Challenges to joint planning, monitoring, and evaluation for nutrition-sensitive agriculture in Ethiopia: an exploratory qualitative study.

Background: Nutrition-sensitive agriculture is an effective multi-sectoral approach to address the underlying causes of malnutrition. However, successful implementation requires the involvement of different sectors to jointly plan, monitor, and evaluate key activities, which is often challenged by contextual barriers. Previous studies in Ethiopia have not adequately explored these contextual barriers. Hence, the current study aimed to qualitatively explore the challenges to joint planning, monitoring, and evaluation for nutrition-sensitive agriculture among sectors in Ethiopia. Methods: A qualitative exploratory study was conducted in Tigray and Southern Nations, Nationalities, and Peoples (SNNP) of Ethiopia regional states in 2017. Ninety-four key informants were purposively selected from government agencies primarily in health and agriculture, from local (kebele) to national levels, and ranging from academic organizations, research institutions, and implementing partners. Researchers developed a semi-structured guide and conducted key informant interviews which were audiotaped, transcribed verbatim in local language, and translated to English. All transcriptions were imported into ATLAS.ti Version 7.5 software for coding and analysis. The data analysis followed an inductive approach. Transcriptions were coded line by line; then similar codes were grouped into categories. Subsequently, non-repetitive themes were identified from the categories using thematic analysis methodology. Results: The following themes were identified as challenges that hinder joint planning, monitoring, and evaluation to link nutrition to agriculture: (1) limited capacity, (2) workload in home sector (agriculture or nutrition), (3) lack of attention to nutrition interventions, (4) inadequate supportive supervision, (5) problematic reporting system, and (6) weak technical coordinating committees. Conclusions and recommendations: Gaps in human and technical resources, limited attention from different sectors, and absence of routine monitoring data hindered joint planning, monitoring, and evaluation activities for nutrition-sensitive agriculture in Ethiopia. Short-term and long-term training for experts and intensification of supportive supervision may address gaps in capacity. Future studies should address whether routine monitoring and surveillance in nutrition-sensitive multi-sectoral activities provides long-term improvement in outcomes.

Temperature-Dependent Liquid Water Structure for Individual Micron-Sized, Supercooled Aqueous Droplets with Inclusions.

Herein, we measure the water structure for individual micron-sized droplets of water, salt water, and water containing biologically and marine relevant atmospheric inclusions as a function of temperature. Individual droplets, formed on a hydrophobic substrate, are analyzed with micro-Raman spectroscopy. Analysis of the Raman spectra in the O-H stretching region shows that the equilibrium of partially and fully hydrogen-bonding water interactions change as temperature decreases up until there is a phase transition to form ice. Using these temperature-dependent measurements, the thermodynamic parameters for the interchange between partially and fully hydrogen-bonded water (PHW ⇄ FHW) for different supercooled droplets (water, salt water, and water containing biologically and marine relevant atmospheric inclusions) have been determined.

Low-Temperature Water Uptake of Individual Marine and Biologically Relevant Atmospheric Particles Using Micro-Raman Spectroscopy.

The interaction of water vapor and the water uptake behavior of atmospheric particles are often investigated as a function of relative humidity (0-100% RH) at ambient temperature. However, lower temperature studies are important to understand how atmospheric particles nucleate ice through various mechanisms including immersion freezing. Immersion freezing requires the formation of a condensed water droplet at lower temperatures prior to freezing. To better understand low-temperature water uptake behavior of marine and biologically relevant atmospheric particles, we have investigated water uptake of single atmospheric particles using a micro-Raman spectrometer coupled to an environmental cell for measurements at lower temperatures and as a function of relative humidity. These particles include sodium chloride, sucrose, Snomax, lipopolysaccharide, and laminarin. Particles range in size from 2 to 3 µm in diameter and can be monitored by using optical microscopy and Raman spectroscopy as a function of relative humidity at temperatures between 253 and 298 K. From the Raman spectra collected, we can determine a Raman growth factor defined as an increase in the intensity of the O-H stretch as a measure of the integrated water content of a particle compared to the dry particle. These data show that for lipopolysaccharide, laminarin, and Snomax, unlike simple saccharides such as sucrose and other soluble organics, as temperature decreases, water uptake begins at lower relative humidity and does not follow a solubility temperature dependence. This suggests that at lower temperatures the particles are adsorbing water on the surface rather than dissolving and absorbing water. Furthermore, repeated water uptake cycles cause a change in the morphology of some of these particles, which is shown to promote water uptake at lower relative humidity. These results give new insights into water uptake of these different marine and biologically relevant particles at low temperature at subsaturation relative humidity prior to droplet formation and immersion freezing.

