Level of completion of a continuum of age-appropriate infant feeding practices and barriers among breastfeeding mothers in Ethiopia: a mixed methods study.

BACKGROUND: Ethiopia has committed to ending undernutrition by implementing nutrition intervention strategies, including promoting optimal feeding and care practices. To monitor and evaluate optimal infant feeding practices, it is crucial to have reliable and quality data on infant feeding indicators. Therefore, this study aimed to evaluate the extent to which breastfeeding mothers in Ethiopia have completed the continuum of age-appropriate infant feeding practices and the barriers they face. METHODS: In this study, a sequential explanatory mixed method design was used. First, using datasets from performance monitoring for action (PMA) in Ethiopia, we estimated the level of the outcome and associated factors. In the quantitative (QUAN) analysis, 1755 mothers of infants were included to generate estimates. A generalized estimating equations logistic regression model was used to identify factors associated with the outcome by accounting for the clustering nature of the data by enumeration area. Then, a qualitative (QUAL) study was conducted with 14 mothers to explore their infant feeding practices using an in-depth interview guide and analyzed using a thematic approach. Results from both quantitative and qualitative data were integrated, described under the identified thematic areas, and interpreted concurrently. RESULTS: This study showed that 13.96% (95% CI: 12.4 to 15.6%) of mothers practiced a complete continuum of age-appropriate infant feeding. Over 8% of mothers did not practice any optimal feeding. Nearly 47% of mothers practiced optimal breastfeeding, and one-fifth of mothers practiced optimal complementary feeding. Results from both quantitative and qualitative data showed that mothers' complete continuum of age-appropriate infant feeding practice was affected by their level of income, knowledge, and attitude towards optimal infant feeding, as well as by important others, including husbands, grandmothers, and health workers. CONCLUSION: The level of a complete continuum of age-appropriate infant feeding practice is low among breastfeeding mothers in Ethiopia. Mothers' optimal feeding practices in Ethiopia are affected by their level of knowledge and attitude towards infant feeding, income or access to food, and health workers or family members. Therefore, collaborative efforts are needed to strengthen mothers' education on the health benefits of optimal infant feeding and design and promote strategies to improve household income or access to diverse food.

Network analysis of mental health problems among adults in Addis Ababa, Ethiopia: a community-based study during the COVID-19 pandemic.

OBJECTIVE: COVID-19 has negatively impacted mental health of adults globally with increased rates of psychiatric comorbidities. However, network analysis studies to examine comorbidities and correlations between symptoms of different mental disorders are uncommon in low-income countries. This study aimed to investigate the network structure of depression, anxiety and perceived stress among adults in Addis Ababa and identify the most central and bridge symptoms within the depressive-anxiety-perceived symptoms network model. DESIGN: Community-based cross-sectional study. SETTING: This study was carried out on a sample of the general population in Addis Ababa during the first year of the COVID-19 pandemic. A total of 1127 participants were included in this study, of which 747 (66.3%) were females, and the mean age was 36 years. PRIMARY AND SECONDARY OUTCOME MEASURES: Symptoms of depression, anxiety and stress were measured using the Patient Health Questionnaire, Generalized Anxiety Disorder Scale and the Perceived Stress Scale, respectively.Network analysis was conducted to investigate the network structure. The centrality index expected influence (EI) and bridge EI (1-step) were applied to determine the central and bridge symptoms. Case-dropping procedure was used to examine the network stability. RESULT: The sad mood (EI=1.52) was the most central and bridge symptom in the depression, anxiety and perceived stress network model. Irritability (bridge EI=1.12) and nervousness and stressed (bridge EI=1.33) also served as bridge symptoms. The strongest edge in the network was between nervousness and uncontrollable worry (weight=0.36) in the anxiety community. The network had good stability and accuracy. The network structure was invariant by gender and age based on the network structure invariance test. CONCLUSIONS: In this study, the sad mood was the core and bridge symptom. This and the other central and bridge symptoms identified in the study should be targeted to prevent mental health disorders and comorbidities among adults.

