Gender exploitative and gender transformative aspects of employing Health Extension Workers under Ethiopia's Health Extension Program.

OBJECTIVES: To apply a gender lens to Ethiopia's Health Extension Program and the role of Health Extension Workers (HEWs). METHODS: Interviews with 45 HEWs and four focus group discussions with 14 of the same HEWS from three regions in rural Ethiopia: Afar Region; Tigray Region (Adwa Woreda); and two locations in Southern Nations, Nationalities and People's Region (Aleta Wondo Woreda and Kafa Zone). Two focus group discussions were conducted in Afar Region with 17 Women Extension Workers employed by Afar Pastoralist Development Association. RESULTS: Using the Gender Equality Continuum as a gender analysis tool, we found that Ethiopia's Health Extension Program is gender aware by directly linking improved health outcomes for women and their empowerment. However, for HEWs who inhabit a gendered space and place from home to district health centres, there can be unexpected consequences that accommodate existing gender inequalities, are blind to them and perhaps even generate new forms of exploitation. CONCLUSIONS: The Health Extension Program could have more transformative outcomes for HEWs and also for communities if changing gender norms was given more attention and constraints to gender equality were reduced. Community Health Worker (CHW) programs should focus on better understanding on the role of gender for CHWs across health systems.

OBJECTIFS: Appliquer une perspective du genre au programme de vulgarisation de la santé en Ethiopie et au rôle des agents de vulgarisation de la santé (AVS). MÉTHODES: Entretiens avec 45 AVS et quatre discussions de groupe avec 14 des mêmes AVS de trois régions rurales en Ethiopie: Région d'Afar, Région de Tigray (Adwa Woreda), et deux endroits dans les Nations du Sud, La Région des Nationalités et du Peuple (Aleta Wondo Woreda et Kafa Zone). Deux discussions de groupe ont été organisées dans la Région d'Afar avec 17 AVS féminins employés par l'Association de Development Pastoraliste de l'Afar. RÉSULTATS: En utilisant le continuum d'égalité des genres comme outil d'analyse du genre, nous avons constaté que le programme de vulgarisation de la santé en Ethiopie était sensible au genre en reliant directement des résultats améliorés en matière de santé pour les femmes et leur autonomisation. Toutefois, pour les AVS vivant dans un espace et un lieu différenciés par le sexe, du domicile au centre de santé, des conséquences inattendues accommodant les inégalités de genre existantes peuvent être omises et peut-être même générer de nouvelles formes d'exploitation. CONCLUSIONS: Le programme de vulgarisation de la santé pourrait avoir plus de résultats transformateurs pour les AVS et pour les communautés si les normes du genre changeantes étaient davantage prises en compte et les contraintes en matière d'égalité des sexes étaient réduites. Les programmes d'agents de santé communautaires (ASC) devraient être axés sur une meilleure compréhension du rôle des genres pour les AVS dans l'ensemble des systèmes de santé.

Factors that hinder or enable maternal health strategies to reduce delays in rural and pastoralist areas in Ethiopia.

OBJECTIVES: To document factors that hinder or enable strategies to reduce the first and second delays of the Three Delays in rural and pastoralist areas in Ethiopia. METHODS: A key informant study was conducted with 44 Health Extension Workers in Afar Region, Kafa Zone (Southern Nation, Nationalities and Peoples' Region), and Adwa Woreda (Tigray Region). Health Extension Workers were trained to interview women and ask for stories about their recent experiences of birth. We interviewed the Health Extension Workers about their experiences referring women for Skilled Birth Attendance and Emergency Obstetric and Newborn Care. Data were analysed using thematic analysis. RESULTS: Themes related to reducing the first delay, such as the tradition of home birth, decision-making, distance and unavailability of transport, did not differ between the three locations. Themes related to reducing the second delay differed substantially. Health Extension Workers in Adwa Woreda were more likely to call ambulances due to support from the Health Development Army and a functioning referral system. In Kafa Zone, some Health Extension Workers were discouraged from calling ambulances as they were used for other purposes. In Afar Region, few Health Extension Workers were called to assist women as most women give birth at home with Traditional Birth Attendants unless they need to travel to health facilities for Emergency Obstetric and Newborn Care. CONCLUSIONS: Initiatives to reduce delays can improve access to maternal health services, especially when Health Extension Workers are supported by the Health Development Army and a functioning referral system, but district (woreda) health offices should ensure that ambulances are used as intended.

