.60 g/dL) than in the G6PDd ACT alone group (- 0.48 g/dL); however, there was no statistically significant difference (P = 0.465). Overall, D14 losses were 0.10 g/dl (95% CI = - 0.00 to 0.20) and 0.05 g/dl (95% CI = - 0.123 to 0.22) in patients with and without SLD-PQ, respectively (P = 0.412). CONCLUSIONS: This study's findings indicate that using SLD-PQ in combination with ACT is safe for uncomplicated P. falciparum malaria regardless of the patient's G6PD status in Ethiopian settings. Caution should be taken in extrapolating this finding in other settings with diverse G6DP phenotypes.

Anopheles larval habitats seasonality and environmental factors affecting larval abundance and distribution in Arjo-Didessa sugar cane plantation, Ethiopia.

BACKGROUND: Water resource development projects are essential for increasing agricultural productivity and ensuring food security. However, these activities require the modification of pre-existing environmental settings, which may alter mosquito larval habitat availability and seasonality. The intensive utilization of current adult vector control tools results in insecticide resistance among the main vectors. When coupled with behavioural resistances, a shift in malaria vector feeding and resting behaviours could compromise the effectiveness of the current adult vector control strategies. Thus, it is important to look for new or alternative vector control interventions for immatures to complement adult control by focusing on different larval habitats and their seasonal availability. Thus, this study investigated larval habitat seasonality and seasonal larval abundance and distribution in irrigated sugar cane plantation settings in Ethiopia. METHODS: Anopheles mosquito larval habitats were surveyed and visited twice a month for a period of 14 months. Anopheline larvae and pupae were collected, reared, and fed finely ground fish food. Adults were provided with sucrose solution and kept under standard conditions. Female Anopheles mosquitoes were identified morphologically and using a species-specific PCR assay. Environmental parameters, which include habitats' physico-chemical characteristics, were assessed. Larval habitat diversity and larval abundance and distribution were determined across different seasons. RESULTS: The study revealed that Anopheles gambiae sensu lato (s.l.) was the most predominant 4197(57%) vector species, followed by Anopheles coustani complex 2388 (32.8%). Molecular analysis of sub-samples of An. gambiae s.l. resulted in Anopheles arabiensis (77.9%) and Anopheles amharicus (21.5%), and the remaining 1.1% (n = 7) sub-samples were not amplified. Physico-chemical parameters such as temperature (t = 2.22, p = 0.028), conductivity (t = 3.21, p = 0.002), dissolved oxygen (t = 7.96, p = 0.001), nitrate ion (t = 2.51, p = 0.013), and ammonium ion (t = 2.26, p = 0.025) showed a significant and direct association with mosquito larval abundance. Furthermore, mosquito larval abundance was correlated with distance to the nearest houses (r = - 0.42, p = 0.001), exposure to sunlight (r = 0.34, p = 0.001), during long and short rainy season animal hoof prints, truck tires/road puddles and rain pools were negatively correlated (r = - 0.22, p = 0.01) and types of habitat (r = - 0.20, p = 0.01). Significant habitat type productivity were observed in man-made pools (t = 3.881, P = 0.01163), rain pools, animal hoof prints, (t = - 4.332, P = 0.00749 in both short and long rainy season, whereas, during dry seasons habitat type productivity almost similar and have no significance difference. CONCLUSION: The study found that different larval habitats had variable productivity in different seasons, and that physical and physicochemical features like ammonium and nitrate, as well as the distance between larval habitats and households, are related to larval production. As a result, vector control should take into account the seasonality of Anopheles larval habitat as well as the impact of pesticide application on larval source management.

Asymptomatic and submicroscopic malaria infections in sugar cane and rice development areas of Ethiopia.