What Is the Role of Civil Society in Multisectoral Nutrition Governance Systems? A Multicountry Review.

BACKGROUND: Solutions to create enabling nutrition environments must come from within communities and involve multiple sectors. As vital actors in community mobilization, rights-based advocacy, and accountable public institutions, civil society organizations (CSOs) can help ensure nutrition programs and policies represent and reach all community members to achieve impact. OBJECTIVES: To review attributes of civic engagement in multisectoral nutrition governance systems and to provide recommendations to increase CSO participation. METHODS: We reviewed 7 national case studies of Civil Society Networks involved with the Scaling Up Nutrition movement and characterized 6 functional attributes of CSOs in multisectoral nutrition governance: identify needs of all community members, mobilize and build civic capacity, advocate for political commitments, inform program design and evaluation, ensure accountability mechanisms in public institutions, and report challenges and successes using broad media campaigns. RESULTS: All studies described government agencies involved with multisectoral nutrition governance systems, at national and subnational levels; however, there was limited evidence of subnational platforms for CSO engagement. Although countries increased investments in public institutions for nutrition, it was unclear whether nutrition service quality improved and none reported corresponding investments in civil society. CONCLUSION: Our characterization identifies strategies to engage CSOs in multisectoral nutrition governance at multiple ecological levels. We hope future adaptation and application of this characterization will increase community ownership and diverse representation in nutrition governance systems. Both of these are key to enabling national and international entities to address malnutrition's underlying determinants in ways that align with local contexts, values, and systems change processes.

Measurements of Immersion Freezing and Heterogeneous Chemistry of Atmospherically Relevant Single Particles with Micro-Raman Spectroscopy.

In the atmosphere, there are several different trajectories by which particles can nucleate ice; two of the major pathways are deposition and immersion freezing. Single particle depositional freezing has been widely studied with spectroscopic methods while immersion freezing has been predominantly studied either for particles within bulk aqueous solutions or using optical imaging of single particles. Of the few existing spectroscopic methods that monitor immersion freezing, there are limited opportunities for investigating the impact of heterogeneous chemistry on freezing. Herein, we describe a method that couples a confocal Raman spectrometer with an environmental cell to investigate single particle immersion freezing along with the capability to investigate in situ the impact of heterogeneous reactions with ozone and other trace gases on ice nucleation. This system, which has been rigorously calibrated (temperature and relative humidity) across a large dynamic range, is used to investigate low temperature water uptake and heterogeneous ice nucleation of atmospherically relevant single particles deposited on a substrate. The use of Raman spectroscopy provides important insights into the phase state and chemical composition of ice nuclei and, thus, insights into cloud formation.

The magnitude of sexual abuse and its physical effects among female children seen at Gandhi Memorial Hospital in Addis Ababa, Ethiopia

Background: Child sexual abuse is a form of abuse that involves sexual activity with a minor. A child does not possess the ability to consent to any form of sexual activity. Therefore, perpetrators who engage in sexual activity with a minor are committing the crime of sexual abuse. The definition of child sexual abuse does not need to include physical contact between a perpetrator and a child. The objective of this study was to assess the magnitude and associated physical consequences of sexual abuse among female children seen at Gandhi Memorial Hospital in Addis Ababa, Ethiopia. Method and Materials: This cross-sectional study identified and reviewed 1,500 reported cases of sexual abuse through hospital records at Gandhi Memorial Hospital (Addis Ababa, Ethiopia) between March 2016 and February 2017. These cases were all perpetrated against females and included both adults and children. From a total of 1,500 cases reviewed, 1,100 involved victims in the pediatric age group (under 18 years) who first presented to the hospital following sexual abuse. Of these 1,100 cases, 292 female children were selected. One study participant was selected for every three victims of child sexual abuse, until the required sample size was met. Data were collected from these 292 cases, and descriptive analysis was used to describe study findings. This analysis included frequencies, percentages, and standard deviations. The socio-demographic and educational status of study participants, as well as the physical findings of the victims on presentation, were analyzed, and presented numerically and as percentages of the total study population. Results: The majority of the victims were referred from Addis Ababa. Among the 292 selected cases, 221 (75.7%) were from Addis Ababa and the rest were from the surrounding areas. The majority of respondents (64.7%) were between 12 and 18 years of age, with a small percentage of respondents (5.8%) between 2 and 3 years of age. Most respondents (242 cases, 82.9%) had no previous history of sexual abuse, but the remaining 50 cases (17.1%) had a previous history of sexual abuse by the same or a different perpetuator. Conclusions: This study provides data, and thus evidence for policymakers and other stakeholders, to strive for an improvement in the security and protection of children, as well as education on the matter of child sexual abuse for parents and guardians. Those who could be involved in the implementation of intervention strategies may include parents, health professionals and pertinent personnel from the Ministry of Health and Ministry of Education. Above all, the data suggest a need for the victims to receive training on how to protect themselves from victimization

Family Medicine in Ethiopia: Lessons from a Global Collaboration.

