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Barrett C, Chiphwanya J, Matipula DE, Douglass J, Kelly-Hope LA, Dean L. Addressing the Syndemic Relationship between Lymphatic Filariasis and Mental Distress in Malawi: The Potential of Enhanced Self-Care. Trop Med Infect Dis 2024; 9:172. [PMID: 39195610 PMCID: PMC11360657 DOI: 10.3390/tropicalmed9080172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Revised: 07/22/2024] [Accepted: 07/23/2024] [Indexed: 08/29/2024] Open
Abstract
Lymphatic filariasis (LF) causes disfiguring and disabling lymphoedema, which can lead to mental distress and requires life-long self-care treatment. This study applies syndemic theory to understand the biosocial relationship between LF and mental distress in Malawi. Using in-depth qualitative methods, we critically evaluate experiences of mental distress and LF through 21 life-history interviews, to narrate experiences from the perspective of persons affected by LF, and to understand how enhanced self-care (ESC) for lymphoedema management disrupts the syndemic relationship. Complementary key informant interviews with Ministry of Health LF programme staff were conducted to further understand intervention and health system delivery. All interviews were recorded, transcribed, and translated, and then subject to thematic analysis. Our findings suggest that for persons affected by LF in Malawi, before being trained in ESC, absent referral pathways, inequalities in healthcare provision or available treatment, and limited knowledge of the condition (LF) drove the syndemic of LF and mental distress. Distress was often exacerbated by stigma and social exclusion, and shaped by intersections of gender, generation, poverty, and extreme climate conditions. We argue that addressing the syndemic suffering associated with LF and mental distress through interventions which center the needs of persons affected is critical in effective and equitable LF care delivery.
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Affiliation(s)
- Carrie Barrett
- Centre for Neglected Tropical Disease, Department of Tropical Disease Biology, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
| | - John Chiphwanya
- National Lymphatic Filariasis Elimination Programme, Ministry of Health, P.O. Box 30377, Lilongwe 3, Malawi
| | - Dorothy E. Matipula
- National Lymphatic Filariasis Elimination Programme, Ministry of Health, P.O. Box 30377, Lilongwe 3, Malawi
| | - Janet Douglass
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, 1 James Cook Drive, Douglas, QLD 4811, Australia
| | - Louise A. Kelly-Hope
- Centre for Neglected Tropical Disease, Department of Tropical Disease Biology, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
- Department of Livestock and One Health, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, 146 Brownlow Hill, Liverpool L3 5RF, UK
| | - Laura Dean
- Centre for Neglected Tropical Disease, Department of Tropical Disease Biology, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
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Tora A, Bremner S, Ali O, Kinfe M, Mengiste A, Anagnostopoulou V, Fekadu A, Davey G, Semrau M. The role of a community conversation intervention in reducing stigma related to lower limb lymphoedema in Northern Ethiopia. BMC Health Serv Res 2024; 24:353. [PMID: 38504232 PMCID: PMC10949692 DOI: 10.1186/s12913-024-10864-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 03/13/2024] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND Stigma related to lower-limb lymphoedema poses a major psychosocial burden to affected persons and acts as a barrier to them accessing morbidity management and disability prevention (MMDP) services. Community Conversation (CC), which actively engages community members and disseminates health information amongst them, is believed to break the vicious cycle of stigma by enhancing disease-related health literacy at the community level. METHODS A quasi-experimental study was conducted in Northern Ethiopia to assess the role of the CC intervention in reducing stigma. In two control districts, a comprehensive and holistic MMDP care package was implemented that included physical health, mental health and psychosocial interventions, whilst in the intervention district the CC intervention was added to the MMDP care package. A total of 289 persons affected by lymphoedema and 1659 community members without lymphoedema were included in the study. RESULTS Over the course of the intervention, in all sites, community members' knowledge about the causes of lymphoedema increased, and perceived social distance and stigmatizing attitudes towards people with lymphoedema decreased in the community, whilst experienced and internalized stigma decreased amongst affected persons. There were no significant changes for perceived social support. However, the changes were greater in the control sites overall, i.e. those districts in which the holistic care package was implemented without CC. CONCLUSION The findings suggest that the CC intervention provides no additional stigma reduction when used alongside a holistic MMDP care package. Provision of comprehensive and holistic MMDP services may be adequate and appropriate to tackle stigma related to lower-limb lymphoedema in a resource-constrained setting like Ethiopia.
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Affiliation(s)
- Abebayehu Tora
- Department of Sociology, Wolaita Sodo University, Wolaita Sodo, Ethiopia.
