Effect of the COVID-19 pandemic on health service utilization across regions of Ethiopia: An interrupted time series analysis of health information system data from 2019-2020

Routine data in a primary care performance dashboard, Ethiopia

Objective

To explore the feasibility of building a primary care performance dashboard using DHIS2 data from Ethiopia's largest urban (Addis Ababa), agrarian (Oromia) and pastoral (Somali) regions.

Methods

We extracted 26 data elements reported by 12 062 health facilities to DHIS2 for the period 1 July 2022 to 30 June 2023. Focusing on indicators of effectiveness, safety and user experience, we built 14 indicators of primary care performance covering reproductive, maternal and child health, human immunodeficiency virus, tuberculosis, noncommunicable disease care and antibiotic prescription. We assessed data completeness by calculating the proportion of facilities reporting each month, and examined the presence of extreme outliers and assessed external validity.

Findings

At the regional level, average completeness across all data elements was highest in Addis Ababa (82.9%), followed by Oromia (66.2%) and Somali (52.6%). Private clinics across regions had low completeness, ranging from 38.6% in Somali to 58.7% in Addis Ababa. We found only a few outliers (334 of 816 578 observations) and noted that external validity was high for 11 of 14 indicators of primary care performance. However, the 12-month antiretroviral treatment retention rate and proportions of patients with controlled diabetes or hypertension exhibited poor external validity.

Conclusion

The Ethiopian DHIS2 contains information for measuring primary care performance, using simple analytical methods, at national and regional levels and by facility type. Despite remaining data quality issues, the health management information system is an important data source for generating health system performance assessment measures on a national scale.

Maternal and Child Health Services Utilization During COVID-19 in Eastern Ethiopia

Objectives: This study aimed to describe the impact of COVID-19 on maternal and child health service utilization in the Eastern part of Ethiopia. Methods: Comparative analysis was used to examine 2 years of maternal and child health service utilization. Data were extracted from client registers. A traditional Expert Modeler and one-way Analysis of Variance were used to compare service utilization before and during the COVID-19 pandemic. Results: A total of 34,576 client records were reviewed, of which 17,100 (49.5%) and 17,476 (50.5%) had visited the MCH service before and during the COVID-19 pandemic, respectively. The total client visit has shown a 2% percentage point increase. However, postnatal care and child immunization services showed a decrease. Moreover, there was a significant difference between service visits before and during COVID-19 (f = 4.6, p < 0.04). Conclusion: Mothers and children have missed or unattended facility appointments due to protective impositions or fear of getting infected with COVID-19, which might suggest a higher proportion of MCH issues were not addressed during the pandemic. The health system should therefore improve its resilience and strengthen its access at the lowest health care inlets.

Patient Satisfaction with the Implementation of Telehealth in Ambulatory Care during the COVID-19 Pandemic: A Single Institution Experience

Background

COVID-19 has reduced the capacity for delivering essential health services due to lockdown restrictions. Telehealth is an effective alternative option to improve healthcare access. However, there remain implementation challenges to patient adoption in resource-limited settings such as Ethiopia. Therefore, the purpose of this study was to assess patient satisfaction following the implementation of telehealth in ambulatory settings during the COVID-19 pandemic.

Methods

A cross-sectional study was conducted at Ayder Comprehensive Specialized Hospital in the Tigray region of Northern Ethiopia. Patients who used the telehealth service were invited to participate in a patient satisfaction survey. All statistical analyses were performed using STATA Version 14.1.

Result

A total of 149 patients have participated in the survey. Out of the total participants, 129 (86.6%) found that telehealth is easy to understand and overall satisfaction for telehealth was 87.9%. About two-thirds of the patients (97, 65.1%) reported that the telehealth visit is just as good as a traditional visit. The vast majority of participants (148, 98.6%) stated that they would definitely or probably use telehealth again and would recommend it to others. The majority of respondents (137, 91.9%) followed the recommendations provided.

Conclusion

Patients have a high level of satisfaction with the use of telehealth during the COVID-19 pandemic. About two-thirds of patients said the telehealth visit was just as good as a traditional visit. The majority of patients followed the recommendations given to them by the healthcare providers and stated that they would definitely or probably use telehealth in the future and would recommend it to others. This high level of patient satisfaction with telehealth implementation suggests that the service could be considered in low-income countries as well.

Baseline and early changes in laboratory parameters predict disease severity and fatal outcomes in COVID-19 patients

Introduction

Coronavirus disease 2019 (COVID-19) has become the worst catastrophe of the twenty-first century and has led to the death of more than 6.9 million individuals across the globe. Despite the growing knowledge of the clinicopathological features of COVID-19, the correlation between baseline and early changes in the laboratory parameters and the clinical outcomes of patients is not entirely understood.

