Inadequate management of pneumonia among children in South Ethiopia: findings from descriptive study

Predictors of recovery time from severe community-acquired pneumonia among paediatrics patients in selected hospitals in Addis Ababa, Ethiopia: an institution-based retrospective cohort study

OBJECTIVE

Severe community-acquired pneumonia (SCAP) is a significant cause of morbidity worldwide and a major cause of morbidity and mortality in developing countries. Ethiopia ranks 6th out of 15 countries with the highest mortality rate due to pneumonia in children under 5 years of age. The aim of this study was to determine the recovery time from SCAP and factors in paediatric patients in selected hospitals in Addis Ababa.

DESIGN, PARTICIPANTS AND SETTING

A retrospective cohort study was conducted among 407 randomly selected paediatric patients admitted with SCAP in Addis Ababa public hospitals from 1 January 2018 to 31 December 2020.

PRIMARY AND SECONDARY OUTCOMES

Recovery time and recovery rate from SCAP were estimated using Kaplan-Meier and simple frequency statistics, respectively, and the adjusted HR with a 95% CI was used to identify associated factors for recovery.

RESULTS

91.5% (95% CI: 88.3% to 94.1%) of children recovered from SCAP with an overall recovery rate of 11.5 (95% CI: 10.37 to 12.76) per 100 person-day observation, and the median recovery time was 6 days. In the multivariable analysis, older age and the absence of comorbidities were protective factors for early recovery, while stunting and late utilisation of medical care were risk factors.

CONCLUSION

The median recovery time after SCAP was very long compared with the optimal recovery time of 3 days given in the British Thoracic Society guidelines. Older age and absence of comorbidities were found to shorten recovery time, whereas stunting and late initiation of treatment delayed recovery. Therefore, measures that increase the recovery rate and shorten the recovery time, such as primary prevention to eliminate malnutrition and increase the utilisation of medical care in the community, should be strengthened, and health workers should focus on the early detection and treatment of comorbid diseases.

Effective coverage of curative child health services in Ethiopia: analysis of the Demographic and Health Survey and Service Provision Assessment survey

OBJECTIVES

Despite a remarkable decline, childhood morbidity and mortality in Ethiopia remain high and inequitable. Thus, we estimated the effective coverage of curative child health services in Ethiopia.

DESIGN

We conducted a cross-sectional analysis of data from the 2016 Ethiopia Demographic and Health Survey (DHS) and the 2014 Ethiopia Service Provision Assessment Plus (SPA+) survey.

SETTING

Nationally representative household and facility surveys.

PARTICIPANTS AND OUTCOMES

We included a sample of 2096 children under 5 years old (from DHS) who had symptoms of one or more common childhood illnesses (diarrhoea, fever and acute respiratory infection) and estimated the percentage of sick children who were taken to a health facility (crude coverage). To construct a quality index of child health services, we used the SPA+ survey, which was conducted in 1076 health facilities and included observations of care for 1980 sick children and surveys of 1908 mothers/caregivers and 5328 health providers. We applied the Donabedian quality of care framework to identify 58 quality parameters (structure, 31; process, 16; and outcome, 11) and used the weighted additive method to estimate the overall quality of care index. Finally, we multiplied the crude coverage by the quality of care index to estimate the effective coverage of curative child health services, nationally and by region.

RESULTS

Among the 2096 sick children, only 38.4% (95% CI: 36.5 to 40.4) of them were taken to a health facility. The overall quality of care was 54.4%, weighted from structure (30.0%), process (9.2%) and outcome (15.2%). The effective coverage of curative child health services was estimated at 20.9% (95%CI: 19.9 to 22.0) nationally, ranging from 16.9% in Somali to 34.6% in Dire Dawa regions.

CONCLUSIONS

System-wide interventions are required to address both demand-side and supply-side bottlenecks in the provision of child health services if child health-related targets are to be achieved in Ethiopia.

