Community and provider perceptions and experiences of cervical cancer screening in Rural Bolivia: a qualitative study.

BACKGROUND: Despite efforts to increase cervical cancer screening access in rural Bolivia, uptake remains low. Bolivia has one of the highest cervical cancer mortality rates in the Americas. As it redoubles efforts to deliver Universal Health Care, the Bolivian government needs information on the factors constraining cervical cancer screening access and utilization, especially in rural areas. METHODS: Our qualitative study explored cervical cancer screening barriers and described community and provider perceptions and experiences of care. Bolivian and US researchers analyzed data collected from eight focus groups with male and female community members (n = 80) and interviews with healthcare providers (n = 6) in four purposively selected rural communities in Hernando Siles, Bolivia. Deductive and inductive codes were used to thematically analyze data using MaxQDA software. RESULTS: Four themes emerged from the data: lack of knowledge/misconceptions, health system inadequacy, lack of confidence in providers, and opportunities for improvement. Both men and women displayed misconceptions about the causes of cervical cancer, its consequences, the recommended screening frequency, and the means of accessing care. Providers noted community members' lack of knowledge and low risk-perception as utilization barriers but also highlighted poor health service quality and inconsistent health education as factors. Poor healthcare quality was a significant barrier; this included poor patient-provider communication, lack of transportation to screening facilities, and severe delays in receiving test results. Providers also noted problems with provider training and physical space for screening. Community members reported low confidence in nurses to perform screening, preferring doctors and specialists. They also expressed discomfort in having male healthcare providers conduct screening. Suggestions for improvements included more intensive cervical cancer outreach to rural areas and having specialists train lower-level providers to perform screening. CONCLUSIONS: Our findings suggest that poor healthcare quality has affected screening uptake in addition to physical barriers to care. They indicate a need for initiatives to reduce reporting time for Pap test results, the incorporation of community-based HPV self-sampling into screening protocols, and the implementation of programs to improve community confidence in providers' ability to perform screening.

"The problem is that our culture is just so messed up about aging." Recruiting older men who have sex with men (MSM) into research studies: an example from a study of aging, HIV, and anal HPV.

BACKGROUND: Anal human papillomavirus (HPV) disproportionately affects men who have sex with men (MSM), particularly those who are older and those living with HIV. After experiencing difficulty recruiting older MSM into a study on aging and anal HPV, we conducted a sub-study to gain feedback on our recruitment methods and explore barriers and facilitators to participating in anal HPV research. METHODS: We conducted focus groups with 30 men who have sex with men (MSM), both HIV-negative and MSM living with HIV, ages 50-75. RESULTS: We identified multiple themes that were barriers to participation including: (1) lack of knowledge about human papillomavirus and anal cancer; (2) research focused on anal cancer or discomfort with topics or procedures concerning the anus; (3) stigma including stigma associated with being men who have sex with men, being out, being a receptive partner, and being considered "older" in the gay community; and (4) confidentiality concerns including a fear of breach of confidentiality. Facilitators to participation were also identified; these motivational factors include altruism, wanting recommendations from a doctor, and desire to receive the best available care. CONCLUSION: Researchers seeking to enroll older men who have sex with men should be aware of these barriers and facilitators to participation in order to maximize recruitment.

Professionalism, stigma, and willingness to provide patient-centered safe abortion counseling and care: a mixed methods study of Ethiopian midwives.

BACKGROUND: Midwives are a large proportion of Ethiopia's health care workforce, and their attitudes and practices shape the quality of reproductive health care, including safe abortion care (SAC) services. This study examines how midwives' conceptions of their professional roles and views on women who have abortions relate to their willingness to provide respectful SAC. METHODS: This study uses a cross-sectional, mixed methods design to conduct a regionally representative survey of midwives in Ethiopia's five largest regions (Oromia; Amhara; Southern Nations, Nationalities, and Peoples [SNNP]; Tigray; and Addis Ababa) with a multistage, cluster sampling design (n = 944). The study reports survey-weighted population estimates and the results of multivariate logistic regression analyzing factors associated with midwives' willingness to provide SAC. Survey data were triangulated with results from seven focus group discussions (FGDs) held with midwives in the five study regions. Deductive and inductive codes were used to thematically analyze these data. RESULTS: The study surveyed 960 respondents. An estimated half of midwives believed that providing SAC was a professional duty. Slightly more than half were willing to provide SAC. A belief in right of refusal was common: two-thirds of respondents said that midwives should be able to refuse SAC provision on moral or religious grounds. Modifiable factors positively associated with willingness to provide SAC were SAC training (AOR 4.02; 95% CI 2.60, 6.20), agreeing that SAC refusal risked women's lives (AOR 1.69; 95% CI 1.20, 2.37), and viewing SAC provision as a professional duty (AOR 1.72; 95% CI 1.23, 2.39). In line with survey findings, a substantial number of FGD participants stated they had the right to refuse SAC. Responses to client scenarios revealed "directive counseling" to be common: many midwives indicated that they would actively attempt to persuade clients to act as they (the midwives) thought was best, rather than support clients in making their own decisions. CONCLUSION: Findings suggest a need for new guidelines to clarify procedures surrounding conscientious objection and refusal to provide SAC, as well as initiatives to equip midwives to provide rights-based, patient-centered counseling and avoid directive counseling.

