Learning from Ethiopia's success in reducing maternal and neonatal mortality through a health systems lens.

BACKGROUND: This study aimed to enhance insights into the key characteristics of maternal and neonatal mortality declines in Ethiopia, conducted as part of a seven-country study on Maternal and Newborn Health (MNH) Exemplars. METHODS: We synthesised key indicators for 2000, 2010 and 2020 and contextualised those with typical country values in a global five-phase model for a maternal, stillbirth and neonatal mortality transition. We reviewed health system changes relevant to MNH over the period 2000-2020, focusing on governance, financing, workforce and infrastructure, and assessed trends in mortality, service coverage and systems by region. We analysed data from five national surveys, health facility assessments, global estimates and government databases and reports on health policies, infrastructure and workforce. RESULTS: Ethiopia progressed from the highest mortality phase to the third phase, accompanied by typical changes in terms of fertility decline and health system strengthening, especially health infrastructure and workforce. For health coverage and financing indicators, Ethiopia progressed but remained lower than typical in the transition model. Maternal and neonatal mortality declines and intervention coverage increases were greater after 2010 than during 2000-2010. Similar patterns were observed in most regions of Ethiopia, though regional gaps persisted for many indicators. Ethiopia's progress is characterised by a well-coordinated and government-led system prioritising first maternal and later neonatal health, resulting major increases in access to services by improving infrastructure and workforce from 2008, combined with widespread community actions to generate service demand. CONCLUSION: Ethiopia has achieved one of the fastest declines in mortality in sub-Saharan Africa, with major intervention coverage increases, especially from 2010. Starting from a weak health infrastructure and low coverage, Ethiopia's comprehensive approach provides valuable lessons for other low-income countries. Major increases towards universal coverage of interventions, including emergency care, are critical to further reduce mortality and advance the mortality transition.

Scoping review of assessment tools for, magnitudes of and factors associated with problem drinking in population-based studies.

BACKGROUND: The term "problem drinking" includes a spectrum of alcohol problems ranging from excessive or heavy drinking to alcohol use disorder. Problem drinking is a leading risk factor for death and disability globally. It has been measured and conceptualised in different ways, which has made it difficult to identify common risk factors for problem alcohol use. This scoping review aims to synthesise what is known about the assessment of problem drinking, its magnitude and associated factors. METHODS: Four databases (PubMed, Embase, PsycINFO, Global Index Medicus) and Google Scholar were searched from inception to 25 November 2023. Studies were eligible if they focused on people aged 15 and above, were population-based studies reporting problem alcohol use and published in the English language. This review was reported based on guidelines from the 'Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews Checklist'. Critical appraisal was done using the Newcastle-Ottawa Scale. RESULTS: From the 14 296 records identified, 10 749 underwent title/abstract screening, of which 352 full-text articles were assessed, and 81 articles were included for data extraction. Included studies assessed alcohol use with self-report quantity/frequency questionnaires, criteria to determine risky single occasion drinking, validated screening tools, or structured clinical and diagnostic interviews. The most widely used screening tool was the Alcohol Use Disorder Identification Test. Studies defined problem drinking in various ways, including excessive/heavy drinking, binge drinking, alcohol use disorder, alcohol abuse and alcohol dependence. Across studies, the prevalence of heavy drinking ranged from <1.0% to 53.0%, binge drinking from 2.7% to 48.2%, alcohol abuse from 4.0% to 19.0%, alcohol dependence from 0.1% to 39.0% and alcohol use disorder from 2.0% to 66.6%. Factors associated with problem drinking varied across studies. These included sociodemographic and economic factors (age, sex, relationship status, education, employment, income level, religion, race, location and alcohol outlet density) and clinical factors (like medical problems, mental disorders, other substance use and quality of life). CONCLUSIONS: Due to differences in measurement, study designs and assessed risk factors, the prevalence of and factors associated with problem drinking varied widely across studies and settings. The alcohol field would benefit from harmonised measurements of alcohol use and problem drinking as this would allow for comparisons to be made across countries and for meta-analyses to be conducted. TRIAL REGISTRATION NUMBER: Open Science Framework ID: https://osf.io/2anj3.