Adherence to WHO guidelines on severe pneumonia management in children and its impact on outcome: an observational study at Jinka General Hospital in Ethiopia

Introduction

Poor adherence to guidelines during empirical antibiotic prescription in low-income countries could increase antimicrobial resistance without improving outcomes. Revised World Health Organization (WHO) guidelines published in 2014 on childhood (2-59 months) pneumonia re-defined the classification of severe pneumonia and changed the first-line treatment. The adherence to WHO guidelines in southern Ethiopia at the hospital level is unknown. We sought to determine the adherence to WHO guidelines on severe pneumonia first-line treatment in children in an Ethiopian referral hospital and assess the impact of non-adherence on patient outcomes.

Methods

An observational study was conducted on all children (2-59 months) clinically diagnosed with severe pneumonia and admitted to the Pediatric Ward of Jinka Hospital from 1 June 2021 to 31 May 2022. Exclusion criteria included a known HIV infection, ongoing antibiotic treatment before the event not related to acute pneumonia, or any other severe bacterial infection, confirmed or suspected. Adherence to guidelines was defined as first-line treatment with ampicillin or benzylpenicillin and gentamicin at the recommended dose. We compared the patients treated adherently vs. non-adherently. For categorical variables, the chi-square or Fisher's exact test was used, while for continuous variables, the Mann-Whitney U-test was used. Multivariate logistic regression was used to evaluate the association between adherence and demographic and clinical characteristics.

Results

During the observational period, 266 patients were registered as having severe pneumonia with an age between 2 and 59 months. After excluding 114 patients due to missing charts or other exclusion criteria, a total of 152 patients were included in the analysis. Of these, 78 (51%) were girls with a median age of 10 months (IQR 7-14). Overall, 75 (49%) patients received therapy according to the WHO guidelines. Compared to patients treated adherently to the guidelines, patients not treated adherently had similar outcomes [median length of stay of 3 (IQR 3-5) and 4 (IQR 3-6) days], median duration of oxygen therapy of 2 (IQR 1-3) for both the groups, and self-discharge rates of 5% and 6.5%, respectively).

Conclusion

Adherence to the revised WHO guideline was limited and not associated with outcomes. Efforts should focus on reducing the gap between theory and practice.

Delay in seeking healthcare for pneumonia and associated factors among mothers/caregivers of children aged 2-59 months in public health facilities in Nekemte town, Ethiopia

BACKGROUND

Pneumonia is the most significant infectious disease and the predominant cause of death among under-five children (U5C) in low- and middle-income countries. It is the second leading cause of death in Ethiopia. Delay in seeking healthcare is one of the contributing factors to pneumonia-associated mortality. There is a limitation to the study aimed at identifying health-seeking behavior and risk factors in the western part of Ethiopia. The study aimed to determine the level of delay in seeking healthcare for pneumonia and associated factors among caregivers of U5C in public health facilities in Nekemte town, Ethiopia.

METHODS

A health facility-based cross-sectional study was conducted from 1st March to 5^thApril, 2022 using a structured interviewer-administered questionnaire to collect data from 410 caregivers of children aged 2-59 months. We used a systematic sampling technique for collecting the data. For analysis, data were entered into Epi Data version 4.6 and exported to SPSS version 25. Binary logistic regression was used to identify the associated factors of delay in seeking healthcare for pneumonia at a p-value < 0.05 using a 95% confidence interval (CI) in multivariable logistic regression.

RESULTS

A proportion of delays in seeking healthcare for pneumonia among children aged 2-59 months is 62.2%. Rural residence (AOR = 2.77, CI:2.48-5.17), child aged ≥12 months (AOR = 5.4,95%CI:4.17-7.20), monthly income < 1000 Ethiopian birr (AOR = 6.11,95%CI:2.16-17.26,), not using health insurance (AOR = 8.93,95%CI:5.43-14.68), use of self-medication (AOR = 10.97,95%CI:1.85-65.3), poor knowledge (AOR = 4.63,95%CI: 1.35-15.9), perceiving illness due to pneumonia as mild (AOR = 14.97,95%CI:9.76-22.9) and no previous admission history (AOR = 2.85,95%CI:1.77-4.56) were significant factors for delay in seeking healthcare for pneumonia among children aged 2-59 months.

