Harmonization of maternal balanced energy-protein supplementation studies for individual participant data (IPD) meta-analyses - finding and creating similarities in variables and data collection.

BACKGROUND: Public health and clinical recommendations are established from systematic reviews and retrospective meta-analyses combining effect sizes, traditionally, from aggregate data and more recently, using individual participant data (IPD) of published studies. However, trials often have outcomes and other meta-data that are not defined and collected in a standardized way, making meta-analysis problematic. IPD meta-analysis can only partially fix the limitations of traditional, retrospective, aggregate meta-analysis; prospective meta-analysis further reduces the problems. METHODS: We developed an initiative including seven clinical intervention studies of balanced energy-protein (BEP) supplementation during pregnancy and/or lactation that are being conducted (or recently concluded) in Burkina Faso, Ethiopia, India, Nepal, and Pakistan to test the effect of BEP on infant and maternal outcomes. These studies were commissioned after an expert consultation that designed recommendations for a BEP product for use among pregnant and lactating women in low- and middle-income countries. The initiative goal is to harmonize variables across studies to facilitate IPD meta-analyses on closely aligned data, commonly called prospective meta-analysis. Our objective here is to describe the process of harmonizing variable definitions and prioritizing research questions. A two-day workshop of investigators, content experts, and advisors was held in February 2020 and harmonization activities continued thereafter. Efforts included a range of activities from examining protocols and data collection plans to discussing best practices within field constraints. Prior to harmonization, there were many similar outcomes and variables across studies, such as newborn anthropometry, gestational age, and stillbirth, however, definitions and protocols differed. As well, some measurements were being conducted in several but not all studies, such as food insecurity. Through the harmonization process, we came to consensus on important shared variables, particularly outcomes, added new measurements, and improved protocols across studies. DISCUSSION: We have fostered extensive communication between investigators from different studies, and importantly, created a large set of harmonized variable definitions within a prospective meta-analysis framework. We expect this initiative will improve reporting within each study in addition to providing opportunities for a series of IPD meta-analyses.

Enhancing Nutrition and Antenatal Infection Treatment (ENAT) study: protocol of a pragmatic clinical effectiveness study to improve birth outcomes in Ethiopia.

INTRODUCTION: The WHO Nutrition Target aims to reduce the global prevalence of low birth weight by 30% by the year 2025. The Enhancing Nutrition and Antenatal Infection Treatment (ENAT) study will test the impact of packages of pregnancy interventions to enhance maternal nutrition and infection management on birth outcomes in rural Ethiopia. METHODS AND ANALYSIS: ENAT is a pragmatic, open-label, 2×2 factorial, randomised clinical effectiveness study implemented in 12 rural health centres in Amhara, Ethiopia. Eligible pregnant women presenting at antenatal care (ANC) visits at <24 weeks gestation are enrolled (n=2400). ANC quality is strengthened across all centres. Health centres are randomised to receive an enhanced nutrition package (ENP) or standard nutrition care, and within each health centre, individual women are randomised to receive an enhanced infection management package (EIMP) or standard infection care. At ENP centres, women receive a regular supply of adequately iodised salt and iron-folate (IFA), enhanced nutrition counselling and those with mid-upper arm circumference of <23 cm receive a micronutrient fortified balanced energy protein supplement (corn soya blend) until delivery. In standard nutrition centres, women receive routine counselling and IFA. EIMP women have additional screening/treatment for urinary and sexual/reproductive tract infections and intensive deworming. Non-EIMP women are managed syndromically per Ministry of Health Guidelines. Participants are followed until 1-month post partum, and a subset until 6 months. The primary study outcomes are newborn weight and length measured at <72 hours of age. Secondary outcomes include preterm birth, low birth weight and stillbirth rates; newborn head circumference; infant weight and length for age z-scores at birth; maternal anaemia; and weight gain during pregnancy. ETHICS AND DISSEMINATION: ENAT is approved by the Institutional Review Boards of Addis Continental Institute of Public Health (001-A1-2019) and Mass General Brigham (2018P002479). Results will be disseminated to local and international stakeholders. REGISTRATION NUMBER: ISRCTN15116516.

