The unfinished agenda and inequality gaps in antenatal care coverage in Ethiopia.

BACKGROUND: Antenatal care is an essential platform to provide all the necessary health interventions during pregnancy that aim to reduce maternal and newborn morbidity and mortality. Although the antenatal care coverage has been increasing in Ethiopia in the last two decades, the country has not been able to meet its own coverage target to date. Most pregnant women who initiated antenatal care also do not complete the full recommended follow up contacts. This study investigated the trend in coverage and the inequalities related to the use of antenatal care in Ethiopia. METHODS: This study utilized data from five rounds of Demographic and Health Surveys (DHSs) conducted in Ethiopia in the period between 2000 and 2019. The DHS respondents were women in the age group 15-49 who had a live birth within the five years preceding the surveys. The outcome of interest for this study was antenatal care utilization coverage. We used concentration curve and concentration index to identify the inequalities using the World Health Organization recommended Health Equity Analysis Toolkit software. We did a regression analysis to identify the drivers of urban-rural inequalities. RESULT: The coverage trend for both initiating Antenatal care and completing the recommended four antenatal contacts showed a steady increase during 2000-2019. However, the coverages have not yet reached the national target and unlikely to meet targets by 2025. Although the economically better-off, urban and educated mother still have a better coverage, the inequality gaps within the wealth, residence and education categories generally showed significant reduction. Women in the lowest wealth quantile, those who were uneducated and those living in rural areas remained disadvantaged. Household economic status and maternal education was the stronger drivers of urban-rural inequalities. CONCLUSION: The Antenatal care coverage is lagging below the country's target. Despite narrowing inequality gaps women from poor households, who are uneducated and residing in rural areas are still less likely to fully attend the recommended number of antenatal care contacts. Addressing these inequalities through a multisectoral efforts is critical to increase the chances of achieving the national antenatal care coverage targets in Ethiopia.

Retention on antiretroviral therapy in person with HIV and viral hepatitis coinfection in Ethiopia: a retrospective cohort study.

BACKGROUND: HIV coinfection with viral hepatitis B (HBV) or viral hepatitis C (HCV) is not uncommon in Ethiopia. Although the coinfections are presumed to interfere with antiretroviral treatment (ART), this is not widely studied in Sub-Saharan African settings. This study was conducted to determine ART retention in persons coinfected with HIV + HBV or HIV + HCV. METHODS: We reviewed the medical records of HIV-positive adults who initiated ART between 2011 to 2018 in four high-burden hospitals of Addis Ababa. Retention in care was the primary outcome of the study, which was compared between HIV and either HBV or HCV coinfected persons, and HIV-monoinfected persons. A parametric Gompertz regression model was used to compare retention between the coinfected and monoinfected groups. RESULTS: A total of 132 coinfected persons and 514 HIV-monoinfected individuals who initiated ART in 2011-2018 were compared. At 12-months of follow-up, 81.06% [95% CI: 73.3-86.9%] of the coinfected and 86.96% [95% CI: 83.7-89.6%] of the monoinfected were still on ART care. Cumulative retention in the coinfected group was 68.93% [60.4-76.3%] versus 80.35% [76.6-83.5%, p = 0.0048] in the monoinfected group. The cumulative retention was lower (61.25, 95% CI: 49.9-71.4%) in male coinfected patients than male monoinfected patients (77.77, 95% CI: 71.8-82.7%, p = 0.0041). In contrast, cumulative retention was similar in females in the coinfected group (80.76, 95% CI:67.3-89.5%) versus the monoinfected group (82.29, 95% CI:77.4-86.3%, p = 0.792). Overall, HIV-positive with viral hepatitis coinfection were 24 and 31% less likely to still be on ART care than the monoinfected group at 12 months and overall, with sub-distribution adjusted hazard ratio (AHR) of 0.76(95% CI:0.61-0.96, p = 0.021) and 0.69(95% CI:0.54-0.87, p = 0.002) respectively. CONCLUSIONS: We observed that coinfected individuals are less likely to stay on ART than HIV monoinfected individuals. The low retention in the coinfected group from this study may affect the success of survival gained in people living with HIV (PLHIV) in the long term. More concerted efforts need to be made to retain coinfected individuals at least at the level of monoinfected persons on long-term ART care. Future studies are needed to better understand the difference in retention, preferable in a prospective manner.

Trends, projection and inequalities in full immunization coverage in Ethiopia: in the period 2000-2019.

