Pregnancy Experiences of Female Sex Workers in Adama City, Ethiopia: Complexity of Partner Relationships and Pregnancy Intentions.

Research and programs for female sex workers (FSWs) tend to focus exclusively on HIV prevention, with little attention paid to how pregnancy affects their lives. We examine the circumstances surrounding pregnancy and childbirth among women selling sex in Ethiopia. In Adama City, researchers asked 30 FSWs aged 18 and older who had ever been pregnant to participate in in-depth interviews. The women reported on pregnancies experienced both before and after they had begun selling sex. They identified some of the fathers as clients, former partners, and current partners, but they did not know the identities of the other fathers. Missed injections, skipped pills, and inconsistent condom use were causes of unintended pregnancy. Abortion was common, typically with a medication regimen at a facility. Comprehensive sexual and reproductive health services should be provided to women who sell sex, in recognition and support of their need for family planning and their desire to plan whether and when to have children.

Changing Gender Norms and Reducing Intimate Partner Violence: Results From a Quasi-Experimental Intervention Study With Young Men in Ethiopia.

Objectives. We assessed the effects of a community-based project in Ethiopia that worked with young men to promote gender-equitable norms and reductions in intimate partner violence (IPV). Methods. A quasi-experimental design was used to assign young Ethiopian men 15 to 24 years of age (809 participants were surveyed at baseline in 2008) to an intervention involving community engagement (CE) activities in combination with interactive group education (GE) sessions promoting gender-equitable norms and violence prevention, an intervention involving CE activities alone, or a comparison group. Results. Participants in the GE + CE intervention were twice as likely (P < .01) as those in the comparison group to show increased support for gender-equitable norms between the baseline and end-line points. Also, the percentage of GE + CE participants who reported IPV toward their partner in the preceding 6 months decreased from 53% to 38% between baseline and end line, and the percentage in the CE-only group decreased from 60% to 37%; changes were negligible in the comparison group. Conclusions. Promoting gender equity is an important strategy to reduce IPV.

Good Health at Low Cost 25 years on: lessons for the future of health systems strengthening.

In 1985, the Rockefeller Foundation published Good health at low cost to discuss why some countries or regions achieve better health and social outcomes than do others at a similar level of income and to show the role of political will and socially progressive policies. 25 years on, the Good Health at Low Cost project revisited these places but looked anew at Bangladesh, Ethiopia, Kyrgyzstan, Thailand, and the Indian state of Tamil Nadu, which have all either achieved substantial improvements in health or access to services or implemented innovative health policies relative to their neighbours. A series of comparative case studies (2009-11) looked at how and why each region accomplished these changes. Attributes of success included good governance and political commitment, effective bureaucracies that preserve institutional memory and can learn from experience, and the ability to innovate and adapt to resource limitations. Furthermore, the capacity to respond to population needs and build resilience into health systems in the face of political unrest, economic crises, and natural disasters was important. Transport infrastructure, female empowerment, and education also played a part. Health systems are complex and no simple recipe exists for success. Yet in the countries and regions studied, progress has been assisted by institutional stability, with continuity of reforms despite political and economic turmoil, learning lessons from experience, seizing windows of opportunity, and ensuring sensitivity to context. These experiences show that improvements in health can still be achieved in countries with relatively few resources, though strategic investment is necessary to address new challenges such as complex chronic diseases and growing population expectations.

Work-related violence and inconsistent condom use with non-paying partners among female sex workers in Adama City, Ethiopia.

BACKGROUND: Although reported condom use between female sex workers and their clients is high in Ethiopia, condom use with regular, non-paying partners remains low, posing a substantial risk of HIV infection to sex workers, their partners and the general population. Previous studies have identified the synergistic effects of substance abuse, violence and HIV risk, but few have examined these inter-relationships among female sex workers and their regular, non-paying partners. This study explored the associations between work-related violence, alcohol abuse and inconsistent condom use among establishment-based female sex workers and their regular, non-paying partners in Adama City, Ethiopia. METHODS: A cross-sectional survey was conducted with 350 establishment-based female sex workers, aged 15-35, at 63 bars, hotels and nightclubs. Multivariate logistic regression analysis was conducted to test the association between work-related violence and condom use with regular, non-paying partners, controlling for age, overall income, education and sex workers' total number of sexual partners in the past week. Alcohol abuse was explored as an effect modifier. RESULTS: Respondents reported a high prevalence of work-related violence (59%) and alcohol abuse (51%). Work-related violence was statistically significantly associated with unprotected sex with regular, non-paying partners among those who abused alcohol (OR: 6.34, 95% CI: 2.43-16.56) and among those who did not (OR: 2.98, 95% CI: 1.36-6.54). Alcohol abuse was not associated with inconsistent condom use within these partnerships, though it may strengthen the effect of work-related violence on unprotected sex. CONCLUSIONS: Findings suggest violence against establishment-based female sex workers is associated with HIV risk within regular, non-paying partnerships. Qualitative work is needed to better understand the links between a violent work environment and condom use with regular, non-paying partners and how interventions can be implemented in this context to prevent violence against sex workers and reduce HIV transmission.

