Challenges and experience of the Ethiopian rural health extension program: implications for reform and revitalization.

BACKGROUND: Despite remarkable gains over the past decade, mounting evidence suggests that Ethiopia's rural health extension program (HEP) is facing serious implementation challenges. We investigated the current and potential future program design and implementation challenges of Ethiopia's rural HEP based on the lived experiences of health extension workers (HEW) implementing the program at the grassroots level. METHODS: We employed a longitudinal qualitative exploration linked to a larger cluster-randomized trial (RCT) which was implemented in 282 villages randomly selected from 18 Kebeles of the Gedeo zone, southern Ethiopia. Data were collected using in-depth interviews with key informants, focus group discussion, and passive observation of program implementation. The data were analyzed manually using a thematic framework analysis approach. Themes and sub-themes were generated by condensing, summarizing, and synthesizing data collected in the field in the form of extended notes and field observation checklists. FINDINGS: Despite considerable gains in availing basic health services to the rural population, HEP seems to suffer serious design and implementation flaws that demand thoughtful and immediate adjustment. The design constraints span from the number and type of intervention packages to the means of dissemination (vehicle) as well as the target population emphasized. As such, some low-cost high-impact interventions that were strongly desired by the community were overlooked, while others were inappropriately packed. The means of distribution - female health extension workers trained with basic prevention skills, were lacking essential skills. They also had high burnout rates and with little engagement with men, were repeatedly mentioned flaws of the program demanding revitalization. Furthermore, the sheer structure of HEP precluded adult and adolescent men, non-reproductive women, and the elderly. CONCLUSION: Despite significant gains over the last couple of months, Ethiopia's rural HEP appears to have reached a tipping point that requires a comprehensive revamp of the program package, means of distribution, and target beneficiaries rather than the "usual" tweaks to reap maximum benefits.

Worldwide magnitude of inguinal hernia: Systematic review and meta-analysis of population-based studies.

This review pooled the magnitude of inguinal hernia based on the available population-based studies conducted throughout the world. We have searched for population-based articles reporting the magnitude of inguinal hernia on PubMed/Medline, EMBASE, Cochrane library and Google Scholar. Random-effect meta-analysis was carried out to pool the magnitude of inguinal hernia and its proportion between male and female subjects. To determine the presence of between-study heterogeneity, I2 and Cochran's Q methods were employed. Publication bias was evaluated by the Egger test and visual examination of a funnel plot. All statistical tests were conducted by Stata version 16 software. Ten population-based studies with a total population of 51,304,093 were incorporated to pool the magnitude of inguinal hernia. The pooled prevalence of inguinal hernia was 7.7% (95% confidence interval: 6.06-9.34). Subgroup analysis showed that the highest pooled prevalence of inguinal hernia (12.72%) was observed in Asia, On the contrary, the lowest pooled prevalence emanated from America, 4.73%. The pooled prevalence of inguinal hernia in males is far higher than females. It was, respectively, 9.61% (95% confidence interval: 6.46-12.76) and 1.31% (95% confidence interval: 0.36-2.26) for males and females. The current meta-analysis revealed a higher burden of inguinal hernia. This finding glares the light that giving greater attention to inguinal hernia is required. It is recommended to identify the significant causes of inguinal hernia and design appropriate prevention as well as management strategies.

The role of multi-dimensional women's empowerment in agriculture to improve the nutritional status of under-five children in rural cash crop producing, resource-limited settings of Ethiopia.

Little is known about the relation between the women empowerment in agriculture index, and health and nutrition outcomes among under-five children in Ethiopia. The study's objective was to examine women's empowerment in agriculture and its association with the nutritional status of children (6-59 months) in rural, cash crop producing, and resource-limited settings of Ethiopia. A community-based cross-sectional study was conducted employing 422 households; having women of reproductive age group and children under-five. Stratified simple random sampling was used to identify households; a simple random sampling was used to select villages and households. Women empowerment in agriculture was measured by the abbreviated women empowerment in agriculture index. Even if the overall multi-dimensional five domains of empowerment index (5DE) was not a significant predictor of nutritional status in children (P > 0⋅05), sub-indicators had a pivotal role in child nutritional status. Disempowerment in decisions about input into production [AOR = 8⋅85], empowerment on control of income [AOR = 0⋅35] and availability of livestock [AOR = 0⋅38] were predictors of child stunting, whereas women's disempowerment in production decisions seems beneficiary for wasting, disempowered women have 84 % less likely to have wasted child than empowered women [AOR = 0⋅16]. Dietary and agricultural diversity [particularly livestock farming], and women's empowerment in production decisions were predictors of better nutritional outcomes in children. Therefore, a concentrated effort is needed towards strengthening the multi-dimensional empowerment of women in agriculture emphasising women's input into production decisions, dietary and agricultural diversification, mainly livestock farming.

