Socio-demographic correlates of unhealthy lifestyle in Ethiopia: a secondary analysis of a national survey.

BACKGROUND: Multiple lifestyle risk factors exhibit a stronger association with non-communicable diseases (NCDs) compared to a single factor, emphasizing the necessity of considering them collectively. By integrating these major lifestyle risk factors, we can identify individuals with an overall unhealthy lifestyle, which facilitates the provision of targeted interventions for those at significant risk of NCDs. The aim of this study was to evaluate the socio-demographic correlates of unhealthy lifestyles among adolescents and adults in Ethiopia. METHODS: A national cross-sectional survey, based on the World Health Organization's NCD STEPS instruments, was conducted in Ethiopia. The survey, carried out in 2015, involved a total of 9,800 participants aged between 15 and 69 years. Lifestyle health scores, ranging from 0 (most healthy) to 5 (most unhealthy), were derived considering factors such as daily fruit and vegetable consumption, smoking status, prevalence of overweight/obesity, alcohol intake, and levels of physical activity. An unhealthy lifestyle was defined as the co-occurrence of three or more unhealthy behaviors. To determine the association of socio-demographic factors with unhealthy lifestyles, multivariable logistic regression models were utilized, adjusting for metabolic factors, specifically diabetes and high blood pressure. RESULTS: Approximately one in eight participants (16.7%) exhibited three or more unhealthy lifestyle behaviors, which included low fruit/vegetable consumption (98.2%), tobacco use (5.4%), excessive alcohol intake (15%), inadequate physical activity (66%), and obesity (2.3%). Factors such as male sex, urban residency, older age, being married or in a common-law relationship, and a higher income were associated with these unhealthy lifestyles. On the other hand, a higher educational status was associated with lower odds of these behaviors. CONCLUSION: In our analysis, we observed a higher prevalence of concurrent unhealthy lifestyles. Socio-demographic characteristics, such as sex, age, marital status, residence, income, and education, were found to correlate with individuals' lifestyles. Consequently, tailored interventions are imperative to mitigate the burden of unhealthy lifestyles in Ethiopia.

'First of all, I need training': a qualitative study evaluating the Fiji community health worker training program.

BACKGROUND: Fiji faces a growing burden of diseases and a significant emigration of health workers, heightening the role of community health workers (CHWs) in healthcare delivery. Effective training is crucial for CHWs to enhance their capacity and service quality. This study evaluates CHW training in Fiji, aiming to identify areas for improvement. METHODS: A qualitative study was conducted, encompassing a review of national policies on CHW training, six focus group discussions, and interviews with CHWs and their supervisors across Fijian subdivisions. This study was collaboratively designed with Fiji's Ministry of Health and Medical Services (MOHMS). Data was transcribed, coded, and thematically analysed using the Community Health Workers Assessment and Improvement Matrix (CHW-AIM). FINDINGS: While CHW training policies in Fiji are well-established, discrepancies exist between the policy and its implementation. Challenges include inconsistent training for new recruits, limited resources, and variability in training content and frequency of training across divisions, especially concerning noncommunicable disease (NCD) training. INTERPRETATION: To enhance the CHW training program in Fiji, a restructuring and standardisation of both pre-service and in-service training is necessary, tailored to the needs of each division. Investment in ongoing capacity building, alongside the development and revision of training guidelines, particularly for managing NCD complications in the community, is crucial. Implementing these changes will enable CHWs in Fiji to be better equipped for providing essential community-based care.

"We just have to help": Community health workers' informal task-shifting and task-sharing practices for hypertension and diabetes care in Nigeria.