Impact of COVID -19 on population health and economic wellbeing in Ethiopia: A national pilot survey

Introduction: The COVD-19 pandemic has resulted in unprecedented global health and economic crisis, particu-larly in countries struggling with poverty. We conducted a national survey to understand the economic and health impacts of COVID-19 in Ethiopia. Methods: A pilot, population-based, cross-sectional survey was conducted among adults randomly selected from the Ethio Telecom list of mobile phone numbers. Participants underwent a comprehensive phone interview about the impact of COVID-19 on their economic well-being and the health-related risks associated with COVID-19. Results: Of 4,180 calls attempted, 1194 were answered, of which a successful interview was made with 614 par-ticipants. COVID-19 affected the family income of 343 [55.9%] participants, 56 [9.1%] lost their job, 105 [17.1%] perceived high stress in their household, and 7 [1.14%] reported death in their family in the past month. The odds of having a decreased income due to COVID-19 were 2.4 times higher among self-employed [adjusted odds ratio (AOR) 2.4, 95% CI (1.58-3.77)] and 2.8 times higher among unemployed [AOR 2.8, 95% CI (1.35-5.85)] participants. Two-hundred twenty-one [36%] participants had comorbidity in their household with hypertension, 72 [11.7%], diabetes,50 [8.1%], asthma, 48 [7.8%], and other chronic diseases, 51 [8.4%]. Forty-six [7.5%] participants had COVID-like symptoms in the previous month, where cough, headache, and fatigue were the most com-mon.

Barriers and Facilitators of Same-Day Antiretroviral Therapy Initiation Among People Newly Diagnosed with HIV in Ethiopia: Qualitative Study Using the Transtheoretical Model of Behavioral Change.

PURPOSE: HIV test and treat approach is currently a strategy used as a part of the prevention and control program in Ethiopia. The strategy adopts initiating antiretroviral therapy (ART) on the same-day as HIV diagnosis or in the next visit. However, there is little evidence on barriers and facilitators of same-day (ART) initiation in Ethiopia. Therefore, this study aimed to investigate barriers and facilitators of same-day (ART) initiation in the northwest Ethiopia. PATIENTS AND METHODS: A qualitative study was conducted in East Gojjam Zone in northwest Ethiopia. Purposively selected HIV patients, healthcare workers, and treatment assistants participated in the qualitative study. Data were collected through in-depth interviews and focus group discussions (FGDs). Coding was done via ATLAS.ti software thematically. The interviews and FGDs were conducted in Amharic (local language) and then transcribed verbatim and translated into English. Coding was done via ATLAS.ti software. The thematic analysis approach was employed using the constructs of the transtheoretical behavioral model (TTM) to show stages of change that newly HIV diagnosed experienced in the course of preparation for treatment initiation. RESULTS: A total of 19 patients, 12 treatment supporters, and 9 healthcare workers participated in the qualitative study. Shocking due to the test result, having no symptoms, mistrust of the test result, and seeking spiritual healing from holy water were the major barriers to start ART in the same-day of diagnosis or within the next visit. CONCLUSION: During HIV diagnosis, more barriers were observed in the early stages, while treatment facilitators emerged in the later stages of TTM. The TTM model can be applied to characterize where participants were in the stages of change.

A Chicken Production Intervention and Additional Nutrition Behavior Change Component Increased Child Growth in Ethiopia: A Cluster-Randomized Trial.

