Active close contact investigation of tuberculosis through computer-aided detection and stool Xpert MTB/RIF among people living in Oromia Region, Ethiopia (CADOOL Study): protocol for a prospective, cross-sectional study.

INTRODUCTION: Pulmonary tuberculosis (TB) is an infectious disease with high incidence in low-income countries (LICs); it remains one of the infectious diseases with the highest mortality in the world, especially in LICs. It is crucial to recognise and diagnose TB as soon as possible, but microbiological tests on sputum are not always sensitive enough. New methods for an early diagnosis of TB are needed. In this study, we will investigate the role of two different tests to detect TB in Ethiopia (where the prevalence of TB is high): molecular search for TB in stool samples with Xpert assay and detection of pulmonary TB signs on chest X-rays with CAD4TB technology. METHODS AND ANALYSIS: A prospective diagnostic test accuracy study during TB active contact investigation will be conducted. In the referral hospital in Southwest Shoa Zone, Oromia Region, Ethiopia, patients with pulmonary TB and a sputum sample positive for Mycobacterium tuberculosis and household contacts of at least 4 years of age will be enrolled, with a target sample size of 231 patients. Trained staff will label household contacts as 'possible TB' cases or not according to their symptoms; when TB is possible, a stool Xpert and computer-aided detection on chest X-ray will be performed, alongside standard diagnostic methods, assessing the diagnostic accuracy of CAD4TB compared with Xpert MTB/RIF during TB contact investigation and the accuracy of stool Xpert compared with sputum Xpert. ETHICS AND DISSEMINATION: This study has been approved by the Oromia Health Bureau Research Ethics Committee (ref no BFO/MBTFH/1-16/100023). All information obtained will be kept confidential. Selected investigators will have access to data, while international partners will sign a dedicated data protection agreement. Eligible participants will receive brief information about the study before being asked to participate and they will provide written informed consent. Results will be disseminated through peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT05818059.

Adherence to WHO guidelines on severe pneumonia management in children and its impact on outcome: an observational study at Jinka General Hospital in Ethiopia.

Introduction: Poor adherence to guidelines during empirical antibiotic prescription in low-income countries could increase antimicrobial resistance without improving outcomes. Revised World Health Organization (WHO) guidelines published in 2014 on childhood (2-59 months) pneumonia re-defined the classification of severe pneumonia and changed the first-line treatment. The adherence to WHO guidelines in southern Ethiopia at the hospital level is unknown. We sought to determine the adherence to WHO guidelines on severe pneumonia first-line treatment in children in an Ethiopian referral hospital and assess the impact of non-adherence on patient outcomes. Methods: An observational study was conducted on all children (2-59 months) clinically diagnosed with severe pneumonia and admitted to the Pediatric Ward of Jinka Hospital from 1 June 2021 to 31 May 2022. Exclusion criteria included a known HIV infection, ongoing antibiotic treatment before the event not related to acute pneumonia, or any other severe bacterial infection, confirmed or suspected. Adherence to guidelines was defined as first-line treatment with ampicillin or benzylpenicillin and gentamicin at the recommended dose. We compared the patients treated adherently vs. non-adherently. For categorical variables, the chi-square or Fisher's exact test was used, while for continuous variables, the Mann-Whitney U-test was used. Multivariate logistic regression was used to evaluate the association between adherence and demographic and clinical characteristics. Results: During the observational period, 266 patients were registered as having severe pneumonia with an age between 2 and 59 months. After excluding 114 patients due to missing charts or other exclusion criteria, a total of 152 patients were included in the analysis. Of these, 78 (51%) were girls with a median age of 10 months (IQR 7-14). Overall, 75 (49%) patients received therapy according to the WHO guidelines. Compared to patients treated adherently to the guidelines, patients not treated adherently had similar outcomes [median length of stay of 3 (IQR 3-5) and 4 (IQR 3-6) days], median duration of oxygen therapy of 2 (IQR 1-3) for both the groups, and self-discharge rates of 5% and 6.5%, respectively). Conclusion: Adherence to the revised WHO guideline was limited and not associated with outcomes. Efforts should focus on reducing the gap between theory and practice.

