Some major school health problems in southern Ethiopia: Malnutrition, parasite infections, and skin problems

God helse og ernæring er viktige forutsetninger for god utdanning. Selv om dødeligheten hos barn i skolealder er lavere enn hos yngre barn, er ernæringsmessige mangler og infeksjonssykdommer fortsatt de hyppigste dødsårsakene. Mange skolebarn er fortsatt underernærte, har tarmparasitter og hudproblemer. Skolehelsetjenesten i landet som Etiopia er svak. Anemi og kronisk underernæring sees ofte hos samme barn, og deler felles risikofaktorer, men få har undersøkt dette i Etiopia. Selv om det er dokumentert en høy forekomst av innvollsormer, er det få studier om intensitet av innvollsormer, noe som er avgjørende for å forstå hvor syke barn blir. Mange skolebarn har skabb eller soppinfeksjoner i huden. Mange barn er også affisert av en «jordloppe»-infeksjon (tunga penetrans). Hovedmålsetningen med avhandlingen var å undersøke hyppig forekommende helseproblemer blant skolebarn i alderen sju til fjorten år i Sør-Etiopia. De spesifikke formålene med avhandlingen var 1/ å undersøke samtidig forekomst av anemi og kronisk underernæring 2/ å kartlegge forekomst og intensitet an innvollsormer blant skolebarn, og 3/ å analysere risikofaktorer for hyppig forekommende hudproblemer som soppinfeksjoner, skabb og jordloppe infeksjoner. Studien ble utført i Wonago området i Gedeo i Sør-Etiopia. Utvalget bestod av 864 skolebarn som ble tilfeldig utvalgt fra 2384 skolebarn i tre skoler på landsbygda. Vi samlet sosiodemografiske data, og målte ernæringsstatus, hemoglobin, forekomst av innvollsormer og hudinfeksjoner. Til å analysere data bruke vi også multivariate, multilevel, mixed-effect, regresjonsmodeller for å forstå hvorledes risikofaktorer på individ, familie, skoleklasse og skolenivå kan forklare resultatene. Dataene i artikkel om hudinfeksjoner ble også analysert med Bayesiansk statistikk. Fattigdom og hygieniske faktorer som hyppighet av handvask, bruk av sko, og tilgang på vaskefasiliteter på skolene forklarte noen av risikofaktorene for flere av infeksjonssykdommene. Studien viser at anemi og kronisk underernæring er et moderat stort helseproblem. Selv om det har vært noen helseprogrammer, er forekomsten av innvollsormer og hudproblemer høy. Risikofaktorer for disse helseproblemet er relatert til faktorer på skolene, i heimene og hos det enkelte skolebarn. Fattigdom og hygieniske faktorer som hyppighet av handvask, bruk av sko, og tilgang på vaskefasiliteter på skolene kan forklare noen av risikofaktorene for flere av infeksjonssykdommene. Avhandlingen, som er en av de første i Etiopia om skolehelse, anbefaler at intervensjoner må omfatte forebyggende og behandlende tiltak både på individ, heim og skolenivå.Background: Even though the global enrolment of children in schools is increasing, school-aged children in Ethiopia are at risk of various health problems, including malnutrition, micronutrient deficiencies, infections with soil-transmitted helminths (STHs), and skin problems. Anemia and stunting are interlinked health problems and share common risk factors, but few studies have investigated their coexistence in Ethiopia. Although there are many school-aged children, few studies have been conducted on the nutritional status of school-aged children in rural southern Ethiopia. In addition, previous studies on helminth infections have focused mainly on urban northern Ethiopia, although southern Ethiopia is a region where access to clean water and sanitation facilities is poor at schools. Furthermore, despite improvements in reporting the prevalence of helminth infections, there are few studies on the intensity of helminth infections in rural southern Ethiopia. The risk factors for intensity of helminth infection were not reported in several previous studies, and the interpretation of helminth data was mainly done according to the categorical outcome (i.e., the presence or absence of helminth infection). Thus, the use of a count model considering helminth egg concentration as an outcome variable is rarely reported. In addition, helminth egg data are usually overly saturated with zeros, and the interpretation of such data requires specific statistical models. However, there have been no studies on helminth egg counts among schoolchildren in Ethiopia that account for excessive zeros and overdispersion. More than half of school-aged children in southern Ethiopia are affected by scabies and tungiasis. Tinea infections are also common skin diseases among school-aged children in Ethiopia, especially tinea capitis, with approximately one-third of these children having experienced this infection at some point. Despite these facts, no compiled reports of such health conditions have been published. Moreover, there have been no studies that have investigated whether a Bayesian model could provide further evidence of these health conditions. Therefore, we applied both frequentist and Bayesian approaches to identify risk factors for scabies, tungiasis, and tinea infections. In our data, individuals were clustered within the same classroom, and classrooms within the same school. Thus, unlike previous studies, we applied a multilevel analysis to account for clustering effects. General objective: The overall objective of this study was to investigate some of the prevalent health problems among schoolchildren aged 7–14 years in rural southern Ethiopia. Specific objectives: 1) To assess