Biomedical waste disposal systems of health facilities in Ethiopia

Background: Biomedical waste generated from health and health-related activities can be grouped as general waste and hazardous waste. This remains true if and only if there is proper on-site handling, such as the segregation and separation of waste based on the type and nature of the source. Methods: A stratified random sampling design was used to provide representative results for Ethiopia, for various types of facility and management authorities, and for each of the 11 regions. Totally, 1327 health facilities were assessed using the World Health Organization (WHO) inventory tools. Results: Nationally, medical waste in 32.6% of the studied health facilities was stored in covered containers, and in about 27% of them it was stored in another protected environment. About 40% of health facilities stored their medical waste in unprotected areas. Twenty-eight (2.6%) and 420 (39.3%) health facilities used 2-chamber industrial incinerators and 1-chamber drum incinerators, respectively. About 58% of health facilities used unsafe waste treatment methods. The proportion of using safe medical waste disposal method was high in referral hospitals (87.9%). This shows the utilization of safe medical waste disposal methods is in decreasing order from higher to lower levels of organization in health facilities. Conclusion: The present study showed a preliminary finding on the waste disposal systems of health facilities at the national level. Dumping biomedical waste outside the health facility is common, and access to common waste facilities is limited. Therefore, a holistic approach to safe medical waste management practices, including the collection process (handling, sorting, and segregation), storage, treatment and final disposal is crucial in all types of health facilities, regardless of the level of organization, ownership, or geographic distribution. Keywords: Health Facility, Biomedical Waste, Disposal, Incinerator, Ethiopi

Geographic differences in maternal and child health care utilization in four Ethiopian regions; a cross-sectional study.

BACKGROUND: Maternal and child health (MCH) care utilization often vary with geographic location. We analyzed the geographic distribution and determinants of utilization of four or more antenatal care visits, health facility delivery, child immunization, and care utilization for common childhood illnesses across four Ethiopian regions. METHODS: A cross-sectional community-based study was employed with two-staged stratified cluster sampling in 46 districts of Ethiopia. A total of 6321 women (13-49 years) and 3110 children below the age of 5 years residing in 5714 households were included. We performed a cluster analysis of the selected MCH care utilization using spatial autocorrelation. We identified district-specific relationships between care coverage and selected factors using geocoded district-level data and ordinary least squares and hotspot analysis using Getis Ord Gi*. RESULTS: Of the 6321women included in the study, 714 had a live birth in the 12 months before the survey. One-third of the women (30, 95% CI 26-34) had made four or more antenatal visits and almost half of the women (47, 95% CI 43-51) had delivered their most recent child at a health facility. Nearly half of the children (48, 95% CI 40-57) with common childhood illnesses (suspected pneumonia, diarrhoea, or fever) sought care at the health facilities. The proportion of fully immunized children was 41% (95%, CI 37-45). Institutional delivery was clustered at district level (spatial autocorrelation, Moron's I = 0.217, P < 0.01). Full immunization coverage was also spatially clustered (Moron's I = 0.156, P-value < 0.1). Four or more antenatal visits were associated with women's age and parity, while the clustering of institutional delivery was associated with the number of antenatal care visits. Clustering of full immunization was associated with household members owning a mobile phone. CONCLUSIONS: This study showed evidence for geographic clustering in coverage of health facility deliveries and immunization at the district level, but not in the utilization of antenatal care and utilization of health services for common childhood illnesses. Identifying and improving district-level factors that influenced these outcomes may inform efforts to achieve geographical equitability and universal health coverage

Caregivers' and Health Extension Workers' Perceptions and Experiences of Outreach Management of Childhood Illnesses in Ethiopia: A Qualitative Study.

