Developing and validating a clinical algorithm for the diagnosis of podoconiosis

BACKGROUND

Difficulties in reliably diagnosing podoconiosis have severely limited the scale-up and uptake of the World Health Organization-recommended morbidity management and disability prevention interventions for affected people. We aimed to identify a set of clinical features that, combined into an algorithm, allow for diagnosis of podoconiosis.

METHODS

We identified 372 people with lymphoedema and administered a structured questionnaire on signs and symptoms associated with podoconiosis and other potential causes of lymphoedema in northern Ethiopia. All individuals were tested for Wuchereria bancrofti-specific immunoglobulin G4 in the field using Wb123.

RESULTS

Based on expert diagnosis, 344 (92.5%) of the 372 participants had podoconiosis. The rest had lymphoedema due to other aetiologies. The best-performing set of symptoms and signs was the presence of moss on the lower legs and a family history of leg swelling, plus the absence of current or previous leprosy, plus the absence of swelling in the groin, plus the absence of chronic illness (such as diabetes mellitus or heart or kidney diseases). The overall sensitivity of the algorithm was 91% (95% confidence interval [CI] 87.6 to 94.4) and specificity was 95% (95% CI 85.45 to 100).

CONCLUSIONS

We developed a clinical algorithm of clinical history and physical examination that could be used in areas suspected or endemic for podoconiosis. Use of this algorithm should enable earlier identification of podoconiosis cases and scale-up of interventions.

'I should not feed such a weak woman'. Intimate partner violence among women living with podoconiosis: A qualitative study in northern Ethiopia

BACKGROUND

Intimate Partner Violence (IPV) is a serious, preventable public health problem that affects millions of people worldwide. Research indicates that adults suffering from long term, disabling conditions are more likely to be victims of IPV due to the intersection of disease-associated stigma and discrimination. IPV in turn is known to worsen the overall health and wellbeing of those affected by it. Little research however explores the relationship between neglected tropical diseases such as podoconiosis and IPV. This study explores the relationship between IPV and podoconiosis in northern Ethiopia with the aim of identifying new avenues for limiting disability and promoting the wellbeing of people affected by this neglected tropical disease.

METHODS

The study was conducted in East and West Gojjam zones, located in the Amhara Regional State of Ethiopia. Research participants were first screened using the domestic violence screening tool Hurt-Insult-Threaten-Scream (HITS). Data were collected by native speakers of the local language (Amharic) in the form of semi-structured interviews during January and February 2016. Thematic and content data analysis was carried out, using the Open Code 3.4 qualitative data analysis software for coding.

RESULTS

A total of 15 women living with podoconiosis and experiencing IPV were interviewed (aged 31 to 75). Women experienced different forms of IPV, including beatings (with or without an object), insults, name calling, undermining, denial of equal rights over common assets, movement monitoring, cheating, abandonment, forced divorce, obstruction of health care access, inhibition of decision-making and sexual coercion. Podoconiosis increases the frequency and severity of IPV and in occasions shapes a change from physical to psychological and financial violence. In turn, frequent episodes of IPV worsen disease outcomes and contribute to disease persistence in the region, in that these impede women's ability to manage the disease and help perpetuate the conditions of poverty that influence disease onset.

CONCLUSIONS

Women living with podoconiosis are victims of various, overlapping forms of IPV that negatively impact their health and wellbeing. Poverty, scarce IPV prevention services in the area together with a social acceptance of IPV and these women's decreased ability to work due to the debilitating effects of podoconiosis and childcare responsibilities frequently prompt these women to tolerate IPV and remain in abusive relationships. Tackling disease-associated taboo and stigma, developing accessible IPV interventions, working towards greater gender equality at the household and societal levels and developing sustainable strategies for improving the socio-economic assets of women affected by podoconiosis are all necessary to both prevent IPV and to improve disease outcome.

Food Insecurity among Households with and without Podoconiosis in East and West Gojjam, Ethiopia

BACKGROUND

Household food insecurity remained one of the most crucial challenges to economic development and has been aggravated by household health conditions. Nearly one billion people are undernourished of which 98% in developing countries like Ethiopia.

OBJECTIVE

To assess households' food insecurity among podoconiosis patients and non-podoconiosis in East and West Gojjam Zone, Ethiopia, 2016.