the prevalence and risk factors for concurrent anemia and stunting (CAS) at the individual, household, and school levels among schoolchildren in rural southern Ethiopia using a multivariate, multilevel, mixed-effect model (Paper I); 2) to assess the prevalence and intensity of helminth infections and identify potential risk factors among schoolchildren in rural southern Ethiopia using a multivariate, multilevel, mixed-effect model and a zero-inflated negative binomial regression model (Paper II); and 3) to investigate the occurrence and risk factors of three parasitic skin diseases (scabies, tungiasis, and tinea) and their risk factors among schoolchildren in rural southern Ethiopia using both frequentist and Bayesian approaches (Paper III). Methods: We conducted this study in the Wonago district of southern Ethiopia. Using a three-stage cluster sampling method, we randomly recruited 4 schools at the first stage, 24 classrooms with 2,384 children at the second stage, and 36 children from each classroom at the third stage, for a total of 864 children aged 7 to 14 years. We recorded weight, height, hemoglobin level, intestinal helminth infections, hygiene practices, dietary habits, household food insecurity, and sociodemographic information and conducted skin examinations. For Papers I and II, a multivariate, multilevel, mixed-effect, logistic regression model was constructed that accounted for random school and classroom effects and identified potential individual-, household-, and school-level risk factors for CAS, as well as any helminth or Trichuris trichiura or Ascaris lumbricoides infection (Papers I and II). A count model with zero-inflated negative binomial (ZINB) regression analysis was performed to estimate potential factors associated with infection intensity using fecal egg counts from T. trichiura and A. lumbricoides infections (Paper II). In Paper III, both frequentist and Bayesian multilevel, mixed-effect, logistic regression models were used to identify potential risk factors for any one of three skin diseases, namely scabies, tungiasis, and tinea, separately. Results: In Paper I, CAS prevalence among schoolchildren was 10.5%, and risk factors for CAS were concentrated at the individual level. The clustering effects, as measured by the intra-cluster correlation coefficient (ICC), were 6.8% at the school level and 19% at the classroom level. Increased age, not washing hands with soap after latrine visits, walking barefoot, T. trichiura infection, and head lice infestation were associated with a high prevalence of CAS. Those using treated drinking water were less likely to have CAS. In Paper II, the prevalence of at least one helminth species was 56%, for while that of T. trichiura and A. lumbricoides was 42.4% and 18.7% among schoolchildren. School and classroom variables for helminth infections explained less than 5% of the variance and thus showed little influence. Being thin, anemic, children with a mother or guardian without formal education, and children in households using open containers for water storage were risk factors for helminths infection. In the ZINB model, older age and unclean fingernails increased the risk of A. lumbricoides infection. Handwashing with soap, deworming, and using water from protected sources reduced the risk of helminth infection. In Paper III, nearly three-quarters of schoolchildren had at least one type of skin disease, with scabies at 5.5% (46/861), tungiasis at 54.4% (468/861), and tinea infections at 39.1% (337/861). In the frequentist model, the cluster effect was insignificant at the school level and 8.8% at the classroom level for each skin problem. In the Bayesian model, the effect was 5.3% at the school level and 16% at the classroom level. For all models, the measured effects were higher than the values in the frequentist model. In the Bayesian model, being a boy, having unclean fingernails, not washing the body and hair weekly with soap, sharing a bed, clothes, or combs, and living in a poor household were risk factors for skin problems, but washing the legs and feet daily with soap was preventative for skin problems. Conclusions: Accounting for school- and classroom-level effects, this thesis identifies CAS as a moderate public health problem, as well as a high burden of helminth infections and skin problems among schoolchildren in southern Ethiopia. The risk of contracting CAS was high with age among those who did not always wash their hands with soap after visiting latrines, walked barefoot, and had T. trichiura infection, so educating children about personal hygiene and providing clean drinking water could reduce the burden of CAS among schoolchildren. Considering clustering at the school and classroom levels and the greater number of zeros in fecal egg counts, we observed associations between helminths and age, thinness, anemia, unclean fingernails, handwashing, deworming treatment, maternal education, household water source, and water storage protection. Therefore, strengthening the school deworming programme could reduce the burden of helminths in schoolchildren. The association between skin problems and most hygiene-related variables requires efforts to improve the personal hygiene of schoolchildren. The wide variation in skin problems across classrooms suggests that there are common risk factors in these locations and that transmission needs to be reduced by downsizing classrooms.Doktorgradsavhandlin

