Problematic khat use as a possible risk factor for harmful use of other psychoactive substances: a mixed method study in Ethiopia

Background: Substance use disorders along with neuropsychiatric disorders contributed about 14% of the global burden of disease. Harmful alcohol use, is a known contributor for many harms (accidents, suicide, violence, and complication of other psychiatric and medical disorders). In the Western countries, alcohol and nicotine are gateway drugs to cannabis use, and cannabis use is a risky behavior for other illicit drugs such as cocaine and heroin. Khat use is another psychoactive substance which is common in East African and Arabian Peninsula. But there is a knowledge gap regarding the position of khat use or problematic khat use in sequential progression of different psychoactive substances. Therefore, we aimed to understand and investigate the relationship of problematic khat use and other psychoactive substances in Ethiopia. Methods: Exploratory mixed methods study was employed. Quantitative cross sectional survey was done among 102 khat users, and 4 focus group discussions and 11 in-depth interviews were conducted to understand the pathways between khat use and other psychoactive substances use in 2014. Non random sampling (purposive and snowballing) was employed for both quantitative and qualitative studies. Khat users from khat cafeterias, shops, and from other open markets of khat in Addis Ababa were invited to participate. Result: Currently significant majorities of khat users (86.3%) used at least one other psychoactive substance after they started khat use. The prevalence of harmful drinking was 53.9% among khat users. Problematic khat use was a significant predictor of harmful drinking (p<0.05). About one from ten respondents engaged to risky sexual behavior pushed by the effect of khat after chewing. Conclusion: The proportion of psychoactive substances use especially harmful drinking among khat users was observed higher compared to other cross sectional surveys conducted among general population. In Ethiopia, intervention and policy on harmful alcohol use could consider problematic khat use as one possible risky factor. A rigorous methodology which could test gateway hypothesis

Challenges and opportunities for implementing integrated mental health care: a district level situation analysis from five low- and middle-income countries.

BACKGROUND: Little is known about how to tailor implementation of mental health services in low- and middle-income countries (LMICs) to the diverse settings encountered within and between countries. In this paper we compare the baseline context, challenges and opportunities in districts in five LMICs (Ethiopia, India, Nepal, South Africa and Uganda) participating in the PRogramme for Improving Mental health carE (PRIME). The purpose was to inform development and implementation of a comprehensive district plan to integrate mental health into primary care. METHODS: A situation analysis tool was developed for the study, drawing on existing tools and expert consensus. Cross-sectional information obtained was largely in the public domain in all five districts. RESULTS: The PRIME study districts face substantial contextual and health system challenges many of which are common across sites. Reliable information on existing treatment coverage for mental disorders was unavailable. Particularly in the low-income countries, many health service organisational requirements for mental health care were absent, including specialist mental health professionals to support the service and reliable supplies of medication. Across all sites, community mental health literacy was low and there were no models of multi-sectoral working or collaborations with traditional or religious healers. Nonetheless health system opportunities were apparent. In each district there was potential to apply existing models of care for tuberculosis and HIV or non-communicable disorders, which have established mechanisms for detection of drop-out from care, outreach and adherence support. The extensive networks of community-based health workers and volunteers in most districts provide further opportunities to expand mental health care. CONCLUSIONS: The low level of baseline health system preparedness across sites underlines that interventions at the levels of health care organisation, health facility and community will all be essential for sustainable delivery of quality mental health care integrated into primary care

Is equal access to higher education in South Asia and sub-Saharan Africa achievable by 2030?

Higher education is back in the spotlight, with post-2015 sustainable development goals emphasising equality of access. In this paper, we highlight the long distance still to travel to achieve the goal of equal access to higher education for all, with a focus on poorer countries which tend to have lower levels of enrolment in higher education. Analysing Demographic and Health Survey data from 35 low- and middle-income countries in sub-Saharan Africa and South Asia, we show wide wealth inequalities in particular, with few if any of the poorest gaining access to higher education in some countries. We further identify that wealth and gender inequalities interact and tend to be wider in countries where levels of higher education are higher. This implies that expansion in access to higher education may predominantly benefit the rich, unless measures are taken to tackle inequalities. We find that that the rates of increase necessary for the attainment of the equal access goal by 2030 are particularly high. They pose a particularly difficult challenge given the access inequalities present from primary and secondary education in a wide majority of countries in our analysis. We therefore suggest that any measures aimed at attaining the goal need to tackle inequalities in access within a system-wide approach, focusing on the level of education at which inequalities initially manifest, alongside higher education.This is the final version of the article. It first appeared from Springer via http://dx.doi.org/10.1007/s10734-016-0039-

Social psychiatry and psychiatric epidemiology functional impairment among people with severe and enduring mental disorder in rural Ethiopia: a cross-sectional study