Impact of the COVID-19 pandemic on mental health care and people with mental health conditions in Ethiopia: the MASC mixed-methods study.

BACKGROUND: The COVID-19 pandemic has had far-reaching effects on the mental health of populations around the world, but there has been limited focus on the impact on people with existing mental health conditions in low-income countries. The aim of this study was to examine impact of the pandemic on mental health care and people with mental health conditions in Ethiopia. METHODS: A convergent mixed methods study was conducted. We systematically mapped information from publicly available reports on impacts of the pandemic on mental health care. Monthly service utilisation data were obtained from Amanuel Mental Specialised Hospital, the main psychiatric hospital, and analysed using segmented Poisson regression (2019 vs. 2020). In-depth interviews were conducted with 16 purposively selected key informants. Framework analysis was used for qualitative data. Findings from each data source were integrated. RESULTS: In the early stages of the pandemic, participants indicated a minimal response towards the mental health aspects of COVID-19. Mental health-related stigma and discrimination was evident. Scarce mental health service settings were diverted to become COVID-19 treatment centres. Mental health care became narrowly biomedical with poorer quality of care due to infrequent follow-up. Households of people with pre-existing mental health conditions in the community reported worsening poverty and decreased access to care due to restricted movement, decreased availability and fear. Lack of reliable medication supplies increased relapse and the chance of becoming chained at home, abandoned or homeless. Caregiver burden was exacerbated. Within mental health facilities, prisons and residential units, infection control procedures did not adequately safeguard those with mental health conditions. Meanwhile, the needs of people with mental health conditions in COVID-19 quarantine and treatment facilities were systematically neglected. Only late in the day were integrated services developed to address both physical and mental health needs. CONCLUSIONS: The COVID-19 pandemic had substantial negative impacts on the lives of people with mental health conditions in Ethiopia. Future emergency response should prioritise the human rights, health, social and economic needs of people with mental health conditions. Integration of mental and physical health care would both expand access to care and increase resilience of the mental health system.

Impact of depression on stroke outcomes among stroke survivors: Systematic review and meta-analysis.

BACKGROUND: Depression may negatively affect stroke outcomes and the progress of recovery. However, there is a lack of updated comprehensive evidence to inform clinical practice and directions of future studies. In this review, we report the multidimensional impact of depression on stroke outcomes. METHODS: Data sources. PubMed, PsycINFO, EMBASE, and Global Index Medicus were searched from the date of inception. Eligibility criteria. Prospective studies which investigated the impact of depression on stroke outcomes (cognition, returning to work, quality of life, functioning, and survival) were included. Data extraction. Two authors extracted data independently and solved the difference with a third reviewer using an extraction tool developed prior. The extraction tool included sample size, measurement, duration of follow-up, stroke outcomes, statistical analysis, and predictors outcomes. Risk of bias. We used Effective Public Health Practice Project (EPHPP) to assess the quality of the included studies. RESULTS: Eighty prospective studies were included in the review. These studies investigated the impact of depression on the ability to return to work (n = 4), quality of life (n = 12), cognitive impairment (n = 5), functioning (n = 43), and mortality (n = 24) where a study may report on more than one outcome. Though there were inconsistencies, the evidence reported that depression had negative consequences on returning to work, functioning, quality of life, and mortality rate. However, the impact on cognition was not conclusive. In the meta-analysis, depression was associated with premature mortality (HR: 1.61 (95% CI; 1.33, 1.96)), and worse functioning (OR: 1.64 (95% CI; 1.36, 1.99)). CONCLUSION: Depression affects many aspects of stroke outcomes including survival The evidence is not conclusive on cognition and there was a lack of evidence in low-income settings. The results showed the need for early diagnosis and intervention of depression after stroke. The protocol was pre-registered on the International Prospective Register of Systematic Review (PROSPERO) (CRD42021230579).

Exploring the perception of key stakeholders toward khat policy approaches in Ethiopia: a qualitative study.

