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Tiruneh GT, Fesseha N, Emaway D, Betemariam W, Nigatu TG, Magge H, Hirschhorn LR. Effect of community-based newborn care implementation strategies on access to and effective coverage of possible serious bacterial infection (PSBI) treatment for sick young infants during COVID-19 pandemic. PLoS One 2024; 19:e0300880. [PMID: 38527000 PMCID: PMC10962833 DOI: 10.1371/journal.pone.0300880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 03/06/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND In Ethiopia, neonatal mortality is persistently high. The country has been implementing community-based treatment of possible serious bacterial infection (PSBI) in young infants when referral to a hospital is not feasible since 2012. However, access to and quality of PSBI services remained low and were worsened by COVID-19. From November 2020 to June 2022, we conducted implementation research to mitigate the impact of COVID-19 and improve PSBI management implementation uptake and delivery in two woredas in Ethiopia. METHODS In April-May 2021, guided by implementation research frameworks, we conducted formative research to understand the PSBI management implementation challenges, including those due to the COVID-19 pandemic. Through a participatory process engaging stakeholders, we designed adaptive implementation strategies to bridge identified gaps using mechanism mapping to achieve implementation outcomes. Strategies included training and coaching, supportive supervision and mentorship, technical support units, improved supply of essential commodities, and community awareness creation about PSBI and COVID-19. We conducted cross-sectional household surveys in the two woredas before (April 2021) and after the implementation of strategies (June 2022) to measure changes in targeted outcomes. RESULTS We interviewed 4,262 and 4,082 women who gave live birth 2-14 months before data collection and identified 374 and 264 PSBI cases in April 2021 and June 2022, respectively. The prevalence of PSBI significantly decreased (p-value = 0.018) from 8.7% in April 2021 to 6.4% while the mothers' care-seeking behavior from medical care for their sick newborns increased significantly from 56% to 91% (p-value <0.01). Effective coverage of severely ill young infants that took appropriate antibiotics significantly improved from 33% [95% CI: 25.5-40.7] to 62% [95% CI: 51.0-71.6]. Despite improvements in the uptake of PSBI treatment, persisting challenges at the facility and systems levels impeded optimal PSBI service delivery and uptake, including perceived low quality of service, lack of community trust, and shortage of supplies. CONCLUSION The participatory design and implementation of adaptive COVID-19 strategies effectively improved the uptake and delivery of PSBI treatment. Support systems were critical for frontline health workers to deliver PSBI services and create a resilient community health system to provide quality PSBI care during the pandemic. Additional strategies are needed to address persistent gaps, including improvement in client-provider interactions, supply of essential drugs, and increased social mobilization strategies targeting families and communities to further increase uptake.
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Affiliation(s)
| | - Nebreed Fesseha
- JSI Research & Training Institute Inc., Addis Ababa, Ethiopia
| | - Dessalew Emaway
- JSI Research & Training Institute Inc., Addis Ababa, Ethiopia
| | - Wuleta Betemariam
- JSI Research & Training Institute Inc., Washington, DC, United States of America
| | | | - Hema Magge
- Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
- Ethiopia and Fenot Project—School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Lisa Ruth Hirschhorn
- Feinberg School of Medicine and Havey Institute of Global Health, Northwestern University, Chicago, Illinois, United States of America
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Tiruneh GT, Hirschhorn LR, Fesseha N, Emaway D, Eifler K, Betemariam W. Care-seeking behaviours of mothers and associated factors for possible serious bacterial infection in young infants during COVID-19 pandemic in Ethiopia: mixed-methods formative research. BMJ Open 2023; 13:e073118. [PMID: 37407046 DOI: 10.1136/bmjopen-2023-073118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/07/2023] Open
Abstract
OBJECTIVES Implementation research was employed to examine rates and contextual factors associated with mothers' care-seeking for their sick neonates and identify challenges for community-based possible serious bacterial infection (PSBI) services access and implementation during the COVID-19 pandemic. DESIGN We conducted formative research involving household survey and programmatic qualitative study. SETTING This formative study was conducted in Dembecha and Lume woredas of Amhara and Oromia regions. PARTICIPANTS Data were captured from 4262 mothers aged 15-49 years who gave live birth 2-14 months before data collection, and interviews with 18 programme managers and 16 service providers in April to May 2021. ANALYSIS A multilevel regression model was employed to identify predictors of maternal care-seeking for PSBI and thematic qualitative analysis to inform strategy development to strengthen PSBI implementation. RESULTS Overall, 12% (95% CI 11.0% to 12.9%) and 8% (95% CI 7.9% to 9.6%) of mothers reported any newborn illness and severe neonatal infection (PSBI), respectively. More than half of mothers sought formal medical care, 56% (95% CI 50.7% to 60.8%) for PSBI. Women who received postnatal care within 6 weeks (adjusted OR (AOR) 2.08; 95% CI 1.12 to 3.87) and complete antenatal care (ie, weight measured, blood pressure taken, urine and blood tested) (AOR 2.04; 95% CI 1.12 to 3.75) had higher odds of care-seeking for PSBI. Conversely, fear of COVID-19 (AOR 0.27; 95% CI 0.15 to 0.47) and residing more than 2 hours of walking distance from the health centre (AOR 0.39; 95% CI 0.16 to 0.93) were negatively associated with care-seeking for severe newborn infection. Multiple pre-existing health system bottlenecks were identified from interviews as barriers to PSBI service delivery and exacerbated by the COVID-19 pandemic. CONCLUSION We found gaps in and factors associated with care-seeking behaviour of mothers for their sick young infants including fear of COVID-19 and pre-existing health system-level barriers. The findings of the study were used to design and implement strategies to mitigate COVID-19 impacts on management of PSBI.