Linking population, fertility, and family planning with adaptation to climate change: perspectives from Ethiopia.

Global climate change is felt disproportionately in the world's most economically disadvantaged countries. As adaption to an evolving climate becomes increasingly salient on national and global scales, it is important to assess how people at the local-level are already coping with changes. Understanding local responses to climate change is essential for helping countries to construct strategies to bolster resilience to current and future effects. This qualitative research investigated responses to climate change in Ethiopia; specifically, how communities react to and cope with climate variation, which groups are most vulnerable, and the role of family planning in increasing resilience. Participants were highly aware of changing climate effects, impacts of rapid population growth, and the need for increased access to voluntary family planning. Identification of family planning as an important adaptation strategy supports the inclusion of rights-based voluntary family planning and reproductive health into local and national climate change adaptation plans.

Client characteristics and HIV risk associated with repeat HIV testing among women in Ethiopia.

In Ethiopia, the number of HIV tests administered doubled from 2007 to 2008. However, very little is known about the number of clients testing repeatedly in one year, or their motivations for doing so. We examine repeat HIV testing among 2,027 Ethiopian women attending eight VCT facilities in 2008. Multivariate logistic regression was used to examine associations between repeat HIV testing and demographic, behavioral, and psychosocial characteristics, as well as HIV status. Nearly 40% of clients had tested previously for HIV. Women with high sexual risk are nearly four times more likely than those with no sexual risk to have tested previously, but HIV prevalence was lower among repeat testers (6.5%) than first-time testers (8.5%). Moderate perceived vulnerability, or feeling powerless to prevent HIV infection, is associated with a 50% increased likelihood of being a repeat tester. High perceived behavioral risk is associated with a 40% reduction in the likelihood a woman is testing for at least the second time. Costs associated with repeat testing should be balanced against identification of new HIV cases and prevention benefits.

Developing scales to measure perceived HIV risk and vulnerability among Ethiopian women testing for HIV.

HIV prevention services are increasingly being used by individuals in developing countries, but we know very little about how self-assessed HIV risk determines health-seeking behavior. People may feel they are at risk of HIV infection for many reasons, including both risky behavior and anxiety associated with heightened HIV awareness. In order to improve the measurement of perceived HIV risk, we developed scales measuring two constructs. Perceived risk is one's self-assessed likelihood of becoming HIV-infected based on HIV knowledge and behavior. Perceived vulnerability is felt susceptibility to HIV infection even in the absence of risk behavior. Items measuring these constructs were included in a voluntary HIV counseling and testing (VCT) client survey, conducted in mid-2008 with 2027 women attending eight Ethiopian VCT facilities. We also conducted in-depth interviews with 22 women in two of the facilities and added items to the scales based on findings from these interviews. All items were validated in a post-enumeration survey. Factor structures of both constructs were examined using exploratory factor analysis. We also calculated Pearson's correlations between the scales and comparable constructs and behaviors. Cronbach's alpha for the perceived risk scale was 0.87 in the initial survey and 0.89 in the validation survey. For the perceived vulnerability scale, Cronbach's alpha was only 0.66 in the initial survey but increased to 0.74 after adding items indicated by the in-depth interviews. The scales are moderately correlated, indicated by a Pearson's correlation of 0.65. Both scales have high construct validity. Perceived risk has a higher correlation with HIV status than does perceived vulnerability, at 39% vs 28%. Conversely, perceived vulnerability is more highly correlated with HIV salience than is perceived risk, at 39% compared to 25%. These findings suggest perceived HIV risk and perceived HIV vulnerability should be measured separately. More information is needed about how these constructs may motivate people to seek HIV prevention services.

Who wants to work in a rural health post? The role of intrinsic motivation, rural background and faith-based institutions in Ethiopia and Rwanda.