BACKGROUND: Chicken production in the context of nutrition-sensitive agriculture may benefit child nutrition in low-income settings. OBJECTIVES: This study evaluated effects of 1) a chicken production intervention [African Chicken Genetic Gains (ACGG)], and 2) the ACGG intervention with nutrition-sensitive behavior change communication (BCC) [ACGG + Agriculture to Nutrition (ATONU)], on child nutrition and health outcomes and hypothesized intermediaries. METHODS: Forty ACGG villages received 25 genetically improved chickens and basic husbandry guidance; of these, 20 ACGG + ATONU villages in addition received a nutrition-sensitive behavior change and homegardening intervention; 20 control clusters received no intervention. We assessed effects of the interventions on height-for-age z scores (HAZ), weight-for-age z scores (WAZ), and weight-for-height z scores (WHZ) at 9 (midline) and 18 mo (endline) through unadjusted and adjusted ordinary least squares (OLS) regressions. We examined the interventions' effects on hypothesized intermediaries including egg production and consumption, dietary diversity, women's empowerment, income, child morbidities, anemia, and chicken management practices through OLS and log binomial models. RESULTS: Data included 829 children aged 0-36 mo at baseline. ACGG + ATONU children had higher midline HAZ [mean difference (MD): 0.28; 95% CI: 0.02, 0.54] than controls. The ACGG group had higher HAZ (MD: 0.28; 95% CI: 0.05, 0.50) and higher WAZ (MD: 0.18; 95% CI: 0.01, 0.36) at endline than controls; after adjusting for potential baseline imbalance, effects were similar but not statistically significant. At endline, differences in ACGG + ATONU children's HAZ and WAZ compared with controls were similar in magnitude to those of ACGG, but not statistically significant. There were no differences in anthropometry between the intervention groups. ACGG + ATONU children had higher dietary diversity and egg consumption than ACGG children at endline. Both interventions showed improvements in chicken management practices. The interventions did not increase anemia, diarrhea, fever, or vomiting, and the ACGG + ATONU group at midline showed reduced risk of fever. CONCLUSIONS: A chicken production intervention with or without nutrition-sensitive BCC may have benefited child nutrition and did not increase morbidity.This trial was registered at clinicaltrials.gov as NCT03152227.

Effect of Implementing a Free Delivery Service Policy on Women's Utilization of Facility-Based Delivery in Central Ethiopia: An Interrupted Time Series Analysis.

BACKGROUND: Access to and utilization of facility delivery services is low in Ethiopia. The government of Ethiopia introduced a free delivery service policy in all public health facilities in 2013 to encourage mothers to deliver in health facilities. Examining the effect of this intervention on the utilization of delivery services is very important. OBJECTIVE: In this study, we assessed the effect of provisions of free maternity care services on facility-based delivery service utilization in central Ethiopia. METHODS: Data on 108 time points were collected on facility-based delivery service utilization (72 pre- and 36 postintervention) for a period of nine years from July 2007 to June 2016. Routine monthly data were extracted from the District Health Information System and verified using data from the delivery ward logbooks across the study facilities. An interrupted time-series analysis was conducted to assess the effect of the intervention. RESULTS: The implementation of the free delivery services policy has significantly increased facility deliveries. During the study period, there was a statistically significant increase in the number of facility-based deliveries after the 24th and 36th months of intervention (p < 0.05). Program effects on the use of public facilities for deliveries were persisted over a longer exposure period. CONCLUSION: The findings suggested that the provision of free delivery services at public health facilities increased facility delivery use. The improved utilization of facility delivery services was more marked over a longer exposure period. Policy-makers may consider mobilizing the communities aware of the program at its instigation.

Are out-of-school adolescents at higher risk of adverse health outcomes? Evidence from 9 diverse settings in sub-Saharan Africa.

