Impact of pharmacist-led interventions on medication-related problems among patients treated for cancer: A systematic review and meta-analysis of randomized control trials

BACKGROUND

Medication-related problems (MRPs) continue to impose a voluminous health impact, particularly among patients on anti-cancer therapy, due to the nature and complexity of the care. Pharmacists have a pivotal role in ensuring the safe, effective, and rational use of medicines in this group of patients.

OBJECTIVES

To examine the impact of pharmacist-led interventions in resolving MRPs among patients treated for cancer.

METHODS

This systematic review and meta-analysis was conducted and reported following the PRISMA protocol and registered in PROSPERO (Registration number: CRD42022311535). Four database searches, PubMed, EMBASE, Cochrane, and International Pharmaceuticals Abstracts, were systematically searched from August 2022 to January 2023. Only randomized control trials (RCTs) were included. The Cochrane risk of bias assessment tool was used to check the quality of the included studies. The outcome measures were overall MRPs, adherence, medication errors, and adverse drug events (ADEs). Data for meta-analysis were analyzed used using STATA version 17 and standardized mean difference effect sizes were calculated for continuous outcomes and odds ratio for categorical outcomes.

RESULTS

Out of the 90 studies screened for eligibility, 20 RCT studies were included for the systematic review and 15 for the meta-analysis. Close to two-thirds of the studies were from Europe (n = 7) and Asia (n = 6). A combination of educational and behavioral intervention strategies were used for a period ranged from 8 days to 12 months. The pharmacist-led intervention improved adherence to treatment by 4.79 times (AOR = 4.79; 95%CI = 2.64, 8.68; p-value<0.0001), reduced the occurrence of ADEs by 1.28 (SMD = -1.28; 95%CI = -0.04-2.52; p-value = 0.04) and decreased the overall MRPs by 0.53 (SMD = -0.53; 95%CI = -0.79, -0.28; p-value<0.0001) compared to control groups.

CONCLUSION

This study found out that pharmacist-led interventions can significantly lower MRPs among patients treated for cancer. Hence, a global concerted effort has to be made to integrate pharmacists in a multidisciplinary direct cancer care.

Global Health Commodities Supply Chain in the Era of COVID-19 Pandemic: Challenges, Impacts, and Prospects: A Systematic Review

Background

The COVID-19 pandemic led to the most substantial health crisis in the 21st Century. This pandemic interrupted the supply of essential commodities for human beings. Among the essential commodities for human survival, disruption of the supply of essential health commodities has become a global concern.

Objective

The study aimed to systematically analyze published articles on the challenges, impacts, and prospects of the global health commodities' supply chain in the era of the COVID-19 pandemic.

Methods

A standard searching strategy was conducted in seven research databases to retrieve pertinent articles. Finally, 459 articles were retrieved for further screening, and only 13 articles were selected for final synthesis.

Results

Almost 38.5% of the studies targeted the supply chain of health commodities used to treat HIV, TB, and malaria. Lockdown policies, travel restrictions, lack of transportation, low manufacturing capacity, and rising costs were the significant challenges indicated for the supply interruption of essential health commodities and COVID-19 vaccines. Findings indicated that the supply interruption of essential health commodities leads to a devastating impact on global health.

Conclusion

Global medicine shortages due to the pandemic crisis can have a devastatingly harmful impact on patient outcomes and might result in a devastatingly long-lasting effect on the health of the world community. Supply-related challenges of the COVID-19 vaccine affect countries' ambitions for achieving herd immunity quickly. Monitoring the pandemic's effect on the health commodities' supply system and designing a short-term and long-term resilient health supply chain system that can cope with current and future health catastrophes is pivotal.

Spatial distribution of zero-dose children in Ethiopia: evidence for a targeted intervention from a large-scale cross-sectional evaluation survey

Background

Ethiopia is the fourth leading contributor to the global total of zero-dose children (those who lack the first dose of diphtheria-tetanus-pertussis containing vaccine) and has substantial regional variations in zero-dose children. This study explored the spatial pattern of zero-dose children aged 12-35 months in Ethiopia.

Methods

A survey was conducted in pastoralist regions, developing regions, newly-established regions, conflict-affected areas, underserved urban populations, hard-to-reach areas, internally displaced populations, and refugees. Spatial autocorrelation was measured using the Global Moran'sIstatistic. Getis-Ord Gi* statistics was applied to calculate the spatial variability of the high and low prevalence rates of zero-dose children. The spatial interpolation technique was also applied to estimate unknown values that fall between known values. Inverse distance weighting interpolation method was used to predict the risk of zero-dose children. ArcGIS version 10.8 was used for the spatial analysis.

Results

A total of 3,646 children aged 12-35 months were included in the study. The spatial distribution of zero-dose children in Ethiopia was non-random (Global Moran'sI = 0.178971, p < 0.001). According to the hotspot analysis, western, eastern and northern parts of Somali and western and central parts of Afar regions had the highest load of zero-dose children (hotspot areas) followed by the Northeastern part of Amhara and southeastern part of Oromia regions. On the other hand, Southern Nations, Nationalities, and Peoples, Sidama, and the Eastern part of the Southwest Ethiopia peoples regions were identified as cold spot areas. The spatial interpolation analysis corresponded with the hotspot analysis results where western and central parts of Afar and western, eastern and northern parts of Somali regions were identified as high-risk areas for zero-dose children. However, Addis Ababa, Dire Dawa, Harari, Southern Nations, Nationalities, and Peoples, Sidama, Southwest Ethiopia Peoples, and parts of Oromia were found to be low-risk areas for zero-dose children.

Conclusion

The spatial analysis identified that zero-dose children had a significant spatial variation across the study areas. High clusters of zero-dose children were detected in Afar and Somali regions. Implementing routine and mop-up vaccination campaigns in the identified hotspot areas will help Ethiopia to improve coverage and reduce immunization inequalities.

Low Measles Vaccination Coverage and Spatial Analysis of High Measles Vaccination Dropout in Ethiopia's Underprivileged Areas

(1) Background: Measles remains a major cause of disease and death worldwide, especially in the World Health Organization African Region. This study aimed to estimate the coverage of measles vaccinations and map the spatial distribution of measles vaccination dropout in Ethiopia; (2) Methods: A cross-sectional survey was conducted in Ethiopia's underprivileged areas. The study included 3646 mothers/caregivers of children. ArcGIS for the spatial analysis, Global Moran's I statistic for spatial autocorrelation, and Getis-Ord Gi* statistics for hot spot analysis were applied; (3) Results: Overall, coverages of measles-containing-vaccine first- and second-doses were 67% and 35%, respectively. Developing regions had the lowest coverages of measles-containing-vaccine first- and second-doses, 46.4% and 21.2%, respectively. On average, the measles vaccination dropout estimate was 48.3%. Refugees had the highest measles vaccination dropout estimate (56.4%). The hot spot analysis detected the highest burden of measles vaccination dropout mainly in the northeastern parts of Ethiopia, such as the Afar Region's zones 1 and 5, the Amhara Region's North Gondar Zone, and peripheral areas in the Benishangul Gumuz Region's Assosa Zone; (4) Conclusions: The overall measles vaccination coverages were relatively low, and measles vaccination dropout estimates were high. Measles vaccination dropout hot spot areas were detected in the northeastern parts of Ethiopia.