BACKGROUND: Khat is an amphetamine-like plant, produced and commonly chewed in Ethiopia by a large group of the population. Although significant multidimensional harms of khat use have been reported, currently, there are no policies or organized activities against khat use in Ethiopia. Therefore, the current study aimed to explore the perception of key stakeholders toward khat policy approaches for Ethiopia. METHODS: A qualitative study was conducted using focus group discussion (FGD) and in-depth interview (IDI). Ten stakeholders participated in the IDIs, and another 15 individuals participated in the FGDs. Key stakeholders were appropriately mapped and purposively selected based on their experience related to khat use and khat harm reduction. Interviews and FGDs were led by the study authors and were audio-recorded. The audio-recorded data were transcribed verbatim and then translated into English language. The data were analyzed using thematic analysis approach. RESULTS: Participants preferred prevention and law regulation measures for khat policy approaches for Ethiopia. Proposed prevention and law regulation measures included regulating the transportation of khat, limiting the minimum age to buy and sell khat, prohibiting khat use at some public places, banning khat advertising and promotion, and imposing excise tax. Individual level khat harm reduction strategies were also proposed to be useful. However, the participants asserted that total khat ban in Ethiopia is not likely to be feasible and acceptable. CONCLUSION: Prevention, treatment or care for individuals with problematic khat use, law regulation, and harm reduction were preferred approaches by stakeholders for khat policy in Ethiopia instead of total banning.

Validation of the Amharic version of Internet Addiction Test-20: a cross-sectional study.

Background: Internet Addiction is defined as excessive internet use or poorly controlled preoccupations, impulses, or behaviors related to computer use and internet access that cause impairment or suffering. It had devastating effect on people lives, families, productivity, academic performance and rarely engaging in criminal acts like alcohol use, drug addiction, or compulsive gambling. This study aimed to investigate the psychometric properties of the Amharic version of Internet Addiction Test-20 among Addis Ababa University, College of Health Sciences medical students, Addis Ababa, Ethiopia. Methods: A cross sectional study was carried out among 410 medical students using a convenience sampling method after stratifying them based on their year level. SPSS Version 23 was used to do Pearson's correlation coefficient to determine the convergent validity of Amharic version of IAT. We computed correlation coefficient between the aggregate scores of IAT-20 and the scores for depressive symptoms, problematic substance use, and other characteristics of participants which was assessed using Patient health questionnaire-9 (PHQ-9), Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) and questionnaire developed to assess demographic and internet use related characteristics, respectively. AMOS 23 software was used to conduct confirmatory factor analysis (CFA) to evaluate the construct validity of Amharic version of IAT. Test-retest reliability was also determined with 2 weeks interval (n = 51). Results: The data confirmed a two-factor structure. Normed Fit Index (NFI) = 0.89, Tucker Lewis Index (TLI) = 0.91 and Comparative Fit Index (CFI) = 0.92, Root Mean Square Error Approximation (RMSEA) = 0.07, and Standardized Root Mean Residual (SRMR) =0.05 indicated a good fit model structure. There was moderate positive correlation between the aggregate scores of IAT-20 and PHQ-9 scores (r = 0.55, p < 0.00), but weak positive correlation between IAT-20 and ASSIST scores (r = 0.14, p < 0.00). IAT-20 was also found to have good internal consistency (Cronbach's alpha = 0.89 for each factor). The test-retest reliability was also good for all items (Intra Class Correlation Coefficient (ICC) > 0.30) except item 16. Conclusion: We found that the IAT-20 is psychometrically sound and a simple screening test for Internet Addiction. However, it is important to acknowledge that further studies are necessary to replicate these findings on diverse population.

Cognitive impairment in people with schizophrenia: an umbrella review.