Inhaled Corticosteroids and the Risk of Lung Cancer in Chronic Obstructive Pulmonary Disease Patients: A Systematic Review and Meta-Analysis.

Background: The global prevalence of chronic obstructive pulmonary disease (COPD) is increasing, and the risk of lung cancer in these patients is high. The use of inhaled corticosteroids (ICSs) in COPD patients could help to decrease potential lung cancer risk. We planned to conduct this systematic review and meta-analysis to determine the role of ICS in the risk of lung cancer among COPD patients. Methods: A comprehensive search of PubMed, Science Direct, Google Scholar, and Cochrane library and a manual search of the list of references were conducted. Studies with cohort, case-control, and randomized clinical trial designs for any ICS use reporting the incidence/hazard ratio (HR) of lung cancer were included. The random-effects model was used to pool hazard ratios. Subgroup analysis and metaregression analysis were employed. Funnel plot and Egger regression test were used to assess publication bias. Results: Combining the results of 14 observations, the pooled HR for cancer risk reduction was 0.69 (95% CI 0.59-0.79), p value ≤ 0.001. The use of ICS in COPD patients showed a 31% reduction in the risk of lung cancer. Subgroup meta-analysis showed a significant reduction in the risk of lung cancer as well. Conclusion: The use of ICS in COPD patients reduces the risk of lung cancer. The risk reduction was independent of smoking status and latency period. Future studies should focus on the optimum dose and controlling confounders like asthma.

Maternal vitamin D and growth of under-five children: a systematic review and meta-analysis of observational and interventional studies.

BACKGROUND: Even though previous systematic reviews have reported on the role of prenatal vitamin D on birth outcomes, its effect on child growth is poorly understood. OBJECTIVE: To synthesize a systematic summary of the literature on the effect of maternal vitamin D supplementation on the linear growth of under-five children. METHOD: This study includes studies (both observational and interventional with a control group) that evaluated the effects of prenatal vitamin D status on child linear growth. The mean child length/length for age with 95% confidence interval (CI) was pooled as the weighted mean difference using a random-effects model. A funnel plot was used to assess potential publication bias. RESULTS: A total of 45 studies and 66 reports covering a total population of 44,992 (19,683 intervention or high vitamin D group, and 25,309 control or low vitamin D group) were analyzed. Studies spanned from 1977 to 2022. The pooled weighted mean difference was 0.4 cm (95% CI: 0.15-0.65). A subgroup analysis, based on vitamin D supplementation frequency, showed that mothers who supplemented monthly or less frequently had a 0.7 cm (95% CI: 0.2-1.16 cm) longer child. Supplementation with a dose of >2000 international units increased child length at birth. The weighted mean difference was 0.35 cm (95% CI: 0.11-0.58). CONCLUSION: The evidence from this review shows that maternal supplementation of vitamin D is associated with increased birth length. This is apparent at higher doses, low frequency (monthly or less frequent), and during the second/third trimester. It appears that vitamin D supplementation during pregnancy is protective of future growth in under-five children. Clinical trials are needed to establish evidence of effectiveness for the frequency and dose of supplementation.

Magnitude and Predictors of In-Hospital Stroke Mortality in Ethiopia: A Systematic Review and Meta-Analysis.

Introduction: Stroke is the second leading cause of mortality worldwide, accounting for approximately 5.5 million deaths each year. Due to demographic and health changes, the epidemiology of stroke is shifting from industrialized to low- and middle-income nations. Ethiopia is a developing country with a population that reflects this shift. Therefore, this systematic review and meta-analysis are aimed at evaluating the extent of in-hospital mortality of both ischemic and hemorrhagic stroke in Ethiopia and determining relevant factors associated with the mortality. Methods: Observational studies published as of July 15, 2020, that reported the magnitude, predictors, and causes of in-hospital mortality of stroke were systematically and comprehensively retrieved using the PRISMA 2020 criteria from databases such as PubMed/MEDLINE, Science Direct, and Google Scholar. The review papers were chosen based on the study methodology (facility-based observational), the study area (Ethiopia), the study population (adult patients with stroke), the outcome (in-hospital mortality), and the fact that they were published in English. Result: A total of 3709 patients with stroke were included in this systematic review and meta-analysis, which included 19 publications. In-hospital mortality was 14.03 percent on average in the studies, with reports ranging from 6.04 percent to 37.37 percent. Patients with hemorrhagic type stroke, admission Glasgow Coma Scale less than or equal to 12, impaired mental status, National Institutes of Health Stroke Scale stroke level greater than 13, prolonged hospital stay, any incontinence, pneumonia, and/or swallowing trouble had an increased risk of death after stroke. Conclusion: The magnitude of in-hospital mortality of patients with stroke in Ethiopia is high. The assessment of the level of consciousness is vital for clinical management and as an indicator of prognosis. Patients with unfavorable prognostic signs, such as entry Glasgow Coma Scale, National Institutes of Health Stroke Scale stroke level > 13, hemorrhagic stroke, pneumonia, incontinence, and dysphagia, should be given priority.