Relationship between Antibiotic Consumption and Resistance: A Systematic Review

Background

Unreserved use of antibiotics exerted selective pressure on susceptible bacteria, resulting in the survival of resistant strains. Despite this, the relationship between antibiotic resistance (ABR) and antibiotic consumption (ABC) is rarely studied. This systematic review aims to review the relationship between ABC and ABR from 2016 to 2022.

Methods

Articles published over 7 years (2016-2022) were searched from December 23 to 31, 2022. The search strategy was developed by using keywords for ABC and ABR. From 3367 articles, 58 eligible articles were included in the final review.

Results

The pooled ABC was 948017.9 DPDs and 4108.6 DIDs where over 70% of antibiotics were from the Watch and Reserve category based on the WHO AWaRe classification. The average pooled prevalence of ABR was 38.4%. Enterococcus faecium (59.4%), A. baumannii (52.6%), and P. aeruginosa (48.6%) were the most common antibiotic-resistant bacteria. Cephalosporins (76.8%), penicillin (58.3%), and aminoglycosides (52%) were commonly involved antibiotics in ABR. The positive correlation between ABR and consumption accounted for 311 (81%). The correlation between ABR P. aeruginosa and ABC accounted for 87 (22.7%), followed by 78 (20.3%) and 77 (20.1%) for ABR E. coli and K. pneumoniae with ABCs, respectively. Consumption of carbapenems and fluoroquinolones was most commonly correlated with resistance rates of P. aeruginosa, K. pneumoniae, E. coli, and A. baumannii.

Conclusion

There is a positive correlation between ABC and the rate of ABR. The review also revealed a cross-resistance between the consumption of different antibiotics and ABR. Optimizing antibiotic therapy and reducing unnecessary ABC will prevent the emergence and spread of ABR. Thus, advocating the implementation of stewardship programs plays a pivotal role in containing ABR.

Access to advanced healthcare services and its associated factors among patients with cervical cancer in Addis Ababa, Ethiopia

Objective

This study aimed to assess the extent of access to healthcare services, perception and associated factors among patients with cervical cancer in Addis Ababa, Ethiopia.

Methods

A facility-based cross-sectional study was conducted from 01 July through 30 August 2023 at two tertiary hospitals. Cases with histopathologic and clinical confirmation of cervical cancer were enrolled using a consecutive sampling technique. Data was collected through a validated questionnaire administered by interviewers using the KoboCollect application. Subsequently, the collected data underwent analysis using Statistical Sciences for Social Sciences (SPSS) version 26.0. Bivariable and multivariable regression models were performed at p ≤ 0.2 and p<0.05 statistical significance, respectively.

Results

A total of 391 patients were enrolled in the study. Health facilities were accessible for obtaining general medical services (56.5%), drugs (57.3%), laboratory diagnosis services (57.0%), imaging diagnosis services (56.8%), and radiotherapy services (55.8%) of the patients. Cost of services was affordable only in 11.5% of the cases. Essential anticancer medicines were out of stock for 229 (58.6%) of the patients during the past three months. About two-thirds of the patients have a good perception of access to healthcare services. In multivariable binary logistic regression, admission to the inpatient (AOR: 0.20, 95% CI: 0.06-0.67), joblessness (AOR: 0.19, 95% CI: 0.08-0.46), lower level of income to the extreme poverty line (3567ETB)(64.9 USD) (AOR: 0.19, 95% CI: 0.10-0.35), no CBHI coverage (AOR: 4.16, 95% CI: 1.76-9.85), having social support (AOR: 3.80; 95% CI: 1.96-7.41), and poor dietary practice (AOR: 2.36, 95% CI: 1.28-4.35) were found to have a statistically significant association with perceived good access to healthcare services.

Conclusion

Only close to a half of the patients with cervical cancer, in Addis Ababa, have adequate access to healthcare services. Nearly two-thirds of the patients reported perceived good access to the services. Many factors were found to show a statistically significant association with patients' perceived access to healthcare services.

A six years trend analysis of systemic antibiotic consumption in Northwest Ethiopia

BACKGROUND

Consumption of antibiotics, a major global threat to public health, is perhaps the key driver of antibiotic resistance. Monitoring antibiotic consumption is crucial to tackling antimicrobial resistance. This study assessed antibiotic consumption trends during the last six years in the Bahir Dar branch of the Ethiopian pharmaceutical supply agency (EPSA), Northwest Ethiopia, in 2022.

METHODS

Retrospective data were collected in August 2022 based on antibiotic distribution data from the Bahir Dar Brach of EPSA from July 2016 to June 2022. Data were analyzed according to the Anatomic Therapeutic Classification (ATC) developed by the World Health Organization (WHO). We measured antibiotic consumption using a defined daily dose per 1000 inhabitants per day (DIDs) based on the Agency's catchment population. Descriptive statistics and trend analyses were conducted.

RESULTS

About 30.34 DIDs of antibiotics were consumed during the six years. The consumption of antibiotics decreased by 87.4%, from 6.9 DIDs in 2016/17 to 0.9 DIDs in 2021/22. Based on the WHO AWaRe classification, 23.39 DIDs (77.1%) of the consumed antibiotics were from the Access category. Consumption of Access category antibiotics was decreased by 72.7% (from 5 to 0.5 DIDs) but Watch antibiotics decreased by 54.3% (from 1.8 to 0.4 DIDs). Oral antibiotics accounted for 29.19 DIDs (96.2%) of all consumed systemic antibiotics. The average cost expenditure per DDD for all antibiotics was 54.1 birr/DDD (0.4-482.3 birr/DDD). Only seven antibiotics accounted for DU90% and the cost expenditure per DDD for the DU90% antibiotics ranged from 0.4/DDD for Doxycycline to 232.8 birr/DDD for Piperacillin/tazobactam. Overall, during the last six years, the most commonly used antibiotic was Amoxicillin (10.1 DIDs), followed by Doxycycline (5.3 DIDs) and Ciprofloxacin (3.4 DIDs).

CONCLUSION

In this study, we found that antibiotic usage was low and continuously declining over time. Minimizing unnecessary antibiotic usage is one possible approach to reduced AMR. However, a shortage of access to important medicines can compromise the quality of treatment and patient outcomes. A prospective study is needed to evaluate the balance of patient outcomes and reduce AMR by optimizing the community consumption of systemic antibiotics.

Vaccination dropout and wealth related inequality among children aged 12-35 months in remote and underserved settings of Ethiopia: a cross-sectional evaluation survey

Background

Vaccination is one of the most cost-effective public health interventions that prevents millions of deaths. Although immunization coverage is increasing globally, many children in low- and middle-income countries drop out of the vaccination continuum. This study aimed at determining vaccination dropout rates and predictors in children aged 12-35 months in remote and underserved areas of Ethiopia.

Methods

This study was part of a cross-sectional evaluation survey that was conducted in 2022 in Ethiopia. The study settings include pastoralist, developing & newly established regions, conflict affected areas, urban slums, internally displaced populations and refugees. A sample of 3,646 children aged 12-35 months were selected using a cluster sampling approach. Vaccination dropout was estimated as the proportion of children who did not get the subsequent vaccine among those who received the first vaccine. A generalized estimating equation was used to assess determinants of the dropout rate and findings were presented using an adjusted odds ratio with 95% confidence interval. Concentration curve and index were used to estimate wealth related inequality of vaccination dropout.