| | - Stephen Bremner
- Centre for Global Health Research, Brighton and Sussex Medical School (BSMS), Brighton, UK
| | - Oumer Ali
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, Addis Ababa, Ethiopia
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Mersha Kinfe
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, Addis Ababa, Ethiopia
| | - Asrat Mengiste
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, Addis Ababa, Ethiopia
| | - Vasso Anagnostopoulou
- Centre for Global Health Research, Brighton and Sussex Medical School (BSMS), Brighton, UK
| | - Abebaw Fekadu
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, Addis Ababa, Ethiopia
- Centre for Global Health Research, Brighton and Sussex Medical School (BSMS), Brighton, UK
| | - Gail Davey
- Centre for Global Health Research, Brighton and Sussex Medical School (BSMS), Brighton, UK
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Maya Semrau
- Centre for Global Health Research, Brighton and Sussex Medical School (BSMS), Brighton, UK
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Barrett C, Chiphwanya J, Chaponda L, Matipula DE, Turner JD, Taylor MJ, Read JM, Kelly-Hope LA. Mental health conditions in people affected by filarial lymphoedema in Malawi: prevalence, associated risk factors and the impact of an enhanced self-care intervention. Int Health 2023; 15:iii14-iii27. [PMID: 38118160 PMCID: PMC10732670 DOI: 10.1093/inthealth/ihad064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 06/18/2023] [Accepted: 09/05/2023] [Indexed: 12/22/2023] Open
Abstract
BACKGROUND This study aimed to determine the key mental health indicators affecting people affected by lymphatic filariasis (LF) lymphoedema by assessing the prevalence of depressive symptoms and quality of life (QOL), identifying associated sociodemographic and clinical risk factors, and evaluating the impact of an enhanced self-care intervention for lymphoedema management. METHODS A prospective cohort study of adults with filarial lymphoedema from two regions of Malawi was conducted over six months in 2021. Depressive symptoms and QOL were assessed using Patient Health Questionnaire (PHQ-9) and LF Specific QOL Questionnaire, respectively, at baseline (pre-intervention), 3- and 6-months (postintervention). Beta regression analysis identified risk factors, and assessed the impact of the intervention. RESULTS Three hundred eleven affected individuals were surveyed with 23% (95% CI 18%-29%) reporting mild/moderate depressive symptoms and 31% (95% CI 26%-37%) reporting moderately low/low QOL. Higher depressive symptom scores were associated with high frequency of acute filarial attack episodes. Individuals with higher depressive symptoms (Adjusted Odds Ratios (AOR) 0.93, 95% CI 0.93-0.93) and lower QOL (AOR 0.98, 0.98-0.98) showed greatest improvement in mental health indicators over 3-months but was not sustained to the same level at 6-months. CONCLUSIONS Sustained morbidity management and psychological support is recommended for affected persons to ensure long-term positive mental health and clinical outcomes. CONTEXTE Cette étude vise à déterminer les principaux indicateurs de santé mentale affectant les personnes atteintes de lymphœdème dû à la filariose lymphatique (FL) en évaluant la prévalence des symptômes dépressifs et la qualité de vie (QV), en identifiant les facteurs de risque sociodémographiques et cliniques associés, et en évaluant l'impact d'une intervention améliorée d'autosoins pour la gestion du lymphœdème. MÉTHODES Une étude de cohorte prospective d'adultes atteints de lymphoedème filaire dans deux régions du Malawi a été menée pendant six mois en 2021. Les symptômes dépressifs et la qualité de vie ont été évalués à l'aide du questionnaire sur la santé des patients (PHQ-9) et du questionnaire sur la qualité de vie spécifique au lymphœdème, respectivement, au début de l'étude (avant l'intervention), et à 3 puis 6 mois après l'intervention. Une analyse de régression beta a permis d'identifier les facteurs de risque et d'évaluer l'impact de l'intervention. RÉSULTATS Trois cent onze personnes affectées ont été interrogées, dont 23% (95% CI 18%-29%) ont déclaré des symptômes dépressifs légers/modérés et 31% (95% CI 26%-37%) ont déclaré une qualité de vie modérément faible/faible. Des scores élevés de symptômes dépressifs ont été associés à une fréquence élevée d'épisodes de crises filariennes aiguës. Les personnes présentant des symptômes dépressifs plus élevés (rapport de cotes ajusté (RCA) 0.93, IC à 95 % 0.93-0.93) et une qualité de vie plus faible (RCA 0.98, 0.98-0.98) ont montré la plus grande amélioration des indicateurs de santé mentale au cours des trois mois, mais cette amélioration ne s'est pas maintenue au même niveau au cours des six mois suivants. CONCLUSION Gestion de la morbidité et soutien psychologique sont des éléments clés pour garantir une santé mentale et des résultats cliniques satisfaisants de personnes atteintes sur le long terme. ANTECEDENTES Este estudio tuvo como objetivo determinar los indicadores clave de salud mental que afectan a las personas afectadas por linfedema por filariasis linfática (FL) mediante la evaluación de la prevalencia de síntomas depresivos y calidad de vida (CdV), la identificación de factores de riesgo sociodemográficos y clínicos asociados, y la evaluación del impacto de una intervención de autocuidado mejorada para el manejo del linfedema. MÉTODOS Se realizó un estudio prospectivo de cohortes de adultos con linfedema filarial de dos regiones de Malawi durante seis meses en 2021. Los síntomas depresivos y la calidad de vida se evaluaron mediante el Cuestionario de Salud del Paciente (PHQ-9) y el Cuestionario de Calidad de Vida específico para el LF Cuestionario, respectivamente, al inicio (preintervención) y a los 3 y 6 meses (posintervención). El análisis de regresión beta identificó los factores de riesgo y evaluó el impacto de la intervención. RESULTADOS Se encuestó a 311 afectados, de los cuales el 23% (IC 95%, 18%-29%) presentaba síntomas depresivos leves/moderados y el 31% (IC 95%, 26%-37%) una CdV moderadamente baja/baja CdV. Las puntuaciones más altas de síntomas depresivos se asociaron con una alta frecuencia de episodios de ataques agudos de filarias. Los individuos con mayores síntomas depresivos (Odds Ratios Ajustados [ORA] 0.93; IC 95%: 0.93-0.93) y menor CdV (ORA 0.98; 0.98-0.98) mostraron la mayor mejoría en los indicadores de salud mental a los 3 meses, pero no se mantuvo al mismo nivel a los 6 meses. CONCLUSIONES Se recomienda el manejo sostenido de la morbilidad y el apoyo psicológico a las personas afectadas para garantizar resultados clínicos y de salud mental positivos a largo plazo.