Risk factors for scabies, tungiasis, and tinea infections among schoolchildren in southern Ethiopia: A cross-sectional Bayesian multilevel model

Background Skin problems cause significant sickness in communities with poor living conditions, but they have received less attention in national or global health studies because of their low mortality rates. In many developing regions, the prevalence of parasitic skin diseases among schoolchildren is not reported. Previous studies thus have attempted to identify risk factors for these conditions using the frequentist approach. This study aimed to assess the occurrence and risk factors of skin infections among rural schoolchildren in southern Ethiopia by combining a frequentist and a Bayesian approach. Methodology/Principal findings Using three-stage random sampling, we assessed 864 schoolchildren aged 7–14 years from the Wonago district in southern Ethiopia. We detected potential risk factors for scabies, tungiasis, and tinea infections and recorded their hygienic practices and socio-demographic information. The frequentist model revealed a clustering effect of 8.8% at the classroom level and an insignificant effect at the school level. The Bayesian model revealed a clustering effect of 16% at the classroom level and 5.3% at the school level. Almost three-fourths of the sample had at least one type of skin problem, and boys were at higher overall risk than girls (adjusted odds ratio [aOR] 1.55 [95% Bayesian credible interval [BCI] 1.01, 2.28). Risk factors included unclean fingernails (aOR 1.85 [95% BCI 1.08, 2.97]); not washing the body (aOR 1.90 [95% BCI 1.21, 2.85]) and hair (aOR 3.07 [95% BCI 1.98, 4.57]) with soap every week; sharing a bed (aOR 1.97 [95% BCI 1.27, 2.89]), clothes (aOR 5.65 [95% BCI 3.31, 9.21]), or combs (aOR 3.65 [95% BCI 2.28, 5.53]); and living in a poor household (aOR 1.76 [95% BCI 1.03, 2.83]). Washing legs and feet with soap daily was identified as a protective factor for each of the three skin diseases (aOR 0.23 [95% BCI 0.15, 0.33]). Conclusions/Significance We observed high variation in skin problems at the classroom level, indicating the presence of shared risk factors in these locations. The findings suggest the need to improve children’s personal hygiene via health education by schoolteachers and health workers. Author summary Skin problems are common disorders in resource poor settings. Scabies and tungiasis are neglected tropical diseases causing significant sickness in communities with poor living conditions. Scabies is dermatosis caused by a burrowing mite, Sarcoptes scabiei var. hominis. Tungiasis is caused by a flea, Tunga penetrans, infesting the skin, usually on the feet or hands. Tinea infection is a fungal dermatophyte infection of the skin and the most common dermatological problem among schoolchildren in Ethiopia, especially tinea capitis. Application of a Bayesian approach to identify possible risk factors for these problems has seldom been used. We found that compared to the frequentist model, the Bayesian model better explained school- and classroom-level variations in skin problems among schoolchildren. Our findings also suggest that transmission of skin infections, especially fungal and scabies infections, frequently occurs in schools and classrooms. We identified several risk factors for these conditions, including low socioeconomic status; unclean fingernails; not washing with soap at least every week; and sharing beds, clothes, and combs. Thus, it is important to improve the personal hygiene of schoolchildren through education. Regular checkups by teachers also can improve skin health and related morbidity in rural schoolchildren in southern Ethiopia.publishedVersio