BACKGROUND: Immunization is among the most cost-effective health interventions to improve child survival. However, many countries in sub-Saharan Africa failed to achieve their national and international coverage targets repeatedly. The present study investigated trends of coverage and inequalities in coverage in Ethiopia. METHODS: This study used data from five rounds of the Demographic and Health Surveys conducted in Ethiopia in 2000, 2005, 2011, 2016, and 2019. The surveys used a multistage cluster sampling procedure to obtain a nationally and sub-nationally representative data. The outcome variables included in the study were full immunization coverage and inequality. The World Health Organization's Health Equity Assessment Toolkit was used to conduct the inequality analysis. Projections for 2025 were based on smoothed averages generated using the demographic and health survey data from 2000 to 2019. RESULTS: The full (basic) immunization coverage in Ethiopia has increased steadily from 14.3% in 2000 to 44.1% in 2019. Based on the average past performance, the immunization coverage is projected to reach 53.6% by 2025, which will be short of the 75% national full (basic) immunization coverage target for the year 2025. Mothers with higher levels of education are more likely to get their children all basic vaccinations than those with lower levels of education. Similarly, the inequality gaps due to wealth and residency are significant; where children in the lowest wealth strata and those living in rural areas remained disadvantaged. CONCLUSION: Despite a steady increase in immunization coverage in the past two decades the country is yet to achieve its immunization target. Thus, more efforts are needed to achieve the current and future national immunization targets. A more focused intervention targeting the disadvantaged groups could be an effective strategy to achieve coverage and minimize the inequality gaps in immunization.

Challenges in delivery of tuberculosis Services in Ethiopian Pastoralist Settings: clues for reforming service models and organizational structures.

BACKGROUND: The End-TB strategy aims to see a world free of tuberculosis (TB) by the coming decade through detecting and treating all cases irrespective of socioeconomic inequalities. However, case detections and treatment outcomes have not been as they should be in Somali pastoral settings of Ethiopia. Hence, this study aimed to explore the challenges that hinder the delivery and utilization of TB services in pastoral areas. METHODS: A qualitative study was conducted between December 2017 and October 2018 among pastoralist patients with delay of ≥2 months in seeking healthcare, healthcare providers and programme managers. Data were collected from different sources using 41 in-depth interviews, observations of facilities and a review meeting of providers from 50 health facilities. The data were transcribed, coded and analyzed to identify pre-defined and emerging sub-themes. ATLAS.ti version 7.0 was used for coding data, categorizing codes, and visualizing networks. RESULTS: Poor knowledge of TB and its services, limited accessibility (unreachability, unavailability and unacceptability), pastoralism, and initial healthcare-seeking at informal drug vendors that provide improper medications were the key barriers hindering the uptake of TB medical services. Inadequate infrastructure, shortage of trained and enthused providers, interruptions of drugs and laboratory supplies, scarce equipment, programme management gaps, lack of tailored approach, low private engagement, and cross-border movement were the major challenges affecting the provision of TB services for pastoral communities. The root factors were limited potential healthcare coverage, lack of zonal and district TB units, mobility and drought, strategy and funding gaps, and poor development infrastructure. CONCLUSION: In pastoral settings of Ethiopia, the major challenges of TB services are limited access, illicit medication practices, inadequate resources, structural deficits, and lack of tailored approaches. Hence, for the pastoral TB control to be successful, mobile screening and treatment modalities and engaging rural drug vendors will be instrumental in enhancing case findings and treatment compliance; whereas, service expansion and management decentralization will be essential to create responsive structures for overcoming challenges.

Determinants of postnatal care utilization in Ethiopia: a multilevel analysis.

BACKGROUND: The expansion of primary health care services in Ethiopia made basic health services available and accessible. The Last Ten Kilometers (L10K) project has strengthened the primary health care system through implementing innovative strategies to engage local communities to improve maternal and newborn health care behavior and practices in Amhara, Oromia, Southern Nations, Nationalities and Peoples [SNNP], and Tigray regions over a decade. Despite the efforts of the government and its partners to improve the use of maternal health services, the coverage of postnatal care is persistently low in the country. This study examined the individual and community level determinants for the persistently low uptake of postnatal care in the project areas. METHODS: The study used a cross-sectional population-based survey that measured maternal and newborn health care practices among women who had live births in the last 12 months preceding the survey in Amhara, Oromia, SNNP, and Tigray regions. Multilevel random effects binary logistic regression analysis was used to assess the independent effects of community-and individual-level factors and moderating effects on the uptake of postnatal care. RESULTS: This study identified region of residence, obstetric factors, and health service-related factors to be significant determinants for use of postnatal care. Obstetric factors include knowledge of obstetric danger signs (AOR: 1.30; 95% CI: 1.05-1.60), cesarean section mode of delivery (AOR: 1.96; 95% CI: 1.28-3.00), and institutional delivery (AOR: 10.29; 95% CI: 7.57-13.98). While the health service-related factors include attended family conversation during pregnancy (AOR: 1.48; 95% CI: 1.04-2.12), birth notification (AOR: 2.66; 95% CI: 2.15-3.29), home visits by community health workers (AOR: 1.98; 95% CI: 1.58-2.50), and being recognized as a model family (AOR: 1.27; 95% CI: 1.03-1.57). CONCLUSION: This study demonstrated that community-level interactions and promotive health services including antepartum home visits by community health workers, family conversation, birth notification, and model family, are important determinants to seek postnatal care. The findings also highlight the need for expansion of health facilities or design appropriate strategies to reach the disadvantaged communities. Program managers are recommended to strengthen community-based interventions to improve postnatal care utilization.