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Affiliation(s)
- Carrie Barrett
- Centre for Neglected Tropical Diseases, Department of Tropical Disease Biology, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | - John Chiphwanya
- National Lymphatic Filariasis Elimination Programme, Ministry of Health, P.O. Box 30377, Lilongwe 3, Malawi
| | - Limbikani Chaponda
- National Lymphatic Filariasis Elimination Programme, Ministry of Health, P.O. Box 30377, Lilongwe 3, Malawi
| | - Dorothy E Matipula
- National Lymphatic Filariasis Elimination Programme, Ministry of Health, P.O. Box 30377, Lilongwe 3, Malawi
| | - Joseph D Turner
- Centre for Neglected Tropical Diseases, Department of Tropical Disease Biology, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | - Mark J Taylor
- Centre for Neglected Tropical Diseases, Department of Tropical Disease Biology, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | - Jonathan M Read
- Lancaster Medical School, South West Drive, Bailrigg, Lancaster, LA1 4ZP, UK
| | - Louise A Kelly-Hope
- Centre for Neglected Tropical Diseases, Department of Tropical Disease Biology, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
- Department of Livestock and One Health, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, 146 Brownlow Hill, Liverpool, L3 5RF, UK
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Tora A, Kinfe M, Ali O, Mengiste A, Ahimed A, Fekadu A, Davey G, Semrau M. A qualitative process evaluation of a community conversation intervention to reduce stigma related to lower limb lymphoedema in Northern Ethiopia. BMC Health Serv Res 2022; 22:1043. [PMID: 35974337 PMCID: PMC9380383 DOI: 10.1186/s12913-022-08335-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 07/11/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Lower limb lymphoedema (swelling of the lower leg) due to Neglected Tropical Diseases (NTDs) such as podoconiosis, lymphatic filariasis and leprosy is common in Ethiopia, imposing huge burdens on affected individuals and communities. Stigma significantly increases the disease burden and acts as a major barrier to accessing lymphoedema care services. A multi-component stigma reduction intervention was implemented in Northern Ethiopia. Community Conversation (CC) was one of the components implemented, and aimed to reduce stigma and enhance access to and uptake of integrated lymphoedema care services with the active engagement of community members. METHODS A cross-sectional qualitative process evaluation was conducted to document lessons focusing on CC's relevance, outcomes and implementation challenges. Data were collected from a total of 55 purposively selected participants (26 from the CC intervention site and 29 from the control site) through key informant interviews, in-depth individual interviews and focus group discussions. RESULTS Community Conversations increased acceptability of health messages about lymphoedema and created peer learning opportunities for unaffected community members. Improvement in the awareness of CC participants about the causes, prevention and treatment of lymphoedema contributed significantly to the reduction of stigmatizing attitudes and discriminatory behaviors, thereby improving access to and utilization of lymphoedema care services provided through primary health care facilities. However, a range of challenges affecting implementation of CC and outcome quality were identified, including perceived complexity of the facilitation guide among facilitators, expectation of incentives among CC participants, inadequate implementation of facilitation principles and procedures, inadequacy of supportive supervision, and low engagement of untrained health workers in CC. CONCLUSIONS With these challenges addressed, the implementation of CC integrated with other lymphoedema care services shows potential to reduce stigma and promote access to lymphoedema care services.
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Affiliation(s)
- Abebayehu Tora
- Department of Sociology, Wolaita Sodo University, Wolaita Sodo, Wolaita Sodo, Ethiopia.
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT- Africa), Addis Ababa University, Addis Ababa, Ethiopia.
| | - Mersha Kinfe
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT- Africa), Addis Ababa University, Addis Ababa, Ethiopia
| | - Oumer Ali
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT- Africa), Addis Ababa University, Addis Ababa, Ethiopia
- Centre for Global Health Research, Brighton and Sussex Medical School (BSMS), Brighton, UK
- Armauer Hansen Research Institute, Addis Ababa, Addis Ababa, Ethiopia
| | - Asrat Mengiste
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT- Africa), Addis Ababa University, Addis Ababa, Ethiopia
| | - Abdulkadir Ahimed
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT- Africa), Addis Ababa University, Addis Ababa, Ethiopia
| | - Abebaw Fekadu
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT- Africa), Addis Ababa University, Addis Ababa, Ethiopia
- Centre for Global Health Research, Brighton and Sussex Medical School (BSMS), Brighton, UK
| | - Gail Davey
- Centre for Global Health Research, Brighton and Sussex Medical School (BSMS), Brighton, UK
- School of Public Health, Addis Ababa University, Addis Ababa, Addis Ababa, Ethiopia
| | - Maya Semrau
- Centre for Global Health Research, Brighton and Sussex Medical School (BSMS), Brighton, UK.