Concurrent anemia and stunting among schoolchildren in Wonago district in southern Ethiopia: a cross-sectional multilevel analysis

Background Even if many schoolchildren in Ethiopia are anemic and stunted, few have studied the co-existence of anemia and stunting among schoolchildren in Ethiopia. In addition, multilevel analysis to explore the variation in prevalence of concurrent anemia and stunting (CAS) across schools and classes is rarely applied. Thus, we aimed to assess the prevalence and risk factors of CAS at the individual, household, and school level among schoolchildren in southern Ethiopia. Methods We recruited 864 students aged 7–14 years from the Wonago district in southern Ethiopia using a three-stage random sampling, assigning four schools to level one, 24 classes to level two. We then randomly selected 36 children from each class, and recorded their weight, height, haemoglobin, intestinal helminthic infections, hygienic practices, dietary practices, household food insecurity, and socio-demographic information. A multivariate, multilevel logistic regression model was applied to detect potential risk factors for CAS. Results The prevalence of CAS was 10.5% (85/810) among schoolchildren, which increased with age in years (adjusted odds ratio [aOR] 1.39 [95% confidence interval 1.13, 1.71, P = 0.002]) and among children who always did not wash their hands with soap after use of latrine (aOR 4.30 [1.21, 15.3, P = 0.02]). Children who walked barefoot (aOR 10.4 [2.77, 39.1, P = 0.001]), were infected with Trichuris trichiura (aOR 1.74 [1.05, 2.88, P = 0.03]), or had head lice infestation (aOR 1.71 [1.01, 2.92, P = 0.04]) had higher CAS prevalence. Prevalence rates of CAS were low in those using treated drinking water (aOR 0.32 [95% CI 0.11, 0.97, P = 0.04]). Most of the risk factors for CAS were identified at the individual level. The clustering effect measured by the intra-cluster correlation coefficient was 6.8% at school level and 19% at class. Conclusion CAS prevalence is a moderate public health problem among schoolchildren in southern Ethiopia and varies across classes and schools. After controlling for clustering effects at the school and class levels, we found an association between CAS and increasing age, not always washing hands with soap after using latrine, walking barefoot, and T. trichiura infection. Using treated water for drinking was found to have a protective effect against CAS. Thus, educating children on personal hygiene and provision of safe drinking water could reduce the CAS burden in schoolchildren in rural areas of southern Ethiopia.publishedVersio

Pancytopenia of Unknown Cause in Adult Patients Admitted to a Tertiary Hospital in Ethiopia: Case series

BACKGROUND: Over the past few years, we have witnessed a dramatic increase in the number of patients presenting with severe pancytopenia to Jimma University Hospital. We now present sociodemographic and clinical characteristics of adult patients admitted with pancytopenia of unknown cause to Jimma University Hospital during the period of March 2015 to June 2016. Complete blood count and other diagnostic tests were done for all patients to uncover underlying causes.RESULT: Out of 65 cases admitted with pancytopenia during the specified period, 40 were excluded for various reasons. The rest 25 patients were included in this review. The mean age was 32.1 years (SD=14.9); 14 were younger than 30 years of age. The mean hemoglobin level, white cell count and platelet count were 48.6 g/L (SD=1.9), 1,918 /μL (SD=879.8) and 36,200 /μL (SD=26,131) respectively. The major presenting symptoms were generalized malaise and fever. No geographic or seasonal clustering of the caseswas seen.CONCLUSION: The number of cases with pancytopenia of unidentified cause seen at the hospital over the specified period is alarmingly high and deserves great attention. The hematologic alteration in most of the patients was found to be severe with poor clinical outcome. This calls for large scale community based investigation to uncover the root cause of the problem.KEYWORDS: Aplastic anemia, Pancytopenia, Ethiopia, Jimm

Risk factors for poor engagement with a smart pillbox adherence intervention among persons on tuberculosis treatment in Ethiopia.

