The role of onsite Implanon insertion training for HEWs for sustainable FP programs in Ethiopia: a mixed-method study.

BACKGROUND: Training health extension workers on Implanon insertion offsite, or away from the workplace, can be cost-intensive, can depend on the human and financial resources of partners, and can compromise routine health services by taking health workers off the job. To address these limitations, the USAID Transform Primary Health Care Activity in Ethiopia designed an onsite Implanon insertion training at the primary health care level. This study compared and documented the implementation experience of onsite vs offsite Implanon insertion training for health extension workers. METHODS: In a mixed-method study conducted in March 2020, the team collected training data from 468 participants-half trained onsite and half offsite-and conducted key informant interviews with 20 purposively sampled individuals. The team analyzed this data, summarizing the data in tables and figures and performing a t test with p value < 0.05 using SPSS v.20. Qualitative data were analyzed manually in Excel and summarized in Word based on emerging themes. RESULTS: Health extension workers trained onsite were away from routine work an average of 3 days compared to 8 days for those trained offsite (P < 0.001). The difference in average per-trainee cost of onsite (2707 Birr = 87.3 USD) and offsite (6006 Birr = 193.7USD) training was significant (P < 0.001). There was no significant difference in mean scores of onsite and offsite trainees on the knowledge pre-test (P < 0.947) and post-test (P < 0.220) or in simulated practice on an arm model (p < 0.202). Onsite trainees, assigned to their own health post for clinical practice, performed Implanon insertions on an average of 10 clients: offsite trainees on an average of 5 clients. Most interview participants reported that the onsite Implanon training was better organized, conducted, followed up, and monitored by health centers to ensure community-level access to Implanon services, with quality and continuity. CONCLUSIONS: Onsite training is a promising approach and minimizes service interruption. It is a likely strategy for on-demand training of health extension workers and immediate assignment of skilled providers to ensure access to and continuity of quality community-level Implanon care. Trial registration N/A.

ASRHR in Ethiopia: reviewing progress over the last 20 years and looking ahead to the next 10 years.

Over the last two decades, improvements in Ethiopia's socio-economic context, the prioritization of health and development in the national agenda, and ambitious national health and development policies and programmes have contributed to improvements in the living standards and well-being of the population as a whole including adolescents. Improvements have occurred in a number of health outcomes, for example reduction in levels of harmful practices i.e., in child marriage and female genital mutilation/cutting (FGM/C), reduction in adolescent childbearing, increase in positive health behaviours, for example adolescent contraceptive use, and maternal health care service use. However, this progress has been uneven. As we look to the next 10 years, Ethiopia must build on the progress made, and move ahead understanding and overcoming challenges and making full use of opportunities by (i) recommitting to strong political support for ASRHR policies and programmes and to sustaining this support in the next stage of policy and strategy development (ii) strengthening investment in and financing of interventions to meet the SRH needs of adolescents (iii) ensuring laws and policies are appropriately communicated, applied and monitored (iv) ensuring strategies are evidence-based and extend the availability of age-disaggregated data on SRHR, and that implementation of these strategies is managed well (v) enabling meaningful youth engagement by institutionalizing adolescent participation as an essential element of all programmes intended to benefit adolescents, and (vi) consolidating gains in the area of SRH while strategically broadening other areas without diluting the ASRHR focus.

Progress in adolescent sexual and reproductive health and rights globally between 1990 and 2016: what progress has been made, what contributed to this, and what are the implications for the future?

This commentary is in response to a paper published in the Lancet entitled: "Progress in adolescent health and well-being: tracking 12 headline indicators for 195 countries and territories, 1990-2016" (Peter Azzopardi et al, 2019). We agree with the authors' overall conclusions that although there has been progress in some health outcomes, health risks and social determinants, the situation has worsened in other areas. Other important messages emerge from studying the data with an adolescent sexual and reproductive health and rights (ASRHR) lens. First, notable - albeit uneven - progress in all the ASRHR indicators has occurred in multi-burden countries. Second, while we cannot assign a cause-effect relationship, it is reasonable to suggest that in addition to secular trends, deliberate global and national investment and action have contributed to and/or accelerated these changes. Third, progress in ASRHR in the multi-burden countries contrasts sharply with increases in rates of tobacco use, binge drinking and overweight and obesity, in all categories of countries. Based on these observations, we submit five implications for action: the adolescent health community must recognize the progress made in ASRHR; acknowledge that increasing investment and action in ASRHR has contributed to these tangible results, which has the potential to grow; build on the gains in ASRHR through concerted action and a focus on implementation science; expand the adolescent health agenda in a progressive and strategic manner; and contribute to wider efforts to respond to adolescents' health needs within the rapidly changing context of the worlds they live in.