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Affiliation(s)
- Gizachew Tadele Tiruneh
- Improving Primary Healthcare Project, JSI Research & Training Institute, Addis Ababa, Ethiopia
- Behavioral Science, Addis Continental Institute of Public Health, Addis Ababa, Ethiopia
| | - Lisa R Hirschhorn
- Feinberg School of Medicine and Havey Institute of Global Health, Northwestern University, Chicago, Illinois, USA
| | - Nebreed Fesseha
- Improving Primary Healthcare Project, JSI Research & Training Institute, Addis Ababa, Ethiopia
| | - Dessalew Emaway
- Improving Primary Healthcare Project, JSI Research & Training Institute, Addis Ababa, Ethiopia
| | - Kristin Eifler
- International Division, JSI Research & Training Institute, Boston, Massachusetts, USA
| | - Wuleta Betemariam
- Center for Healthy Women, Children, and Communities, JSI Research & Training Institute, Washington, DC, USA
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Daka DW, Wordofa MA, Berhanu D, Persson LÅ, Woldie M. Quality of sick child management by health extension workers: role of a complex improvement intervention. BMC Health Serv Res 2023; 23:165. [PMID: 36797722 PMCID: PMC9933397 DOI: 10.1186/s12913-023-09131-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 01/31/2023] [Indexed: 02/18/2023] Open
Abstract
BACKGROUND Despite the expansion of the Integrated Community Case Management services for childhood illness, quality and utilization of services have remained low. To address the problem, the Government of Ethiopia introduced a complex intervention that included community engagement, capacity building of health workers and enhanced district-level ownership of sick child management. We examined whether this complex intervention was associated with improved management of sick children by health extension workers. METHODS The study was conducted in four Ethiopian regions. A baseline survey was conducted in 26 intervention and 26 comparison districts from December 2016 to February 2017, followed by an end-line survey 24 months later. We observed health extension workers' consultations of sick 2-59 months old children. The analysis has evaluated if children with pneumonia, diarrhoea and malnutrition were assessed, classified and treated according to guidelines, and included difference-in-difference analyses. RESULTS We observed 1325 consultations of sick children. At baseline, 86% of the sick children with cough in the intervention areas and 85% in comparison areas were assessed according to the guidelines, without any change at end-line associated with the intervention (difference-in-difference = -21%, p = 0.55). Sixty-two percent of children were assessed for dehydration at baseline in intervention and 47% in comparison areas, with no improvement associated with the intervention. Similarly, 87% of sick children in intervention and 91% in comparison areas were assessed for malnutrition, with no change over time associated with the intervention (difference-in-difference = 5%, p = 0.16). Appropriate pneumonia treatment with antibiotics declined and diarrhea treatment increased in both areas. Half of the malnourished children received ready-to-use therapeutic foods without any improvement associated with the intervention. CONCLUSION The intervention was not associated with improved quality of the health extension workers' management of sick children. The lack of association may be linked to low fidelity in the implementation of the intervention. Our findings suggest that training healthcare providers without continued clinical mentoring and support does not improve the quality of care. Community-based programs can be strengthened by ensuring high coverage and continued clinical mentorships, supportive supervision, and supply of medicines and other essential commodities. TRIAL REGISTRATION NUMBER ISRCTN12040912, retrospectively registered on 19/12/ 2017.
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Affiliation(s)
- Dawit Wolde Daka
- Faculty of Public Health, Department of Health Policy and Management, Jimma University, Jimma, Ethiopia.
