Burden of disease attributable to suboptimal diet, metabolic risks and low physical activity in Ethiopia and comparison with Eastern sub-Saharan African countries, 1990-2015: findings from the Global Burden of Disease Study 2015.

BACKGROUND: Twelve of the 17 Sustainable Development Goals (SDGs) are related to malnutrition (both under- and overnutrition), other behavioral, and metabolic risk factors. However, comparative evidence on the impact of behavioral and metabolic risk factors on disease burden is limited in sub-Saharan Africa (SSA), including Ethiopia. Using data from the Global Burden of Disease (GBD) Study, we assessed mortality and disability-adjusted life years (DALYs) attributable to child and maternal undernutrition (CMU), dietary risks, metabolic risks and low physical activity for Ethiopia. The results were compared with 14 other Eastern SSA countries. METHODS: Databases from GBD 2015, that consist of data from 1990 to 2015, were used. A comparative risk assessment approach was utilized to estimate the burden of disease attributable to CMU, dietary risks, metabolic risks and low physical activity. Exposure levels of the risk factors were estimated using spatiotemporal Gaussian process regression (ST-GPR) and Bayesian meta-regression models. RESULTS: In 2015, there were 58,783 [95% uncertainty interval (UI): 43,653-76,020] or 8.9% [95% UI: 6.1-12.5] estimated all-cause deaths attributable to CMU, 66,269 [95% UI: 39,367-106,512] or 9.7% [95% UI: 7.4-12.3] to dietary risks, 105,057 [95% UI: 66,167-157,071] or 15.4% [95% UI: 12.8-17.6] to metabolic risks and 5808 [95% UI: 3449-9359] or 0.9% [95% UI: 0.6-1.1] to low physical activity in Ethiopia. While the age-adjusted proportion of all-cause mortality attributable to CMU decreased significantly between 1990 and 2015, it increased from 10.8% [95% UI: 8.8-13.3] to 14.5% [95% UI: 11.7-18.0] for dietary risks and from 17.0% [95% UI: 15.4-18.7] to 24.2% [95% UI: 22.2-26.1] for metabolic risks. In 2015, Ethiopia ranked among the top four countries (of 15 Eastern SSA countries) in terms of mortality and DALYs based on the age-standardized proportion of disease attributable to dietary and metabolic risks. CONCLUSIONS: In Ethiopia, while there was a decline in mortality and DALYs attributable to CMU over the last two and half decades, the burden attributable to dietary and metabolic risks have increased during the same period. Lifestyle and metabolic risks of NCDs require more attention by the primary health care system of the country.

Injury-related gaining momentum as external causes of deaths in Ethiopian health and demographic surveillance sites: evidence from verbal autopsy study.

BACKGROUND: In Ethiopia, though all kinds of mortality due to external causes are an important component of overall mortality often not counted or documented on an individual basis. OBJECTIVE: The aim of this study was to describe the patterns of mortality from external causes using verbal autopsy (VA) method at the Ethiopian HDSS Network sites. METHODS: All deaths at Ethiopian HDSS sites were routinely registered and followed up with VA interviews. The VA forms comprised deaths up to 28 days, between four weeks and 14 years and 15 years and above. The cause of a death was ascertained based on an interview with next of families or other caregivers using a standardized questionnaire that draws information on signs, symptoms, medical history and circumstances preceding death after 45 days mourning period. Two physician assigned probable causes of death as underlying, immediate and contributing factors independently using information in VA forms based on the WHO ICD-10 and VA code system. Disagreed cases sent to third physician for independent review and diagnosis. The final cause of death considered when two of the three physicians assigned underlying cause of death; otherwise, labeled as undetermined. RESULTS: In the period from 2009 to 2013, a total of 9719 deaths were registered. Of the total deaths, 623 (6.4%) were from external causes. Of these, accidental drowning and submersion, 136 (21.8%), accidental fall, 113 (18.1%) and transport-related accidents, 112 (18.0%) were the topmost three leading external causes of deaths. About 436 (70.0%) of deaths were from the age group above 15 years old. Drowning and submersion and transport-related accidents were high in age group between 5 and 14 years old. CONCLUSION: In this study, external causes of death are significant public health problems and require attention as one of prior health agenda.

Tuberculosis and HIV are the leading causes of adult death in northwest Ethiopia: evidence from verbal autopsy data of Dabat health and demographic surveillance system, 2007-2013.

BACKGROUND: Reliable data on causes of death form the basis for building evidence on health policy, planning, monitoring, and evaluation. In Ethiopia, the majority of deaths occur at home and civil registration systems are not yet functional. The main objective of verbal autopsy (VA) is to describe the causes of death at the community or population level where civil registration and death certification systems are weak and where most people die at home without having had contact with the health system. METHODS: Causes of death were classified and prepared based on the International Classification of Diseases (ICD-10). The cause of a death was ascertained based on an interview with next of kin or other caregivers using a standardized questionnaire that draws information on signs, symptoms, medical history, and circumstances preceding death. The cause of death, or the sequence of causes that led to death, is assigned based on the data collected by the questionnaire. The complete VA questionnaires were given to two blinded physicians and reviewed independently. A third physician was assigned to review the case when disagreements in diagnosis arose. RESULTS: Communicable diseases (519 deaths [48.0%]), non-communicable diseases (377 deaths [34.8%]), and external causes (113 deaths [10.4%]) were the main causes of death between 2007 and 2013. Of communicable diseases, tuberculosis (207 deaths [19.7%]), HIV/AIDS (96 deaths [8.9%]) and meningitis (76 deaths [7.0%]) were the most common causes of death. CONCLUSION: Tuberculosis, HIV/AIDS, and meningitis were the most common causes of deaths among adults. Death due to non-communicable diseases showed an increasing trend. Increasing community awareness of infections and their interrelationships, tuberculosis case finding, effective local TB programs, successful treatment, and interventions for HIV are supremely important.