CONCLUSION

The study emphasizes that caregivers' delay in seeking healthcare for pneumonia is high. Creating caregivers' awareness or providing adequate health education to develop early healthcare-seeking behavior and encouraging caregivers to use health insurance is essential.

Timely health care seeking and first source of care for acute febrile illness in children in Hawassa, southern Ethiopia

Background

Timely health care seeking with access to quality health care are crucial to improve child survival. We conducted a study which aimed to identify factors influencing timely health care seeking and choice of first source of health care in Ethiopia.

Methods

A total of 535 caregivers who sought health care for febrile children aged under 5 years at a tertiary hospital, and one urban and two rural health centres in Hawassa, southern Ethiopia were recruited to participate in the study from August to November 2019. Caregivers were interviewed using pretested structured questionnaires on socio-demographic and clinical factors to identify associations with health care seeking practice and first source of care, and reasons for particular practices. Delayed care seeking was defined as seeking care from a health facility after 24 hours of onset of fever.

Results

Of 535 caregivers who participated, 271 (50.7%) had sought timely health care; 400 (74.8%) utilized a primary health care (PHC) facility as first source; and 282 (52.7%) bypassed the nearest PHC facility. Rural residents (adjusted odds ratio (AOR) 1.85; 95% CI 1.11–3.09), and those who reported cough (AOR 1.87; 95% CI 1.20–2.93) as a reason for consultation were more likely to delay seeking health care. While caregivers were less likely delayed for children aged 24–35 months (AOR 0.50; 95% CI 0.28–0.87) compared to infants. Utilizing higher-level hospitals as the first source of care was less frequent among rural residents (AOR 0.15; 95% CI 0.06–0.39) and in those with no formal education (AOR 0.03; 95% CI 0.01–0.27). Those having a longer travel time to the provider (AOR 2.11; 95% CI 1.09–4.08) more likely utilized higher hospitals.

Conclusion

We identified a need to improve timely health seeking among rural residents, infants, and those presenting with respiratory symptoms. Improvements may be achieved by educating communities on the need of early care seeking, and ensuring the communities members’ expectations of services at each level consistent with the services capacity.

Health postservice readiness and use of preventive and curative services for suspected childhood pneumonia in Ethiopia: a cross-sectional study

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.

Prevalence of pneumonia and its determinant factors among under-five children in Gamo Zone, southern Ethiopia, 2021

BACKGROUND

Pneumonia, which is a form of acute lower respiratory tract infection, affects the lung parenchyma and destructs alveolar air space. Pneumonia is the leading cause of morbidity and mortality in under-five children. It was estimated that pneumonia kills 900,000 under-five children each year worldwide. Approximately 172 deaths per 1,000 live births occur in sub-Saharan African countries, with pneumonia being the major cause. This study aimed to assess the prevalence and determinant factors of pneumonia inunder-five children in southern Ethiopia.

METHODOLOGY

An institutional cross-sectional study was employed. A total of 239 child-caregiver pairs were included. Data were collected by trained nurses using a semi-structured questionnaire. The collected data were checked for completeness, coded and entered into EPI data version 4.6, and exported to SPSS version 25 for analysis. Results were reported as the mean, frequency, and percentile. Logistic regression was employed to assess statistically significant predictors of pneumonia. Variables with a p-value <0.05 were considered statistically significant factors of pneumonia.

RESULT

The prevalence of pneumonia in the study area was 30%. Among the factors assessed, place of food cooking-inside the living room [adjusted odd ratio (AOR) = 5.79, 95% confidence interval (CI): 2.47-13.58], nonexclusive breastfeeding (AOR = 3.26, 95% CI: 1.42-7.52), vitamin A supplementation status (AOR = 5.62, 95% CI: 2.65-11.94), and vaccination status (AOR = 3.59, 95% CI: 1.49-8.66) were significantly associated with the occurrence of pneumonia in under-five children.

CONCLUSION

This study showed that the prevalence of pneumonia was relatively higher in Arba Minch town than other parts of the country. Place of food cooking, nonexclusive breastfeeding, vitamin A supplementation status, and vaccination status of children were significant factors of pneumonia among under-five children. Enhancing caregivers'/mothers' awareness of predicted factors was needed to reduce the incidence of childhood pneumonia and to enhance children's quality of health.

