Health-related Quality of Life and Well-being Impact of Depression in Ethiopia

Depression is a common mental disorder with significant health, economic and social effects. Despite being ranked among the leading causes of disability, little is known about its impact on quality of life in Ethiopia. This thesis aims to examine the burden of depression in Ethiopia by assessing its impact on quality of life. Specifically, it examines the impact of depression on health related quality of life, health status and subjective well-being; it develops and validates a multidimensional quality of life instrument using the capability approach; and, it examines how depression affects multidimensional quality of life applying the data collected through the instrument. With a secondary data analysis of a national health survey, the thesis first investigates the burden of depression on health-related quality of life and subjective well-being. Specifically, applying recently available information on EQ-5D preference weights for Ethiopian population, it estimates health utility values and analyses the impact of depression on health utilities. In addition, it examines the impact of depression on self-assessed health and satisfaction with health. By developing a contextually relevant instrument using the capability approach, the thesis then provides an analysis of the impact of depression on broader well-being. Specifically, building on works that attempt to operationalise the Sen-Nussbaum’s capability approach, a new capability well-being instrument was designed and validated for use in Ethiopia. The thesis then provides empirical evidence on the impact of depression on well-being by collecting survey data with the new instrument. Working with the limits of the data, studies in the thesis apply statistical methods, such as propensity score matching and instrumental variables, to estimate the potential impact of depression on the outcomes of interest. The empirical results show depression is associated with decrements in health outcomes. Depression is associated with lower health-related quality of life, lower self-rated health and lower health satisfaction. The results are robust to adjustments to socioeconomic, demographic factors and the presence of other common chronic physical illnesses. Depression is associated with lower health outcomes on its own and even lower decrements in health outcomes when comorbid with other chronic illnesses. Additional analyses were also conducted using propensity score matching methods, by matching respondents experiencing depression with respondents who are not depressed but are comparable on the distribution of the socioeconomic, demographic factors and health condition profile. The results can be interpreted as the causal impact of depression, and they show a significant negative impact of depression on health-related quality of life and subjective well-being outcomes. Similarly, the results show that depression is negatively and significantly associated with broader well-being. There is a negative association between depression and wide range of capabilities as well as overall well-being as measured by an aggregate capability index. Accounting for potential endogeneity, the results also show a ceteris paribus impact of depression on well-being. The analyses in this thesis are based on cross-sectional data and may not provide information on causation despite the best attempts to use alternative estimation techniques to address such issues. Further longitudinal work will be needed. However, the thesis tells a story, albeit a snapshot. It tells an untold story on the burden of depression in Ethiopia. It describes how depression is associated with lower health and non-health outcomes. It shows how depression is associated with limitations on broader dimensions and aspects of life. The results will have an important implication in designing intervention and evaluating the impact of policy and program interventions. It will vital to consider the interplay of health and non-health dimensions in assessing the burden of depression, in designing interventions to address mental health problems and in evaluating the effectiveness of such interventions

Competition and Performance of Microfinance Institutions

Abstract This paper examines the effect of competition among microfinance institutions However, ways that ensure lending standards, enhance information sharing and promote efficiency may help overcome the adverse effect of competition without risking growth of the microfinance sector. JEL Codes: G21, L1, O16