Methods

Here, we conducted a time series cross-sectional study aimed at assessing different measured parameters and socio-demographic factors that are associated with disease severity and the outcome of the disease in 268 PCR-confirmed COVID-19 Patients.

Results

We found COVID-19 patients who died had a median age of 61 years (IQR, 50 y - 70 y), which is significantly higher (p < 0.05) compared to those who survived and had a median age of 54 years (IQR, 42y - 65y). The median RBC count of COVID-19 survivors was 4.9 × 106/μL (IQR 4.3 × 106/μL - 5.2 × 106/μL) which is higher (p < 0.05) compared to those who died 4.4 × 106/μL (3.82 × 106/μL - 5.02 × 106/μL). Similarly, COVID-19 survivors had significantly (p < 0.05) higher lymphocyte and monocyte percentages compared to those who died. One important result we found was that COVID-19 patients who presented with severe/critical cases at the time of first admission but managed to survive had a lower percentage of neutrophil, neutrophil to lymphocyte ratio, higher lymphocyte and monocyte percentages, and RBC count compared to those who died.

Conclusion

To conclude here, we showed that simple laboratory parameters can be used to predict severity and outcome in COVID-19 patients. As these parameters are simple, inexpensive, and radially available in most resource-limited countries, they can be extrapolated to future viral epidemics or pandemics to allocate resources to particular patients.

The Need to Establish and Sustain Public Health Emergency Operation Centers for Managing Infectious Disease Outbreaks: Lesson From Response to Louse-Borne Relapsing Fever Outbreak in Jimma, Ethiopia

The coronavirus disease 2019 (COVID-19) pandemic has provided a great lesson for the globe about the necessity and significance of pandemics-related preparedness in all settings. Public health emergency operation centers play critical roles in preparing for and responding to public health events and emergencies by coordinating and pooling resources. In this article, we aimed to share lessons learnt from the public health response to the louse-borne relapsing fever (LBRF) outbreak coordinated by the emergency operation center established to respond to the COVID-19 pandemic in Jimma, Ethiopia.After the major waves of COVID-19 outbreaks in Ethiopia were over, Jimma University Medical Center (JUMC) reported clusters of louse-borne relapsing fever cases from Jimma Main Prison. Accordingly, Jimma Emergency Operation Center (JEOC) established for the COVID-19 pandemic was immediately alerted and effectively coordinated the overall response.As a result, the outbreak was contained within the prison without spreading to the community and the outbreak ended within a shorter period compared to previous LBRF outbreaks in Ethiopia. This indicates the necessity of establishing and sustaining public health emergency operation centers to prepare for and combat potential future public health emergencies.

Estimating the effects of COVID-19 on essential health services utilization in Uganda and Bangladesh using data from routine health information systems

Background

Since March 2020, the coronavirus disease 2019 (COVID-19) pandemic has been a major shock to health systems across the world. We examined national usage patterns for selected basic, essential health services, before and during the COVID-19 pandemic in Uganda and Bangladesh, to determine whether COVID-19 affected reporting of service utilization and the use of health services in each country.

Methods

We used routine health information system data since January 2017 to analyze reporting and service utilization patterns for a variety of health services. Using time series models to replicate pre-COVID-19 trajectories over time we estimated what levels would have been observed if COVID-19 had not occurred during the pandemic months, starting in March 2020. The difference between the observed and predicted levels is the COVID-19 effect on health services.

Results

The time trend models for Uganda and Bangladesh closely replicated the levels and trajectories of service utilization during the 38 months prior to the COVID-19 pandemic. Our results indicate that COVID-19 had severe effects across all services, particularly during the first months of the pandemic, but COVID-19 impacts on health services and subsequent recovery varied by service type. In general, recovery to expected levels was slow and incomplete across the most affected services.

Conclusion

Our analytical approach based on national information system data could be very useful as a form of surveillance for health services disruptions from any cause leading to rapid responses from health service managers and policymakers.

Prevalence and predictors of asymptomatic malaria infection in Boricha District, Sidama Region, Ethiopia: implications for elimination strategies

BACKGROUND

Malaria remains a major public health threat in Ethiopia despite the tremendous progress made towards the 2030 elimination targets. The silent transmission of asymptomatic infection is one of the factors that enhance the persistence of the disease as a public health issue and impedes efforts to eliminate malaria. Thus, this study aimed at investigating the prevalence and risk factors of asymptomatic malaria infection in Boricha district, Sidama region of Ethiopia.

METHODS

A community-based cross-sectional study was conducted in eight selected kebeles (smallest administrative unit) in Boricha district. Representative households were chosen using a multi-stage sampling technique. A total of 573 participants were included in the study. Malaria diagnosis was performed using rapid diagnostic test (RDT) and microscopy. A structured questionnaire was administered to collect socio-demographic information. Epi data 3.1 was employed for data entry, and SPSS version 25 was used for analysis.

