Low and unequal use of outpatient health services in public primary health care facilities in southern Ethiopia: a facility-based cross-sectional study

Background Outpatient department visits per individual for each year are one of the core indicators of healthcare delivery to assess accessibility or quality of services. In addition, this study aimed to assess health service utilisation and disease patterns in southern Ethiopia, by including the health authorities’ suggestions to improve the services. No study has assessed this in Ethiopia previously. Methods An institution-based cross-sectional design study was done in 65 primary health care units in Dale and Wonsho districts, in Sidama region, for all patients visiting health facilities from 1 July 2017 to 30 June 2018. We estimated the utilisation rate as visits per person per year, the odds ratio for health use and proportions of diseases’ diagnoses. The results of our study were presented to local health authorities, and their suggestions for improvements were incorporated into the analysis. Result A total of 81,129 patients visited the health facilities. The annual outpatient health service utilisation was 0.18 (95% CI: 0.18–0.19) new visits per person per year. The health service utilisation rate per year for the rural population was lower than the urban utilisation by 91% (OR = 0.09; 95% CI: 0.08–0.09). Children in the age group of 5–14 years had lower odds of health service utilisation by 78% (OR = 0.22; 95% CI: 0.21–0.23), compared to children under 5 years of age. Females were four times (OR = 4.17; 95% CI: 4.09–4.25) more likely to utilise health services than males. Febrile illness constituted 17.9% (14,847 of 83,148) of the diagnoses in all age groups. Almost half of the febrile cases, 46.5% (3827 of 8233), were among children under 5 years of age. There were very few cases of non-communicable diseases diagnosed in the health facilities. The health authorities suggested improving diagnostic capacities at health centres, enhancing health professionals’ skill and attitudes, and improving affordability and physical accessibility of the services. Conclusion The health service utilisation rate was low in Sidama. The use of health services was lower among rural residents, men, children and elderly, and health post users. Improving the quality, affordability and accessibility of the health services, by involving responsible stakeholders could increase service usage.publishedVersio

Long-term outcome of smear-positive tuberculosis patients after initiation and completion of treatment: A ten-year retrospective cohort study

Background The status of tuberculosis (TB) patients since initiation of treatment is unknown in South Ethiopia. The objective of this study was to assess the long-term outcomes of smear-positive TB patients since initiation and completion of treatment, which includes TB recurrence and mortality of TB patients. Methods We did a retrospective cohort study on 2,272 smear-positive TB patients who initiated treatment for TB from September 1, 2002—October 10, 2012 in health facilities in Dale district and Yirgalem town administration. We followed them from the date of start of treatment to either the date of interview or date of death. Results Recurrence rate of TB was 15.2 per 1000 person-years. Recurrence was higher for re-treatment cases (adjusted hazard ratio (aHR), 2.7; 95% CI, 1.4–5.3). Mortality rate of TB patients was 27.1 per 1,000 person-years. The risk was high for patients above 34 years of age (aHR, 2.1; 95% CI, 1.2–3.9), poor patients (aHR, 1.3; 95% CI, 1.0–1.8), patients with poor treatment outcomes (aHR, 6.7; 95% CI, 5.1–8.9) and for patients treated at least 3 times (aHR 4.8; 95% CI, 2.1–11.1). The excess mortality occurred among patients aged above 34 years was high (41.2/1000 person years). Conclusion High TB recurrence and death of TB patients was observed among our study participants. Follow-up of TB patients with the risk factors and managing them could reduce the TB burden

How many of persistent coughers have pulmonary tuberculosis? Populationbased cohort study in Ethiopia