Effectiveness of same-day antiretroviral therapy initiation in retention outcomes among people living with human immunodeficiency virus in Ethiopia: empirical evidence.

BACKGROUND: In August 2016, Ethiopia endorsed a universal "test and treat" strategy for people living with human immunodeficiency virus (PLHIV) based on World Health Organization recommendation. However, there is limited evidence on the routine application of the same-day "test and treat" recommendation in low-income settings. This study assessed the effect of same-day treatment initiation on individual-level retention at 6- and 12-months follow-up. METHODS: A multicenter facility-based retrospective cohort study was conducted to compare retention-in-care between PLHIV who started antiretroviral therapy (ART) on the same-day and those started ART > 7 days following HIV diagnoses. Participants were at least 15 years-old and were newly diagnosed and started on ART between October 2016 and July 2018 in 11 health facilities in the Amhara region of Ethiopia. Multivariable logistic regression controlling for potential confounders and Kaplan-Meier survival analysis were used to assess differences in outcomes between the groups. RESULTS: In total, 433 PLHIV started ART on the same-day of diagnosis and 555 PLHIV who started ART > 7 days after HIV diagnosis were included in the study. At 6-months, 82.0% (355) in the same-day group vs 89.4% (496) in the > 7 days group were retained-in-care (absolute risk difference (RD) = 7.4%; 95% confidence interval (CI): 2.9-11.8%). At 12-months, 75.8% (328) in the same-day group vs 82.0% (455) in the > 7 days group were retained-in-care (absolute RD = 6.2%; 95% CI: 1.1, 11.4%). The major drop in retention was in the first 30 days following ART initiation among same-day group. After adjusting for baseline and non-baseline covariates, the same-day group was less likely to be retained-in-care at 6- and 12-months (adjusted risk ratio (RR) = 0.89; 95% CI: 0.87, 0.90 and adjusted RR = 0.86; 95% CI: 0.83, 0.89, respectively). CONCLUSIONS: Reduced retention-in-care can threaten the benefit of the same-day "test and treat" policy. The policy needs to be implemented cautiously with greater emphasis on assessment and preparation of PLHIV for ART to ensure treatment readiness before starting them on same-day ART and close monitoring of patients during early follow-up periods.

Delay in diagnosis of pulmonary tuberculosis increases the risk of pulmonary cavitation in pastoralist setting of Ethiopia.

BACKGROUND: Delay in diagnosis and treatment of pulmonary tuberculosis (PTB) leads to severe disease, adverse outcomes and increased transmission. Assessing the extent of delay and its effect on disease progression in TB affected settings has clinical and programmatic importance. Hence, the aim of this study was to investigate the possible effect of delay on infectiousness (cavitation and smear positivity) of patients at diagnosis in Somali pastoralist area, Ethiopia. METHODS: A cross-sectional study was conducted between December 2017 and October 2018, and 434 newly coming and confirmed PTB patients aged ≥15 years were recruited in five facilities. Data were collected using interview, record-review, anthropometry, Acid-fast bacilli and chest radiography techniques. Log-binomial regression models were used to reveal the association of delay and other factors associated with cavitation and smear positivity, and ROC Curve was used to determine discriminative ability and threshold delays. RESULTS: Median age of patients was 30 years. Of all, 62.9% were males, and 46.5% were pastoralists. Median diagnosis delay was 49 days (IQR = 33-70). Cavitation was significantly associated with diagnosis delay [P < 0.001]; 22.2% among patients diagnosed within 30 days of illness and 51.7% if delay was over 30 days. The threshold delay that optimizes cavitation was 43 days [AUC (95% CI) = 0.67(0.62-0.72)]. Smear positivity was significantly increased in patients delayed over 49 days [p = 0.02]. Other factors associated with cavitation were age ≤ 35 years [APR (95% CI) =1.3(1.01-1.6)], chronic diseases [APR (95% CI) = 1.8(1.2-2.6)] and low MUAC*female [APR (95% CI) = 1.8(1.2-2.8)]. Smear positivity was also associated with age ≤ 35 years [APR (95% CI) =1.4(1.1-1.8)], low BMI [APR (95% CI) =1.3(1.01-1.7)] and low MUAC [APR (95% CI) =1.5(1.2-1.9)]. CONCLUSION: This study highlights delay in diagnosis of pulmonary TB remained high and increased infectiousness of patients in pastoral settings of Ethiopia. Hence, delay should be targeted to improve patient outcomes and reduce transmission in such settings.

Socio-cultural factors favoring home delivery in Afar pastoral community, northeast Ethiopia: A Qualitative Study.