BACKGROUND: Building the capacity of local health systems to provide high-quality, self-sustaining medical education and health care is the central purpose for many global health partnerships (GHPs). Since 2001, our global partner consortium collaborated to establish Family Medicine in Ethiopia; the first Ethiopian family physicians graduated in February 2016. METHODS: The authors, representing the primary Ethiopian, Canadian, and American partners in the GHP, identified obstacles, accomplishments, opportunities, errors, and observations from the years preceding residency launch and the first 3 years of the residency. RESULTS: Common themes were identified through personal reflection and presented as lessons to guide future GHPs. LESSON 1: Promote Family Medicine as a distinct specialty. LESSON 2: Avoid gaps, conflict, and redundancy in partner priorities and activities. LESSON 3: Building relationships takes time and shared experiences. LESSON 4: Communicate frequently to create opportunities for success. LESSON 5: Engage local leaders to build sustainable, long-lasting programs from the beginning of the partnership. CONCLUSIONS: GHPs can benefit individual participants, their organizations, and their communities served. Engaging with numerous partners may also result in challenges-conflicting expectations, misinterpretations, and duplication or gaps in efforts. The lessons discussed in this article may be used to inform GHP planning and interactions to maximize benefits and minimize mishaps.

Perspectives of female medical faculty in Ethiopia on a leadership fellowship program.

OBJECTIVES: This study aims to evaluate a leadership fellowship program through perspectives of Ethiopian women medical faculty participants. METHODS: An intensive two-week leadership development fellowship was designed for women faculty from Ethiopian medical schools and conducted from 2011-2015 at the University of Wisconsin-School of Medicine and Public Health in Madison, Wisconsin. Nine Ethiopian women working in early- or mid-level academic positions were selected. Semi-structured interviews were conducted with the fellows. Transcripts were reviewed through qualitative analysis to assess the perceived impact of the training on their careers. Three male academic leaders were interviewed to solicit feedback on the program. RESULTS: Eight of 9 fellows were interviewed. Themes describing the benefits of the fellowship included: increased awareness of gender inequities; enhanced motivation for career advancement; increased personal confidence; and improved leadership skills. Fellows provided suggestions for future training and scaling up efforts to promote gender equity. Male leaders described the benefits of men promoting gender equity within academic health centers. CONCLUSIONS: This paper provides evidence that targeted brief training programs can enhance women's motivation and skills to become effective leaders in academic medicine in Ethiopia. Promoting gender equity in academic medicine is an important strategy to address health workforce shortages and to provide professional role models for female students in the health professions.

Household dietary diversity, vitamin A consumption and food security in rural Tigray, Ethiopia.

OBJECTIVE: To describe: household dietary diversity across four zones in Ethiopia; the relationship between household dietary diversity and consumption of vitamin A-rich foods; and the relationship between household dietary diversity and food security status. DESIGN: This was a cross-sectional survey. Data were collected using structured questionnaires in the local language. Household dietary diversity scores measured types of foods households consumed, and households were classified by food security status using a modified version of the Household Food Insecurity Access Scale. An ordinal logistics regression model was created to assess the relationship between three tiers of dietary diversity (low, medium and high) and food security while controlling for agricultural zone, educational variables and household characteristics. SETTING: Rural households in Tigray, Ethiopia. SUBJECTS: Three hundred households in Tigray, Ethiopia, were interviewed. RESULTS: Of the households, 23, 47 and 30 % had low, medium and high dietary diversity, respectively. Among households with high dietary diversity, eggs and fruit were the most common foods added to the diet. In the fully adjusted model, participants who reported being food secure had 1·8 increased odds of greater dietary diversity (95 % CI 1·0, 3·2) compared with participants who were food insecure. CONCLUSIONS: Food security was positively associated with dietary diversity. In order to enhance health, interventions that improve dietary diversity and vitamin A consumption should remain important areas of focus for health leaders in the region.

Emergency medicine and its development in Ethiopia with emphasis on the role of Addis Ababa University, School of Medicine, Emergency Medicine Department.