OBJECTIVE: To understand the factors influencing health workers' choice to work in rural areas as a basis for designing policies to redress geographic imbalances in health worker distribution. METHODS: A cohort survey of 412 nursing and medical students in Rwanda provided unique contingent valuation data. Using these data, we performed a regression analysis to examine the determinants of future health workers' willingness to work in rural areas as measured by rural reservation wages. These data were also combined with those from an identical survey in Ethiopia to enable a two-country analysis. FINDINGS: Health workers with higher intrinsic motivation - measured as the importance attached to helping the poor - as well as those who had grown up in a rural area and Adventists who had participated in a local bonding scheme were all significantly more willing to work in a rural area. The main result for intrinsic motivation in Rwanda was strikingly similar to the result obtained for Ethiopia and Rwanda combined. CONCLUSION: Intrinsic motivation and rural origin play an important role in health workers' decisions to work in a rural area, in addition to economic incentives, while faith-based institutions can also influence the decision.

Integrating family planning into Ethiopian voluntary testing and counselling programmes.

PROBLEM: Governments and donors encourage the integration of family planning into voluntary testing and counselling (VCT) services. We aimed to determine if clients of VCT services have a need for and will accept quality family planning services. APPROACH: 'Voluntary HIV counselling and testing integrated with contraceptive services' is a proof-of-concept study that interviewed 4019 VCT clients before the addition of family planning services and 4027 different clients after family planning services were introduced. Clients attended eight public VCT facilities in the Oromia region, Ethiopia. The intervention had four components: development of family planning counselling messages for VCT clients, VCT provider training, contraceptive supply provision and monitoring. LOCAL SETTING: Ethiopia's population of 80 million is increasing rapidly at an annual rate of 2.5%. Contraceptive prevalence is only 15%. The estimated adult HIV prevalence rate is 2.1%, with more than 1.1 million people infected. The number of VCT facilities increased from 23 in 2001 to more than 1000 in 2007, and the number of HIV tests taken doubled from 1.7 million tests in 2007 to 3.5 million in 2008. RELEVANT CHANGES: Clients interviewed after the introduction of family planning services received significantly more family planning counselling and accepted significantly more contraceptives than those clients served before the intervention. However, three-quarters of the clients were not sexually active. Of those clients who were sexually active, 70% were using contraceptives. LESSONS LEARNED: The study demonstrated that family planning can be integrated into VCT clinics. However, policy-makers and programme managers should carefully consider the characteristics and reproductive health needs of target populations when making decisions about service integration.

How Can the Health System Retain Women in HIV Treatment for a Lifetime? A Discrete Choice Experiment in Ethiopia and Mozambique.

INTRODUCTION: Option B+, an approach that involves provision of antiretroviral therapy (ART) to all HIV-infected pregnant women for life, is the preferred strategy for prevention of mother to child transmission of HIV. Lifelong retention in care is essential to its success. We conducted a discrete choice experiment in Ethiopia and Mozambique to identify health system characteristics preferred by HIV-infected women to promote continuity of care. METHODS: Women living with HIV and receiving care at hospitals in Oromia Region, Ethiopia and Zambézia Province, Mozambique were shown nine choice cards and asked to select one of two hypothetical health facilities, each with six varying characteristics related to the delivery of HIV services for long term treatment. Mixed logit models were used to estimate the influence of six health service attributes on choice of clinics. RESULTS: 2,033 women participated in the study (response rate 97.8% in Ethiopia and 94.7% in Mozambique). Among the various attributes of structure and content of lifelong ART services, the most important attributes identified in both countries were respectful provider attitude and ability to obtain non-HIV health services during HIV-related visits. Availability of counseling support services was also a driver of choice. Facility type, i.e., hospital versus health center, was substantially less important. CONCLUSIONS: Efforts to enhance retention in HIV care and treatment for pregnant women should focus on promoting respectful care by providers and integrating access to non-HIV health services in the same visit, as well as continuing to strengthen counseling.

Using Health Extension Workers for Monitoring Child Mortality in Real-Time: Validation against Household Survey Data in Rural Ethiopia.

