Prevalence of depression and associated factors among community hosted internally displaced people of Tigray; during war and siege.

BACKGROUND: Displacement is a psychologically stressful event. Since the war began, the people of Tigray were subjected to stressful events such as torture, rape, the killing of a family member, forced displacement, and even ethnic cleansing in their home countries. Especially displaced individuals are faced mental health problems. This study aimed to assess the prevalence of depression and associated factors among community internally displaced people due to the war on Tigray, in 2021. METHODS: The community-based cross-sectional study design was applied from August 06 to 30, 2021 in all Weredas of Tigray. A total of 1,990 cIDP were recruited through a two-stage sampling technique. A structured and standardized questionnaire was used to collect data. Both bivariate and multivariable logistic regression was applied to identify associated risk factors and AOR with 95% confidence interval was used to select statistically significant variables. RESULTS: The prevalence of depression among internally displaced people was 81.2% (95% CI: 79.4-83%), with more than 60% categorized as moderate and severe depression. The married and divorced marital status, being government employee, having family size > = 4, destruction of household fixed assets, looting of cereals, and having disabled family members due to the war were the significantly associated risk factors of depression. CONCLUSIONS: The prevalence of depression among community internally displaced people during the war on Tigray is very high compared to other studies conducted elsewhere. Almost 8 of 10 IDPs are developed depression and this is a very series health issue that needs immediate intervention by local, international organizations and communities around the world.

Burdens of non-communicable disease attributable to metabolic risk factors in Australia, 1990-2019: joinpoint regression analysis of the Global Burden of Disease Study.

BACKGROUND: Long-term and comparative assessments of trends in non-communicable disease (NCD) burden attributable to metabolic risk are sparse. This study aimed to assess burdens and trends of NCD attributable to metabolic risk factors in Australia, 1990-2019. DESIGN: Population-based observational study. SETTINGS AND DATA SOURCE: Data were extracted from the Global Burden of Disease Study 2019 for Australia and trends in NCD burden attributable metabolic risks were estimated using the joinpoint regression model. MAIN OUTCOME MEASURES: NCD deaths and disability-adjusted life-years (DALYs) attributed to metabolic risk factors, 1990-2019. RESULTS: Results indicate a 1.1% yearly increase in exposure to combined metabolic risk factors from 1990 to 2019. Between 1990 and 2019, the estimated absolute number of deaths from NCDs attributed to combined metabolic risks increased by 17.0%. However, metabolic risk-related NCD burdens in Australia decreased between 1990 and 2019. In 2019, 34.0% of NCD deaths and 20.0% of NCD DALYs were attributed to metabolic risk factors, compared with 42.9% and 24.4%, respectively, in 1990. In 2019, cardiovascular diseases (CVDs), neoplasms and chronic kidney diseases were the most common NCD deaths attributed to metabolic risks. High body mass index accounted for the highest proportion of diabetes deaths (47.0%) and DALYs (58.1%) as well as chronic kidney disease deaths (35.4%) and DALYs (39.7%). Similarly, high systolic blood pressure contributed to a high proportion of chronic kidney disease deaths (60.9%) and DALYs (53.2%), and CVDs deaths (44.0%) and DALYs (46.0%). CONCLUSION: While the contribution of metabolic risk factors to the burden of NCDs has declined from 1990 to 2019, their role in NCD death and disability remains a challenge as the prevalence of these risk factors has increased. Prevention strategies should focus on metabolic risks particularly high body mass index and high systolic blood pressure to substantially reduce NCD burdens.

Prevalence of chronic non-communicable diseases in Ethiopia: A systematic review and meta-analysis of evidence.