Objective Many individuals with persistent cough and smear microscopy-negative sputum test for tuberculosis (TB) remain at risk of developing the disease. This study estimates the incidence of pulmonary TB (PTB) among initially smear-negative persistent coughers and its risk factors. Design A prospective population-based follow-up study. Setting Health extension workers visited all households in Dale woreda three times at 4-month intervals in 2016–2017 to identify individuals with symptoms compatible with TB (presumptive TB) using pretested and semistructured questionnaires. Participants We followed 3484 presumptive TB cases (≥15 years) with an initial smear-negative TB (PTB) test. Outcome measures Bacteriologically confirmed PTB (PTB b+) and clinically diagnosed PTB (PTB c+). Results 3484 persons with initially smear-negative presumptive PTB were followed for 2155 person-years (median 0.8 years); 90 individuals had PTB b+ and 90 had PTB c+. The incidence rates for PTB b+ and PTB c+ were both 4176 (95% CI 3378 to 5109) per 100 000 person-years. We used penalised (lasso) and non-penalised proportional hazards Cox regression models containing all exposures and outcomes to explore associations between exposures and outcomes. In lasso regression, the risk of development of PTB b+ was 63% (HR 0.37) lower for people aged 35–64 years and 77% (HR 0.23) lower for those aged ≥65 years compared with 15–34 year-olds. Men had a 62% (HR 1.62) greater risk of PTB b+ development than women. The risk of PTB c+ was 39% (HR 0.61) lower for people aged 35–54 years than for those aged 15–34 years. Men had a 56% (HR 1.56) greater risk of PTB c+ development than women. Conclusions PTB incidence rate among persistent coughers was high, especially among men and young adults, the latter signifying sustained transmission. Awareness about this among healthcare workers may improve identification of more new TB cases.publishedVersio

Tuberculosis control in Sidama in Ethiopia. Programme performance and spatial epidemiology

The Sustainable Development Goals are to end the TB epidemic by reducing the incidence of TB by 90 % and by reducing mortality by 95% by 2035 from what was in 2015. Globally, access to TB diagnostic and treatment facilities (DOTS) has improved, and millions of TB cases have been notified and treated, which has resulted in many lives being saved. In recent years in Ethiopia, TB control services have been substantially expanded and decentralized, which has improved access to TB care. Assessing trends in TB programme performance (case notification and treatment outcomes), as well as the spatial distribution and variations of the disease, could help in understanding the differentials in accessibility to TB control services, the distribution of disease burden and help in understanding the effectiveness of TB control programmes. We assessed the distribution of- and accessibility to TB control facilities and trends in TB control programme performance in both urban and rural settings, by age category and by gender, and assessed the case notification rates of childhood TB over 10 years. We also assessed trends of the treatment outcomes of TB cases in order to identify high-risk groups for adverse treatment outcomes. Lastly, we explored spatial distribution and spatio-temporal clustering of the disease over 10 years to identify areas with the highest TB case notifications, and to identify the spatial variations in disease occurrence. Over 10 years, the accessibility to- and coverage of TB control facilities has improved. Thus, TB control service coverage increased by 36%, and the proportion of locations within 10 km of the nearest TB diagnostic facility also increased. However, we noted variations in physical accessibility between areas in the study area. The mean distance from the nearest smear microscopy unit was 7.6 km in 2003 and declined to 3.2 km in 2012. The substantial expansion of primary health-care services, including TB control facilities and community-based intervention, has contributed to an increase in TB CNRs and treatment outcomes. From this finding, we suggest that a concerted effort be made to improve the accessibility to TB control facilities in areas with low case notification and poor accessibility. An analysis of the trends of TB case notification and treatment outcomes in different settings based on the correct address, by age category and gender, and place of residence, could help understand the performance of TB control programmes and the epidemiology of TB within a community. We found that the CNRs for all forms of- and smear-positive TB increased steadily between 2003 and 2012. The CNR of smear-positive TB in the 45-year and above age groups rose by nearly fourfold. The disparity between men and women in CNR declined from 16 per 100,000 people in 2003 to eight per 100,000 people in 2012, with the male to female ratio also declining from 1.3:1 to 1.1:1. The increase in CNRs could be attributed to improved access to TB care and community-based interventions. Over a decade, treatment success increased, whereas mortality and lost-to-follow-up declined. However, more deaths occurred among smear-negative TB cases, in children and among older patients. Targeted interventions are needed to address high-risk groups for adverse treatment outcomes. The burden of childhood TB is one of the indicators used for assessing the ongoing transmission of the disease within a community. Assessing the case notification and treatment outcome of childhood TB could provide essential evidence to help understand the effectiveness of TB control programmes and the disease burden. Thus, we assessed childhood TB case notification and treatment outcomes over a decade. The mean CNRs for new cases of TB of all forms were 30 per 100,000 children, and no decline was observed in childhood TB cases over a 10-year study period. A community-based active case-finding intervention increased TB case notification in adults and in older children (10-14-year-olds); however, the case notification did not increase among younger children (less than five-years old). This could be explained by inadequate diagnostic facilities for childhood TB despite the community-based intervention, which focuses on symptomatic screening, followed by sputum-smear microscopy and the substantial expansion of TB control services. Better diagnostic facilities and interventions are required to increase case detection, and to improve treatment outcome among younger children. The burden of TB varies between- and within countries because of differentials in health service performance and the varying distribution of risk factors that increase the transmission of- and susceptibility to the disease. An analysis of the disease burden in coarser geographic or administrative units could hide the burden of the disease at lower administrative units. Therefore, we assessed the distribution of the disease in different geographic settings in the study area, and looked for the pattern of the disease transmission over years, as well as for evidence of spatiotemporal clustering. We found spatial variations in both the disease distribution and spatial and space-time clustering of the disease in the central, northern and northwestern areas of the study area. This could be explained by sustained transmission, disproportionate distribution of risk factors, varying access to TB care and varying TB programme performance, all of which require targeted interventions. In conclusion, in a population with a high prevalence of tuberculosis, we show that access to tuberculosis diagnostic and treatment facilities, in addition to the performance of TB control programmes, improved from 2003 to 2012. However, we identified areas with poor accessibility to diagnostic and treatment facilities. The low and constant case notification rate in childhood TB is an area of concern, and may indicate an underdiagnosis of childhood tuberculosis. Moreover, the distribution of tuberculosis has changed over time, and in different areas, thereby suggesting a high transmission or variable access to diagnosis and treatment. As a result, the variations in case notification rates, and in accessibility to tuberculosis control services represent challenges on how to improve the organization and performance of TB control