BACKGROUND: Despite expanding the number of health facilities, Ethiopia has still the highest home delivery services utilization. Health care service utilization varies between regions within the country. This study explored the socio-cultural factors influencing health facility delivery in a pastoralist region of Afar, Ethiopia. METHODS: An explorative qualitative study was conducted in October-December 2015. A total of 18 focus group discussions were conducted separately with mothers, male tribal leaders and religious leaders. In addition, 24 key informant interviews were conducted with Women's Affairs Bureau and district health office experts and traditional birth attendants and all were selected purposively. Data were coded and categorized using open code software and analyzed based on a thematic approach. RESULTS: The social factors that affect the choice of delivery place include workload, lack of independence and decision-making power of women, and lack of substitute for childcare and household chores during pregnancy and childbirth. The cultural and spiritual factors include assuming delivery as natural process ought to happen at home, trust in traditional birth attendants, traditional practices during and after delivery and faithful to religion practice, besides, denial by health facilities to benign traditional and spiritual practices such as prayers and traditional food preparations to be performed over there. CONCLUSION: Socio-cultural factors are far more than access to health centers as barriers to the utilization of health facilities for child birth. The provision of a maternity waiting home around the health facilities can alleviate some of these socio-cultural barriers.

Knowledge and perception towards net care and repair practice in Ethiopia.

BACKGROUND: Long-lasting insecticidal nets (LLINs) are a key malaria control intervention. Although LLINs are presumed to be effective for 3 years under field or programmatic conditions, net care and repair approaches by users influence the physical and chemical durability. Understanding how knowledge, perception and practices influence net care and repair practices could guide the development of targeted behavioural change communication interventions related to net care and repair in Ethiopia and elsewhere. METHODS: This population-based, household survey was conducted in four regions of Ethiopia [Amhara, Oromia, Tigray, Southern Nations Nationalities Peoples Region (SNNPR)] in June 2015. A total of 1839 households were selected using multi-stage sampling procedures. The household respondents were the heads of households. A questionnaire was administered and the data were captured electronically. STATA software version 12 was used to analyse the data. Survey commands were used to account for the multi-stage sampling approach. Household descriptive statistics related to characteristics and levels of knowledge and perception on net care and repair are presented. Ordinal logistic regression was used to identify factors associated with net care and repair perceptions. RESULTS: Less than a quarter of the respondents (22.3%: 95% CI 20.4-24.3%) reported adequate knowledge of net care and repair; 24.6% (95% CI 22.7-26.5%) of the respondents reported receiving information on net care and repair in the previous 6 months. Thirty-five per cent of the respondents (35.1%: 95% CI 32.9-37.4%) reported positive perceptions towards net care and repair. Respondents with adequate knowledge on net care and repair (AOR 1.58: 95% CI 1.2-2.02), and those who discussed net care and repair with their family (AOR 1.47: 95% CI 1.14-1.89) had higher odds of having positive perceptions towards net care and repair. CONCLUSIONS: The low level of reported knowledge on net care and repair, as well as the low level of reported positive perception towards net repair need to be addressed. Targeted behavioural change communication campaigns could be used to target specific groups; increased net care and repair would lead to longer lasting nets.

Prevalence and Incidence of Smear-Positive Pulmonary Tuberculosis in the Hetosa District of Arsi Zone, Oromia Regional State of Central Ethiopia.

BACKGROUND: The real burden of smear-positive (PTB+) and bacteriologically confirmed tuberculosis (BCTB) in Ethiopia is not known. Thus, the aim of this community-based study was to measure the prevalence and incidence of tuberculosis in the Hetosa District of Oromia Region, Ethiopia. METHODS: First, a population-based cross-sectional survey was conducted on a total of 33,073 individuals aged ≥ 15 years to determine the prevalence of PTB+ and BCTB cases. Then, in order to determine the incidence, a prospective follow-up was carried out on 32,800 individuals found to be either free from symptoms suggestive of TB (SSTB) during the baseline survey or had symptoms suggestive of TB but yielded negative bacteriological examination results. We identified 1,041 presumptive TB cases at the baseline survey, and 1,468 in the follow-up study. Each participants with cough of more than two weeks were provided spot and morning sputum samples for acid-fast bacilli sputum microscopy and culture. RESULTS: At the baseline survey, 43 BCTB cases were identified. Thirty six of these were both smear- and culture-positive while seven were only culture-positive. In the follow-up study, however, 76 BCTB cases were diagnosed and 70 of these were found to be both smear- and culture-positive while six were culture-positive only. The adjusted prevalence of PTB+ and BCTB in the study area was 109 and 132/100,000 persons, respectively. Moreover, the incidences of PTB+ and BCTB were 214 and 232/100,000 persons per year (py), respectively. The ratio of the passive to active case finding was 1:0.96 (45/43). For every TB case identified through the existing passive case diagnosis, there was an almost equal number (0.96) of undiagnosed infectious TB cases in the community. A family history of TB contact was independently associated with a high risk of TB (TB prevalence, AOR, 13; 95% CI: 6.55-15.33) and (TB incidence, aIRR 4.11, 95% CI: 2.18-7.77). CONCLUSIONS AND RECOMMENDATIONS: The prevalence and incidence of smear-positive and bacteriologically confirmed TB cases were high in the study area. For every case of smear-positive TB receiving treatment, there was an almost equal (0.96) number of undetected infectious bacteriologically confirmed TB case in the community. The high proportion of undetected infectious TB cases in the community could possibly be due to the sub-optimal performance of Directly Observed Treatment Short-course (DOTS) in detecting 70% of infectious TB cases, as well as attaining a cure rate of 85% in the study area. Family history of TB contact has substantaially increased the risk of developing the disease, and there is a need to improve ways of identifying TB cases and intensify mechanisms of tracing contacts among household members of PTB+ cases.