BACKGROUND: Water resource development projects, such as dams and irrigation schemes, have a positive impact on food security and poverty reduction. However, such projects could increase prevalence of vector borne disease, such as malaria. This study investigate the impact of different agroecosystems and prevalence of malaria infection in Southwest Ethiopia. METHODS: Two cross-sectional surveys were conducted in the dry and wet seasons in irrigated and non-irrigated clusters of Arjo sugarcane and Gambella rice development areas of Ethiopia in 2019. A total of 4464 and 2176 study participants from 1449 households in Arjo and 546 households in Gambella enrolled in the study and blood samples were collected, respectively. All blood samples were microscopically examined and a subset of microscopy negative blood samples (n = 2244) were analysed by qPCR. Mixed effect logistic regression and generalized estimating equation were used to determine microscopic and submicroscopic malaria infection and the associated risk factors, respectively. RESULTS: Prevalence by microscopy was 2.0% (88/4464) in Arjo and 6.1% (133/2176) in Gambella. In Gambella, prevalence was significantly higher in irrigated clusters (10.4% vs 3.6%) than in non-irrigated clusters (p < 0.001), but no difference was found in Arjo (2.0% vs 2.0%; p = 0.993). On the other hand, of the 1713 and 531 samples analysed by qPCR from Arjo and Gambella the presence of submicroscopic infection was 1.2% and 12.8%, respectively. Plasmodium falciparum, Plasmodium vivax, and Plasmodium ovale were identified by qPCR in both sites. Irrigation was a risk factor for submicroscopic infection in both Arjo and Gambella. Irrigation, being a migrant worker, outdoor job, < 6 months length of stay in the area were risk factors for microscopic infection in Gambella. Moreover, school-age children and length of stay in the area for 1-3 years were significant predictors for submicroscopic malaria in Gambella. However, no ITN utilization was a predictor for both submicroscopic and microscopic infection in Arjo. Season was also a risk factor for microscopic infection in Arjo. CONCLUSION: The study highlighted the potential importance of different irrigation practices impacting on submicroscopic malaria transmission. Moreover, microscopic and submicroscopic infections coupled with population movement may contribute to residual malaria transmission and could hinder malaria control and elimination programmes in the country. Therefore, strengthening malaria surveillance and control by using highly sensitive diagnostic tools to detect low-density parasites, screening migrant workers upon arrival and departure, ensuring adequate coverage and proper utilization of vector control tools, and health education for at-risk groups residing or working in such development corridors is needed.

Exploring the perception of key stakeholders toward khat policy approaches in Ethiopia: a qualitative study.

BACKGROUND: Khat is an amphetamine-like plant, produced and commonly chewed in Ethiopia by a large group of the population. Although significant multidimensional harms of khat use have been reported, currently, there are no policies or organized activities against khat use in Ethiopia. Therefore, the current study aimed to explore the perception of key stakeholders toward khat policy approaches for Ethiopia. METHODS: A qualitative study was conducted using focus group discussion (FGD) and in-depth interview (IDI). Ten stakeholders participated in the IDIs, and another 15 individuals participated in the FGDs. Key stakeholders were appropriately mapped and purposively selected based on their experience related to khat use and khat harm reduction. Interviews and FGDs were led by the study authors and were audio-recorded. The audio-recorded data were transcribed verbatim and then translated into English language. The data were analyzed using thematic analysis approach. RESULTS: Participants preferred prevention and law regulation measures for khat policy approaches for Ethiopia. Proposed prevention and law regulation measures included regulating the transportation of khat, limiting the minimum age to buy and sell khat, prohibiting khat use at some public places, banning khat advertising and promotion, and imposing excise tax. Individual level khat harm reduction strategies were also proposed to be useful. However, the participants asserted that total khat ban in Ethiopia is not likely to be feasible and acceptable. CONCLUSION: Prevention, treatment or care for individuals with problematic khat use, law regulation, and harm reduction were preferred approaches by stakeholders for khat policy in Ethiopia instead of total banning.

Comparative efficacy and safety of anti-infective drugs for patients with mild to severe COVID-19: A systematic review and network meta-analysis of randomized controlled trials.

Background: Different anti-infective drugs have been proposed for the treatment of patients with COVID-19. We carried out a network meta-analysis to assess their relative efficacy and safety. Methods: We searched relevant databases for all randomized controlled trials that reported the efficacy and or safety of any anti-infective drugs published up to April 30, 2022 for different outcomes. We did both pairwise and network meta-analysis with 95% confidence intervals using a fixed-effect model. We assessed studies for quality of evidence using an extension of the standard Grading of Recommendations, Assessment, Development and Evaluation approach considering P<0.05 to be statistically significant. Results: We included 68 RCTs for 27,680 participants on 22 anti-infective drugs. For clinical recovery at 14 days Ivermectin (OR= 3.00, 95%CI: [1.82; 4.96]; p < 0.0001; moderate certainty evidence), Baricitinib plus Remdesivir (OR= 2.20, 95%CI: [1.35; 3.53]; p = 0.005; low certainty evidence), and Favipiravir (OR= 2.16, 95%CI: [1.27; 3.68]; p = 0.004; moderate certainty evidence) were statistically effective than standard of care. There was no statistically significant difference between treatments for the viral clearance at 14 days outcome and standard of care. In terms of death outcome, only combined therapy of Baricitinib and Remdesivir showed statistically significant risks of ratio (RR= 0.47, 95%CI: [0.23; 0.99]; p = 0.03). Arbidol (RR= 0.46, 95% CI: [0.23; 0.95]; p = 0.04) was statistically safe drug than standard of care. Conclusion: This Network Meta-analysis suggests that Baricitinib plus Remdesivir is more effective than the other anti-infective drugs in treating patients with COVID-19 in terms of clinical recovery at 14 days, mortality and adverse events outcomes.