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Dellar R, Ali O, Kinfe M, Mengiste A, Davey G, Bremner S, Semrau M, Fekadu A. Effect of a Community-Based Holistic Care Package on Physical and Psychosocial Outcomes in People with Lower Limb Disorder Caused by Lymphatic Filariasis, Podoconiosis, and Leprosy in Ethiopia: Results from the EnDPoINT Pilot Cohort Study. Am J Trop Med Hyg 2022; 107:tpmd211180. [PMID: 35895351 PMCID: PMC9490655 DOI: 10.4269/ajtmh.21-1180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 02/18/2022] [Indexed: 11/07/2022] Open
Abstract
Lymphatic filariasis (LF), podoconiosis, and leprosy are highly stigmatized neglected tropical diseases that can cause lower limb swelling and deformity. Simple interventions to support self-care can reduce their physical impacts, but little is known about how to address the psychosocial needs of people living with the diseases, and about how to scale-up morbidity reduction programs. EnDPoINT is a multistage implementation study designed to address these knowledge gaps by developing and evaluating a holistic care package that can be integrated into the Ethiopian health system. This article presents the quantitative results from the EnDPoINT pilot, in which the effectiveness of the care package was assessed in 251 participants from one district in northern Ethiopian using a pre-post design. Reductions 12 months after care package initiation were seen in attacks of acute adenolymphangitis (adjusted odds ratio for attack in last month 0.005; 95% CI 0.001, 0.02; P < 0.001), lower limb and foot circumference (mean difference lower limb circumference -2.0 cm; 95% CI -2.3, -1.8; P < 0.001; foot circumference -2.3 cm; 95% CI -2.5, -2.0; P < 0.001), and lymphedema stage (mean reduction in stage -0.27; 95% CI -0.37, -0.19; P < 0.001). Significant improvements were also observed in scores assessing disability, quality-of-life, depression, stigma, discrimination, and social support. This study thus suggests that the EnDPoINT care package is highly effective in reducing morbidity in people living with LF, podoconiosis, and leprosy in northern Ethiopia.
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Affiliation(s)
- Rachael Dellar
- Brighton and Sussex Centre for Global Health Research, Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom
| | - Oumer Ali
- Brighton and Sussex Centre for Global Health Research, Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom
- Center for Innovative Drug Development and Therapeutic Trials for Africa, Addis Ababa University, Addis Ababa, Ethiopia
| | - Mersha Kinfe
- Center for Innovative Drug Development and Therapeutic Trials for Africa, Addis Ababa University, Addis Ababa, Ethiopia
| | - Asrat Mengiste
- Center for Innovative Drug Development and Therapeutic Trials for Africa, Addis Ababa University, Addis Ababa, Ethiopia
| | - Gail Davey
- Brighton and Sussex Centre for Global Health Research, Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Stephen Bremner
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom
| | - Maya Semrau
- Brighton and Sussex Centre for Global Health Research, Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom
| | - Abebaw Fekadu
- Brighton and Sussex Centre for Global Health Research, Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom
- Center for Innovative Drug Development and Therapeutic Trials for Africa, Addis Ababa University, Addis Ababa, Ethiopia
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Davies B, Kinfe M, Ali O, Mengiste A, Tesfaye A, Wondimeneh MT, Davey G, Semrau M. Stakeholder perspectives on an integrated package of care for lower limb disorders caused by podoconiosis, lymphatic filariasis or leprosy: A qualitative study. PLoS Negl Trop Dis 2022; 16:e0010132. [PMID: 35061673 PMCID: PMC8809619 DOI: 10.1371/journal.pntd.0010132] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 02/02/2022] [Accepted: 01/04/2022] [Indexed: 11/21/2022] Open
Abstract
Background Lower limb disorders including lymphoedema create a huge burden for affected persons in their physical and mental health, as well as socioeconomic and psychosocial consequences for them, their families and communities. As routine health services for the integrated management and prevention of lower limb disorders are still lacking, the ‘Excellence in Disability Prevention Integrated across Neglected Tropical Diseases’ (EnDPoINT) study was implemented to assess the development and delivery of an integrated package of holistic care–including physical health, mental health and psychosocial care–within routine health services for persons with lower limb disorders caused by podoconiosis, lymphatic filariasis and leprosy. Methodology/Principal findings This study was part of the first of three phases within EnDPoINT, involving the development of the integrated care package. Focus group discussions and key informant interviews were undertaken with 34 participants between January–February 2019 in Awi zone, Ethiopia, in order to assess the draft care package’s feasibility, acceptability and appropriateness. Persons affected by lower limb disorders such as lymphoedema experience stigma, exclusion from families, communities and work as well as physical and financial hardship. Beliefs in disease causation inhibit affected persons from accessing care. Ignorance was a barrier for health care providers as well as affected persons. Training and education of affected persons, communities and caregivers is important in improving care access. It also requires time, space, materials and financial resources. Both top-down and grass roots input into service development are key, as well as collaboration across stakeholders including charities, community leaders and “expert patients”. Conclusions/Significance This study highlighted the need for the EnDPoINT integrated care package and provided suggestions for solutions according to its three aspects of integrated care (integration into routine care; integration of mental health and psychosocial care; and integration of care across the three diseases), thereby giving support for its feasibility, acceptability and appropriateness. Lower limb disorders including lymphoedema are prevalent in Ethiopia as a common endpoint of varying causes such as podoconiosis, leprosy and lymphatic filariasis. This study involved the development of a comprehensive integrated and holistic care package for lower limb disorders into routine health care services. It used interviews and focus groups to assess feasibility, acceptability and appropriateness of the draft care package. We found that persons affected by lower limb disorders had many negative experiences due to their condition, especially related to stigma, that included physical, financial and psychological sequelae. Neglect was paramount, with financial neglect in central budgets, a lack of knowledge by care givers and a lack of awareness among affected persons and their communities, all contributing to inadequate care provision and access. Affected persons, communities and caregivers may benefit from provision of learning opportunities about the prevention and treatment of lower limb disorders; and resources are crucial in engendering change, including material goods, time to provide care, and collaborative work to create a culture shift and address stigma.