The Effect of Peer Education in Dispelling Myths and Misconceptions about Long-Acting Reversible Contraception among Ethiopian Youth.

Robust evidence, including systematic reviews and recommendations from the 2016 Lancet Commission on Adolescent Health and Wellbeing, does not wholly support the unambiguous endorsement of peer-led community-based interventions. This study evaluated the effectiveness of an intensive three-day training for peer educators (PE) on dispelling myths and misconceptions about long-acting reversible contraceptives (LARCs) among Ethiopian youth. Post-training, PEs conducted demand-generation activities with their peers to encourage LARCs referrals. A convenience purposive sampling technique was used to select 20 health centers where peer educators referred clients: 10 each in Amhara and Tigray regions. The health centers were randomly allocated to the intervention (five) and non-intervention (five) study arms. Data were abstracted from the peer educators' monthly reporting forms over an 11-month period: 5 months pre-intervention and 6 months post-intervention. Analysis of family planning and LARCs referrals and chi-square tests of association were conducted. Odds of LARCs referrals at pre-intervention (0.96), fell to 0.83 for the post-intervention phase (p-value <0.6). Challenges, largely with data collection and reporting, may have exposed the study to Type II errors. We recommend focused and rigorous data collection in a multi-country 2X2 factorial design cluster randomized holistic intervention (service providers/clinic and PEs/community) trial to comprehensively determine effectiveness on demand for and uptake of LARCs among youth.

Improving Contraceptive Access, Use, and Method Mix by Task Sharing Implanon Insertion to Frontline Health Workers: The Experience of the Integrated Family Health Program in Ethiopia.

In 2009, the Ethiopian Federal Ministry of Health launched an Implanon scale-up program with the goal of improving the availability of long-acting reversible contraceptive (LARC) methods at the community level. The Integrated Family Health Program (IFHP) supported the ministry to train Health Extension Workers (HEWs), a cadre of frontline health workers, on Implanon insertion. Prior to this task-sharing initiative, HEWs were only permitted to provide short-acting contraceptive methods; Implanon insertion services were only available at higher-level health facilities, such as health centers and above. To train HEWs on Implanon insertion, IFHP followed a phase-based approach, which consisted of a learning phase (July to September 2009) that transitioned into a scale-up phase (December 2009 to December 2015). Training began with a series of service delivery-based training of trainers (TOT) sessions for clinical care providers selected from health centers followed by rollout trainings on Implanon insertion for HEWs selected from health posts. Immediately after the Implanon rollout trainings, each trained HEW was provided with consumables and Implanon implants to enable them to initiate the Implanon services at their respective health post. To reinforce knowledge and skills, we conducted mentoring visits and performance review meetings. From July 2009 to September 2015, 98 TOT sessions trained 2,328 clinicians and 320 rollout trainings reached 8,436 HEWs. A total of 1,382,318 women received contraceptive services through any IFHP-supported service delivery point, 1,273,990 of whom received an Implanon implant. The IFHP approach proved to be a successful model for increasing access to contraceptive methods in the community, and the program supported the integration of Implanon services into the existing public health service delivery system.

Strengthening Youth Friendly Health Services through Expanding Method Choice to include Long-Acting Reversible Contraceptives for Ethiopian Youth.

Despite robust evidence regarding long-acting reversible contraceptive (LARC) low failure rates, immediate return to fertility and safety, LARC uptake among youth is low. We evaluated the effect on contraceptive uptake of training youth-friendly service providers to counsel and provide all contraceptive methods including LARCs in the same unit. A convenience purposive sampling technique was used to select 20 youth friendly health units; ten each in Amhara and Tigray regions, Ethiopia; randomly allocated to the intervention (five) and non-intervention (five) arms. Data were abstracted from the family planning registers over an eleven-month period: three months pre-intervention and eight months post-intervention. Analysis of contraceptive uptake and chi-square tests of association were conducted. The number of LARCs new acceptors in the intervention arm was 781 (pre-intervention=116; post intervention=665) as compared to 358 in the non-intervention arm (pre-intervention=95; post intervention=263). Odds of adopting LARCs at pre-intervention (0.70); rose to 1.30 for the post-intervention phase (p-value <0.0001); comparing intervention to non-intervention study arms. Training youth friendly service providers to counsel and provide all contraceptive methods including LARCs in one location resulted in higher LARCs uptake for all sexually active young women; including those planning on delaying their first pregnancy.

Knowledge and Awareness of Cervical Cancer among HIV-Infected Women in Ethiopia.