BACKGROUND: Ethiopia has scaled up its community-based programs over the past decade by training and deploying health extension workers (HEWs) in rural communities throughout the country. Consequently, child mortality has declined substantially, placing Ethiopia among the few countries that have achieved the United Nations' fourth Millennium Development Goal. As Ethiopia continues its efforts, results must be assessed regularly to provide timely feedback for improvement and to generate further support for programs. More specifically the expansion of HEWs at the community level provides a unique opportunity to build a system for real-time monitoring of births and deaths, linked to a civil registration and vital statistics system that Ethiopia is also developing. We tested the accuracy and completeness of births and deaths reported by trained HEWs for monitoring child mortality over 15 -month periods. METHODS AND FINDINGS: HEWs were trained in 93 randomly selected rural kebeles in Jimma and West Hararghe zones of the Oromia region to report births and deaths over a 15-month period from January, 2012 to March, 2013. Completeness of number of births and deaths, age distribution of deaths, and accuracy of resulting under-five, infant, and neonatal mortality rates were assessed against data from a large household survey with full birth history from women aged 15-49. Although, in general HEWs, were able to accurately report events that they identified, the completeness of number of births and deaths reported over twelve-month periods was very low and variable across the two zones. Compared to household survey estimates, HEWs reported only about 30% of births and 21% of under-five deaths occurring in their communities over a twelve-month period. The under-five mortality rate was under-estimated by around 30%, infant mortality rate by 23% and neonatal mortality by 17%. HEWs reported disproportionately higher number of deaths among the very young infants than among the older children. CONCLUSION: Birth and death data reported by HEWs are not complete enough to support the monitoring of changes in childhood mortality. HEWs can significantly contribute to the success of a CRVS in Ethiopia, but cannot be relied upon as the sole source for identification of vital events. Further studies are needed to understand how to increase the level of completeness.

Providing family planning in Ethiopian voluntary HIV counseling and testing facilities: client, counselor and facility-level considerations.

BACKGROUND: Governments and donors encourage the integration of family planning into voluntary HIV counseling and testing (VCT) services. We aimed to determine whether VCT counselors could feasibly offer family planning and whether clients would accept such services. DESIGN AND METHODS: We employed a quasi-experimental, pre and postintervention survey design, interviewing 4019 VCT clients attending eight Ethiopian public sector facilities and 4027 additional clients 18 months after introducing family planning services in the same facilities. We constructed sex-stratified multilevel models assessing three outcomes: whether clients received contraceptive counseling, whether clients obtained contraceptive methods during VCT and whether clients intended to use condoms consistently after VCT. RESULTS: Clients demonstrated lower than expected immediate need for contraception. After intervention, only 29% of women had sex in the past 30 days, and 74% of these women were already using contraceptives. Despite the relatively low risk this population had for unwanted pregnancy, family planning counseling in VCT increased from 2 to 41% for women and from 3 to 29% for men (P < 0.01). Approximately, 6% of clients received contraceptive methods. However, sexually active men and women and those with more perceived HIV risk were more likely to obtain contraceptives and intend to use condoms consistently. Men attending facilities with higher client loads were 88% less likely to receive family planning information and 93% less likely to receive contraceptives than those attending facilities with lower client loads. Male and female clients whose counselors perceived contraceptive availability to be adequate were four and two times more likely, respectively, to receive contraceptive methods than those counseled by providers who felt supplies were inadequate (P < 0.01). CONCLUSION: Integrating VCT and family planning services is likely to be an effective programmatic option, but populations at risk for HIV or unintended pregnancy should be targeted.

Educational attainment and HIV status among Ethiopian voluntary counseling and testing clients.

We examined the association between HIV infection and educational attainment level among a population of 34,512 voluntary counseling and testing (VCT) clients in Ethiopia, using client data from the Family Guidance Association of Ethiopia (FGAE). Overall, more than 50 percent of the VCT clients report at least secondary level educational attainment, and HIV prevalence is 8.5 percent for men and 14.3 percent for women. HIV prevalence decreases significantly with each increase in education level for both men and women, and this association persists at secondary and higher education levels in the multivariate model. Male and female VCT clients with more than secondary level education are 58 percent and 66 percent (respectively) less likely to be HIV-positive than those with no education. HIV prevention and treatment interventions in Ethiopia should target less educated segments of the population including women, who have higher HIV prevalence and lower educational attainment than men.

Does the delivery of integrated family planning and HIV/AIDS services influence community-based workers' client loads in Ethiopia?

Community-based reproductive health agents (CBRHAs) can increase community knowledge of and offer immediate access to reproductive health services, including HIV/AIDS. Due to growing interest in integration of family planning and HIV services in Ethiopia, it is important to examine whether CBRHAs are efficiently offering both service types. The present analysis uses survey data collected from Ethiopian CBRHAs and examines associations between agents' demographic, personality and work-related characteristics and their capacity to provide integrated services and have high client volumes. Multivariate probit and bivariate probit regression models are fitted for the two outcomes of interest. Nearly half of CBRHAs in our sample offer integrated services, but this is not jointly associated with increased productivity. Personality traits and work experience are more strongly associated with agents' capacity to provide integrated services than demographic characteristics, while agents' gender and work-related characteristics are significantly associated with increased likelihood of serving more clients.