Implementation of quality improvement for community-based health services: what worked, what didn’t, and why? A case study in Ethiopia

Background: Recently, there has been a growing interest in quality improvement (QI) interventions to enhance the health care services provision. However, applying QI interventions to community-based health services (CBHS) is still a limited practice. Strengthening Ethiopia’s Urban Health Program (SEUHP), implemented by John Snow, Inc., used QI principles to address certain challenges in the implementation of the urban health extension program (UHEP). QI activities aimed to improve referral systems between the UHEP and health centers (HCs), strengthen the defaulter tracing system, and enhance linkages and integration between facility-based primary health services and community-based extension services. Aim: This case study reviews the implementation and documents lessons learned from the SEUHP QI intervention. Method: Assessment and multiple case study design to review the implementation and document lessons learned. The study reviews multiple data sources and qualitatively analyzes the experience of QI teams (QIT) in different regions in Ethiopia. Findings: The functionality of the QIT varies across the regions. Where QI interventions function, demand for specific health services increased and QITs met targeted improvement objectives. The linkage and integration between the community-based UHEP extension services and facility health services improved as the result of QI intervention. Conclusion: This case study provides evidence that, despite challenges, QI interventions can be an important tool for facilitating health services. Functional QITs helped motivate Urban Health Extension Professionals (UHE-ps) to effectively execute their job. The QIT’s commitment, the regularity of QIT meetings, and the engagement of all staff and community groups are key factors in the successful implementation of QI initiatives that resulted in improved quality of service provision. [Ethiop. J. Health Dev. 2020; 34(Special issue 2):54-61] Keywords: Quality Improvement, Community, Urban Health, Ethiopi

Stunting disparities and its associated factors among preschool children of employed and unemployed mothers in Gondar City: a comparative community-based cross-sectional study

IntroductionA stunted child refers to a child who is too short for his/her age, which is the most common cause of morbidity and mortality in children under five in developing countries. Stunting in preschool children is caused by a multitude of socioeconomic and child-related factors, including the employment status of women. This study aimed to compare the prevalence and factors associated with stunting of preschool children among employed and unemployed mothers in Gondar city, Northwest Ethiopia, in 2021.MethodsFrom 30 February to 30 March 2021, a community-based comparative cross-sectional study was conducted among 770 preschool children of employed and unemployed mothers in Gondar city. A structured questionnaire-based interview with anthropometric measurements was used to collect data. A multi-stage sampling technique was used. Data were entered into EPI Info version 7.22 and transferred to Stata version 14 for further analysis. To identify factors associated with stunting, a binary logistic regression analysis was used. The presence of an association was declared based on a p-value of <0.05 and confidence intervals.ResultsA total of 770 preschool children participated in the study. The overall prevalence of stunting among preschool children was 39.7% (95% CI: 36.3–43.2). The prevalence was higher among preschool children of employed mothers (42.6%) (95% CI: 37.6–47.5) than among unemployed mothers (36.7%) (95% CI: 32.0–41.7). Maternal age [AOR = 2.8, 95% CI: 1.26–6.34] and wealth status [AOR = 0.32, 95% CI: 0.18–0.57] were significantly associated with stunting among unemployed mothers, while family size [AOR = 7.19, 95% CI: 2.95–17.5], number of children under the age of five [AOR = 1.92, 95% CI: 1.12–3.29], and having a home servant [AOR = 0.126, 95% CI: 0.06–0.26] were associated with stunting of preschool children among employed mothers.ConclusionStunting is more common in preschool children of employed mothers than in those of unemployed mothers. As a result, interventions such as raising awareness among employed mothers to devote time and care to their children, as well as concerned bodies assisting women with preschool or under-five children, is required. The nutrition intervention should focus on encouraging dietary diversity to combat the existing nutrition-associated stunting in children. Similarly, further research on the difference between employed and unemployed mothers' child stunting status as well as an investigation of extra variables such as the number of hours worked by an employed mother is also recommended to upcoming researchers

Evidence of the interplay of genetics and culture in Ethiopia.

Funder: RCUK | Natural Environment Research Council (NERC); doi: https://doi.org/10.13039/501100000270The rich linguistic, ethnic and cultural diversity of Ethiopia provides an unprecedented opportunity to understand the level to which cultural factors correlate with-and shape-genetic structure in human populations. Using primarily new genetic variation data covering 1,214 Ethiopians representing 68 different ethnic groups, together with information on individuals' birthplaces, linguistic/religious practices and 31 cultural practices, we disentangle the effects of geographic distance, elevation, and social factors on the genetic structure of Ethiopians today. We provide evidence of associations between social behaviours and genetic differences among present-day peoples. We show that genetic similarity is broadly associated with linguistic affiliation, but also identify pronounced genetic similarity among groups from disparate language classifications that may in part be attributable to recent intermixing. We also illustrate how groups reporting the same culture traits are more genetically similar on average and show evidence of recent intermixing, suggesting that shared cultural traits may promote admixture. In addition to providing insights into the genetic structure and history of Ethiopia, we identify the most important cultural and geographic predictors of genetic differentiation and provide a resource for designing sampling protocols for future genetic studies involving Ethiopians