Cost-effectiveness of pulse oximetry and integrated management of childhood illness for diagnosing severe pneumonia

Pneumonia is a major killer of children younger than five years old. In resource constrained health facilities, the capacity to diagnose severe pneumonia is low. Therefore, it is important to identify technologies that improve the diagnosis of severe pneumonia at the lowest incremental cost. The objective of this study was to conduct a health economic evaluation of standard integrated management of childhood illnesses (IMCI) guideline alone and combined use of standard IMCI guideline and pulse oximetry in diagnosing childhood pneumonia. This is a cluster-randomized controlled trial conducted in health centres in southern Ethiopia. Two methods of diagnosing pneumonia in children younger than five years old at 24 health centres are analysed. In the intervention arm, combined use of the pulse oximetry and standard IMCI guideline was used. In the control arm, the standard IMCI guideline alone was used. The primary outcome was cases of diagnosed severe pneumonia. Provider and patient costs were collected. A probabilistic decision tree was used in analysis of primary trial data to get incremental cost per case of diagnosed severe pneumonia. The proportion of children diagnosed with severe pneumonia was 148/928 (16.0%) in the intervention arm and 34/876 (4.0%) in the control arm. The average cost per diagnosed severe pneumonia case was USD 25.74 for combined use of pulse oximetry and standard IMCI guideline and USD 17.98 for standard IMCI guideline alone. The incremental cost of combined use of IMCI and pulse oximetry was USD 29 per extra diagnosed severe pneumonia case compared to standard IMCI guideline alone. Adding pulse oximetry to the diagnostic toolkit in the standard IMCI guideline could detect and treat one more child with severe pneumonia for an additional investment of USD 29. Better diagnostic tools for lower respiratory infections are important in resource-constrained settings, especially now during the COVID-19 pandemic.

Experiences From an Implementation Model of ARI Diagnostic Device in Pneumonia Case Management Among Under-5 Children in Peripheral Healthcare Centers in India

OBJECTIVES

To address pneumonia, a major killer of under-5 children in India, a multimodal pulse oximeter was implemented in Health and Wellness Centers. Given the evidence of pulse oximetry in effective pneumonia management and taking into account the inadequate skills of front-line healthcare workers in case management, the device was introduced to help them readily diagnose and treat a child and to examine usability of the device.

DESIGN

The implementation was integrated with the routine OPD of primary health centers for 15 months after healthcare workers were provided with an abridged IMNCI training. Monthly facility data was collected to examine case management with the diagnostic device. Feedback on usefulness of the device was obtained.

SETTING

Health and Wellness Centers (19) of 7 states were selected in consultation with state National Health Mission based on patient footfall.

PARTICIPANTS

Under-5 children presenting with ARI symptoms at the OPD.

RESULTS

Of 4846 children, 0.1% were diagnosed with severe pneumonia and 23% were diagnosed with pneumonia. As per device readings, correct referrals were made of 77.6% of cases of severe pneumonia, and 81% of pneumonia cases were correctly given antibiotics. The Pulse oximeter was highly acceptable among health workers as it helped in timely classification and treatment of pneumonia. It had no maintenance issue and battery was long-lasting.

CONCLUSION

Pulse oximeter implementation was doable and acceptable among health workers. Together with IMNCI training, PO in primary care settings is a feasible approach to provide equitable care to under-5 children.

District health managers perspectives of introducing a new service: a qualitative study of the community-based newborn care programme in Ethiopia

BACKGROUND

The planning, resourcing, implementation and monitoring of new programmes by district health managers is integral for success and sustainability. Ethiopia introduced the Community-Based Newborn Care programme in 2014 to improve newborn survival: an innovative component allowed community health workers to provide antibiotics for young infants with possible serious bacterial infection when referral was not possible. Informed by the World Health Organization health system building block framework, we aimed to study the capacity and operational challenges of introducing this new health service from the perspective of programme implementers and managers at the district level 20 months after programme initiation.

