Use of Electronic Quality Monitoring Tool and Central Dashboard to Improve Clinical and Programmatic Decisions

The HIV service quality improvement tool is deployed in 123 health facilities in Ethiopia. The tool uses a central dashboard for visualization and decision making at the health facility and higher levels of the health systems. The dashboard is developed on excel with analytics about HIV testing, case finding, treatment linkage and quality indicators. The dashboard was developed based on the requirements requested during discussions with HIV clinicians and the program team.

Implementing six multi-month dispensing of antiretroviral therapy in Ethiopia: perspectives of clients and healthcare workers

BACKGROUND

Multi-month dispensing (MMD) of antiretroviral therapy (ART) is an integral component of differentiated HIV service delivery for people living with HIV (PLHIV). Although many countries have scaled up ART dispensing to 3-month intervals, Ethiopia was the first African country to implement six-month dispensing (6-MMD) at scale, introducing its Appointment Spacing Model (ASM) for people doing well on ART in 2017. As of June 2021, 51.4% (n = 215,101) of PLHIV on ART aged ≥ 15 years had enrolled in ASM. Since little is known about the benefits and challenges of ASM perceived by Ethiopian clients and their healthcare workers (HCWs), we explored how the ASM was being implemented in Ethiopia's Oromia region in September 2019.

METHODS

Using a parallel convergent mixed-methods study design, we conducted 6 focus groups with ASM-eligible enrolled clients, 6 with ASM-eligible non-enrolled clients, and 22 in-depth interviews with HCWs. Data were audio-recorded, transcribed and translated into English. We used thematic analysis, initially coding deductively, followed by inductive coding of themes that emerged from the data, and compared the perspectives of ASM-enrolled and non-enrolled clients and their HCWs.

RESULTS

Participants enrolled in ASM and HCWs perceived client-level ASM benefits to include time and cost-savings, fewer work disruptions, reduced stigma due to fewer clinic visits, better medication adherence and improved overall health. Perceived health system-level benefits included improved quality of care, decongested facilities, reduced provider workloads, and improved record-keeping. Although non-enrolled participants anticipated many of the same benefits, their reasons for non-enrollment included medication storage challenges, concerns over less frequent health monitoring, and increased stress due to the large quantities of medicines dispensed. Enrolled participants and HCWs identified similar challenges, including client misunderstandings about ASM and initial ART stock-outs.

CONCLUSIONS

ASM with 6-MMD was perceived to have marked benefits for clients and health systems. Clients enrolled in the ASM and their HCWs had positive experiences with the model, including perceived improvements in efficiency, quality and convenience of HIV treatment services. The concerns of non-ASM enrolled participants suggest the need for enhanced client education about the model and more discreet and efficiently packaged ART and highlight that ASM is not ideal for all clients.

Efficiency of TB service provision in the public and private health sectors in Ethiopia

BACKGROUND: The Ethiopian Government has identified efficiency of TB services as a key priority in planning and budgeting. Understanding the magnitude and sources of inefficiencies is key to ensuring value for money and improved service provision, and a requirement from donors to justify resource needs. This study identifies the cost of providing a wide range of TB services in public and private facilities in Ethiopia.METHODS: Financial and economic unit costs were estimated from a health provider´s perspective, and collected retrospectively in 26 health facilities using both top-down (TD) and bottom-up (BU) costing approaches for each TB service output. Capacity inefficiency was assessed by investigating the variation between TD and BU unit costs where the factor was 2.0 or more.RESULTS: Overall, TD unit costs were two times higher than BU unit costs. There was some variation across facility ownership and level of care. Unit costs in urban facilities were on average 3.8 times higher than in rural facilities.CONCLUSION: We identified some substantial inefficiencies in staff, consumable and capital inputs. Addressing these inefficiencies and rearranging the TB service delivery modality would be important in ensuring the achievement of the country´s End TB strategy.

Assessment of patient satisfaction towards auditable pharmaceutical transactions and services implemented in outpatient hospital pharmacy in Ethiopia

BACKGROUND

Patient satisfaction is a widely used indicator to measure quality of pharmacy services. Currently, a transformational pharmacy service called auditable pharmaceutical transactions and services is being implemented nationally in Ethiopia. However, there is a dearth of evidence regarding the national impact of this system on patient satisfaction.

OBJECTIVE

To assess patient satisfaction in hospital pharmacies that have implemented auditable pharmaceutical transactions and services in Ethiopia.