When health care workers refuse to provide safe abortion care (SAC) for religious, moral, or personal reasons, they jeopardize their clients' health and violate the right to care. Scholars believe that health care workers' professional commitments to patient care and to their profession's goals can help them prioritize patient care over their personal biases. The Ethiopian government has assigned midwives a central responsibility to provide SAC, but there is no comprehensive understanding of Ethiopian midwives' willingness to provide SAC and allied rationales, or the relationships between their sense of professional duty and willingness to provide.To answer these questions, a survey and focus groups with midwives in Ethiopia's five most populated regions were conducted. Almost half of midwives were unwilling to provide SAC, and half disbelieved that it was midwives' duty to do so. Most believed that midwives should be able to refuse to provide SAC based on religious or moral objections. Midwives were motivated to provide care by a belief that clients would die without care and by a sense of professional duty. When asked about how they would treat women requesting abortion care and contraceptives, many midwives said that they would encourage the woman to do what the midwife him- or herself thought best, rather than support her in making her own decision.These regionally representative findings suggest the need for new provider guidelines to clarify practices surrounding conscientious objection and refusal to provide safe abortion care and for programs to better train midwives to provide respectful counseling.

Perceptions of cervical cancer care among Ethiopian women and their providers: a qualitative study.

BACKGROUND: Cervical cancer is the second most commonly diagnosed cancer among Ethiopian women, killing an estimated 4700 women each year. As the government rolls out the country's first national cancer control strategy, information on patient and provider experiences in receiving and providing cervical cancer screening, diagnosis, and treatment is critical. METHODS: This qualitative study aimed to assess the availability of cervical cancer care; explore care barriers and sources of delay; and describe women's and providers' perceptions and experiences of care. We analyzed data from 45 informants collected at 16 health centers, district hospitals and referral hospitals in East Gojjam Zone and a support center in Addis Ababa. Thirty providers and ten women receiving care were interviewed, and five women in treatment or post-treatment participated in a focus group discussion. Deductive and inductive codes were used to thematically analyze data. RESULTS: Providers lacked equipment and space to screen and treat patients and only 16% had received in-service cervical cancer training. Consequently, few facilities provided screening or preventative treatment. Patients reported low perceptions of risk, high stigma, a lack of knowledge about cervical cancer, and delayed care initiation. All but one patient sought care only when she became symptomatic, and, pre-diagnosis, only half of the patients knew about cervical cancer. Even among those aware of cervical cancer, many assumed they were not at risk because they were not sexually active. Misdiagnosis was another common source of delay experienced by half of the patients. Once diagnosed, women faced multiple-month waits for referrals, and, once in treatment, broken equipment and shortages of hospital beds resulted in additional delays. Barriers to therapeutic treatment included a lack of housing and travel funds. Patient-provider communication of cancer diagnosis was often lacking. CONCLUSIONS: In-service provider training should be intensified and should include discussions of cervical cancer symptoms. Better distribution of screening and diagnostic supplies to lower-level facilities and better maintenance of treatment equipment at tertiary facilities are also a priority. Expanded cervical cancer health education should focus on stigma reduction and emphasize a broad, wide-spread risk of cervical cancer.

Cervical cancer is the second most commonly diagnosed cancer among Ethiopian women, killing an estimated 4700 women each year. This study aimed to assess patient and provider experiences in receiving and providing cervical cancer screening, diagnosis, and treatment. We interviewed 30 midlevel providers and ten women receiving care and held a focus group discussion with five women who were receiving treatment or who had recently completed treatment. Patients reported bottlenecks and delays at each stage of care. Low perception of risk, high stigma, and a lack of knowledge about cervical cancer among both providers and patients, were significant sources of delay in initiating care. Few patients had been aware of cervical cancer before they were diagnosed and of those who were aware, many assumed that they were not at risk because they were not sexually active. Misdiagnosis was another common source of delay. Once diagnosed correctly, women faced multiple-month delays after referrals, and, once in treatment, broken equipment and a shortage of hospital beds resulted in additional delays. The most frequently mentioned barriers to care were a lack of housing and travel funds while receiving treatment in the capital. Patient-provider communication of cancer diagnosis was often poor. Our findings suggest the need to intensify in-service training for providers, focusing initially on alerting them to cervical cancer symptoms. Better distribution of screening and diagnostic supplies to lower-level facilities and better maintenance of treatment equipment at tertiary facilities should also be a priority.

Effect of a self-care educational intervention to improve self-care adherence among patients with chronic heart failure: a clustered randomized controlled trial in Northwest Ethiopia.