| | - Muluemebet Abera Wordofa
- grid.411903.e0000 0001 2034 9160Faculty of Public Health, Department of Population and Family Health, Jimma University, Jimma, Ethiopia
| | - Della Berhanu
- grid.452387.f0000 0001 0508 7211Ethiopian Public Health Institute, Addis Ababa, Ethiopia ,grid.8991.90000 0004 0425 469XThe London School of Hygiene & Tropical Medicine, London, UK
| | - Lars Åke Persson
- grid.452387.f0000 0001 0508 7211Ethiopian Public Health Institute, Addis Ababa, Ethiopia ,grid.8991.90000 0004 0425 469XThe London School of Hygiene & Tropical Medicine, London, UK
| | - Mirkuzie Woldie
- grid.411903.e0000 0001 2034 9160Faculty of Public Health, Department of Health Policy and Management, Jimma University, Jimma, Ethiopia ,Fenot Project, University of British Columbia, School of Public Health and Population, Addis Ababa, Ethiopia
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Gebregizabher FA, Medhanyie AA, Bezabih AM, Persson LÅ, Abegaz DB. Is Women's Engagement in Women's Development Groups Associated with Enhanced Utilization of Maternal and Neonatal Health Services? A Cross-Sectional Study in Ethiopia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1351. [PMID: 36674107 PMCID: PMC9858998 DOI: 10.3390/ijerph20021351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 01/02/2023] [Accepted: 01/03/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND In Ethiopia, the Women Development Group program is a community mobilization initiative aimed at enhancing Universal Health Coverage through supporting the primary healthcare services for mothers and newborns. This study aimed to assess the association between engagement in women's groups and the utilization of maternal and neonatal health services. METHOD A cluster-sampled community-based survey was conducted in Oromia, Amhara, Southern Nations, Nationalities and Peoples, and Tigray regions of Ethiopia from mid-December 2018 to mid-February 2019. Descriptive and logistic regression analyses were performed, considering the cluster character of the sample. RESULTS A total of 6296 women (13 to 49 years) from 181 clusters were interviewed. Of these, 896 women delivered in the 12 months prior to the survey. Only 79 (9%) of these women including Women Development Group leaders reported contact with Women Development Groups in the last 12 months preceding the survey. Women who had educations and greater economic status had more frequent contact with Women Development Group leaders. Women who had contact with Women Development Groups had better knowledge on pregnancy danger signs. Being a Women Development Group leader or having contact with Women Development Groups in the last 12 months were associated with antenatal care utilization (AOR 2.82, 95% CI (1.23, 6.45)) but not with the use of facility delivery and utilization of postnatal care services. CONCLUSIONS There is a need to improve the organization and management of the Women Development Group program as well as a need to strengthen the Women Development Group leaders' engagement in group activities to promote the utilization of maternal and neonatal health services.
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Affiliation(s)
- Fisseha Ashebir Gebregizabher
- Tigray Regional Health Bureau, Mekelle P.O. Box 07, Ethiopia
- School of Public Health, College of Health Sciences, Mekelle University, Mekelle P.O. Box 1871, Ethiopia
| | - Araya Abrha Medhanyie
- School of Public Health, College of Health Sciences, Mekelle University, Mekelle P.O. Box 1871, Ethiopia
| | - Afework Mulugeta Bezabih
- School of Public Health, College of Health Sciences, Mekelle University, Mekelle P.O. Box 1871, Ethiopia
| | - Lars Åke Persson
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK
- Ethiopian Public Health Institute, Addis Ababa P.O. Box 1242, Ethiopia
| | - Della Berhanu Abegaz
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK
- Ethiopian Public Health Institute, Addis Ababa P.O. Box 1242, Ethiopia
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Basil L, Thompson M, Marx MA, Frost E, Mohan D, Traore S, Zanre J, Coulibaly B, Gueye BY, Nkurabagaya T, Poda G, Moussa K, El-Kalaawy F, Angelaksi C. Comparing program supervision with an external RADAR evaluation of quality of care in integrated community case management for childhood illnesses in Mali. Glob Health Action 2022; 15:2006424. [PMID: 36098951 PMCID: PMC9481102 DOI: 10.1080/16549716.2021.2006424] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Many countries have adopted integrated community case management (iCCM) to reduce mortality among children under five years from common childhood illnesses. The 2016-2020 Malian Red Cross iCCM program trained 441 Community Health Workers (CHWs) to treat malaria, pneumonia, diarrhea, and malnutrition for children under five years of age in six districts. Implementation strength and quality of care (QoC) were assessed through the program's supervision function, using the Malian Ministry of Health's system. OBJECTIVE This paper compares methods and results of program supervision data and an independent evaluation to assess the effectiveness of program implementation and supervision and inform program improvement. It also presents the benefits and limitations of each method. METHOD An independent QoC evaluation was conducted using tools developed by the Real Accountability: Data Analysis for Results (RADAR) project, hereafter referred to as the RADAR evaluation. RADAR evaluation data collected in July and August 2018 were compared with program supervision data collected mostly between May and December 2018. RESULTS The RADAR evaluation provided detailed findings on correct assessment, classification, and treatment per illness, medication type, and dosage. Program supervision combined the findings for all illnesses, medication type, and dosage due to limitations in the data collection process. Six indicators were comparable between both methods. Findings were similar for temperature and mid-upper arm circumference measurements but diverged between program supervision and the RADAR evaluation, respectively, on correct classification for all illnesses (87.1% vs. 65.3%), correct treatment for all illnesses (69.5% vs. 39.8%), correct respiratory rate counting (88.5% vs. 54.7%), and administering the first dose by CHW (75.4% vs. 65.0%). Findings from the RADAR evaluation guided improvements in program supervision. CONCLUSIONS A robust program supervision system can serve as a credible method to assess QoC. However, a rigorous independent QoC evaluation provides a valuable benchmark to gauge the effectiveness of the supervisory process.