INTRODUCTION: Globally Emergency Medicine (EM) is young discipline and even in developed countries it is about five decades old. In Ethiopia formal pre-hospital care or hospital based Emergency department (ED) development is a recent phenomenon and this article describes development of Emergency Medicine care in Ethiopia before, around and after Ethiopia millennium. METHODOLOGY: Documents related to emergency medicine development and implementation from different government and nongovernmental data sources are used as a resource for this article. RESULTS: Emergency Medicine task force (EMTF) has been established in Addis Ababa University (AAU) school of Medicine (SOM) in June 2006 and the taskforce has closely worked with Federal Ministry of Health (FMOH) and Addis Ababa city council Health Bureau (AACCHB). In addition to the main actors many partners have contributed significantly to this initiative. Some of the developments were establishment of emergency departments in Tikur Anbessa Specialized Hospital (TASH) and the restructuring of EM service by FMOH. Emergency care has been considered as a crucial service in hospitals' service along with outpatient and inpatient services. Furthermore, Pre-hospital care initiatives have been commenced in Addis Ababa and expanded to the regions with a arrangement of one or two ambulances to small districts having 100,000 population. There have also been key achievement in human resource development, notably the establishment of EM residency and MSC in EM and critical care nursing. Prehospital care givers training programs in order to produce emergency medicine technicians (EMT) have been started in various regional health professionals training centers. Furthermore, EM module has been included in the current undergraduate medical education. The Ethiopian society of emergency professionals (ESEP) has been established with members from different categories of emergency medicine professionals. In all these developments the emergency medicine training center in the emergency department of AAU has played key role in the training of human resources in different categories. DISCUSSION AND CONCLUSION: The recent successes in EM development is due to concerted efforts of the FMOH, AAU SOM and AACCHB along with committed partners. Hence, it is concluded that consistent local efforts and relevant stakeholders support in EM has resulted in successful development of the field in the country.

Development of pediatric emergency medicine at Addis Ababa University/Tikuranbessa Specialized Hospital, Ethiopia.

BACKGROUND: In the world emergencies occur everywhere, and each day they consume ressources regardless of whether there are systems capable of achieving good outcomes. Low-income countries suffer the most highest rates of every category of injury--from traffic and the highest rates of acute complications of communicable diseases including tuberculosis, malaria and HIV. OBJECTIVE: To describe the development of pediatrics emergency medicine at Tikur Anbesa Specialized Hospital METHODS: A twinning partnership model was used in developing a pediatric emergency medicine training program helps in development of pediatrics emergency system. RESULTS: Strengthening the capacity of Addis Ababa University (AAU), Tikur Anbessa Hospital (TASH) to provide pediatric emergency medical services through improved organization of the pediatrics emergency department and strengthening of continuing education opportunities for faculty and staff capacity building by this improving quality of care in pediatrics patients in the country. CONCLUSION: The Addis Ababa University, University of Wiscosin and People to People partners intend to continue working together to strengthening and developing effetive systems to deliver quality pediatrics emergency medicine care troughout all regions of Ethiopia.

Enhancing emergency medicine initiatives with a quality improvement program: lessons learned in the emergency department of Tikur Anbessa Hospital, Addis Ababa Ethiopia.

INTRODUCTION: A Twinning Partnership between the University of Wisconsin-Madison (UW) and Addis Ababa University (AAU) in Addis Ababa, Ethiopia was formed to strengthen the development of emergency medical services at AAU's Tikur Anbessa Specialized Hospital (TASHI) through medical education and exchanges. The Twinning philosophy which emphasizes collaboration and joint learning was an ideal program in which QI program was incorporated to maximize success, promote sustainability, and reinforce basic principles for effective healthcare service delivery. This article describes the QI methodology, capacity building strategy, implementation approach, and lessons learned. METHODOLOGY: QI initiative at TASH ED started during EM fellowship in 2010 when Priority problems in the department were identified, and root cause analysis and possible strategies for improvement were devised. Then Baseline and sensitization was undertaken which was followed by Quality Improvement Projects cycles. The Federal Ministry of health key performance indicators (KPI) were used as standard and measurement tool when it was relevant. The findings were analyzed and trends presented to the ED staff and other stakeholders. RESULTS: In the past four years Since QI initiatives started in TASH EM department different achievements have been registered. The main developments were capacity building with QI training of EM fellows, EM residents and EM and critical care nurses. QI Training was also conducted to Tikur Anbessa Hospital and college of health sciences leadership. In addition, various QI projects have been designed and started, while some are finalized and the rest are on implementation. DISCUSSION: The QI experience in the department suggests that a QI program can effectively support, complement, and enhance health system strengthening partnerships, and that establishment of a QI program at the department level is feasible and beneficial, enhancing the adoption and sustainability of health care improvements such as marked improvements in triage, improved infection control and other critical improvements. Therefore, program leaders have determined that scale-up to a hospital-wide QI program is needed to fully realize the potential for increased quality, efficiency and system strengthening.