Constructing diagnostic likelihood: clinical decisions using subjective versus statistical probability.

BACKGROUND: Although physicians are highly trained in the application of evidence-based medicine, and are assumed to make rational decisions, there is evidence that their decision making is prone to biases. One of the biases that has been shown to affect accuracy of judgements is that of representativeness and base-rate neglect, where the saliency of a person's features leads to overestimation of their likelihood of belonging to a group. This results in the substitution of 'subjective' probability for statistical probability. METHODS: This study examines clinicians' propensity to make estimations of subjective probability when presented with clinical information that is considered typical of a medical condition. The strength of the representativeness bias is tested by presenting choices in textual and graphic form. Understanding of statistical probability is also tested by omitting all clinical information. RESULTS: For the questions that included clinical information, 46.7% and 45.5% of clinicians made judgements of statistical probability, respectively. Where the question omitted clinical information, 79.9% of clinicians made a judgement consistent with statistical probability. There was a statistically significant difference in responses to the questions with and without representativeness information (χ2 (1, n=254)=54.45, p<0.0001). CONCLUSIONS: Physicians are strongly influenced by a representativeness bias, leading to base-rate neglect, even though they understand the application of statistical probability. One of the causes for this representativeness bias may be the way clinical medicine is taught where stereotypic presentations are emphasised in diagnostic decision making.

The place of birth in Kafa Zone, Ethiopia.

In this qualitative study, I used an ethnographic approach to provide an understanding about the place of birth in rural and semiurban Kafa Zone, Ethiopia. I interviewed women about birth at home and asked what would happen if there were serious problems and a woman was taken to a health facility. The development of health services aimed at reducing maternal mortality implies that the place of birth must change from home to health facility, but the distance from international policy to its implementation is vast and the pathway is not a direct, linear route.

Associations of weight changes with all-cause, cancer and cardiovascular mortality: A prospective cohort study.

Objectives: Previous studies suggest that changes in body weight can lead to an increased risk of mortality in the general population, although the results are controversial. The current study sought to investigate this association further using data from the UK Biobank. Study design: This is a large prospective population-based cohort study. Data were derived from the UK Biobank, with the initial assessments commencing between 2006 and 2010. Methods: Proportional hazard models were used to assess the association between self-reported weight change and risk of all-cause, cancer and cardiovascular mortality. The effect of gender was also investigated. Results: Of 433,829 participants with data for self-reported weight change, the mean age was 56 (standard deviation [SD]: 8.1) years and 55% were female. In total, 55% of participants reported no weight change, 28% gained weight, 15% lost weight, 2% did not know and 0.1% preferred not to give an answer. The median follow-up was 7.1 (interquartile range [IQR]: 6.4-7.8) years. Compared with participants with no weight change, those with weight loss had an increased risk of all-cause mortality (adjusted hazard ratio [HR] 1.25, 95% confident interval [CI] 1.18-1.32), cancer death (HR 1.17, 95% CI 1.08-1.27) and cardiovascular death (HR 1.26, 95% CI 1.12-1.43). Similarly, participants reporting weight gain also had an increased risk of all-cause mortality (HR 1.08, 95% CI 1.02-1.13), cancer death (HR 1.14, 95% CI 1.07-1.22) and cardiovascular death (HR 1.27, 95% CI 1.14-1.42). Participants who had a response 'do not know' or 'prefer not to answer' showed an increased risk of all-cause and cardiovascular mortality, particularly in men. Conclusions: The results of this study highlight the importance of maintaining a stable weight in middle-aged adults. Further studies are needed to understand the pathophysiology of weight change and its effects on mortality.

Association of red and processed meat consumption with cardiovascular morbidity and mortality in participants with and without obesity: A prospective cohort study.