National mortality burden due to communicable, non-communicable, and other diseases in Ethiopia, 1990-2015: findings from the Global Burden of Disease Study 2015.

BACKGROUND: Ethiopia lacks a complete vital registration system that would assist in measuring disease burden and risk factors. We used the Global Burden of Diseases, Injuries, and Risk Factors Study 2015 (GBD 2015) estimates to describe the mortality burden from communicable, non-communicable, and other diseases in Ethiopia over the last 25 years. METHODS: GBD 2015 mainly used cause of death ensemble modeling to measure causes of death by age, sex, and year for 195 countries. We report numbers of deaths and rates of years of life lost (YLL) for communicable, maternal, neonatal, and nutritional (CMNN) disorders, non-communicable diseases (NCDs), and injuries with 95% uncertainty intervals (UI) for Ethiopia from 1990 to 2015. RESULTS: CMNN causes of death have declined by 65% in the last two-and-a-half decades. Injury-related causes of death have also decreased by 70%. Deaths due to NCDs declined by 37% during the same period. Ethiopia showed a faster decline in the burden of four out of the five leading causes of age-standardized premature mortality rates when compared to the overall sub-Saharan African region and the Eastern sub-Saharan African region: lower respiratory infections, tuberculosis, HIV/AIDS, and diarrheal diseases; however, the same could not be said for ischemic heart disease and other NCDs. Non-communicable diseases, together, were the leading causes of age-standardized mortality rates, whereas CMNN diseases were leading causes of premature mortality in 2015. Although lower respiratory infections, tuberculosis, and diarrheal disease were the leading causes of age-standardized death rates, they showed major declines from 1990 to 2015. Neonatal encephalopathy, iron-deficiency anemia, protein-energy malnutrition, and preterm birth complications also showed more than a 50% reduction in burden. HIV/AIDS-related deaths have also decreased by 70% since 2005. Ischemic heart disease, hemorrhagic stroke, and ischemic stroke were among the top causes of premature mortality and age-standardized death rates in Ethiopia in 2015. CONCLUSIONS: Ethiopia has been successful in reducing deaths related to communicable, maternal, neonatal, and nutritional deficiency diseases and injuries by 65%, despite unacceptably high maternal and neonatal mortality rates. However, the country's performance regarding non-communicable diseases, including cardiovascular disease, diabetes, cancer, and chronic respiratory disease, was minimal, causing these diseases to join the leading causes of premature mortality and death rates in 2015. While the country is progressing toward universal health coverage, prevention and control strategies in Ethiopia should consider the double burden of common infectious diseases and non-communicable diseases: lower respiratory infections, diarrhea, tuberculosis, HIV/AIDS, cardiovascular disease, cancer, and diabetes. Prevention and control strategies should also pay special attention to the leading causes of premature mortality and death rates caused by non-communicable diseases: cardiovascular disease, cancer, and diabetes. Measuring further progress requires a data revolution in generating, managing, analyzing, and using data for decision-making and the creation of a full vital registration system in the country.

National disability-adjusted life years (DALYs) for 257 diseases and injuries in Ethiopia, 1990-2015: findings from the global burden of disease study 2015.

BACKGROUND: Disability-adjusted life years (DALYs) provide a summary measure of health and can be a critical input to guide health systems, investments, and priority-setting in Ethiopia. We aimed to determine the leading causes of premature mortality and disability using DALYs and describe the relative burden of disease and injuries in Ethiopia. METHODS: We used results from the Global Burden of Diseases, Injuries, and Risk Factors Study 2015 (GBD 2015) for non-fatal disease burden, cause-specific mortality, and all-cause mortality to derive age-standardized DALYs by sex for Ethiopia for each year. We calculated DALYs by summing years of life lost due to premature mortality (YLLs) and years lived with disability (YLDs) for each age group and sex. Causes of death by age, sex, and year were measured mainly using Causes of Death Ensemble modeling. To estimate YLDs, a Bayesian meta-regression method was used. We reported DALY rates per 100,000 for communicable, maternal, neonatal, and nutritional (CMNN) disorders, non-communicable diseases, and injuries, with 95% uncertainty intervals (UI) for Ethiopia. RESULTS: Non-communicable diseases caused 23,118.1 (95% UI, 17,124.4-30,579.6), CMNN disorders resulted in 20,200.7 (95% UI, 16,532.2-24,917.9), and injuries caused 3781 (95% UI, 2642.9-5500.6) age-standardized DALYs per 100,000 in Ethiopia in 2015. Lower respiratory infections, diarrheal diseases, and tuberculosis were the top three leading causes of DALYs in 2015, accounting for 2998 (95% UI, 2173.7-4029), 2592.5 (95% UI, 1850.7-3495.1), and 2562.9 (95% UI, 1466.1-4220.7) DALYs per 100,000, respectively. Ischemic heart disease and cerebrovascular disease were the fourth and fifth leading causes of age-standardized DALYs, with rates of 2535.7 (95% UI, 1603.7-3843.2) and 2159.9 (95% UI, 1369.7-3216.3) per 100,000, respectively. The following causes showed a reduction of 60% or more over the last 25 years: lower respiratory infections, diarrheal diseases, tuberculosis, neonatal encephalopathy, preterm birth complications, meningitis, malaria, protein-energy malnutrition, iron-deficiency anemia, measles, war and legal intervention, and maternal hemorrhage. CONCLUSIONS: Ethiopia has been successful in reducing age-standardized DALYs related to most communicable, maternal, neonatal, and nutritional deficiency diseases in the last 25 years, causing a major ranking shift to types of non-communicable disease. Lower respiratory infections, diarrheal disease, and tuberculosis continue to be leading causes of premature death, despite major declines in burden. Non-communicable diseases also showed reductions as premature mortality declined; however, disability outcomes for these causes did not show declines. Recently developed non-communicable disease strategies may need to be amended to focus on cardiovascular diseases, cancer, diabetes, and major depressive disorders. Increasing trends of disabilities due to neonatal encephalopathy, preterm birth complications, and neonatal disorders should be emphasized in the national newborn survival strategy. Generating quality data should be a priority through the development of new initiatives such as vital events registration, surveillance programs, and surveys to address gaps in data. Measuring disease burden at subnational regional state levels and identifying variations with urban and rural population health should be conducted to support health policy in Ethiopia.