Fournier's gangrene in an eight-day-old male neonate, a case report.

INTRODUCTION AND IMPORTANCE: Fournier's gangrene is necrotizing fasciitis of the scrotum and perineal area. It is a polymicrobial infection of perianal origin characterized by rapid necrotizing spread along fascial planes to abdominal wall and flank area. The very rare nature of this illness in neonates makes it important to take a lesson in subsequent management of similar cases. CASE PRESENTATION: An eight days old male neonate come with compliant of high-grade intermittent fever, scrotal swelling, crying during urination and irritability of 3 days duration. Objectively he has temperature of 38.8 degree Celsius, pulse rate of 172 and blackish ulcerated scrotum with minimal puss discharge. Blood work showed leukocytosis and scrotal ultrasound ruled out other pathology. CLINICAL DISCUSSION: Identifiable causes constitute about 80% of the cases. Culture from the puss in our case showed polymicrobial cause. Mortality is mainly due severe sepsis, coagulopathy and renal failure. Medical management include optimization of cardiorespiratory status with cautious resuscitation, respiratory support and inotropic support with severe cases. Prompt surgical debridement, incision and drainage help reduce ongoing infection and systemic toxicity. CONCLUSION: The poor hygiene and immature immune response are the likely predisposing factors. Medical management with broad spectrum antibiotics and surgical debridement are cornerstones for good recovery.

Magnitude, Trends, and Determinants of Iodized Salt Availability among Households in Ethiopia: Analysis of Ethiopian Demographic and Health Surveys (2000-2016).

BACKGROUND: Iodine deficiency causes various health problems such as mental defects, goiter, reproductive damage, hypo and hyperthyroidism, stillbirth, abortion, congenital abnormalities, cretinism, mental retardation, muscle anomalies, and reduced work output. Although the adverse effects on health and socio-economic development are well known, they persisted as a public health problem worldwide. Salt iodization is recommended as a simple cost-effective method to prevent iodine deficiency disorders. This study aimed to determine the magnitude, trends, and determinants of iodized salt availability in the household in Ethiopia. METHODS: The current study used the Ethiopian Demographic and Health Surveys conducted from 2000 to 2016 with a total of 57 939 households. Descriptive statistics were performed on selected background characteristics to provide an overall picture of the sample after considering sample weights. To ensure the representativeness of the sample we applied a complex sample design considering household weights, primary sampling units, and the strata associated with it. The Cochran-Armitage test was performed to assess the trend of iodized salt availability in the household. Multivariate logistic regression was used to determine the association between the dependent variable and independent variables. A significance level of .05 was chosen for all analyses. RESULTS: The magnitude of iodized salt availability in the household was 28.45% in 2000, 54.34% in 2005, 15.42% in 2011, and 89.28% in 2016. Iodized salt availability increased from 28.45% [95% CI: 27.69-29.21] in 2000 to 89.28% [95% CI: 88.79-89.75] in 2016. Despite the decline from 2005 to 2011 in the percentage of households with iodized salt, overall, there was a significant increment from 2000 to 2016 in Ethiopia (P-value <.001). There were differences in the status of salt iodization in the administrative region, wealth, family size, and ownership of radio or television. CONCLUSION: Remarkable progress has been made in Ethiopia regarding iodized salt availability in recent years. Besides the current efforts to achieve universal salt iodization, future interventions should prioritize specific groups like those with lower socioeconomic status and geographic areas with lower availability of iodized salt in the household.

The effect of vitamin C supplementation on lipid profile of type 2 diabetic patients: a systematic review and meta-analysis of clinical trials.