Determinants of asthma among adults in Tigray, Northern Ethiopia: a facility-based case-control study.

Background: Asthma is a public health concern affecting millions of productive age groups. Several studies were conducted on the determinants of asthma in children. However, little is known about the determinants of asthma among adults in Ethiopia. Understanding the determinants of asthma among adults can help reduce its burden. This study was aimed at identifying determinant factors for developing asthma among adults in Tigray hospitals. Methods: A facility-based, unmatched case-control study design was conducted from January 1 to April 26, 2019. A total of 698 participants (228 cases and 470 controls) completed their guided interviews using structured and pretested questionnaires by trained data collectors. A modified standard questionnaire from the European Community Respiratory Health Survey II (ECRHS II) was used to collect the data. The case definition was patients having asthma, and the control definition was patients without asthma. Data were entered and cleaned using Epi Data Manager Version 3.1 software and imported to statistical packages for social sciences Version 25 software for analysis. To identify asthma determinants, bivariate and multivariable logistic regression models were fitted. Results: The response rate for both cases and controls was 95.9%. The odds of developing asthma was nearly twice higher among those who resided in urban (AOR = 1.68; 95% CI [1.13-2.50]), more than twice higher among those who have income less than 1000 ETB (AOR = 2.3; 95% CI [1.17-4.56]), twice higher among those who had history of skin allergy (AOR = 2.09; 95% CI [1.14-3.86]), over four times higher among those with family history of asthma (AOR = 4.26; 95% CI [2.63-6.91]), three times higher among those having house dust or smoke exposure (AOR = 3.01; 95% CI [1.96-4.64]), over five times higher among those lifetime firewood users (AOR = 5.39; 95% CI [3.34-8.72]), door opening while cooking (AOR = 0.35; 95% CI [0.26-0.55]), nearly two times higher among those having house dampness (AOR = 1.98; 95% CI [1.069-3.68]), over seven times higher among pet owners (AOR = 7.46; 95% CI [4.04-13] and almost twice higher among those who were physically inactive (AOR = 1.75; 95% CI [1.11-2.85]). Conclusion: Asthma has been associated with urbanization, low income, a history of allergic diseases, indoor smoke or dust, firewood use, pet ownership, and a sedentary lifestyle. The community should be informed about the known risks and implement preventive steps like opening a door while cooking to lower the risk of asthma.

Perception of affordable diet is associated with pre-school children's diet diversity in Addis Ababa, Ethiopia: the EAT Addis survey.

BACKGROUND: Despite improvements in food access and nutrition security over the last few decades, malnutrition remains a major public health problem. One of the significant contributors to these problems is affordability of nutritious food. This study aimed to examine the association between perceived food affordability and pre-school children's diet diversity in Addis Ababa, Ethiopia. METHODS: Cross-sectional data from 2017 to 18 were used for the analysis. A 24-hour dietary recall assessment was done to assess children's dietary diversity (DD). We used a modified operational definition of affordability indicator called perceived affordability of dietary diversity (afford-DD) to evaluate the impact of the food environment in terms of affordability at the household level. A sample (n 4,898) of children aged 6-59 months representative of households in Addis Ababa was randomly selected using a multistage sampling procedure including all districts in the city. Mixed-effects linear regression models were used to assess the association between children's DD and afford-DD. RESULTS: The survey revealed that the mean (standard deviation [SD]) of children's DD was 3.9 [± 1.4] while the mean [SD] of afford-DD was 4.6 [± 2.1]. Overall, 59.8% of children met the minimum dietary diversity (≥ 4 food groups). White roots and tubers were the most commonly consumed food groups regardless of their affordability. Considerable variations were observed between households that reported the food item affordable and not affordable in consumption of Vitamin A rich vegetables and fruits, meat and fish, egg, and dairy. The children's DD was positively associated with afford-DD after adjusting for maternal education, household wealth status and other relevant confounding. Higher maternal education modified the association between affordability and children's diet diversity. CONCLUSIONS: This study suggests higher perceived food affordability was associated with better diet diversity in children. A higher level of maternal education had the potential to mitigate affordability challenges in meeting the children's dietary diversity needs. Our study emphasizes the need for inclusive food programs and nutrition interventions addressing social differences, intensifying efforts to make nutrient-rich diets affordable for the less privileged, and highlights the potential benefits of targeting maternal education in addressing child dietary diversity.