Trends and causes of maternal mortality in Ethiopia during 1990-2013: findings from the Global Burden of Diseases study 2013.

BACKGROUND: Maternal mortality is noticeably high in sub-Saharan African countries including Ethiopia. Continuous nationwide systematic evaluation and assessment of the problem helps to design appropriate policy and strategy in Ethiopia. This study aimed to investigate the trends and causes of maternal mortality in Ethiopia between 1990 and 2013. METHODS: We used the Global Burden of Diseases and Risk factors (GBD) Study 2013 data that was collected from multiple sources at national and subnational levels. Spatio-temporal Gaussian Process Regression (ST-GPR) was applied to generate best estimates of maternal mortality with 95% Uncertainty Intervals (UI). Causes of death were measured using Cause of Death Ensemble modelling (CODEm). The modified UNAIDS EPP/SPECTRUM suite model was used to estimate HIV related maternal deaths. RESULTS: In Ethiopia, a total of 16,740 (95% UI: 14,197, 19,271) maternal deaths occurred in 1990 whereas there were 15,234 (95% UI: 11,378, 19,871) maternal deaths occurred in 2013. This finding shows that Maternal Mortality Ratio (MMR) in Ethiopia was still high in the study period. There was a minimal but insignificant change of MMR over the last 23 years. The results revealed Ethiopia is below the target of Millennium Development Goals (MGDs) related to MMR. The top five causes of maternal mortality in 2013 were other direct maternal causes such as complications of anaesthesia, embolism (air, amniotic fluid, and blood clot), and the condition of peripartum cardiomyopathy (25.7%), complications of abortions (19.6%), maternal haemorrhage (12.2%), hypertensive disorders (10.3%), and maternal sepsis and other maternal infections such as influenza, malaria, tuberculosis, and hepatitis (9.6%). Most of the maternal mortality happened during the postpartum period and majority of the deaths occurred at the age group of 20-29 years. Overall trend showed that there was a decline from 708 per 100,000 live births in 1990 to 497 per 100,000 in 2013. The annual rate of change over these years was -1.6 (95% UI: -2.8 to -0.3). CONCLUSION: The findings of the study highlight the need for comprehensive efforts using multisectoral collaborations from stakeholders for reducing maternal mortality in Ethiopia. It is worthwhile for policies to focus on postpartum period.

Differences in spatial distributions of iron supplementation use among pregnant women and associated factors in Ethiopia: evidence from the 2011 national population based survey.

BACKGROUND: Iron supplementation during pregnancy prevents against low birth weight, incidence of prematurity and postpartum hemorrhage. However, the coverage of iron supplementation is still low in Ethiopia. This study aimed to investigate the spatial variations and associated factors of iron supplementation during pregnancy using the 2011 national demographic and health survey data. METHODS: This study used secondary data from the 2011 Ethiopian demographic and health survey. The survey was cross sectional and used a multistage cluster sampling procedure. A logistic regression statistical model using adjusted odds ratio (AOR) and 95% confidence interval (CI) was used to identify the associated factors. Getis-Ord G-statistic was used to identify high and low hotspot areas of iron tablet supplementation during pregnancy. RESULTS: The coverage of iron tablet supplementation was 17.1% [95%CI: (16.3-17.9)] with the highest coverage of 38.9% [95%CI: (32.4--46.1)] in Addis Ababa followed by Tigray regional state with 33.8% [95%CI: (29.9-38.00)]. The lowest coverage was found in Oromiya regional state at 11.9% [95%CI: (10.7-13.0)]. Multivariable analysis showed that mothers who were aware of the Community Conversation Program had 20% [AOR = 1.2; 95% CI: (1.04-1.4)] higher odds of taking iron tablets. The odds of taking iron tablets was 2.9 times [AOR = 2.9; 95% CI: (2.3-3.7)] higher among those who took deworming tablets. Those mothers who attended the minimum four antenatal visits recommended by WHO were 3.9 times [AOR = 3.9; 95% CI: (3.3-4.6)] more likely and those mothers in the age group 31-49 years were 2.9 times [AOR = 2.9; 95% CI: (1.1-7.4)] more likely to use iron tablets as compared to those mothers who did not attend antenatal care and mothers in the age group less than 20 years. Mothers having a family size of 10 and above had 32% [AOR = 0.68; 95% CI: (0.49-0.97)] lower odds of taking iron tablets during pregnancy. The spatial analysis found that only northern, central and eastern parts of Ethiopia were identified as hotspots of iron supplementation. CONCLUSION: Iron supplementation use was not equally distributed in Ethiopia, with relatively higher prevalence in Tigray, Addis Ababa and Harari regional states. Attention should be given to younger age mothers, mothers with large family size and mothers who reside in areas with low coverage of iron tablet distribution. Promotion of antenatal care services based on the WHO standard can be used as an intervention for improving iron supplementation during pregnancy.