INTRODUCTION: Ethiopian Health Extension Workers provide facility-based and outreach services, including home visits to manage sick children, aiming to increase equity in service coverage. Little is known about the scope of the outreach services and caregivers' and health workers' perceptions of these services. We aimed at exploring mothers' and health extension workers' perceptions and experiences of the outreach services provided for the management of childhood illnesses. METHODS: Four focus groups and eight key informant interviews were conducted. A total of 45 community members participated. Interviews were recorded, transcribed verbatim, and translated into English. We applied thematic content analysis, identified challenges in providing outreach services, and suggestions for improvement. We balanced the data collection by selecting half of the participants for interview and focus group discussions from remote areas and the other half from areas closer to the health posts. RESULTS: Mothers reported that health extension workers visited their homes for preventive services but not for managing childhood illnesses. They showed lack of trust in the health workers' ability to treat children at home. The health extension workers reported that they provide sick children treatment during outreach services but also stated that in most cases, mothers visit the health posts when their child is sick. On the other hand, mothers considered distance from home to health post not to be a problem if the quality of services improved. Workload, long distances, and lack of incentives were perceived as demotivating factors for outreach services. The health workers called for support, incentives, and capacity development activities. CONCLUSIONS: Mothers and health extension workers had partly divergent perceptions of whether outreach curative services for children were available. Mothers wanted improvements in the quality of services while health workers requested capacity development and more support for providing effective community-based child health services

Socio-cultural Beliefs and Practices Influencing Institutional Delivery Service Utilization in Three Communities of Ethiopia: A Qualitative Study

BACKGROUND: The influence of socio-cultural factors on institutional birth is not sufficiently documented in Ethiopia. Thus, this study explores socio-cultural beliefs and practices during childbirth and its influences on the utilization of institutional delivery services.METHODS: A qualitative study was conducted in three regions of Ethiopia through eight focus group discussions (with women) and thirty in-depth interviews with key informants which included health workers, community volunteers, and leaders. The data were analyzed thematically.RESULTS: The study identified six overarching socio-cultural factors influencing institutional birth in the study communities. The high preference for traditional birth attendants (TBAs) and home as it is intergenerational culture and suitable for privacy are among the factors. Correspondingly, culturally unacceptable birth practices at health facilities (such as birth position, physical assessment, delivery coach) and inconvenience of health facility setting to practice traditional birth rituals such as newborn welcoming ceremony made women avoid health facility birth. On the other hand, misperceptions and worries on medical interventions such as episiotomy, combined with mistreatment from health workers, and lack of parent engagement in delivery process discouraged women from seeking institutional birth. The provision of delivery service by male health workers was cited as a social taboo and against communities' belief system which prohibited women from giving birth at a health facility.CONCLUSIONS: Multiple socio-cultural factors and perceptions were generally affected utilization of institutional birth in study communities. Hence, culturally competent interventions through education, re-orientation, and adaptation of beneficial norms combined with women friendly care are essential to promote health facility birth.

Distance, difference in altitude and socioeconomic determinants of utilisation of maternal and child health services in Ethiopia: a geographic and multilevel modelling analysis.

Objective We assessed whether geographic distance and difference in altitude between home to health facility and household socioeconomic status were associated with utilisation of maternal and child health services in rural Ethiopia. Design Household and health facility surveys were conducted from December 2018 to February 2019.SettingForty-six districts in the Ethiopian regions: Amhara, Oromia, Tigray and Southern Nations, Nationalities, and Peoples. Participants A total of 11 877 women aged 13-49 years and 5786 children aged 2-59 months were included.Outcome measuresThe outcomes were four or more antenatal care visits, facility delivery, full child immunisation and utilisation of health services for sick children. A multilevel analysis was carried out with adjustments for potential confounding factors. Results Overall, 39% (95% CI: 35 to 42) women had attended four or more antenatal care visits, and 55% (95% CI: 51 to 58) women delivered at health facilities. One in three (36%, 95% CI: 33 to 39) of children had received full immunisations and 35% (95% CI: 31 to 39) of sick children used health services. A long distance (adjusted OR (AOR)=0.57; 95% CI: 0.34 to 0.96) and larger difference in altitude (AOR=0.34; 95% CI: 0.19 to 0.59) were associated with fewer facility deliveries. Larger difference in altitude was associated with a lower proportion of antenatal care visits (AOR=0.46; 95% CI: 0.29 to 0.74). A higher wealth index was associated with a higher proportion of antenatal care visits (AOR=1.67; 95% CI: 1.02 to 2.75) and health facility deliveries (AOR=2.11; 95% CI: 2.11 to 6.48). There was no association between distance, difference in altitude or wealth index and children being fully immunised or seeking care when they were sick. Conclusion Achieving universal access to maternal and child health services will require not only strategies to increase coverage but also targeted efforts to address the geographic and socioeconomic differentials in care utilisation, especially for maternal health. Trial registration number ISRCTN12040912