BACKGROUND: As the burden of cardiovascular disease increases in sub-Saharan Africa, there is a growing need for low-cost interventions to mitigate its impact. Providing self-care health education to patients with chronic heart failure (CHF) is recommended as an intervention to prevent complications, improve quality of life, and reduce financial burdens on fragile health systems. However, little is known about health education's effectiveness at improving CHF self-management adherence in sub-Saharan Africa. Therefore the present study aimed to assess the effectiveness of an educational intervention to improve self-care adherence among patients with CHF at Debre Markos and Felege Hiwot Referral Hospitals in Northwest Ethiopia. METHODS: To address this gap, we adapted a health education intervention based on social cognitive theory comprising of intensive four-day training and, one-day follow-up sessions offered every four months. Patients also received illustrated educational leaflets. We then conducted a clustered randomized control trial of the intervention with 186 randomly-selected patients at Debre Markos and Felege Hiwot referral hospitals. We collected self-reported data on self-care behavior before each educational session. We analyzed these data using a generalized estimating equations model to identify health education's effect on a validated 8-item self-care adherence scale. RESULTS: Self-care adherence scores were balanced at baseline. After the intervention, patients in the intervention group (n = 88) had higher adherence scores than those in the control group (n = 98). This difference was statistically significant (ß = 4.15, p < 0.05) and increased with each round of education. Other factors significantly associated with adherence scores were being single (ß = - 0.25, p < 0.05), taking aspirin (ß = 0.76, p < 0.05), and having a history of hospitalization (ß = 0.91, p < 0.05). CONCLUSIONS: We find that self-care education significantly improved self-care adherence scores among CHF patients. This suggests that policymakers should consider incorporating self-care education into CHF management. TRIAL REGISTRATION NUMBER: PACTR201908812642231.

Youths' perceptions of community health workers' delivery of family planning services: a cross-sectional, mixed-methods study in Nakaseke District, Uganda.

BACKGROUND: High rates of unintended adolescent pregnancy are a significant health problem in Uganda. To improve access to family planning (FP) services, community-based Village Health Teams (VHTs) are widely employed in Uganda to deliver education and services. However, evaluations of FP programs suggest that mainly older, married women use VHT FP services. METHODS: To better understand youth reluctance to use VHTs, we collected quantitative FP and contraceptive-seeking behavior data from a survey of 250 youths aged 15-25 in randomly selected households in Nakaseke District, which we triangulated with data from 3 focus group discussions (FGDs) (n = 15). RESULTS: Most respondents received FP services from the formal health sector, not VHTs. Only half had talked to a VHT, but 65% knew that VHTs provide free FP services, and most (82%) felt comfortable talking to VHTs about FP. The main reasons for discomfort were fear that VHTs would violate privacy (mentioned by 60% of those not comfortable), that VHTs would talk to parents (33%), shyness (mentioned by 42% of those ≤18), and fear of being judged (14%). Concern about side effects was the most common reason for not using FP methods. Survey respondents said having VHTs of the same sex was important, particularly those in the youngest age group (OR = 4.45; 95%CI: 1.24, 16.00) and those who were unmarried (OR = 5.02; 95%CI: 2.42, 10.39). However, FGD participants (who were older than survey respondents on average) often preferred older VHTs of the opposite sex, whom they viewed as more professional and trustworthy. Respondents said the primary deciding factors for using VHTs were whether privacy would be respected, the proximity of care, and the respectfulness of care. CONCLUSIONS: VHTs are a known source of FP services but not widely used by youth due to privacy and quality of care concerns. VHT messaging and training should increase focus on ensuring privacy, protecting confidentiality, providing respectful care, and addressing concerns about contraceptive side effects. Preferences for VHTs of similar age and sex may be more important for younger adolescents than older youths for whom quality concerns predominate.

Understanding policy change for obesity prevention: learning from sugar-sweetened beverages taxes in Mexico and Chile.

This article examines the policy change process that resulted in the current sugar-sweetened beverages taxes in Mexico and Chile, using the Kaleidoscope Model for Policy Change, a framework developed for nutrition and food policy change analysis. We used a qualitative study design, including 24 key informant (KI) interviews (16 researchers, 5 civil society representatives and 3 food/beverage industry representatives), encompassing global and in-country perspectives. The analysis shows concurrence with the Kaleidoscope Model, highlighting commonalities in the policy change process. These included the importance of focusing events and coalitions for agenda-setting. Both top-down executive leadership and bottom-up pressure from civil society coalitions were important for the policy adoption as were flexible framing of the tax, and taking advantage of windows of opportunity. In both countries, the tax resulted from national, revenue-seeking fiscal reforms and in sub-optimal tax rates, as a result of the industry influence. KIs also discussed emerging evaluation results, highlighting differences in interpretation concerning the magnitude of change from the tax, and shared potential modifications to the current policies. This analysis contributes to a greater understanding of the policy change process focused on obesity prevention, using an innovative theoretical framework developed specifically for food and nutrition policy.

Immunological Treatment Failure Among Adult Patients Receiving Highly Active Antiretroviral Therapy in East Africa: A Systematic Review and Meta-Analysis.

