HIV treatment cascade among female sex workers in Ethiopia: Assessment against the UNAIDS 90-90-90 targets.

BACKGROUND: HIV treatment cascades for HIV-positive female sex workers (FSWs) have been challenged by the overlapping stigma and discrimination associated with both their sex work and HIV status. This study aims to assess the proportion of HIV-positive FSWs who access care and treatment in Ethiopia. METHOD: A cross-sectional study with a respondent-driven sampling technique was used to enroll 6,085 female sex workers from January to June 2020. Interviews were conducted to assess the FSWs' HIV status awareness and access to ART. A blood sample was drawn to determine the current HIV status and viral load level. Logistic regression was run to identify factors associated with FSWs' HIV status awareness. RESULTS: Of the total 1140 HIV-positive FSWs, 50.38% knew they were HIV positive; 92.88% of those who knew their status were on ART, and 91.68% of those on ART had attained viral suppression of less than 1000 copies per milliliter. The adjusted odds of knowing HIV status was 3.20 (95% CI; 2.00, 5.13) among those aged 35 years and older, 1.81 (95% CI; 1.05, 3.12) among widowed, and 1.73 (95% CI; 1.28, 2.32) in those who did not perceive the risk of HIV acquisition. CONCLUSION: Only about half of HIV-positive FSWs knew they were HIV positive. More than 90% of those who knew their status were put on ART and achieved viral suppression. The weakest point in achieving HIV control among FSWs is the identification of those living with HIV.

Trends, projection and inequalities in full immunization coverage in Ethiopia: in the period 2000-2019.

BACKGROUND: Immunization is among the most cost-effective health interventions to improve child survival. However, many countries in sub-Saharan Africa failed to achieve their national and international coverage targets repeatedly. The present study investigated trends of coverage and inequalities in coverage in Ethiopia. METHODS: This study used data from five rounds of the Demographic and Health Surveys conducted in Ethiopia in 2000, 2005, 2011, 2016, and 2019. The surveys used a multistage cluster sampling procedure to obtain a nationally and sub-nationally representative data. The outcome variables included in the study were full immunization coverage and inequality. The World Health Organization's Health Equity Assessment Toolkit was used to conduct the inequality analysis. Projections for 2025 were based on smoothed averages generated using the demographic and health survey data from 2000 to 2019. RESULTS: The full (basic) immunization coverage in Ethiopia has increased steadily from 14.3% in 2000 to 44.1% in 2019. Based on the average past performance, the immunization coverage is projected to reach 53.6% by 2025, which will be short of the 75% national full (basic) immunization coverage target for the year 2025. Mothers with higher levels of education are more likely to get their children all basic vaccinations than those with lower levels of education. Similarly, the inequality gaps due to wealth and residency are significant; where children in the lowest wealth strata and those living in rural areas remained disadvantaged. CONCLUSION: Despite a steady increase in immunization coverage in the past two decades the country is yet to achieve its immunization target. Thus, more efforts are needed to achieve the current and future national immunization targets. A more focused intervention targeting the disadvantaged groups could be an effective strategy to achieve coverage and minimize the inequality gaps in immunization.

Predictors of maternal and newborn health service utilization across the continuum of care in Ethiopia: A multilevel analysis.

BACKGROUND: The continuum of care for maternal and newborn health is a systematic approach for delivery of an integrated effective package of life-saving interventions throughout pregnancy, childbirth, and postpartum as well as across levels of service delivery to women and newborns. Nonetheless, in low-income countries, coverage of these interventions across the life cycle continuum is low. This study examined the predictors of utilization of maternal and newborn health care services along the continuum of care in Ethiopia. METHODS: This was a cross-sectional population-based study. We measured maternal and newborn health care utilization practices among women who had live births in the last 12 months preceding the survey in Amhara, Oromia, SNNP, and Tigray regions of Ethiopia. We fitted multilevel random-effects logistic regression models to examine the predictors of the continuum of care accounting for the survey design, and individual, and contextual characteristics of the respondents. RESULTS: Our analysis revealed that only one-fifth of women utilized maternal and newborn health services across the antepartum, intrapartum, and postpartum continuum; most women discontinued at the postpartum stage. Continued use of services varied significantly across wealth, model family, prenatal stay at maternity waiting homes, antenatal care in the first trimester, complete antenatal care service, and the administrative region at all antepartum, intrapartum, and postpartum stages. Moreover, family conversation during pregnancy [AOR: 2.12; 95% CI: 1.56-2.88], delivery by cesarean [AOR: 2.70; 95% CI: 1.82-4.02] and birth notified to health extension workers [AOR: 1.95; 95% CI: 1.56-2.43] were found to be predictors of the continuum of care at the postpartum stage. CONCLUSION: In Ethiopia, despite good access to antepartum care, compliance with continuity of care across the pathway decreased with significant inequitable distributions, the poorest segment of the population being at most disadvantage. The main modifiable program factors connected to the continued uptake of maternal health services include family conversation, pregnant women conference, complete antenatal care, antenatal care in the first trimester, and birth notification.

