Khat chewing among Ethiopian University Students--a growing concern.

BACKGROUND: Khat has amphetamine like effect. Students chew khat to stay alert. It has various negative physical, mental, social and cognitive effects. Poor academic performance has been associated with khat. The purpose of this study was to determine the prevalence and identify factors associated with khat chewing among Ethiopian University students. METHODS: A cross sectional study was conducted on Bahir Dar University Students. A self-administered questionnaire was completed by 3268 students. Proportion was calculated to estimate prevalence of khat chewing. Logistic regression was used to identify factors associated with khat chewing. RESULTS: Lifetime prevalence of khat chewing was 24% (95% Confidence Interval: 22.5%, 26.6%). Half of these are current khat users with a prevalence of 12.7% (95% Confidence Interval: 11.5%, 13.9%). Male students Adjusted Odds Ratio (AOR) = 3.3 (95% Confidence Interval: 1.8, 6.0), students living in off campus housing AOR = 3.0 (95% Confidence Interval: 1.5, 6.0), students who have khat user friends AOR = 4.2 (95% Confidence Interval: 2.6, 6.9), and students who perceive khat use improves academic performance AOR = 6.6 (95% Confidence Interval: 4.6, 9.5) are more likely to use khat. CONCLUSIONS: Prevalence of current use of khat reported in this study is higher than recent study done on university students in Ethiopia and heavily influenced with peer practice.

Modern contraceptive utilization among female ART attendees in health facilities of Gimbie town, West Ethiopia.

BACKGROUND: In many areas of the world where HIV prevalence is high, rates of unintended pregnancy have also been shown to be high. Of all pregnancies worldwide in 2008, 41% were reported as unintended and approximately 50% of these ended in abortion. To address these problems family planning is the best solution. Therefore, the purpose of the study was to assess modern contraceptive use among females on ART in health facilities of Gimbie town, Western Ethiopia. METHODS: A facility based cross-sectional study was conducted in Gimbie town, western Ethiopia from December 2012 to January 2013. HIV infected women of reproductive age group (15-49 years) who came for ART care follow up during the data collection period were included in the study. Data was collected using an interviewer administered questionnaire. Binary logistic regression and multivariate analysis were employed using SPSS version 17. RESULTS: Three hundred ninety five women on ART have participated in the study. More than half, 224 (56.7%), of the respondents were using modern contraceptive, of whom 67 (30%) use dual contraceptive method. Having information on modern contraception is positively associated with modern contraceptive use with (AOR=6.3, 95% CI (1.67, 24.1)) and respondents who have family size ≤4 were 50% less contraceptive users than those who have family size >4 (AOR=0.51, 95% CI (0.27, 0.96)). CONCLUSION: In this study contraceptive use among HIV positive women is better than the general population. However, use of dual methods, long acting and permanent method of contraceptives were found to be low. Continuous and targeted information provision on modern contraceptive should be done.

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.

The association between quality of contraceptive counseling and selection of contraceptive method post-counseling among women in Ethiopia.

OBJECTIVES: To better understand the relationship between high-quality contraceptive counseling and met family planning needs, we examined the association between quality of counseling and selection of a method postvisit among women requesting contraception in Ethiopia. STUDY DESIGN: We used post-counseling survey data from women receiving care in public health centers and nongovernmental clinics in three regions in Ethiopia. Among women whose reason for visit was requesting a contraceptive method, we examined the association between scores on the validated quality of contraceptive counseling (QCC) scale and subscales and selection of a method post-counseling (primary analysis) and type of method selected (secondary analysis). We conducted mixed-effects multivariable logistic regression for the primary analysis and multinomial regression for the secondary analysis. RESULTS: There was a nonsignificant increase in odds of selecting contraception with increasing total QCC scale scores (adjusted odds ratio [aOR] 2.35, 0.43-12.95). However, among women experiencing no disrespect and abuse, there was increasing odds of selecting contraception (aOR 3.46, 95% CI 1.09-10.99) and likelihood of selecting injectable contraception (adjusted relative risk ratio 4.27, 95% CI 1.34-13.60) compared to women experiencing disrespect and abuse. Additionally, 168 (32.1%) of women felt pressured by their provider to use a certain method of which>50% selected long-acting reversible contraception. CONCLUSIONS: Increasing QCC is associated with selecting contraception among women requesting contraception. Additionally, probing for negative experiences can reveal feelings of disrespect and abuse that could lead women to avoid selecting contraception or feeling pressured to use methods heavily promoted by providers. IMPLICATIONS: Our study assesses contraceptive counseling quality using a validated tool with items on provider pressure and other forms of disrespect and abuse; findings highlight the importance of respectful treatment in meeting women's needs and the potential influence of disrespect on decision to select contraception and type of method selected.