Purpose: Evidence regarding functional impairment in people with severe mental disorders (SMD) is sparse in low and middle-income countries. The aim of this study was to identify factors associated with functional impairment in people with enduring SMD in a rural African setting. Methods: A cross-sectional study was conducted at the baseline of a health service intervention trial. A total of 324 participants were recruited from an existing communityascertained cohort of people with SMD (n= 218), and attendees at the Butajira General Hospital psychiatric clinic (n= 106). Inclusion criteria defined people with SMD who had ongoing need for care: those who were on psychotropic medication, currently symptomatic or had a relapse in the preceding two years. The World Health Organization Disability Assessment schedule (WHODAS-2.0) and the Butajira Functioning Scale (BFS), were used to assess functional impairment. Multivariable negative binomial regression models were fitted to investigate the association between demographic, socio-economic and clinical characteristics, and functional impairment. Results: Increasing age, being unmarried, rural residence, poorer socio-economic status, symptom severity, continuous course of illness, medication side effects and internalized stigma were associated with functional impairment across self reported and caregiver responses for both the WHODAS and the BFS. Diagnosis per se was not associated consistently with functional impairment. Conclusion: To optimize functioning in people with chronic SMD in this setting, services need to target residual symptoms, poverty, medication side effects and internalized stigma. Testing the impact of community interventions to promote recovery will be useful. Advocacy for more tolerable treatment options is warranted

Five-year mortality in a cohort of people with schizophrenia in Ethiopia

<p>Abstract</p> <p>Background</p> <p>Schizophrenia is associated with a two to three fold excess mortality. Both natural and unnatural causes were reported. However, there is dearth of evidence from low and middle income (LAMIC) countries, particularly in Africa. To our knowledge this is the first community based report from Africa.</p> <p>Methods</p> <p>We followed a cohort of 307 (82.1% males) patients with schizophrenia for five years in Butajira, rural Ethiopia. Mortality was recorded using broad rating schedule as well as verbal autopsy. Standardized Mortality Ratio (SMR) was calculated using the mortality in the demographic and surveillance site as a reference.</p> <p>Result</p> <p>Thirty eight (12.4%) patients, 34 men (11.1%) and 4 women (1.3%), died during the five-year follow up period. The mean age (SD) of the deceased for both sexes was 35 (7.35). The difference was not statistically significant (p = 0.69). It was 35.3 (7.4) for men and 32.3 (6.8) for women. The most common cause of death was infection, 18/38 (47.4%) followed by severe malnutrition, 5/38 (13.2%) and suicide 4/38 (10.5%). The overall SMR was 5.98 (95% CI = 4.09 to7.87). Rural residents had lower mortality with adjusted hazard ratio (HR) of 0.30 (95% CI = 0.12-0.69) but insidious onset and antipsychotic treatment for less than 50% of the follow up period were associated with higher mortality, adjusted HR 2.37 (95% CI = 1.04-5. 41) and 2.66(1.054-6.72) respectively.</p> <p>Conclusion</p> <p>The alarmingly high mortality observed in this patient population is of major concern. Most patients died from potentially treatable conditions. Improving medical and psychiatric care as well as provision of basic needs is recommended.</p

Longitudinal Trends in Childbirth Practices in Ethiopia

Objectives This study examines the influence of women’s birth practices on their daughters’ location of childbirth in Ethiopia, investigating the importance of intergenerational patterns of care on contemporary birth practices. Methods A qualitative survey of women aged 60 and over in three cities in Ethiopia. Results Nearly all first generation women gave birth at home, but the majority of their daughters give birth in facilities. Perceptions of childbirth practices among both women and their daughters have shifted towards facility births, despite the prevalence of home birth in the previous generation. Conclusions Birth culture has experienced a profound shift in Ethiopia within one generation, especially in urban areas, where health facilities are more easily accessible. Older generations of women have positive attitudes towards facility birth, and can help influence their daughters to give birth with medical assistance. This aligns with both national and global maternal health policies which promote safe motherhood through facility birth

Exploring barriers to the use of formal maternal health services and priority areas for action in Sidama zone, southern Ethiopia.

In 2015 the maternal mortality ratio for Ethiopia was 353 per 100,000 live births. Large numbers of women do not use maternal health services. This study aimed to identify factors influencing the use of maternal health services at the primary health care unit (PHCU) level in rural communities in Sidama zone, south Ethiopia in order to design quality improvement interventions. We conducted a qualitative study in six woredas in 2013: 14 focus group discussions (FGDs) and 44 in-depth interviews with purposefully selected community members (women, male, traditional birth attendants, local kebele administrators), health professionals and health extension workers (HEWs) at PHCUs. We digitally recorded, transcribed and thematically analysed the interviews and FGDs using Nvivo. The 'three delay model' informed the analytical process and discussion of barriers to the use of maternal health services. Lack of knowledge on danger signs and benefits of maternal health services; cultural and traditional beliefs; trust in TBAs; lack of decision making power of women, previous negative experiences with health facilities; fear of going to an unfamiliar setting; lack of privacy and perceived costs of maternal health services were the main factors causing the first delay in deciding to seek care. Transport problems in inaccessible areas were the main contributing factor for the second delay on reaching care facilities. Lack of logistic supplies and equipment, insufficient knowledge and skills and unprofessional behaviour of health workers were key factors for the third delay in accessing quality care. Use of maternal health services at the PHCU level in Sidama zone is influenced by complex factors within the community and health system. PHCUs should continue to implement awareness creation activities to improve knowledge of the community on complications of pregnancy and benefits of maternal health services. The health system has to be responsive to community's cultural norms and practices. The mangers of the woreda health office and health centres should take into account the available budgets; work on ensuring the necessary logistics and supplies to be in place at PHCU