METHODS

This qualitative study was part of a programme evaluation. From November to December of 2015, we conducted 28 semi-structured interviews with staff at district health offices, health centres and implementing Non-Governmental Organisations in 15 districts of four regions of Ethiopia. Verbatim transcripts were analysed using a priori and emerging themes.

RESULTS

In line with the government's commitment to treat sick newborns close to their homes, participants reported that community health workers had been successfully trained to provide injectable antibiotics. However, the Community-Based Newborn Care programme was scaled up without allowing the health system to adapt to programme needs. There were inadequate processes and standards to ensure consistent availability of (1) trained staff for technical supervision, (2) antibiotics and (3) monitoring data specific to the programme. Furthermore, Non-Governmental Organizations played a central implementing role, which had implications for the long-term district level ownership and thus for the sustainability of the programme.

CONCLUSION

In settings where sustainable local implementation depends on district-level health teams, new programmes should assess health system preparedness to absorb the service, and plan accordingly. Our findings can inform policy makers and implementers about the pre-conditions for a health system to introduce similar services and maximize long-term success.

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

BACKGROUND

Outpatient department visits per individual for each year are one of the core indicators of healthcare delivery to assess accessibility or quality of services. In addition, this study aimed to assess health service utilisation and disease patterns in southern Ethiopia, by including the health authorities' suggestions to improve the services. No study has assessed this in Ethiopia previously.

METHODS

An institution-based cross-sectional design study was done in 65 primary health care units in Dale and Wonsho districts, in Sidama region, for all patients visiting health facilities from 1 July 2017 to 30 June 2018. We estimated the utilisation rate as visits per person per year, the odds ratio for health use and proportions of diseases' diagnoses. The results of our study were presented to local health authorities, and their suggestions for improvements were incorporated into the analysis.

RESULT

A total of 81,129 patients visited the health facilities. The annual outpatient health service utilisation was 0.18 (95% CI: 0.18-0.19) new visits per person per year. The health service utilisation rate per year for the rural population was lower than the urban utilisation by 91% (OR = 0.09; 95% CI: 0.08-0.09). Children in the age group of 5-14 years had lower odds of health service utilisation by 78% (OR = 0.22; 95% CI: 0.21-0.23), compared to children under 5 years of age. Females were four times (OR = 4.17; 95% CI: 4.09-4.25) more likely to utilise health services than males. Febrile illness constituted 17.9% (14,847 of 83,148) of the diagnoses in all age groups. Almost half of the febrile cases, 46.5% (3827 of 8233), were among children under 5 years of age. There were very few cases of non-communicable diseases diagnosed in the health facilities. The health authorities suggested improving diagnostic capacities at health centres, enhancing health professionals' skill and attitudes, and improving affordability and physical accessibility of the services.

CONCLUSION

The health service utilisation rate was low in Sidama. The use of health services was lower among rural residents, men, children and elderly, and health post users. Improving the quality, affordability and accessibility of the health services, by involving responsible stakeholders could increase service usage.

Coverage of antenatal, intrapartum, and newborn care in 104 districts of Ethiopia: A before and after study four years after the launch of the national Community-Based Newborn Care programme

BACKGROUND

Access to health services across the continuum of care improves maternal and newborn health outcomes. Ethiopia launched the Community-Based Newborn Care programme in 2013 to increase the coverage of antenatal care, institutional delivery, postnatal care and newborn care. The programme also introduced gentamicin and amoxicillin treatment by health extension workers for young infants with possible serious bacterial infection when referral was not possible. This study aimed to assess the extent to which the coverage of health services for mothers and their young infants increased after the initiation of the programme.

METHODS

A baseline survey was conducted in October-December 2013 and a follow-up survey four years later in November-December 2017. At baseline, 10,224 households and 1,016 women who had a live birth in the 3-15 months prior to the survey were included. In the follow-up survey, 10,270 households and 1,057 women with a recent live birth were included. Women were asked about their experience of care during pregnancy, delivery and postpartum periods, as well as the treatment provided for their child's illness in the first 59 days of life.