Reduction of the Quality of Contraceptive Counseling (QCC) scale to a short version (QCC-10) in Ethiopia, India, and Mexico.

OBJECTIVE: To reduce the Quality of Contraceptive Counseling (QCC) scale to a shortened version, coined the QCC-10, for use in measuring client-reported quality of counseling across varied settings. STUDY DESIGN: Secondary psychometric analysis of data collected for validating full versions of the QCC scale (QCC-Mexico, QCC-Ethiopia, QCC-India) and expert voting to reduce the original 26 QCC items to a 10-item set. RESULTS: Exploratory factor analysis revealed a clear one-factor solution for the QCC-10 in each country. Factor loadings were consistently >0.4 for all but two items; both were retained due to their importance to content validity. Internal consistency reliability of the QCC-10 was α=0.8 in Mexico and Ethiopia, and α=0.5 in India. QCC-10 scores were highly and positively correlated with a dichotomous overall measure of client experience and intention to initiate selected method, indicating convergent validity. CONCLUSION: The QCC-10 offers an innovative, cross-cultural approach to measuring quality in contraceptive counseling. Future efforts should examine its validity and reliability for use globally, with additional exploration of how to best measure negative aspects of care, particularly in India where such items were problematic. Thoughtful, nuanced measurement of client perspectives on their counseling experiences, available via the QCC-10, is critical to monitoring and improving quality of person-centered care and the fulfilment of human rights in contraceptive services worldwide. IMPLICATIONS: Cross-cultural, person-centered measures of quality in contraceptive counseling, such as the QCC-10, can help inform efforts to improve quality of family planning services and fulfillment of human rights. Future work will continue to explore the validity of this 10-item measure for use in various settings.

Adaptation and validation of the quality of contraceptive counseling (QCC) scale for use in Ethiopia and India.

We adapted the Quality of Contraceptive Counseling (QCC) scale, originally constructed in Mexico, for Ethiopia and India to expand its utility for measurement of client experiences with counseling. Scale items were modified based on prior research on women's preferences for counseling in each country, and refined through cognitive interviews (n = 20 per country). We tested the items through client exit surveys in Addis Ababa, Ethiopia (n = 599), and Vadodara, India (n = 313). Psychometric analyses revealed the adapted scales were valid and reliable for use, and the final scales retained content validity according to the original published QCC construct definition. Specifically, confirmatory factor analysis revealed high factor loadings for almost all items on the original dimensions: Information Exchange, Interpersonal Relationship, Disrespect and Abuse. Internal consistency reliability was high in both settings (Alpha = 0.92 for QCC-Ethiopia and 0.74 for QCC-India). Final item pools contained 26 items in the QCC-Ethiopia Scale and 23 in the QCC-India Scale. Correlation analyses established convergent validity. QCC Scales and subscales fill a gap in measurement tools for ensuring high quality of care and fulfillment of human rights in contraceptive services, and consistent findings across continents suggest versatility in use across different contexts.

Balancing client preferences and population-level goals: a qualitative study of the ways in which public health providers and facility administrators interpret and incentivise quality of care in contraceptive counselling in Ethiopia, Mexico and India.

Recent work in family planning has shifted from an instrumentalist perspective on quality in contraceptive counselling, which views quality as a means to encourage contraceptive uptake, to privilege quality of care as a valued end in itself. In this context of shifting narratives about quality, it is important to understand how health systems and providers navigate potential conflicts between instrumentalist definitions of quality versus a person-centred definition that considers meeting clients' contraceptive needs and preferences as an important end goal in and of itself. However, we know little about how providers and other health system stakeholders interpret the concept of quality in counselling, and how their experiences with different quality monitoring systems influence their ability to provide person-centred care. This qualitative study draws from 51 in-depth interviews with public healthcare providers and health facility administrators in Ethiopia, Mexico and India. Across all three countries, except for some cases in India, administrators were concerned with encouraging uptake of contraceptives in order to meet local and national level goals on contraceptive uptake and maternal health. In contrast, providers were more concerned with responding to client desires and needs. However, participants across all levels shared the opinion that successful counselling should end with contraceptive uptake. We conclude that the instrumentalist view of quality counselling continues to prevail across all three countries. Our findings suggest that encouraging healthcare providers and administrators to meet even relatively broad targets set by government reinforces an instrumentalist approach, as opposed to an approach that privileges person-centred care.

Quality of care from the perspective of people obtaining abortion: a qualitative study in four countries.