Spatio-Temporal Analysis of Smear-Positive Tuberculosis in the Sidama Zone, Southern Ethiopia

Background Tuberculosis (TB) is a disease of public health concern, with a varying distribution across settings depending on socio-economic status, HIV burden, availability and performance of the health system. Ethiopia is a country with a high burden of TB, with regional variations in TB case notification rates (CNRs). However, TB program reports are often compiled and reported at higher administrative units that do not show the burden at lower units, so there is limited information about the spatial distribution of the disease. We therefore aim to assess the spatial distribution and presence of the spatio-temporal clustering of the disease in different geographic settings over 10 years in the Sidama Zone in southern Ethiopia. Methods A retrospective space–time and spatial analysis were carried out at the kebele level (the lowest administrative unit within a district) to identify spatial and space-time clusters of smear-positive pulmonary TB (PTB). Scan statistics, Global Moran’s I, and Getis and Ordi (Gi*) statistics were all used to help analyze the spatial distribution and clusters of the disease across settings. Results A total of 22,545 smear-positive PTB cases notified over 10 years were used for spatial analysis. In a purely spatial analysis, we identified the most likely cluster of smear-positive PTB in 192 kebeles in eight districts (RR= 2, p<0.001), with 12,155 observed and 8,668 expected cases. The Gi* statistic also identified the clusters in the same areas, and the spatial clusters showed stability in most areas in each year during the study period. The space-time analysis also detected the most likely cluster in 193 kebeles in the same eight districts (RR= 1.92, p<0.001), with 7,584 observed and 4,738 expected cases in 2003-2012. Conclusion The study found variations in CNRs and significant spatio-temporal clusters of smear-positive PTB in the Sidama Zone. The findings can be used to guide TB control programs to devise effective TB control strategies for the geographic areas characterized by the highest CNRs. Further studies are required to understand the factors associated with clustering based on individual level locations and investigation of cases

Trends of tuberculosis case notification and treatment outcomes in the sidama zone, southern ethiopia: Ten-year retrospective trend analysis in urban-rural settings