Background: Non-communicable diseases (NCDs) are a growing global health challenge disproportionately impacting low- and middle-income settings, including Ethiopia. Currently, the body of evidence describing the burden of NCDs is fragmented, inconsistent, health facility- or institution-based, and out-dated in Ethiopia. We conducted a systematic review of the literature and meta-analysis of the prevalence of NCDs in community settings in Ethiopia. Review methodology: Community-based quantitative studies published in English between January 1st, 2012, and June 30th, 2022, that reported on the prevalence of NCDs in Ethiopia were included. A systematic search of Medline, Embase, Scopus, CINAHL, and Global Health using pretested search terms related to NCDs was conducted, and data were extracted using a piloted data extraction proforma adapted from the Joanna Briggs Institute tool. Meta-analysis was performed using Stata 16. While the pooled prevalence of Diabetes Mellitus (DM) and undiagnosed (DM) was computed and presented using forest plots, then overall prevalence of NCDs and other various types of NCDs were narratively synthesized. I 2 was used to assess heterogeneity. Studies that did not fulfill the criteria (used similar tool to measure the types of NCDs) for meta-analysis were narratively synthesized. Results: Twenty-two studies met the inclusion criteria. Five studies measured the prevalence of NCDs (all NCDs together), ranging from 29 to 35% (prevalence estimates not pooled). The pooled prevalence of Diabetes Mellitus (DM) across ten studies was 5% (95% CI: 4-7%). Three studies each reported on the prevalence of undiagnosed DM (pooled prevalence 5%, 95% CI: 4-7%) and pre-DM (pooled prevalence 7%, 95% CI: 3-14%%). In a narrative analysis the prevalence of cardiovascular conditions ranged from 13.4 to 32.2% (n = 3 studies), cancer mortality ranged from 4 to 18% (n = 3 studies) and respiratory conditions ranged from 1 to 18% (n = 3 studies). Some studies have determined more than one NCDs and that is why the total number of studies are exceeding more than twenty studies. Conclusion and recommendations: Our analysis found that approximately one-third of Ethiopians have an NCD, with cardiovascular diseases the most common of all NCDs. The prevalence of respiratory conditions also appears high, but there are insufficient data for a pooled estimate. Whilst the prevalence of DM appears relatively low, there is evidence that the magnitude is increasing. Public health actions to address the high burden of cardiovascular and respiratory diseases, as well as the increasing magnitude of DM in Ethiopia, must be prioritized. Systematic review registration: PROSPERO [CRD42020196815].

Explaining health inequalities in Australia: the contribution of income, wealth and employment.

BACKGROUND: Studies show widespread widening of socioeconomic and health inequalities. Comprehensive primary health care has a focus on equity and to enact this requires more data on drivers of the increase in inequities. Hence, we examined trends in the distribution of income, wealth, employment and health in Australia. METHODS: We analysed data from the Public Health Information Development Unit and Australian Bureau of Statistics. Inequalities were assessed using rate ratios and the slope index of inequality. RESULTS: We found that the social gradient in health, income, wealth and labour force participation has steepened in Australia, and inequalities widened between the quintile living in the most disadvantaged areas and the quintile living in the least disadvantaged areas. CONCLUSION: Widening income, wealth and employment inequalities have been accompanied by increasing health inequalities, and have reinforced and amplified adverse health effects, leading to increased mortality inequality. Effective comprehensive primary health care needs to be informed by an understanding of structural factors driving economic and health inequities.

The Magnitude of NCD Risk Factors in Ethiopia: Meta-Analysis and Systematic Review of Evidence.

BACKGROUND: Non-communicable Diseases (NCDs) and their risk factors are the leading contributors to morbidity and mortality globally, particularly in low- and middle-income countries including Ethiopia. To date, there has been no synthesis of the literature on the relative prevalence of NCD risk factors in Ethiopia. METHODOLOGY: We conducted a systematic review and meta-analysis of primary studies reporting on the prevalence of NCD risk factors in Ethiopia published in English from 2012 to July 2020. Pre-tested NCD search terms were applied to Medline, Embase, Scopus, CINAHL, and Global Health. Three reviewers screened and appraised the quality of the identified papers. Data extraction was conducted using a pilot tested proforma. Meta-analysis was conducted using Stata 16 and pooled prevalence estimated with associated 95% confidence intervals. Clinically heterogeneous studies that did not fulfil the eligibility criteria for meta-analysis were narratively synthesised. I2 was used to assess statistical heterogeneity. RESULTS: 47 studies fulfilled the inclusion criteria and contributed 68 NCD risk factor prevalence estimates. Hypertension was the most frequently examined NCD risk factor, with a pooled prevalence of 21% (n = 27 studies). The pooled prevalence percentages for overweight and obesity were 19.2% and 10.3%, respectively (n = 7 studies each), with a combined prevalence of 26.8% (n = 1 study). It was not possible to pool the prevalence of alcohol consumption, smoking, metabolic disorders, or fruit consumption because of heterogeneity across studies. The prevalence of alcohol use, as reported from the included individual studies, ranged from 12.4% to 13.5% (n = 7 studies). More than 90% of participants met the WHO-recommended level of physical activity (n = 5 studies). The prevalence of smoking was highly variable, ranging between 0.8% and 38.6%, as was the prevalence of heavy alcohol drinking (12.4% to 21.1%, n = 6 studies) and metabolic syndrome (4.8% to 9.6%, n = 5 studies). Fruit consumption ranged from 1.5% up to the recommended level, but varied across geographic areas (n = 3 studies). CONCLUSION AND RECOMMENDATIONS: The prevalence of NCD risk factors in Ethiopia is relatively high. National NCD risk factor surveillance is required to inform the prioritisation of policies and interventions to reduce the NCD burden in Ethiopia.