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Affiliation(s)
- Luay Basil
- Global Programs, Canadian Red Cross, Ottawa, Canada
| | | | - Melissa A Marx
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Emily Frost
- Office of Science and Strategy, March of Dimes, Arlington, VA, USA
| | - Diwakar Mohan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Sinaly Traore
- Department of Health, Malian Red Cross, Bamako, Mali
| | - Jules Zanre
- Global Programs, Canadian Red Cross, Ottawa, Canada
| | | | | | | | | | - Kone Moussa
- Department of Health, Malian Red Cross, Bamako, Mali
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Wuneh AD, Bezabih AM, Okwaraji YB, Persson LÅ, Medhanyie AA. Wealth and Education Inequities in Maternal and Child Health Services Utilization in Rural Ethiopia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:5421. [PMID: 35564817 PMCID: PMC9099508 DOI: 10.3390/ijerph19095421] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 04/21/2022] [Accepted: 04/25/2022] [Indexed: 12/04/2022]
Abstract
As part of the 2030 maternal and child health targets, Ethiopia strives for universal and equitable use of health services. We aimed to examine the association between household wealth, maternal education, and the interplay between these in utilization of maternal and child health services. Data emanating from the evaluation of the Optimizing of Health Extension Program intervention. Women in the reproductive age of 15 to 49 years and children aged 12-23 months were included in the study. We used logistic regression with marginal effects to examine the association between household wealth, women's educational level, four or more antenatal care visits, skilled assistance at delivery, and full immunization of children. Further, we analyzed the interactions between household wealth and education on these outcomes. Household wealth was positively associated with skilled assistance at delivery and full child immunization. Women's education had a positive association only with skilled assistance at delivery. Educated women had skilled attendance at delivery, especially in the better-off households. Our results show the importance of poverty alleviation and girls' education for universal health coverage.
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Affiliation(s)
- Alem Desta Wuneh
- School of Public Health, College of Health Sciences, Mekelle University, Mekelle P.O. Box 1871, Ethiopia; (A.M.B.); (A.A.M.)
| | - Afework Mulugeta Bezabih
- School of Public Health, College of Health Sciences, Mekelle University, Mekelle P.O. Box 1871, Ethiopia; (A.M.B.); (A.A.M.)
| | - Yemisrach Behailu Okwaraji
- London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK; (Y.B.O.); (L.Å.P.)
- Ethiopian Public Health Institute, Addis Ababa P.O. Box 1242, Ethiopia
| | - Lars Åke Persson
- London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK; (Y.B.O.); (L.Å.P.)
- Ethiopian Public Health Institute, Addis Ababa P.O. Box 1242, Ethiopia
| | - Araya Abrha Medhanyie
- School of Public Health, College of Health Sciences, Mekelle University, Mekelle P.O. Box 1871, Ethiopia; (A.M.B.); (A.A.M.)
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Tariku A, Berhane Y, Worku A, Biks GA, Persson LÅ, Okwaraji YB. Health postservice readiness and use of preventive and curative services for suspected childhood pneumonia in Ethiopia: a cross-sectional study. BMJ Open 2022; 12:e058055. [PMID: 35477882 PMCID: PMC9047705 DOI: 10.1136/bmjopen-2021-058055] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 04/08/2022] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Pneumonia is the single-leading cause of infectious disease deaths in children under-5. Despite this challenge, the utilisation of preventive and curative child health services remains low in Ethiopia. We investigated the association between health post service readiness and caregivers' awareness of pneumonia services, care-seeking and utilisation of pneumonia-relevant immunisation in four Ethiopian regions. DESIGN AND SETTING This cross-sectional study was conducted in 52 districts of four regions of Ethiopia from December 2018 to February 2019. The health posts preparedness for sick child care was assessed using the WHO Health Service Availability and Readiness Assessment tool. Multilevel analyses were employed to examine the associations between health post readiness and household-level awareness and utilisation of services. PARTICIPANTS We included 165 health posts, 274 health extension workers (community health workers) and 4729 caregivers with 5787 children 2-59 months. OUTCOME MEASURES Awareness of pneumonia treatment, care-seeking behaviour and coverage of pentavalent-3 immunisation. RESULTS Only 62.8% of health posts were ready to provide sick child care services. One-quarter of caregivers were aware of pneumonia services, and 56.8% sought an appropriate care provider for suspected pneumonia. Nearly half (49.3%) of children (12-23 months) had received pentavalent-3 immunisation. General health post readiness was not associated with caregivers' awareness of pneumonia treatment (adjusted OR, AOR 0.9, 95% CI 0.7 to 1.1) and utilisation of pentavalent-3 immunisation (AOR=1.2, 95% CI 0.8 to 1.6), but negatively associated with care-seeking for childhood illnesses (AOR=0.6, 95% CI 0.4 to 0.8). CONCLUSION We found no association between facility readiness and awareness or utilisation of child health services. There were significant deficiencies in health post preparedness for services. Caregivers had low awareness and utilisation of pneumonia-related services. The results underline the importance of enhancing facility preparedness, providing high-quality care and intensifying demand generation efforts to prevent and treat pneumonia.