Introduction: Nigeria's skilled health professional health workforce density is insufficient to achieve its national targets for non-communicable diseases (NCD) which include 25% reduction in the prevalence of diabetes and hypertension, particularly at the primary health care (PHC) level. This places a great demand on community health workers (CHWs) who constitute the majority of PHC workers. Traditionally, CHWs are mainly involved in infectious diseases programmes, and maternal and child health services. Their involvement with prevention and control of NCDs has been minimal. With government prioritization of PHC for combating the rising NCD burden, strengthening CHWs' skills and competencies for NCD care delivery is crucial. Methods: We conducted a mixed methods study to explore the roles and practices of CHWs in the delivery of hypertension and diabetes care at PHC facilities in four states (two each in northern and southern regions) in Nigeria. We reviewed the National Standing Orders that guide CHWs' practices at the PHC facilities and administered a survey to 76 CHWs and conducted 13 focus groups (90 participants), and in-depth individual interviews with 13 CHWs and 7 other local and state government stakeholders. Results: Overall, we found that despite capacity constraints, CHWs frequently delivered services beyond the scope of practice stipulated in the National Standing Orders. Such informal task-shifting practices were primarily motivated by a need to serve the community. Discussion: While these practices may partially support health system functions and address unmet need, they may also lead to variable care quality and safety. Several factors could mitigate these adverse impacts and strengthen CHW roles in the health system. These include a stronger enabling policy environment to support NCD task-sharing, investment in continuous capacity building for CHWs, improved guidelines that can be implemented at the point of care, and improved coordination processes between PHC and higher-level facilities.

The organisation of primary health care service delivery for non-communicable diseases in Nigeria: A case-study analysis.

As chronic diseases, non-communicable diseases (NCDs) require sustained person-centred and community-based care. Given its direct link to communities and households, Primary Health Care (PHC) is well positioned to achieve such care. In Nigeria, the national government has prioritized PHC system strengthening as a means of achieving national NCD targets. However, strengthening PHC systems for NCDs require re-organization of PHC service delivery, based on contextual understanding of existing facilitators and barriers to PHC service delivery for NCDs. We conducted a mixed method case study to explore NCD service delivery with 13 PHC facilities serving as the cases of interest. The study was conducted in two northern and two southern states in Nigeria-and included qualitative interviews with 25 participants, 13 focus group discussion among 107 participants and direct observation at the 13 PHCs. We found that interprofessional role conflict among healthcare workers, perverse incentives to sustain the functioning of PHC facilities in the face of government under-investment, and the perception of PHC as an inferior health system were major barriers to improved organisation of NCD management. Conversely, the presence of physicians at PHC facilities and involvement of civil society organizations in aiding community linkage were key enablers. These marked differences in performance and capacity between PHC facilities in northern compared to southern states, with those in the south better organised to deliver NCD services. PHC reforms that are tailored to the socio-political and economic variations across Nigeria are needed to improve capacity to address NCDs.

Community health extension workers' training and supervision in Ethiopia: Exploring impact and implementation challenges for non-communicable disease service delivery.

Training and supervision of health workers are critical components of any health system;thus, we assessed how they impact health extension workers' (HEWs) role in non-communicable disease (NCD) service delivery in Ethiopia's health extension program (HEP), using an in-depth qualitative study conducted in 2019.The study covered two regions-the Tigray and the South Nations, Nationalities and Peoples Region (SNNPR)-and involved the Federal Ministry of Health. We conducted twenty-seven key informant interviews with federal and regional policymakers, district health officials, health centre representatives and HEWs.Participants highlighted substantial implementation challenges with training and supervision practices delivered via the HEP. Training for NCDs lacked breadth and depth. IT was described as inconsistently delivered with variable availability within and between regions;and when available, the quality was low with scant content specific to NCDs. HEP supervision was inconsistent and, rather than being supportive, mainly focused on finding faults in HEW work practices. Supervisors themselves had skill gaps in critical areas overall, and specifically concerning NCDs. HEWs' performance appraisal encompassed too many indicators, leading to excessive complexity, which was burdensome to HEWs. This, negatively impacted HEW motivation and compromised service delivery. HEW involvement in non-HEP activities (such as promoting other government programs) often competed with their core mandates, thus affecting HEP service delivery.Efforts to address training and supervision constraints in Ethiopia's HEP should focus on improving the quality of NCD training for HEWs and supervisors, shifting from authoritative to supportive supervision, simplifying performance appraisal and reducing competing attention from other programs.