Introduction. Cervical cancer is one of the leading causes of cancer death among Ethiopian women. Low awareness of cervical cancer, in combination with low health care seeking behavior, is a key challenge for cervical cancer prevention. This study assessed the knowledge of cervical cancer among HIV-infected women in Ethiopia. Methods. A facility-based cross-sectional survey was conducted from August to September 2012 among HIV-infected women between 21 and 49 years of age. Basic descriptive statistics were performed using SPSS. Results. A total of 432 HIV-infected women participated in this study. About 71% of participants had ever heard of cervical cancer. Among women who had ever heard of cervical cancer, 49% did not know the cause while 74% were able to identify at least one risk factor for cervical cancer. Only 33% of women were able to correctly address when women should seek care and 33% identified at least one treatment option for cervical cancer. Conclusion. This study revealed that knowledge about cervical cancer was generally low, in particular for health care seeking behavior and treatment of cervical cancer. Health awareness programs should be strengthened at both community and health facility levels with emphasis highlighting the causes, risk factors, care seeking behaviors, and treatment options for cervical cancer.

Expanding Access to the Intrauterine Device in Public Health Facilities in Ethiopia: A Mixed-Methods Study.

In Ethiopia, modern contraceptive prevalence among currently married women nearly tripled over the last decade, but the method mix remains skewed toward short-acting methods. Since 2011, the Integrated Family Health Program (IFHP+), jointly implemented by Pathfinder International and John Snow Inc., has supported the Federal Ministry of Health to introduce intrauterine devices (IUDs) in more than 800 health centers across 4 regions to improve access to a wider range of methods. Between March and August 2014, Pathfinder conducted a mixed-methods study in 40 purposively selected health centers to assess shifts in the contraceptive method mix following introduction of IUDs using data from family planning registers; determine the characteristics of IUD users through a cross-sectional survey of 2,943 family planning clients who accepted the IUD; explore reasons for method discontinuation among 165 clients seeking IUD removal services; and identify facilitators and barriers to IUD use through focus group discussions (N = 115 clients) and key informant interviews (N = 36 providers, facility heads, and health office heads). Introduction of IUDs into the 40 health centers participating in the study was correlated with a statistically significant increase in the contribution of all long-acting reversible contraceptives (LARCs)-both IUDs and implants-to the method mix, from 6.9% in 2011 to 20.5% in 2014 (P<.001). Our study found that latent demand for the IUD was more prevalent than anticipated and that the method was acceptable to a broad cross-section of women. Of the 2,943 women who sought IUDs during the 6-month study period, 18.0% were new contraceptive users (i.e., those using a contraceptive method for the first time ever), 44.7% reported no educational attainment, 62.5% were from rural areas, and 59.3% were younger than 30 years old, with almost 3 in 10 (27.7%) under the age of 25. The most commonly cited reason for seeking IUD removal services was a desire to become pregnant (43% of women). Qualitative data indicated that while acceptability of the method is growing, limited community awareness, myths and misconceptions about the IUD, and infrastructure deficits at health centers must be addressed to further expand access to a broad range of contraceptive methods.

The Single-Visit Approach as a Cervical Cancer Prevention Strategy Among Women With HIV in Ethiopia: Successes and Lessons Learned.

INTRODUCTION: Cervical cancer is the second most common form of cancer for women in Ethiopia. Using a single-visit approach to prevent cervical cancer, the Addis Tesfa (New Hope) project in Ethiopia tested women with HIV through visual inspection of the cervix with acetic acid wash (VIA) and, if tests results were positive, offered immediate cryotherapy of the precancerous lesion or referral for loop electrosurgical excision procedure (LEEP). The objective of this article is to review screening and treatment outcomes over nearly 4 years of project implementation and to identify lessons learned to improve cervical cancer prevention programs in Ethiopia and other resource-constrained settings. METHODS: We analyzed aggregate client data from August 2010 to March 2014 to obtain the number of women with HIV who were counseled, screened, and treated, as well as the number of annual follow-up visits made, from the 14 tertiary- and secondary-level health facilities implementing the single-visit approach. A health facility assessment (HFA) was also implemented from August to December 2013 to examine the effects of the single-visit approach on client flow, staff workload, and facility infrastructure 3 years after initiating the approach. RESULTS: Almost all (99%) of the 16,632 women with HIV counseled about the single-visit approach were screened with VIA during the study period; 1,656 (10%) of them tested VIA positive (VIA+) for precancerous lesions. Among those who tested VIA+ and were thus eligible for cryotherapy, 1,481 (97%) received cryotherapy treatment, but only 80 (63%) women eligible for LEEP actually received the treatment. The HFA results showed frequent staff turnover, some shortage of essential supplies, and rooms that were judged by providers to be too small for delivery of cervical cancer prevention services. CONCLUSION: The high proportions of VIA screening and cryotherapy treatment in the Addis Tesfa project suggest high acceptance of such services by women with HIV and feasibility of implementation in secondary- and tertiary-level health facilities. However, success of cervical cancer prevention programming must address wider health system challenges to ensure sustainability and appropriate scale-up to the general population of Ethiopia and other resource-constrained settings.