BACKGROUND: Non-adherence to tuberculosis treatment increases the risk of poor treatment outcomes. Digital adherence technologies (DATs), including the smart pillbox (EvriMED), aim to improve treatment adherence and are being widely evaluated. As part of the Adherence Support Coalition to End TB (ASCENT) project we analysed data from a cluster-randomised trial of DATs and differentiated care in Ethiopia to examine individual-factors for poor engagement with the smart pillbox. METHODS: Data were obtained from a cohort of trial participants with drug-sensitive tuberculosis (DS-TB) whose treatment started between 1 December 2020 and 1 May 2022, and who were using the smart pillbox. Poor engagement with the pillbox was defined as (i) > 20% days with no digital confirmation and (ii) the count of days with no digital confirmation, and calculated over a two evaluation periods (56-days and 168-days). Logistic random effects regression was used to model > 20% days with no digital confirmation and negative binomial random effects regression to model counts of days with no digital confirmation, both accounting for clustering of individuals at the facility-level. RESULTS: Among 1262 participants, 10.8% (133/1262) over 56-days and 15.8% (200/1262) over 168-days had > 20% days with no digital confirmation. The odds of poor engagement was less among participants in the higher stratum of socio-economic position (SEP) over 56-days. Overall, 4,689/67,315 expected doses over 56-days and 18,042/199,133 expected doses over 168-days were not digitally confirmed. Compared to participants in the poorest SEP stratum, participants in the wealthiest stratum had lower rates of days not digitally confirmed over 168-days (adjusted rate ratio [RRa]:0.79; 95% confidence interval [CI]: 0.65, 0.96). In both evaluation periods (56-days and 168-days), HIV-positive status (RRa:1.29; 95%CI: 1.02, 1.63 and RRa:1.28; 95%CI: 1.07, 1.53), single/living independent (RRa:1.31; 95%CI: 1.03, 1.67 and RRa:1.38; 95%CI: 1.16, 1.64) and separated/widowed (RRa:1.40; 95%CI: 1.04, 1.90 and RRa:1.26; 95%CI: 1.00, 1.58) had higher rates of counts of days with no digital confirmation. CONCLUSION: Poorest SEP stratum, HIV-positive status, single/living independent and separated/ widowed were associated with poor engagement with smart pillbox among people with DS-TB in Ethiopia. Differentiated care for these sub-groups may reduce risk of non-adherence to TB treatment

Evaluation of implementation and effectiveness of digital adherence technology with differentiated care to support tuberculosis treatment adherence and improve treatment outcomes in Ethiopia: a study protocol for a cluster randomised trial.

BACKGROUND: Digital adherence technologies (DATs) are recommended to support patient-centred, differentiated care to improve tuberculosis (TB) treatment outcomes, but evidence that such technologies improve adherence is limited. We aim to implement and evaluate the effectiveness of smart pillboxes and medication labels linked to an adherence data platform, to create a differentiated care response to patient adherence and improve TB care among adult pulmonary TB participants. Our study is part of the Adherence Support Coalition to End TB (ASCENT) project in Ethiopia. METHODS/DESIGN: We will conduct a pragmatic three-arm cluster-randomised trial with 78 health facilities in two regions in Ethiopia. Facilities are randomised (1:1:1) to either of the two intervention arms or standard of care. Adults aged ≥ 18 years with drug-sensitive (DS) pulmonary TB are enrolled over 12 months and followed-up for 12 months after treatment initiation. Participants in facilities randomised to either of the two intervention arms are offered a DAT linked to the web-based ASCENT adherence platform for daily adherence monitoring and differentiated response to patient adherence for those who have missed doses. Participants at standard of care facilities receive routine care. For those that had bacteriologically confirmed TB at treatment initiation and can produce sputum without induction, sputum culture will be performed approximately 6 months after the end of treatment to measure disease recurrence. The primary endpoint is a composite unfavourable outcome measured over 12 months from TB treatment initiation defined as either poor end of treatment outcome (lost to follow-up, death, or treatment failure) or treatment recurrence measured 6 months after the scheduled end of treatment. This study will also evaluate the effectiveness, feasibility, and cost-effectiveness of DAT systems for DS-TB patients. DISCUSSION: This trial will evaluate the impact and contextual factors of medication label and smart pillbox with a differentiated response to patient care, among adult pulmonary DS-TB participants in Ethiopia. If successful, this evaluation will generate valuable evidence via a shared evaluation framework for optimal use and scale-up. TRIAL REGISTRATION: Pan African Clinical Trials Registry PACTR202008776694999, https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=12241 , registered on August 11, 2020

Measuring socioeconomic inequalities in postnatal health checks for newborns in Ethiopia: a decomposition analysis