Results

A total of 3,646 caregivers of children participated in the study with a response rate of 97.7%. The BCG to Penta-3 (52.5%), BCG to MCV-2 (57.4%), and Penta-1 to Penta-3 (43.9%) dropouts were all high. The highest Penta-1 to Penta-3 dropout rate was found in developing regions (60.1%) and the lowest was in urban slums (11.2%). Caregivers who were working outside their homes [AOR (95% CI) = 3.67 (1.24-10.86)], who had no postnatal care follow-up visits [AOR (95%CI) = 1.66 (1.15-2.39)], who did not receive a service from a skilled birth attendant [AOR (95%CI) = 1.64 (1.21-2.27)], who were older than 45 years [AOR (95% CI) = 12.49 (3.87-40.33)], and who were less gender empowered [AOR (95%CI) = 1.63 (1.24-2.15)] had increased odds of Penta-1 to Penta-3 dropout. The odds of dropout for children from poor caregivers was nearly two times higher compared to their wealthy counterparts [AOR (95%CI) = 1.87 (1.38-2.52)].

Conclusion

Vaccination dropout estimates were high among children residing in remote and underserved settings. Poor wealth quintile, advanced maternal age, low women empowerment, and limited utilization of maternity care services contributed to vaccination dropout.

Access to essential psychotropic medicines in Addis Ababa: A cross-sectional study

BACKGROUND

Mental disorders are becoming a growing public health problem worldwide, especially in low- and middle-income countries. Regular and adequate supplies of appropriate, safe, and affordable medications are required to provide quality mental health services. However, significant proportions of the population with severe mental disorders are not getting access to treatment. Among others, the availability and affordability of psychotropic medicines are significant barriers for many patients in meeting their medication needs. This study aimed to assess the availability, prices, and affordability of essential psychotropic medicines in the private and public health sectors of Addis Ababa, the capital city of Ethiopia.

METHODS

A cross-sectional study design was used in 60 retail medicine outlets from the public and private sectors. Stratified random and quota sampling were applied to select the retail outlets. Data was entered and analyzed using the preprogrammed WHO/HAI workbook and SPSS V.25.

RESULTS

The mean availability of Lower Priced Generic (LPG) psychotropic medicines was 24.33% in Addis Ababa (28.7% in the public sector and 19.80% in the private sector). The Patient prices for the LPG ranged from 0.52-6.43 MPRs in public and 1.08-24.28 MPRs in private sectors. Standard treatment costs varied from 0.1-7.8 days' wages in public and 0.8-25 days' wages in private sectors for the lowest-paid government worker to purchase a month's supply.

CONCLUSIONS

Essential psychotropic medicines were poorly available, with high prices and low affordability in Addis Ababa. An efficient supply across all levels of care and financial protection for essential medicines should be in place to ensure access.

Factors Affecting Inventory Management Performance of Tracer Medicines Across Primary Health Care Units, Gamo Zone, Southern Nations Nationalities and People's Region, Ethiopia

Background

Inventory management ensures access to tracer medicines (TMs) for priority health-care needs. Factors that impede its performance across primary health-care units (PHCUs) are less explored in Ethiopia. The current study assessed factors affecting the inventory management performance of TMs across PHCUs, Gamo zone.

Methods

A cross-sectional survey was conducted in 46 PHCUs between April 1 and May 30, 2021. The data were collected using document review and physical observation. A stratified simple random sampling was employed. The data were analyzed by SPSS version 20. The results were summarized as mean and percentage. Pearson's product-moment coefficient and ANOVA were employed at a 95% CI. The correlation test established the relationships between dependent and independent variables. ANOVA test compared the performance between PHCUs.

Results

The inventory management performance of TMs across PHCUs is below the standard. On average stock according to the plan is 18%, the stock-out rate is 43%, the inventory accuracy rate is 78.5%, and availability across PHCUs is 78%. 72.3% of visited PHCUs fulfill storage condition criteria. Inventory management performance decreases downward the levels of PHCUs. There is a positive correlation between the availability of TMs and supplier order fill rate, r = 0.82, p < 0.01; between the availability of TMs and report accuracy, r = 0.54, p < 0.001; and between TMs stocked according to the plan and supplier order fill rate, r = 0.46, p < 0.01. The inventory accuracy was significantly different between primary hospitals and health posts (p = 0.009, 95% C.I = [7.57, 60.93]); and health centers and health posts (p = 0.016, 95% CI = [2.32, 25.97]).

Conclusion

The inventory management performance of TMs is below the standard. It is attributable to supplier performance, the quality of the report, and performance variation across PHCUs. These result in the interruption of TMs in PHCUs.

Prevalence, Perception and Predictors of Concomitant Herbal Medicine Use among HIV/AIDS and Tuberculosis Patients in Metekel Zone, Northwest Ethiopia: A Cross-Sectional Study

BACKGROUND

The use of herbal medicine is common in Ethiopia. However, evidence on the extent and predictors of concomitant use of herbal medicine with conventional treatment among HIV/AIDS and tuberculosis patients is limited.

OBJECTIVE

To assess the extent of concomitant use of herbal medicine with conventional therapy and associated factors among HIV/AIDS and tuberculosis patients in Metekel Zone, Northwest Ethiopia.

METHOD

A cross-sectional study was conducted from January to March 2020. HIV/AIDS and tuberculosis patients who visited the health facilities during the study were interviewed face-to-face using a structured and pretested questionnaire. The descriptive statistics and univariate and multivariate logistic regression analyses were conducted using SPSS version 25. A P-value of <0.05 was considered significant.

RESULTS

412 patients on conventional treatment were included in this study; 355 (86.2%) were HIV patients, and 57 (13.8%) were TB patients. More than half, 217 (52.7%) participants reported using herbal medicine while on conventional therapy. Among those who claimed to have used herbal medicines, 32 (14.7%) received herbal medicine from traditional healers. About four of five herbal users did not disclose their use to their healthcare providers. The type of health facility on follow-up (P=0.03), disease status (P=0.01), occupation (P=0.02), discontinuing ART (P=0.03), and encountering side (P=0.04) were the determinant factors for the use of herbal medicine among our study participants.

CONCLUSION

In the Metekel Zone, concomitant consumption of herbal medication is common among HIV/AIDS and tuberculosis patients. Furthermore, most patients did not disclose the healthcare practitioners about their herbal use. Therefore, healthcare practitioners must assess and counsel patients regarding the potential adverse effects and herb-drug interaction to optimize therapy.

Anticoagulation control, outcomes, and associated factors in long-term-care patients receiving warfarin in Africa: a systematic review

Background

Oral anticoagulation therapy with warfarin requires frequent monitoring level of anticoagulation by the international normalized ratio (INR). In Africa, studies that explore anticoagulation control, treatment outcomes, and associated factors are reported in various ways in long-term patients receiving warfarin therapy to generate concrete scientific evidence.

Methods

The literature search was conducted in PubMed, Cochrane Library, African Journal of Online databases, Google Scholar, and Google. An advanced search strategy was computed to retrieve relevant studies related to anticoagulation control and outcomes. Duplication, title and abstract screening, and full-text assessment were conducted in Covidence software. Study quality was assessed using the Joanna Briggs Institute Critical appraisal quality assessment tool. The systematic review is registered in PROSPERO (CRD42021260772) and performed based on the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guideline.