Delay in diagnosis of pulmonary tuberculosis in low-and middle-income settings: systematic review and meta-analysis.

BACKGROUND: Assessment of delays in seeking care and diagnosis of tuberculosis is essential to evaluate effectiveness of tuberculosis control programs, and identify programmatic impediments. Thus, this review of studies aimed to examine the extent of patient, health system, and total delays in diagnosis of pulmonary tuberculosis in low- and middle- income countries. METHODS: It was done following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Electronic databases were searched to retrieve studies published from 2007 to 2015 including Pubmed central, Springer link, Hinari and Google scholar. Searching terms were pulmonary tuberculosis, health care seeking, health care seeking behavior, patient delay, diagnostic delay, health system delay, provider delay, and doctor delay. Retrieved studies were systematically reviewed and summarized using Comprehensive Meta-analysis software. RESULTS: Forty studies involving 18,975 patients qualified for systematic review, and 14 of them qualified for meta-analysis. The median diagnostic delay ranged from 30 to 366.5 days [IQR = 44-77.8], with a 4-199 days [IQR = 15-50] and 2-128.5 days [IQR = 12-34] due to patient and health system delays, respectively. The meta-analysis showed 42% of pulmonary tuberculosis patients delayed seeking care by a month or more; uneducated patients [pooled OR = 1.5, 95%CI = 1.1-1.9] and those who sought initial care from informal providers [pooled OR = 3, 95%CI = 2.3-3.9] had higher odds of patient delay. CONCLUSION: Delay in diagnosis is still a major challenge of tuberculosis control and prevention programs in low- and middle- income settings. Efforts to develop new strategies for better case-finding using the existing systems and improving patients' care seeking behavior need to be intensified.

Primary and secondary anti-tuberculosis drug resistance in Hitossa District of Arsi Zone, Oromia Regional State, Central Ethiopia.

BACKGROUND: Multidrug-resistant tuberculosis (MDR-TB) drugs which is resistant to the major first-line anti-TB drugs, Isoniazid and Rifampicin, has become a major global challenge in tuberculosis (TB) control programme. However, its burden at community level is not well known. Thus, the aim of study was to assess the prevalence of primary and secondary resistance to any first line anti-TB drugs and MDR TB in Hitossa District of Oromia Regional State, Central Ethiopia. METHODS: Population based cross- sectional study was conducted on individuals aged ≥15 years. Those with symptoms suggestive of TB were interviewed and two sputum specimens were collected from each and examined using Lowenstein-Jensen (LJ) culture medium. Further, the isolates were confirmed by the Ziehl-Neelsen microscopic examination method. Drug susceptibility test (DST) was also conducted on LJ medium using a simplified indirect proportion method. The resistance strains were then determined by percentage of colonies that grew on the critical concentration of Isoniazid, Streptomycin, Rifampicin and Ethambutol. RESULTS: The overall resistance of all forms of TB to any first-line anti-TB drug was 21.7 %. Of the total new and previously treated culture positive TB cases, 15.3 and 48.8 % respectively were found to be a resistant to any of the first-line anti-TB drugs. Further, of all forms of TB, the overall resistance of MDR-TB was 4.7 %. However, of the total new TB cases, 2.4 % had primary while 14.3 % had secondary MDR-TB. Resistance to any of the first-line anti-TB drugs (adjusted odd ratio (AOR), 8.1; 95 % CI: 2.26-29.30) and MDR-TB (AOR), 7.1; 95 % CI: 2.6-43.8) was found to be linked with previous history of anti-TB treatment. CONCLUSIONS: The study has identified a high rate of primary and secondary resistance to any of the first-line anti-TB drugs and MDR-TB in the study area. The resistance may have resulted from sub-optimal performance of directly observed treatment short-course (DOTS) programme in the detecting infectious TB cases and cure rates in the study area. Anti-TB drug resistance is linked with previous TB treatment. There is a need to strengthen DOTS and DOTS-Plus programmes and expand MDR-TB diagnostic facilities in order to timely diagnose MDR-TB cases and provide appropriate treatment to prevent the spread of MDR-TB in Ethiopia.