Characteristics and impacts ofSystematic review nutritional programmes to address undernutrition of adults living with HIV in sub-Saharan Africa: a systematic review of evidence.

OBJECTIVES: Although some studies have identified various challenges affecting nutritional programmes to effectively tackle undernutrition among people living with HIV, evidence about the characteristics and impacts of these programmes on weight-related nutritional outcomes varies based on country contexts, specific programme goals and the implementation processes. This systematic review sought to synthesise evidence on the characteristics and impact of nutritional programmes on weight-related nutritional outcomes of people living with HIV in sub-Saharan Africa. DESIGN: Systematic review. DATA SOURCES: We searched for primary studies published in the following databases: Web of Science, Medline, Scopus, ScienceDirect, ProQuest and Google Scholar, supplemented by checking reference lists of included papers. ELIGIBILITY CRITERIA: Studies published from 2005 to 10 July 2020 and reporting on the weight-related nutritional outcomes of undernourished people enrolled in nutritional programmes in HIV care in sub-Saharan Africa were included. DATA EXTRACTION AND SYNTHESIS: Data were extracted using a data extraction proforma. Weight-related nutritional outcomes of people living with HIV before and after enrolment in a nutritional programme were compared and narratively synthesised. RESULTS: Sixteen studies assessing the impact of nutritional programmes in HIV care on weight-related nutritional outcomes were included. Of these, 13 examined nutritional programmes implemented in health facilities and the remaining three were delivered outside of health facilities. Nutritional recovery (defined differently in the studies) ranged from 13.1% to 67.9%. Overall programme failure rate, which included default after enrolment in a nutritional programme or non-response, ranged from 37.6% to 48.0%. More specifically, non-response to a nutritional programme ranged from 21.0% to 67.4% and default from the programme ranged from 19.0% to 70.6%. Key sociodemographic, clinical and nutritional characteristics that affect nutritional recovery, non-response and default were also identified. CONCLUSIONS AND RECOMMENDATIONS: Nutritional programmes in HIV care have led to some improvements in weight-related nutritional outcomes among people living with HIV. However, the programmes were characterised by a high magnitude of default and non-response. To improve desired weight-related nutritional outcomes of people living with HIV, a holistic approach that addresses longer-term determinants of undernutrition is needed. PROSPERO REGISTRATION NUMBER: CRD42020196827.

Mapping national, regional and local prevalence of hypertension and diabetes in Ethiopia using geospatial analysis.

OBJECTIVES: This study aimed to map the national, regional and local prevalence of hypertension and diabetes in Ethiopia. DESIGN AND SETTING: Nationwide cross-sectional survey in Ethiopia combined with georeferenced ecological level data from publicly available sources. PARTICIPANTS: 9801 participants aged between 15 and 69 years. PRIMARY OUTCOME MEASURES: Prevalence of hypertension and diabetes were collected using the WHO's STEPS survey approach. Bayesian model-based geostatistical techniques were used to estimate hypertension and diabetes prevalence at national, regional and pixel levels (1×1 km2) with corresponding 95% credible intervals (95% CrIs). RESULTS: The national prevalence was 19.2% (95% CI: 18.4 to 20.0) for hypertension and 2.8% (95% CI: 2.4 to 3.1) for diabetes. Substantial variation was observed in the prevalence of these diseases at subnational levels, with the highest prevalence of hypertension observed in Addis Ababa (30.6%) and diabetes in Somali region (8.7%). Spatial overlap of high hypertension and diabetes prevalence was observed in some regions such as the Southern Nations, Nationalities and People's region and Addis Ababa. Population density (number of people/km2) was positively associated with the prevalence of hypertension (ß: 0.015; 95% CrI: 0.003-0.027) and diabetes (ß: 0.046; 95% CrI: 0.020-0.069); whereas altitude in kilometres was negatively associated with the prevalence of diabetes (ß: -0.374; 95% CrI: -0.711 to -0.044). CONCLUSIONS: Spatial clustering of hypertension and diabetes was observed at subnational and local levels in Ethiopia, which was significantly associated with population density and altitude. The variation at the subnational level illustrates the need to include environmental drivers in future NCDs burden estimation. Thus, targeted and integrated interventions in high-risk areas might reduce the burden of hypertension and diabetes in Ethiopia.