Priority age targets for COVID-19 vaccination in Ethiopia under limited vaccine supply.

The worldwide inequitable access to vaccination claims for a re-assessment of policies that could minimize the COVID-19 burden in low-income countries. Nine months after the launch of the national vaccination program in March 2021, only 3.4% of the Ethiopian population received two doses of COVID-19 vaccine. We used a SARS-CoV-2 transmission model to estimate the level of immunity accrued before the launch of vaccination in the Southwest Shewa Zone (SWSZ) and to evaluate the impact of alternative age priority vaccination targets in a context of limited vaccine supply. The model was informed with available epidemiological evidence and detailed contact data collected across different geographical settings (urban, rural, or remote). We found that, during the first year of the pandemic, the mean proportion of critical cases occurred in SWSZ attributable to infectors under 30 years of age would range between 24.9 and 48.0%, depending on the geographical setting. During the Delta wave, the contribution of this age group in causing critical cases was estimated to increase on average to 66.7-70.6%. Our findings suggest that, when considering the vaccine product available at the time (ChAdOx1 nCoV-19; 65% efficacy against infection after 2 doses), prioritizing the elderly for vaccination remained the best strategy to minimize the disease burden caused by Delta, irrespectively of the number of available doses. Vaccination of all individuals aged ≥ 50 years would have averted 40 (95%PI: 18-60), 90 (95%PI: 61-111), and 62 (95%PI: 21-108) critical cases per 100,000 residents in urban, rural, and remote areas, respectively. Vaccination of all individuals aged ≥ 30 years would have averted an average of 86-152 critical cases per 100,000 individuals, depending on the setting considered. Despite infections among children and young adults likely caused 70% of critical cases during the Delta wave in SWSZ, most vulnerable ages should remain a key priority target for vaccination against COVID-19.

International medical electives in Sub-Saharan Africa: experiences from a 19-year NGO-driven initiative.

BACKGROUND: Mainstream medical education remains largely focused on national health issues. Therefore, in order to expose medical students to international health issues, it is beneficial to facilitate international medical electives. METHODS: This article describes the Junior Project Officer (JPO) program, a medical experience based on clinical electives in Sub-Saharan Africa, supported by a Non-Governmental Organisation (NGO). Residents spend 6 months as part of a multidisciplinary medical team in Africa. A post-elective online survey was administered to all who participated in the program in the period 2002-2020. The questionnaire comprised three domains: (i) general and pre-departure information; (ii) the experience; (iii) the post-experience. RESULTS: Questionnaires were received from 157/241 subjects, a response rate of 65%. The most common specialties were pediatrics, public health, and internal medicine. Of all, 87% carried out clinical activities; 45% also worked in the management of health services, and 60% carried out research activities. About 64% reported difficulties linked to a lack of equipment, different ways of working (57%), and exposure to situations for which they did not feel technically prepared (56%). In 25% of cases, residents reported that their school's attitude to their doing the elective was not positive: upon their return, over 50% felt that their experience was not sufficiently valued by their institution. Respondents considered the experience important for professional and personal growth (93% and 80% respectively ). Forty-two participants (27%) reported that the experience had a significant impact on their future career choices. CONCLUSION: Despite the difficulties encountered, a well-structured experience in international health can have a positive impact on residents, professionally and personally. Key factors behind the positive outcomes are the substantial length (6 months) of the experience, and the long term working relationships between the sending and receiving institutions. The schools in Italy that provide the students for the electives need to see more evidence that international electives are worth the investment.

Epidemiological factors affecting outpatient department service utilization and hospitalization in patients with diabetes: A time-series analysis from an Ethiopian hospital between 2018 and 2021.