Trends, causes, and risk factors of mortality among children under 5 in Ethiopia, 1990-2013: findings from the Global Burden of Disease Study 2013.

BACKGROUND: Ethiopia has made remarkable progress in reducing child mortality over the last two decades. However, the under-5 mortality rate in Ethiopia is still higher than the under-5 mortality rates of several low- and middle-income countries (LMIC). On the other hand, the patterns and causes of child mortality have not been well investigated in Ethiopia. The objective of this study was to investigate the mortality trend, causes of death, and risk factors among children under 5 in Ethiopia during 1990-2013. METHODS: We used Global Burden of Disease (GBD) 2013 data. Spatiotemporal Gaussian Process Regression (GPR) was applied to generate best estimates of child mortality with 95% uncertainty intervals (UI). Causes of death by age groups, sex, and year were measured using Cause of Death Ensemble modeling (CODEm). For estimation of HIV/AIDS mortality rate, the modified UNAIDS EPP-SPECTRUM suite model was used. RESULTS: Between 1990 and 2013 the under-5 mortality rate declined from 203.9 deaths/1000 live births to 74.4 deaths/1000 live births with an annual rate of change of 4.6%, yielding a total reduction of 64%. Similarly, child (1-4 years), post-neonatal, and neonatal mortality rates declined by 75%, 64%, and 52%, respectively, between 1990 and 2013. Lower respiratory tract infection (LRI), diarrheal diseases, and neonatal syndromes (preterm birth complications, neonatal encephalopathy, neonatal sepsis, and other neonatal disorders) accounted for 54% of the total under-5 deaths in 2013. Under-5 mortality rates due to measles, diarrhea, malaria, protein-energy malnutrition, and iron-deficiency anemia declined by more than two-thirds between 1990 and 2013. Among the causes of under-5 deaths, neonatal syndromes such as sepsis, preterm birth complications, and birth asphyxia ranked third to fifth in 2013. Of all risk-attributable deaths in 1990, 25% of the total under-5 deaths (112,288/435,962) and 48% (112,288/232,199) of the deaths due to diarrhea, LRI, and other common infections were attributable to childhood wasting. Similarly, 19% (43,759/229,333) of the total under-5 deaths and 45% (43,759/97,963) of the deaths due to diarrhea and LRI were attributable to wasting in 2013. Of the total diarrheal disease- and LRI-related deaths (n = 97,963) in 2013, 59% (57,923/97,963) of them were attributable to unsafe water supply, unsafe sanitation, household air pollution, and no handwashing with soap. CONCLUSIONS: LRI, diarrheal diseases, and neonatal syndromes remain the major causes of under-5 deaths in Ethiopia. These findings call for better-integrated newborn and child survival interventions focusing on the main risk factors.

Geographic Variation and Factors Associated with Female Genital Mutilation among Reproductive Age Women in Ethiopia: A National Population Based Survey.

BACKGROUND: Female genital mutilation (FGM) is a common traditional practice in developing nations including Ethiopia. It poses complex and serious long-term health risks for women and girls and can lead to death. In Ethiopia, the geographic distribution and factors associated with FGM practices are poorly understood. Therefore, we assessed the spatial distribution and factors associated with FGM among reproductive age women in the country. METHOD: We used population based national representative surveys. Data from two (2000 and 2005) Ethiopian demographic and health surveys (EDHS) were used in this analysis. Briefly, EDHS used a stratified, two-stage cluster sampling design. A total of 15,367 (from EDHS 2000) and 14,070 (from EDHS 2005) women of reproductive age (15-49 years) were included in the analysis. Three outcome variables were used (prevalence of FGM among women, prevalence of FGM among daughters and support for the continuation of FGM). The data were weighted and descriptive statistics (percentage change), bivariate and multivariable logistic regression analyses were carried out. Multicollinearity of variables was assessed using variance inflation factors (VIF) with a reference value of 10 before interpreting the final output. The geographic variation and clustering of weighted FGM prevalence were analyzed and visualized on maps using ArcGIS. Z-scores were used to assess the statistical difference of geographic clustering of FGM prevalence spots. RESULT: The trend of FGM weighted prevalence has been decreasing. Being wealthy, Muslim and in higher age categories are associated with increased odds of FGM among women. Similarly, daughters from Muslim women have increased odds of experiencing FGM. Women in the higher age categories have increased odds of having daughters who experience FGM. The odds of FGM among daughters decrease with increased maternal education. Mass media exposure, being wealthy and higher paternal and maternal education are associated with decreased odds of women's support of FGM continuation. FGM prevalence and geographic clustering showed variation across regions in Ethiopia. CONCLUSION: Individual, economic, socio-demographic, religious and cultural factors played major roles in the existing practice and continuation of FGM. The significant geographic clustering of FGM was observed across regions in Ethiopia. Therefore, targeted and integrated interventions involving religious leaders in high FGM prevalence spot clusters and addressing the socio-economic and geographic inequalities are recommended to eliminate FGM.