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Affiliation(s)
- Amare Tariku
- Department of Human Nutrition, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Amhara Region, Ethiopia
- Department of Epidemiology and Biostatistics and Department of Reproductive Health and Population, Addis Continental Institute of Public Health, Addis Ababa, Ethiopia
| | - Yemane Berhane
- Department of Epidemiology and Biostatistics and Department of Reproductive Health and Population, Addis Continental Institute of Public Health, Addis Ababa, Ethiopia
| | - Alemayehu Worku
- Department of Epidemiology and Biostatistics and Department of Reproductive Health and Population, Addis Continental Institute of Public Health, Addis Ababa, Ethiopia
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Gashaw Andargie Biks
- Department of Health System and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Lars Åke Persson
- London School of Hygiene and Tropical Medicine, London, UK
- Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Yemisrach Behailu Okwaraji
- London School of Hygiene and Tropical Medicine, London, UK
- Ethiopian Public Health Institute, Addis Ababa, Ethiopia
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Adegnika AA, Amuasi JH, Basinga P, Berhanu D, Medhanyie AA, Okwaraji YB, Persson LÅ, Savadogo B, Schellenberg J, Steinmann P. Embed capacity development within all global health research. BMJ Glob Health 2021; 6:bmjgh-2020-004692. [PMID: 33597279 PMCID: PMC7893651 DOI: 10.1136/bmjgh-2020-004692] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 01/15/2021] [Accepted: 01/20/2021] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - John H Amuasi
- School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Paulin Basinga
- Bill & Melinda Gates Foundation, Seattle, Washington, USA
| | - Della Berhanu
- London School of Hygiene & Tropical Medicine, London, UK
| | - Araya Abrha Medhanyie
- MARCH Research Centre and School of Public Health, Mekelle University, Mekelle, Tigray, Ethiopia
| | | | | | | | | | - Peter Steinmann
- Swiss Tropical and Public Health Institute, Basel, Basel-Stadt, Switzerland
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Beyene H, Kassa DH, Tadele HD, Persson L, Defar A, Berhanu D. Factors associated with the referral of children with severe illnesses at primary care level in Ethiopia: a cross-sectional study. BMJ Open 2021; 11:e047640. [PMID: 34112644 PMCID: PMC8194336 DOI: 10.1136/bmjopen-2020-047640] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
CONTEXT AND OBJECTIVE Ethiopia's primary care has a weak referral system for sick children. We aimed to identify health post and child factors associated with referrals of sick children 0-59 months of age and evaluate the healthcare providers' adherence to referral guidelines. DESIGN A cross-sectional facility-based survey. SETTING This study included data from 165 health posts in 52 districts in four Ethiopian regions collected from December 2018 to February 2019. The data included interviews with health extension workers, assessment of health post preparedness, recording of global positioning system (GPS)-coordinates of the health post and the referral health centre, and reviewing registers of sick children treated during the last 3 months at the health posts. We analysed the association between the sick child's characteristics, health post preparedness and distance to the health centre with referral of sick children by multivariable logistic regressions. OUTCOME MEASURE Referral to the nearest health centre of sick young infants aged 0-59 days and sick children 2-59 months. RESULTS The health extension workers referred 39/229 (17%) of the sick young infants and 78/1123 (7%) of the older children to the next level of care. Only 18 (37%) sick young infants and 22 (50%) 2-59 months children that deserved urgent referral according to guidelines were referred. The leading causes of referral were possible serious bacterial infection and pneumonia. Those being classified as a severe disease were referred more frequently. The availability of basic amenities (adjusted OR, AOR=0.38, 95% CI 0.15 to 0.96), amoxicillin (AOR=0.41, 95% CI 0.19 to 0.88) and rapid diagnostic test (AOR=0.18, 95% CI 0.07 to 0.46) were associated with less referral in the older age group. CONCLUSION Few children with severe illness were referred from health posts to health centres. Improving the health posts' medicine and diagnostic supplies may enhance adherence to referral guidelines and ultimately reduce child mortality.