Exploring complementary and competitive relations between non-communicable disease services and other health extension programme services in Ethiopia: a multilevel analysis.

BACKGROUND: Ethiopia has recently revitalised its health extension programme (HEP) to address the rising burden of non-communicable diseases (NCDs). We examined the effects of existing essential HEP services on the uptake of NCD preventive services. METHODS: We applied a mixed-effect non-linear model with a logit link function to identify factors associated with a community resident's probability of receiving NCD prevention services through the HEP. The data were drawn from the Ethiopian HEP assessment Survey conducted in all regions. The analysis included 9680 community residents, 261 health extension workers (HEWs), 153 health posts, 119 health centres, 55 districts and 9 regions, which we combined hierarchically into a single database. RESULTS: In the 12 months before the survey, 22% of the sample population reported receiving NCD preventive service at least once. The probability of receiving NCD prevention service increased by up to 25% (OR=1.25, CI 1.01 to 1.53) if health centres routinely gathered NCD data from health posts and by up to 48% (OR=.48, CI 1.24 to 1.78) if they provided general (ie, non-NCD specific) training to HEWs. NCD preventive service uptake also increased if the HEW held level IV qualification (OR=1.32, CI 1.06 to 1.65) and lived in the community (OR=1.24, CI 1.03 to 1.49). Conversely, if facilities delayed general performance reviews of HEWs by a month, uptake of NCD prevention services decreased by 6% (OR=0.94, CI 0.91 to 0.97). We observed that better HIV/AIDS programme performance was associated with a lower uptake of NCD preventive services (OR=0.15, CI 0.03 to 0.85). CONCLUSION: Despite efforts to improve NCD services through the HEP, the coverage remains limited. A strong HEP is good for the uptake of NCD preventive services. However, integration requires a careful balance, so that the success already recorded for some existing programmes is not lost.

It is not all about salary: a discrete-choice experiment to determine community health workers' motivation for work in Nigeria.

INTRODUCTION: Community health workers (CHWs) constitute the majority of primary healthcare (PHC) workers in Nigeria, yet little is understood about their motivations or the most effective interventions to meet their needs to ensure quality health coverage across the country. We aimed to identify factors that would motivate CHWs for quality service delivery. METHODS: A discrete-choice experiment was conducted among 300 CHWs across 44 PHC facilities in the Federal Capital Territory, Abuja Nigeria. Based on the literature review and qualitative research, five attributes, namely: salary, educational opportunities, career progression and in-service training, housing and transportation, were included in the experiment. CHWs were presented with 12 unlabelled choice sets, using tablet devices, and asked to choose which of two hypothetical jobs they would accept if offered to them, or whether they would take neither job. Mixed multinomial logistic models were used to estimate stated preferences for the attributes and the likely uptake of jobs under different policy packages was simulated. RESULTS: About 70% of the respondents were women and 39% worked as volunteers. Jobs that offered career progression were the strongest motivators among the formally employed CHWs (ß=0.33) while the 'opportunity to convert from CHW to another cadre of health workers, such as nursing' was the most important motivator among the volunteers' CHWs (ß=0.53). CHWs also strongly preferred jobs that would offer educational opportunities, including scholarship (ß=0.31) and provision of transport allowances (ß=0.26). Policy scenario modelling predicted combined educational opportunities, career progression opportunities and an additional 10% of salary as incentives was the employment package that would be most appealing to CHWs. CONCLUSION: CHWs are motivated by a mix of non-financial and financial incentives. Policy interventions that would improve motivation should be adequate to address various contexts facing different CHWs and be flexible enough to meet their differing needs.

Health system capacity and readiness for delivery of integrated non-communicable disease services in primary health care: A qualitative analysis of the Ethiopian experience.