Validation of the Problematic Khat Use Screening Test: A Cross-Sectional Study.

AIM: The study aimed to evaluate the psychometric properties of the Problematic Khat Use Screening Test (PKUST-17) in Ethiopia. METHODS: A validation study of PKUST-17 was carried out among 510 khat users, using a house-to-house survey. Confirmatory factor analysis and 2-parametric item response theory (IRT) were used to evaluate the construct validity of PKUST-17. We also used Spearman's rank-order correlation coefficient and other test statistics to assess the convergent validity of PKUST-17 with depression symptoms, functional impairment, and other characteristics of participants. We generated latent classes of problematic khat use using latent profile analysis (LPA) and validated the classes using multinomial logistic regression. RESULTS: The data confirm the unidimensional model of the PKUST-17. The internal consistency of PKUST-17 was excellent (Cronbach's alpha = 0.93). IRT discrimination parameters indicated that each item had a strong ability to distinguish participants across the spectrum of problematic khat use (α thresholds range from 1.02 to 2.9). The items were fairly or moderately severe to be endorsed by participants (ß thresholds vary from 1.43 to 5.57). The LPA identified three latent classes which have severity differences: mild (34%), moderate (34%), and severe (32%) problematic khat use. Depression symptoms, functional impairment, and other khat use patterns were also associated with moderate and severe problematic khat use class membership compared to mild problematic khat use class. CONCLUSION: We found that the PKUST-17 is a culturally appropriate, brief, easy to use, and psychometrically sound screening test. PKUST-17 can be used to screen khat users with different levels of risk for providing stepped care at different healthcare levels, including integration of services in primary care. Future studies need to test the predictive capacity of the PKUST-17 for khat-related harms.

Impact of COVID-19 on population health and economic wellbeing in Ethiopia: A national pilot survey.

Introduction: The COVD-19 pandemic has resulted in unprecedented global health and economic crisis, particularly in countries struggling with poverty. We conducted a national survey to understand the economic and health impacts of COVID-19 in Ethiopia. Methods: A pilot, population-based, cross-sectional survey was conducted among adults randomly selected from the Ethio Telecom list of mobile phone numbers. Participants underwent a comprehensive phone interview about the impact of COVID-19 on their economic well-being and the health-related risks associated with COVID-19. Results: Of 4,180 calls attempted, 1194 were answered, of which a successful interview was made with 614 participants. COVID-19 affected the family income of 343 [55.9%] participants, 56 [9.1%] lost their job, 105 [17.1%] perceived high stress in their household, and 7 [1.14%] reported death in their family in the past month. The odds of having a decreased income due to COVID-19 were 2.4 times higher among self-employed [adjusted odds ratio (AOR) 2.4, 95% CI (1.58-3.77)] and 2.8 times higher among unemployed [AOR 2.8, 95% CI (1.35-5.85)] participants. Two-hundred twenty-one [36%] participants had comorbidity in their household with hypertension, 72 [11.7%], diabetes,50 [8.1%], asthma, 48 [7.8%], and other chronic diseases, 51 [8.4%]. Forty-six [7.5%] participants had COVID-like symptoms in the previous month, where cough, headache, and fatigue were the most common. Conclusion: COVID-19 posed serious economic pressure on households. Self-employed and unemployed were the most affected. Continuous surveillance is needed to actively monitor the impact of COVID-19 in the community and safeguard the economic and health well-being of individuals and households.

Psychological distress among Ethiopian migrant returnees who were in quarantine in the context of COVID-19: institution-based cross-sectional study.

BACKGROUND: In association with the novel coronavirus (SARS-CoV-2) disease 2019 (COVID-19) pandemic, many numbers of Ethiopian migrants are returning to their home country, and they are required to stay in mandatory quarantine centers. This results in severe disruptions of life routines, social isolation, and loss of freedom. Studies on psychological distress among Ethiopian migrant returnees in the context of COVID-19 are scarce. This study aimed to investigate the prevalence of psychological distress and associated factors among migrant returnees who were in quarantine during the time of COVID-19. METHODS: A cross-sectional study was conducted with 405 migrant returnees recruited from quarantine centers in Addis Ababa. We developed a structured questionnaire to collect data on sociodemographic, migration related, quarantine related and COVID-19 related characteristics of participants. We used the 21 item Depression, Anxiety and Stress Scale to assess psychological distress. Univariate and multivariable negative binomial regression models were fitted to assess the association between exposure variables with depression, anxiety and stress separately. RESULTS: A little more than half of the participants (55%) had depressive symptoms; around half had anxiety symptoms (48.9%) and more than a third (35.6%) experienced symptoms of stress. We found significantly higher prevalence of anxiety (ARR = 0.59; 95% CI = 0.39, 0.91) and depressive symptoms (ARR = 0.56; 95% CI = 0.39, 0.81) among women than men. Fear of discrimination after the quarantine was significantly associated with depressive (ARR = 0.76; 95% CI = 0.63, 0.92) and anxiety symptoms (ARR = 0.77; 95% CI = 0.62, 0.97). Experiencing COVID-19 like symptoms is associated with depressive (ARR = 0.40; 95% CI = 0.25, 0.65), anxiety (ARR = 0.35; 95% CI = 0.20, 0.62) and stress symptoms (ARR = 0.43; 95% CI = 0.28, 0.66). Have no a plan of what to do after the quarantine (ARR = 1.30; 95% CI = 1.09, 1.54) was significantly associated with increasing stress scores. CONCLUSIONS: We found a very high prevalence of depressive, anxiety and stress symptoms among Ethiopian migrant returnees who were in quarantine due to the COVID-19 pandemic. Screening, integration of mental health services with other socioeconomic and psychosocial services, and effective and efficient referral may be useful to address the burden of psychological distress in this group.