OBJECTIVES: We analysed mutually comparable surveys on adolescent attitudes and behaviours from nine sites in seven sub-Saharan African countries, to determine the relationship between school enrolment and adolescent health outcomes. METHODS: Data from the Africa Research, Implementation Science, and Education Network cross-sectional adolescent health surveys were used to examine the associations of current school enrolment, self-reported general health and four major adolescent health domains: (i) sexual and reproductive health; (ii) nutrition and non-communicable diseases; (iii) mental health, violence and injury; and (iv) healthcare utilisation. We used multivariable Poisson regression models to calculate relative risk ratios with 95% confidence intervals (CI), controlling for demographic and socio-economic characteristics. We assessed heterogeneity by gender and study site. RESULTS: Across 7829 adolescents aged 10-19, 70.5% were in school at the time of interview. In-school adolescents were 14.3% more likely (95% CI: 6-22) to report that their life is going well; 51.2% less likely (95% CI: 45-67) to report ever having had sexual intercourse; 32.6% more likely (95% CI: 9-61) to report unmet need for health care; and 30.1% less likely (95% CI: 15-43) to report having visited a traditional healer. School enrolment was not significantly associated with malnutrition, low mood, violence or injury. Substantial heterogeneity was identified between genders for sexual and reproductive health, and in-school adolescents were particularly less likely to report adverse health outcomes in settings with high average school enrolment. CONCLUSIONS: School enrolment is strongly associated with sexual and reproductive health and healthcare utilisation outcomes across nine sites in sub-Saharan Africa. Keeping adolescents in school may improve key health outcomes, something that can be explored through future longitudinal, mixed-methods, and (quasi-)experimental studies.

OBJECTIFS: Nous avons analysé des enquêtes mutuellement comparables sur les attitudes et les comportements d'adolescents dans neuf sites dans sept pays d'Afrique subsaharienne, afin de déterminer la relation entre la scolarisation et les résultats de la santé des adolescents. MÉTHODES: Des données provenant d'enquêtes transversales sur la santé des adolescents menées par le Réseau Africain de Recherche, d'Implémentation, de Science et d'Education ont été utilisées pour examiner les associations existant entre la scolarisation, l'état de santé général autodéclaré et les quatre principaux domaines de la santé des adolescents: (i) santé sexuelle et reproductive ; (ii) nutrition et maladies non transmissibles; (iii) santé mentale, violence et blessures et (iv) utilisation des soins de santé. Nous avons utilisé des modèles de régression multivariée de Poisson pour calculer les rapports de risque relatifs avec des intervalles de confiance (IC) à 95%, en tenant compte des caractéristiques démographiques et socioéconomiques. Nous avons évalué l'hétérogénéité par sexe et par site d'étude. RÉSULTATS: Sur 7.829 adolescents âgés de 10 à 19 ans, 70,5% étaient à l'école au moment de l'enquête. Les adolescents scolarisés étaient 14,3% (IC95%: 6-22) plus susceptibles de déclarer que leur vie se passait bien, 51,2% (IC95%: 45-67) moins susceptibles de déclarer avoir déjà eu des rapports sexuels, 32,6% (IC95%: 39-91) plus susceptibles de signaler un besoin de soins de santé non satisfait et 30,1% (IC95%: 15-43) moins susceptibles de déclarer avoir rendu visite à un guérisseur traditionnel. La scolarisation n'était pas associée de manière significative à la malnutrition, à la mauvaise humeur, à la violence ou aux blessures. Une hétérogénéité substantielle a été identifiée entre les sexes pour la santé sexuelle et reproductive, et les adolescents scolarisés étaient particulièrement moins susceptibles de faire état de résultats défavorables pour la santé dans les milieux où la moyenne de scolarisation était élevée. CONCLUSIONS: La scolarisation est fortement associée aux résultats en matière de santé sexuelle et reproductive et d'utilisation des soins de santé dans neuf sites en Afrique subsaharienne. Garder les adolescents à l'école peut améliorer les principaux résultats de santé, ce qui peut être exploré dans le cadre de futures études longitudinales.

Quality of intrapartum and newborn care in Tigray, Northern Ethiopia.