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Affiliation(s)
- Habtamu Beyene
- Regional Health Bureau, Southern Nations Nationalities and Peoples' Region, Hawassa, Ethiopia
- College of Medicine and Health Sciences, School of Public Health, Hawassa University, Hawassa, Sidama, Ethiopia
| | - Dejene Hailu Kassa
- College of Medicine and Health Sciences, School of Public Health, Hawassa University, Hawassa, Sidama, Ethiopia
| | - Henok Dangiso Tadele
- College of Health Sciences, Department of Paediatrics and Child Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Lars Persson
- London School of Hygiene and Tropical Medicine, Faculty of Infectious and Tropical Diseases, London, UK
- Health System and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Atkure Defar
- Health System and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
- Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Della Berhanu
- London School of Hygiene and Tropical Medicine, Faculty of Infectious and Tropical Diseases, London, UK
- Health System and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
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Getachew T, Abebe SM, Yitayal M, Bergström A, Persson LA, Berhanu D. Health extension workers' perceived health system context and health post preparedness to provide services: a cross-sectional study in four Ethiopian regions. BMJ Open 2021; 11:e048517. [PMID: 34108171 PMCID: PMC8191611 DOI: 10.1136/bmjopen-2020-048517] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE The health system context influences the implementation of evidence-based practices and quality of healthcare services. Ethiopia aims at reaching universal health coverage but faces low primary care utilisation and substandard quality of care. We assessed the health extension workers' perceived context and the preparedness of health posts to provide services. SETTING This study was part of evaluating a complex intervention in 52 districts of four regions of Ethiopia. This paper used the endline data collected from December 2018 to February 2019. PARTICIPANTS A total of 152 health posts and health extension workers serving selected enumeration areas were included. OUTCOME MEASURES We used the Context Assessment for Community Health (COACH) tool and the Service Availability and Readiness Assessment tool. RESULTS Internal reliability of COACH was satisfactory. The dimensions community engagement, work culture, commitment to work and leadership all scored high (mean 3.75-4.01 on a 1-5 scale), while organisational resources, sources of knowledge and informal payments scored low (1.78-2.71). The general service readiness index was 59%. On average, 67% of the health posts had basic amenities to provide services, 81% had basic equipment, 42% had standard precautions for infection prevention, 47% had test capacity for malaria and 58% had essential medicines. CONCLUSION The health extension workers had a good relationship with the local community, used data for planning, were highly committed to their work with positive perceptions of their work culture, a relatively positive attitude regarding their leaders, and reported no corruption or informal payments. In contrast, they had insufficient sources of information and a severe lack of resources. The health post preparedness confirmed the low level of resources and preparedness for services. These findings suggest a significant potential contribution by health extension workers to Ethiopia's primary healthcare, provided that they receive improved support, including new information and essential resources.
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Affiliation(s)
- Theodros Getachew
- Health System and Reproductive Health Research Directtorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
- Institute of Public Health, University of Gondar College of Medicine and Health Sciences, Gondar, Ethiopia
| | - Solomon Mekonnen Abebe
- Institute of Public Health, University of Gondar College of Medicine and Health Sciences, Gondar, Ethiopia
| | - Mezgebu Yitayal
- Institute of Public Health, University of Gondar College of Medicine and Health Sciences, Gondar, Ethiopia
| | | | - Lars-Ake Persson
- Health System and Reproductive Health Research Directtorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
- London School of Hygiene and Tropical Medicine, London, UK
| | - Della Berhanu
- Health System and Reproductive Health Research Directtorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
- London School of Hygiene and Tropical Medicine, London, UK
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Miller NP, Bagheri Ardestani F, Wong H, Stokes S, Mengistu B, Paulos M, Agonafir N, Sylla M, Ameha A, Birhanu BG, Khan S, Lemango ET. Barriers to the utilization of community-based child and newborn health services in Ethiopia: a scoping review. Health Policy Plan 2021; 36:1187-1196. [PMID: 33885143 PMCID: PMC8496769 DOI: 10.1093/heapol/czab047] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 03/22/2021] [Accepted: 04/01/2021] [Indexed: 12/24/2022] Open
Abstract
The Ethiopian Federal Ministry of Health and partners have scaled up integrated
community case management (iCCM) and community-based newborn care (CBNC),
allowing health extension workers (HEWs) to manage the major causes of child and
newborn death at the community level. However, low service uptake remains a key
challenge. We conducted a scoping review of peer-reviewed and grey literature to
assess barriers to the utilization of HEW services and to explore potential
solutions. The review, which was conducted to inform the Optimizing the Health
Extension Program project, which aimed to increase the utilization of iCCM and
CBNC services, included 24 peer-reviewed articles and 18 grey literature
documents. Demand-side barriers to utilization included lack of knowledge about
the signs and symptoms of childhood illnesses and danger signs; low awareness of
curative services offered by HEWs; preference for home-based care, traditional
care, or religious intervention; distance, lack of transportation and cost of
care seeking; the need to obtain husband’s permission to seek care and
opposition of traditional or religious leaders. Supply-side barriers included
health post closures, drug stockouts, disrespectful care and limited skill and
confidence of HEWs, particularly with regard to the management of newborn
illnesses. Potential solutions included community education and demand
generation activities, finding ways to facilitate and subsidize transportation
to health facilities, engaging family members and traditional and religious
leaders, ensuring consistent availability of services at health posts and
strengthening supervision and supply chain management. Both demand generation
and improvement of service delivery are necessary to achieve the expected impact
of iCCM and CBNC. Key steps for improving utilization would be carrying out
multifaceted demand generation activities, ensuring availability of HEWs in
health posts and ensuring consistent supplies of essential commodities. The
Women’s Development Army has the potential to improving linkages between
HEWs and communities, but this strategy needs to be strengthened to be
effective.