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Affiliation(s)
- Bethany Davies
- Centre for Global Health Research, Brighton and Sussex Medical School, Brighton, United Kingdom
- * E-mail: (BD); (MS)
| | - Mersha Kinfe
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, Addis Ababa, Ethiopia
| | - Oumer Ali
- Centre for Global Health Research, Brighton and Sussex Medical School, Brighton, United Kingdom
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, Addis Ababa, Ethiopia
| | - Asrat Mengiste
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, Addis Ababa, Ethiopia
| | - Abraham Tesfaye
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, Addis Ababa, Ethiopia
| | | | - Gail Davey
- Centre for Global Health Research, Brighton and Sussex Medical School, Brighton, United Kingdom
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Maya Semrau
- Centre for Global Health Research, Brighton and Sussex Medical School, Brighton, United Kingdom
- * E-mail: (BD); (MS)
| | - EnDPoINT Research Team and Consortium
- Centre for Global Health Research, Brighton and Sussex Medical School, Brighton, United Kingdom
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, Addis Ababa, Ethiopia
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
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Esubalew H, Wubie M, Tafere Y, Gietaneh W, Endalew B, Habtegiorgis SD, Gebre T, Tesfaw E, Abiy H, Telayneh AT. Self-Care Practice and Its Associated Factors Among Podoconiosis Patients in East Gojjam Zone, North West Ethiopia. Patient Prefer Adherence 2022; 16:1971-1981. [PMID: 35958889 PMCID: PMC9362903 DOI: 10.2147/ppa.s376557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 07/29/2022] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Podoconiosis is endemic non-filarial elephantiasis of the lower legs swelling caused by barefoot exposure to red clay soil. The burden of disability occurs among the poorest populations. Self-care practice is the most cost-effective prevention strategy practiced at home to improve lymphedema, working functionality, and quality of life. Despite this, there is a scarce of knowledge about self-care practices and associated factors among podoconiosis patients in Ethiopia. OBJECTIVE To determine self-care practice and its associated factors among podoconiosis patients in East Gojjam zone North West, Ethiopia. METHODS Community-based cross-sectional study design was used among 633 podoconiosis patients. Computer-generated simple random sampling technique was used to recruit participants. All patients who started podoconiosis treatment were the source population. Data were entered using Epidata version 3.1 and exported to SPSS version 25 for cleaning and analysis. Variables with 95% CI corresponding AOR were used to identify statistically significant factors for self-care practice. RESULTS In this study, the self-care practice of podoconiosis patient was 64%. Females [AOR: 0.38 (95% CI: 0.22, 0.65)], 55-65 years age [AOR: 0.41 (95% CI: 0.22, 0.74)], above 65 years age [AOR: 0.22 (95% CI: 0.11, 0.450)], 4-6 km distance from water source [AOR: 0.06 (95% CI: 0.03, 0.12)], above 6 km distance from water source [AOR: 0.03 (95% CI: 0.01, 0.09)], educational level [AOR: 0.05 (95% CI: 0.01, 0.40)], marital status [AOR: 5.40 (95% CI: 2.30, 12.90)], and distance from health institution [AOR: 0.35 (95% CI: 0.23, 0.54)] were statistically identified associated factors for self-care practice of podoconiosis patient. CONCLUSION In this study, the self-care practice of podoconiosis patients was not well practiced. Socio-demographic factors are identified as associated factors for self-care practice. Strengthening health education and behavioral changes are required to improve self-care practice.
