Cost and Cost-Effectiveness of Smear-Positive Tuberculosis Treatment by Health Extension Workers in Southern Ethiopia: A Community Randomized Trial

by HEWs in the health posts and general health workers at health facility were compared along a community-randomized trial. Costs were analysed from societal perspective in 2007 in US $using standard methods. We prospectively enrolled smear positive patients, and calculated cost-effectiveness as the cost per patient successfully treated. The total cost for each successfully treated smear-positive patient was higher in health facility ($158.9) compared with community ($61.7). Community-based treatment reduced the total, patient and caregiver cost by 61.2$8.80 (14.3 % of total cost) on health service per patient treated in the community. Conclusions/Significance: Community-based treatment by HEWs costs only 39 % of what treatment by general health workers costs for similar outcomes. Involving HEWs in TB treatment is a cost effective treatment alternative to the health service, to the patients and the family. There is an economic and public health reason to consider involving HEWs in TB treatment in Ethiopia. However, community-based treatment requires initial investment to start its implementation, training and supervision

Applied research on health extension workers using ehealth to strengthen equitable systems in Southern Ethiopia health

The project successfully established an eHealth system in Southern Ethiopia. It provided training for and engaging of health extension workers (HEWs), supervisors, Health Management Information System (HMIS) focal persons, and policy makers. It was conducted in Sidama and Gedeo zones in Southern Ethiopia, with Sidama zone being the intervention zone, and Gedeo the control zone. Over 60 female health extension workers were trained. Data can be collected in real-time and is accessible throughout all levels of the health system. This has created stronger links with policy makers for action. Over 200,000 rural women and men benefit from improved health services

Exploring providers’ perspectives of a community based TB approach in Southern Ethiopia: implication for community based approaches

Abstract Background There is increasing interest in the role of close-to-community providers in supporting universal health coverage, but questions remain about the best approaches to supporting and motivating these providers, and the optimal package they can deliver indifferent contexts and support required. We report on the experiences of different health providers involved in a community based intervention to support access to tuberculosis diagnosis and treatment in Southern Ethiopia. Methods The aim of the study is to explore the experiences of health providers in delivering a community-based tuberculosis package in southern Ethiopia and to draw lessons for community-based programmes. A qualitative methodology was used. Methods included in-depth interviews (IDIs, n= 37) with all health provider groups: Community health promoters (CHPs), health extension workers (HEWs), district supervisors and laboratory technicians were undertaken to obtain a detailed understanding of the experiences of providers in the community based tuberculosis package. These were complemented with cadre specific focus group discussions (n= 3). We used the framework approach for qualitative analysis. Results The key theme that emerged was the positive impact the community-based intervention had on vulnerable groups’ access to diagnosis, care and treatment for tuberculosis. Providers found the positive feedback from, and visible impact on, communities very motivating. Other themes related to motivation and performance included supervision and support; learning new skills; team problem solving/ addressing challenges and incentives. Against the backdrop of the Ethiopian Health Extension Programme (HEP), HEWs were successfully able to take on new tasks (collecting sputum and preparing smears) with additional training and appropriate support from supervisors, laboratory technicians and CHPs. Conclusion All categories of providers were motivated by the high visible impact of the community-based intervention on poor and vulnerable communities and households. HEWs role in the community-based intervention was supported and facilitated through the structures and processes established within the community-based intervention and the broader nation-wide Health Extension Programme. Within community based approaches there is need to develop context embedded strategies to support, sustain and motivate this critical cadre who play a pivotal role in linking health systems and rural communities

High utility of active tuberculosis case finding in an Ethiopian prison

SETTING: Hawassa Prison, Southern Region of Ethiopia. OBJECTIVE: To determine the burden of pulmonary tuberculosis (TB) using active case finding among prisoners. DESIGN: In this cross-sectional study, prisoners were screened for TB using a symptom screen. Those with cough of 2 weeks had spot and morning sputum samples collected for acid-fast bacilli (AFB) smear microscopy and molecular diagnostic testing (Xpert® MTB/RIF). RESULTS: Among 2068 prisoners, 372 (18%) had a positive cough screen. The median age of these 372 persons was 23 years, 97% were male and 63% were from urban areas. Among those with a positive symptom screen, 8 (2%) were AFB sputum smear-positive and 31 (8%) were Xpert-positive. The point prevalence of pulmonary TB at the prison was 1748 per 100 000 persons. In multivariate analysis, persons with cough >4 weeks were more likely to have TB (OR 3.34, 95%CI 1.54–7.23). CONCLUSION: A high prevalence of TB was detected among inmates at a large Ethiopian prison. Active case finding using a cough symptom screen in combination with Xpert had high utility, and has the potential to interrupt transmission of Mycobacterium tuberculosis in correctional facilities in low- and middle-income, high-burden countries