BACKGROUND: Quality intrapartum and newborn care is considered to be poor in Sub-Saharan Africa. However, studies done in Ethiopia are limited. Therefore, this study was conducted to assess the magnitude and factors associated with quality intrapartum and newborn care in Tigray, Northern Ethiopia. METHODS: Facility based survey was conducted from December 2014 to February 2015 in Tigray, Northern Ethiopia. The quality of intrapartum care provided by a total of 106 skilled birth attendants to 216 labouring mothers and newborns were observed during childbirth in the health facilities. Standardized questionnaires and checklist were utilized to collect data. Quality of intrapartum service was measured using standard intrapartum criteria. Thus, good quality service was considered if the mother and newborn scored 75% or more of the intrapartum criteria during childbirth. Binary and multiple logistic regression model was used to determine the factors associated with quality intrapartum and newborn care services. RESULTS: 29.2% of mothers and 67.6% newborns received good quality care during intrapartum and immediate postpartum periods respectively. However, only 47.2% of mothers and newborns received a friendly care during childbirths. The independent predictors of quality intrapartum and newborn care were the appropriate use of partograph (AOR 3.92; 95% CI 1.78, 8.63), friendly maternal and newborn care services (AOR 7.9; 95% CI 3.59, 17.33), more than two years working experience (AOR 0.31; 95% CI 0.13, 0.73) and using services in different Zones in the study area. CONCLUSIONS: The quality intrapartum care is poor in the study area and it is associated with inappropriate use of partograph, unfriendly care, and experience of health providers. Scaling up obstetric service, continuous training and motivation of service providers and revising the criterion for accreditation of service providers are important.

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.

An integrated community-based outpatient therapeutic feeding programme for severe acute malnutrition in rural Southern Ethiopia: Recovery, fatality, and nutritional status after discharge.

A scaled up and integrated outpatient therapeutic feeding programme (OTP) brings the treatment of severely malnourished children closer to the community. This study assessed recovery from severe acute malnutrition (SAM), fatality, and acute malnutrition up to 14 weeks after admission to a programme integrated in the primary health care system. In this cohort study, 1,048 children admitted to 94 OTPs in Southern Ethiopia were followed for 14 weeks. Independent anthropometric measurements and information on treatment outcome were collected at four home visits. Only 32.7% (248/759) of children with SAM on admission fulfilled the programme recovery criteria at the time of discharge (i.e., gained 15% in weight, or oedema, if present at admission, was resolved at discharge). Of all children admitted to the programme for whom nutritional assessment was done 14 weeks later, 34.6% (321/928) were severely malnourished, and 37.5% (348/928) were moderately malnourished; thus, 72.1% were acutely malnourished. Of the children, 27/982 (2.7%) had died by 14 weeks, of whom all but one had SAM on admission. Children with severe oedema on admission had the highest fatality rate (12.0%, 9/75). The median length of admission to the programme was 6.6 weeks (interquartile range: 5.3, 8.4 weeks). Despite children participating for the recommended duration of the programme, many children with SAM were discharged still acutely malnourished and without reaching programme criteria for recovery. For better outcome of OTP, constraints in service provision by the health system as well as challenges of service utilization by the beneficiaries should be identified and addressed.

Quality of the delivery services in health facilities in Northern Ethiopia.

BACKGROUND: Substantial improvements have been observed in the coverage of and access to maternal health service, especially in skilled birth attendants, in Ethiopia. However, the quality of care has been lagging behind. Therefore, this study investigated the status of the quality of delivery services in Northern Ethiopia. METHODS: A facility based survey was conducted from December 2014 to February 2015 in Northern Ethiopia. The quality of delivery service was assessed in 32 health facilities using a facility audit checklist, by reviewing delivery, by conducting in-depth interview and observation, and by conducting exit interviews with eligible mothers. Facilities were considered as 'good quality' if they scored positively on 75% of the quality indicators set in the national guidelines for all the three components; input (materials, infrastructure, and human resource), process (adherence to standard care procedures during intrapartum and immediate postpartum periods) and output (the mothers' satisfaction and utilization of lifesaving procedures). RESULTS: Overall 2 of 32 (6.3%) of the study facilities fulfilled all the three quality components; input, process and output. Two of the three components were assessed as good in 11 of the 32 (34.4%) health facilities. The input quality was the better of the other quality components; which was good in 21 out of the 32 (65.6%) health facilities. The process and output quality was good in only 10 of the 32 (31.3%) facilities. CONCLUSIONS: Only 6.3% of the studied health facilities had good quality in all three dimensions of quality measures that was done in accordance to the national delivery service guidelines. The most compromised quality component was the process. Systematic and sustained efforts need to be strengthened to improve all dimensions of quality in order to achieve the desired quality of delivery services and increase the proportion of births occurring in health facilities.