Preliminary Report: Missense mutations in the APOL gene family are associated with end stage kidney disease risk previously attributed to the MYH9 gene

MYH9 has been proposed as a major genetic risk locus for a spectrum of non-diabetic end stage kidney disease (ESKD). We use recently released sequences from the 1000 Genomes Project to identify two western African specific missense mutations (S342G and I384M) in the neighbouring APOL1 gene, and demonstrate that these are more strongly associated with ESKD than previously reported MYH9 variants. We also show that the distribution of these risk variants in African populations is consistent with the pattern of African ancestry ESKD risk previously attributed to the MYH9 gene. Additional associations were also found among other members of the APOL gene family, and we propose that ESKD risk is caused by western African variants in members of the APOL gene family, which evolved to confer protection against pathogens, such as Trypanosoma.Comment: 25 pages, 6 figure

Measuring progress and projecting attainment on the basis of past trends of the health-related Sustainable Development Goals in 188 countries: an analysis from the Global Burden of Disease Study 2016

The UN’s Sustainable Development Goals (SDGs) are grounded in the global ambition of “leaving no one behind”. Understanding today’s gains and gaps for the health-related SDGs is essential for decision makers as they aim to improve the health of populations. As part of the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016), we measured 37 of the 50 health-related SDG indicators over the period 1990–2016 for 188 countries, and then on the basis of these past trends, we projected indicators to 2030

Global, regional, and national disability-adjusted life-years (DALYs) for 333 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016

BACKGROUND: Measurement of changes in health across locations is useful to compare and contrast changing epidemiological patterns against health system performance and identify specific needs for resource allocation in research, policy development, and programme decision making. Using the Global Burden of Diseases, Injuries, and Risk Factors Study 2016, we drew from two widely used summary measures to monitor such changes in population health: disability-adjusted life-years (DALYs) and healthy life expectancy (HALE). We used these measures to track trends and benchmark progress compared with expected trends on the basis of the Socio-demographic Index (SDI). METHODS: We used results from the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 for all-cause mortality, cause-specific mortality, and non-fatal disease burden to derive HALE and DALYs by sex for 195 countries and territories from 1990 to 2016. We calculated DALYs by summing years of life lost and years of life lived with disability for each location, age group, sex, and year. We estimated HALE using age-specific death rates and years of life lived with disability per capita. We explored how DALYs and HALE differed from expected trends when compared with the SDI: the geometric mean of income per person, educational attainment in the population older than age 15 years, and total fertility rate. FINDINGS: The highest globally observed HALE at birth for both women and men was in Singapore, at 75·2 years (95% uncertainty interval 71·9-78·6) for females and 72·0 years (68·8-75·1) for males. The lowest for females was in the Central African Republic (45·6 years [42·0-49·5]) and for males was in Lesotho (41·5 years [39·0-44·0]). From 1990 to 2016, global HALE increased by an average of 6·24 years (5·97-6·48) for both sexes combined. Global HALE increased by 6·04 years (5·74-6·27) for males and 6·49 years (6·08-6·77) for females, whereas HALE at age 65 years increased by 1·78 years (1·61-1·93) for males and 1·96 years (1·69-2·13) for females. Total global DALYs remained largely unchanged from 1990 to 2016 (-2·3% [-5·9 to 0·9]), with decreases in communicable, maternal, neonatal, and nutritional (CMNN) disease DALYs offset by increased DALYs due to non-communicable diseases (NCDs). The exemplars, calculated as the five lowest ratios of observed to expected age-standardised DALY rates in 2016, were Nicaragua, Costa Rica, the Maldives, Peru, and Israel. The leading three causes of DALYs globally were ischaemic heart disease, cerebrovascular disease, and lower respiratory infections, comprising 16·1% of all DALYs. Total DALYs and age-standardised DALY rates due to most CMNN causes decreased from 1990 to 2016. Conversely, the total DALY burden rose for most NCDs; however, age-standardised DALY rates due to NCDs declined globally. INTERPRETATION: At a global level, DALYs and HALE continue to show improvements. At the same time, we observe that many populations are facing growing functional health loss. Rising SDI was associated with increases in cumulative years of life lived with disability and decreases in CMNN DALYs offset by increased NCD DALYs. Relative compression of morbidity highlights the importance of continued health interventions, which has changed in most locations in pace with the gross domestic product per person, education, and family planning. The analysis of DALYs and HALE and their relationship to SDI represents a robust framework with which to benchmark location-specific health performance. Country-specific drivers of disease burden, particularly for causes with higher-than-expected DALYs, should inform health policies, health system improvement initiatives, targeted prevention efforts, and development assistance for health, including financial and research investments for all countries, regardless of their level of sociodemographic development. The presence of countries that substantially outperform others suggests the need for increased scrutiny for proven examples of best practices, which can help to extend gains, whereas the presence of underperforming countries suggests the need for devotion of extra attention to health systems that need more robust support. FUNDING: Bill & Melinda Gates Foundation