Community participation and maternal health service utilization: lessons from the health extension programme in rural southern Ethiopia

Background Health extension workers (HEWs) are the implementers of the unique primary health care programme of Ethiopia. They facilitate community participation in maternal health service delivery via the health development army (HDA) and pregnant women forums (PWFs). As part of a quality improvement intervention, HEWs received training, guidance and supervision focused on facilitation of HDA meetings and PWFs. We aimed to assess the effect of the intervention on maternal health service utilization and explore the perceptions of stakeholders regarding efforts to enhance community participation in maternal health. Methods We conducted a mixed method study in Shebedino woreda (district), Sidama Zone, southern Ethiopia. The research team observed HDA meetings and PWFs (15), conducted in-depth interviews with 32 HEWs, 8 HEW supervisors and maternal health program managers, and conducted 8 focus group discussions (FGDs) with community members. The interviews and FGDs were recorded, transcribed, translated, coded in Nvivo and thematically analysed. We also collected quantitative data on HDA and PWF participation, antenatal care attendance and skilled delivery and analysed using Excel (Microsoft Inc, Seattle, WA, USA). Results The proportion of HDA leaders and pregnant women who attended the HDA and PWF meetings increased by 30.6% and 36% respectively, over 18 months of the intervention. The percentage of pregnant women identified and referred by HDA leaders increased from 42% to 85%, the antenatal care utilization increased from 73.4% to 77.6% and skilled delivery increased from 76.7% to 83.3%,) (p<0.05). From interviews with stakeholders, we found improved awareness about maternal health services and increased health seeking behaviour. However, lack of incentives and reporting formats for HDA leaders, absenteeism and limited support from kebele administrators constrained community participation in maternal health. Conclusion With focused training, guidance and regular supportive supervision, HEWs were able to stimulate and enhance community participation, resulting in better maternal health service utilization in rural communities. HEWs, volunteer HDAs, pregnant women and the wider community have a role to play in quality improvement of maternal health services

Women health extension workers: Capacities, opportunities and challenges to use eHealth to strengthen equitable health systems in Southern Ethiopia.

OBJECTIVES: This study assesses the feasibility of female health extension workers (HEWs) using eHealth within their core duties, supporting both the design and capacity building for an eHealth system project focussed initially on tuberculosis, maternal child health, and gender equity. PARTICIPANTS: Health extension workers, Health Centre Heads, District Health Officers, Zonal Health Department and Regional Health Bureau representatives in Southern Ethiopia. SETTING: The study was undertaken in Southern Ethiopia with three districts in Sidama zone (population of 3.5 million) and one district in Gedeo zone (control zone with similar health service coverage and population density). METHODS: Mixed method baseline data collection was undertaken, using quantitative questionnaires (n = 57) and purposively sampled qualitative face-to-face semi-structured interviews (n = 10) and focus group discussions (n = 3). RESULTS: Themes were identified relating to HEW commitment and role, supervision, and performance management. The Health Management Information System (HMIS) was seen as important by all participants, but with challenges of information quality, accuracy, reliability and timeliness. Participants' perceptions varied by group regarding the purpose and benefits of HMIS as well as the potential of an eHealth system. Mobile phones were used regularly by all participants. CONCLUSION: eHealth technology presents a new opportunity for the Ethiopian health system to improve data quality and community health. Front-line female HEWs are a critical bridge between communities and health systems. Empowering HEWs, supporting them and responding to the challenges they face will be an important part of ensuring the sustainability and responsiveness of eHealth strategies. Findings have informed the subsequent eHealth technology design and implementation, capacity strengthening approach, supervision, and performance management approach

Health extension workers improve tuberculosis case finding and treatment outcome in Ethiopia: a large-scale implementation study.