Food insecurity and work impairment in people with severe mental disorders in a rural district of Ethiopia: a cross-sectional survey.

PURPOSE: In this study, we aimed to identify factors associated with severe food insecurity and work impairment in people with severe mental disorders (SMD) in a rural African setting, with a view to identifying potential areas for intervention. METHODS: A community-based, cross-sectional survey was conducted in Sodo district, south central Ethiopia. Key informant-identified people with possible SMD were referred for assessment by trained primary care workers and received confirmatory psychiatric diagnoses from psychiatric nurses using a standardized clinical interview. Food insecurity was measured using a locally validated measure, the Household Food Insecurity Access Scale (HFIAS). Work impairment was assessed using the Longitudinal Interval Follow-up Evaluation-Range of Impaired Functioning Tool. Potential moderator variables were specified a priori. RESULTS: A total of 282 people with SMD participated in the study. The proportion of participants reporting severe food insecurity was 32.5% (n = 94), with 53.6% (n = 147) of participants reporting severe work impairment. In the multivariable model, severe food insecurity was associated with poor social support, experience of negative discrimination, higher disability and lower household annual income, but not with symptom severity or work impairment. Work impairment was associated significantly with symptom severity and disability. CONCLUSION: Work impairment and food insecurity were associated with distinct explanatory factors: predominantly social factors associated with food insecurity and clinical factors associated with work productivity. Longitudinal and intervention studies are needed to evaluate the extent to which clinical interventions need to be augmented by social interventions to alleviate food insecurity in people with SMD.

Functional impairment among people with severe and enduring mental disorder in rural Ethiopia: a cross-sectional study.

PURPOSE: Evidence regarding functional impairment in people with severe mental disorders (SMD) is sparse in low- and middle-income countries. The aim of this study was to identify factors associated with functional impairment in people with enduring SMD in a rural African setting. METHODS: A cross-sectional study was conducted at the baseline of a health service intervention trial. A total of 324 participants were recruited from an existing community-ascertained cohort of people with SMD (n = 218), and attendees at the Butajira General Hospital psychiatric clinic (n = 106). Inclusion criteria defined people with SMD who had ongoing need for care: those who were on psychotropic medication, currently symptomatic or had a relapse in the preceding 2 years. The World Health Organization Disability Assessment schedule (WHODAS-2.0) and the Butajira Functioning Scale (BFS) were used to assess functional impairment. Multivariable negative binomial regression models were fitted to investigate the association between demographic, socio-economic and clinical characteristics, and functional impairment. RESULTS: Increasing age, being unmarried, rural residence, poorer socio-economic status, symptom severity, continuous course of illness, medication side effects, and internalized stigma were associated with functional impairment across self-reported and caregiver responses for both the WHODAS and the BFS. Diagnosis per se was not associated consistently with functional impairment. CONCLUSION: To optimize functioning in people with chronic SMD in this setting, services need to target residual symptoms, poverty, medication side effects, and internalized stigma. Testing the impact of community interventions to promote recovery will be useful. Advocacy for more tolerable treatment options is warranted.

Validation of the World Health Organization Disability Assessment Schedule in people with severe mental disorders in rural Ethiopia.