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Affiliation(s)
| | - Moges Wubie
- Department of Public Health, College of Health Science, Debre Markos University, Debre Markos, Ethiopia
| | - Yilkal Tafere
- Department of Public Health, College of Health Science, Debre Markos University, Debre Markos, Ethiopia
| | - Wodaje Gietaneh
- Department of Public Health, College of Health Science, Debre Markos University, Debre Markos, Ethiopia
| | - Bekalu Endalew
- Department of Public Health, College of Health Science, Debre Markos University, Debre Markos, Ethiopia
| | | | - Tsige Gebre
- Department of Public Health, College of Health Science, Debre Markos University, Debre Markos, Ethiopia
| | - Eyerus Tesfaw
- Department of Public Health, College of Health Science, Debre Markos University, Debre Markos, Ethiopia
| | - Hailemariam Abiy
- Department of Public Health, College of Health Science, Debre Markos University, Debre Markos, Ethiopia
| | - Animut Takele Telayneh
- Department of Public Health, College of Health Science, Debre Markos University, Debre Markos, Ethiopia
- Correspondence: Animut Takele Telayneh, Debre Markos University, P.O. Box 269, Debre Markos, Ethiopia, Tel +251918215993, Email
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Dellar R, Ali O, Kinfe M, Tesfaye A, Fekadu A, Davey G, Semrau M, Bremner S. Knowledge, attitudes and practices of health professionals towards people living with lymphoedema caused by lymphatic filariasis, podoconiosis and leprosy in northern Ethiopia. Int Health 2021; 14:530-536. [PMID: 34634104 PMCID: PMC9450644 DOI: 10.1093/inthealth/ihab067] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/12/2021] [Accepted: 09/23/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Podoconiosis, lymphatic filariasis and leprosy are highly stigmatised neglected tropical diseases that cause lymphoedema. Their enormous impacts on health-related quality of life, mental health and economic productivity can be significantly reduced by morbidity management and disability prevention (MMDP) services, but to deliver such services requires appropriate training of healthcare professionals. The aim of this study was to assess the knowledge, attitudes and practices (KAP) of rural Ethiopian healthcare professionals towards people with lymphoedema as a way to assess training needs. METHODS This study used questionnaires to quantitatively assess KAP towards people with lymphoedema among rural healthcare professionals in northwest Ethiopia before and 12 months after a short training intervention. RESULTS Questionnaires were administered to 14 health professionals at baseline and 21 at follow-up. At baseline, 71% (10/14) were found to hold at least one stigmatising attitude towards lymphoedema patients, compared with 66% (14/21) at follow-up. Large gaps in knowledge were noted, with many unable to identify ways of treating/preventing the diseases. CONCLUSIONS This study showed high proportions of healthcare workers holding stigmatising views and lacking essential knowledge about lymphoedema. To maximise the impact of MMDP interventions, further research is urgently needed to understand how to address these issues.
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Affiliation(s)
- Rachael Dellar
- Brighton and Sussex Centre for Global Health Research, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - Oumer Ali
- Brighton and Sussex Centre for Global Health Research, Brighton and Sussex Medical School, University of Sussex, Brighton, UK.,Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, Addis Ababa, Ethiopia
| | - Mersha Kinfe
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, Addis Ababa, Ethiopia
| | - Abraham Tesfaye
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, Addis Ababa, Ethiopia
| | - Abebaw Fekadu
- Brighton and Sussex Centre for Global Health Research, Brighton and Sussex Medical School, University of Sussex, Brighton, UK.,Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, Addis Ababa, Ethiopia
| | - Gail Davey
- Brighton and Sussex Centre for Global Health Research, Brighton and Sussex Medical School, University of Sussex, Brighton, UK.,School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Maya Semrau
- Brighton and Sussex Centre for Global Health Research, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - Stephen Bremner
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
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9
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Ali O, Kinfe M, Semrau M, Tora A, Tesfaye A, Mengiste A, Davey G, Fekadu A. A qualitative study on the implementation of a holistic care package for control and management of lymphoedema: experience from a pilot intervention in northern Ethiopia. BMC Health Serv Res 2021; 21:1065. [PMID: 34625080 PMCID: PMC8501530 DOI: 10.1186/s12913-021-07088-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 09/21/2021] [Indexed: 01/02/2023] Open
Abstract
Background Neglected Tropical Diseases (NTDs) such as podoconiosis, lymphatic filariasis (LF) and leprosy mainly affect communities in low resource settings. These diseases are associated with physical disability due to lymphoedema as well as poor mental health and psychosocial outcomes. Integration of care across these NTDs at primary health care level, which includes mental health and psychosocial care alongside physical health care, is increasingly recommended. Methods A holistic integrated care package was developed and piloted as part of the EnDPoINT project in Gusha district, Awi zone, Ethiopia. The intervention was conducted at the health care organization, health facility and community levels. To assess the impact of the care package in terms of acceptability, scalability, sustainability and barriers to implementation, a qualitative study was conducted in January 2020. This included four focus group discussions (29 participants) and ten key informant interviews with decision makers, health professionals, patients, and community representatives. Results The integrated lymphoedema care package was found to be efficient compared to vertical programs in saving time and resources. It also resulted in improved awareness of the causes, treatment and prevention of lymphoedema, in marked improvements in the lymphoedema, and in reduced stigma and discrimination. The care package was found to be acceptable to patients, health professionals and decision makers. The barriers to integrated care were unrealistic patient expectations, inadequate dissemination across health workers, and poor transportation access. Health professionals, decision makers and patients believed the integrated lymphoedema care package to be scalable and sustainable. Conclusion The integrated holistic care package was found to be acceptable to patients, health professionals and decision makers. We recommend its scale-up to other endemic districts. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-07088-7.