Background: The burden of diabetes-related deaths reached two million in 2019 globally. Accessibility to health care services and adherence to follow-up and therapy are key to improving outcomes for diabetic patients. We aimed to assess outpatient department (OPD) service utilization and diabetes-related hospitalizations over a period of 44 months. Methods: A retrospective cohort study was conducted on OPD visits and hospitalizations recorded between January 1, 2018, and August 31, 2021, at the St Luke Catholic Hospital (Ethiopia). All diabetic patients were included in the analysis. A linear regression model was used for univariate analysis of OPD visits and hospitalizations and their association with potential predictors. The autoregressive integrated moving average (ARIMA) method was applied to both the time series of OPD visits and hospitalizations. Potential predictors were sociodemographic factors, COVID-19 cases, mean monthly temperature and precipitations. Results: In the time series analysis, OPD visits increased over time (P < 0.01) while hospitalizations were stable. The time series model was ARIMA (0,1,1) for OPD visits and ARIMA (0,0,0) for hospitalizations. There were 1685 diabetes OPD patients (F = 732, 43%). Females had an average of 16% fewer OPD accesses per month (P < 0.01) and a lower number of hospitalizations per month (P = 0.03). There were 801 patients missing follow-up (48%). The time between follow-up increased with age (P < 0.01). OPD visits decreased differently by geographic area as COVID-19 cases increased (P < 0.01). There were 57 fewer forecast OPD visits per month on average using COVID-19 cases as ARIMA regressor. The odds ratio (OR) of new diagnosis at hospitalization was lower in patients with type 2 diabetes (OR = 0.26, 95% CI = 0.14-0.49, P = 0.02). Conclusions: Despite an increase in OPD visits for diabetic patients over the study period, the number of losses at follow-up and diagnoses at hospitalization remains high. Female sex, older age, and COVID-19 were associated with impaired OPD service accessibility. Primary health care should be implemented to achieve better health coverage and improve diabetes management.

Medical Electives in Sub-Saharan Africa: A 15-Year Student/NGO-Driven Initiative.

Medical schools are developing global health programmes, and medical students are requesting global health training and creating opportunities when these are not provided by medical schools. This article described the Wolisso Project (WP), a medical experience on clinical electives in Sub-Saharan Africa, driven by a collaboration between a student organisation and a Nongovernmental Organization (NGO). Preclinical medical students spent 4 weeks as part of a multidisciplinary medical team in Africa. Post-elective questionnaires were administered to all subjects who participated in the project. Of all, 141 students responded to the questionnaire. The participants came from 30 Italian universities. The main difficulties reported are due to the lack of resources for the exercise of the medical activity, and difficulties related to language and communication. The African experience had a positive impact on the progress of the studies upon return, with an increase in determination and motivation. The experience had also positive influences on the future professional choices and carriers. The experience seems to contribute not only to the professional growth, but also to the personal development. A key factor in the positive outcomes of this experience is it being implemented by an NGO with long-term working relationships with the African populations. Another is that the project is carried out in health facilities where NGO staff have been working for a long time. These factors reduce the potential risks connected with this type of experience. They ensure a satisfactory level of supervision, the lack of which has been a serious problem in many similar experiences. A well-structured, mentored experience in international health can have a positive impact on preclinical students' attitudes, including their compassion, volunteerism, and interest in serving underserved populations. Only a small number of Italian universities facilitate pre-graduate medical elective experiences in LMICs. The WP seems to be attempting to compensate for the lack of international experience in LMICs offered by universities. Italian medical schools should incorporate changes in their curricula to train socially responsible physicians.

Parents' Experience and Satisfaction in Neonatal Intensive Care Units in Ethiopia: A Multicenter Cross-Sectional Study Using an Adapted Version of EMPATHIC-N.