BACKGROUND: Minimizing antiretroviral treatment failure is crucial for improving patient health and for maintaining long-term access to care in low-income settings such as eastern Africa. To develop interventions to support adherence, policymakers must understand the extent and scope of treatment failure in their programs. However, estimates of treatment failure in eastern Africa have been variable and inconclusive. OBJECTIVE: This systematic review and meta-analysis sought to determine the pooled prevalence of immunological failure among adults receiving antiretroviral therapy in eastern Africa. METHODS: We performed a systematic search of the PubMed, Google Scholar, Excerpta Medica Database, and the World Health Organization's Hinari portal (which includes the Scopus, African Index Medicus, and African Journals Online databases) databases. Unpublished studies were also accessed from conference websites and university repositories. We used Stata version 14 for data analysis. The Cochrane Q test and I 2 test statistic were used to test for heterogeneity across the studies. Due to high levels of heterogeneity, a random effects model was used to estimate the pooled prevalence of immunological failure. Begg and Egger tests of the intercept in the random effects model were used to check for publication bias. RESULTS: After removing duplicates, 25 articles remained for assessment and screening. After quality screening, 15 articles were deemed eligible and incorporated into the final analysis. The average pooled estimate of immunological treatment failure prevalence was found to be 21.89% (95% CI, 15.14-28.64). In the subgroup analysis conducted by geographic region, the pooled prevalence of immunological treatment failure in Ethiopia was 15.2% (95% CI, 12.27-18.13) while in Tanzania it was 53.93% (95% CI, 48.14-59.73). Neither the results of Egger test or Begg tests suggested publication bias; however, on visual examination, the funnel plot appeared asymmetric. The large heterogeneity across the studies could be explained by study country. CONCLUSION: Immunological treatment failure among patients receiving antiretroviral therapy in eastern Africa was high, and greater than previously reported. The relatively low rates of treatment failure found in Ethiopia suggest that its health extension program should be studied as a model for improving adherence in the region. (Curr Ther Res Clin Exp. 2021; 82:XXX-XXX) © 2021 Elsevier HS Journals, Inc.

Evidence-Based Practice and Associated Factors Among Health Care Providers Working in Public Hospitals in Northwest Ethiopia During 2017.

BACKGROUND: Despite the fact that evidence-based practice (EBP) is believed to be associated with improved health, safety, and cost outcomes, most medical practice in low- and middle-income countries such as Ethiopia is not evidence-based. Understanding the extent of and barriers to EBP in Ethiopia is important for learning how to best to improve quality of care. Few studies have assessed EBP in Ethiopia. OBJECTIVE: This study aimed to assess reported level of EBP and associated factors among health care providers working in public hospitals in northwest Ethiopia. METHODS: A cross-sectional study was conducted with 415 randomly selected nurses, midwives, and physicians using stratified sampling (97.6% response rate). Data were collected using a structured, self-administered questionnaire that was developed by reviewing the literature and adapting the Melnyk and Fineout-Overholt EBP Implementation Scale. After validating scales, bivariate and multivariate linear regression models were used to identify factors associated with EBP implementation. RESULTS: The mean EBP implementation score was 10.3 points out of a possible 32 points and 60% of respondents scored below average. Most (60.2%) respondents reported poor confidence in their ability to judge the quality of research and half (50.1%) said that they were unable to find resources for implementing EBP. The most frequently mentioned barriers to EBP were lack of training (81.2%), poor health facility infrastructure (79.3%), and lack of formal EBP/patient education units in facilities (78.0%). The factors found to be significantly and independently associated with EBP implementation were years of work experience (ß = -0.10; P < 0.05); having been trained as a bachelor's degree-level nurse (ß = 3.45; P < 0.001) or a bachelor's degree-level midwife (ß = 2.96; P < 0.001), a general practitioner (ß = 7.86; P < 0.001), or a specialist physician (ß = 15.04; P < 0.001) rather than a diploma-level nurse; working in a pediatrics ward (ß = -1.74; P < 0.05); and reporting as barriers either a lack of clarity on the importance of EBP (ß = -0.93; P < 0.05) or a lack of orientation sessions on new health priorities (ß = -0.91; P < 0.05). CONCLUSIONS: Health professionals had low levels of EBP implementation and poor EBP skills. These problems were particularly acute for providers with lower levels of training. A large number of respondents reported structural and institutional barriers to EBP. These results suggest that clear leadership and ongoing, cross-disciplinary, skill-building approaches are needed to increase EBP implementation in Ethiopia. (Curr Ther Res Clin Exp. 2020; 81:XXX-XXX).

The effect of disclosure on adherence to antiretroviral therapy among adults living with HIV in Ethiopia: a systematic review and meta-analysis.