Intrahousehold food allocation social norms and food taboos in rural Ethiopia: The case of adolescent girls.

Background: In low-income countries, social norms play a significant role in intrahousehold food allocation practices. These norms can sometimes lead to discrimination against specific groups, posing a public health concern. This study focuses on the social norm surrounding food allocation within households and food taboos affecting adolescent girls in rural Ethiopia. Method: A qualitative study was conducted using vignettes as prompts for 20 focus group discussions and 32 in-depth interviews. The vignettes were tailored to the local context. Participants were chosen purposefully, and data were collected in a comfortable setting. All sessions were recorded and transcribed verbatim. Data analysis was done using Open Code qualitative analysis software with a thematic framework approach. Findings: In the community, adolescent girls were expected to eat after serving the male family members. Those who did not follow this expectation faced sanctions such as being labeled as disrespectful and could even be insulted or beaten by their spouses and siblings. However, there were some exceptions to this rule, such as when girls were giving birth, breastfeeding, sick, or when male family members were traveling. Certain foods were also prohibited for adolescent girls, including spicy foods like chili, animal products such as meat and milk, and nuts. These foods were believed to increase girls' sexual desire, potentially leading them to engage in premarital or extramarital sex. Additionally, eating outside of the house was not considered appropriate behavior for adolescent girls in this community. Conclusion: In many households, social norms dictate that adolescent girls are not given enough food or are denied essential nutrients for their health. It is important to challenge these norms to ensure fair food distribution within households and support the healthy development of adolescent girls.

Balanced Energy Protein Supplementation in Pregnancy: Adherence and Acceptability among Pregnant Women in Rural Ethiopia.

Background: Balanced energy protein (BEP) supplementation in pregnant women in low-and middle-income countries may reduce the risk of stillbirth and low birth weight. Objectives: The objective of this study was to assess the adherence to and acceptability of a corn-soy blend (CSB) BEP product among pregnant women in rural Ethiopia. Methods: This formative study was conducted from October to November 2018 among pregnant women in the rural Amhara region of Ethiopia prior to initiation of a clinical effectiveness study (ISRCTN: 15116516). We assessed adherence and acceptability of a micronutrient-fortified CSB BEP supplement among 40 pregnant women during a 4-wk utilization period. Acceptability was assessed using a 7-point Likert-style scale about the hedonic characteristics of the BEP product at 2 wk and 4 wk. Adherence was assessed by weekly monitoring and empty sachet counts for BEP consumption over 4 wk. Results: Adherence to the BEP was, on average, 89% over the month-long pilot. The BEP product was rated favorably (mean Likert score >6 of 7) for the following domains: color, taste, odor, and likeability at mid and endpoints. Women found the product convenient to eat [mean (standard deviation [SD] = 5.9 (1.0))] and filling (mean (SD) = 6.1 (1.5) out of 7). Scores on acceptability and perception of the product remained stable throughout the duration of use. A majority of women (63%) reported consuming the BEP as a snack to supplement meals and splitting the serving over 2 or more sessions (68%). A quarter of respondents reported sharing the supplement with family members. Conclusions: Adherence and acceptability of the CSB BEP product were high among this population in rural Amhara, Ethiopia. This formative data was important to select the final product and shape the counseling and delivery of BEP in the parent study.

Targeting strategies of antenatal balanced energy and protein supplementation in Addis Ababa, Ethiopia: study protocol for a randomized effectiveness study.