Choosing Anthropometric Indicators to Monitor the Response to Treatment for Severe Acute Malnutrition in Rural Southern Ethiopia-Empirical Evidence.

The World Health Organization (WHO) recommends the assessment of nutritional recovery using the same anthropometric indicator that was used to diagnose severe acute malnutrition (SAM) in children. However, related empirical evidence from low-income countries is lacking. Non-oedematous children (n = 661) aged 6-59 months admitted to a community-based outpatient therapeutic program for SAM in rural southern Ethiopia were studied. The response to treatment in children admitted to the program based on the mid-upper arm circumference (MUAC) measurement was defined by calculating the gains in average MUAC and weight during the first four weeks of treatment. The children showed significant anthropometric changes only when assessed with the same anthropometric indicator used to define SAM at admission. Children with the lowest MUAC at admission showed a significant gain in MUAC but not weight, and children with the lowest weight-for-height/length (WHZ) showed a significant gain in weight but not MUAC. The response to treatment was largest for children with the lowest anthropometric status at admission in either measurement. MUAC and weight gain are two independent anthropometric measures that can be used to monitor sufficient recovery in children treated for SAM. This study provides empirical evidence from a low-income country to support the recent World Health Organization recommendation.

Barriers to providing quality emergency obstetric care in Addis Ababa, Ethiopia: Healthcare providers' perspectives on training, referrals and supervision, a mixed methods study.

BACKGROUND: Increasing women's access to and use of facilities for childbirth is a critical national strategy to improve maternal health outcomes in Ethiopia; however coverage alone is not enough as the quality of emergency obstetric services affects maternal mortality and morbidity. Addis Ababa has a much higher proportion of facility-based births (82%) than the national average (11%), but timely provision of quality emergency obstetric care remains a significant challenge for reducing maternal mortality and improving maternal health. The purpose of this study was to assess barriers to the provision of emergency obstetric care in Addis Ababa from the perspective of healthcare providers by analyzing three factors: implementation of national referral guidelines, staff training, and staff supervision. METHODS: A mixed methods approach was used to assess barriers to quality emergency obstetric care. Qualitative analyses included twenty-nine, semi-structured, key informant interviews with providers from an urban referral network consisting of a hospital and seven health centers. Quantitative survey data were collected from 111 providers, 80% (111/138) of those providing maternal health services in the same referral network. RESULTS: Respondents identified a lack of transportation and communication infrastructure, overcrowding at the referral hospital, insufficient pre-service and in-service training, and absence of supportive supervision as key barriers to provision of quality emergency obstetric care. CONCLUSIONS: Dedicated transportation and communication infrastructure, improvements in pre-service and in-service training, and supportive supervision are needed to maximize the effective use of existing human resources and infrastructure, thus increasing access to and the provision of timely, high quality emergency obstetric care in Addis Ababa, Ethiopia.

Subclinical Iodine Deficiency among Pregnant Women in Haramaya District, Eastern Ethiopia: A Community-Based Study.

