Balanced Energy Protein Supplementation in Pregnancy: Adherence and Acceptability among Pregnant Women in Rural Ethiopia.

BACKGROUND: Balanced energy protein (BEP) supplementation in pregnant women in low-and middle-income countries may reduce the risk of stillbirth and low birth weight. OBJECTIVES: The objective of this study was to assess the adherence to and acceptability of a corn-soy blend (CSB) BEP product among pregnant women in rural Ethiopia. METHODS: This formative study was conducted from October to November 2018 among pregnant women in the rural Amhara region of Ethiopia prior to initiation of a clinical effectiveness study (ISRCTN: 15116516). We assessed adherence and acceptability of a micronutrient-fortified CSB BEP supplement among 40 pregnant women during a 4-wk utilization period. Acceptability was assessed using a 7-point Likert-style scale about the hedonic characteristics of the BEP product at 2 wk and 4 wk. Adherence was assessed by weekly monitoring and empty sachet counts for BEP consumption over 4 wk. RESULTS: Adherence to the BEP was, on average, 89% over the month-long pilot. The BEP product was rated favorably (mean Likert score >6 of 7) for the following domains: color, taste, odor, and likeability at mid and endpoints. Women found the product convenient to eat [mean (standard deviation [SD] = 5.9 (1.0))] and filling (mean (SD) = 6.1 (1.5) out of 7). Scores on acceptability and perception of the product remained stable throughout the duration of use. A majority of women (63%) reported consuming the BEP as a snack to supplement meals and splitting the serving over 2 or more sessions (68%). A quarter of respondents reported sharing the supplement with family members. CONCLUSIONS: Adherence and acceptability of the CSB BEP product were high among this population in rural Amhara, Ethiopia. This formative data was important to select the final product and shape the counseling and delivery of BEP in the parent study

Reported Barriers to Healthcare Access and Service Disruptions Caused by COVID-19 in Burkina Faso, Ethiopia, and Nigeria: A Telephone Survey.

The coronavirus disease 2019 (COVID-19) pandemic may have short-term and long-term impacts on health services across sub-Saharan African countries. A telephone survey in Burkina Faso, Ethiopia, and Nigeria was conducted to assess the effects of the pandemic on healthcare services from the perspectives of healthcare providers (HCPs) and community members. A total of 900 HCPs (300 from each country) and 1,797 adult community members (approximately 600 from each country) participated in the study. Adjusted risk ratios (ARRs) and 95% confidence intervals (CIs) were computed using modified Poisson regression. According to the HCPs, more than half (56%) of essential health services were affected. Child health services and HIV/surgical/other services had a slightly higher percentage of interruption (33%) compared with maternal health services (31%). A total of 21.8%, 19.3%, and 7.7% of the community members reported that their family members and themselves had difficulty accessing childcare services, maternal health, and other health services, respectively. Nurses had a lower risk of reporting high service interruptions than physicians (ARR, 0.85; 95% CI, 0.56-0.95). HCPs at private facilities (ARR, 0.71; 95% CI, 0.59-0.84) had a lower risk of reporting high service interruptions than those at governmental facilities. Health services in Nigeria were more likely to be interrupted than those in Burkina Faso (ARR, 1.38; 95% CI, 1.19-1.59). Health authorities should work with multiple stakeholders to ensure routine health services and identify novel and adaptive approaches to recover referral services, medical care, maternal and child health, family planning, immunization and health promotion, and prevention during the COVID-19 era

COVID-19 Knowledge, Perception, Preventive Measures, Stigma, and Mental Health Among Healthcare Workers in Three Sub-Saharan African Countries: A Phone Survey.

The coronavirus disease 2019 (COVID-19) pandemic is an unprecedented public health crisis globally. Understanding healthcare providers' (HCPs') knowledge and perceptions of COVID-19 is crucial to identifying effective strategies to improve their ability to respond to the pandemic in sub-Saharan Africa. A phone-based survey of 900 HCPs in Burkina Faso, Ethiopia, and Nigeria (300 per country) was conducted to assess knowledge, perceptions, COVID-19 prevention measures, stigma, and mental health of HCPs. Modified Poisson regression models were used to evaluate predictors of knowledge, perceptions, and prevention measures; adjusted risk ratios (ARRs) and 95% confidence intervals (CIs) were calculated. Three-fourths of the HCPs had adequate knowledge, and over half had correct perceptions of risk and high levels of self-reported prevention measures. The majority of the HCPs (73.7%) reported self-perceived social stigma. There was relatively low prevalence of depression (6.6%), anxiety (6.6%), or psychological distress (18%). Compared with doctors, being a nurse was associated with lower levels of knowledge (ARR: 0.83; 95% CI: 0.77-0.90) and was also negatively associated with having correct perceptions toward COVID-19 (AOR: 0.82; 95% CI: 0.73-0.92). HCPs treating COVID-19 patients had higher likelihood of having high levels of prevention measures (AOR: 1.37; 95% CI: 1.23-1.53). Despite high levels of knowledge among HCPs in sub-Saharan Africa, there is a need to improve COVID-19 perceptions and compliance with prevention measures as well as address social stigma toward HCPs to better ensure their safety and prepare them to deliver health services

Effect of birthweight measurement quality improvement on low birthweight prevalence in rural Ethiopia.