Neglected Tropical Diseases (NTD) service availability at health facilities in Ethiopia: Evidence from 2014 Ethiopian service provision assessment

Background: Neglected tropical diseases (NTDs) are a group of infections which are especially endemic in low-income populations in developing regions of Africa, Asia, and the Americas. In sub-Saharan Africa, the impact of these diseases as a group is comparable to malaria and tuberculosis. The diseases recognized as neglected tropical diseases by the World Health Organization (WHO) are: Chagas disease, Cysticercosis and taeniasis, Dengue fever, Dracunculiasis, Echinococcosis, Human African trypanosomiasis, Leishmaniasis, Leprosy, Lymphatic filariasis, Onchocerciasis, Rabies, Schistosomiasis, Soil-transmitted helminthiasis, Trachoma, and Yaws. Most of these diseases are either preventable through mass drug administration (MDA) and proper hygiene and sanitation, or treatable through systematic case finding and management. This study was conducted with the aim of assessing the availability of services for neglected tropical diseases management at health facilities in Ethiopia.Method: The assessment is part of the 2014 Ethiopian Service Provision Assessment Plus (ESPA+) Survey. A total of 873 health facilities were assessed for this analysis. All Hospitals, selected health centre, and private clinics were assessed if they provide services for Neglected Tropical Diseases.Result: More than half of all health facilities offer services for both soil transmitted helminthes (64 percent), and services for trachoma (60 percent). About four of every ten health facilities offer services for schistosomiasis. On the other hand, services for onchocerciasis, leishmanianis and lymphatic filariases were available in less than a third of all health facilities (27%, 25% and 24%, respectively).Conclusion and recommendation: Even though, the availability of service for neglected tropical disease in health facilities is relatively good in general, there should be equitable distribution of neglected tropical disease service provision among regions. And private facilities should give emphasis for the provision of these services. Key words: Service Availability, NTDs, SPA+, Ethiopia

Implementation of the 'Optimising the Health Extension Program' Intervention in Ethiopia: A Process Evaluation Using Mixed Methods.

An intervention called 'Optimising the Health Extension Program', aiming to increase care-seeking for childhood illnesses in four regions of Ethiopia, was implemented between 2016 and 2018, and it included community engagement, capacity building, and district ownership and accountability. A pragmatic trial comparing 26 districts that received the intervention with 26 districts that did not found no evidence to suggest that the intervention increased utilisation of services. Here we used mixed methods to explore how the intervention was implemented. A fidelity analysis of each 31 intervention activities was performed, separately for the first phase and for the entire implementation period, to assess the extent to which what was planned was carried out. Qualitative interviews were undertaken with 39 implementers, to explore the successes and challenges of the implementation, and were analysed by using thematic analysis. Our findings show that the implementation was delayed, with only 19% (n = 6/31) activities having high fidelity in the first phase. Key challenges that presented barriers to timely implementation included the following: complexity both of the intervention itself and of administrative systems; inconsistent support from district health offices, partly due to competing priorities, such as the management of disease outbreaks; and infrequent supervision of health extension workers at the grassroots level. We conclude that, for sustainability, evidence-based interventions must be aligned with national health priorities and delivered within an existing health system. Strategies to overcome the resulting complexity include a realistic time frame and investment in district health teams, to support implementation at grassroots level

Factors associated with the referral of children with severe illnesses at primary care level in Ethiopia: a cross-sectional study.

Context and objective Ethiopia's primary care has a weak referral system for sick children. We aimed to identify health post and child factors associated with referrals of sick children 0-59 months of age and evaluate the healthcare providers' adherence to referral guidelines. Design A cross-sectional facility-based survey. Setting This study included data from 165 health posts in 52 districts in four Ethiopian regions collected from December 2018 to February 2019. The data included interviews with health extension workers, assessment of health post preparedness, recording of global positioning system (GPS)-coordinates of the health post and the referral health centre, and reviewing registers of sick children treated during the last 3 months at the health posts. We analysed the association between the sick child's characteristics, health post preparedness and distance to the health centre with referral of sick children by multivariable logistic regressions. Outcome measure Referral to the nearest health centre of sick young infants aged 0-59 days and sick children 2-59 months.ResultsThe health extension workers referred 39/229 (17%) of the sick young infants and 78/1123 (7%) of the older children to the next level of care. Only 18 (37%) sick young infants and 22 (50%) 2-59 months children that deserved urgent referral according to guidelines were referred. The leading causes of referral were possible serious bacterial infection and pneumonia. Those being classified as a severe disease were referred more frequently. The availability of basic amenities (adjusted OR, AOR=0.38, 95% CI 0.15 to 0.96), amoxicillin (AOR=0.41, 95% CI 0.19 to 0.88) and rapid diagnostic test (AOR=0.18, 95% CI 0.07 to 0.46) were associated with less referral in the older age group. Conclusion Few children with severe illness were referred from health posts to health centres. Improving the health posts' medicine and diagnostic supplies may enhance adherence to referral guidelines and ultimately reduce child mortality