METHOD

This is a national study conducted based on a cross-sectional study design. Data were collected using a structured questionnaire from September 5 to October 5, 2020. The collected data was analyzed using spreadsheet excel and Statistical Package for the Social Sciences (SPSS) version 23. The proportions, ratios, and percentages were used for presenting data. A binary logistic regression test was used to determine the association of patient satisfaction with dispensary infrastructure, medicines availability, scores of labeling, and scores of patient knowledge on dispensed medicines. A p value < 0.05 was considered statistically significant.

RESULT

A total of 650 participants were included in this study for whom a total of 1422 medicines were prescribed which gives an average of 2.19 medicine per patient. The availability of the prescribed medicines in the pharmacies was 1061 (75%), and the affordability of medicines was 1.93 WD that indicates an unaffordable price. The average written medication labels score of 3.1 out of 8 points and the average patient knowledge score for correct usage of medicines was 4.5 out of 6 points. Overall, 585 (90%) of patients reported being satisfied with pharmacy services; the counseling skill of pharmacists 609 (93.7%), and dispensing area 607 (93.4%) cited the most. The only significantly associated factor for satisfaction was the infrastructure of the pharmacy.

CONCLUSION

Overall satisfaction of patients with the auditable pharmaceutical transactions and services implemented in hospital pharmacy services was generally high. The participants were most satisfied with the pharmacist counseling and dispensary area. The medication availability is moderate but the cost is unaffordable. Advanced infrastructures have resulted in a significant improvement in patient satisfaction.

Tuberculosis treatment outcome among patients treated in public primary healthcare facility, Addis Ababa, Ethiopia: a retrospective study

Background

Despite the availability of effective drugs, tuberculosis remains a major public health problem that predominantly affects low- and middle-income countries. This study aimed to assess tuberculosis treatment outcomes among patients treated at one of the primary health care levels in Addis Ababa, Ethiopia.

Methods

An institutional-based retrospective cross-sectional study was conducted at a tuberculosis clinic in public primary healthcare facility. The study populations were all patients with tuberculosis who had been completed their treatment course in the center from July 2014 to July 2018. After getting Ethical clearance and permission from the health center, trained data collectors working in the center were recruited. The collected data were checked for completeness every day by the principal investigators. Data were edited, cleaned, and analyzed using SPSS version 25. Descriptive statistics were used to summarize the data while multinomial logistic regression was employed to explore associations among variables of interest, and p < 0.05 was considered as statistically significant.

Results

A total of 352 patients with tuberculosis were included for the study with a median age of 25 years which ranged from 1 to79 year. Most (36.4%) participants were in the age group of 15 to 24 years. The majority (38.8%) of patients had extrapulmonary tuberculosis, 11.9% of them were HIV positive and only two had family history of tuberculosis. Regarding treatment outcome, 238(67.6%) completed the treatment, 95(27%) cured and the rest were unsuccessful treatment outcomes 19(5.4%) either died, defaulted or treatment failed. The odds ratio for cured in relation to unsuccessful treatment outcome was found to be significantly higher in HIV negative patients (AOR = 6.1; 95%CI 2.1–13.9) compared with those patients tested positive for HIV. While patients with smear-positive pulmonary tuberculosis (AOR = 10.5, 95% CI 5.36–16.31) were significantly associated with the odds of having complete treatment cure as compared to patients with extrapulmonary tuberculosis. Similarly being HIV positive and extrapulmonary tuberculosis were predicting factors for unsuccessful treatment compared with their counterparts.

Conclusions

The finding of the present study showed that successful tuberculosis treatment outcome was found to be optimal.

Outcome of Acute Deep Venous Thrombosis Using Standard Treatment versus Thrombolytics: A Literature Review

Deep vein thrombosis (DVT) is a major health problem affectinga significant portion of population. Primary complications are Pulmonary Embolism (PE) in the short term and Post-Thrombotic Syndrome (PTS) in the long term. Thrombolytic drugs act by activating plasminogen which in turn forms the enzyme plasmin. Plasmin consequently degrades blood clots by breaking down the fibrin molecules which make up the clots help to degrade the already formed clot. They can be used using different route of administration, doses and durations. The purpose of this systematic review was to assess the outcome of thrombolytic therapy in terms of the efficacy, safety and effectiveness of the medicines. Electronic searches of databases (MEDLINE and Google Scholar) were queried for articles written in English since 2000 GC. A total of 760 results were obtained using the search keys, and after excluding duplicates, 275 articles were selected. Finally, 9 randomized controlled trials (RCTs) which met the language of publication, study design and exclusion criteria were included in this systematic review. The data were obtained from nine trials (6 countries), providing a study-level data of 1309 participants. Almost all studies revealed that thrombolytic treatment was effective in the management of acute DVT. In most of the studies, the rate of rethrombosis was lower in case of thrombolytic than standard management. Hence, addition of thrombolytic results in persistence and increases the clinical benefits. Thrombolytic therapy was very effective in reversing closed veins, in boosting the patency rate,whilereflux was higher in patients treated with anticoagulants. Thrombolytic offers potential advantages over the standard treatment of DVT by reducing the proportion of patients with chronic disabling leg symptoms (such as PTS) by triple in the longer term. However, the incident of major bleeding was higher in patients receiving thrombolytics than anticoagulants.