The COVID-19 pandemic and healthcare systems in Africa: a scoping review of preparedness, impact and response.

BACKGROUND: The COVID-19 pandemic has overwhelmed health systems in both developed and developing nations alike. Africa has one of the weakest health systems globally, but there is limited evidence on how the region is prepared for, impacted by and responded to the pandemic. METHODS: We conducted a scoping review of PubMed, Scopus, CINAHL to search peer-reviewed articles and Google, Google Scholar and preprint sites for grey literature. The scoping review captured studies on either preparedness or impacts or responses associated with COVID-19 or covering one or more of the three topics and guided by Arksey and O'Malley's methodological framework. The extracted information was documented following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension checklist for scoping reviews. Finally, the resulting data were thematically analysed. RESULTS: Twenty-two eligible studies, of which 6 reported on health system preparedness, 19 described the impacts of COVID-19 on access to general and essential health services and 7 focused on responses taken by the healthcare systems were included. The main setbacks in health system preparation included lack of available health services needed for the pandemic, inadequate resources and equipment, and limited testing ability and surge capacity for COVID-19. Reduced flow of patients and missing scheduled appointments were among the most common impacts of the COVID-19 pandemic. Health system responses identified in this review included the availability of telephone consultations, re-purposing of available services and establishment of isolation centres, and provisions of COVID-19 guidelines in some settings. CONCLUSIONS: The health systems in Africa were inadequately prepared for the pandemic, and its impact was substantial. Responses were slow and did not match the magnitude of the problem. Interventions that will improve and strengthen health system resilience and financing through local, national and global engagement should be prioritised.

The impact of war on the health system of the Tigray region in Ethiopia: an assessment.

The war in Tigray region of Ethiopia that started in November 2020 and is still ongoing has brought enormous damage to the health system. This analysis provides an assessment of the health system before and during the war. Evidence of damage was compiled from November 2020 to June 2021 from various reports by the interim government of Tigray, and also by international non-governmental organisations. Comparison was made with data from the prewar calendar year. Six months into the war, only 30% of hospitals, 17% of health centres, 11.5% of ambulances and none of the 712 health posts were functional. As of June 2021, the population in need of emergency food assistance in Tigray increased from less than one million to over 5.2 million. While the prewar performance of antenatal care, supervised delivery, postnatal care and children vaccination was 64%, 73%, 63% and 73%, respectively, but none of the services were likely to be delivered in the first 90 days of the war. A conservative estimate places the number of girls and women raped in the first 5 months of the war to be 10 000. These data indicate a widespread destruction of livelihoods and a collapse of the healthcare system. The use of hunger and rape as a weapon of war and the targeting of healthcare facilities are key components of the war. To avert worsening conditions, an immediate intervention is needed to deliver food and supplies and rehabilitate the healthcare delivery system and infrastructure.

Experience of nutritional counselling in a nutritional programme in HIV care in the Tigray region of Ethiopia using the socio-ecological model.