The unfinished agenda and inequality gaps in antenatal care coverage in Ethiopia.

BACKGROUND: Antenatal care is an essential platform to provide all the necessary health interventions during pregnancy that aim to reduce maternal and newborn morbidity and mortality. Although the antenatal care coverage has been increasing in Ethiopia in the last two decades, the country has not been able to meet its own coverage target to date. Most pregnant women who initiated antenatal care also do not complete the full recommended follow up contacts. This study investigated the trend in coverage and the inequalities related to the use of antenatal care in Ethiopia. METHODS: This study utilized data from five rounds of Demographic and Health Surveys (DHSs) conducted in Ethiopia in the period between 2000 and 2019. The DHS respondents were women in the age group 15-49 who had a live birth within the five years preceding the surveys. The outcome of interest for this study was antenatal care utilization coverage. We used concentration curve and concentration index to identify the inequalities using the World Health Organization recommended Health Equity Analysis Toolkit software. We did a regression analysis to identify the drivers of urban-rural inequalities. RESULT: The coverage trend for both initiating Antenatal care and completing the recommended four antenatal contacts showed a steady increase during 2000-2019. However, the coverages have not yet reached the national target and unlikely to meet targets by 2025. Although the economically better-off, urban and educated mother still have a better coverage, the inequality gaps within the wealth, residence and education categories generally showed significant reduction. Women in the lowest wealth quantile, those who were uneducated and those living in rural areas remained disadvantaged. Household economic status and maternal education was the stronger drivers of urban-rural inequalities. CONCLUSION: The Antenatal care coverage is lagging below the country's target. Despite narrowing inequality gaps women from poor households, who are uneducated and residing in rural areas are still less likely to fully attend the recommended number of antenatal care contacts. Addressing these inequalities through a multisectoral efforts is critical to increase the chances of achieving the national antenatal care coverage targets in Ethiopia.

Thyroid Hormone Tests Ordering Practice and Cost-Effectiveness in Samples Referred to International Clinical Laboratories from Addis Ababa Health Facilities.

BACKGROUND: Thyroid dysfunction accounts for majority of endocrine disorders. In sub-Saharan Africa Graves' disease and hypothyroidism have accounted for 13.1% and 8.8% while the burden of thyroid disorder has ranged from 6.18 to47.34% among countries in the Arab world. The cost for a primary thyroid test done to evaluate the gland function constituted a large proportion of the public health budget. For instance, 10 million thyroid functions have been done each year by laboratories which cost 30 million UK pounds, and they represent 8% of laboratory charge in the US. When a TSH-only protocol (guideline) was used, 95% of the requests were sufficient for diagnosis without requiring further tests, thereby resulting in 50% savings on FT4 reagent and reducing the annual TFT reagent cost by 25%. This is an original study, and its objective was to assess the ordering pattern of TSH tests and their cost-effectiveness in patients' samples referred to ICL from Addis Ababa health facilities between July2015 to June 2016. METHOD: An institution-based cross-sectional study design was utilized to study the ordering pattern of thyroid function tests using one-year retrospective data from ICL. RESULTS: Thyroid profiles were ordered more frequently (49.5%) compared to TSH only (24.3%). An additional 2625.70 USD was paid by patients for individual components in the profile tests that turned out normal. CONCLUSION: Guidelines advocate TSH as the initial test for thyroid dysfunction, but the use of a combination of tests is more common.