Assessment of Directly Observed Therapy (DOT) following tuberculosis regimen change in Addis Ababa, Ethiopia: a qualitative study.

BACKGROUND: Tuberculosis remains a major public health problem in Ethiopia. In 2010 the TB treatment regimen was shortened from 8 to 6-months treatment. With this new regimen, the full course of treatment should be taken under Directly Observed Therapy (DOT) unlike the 8-month regimen where TB patients were only observed during the intensive phase, this has not been tried before and may be difficult to implement. Therefore this study aimed to investigate the experiences from both TB patients and health care providers' perspective of implementing DOT for the full course of TB treatment. METHODS: Qualitative study consisted of 11 in-depth interviews and 4 Focus Group Discussions (FDGs) were conducted between March and April, 2014. Overall, 18 TB patients and 16 HCPs were involved from three selected public health facilities (2 Health Centers and 1 Hospital) in Addis Ababa, Ethiopia. Qualitative data analysis software (Open Code Version 3.5) was employed to identify the key issues from these interviews through coding, categorization and grouping into emergent themes. RESULTS: Participants reported that making a daily visit to health facilities for DOT was difficult due to the distance of the facilities from their residences, lack of or high transportation cost and had undesired implications on their work and social lives. TB patients had to overcome many challenges to comply with TB treatment on a daily basis. HCPs also indicated the difficulties of implementing facility based daily DOT mainly due the implication it had on their TB patients and stated DOT had not always been implemented for the full course as recommended. HCPs also shared deep concern regarding the risk of acquiring multiple drug resistant TB. CONCLUSION: This study indicated there are several challenges associated with facility based daily DOT as a method of TB treatment supervision in public health facilities in Addis Ababa. This may be indicative of the situation in other health facilities in Addis Ababa as well as elsewhere in the country. Hence the TB control program has to explore how best to improve TB treatment delivery options to ensure adequate treatment. A more patient-centered approach could be strengthened by further decentralizing the DOT to the community level in order to ensure adherence of patients to their TB treatment.

Magnitude and factors associated with institutional delivery service utilization among childbearing mothers in Cheha district, Gurage zone, SNNPR, Ethiopia: a community based cross sectional study.

BACKGROUND: Ethiopia is one of the six countries that contributes' to more than 50 % of worldwide maternal deaths. While it is revealed that delivery attended by skilled provider at health facility reduced maternal deaths, more than half of all births in Ethiopia takes place at home. According to EDHS 2011 report nine women in every ten deliver at home in Ethiopia. The situation is much worse in southern region. The aim of our study is to measure the prevalence and to identify factors associated with institutional delivery service utilization among childbearing mothers in Cheha District, SNNPR, Ethiopia. METHODS: A community based cross sectional survey was conducted in Cheha District from Dec 22, 2012 to Jan 11, 2013. Multistage sampling method was employed and 816 women who gave birth within the past 2 years and lived in Cheha district for minimum of one year prior to the survey were involved in the study. Data was entered and analyzed using Epi Info Version 7 and SPSS Version 16. Frequencies and binary logistic regression were done. Factors affecting institutional delivery were determined using multivariate logistic regression. RESULTS: A total of 31 % of women gave birth to their last child at health facility. Place of residence, ability to afford for the whole process to get delivery service at health facility, traveling time that takes to reach to health institution which provides delivery service, husband's attitude towards institutional delivery, counseling about where to deliver during ANC visit and place of birth of the 2(nd) youngest child were found to have statistically significant association with institutional delivery. CONCLUSION: Institutional delivery is low in the study area. Access to health service was found to be the most important predictor of institutional delivery among others. Accessing health facility within reasonable travel time; providing health education and BCC services to husbands and the community at large on importance of using health institution for delivery service; working to improve women's economic status; counseling women to give birth at health institution during their ANC visit and exploring the overall quality of ANC service are some of the areas where much work is needed to improve institutional delivery.

Trends in TB case notification over fifteen years: the case notification of 25 Districts of Arsi Zone of Oromia Regional State, Central Ethiopia.