METHOD

A community based comparative cross sectional study was conducted in East and West Gojjam, 2016. Multi-stage sampling technique was employed to select 208 podoconiosis and 400 non-podoconiosis household heads. Data was collected by using structured and pretested questionnaires. The collected data was cleaned, coded and entered into Epi data then exported to SPSS version 22. Descriptive and inferential statistics was performed. Both bivariate and multivariate logistic regression analyses was employed. The association was measured by adjusted odds ratio (AOR), 95%CI (confidence interval) and P < 0.05 was considered statistically significant.

RESULT

A total of 608 study participants were involved in this study. Food insecurity podoconiosis patients and non-podoconiosis household was 83.7%, 53% respectively (p = 0.0001). Podoconiosis and non- podoconiosis whose heads could not read and write AOR = 5.84, (95% CI: 2.14, 15.95) and AOR = 1.70, (95% CI: 1.06, 2.72) were food insecure respectively. Podoconiosis patients without off farm activities AOR = 4.90, (95% CI: 1.60, 14.95), not using fertilizer AOR = 4.38, (95% CI: 1.15, 16.67) and living at > 5 kilo meter distance from market AOR = 4.47, (95% CI: 1.38, 14.48) were food insecure. Non-podoconiosis heads with no perennial plant AOR = 2.11, (95% CI: 1.17, 3.34), not using improved seeds AOR = 2.20, (95% CI: 1.25, 3.87), no access to asset building program AOR = 2.07, (95% CI: 1.27, 3.34), living in medium and low altitude AOR = 8.87, (95% CI: 1.81, 43.40) and AOR = 10.04, (95% CI: 1.90, 52.93) were food insecure.

CONCLUSION

Food insecurity was higher among podoconiosis than non-podoconiosis households. Being a female, unable to read and write absence of off farm activities, not using of fertilizers and living in more distance from market were significantly associated with food insecurity among podoconiosis patients. Special emphasis should be given for improvement of food security of podoconiosis and non-podoconiosis households.

Rapid Ethical Appraisal: A tool to design a contextualized consent process for a genetic study of podoconiosis in Ethiopia

Background: Obtaining genuine informed consent from research participants in developing countries can be difficult, partly due to poor knowledge about research process and research ethics. The situation is complicated when conducting genomic research on a disease considered familial and a reason for stigmatisation. Methods: We used a Rapid Ethical Appraisal tool to assess local factors that were barriers to getting genuine informed consent prior to conducting a genetic study of podoconiosis (non-filarial elephantiasis) in two Zones of Ethiopia. The tool included in-depth interviews and focus group discussions with patients, healthy community members, field workers, researchers/Institutional Review Board (IRB) members, elders, religious leaders, and podoconiosis administrators who work closely with patients. Results: Most patients and healthy community members did not differentiate research from routine clinical diagnosis. Participants felt comfortable when approached in the presence of trusted community members. Field workers and podoconiosis administrators preferred verbal consent, whereas the majority of patients and healthy community members prefer both verbal and written consent. Participants better understood genetic susceptibility concepts when analogies drawn from their day-to-day experience were used. The type of biological sample sought and gender were the two most important factors affecting the recruitment process. Most researchers and IRB members indicated that reporting incidental findings to participants is not a priority in an Ethiopian context. Conclusions: Understanding the concerns of local people in areas where research is to be conducted facilitates the design of contextualized consent processes appropriate for all parties and will ultimately result in getting genuine consent.

Willingness to pay for footwear, and associated factors related to podoconiosis in northern Ethiopia

BACKGROUND

In Northern Ethiopia, use of footwear by the rural community is limited, and non-governmental organizations provide footwear for school children as a means of preventing podoconiosis. However, this is not a sustainable strategy. This study assessed willingness to pay for footwear among people with and without podoconiosis.

METHODS

A comparative cross-sectional community-based study was conducted in Mecha and Gozamen woredas among randomly selected people with and without podoconiosis. Trained health extension workers collected data using an interviewer-administered structured questionnaire. The data were entered into EPI-Data and exported to SPSS version 16.0 statistical software package for analysis.

RESULTS

The willingness to pay for footwear among people with and without podoconiosis was 72.3% and 76.7% respectively (p=0.30). People with podoconiosis in the lower quintiles of economic status were less likely to be willing to pay for footwear than those in the higher quintiles.