RESULTS

Between baseline and follow-up surveys the proportion of women reporting at least one antenatal care visit increased by 15 percentage points (95% CI: 10,19), four or more antenatal care visits increased by 17 percentage points (95%CI: 13,22), and institutional delivery increased by 40 percentage points (95% CI: 35,44). In contrast, the proportion of newborns with a postnatal care visit within 48 hours of birth decreased by 6 percentage points (95% CI: -10, -3) for home deliveries and by 14 percentage points (95% CI: -21, -7) for facility deliveries. The proportion of mothers reporting that their young infant with possible serious bacterial infection received amoxicillin for seven days increased by 50 percentage points (95% CI: 37,62) and gentamicin for seven days increased by 15 percentage points (95% CI: 5,25). Concurrent use of both antibiotics increased by 12 percentage points (95% CI: 4,19).

CONCLUSION

The Community-Based Newborn Care programme was an ambitious initiative to enhance the access to services for pregnant women and newborns. Major improvements were seen for the number of antenatal care visits and institutional delivery, while postnatal care remained alarmingly low. Antibiotic treatment for young infants with possible serious bacterial infection increased, although most treatment did not follow national guidelines. Improving postnatal care coverage and using a simplified antibiotic regimen following recent World Health Organization guidelines could address gaps in the care provided for sick young infants.

Does a complex intervention targeting communities, health facilities and district health managers increase the utilisation of community-based child health services? A before and after study in intervention and comparison areas of Ethiopia

INTRODUCTION

Ethiopia successfully reduced mortality in children below 5 years of age during the past few decades, but the utilisation of child health services was still low. Optimising the Health Extension Programme was a 2-year intervention in 26 districts, focusing on community engagement, capacity strengthening of primary care workers and reinforcement of district accountability of child health services. We report the intervention's effectiveness on care utilisation for common childhood illnesses.

METHODS

We included a representative sample of 5773 households with 2874 under-five children at baseline (December 2016 to February 2017) and 10 788 households and 5639 under-five children at endline surveys (December 2018 to February 2019) in intervention and comparison areas. Health facilities were also included. We assessed the effect of the intervention using difference-in-differences analyses.

RESULTS

There were 31 intervention activities; many were one-off and implemented late. In eight districts, activities were interrupted for 4 months. Care-seeking for any illness in the 2 weeks before the survey for children aged 2-59 months at baseline was 58% (95% CI 47 to 68) in intervention and 49% (95% CI 39 to 60) in comparison areas. At end-line it was 39% (95% CI 32 to 45) in intervention and 34% (95% CI 27 to 41) in comparison areas (difference-in-differences -4 percentage points, adjusted OR 0.49, 95% CI 0.12 to 1.95). The intervention neither had an effect on care-seeking among sick neonates, nor on household participation in community engagement forums, supportive supervision of primary care workers, nor on indicators of district accountability for child health services.

CONCLUSION

We found no evidence to suggest that the intervention increased the utilisation of care for sick children. The lack of effect could partly be attributed to the short implementation period of a complex intervention and implementation interruption. Future funding schemes should take into consideration that complex interventions that include behaviour change may need an extended implementation period.

TRIAL REGISTRATION NUMBER

ISRCTN12040912.

Insufficient referral practices of sick children in Ethiopia shown in a cross-sectional survey

AIM

This study aimed at assessing the referral of sick young infants and children from the community, health posts and health centres to higher levels.

METHODS

A cross-sectional survey was conducted in four of the largest Ethiopian regions from December 2016 to February 2017. Referral practices were assessed at each level in 46 districts of these regions. Interviews were supplemented by reviews of registers at health posts and health centres.

RESULTS

The women's development group leaders, who do not provide health services, referred half of the sick children they visited in the community to the health posts. The health extension workers referred 16% of the sick young infants and 6% of older infants and children to higher levels. From health centres, the health workers referred 6% of sick young infants and 1% of older infants and children to hospital. Many cases of possible severe bacterial infection were not referred to higher levels. A functional ambulance was available for a bit more than a third of the health centres.

CONCLUSION

Referral practices of sick young infants and children at all levels were weak that may threaten the continued reduction of child mortality in Ethiopia. Referral logistics were insufficient, which partly could explain the missing referrals of severely ill infants and children.

