It Takes a Village: Bringing Palliative Care to Ethiopia.

In Ethiopia, there is a great need for culturally relevant, sustainable palliative care. Profound poverty and limited health care resources magnify the impact of disease in Ethiopia, one of the poorest countries in the world. The impacts of high burden of disease and poor access to health care include physical suffering, and detrimental economic effects. Thus, the potential for palliative care to improve health care allocation and reduce suffering is substantial. An immediate action could include harnessing the infrastructure of the iddir, which are centuries-old, indigenous neighborhood organizations that provide care and support for families during the time of a death. We propose a model of community-based palliative care instantiated within iddirs, in which they are trained as volunteers to deliver basic palliative care. Shifting the gaze of global health research towards local solutions in Ethiopia may reveal sustainable, effective strategies to improve care for millions in this vulnerable population.

Performance of screening tools for cervical neoplasia among women in low- and middle-income countries: A systematic review and meta-analysis.

OBJECTIVE: To evaluate the performance of visual inspection with acetic acid (VIA) testing, visual inspection with Lugol's iodine (VILI), primary HPV testing, and conventional Pap smear in detecting CIN2+ among non-pregnant women aged 30-65 in LMICs between 1990 and 2020. DESIGN: Systematic review and meta-analysis. SETTING AND PARTICIPANTS: Low- and middle-income countries, non-pregnant women aged 30-65. METHODS: CENTRAL (Cochrane Library), CINAHL, Embase, Global Health, PubMed, and Web of Science databases were systematically searched to identify studies evaluating the performance of cervical cancer screening methods in LMICs. A diagnostic test accuracy meta-analysis was conducted to evaluate the performance of 4 screening methods in detecting CIN2+ relative to biopsy or cytology reference standards. Pooled statistics for sensitivity, specificity, diagnostic odds ratios, and summary receiver operating characteristic curves were determined for each method. Subgroup analyses were performed to examine whether there was variation in performance based on different reference standards for defining CIN2+, specifically: colposcopy-directed biopsy, biopsy alone, colposcopy alone, or liquid-based cytology. RESULTS: Eighteen studies were identified through systematic review. Twelve studies were included in meta-analysis; 11 were cross-sectional and 1 was a randomized controlled clinical trial. The remaining six of the eighteen studies were inclided in a narrative syntehsis. Pooled estimates for sensitivity for VIA, VILI, primary HPV testing, and conventional Pap smear were 72.3%, 64.5%, 79.5%, and 60.2%, respectively; pooled estimates for specificity were 74.5%, 68.5%, 72.6%, and 97.4%, respectively; the diagnostic odds ratios were 7.31, 3.73, 10.42, 69.48, respectively; and the area under the summary receiver operating characteristic curves were 0.766, 0.647, 0.959, and 0.818, respectively. Performance of the screening method varied based on the reference standard used; pooled estimates using either colposcopy-directed biopsy or biopsy alone as the reference standard generally reported lower estimates; pooled estimates using either colposcopy alone or liquid-based cytology as references reported higher estimates. CONCLUSIONS AND IMPLICATIONS: This meta-analysis found primary HPV testing to be the highest performing cervical cancer screening method in accurately identifying or excluding CIN2+. Further evaluation of performance at different CIN thresholds is warranted.

Calling non-governmental organisations to strengthen primary health care: Lessons following Alma-Ata.

BACKGROUND: The Alma-Ata Declaration's commitment to primary health care (PHC) reaches its 40th anniversary in 2018. Over the last 40 years, the number of non-governmental organisations (NGOs) working in low-income countries (LICs) has rapidly multiplied, and over time, NGOs have both positively and negatively impacted equity, effectiveness, appropriateness and efficiency of PHC systems in LICs. AIM: The authors aim to demonstrate that at the 40th anniversary of the Alma-Ata Declaration's commitment to PHC, NGOs are particularly poised to strengthen PHC in LICs. METHODS: In this letter, the authors reflect on how NGOs have both positively and negatively impacted equity, effectiveness, appropriateness and efficiency of PHC systems based on their experience working with NGOs in LICs. RESULTS: NGOs are poised to strengthen PHC in LICs in four distinct ways: assisting with local human resources development, strengthening local information systems, enabling community-based health services and testing innovative service delivery projects. CONCLUSIONS: The authors call for NGOs to commit their expertise and resources to long-term strengthening of PHC in LICs and to critically examine the factors that prevent or assist them in this goal. As the principles of Alma-Ata are renewed, NGOs should be responsibly engaged in strengthening the declaration's goal of 'health for all'.

Family Medicine Residents' Attitudes About Training in Ethiopia and the United States.

BACKGROUND AND OBJECTIVES: In Ethiopia, family medicine began in 2013. The objective of this study was to compare family medicine residents' attitudes about training in Ethiopia with those at a program in the United States. METHODS: Family medicine residents at Addis Ababa University in Addis Ababa, Ethiopia and the University of Maryland in Baltimore, Maryland completed a 43-item Likert scale survey in 2017. The survey assessed residents' attitudes about residency education, patient care, independence as family physicians, finances, impact of residency on personal life, and women's issues. We calculated descriptive statistics on the demographics data and analyzed survey responses using a two-sample t-test. RESULTS: A total of 18 (75%) Ethiopian residents and 18 (60%) US residents completed the survey (n=36). The Ethiopian residents had a wider age distribution (25-50 years) than the US residents (25-34 years). More US residents were female (72%) compared to the Ethiopian cohort (50%), while more Ethiopian residents were married (72%) compared to the US cohort (47%). There were statistically significant differences in attitudes toward patient care (P=0.005) and finances (P<0.001), differences approaching significance in attitudes toward residency education, and no significant differences in independence as family physicians, the impact of residency on personal life, and women's issues in family medicine. CONCLUSIONS: Across two very different cultures, resident attitudes about independence as family physicians, the impact of residency on personal life and women's issues, were largely similar, while cross-national differences in attitudes were found relative to residency education, patient care, and finances.