BACKGROUND: The World Health Organization Disability Assessment Schedule (WHODAS-2.0) has been adapted and validated in several cultures, but data on performance in the African context are lacking. The aim of the study was to evaluate the validity and psychometric properties of the WHODAS-2.0 among people with severe mental disorders (SMD) and their caregivers in a rural African setting. METHODS: The content validity of the 36 item WHODAS was assessed using free listing and pile sorting in 36 community members. Cognitive interviewing was conducted with 20 people with SMD and 20 caregivers to assess comprehensibility. Convergent validity and sensitivity to change were evaluated in a facility-based cohort study of new or acutely relapsed cases of people with SMD (n = 150) and their caregivers (n = 150) consecutively recruited from a psychiatric clinic. A repeat assessment was conducted in a sub-sample (n = 84) after 6 weeks. Confirmatory factor analysis was used to evaluate construct validity in people with SMD (n = 250) and their caregivers (n = 250). RESULTS: Internal consistency of the items of the overall scale and each domain ranged from very good (alpha = 0.82) to excellent (alpha = 0.98). Scores on the WHODAS-2.0 correlated highly with a locally developed measure of functioning (r = 0.88) and moderately with clinical symptom severity (r = 0.52). The WHODAS- 2.0 was sensitive to treatment changes (effect size = 0.50). As hypothesized, the six sub-scales loaded highly onto the general disability factor and each item loaded significantly onto their respective domains. The factor loadings of each item in the one factor model of the brief version of WHODAS (12 item) were also high. For both 12- and 36-item scales the goodness of fit indices, were close to, but outside of, recommended ranges. The caregiver data of both the 36 and 12 item versions had similar psychometric properties, but higher mean values and better responsiveness to change. CONCLUSIONS: Our study showed that both the 12 and 36 item versions of the WHODAS 2.0 have acceptable validity and psychometric properties and can be used as a cross-cultural measure; however, careful and rigorous adaptation is required for rural African settings.

Prevalence and associated factors of common mental disorders among Ethiopian migrant returnees from the Middle East and South Africa.

BACKGROUND: Ethiopian migrants to the Middle East and South Africa experience a range of problems at various stages of their migration including overwork, sleep deprivation, denial of food, emotional abuse, difficulty adapting to the host culture, salary denial, sexual abuse, labor exploitation, confiscation of their travel documents, confinement, denial of medication, lack of access to legal service and degrading attitude by employers, traffickers and smugglers. These experiences can be associated with different types of mental disorders. This study sought to determine the prevalence of common mental disorders (CMD) and socio-demographic and other migration related associated factors among Ethiopian migrant returnees from the Middle East and South Africa. METHOD: A cross-sectional study was conducted using non-probability (i.e. purposive, availability and snowball) sampling techniques. Migrant returnees (n = 1036) were contacted individually at their homes in eight high prevalent immigrant returnee locations in Ethiopia. Common mental disorders were assessed using the self-reporting questionnaire (SRQ-20) and a structured questionnaire was employed to collect data on socio-demographic and migration related characteristics. Data were analyzed using descriptive statistics, univariate logistic regression, and multivariable logistic regression. RESULTS: The prevalence of CMD among migrant returnees was found to be 27.6%. Highly prevalent specific CMD symptoms included headaches, poor appetite, being tired, sleeping problems, and feeling unhappy or nervous. Being originally from Amhara and Oromia regions, being Christian, being divorced, not receiving salary on time, not being able to contact family, unable to prepare for domestic labor abroad, lack of cross- cultural awareness, and lack of knowledge and skills for work were all important risk factors for CMD. Migrants experienced adversities at different stages of their migration which are associated with psychological distress and even to long term mental illnesses. CONCLUSIONS: CMD symptoms were found to be prevalent among Ethiopian migrant returnees. As pre-migration factors are associated with CMD symptoms, pre-departure training could be useful to mitigate the risk factors. Creating and routinely arranging mental health interventions and rehabilitation services are advisable for returnees who are screened for, or diagnosed with, mental health problems.

Developing a measure of mental health service satisfaction for use in low income countries: a mixed methods study.

BACKGROUND: Service satisfaction is integral to quality of care and measures are therefore considered important indicators of quality. Patient's responses to their experiences of using services are under-researched in the context of mental healthcare in low income countries. Our aim was to use mixed methods to develop a new measure of satisfaction for use among consumers of the new models of mental healthcare which are currently being scaled-up. METHODS: We used qualitative methods to explore the concept of service satisfaction. On the basis of these findings, we developed a new 'Mental health service satisfaction scale' (MHSSS v0.0) by adapting existing measures of service satisfaction. We evaluated psychometric properties of the new measure, among a sample of service users with severe mental disorder (SMD) (n = 200) and caregivers (n = 200). Following expert review, a modified version of the measure was developed (MHSSS v1.0) and psychometric properties were examined with data from a second independent sample (n = 150 service users with SMD and n = 150 caregivers). RESULTS: Factors identified in analysis of the first quantitative sample coincide with core concepts of service satisfaction as reported in the literature and were reflected in the key themes which emerged from our qualitative study: interpersonal factors, efficacy, communication, technical competency and adequacy of facilities. There was generally consensus among caregivers and service users regarding dimensions of satisfaction. However there was evidence of some differences in prioritization. Revisions made to version 0.0 of the Mental Health Service Satisfaction Scale (MHSSS) led to an improved instrument, with excellent internal consistency, convergent validity and factor loadings indicative of a uni-dimensional construct. CONCLUSIONS: Our findings suggest that conceptions of service satisfaction among people accessing a service for SMD are broadly similar with those established in the literature. Our findings indicate that the MHSSS might be a useful candidate for inclusion in the new toolkit of measures needed to facilitate monitoring of service satisfaction which will be crucial to quality improvement.