Socio-cultural factors favoring home delivery in Afar pastoral community, northeast Ethiopia: A Qualitative Study.

BACKGROUND: Despite expanding the number of health facilities, Ethiopia has still the highest home delivery services utilization. Health care service utilization varies between regions within the country. This study explored the socio-cultural factors influencing health facility delivery in a pastoralist region of Afar, Ethiopia. METHODS: An explorative qualitative study was conducted in October-December 2015. A total of 18 focus group discussions were conducted separately with mothers, male tribal leaders and religious leaders. In addition, 24 key informant interviews were conducted with Women's Affairs Bureau and district health office experts and traditional birth attendants and all were selected purposively. Data were coded and categorized using open code software and analyzed based on a thematic approach. RESULTS: The social factors that affect the choice of delivery place include workload, lack of independence and decision-making power of women, and lack of substitute for childcare and household chores during pregnancy and childbirth. The cultural and spiritual factors include assuming delivery as natural process ought to happen at home, trust in traditional birth attendants, traditional practices during and after delivery and faithful to religion practice, besides, denial by health facilities to benign traditional and spiritual practices such as prayers and traditional food preparations to be performed over there. CONCLUSION: Socio-cultural factors are far more than access to health centers as barriers to the utilization of health facilities for child birth. The provision of a maternity waiting home around the health facilities can alleviate some of these socio-cultural barriers.

Reasons for low level of skilled birth attendance in Afar pastoralist community, North East Ethiopia: a qualitative exploration.

INTRODUCTION: Ethiopia has expanded the number of health facilities that offer maternal health services during the last two decades. However, the utilization of skilled birth attendants in health facilities is still very low especially among the pastoralist regions of the country. This study explored why women in the pastoralist region of Afar, Ethiopia still prefer to give birth at home. METHODS: A qualitative study approach was used to collect information from October to December 2015. A total of eighteen focus group discussions and twenty-four key informant interviews were conducted. Focus group discussions were separately conducted with mothers and male tribal or religious leaders. Key informant interviews were conducted with heads of Women's Affairs Bureau, district health office heads and traditional birth attendants. Data were coded and categorized using open code software for qualitative data management and analyzed based on a thematic approach. RESULTS: Women preferred to deliver at home due to lack of awareness about the benefits of maternity health facilities, their nomadic lifestyle, lack of confidence and trust in health workers and their close affinity and easy access to traditional birth attendants. Supply-side barriers included distant health facilities, lack of transportation and poor health care. CONCLUSION: Demand and supply related factors were identified as barriers to utilization of skilled birth attendants. Increasing awareness, bringing the service closer, arranging maternity waiting area around health facilities, and creating client-friendly service were found critical. Future research to define and improve services and approaches suitable for pastoralist population is warranted.

Delay in diagnosis of pulmonary tuberculosis in low-and middle-income settings: systematic review and meta-analysis.

BACKGROUND: Assessment of delays in seeking care and diagnosis of tuberculosis is essential to evaluate effectiveness of tuberculosis control programs, and identify programmatic impediments. Thus, this review of studies aimed to examine the extent of patient, health system, and total delays in diagnosis of pulmonary tuberculosis in low- and middle- income countries. METHODS: It was done following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Electronic databases were searched to retrieve studies published from 2007 to 2015 including Pubmed central, Springer link, Hinari and Google scholar. Searching terms were pulmonary tuberculosis, health care seeking, health care seeking behavior, patient delay, diagnostic delay, health system delay, provider delay, and doctor delay. Retrieved studies were systematically reviewed and summarized using Comprehensive Meta-analysis software. RESULTS: Forty studies involving 18,975 patients qualified for systematic review, and 14 of them qualified for meta-analysis. The median diagnostic delay ranged from 30 to 366.5 days [IQR = 44-77.8], with a 4-199 days [IQR = 15-50] and 2-128.5 days [IQR = 12-34] due to patient and health system delays, respectively. The meta-analysis showed 42% of pulmonary tuberculosis patients delayed seeking care by a month or more; uneducated patients [pooled OR = 1.5, 95%CI = 1.1-1.9] and those who sought initial care from informal providers [pooled OR = 3, 95%CI = 2.3-3.9] had higher odds of patient delay. CONCLUSION: Delay in diagnosis is still a major challenge of tuberculosis control and prevention programs in low- and middle- income settings. Efforts to develop new strategies for better case-finding using the existing systems and improving patients' care seeking behavior need to be intensified.