Cognitive impairment is one of the core symptoms of schizophrenia. Quite a number of systematic reviews were published related to cognitive impairment in people with schizophrenia (PWS). This umbrella review, therefore, aimed at reviewing and synthesizing the findings of systematic reviews related to domains of cognition impaired and associated factors in PWS. We searched four electronic databases. Data related to domains, occurrence, and associated factors of cognitive impairment in PWS were extracted. The quality of all eligible systematic reviews was assessed using A MeaSurement Tool to Assess methodological quality of systematic Review (AMSTAR) tool. Results are summarized and presented in a narrative form. We identified 63 systematic reviews fulfilling the eligibility criteria. The included reviews showed that PWS had lower cognitive functioning compared to both healthy controls and people with affective disorders. Similar findings were reported among psychotropic free cases and people with first episode psychosis. Greater impairment of cognition was reported in processing speed, verbal memory, and working memory domains. Greater cognitive impairment was reported to be associated with worse functionality and poor insight. Cognitive impairment was also reported to be associated with childhood trauma and aggressive behaviour. According to our quality assessment, the majority of the reviews had moderate quality. We were able to find a good number of systematic reviews on cognitive impairment in PWS. The reviews showed that PWS had higher impairment in different cognitive domains compared to healthy controls and people with affective disorders. Impairment in domains of memory and processing speed were reported frequently.

Validation of the Problematic Khat Use Screening Test: A Cross-Sectional Study.

AIM: The study aimed to evaluate the psychometric properties of the Problematic Khat Use Screening Test (PKUST-17) in Ethiopia. METHODS: A validation study of PKUST-17 was carried out among 510 khat users, using a house-to-house survey. Confirmatory factor analysis and 2-parametric item response theory (IRT) were used to evaluate the construct validity of PKUST-17. We also used Spearman's rank-order correlation coefficient and other test statistics to assess the convergent validity of PKUST-17 with depression symptoms, functional impairment, and other characteristics of participants. We generated latent classes of problematic khat use using latent profile analysis (LPA) and validated the classes using multinomial logistic regression. RESULTS: The data confirm the unidimensional model of the PKUST-17. The internal consistency of PKUST-17 was excellent (Cronbach's alpha = 0.93). IRT discrimination parameters indicated that each item had a strong ability to distinguish participants across the spectrum of problematic khat use (α thresholds range from 1.02 to 2.9). The items were fairly or moderately severe to be endorsed by participants (ß thresholds vary from 1.43 to 5.57). The LPA identified three latent classes which have severity differences: mild (34%), moderate (34%), and severe (32%) problematic khat use. Depression symptoms, functional impairment, and other khat use patterns were also associated with moderate and severe problematic khat use class membership compared to mild problematic khat use class. CONCLUSION: We found that the PKUST-17 is a culturally appropriate, brief, easy to use, and psychometrically sound screening test. PKUST-17 can be used to screen khat users with different levels of risk for providing stepped care at different healthcare levels, including integration of services in primary care. Future studies need to test the predictive capacity of the PKUST-17 for khat-related harms.

Exploring the concept of problematic khat use in the Gurage community, South Central Ethiopia: a qualitative study.

OBJECTIVE: This study aimed to explore how problematic khat use is characterised in the Gurage community in South Central Ethiopia. DESIGN: Qualitative study. SETTING: Gurage community in South Central Ethiopia. PARTICIPANTS: We conducted indepth interviews with 14 khat users and 5 non-khat users, and three focus group discussions with khat users. METHODS: All participants were selected purposively based on their exposure to khat or khat use. We used an interview guide to explore the perceptions of participants about khat use and problematic khat use. We analysed the data thematically using OpenCode V.4.03 software. We used iterative data collection and analysis, triangulation of methods, and respondent validation to ensure scientific rigour. FINDINGS: We identified three major themes: sociocultural khat use, khat suse (khat addiction) and negative consequences of khat use. Sociocultural khat use included a broad range of contexts and patterns, including use of khat for functional, social, cultural and religious reasons. Khat addiction was mainly explained in terms of associated khat withdrawal experiences, including harara/craving and inability to quit. We identified mental health, sexual life, physical health, social and financial negative consequences of khat use. The local idiom jezba was used to label a subgroup of individuals with khat suse (khat addiction). CONCLUSION: The study has identified what constitutes normative and problematic khat use in the Gurage community in South Central Ethiopia. Problematic khat use is a broad concept which includes frequency, reasons, contexts, negative consequences and addiction to khat. Insights generated can be used to inform future studies on the development of tools to measure problematic khat use.

Definition and Validity of the Construct "Problematic Khat Use": A Systematic Review.