OBJECTIVE: There is increasing evidence that red and processed meat consumption is associated with increased risk of cardiovascular (CV) disease. However, little literature reported the association among people with obesity versus those without obesity. We sought to investigate this using the UK Biobank data. METHODS: In this large prospective population-based cohort study, the red and processed meat consumption was assessed through the UK Biobank touch-screen questionnaire at baseline. The estimated hazards ratios (HRs) with 95% confidence intervals (CIs) were obtained from the Cox proportional hazard models to assess the association between red and processed meat consumption and the risk of CV death, cerebrovascular, and ischemic heart diseases in participants with and without obesity. RESULTS: Of 428,070 participants, 100,175 (23.4%) were obese with the mean age of 56 (SD: 7.9) years old and 54% were female. Participants without obesity, the mean age was 56 (SD: 5.2) years old and 55% were female. The overall median follow-up was 7.2 (IQR: 6.5-7.8) years. red and processed meat consumption had increased risk of CV death (HR (95%CI):1.04 (1.01-1.08) per week serve for participants with obesity and 1.04 (1.02-1.07) for those without obesity) after adjusted for age, sex, ethnicity, education, smoking and alcohol status and overall health. The moderate positive association between red and processed meat consumption and ischemic heart disease was only observed in participants without obesity (HR (95%CI): 1.15 (1.00-1.31) for the highest versus lowest terciles of red and processed meat consumption). No association was found with cerebrovascular disease in the participants regardless of obesity. CONCLUSIONS: Consumption frequency of red and processed meat is associated with higher risk of CV death regardless of obesity. The risk of ischemic heart disease associated with red and processed meat consumption may be higher in participants without obesity. Further studies are needed to understand the full extent of the mechanism of the association.

COVID-19 Pandemic-Medical Education Adaptations: the Power of Students, Staff and Technology.

The coronavirus pandemic has profoundly changed the way medical education is delivered globally. Our group reports an insight into the adaptations and innovations made by the School of Medicine at Anglia Ruskin University.

Body mass index and all-cause mortality in heart failure patients with normal and reduced ventricular ejection fraction: a dose-response meta-analysis.

BACKGROUND: For patients with heart failure, there is an inverse relation between body mass index (BMI) and mortality, sometimes called the obesity-paradox. However, the relationship might be either U- or J-shaped and might differ between patients with reduced (HFrEF) or preserved left ventricular ejection fraction (HFpEF). We sought to investigate this further in a dose-response meta-analysis of published studies. METHODS: PubMed and Embase from June 1980 to April 2017 were searched for prospective cohort studies evaluating associations between BMI and all-cause mortality in patients with HFrEF (LVEF < 40%) or HFpEF (LVEF ≥ 50%). Summary estimated effect sizes were obtained by using a random-effects model. Potential non-linear relationships were evaluated by using random-effects restricted cubic spline models. RESULTS: Ten studies were identified that included 96,424 patients of whom 59,263 had HFpEF (mean age 68 years of whom 38% were women) and 37,161 had HFrEF (mean age 60 years of whom 17% were women). For patients with HFpEF, the summary hazard ratio (HR) for all-cause mortality was: 0.93 (95% CI 0.89-0.97) per 5 units increase in BMI (I2 = 75.8%, p for heterogeneity = 0.01 and Begg's test, p = 1.0, Egger's test, p = 0.29) but the association was U-shaped (p for non-linearity < 0.01) with the nadir of risk at a BMI of 32-33 kg/m2. For patients with HFrEF, the summary HR for all-cause mortality was: 0.96 (95% CI 0.92-0.99) (I2 = 95%, p for heterogeneity < 0.001 and Begg's test, p = 0.45, Egger's test, p = 0.01). The relationship was also U-shaped (p < 0.01), although 'flatter' than for HFpEF, with the nadir at a BMI of 33 kg/m2. CONCLUSIONS: For patients with heart failure, the relation between BMI and mortality is U-shaped with a similar nadir of risk for HFpEF and HFrEF at a BMI of 32-33 kg/m2. Whether interventions that alter weight in either direction can alter risk is unknown.

"We Prefer the Friendly Approach and Not the Facility": On the Value of Qualitative Research in Ethiopia.