OBJECTIVE: This qualitative study aimed to identify person-centred domains that would contribute to the definition and measurement of abortion quality of care based on the perceptions, experiences and priorities of people seeking abortion. METHODS: We conducted interviews with people seeking abortion aged 15-41 who obtained care in Argentina, Bangladesh, Ethiopia or Nigeria. Participants were recruited from hospitals, clinics, pharmacies, call centres and accompaniment models. We conducted thematic analysis and quantified key domains of quality identified by the participants. RESULTS: We identified six themes that contributed to high-quality abortion care from the clients' perspective, with particular focus on interpersonal dynamics. These themes emerged as participants described their abortion experience, reflected on their interactions with providers and defined good and bad care. The six themes included (1) kindness and respect, (2) information exchange, (3) emotional support, (4) attentive care throughout the process, (5) privacy and confidentiality and (6) prepared for and able to cope with pain. CONCLUSIONS: People seeking abortion across multiple country contexts and among various care models have confirmed the importance of interpersonal care in quality. These findings provide guidance on six priority areas which could be used to sharpen the definition of abortion quality, improve measurement, and design interventions to improve quality.

"I was afraid they will be judging me and even deny me the service": Experiences of denial and dissuasion during abortion care in Ethiopia.

Introduction: Disrespect and abuse are components of poor quality abortion care. This analysis aimed to understand negative experiences of care from perspectives of abortion clients in public and private facilities in Ethiopia. Study Design: We conducted 23 in-depth interviews with people who obtained abortion care in Addis Ababa, Ethiopia as well as Aksum and Mekele in Tigray State, Ethiopia. The interviews were coded using a priori and emergent codes and we conducted thematic analysis to understand negative interactions with providers from participant's perspectives. Results: Participants experienced denial of abortion services along their pathway to care and attempts by providers to dissuade them prior to providing an abortion. Underlying both the denial and the dissuasion were reports of disrespect and condemnation from providers. Participants described how providers doubted or forced them to justify their reasons for having an abortion, stigmatized them for seeking multiple abortions or later abortions, and ascribed misinformation about abortion safety. Despite reports of denial, dissuasion, and disrespect, abortion clients generally felt that providers had their best interest at heart and were grateful for having access to an abortion. Conclusions: Participants in Ethiopia experienced providers as gatekeepers to legal abortion services, facing disrespect and judgment at facilities where they sought care. Interventions aimed at increasing awareness of abortion laws such that clients understand their rights and values clarification interventions for providers could help reduce barriers to accessing care and improve the quality of abortion services.

Determinants of Mother-to-Child Transmission of HIV in Public Hospitals of West Shewa Zone, Central Ethiopia: Case-Control Study.

BACKGROUND: Mother-to-child transmission (MTCT) of human immune deficiency virus (HIV) is the infection of baby by HIV that originated from an HIV-positive mother during pregnancy and breast feeding. Without intervention, the transmission rate of HIV ranges from 15-45%, which can be reduced to below 5% with effective intervention. In Ethiopia, the final mother-to-child transmission rate was 15% in 2016, which was much higher than the target of the country to reduce transmission to lower than 5% by 2020. The study aims to identify determinants of transmission of HIV from mother to child in the West Shewa Zone. METHODS: An unmatched case-control study, among children less than 5 years who tested HIV positive and negative, at the end of PMTC follow-up, N=96 (24 cases, 72 controls) was conducted during June to August 2019, focusing on PCR done during the last 2 years (June 2017 to July 2019), in public hospitals. Data were collected using a structured questionnaire and data abstraction forms from mothers of exposed infants, medical records of mothers and children. RESULTS: The majority of cases (17, 70.8%) were not included in the option B+ program, but only 11.1% of controls were not included. Home delivery (adjusted odds ratio (AOR)=6.047, confidence interval (CI)=1.549-29.230), non-inclusion into option B+ (AOR=18.0, 95% CI=5.0-68.1), and partner non-involvement to HIV care (AOR=7.3, 95% CI=1.14-37.459) had higher odds of transmitting HIV, while a mother-to-mother support program decreases the chance of transmission by 86.5% (AOR=0.135, 95% CI=0.11-0.396) when compared to their counterparts. CONCLUSION: Mother-to-mother support programs have a protective effect, while non-inclusion to option B+, partner non-involvement in HIV care, home delivery, and poor antenatal care (ANC) practices were determinant factors of HIV transmission from mother to child.

Incidence and predictors of extrapulmonary tuberculosis among people living with Human Immunodeficiency Virus in Addis Ababa, Ethiopia: A retrospective cohort study.