Social determinants of HIV infection, hotspot areas and subpopulation groups in Ethiopia: evidence from the National Demographic and Health Survey in 2011.

OBJECTIVE: This study identifies social determinants of HIV infection, hotspot areas and subpopulation groups in Ethiopia. DESIGN: The study used data from the 2011 Ethiopian Demographic and Health Survey (EDHS). Sample blood tests from the finger pricks collected on filter paper cards were labelled with a barcode unique to each respondent. Spatial scan statistics and geographic information system tools were used to map hotspot areas of HIV prevalence. Bivariate and multivariable logistic regression models were used to identify social determinants of HIV infection. POPULATION: A total of 30,625 adults (16,515 women and 14,110 men) were included from 11 administrative states of Ethiopia. MAIN OUTCOME MEASURES: Laboratory-confirmed HIV serostatus is the main outcome variable. RESULTS: HIV prevalence reached 10-21% in the central, eastern and western geographic clusters of Ethiopia. Multivariable analysis showed that individuals who were in the middle, richer and richest wealth quintiles had increased odds of having HIV over those in the poorest quintile. Adults who had primary, secondary and higher educational levels had higher odds of being HIV positive than non-educated individuals. The odds of having HIV were higher among adults who had multiple lifetime sexual partners than those with a single partner. An increasing odds of HIV infection were observed among adults in the age groups of 25-29, 30-34, 35-39 and 40-45 years compared with adults in the age group of 45-49 years. Merchants had higher odds of being HIV positive than those who were not employed. The odds of having HIV were higher among urban residents and females than among rural residents and males, respectively. CONCLUSIONS: This study found statistically significant HIV concentrations in administrative zones of central, eastern and western Ethiopia. Geospatial monitoring and targeting of prevention strategies for specific population groups is recommended.

Socio-medical determinants of timely breastfeeding initiation in Ethiopia: Evidence from the 2011 nation wide Demographic and Health Survey.

BACKGROUND: Early initiation of breastfeeding is a simple and cost effective intervention to advance the health of mothers and newborns. The World Health Organization (WHO) and United Nations Children's Fund (UNICEF) recommend that breastfeeding should be initiated within one hour of birth. The aim of this study is to identify factors associated with timely initiation of breastfeeding among mothers in Ethiopia within one hour of birth. METHODS: This study used data from the 2011 Ethiopia Demographic and Health Survey. A total of 11,654 households were included in the analysis from 11 administrative states of Ethiopia. Bivariate and multivariable logistic regression models with adjusted odds ratio (AOR) and 95 % confidence intervals (CI) were used to quantify predictors of early breastfeeding initiation. RESULTS: The overall prevalence of timely breastfeeding initiation was 52 % (95 % CI: 51.09, 52.91). The prevalence was higher in urban settings (61.4 %; 95 % CI: 58.85, 63.85) than in rural areas (52.3 %; 95 % CI: 51.33, 53.28). The highest prevalence was found in Addis Ababa 71.5 % (95 % CI: 64.88, 77.12) while the lowest prevalence was 41.7 % (95 % CI: 36.62, 47.00) in Somali regional state. Multivariable logistic regression analysis showed that rural mothers had 39 % lower odds of timely breastfeeding initiation (AOR 0.61; 95 % CI: 0.50, 0.76) compared to urban mothers. Mothers who had secondary education or higher had 60 % higher odds of timely breastfeeding initiation (AOR 1.6; 95 % CI: 1.02, 2.44) than never educated mothers. Mothers who had caesarian deliveries had 61 % lower odds of timely breastfeeding initiation (AOR 0.39; 95 % CI: 0.22, 0.71) compared to vaginal deliveries. Working mothers were 23 % less likely to timely initiate breastfeeding (AOR 0.77; 95 % CI: 0.69, 0.85) compared to housewives. Female infants had a 20 % higher chance of timely breastfeeding initiation (AOR 1.2; 95 % CI: 1.05, 1.30) compared to male infants. CONCLUSION: Early initiation of breastfeeding within the first hour after birth was not optimal  in Ethiopia. Factors such as place of residence, educational level, occupation, gender of the newborn and type of delivery should be considered in any intervention program in order to enhance timely breastfeeding initiation.

Factors influencing full immunization coverage among 12-23 months of age children in Ethiopia: evidence from the national demographic and health survey in 2011.