CONCLUSIONS

There is substantial willingness to pay for footwear. The expressed willingness to pay indicates demand for footwear in the community, suggesting an opportunity for shoe companies. There are still a substantial proportion of individuals not willing to pay for footwear. This requires intensified public education and social transformation to bring about change in behavior towards footwear use if elimination of podoconiosis within our generation is to be achieved.

Using Qualitative Methods to Explore Lay Explanatory Models, Health-Seeking Behaviours and Self-Care Practices of Podoconiosis Patients in North-West Ethiopia

Background

Podoconiosis (endemic non-filarial elephantiasis) is a chronic, non-infectious disease resulting from exposure of bare feet to red-clay soil in tropical highlands. This study examined lay beliefs about three under-researched aspects of podoconiosis patients’ care: explanatory models, health-seeking behaviours and self-care.

Methods

In-depth interviews and focus group discussions were undertaken with 34 participants (19 male, 15 female) between April-May 2015 at podoconiosis treatment centres across East and West Gojjam regions in north-west Ethiopia.

Results

Explanatory models for podoconiosis included contamination from blood, magic, soil or affected individuals. Belief in heredity or divine punishment often delayed clinic attendance. All participants had tried holy water treatment and some, holy soil. Herbal treatments were considered ineffectual, costly and appeared to promote fluid escape. Motivators for clinic attendance were failure of traditional treatments and severe or disabling symptoms. Patients did not report self-treatment with antibiotics. Self-care was hindered by water being unavailable or expensive and patient fatigue.

Conclusion

A pluralistic approach to podoconiosis self-treatment was discovered. Holy water is widely valued, though some patients prefer holy soil. Priests and traditional healers could help promote self-care and “signpost” patients to clinics. Change in behaviour and improving water access is key to self-care.

Podoconiosis is a disease that is caused by long-term exposure to red clay soil found in tropical highland areas. This causes swelling of the legs, episodes of intense pain and severe disability. Sufferers of the condition experience stigma and exclusion from the community. Previous work has demonstrated a low rate of re-attendance to clinics and that many patients fail to adhere to their treatment regime of improving foot hygiene. The present study explored areas of health-seeking behaviour and self-care practices to discover the reason behind these failures. It was found that explanatory models of disease causation had a significant impact on decisions to seek healthcare and that participants only turned to Western medical clinics after failure of traditional treatments and with particularly severe symptoms. We identified several form of traditional treatment for the disease, and these tended to be based on cleansing, fluid extraction or faith/symbolism. The most important barrier to self-care and adhering to treatment regimens was an inability to collect adequate water. We call for greater integration with traditional healers, improved access to water through collaboration with other NGOs and the government and the use of expert patients to disseminate information and signpost patients to clinics.

Reasons for loss to follow-up of patients with podoconiosis in the Amhara Region, northern Ethiopia

BACKGROUND

Podoconiosis is a non-infectious form of tropical lymphoedema characterised by swelling of the feet and lower legs. Treatment is simple and effective yet evidence indicates that a proportion of patients become lost to follow-up.

METHODS

This study was a quantitative questionnaire-based study which aimed to identify the most common reasons for loss to follow-up of patients. A total of 191 participants registered with the International Orthodox Christian Charities (IOCC) who had become lost to follow-up were included in a cross-sectional survey based in the Amhara Region, northern Ethiopia.

RESULTS

The most common reason was distance, stated by 26.7% (51/191). This was significantly associated with living further from the treatment site (p=0.02). Having had podoconiosis for longer was protective against this (p=0.03). For each additional hour of travel time a patient lived from the treatment centre, the odds of them reporting 'distance' as the main reason for becoming lost to follow-up increased by 1.61 (95% CI: 1.25-2.08).

CONCLUSIONS

The consequences of podoconiosis are exacerbated by walking long distances, but in most areas, this is currently required of patients in order to receive treatment. We recommend expansion of services to widen treatment availability, since provision of transport to and from treatment centres is unlikely to be feasible.