Background: In neonatal intensive care units (NICU) setting, parents' experience and satisfaction permit to evaluate clinical practice and improve the care of infants and parents. Little is known about this topic in low resource settings. The aim of this study was to (1) translate, adapt and validate the EMpowerment of PArents in THe Intensive Care-Neonatology (EMPHATIC-N) questionnaire in two languages in Ethiopia (2) explore parents' satisfaction with the care received in the NICUs in three hospitals; and, (3) explore socio-demographic characteristics and level of the NICU influence on the EMPATHIC-N domains. Methods: This was a cross-sectional multicenter study. Participants were recruited from three different NICUs in Ethiopia upon discharge. We reduced the original EMPATHIC-N instrument to 38 items, culturally adapted and validated it in two local languages. Confirmatory Factor Analysis (CFA) was applied to verify the factor structure of the questionnaire, investigating the relationship between items and the five latent domains. Single item scores and the aggregate scores of the domains were investigated across NICUs and in the sample overall. Differences in the distribution of the domain scores were tested according to socio-demographic participants' characteristics. The scores of four general questions about overall experience and satisfaction were investigated in relation to the participant's characteristics and NICU levels. Qualitative data were collected using four open-ended questions and a synthesis of results was provided. Results: Almost all the parents answered to the questionnaire (92%, n = 386). Questionnaire items on satisfaction on average scored more than four. The highest mean scores were obtained for Parental participation (median: 5.17; iqr: 4.67-5.62), while they were lower for Organization/Hospital environment (median: 4.67; iqr:4.33-5.17). Different levels of parent satisfaction were observed across the NICU levels showing a statistically higher satisfaction in level II NICU compared to the other levels. Education, place of residence and length of stay were associated with parental satisfaction and experience. Conclusion: This study validated two Ethiopian versions of the EMPATHIC-N questionnaire to assess parents' experience and satisfaction during their child's stay in the NICU. The differences found across the three levels of NICU suggest the need to further investigate the determinants of satisfaction.

The effectiveness of maternity waiting homes in reducing perinatal mortality: a case-control study in Ethiopia.

BACKGROUND: The 2030 Agenda for Sustainable Development aims to reduce neonatal mortality to at least 12 per 1000 live births. Most of the causes can be prevented or cured. Access to quality healthcare during pregnancy and labour is the key to reduce perinatal deaths, and maternity waiting homes (MWHs) may have an impact, especially for women who live far from the healthcare system. We conducted a case-control study to evaluate the effectiveness of MWH in reducing perinatal mortality in a secondary hospital in Ethiopia. METHODS: We did a nested case-control study from January 2014 through December 2017. The enrolled cases were mothers whose childbirth resulted in stillbirth or early neonatal death. The controls were mothers with an alive baby at 7 days or with an alive baby on discharge. We collected demographic, anamnestic, pregnancy-related and obstetric-related data. The effectiveness of the MWH on perinatal death was assessed by a logistic regression model, adjusted for all other variables investigated as potential confounders. We also did a sensitivity analysis to explore the role of twin pregnancies. RESULTS: We included 1175 cases and 2350 controls. The crude analysis showed a protective effect of the MWH towards perinatal mortality (OR=0.700; 95% CI: 0.505 to 0.972), even more protective after adjustment for confounders (adjusted OR (AOR)=0.452; 95% CI: 0.293 to 0.698). Sensitivity analyses showed a consistent result, even excluding twin pregnancies (AOR=0.550; 95% CI: 0.330 to 0.917). CONCLUSION: MWHs appear to reduce perinatal mortality by 55%. Our findings support the decision to invest in MWH to support pregnant women with higher quality and more comprehensive healthcare strategy, including quality antenatal care in peripheral primary care clinics, where risk factors can be recognised and women can be addressed for admission to MWH.

Modeling the interplay between demography, social contact patterns, and SARS-CoV-2 transmission in the South West Shewa Zone of Oromia Region, Ethiopia.

BACKGROUND: COVID-19 spread may have a dramatic impact in countries with vulnerable economies and limited availability of, and access to, healthcare resources and infrastructures. However, in sub-Saharan Africa, a low prevalence and mortality have been observed so far. METHODS: We collected data on individuals' social contacts in the South West Shewa Zone (SWSZ) of Ethiopia across geographical contexts characterized by heterogeneous population density, work and travel opportunities, and access to primary care. We assessed how socio-demographic factors and observed mixing patterns can influence the COVID-19 disease burden, by simulating SARS-CoV-2 transmission in remote settlements, rural villages, and urban neighborhoods, under school closure mandate. RESULTS: From national surveillance data, we estimated a net reproduction number of 1.62 (95% CI 1.55-1.70). We found that, at the end of an epidemic mitigated by school closure alone, 10-15% of the population residing in the SWSZ would have been symptomatic and 0.3-0.4% of the population would require mechanical ventilation and/or possibly result in a fatal outcome. Higher infection attack rates are expected in more urbanized areas, but the highest incidence of critical disease is expected in remote subsistence farming settlements. School closure contributed to reduce the reproduction number by 49% and the attack rate of infections by 28-34%. CONCLUSIONS: Our results suggest that the relatively low burden of COVID-19 in Ethiopia observed so far may depend on social mixing patterns, underlying demography, and the enacted school closures. Our findings highlight that socio-demographic factors can also determine marked heterogeneities across different geographical contexts within the same region, and they contribute to understand why sub-Saharan Africa is experiencing a relatively lower attack rate of severe cases compared to high-income countries.