BACKGROUND: The aims of tuberculosis (TB) control programme are to detect TB cases and treat them to disrupt transmission, decrease mortality and avert the emergence of drug resistance. In 1992, DOTS strategy was started in Arsi zone and since 1997 it has been fully implemented. However, its impact has not been assessed. The aim of this study was, to analyze the trends in TB case notification and make a comparison among the 25 districts of the zone. METHODS: A total of 41,965 TB patients registered for treatment in the study area between 1997 and 2011 were included in the study. Data on demographic characteristics, treatment unit, year of treatment and disease category were collected for each patient from the TB Unit Registers. RESULTS: The trends in all forms of TB and smear positive pulmonary TB (PTB+) case notification increased from 14.3 to 150 per 100,000 population, with an increment of 90.4% in fifteen years. Similarly, PTB+ case notification increased from 6.9 to 63 per 100,000 population, an increment of 89% in fifteen years. The fifteen-year average TB case notification of all forms varied from 60.2 to 636 (95% CI: 97 to 127, P<0.001) and PTB+ from 10.9 to 163 per 100,000 population (95% CI: 39 to 71, p<0.001) in the 25 districts of the zone. Rural residence (AOR, 0.23; 95% CI: 0.21 to 0.26) and districts with population ratio to DOTS sites of more than 25,000 population (AOR, 0.40; 95% CI: 0.35 to 0.46) were associated with low TB case notification. TB case notifications were significantly more common among 15-24 years of age (AOR, 1.19; 95% CI:1.03 to 1.38), PTB- (AOR, 1.46; 95% CI: 1.33 to 64) and EPTB (AOR, 1.49; 95% CI; 1.33 to 1.60) TB cases. CONCLUSIONS: The introduction and expansion of DOTS in Arsi zone has improved the overall TB case notification. However, there is inequality in TB case notification across 25 districts of the zone. Further research is, recommended on the prevalence, incidence of TB and TB treatment outcome to see the differences in TB distribution and performance of DOTS in treatment outcomes among the districts.

Knowledge and practice of tuberculosis infection control among health professionals in Northwest Ethiopia; 2011.

BACKGROUND: Tuberculosis (TB) is highly prevalent in sub-Saharan Africa, making the risk of infection transmission high in these countries. Despite high prevalence of TB and expected high probability of nosocomial transmission in Ethiopia, a rapid assessment done in 2008 revealed that most health facilities in Ethiopia do not use tuberculosis infection control (TBIC) practices. Patients and providers are therefore at risk of exposure to TB, especially at high case load facilities. The purpose of this study was to assess TBIC knowledge and practices among health professionals working in hospitals in the Amhara region of Northwest Ethiopia. METHODS: An institution-based hybrid study was implemented form August 2010 to January 2011. The subjects were health professionals who were proportionally selected from each hospital. Subjects self-administered a questionnaire that contained sections on socio-demographics and on TBIC knowledge and practice. Those answering ≥60% of knowledge questions correctly and ≥50% of practice questions correctly were considered to have good knowledge and practice, respectively. RESULTS: A total of 313 healthcare professionals were enrolled from four healthcare facilities. The response rate was 96%. Only 18.8% received in-service training. Among those who were trained, 74.4%, 95% CI (69.6, 79.3%) were found to have good knowledge and 63.2%, 95% CI (57.9, 68.6%) good practice on TBIC. Training was found to be a predictor of TBIC knowledge, AOR* 3.386 and 95% CI (1.377, 8.330) while knowledge of TBIC was a strong predictor of good TBIC practice, AOR* 10.667 and 95% CI (5.769, 19.721). CONCLUSIONS: Though the majority of the respondents had good TBIC knowledge and practice, a considerable proportion of healthcare professionals were not trained on TBIC. Respondents trained on TBIC were found to be more knowledgeable than those not trained. Similarly, respondents with good TBIC knowledge were 10 times more likely to have good TBIC practice compared to those with poor TBIC knowledge. Training was not found to have an effect on TBIC practice. *Adjusted Odds Ratio.

Intrahousehold food allocation social norms and food taboos in rural Ethiopia: The case of adolescent girls.

Background: In low-income countries, social norms play a significant role in intrahousehold food allocation practices. These norms can sometimes lead to discrimination against specific groups, posing a public health concern. This study focuses on the social norm surrounding food allocation within households and food taboos affecting adolescent girls in rural Ethiopia. Method: A qualitative study was conducted using vignettes as prompts for 20 focus group discussions and 32 in-depth interviews. The vignettes were tailored to the local context. Participants were chosen purposefully, and data were collected in a comfortable setting. All sessions were recorded and transcribed verbatim. Data analysis was done using Open Code qualitative analysis software with a thematic framework approach. Findings: In the community, adolescent girls were expected to eat after serving the male family members. Those who did not follow this expectation faced sanctions such as being labeled as disrespectful and could even be insulted or beaten by their spouses and siblings. However, there were some exceptions to this rule, such as when girls were giving birth, breastfeeding, sick, or when male family members were traveling. Certain foods were also prohibited for adolescent girls, including spicy foods like chili, animal products such as meat and milk, and nuts. These foods were believed to increase girls' sexual desire, potentially leading them to engage in premarital or extramarital sex. Additionally, eating outside of the house was not considered appropriate behavior for adolescent girls in this community. Conclusion: In many households, social norms dictate that adolescent girls are not given enough food or are denied essential nutrients for their health. It is important to challenge these norms to ensure fair food distribution within households and support the healthy development of adolescent girls.

Timely initiation of complementary feeding and associated factors among children aged 6 to 12 months in Northern Ethiopia: an institution-based cross-sectional study.