Determinants of full valid vaccine dose administration among 12-32 months children in Ethiopia: Evidence from the Ethiopian 2012 national immunization coverage survey

Introduction: According to the 2012 national immunization coverage survey report of Ethiopia, EPI coverage by antigen is 79.6% for BCG, 80.0% for DPT-HepB-Hib1 90.1% for OPV1 65.7%; for adjusted DPT-HepB-Hib 3; 65.7 % for OPV3 and 68.2% for Measles. Similarly, the prevalence of full vaccination was 50%. However, the prevalence of valid vaccination dose for all vaccines is 18.6 %. Therefore, the aim of this study is to identify factors that determine the administration of full valid vaccines dose to set effective interventions.Methods: Data was obtained from the 2012 Immunization Coverage survey of Ethiopia, a cross- sectional study administered at the household level. Data were analyzed using SPSS version 20. Binary and multivariate logistic regression with 95% CI was done to assess factors associated with getting full valid vaccination dose. Results: As documented from the 2012 national immunization coverage survey, the coverage of full valid vaccination dose were very low as compared to full immunization coverage that is 18.6% Vs 50%, respectively. Urban residence 2.6 (95% CI: 2.50, 2.68), mothers with age groups of 21-34 and &gt;35 were 1.26 (95% CI: 1.22, 1.29) and 2.4 (95% CI: 2.3, 2.44); children with caretakers with primary, secondary, and higher level of education were 1.6 (95% CI: 1.22, 1.29), 2.8 (95% CI: 2.76, 2.92), and 2.2 (95% CI: 2.13, 2.27) times more likely to get valid vaccination dose.Conclusion: The rich wealth quintile, rural place of residence, living more than 5km proximity to nearest health facility, having more than six sibling, having teenage (&lt;20years old) mother, having mother with no formal education, having mother/ care giver with no card or family folder which state children vaccination status sources, and having mother who did not heard a message about importance of vaccine were found to be the independent determinants of low valid dose immunization. The efforts at all level to increase full valid vaccination coverage by targeting activities to socio-economic, socio-demographic, organizational, and related determinants. [Ethiop. J. Health Dev. 2016;30(3):135-141]Keywords: Valid dose, vaccination, Ethiopi

Health system capacity for Tuberculosis Care in Ethiopia: evidence from national representative survey

Objective The objective of this study was to evaluate the TB health system capacity and its variations by location and types of health facilities in Ethiopia. Settings The study included 873 public and private health facilities all over Ethiopia. Design We used the Service Provision Assessment plus (SPA+) survey data that were collected in 2014 in all hospitals and randomly selected health centers and private facilities in all regions of Ethiopia. We assessed structural, process and overall health system capacity based on the Donabedian quality of care model. Multiple linear regression and spatial analysis were done to assess TB capacity score variation across regions. Results A total of 873 health facilities were included in the analysis. The overall TB care capacity score was 76.7%, 55.9% and 37.8% in public hospitals, health centers and private facilities respectively. The health system capacity score for TB was higher in the urban (60.4%) facilities compared to that of the rural (50.0%) facilities (β=8.0, 95%CI: 4.4, 11.6). Health centers (β= 16.2, 95%CI: -20.0, -12.3) and private health facilities (β= -38.3, 95%CI: -42.4, -35.1) had lower TB care capacity score than hospitals. Overall TB care capacity score were lower in Western and Southern western Ethiopia and in Benishangul Gumz and Gambella regions. Conclusions The health system capacity score for TB care in Ethiopia varied across regions. Health system capacity improvement interventions should focus on the private sectors and health facilities in the rural and remote areas to ensure equity and improve quality of care