Development and validation of a contextual measure of functioning for people living with severe mental disorders in rural Africa.

BACKGROUND: Most measures of functioning in people with severe mental disorders (SMD) have been developed in Western societies. Many of the questions in these scales are culture-bound, fail to capture differentiation of tasks by gender and are difficult to adapt to other contexts. The aim of this study was to develop a measure of functioning for people with SMD which is contextually appropriate for a rural African setting. METHODS: A review of existing scales, a qualitative study, free listing and pile sorting exercises, and expert consensus were used to establish a pool of items. Cognitive interviewing guided initial item reduction and refinement. The resulting scale was pilot-tested in people with SMD (n = 200) and their caregivers (n = 200) to inform further item reduction based on psychometric properties. The final Butajira Functioning Scale (BFS) comprised 33 items that were common to both men and women, and an additional eight items for women only, covering the following domains: self-care, work, and family and community participation. Psychometric properties of the finalized BFS were examined in a facility-based sample of 150 people with SMD and their caregivers (n = 150), with longitudinal follow-up of n = 84. RESULTS: The BFS in people with SMD had excellent internal consistency (Cronbach's α = 0.99), acceptable convergent validity (r = 0.88 with the World Health Organization Disability Assessment Schedule [WHODAS-2.0] and r = 0.32 with the Brief Psychiatric Rating Scale [BPRS-E]) and was sensitive to change following treatment (effect size =0.50). Addition of the items specific to women did not improve the psychometric properties. The caregiver version had similar psychometric properties but higher mean values for each item and better responsiveness to change. Exploratory factor analysis of the BFS provided evidence of construct validity, with four underlying dimensions. CONCLUSIONS: We have developed a measure of functioning for people with SMD in a rural, low income country setting with acceptable psychometric properties. The BFS is easy to administer, sensitive to changes following treatment and has content, construct and convergent validity. The BFS includes domains from existing measures, but has more emphasis on social and occupational domains, which reflects priorities in the setting.

Conceptualizing and contextualizing functioning in people with severe mental disorders in rural Ethiopia: a qualitative study.

BACKGROUND: The functional outcome of people with severe mental disorders (SMD) is purported to be better in low- and middle-income countries compared to high-income countries; however, cross-cultural measures of functioning may not capture adequately the relevant functional activities in rural, non-Western settings. This study aimed to gain in-depth understanding of day-to-day functioning in a rural Ethiopian setting and the functional impairments associated with SMD. METHOD: A qualitative study was carried out in the Butajira area, south Ethiopia. In-depth interviews were conducted with people with SMD (n = 6), religious healers (n = 2) and psychiatric nurses (n = 2). Four focus group discussions were carried out with caregivers of people with SMD (n = 37) and one with project outreach workers (n = 5). A thematic analysis approach was used. RESULTS: Participants emphasized that functional impairment in people with SMD arose not only because of the symptoms associated with the illness, but also due to poverty, social exclusion and lack of social support. Within this rural community, the ability to work productively, engage in family life, maintain self-care and fulfill social obligations were the most highly valued domains of functioning. A wide range of farming tasks were elaborated in detail and noted to be of varying levels of difficulty. Although many people with symptomatic SMD were reported to be able to carry out simple farming tasks, this was distinguished from effective farming. Gender differences were most apparent in the domains of work and family life. Impaired functioning was reported to have a critical immediate impact on survival and longer-term impacts on the lifetime opportunities of people with SMD, their caregivers and the younger generation within the family. CONCLUSIONS: The study indicates that tackling social exclusion and poverty is needed alongside medical treatment through contextual community based rehabilitation programs. The gendering of functional roles and the complexity of work activities in this subsistence farming community lend support to arguments for locally contextualized measures of functioning in people with SMD.

Challenges and coping mechanisms of parents of children with attention deficit hyperactivity disorder in Addis Ababa, Ethiopia: a qualitative study.