Outcome of Acute Deep Venous Thrombosis Using Standard Treatment versus Thrombolytics: A Literature Review

Deep vein thrombosis (DVT) is a major health problem affectinga significant portion of population. Primary complications are Pulmonary Embolism (PE) in the short term and Post-Thrombotic Syndrome (PTS) in the long term. Thrombolytic drugs act by activating plasminogen which in turn forms the enzyme plasmin. Plasmin consequently degrades blood clots by breaking down the fibrin molecules which make up the clots help to degrade the already formed clot. They can be used using different route of administration, doses and durations. The purpose of this systematic review was to assess the outcome of thrombolytic therapy in terms of the efficacy, safety and effectiveness of the medicines. Electronic searches of databases (MEDLINE and Google Scholar) were queried for articles written in English since 2000 GC. A total of 760 results were obtained using the search keys, and after excluding duplicates, 275 articles were selected. Finally, 9 randomized controlled trials (RCTs) which met the language of publication, study design and exclusion criteria were included in this systematic review. The data were obtained from nine trials (6 countries), providing a study-level data of 1309 participants. Almost all studies revealed that thrombolytic treatment was effective in the management of acute DVT. In most of the studies, the rate of rethrombosis was lower in case of thrombolytic than standard management. Hence, addition of thrombolytic results in persistence and increases the clinical benefits. Thrombolytic therapy was very effective in reversing closed veins, in boosting the patency rate,whilereflux was higher in patients treated with anticoagulants. Thrombolytic offers potential advantages over the standard treatment of DVT by reducing the proportion of patients with chronic disabling leg symptoms (such as PTS) by triple in the longer term. However, the incident of major bleeding was higher in patients receiving thrombolytics than anticoagulants.

Pattern of antibiotics use, incidence and predictors of surgical site infections in a Tertiary Care Teaching Hospital

Objective

Surgical site infections (SSIs) were the most common healthcare-associated infection mainly in developing countries. Inappropriate use of surgical antibiotic prophylaxis, in terms of antibiotic choice, timing, and duration, can lead to the selection of resistant microorganisms and high costs. The aim of this study was to investigate the pattern of antibiotic use, incidence and predictors of SSIs at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia.

Results

From 131 patients, 55.7% were male study participants. Ninety (68.7%) patients received preoperative prophylaxis. Ceftriaxone was the most 76 (84.5%) prescribed agent for prophylaxis. Twenty-seven (20.6%) patients developed surgical site infection. Previous surgery AOR = 3.22 (95% CI [1.14–9.13]) and alcohol use AOR = 7.04 (95% CI [2.56–23.12, p = 0.000]) were independent predictors of SSIs in multivariate logistic regression analysis.

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3643-8) contains supplementary material, which is available to authorized users.

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.

Characteristics and outcomes of adult Ethiopian patients enrolled in HIV care and treatment: a multi-clinic observational study

Background

We describe trends in characteristics and outcomes among adults initiating HIV care and treatment in Ethiopia from 2006-2011.

Methods

We conducted a retrospective longitudinal analysis of HIV-positive adults (≥15 years) enrolling at 56 Ethiopian health facilities from 2006–2011. We investigated trends over time in the proportion enrolling through provider-initiated counseling and testing (PITC), baseline CD4+ cell counts and WHO stage. Additionally, we assessed outcomes (recorded death, loss to follow-up (LTF), transfer, and total attrition (recorded death plus LTF)) before and after ART initiation. Kaplan-Meier techniques estimated cumulative incidence of these outcomes through 36 months after ART initiation. Factors associated with LTF and death after ART initiation were estimated using Hazard Ratios accounting for within-clinic correlation.