Moving towards universal health coverage for mental disorders in Ethiopia

Background: People with mental disorders in low-income countries are at risk of being left behind during efforts to expand universal health coverage. Aims: To propose context-relevant strategies for moving towards universal health coverage for people with mental disorders in Ethiopia. Methods: We conducted a situational analysis to inform a SWOT analysis of coverage of mental health services and financial risk protection, health system characteristics and the macroeconomic and fiscal environment. In-depth interviews were conducted with five national experts on health financing and equity and analysed using a thematic approach. Findings from the situation analysis and qualitative study were used to develop recommended strategies for adequate, fair and sustainable financing of mental health care in Ethiopia. Results: Opportunities for improved financing of mental health care identified from the situation analysis included: a significant mental health burden with evidence from strong local epidemiological data; political commitment to address that burden; a health system with mechanisms for integrating mental health into primary care; and a favourable macro-fiscal environment for investment in human capabilities. Balanced against this were constraints of low current general government health expenditure, low numbers of mental health specialists, weak capacity to plan and implement mental health programmes and low population demand for mental health care. All key informants referred to the under-investment in mental health care in Ethiopia. Respondents emphasised opportunities afforded by positive rates of economic growth in the country and the expansion of community-based health insurance, as well as the need to ensure full implementation of existing task-sharing programmes for mental health care, integrate mental health into other priority programmes and strengthen advocacy to ensure mental health is given due attention. Conclusion: Expansion of public health insurance, leveraging resources from high-priority SDG-related programmes and implementing existing plans to support task-shared mental health care are key steps towards universal health coverage for mental disorders in Ethiopia. However, external donors also need to deliver on commitments to include mental health within development funding. Future researchers and planners can apply this approach to other countries of sub-Saharan Africa and identify common strategies for sustainable and equitable financing of mental health care

Towards effective and sustainable global academic partnerships through a maturity model informed by the capability approach

BackgroundShortage of skilled workforce is a global concern but represents a critical bottleneck to Africa’s development. While global academic partnerships have the potential to help tackle this development bottleneck, they are criticised for inadequate attention to equity, impact, and sustainability. We propose a new values-driven partnership model for sustainable and equitable global partnerships that achieve impact.MethodThe model was based on the authors’ experiences of participation in over 30 partnerships and used insights from the Capability Approach.ResultsWe developed an Academic Partnership Maturity Model, with five levels of maturity, extending from pre-contemplative to mature partnerships. The level of maturity increases depending on the level of freedom, equity, diversity, and agency afforded to the partners. The approach offers a framework for establishing a forward-looking partnership anchored in mutual learning, empowerment, and autonomy.ConclusionThis is a pragmatic model limited by the biases of experiential knowledge. Further development of the concept, including metrics and an evaluation tool kit are needed to assist partners and funders

Challenges for research uptake for health policymaking and practice in low- and middle-income countries:a scoping review

BACKGROUND: An estimated 85% of research resources are wasted worldwide, while there is growing demand for context-based evidence-informed health policymaking. In low- and middle-income countries (LMICs), research uptake for health policymaking and practice is even lower, while little is known about the barriers to the translation of health evidence to policy and local implementation. We aimed to compile the current evidence on barriers to uptake of research in health policy and practice in LMICs using scoping review.METHODS: The scoping review followed the Preferred Reporting Items for Systematic Review and Meta-Analyses-extension for Scoping Reviews (PRISMA-ScR) and the Arksey and O'Malley framework. Both published evidence and grey literature on research uptake were systematically searched from major databases (PubMed, Cochrane Library, CINAHL (EBSCO), Global Health (Ovid)) and direct Google Scholar. Literature exploring barriers to uptake of research evidence in health policy and practice in LMICs were included and their key findings were synthesized using thematic areas to address the review question.RESULTS: A total of 4291 publications were retrieved in the initial search, of which 142 were included meeting the eligibility criteria. Overall, research uptake for policymaking and practice in LMICs was very low. The challenges to research uptake were related to lack of understanding of the local contexts, low political priority, poor stakeholder engagement and partnership, resource and capacity constraints, low system response for accountability and lack of communication and dissemination platforms.CONCLUSION: Important barriers to research uptake, mainly limited contextual understanding and low participation of key stakeholders and ownership, have been identified. Understanding the local research and policy context and participatory evidence production and dissemination may promote research uptake for policy and practice. Institutions that bridge the chasm between knowledge formation, evidence synthesis and translation may play critical role in the translation process

Burden of neglected tropical diseases and access to medicine and diagnostics in Ethiopia:a scoping review