BACKGROUND: Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder that has manifestations of inattention, hyperactivity, and impulsivity. It affects every facet of a child's life, including one's own emotions, family and school life, and social interaction. The few available studies on ADHD conducted in Ethiopia focus on teachers' awareness and the prevalence of ADHD. None of these studies has taken into account parents of children who have ADHD. The present study, therefore, aimed to find out the challenges and coping mechanisms of parents who have children with ADHD. METHODS: A phenomenological qualitative study was conducted to explore the experiences of parents who have children with ADHD. The study was carried out in Addis Ababa, the capital city of Ethiopia. Fourteen parents and two healthcare providers were involved in the study. Participants were selected using a purposive sampling technique. In-depth interviews were conducted with parents of children with ADHD (n = 8) and healthcare providers (n = 2). One focus group discussion (FGD), consisting of six members, was also conducted with parents. A topic guide for conducting the interviews and FGD was developed. Interviews and the FGD were audio-recorded. The data were transcribed verbatim, translated into English, and then analyzed using a thematic analysis approach. RESULTS: With regard to challenges of parents of children with ADHD, three themes emerged: social challenges, economic challenges and psychological challenges. Stigma is found to be the most common challenge. Other challenges included worry about the child's future, lack of social support, strained relationships with others, impact on their job, and marital conflict. Concerning coping mechanisms, two themes emerged: Inward and outward means of coping. The inward means of coping included prayer and developing an optimistic mindset whereas the outward means were family support, healthcare providers' guidance, and social avoidance. CONCLUSIONS: The study found that parents of children with ADHD experience several aspects of psychological, social, and economic challenges. Support from healthcare professionals, family members, and the community at large is found to be useful for parents to cope with these challenges. Future research should focus on evaluating interventions that would help parents with ADHD cope with the challenges they experience.

Developing interventions to improve detection of depression in primary healthcare settings in rural Ethiopia.

BACKGROUND: The poor detection of depression in primary healthcare (PHC) in low- and middle-income countries continues to threaten the plan to scale up mental healthcare coverage. AIMS: To describe the process followed to develop an intervention package to improve detection of depression in PHC settings in rural Ethiopia. METHOD: The study was conducted in Sodo, a rural district in south Ethiopia. The Medical Research Council's framework for the development of complex interventions was followed. Qualitative interviews, observations of provider-patient communication, intervention development workshops and pre-testing of the screening component of the intervention were conducted to develop the intervention. RESULTS: A multicomponent intervention package was developed, which included (a) manual-based training of PHC workers for 10 days, adapted from the World Health Organization's Mental Health Gap Action Programme Intervention Guide, with emphasis on depression, locally identified depressive symptoms, communication skills, training by people with lived experience and active learning methods; (b) screening for culturally salient manifestations of depression, using a four-item tool; (c) raising awareness among people attending out-patient clinics about depression, using information leaflets and health education; and (d) system-level interventions, such as supportive supervision, use of posters at health facilities and a decision support mobile app. CONCLUSIONS: This contextualised, multicomponent intervention package may lead to meaningful impact on the detection of depression in PHC in rural Ethiopia and similar settings. The intervention will be pilot tested for feasibility, acceptability and effectiveness before its wider implementation.

The effect of single low-dose primaquine treatment for uncomplicated Plasmodium falciparum malaria on hemoglobin levels in Ethiopia: a longitudinal cohort study.

Background: To interrupt residual malaria transmission and achieve successful elimination of P. falciparum in low-transmission settings, the World Health Organization (WHO) recommends the administration of a single dose of 0.25 mg/kg (or 15 mg/kg for adults) primaquine (PQ) combined with artemisinin-based combination therapy (ACT) without glucose-6-phosphate dehydrogenase (G6PD) testing. However, due to the risk of hemolysis in patients with G6PD deficiency (G6PDd), PQ use is not as common. Thus, this study aimed to assess the safety of a single low dose of PQ administered to patients with G6PD deficiency. Methods: An observational cohort study was conducted with patients treated for uncomplicated P. falciparum malaria with either single-dose PQ (0.25 mg/kg) (SLD PQ) + ACT or ACT alone. Microscopy-confirmed uncomplicated P. falciparum malaria patients visiting public health facilities in Arjo Didessa, Southwest Ethiopia, were enrolled in the study from September 2019 to November 2022. Patients with uncomplicated P. falciparum malaria were followed up for 28 days through clinical and laboratory diagnosis, such as measurements of G6PD levels and hemoglobin (Hb) concentrations. G6PD levels were masured by a quantiative biosensor machine. Patient interviews were also conducted, and the type and frequency of clinical complaints were recorded. Hb data were taken on days (D) 7, 14, 21, and 28 following treatment with SLD-PQ + ACT or ACT alone. Results: A total of 249 patients with uncomplicated P. falciparum malaria were enrolled in this study. Of these, 83 (33.3%) patients received ACT alone, and 166 (66.7%) received ACT combined with SLD-PQ treatment. The median age of the patients was 20 (IQR 14) years. G6PD deficiency was found in 17 (6.8%) patients, 14 males and 3 females. There were 6 (7.2%) and 11 (6.6%) phenotypic G6PD-deficient patients in the ACT alone and ACT + SLD-PQ arms, respectively. The mean Hb levels in patients treated with ACT + SLD-PQ were reduced by an average of 0.45 g/dl (95% CI = 0.39 to 0.52) in the posttreatment phase (D7) compared to a reduction of 0.30 g/dl (95% CI = 0.14 to -0.47) in patients treated with ACT alone (P = 0.157). A greater mean Hb reduction was observed on day 7 in the G6PD deficiency group (-0.56 g/dL) than in the G6PD normal group (-0.39 g/dL); however, there was no statistically significant difference (P = 0.359). Overall, D14 losses were 0.10 g/dl (95% CI = -0.00 to 0.20) and 0.05 g/dl (95% CI = -0.123 to 0.22) in patients with and without SLD-PQ, respectively (P = 0.412). Conclusions: Our findings showed that single low-dose primaquine (SLD-PQ) treatment for uncomplicated P. falciparum malaria is safe and does not increase the risk of hemolysis in G6PDd patients. This evidence suggests that the wider deployment of SLD-PQ for P. falciparum is part of a global strategy for eliminating P. falciparum malaria.