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Affiliation(s)
- Oumer Ali
- CDT-Africa, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia. .,Centre for Global Health Research, Brighton and Sussex Medical School, Falmer Campus, University of Sussex, Brighton, BN1 9PX, UK.
| | - Mersha Kinfe
- CDT-Africa, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Maya Semrau
- Centre for Global Health Research, Brighton and Sussex Medical School, Falmer Campus, University of Sussex, Brighton, BN1 9PX, UK
| | - Abebayehu Tora
- CDT-Africa, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.,Department of Sociology, Wolaita Sodo University, Sodo, Ethiopia
| | - Abraham Tesfaye
- CDT-Africa, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Asrat Mengiste
- CDT-Africa, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Gail Davey
- Centre for Global Health Research, Brighton and Sussex Medical School, Falmer Campus, University of Sussex, Brighton, BN1 9PX, UK.,College of Health Sciences, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Abebaw Fekadu
- CDT-Africa, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.,Centre for Global Health Research, Brighton and Sussex Medical School, Falmer Campus, University of Sussex, Brighton, BN1 9PX, UK
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10
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Deribe K, Mackenzie CD, Newport MJ, Argaw D, Molyneux DH, Davey G. Podoconiosis: key priorities for research and implementation. Trans R Soc Trop Med Hyg 2021; 114:889-895. [PMID: 33169167 PMCID: PMC7738650 DOI: 10.1093/trstmh/traa094] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/31/2020] [Accepted: 08/27/2020] [Indexed: 12/14/2022] Open
Abstract
Podoconiosis is a non-infectious tropical lymphoedema causing swelling of the lower legs. Podoconiosis is associated with stigma, depression and reduced productivity, resulting in significant socio-economic impacts for affected individuals, families and communities. It is caused by barefoot exposure to soils and affects disadvantaged populations. Evidence from the past 5 y suggests that podoconiosis is amenable to public health interventions, e.g. footwear and hygiene-based morbidity management, which reduce acute clinical episodes. Although much has been learned in recent years, advances in care for these patients and worldwide control requires further reliable and relevant research. To develop a comprehensive global control strategy, the following key research priorities are important: better understanding of the global burden of podoconiosis through extended worldwide mapping, development of new point-of-care diagnostic methods and approaches to define the presence of the environmental characteristics that contribute to the development of the condition, improving treatment through an increased understanding of the pathogenesis of dermal changes over time, improved understanding of optimal ways of providing patient care at the national level, including research to optimize behavioural change strategies, determine the optimum package of care and integrate approaches to deliver robust surveillance, monitoring and evaluation of control programmes.
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Affiliation(s)
- Kebede Deribe
- Brighton and Sussex Centre for Global Health Research, Department of Global Health and Infection, Brighton and Sussex Medical School, Brighton BN1 9PX, UK.,School of Public Health, College of Health Sciences, Addis Ababa University, PO Box 9086, Addis Ababa, Ethiopia
| | | | - Melanie J Newport
- Brighton and Sussex Centre for Global Health Research, Department of Global Health and Infection, Brighton and Sussex Medical School, Brighton BN1 9PX, UK
| | - Daniel Argaw
- World Health Organization, Control of Neglected Tropical Diseases, Geneva 1211, Switzerland
| | | | - Gail Davey
- Brighton and Sussex Centre for Global Health Research, Department of Global Health and Infection, Brighton and Sussex Medical School, Brighton BN1 9PX, UK.,School of Public Health, College of Health Sciences, Addis Ababa University, PO Box 9086, Addis Ababa, Ethiopia
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11
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Infrared Thermal Imaging as a Novel Non-Invasive Point-of-Care Tool to Assess Filarial Lymphoedema. J Clin Med 2021; 10:jcm10112301. [PMID: 34070599 PMCID: PMC8198125 DOI: 10.3390/jcm10112301] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/19/2021] [Accepted: 05/21/2021] [Indexed: 12/13/2022] Open
Abstract
Lymphatic filariasis causes disfiguring and disabling lymphoedema, which is commonly and frequently exacerbated by acute dermatolymphangioadenitis (ADLA). Affected people require long-term care and monitoring but health workers lack objective assessment tools. We examine the use of an infrared thermal imaging camera as a novel non-invasive point-of-care tool for filarial lower-limb lymphoedema in 153 affected adults from a highly endemic area of Bangladesh. Temperature differences by lymphoedema stage (mild, moderate, severe) and ADLA history were visualised and quantified using descriptive statistics and regression models. Temperatures were found to increase by severity and captured subclinical differences between no lymphoedema and mild lymphoedema, and differences between moderate and severe stages. Toes and ankle temperatures detected significant differences between all stages other than between mild and moderate stages. Significantly higher temperatures, best captured by heel and calf measures, were found in participants with a history of ADLA, compared to participants who never had ADLA, regardless of the lymphoedema stage. This novel tool has great potential to be used by health workers to detect subclinical cases, predict progression of disease and ADLA status, and monitor pathological tissue changes and stage severity following enhanced care packages or other interventions in people affected by lymphoedema.