Results

Out of 298 identified articles, 18 articles were eligible for the final review and analysis. The mean of 39.4 ± 8.4% time in therapeutic range (TTR) (29.4 to 57.3%), 36.7 ± 11.5% TTR (range 25.2–49.7%) and 46% TTR (43.5–48.5%) was computed from studies that determined TTR by Rosendaal, direct and cross-section-of-the-files methods, respectively. In this review, the lowest percentage of TTR was 13.7%, while the highest was 57.3%. The highest percentage of patients (32.25%) who had TTR ≥ 65% was reported in Tunisia, but the lowest percentages were in Namibia (10%, TTR ≥ 65%) and Kenya (10.4%, TTR ≥ 70%). Most of the included studies (11 out of 18) used Rosendaal’s method while the direct method was employed by three studies. Generally, 10.4–32.3% of study participants achieved desired optimal anticoagulation level. Regarding secondary outcomes, 1.6–7.5% and 0.006–59% of patients experienced thromboembolic complications and bleeding events, respectively. Having chronic comorbidities, taking more than two drugs, and presence of medications that potentially interact with warfarin, and patient-related factors (patients aged < 50 years old, female gender, lower education level, smoking history) were the frequently reported predictors of poor anticoagulation therapy.

Conclusions

Oral anticoagulation control was suboptimal in patients taking warfarin as evidenced by low TTR in Africa. Therefore, there is an urgent need for further improving oral anticoagulation management services.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12959-022-00416-9.

Challenges of Anticoagulation Management Service and Need of Establishing Pharmacist-Led Anticoagulation Clinic in Tertiary Care Teaching Hospital, Ethiopia: A Qualitative Study

Pupose

To explore the challenges of anticoagulation management (AMS) and assess the need for establishing a pharmacist-led anticoagulation clinic (PLAC) at Tikur Anbessa Specialized Hospital (TASH) in Addis Ababa, Ethiopia.

Methods

We conducted a qualitative study at TASH. Using a semistructured interview guide, we interviewed 15 physicians from different specialties, heads of pharmacy and laboratory departments. We also included 20 patients to explore their general perceptions, and experiences with and challenges of AMS; and the need to implement PLAC in the hospital.

Results

Only three physicians responded that they had protocols for initiating and maintaining warfarin dosing. Having protocols for venous thromboembolism (VTE) risk assessment, VTE prophylaxis and treatment, bleeding risk assessment, and contraindication to anticoagulant therapy were reported by seven, six, four, and three participants, respectively. Lack of trained healthcare professionals and a separate AMS clinic, inconsistency in INR testing and anticoagulant availability, and longer appointment times were the biggest challenges of the existing AMS, according to 80% of respondents. Fourteen patient respondents indicated that their satisfaction with the AMS was affected by long wait times and inconsistent availability of anticoagulants and INR testing. The head of the laboratory stated that the facilities for INR testing are inadequate and affect the quality of AMS and customer satisfaction, and supplemented by the head of the pharmacy by adding irregularities of supplies and inadequate counseling on anticoagulants. Respondents suggested that there is a need to establish a PLAC with well-adopted standard operating procedures, qualified manpower, adequate training of assigned staff, and sustained supply of anticoagulants and INR testing.

Conclusion

The hospital’s AMS is not optimal to provide adequate services during the study period. Based on these findings and recommendations, the supporting literature, and the experiences of other facilities, the PLAC was established in TASH.

Cost-utility analysis of antimicrobial stewardship programme at a tertiary teaching hospital in Ethiopia

OBJECTIVE

Antimicrobial stewardship (AMS) significantly reduces inappropriate antibiotic use and improves patient outcomes. In low-resource settings, AMS implementation may require concurrent strengthening of clinical microbiology capacity therefore additional investments. We assessed the cost-effectiveness of implementing AMS at Tikur Anbessa Specialised Hospital (TASH), a tertiary care hospital in Ethiopia.

DESIGN

We developed a Markov cohort model to assess the cost-utility of pharmacist-led AMS with concurrent strengthening of laboratory capacity compared with usual care from a 'restricted societal' perspective. We used a lifetime time horizon and discounted health outcomes and cost at 3% annually. Data were extracted from a prospective study of bloodstream infections among patients hospitalised at TASH, supplemented by published literature. We assessed parameter uncertainty using deterministic and probabilistic sensitivity analyses.

SETTING

Tertiary care hospital in Ethiopia, with 800 beds and serves over half a million patients per year.

POPULATION

Cohort of adults and children inpatient population aged 19.8 years at baseline.

INTERVENTION

Laboratory-supported pharmacist-led AMS compared with usual care. Usual care is defined as empirical initiation of antibiotic therapy in the absence of strong laboratory and AMS.

OUTCOME MEASURES

Expected life-years, quality-adjusted life-years (QALYs), costs (US$2018) and incremental cost-effectiveness ratio.

RESULTS

Laboratory-supported AMS strategy dominated usual care, that is, AMS was associated with an expected incremental gain of 38.8 QALYs at lower expected cost (incremental cost savings:US$82 370) per 1000 patients compared with usual care. Findings were sensitive to medication cost, infection-associated mortality and AMS-associated mortality reduction. Probabilistic sensitivity analysis demonstrated that AMS programme was likely to be cost-effective at 100% of the simulation compared with usual care at 1%-51% of gross domestic product/capita.

CONCLUSION

Our study indicates that laboratory-supported pharmacist-led AMS can result in improved health outcomes and substantial healthcare cost savings, demonstrating its economic advantage in a tertiary care hospital despite greater upfront investments in a low-resource setting.

Patient Satisfaction with HIV/AIDS Services in Health Centers of East Shoa Zone, Oromia, Ethiopia: A Cross-Sectional Study

Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) is a major public health, social, and economic problem in Ethiopia. Even though the government is working to scale up Anti-Retroviral Therapy (ART) services, patient loss to follow-up and ensuring adherence to ART regimens remain major challenges of the ART program in the country; little has also been done on the assessment of patient satisfaction on different HIV/AIDS service dimensions. This study aimed at assessing patient satisfaction with HIV/AIDS services in health centers of East Shoa Zone, Oromia region, Ethiopia. The study employed a cross-sectional survey between February and May 2017. Data was collected through exit interviews using five-point Likert scale-based questions and analyzed using Statistical Package for Social Sciences (SPSS) version 20. The overall mean patient satisfaction score was 3.16 (SD = 0.87) on a 1 to 5 scale. Availability of anti-Tuberculosis (anti TB) drugs in pharmacy was an item with the highest mean satisfaction score (4.18 ± 0.61) while waiting time to get pharmacy service was ranked least by the patients (mean score of 1.92, SD = 0.81). Merchants and students were more likely to be satisfied compared to other occupational groups. Overall, there was a wider gap in the study facilities concerning patient satisfaction and, therefore, health facility managers, Zonal and Woreda health offices, and Oromia Region Health Bureau should work in collaboration with other stakeholders to improve patient satisfaction with items for which the satisfaction score was low.

Catastrophic healthcare expenditure and coping strategies among patients attending cancer treatment services in Addis Ababa, Ethiopia

BACKGROUND

With the rapid increase in magnitude and mortality of cancer, which is costly disease to manage, several patients particularly in developing countries are facing a huge financial burden. The study aimed to examine the incidence of catastrophic health expenditure (CHE), identify associated factors and coping strategies among patients attending cancer treatment services in Addis Ababa, Ethiopia.