BACKGROUND: Non-communicable diseases (NCDs) now account for about 71% and 32% of all the deaths globally and in Ethiopia. Primary health care (PHC) is a vital instrument to address the ever-increasing burden of NCDs and is the best strategy for delivering integrated and equitable NCD care. We explored the capacity and readiness of Ethiopia's PHC system to deliver integrated, people-centred NCD services. METHODS: A qualitative study was conducted in two regions and Federal Ministry of Health, Addis Ababa, Ethiopia. We carried out twenty-two key informant interviews with national and regional policymakers, officials from a partner organisation, woreda/district health office managers and coordinators, and PHC workers. Data were coded and thematically analysed using the World Health Organization (WHO) Operational Framework for PHC. RESULTS: Although the rising NCD burden is well recognised in Ethiopia, and the country has NCD-specific strategies and some interventions in place, we identified critical gaps in several levers of the WHO Operational Framework. Many compared the under-investment in NCDs contrasted with Ethiopia's successful PHC models established for maternal and child health and communicable disease programs. Insufficient political commitment and leadership required to integrate NCD services at the PHC level and weaknesses in governance structures, inter-sectoral coordination, and funding for NCDs were identified as significant barriers to strengthening PHC capacity to address NCDs. Among the operational-focussed levers, fragmented information management systems and inadequate equipment and medicines were identified as critical bottlenecks. The PHC workforce was also considered insufficiently skilled and supported to provide NCD services in PHC facilities. CONCLUSION: Strengthening NCD prevention and control through PHC in Ethiopia requires greater political commitment and investment at all health system levels. Prior success strategies with other PHC programs could be adapted and applied to NCD policies and practice, giving due consideration for the unique nature of the NCD program.

Aligning policymaking in decentralized health systems: Evaluation of strategies to prevent and control non-communicable diseases in Nigeria.

Noncommunicable diseases (NCDs) are leading causes of death globally and in Nigeria they account for 29% of total deaths. Nigeria's health system is decentralized. Fragmentation in governance in federalised countries with decentralised health systems is a well-recognised challenge to coherent national health policymaking. The policy response to the rising NCD burden therefore requires strategic intent by national and sub-national governments. This study aimed to understand the implementation of NCD policies in Nigeria, the role of decentralisation of those policies, and to consider the implications for achieving national NCD targets. We conducted a policy analysis combined with key informant interviews to determine to what extent NCD policies and strategies align with Nigeria's decentralised health system; and the structure and process within which implementation occurs across the various tiers of government. Four inter-related findings emerged: NCD national policies are 'top down' in focus and lack attention to decentralisation to subnational and frontline care delivery levels of the health system; there are defective coordination mechanisms for NCD programmes which are underpinned by weak regional organisational structures; financing for NCDs are administratively burdensome and fragmented; and frontline NCD service delivery for NCDs are not effectively being integrated with other essential PHC services. Despite considerable progress being made with development of national NCD policies, greater attention on their implementation at subnational levels is needed to achieve more effective service delivery and progress against national NCD targets. We recommend strengthening subnational coordination mechanisms, greater accountability frameworks, increased and more efficient funding, and greater attention to integrated PHC service delivery models. The use of an effective bottom-up approach, with consideration for decentralization, should also be engaged at all stages of policy formulation.

The impact of war on the health system of the Tigray region in Ethiopia: an assessment.

The war in Tigray region of Ethiopia that started in November 2020 and is still ongoing has brought enormous damage to the health system. This analysis provides an assessment of the health system before and during the war. Evidence of damage was compiled from November 2020 to June 2021 from various reports by the interim government of Tigray, and also by international non-governmental organisations. Comparison was made with data from the prewar calendar year. Six months into the war, only 30% of hospitals, 17% of health centres, 11.5% of ambulances and none of the 712 health posts were functional. As of June 2021, the population in need of emergency food assistance in Tigray increased from less than one million to over 5.2 million. While the prewar performance of antenatal care, supervised delivery, postnatal care and children vaccination was 64%, 73%, 63% and 73%, respectively, but none of the services were likely to be delivered in the first 90 days of the war. A conservative estimate places the number of girls and women raped in the first 5 months of the war to be 10 000. These data indicate a widespread destruction of livelihoods and a collapse of the healthcare system. The use of hunger and rape as a weapon of war and the targeting of healthcare facilities are key components of the war. To avert worsening conditions, an immediate intervention is needed to deliver food and supplies and rehabilitate the healthcare delivery system and infrastructure.