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Affiliation(s)
- Nathan P Miller
- Health Section, UNICEF, 3 UN Plaza, New York, NY 10017, USA.,Department of Population and Family Health, Mailman School of Public Health, Columbia University, 722 West 168th St., New York, NY 10032, USA
| | | | - Hayes Wong
- Department of Population and Family Health, Mailman School of Public Health, Columbia University, 722 West 168th St., New York, NY 10032, USA
| | - Sonya Stokes
- Department of Population and Family Health, Mailman School of Public Health, Columbia University, 722 West 168th St., New York, NY 10032, USA
| | - Birkety Mengistu
- PATH Ethiopia, Bole Medhaniyalem Street #03, Bole, Addis Ababa, Ethiopia
| | - Meron Paulos
- PATH Ethiopia, Bole Medhaniyalem Street #03, Bole, Addis Ababa, Ethiopia
| | - Nesibu Agonafir
- PATH Ethiopia, Bole Medhaniyalem Street #03, Bole, Addis Ababa, Ethiopia
| | - Mariame Sylla
- Health Section, UNICEF Ethiopia, UNECA Compound, Zambezi Building, Addis Ababa, Ethiopia
| | - Agazi Ameha
- Health Section, UNICEF Ethiopia, UNECA Compound, Zambezi Building, Addis Ababa, Ethiopia
| | - Bizuhan Gelaw Birhanu
- Health Section, UNICEF Ethiopia, UNECA Compound, Zambezi Building, Addis Ababa, Ethiopia
| | - Sadaf Khan
- Maternal Newborn Child Health and Nutrition, PATH, 2201 Westlake Ave. Ste 200, Seattle, WA 98121, USA
| | - Ephrem Tekle Lemango
- Programs Section, Maternal, Child Health and Nutrition Directorate, Ministry of Health, Sudan Street, Addis Ababa, Ethiopia
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Defar A, Alemu K, Tigabu Z, Persson LÅ, Okwaraji YB. Caregivers' and Health Extension Workers' Perceptions and Experiences of Outreach Management of Childhood Illnesses in Ethiopia: A Qualitative Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18073816. [PMID: 33917415 PMCID: PMC8038672 DOI: 10.3390/ijerph18073816] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 03/26/2021] [Accepted: 03/31/2021] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Ethiopian Health Extension Workers provide facility-based and outreach services, including home visits to manage sick children, aiming to increase equity in service coverage. Little is known about the scope of the outreach services and caregivers' and health workers' perceptions of these services. We aimed at exploring mothers' and health extension workers' perceptions and experiences of the outreach services provided for the management of childhood illnesses. METHODS Four focus groups and eight key informant interviews were conducted. A total of 45 community members participated. Interviews were recorded, transcribed verbatim, and translated into English. We applied thematic content analysis, identified challenges in providing outreach services, and suggestions for improvement. We balanced the data collection by selecting half of the participants for interview and focus group discussions from remote areas and the other half from areas closer to the health posts. RESULTS Mothers reported that health extension workers visited their homes for preventive services but not for managing childhood illnesses. They showed lack of trust in the health workers' ability to treat children at home. The health extension workers reported that they provide sick children treatment during outreach services but also stated that in most cases, mothers visit the health posts when their child is sick. On the other hand, mothers considered distance from home to health post not to be a problem if the quality of services improved. Workload, long distances, and lack of incentives were perceived as demotivating factors for outreach services. The health workers called for support, incentives, and capacity development activities. CONCLUSIONS Mothers and health extension workers had partly divergent perceptions of whether outreach curative services for children were available. Mothers wanted improvements in the quality of services while health workers requested capacity development and more support for providing effective community-based child health services.
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Affiliation(s)
- Atkure Defar
- Ethiopian Public Health Institute, Addis Ababa P.O. Box 1242, Ethiopia; (L.Å.P.); (Y.B.O.)
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar P.O. Box 196, Ethiopia;
- Correspondence:
| | - Kassahun Alemu
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar P.O. Box 196, Ethiopia;
| | - Zemene Tigabu
- Department of Paediatrics and Child Health, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar P.O. Box 196, Ethiopia;
| | - Lars Åke Persson
- Ethiopian Public Health Institute, Addis Ababa P.O. Box 1242, Ethiopia; (L.Å.P.); (Y.B.O.)
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Yemisrach B. Okwaraji
- Ethiopian Public Health Institute, Addis Ababa P.O. Box 1242, Ethiopia; (L.Å.P.); (Y.B.O.)