Results

93,418 adults enrolled into HIV care; 53,300 (57%) initiated ART. The proportion enrolled through PITC increased from 27.6% (2006–2007) to 44.8% (2010–2011) (p < .0001). Concurrently, median enrollment CD4+ cell count increased from 158 to 208 cells/mm³ (p < .0001), and patients initiating ART with advanced WHO stage decreased from 56.6% (stage III) and 15.0% (IV) in 2006–2007 to 47.6% (stage III) and 8.5% (IV) in 2010–2011. Median CD4+ cell count at ART initiation remained stable over time. 24% of patients were LTF before ART initiation. Among those initiating ART, attrition was 30% after 36 months, with most occurring within the first 6 months. Recorded death after ART initiation was 6.4% and 9.2% at 6 and 36 months, respectively, and decreased over time. Younger age, male gender, never being married, no formal education, low CD4+ cell count, and advanced WHO stage were associated with increased LTF. Recorded death was lower among younger adults, females, married individuals, those with higher CD4+ cell counts and lower WHO stage at ART initiation.

Conclusions

Over time, enrollment in HIV care through outpatient PITC increased and patients enrolled into HIV care at earlier disease stages across all HIV testing points. However, median CD4+ cell count at ART initiation remained steady. Pre- and post-ART attrition (particularly in the first 6 months) have remained major challenges in ensuring prompt ART initiation and retention on ART.

Khat and alcohol use and risky sex behaviour among in-school and out-of-school youth in Ethiopia

Background

Khat (an evergreen plant with amphetamine-like properties) and alcohol are widely consumed among the youth of Ethiopia. However, their relationship to risky sexual behaviour is not well described. This study was conducted to describe the magnitude of risky sexual behaviour (unprotected sex and early initiation of sexual activity) and its association with Khat and alcohol consumption in Ethiopian youths.

Methods

A probabilistic national sample of 20,434 in-school and out-of-school youths aged between 15 and 24 years of age was selected and interviewed regarding their sexual behavior and substance use.

Results

Over 20% of out-of-school youth had unprotected sex during the 12-month period prior to interview compared to 1.4% of in-school youth. Daily Khat intake was also associated with unprotected sex: adjusted OR (95% CI) = 2.26 (1.92, 2.67). There was a significant and linear association between alcohol intake and unprotected sex, with those using alcohol daily having a three fold increased odds compared to those not using it: adj. OR (95% CI) = 3.05 (2.38, 3.91). Use of substances other than Khat was not associated with unprotected sex, but was associated with initiation of sexual activity: adj. OR (95% CI) = 2.54 (1.84, 3.51).

Conclusion

A substantial proportion of out-of-school youth engage in risky sex. The use of Khat and alcohol and other substances is significantly and independently associated with risky sexual behaviour among Ethiopian youths.

Overall HIV-1 prevalence in pregnant women over-estimates HIV-1 in the predominantly rural population of Afar Region

The appropriateness of sentinel sero-surveillance based upon ante-natal clinic (ANC) attendees to estimate HIV-1 prevalence in the general population has been questioned. In Ethiopia, where the population is heterogeneous and where economic and practical barriers to ANC attendance exist, problems of extrapolation may be exacerbated. We planned an unlinked anonymous sero-survey which included data on basic population characteristics to investigate whether sero-surveillance data from ANCs in Afar Region might be taken to represent the situation among the general population of the Region. 371 pregnant women attending Dubti Hospital and Assayta Health Centre were tested for HIV-1 (using a single ELISA test) and active syphilis (RPR test). Socio-demographic characteristics were collected for each woman. Of the women tested, 278 (75%) were 28 years of age or younger. Two hundred eighty (76%) were urban residents and 237 (64%) described themselves as being of Amhara ethnicity. Overall, 73 (19.7%) were HIV-1 positive, but prevalence was three times higher among the 237 women of Amhara ethnicity compared to the 112 of Afar ethnicity (24.9% vs 8.0%, p < 0.001), and almost three times higher for urban compared to rural residents (23.2% vs 8.8%, p < 0.001). Positive RPR results were strongly associated with HIV-1 infection (OR 3.37, 95% CI 1.47-7.71). According to the Demographic and Health Survey (DHS) 2000, only 4.5% of the population of Afar Region is of Amhara ethnicity, and 7.8% urban residents. We have demonstrated that basing ANC sero-surveillance in urban areas of Afar Region over-samples urban residents of Amhara ethnicity and yields a major over-estimation of overall HIV-1 prevalence for the Region. Reliable estimation of HIV-1 prevalence in Afar Region will require more flexible strategies that permit sampling of rural Afar residents.

Parasight-F dipstick antigen test in the diagnosis of falciparum malaria in Ethiopia

OBJECTIVE

To determine the shelf life, rapidity and diagnostic performance of ParaSight-F.

DESIGN

Prospective randomised study.

SETTINGS

Malaria diagnostic and treatment posts and health centres in central-southern part of the Ethiopian Rift Valley.