Background. Iodine deficiency in pregnancy is a worldwide problem. This study aimed to assess prevalence and predictors of subclinical iodine deficiency among pregnant women in Haramaya district, eastern Ethiopia. Methods. A cross-sectional, community-based study was conducted on 435 pregnant women existing in ten randomly selected rural kebeles (kebele is the smallest administrative unit in Ethiopia). Data on the study subjects' background characteristics, dietary habits, and gynecological/obstetric histories were collected via a structured questionnaire. UIC of <150 µg/L defined subclinical iodine deficiency. Data were analyzed by Stata 11. A multivariable logistic regression was used to identify the predictors of subclinical iodine deficiency. Results. The median urinary iodine concentration (MUIC) was 58.1 µg/L and 82.8% of the women who had subclinical iodine deficiency. The risk of subclinical iodine deficiency was reduced by the use of iodized salt (AOR = 0.13) and by intake of milk twice a month or more (AOR = 0.50), but it was increased by maternal illiteracy (AOR = 3.52). Conclusion. Iodine nutritional status of the pregnant women was poor. This shows that women and their children are exposed to iodine deficiency and its adverse effects. Thus, they need urgent supplementation with iodine and improved access to and intake of iodized salt and milk during pregnancy.

Barriers to diabetes medication adherence in North West Ethiopia.

BACKGROUND: Low adherence to prescribed diabetes medications is one of the major reasons to poor glycemic control in developing countries. Therefore, this study attempted to assess the magnitude of medication adherence and factors associated with it among adult persons with diabetes in northwest Ethiopia. METHOD: This study utilized a cross sectional study design with internal comparison. The study population was adult persons with diabetes attending the Diabetes Referral Clinic of Gondar University Hospital. Adherence was assessed using the eight-item Morisky Medication Adherence Scale (MMAS-8). In addition laboratory tests and chart reviews were carried out to collect relevant data. Ordinary logistic regression was used to identify factors associated with adherence. RESULT: A total of 391 patients were studied. Based on the MMAS-8 scale, the self-reported adherence to diabetic medication was low for 25.4% [95% CI: 21, 29] of the patients, medium for 28.7% [95% CI: 24, 33], and high for 45.9% [95% CI: 41, 50] of the patients. The Mean (±SD) of glycosylated hemoglobin for the low adherence group was 8.2% (±2.1). It was 8.1% (±2.0), for the medium, and 7.4% (±1.6) for the high adherence group. In the multivariate analysis poor wealth status (AOR = 1.99; 1.15, 3.43), using traditional treatment (AOR = 2.90; 1.03, 8.15), and service dissatisfaction (AOR = 2.23; 1.04, 4.80) were significantly associated with low adherence to prescribed diabetic medications. CONCLUSION: Over half of the persons with diabetes did not adhere to medications. Adherence was poor among users of traditional treatment and those dissatisfied with services. Developing a more intensive communication strategies and improving the quality of services could improve the level of adherence.

A description of malaria sentinel surveillance: a case study in Oromia Regional State, Ethiopia.

BACKGROUND: In the context of the massive scale up of malaria interventions, there is increasing recognition that the current capacity of routine malaria surveillance conducted in most African countries through integrated health management information systems is inadequate. The timeliness of reporting to higher levels of the health system through health management information systems is often too slow for rapid action on focal infectious diseases such as malaria. The purpose of this paper is to: 1) describe the implementation of a malaria sentinel surveillance system in Ethiopia to help fill this gap; 2) describe data use for epidemic detection and response as well as programmatic decision making; and 3) discuss lessons learned in the context of creating and running this system. CASE DESCRIPTION: As part of a comprehensive strategy to monitor malaria trends in Oromia Regional State, Ethiopia, a system of ten malaria sentinel sites was established to collect data on key malaria morbidity and mortality indicators. To ensure the sentinel surveillance system provides timely, actionable data, the sentinel facilities send aggregate data weekly through short message service (SMS) to a central database server. Bland-Altman plots and Poisson regression models were used to investigate concordance of malaria indicator reports and malaria trends over time, respectively. DISCUSSION: This paper describes three implementation challenges that impacted system performance in terms of: 1) ensuring a timely and accurate data reporting process; 2) capturing complete and accurate patient-level data; and 3) expanding the usefulness and generalizability of the system's data to monitor progress towards the national malaria control goals of reducing malaria deaths and eventual elimination of transmission. CONCLUSIONS: The use of SMS for reporting surveillance data was identified as a promising practice for accurately tracking malaria trends in Oromia. The rapid spread of this technology across Africa offers promising opportunities to collect and disseminate surveillance data in a timely way. High quality malaria surveillance in Ethiopia remains a resource intensive activity and extending the generalizability of sentinel surveillance findings to other contexts remains a major limitation of these strategies.