BACKGROUND: Low birthweight (LBW) (< 2500 g) is a significant determinant of infant morbidity and mortality worldwide. In low-income settings, the quality of birthweight data suffers from measurement and recording errors, inconsistent data reporting systems, and missing data from non-facility births. This paper describes birthweight data quality and the prevalence of LBW before and after implementation of a birthweight quality improvement (QI) initiative in Amhara region, Ethiopia. METHODS: A comparative pre-post study was performed in selected rural health facilities located in West Gojjam and South Gondar zones. At baseline, a retrospective review of delivery records from February to May 2018 was performed in 14 health centers to collect birthweight data. A birthweight QI initiative was introduced in August 2019, which included provision of high-quality digital infant weight scales (precision 5 g), routine calibration, training in birth weighing and data recording, and routine field supervision. After the QI implementation, birthweight data were prospectively collected from late August to early September 2019, and December 2019 to June 2020. Data quality, as measured by heaping (weights at exact multiples of 500 g) and rounding to the nearest 100 g, and the prevalence of LBW were calculated before and after QI implementation. RESULTS: We retrospectively reviewed 1383 delivery records before the QI implementation and prospectively measured 1371 newborn weights after QI implementation. Heaping was most frequently observed at 3000 g and declined from 26% pre-initiative to 6.7% post-initiative. Heaping at 2500 g decreased from 5.4% pre-QI to 2.2% post-QI. The percentage of rounding to the nearest 100 g was reduced from 100% pre-initiative to 36.5% post-initiative. Before the QI initiative, the prevalence of recognized LBW was 2.2% (95% confidence interval [CI]: 1.5-3.1) and after the QI initiative increased to 11.7% (95% CI: 10.1-13.5). CONCLUSIONS: A QI intervention can improve the quality of birthweight measurements, and data measurement quality may substantially affect estimates of LBW prevalence

COVID-19 Preventive Practices, Psychological Distress, and Reported Barriers to Healthcare Access during the Pandemic among Adult Community Members in Sub-Saharan Africa: A Phone Survey

The COVID-19 pandemic has had serious negative health and economic impacts in sub-Saharan Africa. Continuous monitoring of these impacts is crucial to formulate interventions to minimize the consequences of COVID-19. This study surveyed 2,829 adults in urban and rural sites among five sub-Saharan African countries: Burkina Faso, Ethiopia, Nigeria, Tanzania, and Ghana. Participants completed a mobile phone survey that assessed self-reported sociodemographics, COVID-19 preventive practices, psychological distress, and barriers to healthcare access. A modified Poisson regression model was used to estimate adjusted prevalence ratios (aPRs) and 95% CIs to investigate potential factors related to psychological distress and barriers to reduced healthcare access. At least 15.6% of adults reported experiencing any psychological distress in the previous 2 weeks, and 10.5% reported that at least one essential healthcare service was difficult to access 2 years into the pandemic. The majority of participants reported using several COVID-19 preventive methods, with varying proportions across the sites. Participants in the urban site of Ouagadougou, Burkina Faso (aPR: 2.29; 95% CI: 1.74–3.03) and in the rural site of Kintampo, Ghana (aPR: 1.68; 95% CI: 1.21–2.34) had a higher likelihood of experiencing any psychological distress compared with those in the rural area of Nouna, Burkina Faso. Loss of employment due to COVID-19 (aPR: 1.77; 95% CI: 1.47–2.11) was also associated with an increased prevalence of psychological distress. The number of children under 5 years in the household (aPR: 1.23; 95% CI: 1.14–1.33) and participant self-reported psychological distress (aPR: 1.83; 95% CI: 1.48–2.27) were associated with an increased prevalence of reporting barriers to accessing health services, whereas wage employment (aPR: 0.67; 95% CI: 0.49–0.90) was associated with decreased prevalence of reporting barriers to accessing health services. Overall, we found a high prevalence of psychological distress and interruptions in access to healthcare services 2 years into the pandemic across five sub-Saharan African countries. Increased effort and attention should be given to addressing the negative impacts of COVID-19 on psychological distress. An equitable and collaborative approach to new and existing preventive measures for COVID-19 is crucial to limit the consequences of COVID-19 on the health of adults in sub-Saharan Africa

COVID-19 vaccine hesitancy and its determinants among sub-Saharan African adolescents.