"This Is Not Our Disease": A Qualitative Study of Influencers of COVID-19 Preventive Behaviours in Nguenyyiel Refugee Camp (Gambella, Ethiopia).

The COVID-19 pandemic has infected more than 263 million people and claimed the lives of over 5 million people worldwide. Refugees living in camp settings are particularly vulnerable to infection because of the difficulty implementing preventive measures and lack of medical resources. However, very little is known about the factors that influence the behavioural response of refugees towards COVID-19. There is an urgent need for field evidence to inform the design and implementation of a robust social and behaviour change communication strategy to respond to the threat posed by COVID-19 in humanitarian settings. This study examines factors influencing COVID-19-related behavioural decisions in the Nguenyyiel refugee camp located in Gambella, Ethiopia using data collected from focus group discussions and key informant interviews in September 2020. The evidence suggests that while a number of factors have been facilitating the adoption of COVID-19 prevention measures, including good general knowledge about the virus and the necessary preventive strategies and the active engagement by community leaders and non-governmental organisations, important structural and cultural factors have hindered the uptake of COVID-19 prevention measures. These include: difficultly staying at home to minimise physical contact; overcrowding in the camp and within home dwellings; a lack of hand sanitizers and masks and of funds to purchase these; inconsistent use of facemasks when available; COVID-19 denial and misconceptions about the disease, and other cultural beliefs and habits. Overall, the study found that refugees perceived COVID-19 to pose a low threat (susceptibility and severity) and had mixed beliefs about the efficacy of preventive behaviours. This study identified gaps in the existing information education and communication strategy, including a lack of consistency, inadequate messaging, and a limited use of communication channels. While awareness of COVID-19 is a necessary first step, it is not sufficient to increase adoption of prevention measures in this setting. The current communication strategy should move beyond awareness raising and emphasise the threat posed by COVID-19 especially among the most vulnerable members of the camp population. This should be accompanied by increased community support and attention to other barriers and incentives to preventive behaviours.

The hidden burden of measles in Ethiopia: how distance to hospital shapes the disease mortality rate.

BACKGROUND: A sequence of annual measles epidemics has been observed from January 2013 to April 2017 in the South West Shoa Zone of the Oromia Region, Ethiopia. We aimed at estimating the burden of disease in the affected area, taking into account inequalities in access to health care due to travel distances from the nearest hospital. METHODS: We developed a dynamic transmission model calibrated on the time series of hospitalized measles cases. The model provided estimates of disease transmissibility and incidence at a population level. Model estimates were combined with a spatial analysis to quantify the hidden burden of disease and to identify spatial heterogeneities characterizing the effectiveness of the public health system in detecting severe measles infections and preventing deaths. RESULTS: A total of 1819 case patients and 36 deaths were recorded at the hospital. The mean age was 6.0 years (range, 0-65). The estimated reproduction number was 16.5 (95% credible interval (CI) 14.5-18.3) with a cumulative disease incidence of 2.34% (95% CI 2.06-2.66). Three thousand eight hundred twenty-one (95% CI 1969-5671) severe cases, including 2337 (95% CI 716-4009) measles-related deaths, were estimated in the Woliso hospital's catchment area (521,771 inhabitants). The case fatality rate was found to remarkably increase with travel distance from the nearest hospital: ranging from 0.6% to more than 19% at 20 km. Accordingly, hospital treatment prevented 1049 (95% CI 757-1342) deaths in the area. CONCLUSIONS: Spatial heterogeneity in the access to health care can dramatically affect the burden of measles disease in low-income settings. In sub-Saharan Africa, passive surveillance based on hospital admitted cases might miss up to 60% of severe cases and 98% of related deaths.