Lifesaving emergency obstetric services are inadequate in south-west Ethiopia: a formidable challenge to reducing maternal mortality in Ethiopia.

BACKGROUND: Most maternal deaths take place during labour and within a few weeks after delivery. The availability and utilization of emergency obstetric care facilities is a key factor in reducing maternal mortality; however, there is limited evidence about how these institutions perform and how many people use emergency obstetric care facilities in rural Ethiopia. We aimed to assess the availability, quality, and utilization of emergency obstetric care services in the Gamo Gofa Zone of south-west Ethiopia. METHODS: We conducted a retrospective review of three hospitals and 63 health centres in Gamo Gofa. Using a retrospective review, we recorded obstetric services, documents, cards, and registration books of mothers treated and served in the Gamo Gofa Zone health facilities between July 2009 and June 2010. RESULTS: There were three basic and two comprehensive emergency obstetric care qualifying facilities for the 1,740,885 people living in Gamo Gofa. The proportion of births attended by skilled attendants in the health facilities was 6.6% of expected births, though the variation was large. Districts with a higher proportion of midwives per capita, hospitals and health centres capable of doing emergency caesarean sections had higher institutional delivery rates. There were 521 caesarean sections (0.8% of 64,413 expected deliveries and 12.3% of 4,231 facility deliveries). We recorded 79 (1.9%) maternal deaths out of 4,231 deliveries and pregnancy-related admissions at institutions, most often because of post-partum haemorrhage (42%), obstructed labour (15%) and puerperal sepsis (15%). Remote districts far from the capital of the Zone had a lower proportion of institutional deliveries (<2% of expected births compared to an overall average of 6.6%). Moreover, some remotely located institutions had very high maternal deaths (>4% of deliveries, much higher than the average 1.9%). CONCLUSION: Based on a population of 1.7 million people, there should be 14 basic and four comprehensive emergency obstetric care (EmOC) facilities in the Zone. Our study found that only three basic and two comprehensive EmOC service qualifying facilities serve this large population which is below the UN's minimum recommendation. The utilization of the existing facilities for delivery was also low, which is clearly inadequate to reduce maternal deaths to the MDG target.

Death and seeking alternative therapy largely accounted for lost to follow-up of patients on ART in northwest Ethiopia: a community tracking survey.

BACKGROUND: Antiretroviral treatment programs in sub-Saharan African countries are highly affected by LTF. Tracking patients lost to follow-up and understanding their status is essential to maintain program quality and to develop targeted interventions to prevent LTF. We aimed to determine the outcome and factors associated with LTF. METHOD: A lost to follow-up community tracking survey was conducted to determine the reasons, outcomes and factors associated with LTF at the University of Gondar Hospital, northwest Ethiopia. All patients were tracked at home to ascertain outcome status for lost to follow-up (death and non-death losses). RESULT: Out of the 551 patients LTF, 486 (88.20%) were successfully tracked. Death was the most common reason accounted for 233 (47.94%) of the lost to follow-up. Reasons for non-deaths losses include: stopped antiretroviral treatment due to different reasons, 135(53.36%), and relocation to another antiretroviral treatment program by self-transfer, 118(46.64%). The rate of mortality in the first six months was 72.12 per 100 person-years (95% CI: 61.80-84.24) but this sharply decreased after 12 months to 7.92 per 100 person-years (95% CI: 4.44-14.41). Baseline clinical characteristics were strongly associated with mortality. CONCLUSION: Death accounts for about half of the loss to follow up. Most deaths occur in the first six months of loss. Seeking alternative therapy is another major reason for loss to follow up. Early tracking mechanisms are necessary to prevent death.