BACKGROUND: Several factors have been identified as being associated with increased adherence to antiretroviral therapy, including sero-status disclosure; however, studies examining the effect of disclosure on ART adherence in Ethiopia have had inconsistent findings. This systematic review and meta-analysis therefore aims to estimate the pooled effect of disclosure on adherence to ART among adults living with HIV in Ethiopia. METHODS: We performed a systematic search for articles reporting on peer-reviewed, quantitative, English-language observational studies of reporting the association between self sero-status disclosure and good ART adherence in adults living with HIV/AIDS in Ethiopia during published from 2010 to 2015. We searched four electronic databases: PubMed/Medline, the World Health Organization's Hinari portal (which includes the SCOPUS, African Index Medicus, and African Journals Online databases) for studies from December 1, 2017 to January 30, 2018. We also searched university repositories and conference abstracts for unpublished studies. We conducted a meta-analysis for the pooled effect of adherence using a random effects model in Stata version 14 and assessed publication bias using the Egger's test for funnel plot asymmetry. RESULTS: Our search returned in 179 studies, of which seven (3.9%), were eligible and included in the final meta-analysis. The seven included studies were conducted from 2010 to 2015. Our analysis found that disclosure had a significant effect on the adherence to ART in adult patients living with HIV. Patients who disclosed were 1.64 times more likely to have good adherence to ART compared with those who did not (OR: 1.64, 95% CI: 1.11, 2.42). The small number of studies eligible for review and differences in study definitions of adherence and disclosure were the main limitations of this study. CONCLUSION: This review found a statistically significant positive effect of disclosure status on the adherence to ART in adult patients living with HIV in Ethiopia. This suggests that Ethiopia's national treatment and prevention programs should redouble efforts to encourage self-disclosure among people living with HIV/AIDS. Encouraging supportive social environments for disclosure, and promoting partner notification and partner disclosure support initiatives might be particularly helpful in this regard.

Prevalence of goiter among children in Ethiopia and associated factors: a systematic review and meta-analysis.

BACKGROUND: The distribution of goiter among children and its risk factors are not well investigated in Ethiopia. Therefore, this systematic review and meta-analysis was designed to determine the pooled prevalence of goiter and its associated factors among children in Ethiopia. METHODS: Electronic web-based searches of PubMed, Google Scholar, EMBASE, and the World Health Organization's Hinari portal (which includes the SCOPUS, African Index Medicus, and African Journals Online databases) were conducted to find primary studies. Relevant data were extracted and descriptive summaries of the studies were presented in tables. The I2 statistic was used to assess heterogeneity across studies. Funnel plot asymmetry and Egger's tests were used to check for publication bias. A random effects model was used to estimate the pooled prevalence of goiter. Odds ratios (OR) with 95% Confidence Intervals (CI) were also used to determine the association of identified variables with goiter. All statistical analyses were conducted using Stata version 14 software. RESULTS: Our search identified 982 studies, of which, 19 articles were eligible for inclusion in the final meta-analysis. The pooled estimate of goiter among children in Ethiopia was 40.50% (95% CI: 33.6-47.40). The regional distribution of goiter ranged from 44.22 (95% CI: 17.44-71) in Southern Nations Nationalities and Peoples' Region, to 32.79% (95% CI: 19.86-45.73) in Benishangul Gumez region. The prevalence of goiter among female children (44.34%) was higher than among male (32.88%) children. Goiter prevalence was also significantly higher among children who consumed vegetables three or more times per week OR = 1.3 (95% CI: 1.02-1.66); those who had family history of goiter, OR = 2.38 (95% CI: 1.9-2.99); and those whose family stored salt near to fires, OR = 1.4 l (95% CI: 1.1-1.79). CONCLUSION: The prevalence of goiter among children in Ethiopia was high, and endemic according to the WHO criteria. Our findings suggest the need for interventions to improve salt iodization, and for improved health education on appropriate salt storage. In addition, more research may be needed to improve our understanding of foods that increase the risk of goiter among children.

Outsiders, insiders, and intermediaries: village health teams' negotiation of roles to provide high quality sexual, reproductive and HIV care in Nakaseke, Uganda.

BACKGROUND: Community health workers, known as Village Health Teams (VHTs) in Uganda, play a central role in increasing access to community-based health services. The objective of this research is to explore tensions that may emerge as VHTs navigate multiple roles as community members and care providers particularly when providing sensitive reproductive health and HIV care. METHODS: Twenty-five VHTs from a rural clinic in Uganda completed semi-structured interviews focused on experiences providing services. Interview questions focused on challenges VHTs face providing services and strategies for improving quality care. After translation from Luganda and transcription, interviews were analyzed using content analysis to identify emergent themes. RESULTS: Most VHTs were female (n = 16). The average age was 46, and average length of VHT work, 11 years. Analyses revealed that all VHTs capitalized upon the duality of their position, shifting roles depending upon context. Three themes emerged around VHTs' perceptions of their roles: community insiders, professional outsiders, and intermediaries. A caregiver "insider" role facilitated rapport and discussion of sensitive issues. As community members, VHTs leveraged existing community structures to educate clients in familiar settings such as "drinking places". However, this role posed challenges as some VHTs felt compelled to share their own resources including food and transport money. Occupying a professional outsider role offered VHTs respect. Their specialized knowledge gave them authority to counsel others on effective forms of family planning. However, some VHTs faced opposition, suspicions about their motives, and violence in this role. In balancing these two roles, the VHTs adopted a third as intermediaries, connecting the community to services in the formalized health care system. Participants suggested that additional training, ongoing supervision, and the opportunity to collaborate with other VHTs would help them better navigate their different roles and, ultimately, improve the quality of service. CONCLUSIONS: As countries scale up family planning and HIV services using VHTs, supportive supervision and ethical dilemma training are recommended so VHTs are prepared for the challenges of assuming multiple roles within communities.

Professional Pragmatism and Abortion Stigma: Assessing the Performance of the Stigmatizing Attitudes, Beliefs and Actions Scale (SABAS) among Ethiopian Midwives.