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Tesfaye A, Semrau M, Ali O, Kinfe M, Tamiru M, Fekadu A, Davey G. Development of an integrated, holistic care package for people with lymphoedema for use at the level of the Primary Health Care Unit in Ethiopia. PLoS Negl Trop Dis 2021; 15:e0009332. [PMID: 33878110 PMCID: PMC8086999 DOI: 10.1371/journal.pntd.0009332] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 04/30/2021] [Accepted: 03/25/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Neglected Tropical Diseases (NTDs) are a group of several communicable and non-communicable diseases prevalent in tropical and subtropical areas. The co-endemicity of these diseases, the similarity of their clinical signs, and the need to maximize limited financial and human resources suggest the importance of adoptingan integratedapproach to their prevention and treatment. AIMS This study describes the development of a comprehensive package of physical, mental health and psychosocial care for people with lower-limb lymphoedema caused bypodoconiosis, lymphatic filariasis (LF)or leprosy as part of the EnDPoINT program in Ethiopia. METHOD The care package was developed using a mixed-methods approach, consisting of a literature review, situational analysis, Theory of Change (ToC) workshops, qualitative research, and additional workshops to fine-tune the draft care package. The care package was developed between March 2018 and January 2020 in Addis Ababa and the implementation research site, Awi zone in the North-West of Ethiopia. RESULTS The holistic care package includes components implemented at three levels of the health care system:health organization, facility, and community. Sections of the care package are directed at strengthening capacity building, program management, community engagement, awareness-raising, stigma-reduction, morbidity management, disability prevention, follow-up visits, referral linkage, community-based rehabilitation, and monitoring and evaluation. CONCLUSIONS The study developed a holistic integrated care package for lower limb disorder and co-morbid mental health problems caused by podoconiosis, LF or leprosy. The approach has the potential to significantly reduce lower limb disorder-associated morbidity, disability, and psychosocial problems. It also standardizes a scalable approach appropriate for the Ethiopian setting and, most likely, other countries where these NTDs are present.
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Affiliation(s)
- Abraham Tesfaye
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, Addis Ababa, Ethiopia
| | - Maya Semrau
- Brighton and Sussex Centre for Global Health Research, Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom
| | - Oumer Ali
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, Addis Ababa, Ethiopia
- Brighton and Sussex Centre for Global Health Research, Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom
| | - Mersha Kinfe
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, Addis Ababa, Ethiopia
| | | | - Abebaw Fekadu
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, Addis Ababa, Ethiopia
| | - Gail Davey
- Brighton and Sussex Centre for Global Health Research, Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
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13
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Hounsome N, Kinfe M, Semrau M, Ali O, Tesfaye A, Mengiste A, Bremner S, Ahmed A, Fekadu A, Davey G. Economic assessment of a community-based care package for people with lower limb disorder caused by lymphatic filariasis, podoconiosis and leprosy in Ethiopia. Trans R Soc Trop Med Hyg 2020; 114:1021-1034. [PMID: 33169165 PMCID: PMC7738652 DOI: 10.1093/trstmh/traa111] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/17/2020] [Accepted: 10/07/2020] [Indexed: 11/30/2022] Open
Abstract
We conducted an implementation research study to integrate a holistic package of physical health, mental health and psychosocial care for podoconiosis, lymphatic filariasis and leprosy into routine healthcare in Gusha cluster, Guagusa Shikudad district, northwest Ethiopia. The healthcare package included training patients in lower limb hygiene and skin care and provision of shoes, hygiene supplies and medication. The implementation activities included training events, workshops, awareness raising, self-help groups, supportive supervision, staff secondments and advisory board meetings. The cost of implementing the care package in Gusha cluster, with a population of 30 558 people, was 802 655 Ethiopian birr (ETB) (£48 159) and the cost of delivering care to 235 participants was 204 388 ETB (£12 263), or 870 ETB (£52) per person. There was a 35% decrease in the mean disability scores (measured using the World Health Organization Disability Assessment Schedule 2.0) and a 45% improvement in the dermatology-specific quality of life (measured using the Dermatology Life Quality Index) at the 3-month follow-up compared with baseline. There were reductions in the number of days with symptoms, days off usual activities/work and days with reduced activity due to illness, all of which were statistically significant. Our pilot suggests that integration of the care package into routine healthcare in Ethiopia may be effective in improving health-related quality of life and disability and reducing time out of economic activity due to illness.
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Affiliation(s)
- Natalia Hounsome
- Brighton and Sussex Centre for Global Health Research, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - Mersha Kinfe
- Center for Innovative Drug Development and Therapeutic Trials for Africa, Addis Ababa University, Addis Ababa, Ethiopia
| | - Maya Semrau
- Brighton and Sussex Centre for Global Health Research, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - Oumer Ali
- Center for Innovative Drug Development and Therapeutic Trials for Africa, Addis Ababa University, Addis Ababa, Ethiopia
| | - Abraham Tesfaye
- Center for Innovative Drug Development and Therapeutic Trials for Africa, Addis Ababa University, Addis Ababa, Ethiopia
| | - Asrat Mengiste
- Center for Innovative Drug Development and Therapeutic Trials for Africa, Addis Ababa University, Addis Ababa, Ethiopia
| | - Stephen Bremner
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - Abdulkadir Ahmed
- Center for Innovative Drug Development and Therapeutic Trials for Africa, Addis Ababa University, Addis Ababa, Ethiopia
| | - Abebaw Fekadu
- Center for Innovative Drug Development and Therapeutic Trials for Africa, Addis Ababa University, Addis Ababa, Ethiopia
| | - Gail Davey
- Brighton and Sussex Centre for Global Health Research, Brighton and Sussex Medical School, University of Sussex, Brighton, UK.,School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
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