BackgroundAddressing health inequity is a top priority for achieving sustainable development goals. The existing evidences in Ethiopia have shown that there are substantial inequalities in the use of health services among various socioeconomic strata. Therefore, the present study aimed to measure socioeconomic inequalities and the contributing factors in postnatal health checks for newborns in Ethiopia.MethodsWe used a secondary data from the recent 2019 Ethiopia Mini Demographic and Health Survey dataset. The study includes a weighted sample of 2,105 women who gave birth in the 2 years preceding to the survey. The study participants were selected using two stage cluster sampling techniques. The socioeconomic inequality in postnatal health checks for newborns was measured using the Erreygers Normalized Concentration Index (ECI) and illustrated by the concentration curve. A decomposition analysis was done to identify factors contributing to the socioeconomic related inequality in postnatal health checks for newborns in Ethiopia.ResultsThe concentration curve of postnatal health checks for newborns lay below the line of equality, and the Erreygers normalized concentration index was 0.133, with a standard error = 0.0333, and a p value <0.001; indicating that the postnatal health check for newborns was disproportionately concentrated among newborns with higher socioeconomic status. The decomposition analysis reported that antenatal care (ANC) visit (59.22%), household wealth index (34.43%), and educational level of the mother (8.58%) were the major contributors to the pro-rich socioeconomic inequalities in postnatal health checks for newborns.ConclusionThe finding revealed that there is a pro-rich inequality in postnatal health checks for newborns in Ethiopia. To reduce the observed socioeconomic health inequality, the government needs to improve ANC visits, implement strategies to access health service for economically disadvantaged groups, and increase educational attainment among women

Healthcare Access and Quality Index based on mortality from causes amenable to personal health care in 195 countries and territories, 1990-2015 : a novel analysis from the Global Burden of Disease Study 2015

Background National levels of personal health-care access and quality can be approximated by measuring mortality rates from causes that should not be fatal in the presence of effective medical care (ie, amenable mortality). Previous analyses of mortality amenable to health care only focused on high-income countries and faced several methodological challenges. In the present analysis, we use the highly standardised cause of death and risk factor estimates generated through the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) to improve and expand the quantification of personal health-care access and quality for 195 countries and territories from 1990 to 2015. Methods We mapped the most widely used list of causes amenable to personal health care developed by Nolte and McKee to 32 GBD causes. We accounted for variations in cause of death certification and misclassifications through the extensive data standardisation processes and redistribution algorithms developed for GBD. To isolate the effects of personal health-care access and quality, we risk-standardised cause-specific mortality rates for each geography-year by removing the joint effects of local environmental and behavioural risks, and adding back the global levels of risk exposure as estimated for GBD 2015. We employed principal component analysis to create a single, interpretable summary measure-the Healthcare Quality and Access (HAQ) Index-on a scale of 0 to 100. The HAQ Index showed strong convergence validity as compared with other health-system indicators, including health expenditure per capita (r= 0.88), an index of 11 universal health coverage interventions (r= 0.83), and human resources for health per 1000 (r= 0.77). We used free disposal hull analysis with bootstrapping to produce a frontier based on the relationship between the HAQ Index and the Socio-demographic Index (SDI), a measure of overall development consisting of income per capita, average years of education, and total fertility rates. This frontier allowed us to better quantify the maximum levels of personal health-care access and quality achieved across the development spectrum, and pinpoint geographies where gaps between observed and potential levels have narrowed or widened over time. Findings Between 1990 and 2015, nearly all countries and territories saw their HAQ Index values improve; nonetheless, the difference between the highest and lowest observed HAQ Index was larger in 2015 than in 1990, ranging from 28.6 to 94.6. Of 195 geographies, 167 had statistically significant increases in HAQ Index levels since 1990, with South Korea, Turkey, Peru, China, and the Maldives recording among the largest gains by 2015. Performance on the HAQ Index and individual causes showed distinct patterns by region and level of development, yet substantial heterogeneities emerged for several causes, including cancers in highest-SDI countries; chronic kidney disease, diabetes, diarrhoeal diseases, and lower respiratory infections among middle-SDI countries; and measles and tetanus among lowest-SDI countries. While the global HAQ Index average rose from 40.7 (95% uncertainty interval, 39.0-42.8) in 1990 to 53.7 (52.2-55.4) in 2015, far less progress occurred in narrowing the gap between observed HAQ Index values and maximum levels achieved; at the global level, the difference between the observed and frontier HAQ Index only decreased from 21.2 in 1990 to 20.1 in 2015. If every country and territory had achieved the highest observed HAQ Index by their corresponding level of SDI, the global average would have been 73.8 in 2015. Several countries, particularly in eastern and western sub-Saharan Africa, reached HAQ Index values similar to or beyond their development levels, whereas others, namely in southern sub-Saharan Africa, the Middle East, and south Asia, lagged behind what geographies of similar development attained between 1990 and 2015. Interpretation This novel extension of the GBD Study shows the untapped potential for personal health-care access and quality improvement across the development spectrum. Amid substantive advances in personal health care at the national level, heterogeneous patterns for individual causes in given countries or territories suggest that few places have consistently achieved optimal health-care access and quality across health-system functions and therapeutic areas. This is especially evident in middle-SDI countries, many of which have recently undergone or are currently experiencing epidemiological transitions. The HAQ Index, if paired with other measures of health-systemcharacteristics such as intervention coverage, could provide a robust avenue for tracking progress on universal health coverage and identifying local priorities for strengthening personal health-care quality and access throughout the world. Copyright (C) The Author(s). Published by Elsevier Ltd.Peer reviewe