METHODS

A hospital-based cross-sectional survey of patients with cancer was conducted in public and private hospitals between January and March 2018. Data was collected using a structured questionnaire. All direct medical and nonmedical expenditures were measured and reported as expenditure (US$) per patient (1US$ equivalent to 23.41 Ethiopian Birr). The CHE was estimated using a threshold of 10% of annual household income.

RESULTS

A total of 352 (response rate of 87.1%) participants were interviewed. Majority (73.3%) of the respondents were females; most (94%) from public hospitals and their mean (±SD) age was 48 ± 13.2 years. Vast majority (74.4%) of patients experienced CHE with mean overall expenditure of $2366 per patient (median: $1708). Medical expenditure shared the highest overall expenditure (83.6%) with mean medical and nonmedical costs of $1978 (median: $1394) and $388 (median: $222), respectively. Patients who took greater than six cycles of chemotherapy (AOR: 3.64; 95% CI: 1.11-11.92), and age (AOR: 1.03; 95% CI: 1.01-1.06) were significantly associated with CHE. Household saving (85.5%) followed by financial support received (43.0%) was the main coping strategy.

CONCLUSION

A substantial number of patients with cancer were exposed to CHE with a considerable medical expenditure. Hence, in addition to the popularization of the already introduced health insurance scheme, other better prepayment or insurance mechanisms should also be considered to ensure financial risk protection and realize universal health coverage for patients with cancer.

Half of Prescribed Antibiotics Are Not Needed: A Pharmacist-Led Antimicrobial Stewardship Intervention and Clinical Outcomes in a Referral Hospital in Ethiopia

Intense antibiotic consumption in Low- and Middle-Income Countries (LMICs) is fueled by critical gaps in laboratory infrastructure and entrenched syndromic management of infectious syndromes. Few data inform the achievability and impact of antimicrobial stewardship interventions, particularly in Sub-Saharan Africa. Our goal was to demonstrate the feasibility of a pharmacist-led laboratory-supported intervention at Tikur Anbessa Specialized Hospital in Addis Ababa, Ethiopia, and report on antimicrobial use and clinical outcomes associated with the intervention.

Methods: This was a single-center prospective quasi-experimental study conducted in two phases: (i) an intervention phase (November 2017 to August 2018), during which we implemented weekly audit and immediate (verbal and written) feedback sessions on antibiotic prescriptions of patients admitted in 2 pediatric and 2 adult medicine wards, and (ii) a post-intervention phase (September 2018 to January 2019) during which we audited antibiotic prescriptions but provided no feedback to the treating teams. The intervention was conducted by an AMS team consisting of 4 clinical pharmacists (one trained in AMS) and one ID specialist. Our primary outcome was antimicrobial utilization (measured as days of therapy (DOT) per 1,000 patient-days and duration of antibiotic treatment courses); secondary outcomes were length of hospital stay and in-hospital all-cause mortality. A multivariable logistic regression model was used to explore factors associated with all-cause in-hospital mortality.

Results: We collected data on 1,109 individual patients (707 during the intervention and 402 in the post-intervention periods). Ceftriaxone, vancomycin, cefepime, meropenem, and metronidazole were the most commonly prescribed antibiotics; 96% of the recommendations made by the AMS team were accepted. The AMS team recommended to discontinue antibiotic therapy in 54% of cases during the intervention period. Once the intervention ceased, total antimicrobial use increased by 51.6% and mean duration of treatment by 4.1 days/patient. Mean LOS stay as well as crude mortality also increased significantly in the post-intervention phase (LOS: 24.1 days vs. 19.8 days; in hospital death 14.7 vs. 6.9%). The difference in mortality remained significant after adjusting for potential confounders.

Conclusions: A pharmacist-led AMS intervention focused on duration of antibiotic treatment was feasible and had good acceptability in our setting. Cessation of audit-feedback activities was associated with immediate and sustained increases in antibiotic consumption reflecting a rapid return to baseline (pre-intervention) prescribing practices, and worse clinical outcomes (increased length of stay and in-hospital mortality). Pharmacist-led audit-feedback activities can effectively reduce antimicrobial consumption and result in better-quality care, but require organizational leadership's commitment for sustainable benefits.

Religion, Spirits, Human Agents and Healing: A Conceptual Understanding from a Sociocultural Study of Tehuledere Community, Northeastern Ethiopia

This paper explores the relationship among religion, spirits and healing in the Tehuledere community in the northeastern part of Ethiopia and focuses on how this knowledge can inform primary healthcare reform. The study employed qualitative ethnographic methods. Participatory observation, over a total of 5 months during the span of 1 year, was supplemented by focus group discussions (96 participants in 10 groups) and in-depth interviews (n = 20) conducted with key informants. Data were analyzed thematically using narrative strategies. The present study revealed that members of the study community perceive health, illness and healing as being given by God. Many of the Tehuledere people attribute illness to the wrath of supernatural forces. Healing is thought to be mitigated by divine assistance obtained through supplication and rituals and through the healing interventions of nature spirit actors. We found that the health, illnesses and healing were inextricably linked to religious and spiritual beliefs. Our findings suggest that religious and spiritual elements should be considered when drafting and implementing primary healthcare strategies for the study communities and similar environments and populations around the globe.

Health-related quality of life and associated factors among cervical cancer patients at Tikur Anbessa specialized hospital, Addis Ababa, Ethiopia

BACKGROUND

Cancer of the cervix is the most frequent cancer among women in Ethiopia. The disease burden and its treatment adversely affects patients' health-related quality of life (HRQoL). We aimed to investigate the HRQoL and its predictors among cervical cancer patients in Ethiopia.

METHODS

A hospital-based cross-sectional study was conducted from January to June 2018 at the oncology unit of Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia. A total of 404 cervical cancer patients were interviewed using validated Amharic version of the European Organization for Research and Treatment of Cancer module (EORTC QLQ-C30), cervical cancer module (EORTC QLQ-CX24), and Euro Quality of Life Group's 5-Domain Questionnaires 5-Levels (EQ-5D) questionnaires. ANOVA test was used to determine the effect of patients' characteristics on mean scores of the different domains of HRQoL and stepwise multivariable logistic regression was performed to identify predictors of HRQoL. Coefficients of level-specific utility values obtained from a hybrid regression model for the Ethiopian general population were used to compute utility.

RESULTS

The mean age of patients was 52.1 ± 10.4 years and 379 (93.8%) of the patients were receiving service at the outpatient clinic. About one-third (35%) of patients were diagnosed with stage IV cervical cancer. Mean global health status/QoL, mean utility and visual analog scale scores were 48.3 ± 23.77, 0.77 and 65.7 ± 20.83, respectively. Physical functioning (AOR = 4.98, 95% CI:2.16-11.49), emotional functioning (AOR = 5.25, 95% CI:2.26-12.17), pain (AOR = 5.79, 95% CI:2.30-14.57), and symptom experience (AOR = 4.58, 95% CI:1.95-10.79) were associated with patients' HRQoL.

CONCLUSIONS

Cervical cancer significantly affects patient's HRQoL and hence, efforts to improve HRQoL should be commenced especially in terms of physical and emotional functioning, pain, and symptom experience.

Factors contributing to medicines wastage in public health facilities of South West Shoa Zone, Oromia Regional State, Ethiopia: a qualitative study

Background

Medicines wastage is one of the challenges of health supply chain management in developing countries including Ethiopia. However, there is lack of objective evidence on the detailed underlying causes of medicines wastage. Therefore, the aim of this study is to explore factors contributing for medicines wastage in selected public health facilities of South West Shoa Zone, Oromia Regional State, Ethiopia.