RESULTS

Of the 573 asymptomatic participants tested, 6.1% were found to be positive by RDT and 4.0% by microscopy. Participants aged under 5 years (AOR = 1.57, 95% CI 0.46-5.39) and 5-14 years old (AOR = 2.42, 95% CI 1.08-5.40), Insecticide-treated net utilization (AOR = 8.41; 95% CI 1.09-65.08), travel history (AOR = 6.85, 95% CI 2.32-20.26) and living in a house with windows (AOR = 2.11, 95% CI 1.02-4.36) were significantly associated with the asymptomatic malaria infection.

CONCLUSION

The findings of this study revealed that prevalence of asymptomatic malaria infection was higher in the study area. As a result, rigorous implementation of existing interventions, such as vector control and anti-malaria drugs, is strongly recommended. In addition, devising new ones that are suited to the contextual situations is highly suggested.

Impacts of COVID-19 on reproductive health service provision, access, and utilization in Ethiopia: Results from a qualitative study with service users, providers, and stakeholders

Ethiopia has made significant improvements to sexual and reproductive health (SRH) in recent decades, yet the COVID-19 pandemic brought new challenges to SRH service delivery. In the early months of the pandemic, health facility and health management information system data showed reductions in SRH service utilization, however more evidence is needed on ongoing SRH impacts to inform policy and program decision-making. Our study aimed to assess the impacts of COVID-19 on SRH service utilization and access from the perspective of providers, clients, and stakeholders in Addis Ababa and Amhara Regional State. We collected data from May through July 2021 via six focus group discussions with health service providers, 50 in-depth interviews with SRH service clients and 15 key informant interviews with policy and programmatic stakeholders. All audio recordings were transcribed and translated from Amharic into English. Data were coded and analyzed for content and themes using Excel and NVivo 10. We found that COVID-19 and associated public health mitigation measures had consequences on SRH prioritization, funding, and service delivery. Efforts to halt the spread of COVID-19, such as gathering and transportation restrictions, also reduced access to SRH services. Fear of infection, costly and inaccessible transportation, commodity stockouts, and limited service availability all impeded access to and use of SRH services. For some women, this meant losing timely access to contraception and subsequently facing unwanted pregnancies. Providers experienced increased workloads, anxiety, and stigma as possible sources of infection. Our findings offer useful learnings for program and policy stakeholders aiming to meet SRH needs during the pandemic, and during times of crisis more broadly.

Poor adherence to antiretroviral therapy among adult people living with HIV initiated during the COVID-19 epidemic waves – observations at the University Teaching Hospital in Lusaka, Zambia

Background

Coronavirus disease 2019 (COVID-19)-related disruptions in healthcare services and clinical outcomes have been predicted and documented. However, little is known about how antiretroviral therapy (ART) adherence disruptions caused by the COVID-19 pandemic have manifested amidst the ‘Undetectable = Untransmittable' campaign initiative. Using a patient's viral load as a proxy for medication adherence, our study aimed to determine the adherence to ART on first-line medications among adult people living with human immunodeficiency virus (PLWHIV) at the University Teaching Hospital in Lusaka, Zambia during the pandemic.

Methods

This was a hospital-based cross-sectional study. Secondary data of PLWHIV registered to receive ART from the Adult Infectious Disease Centre was extracted from the SmartCare® electronic health record system to constitute a resultant data set that this study used. The data extraction form was used to extract values of dependent (ART adherence measured by viral load detectability) and independent variables and imported them into the statistical analysis tool, STATA version 16.1 MP. Descriptive statistics of individual characteristics, testing for associations using Pearson's chi-square test, and stratified and combined multivariable logistic regression were performed.

Results

Of the 7,281 adult PLWHIV included in this study, 9.0% (95% CI 8.3–9.6%) were virally detectable. Estimates of the odds ratios of detectable viral load remained significantly higher among adult PLWHIV who were initiated on ART after the U=U campaign was launched in Zambia and were on a monthly 2.51 (1.31–9.03) or 6-monthly 4.75 (3.52–6.41) dispensing of a dolutegravir-based regimen and those on 6-monthly dispensing of an efavirenz-based regimen 4.67 (2.16–10.08) compared to their counterparts. Overall estimates showed us the same picture 4.14 (3.22–5.31), having adjusted for all other predictor variables.

Conclusion

We found that a high proportion of people with detectable viral load in the study population, irrespective of medication refill interval and type of regimen, was concentrated among adult PLWHIV who started treatment during the COVID-19 epidemic waves, as compared to those who started treatment before the pandemic. This observed disparity suggests the inherent impact of the pandemic on the adherence to ART among adult PLWHIV in Lusaka, Zambia. This further illustrates how exposed program responses are to external shocks, especially in already weakened health systems, and the need to create program response buffers and resilient program-specific strategies to minimize the effect of external disruptions.