BackgroundTuberculosis (TB) is a major cause of death in Ethiopia. One of the main barriers for TB control is the lack of access to health services.MethodsWe evaluated a diagnostic and treatment service for TB based on the health extension workers (HEW) of the Ethiopian Health Extension Programme in Sidama Zone, with 3.5 million population. We added the services to the HEW routines and evaluated their effect over 4.5 years. 1024 HEWs were trained to identify individuals with symptoms of TB, request sputum samples and prepare smears. Smears were transported to designated laboratories. Individuals with TB were offered treatment at home or the local health post. A second zone (Hadiya) with 1.2 million population was selected as control. We compared TB case notification rates (CNR) and treatment outcomes in the zones 3 years before and 4.5 years after intervention.ResultsHEWs identified 216 165 individuals with symptoms and 27 918 (12%) were diagnosed with TB. Smear-positive TB CNR increased from 64 (95% CI 62.5 to 65.8) to 127 (95% CI 123.8 to 131.2) and all forms of TB increased from 102 (95% CI 99.1 to 105.8) to 177 (95% CI 172.6 to 181.0) per 100 000 population in the first year of intervention. In subsequent years, the smear-positive CNR declined by 9% per year. There was no change in CNR in the control area. Treatment success increased from 76% before the intervention to 95% during the intervention. Patients lost to follow-up decreased from 21% to 3% (pConclusionA community-based package significantly increased case finding and improved treatment outcome. Implementing this strategy could help meet the Ethiopian Sustainable Development Goal targets

Sub-national prevalence survey of tuberculosis in rural communities of Ethiopia

Abstract Background Tuberculosis is a major public health problem with varying prevalence in different settings. National prevalence surveys provide evidence for planning and decision making. However, they lack the capacity to estimate subnational magnitude that affected the capacity to make selected intervention based on the prevalence. Ethiopia is among high TB burden countries with estimated prevalence of 108 per 100,000 population varying by regions. We aimed to study sub national prevalence of smear-positive TB in rural communities of southern Ethiopia. Methods This cross-sectional study, enrolled community members aged over 14 years who had cough of at least two weeks duration. Two sputum samples were collected and examined by using smear microscopy. Results 38,304 eligible people were enumerated (10,779 from Hadiya, 10,059 from Gurage and 17,466 from Sidama) and indentified 960 presumptive cases. 16, 14 and 14 smear-positive pulmonary TB cases were identified respectively. The point prevalence of smear-positive TB were 148 per 100,000 population (95% CI: 91–241) in Hadiya, 139 per 100,000 population (95% CI: 83–234) in Gurage and 80/100,000 population (95%CI: 48–135) in Sidama zone. Gurage zone had the highest prevalent to notified cases of seven to one. Conclusions The prevalence of smear positive TB varies by districts and is high in rural southern Ethiopia compared to the estimated national prevalence. More TB patients remain missed and unreached, impacting negatively on health outcomes. TB case finding approaches should be revisited and innovative approaches and tools to identify missing people with TB should be scaled up

Microbead-based spoligotyping of Mycobacterium tuberculosis from Ziehl-Neelsen-stained microscopy preparations in Ethiopia

The worldwide dissemination of Mycobacterium tuberculosis strains has led to the study of their genetic diversity. One of the most used genotyping methods is spoligotyping, based on the detection of spacers in the clustered regularly interspaced short palindromic repeats (CRISPR) locus. This study assessed the performance of a microbead-based spoligotyping assay using samples extracted from Ziehl-Neelsen-stained smear-microscopy preparations and described the genetic diversity of Mycobacterium tuberculosis among new TB patients in Southern Nations, Nationalities and Peoples’ Region (SNNPR) in Ethiopia. Among the 91 samples analysed, 59 (64.8%) generated spoligotyping patterns. Fifty (84.7%) samples were classified into 12 clusters (mostly Lineage 4 or 3) comprising 2–11 samples and nine had unique spoligotyping patterns. Among the 59 spoligotyping patterns, 25 belonged to the T1 sublineage, 11 to the T3-ETH, 5 to the URAL, 4 to the H3 and 14 to other L4 sublineages. There was a remarkable variation in genetic distribution in SNNPR compared to other regions of the country. Microbead-based spoligotyping is an easy-to-perform, high-throughput assay that can generate genotyping information using material obtained from smear microscopy preparations. The method provides an opportunity to obtain data of the M. tuberculosis genetic epidemiology in settings with limited laboratory resources