BACKGROUND: More than 1.7 billion people are affected by neglected tropical diseases (NTDs) worldwide. Forty percent of the NTD-affected people live in Africa with the poorest, most vulnerable, and hard to reach geographical areas. The NTDs cause significant social and economic burden and deepen marginalization and stigmatization. The World Health Organization's current roadmap for NTD aims to prevent, control, eliminate, or eradicate 20 tropical diseases. Ethiopia experiences a high burden of these diseases, but current access to diagnostics, medicine, and/or care has been little explored to inform the country's NTD strategic plan. The overall purpose of the scoping review was to map and characterize the burden of NTDs and challenges in access to diagnostics, medicine, and/or care in Ethiopia.METHODS: A systematic search of evidence was conducted in PubMed, Cochrane Library, and Google Scholar from January 2000 until May 2022, without restrictions of language or study design. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Review was followed for screening of studies. Key findings were extracted and narrated qualitatively.RESULTS: The search resulted in 4532 articles, of which 105 met the inclusion criteria and were included in the scoping review under three themes: burden of NTDs, access to diagnostics, medicine and/or care, and key barriers. Although gains have been made in the prevention and control of NTDs in Ethiopia, the burden remains high, and progress in access to diagnostics, medicine/drugs, and/or care is very slow. Poverty, poor quality of life, and underfunding of NTD programs decelerate the process of NTD elimination program in the country.CONCLUSIONS: The scoping review identified a considerable number of studies on the burden of NTDs in Ethiopia and strategies for diagnosis, treatment, and/or care; however, there is a paucity of evidence on the suitability and potential benefits of novel diagnostic technologies and medicines in the country. A regular review and analysis of such country-level evidence is important to inform the country NTDs roadmap and local implementation strategies

Barriers and facilitators of maternal health care services use among pastoralist women in Ethiopia: Systems thinking perspective

We explored the barriers and facilitators of maternal health care service use among women in the pastoralist region of Ethiopia. We used a mixed methods design—focus group discussions, key informant interviews, review of the literature and Participatory Ethnographic Evaluation Research (PEER) methods followed by a household survey among randomly chosen pastoralist women of reproductive age (n = 1,499). We used multi-variable regression analyses, and a p value ≤ 0.05 was set to determine statistical significance. In addition, we analysed qualitative data thematically and developed a causal loop diagram using dynamic synthesis methodology to analyse non-linearity, intricate relationships of the variable of interests. In this study, 20.6% of women used modern contraceptive methods, 44.6% had four or more antenatal visits and 38.4% of sampled women received skilled delivery services. We observed multiple individual and community related factors such as education, income and women’s and their partner’s knowledge, perceptions, husband approval, social norms and value-expectations and providers’ gender preferences and health systems factors such as access to health facilities, place of living, provider's cultural competency skills, supplies, delivery positions, economic and political stability, and provider's attitude were linked to maternal health care services utilization among women in pastoralist regions. Approaches towards pastoralists’ health care delivery systems should be responsive to their cultural and political ecology and human agency

Poor sleep quality and associated factors among adult chronic kidney disease patients