BACKGROUND: Immunization remains one of the most important public health interventions to reduce child morbidity and mortality. The 2011 national demographic and health survey (DHS) indicated low full immunization coverage among children aged 12-23 months in Ethiopia. Factors contributing to the low coverage of immunization have been poorly understood. The aim of this study was to identify factors associated with full immunization coverage among children aged 12-23 months in Ethiopia. METHODS: This study used the 2011 Ethiopian demographic and health survey data. The survey was cross sectional by design and used a multistage cluster sampling procedure. A total of 1,927 mothers with children of 12-23 months of age were extracted from the children's dataset. Mothers' self-reported data and observations of vaccination cards were used to determine vaccine coverage. An adjusted odds ratio (AOR) with 95% confidence intervals (CI) was used to outline the independent predictors. RESULTS: The prevalence of fully immunized children was 24.3%. Specific vaccination coverage for three doses of DPT, three doses of polio, measles and BCG were 36.5%, 44.3%, 55.7% and 66.3%, respectively. The multivariable analysis showed that sources of information from vaccination card [AOR 95% CI; 7.7 (5.95-10.06)], received postnatal check-up within two months after birth [AOR 95% CI; 1.8 (1.28-2.56)], women's awareness of community conversation program [AOR 95% CI; 1.9 (1.44-2.49)] and women in the rich wealth index [AOR 95% CI; 1.4 (1.06-1.94)] were the predictors of full immunization coverage. Women from Afar [AOR 95% CI; 0.07 (0.01-0.68)], Amhara [AOR 95% CI; 0.33 (0.13-0.81)], Oromiya [AOR 95% CI; 0.15 (0.06-0.37)], Somali [AOR 95% CI; 0.15 (0.04-0.55)] and Southern Nation and Nationalities People administrative regions [AOR 95% CI; 0.35 (0.14-0.87)] were less likely to fully vaccinate their children. CONCLUSION: The overall full immunization coverage in Ethiopia was considerably low as compared to the national target set (66%). Health service use and access to information on maternal and child health were found to predict full immunization coverage. Appropriate strategies should be devised to enhance health information and accessibility for full immunization coverage by addressing the variations among regions.

Khat Chewing Practice and Associated Factors among Adults in Ethiopia: Further Analysis Using the 2011 Demographic and Health Survey.

BACKGROUND: Khat chewing has become a highly prevalent practice and a growing public health concern in Ethiopia. Although there have been many small scale studies, very limited national information has been available in the general population. This study aimed to identify factors associated with khat chewing practice among Ethiopian adults. METHODS: The study used the 2011 Ethiopian demographic and health survey data. The survey was cross-sectional by design and used a multistage cluster sampling procedure. Bivariate and multivariable logistic regression models with adjusted odds ratio (AOR) and their 95% confidence intervals (CI) were used to quantify the predictors. RESULTS: The overall khat chewing prevalence was 15.3% (95% CI: 14.90-15.71). Regional variation was observed with the highest in Harari [(53.2% (95% CI: 43.04-63.28)] and lowest in Tigray regional state [(1.1% (95% CI: 0.72-1.66)]. Multivariable analysis showed that Islam followers were 23.8 times more likely to chew khat as compared to Orthodox followers. Being a resident in Oromiya, South Nation, Nationalities and People (SNNP), Gambella, Harari and Dire Dawa regions had 1.9, 1.6, 3.1, 5.2 and 3.5 times higher odds of chewing khat as compared to Addis Ababa residents, respectively. Adults in the age group 45-49 years were 3.6 times more likely to chew khat as compared to 15-19 years. The middle and richest wealth quintiles were 1.3 and 1.5 times more likely to chew khat, respectively, as compared to the poorest category. Rural residents had 1.3 odds of chewing khat than urban residents. Those individuals who had occupation in sales, agriculture, service sector, skilled and unskilled manual workers were 1.6, 1.3, 2.4, 1.7 and 2.3 times more likely to chew khat, respectively, as compared to those who have no occupation. Females were 77% less likely to chew khat as compared to males. Formerly married and those experienced in child death had 1.4 and 1.2 times higher odds to chew khat as compared with those never married and never had child death, respectively. Those who attended mass media were 1.4 times more likely to chew khat compared with not attended. CONCLUSION: Khat chewing is a public health concern in Ethiopia. The highest wealth quintiles, older age group, rural residence, child death, formerly married, males, regions of Oromiya, SNNP, Gambella, Harari and Dire Dawa and Islamic followers had statistically significant association with khat chewing. Due attention needs to be given for these factors in any intervention procedures.

Tobacco use and associated factors among adults in Ethiopia: further analysis of the 2011 Ethiopian Demographic and Health Survey.

BACKGROUND: Tobacco is one of the leading preventable causes of non-communicable diseases. Previous studies gave due emphasis only for cigarette smoking with little attention given for other types of tobacco use. This study describes the prevalence of all common forms of tobacco use and identify associated factors among adults in Ethiopia. METHODS: The study used data from the 2011 Ethiopian demographic and health survey. An index was constructed from yes or no responses for common types of tobacco use. Bivariate and multivariate logistic regression statistical models were employed to determine associated factors with tobacco using adjusted odds ratios (AOR) and their 95 % confidence intervals (CI). RESULTS: The overall prevalence of tobacco use was 4.1 % [95 % CI: (3.93-4.37)]. The highest prevalence 16.9 % [95 % CI: (11.02-23.76)] in Gambella and the lowest 0.8 % [95 % CI: (0.48-1.29)] in Tigray regions were reported. The odds of tobacco use in the age group 20-24 and 45-49 years were [AOR = 2.3; 95 % CI: (1.60-3.21)] and [AOR = 9.1; 95 % CI: (6.06-13.54)] more likely to use tobacco, respectively, as compared to the age group 15-19 years. Traditional religion [AOR = 5.5; 95 % CI: (3.96-7.55)], Catholics [AOR = 3.40; 95 % CI: (2.03-5.69)] and Islamic followers [AOR = 2.8; 95 % CI: (2.31-3.32)] had higher odds of using tobacco as compared to Orthodox religion followers. Adults in the poorest wealth quintile were [AOR = 1.4; 95 % CI: (1.05-1.79)] more likely to use tobacco as compared to the richest wealth quintile. The odds of tobacco use among males were higher as compared to females [AOR = 13.08; 95 % CI: (10.24-16.72)]. Formerly married adults were [AOR = 1.71; 95 % CI: (1.20-2.34)] more likely to use tobacco as compared to never married. Adults who were professionally working [AOR = 0.49; 95 % CI: (0.29-0.85)] had less likely to use tobacco as compared to non-working adults. However, adults who were working in sales, skilled and unskilled occupations had [AOR = 1.6; 95 % CI: (1.18-2.24)], [AOR = 1.7, 95 % CI: (1.21-2.50)] and [AOR = 3.8 95 % CI: (2.27-6.23)] more likely to use tobacco, respectively, as compared to non-working adults. Individuals who had experience of child death were [AOR = 1.4; 95 % CI: (1.17-1.63)] more likely to use tobacco as compared to their counterparts. CONCLUSION: The overall prevalence of tobacco use seems low in Ethiopia. However, a significant regional variation of tobacco use was observed. A tailored public health interventions targeting regions with high prevalence of tobacco use is recommended.