BACKGROUND: Problematic khat use, not khat use per se, is a public health and social concern for the public, researchers, and policy makers. However, the construct problematic khat use is not well-established and not fully recognized in the modern definition of substance use disorders including Diagnostic Statistic Manual (DSM-5) and international classification of diseases (ICD-10), although DSM-5 included it in the "stimulant use disorder" category. Existing scoping reviews have focused on khat use, which could not allow the differentiation of khat use from problematic khat use. Thus, the aim of this systematic review was to define and validate the construct problematic khat use. METHODS: This systematic review was reported following the PRISMA guidelines. We searched all English language studies without publication date restriction from 5 databases; PubMed, EMBASE, psychINFO, SocINDEX, and Google scholar. All studies that defined, explored, evaluated, or measured the construct problematic khat use were included. Adapted data extraction tool and criteria for quality evaluation were employed. We presented the results in tables and thematic synthesis of the major findings. RESULT: Overall, 30 qualitative and cross-sectional design studies were included. Associated harms with khat use, an increased amount used, increased frequency of use, and withdrawal experiences were indicators of problematic khat use. Using khat on an average of 3 or more times per week and using other psychoactive substances during and after khat use were frequently used to define problematic khat use. The most frequently reported withdrawal symptoms were depressed mood, irritability, fatigue, lack of motivation, increased sleep, and appetite. The existing measures (severity of dependence scale and DSM-5) of problematic khat use had psychometrically acceptable properties in terms of construct, criterion, and convergent validity, but they are poor in terms of other domains of validity including content, conceptual, and semantic validity. CONCLUSION: Problematic khat use constitutes, but is not limited to, harms, increased use over time, and frequent engagement in other psychoactive substances misuse. Khat use is different from problematic khat use since it is occasional and used for prayer, social, and functional reasons. Strong empirical studies that could establish thresholds for patterns of problematic khat use and a culturally suitable problematic khat use measures that follows a bottom-up approach of scale development are warranted.

Prevalence and Associated Factors of Mental Distress among Caregivers of Patients with Epilepsy in Ethiopia: A Cross-Sectional Study Design.

BACKGROUND: Caregiving to individuals with mental illness is a broad responsibility, including not only practical help and care but also emotional support. Cross-sectional studies in different localities suggested a significant burden of mental distress among caregivers of patients with epilepsy, but we are not aware about the condition in Ethiopia. Therefore, the aim of the current study is to assess the prevalence and associated factors of mental distress among caregivers of patients with epilepsy in Ethiopia. METHODS: An institutional based cross-sectional study was conducted in Neuropsychiatric Department of Amanuel Mental Specialized Hospital, Addis Ababa, Ethiopia. Using systematic random sampling technique, 409 caregivers participated in the study. Data was collected by face to face interview using standardized and validated Kessler Psychological Distress Scale (K-10) to assess mental distress. Descriptive, bivariate, and multivariate logistic regression models were used for analysis. Adjusted Odd Ratio (AOR) with 95% Confidence Interval (CI) was used to show the odds, and P-value < 0.05 was considered as statistically significant. RESULTS: The mean age of respondents was 43.3 years with standard deviation of ±11.4 years. Two hundred eighteen (53.3%) of the respondents were male. The prevalence of mental distress was found to be 27.1% with 95% CI [22.6-31.1]. Relationship with patient of being mother [AOR: 5.67, 95% CI: (1.68-13.70)], father [AOR: 4.42, 95% CI: (1.25-12.58)], wife/husband [AOR: 10.59, 95% CI: (2.43-14.19)], and child [AOR: 5.37, 95% CI: (1.27-12.69)]; caring for young person below 20 years of age [AOR: 4.00, 95% CI: (1.43-11.21)]; poor social support [AOR: 7.26, 95% CI: (3.60-14.65)]); and experienced stigma [AOR: 3.03, 95% CI: (1.63-5.66)] were statistically and significantly associated factors of mental distress among caregivers of patients with epilepsy. CONCLUSION AND RECOMMENDATION: We found a lower prevalence of mental distress among caregivers of patients with epilepsy compared to other low- and middle-income settings. Being caring for young patients, being parents to the patient, poor social support, and stigma were statistically significant associated factors of mental distress among caregivers. Therefore, appropriate psychosocial interventions are warranted to be designed and implemented emphasizing the aforementioned associated factors.