Methods

A qualitative study was conducted in 10 public health facilities (1 General hospital and 9 health centers). An in-depth interview with flexible probing techniques was employed to collect the data from 20 key informants from May 2, 2016 to May 27, 2016. A semi structured interview guide was prepared to explore key informants’ idea about current situation of contributing factors and efforts made to reduce medicines wastage in public health facilities. A thematic analysis was then used to analyze the data.

Results

Almost all key informants felt that medicines wastage is increasing from time to time in their health facility due to supplier’s issuing of medicines without health facilities’ needs and request, failure to follow first expired first out principle in issuing medicines from stores to different dispensing units, lack of communication between supplier and health facilities, inadequate number of pharmacy personnel and weak monitoring system of supply chain in the health facilities. They also revealed budget constraint, stock out of medicines and congested store are of the major challenge that are compromising their service provision.

Conclusion

Medicine wastage is an ever-increasing problem in public health facilities of South West Shoa Zone. The problem is exacerbated due to absence of mechanisms to minimize the wastage. Health facilities, therefore, should place a mechanism to exchange medicines from overstocked facilities to under stocked ones; has to improve store management capacity by employing competent professionals, equipping the store with necessary technology and introducing a monitoring and evaluating health supply chain performance system in the health facilities.

Health-related quality of life and its predictors among patients with breast cancer at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia

Background

Breast cancer is the second most prevalent malignancy in Ethiopia and severely affects patients’ health-related quality of life (HRQOL). We aimed to assess HRQoL, factors influencing HRQoL, and utilities among breast cancer patients at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia.

Methods

A hospital-based cross-sectional study was conducted in Tikur Anbessa Specialized Hospital from December 2017 to February, 2018. A total of 404 breast cancer patients were interviewed using the validated Amharic version of the European Organization for Research and Treatment of Cancer module (EORTC QLQ-C30), EORTC QLQ-BR23, and Euro Quality of Life Group’s 5-Domain Questionnaires 5 Levels (EQ-5D-5 L) instruments. Mean scores and mean differences of EORTC- QLQ-C30 and EORTC- QLQ-BR23 were calculated. One-way ANOVA test was employed to determine the significance of mean differences among dependent and independent variables while stepwise multivariate logistic regression was used to identify factors associated with the global quality of life (GQOL). Coefficients and level specific utility values obtained from a hybrid regression model for the Ethiopian population were used to compute utility values of each health state. Data was analyzed using SPSS version 23.

Results

The mean age of patients was 43.94 ± 11.72 years. The mean score for GQoL and visual analog scale was 59.32 ± 22.94 and 69.94 ± 20.36, respectively while the mean utility score was 0.8 ± 0.25. Predictors of GQoL were stage of cancer (AOR = 7.94; 95% CI: 1.83–34.54), cognitive functioning (AOR = 2.38; 95% CI: 1.32–4.31), pain (AOR = 7.99; 95% CI: 4.62–13.83), financial difficulties (AOR = 2.60; 95% CI: 1.56–4.35), and future perspective (AOR = 2.08; 95% CI: 1.24–3.49).

Conclusions

The overall GQoL of breast cancer patients was moderate. Targeted approaches to improve patients’ HRQoL should consider stage of cancer, cognitive functioning, pain, financial status and worries about the patient’s future health. This study also provides estimates of EQ-5D utility scores that can be used in economic evaluations.

Valuing Health State: An EQ-5D-5L Value Set for Ethiopians

OBJECTIVES

There is a growing interest in health technology assessment and economic evaluations in developing countries such as Ethiopia. The objective of this study was to derive an EQ-5D-5L value set from the Ethiopian general population to facilitate cost utility analysis.

METHODS

A nationally representative sample (N = 1050) was recruited using a stratified multistage quota sampling technique. Face-to-face, computer-assisted interviews using the EuroQol Portable Valuation Technology (EQ-PVT) protocol of composite time trade-off (c-TTO) and discrete choice experiments (DCEs) were undertaken to elicit preference scores. The feasibility of the EQ-PVT protocol was pilot tested in a sample of the population (n = 110). A hybrid regression model combining c-TTO and DCE data was used to estimate the final value set.

RESULTS

In the pilot study, the acceptability of the tasks was good, and there were no special concerns with undertaking the c-TTO and DCE tasks. The coefficients generated from a hybrid model were logically consistent. The predicted values for the EQ-5D-5L ranged from -0.718 to 1. Level 5 anxiety/depression had the largest impact on utility decrement (-0.458), whereas level 5 self-care had the least impact (-0.222). The maximum predicted value beyond full health was 0.974 for the 11112 health state.

CONCLUSIONS

This is the first EQ-5D-5L valuation study in Africa using international valuation methods (c-TTO and DCE) and also the first using the EQ-PVT protocol to derive a value set. We expect that the availability of this value set will facilitate health technology assessment and health-related quality-of-life research and inform policy decision making in Ethiopia.

Willingness to pay for social health insurance and its determinants among public servants in Mekelle City, Northern Ethiopia: a mixed methods study

Background

Owing to lack of adequate healthcare financing, access to at least the basic health services is still a problem in Ethiopia. With the intention of raising funds and ensuring universal health coverage, a mandatory health insurance scheme has been introduced. The Community Based Health Insurance has been implemented in all regions of the country, while implementation of social health insurance was delayed mainly due to resistance from public servants. This study was, therefore, aimed to assess willingness to pay for social health insurance and its determinant factors among public servants in Mekelle city, Northern Ethiopia.

Methods

A concurrent mixed approach of cross-sectional study design using double bound dichotomous choice contingent valuation method and qualitative focus group discussions was employed. A total 384 public servants were recruited from randomly selected institutions and six focus group discussions (n = 36) were carried out with purposively selected respondents. Participants’ mean willingness to pay (WTP) and independent predictors of WTP were identified using an interval data logit model. Qualitative data were analyzed using thematic analysis.

Results

From the 384 participants, 381 completed the interview, making a response rate of 99.2%. Among these respondents 85.3% preferred social health insurance and were willing to pay for the scheme. Their estimated mean WTP was 3.6% of their monthly salary. Lack of money to pay (42.6%) was the major stumbling block to enrolling in the scheme. Respondents’ WTP was significantly positively associated with their level of income but their WTP decreased with increasing age and educational status. On the other hand, a majority of focus group discussion participants were not willing to pay the 3% premium set by the government unless some preconditions were satisfied. The amount of premium contribution, benefit package and poor quality of health service were the major factors affecting their WTP.

Conclusion

The majority of the public servants were willing to be part of the social health insurance scheme, with a mean WTP of 3.6% of their monthly salary. This was greater than the premium proposed by the government (3%). This can pave the way to start the scheme but attention should focus on improving the quality of health services.

Electronic supplementary material

The online version of this article (10.1186/s12962-019-0171-x) contains supplementary material, which is available to authorized users.