This study assessed the applicability to medical professionals in Ethiopia of an abortion stigma assessment tool developed for community members, and examined the relationship between stigma and willingness to provide safe abortion care (SAC). The Stigmatizing Attitudes, Beliefs and Actions Scale (SABAS) was fielded to a convenience sample of 397 Ethiopian midwives. Scale reliability and validity were assessed, and associations were examined using multivariate linear and logistic regression. Levels of stigma were low compared to those reported elsewhere, and 49% of midwives were willing to provide SAC. The revised SABAS was reliable (alpha = 0.82), but items did not group into SABAS' conceptual categories, and some had limited face validity. SABAS scores had a small but significant negative association with willingness to provide SAC (OR=0.95, p < 0.05), with negative stereotyping subscale items most predictive. SABAS' limitations found here suggest the need for an adapted scale for medical professionals.

Midwives' and patients' perspectives on disrespect and abuse during labor and delivery care in Ethiopia: a qualitative study.

BACKGROUND: It is increasingly recognized that disrespect and abuse of women during labor and delivery is a violation of a woman's rights and a deterrent to the use of life-saving, facility-based labor and delivery services. In Ethiopia, rates of skilled birth attendance are still only 28% despite a recent dramatic national scale up in the numbers of trained providers and facilities. Concerns have been raised that womens' perceptions of poor quality of care and fear of mistreatment might contribute to this low utilization. This study examines the experiences of disrespect and abuse in maternal care from the perspectives of both providers and patients. METHODS: We conducted 45 in-depth interviews at four health facilities in Debre Markos, Ethiopia with midwives, midwifery students, and women who had given birth within the past year. Students and providers also took a brief quantitative survey on patients' rights during labor and delivery and responded to clinical scenarios regarding the provision of stigmatized reproductive health services. RESULTS: We find that both health care providers and patients report frequent physical and verbal abuse as well as non-consented care during labor and delivery. Providers report that most abuse is unintended and results from weaknesses in the health system or from medical necessity. We uncovered no evidence of more systematic types of abuse involving detention of patients, bribery, abandonment or ongoing discrimination against particular ethnic groups. Although health care providers showed good basic knowledge of confidentiality, privacy, and consent, training on the principles of responsive and respectful care, and on counseling, is largely absent. Providers indicated that they would welcome related practical instruction. Patient responses suggest that women are aware that their rights are being violated and avoid facilities with reputations for poor care. CONCLUSIONS: Our results suggest that training on respectful care, offered in the professional ethics modules of the national midwifery curriculum, should be strengthened to include greater focus on counseling skills and rapport-building. Our findings also indicate that addressing structural issues around provider workload should complement all interventions to improve midwives' interpersonal interactions with women if Ethiopia is to increase provision of respectful, patient-centered maternity care.

Breastfeeding and Incarceration: An Analysis of California County Jails' Written Breast Milk Feeding Policies.

Between 1980 and 2019, the number of incarcerated women rose by more than 700%. Rising imprisonment of women corresponds with an increase in incarcerated lactating people. In 2018, California signed Assembly Bill (AB) 2507, requiring county jails to develop and implement a breast milk feeding policy for incarcerated women who wish to express their breast milk. We conducted a cross-sectional, descriptive study to determine if California's 58 counties created policies compliant with AB2507. Additionally, policies were analyzed for inclusion of evidence-based breastfeeding and lactation management practices and given a letter grade for their performance. Public records act requests were sent to all California counties, requesting their breast milk feeding policies. Of the 55 counties that responded, 51 had policies. Twenty-eight (51%) counties were in full compliance and 27 (49%) counties lacked compliance. No counties received letter grade A and 48 (87%) counties received letter grade C or below. Results reveal a discrepancy between legally compliant policies and evidence-based practices. The California county jail management needs increased surveillance to ensure policies are in full compliance and reflect best practices. Further research is required to investigate the actual implementation of compliant written breastfeeding policies.

Incidence and predictors of mortality among adolescents on antiretroviral therapy in Amhara Region, Ethiopia: a retrospective cohort analysis.