Problematic khat use as a possible risk factor for harmful use of other psychoactive substances: a mixed method study in Ethiopia.

BACKGROUND: Substance use disorders along with neuropsychiatric disorders contributed about 14% of the global burden of disease. Harmful alcohol use, is a known contributor for many harms (accidents, suicide, violence, and complication of other psychiatric and medical disorders). In the Western countries, alcohol and nicotine are gateway drugs to cannabis use, and cannabis use is a risk factor for other illicit drugs such as cocaine and heroin. Khat use is another psychoactive substance which is common in East African and Arabian Peninsula. But there is a knowledge gap regarding the position of khat use or problematic khat use in sequential progression of different psychoactive substances. Therefore, we aimed to understand and investigate the relationship of problematic khat use and other psychoactive substances in Ethiopia. METHODS: Exploratory mixed methods study was employed. Quantitative cross sectional survey was done among 102 khat users, and 4 focus group discussions and 11 in-depth interviews were conducted to understand the pathways between khat use and other psychoactive substances use in 2014. Non random sampling (purposive and snowballing) was employed for both quantitative and qualitative studies. Khat users from khat cafeterias, shops, and from other open markets of khat in Addis Ababa were invited to participate. RESULT: Currently significant majorities of khat users (86.3%) used at least one other psychoactive substance after they started khat use. The prevalence of harmful drinking was 53.9% among khat users. Problematic khat use was a significant predictor of harmful drinking (p < 0.05). About one from ten respondents engaged to risky sexual behavior pushed by the effect of khat after chewing. CONCLUSION: The proportion of psychoactive substances use especially harmful drinking among khat users was observed higher compared to other cross sectional surveys conducted among general population. In Ethiopia, intervention and policy on harmful alcohol use could consider problematic khat use as one possible risky factor. A rigorous methodology which could test gateway hypothesis of problematic psychoactive substances use could be warranted.

What constitutes problematic khat use? An exploratory mixed methods study in Ethiopia.

BACKGROUND: Khat is a psycho-stimulant herb, which has been in use in traditional societies in East Africa and the Middle East over many centuries. Although khat is reported to cause various health problems, what constitutes problematic khat use has never been systematically investigated. This study explored the acceptable and problematic uses of khat from the perspective of users. METHODS: The study used a mixed methods design (exploratory sequential) in which qualitative (emic) data were collected to develop a framework to define problematic khat use. The qualitative data were gathered through in-depth interviews (N = 13) and focus group discussions (N = 34). By supplementing the emic experiences considered to constitute problematic khat use with an etic definition, DSM-5 criteria for stimulant related disorders, a structured questionnaire was developed. Subsequently a cross-sectional evaluation of 102 respondents was carried out. Respondents both for qualitative and quantitative study were selected through purposive sampling and snowballing methods. Qualitative data were transcribed and subjected to thematic analysis whereas quantitative data were analyzed using descriptive and nonparametric statistics. RESULTS: Khat use was acceptable socio-culturally and for functional purposes. However, even in these acceptable contexts there was a restriction to the amount, frequency and type of khat used, and in relation to the experience of the individual using khat and other personal characteristics. More specifically, khat use was considered problematic if there was: 1) Impairment (in social and occupational functioning); 2) loss of control in the use of khat; and 3) withdrawal symptoms when not using khat. Among the participants who use khat (n = 102), 45.1% (n = 46) used khat on a daily basis. The commonest indicators of problematic khat use endorsed by the khat users were loss of control over chewing (73.5%), continuing use of khat despite harm (72.5%) and efforts to avoid withdrawal from khat (61.8%). CONCLUSION: Despite reported religious, sociocultural and functional benefits to the use of khat, those with defined problematic khat use have impaired mental health, and social and occupational performance. Comparison of these respondent defined indicators of problem behavior matched almost completely to the DSM-5 (etic-defined) understanding of problematic stimulant use. Although the findings have relevant clinical, research and policy implications, the study focused on users purposively identified. Future larger scale definitive studies are required to make concrete policy recommendations.