BACKGROUND: Extrapulmonary tuberculosis is an emerging public health problem among HIV positives compared to the general population. This study aimed to assess the incidence and predictors of extrapulmonary tuberculosis among people living with HIV in selected health facilities in Addis Ababa, Ethiopia, from 01 January 2013 up to 31 December 2018. METHODS: A retrospective cohort study design was employed based on data collected from 566 HIV positive individuals. Data were entered using EpiInfo version 7.1 and analyzed by SPSS version 20. The incidence rate was determined per 100 person-years. Kaplan-Meier estimates used to estimate survivor and the hazard function, whereas log-rank tests used to compare survival curves and hazard across different categories. Cox proportional hazard model was used to identify the predictors and 95%CI of the hazard ratio were computed. P-value<0.05 in the multivariable analysis was considered statistically significant. RESULTS: Five hundred sixty-six HIV positive individuals were followed for 2140.08 person-years. Among them, 72 developed extrapulmonary tuberculosis that gives an incidence rate of 3.36/100 person-years (95%CI = 2.68-4.22). The most frequent forms of extrapulmonary tuberculosis were; lymph node tuberculosis (56%, 41) followed equally by pleural tuberculosis (15%, 11) and disseminated tuberculosis (15%, 11). The majority (70.83%) of the cases occurred within the first year of follow-up. In multivariable Cox regression analysis, baseline WHO stage III/IV (AHR = 2.720, 95%CI = 1.575-4.697), baseline CD4 count<50cells/µl (AHR = 4.073, 95%CI = 2.064-8.040), baseline CD4 count 50-200 cells/µl (AHR = 2.360, 95%CI = 1.314-4.239) and baseline Hgb<10 mg/dl (AHR = 1.979, 95%CI = 1.091-3.591) were the independent risk factors. While isoniazid prophylaxis (AHR = 0.232, 95%CI = 0.095-0.565) and taking antiretroviral drugs (AHR = 0.134, 95%CI = 0.075-0.238) had a protective benefit. CONCLUSION: Extrapulmonary tuberculosis co-infection was common among HIV positive individuals, and mostly occurred in those with advanced immune suppression. The risk decreases in those taking antiretroviral therapy and took isoniazid preventive treatment. Screening of HIV positives for extrapulmonary tuberculosis throughout their follow-up would be important.

Podoconiosis: a tropical model for gene-environment interactions?

Podoconiosis (endemic non-filarial elephantiasis) is a geochemical disease occurring in individuals exposed to red clay soil derived from alkalic volcanic rock. It is a chronic, debilitating disorder and a considerable public health problem in at least 10 countries in tropical Africa, Central America and northern India. Only a small proportion of individuals exposed to red clay develop disease and familial clustering of cases occurs, so we tested the hypothesis that disease occurs in genetically susceptible individuals on exposure to an environmental element in soil. Using multiple statistical genetic techniques we estimated sibling recurrence risk ratio (lambda(s)) and heritability for podoconiosis, and conducted segregation analysis on 59 multigenerational affected families from Wolaitta Zone, southern Ethiopia. We estimated the lambda(s) to be 5.07. The heritability of podoconiosis was estimated to be 0.629 (SE 0.069, P=1x10(-7)). Segregation analysis showed that the most parsimonious model was that of an autosomal co-dominant major gene. Age and use of footwear were significant covariates in the final model. Host genetic factors are important determinants of susceptibility to podoconiosis. Identification of the gene(s) involved will lead to better understanding of the gene-environment interactions involved in the pathogenesis of podoconiosis and other complex multifactorial conditions.

Prevalence and predictors of harmful khat use among university students in ethiopia.

Comprehensive assessment of harmful khat use is lacking because often researchers rely on a simple tool for studying it. The aim of this study was to determine the prevalence and predictors of harmful khat use among Ethiopian university students by developing a comprehensive scale based on Alcohol Use Identification Test, Severity of Dependency Syndrome scale, and International Classification of Diseases definition of harmful substance use. Logistic regression was performed to identify predictors of harmful khat use. One in five current khat user students were identified as harmful khat users [20.6% (95% CI: 14.3-22.3)]. Harmful khat use in this study was strongly associated with chewing at commercial places [adjusted odds ratio (AOR) = 2.32 (95% CI: 1.01-5.33)], and having non-student friends accompanying the khat-chewing ceremony [AOR = 3.77 (95% CI: 1.09-13.03). Students who started chewing khat at the age of 20 years or later [AOR = 0.19 (95% CI: 0.07-0.55)] and those who preferred to study in the library [AOR = 0.31(95% CI: 0.12-0.81)] were less likely to be harmful khat users. The university authorities, in addition to provision of student guidance on substance-use prevention, need to work in collaboration with the surrounding community and responsible public authorities in order to reduce harmful use of khat by their students.