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
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Getachew T, Abebe SM, Yitayal M, Persson LÅ, Berhanu D. Association between a complex community intervention and quality of health extension workers' performance to correctly classify common childhood illnesses in four regions of Ethiopia. PLoS One 2021; 16:e0247474. [PMID: 33711024 PMCID: PMC7954333 DOI: 10.1371/journal.pone.0247474] [Citation(s) in RCA: 3] [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: 03/20/2020] [Accepted: 02/07/2021] [Indexed: 12/20/2022] Open
Abstract
Background Due to low care utilization, a complex intervention was done for two years to optimize the Ethiopian Health Extension Program. Improved quality of the integrated community case management services was an intermediate outcome of this intervention through community education and mobilization, capacity building of health workers, and strengthening of district ownership and accountability of sick child services. We evaluated the association between the intervention and the health extension workers’ ability to correctly classify common childhood illnesses in four regions of Ethiopia. Methods Baseline and endline assessments were done in 2016 and 2018 in intervention and comparison areas in four regions of Ethiopia. Ill children aged 2 to 59 months were mobilized to visit health posts for an assessment that was followed by re-examination. We analyzed sensitivity, specificity, and difference-in-difference of correct classification with multilevel mixed logistic regression in intervention and comparison areas at baseline and endline. Results Health extensions workers’ consultations with ill children were observed in intervention (n = 710) and comparison areas (n = 615). At baseline, re-examination of the children showed that in intervention areas, health extension workers’ sensitivity for fever or malaria was 54%, 68% for respiratory infections, 90% for diarrheal diseases, and 34% for malnutrition. At endline, it was 40% for fever or malaria, 49% for respiratory infections, 85% for diarrheal diseases, and 48% for malnutrition. Specificity was higher (89–100%) for all childhood illnesses. Difference-in-differences was 6% for correct classification of fever or malaria [aOR = 1.45 95% CI: 0.81–2.60], 4% for respiratory tract infection [aOR = 1.49 95% CI: 0.81–2.74], and 5% for diarrheal diseases [aOR = 1.74 95% CI: 0.77–3.92]. Conclusion This study revealed that the Optimization of Health Extension Program intervention, which included training, supportive supervision, and performance reviews of health extension workers, was not associated with an improved classification of childhood illnesses by these Ethiopian primary health care workers. Trial registration ISRCTN12040912, http://www.isrctn.com/ISRCTN12040912.
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Affiliation(s)
- Theodros Getachew
- Health System and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
- College of Medicine and Health Sciences, Institute of Public Health, University of Gondar, Gondar, Ethiopia
- * E-mail:
| | - Solomon Mekonnen Abebe
- College of Medicine and Health Sciences, Institute of Public Health, University of Gondar, Gondar, Ethiopia
| | - Mezgebu Yitayal
- College of Medicine and Health Sciences, Institute of Public Health, University of Gondar, Gondar, Ethiopia
| | - Lars Åke Persson
- Health System and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Della Berhanu
- Health System and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Okwaraji YB, Hill Z, Defar A, Berhanu D, Wolassa D, Persson LÅ, Gonfa G, Schellenberg JA. Implementation of the 'Optimising the Health Extension Program' Intervention in Ethiopia: A Process Evaluation Using Mixed Methods. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E5803. [PMID: 32796574 PMCID: PMC7459764 DOI: 10.3390/ijerph17165803] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/07/2020] [Accepted: 08/09/2020] [Indexed: 01/10/2023]
Abstract
An intervention called 'Optimising the Health Extension Program', aiming to increase care-seeking for childhood illnesses in four regions of Ethiopia, was implemented between 2016 and 2018, and it included community engagement, capacity building, and district ownership and accountability. A pragmatic trial comparing 26 districts that received the intervention with 26 districts that did not found no evidence to suggest that the intervention increased utilisation of services. Here we used mixed methods to explore how the intervention was implemented. A fidelity analysis of each 31 intervention activities was performed, separately for the first phase and for the entire implementation period, to assess the extent to which what was planned was carried out. Qualitative interviews were undertaken with 39 implementers, to explore the successes and challenges of the implementation, and were analysed by using thematic analysis. Our findings show that the implementation was delayed, with only 19% (n = 6/31) activities having high fidelity in the first phase. Key challenges that presented barriers to timely implementation included the following: complexity both of the intervention itself and of administrative systems; inconsistent support from district health offices, partly due to competing priorities, such as the management of disease outbreaks; and infrequent supervision of health extension workers at the grassroots level. We conclude that, for sustainability, evidence-based interventions must be aligned with national health priorities and delivered within an existing health system. Strategies to overcome the resulting complexity include a realistic time frame and investment in district health teams, to support implementation at grassroots level.
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Affiliation(s)
- Yemisrach B. Okwaraji
- London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK; (D.B.); (L.Å.P.); (J.A.S.)
- Ethiopian Public Health Institute, Addis Ababa 5654, Ethiopia; (A.D.); (D.W.); (G.G.)
| | - Zelee Hill
- Institute for Global Health, University College London, London WC1E 6BT, UK;
| | - Atkure Defar
- Ethiopian Public Health Institute, Addis Ababa 5654, Ethiopia; (A.D.); (D.W.); (G.G.)
- Institute of Public Health, College of Medicine and Health Science, University of Gondar, Gondar 41822, Ethiopia
| | - Della Berhanu
- London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK; (D.B.); (L.Å.P.); (J.A.S.)
- Ethiopian Public Health Institute, Addis Ababa 5654, Ethiopia; (A.D.); (D.W.); (G.G.)
| | - Desta Wolassa
- Ethiopian Public Health Institute, Addis Ababa 5654, Ethiopia; (A.D.); (D.W.); (G.G.)
| | - Lars Åke Persson
- London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK; (D.B.); (L.Å.P.); (J.A.S.)
- Ethiopian Public Health Institute, Addis Ababa 5654, Ethiopia; (A.D.); (D.W.); (G.G.)
| | - Geremew Gonfa
- Ethiopian Public Health Institute, Addis Ababa 5654, Ethiopia; (A.D.); (D.W.); (G.G.)
| | - Joanna A. Schellenberg
- London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK; (D.B.); (L.Å.P.); (J.A.S.)
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