Evaluation of a maternal health care project in South West Shoa Zone, Ethiopia: before-and-after comparison.

BACKGROUND: Despite recent achievements in health targets, Ethiopia still faces challenges in health service delivery. Between 2012 and 2015, a non-governmental organisation (NGO), Doctors with Africa CUAMM, implemented a multifaceted project aimed at improving access to maternal and child health services in three districts in Ethiopia. This paper evaluates the performance of this project, based on four maternal health indicators. METHODS: A before-and-after study utilising data collected through cross-sectional surveys involving 999 women was conducted. The date of delivery was used to stratify the intervention period as follows: pre-intervention, early intervention, and late intervention. Changes during the intervention in the coverage of four antenatal care (ANC) visits, receipt of three basic components of ANC, skilled birth attendant (SBA) at delivery, and postnatal care (PNC) in seven days were assessed using logistic regression, adjusting for socio-demographic factors. RESULTS: There was an increase in the coverage of receipt of all three ANC components and SBA at delivery between the pre-intervention period and the late intervention period. The percent of health centre deliveries increased from 7.3 % in the pre-intervention period to 35.6 % in the late intervention period. The odds of receiving all three components of ANC were twice higher in the late intervention period than in the pre-intervention period (OR 2.09; 95 % CI 1.12-3.89). The odds of SBA at delivery were five times higher in the late intervention period than in the pre-intervention period (OR 5.04; 95 % CI 2.53-10.06). There was no significant change in the coverage of four ANC visits and PNC after accounting for sociodemographic factors. CONCLUSIONS: This NGO implemented maternal health project in three districts in Ethiopia was associated with increased likelihood that a pregnant woman would receive three basic components of ANC and be assisted by a SBA at delivery. Increase in skilled birth attendance was driven by increased utilisation of health centres. More efforts are needed to bolster the coverage of ANC and PNC.

Is a woolen cap effective in maintaining normothermia in low-birth-weight infants during kangaroo mother care? Study protocol for a randomized controlled trial.

BACKGROUND: Neonatal hypothermia is an important challenge associated with morbidity and mortality. Preventing neonatal hypothermia is important in high-resource countries, but is of fundamental importance in low-resource settings where supportive care is limited. Kangaroo mother care (KMC) is a low-cost intervention that, whenever possible, is strongly recommended for temperature maintenance. During KMC, the World Health Organization (WHO) guidelines recommend the use of a cap/hat, but its effect on temperature control during KMC remains to be established. In the hospitals participating in the projects of the non-governmental organization CUAMM, KMC represents a standard of care, but the heads of the babies often remain uncovered due to local habits or to the unavailability of a cap. The aim of the present study will be to assess the effectiveness and safety of using a woolen cap in maintaining normothermia in low-birth-weight infants (LBWI) during KMC. METHODS/DESIGN: This is a multicenter (three hospitals), multicountry (three countries), prospective, unblinded, randomized controlled trial of KMC treatment with and without a woolen cap in LBWI. After obtaining parental consent, all infants with a birth weight below 2500 g and who are candidates for KMC, based on the clinical decision of the attending physician, will be assigned to the KMC with a woolen cap group or to the KMC without a woolen cap group in a 1:1 ratio according to a computer-generated, randomized sequence. The duration of the study will be until the patient's discharge, with a maximum treatment duration of 7 days. The primary outcome measure will be whether the infants' temperatures remain within the normal range (36.5-37.5 °C) in the course of KMC during the intervention. In all participants, axillary temperature will be measured with a digital thermometer four times per day. In addition, maternal and room temperature will be recorded. Secondary outcome measures will be: episodes of apnea; sepsis; mortality before hospital discharge; in-hospital growth; and age at discharge. DISCUSSION: The findings of this study will be important for other units/settings in high- as well low-resource countries where KMC is routinely performed. Based on the results of the present study, we could speculate whether the use of a woolen cap may help to maintain the neonate within the normal thermal range. Furthermore, potential complications such as hyperthermia will be strictly monitored and collected. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02645526 (registered on 31 December 2015).

Ambulance referral for emergency obstetric care in remote settings.