The impact of urbanization expansion on agricultural land in Ethiopia: A review

In a country like Ethiopia where the vast majority of the populations are employed in agriculture, land is an important economic resource for the development of rural livelihoods. Agricultural land in peri-urban areas is, however, transformed into built-up regions through horizontal urban expansion that has an effect on land use value. In recent years Ethiopia has been experiencing rapid urbanization, which has led to an ever-increasing demand for land in peri-urban areas for housing and other nonagricultural activities that pervades agricultural land. There is a high demand for informal and illegal peri-urban land which has been held by peri-urban farmers, and this plays a vital role in the unauthorized and sub-standard house construction on agricultural land. This urbanization has not been extensively reviewed and documented. In this review an attempt has been made to assess the impacts of rapid urbanization on agricultural activities. Urban expansion has reduced the areas available for agriculture, which has seriously impacted upon peri-urban farmers that are often left with little or no land to cultivate and which has increased their vulnerability. Housing encroachments have been observed to be uncontrolled due to a weak government response to the trend of unplanned city expansion. This has left peri-urban farmers exposed to the negative shocks of urbanization because significant urbanization-related agricultural land loss has a positive correlation with grain production decrease. Appropriate governing bodies should control urban development in order to control the illegal and informal spread of urbanization on agricultural land that threatens food production

Climate-smart agriculture in Ethiopia: Adoption of multiple crop production practices as a sustainable adaptation and mitigation strategies

Given that Ethiopian agriculture is seriously threatened by climate change, understanding the factors that influencing the adoption of various climate-smart agricultural (CSA) practices supports policy interventions to reduce negative effects of climate change. Therefore, this study was aimed at exploring determinants of the adoption of multiple CSA practices by focusing on crop production. This study used data from 271 randomly selected smallholder farmers from the Gamo, Gofa and Konso zones of Southern Ethiopia, and a multivariate probit (MVP) model was used to analyze the data. Crop diversification, irrigation, drought-tolerant and early-maturing crop varieties, integrated soil fertility management, and integrated pest management were prominent CSA practices to improve crop productivity, increase adaptivity capacity, and mitigate the adverse climate change effects in the study area. The study's findings indicate that the adoption of CSA practices varies considerably between farmers and agroecology. The MVP simulation result reveals that farmers’ adoption decisions for CSA practices are highly interdependent, indicating that farmers adopt two or more adaptation and mitigation strategies as mutual CSA practices. Furthermore, the regression result reveals that the education level of farmers, extension contact, accessing climate variability information, access to irrigation facilities, and social group participation were similar underlying factors that affected the adoption decision of CSA practices. By providing climate change information, respective organizations should encourage farmers to utilize available alternate irrigation access and climate-resilient crop varieties. In addition, strengthening social norms through agricultural cooperatives and training on the application of integrated pest management and soil fertility management are suggested to spur farmers' CSA uptake

Prevalence and Associated Factors of Depression among Pregnant Mothers Who Had Intimate Partner Violence during Pregnancy Attending Antenatal Care at Gondar University Hospital Northwest Ethiopia in 2020

Background. Antenatal depression is the major obstetric problem that led to significant maternal and perinatal morbidity and mortality worldwide, especially in the third world. However, in Ethiopia this prevalence and association were not studied, as result, this study investigated the prevalence and associated factors of antenatal depression among pregnant mothers who had intimate partner violence during pregnancy. Methodology. An institution-based cross-sectional study was done among 409 pregnant mothers who had intimate partner violence during pregnancy from May to July 2019 at Gondar University Hospital. All pregnant mothers who came for ANC follow-up during the study period approached for screening of intimate partner violence during pregnancy using standard and validated screening method and instrument of the WHO multicountry study on women’s health and domestic violence to evaluate intimate partner violence, and we use EPDS for the evaluation of antenatal depression validated in Ethiopia with a cut point of 13. Result. Prevalence of depression among pregnant mothers who had any form of intimate partner violence during pregnancy was 35%: physical abuse (AOR=1.8; 95% CI: 1.19, 3.30), more than one type of abuse (AOR=10.18; 95% CI: 7.10, 16.18), poor social support (AOR=5.81; 95% CI: 1.12, 13.12), and pregnant mothers whose partner drunk for the past twelve months (AOR=7.16; 95% CI: 183, 8.00) were significantly associated with antenatal depression. Conclusion. High prevalence of antenatal depression among pregnant mothers who had intimate partner violence during pregnancy was highly associated with physical abuse, more than one type of abuse, lack of social support, and partner of pregnant mothers who is a drunk. Hence, this is important to create a screening program and prevention strategy of intimate partner violence during pregnancy at the time of antenatal follow-up to prevent and early identify its morbidity and mortality