BACKGROUND AND AIMS: We conducted a systematic review and meta-analysis of clinical trials evaluating the role of vitamin C supplementation on lipid profiles among diabetic patients to summarize the available findings. METHODS: A comprehensive search of PubMed, ScienceDirect, Google Scholar, and Cochrane Library databases was performed. Clinical trials conducted on adult type 2 diabetic patients evaluating the effect of vitamin C supplementation and reported lipid profiles (cholesterol (TC), triglycerides (TG), low density lipoprotein (LDL), high density lipoprotein (HDL)) were included. Weighted mean difference (WMD) was calculated. RESULTS: Vitamin C supplementation had no significant effect on TC (WMD = - 4.36 mg/dl (95% CI - 10.24, 1.52) p-value = 0.146), LDL level (WMD = 2.73 mg/dl (95% CI - 1.72, 7.17) p-value = 0.229), and HDL level (WMD = 0.91 mg/dl (CI - 0.45, 2.27) p-value = 0.191). However, it reduced TG and secondary outcomes (FBS and HgA1C): TG (WMD = - 11.15 mg/dl (95% CI - 21.58, - 0.71) p-value = 0.036), FBS (WMD = - 16.94 mg/dl CI - 21.84, - 12.04, p-value = 0.000), and HgA1C (WMD = - 1.01% CI - 1.18, - 0.83, p-value = 0.001. Subgroup analysis also depicted younger patients, longer duration of treatment and higher dose were important factors. In addition, meta-regression analysis indicated the significant role of patient age, duration of treatment, supplementation dose, BMI and other baseline variables. CONCLUSION: There is no adequate evidence to support vitamin C supplementation for dyslipidemias in diabetic patients. Specific group of patients might have benefited including younger diabetic patients. Future researches should give emphasis on the duration of treatment, the dose of vitamin C and baseline values.

Prenatal vitamin D supplementation and child respiratory health: A systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Systematic review and meta-analyses of observational studies on maternal vitamin D status and risk of respiratory allergic conditions indicated that mothers who had supplementation during pregnancy could decrease the risk of recurrent wheeze or asthma in their offspring. OBJECTIVES: We conducted this meta-analysis of Randomized Controlled Trials with the primary intention of detecting the effect of prenatal vitamin D supplementation on the offspring's asthma. Secondary outcomes under respiratory health include eczema, lower respiratory tract infections, Immunoglobulin E positive test, upper respiratory tract infections, and allergic rhinitis. METHODS: A comprehensive search of PubMed, ScienceDirect, Google Scholar, and Cochrane Library databases was performed to retrieve randomized controlled trials. Risk Ratio with 95% confidence intervals was computed from dichotomous data using a random-effects model, with I2 >50% representing notable heterogeneity. RESULTS: Six clinical trials met the inclusion criteria, involving a total of 2898 subjects (1461 experimental group and 1437 control group). There was non-significant inverse relationship between vitamin D intake during pregnancy and the occurrence of asthma in offspring (pooled RR = 0.89, 95% CI = 0.69-1.15, I 2  = 46% and Z-static = 0.90, P-value = 0.37). There is no significant difference in the risk of assessed childhood respiratory problems due to maternal supplementation of vitamin D during pregnancy. CONCLUSION AND IMPLICATIONS: Currently, there is no fertile evidence to promote vitamin D supplementation in pregnancy for childhood respiratory health. Future clinical trials should emphasize early initiation of vitamin D supplementation, consider 6 weeks to 6 months postnatal critical window for vitamin D deficiency for offspring, lower risk dose of vitamin D, and identify different phenotypes of asthma and response to vitamin D supplementation.

Nutritional paradox in Ethiopian women: Multilevel multinomial analysis.

BACKGROUND: Nutrition-related diseases have emerged at a faster rate in lower economic conditions before the battle against poverty and undernutrition has been won. In Ethiopia, the double burden of malnutrition seems to come sooner. The present study aims to determine the prevalence and identify the determinants of malnutrition among reproductive-age women using the 2016 Ethiopian Demographic and Health Survey dataset. METHODS: Data from Ethiopian Demographic and Health Survey 2016 were used to identify individual and community-level associated factors of malnutrition among reproductive-age women. Nonpregnant, non-puerperal women aged 15-49 were included. Six hundred forty-two communities and 11,513 women were involved from this nationally representative data. The analysis was done using multi-level mixed-effects multinomial logistic regression to determine fixed effects of individual and community-level factors and random intercept of between characteristics. RESULTS: Thirty-seven percent of the women had malnutrition generally. One-quarter of Ethiopian women were underweight and 11.8% were overweight/obese. Household wealth, women's age and contraceptive use were individual factors negatively associated with undernutrition. Region, place of residence and community-level wealth were cluster characteristics associated with undernutrition. On the other hand, the educational status of women, household wealth index, women's age, contraceptive use, breastfeeding, region and place of residence were the factors associated with overweight. Wealthier women had lowest of the odds for undernutrition OR = 0.84 (95% CI, 0.71, 0.98: P-value < 0.05). Middle-aged women had lower odds of being underweight, whereas reproductive-age extremities on both ends were prone to malnutrition. Modern contraceptive use had decreased the odds of being underweight OR = 0.71 (95% CI 0.63, 0.81 P-value <0.05). Women residing in rural areas had higher odds for undernutrition OR = 1.31 (95% CI 1.10, 1.56: p-value <0.001). In the same scenario, wealthier cluster had lower odds for undernutrition as rivalled with poorer clusters OR = 0.75 (95% CI 0.65, 0.87: P-value < 0.0001). CONCLUSION: Nutritional paradox in the form of overweight/obesity and underweight exists in Ethiopian women. Underweight has a high prevalence and it is in a serious situation, whereas, the burden of overweight/obesity is rising. Both individual and community-level characteristics were significant predictors of malnutrition in Ethiopian women. Besides, the individual-level factors, interventions should also consider community-level associates in tackling malnutrition.