Barriers to access and re-attendance for treatment of podoconiosis: a qualitative study in northern Ethiopia

BACKGROUND

Podoconiosis is a chronic non-infectious lymphoedema affecting individuals exposed to red clay soil in endemic areas. Evidence from International Orthodox Christian Charities (IOCC) treatment centers' registers suggests that a significant proportion of registered patients with podoconiosis fail to re-attend for treatment, putting them at risk of worsening disability associated with the lymphoedema and attacks of acute adenolymphangitis. The aim of this study was to explore barriers to access and re-attendance of patients with podoconiosis in northern Ethiopia.

METHODS

A cross-sectional qualitative study was conducted at three IOCC treatment sites from February to April 2013. Twenty-eight patients and three project leaders took part in in-depth interviews. Three focus group discussions were undertaken with 22 patients, patient association leaders and project staff members.

RESULTS

Barriers to access and to continued attendance at treatment centers were recognized by all participant groups. The following reasons were reported: lay beliefs about the disease's causation and presentation, occupational, geographic and financial barriers, stigma and conflicting expectations of treatment services.

CONCLUSIONS

This study illustrates the multiple, step-wise barriers to accessing treatment faced by podoconiosis patients. These factors are dynamic, frequently interact and result from competing social and economic priorities.

Podoconiosis patients' willingness to pay for treatment services in Northwest Ethiopia: potential for cost recovery

BACKGROUND

Podoconiosis is non-filarial elephantiasis of the lower legs. It is more commonly found in tropical Africa, Central and South America, and northwest India. In Ethiopia, a few non-governmental organizations provide free treatment to podoconiosis patients, but sustainability of free treatment and scale-up of services to reach the huge unmet need is challenged by resource limitations. We aimed to determine podoconiosis patient's willingness to pay (WTP) for a treatment package (composed of deep cleaning of limbs with diluted antiseptic solution, soap, and water, bandaging, application of emollient on the skin, and provision of shoes), and factors associated with WTP in northwestern Ethiopia.

METHODS

A cross-sectional study was conducted among randomly selected untreated podoconiosis patients (n=393) in Baso Liben woreda, northwestern Ethiopia. The contingent valuation method was used with a pre-tested interviewer-administered questionnaire.

RESULTS

The majority of podoconiosis patients (72.8%) were willing to pay for treatment services. The median WTP amount was 64 Birr (US$ 3.28) per person per year. More than one-third of patients (36.7%) were willing to pay at least half of the full treatment cost and 76.2% were willing to pay at least half of the cost of shoes. A multivariate analysis showed that having a higher monthly income, being a woman, older age, being aware of the role of shoes to prevent podoconiosis, and possession of a functional radio were significantly associated with higher odds of WTP.

CONCLUSIONS

The considerable WTP estimates showed that podoconiosis treatment could improve sustainability and service utilization. A subsidized cost recovery scheme could reduce treatment costs and more feasibility integrate podoconiosis treatment service with other NTDs and the government's primary health care system.

Assessment of voluntary counseling and testing service utilization and associated factors among Debre Markos University Students, North West Ethiopia: a cross-sectional survey in 2011

Background

Voluntary Counseling and Testing (VCT) is the key entry point to prevention, care, treatment and support services, where people learn whether they are infected or not and to understand the implications of their HIV status and make informed choices for the future.

Methods

A cross sectional study design was done among 753 students drawn from selected departments in Debre Markos University, Ethiopia, using multi-stage sampling technique. Self-administered questionnaire was used to estimate the prevalence of VCT service utilization and to assess associated factors. Data were entered and analyzed using SPSS version 16.

Results

711 students were participated in the study, of whom, 521 were males. Majority (93.8%) were within the age range of 15 to 24 years. The mean age was 21.5 (3.2±); most of the respondents (91.6%) were single. Majority (81.4%) heard about the confidential VCT service, and their major sources of information were mass media (73.3%) and health workers (71.1%). The study revealed that 58.5% of the study participants had undergone voluntary counseling and testing. It was shown that VCT service utilization was significantly associated with availability of ART drug in VCT site, heard presence of confidentiality, perceived stigma, risk perception and knowledge about HIV.

Conclusion

The major factors identified for increased VCT service utilization were knowledge about availability of ART drug in VCT site, information about confidentiality, absence of perceived stigma, higher risk perception and knowledge about HIV. Therefore, actions targeting on these predictors are necessary to effectively enhance the use of the VCT services utilization.