Reliability and validity of the Amharic version of European Organization for Research and Treatment of cervical Cancer module for the assessment of health related quality of life in women with cervical cancer in Addis Ababa, Ethiopia

Background

Cervical cancer is among the leading gynecological cancers affecting women worldwide. Maintenance and improvement of cervical cancer patients‘health related quality of life (HRQoL) is an important issue. The cervical cancer specific quality of life module of the European Organization for Research and Treatment of Cancer (EORTC QLQ-CX24) is the most commonly used tool, however, it is not validated in Ethiopia. Hence, the present study aimed to assess the psychometric properties of the tool among Ethiopian cervical cancer patients.

Methods

Hospital based cross-sectional study was done in Tikur Anbessa Specialized Hospital (TASH), Addis Ababa, Ethiopia from January to February, 2018. The module was translated through forward-backward translation approach and pilot tested according to the EORTC Guidelines. One hundered and seventy one patients with confirmed cervical cancer were enrolled for the study. Amharic versions of EORTC QLQ-C30 and EORTC QLQ-CX24 were used to collect data along with socio-demographic and clinical characteristics. Descriptive statistics were used to assess socio-demographic and clinical characteristics of patients. The Psychometric properties of the EORTC QLQ-CX24 were evaluated in terms of acceptability, internal consistency, construct, concurrent and known group validity using SPSS version 22.

Results

One hundred seventy one cervical cancer patients were enrolled in the study, with a mean age of 52.15 ± 10.4 years. The EORTC QLQ-CX24 was found to be acceptable with high compliance and low missing responses. The Cronbach’s alpha ranged from 0.70–0.84, indicating the reliability of the scales. Convergent and discriminant validity in multitrait scaling analysis was adequate. The EORTC QLQ-C30 subscales and EORTC QLQ-CX24 subscales had a weak to strong correlation, indicating concurrent validity. The scales and single-item measures were able to discriminate between subgroups of patients differing with regard to performance status, cancer stage and treatment status, indicating clinical validity.

Conclusion

Amharic version of the EORTC QLQ-CX24 questionnaire is a valid and reliable tool and could be used for clinical and epidemiological cancer researches to study the HRQoL of patients with cervical cancer in Ethiopia.

Opportunities and barriers to implementing antibiotic stewardship in low and middle-income countries: Lessons from a mixed-methods study in a tertiary care hospital in Ethiopia

Background

Global action plans to tackle antimicrobial resistance (AMR) include implementation of antimicrobial stewardship (AMS), but few studies have directly addressed the challenges faced by low and middle-income countries (LMICs). Our aim was to explore healthcare providers’ knowledge and perceptions on AMR, and barriers/facilitators to successful implementation of a pharmacist-led AMS intervention in a referral hospital in Ethiopia.

Methods

Tikur Anbessa Specialized Hospital (TASH) is an 800-bed tertiary center in Addis Ababa, and the site of an ongoing 4-year study on AMR. Between May and July 2017, using a mixed approach of quantitative and qualitative methods, we performed a cross-sectional survey of pharmacists and physicians using a pre-tested questionnaire and semi-structured interviews of purposively selected respondents until thematic saturation. We analyzed differences in proportions of agreement between physicians and pharmacists using χ² and fisher exact tests. Qualitative data was analyzed thematically.

Findings

A total of 406 survey respondents (358 physicians, 48 pharmacists), and 35 key informants (21 physicians and 14 pharmacists) were enrolled. The majority of survey respondents (>90%) strongly agreed with statements regarding the global scope of AMR, the need for stewardship, surveillance and education, but their perceptions on factors contributing to AMR and their knowledge of institutional resistance profiles for common bacteria were less uniform. Close to 60% stated that a significant proportion of S. aureus infections were caused by methicillin-resistant strains (an incorrect statement), while only 48% thought a large proportion of gram-negative infections were caused by cephalosporin-resistant strains (a true statement). Differences were noted between physicians and pharmacists: more pharmacists agreed with statements on links between use of broad-spectrum antibiotics and AMR (p<0.022), but physicians were more aware that lack of diagnostic tests led to antibiotic overuse (p<0.01). More than cost, fear of treatment failure and of retribution from senior physicians were major drivers of antibiotic prescription behavior particularly among junior physicians. All respondents identified high turnover of pharmacists, poor communication between the laboratory, pharmacists and clinicians as potential challenges; but the existing hierarchical culture and academic setting were touted as opportunities to implement AMS in Ethiopia.

Conclusions

This knowledge and perceptions survey identified specific educational priorities and implementation strategies for AMS in our setting. This is likely also true in other LMICs, where expertise and infrastructure may be lacking.

Coverage of azithromycin mass treatment for trachoma elimination in Northwestern Ethiopia: a community based cross-sectional study

BACKGROUND

Mass drug administration with antibiotics predominantly with azithromycin is one of the four arms of the SAFE strategy. The elimination of ocular chlamydial infection is only achieved as long as the azithromycin mass treatments (AMT) are given frequently enough and at a high enough coverage. This study was conducted to assess the coverage of azithromycin mass treatment and its determinants in Awi Zone, Northwestern Ethiopia.

METHODS

House to house survey using a structured questionnaire was done between July 7 to July 25, 2013. Coverage is defined as the proportion of individuals in the eligible population who actually ingested the Azithromycin during the Campaign.

RESULTS

A total of 1267 households were enrolled in the survey in which 5826 eligible members were living in these households. Almost half (54.6%) of the community members who were eligible for all six campaigns had participated in more than three campaigns of azithromycin mass treatment. The overall average self-reported coverage of the azithromycin mass treatment (AMT) in all six campaigns was 62.8% (64% in rural vs. 61.6% urban). On average, each eligible person had taken the drug 3.77 times. The rural residents were significantly more likely to have received treatment during the last round of AMT in 2012 {AOR = 2.35; 95% CI [1.80-3.06]}. Azithromycin uptake status of female household heads was less than the corresponding male household heads {AOR = 0.41; 95% CI [0.24-0.72]}. Household heads' awareness about trachoma (AOR = 2.55; 95% CI [1.19-5.44]) and AMT {AOR = 7.19; 95% CI [3.27-15.82]} had positive association with acceptability.

CONCLUSION

The overall average AMT coverage was found to be low. There was low coverage of the treatment in the urban community as compared to the rural residents. Misconceptions of household heads about trachoma and azithromycin have negatively affected the coverage. Further work on why female household heads are associated with higher risk of non-participation in AMT is warranted. Strengthening awareness creation and consideration of additional campaigns is essential.

Quality of anticoagulation management with warfarin among outpatients in a tertiary hospital in Addis Ababa, Ethiopia: a retrospective cross-sectional study

Background

Warfarin is the most widely used anticoagulant in the world. The difficulty of managing warfarin contributes to great potential for patient harm, both from excessive anticoagulation and insufficient anticoagulation. This study assessed the International Normalized Ratio (INR) control outcome measures and warfarin dose adjustment practices at cardiology and hematology outpatient clinics at a teaching hospital in Addis Ababa, Ethiopia.

Methods

The study was based on a cross - sectional study design involving 360 retrospective patients’ chart review among outpatients who received warfarin for its various indications.

Results

The mean frequency of INR monitoring per patient was 62.9 days (17.2–143.7 days).

Patients spent 52.2%, 29.0% and 18.8% of the time in sub-therapeutic, therapeutic and supra-therapeutic ranges, respectively. The daily warfarin dose was increased 50.9% and 36.9% and decreased in 52.8% and 60.9% of the time for occurrences of sub-therapeutic and supra-therapeutic INRs to achieve target ranges of 2.0–3.0 and 2.5–3.5, respectively.