OBJECTIVE: To evaluate the functionality of an ambulance service dedicated to emergency obstetric care (EmOC) that referred pregnant women to health centers for delivery assistance or to a hospital for the management of obstetric complications. METHODS: A retrospective study investigated an ambulance referral system for EmOC in a rural area of Ethiopia between July 1 and December 31, 2013. The service was available 24h a day and was free of charge. Women requesting referral were transported to nearby health centers. Assistance was provided locally for uncomplicated deliveries. Women with obstetric complications were referred from health centers to a hospital. RESULTS: A total of 528 ambulance referrals were recorded. The majority of patients (314 [59.5%]) were transported from villages to health centers. The remaining individuals were brought to a hospital, having been referred from health centers (179 [33.9%]) or were referred directly from villages owing to hospital proximity (35 [6.6%]). Of the 179 patients referred to the hospital from health centers, 84 (46.9%) were diagnosed with major direct obstetric complications. No maternal deaths were recorded among patients using the ambulance service. The cost of the ambulance service was US$ 18.47 per referred patient. CONCLUSIONS: An ambulance service dedicated to EmOC that interconnected health centers and a hospital facilitated referrals and better utilized local resources.

Improving referrals and integrating family planning and HIV services through organizational network strengthening.

BACKGROUND: The service needs of people with human immunodeficiency virus (HIV) in low-income settings are wide-ranging. Service provision in a community is often disjointed among a variety of providers. We sought to reduce unmet patient needs by increasing referral coordination for HIV and family planning, measured as network density, with an organizational network approach. METHODS: We conducted organizational network analysis on two networks in sub-cities of Addis Ababa, Ethiopia. There were 25 organizations in one sub-city network and 26 in the other. In one of them we sought to increase referrals through three network strengthening meetings. We then conducted the network analysis again in both sub-cities to measure any changes since baseline. We also quantitatively measured reported client service needs in both sub-cities before and after the intervention with two cross-sectional samples of face-to-face interviews with clients (459 at baseline and 587 at follow-up). RESULTS: In the sub-city with the intervention, the number of referral connections between organizations, measured as network density, increased 55%. In the control community, the density decreased over the same period. Reported unmet client service needs declined more consistently across services in the intervention community. DISCUSSION: This quasi experiment demonstrated that (1) an organizational network analysis can inform an intervention, (2) a modest network strengthening intervention can enhance client referrals in the network, (3) improvement in client referrals was accompanied by a decrease in atient-reported unmet needs and (4) a series of network analyses can be a useful evaluation tool.

Integration opportunities for HIV and family planning services in Addis Ababa, Ethiopia: an organizational network analysis.

BACKGROUND: Public health resources are often deployed in developing countries by foreign governments, national governments, civil society and the private health clinics, but seldom in ways that are coordinated within a particular community or population. The lack of coordination results in inefficiencies and suboptimal results. Organizational network analysis can reveal how organizations interact with each other and provide insights into means of realizing better public health results from the resources already deployed. Our objective in this study was to identify the missed opportunities for the integration of HIV care and family planning services and to inform future network strengthening. METHODS: In two sub-cities of Addis Ababa, we identified each organization providing either HIV care or family planning services. We interviewed representatives of each of them about exchanges of clients with each of the others. With network analysis, we identified network characteristics in each sub-city network, such as referral density and centrality; and gaps in the referral patterns. The results were shared with representatives from the organizations. RESULTS: The two networks were of similar size (25 and 26 organizations) and had referral densities of 0.115 and 0.155 out of a possible range from 0 (none) to 1.0 (all possible connections). Two organizations in one sub-city did not refer HIV clients to a family planning organization. One organization in one sub-city and seven in the other offered few HIV services and did not refer clients to any other HIV service provider. Representatives from the networks confirmed the results reflected their experience and expressed an interest in establishing more links between organizations. CONCLUSIONS: Because of organizations not working together, women in the two sub-cities were at risk of not receiving needed family planning or HIV care services. Facilitating referrals among a few organizations that are most often working in isolation could remediate the problem, but the overall referral densities suggests that improved connections throughout might benefit conditions in addition to HIV and family planning that need service integration.