BACKGROUND: Antenatal balanced energy and protein (BEP) supplements have well-documented benefits for pregnancy outcomes. However, considerable practical gaps remain in the effective and cost-effective delivery of antenatal BEP supplements at scale in low- and middle-income countries. METHODS: A randomized effectiveness study will be conducted in two sub-cities of Addis Ababa, Ethiopia, to evaluate the effectiveness, cost-effectiveness, and implementation of different targeting strategies of antenatal BEP supplements. Pregnant women aged 18 to 49, with a gestational age of 24 weeks or less, and attending antenatal visits in one of the nine study health facilities are eligible for enrollment. In six of the health facilities, participants will be randomized to one of three study arms: control (Arm 1), targeted BEP provision based on baseline nutritional status (Arm 2), and targeted BEP supplementation based on baseline nutritional status and monthly gestational weight gain (GWG) monitoring (Arm 3). In the remaining three facilities, participants will be assigned to universal BEP provision (Arm 4). Participants in Arms 2 and 3 will receive BEP supplements if they have undernutrition at enrollment, as defined by a baseline body mass index less than 18.5 kg/m2 or mid-upper arm circumference less than 23 cm. In Arm 3, in addition to targeting based on baseline undernutrition, regular weight measurements will be used to identify insufficient GWG and inform the initiation of additional BEP supplements. Participants in Arm 4 will receive BEP supplements until the end of pregnancy, regardless of baseline nutritional status or GWG. All participants will receive standard antenatal care, including iron and folic acid supplementation. A total of 5400 pregnant women will be enrolled, with 1350 participants in each arm. Participants will be followed up monthly during their visits to the antenatal facilities until delivery. Maternal and infant health status will be evaluated within 72 h after delivery and at 6 weeks postpartum. The effectiveness and cost-effectiveness of the different BEP targeting strategies in preventing adverse pregnancy outcomes will be compared across arms. Qualitative data will be analyzed to assess the feasibility, acceptability, and implementation of different supplementation strategies. DISCUSSION: This study will inform global recommendations and operational guidelines for the effective and cost-effective delivery of antenatal BEP supplements. The targeted approaches have the potential for broader scale-up in Ethiopia and other low-resource settings with a high burden of undernutrition among pregnant women. TRIAL REGISTRATION: ClinicalTrials.gov registration number: NCT06125860. Registered November 9, 2023.

Birth outcomes and survival by sex among newborns and children under 2 in the Birhan Cohort: a prospective cohort study in the Amhara Region of Ethiopia.

INTRODUCTION: Despite the progress in reducing child mortality, the rate remains high, particularly in sub-Saharan African countries. Limited data exist on child survival and other birth outcomes by sex. This study compared survival rates and birth outcomes by sex among neonates and children under 2 in Ethiopia. METHODS: Women who gave birth after 28 weeks of gestation and their newborns were included in the analysis. Survival probabilities were estimated for males and females in the neonatal period as well as the 2-year period following birth using Kaplan-Meier curves. HRs and 95% CIs were compared between males and females under 2. Descriptive statistics and χ2 tests were used to determine the sex-disaggregated variation in the birth outcomes of preterm birth, low birth weight (LBW), stillbirth, small for gestational age (SGA) and large for gestational age (LGA). RESULTS: The study included a total of 3904 women and child pairs. The neonatal mortality rate for males (3.4%, 95% CI 2.6% to 4.2%) was higher compared with females (1.7%, 95% CI 1.1% to 2.3%). The hazard of death during the first 28 days of life was approximately two times higher for males compared with females (HR 1.99, 95% CI 1.30 to 3.06) but was not significantly different after this period. While there was a non-significant difference between males and females in the proportion of preterm, LBW and LGA births, we found a significantly higher proportion of stillbirth (2.7% vs 1.3%, p=0.003) and SGA (20.5% vs 15.6%, p<0.001) for males compared with females. CONCLUSIONS: This study identified a significant sex difference in mortality and birth outcomes. We recommend focusing future research on the mechanisms of these sex differences in order to better design intervention programmes to reduce disparities and improve outcomes for neonates.