Conclusion

The quality of anticoagulation management with warfarin among outpatients in Tikur Anbessa Specialized Hospital was sub-optimal. This was reflected by low Time in Therapeutic Range (TTR), longer than recommended INR monitoring frequency, and minimal actions taken to adjust warfarin dose after occurrences of non-therapeutic INRs.

Ethiopian patients' perceptions of anti-diabetic medications: implications for diabetes education

Background

The purpose of this study is to explore medication-related perceptions of adult patients with type 2 diabetes attending treatment in public hospitals of urban centers in central Ethiopia.

Methods

Qualitative in-depth interviews were held with 39 participants selected to represent a range of treatment experiences and socio-demographic characteristics who were attending their treatment in 3 public hospitals. Interviews continued until key themes were saturated. The interview and analysis was guided by Horne’s necessity-concerns model.

Results

The findings revealed medication-related perceptions some of which were similar to those of Western patients and others that seem to be informed by local socio-cultural contexts. Participants’ perceptions focused on the necessity of and concerns about their anti-diabetic medications, giving more emphasis to the latter. Concerns were expressed about both perceived and experienced adverse effects, inconveniences in handling the medications and access. It was evident that some of these concerns were exaggerated but could nevertheless negatively affect adherence to prescribed medications including resistance to initiate insulin with potential impact on health outcomes.

Conclusions

Understanding patients’ perceptions of their medications is critical for developing a diabetes education program that considers local contexts and beliefs to enhance adherence. Education programs should consider patients’ concerns about medication adverse effects and reasons for use so as to improve their adherence and health outcomes.

Effectiveness of isoniazid preventative therapy in reducing incidence of active tuberculosis among people living with HIV/AIDS in public health facilities of Addis Ababa, Ethiopia: a historical cohort study

BACKGROUND

Human Immunodeficiency Virus (HIV) pandemic has exacerbated tuberculosis disease especially in Sub-Saharan African countries. The World Health Organization (WHO) and Joint United Nations Program on HIV/AIDS (UNAIDS) have recommended Isoniazid Preventive Therapy (IPT) for HIV infected patients to reduce the burden of tuberculosis (TB). Ethiopia has been implementing IPT since 2007. However, effectiveness of IPT in averting occurrence of active tuberculosis among HIV infected patients has not been assessed.

METHODS

Retrospective cohort study was employed using secondary data from public health institutions of Addis Ababa. Descriptive statistics and Generalized Linear Model based on Poisson regression was used for data analysis.

RESULTS

From 2524 HIV infected patients who were followed for 4106 Person-Years, a total of 277 incident Tuberculosis (TB) cases occurred. TB Incidence Rate was 0.21/100 Person-Year, 0.86/100 Person-Year & 7.18/100 Person-Year among IPT completed, in-completed and non-exposed patients, respectively. The adjusted Incidence Rate Ratio (aIRR) among IPT completed vs. non-exposed patients was 0.037 (95% CI, 0.016-0.072). Gender, residence area, employment status, baseline WHO stage of the disease (AIDS) and level of CD4 counts were identified as risk factors for TB incidence. The aIRR among patients who took Highly Active Anti- Retroviral Therapy (HAART) with IPT compared to those who took HAART alone was 0.063 (95% CI 0.035-0.104). IPT significantly reduced occurrence of active TB for 3 years.

CONCLUSIONS

IPT significantly reduced tuberculosis incidence by 96.3% compared to IPT non-exposed patients. Moreover concomitant use of HAART with IPT has shown a significant reduction in tuberculosis incidence by 93.7% than the use of HAART alone. Since IPT significantly protected occurrence of active TB for 3 years, its implementation should be further strengthened in the country.

Health seeking behavior and use of medicinal plants among the Hamer ethnic group, South Omo zone, southwestern Ethiopia

BACKGROUND

Health seeking behavior of people around the globe is affected by different socio-cultural and economic factors. In Ethiopia, people living in rural areas in particular, are noted for their use of medicinal plants as a major component of their health care option. This study was conducted to document ethnopharmacological information of the Hamer semi-pastoralists ethnic group in southwestern Ethiopia.

METHODS

A cross-sectional study was carried out whereby information on demographic characteristics, prevalence of perceived illnesses, factors associated with preference of health care seeking options, medicinal plants used and hoarded as well as some healers' socio-economic characteristics were collected using two sets of semi-structured questionnaires - one for household (HH) heads and the other for traditional healers supplemented by focus group discussions (FGDs). Households were selected using a cluster sampling followed by systematic sampling techniques; whereas healers and FGD participants were purposively selected with the assistance of local leaders and elders from the community.

RESULTS

The study revealed that the use of traditional medicine among the Hamer ethnic group is very high. Females preferred traditional medicine more than males. The main reasons for this preference include effectiveness, low cost and ease of availability. Malaria (gebeze) was the most frequently occurring illness in the area identified by all FGD participants. A total of 60 different medicinal plants were reported [34 by HH respondents, 14 by traditional healers and 12 by both]. Fifty-one medicinal plants were fully identified, 3 at generic level and 6 have not yet been identified.

CONCLUSION

It can be concluded that traditional medical practices, particularly herbal aspect, is widely used by the Hamer ethnic group, although health seeking behavior of the community is affected by different socio-economic and cultural factors.

HIV/AIDS related commodities supply chain management in public health facilities of Addis Ababa, Ethiopia: a cross-sectional survey

Background

A wide range of pharmaceutical products are needed for diagnosis, treatment, and prevention of HIV/AIDS. However, interrupted supplies and stock-outs are the major challenges in the supply chain of ARV medicines and related commodities. The aim of this study was to assess the supply chain management of HIV/AIDS related commodities in public health facilities of Addis Ababa, Ethiopia.

Methods

A descriptive cross-sectional survey complemented by qualitative method was conducted in 24 public health facilities (4 hospitals and 20 health centers). A semi-structured questionnaire and observation check list were used to collect data on HIV/AIDS related service, reporting and ordering; receiving, transportation and storage condition of ARV medicines and test kits; and supportive supervision and logistics management information system. In addition, in-depth interview with flexible probing techniques was used to complement the quantitative data with emphasis to the storage condition of ARV medicines and test kits. Quantitative data was analyzed using SPSS version-20. Analysis of qualitative data involved rigorous reading of transcripts in order to identify key themes and data was analyzed using thematic approach.

Results

The study revealed that 16 health centers and one hospital had recorded and reported patient medication record. Six months prior to the study, 14 health centers and 2 hospitals had stopped VCT services for one time or more. Three hospitals and 18 health centers claimed to have been able to submit the requisition and report concerning ARV medicines to Pharmaceutical Fund and Supply Agency according to the specific reporting period. More than three-fourth of the health centers had one or more emergency order of ARV medicines on the day of visit, while all of hospitals had emergency order more than 3 times within 6 months prior to the study. All of the hospitals and nearly half of the health centers had an emergency order of test kits more than 3 times in the past 6 months. Overall, nearly 3/4th of the health facilities faced stock-out of one or more ARV medicines and test kits on the day of visit.

Conclusion

There was no adequate data on patient medication record and stock status of HIV/AIDS related commodities. Moreover there were frequent stock-outs of ARV medicines and HIV test kits, which was an indicator of the weak supply chain management. Hospitals and health centers, therefore, should devise a system to capture and make use of patient medication record and stock status information so as to ensure continuous supply of the commodities.