The COVID-19 pandemic and healthcare systems in Africa: a scoping review of preparedness, impact and response.

BACKGROUND: The COVID-19 pandemic has overwhelmed health systems in both developed and developing nations alike. Africa has one of the weakest health systems globally, but there is limited evidence on how the region is prepared for, impacted by and responded to the pandemic. METHODS: We conducted a scoping review of PubMed, Scopus, CINAHL to search peer-reviewed articles and Google, Google Scholar and preprint sites for grey literature. The scoping review captured studies on either preparedness or impacts or responses associated with COVID-19 or covering one or more of the three topics and guided by Arksey and O'Malley's methodological framework. The extracted information was documented following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension checklist for scoping reviews. Finally, the resulting data were thematically analysed. RESULTS: Twenty-two eligible studies, of which 6 reported on health system preparedness, 19 described the impacts of COVID-19 on access to general and essential health services and 7 focused on responses taken by the healthcare systems were included. The main setbacks in health system preparation included lack of available health services needed for the pandemic, inadequate resources and equipment, and limited testing ability and surge capacity for COVID-19. Reduced flow of patients and missing scheduled appointments were among the most common impacts of the COVID-19 pandemic. Health system responses identified in this review included the availability of telephone consultations, re-purposing of available services and establishment of isolation centres, and provisions of COVID-19 guidelines in some settings. CONCLUSIONS: The health systems in Africa were inadequately prepared for the pandemic, and its impact was substantial. Responses were slow and did not match the magnitude of the problem. Interventions that will improve and strengthen health system resilience and financing through local, national and global engagement should be prioritised.

COVID-19 in Ethiopia: a geospatial analysis of vulnerability to infection, case severity and death.

BACKGROUND: COVID-19 has caused a global public health crisis affecting most countries, including Ethiopia, in various ways. This study maps the vulnerability to infection, case severity and likelihood of death from COVID-19 in Ethiopia. METHODS: Thirty-eight potential indicators of vulnerability to COVID-19 infection, case severity and likelihood of death, identified based on a literature review and the availability of nationally representative data at a low geographic scale, were assembled from multiple sources for geospatial analysis. Geospatial analysis techniques were applied to produce maps showing the vulnerability to infection, case severity and likelihood of death in Ethiopia at a spatial resolution of 1 km×1 km. RESULTS: This study showed that vulnerability to COVID-19 infection is likely to be high across most parts of Ethiopia, particularly in the Somali, Afar, Amhara, Oromia and Tigray regions. The number of severe cases of COVID-19 infection requiring hospitalisation and intensive care unit admission is likely to be high across Amhara, most parts of Oromia and some parts of the Southern Nations, Nationalities and Peoples' Region. The risk of COVID-19-related death is high in the country's border regions, where public health preparedness for responding to COVID-19 is limited. CONCLUSION: This study revealed geographical differences in vulnerability to infection, case severity and likelihood of death from COVID-19 in Ethiopia. The study offers maps that can guide the targeted interventions necessary to contain the spread of COVID-19 in Ethiopia.

Risk factors for COVID-19 infection, disease severity and related deaths in Africa: a systematic review.

OBJECTIVE: The aim of this study was to provide a comprehensive evidence on risk factors for transmission, disease severity and COVID-19 related deaths in Africa. DESIGN: A systematic review has been conducted to synthesise existing evidence on risk factors affecting COVID-19 outcomes across Africa. DATA SOURCES: Data were systematically searched from MEDLINE, Scopus, MedRxiv and BioRxiv. ELIGIBILITY CRITERIA: Studies for review were included if they were published in English and reported at least one risk factor and/or one health outcome. We included all relevant literature published up until 11 August 2020. DATA EXTRACTION AND SYNTHESIS: We performed a systematic narrative synthesis to describe the available studies for each outcome. Data were extracted using a standardised Joanna Briggs Institute data extraction form. RESULTS: Fifteen articles met the inclusion criteria of which four were exclusively on Africa and the remaining 11 papers had a global focus with some data from Africa. Higher rates of infection in Africa are associated with high population density, urbanisation, transport connectivity, high volume of tourism and international trade, and high level of economic and political openness. Limited or poor access to healthcare are also associated with higher COVID-19 infection rates. Older people and individuals with chronic conditions such as HIV, tuberculosis and anaemia experience severe forms COVID-19 leading to hospitalisation and death. Similarly, high burden of chronic obstructive pulmonary disease, high prevalence of tobacco consumption and low levels of expenditure on health and low levels of global health security score contribute to COVID-19 related deaths. CONCLUSIONS: Demographic, institutional, ecological, health system and politico-economic factors influenced the spectrum of COVID-19 infection, severity and death. We recommend multidisciplinary and integrated approaches to mitigate the identified factors and strengthen effective prevention strategies.