Quality of life of Ethiopian women after fistula repair: implications on rehabilitation and social reintegration policy and programming.

Despite growing recognition of the importance of linking obstetric fistula prevention and treatment strategies with rehabilitation and social reintegration programmes, little research and programming has been oriented toward this goal. Using in-depth interviews, this study aimed to examine the experiences of 51 Ethiopian women after fistula repair surgery to identify priority post-repair interventions that could maximise their quality of life. The results showed that the majority of women felt a dramatic sensation of relief and happiness following repair, yet some continued to experience mental anguish, stigma, and physical problems regardless of the outcome of the procedure. All women suffered intense fear of developing another fistula, most commonly from sex or childbirth. Despite this, the majority of women had sex or planned to do so, while a smaller cohort avoided intercourse and childbearing, thus subjecting them to isolation, marital conflict, and/or economic vulnerability. Our findings suggest that obstetric fistula programmes should integrate (1) post-repair counselling about fistula and risk factors for recurrence, (2) community-based follow-up care, (3) linkages to income-generating opportunities, (4) engagement of women affected by fistula for community outreach, and (5) metrics for evaluating rehabilitation and social reintegration efforts to ensure women regain healthy, productive lives.

Addressing unmet need for long-acting family planning in Ethiopia: uptake of single-rod progestogen contraceptive implants (Implanon) and characteristics of users.

OBJECTIVE: To describe women who accept single-rod progestogen contraceptive implants (Implanon; N.V. Organon, Oss, Netherlands) from community health workers in Ethiopia and to assess whether community-based provision addresses unmet need for contraception. METHODS: Women who accepted Implanon during training events in 4 regions were asked about their characteristics and use of family planning. They were compared with implant users nationally and women with unmet need in the Ethiopia Demographic and Health Survey (DHS). Differences between groups were tested using 2-sample comparisons of proportions and means. RESULTS: On average, Implanon acceptors were younger and had more years of education and fewer children than implant users nationally. Almost one-quarter (22.9%) of all participants had never used contraception before; this was slightly higher among women who chose Implanon (23.1% vs 16.4%; P=0.04). Acceptors were also less likely than non-acceptors to be using contraception (70.8% vs 77.3%; P<0.05) but all women interviewed were more likely to be using contraception than the rural population. Women who accepted Implanon were younger but more educated than women with unmet need for contraception in the 2005 DHS. CONCLUSION: Provision of Implanon at the community level through community health workers is effective in reaching women with the greatest need for contraception.

25 years of public health leadership in Africa: the Ethiopian Public Health Association.

This commentary discusses the historical development, organization and activities of the Ethiopian Public Health Association (EPHA), a professional civil society organization that operates on the principles of protection of public interest and professional standards in health in areas of health development in Ethiopia. The important roles played by the EPHA in health training, research and policy advocacy have been highlighted. Some of the important health system interventions that have been effected in the country through the influence and active participation of the Association have also been pointed out. As an active member of the Executive Board of the World Federation of Public Health Associations, EPHA serves as a role model for public health professional associations in the African Region with regard to increasing their influence in health policy and interventions within their respective countries.

Knowledge and attitude of health professionals in relation to the integration of leprosy control into the general health service in Ethiopia

Since the introduction of multidrug therapy for leprosy patients, the integration of leprosy control in the general health service (GHS) system has been an issue of debate. In Ethiopia, the present policy stresses integrated management of diseases. In spite of the policy, however, leprosy control was a vertical program until 1998 in most parts of the country. A descriptive cross-section study was conducted in the southern region of Ethiopia from October 1996 to March 1997 to determine the levels of involvement of the GHS staff and to identify obstacles to their involvement in the management of leprosy patients. Through a written questionnaire, data were collected from 240 GHS staff, including doctors, nurses and health assistants. It was found that 6% of the GHS staff was involved in leprosy control activities, mainly case finding and health education. Negative attitudes toward leprosy workers were held by 13% of the GHS staff while 40% had intermediate attitudes and the remaining 47% had positive attitudes. Statistically significant differences were found with regard to the level of knowledge among different health professionals, type of health institutions and years of service. The levels of involvement, knowledge and attitude of GHS staff showed that lack of integration and training were core problems. Hence, policy makers should give due attention to promoting the involvement of the GHS staff by integrating the program into the GHS system using the approach already in place in certain parts of the country.