BACKGROUND: Exclusive breastfeeding (EBF) for the first six months of life is critical for the wellbeing of the child. In the mean while, timely initiation and starting nutritionally-adequate, safe, age-appropriate complementary feeding at six months is recommended for the better health and development of infants. According to the Ethiopian Demographic and Health Survey 2011, timely initiation of complementary feeding in Ethiopia at the 6th month was only 51%. The purpose of this study is to determine the magnitude of timely initiation of complementary feeding and associated factors in Mekelle town, Northern Ethiopia. METHODS: An institutional based cross-sectional study design was conducted among 422 mothers of infants aged from six months to one year selected from six public health facilities. Sample size proportional to the patient flow rate of each institution was allocated and systematic random sampling method was used to get the study participant. An exit interview using structured questionnaire was conducted about their experience on complementary feeding and related experience. The questionnaire was pretested among 21 mothers. Data were entered with EPI info version 3.5.1 and cleaning and analysis was done by using SPSS version 16. Frequencies distribution, binary and multiple logistic regressions were done. OR and 95% confidence interval was computed. RESULT: The prevalence of timely initiation of complementary feeding at sixth month was 62.8% (265/422, 95% C.I: 58.1, 67.31%). Educational level, occupation of mother, parity, having ANC follow up, and birth preparedness were found to be independent predictor of timely initiation of complementary feeding. CONCLUSIONS: Almost two-third of mothers initiated complementary feeding at six month of child' age as recommended. This was relatively higher prevalence than most developing countries. However, significant proportion of mothers still did not initiate complementary feeding timely. Mothers who are illiterate and completed only primary school need more attention. All mothers must be encouraged to make antenatal care follow up.

Predictors of loss to follow-up before HIV treatment initiation in Northwest Ethiopia: a case control study.

BACKGROUND: In Ethiopia, there is a growing concern about the increasing rates of loss to follow-up (LTFU) in HIV programs among people waiting to start HIV treatment. Unlike other African countries, there is little information about the factors associated with LTFU among pre-antiretroviral treatment (pre-ART) patients in Ethiopia. We conducted a case-control study to investigate factors associated with pre-ART LTFU in Ethiopia. METHODS: Charts of HIV patients newly enrolled in HIV care at Gondar University Hospital (GUH) between September 11, 2008 and May 8, 2011 were reviewed. Patients who were "loss to follow-up" during the pre-ART period were considered to be cases and patients who were "in care" during the pre-ART period were controls. Logistic regression analysis was used to explore factors associated with pre-ART LTFU. RESULTS: In multivariable analyses, the following factors were found to be independently associated with pre-ART LTFU: male gender [Adjusted Odds Ratio (AOR) = 2.00 (95% CI: 1.15, 3.46)], higher baseline CD4 cell count (251-300 cells/µl [AOR = 2.64 (95% CI: 1.05, 6.65)], 301-350 cells/µl [AOR = 5.21 (95% CI: 1.94, 13.99)], and >350 cells/µl [AOR = 12.10 (95% CI: 6.33, 23.12)] compared to CD4 cell count of ≤ 200 cells/µl) and less advanced disease stage (WHO stage I [AOR = 2.81 (95% CI: 1.15, 6.91)] compared to WHO stage IV). Married patients [AOR = 0.39 (95% CI: 0.19, 0.79)] had reduced odds of being LTFU. In addition, patients whose next visit date was not documented on their medical chart [AOR = 241.39 (95% CI: 119.90, 485.97)] were more likely to be LTFU. CONCLUSION: Our study identified various factors associated with pre-ART LTFU. The findings highlight the importance of giving considerable attention to pre-ART patients' care from the time that they learn of their positive HIV serostatus. The completeness of the medical records, the standard of record keeping and obstacles to retrieving charts also indicate a serious problem that needs due attention from clinicians and data personnel.

Long distance travelling and financial burdens discourage tuberculosis DOTs treatment initiation and compliance in Ethiopia: a qualitative study.

BACKGROUND: Timely tuberculosis treatment initiation and compliance are the two key factors for a successful tuberculosis control program. However, studies to understand patents' perspective on tuberculosis treatment initiation and compliance have been limited in Ethiopia. The aim of this study is to attempt to do that in rural Ethiopia. METHODS: This qualitative, phenomenological study conducted 26 in-depth interviews with tuberculosis patients. A thematic content analysis of the interviews was performed using the Open Code software version 3.1. RESULTS: We found that lack of geographic access to health facilities, financial burdens, use of traditional healing systems and delay in diagnosis by health care providers were the main reasons for not initiating tuberculosis treatment timely. Lack of geographic access to health facilities, financial burdens, quality of health services provided and social support were also identified as the main reasons for failing to fully comply with tuberculosis treatments. CONCLUSIONS: This study highlighted complexities surrounding tuberculosis control efforts in Dabat District. Challenges of geographic access to health care facilities and financial burdens were factors that most influenced timely tuberculosis treatment initiation and compliance. Decentralization of tuberculosis diagnosis and treatment services to peripheral health facilities, including health posts is of vital importance to make progress toward achieving tuberculosis control targets in Ethiopia.