Learning from developing countries in strengthening health systems: an evaluation of personal and professional impact among global health volunteers at Addis Ababa University's Tikur Anbessa Specialized Hospital (Ethiopia).

BACKGROUND: The positive impact of global health activities by volunteers from the United States in low-and middle-income countries has been recognized. Most existing global health partnerships evaluate what knowledge, ideas, and activities the US institution transferred to the low- or middle-income country. However, what this fails to capture are what kinds of change happen to US-based partners due to engagement in global health partnerships, both at the individual and institutional levels. "Reverse innovation" is the term that is used in global health literature to describe this type of impact. The objectives of this study were to identify what kinds of impact global partnerships have on health volunteers from developed countries, advance this emerging body of knowledge, and improve understanding of methods and indicators for assessing reverse innovation. METHODS: The study population consisted of 80 US, Canada, and South Africa-based health care professionals who volunteered at Tikur Anbessa Specialized Hospital in Ethiopia. Surveys were web-based and included multiple choice and open-ended questions to assess global health competencies. The data were analyzed using IBRM SPSS® version 21 for quantitative analysis; the open-ended responses were coded using constant comparative analysis to identify themes. RESULTS: Of the 80 volunteers, 63 responded (79 percent response rate). Fifty-two percent of the respondents were male, and over 60 percent were 40 years of age and older. Eighty-three percent reported they accomplished their trip objectives, 95 percent would participate in future activities and 96 percent would recommend participation to other colleagues. Eighty-nine percent reported personal impact and 73 percent reported change on their professional development. Previous global health experience, multiple prior trips, and the desire for career advancement were associated with positive impact on professional development. CONCLUSION: Professionally and personally meaningful learning happens often during global health outreach. Understanding this impact has important policy, economic, and programmatic implications. With the aid of improved monitoring and evaluation frameworks, the simple act of attempting to measure "reverse innovation" may represent a shift in how global health partnerships are perceived, drawing attention to the two-way learning and benefits that occur and improving effectiveness in global health partnership spending.

Creating change through collaboration: a twinning partnership to strengthen emergency medicine at Addis Ababa University/Tikur Anbessa Specialized Hospital--a model for international medical education partnerships.

BACKGROUND: Morbidity and mortality due to the lack of an organized emergency medical care system are currently high in Ethiopia. Doctors, nurses, and other medical staff often have limited or no formal training on how to handle emergencies. Because of insufficient human and resource capacity needed to assess and treat acutely ill patients, many who are injured may die unnecessarily, at the site of injury, during transport, or at the hospital. OBJECTIVES: This article describes the development of a twinning partnership between Addis Ababa University (AAU), the University of Wisconsin-Madison (UW), and the nonprofit organization People to People (P2P), to strengthen emergency care at Tikur Anbessa Specialized Hospital (TASH) and increase the number of trained emergency medical professionals. METHODS: The partnership applied the six-phase twinning partnership model, with the overall goal of enhancing and strengthening emergency and trauma care by building institutional and human resource capacity. This was achieved by 1) developing local leaders in emergency medicine (EM), 2) creating training modules adapted to the Ethiopian context, 3) launching an emergency training center, and 4) supporting academic program development. The authors evaluated the program's effectiveness based on our achievements toward these goals. RESULTS: Results include: 1) eight Ethiopian faculty completed a condensed EM fellowship in the United States. Now six Ethiopian physicians serve as EM faculty and two as pediatric EM faculty. 2) Nine emergency training modules were adapted to the Ethiopian context. 3) An emergency training center was opened in 2010 and to date has trained over 4,000 Ethiopian medical professionals. 4) Two academic training programs (EM residency and masters nursing programs) were initiated. CONCLUSIONS: With many complex factors affecting the burden of emergency care, innovative and interdisciplinary collaborations are needed in Ethiopia to train medical workers, build local leadership capacity, strengthen infrastructure, and inform policies. The short-term achievements of this twinning model could suggest that long-term, institution-to-institution collaborations that are driven by local stakeholders are an effective strategy to create equitable relationships and build sustainable health systems and may serve as a model for other global health partnerships.