Anaemia prevalence and associated factors among lactating mothers in Ethiopia: evidence from the 2005 and 2011 demographic and health surveys.

OBJECTIVE: To identify factors associated with anaemia in lactating mothers in Ethiopia. DESIGN: A cross-sectional secondary analysis of data pooled from two rounds of the 2005 and 2011 Ethiopian Demographic and Health Survey (EDHS) was used. A multivariate logistic regression model was applied to determine the factors associated with anaemia. POPULATION: A total of 7332 lactating mothers (2285 from EDHS 2005 and 5047 from EDHS 2011) were included from 11 administrative states of Ethiopia. MAIN OUTCOME MEASURES: Lactating mothers considered anaemic if haemoglobin level <12 g/dL. RESULTS: The overall prevalence of anaemia among lactating mothers was 22.1% (95% CI 21.13% to 23.03%). The highest prevalence was 48.7% (95% CI 40.80% to 56.62%) found in the Somali region, followed by 43.8% (95% CI 31.83% to 56.87%) in the Afar region. The multivariate statistical model showed that having a husband who had attended primary education (adjusted OR (AOR) 0.79; 95% CI 0.68 to 0.91), working during the 12 months preceding the survey (AOR 0.71; 95% CI 0.63 to 0.80), having a normal maternal body mass index (18.5-24.99 kg/m(2)) (AOR 0.78; 95% CI 0.68 to 0.89), being in the middle wealth quintile (AOR 0.83; 95% CI 0.71 to 0.98) or rich wealth quintile (AOR 0.83; 95% CI 0.70 to 0.98), having ever used family planning (AOR 0.68; 95% CI 0.57 to 0.80), having attended antenatal care (ANC) for the indexed pregnancy four times or more (AOR 0.73; 95% CI 0.59 to 0.91), having experienced time variation between the two surveys (AOR 0.73; 95% CI 0.64 to 0.85), and breastfeeding for 2 years (AOR 0.76; 95% CI 0.66 to 0.87) were factors associated with lower odds of having anaemia in lactating mothers. CONCLUSIONS: Anaemia is highly prevalent among lactating mothers, particularly in the pastoralist communities of Somali and Afar. Promoting partner education, improving maternal nutritional status, and creating behavioural change to use family planning and ANC services at health facilities are recommended interventions to reduce the prevalence of anaemia among lactating mothers in Ethiopia.

Poor linkages in maternal health care services-evidence on antenatal care and institutional delivery from a community-based longitudinal study in Tigray region, Ethiopia.

BACKGROUND: Progress towards attaining the maternal mortality and maternal health targets set by Millennium Development Goal 5 has been slow in most African countries. Assessing antenatal care and institutional delivery service utilization and their determinants is an important step towards improving maternal health care services. METHODS: Data were drawn from the longitudinal database of Kilite-Awlaelo Health and Demographic Surveillance System. A total of 2361 mothers who were pregnant and who gave birth between September 2009 and August 2013 were included in the analysis. Potential variables to explain antenatal care and institutional delivery service utilization were extracted, and descriptive statistics and logistic regression were used to determine the magnitude of maternal health care service utilization and associated factors, respectively. RESULTS: More than three-quarters, 76% [95% CI: 74.8%-78.2%] (n = 1806), of mothers had undergone at least one antenatal care visit during their previous pregnancy. However, only 27% [95% CI: 25.3%-28.9%] (n = 639) of mothers gave birth at a health institution. Older mothers, urban residents, mothers with higher education attainment, and farmer mothers were more likely to use antenatal care. Institutional delivery services were more likely to be used among older mothers, urban residents, women with secondary education, mothers who visited antenatal care, and mothers with lower parity. CONCLUSIONS: Despite a relatively high proportion of mothers attending antenatal care services at least once, we found low levels of institutional delivery service utilization. Health service providers in Kilite-Awlaelo should be particularly vigilant regarding the additional maternal health needs of rural and less educated women with high parity.

HIV related risk behaviours among taxi drivers and their assistants in Addis Ababa, Ethiopia: descriptive cross-sectional survey.