OBJECTIVE: This study aimed to assess the incidence and predictors of mortality in adolescents receiving antiretroviral therapy (ART) in Ethiopia's Amhara Region. DESIGN: We conducted an institution-based retrospective follow-up study. SETTINGS: The study was conducted at Amhara Region's comprehensive specialised hospitals in Ethiopia. PARTICIPANTS: We included 961 randomly selected medical records of adolescents receiving ART between January 2005 and June 2020. PRIMARY AND SECONDARY OUTCOMES: The incidence of mortality since ART treatment initiation served as the primary outcome, and predictors of mortality served as secondary outcomes. We used Cox proportional hazard regression to examine the relationship between mortality and its predictors. Variables with p values<0.05 in the multivariable analysis were considered statistically significant mortality predictors. Adjusted HR (aHR) with 95% CI was used to measure the strength of association. RESULTS: More than half (n=496, 53.5%) of the adolescents living with HIV (ALHIV) were girls. The adolescent mortality rate was 1.52 (95% CI: 1.04 to 1.53) per 100 person-years throughout the follow-up period of 81 583 adolescent months. Mortality was higher for ALHIV who had not received formal education (aHR: 3.27, 95% CI: 1.36 to 7.87), had widowed parents (aHR: 1.85, CI: 95% 1.01 to 3.56) or received no social support (aHR: 2.81, 95% CI: 1.69 to 4.67). Adolescents who had opportunistic infections (OIs) at ART initiation (aHR: 1.94, 95% CI: 1.19 to 3.14), low haemoglobin (Hgb/g/l) levels (aHR: 2.17, 95% CI: 1.08 to 4.18), a bedridden functional status (aHR: 3.11, 95% CI: 1.64 to 5.72), stage IV clinical staging (aHR: 3.03, 95% CI: 1.46 to 6.30), non-disclosing status (aHR: 2.24, 95% CI:1.36 to 3.69) and CD4 count 200-350 cells/mm3 (aHR: 2.17, 95% CI: 1.08 to 4.18) also had a higher risk of death. Not receiving cotrimoxazole preventive therapy (aHR: 1.85, 95% CI: 1.07 to 3.22) and poor adherence to ART (aHR: 2.24, 95% CI: 1.27 to 3.95), compared with adherent, was associated with higher mortality risk. Changed treatment regimens were associated with lower mortality (aHR: 0.59, 95% CI: 0.35 to 0.98). CONCLUSIONS: Our study found a lower mortality rate for adolescents with HIV than previous Ethiopian studies, but our significant mortality predictors were similar to those found in earlier studies of adults and adolescents. Our findings reveal a potential point for health service improvement in Ethiopia: incorporating monitoring of Hgb levels into patient follow-up care, supporting recommendations that clinicians emphasise managing OIs and providing counselling services to improve adherence.

The proportion of loss to follow-up from antiretroviral therapy (ART) and its association with age among adolescents living with HIV in sub-Saharan Africa: A systematic review and meta-analysis.

BACKGROUND: Human immunodeficiency virus (HIV) remains a global health threat, especially in developing countries. The successful scale-up of antiretroviral therapy (ART) programs to address this threat is hindered by a high proportion of patient loss to follow-up (LTFU). LTFU is associated with poor viral suppression and increased mortality. It is particularly acute among adolescents, who face unique adherence challenges. Although LTFU is a critical obstacle on the continuum of care for adolescents, few regional-level studies report the proportion of LTFU among adolescents receiving ART. Therefore, a systematic review and meta-analysis were conducted to estimate the pooled LTFU in ART programs among adolescents living with HIV in sub-Saharan Africa (SSA). METHODS: We searched five databases (PubMed, Embase (Elsevier), PsycINFO, CINAHL, and Scopus) for articles published between 2005 and 2020 and reference lists of included articles. The PRISMA guidelines for systematic reviews were followed. A standardised checklist to extract data was used. Descriptive summaries were presented using narrative tables and figures. Heterogeneity within the included studies was examined using the Cochrane Q test statistics and I2 test. Random effect models were used to estimate the pooled prevalence of LTFU among ALHIV. We used Stata version 16 statistical software for our analysis. RESULTS: Twenty-nine eligible studies (n = 285,564) were included. An estimated 15.07% (95% CI: 11.07, 19.07) of ALHIV were LTFU. Older adolescents (15-19 years old) were 43% (AOR = 0.57, 95% CI: 0.37, 0.87) more likely to be LTFU than younger (10-14 years old) adolescents. We find an insignificant relationship between gender and LTFU (AOR = 0.95, 95% CI: 0.87, 1.03). A subgroup analysis found that regional differences in the proportion of adolescent LTFU were not statistically significant. The trend analysis indicates an increasing proportion of adolescent LTFU over time. CONCLUSIONS AND RECOMMENDATIONS: The proportion of LTFU among HIV-positive adolescents in SSA seems higher than those reported in other regions. Older adolescents in the region are at an increased risk for LTFU than younger adolescents. These findings may help policymakers develop appropriate strategies to retain ALHIV in ART services. Such strategies could include community ART distribution points, appointment spacing, adherence clubs, continuous free access to ART, and community-based adherence support.

Use of actigraphy and sleep diaries to assess sleep and academic performance in pharmacy students.

INTRODUCTION: Sleep parameters have been shown to correlate with academic performance. Current studies assessing sleep in doctor of pharmacy (PharmD) students rely on self-reported sleep parameters and academic performance. The objectives of this study were to describe and compare sleep parameters in pharmacy students using actigraphy and sleep diaries and to assess the correlation of sleep parameters with academic performance. METHODS: This prospective cohort study with convenience sampling assessed sleep parameters in pharmacy students. Thirty-five students completing the second year of a PharmD program participated in the study. Participants wore actigraph watches and maintained sleep diaries for seven consecutive days during the spring and fall semesters, while classes were in session, except for one week prior to exams and the week of exams. Academic performance was tracked during fall and spring semesters. RESULTS: Actigraphy and sleep diaries showed significant differences in sleep latency (SL), actual sleep time (AST), wake bouts, and sleep efficiency (SE). Actigraphy results indicated that the participants fell asleep faster (SL), slept a shorter duration (AST), had more wake bouts, and lower SE than results reported in the sleep diaries. SE and SL from the sleep diaries positively correlated with the fall semester pharmaceutical sciences course and overall spring semester academic performance. Actigraphy recorded AST correlated with performance in both semesters' clinical sciences courses. CONCLUSIONS: The results of actigraphy differed from the sleep diaries. More studies are needed to assess differences in detection of sleep parameters using sleep diaries and actigraphs.