Background: Ethiopia is one of the high tuberculosis (TB) burden countries. An analysis of trends and differentials in case notifications and treatment outcomes of TB may help improve our understanding of the performance of TB control services. Methods: A retrospective trend analysis of TB cases was conducted in the Sidama Zone in southern Ethiopia. We registered all TB cases diagnosed and treated during 2003–2012 from all health facilities in the Sidama Zone, and analysed trends of TB case notification rates and treatment outcomes. Results: The smear positive (PTB+) case notification rate (CNR) increased from 55 (95% CI 52.5–58.4) to 111 (95% CI 107.4–114.4) per 105 people. The CNRs of PTB+ in people older than 45 years increased by fourfold, while the mortality of cases during treatment declined from 11% to 3% for smear negative (PTB-) (X2trend, P<0.001) and from 5% to 2% for PTB+ (X2trend, P<0.001). The treatment success was higher in rural areas (AOR 1.11; CI 95%: 1.03–1.2), less for PTB- (AOR 0.86; CI 95%: 0.80–0.92) and higher for extra-pulmonary TB (AOR 1.10; CI 95%: 1.02–1.19) compared to PTB+. A higher lost-to-follow up was observed in men (AOR 1.15; CI 95%: 1.06–1.24) and among PTB- cases (AOR 1.14; CI 95%: 1.03–1.25). More deaths occurred in PTB-cases (AOR 1.65; 95% CI: 1.44–1.90) and among cases older than 65 years (AOR 3.86; CI 95%: 2.94–5.10). Lastly, retreatment cases had a higher mortality than new cases (6% vs 3%). Conclusion: Over the past decade TB CNRs and treatment outcomes improved, whereas the disparities of disease burden by gender and place of residence reduced and mortality declined. Strategies should be devised to address higher risk groups for poor treatment outcomes

Births and deaths in Sidama in southern Ethiopia: findings from the 2018 Dale-Wonsho Health and Demographic Surveillance System (HDSS)

Background Sidama is one of the most densely populated areas in Ethiopia. Information about the demographic characteristics is scarce, and most studies were census based on interviews. Earlier population studies from Ethiopia did not sufficiently address the validity of measuring births, deaths, and age-composition. Objective To investigate the population characteristics in Sidama with an emphasis on fertility estimates, age, and death reporting. Methods This is a mixed-method cross-sectional study, conducted in Sidama in southern Ethiopia, using baseline data of newly established Dale-Wonsho Health and Demographic Surveillance System site in 2018. We used quantitative data of 5179 randomly selected households having 25,144 individuals. We collected information on deaths in the same study period and population from the traditional burial associations (Iddir). Qualitative data were collected using focus group discussions, and in-depth interviews. Life tables, age reliability indices and logistic regression were used to analyse the data. Results The total fertility rate was 2.9 children/woman, the crude birth rate was 22.8/1000 population and the crude death rate was 5.2/1000 population. The dependency ratio was 66/100 working-age population. Urban residents had higher birth rates (OR = 1.4 (95% CL: 1.05–1.78), and women with basic education had lower birth rates (OR = 0.6 (95% CL: 0.46–0.78) compared to those with no education. The age accuracy indices showed unreliable age reporting. The number of deaths increased from 29 to 132 when death reports from the Iddirs were included. There was under-reporting of neonatal and deaths of young children. Substituting national and regional mortality estimates, the life expectancy declined to an average of 53 years (range 48–58 years). Conclusion The fertility rate in Sidama is lower than previously reported and is affected by age, residence and education. As we have identified important measurement and reporting errors, future demographic surveillance sites should consider these limitations

Accessibility to tuberculosis control services and tuberculosis programme performance in southern Ethiopia

Background: Despite the expansion of health services and community-based interventions in Ethiopia, limited evidence exists about the distribution of and access to health facilities and their relationship with the performance of tuberculosis (TB) control programmes. We aim to assess the geographical distribution of and physical accessibility to TB control services and their relationship with TB case notification rates (CNRs) and treatment outcome in the Sidama Zone, southern Ethiopia. Design: We carried out an ecological study to assess physical accessibility to TB control facilities and the association of physical accessibility with TB CNRs and treatment outcome. We collected smear-positive pulmonary TB (PTB) cases treated during 2003–2012 from unit TB registers and TB service data such as availability of basic supplies for TB control and geographic locations of health services. We used ArcGIS 10.2 to measure the distance from each enumeration location to the nearest TB control facilities. A linear regression analysis was employed to assess factors associated with TB CNRs and treatment outcome. Results: Over a decade the health service coverage (the health facility–to-population ratio) increased by 36% and the accessibility to TB control facilities also improved. Thus, the mean distance from TB control services was 7.6 km in 2003 (ranging from 1.8 to 25.5 km) between kebeles (the smallest administrative units) and had decreased to 3.2 km in 2012 (ranging from 1.5 to 12.4 km). In multivariate linear regression, as distance from TB diagnostic facilities (b-estimate=−0.25, p<0.001) and altitude (b-estimate=−0.31, p<0.001) increased, the CNRs of TB decreased, whereas a higher population density was associated with increased TB CNRs. Similarly, distance to TB control facilities (b-estimate=−0.27, p<0.001) and altitude (b-estimate=−0.30, p<0.001) were inversely associated with treatment success (proportion of treatment completed or cured cases). Conclusions: Accessibility to TB control services improved despite the geographic variations. TB CNRs were higher in areas where people had better access to diagnostic and treatment centres. Community-based interventions also played an important role for the increased CNRs in most areas