SUBJECTS

Three hundred and eighty two subjects randomly selected.

MAIN OUTCOME MEASURES

Double blind evaluation of the sensitivity, specificity and predictive values of PFT versus CBF.

RESULTS

The point prevalence was found to be 29.7% with species dominance of P. falciparum to P. vivax in the ratio of 4:1. The ParaSight-F test showed, considering P. falciparum only, a sensitivity of 92.5% and specificity of 93%. A remarkably high positive predictive value (PPV) of 82% as well as a negative predictive value (NPV) of 99% was obtained. Considering all species of Plasmodium, sensitivity was 78.6% and specificity 93%, with PPV and NPV of 82% and 91% respectively. Moreover, PFT was found to be rapid with a batch of ten-strips--a rack completed in 30 to 50 minutes, which was five to six times faster than CBF reading. In shelf-life studies, after one year of storage at room temperature, results were found similar to the original readings, indicating the stability and long durability of the test strips.

CONCLUSION

In their durability and high diagnostic performances, both the microscopic slide readings and PFT were found comparable and interchangeable, and advantage in endemic areas where laboratory facilities are not available. The rapidity of PFT may be of greater value during malaria epidemics. But during non-epidemic seasons, the inability of PFT not to detect all forms of malaria remains a draw back.

Cryptosporidiosis in children seen at the children's clinic of Yekatit 12 Hospital, Addis Ababa

The stools of 214 children under five years of age with diarrhoea were examined for Cryptosporidium oocysts using the Modified Ziehl Nelson Technique. Twelve (5.6%) of the children had Cryptosporidium oocysts in their faeces. All of these were above 6 months of age and were either partially or fully weaned. There were 15 exclusively breast fed children of whom 11 were less than 6 months of age. None of these cases had the evidence of Cryptosporidial infection. The present study indicates the importance of Cryptosporidium as a possible etiologic agent in patients with diarrhoeal diseases. However, a comprehensive investigation is needed in order to rule out other enteropathogens.

Hookworm infection among the Melka Sedi banana plantation residents, middle Awash Valley, Ethiopia

A study of intestinal parasites was done among the people who lived within the banana plantation zone of the Melka Sedi Agricultural Enterprise, Awash Valley, Ethiopia in April 1987. The methods of parasite detection were the Ritchie formal ether and the charcoal culture method for hookworm larvae species identification. From the total 633 population, 311 were examined at random of whom 60.8% were positive for one or more intestinal parasites. Eight parasites were encountered, Ascaris lumbricoides in 1.3%, Trichuris trichiura in 6.4%, Strongyloides stercoralis in 3.9%, hookworm in 53.1%, Taenia sp. in 3.5%, Schistosoma mansoni in 1.9%, Entamoeba histolytica in 0.6% and Hymenolepis sp. in 0.6%. Prevalence of hookworm infection was significantly higher than that of any of the other parasites (p less than 0.001). In the hookworm infected individuals there were more males than females, and the 25 to 34 year age group had significantly higher infection rates (p less than 0.05). The majority of those with hookworm were banana plantation workers. This communication emphasizes the basic guidelines for control and prevention of hookworm and other related faecal/soil-borne infections in this and similar agricultural settings.

Evaluation of the modified Baermann's method in the laboratory diagnosis of Strongyloides stercoralis

This study compares the modified Baermann's method with the formol-ether concentration and the direct/saline techniques in the diagnosis of Strongyloides stercoralis larvae in stool specimens. This study was conducted at Wonji-Shewa Sugar Estate located at about 110 kms. south east of Addis Abeba. Of the 718 randomly selected and examined stool specimens, 125 were found positive for Strongyloides stercoralis. Of these 98% were recovered by the modified Baermann's method, 23% by the formol-ether, and 22% by the direct saline techniques. The rate of recovery by the modified Baermann's method was significantly different (p less than 0.001) compared with those of the direct and the formol-ether concentration techniques. There was no difference (p greater than 0.1) between the direct saline and the formol-ether methods. The modified Baermann's method accounted for over 60% of the total positive findings. Furthermore, the sensitivity of the method excelled the other two techniques by four fold. Thus, the modified Baermann's method by the Merck and Sharp Dohme Company is effective, cheap and simple to use and hence recommended for routine use and epidemiological surveys.

A new suspected focus of Schistosoma haematobium in the Metema area, Gonder administrative region, north-west Ethiopia

Two cases of Schistosoma haematobium, one in a 10 year old boy who was born in Metema and had never left the area, and another from a Sudaness refugee, are reported. Further investigation is required to verify if S. haematobium has been imported from Sudan or is being transmitted in Metema.