Anemia and Its Associated Factors Among Type 2 Diabetes Mellitus Patients Attending Debre Berhan Referral Hospital, North-East Ethiopia: A Cross-Sectional Study.

PURPOSE: Anemia is one of the common complications of diabetes mellitus (DM), which has an adverse effect on the progression and development of other diabetes-related complications. In spite of this, relatively little information is available on the prevalence of anemia and associated factors among type 2 diabetes mellitus (T2DM) patients in Ethiopia, particularly in the study area. Thus, this study assessed the prevalence of anemia and associated factors among T2DM patients at Debre Berhan Referral Hospital (DBRH), North-East, Ethiopia. PATIENTS AND METHODS: A hospital-based cross-sectional study was conducted from April 1 to May 30, 2019, among 249 T2DM patients with follow up at DBRH, selected using a systematic random sampling technique. Data were collected by face-to-face interviews, anthropometric measurements, and laboratory tests; such as hemoglobin measurements, red blood indices, and serum creatinine analysis. The data were coded and entered into Epi-data manager version 4.4.1.0, and analysis by using SPSS version 22 was carried out. To identify the determinant factors of anemia, bivariate and multivariate logistic regression analyses were performed. P-value <0.05 was considered as statistically significant. RESULTS: The study showed 20.1% of the participants were anemic. Being age >60 years (AOR=3.06, 95% CI: 1.32-7.11), poor glycemic control (AOR=2.95, 95% CI: 1.22-7.15), eGFR 60-89.9 mL/min/1.73m2 (AOR=2.91, 95% CI: 1.15-7.37), eGFR <60 mL/min/1.73m2 (AOR=6.58, 95% CI: 2.42-17.93), DM duration >10 years (AOR= AOR=2.75, 95% CI: 1.17-6.48), and having diabetic complications (AOR=3.81, 95% CI: 1.65-8.81) were significantly associated with anemia. CONCLUSION: One out of five T2DM patients had anemia. Poor glycemic control, decreased eGFR, presence of DM complications, duration of DM >10 years, and age >60 years were significantly associated with the occurrence of anemia among T2DM. Regular screening for anemia in all T2DM patients may help in the early detection and management of anemia.

Individual and community level associates of contraceptive use in Ethiopia: a multilevel mixed effects analysis.

BACKGROUND: Family planning is one of the four pillars of safe motherhood initiative to reduce maternal death in developing countries. Despite progress in contraceptive use, unmet needs are wide open and fertility remains high. Ethiopia have a higher fertility rate which contributes to maternal and child health destitution, putting pressure on the already weak health system. This study examined individual and community-level factors associated with contraceptive use in Ethiopia. METHODS: Data from Ethiopian Demographic and Health Survey 2016 were used to identify individual and community level associated factors among reproductive-age women. Non-pregnant, fecund and sexually active women aged 15-49 were included. Six hundred forty-two communities and 6854 women were involved from this two-stage cluster sampled data. The analysis was done using two-level mixed-effects logistic regression to determine fixed effects of individual and community-level factors and random intercept of between characteristics. RESULTS: From the total eligible women for contraceptive use 2393 (34.9%) of them were users. Injectables were the commonest of all contraceptive methods. Various individual-level variables were associated with contraceptive use. Household wealth index, women's age, number of living children, husband's occupation, ever experience of a terminated pregnancy, current working status of the women, number of births in the last 3 years, and hearing of FP messages through different media were significantly associated individual-level variables after adjusting other factors. Community characteristics like region, place of residence, religion, and community-level wealth were the factors associated with contraceptive use. CONCLUSION: Both individual and community-level characteristics were significant predictors of use of contraceptives in Ethiopian women. Besides the individual-level factors, interventions should also consider community-level associates.