BACKGROUND: In many resource-poor settings, nutritional counselling is one of the key components of nutrition support programmes aiming to improve nutritional and health outcomes amongst people living with HIV. Counselling methods, contents and recommendations that are culturally appropriate, locally tailored and economically affordable are essential to ensure desired health and nutritional outcomes are achieved. However, there is little evidence showing the effectiveness of counselling in nutritional programmes in HIV care, and the extent to which counselling policies and guidelines are translated into practice and utilised by people with HIV suffering from undernutrition. This study aimed to explore these gaps in the Tigray region of Ethiopia. METHODS AND PARTICIPANTS: A qualitative study was conducted in Tigray region Ethiopia between May and August 2016. Forty-eight individual interviews were conducted with 20 undernourished adults living with HIV and 15 caregivers of children living with HIV enrolled in a nutritional programme in three hospitals, as well as 11 health providers, and 2 programme managers. Data analysis was undertaken using the Framework approach and guided by the socio-ecological model. Qualitative data analysis software (QSR NVivo 11) was used to assist data analysis. The study findings are presented using the consolidated criteria for the reporting of qualitative research (COREQ). RESULT: The study highlighted that nutritional counselling as a key element of the nutritional programme in HIV care varied in scope, content, and length. Whilst the findings clearly demonstrated the acceptability of the nutritional counselling for participants, a range of challenges hindered the application of counselling recommendations in participants' everyday lives. Identified challenges included the lack of comprehensiveness of the counselling in terms of providing advice about the nutritional support and dietary practice, participants' poor understanding of multiple issues related to nutrition counselling and the nutrition programme, lack of consistency in the content, duration and mode of delivery of nutritional counselling, inadequate refresher training for providers and the absence of socioeconomic considerations in nutritional programme planning and implementation. Evidence from this study suggests that counselling in nutritional programmes in HIV care was not adequately structured and lacked a holistic and comprehensive approach. CONCLUSION: Nutritional counselling provided to people living with HIV lacks comprehensiveness, consistency and varies in scope, content and duration. To achieve programme goal of improved nutritional status, counselling guidelines and practices should be structured in a way that takes a holistic view of patient's life and considers cultural and socioeconomic situations. Additionally, capacity development of nutritional counsellors and health providers is highly recommended to ensure counselling provides assistance to improve the nutritional well-being of people living with HIV.

COVID-19 in Ethiopia: a geospatial analysis of vulnerability to infection, case severity and death.

BACKGROUND: COVID-19 has caused a global public health crisis affecting most countries, including Ethiopia, in various ways. This study maps the vulnerability to infection, case severity and likelihood of death from COVID-19 in Ethiopia. METHODS: Thirty-eight potential indicators of vulnerability to COVID-19 infection, case severity and likelihood of death, identified based on a literature review and the availability of nationally representative data at a low geographic scale, were assembled from multiple sources for geospatial analysis. Geospatial analysis techniques were applied to produce maps showing the vulnerability to infection, case severity and likelihood of death in Ethiopia at a spatial resolution of 1 km×1 km. RESULTS: This study showed that vulnerability to COVID-19 infection is likely to be high across most parts of Ethiopia, particularly in the Somali, Afar, Amhara, Oromia and Tigray regions. The number of severe cases of COVID-19 infection requiring hospitalisation and intensive care unit admission is likely to be high across Amhara, most parts of Oromia and some parts of the Southern Nations, Nationalities and Peoples' Region. The risk of COVID-19-related death is high in the country's border regions, where public health preparedness for responding to COVID-19 is limited. CONCLUSION: This study revealed geographical differences in vulnerability to infection, case severity and likelihood of death from COVID-19 in Ethiopia. The study offers maps that can guide the targeted interventions necessary to contain the spread of COVID-19 in Ethiopia.

Risk factors for COVID-19 infection, disease severity and related deaths in Africa: a systematic review.

OBJECTIVE: The aim of this study was to provide a comprehensive evidence on risk factors for transmission, disease severity and COVID-19 related deaths in Africa. DESIGN: A systematic review has been conducted to synthesise existing evidence on risk factors affecting COVID-19 outcomes across Africa. DATA SOURCES: Data were systematically searched from MEDLINE, Scopus, MedRxiv and BioRxiv. ELIGIBILITY CRITERIA: Studies for review were included if they were published in English and reported at least one risk factor and/or one health outcome. We included all relevant literature published up until 11 August 2020. DATA EXTRACTION AND SYNTHESIS: We performed a systematic narrative synthesis to describe the available studies for each outcome. Data were extracted using a standardised Joanna Briggs Institute data extraction form. RESULTS: Fifteen articles met the inclusion criteria of which four were exclusively on Africa and the remaining 11 papers had a global focus with some data from Africa. Higher rates of infection in Africa are associated with high population density, urbanisation, transport connectivity, high volume of tourism and international trade, and high level of economic and political openness. Limited or poor access to healthcare are also associated with higher COVID-19 infection rates. Older people and individuals with chronic conditions such as HIV, tuberculosis and anaemia experience severe forms COVID-19 leading to hospitalisation and death. Similarly, high burden of chronic obstructive pulmonary disease, high prevalence of tobacco consumption and low levels of expenditure on health and low levels of global health security score contribute to COVID-19 related deaths. CONCLUSIONS: Demographic, institutional, ecological, health system and politico-economic factors influenced the spectrum of COVID-19 infection, severity and death. We recommend multidisciplinary and integrated approaches to mitigate the identified factors and strengthen effective prevention strategies.