BackgroundPoor sleep quality is a common concern in chronic kidney disease (CKD) patients, which can accelerate the progression of chronic renal disease and negatively impact their health-related quality of life, potentially leading to greater morbidity and mortality rates. It can also have an effect on the immune system, cognitive function, and emotional well-being of CKD patients. Furthermore, poor sleep quality may contribute to drug noncompliance and decreased participation in the entire treatment plan. Nonetheless, no research has been undertaken in Ethiopia on the prevalence of poor sleep quality and its associated factors among CKD patients.ObjectiveThis study aimed to assess the prevalence of poor quality of sleep and associated factors among chronic kidney disease patients at the University of Gondar Comprehensive Specialized and Felege Hiwot Referral Hospitals in 2020.MethodsA cross-sectional study design was implemented at the University of Gondar Comprehensive Specialized and Felege Hiwot Referral Hospitals between February and April 2020. The study participants were chosen through systematic random sampling techniques. The Pittsburgh Sleep Quality Index (PSQI), a validated assessment tool, was utilized to measure sleep quality. A PSQI total score > 5 was used as an indicator of poor sleep quality. Subsequently, the data obtained were entered into Epi Data version 3.0 and then transferred to STATA 14 for analysis. Both bivariable and multivariable binary logistic regression analyses were performed to recognize factors associated with poor sleep quality. In the multivariable logistic regression analysis, variables demonstrating a p-value of ≤0.05 were considered statistically associated to poor sleep quality.ResultsIn this study, 424 CKD patients were included. Among screened CKD patients, 42.9% tested positive for poor sleep quality with a 95% CI (38 to 47%). Independent predictors of poor sleep quality among CKD patients were common mental disorder [AOR = 1.8, 95% CI (1.19–2.89)], anemia [AOR = 2.7, 95% CI (1.71–4.36)], declined eGFR between 60 and 89.9 [AOR = 1.6; 95% CI (2.28–5.54)], 30–59.9 [AOR = 2.6, 95% CI (1.53–4.43)], and ≤ 30 [AOR = 3.8, 95% CI (1.17–12.61)], age > 50 years [AOR = 1.7(1.11–2.69)] and duration of disease 2.9 [AOR = 2.9, 95% CI (1.77–4.90)].ConclusionIn our study, almost 1 out of 2 CKD patients assessed for poor sleep quality tested positive. It was noted that poor sleep quality was more frequent among CKD patients with common mental disorders, anemia, decreased eGFR levels, individuals aged over 50 years, and those with a longer duration of the disease. Consequently, it’s advised to regularly screen these CKD patients for poor sleep quality

Determinants of multimorbidity in low‐ and middle‐income countries: A systematic review of longitudinal studies and discovery of evidence gaps

Summary: Multimorbidity—the coexistence of at least two chronic health conditions within the same individual—is an important global health challenge. In high‐income countries (HICs), multimorbidity is dominated by non‐communicable diseases (NCDs); whereas, the situation may be different in low‐ and middle‐income countries (LMICs), where chronic communicable diseases remain prominent. The aim of this systematic review was to identify determinants (including risk and protective factors) and potential mechanisms underlying multimorbidity from published longitudinal studies across diverse population‐based or community‐dwelling populations in LMICs. We systematically searched three electronic databases (Medline, Embase, and Global Health) using pre‐defined search terms and selection criteria, complemented by hand‐searching. All titles, abstracts, and full texts were independently screened by two reviewers from a pool of four researchers. Data extraction and reporting were according to Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines. Methodological quality and risk of bias assessment was performed using the Newcastle‐Ottawa Scale for cohort studies. Data were summarized using narrative synthesis. The search yielded 1782 records. Of the 52 full‐text articles included for review, 8 longitudinal population‐based studies were included for final data synthesis. Almost all studies were conducted in Asia, with only one from South America and none from Africa. All studies were published in the last decade, with half published in the year 2021. The definitions used for multimorbidity were heterogeneous, including 3–16 chronic conditions per study. The leading chronic conditions were heart disease, stroke, and diabetes, and there was a lack of consideration of mental health conditions (MHCs), infectious diseases, and undernutrition. Prospectively evaluated determinants included socio‐economic status, markers of social inequities, childhood adversity, lifestyle behaviors, obesity, dyslipidemia, and disability. This review revealed a paucity of evidence from LMICs and a geographical bias in the distribution of multimorbidity research. Longitudinal research into epidemiological aspects of multimorbidity is warranted to build up scientific evidence in regions beyond Asia. Such evidence can provide a detailed picture of disease development, with important implications for community, clinical, and interventions in LMICs. The heterogeneity in study designs, exposures, outcomes, and statistical methods observed in the present review calls for greater methodological standardisation while conducting epidemiological studies on multimorbidity. The limited evidence for MHCs, infectious diseases, and undernutrition as components of multimorbidity calls for a more comprehensive definition of multimorbidity globally

Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations. METHODS The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model-a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates-with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality-which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds. FINDINGS The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2-100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1-290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1-211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4-48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3-37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7-9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles. INTERPRETATION Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere. FUNDING Bill & Melinda Gates Foundation