COVID-19 vaccine hesitancy among adolescents poses a challenge to the global effort to control the pandemic. This multi-country survey aimed to assess the prevalence and determinants of COVID-19 vaccine hesitancy among adolescents in sub-Saharan Africa between July and December 2021. The survey was conducted using computer-assisted telephone interviewing among adolescents in five sub-Saharan African countries, Burkina Faso, Ethiopia, Ghana, Nigeria, and Tanzania. A rural area and an urban area were included in each country (except Ghana, which only had a rural area), with approximately 300 adolescents in each area and 2662 in total. Sociodemographic characteristics and perceptions and attitudes on COVID-19 vaccines were measured. Vaccine hesitancy was defined as definitely not getting vaccinated or being undecided on whether to get vaccinated if a COVID-19 vaccine were available. Log-binomial models were used to calculate the adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) for associations between potential determinants and COVID-19 vaccine hesitancy. The percentage of COVID-19 vaccine hesitancy was 14% in rural Kersa, 23% in rural Ibadan, 31% in rural Nouna, 32% in urban Ouagadougou, 37% in urban Addis Ababa, 48% in rural Kintampo, 65% in urban Lagos, 76% in urban Dar es Salaam, and 88% in rural Dodoma. Perceived low necessity, concerns about vaccine safety, and concerns about vaccine effectiveness were the leading reasons for hesitancy. Healthcare workers, parents or family members, and schoolteachers had the greatest impacts on vaccine willingness. Perceived lack of safety (aPR: 3.52; 95% CI: 3.00, 4.13) and lack of effectiveness (aPR: 3.46; 95% CI: 2.97, 4.03) were associated with greater vaccine hesitancy. The prevalence of COVID-19 vaccine hesitancy among adolescents is alarmingly high across the five sub-Saharan African countries, especially in Tanzania. COVID-19 vaccination campaigns among sub-Saharan African adolescents should address their concerns and misconceptions about vaccine safety and effectiveness

Continued disruptions in health care services and mental health among health care providers during the COVID-19 pandemic in five sub-Saharan African countries.

BACKGROUND: Continuous monitoring of the pandemic's impact on health service provision and mental health, COVID-19 perceptions, and compliance with prevention measures among health care providers (HCPs) can help with mitigating the pandemic's negative effects. METHODS: A computer-assisted telephone interviewing (CATI) survey was conducted among 1499 HCPs in Burkina Faso (Ouagadougou), Ethiopia (Addis Ababa), Nigeria (Lagos and Ibadan), Tanzania (Dar es Salaam), and Ghana (Kintampo). Self-reported mental health, perceptions of the COVID-19 pandemic, and prevention measures available in the workplace were assessed. HCPs' responses to questions regarding the impact of COVID-19 on nine essential health services were summed into a score; high service disruption was defined as a score higher than the total average score across all sites. Modified Poisson regression was used to identify potential factors related to high service disruption. RESULTS: Overall, 26.9% of HCPs reported high service disruption, with considerable differences across sites (from 1.6% in Dar es Salaam to 45.0% in Addis Ababa). A considerable proportion of HCPs reported experiencing mild psychological distress (9.4%), anxiety (8.0%), and social avoidance or rejection (13.9%) due to their profession. Participants in Addis Ababa (absolute risk ratio (ARR) = 2.10; 95% confidence interval (CI) = 1.59-2.74), Lagos (ARR = 1.65; 95% CI = 1.24-2.17), and Kintampo (ARR = 2.61; 95% CI = 1.94-3.52) had a higher likelihood of reporting high service disruption compared to those in Ouagadougou. Reporting ever-testing for COVID-19 (ARR = 0.82; 95% CI = 0.69-0.97) and the presence of COVID-19 guidelines in the workplace (ARR = 0.63; 95% CI = 0.53-0.77) were both associated with lower reported health service disruption among HCPs. CONCLUSION: The COVID-19 pandemic continues to disrupt essential health services and present a challenge to HCPs' mental health, with important differences across countries and settings; interventions are needed to mitigate these negative effects of the pandemic

Harmonization of maternal balanced energy-protein supplementation studies for individual participant data (IPD) meta-analyses - finding and creating similarities in variables and data collection