Some major school health problems in southern Ethiopia: Malnutrition, parasite infections, and skin problems

God helse og ernæring er viktige forutsetninger for god utdanning. Selv om dødeligheten hos barn i skolealder er lavere enn hos yngre barn, er ernæringsmessige mangler og infeksjonssykdommer fortsatt de hyppigste dødsårsakene. Mange skolebarn er fortsatt underernærte, har tarmparasitter og hudproblemer. Skolehelsetjenesten i landet som Etiopia er svak. Anemi og kronisk underernæring sees ofte hos samme barn, og deler felles risikofaktorer, men få har undersøkt dette i Etiopia. Selv om det er dokumentert en høy forekomst av innvollsormer, er det få studier om intensitet av innvollsormer, noe som er avgjørende for å forstå hvor syke barn blir. Mange skolebarn har skabb eller soppinfeksjoner i huden. Mange barn er også affisert av en «jordloppe»-infeksjon (tunga penetrans). Hovedmålsetningen med avhandlingen var å undersøke hyppig forekommende helseproblemer blant skolebarn i alderen sju til fjorten år i Sør-Etiopia. De spesifikke formålene med avhandlingen var 1/ å undersøke samtidig forekomst av anemi og kronisk underernæring 2/ å kartlegge forekomst og intensitet an innvollsormer blant skolebarn, og 3/ å analysere risikofaktorer for hyppig forekommende hudproblemer som soppinfeksjoner, skabb og jordloppe infeksjoner. Studien ble utført i Wonago området i Gedeo i Sør-Etiopia. Utvalget bestod av 864 skolebarn som ble tilfeldig utvalgt fra 2384 skolebarn i tre skoler på landsbygda. Vi samlet sosiodemografiske data, og målte ernæringsstatus, hemoglobin, forekomst av innvollsormer og hudinfeksjoner. Til å analysere data bruke vi også multivariate, multilevel, mixed-effect, regresjonsmodeller for å forstå hvorledes risikofaktorer på individ, familie, skoleklasse og skolenivå kan forklare resultatene. Dataene i artikkel om hudinfeksjoner ble også analysert med Bayesiansk statistikk. Fattigdom og hygieniske faktorer som hyppighet av handvask, bruk av sko, og tilgang på vaskefasiliteter på skolene forklarte noen av risikofaktorene for flere av infeksjonssykdommene. Studien viser at anemi og kronisk underernæring er et moderat stort helseproblem. Selv om det har vært noen helseprogrammer, er forekomsten av innvollsormer og hudproblemer høy. Risikofaktorer for disse helseproblemet er relatert til faktorer på skolene, i heimene og hos det enkelte skolebarn. Fattigdom og hygieniske faktorer som hyppighet av handvask, bruk av sko, og tilgang på vaskefasiliteter på skolene kan forklare noen av risikofaktorene for flere av infeksjonssykdommene. Avhandlingen, som er en av de første i Etiopia om skolehelse, anbefaler at intervensjoner må omfatte forebyggende og behandlende tiltak både på individ, heim og skolenivå