The Association between Intrahousehold Food Allocation Social Norms and Thinness among Young Adolescent Girls: A Community-Based Study.

Background: Inequalities in food allocation related to social norms among household members significantly affect the nutritional status and well-being of the vulnerable members of the household, such as adolescent girls. This study assesses the association between social norms related to intrahousehold food allocation and young adolescent girls' thinness. Materials and Methods: The study involved 1,083 pairs of mothers/caregivers and young adolescent girls. Data were collected using a structured and pretested questionnaire. Multilevel mixed-effect logistic regression analysis was employed to examine associations using STATA/SE V.14 statistical software. In addition, a stratified analysis was done to investigate the effect of social norms on thinness in food-secure and food-insecure households. Result: The overall prevalence of young adolescent girls' thinness was 15.70% (95% CI 13.52-17.86%). Young adolescent girls' thinness was associated with mothers'/caregivers' conformity to inequitable intrahousehold food allocation social norms in food-secure households [Adjusted odds ratio (AOR): 1.43, 95% CI: 1.14-1.80] but not in food-insecure households. Conclusion: Nearly 16% of adolescent girls were thin. Mothers/female caregivers conforming to inequitable intrahousehold food allocation social norms compromise the nutritional status of adolescent girls, particularly in food-secure households. The lack of statistically significant association in food-insecure households hints at the need to address inequality in food-secure households while addressing food shortage to improve the nutritional status of adolescents in low-income countries. We also recommend more studies in different sociocultural contexts to fully gather the evidence for adopting appropriate policies and practices.

A prospective observational study of nurses performing minimally invasive tissue sampling of brain, liver, and lung tissues among deceased neonates and stillbirths in Ethiopia.

Background: With a neonatal mortality rate of 33 per 1,000 live births in 2019, Ethiopia is striving to attain the Sustainable Development Goal target of 12 deaths per 1,000 live births by 2030. A better understanding of the major causes of neonatal mortality is needed to effectively design and implement interventions to achieve this goal. Minimally Invasive Tissue Sampling (MITS), an alternative to conventional autopsy, requires fewer resources and through task-shifting of sample collection from pathologists to nurses, has the potential to support the expansion of pathology-based post-mortem examination and improve mortality data. This paper evaluates the accuracy and adequacy of MITS performed by nurses at a tertiary and general hospital and in the home of the deceased. Methods: Nurses in a tertiary and general hospital in Ethiopia were trained in MITS sample collection on neonatal deaths and stillbirths using standardized protocols. MITS sample collection was performed by both pathologists and nurses in the tertiary hospital and by nurses in the general hospital and home-setting. Agreement in the performance of MITS between pathologists and nurses was calculated for samples collected at the tertiary hospital. Samples collected by nurses in the general hospital and home-setting were evaluated for technical adequacy using preestablished criteria. Results: One hundred thirty-nine MITS were done: 125 in hospitals and 14 inside homes. There was a perfect or almost perfect agreement between the pathologists and the nurses in the tertiary hospital using Gwet's agreement interpretation criteria. The adequacy of MITS samples collected by nurses in the general hospital was more than 72% when compared to the preset criteria. The adequacy of the MITS sampling yield ranged from 87% to 91% on liveborn neonatal deaths and 76% for the liver, right and left lungs and 55% for brain tissues in stillbirths. Conclusions: This study demonstrated that task-shifting MITS sample collection to nurses can be achieved with comparable accuracy and adequacy as pathologists. Our study showed that with standardized training and supportive supervision MITS sample collection can be conducted by nurses in a tertiary, general hospital and, at the home of the deceased. Future studies should validate and expand on this work by evaluating task-shifting of MITS sample collection to nurses within community settings and with larger sample sizes.