Determinants of undernutrition among adult patients receiving antiretroviral therapy at Debre Markos referral hospital, Northwest Ethiopia: a case-control study design.

BACKGROUND: A complex and negatively reinforcing relationship exists between infection with Human Immune Deficiency Virus (HIV) and malnutrition. HIV-induced immune impairment and its resulting opportunistic infections (OIs) can lead to malnutrition and nutritional deficits, can, in turn, hasten the progression of HIV infection and reduce chances of survival. The determinants of undernutrition among patients receiving antiretroviral therapy (ART) is poorly understood in Ethiopia, despite a high prevalence of food-insecurity that overlaps with a generalized HIV/AIDS epidemic. Therefore, this study aimed to assess determinants of undernutrition among adult patients receiving antiretroviral therapy at Debre Markos Referral Hospital in Northwest Ethiopia. METHODS: We conducted an institution-based, unmatched, case-control study with 636 adult patients receiving antiretroviral therapy. We randomly selected 212 patients with poor nutritional outcomes (cases) and 424 without undernutrition (controls) and then conducted a chart review to collect information on their treatment, socio-economic, and demographic background. Data were analyzed using bivariable and multivariable logistic regression to identify factors associated with under nutrition. RESULTS: We found that greater age (AOR = 1.02, 95% CI: 1.01,1.05), fair or poor adherence (AOR = 2.77, 95% CI: 1.40, 5.50 and AOR = 4.72, 95% CI: 1.92, 11.6), and the presence of OIs (AOR = 1.70, 95% CI: 1.12, 2.52), anemia (AOR = 1.81, 95% CI: 1.07, 3.07), or eating problems (AOR = 3.40, 95% CI: 2.27, 5.10), were all independently and positively associated with under nutrition. Starting treatment with a medium or low CD4 count was protective (AOR = 0.61, 95% CI: 0.39, 0.96 and AOR = 0.49, 95% CI: 0.27, 0.88). Having social support (AOR = 0.64, 95% CI: 0.43, 0.95), and having a source of informal care-giving (AOR = 0.48, 95% CI: 0.27, 0.84), reduced the odds of undernutrition. CONCLUSION: Our findings support calls for treating HIV infection early and aggressively, while closely monitoring patients for opportunistic infections that might affect eating and drug side effects that may affect appetite. The role of disclosure, peer-caregivers and age in preventing undernutrition should be explored in future research.

Depression among epileptic patients and its association with drug therapy in sub-Saharan Africa: A systematic review and meta-analysis.

BACKGROUND: Despite the high prevalence of epilepsy in sub-Saharan Africa and the established relationship between depression and epilepsy, the extent of comorbid epilepsy and depression in the region is still poorly understood. The objective of this systematic review and meta-analysis is to address this gap in the literature by determining the pooled prevalence of depression among epileptic patients in sub-Saharan Africa. METHODS: A systematic desk review and electronic web-based search of PubMed, Google Scholar, EMBASE, PsycINFO and the World Health Organization's Hinari portal (which includes the SCOPUS, African Index Medicus, and African Journals Online databases) conducted from December 2, 2017 to February 30, 2018, identified peer-reviewed, original research articles and doctoral dissertations using pre-defined quality and inclusion criteria. Relevant data were extracted and descriptive summaries of the studies presented in tabular form. The I2 statistic was used to assess heterogeneity across studies. Funnel plot asymmetry and Egger's tests were used to check for publication bias and the methodological quality of the included studies were assessed using the scale developed by Hoy and colleagues. The pooled prevalence of comorbidity at a 95% confidence interval (CI) was determined by applying a trim and fill analysis in a random-effects model. RESULTS: Our search identified 167 studies, of which 14 original research articles and two doctoral dissertations reporting on case-control and cross-sectional studies were eligible for inclusion in the final analysis. The pooled estimate of prevalence of depression among patients with epilepsy was 32.71% (95% CI: 25.50-39.91%). Regional sub-group analysis found that the pooled prevalence in East Africa was 34.52% (95% CI: 23.53-45.51%) and 29.69% (95% CI: 22.7-36.68%) in Southern and West Africa. The odds of depression among epileptic patients receiving polytherapy were 2.65 higher than in those receiving monotherapy (95% CI: 1.49-4.71, I2 = 79.1%, p < 0.05). CONCLUSION: Our findings indicate high comorbidity in sub-Saharan Africa and suggest that it may be more prevalent there than elsewhere. Comorbidity is statistically associated with polytherapy in the studies reviewed. Given the high levels of comorbidity in the region, more attention should be paid to incorporating depression screening and treatment into existing epilepsy programs and to revising treatment guidelines on comorbid depression to reduce polytherapy.