Higher outdoor mosquito density and Plasmodium infection rates in and around malaria index case households in low transmission settings of Ethiopia: Implications for vector control.

BACKGROUND: Understanding the clustering of infections for persistent malaria transmission is critical to determining how and where to target specific interventions. This study aimed to determine the density, blood meal sources and malaria transmission risk of anopheline vectors by targeting malaria index cases, their neighboring households and control villages in Arjo-Didessa, southwestern Ethiopia. METHODS: An entomological study was conducted concurrently with a reactive case detection (RCD) study from November 2019 to October 2021 in Arjo Didessa and the surrounding vicinity, southwestern Ethiopia. Anopheline mosquitoes were collected indoors and outdoors in index case households and their surrounding households (neighboring households), as well as in control households, using pyrethrum spray cache (PSC) and U.S. Centers for Disease Control and Prevention (CDC) light traps. Adult mosquitoes were morphologically identified, and speciation in the Anopheles gambiae complex was done by PCR. Mosquito Plasmodium infections and host blood meal sources were detected by circumsporozoite protein enzyme-linked immunosorbent assay (CSP-ELISA) and cytochrome b-based blood meal PCR, respectively. RESULTS: Among the 770 anopheline mosquitoes collected, An. gambiae sensu lato (A. gambiae s.l.) was the predominant species, accounting for 87.1% (n = 671/770) of the catch, followed by the Anopheles coustani complex and Anopheles pharoensis, which accounted for 12.6% (n = 97/770) and 0.26% (n = 2/770) of the catch, respectively. From the sub-samples of An. gambiae s.l.analyzed with PCR, An. arabiensis and Anopheles amharicus were identified. The overall mean density of mosquitoes was 1.26 mosquitoes per trap per night using the CDC light traps. Outdoor mosquito density was significantly higher than indoor mosquito density in the index and neighboring households (P = 0.0001). The human blood index (HBI) and bovine blood index (BBI) of An. arabiensis were 20.8% (n = 34/168) and 24.0% (n = 41/168), respectively. The overall Plasmodium sporozoite infection rate of anophelines (An. arabiensis and An. coustani complex) was 4.4% (n = 34/770). Sporozoites were detected indoors and outdoors in captured anopheline mosquitoes. Of these CSP-positive species for Pv-210, Pv-247 and Pf, 41.1% (n = 14/34) were captured outdoors. A significantly higher proportion of sporozoite-infected mosquitoes were caught in index case households (5.6%, n = 8/141) compared to control households (1.1%, n = 2/181) (P = 0.02), and in neighboring households (5.3%, n = 24/448) compared to control households (P = 0.01). CONCLUSIONS: The findings of this study indicated that malaria index cases and their neighboring households had higher outdoor mosquito densities and Plasmodium infection rates. The study also highlighted a relatively higher outdoor mosquito density, which could increase the potential risk of outdoor malaria transmission and may play a role in residual malaria transmission. Thus, it is important to strengthen the implementation of vector control interventions, such as targeted indoor residual spraying, long-lasting insecticidal nets and other supplementary vector control measures such as larval source management and community engagement approaches. Furthermore, in low transmission settings, such as the Arjo Didessa Sugarcane Plantation, providing health education to local communities, enhanced environmental management and entomological surveillance, along with case detection and management by targeting of malaria index cases and their immediate neighboring households, could be important measures to control residual malaria transmission and achieve the targeted elimination goals.