BACKGROUND: Quantitative research is useful for answering 'how many' or 'how much' questions, while qualitative research helps answer 'why' and 'how' questions. Most research about health extension workers (HEWs) has been quantitative and few studies examine the experiences of HEWs themselves. This qualitative study draws attention to the gendered dynamics of human resources for health at the community level. METHODS: Focus Group Discussions (FGDs) with 14 HEWs (two FGDs in Afar Region and two in Southern Nations Nationality and Peoples Region), and interviews with 45 HEWs from Afar Region, SNNPR and Adwa (Tigray Region) were conducted to identify how gender issues affected their well-being. Questions were designed to explore personal safety, stress, autonomy, self-esteem, family, other social relationships, as we wanted to analyze the extent to which these gendered issues affected HEWs in their day-to-day work. RESULTS: By employing female HEWs, the Health Extension Program (HEP) has seen substantial gains in 'practical' gender needs by improving women's access to, and utilization of maternal and child health services. Although the HEP has the potential to be gender transformative by providing employment for HEWs, there is limited evidence that it 'strategically' advances women's position. Many HEWs had heavy workloads, received low pay relative to other public sector jobs and lacked opportunity to transfer or upgrade their skills and advance within the health workforce hierarchy. CONCLUSION: Qualitative research can provide complex descriptions of the social world to better understand what people such as HEWs say and the meanings they give, thus providing explanations for some health problems outside disciplinary boundaries.

Determinants of delay in timely treatment seeking for diarrheal diseases among mothers with under-five children in central Ethiopia: A case control study.

BACKGROUND: Delays in seeking timely appropriate care contributes to a large number of deaths from diarrhea in children. This study aimed to identify determinants of delays in seeking timely treatment by mothers/caregivers of under-five children with diarrheal diseases. METHODS: We used an unmatched case-control study from February-March 2017 among 316 children: 158 cases and 158 controls. Cases were mothers/caregivers with under-five children who had signs/symptoms of diarrhea and sought treatment after 24 hours onset of symptom. Controls sought treatment within 24 hours. Field workers collected data using a pre-tested standardized questionnaire. Multivariate logistic regression was conducted to identify determinants of delay in timely diarrhea treatment seeking. Statistical significance was declared by using a p-value<0.05 and 95% of confidence interval (CI) for an adjusted-odds ratio (AOR). RESULTS: The determinants of delay in timely treatment seeking of mothers/caregivers of under-five children with diarrheal diseases were children <24months (AOR = 1.9,95%CI:1.1-3.4); fail to attend school (AOR = 2.4, 95%CI:1.2-4.6); being female children (AOR = 1.7,95%CI:1.05-2.9); preferring government health facility for the treatment of children with diarrheal diseases (AOR = 2.9, 95%CI, 1.3-6.7); lack of past history taking children to health facility and lack of counseling (AOR = 4.8, 95%CI:2.0-12.1); being in the15-25 years age (AOR = 1.7, 95%CI:1.1-3.0) and taking children to a health facility as a first response to diarrhea (AOR = 0.1, 95%CI:0.01-0.8). CONCLUSIONS: Age of the child, maternal age, and disease related determinants were determinants for seeking timely treatment to diarrheal diseases. Providing skilled based health education and counseling to mothers/caregivers on seeking timely treatment and taking children with diarrheal diseases to a health facility as a first response to diarrhea is a paramount intervention to reduce morbidity and mortality of children.

The Role of Health Extension Workers in Linking Pregnant Women With Health Facilities for Delivery in Rural and Pastoralist Areas of Ethiopia.

BACKGROUND: Women's preference to give birth at home is deeply embedded in Ethiopian culture. Many women only go to health facilities if they have complications during birth. Health Extension Workers (HEWs) have been deployed to improve the utilization of maternal health services by bridging the gap between communities and health facilities. This study examined the barriers and facilitators for HEWs as they refer women to mid-level health facilities for birth. METHODS: A qualitative study was conducted in three regions: Afar Region, Southern Nations Nationalities and People's Region and Tigray Region between March to December 2014. Interviews and focus group discussions were conducted with 45 HEWs, 14 women extension workers (employed by Afar Pastoralist Development Association, Afar Region) and 11 other health workers from health centers, hospitals or health offices. Data analysis was done based on collating the data and identifying key themes. RESULTS: Barriers to health facilities included distance, lack of transportation, sociocultural factors and disrespectful care. Facilitators for facility-based deliveries included liaising with Health Development Army (HDA) leaders to refer women before their expected due date or if labour starts at home; the introduction of ambulance services; and, provision of health services that are culturally more acceptable for women. CONCLUSION: HEWs can effectively refer more women to give birth in health facilities when the HDA is well established, when health staff provide respectful care, and when ambulance is available at any time.