Magnitude and factors associated with institutional delivery service utilization among childbearing mothers in Cheha district, Gurage zone, SNNPR, Ethiopia: a community based cross sectional study.

BACKGROUND: Ethiopia is one of the six countries that contributes' to more than 50 % of worldwide maternal deaths. While it is revealed that delivery attended by skilled provider at health facility reduced maternal deaths, more than half of all births in Ethiopia takes place at home. According to EDHS 2011 report nine women in every ten deliver at home in Ethiopia. The situation is much worse in southern region. The aim of our study is to measure the prevalence and to identify factors associated with institutional delivery service utilization among childbearing mothers in Cheha District, SNNPR, Ethiopia. METHODS: A community based cross sectional survey was conducted in Cheha District from Dec 22, 2012 to Jan 11, 2013. Multistage sampling method was employed and 816 women who gave birth within the past 2 years and lived in Cheha district for minimum of one year prior to the survey were involved in the study. Data was entered and analyzed using Epi Info Version 7 and SPSS Version 16. Frequencies and binary logistic regression were done. Factors affecting institutional delivery were determined using multivariate logistic regression. RESULTS: A total of 31 % of women gave birth to their last child at health facility. Place of residence, ability to afford for the whole process to get delivery service at health facility, traveling time that takes to reach to health institution which provides delivery service, husband's attitude towards institutional delivery, counseling about where to deliver during ANC visit and place of birth of the 2(nd) youngest child were found to have statistically significant association with institutional delivery. CONCLUSION: Institutional delivery is low in the study area. Access to health service was found to be the most important predictor of institutional delivery among others. Accessing health facility within reasonable travel time; providing health education and BCC services to husbands and the community at large on importance of using health institution for delivery service; working to improve women's economic status; counseling women to give birth at health institution during their ANC visit and exploring the overall quality of ANC service are some of the areas where much work is needed to improve institutional delivery.

Assessment of Directly Observed Therapy (DOT) following tuberculosis regimen change in Addis Ababa, Ethiopia: a qualitative study.

BACKGROUND: Tuberculosis remains a major public health problem in Ethiopia. In 2010 the TB treatment regimen was shortened from 8 to 6-months treatment. With this new regimen, the full course of treatment should be taken under Directly Observed Therapy (DOT) unlike the 8-month regimen where TB patients were only observed during the intensive phase, this has not been tried before and may be difficult to implement. Therefore this study aimed to investigate the experiences from both TB patients and health care providers' perspective of implementing DOT for the full course of TB treatment. METHODS: Qualitative study consisted of 11 in-depth interviews and 4 Focus Group Discussions (FDGs) were conducted between March and April, 2014. Overall, 18 TB patients and 16 HCPs were involved from three selected public health facilities (2 Health Centers and 1 Hospital) in Addis Ababa, Ethiopia. Qualitative data analysis software (Open Code Version 3.5) was employed to identify the key issues from these interviews through coding, categorization and grouping into emergent themes. RESULTS: Participants reported that making a daily visit to health facilities for DOT was difficult due to the distance of the facilities from their residences, lack of or high transportation cost and had undesired implications on their work and social lives. TB patients had to overcome many challenges to comply with TB treatment on a daily basis. HCPs also indicated the difficulties of implementing facility based daily DOT mainly due the implication it had on their TB patients and stated DOT had not always been implemented for the full course as recommended. HCPs also shared deep concern regarding the risk of acquiring multiple drug resistant TB. CONCLUSION: This study indicated there are several challenges associated with facility based daily DOT as a method of TB treatment supervision in public health facilities in Addis Ababa. This may be indicative of the situation in other health facilities in Addis Ababa as well as elsewhere in the country. Hence the TB control program has to explore how best to improve TB treatment delivery options to ensure adequate treatment. A more patient-centered approach could be strengthened by further decentralizing the DOT to the community level in order to ensure adherence of patients to their TB treatment.

Long distance travelling and financial burdens discourage tuberculosis DOTs treatment initiation and compliance in Ethiopia: a qualitative study.