Background: Public health and clinical recommendations are established from systematic reviews and retrospective meta-analyses combining effect sizes, traditionally, from aggregate data and more recently, using individual participant data (IPD) of published studies. However, trials often have outcomes and other meta-data that are not defined and collected in a standardized way, making meta-analysis problematic. IPD meta-analysis can only partially fix the limitations of traditional, retrospective, aggregate meta-analysis; prospective meta-analysis further reduces the problems. Methods: We developed an initiative including seven clinical intervention studies of balanced energy-protein (BEP) supplementation during pregnancy and/or lactation that are being conducted (or recently concluded) in Burkina Faso, Ethiopia, India, Nepal, and Pakistan to test the effect of BEP on infant and maternal outcomes. These studies were commissioned after an expert consultation that designed recommendations for a BEP product for use among pregnant and lactating women in low- and middle-income countries. The initiative goal is to harmonize variables across studies to facilitate IPD meta-analyses on closely aligned data, commonly called prospective meta-analysis. Our objective here is to describe the process of harmonizing variable definitions and prioritizing research questions. A two-day workshop of investigators, content experts, and advisors was held in February 2020 and harmonization activities continued thereafter. Efforts included a range of activities from examining protocols and data collection plans to discussing best practices within field constraints. Prior to harmonization, there were many similar outcomes and variables across studies, such as newborn anthropometry, gestational age, and stillbirth, however, definitions and protocols differed. As well, some measurements were being conducted in several but not all studies, such as food insecurity. Through the harmonization process, we came to consensus on important shared variables, particularly outcomes, added new measurements, and improved protocols across studies. Discussion: We have fostered extensive communication between investigators from different studies, and importantly, created a large set of harmonized variable definitions within a prospective meta-analysis framework. We expect this initiative will improve reporting within each study in addition to providing opportunities for a series of IPD meta-analyses

Enhancing Nutrition and Antenatal Infection Treatment (ENAT) study: protocol of a pragmatic clinical effectiveness study to improve birth outcomes in Ethiopia.

INTRODUCTION: The WHO Nutrition Target aims to reduce the global prevalence of low birth weight by 30% by the year 2025. The Enhancing Nutrition and Antenatal Infection Treatment (ENAT) study will test the impact of packages of pregnancy interventions to enhance maternal nutrition and infection management on birth outcomes in rural Ethiopia. METHODS AND ANALYSIS: ENAT is a pragmatic, open-label, 2×2 factorial, randomised clinical effectiveness study implemented in 12 rural health centres in Amhara, Ethiopia. Eligible pregnant women presenting at antenatal care (ANC) visits at &lt;24 weeks gestation are enrolled (n=2400). ANC quality is strengthened across all centres. Health centres are randomised to receive an enhanced nutrition package (ENP) or standard nutrition care, and within each health centre, individual women are randomised to receive an enhanced infection management package (EIMP) or standard infection care. At ENP centres, women receive a regular supply of adequately iodised salt and iron–folate (IFA), enhanced nutrition counselling and those with mid-upper arm circumference of &lt;23 cm receive a micronutrient fortified balanced energy protein supplement (corn soya blend) until delivery. In standard nutrition centres, women receive routine counselling and IFA. EIMP women have additional screening/treatment for urinary and sexual/reproductive tract infections and intensive deworming. Non-EIMP women are managed syndromically per Ministry of Health Guidelines. Participants are followed until 1-month post partum, and a subset until 6 months. The primary study outcomes are newborn weight and length measured at &lt;72 hours of age. Secondary outcomes include preterm birth, low birth weight and stillbirth rates; newborn head circumference; infant weight and length for age z-scores at birth; maternal anaemia; and weight gain during pregnancy. ETHICS AND DISSEMINATION: ENAT is approved by the Institutional Review Boards of Addis Continental Institute of Public Health (001-A1-2019) and Mass General Brigham (2018P002479). Results will be disseminated to local and international stakeholders. REGISTRATION NUMBER: ISRCTN15116516

sj-docx-1-smo-10.1177_20503121241233232 – Supplemental material for Facilitators and barriers to implementing chest radiography in tuberculosis systematic screening of clinically high-risk groups in Ethiopia: A qualitative study

Supplemental material, sj-docx-1-smo-10.1177_20503121241233232 for Facilitators and barriers to implementing chest radiography in tuberculosis systematic screening of clinically high-risk groups in Ethiopia: A qualitative study by Yishak Abraham, Tsegahun Manyazewal, Zekarias Amdemariam, Hezkiel Petros, Firehiwot Ayenadis, Hana Mekonen and Firehiwot Workneh in SAGE Open Medicine</p