Health Extension Workers' and Mothers' Attitudes to Maternal Health Service Utilization and Acceptance in Adwa Woreda, Tigray Region, Ethiopia.

BACKGROUND: The maternal health system in Ethiopia links health posts in rural communities (kebeles) with district (woreda) health centres, and health centres with primary hospitals. At each health post two Health Extension Workers (HEWs) assist women with birth preparedness, complication readiness, and mobilize communities to facilitate timely referral to mid-level service providers. This study explored HEWs' and mother's attitudes to maternal health services in Adwa Woreda, Tigray Region. METHODS: In this qualitative study, we trained 16 HEWs to interview 45 women to gain a better understanding of the social context of maternal health related behaviours. Themes included barriers to health services; women's social status and mobility; and women's perceptions of skilled birth attendant's care. All data were analyzed thematically. FINDINGS: There have been substantial efforts to improve maternal health and reduce maternal mortality in Adwa Woreda. Women identified barriers to healthcare including distance and lack of transportation due to geographical factors; the absence of many husbands due to off-woreda farming; traditional factors such as zwar (some pregnant women are afraid of meeting other pregnant women), and discouragement from mothers and mothers-in-law who delivered their children at home. Some women experienced disrespectful care at the hospital. Facilitators to skilled birth attendance included: identification of pregnant women through Women's Development Groups (WDGs), and referral by ambulance to health facilities either before a woman's Expected Due Date (EDD) or if labour started at home. CONCLUSION: With the support of WDGs, HEWs have increased the rate of skilled birth attendance by calling ambulances to transfer women to health centres either before their EDD or when labour starts at home. These findings add to the growing body of evidence that health workers at the community level can work with women's groups to improve maternal health, thus reducing the need for emergency obstetric care in low-income countries.

Barriers and facilitators to accessing skilled birth attendants in Afar region, Ethiopia.

OBJECTIVE: to explore barriers and facilitators that enable women to access skilled birth attendance in Afar Region, Ethiopia. DESIGN: researchers used a Key Informant Research approach (KIR), whereby Health Extension Workers participated in an intensive training workshop and conducted interviews with Afar women in their communities. Data was also collected from health-care workers through questionnaires, interviews and focus groups. PARTICIPANTS: fourteen health extension workers were key informants and interviewers; 33 women and eight other health-care workers with a range of experience in caring for Afar childbearing women provided data as individuals and in focus groups. FINDINGS: participants identified friendly service, female skilled birth attendants (SBA) and the introduction of the ambulance service as facilitators to SBA. There are many barriers to accessing SBA, including women׳s low status and restricted opportunities for decision making, lack of confidence in health-care facilities, long distances, cost, domestic workload, and traditional practices which include a preference for birthing at home with a traditional birth attendant. KEY CONCLUSIONS: many Afar men and women expressed a lack of confidence in the services provided at health-care facilities which impacts on skilled birth attendance utilisation. IMPLICATIONS FOR PRACTICE: ambulance services that are free of charge to women are effective as a means to transfer women to a hospital for emergency care if required and expansion of ambulance services would be a powerful facilitator to increasing institutional birth. Skilled birth attendants working in institutions need to ensure their practice is culturally, physically and emotionally safe if more Afar women are to accept their midwifery care. Adequate equipping and staffing of institutions providing emergency obstetric and newborn care will assist in improving community perceptions of these services. Most importantly, mutual respect and collaboration between traditional birth attendants (Afar women׳s preferred caregiver), health extension workers and skilled birth attendants will help ensure timely consultation and referral and reduce delay for women if they require emergency maternity care.

Modulators of the human CCR5 receptor. Part 1: Discovery and initial SAR of 1-(3,3-diphenylpropyl)-piperidinyl amides and ureas.

Investigation of weak screening hits led to the identification of N-alkyl-N-[1-(3,3-diphenylpropyl)piperidin-4-yl]-2-phenylacetamides and N-alkyl-N-[1-(3,3-diphenylpropyl)piperidin-4-yl]-N'-benzylureas as potent, selective ligands for the human CCR5 chemokine receptor.