Incidence of postpartum and neonatal illnesses and utilization of healthcare services in rural communities in southern Ethiopia: A prospective cohort study

Although improving postpartum and neonatal health is a key element of the Ethiopian health extension program, the burdens of postpartum and neonatal illnesses and healthcare-seeking in rural communities in Ethiopia are poorly characterized. Therefore, we aimed to assess the incidence and risk factors for these illnesses and measure the utilization of healthcare services. We conducted a prospective cohort study of 784 postpartum women and their 772 neonates in three randomly selected kebeles in rural southern Ethiopia. Eight home follow-up visits were conducted during the first 42 postpartum days, and six neonate follow-ups were conducted at the same home over the first 28 days of life. The Prentice, Williams, and Peterson’s total time Cox-type survival model was used for analysis. We recorded 31 episodes of postpartum illness per 100 women-weeks (95% confidence interval [CI]: 30%, 32%) and 48 episodes of neonatal illness per 100 neonate-weeks (95% CI: 46%, 50%). Anemia occurred in 19% of women (95% CI: 17%, 22%) and low birth weight (<2,500g) in 15% of neonates (95% CI: 13%, 18%). However, only 5% of postpartum women (95% CI: 4%, 7%) and 4% of neonate (95% CI: 3%, 5%) reported utilizing healthcare services. Walking over 60 minutes to access healthcare was a factor of both postpartum illnesses (AHR = 2.61; 95% CI: 1.98, 3.43) and neonatal illnesses (AHR = 2.66; 95% CI: 2.12, 3.35)). Birth weight ≥2500g was identified factor of neonatal illnesses (AHR = 0.39; 95% CI: 0.33, 0.46). Compared with younger mothers, older mothers with sick newborns (AHR = 1.22; 95% CI: 1.00, 1.50) or postpartum illnesses (AHR = 1.40; 95% CI: 1.03, 1.89) were more likely to seek healthcare. Reasons for not utilizing healthcare services included a belief that the illnesses were not serious or would resolve on their own, little confidence in the healthcare institutions, and the inability to afford the cost. The burden of postpartum and neonatal illnesses in rural communities of southern Ethiopia remains high. Unfortunately, few participants utilized healthcare services. We recommend strengthening the health system that enables identifying, managing, treating, and referring maternal and neonatal illnesses and provide reasonable healthcare at the community level.

Pulse oximeter with integrated management of childhood illness for diagnosis of severe childhood pneumonia at rural health institutions in Southern Ethiopia: results from a cluster-randomised controlled trial

OBJECTIVE

To assess whether pulse oximetry improves health workers' performance in diagnosing severe childhood pneumonia at health centres in Southern Ethiopia.

DESIGN

Parallel cluster-randomised trial.

SETTING

Government primary health centres.

PARTICIPANTS

Twenty-four health centres that treat at least one pneumonia case per day in Southern Ethiopia. Children aged between 2 months and 59 months who present at health facilities with cough or difficulty breathing were recruited in the study from September 2018 to April 2019.

INTERVENTION ARM

Use of the Integrated Management of Childhood Illness (IMCI) algorithm and pulse oximeter.

CONTROL ARM

Use of the IMCI algorithm only.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the proportion of children diagnosed with severe pneumonia. Secondary outcomes included referred cases of severe pneumonia and treatment failure on day 14 after enrolment.

RESULT

Twenty-four health centres were randomised into intervention (928 children) and control arms (876 children). The proportion of children with severe pneumonia was 15.9% (148 of 928 children) in the intervention arm and 3.9% (34 of 876 children) in the control arm. After adjusting for differences in baseline variables children in the intervention arm were more likely to be diagnosed as severe pneumonia cases as compared with those in the control arm (adjusted OR: 5.4, 95% CI 2.0 to 14.3, p=0.001).

CONCLUSION

The combined use of IMCI and pulse oximetry in health centres increased the number of diagnosed severe childhood pneumonia.

TRIAL REGISTRATION NUMBER

PACTR201807164196402.