BACKGROUND: Risk taking behaviours in relation to HIV among the mobile population is a growing public health concern in many developing countries, including Ethiopia. The aim of this study was to describe risky sexual behaviours and associated factors among male taxi drivers and assistants in Addis Ababa. METHODS: A descriptive cross-sectional survey design with multistage cluster sampling procedure was employed to select 615 individuals for interview. RESULTS: Seventy six percent of the respondents were sexually active. Nearly 31% of the respondents reported casual sex and 7% of them did not use a condom with their most recent casual sex partner. More than half (58.5%) of the respondents had no condom use efficacy. Condom breakage and/or slippage during sex had been encountered by 44% of respondents with casual partners and sex during menstruation had ever occurred among 17% of respondents. Eleven percent had experienced sex with female sex workers. Thirty-three percent of the respondents were unfaithful to their spouse/steady partners. Multivariate analysis revealed that living with parents [AOR 95% CI; 2(1.14-3.60)], non-khat chewers [AOR 95% CI; 3.7(2.13-6.31)], never taken VCT [AOR 95% CI; 3.5(1.84-6.72)], middle-class monthly cash gain [AOR 95% CI; 0.5(0.25-0.98)] and more years of experience working on a taxi [AOR 95% CI; 0.17(0.60-0.47)] were statistically significant to influence lifetime abstinence. Non-khat chewers [AOR 95% CI; 0.53(0.37-0.78)], never taken VCT [AOR 95% CI; 0.54(0.36-0.88)] and higher monthly cash gain [AOR 95% CI; 2.9(1.14-7.19)] had a statistically significant association with condom use efficacy. Living with parents [AOR 95% CI; 2(1.31-3.72)], living with friends [AOR 95% CI; 6.4(3.13-12.89)] and non-khat chewers [AOR 95% CI; 2(1.34-3.53)] were risk factors found to be associated with faithfulness. CONCLUSIONS: Risky sexual behaviours in this sub-population were considerable and associated factors were found to be multidimensional. Therefore, there is a need for robust intervention strategies such as tailored serial radio program targeting taxi drivers and their assistants.

Geographical variation and factors influencing modern contraceptive use among married women in Ethiopia: evidence from a national population based survey.

BACKGROUND: Modern contraceptive use persists to be low in most African countries where fertility, population growth, and unmet need for family planning are high. Though there is an evidence of increased overall contraceptive prevalence, a substantial effort remains behind in Ethiopia. This study aimed to identify factors associated with modern contraceptive use and to examine its geographical variations among 15-49 married women in Ethiopia. METHODS: We conducted secondary analysis of 10,204 reproductive age women included in the 2011 Ethiopia Demographic and Health Survey (DHS). The survey sample was designed to provide national, urban/rural, and regional representative estimates for key health and demographic indicators. The sample was selected using a two-stage stratified sampling process. Bivariate and multivariate logistic regressions were applied to determine the prevalence of modern contraceptive use and associated factors in Ethiopia. RESULTS: Being wealthy, more educated, being employed, higher number of living children, being in a monogamous relationship, attending community conversation, being visited by health worker at home strongly predicted use of modern contraception. While living in rural areas, older age, being in polygamous relationship, and witnessing one's own child's death were found negatively influence modern contraceptive use. The spatial analysis of contraceptive use revealed that the central and southwestern parts of the country had higher prevalence of modern contraceptive use than that of the eastern and western parts. CONCLUSION: The findings indicate significant socio-economic, urban-rural and regional variation in modern contraceptive use among reproductive age women in Ethiopia. Strengthening community conversation programs and female education should be given top priority.

A population based survey in Ethiopia using questionnaire as proxy to estimate obstetric fistula prevalence: results from demographic and health survey.

BACKGROUND: Obstetric Fistula (OF) remains a major public health problem in areas where unattended obstructed labor is common and maternal mortality is high. Obstetric Fistula was able to be prevented, treated and eradicated in high-income countries; however, it still affects many women in low-income countries. To our knowledge, only few studies have described the prevalence and factors associated with Obstetric Fistula in Ethiopia in population-based surveys. OBJECTIVE: The aim of this study is to describe the prevalence and factors associated with Obstetric Fistula in Ethiopia. METHODS: The study used women's dataset from the 2005 Ethiopian Demographic and Health Survey. The survey sample was designed to provide national, urban/rural, and regional representative estimates of key health and demographic indicators. The sample was selected using a two-stage stratified sampling process. OF was measured using questionnaire. The data is analyzed using descriptive and multivariate statistical methods to determine factors associated with Obstetric Fistula. RESULTS: A total of 14,070 women of reproductive age group were included in the survey. Of which 23.2% ever heard of obstetric fistula. Among women who ever given birth (9,713), some 103 (1.06%, 95% CI; 0.89%-1.31%) experienced obstetric fistula in their lifetime, which means 10.6 per 1000 women who ever gave birth. It is estimated that in Ethiopia nearly 142,387 (95% CI: 115,080-169,694) of obstetric fistula patients exist. Those women who are circumcised had higher odds of reporting the condition (Chi square = 4.41, p-value = 0.036). In the logistic regression model women from rural areas were less likely to report obstetric fistula than their urban counterparts (OR = 0.21, 95% CI: 0.06-0.69). Women who gave birth 10 or more had higher odds of developing obstetric fistula than women with 1-4 child (OR = 4.34; 95% CI; 1.29-14.55). CONCLUSIONS: Obstetric fistula is a major public and reproductive health concern in Ethiopia. This calls for increased access to emergency obstetric care, expansion of fistula repair service and active finding of women with OF with campaigns of ending fistula is recommended.