BACKGROUND: Timely tuberculosis treatment initiation and compliance are the two key factors for a successful tuberculosis control program. However, studies to understand patents' perspective on tuberculosis treatment initiation and compliance have been limited in Ethiopia. The aim of this study is to attempt to do that in rural Ethiopia. METHODS: This qualitative, phenomenological study conducted 26 in-depth interviews with tuberculosis patients. A thematic content analysis of the interviews was performed using the Open Code software version 3.1. RESULTS: We found that lack of geographic access to health facilities, financial burdens, use of traditional healing systems and delay in diagnosis by health care providers were the main reasons for not initiating tuberculosis treatment timely. Lack of geographic access to health facilities, financial burdens, quality of health services provided and social support were also identified as the main reasons for failing to fully comply with tuberculosis treatments. CONCLUSIONS: This study highlighted complexities surrounding tuberculosis control efforts in Dabat District. Challenges of geographic access to health care facilities and financial burdens were factors that most influenced timely tuberculosis treatment initiation and compliance. Decentralization of tuberculosis diagnosis and treatment services to peripheral health facilities, including health posts is of vital importance to make progress toward achieving tuberculosis control targets in Ethiopia.

Prevalence of institutional delivery and associated factors in Dodota Woreda (district), Oromia regional state, Ethiopia.

BACKGROUND: Giving birth in a medical institution under the care and supervision of trained health-care providers promotes child survival and reduces the risk of maternal mortality. According to Ethiopian Demographic and Health Survey (EDHS) 2005 and 2011, the proportion of women utilizing safe delivery service in the country in general and in Oromia region in particular is very low. About 30% of the eligible mothers received Ante Natal Care (ANC) service and only 8% of the mothers sought care for delivery in the region. The aim of this study is to determine the prevalence of institutional delivery and understand the factors associated with institutional delivery in Dodota, Woreda, Oromia Region. METHODS: A community based cross sectional study that employed both quantitative and a supplementary qualitative method was conducted from Jan 10-30, 2011 in Dodota Woreda. Multi stage sampling method was used in selection of study participants and total of 506 women who gave birth in the last two years were interviewed. Qualitative data was collected through focus group discussions (FGDs). Data was entered and analyzed using EPI info 3.5.1 and SPSS version 16.0. Frequencies, binary and multiple logistic regression analysis were done, OR and 95% confidence interval were calculated. RESULTS: Only 18.2% of the mothers gave birth to their last baby in health facilities. Urban residence, educational level of mothers, pregnancy related health problems, previous history of prolonged labour, and decision made by husbands or relatives showed significant positive association with utilization of institutional delivery services (P < 0.05). While ANC attendance during the index pregnancy did not show any association. CONCLUSION: Institutional Delivery is low. Increasing accessibility of the delivery services and educating husbands not only mothers appear very important factors in improving institutional delivery. Health education on the importance of institutional delivery should also address the general population. The quality and content of the ANC services need to be investigated.

Patient and health service delay in the diagnosis of pulmonary tuberculosis in Ethiopia.

BACKGROUND: Delay in the diagnosis of tuberculosis may worsen the disease, increase the risk of death and enhance tuberculosis transmission in the community. This study aims to determine the length of delay between the onset of symptoms and patients first visit to health care (patient delay), and the length of delay between health care visit and the diagnosis of tuberculosis (health service delay). METHODS: A cross sectional survey that included all the public health centres was conducted in Addis Ababa from August 1 to December 31 1998. Patients were interviewed on the same day of diagnosis using structured questionnaire. RESULTS: 700 pulmonary TB patients were studied. The median patient delay was 60 days and mean 78.2 days. There was no significant difference in socio-demographic factors in those who delayed and came earlier among smear positives. However, there was a significant difference in distance from home to health institute and knowledge about TB treatment among the smear negatives. The health service delay was low (median 6 days; mean 9.5 days) delay was significantly lower in smear positives compared to smear negatives. Longer health service delay (delay more than 15 days) was associated with far distance. CONCLUSIONS: The time before diagnosis in TB patients was long and appears to be associated with patient inadequate knowledge of TB treatment and distance to the health centre. Further decentralization of TB services, the use of some components of active case finding, and raising public awareness of the disease to increase service utilization are recommended.