Identifying geographical heterogeneity of pulmonary tuberculosis in southern Ethiopia: a method to identify clustering for targeted interventions

Background Previous studies from Ethiopia detected disease clustering using broader geographic settings, but limited information exists on the spatial distribution of the disease using residential locations. An assessment of predictors of spatial variations of TB at community level could fill the knowledge gaps, and helps in devising tailored interventions to improve TB control. Objective To assess the pattern of spatial distribution of pulmonary tuberculosis (PTB) based on geographic locations of individual cases in the Dale district and Yirga Alem town in southern Ethiopia. Methods The socio-demographic characteristics of PTB cases were collected using a structured questionnaire, and spatial information was collected using geographic position systems. We carried out Getis and Ord (Gi*) statistics and scan statistics to explore the pattern of spatial clusters of PTB cases, and geographically weighted regression (GWR) was used to assess the spatial heterogeneities in relationship between predictor variables and PTB case notification rates (CNRs). Results The distribution of PTB varied by enumeration areas within the kebeles, and we identified areas with significant hotspots in various areas ineach year. In GWR analysis, the disease distribution showed a geographic heterogeneity (non-stationarity) in relation to physical access (distance to TB control facilities) and population density (AICc = 5591, R2 = 0.3359, adjusted R2 = 0.2671). The model explained 27% of the variability in PTB CNRs (local R2 ranged from 0.0002–0.4248 between enumeration areas). The GWR analysis showed that areas with high PTB CNRs had better physical accessibility to TB control facilities and high population density. The effect of physical access on PTB CNRs changed after the coverage of TB control facilities was improved. Conclusion We report a varying distribution of PTB in small and different areas over 10 years. Spatial and temporal analysis of disease distribution can be used to identify areas with a high burden of disease and predictors of clustering, which helps in making policy decisions and devising targeted interventions

Low case notification rates of childhood tuberculosis in southern Ethiopia

Background: Childhood tuberculosis (TB) is a public health concern causing considerable mortality. However, control of childhood TB receives little attention. The control efforts could be inadequate because of challenges associated with difficulties in diagnosing the disease in children. Understanding the burden of the disease among children is important to assess the ongoing transmission of the disease in a community and improving TB control efforts. This study was carried out to assess TB case notification rates (CNRs) and treatment outcomes in children aged less than 15 years over a ten-year period. Methods: Data were collected from unit TB registers from all health facilities providing TB treatment in the Sidama Zone in Ethiopia. We analysed the CNRs and treatment outcomes by age category, gender, and place of residence. We used logistic regression analysis to identify factors associated with treatment outcomes and to control for confounding. Results: A total of 4,656 cases of children less than 15 years of age were notified as diagnosed and treated for TB, constituting 13 % of all notified TB cases in the study area. The mean CNRs per 100,000 children less than 15 years were 30 for all new cases of TB, 28 for rural cases, 67 for urban cases, 28 in boys, and 32 in girls. The proportions of treatment success were 82 % for new and 77 % for retreatment cases for the entire study period and increased to 93 % for new cases in 2012 (X2 trend, P < 0.001). Children less than five years old had a lower treatment success [adjusted odds ratio (AOR) 0.64 (95 % CI, 0.52-0.80)] and higher deaths [AOR 2 (95 % CI, 1.27–3.12)]. The proportion of children who died during treatment among children in the less than 2-year-old age group was three times higher than children in the 2 year and above age groups [AOR 3.34 (95 % CI, 1.92–5.82)]. Conclusion: The CNRs of childhood TB were low in Sidama. Children less than 5 years old had a higher proportion of deaths. Efforts need to be made to improve the diagnosis and treatment of TB among children