How well are non-communicable disease services being integrated into primary health care in Africa: A review of progress against World Health Organization's African regional targets.

OBJECTIVE: In Africa, mortality due to non-communicable diseases (NCDs) is projected to overtake the combined mortality from communicable, maternal, neonatal, and nutritional diseases by 2030. To address this growing NCD burden, primary health care (PHC) systems will require substantial re-orientation. In this study, we reviewed the progress of African countries towards integrating essential NCD services into PHC. METHODS: A review of World Health Organization (WHO) reports was conducted for all 47 countries in the WHO African Region. To report each country's progress, we used an a priori framework developed by the WHO regional office for Africa (AFRO). Twelve indicators were used to measure countries' progress. The proportion of countries meeting each indicator was tabulated using a heat map. Correlation between country income status and attainment of each indicator was also assessed. FINDINGS: No country met all the recommended indicators to integrate NCD services into PHC and seven countries met none of the indicators. Few countries (30%) had nationally approved guidelines for NCD management and very few reported availabilities of all essential NCD medicines (13%) and technologies (11%) in PHC facilities. There was no overall correlation between a country's GDP per capita and the aggregate of targets being met (rho = 0.23; P = .12). There was, however, a modestly negative correlation between out-of-pocket expenditure and overall country progress (rho = -0.58; P < .001). CONCLUSION: Progress by AFRO Member States in integrating NCD care into PHC is variable across the region. Enhanced government commitment and judicious resource allocation to prioritize NCDs are needed. Particular areas of focus include increasing the uptake of simplified guidelines for NCDs; increasing workforce capacity to manage NCDs; and removing access barriers to essential medicines and basic diagnostic technologies.

A qualitative study of drivers of psychoactive substance use among Mekelle University students, Northern Ethiopia.

BACKGROUND: Psychoactive substance (PS) use is a public health concern among University students. Understanding the factors underlay the use helps to underpin effective preventive interventions. However, there is dearth of exploratory studies on the drivers of psychoactive substance use in Ethiopian universities. Here, we aimed to explore the drivers for psychoactive substance use among Mekelle University undergraduate students. METHODS: Exploratory qualitative study was conducted from April 1 to May 30, 2017. We conducted five focus group discussions (FGDs) and eleven in-depth interviews (IDIs) with students, proctors and bar owners. We also conducted three round interviews within two weeks interval with each of four key-informant researchers (KIR). Participants were selected purposively and the investigators conducted the discussions and the interviews using semi-structured guides. Data were audio-recorded, transcribed verbatim and imported into qualitative data analysis software for coding and analysis. An inductive approach was applied to crystalize non-repetitive emerging themes overarching the drivers for psychoactive substance use among university students. RESULTS: The following themes emerged as drivers for psychoactive substance use among University students; (1)feeling helpless following detachment from family, (2) prior experience with substances, (3) socialization reasons, (4) low academic performance, (5) physical environment (explained by easy access to substance and limited recreational alternatives), and (6) sub-optimal organizational support. CONCLUSIONS: Multiple drivers that range from individual to structural levels are involved in university student's use of psychoactive substances, with socialization process at the center of the factors. Thus, the study appeals for a range of multifaceted interventions directed to the individual, interpersonal and organizational level factors.