Relapse into Undernutrition in a Nutritional Program in HIV Care and the Impact of Food Insecurity: A Mixed-Methods Study in Tigray Region, Ethiopia.

The relapse into undernutrition after nutritional recovery among those enrolled in a nutritional program is a common challenge of nutritional programs in HIV care settings, but there is little evidence on the determinants of the relapse. Nutritional programs in HIV care settings in many countries are not well designed to sustain the gains obtained from enrolment in a nutritional program. This study examined relapse into undernutrition and associated factors among people living with HIV in the Tigray region of Ethiopia. The study employed a mixed-methods approach, involving quantitative and qualitative studies. Among those who graduated from the nutritional program, 18% of adults and 7% of children relapsed into undernutrition. The mean time to relapse for adults was 68.5 months (95% CI, 67.0-69.9). Various sociodemographic, clinical, and nutritional characteristics were associated with a relapse into undernutrition. A considerable proportion of adults and children relapsed after nutritional recovery. Food insecurity and poor socioeconomic status were a common experience among those enrolled in the nutritional program. Hence, nutritional programs should design strategies to sustain the nutritional gains of those enrolled in the nutritional programs and address the food insecurity which was reported as one of the contributors to relapse into undernutrition among the program participants.

Stigma and discrimination: barriers to the utilisation of a nutritional program in HIV care services in the Tigray region, Ethiopia.

BACKGROUND: In Ethiopia, stigmatising attitudes towards people living with HIV have reduced over time. This is mainly due to improved HIV knowledge and the expansion of access to HIV care and support services. However, HIV stigma and discrimination remain a key challenge and have negative impacts on access to and utilisation of HIV services including nutritional programs in the HIV care setting. A small number of studies have examined the experience of stigma related to nutritional programs, but this is limited. This study explored HIV status disclosure and experience of stigma related to a nutritional program in HIV care settings in Ethiopia and impacts on nutritional program utilisation. METHODS: As part of a larger study, qualitative in-depth interviews were conducted with 20 adults living with HIV, 15 caregivers of children living with HIV and 13 program staff working in the nutritional program in three hospitals in the Tigray region of Northern Ethiopia. Framework thematic analysis was employed to analyse the data and NVivo 11 was used to analyse the qualitative interview data. This study is presented based on the consolidated criteria for reporting of qualitative research (COREQ). RESULTS: The study found varying levels of positive HIV status disclosure, depending on who the target of disclosure was. Disclosing to family members was reported to be less problematic by most participants. Despite reported benefits of the nutritional program in terms of improving weight and overall health status, adults and caregivers of children living with HIV revealed experiences of stigma and discrimination that were amplified by enrolment to the nutritional program and concerns about unwanted disclosure of positive HIV status. This was due to: a) transporting, consuming and disposing of the nutritional support (Plumpynut/sup) itself, which is associated with HIV in the broader community; b) required increased frequency of visits to HIV services for those enrolled in the nutritional program and associated greater likelihood of being seen there. CONCLUSION: There was evidence of concerns about HIV-related stigma and discrimination among individuals enrolled in this program and their family members, which in turn negatively affected the utilisation of the nutritional program and the HIV service more broadly. Stigma and discrimination are a source of health inequity and undermine access to the nutritional program and other HIV services. Nutritional programs in HIV care should include strategies to take these concerns into account by mainstreaming stigma prevention and mitigation activities. Further research should be done to identify innovative ways of facilitating social inclusion to mitigate stigma and improve utilisation.

Economic evaluations considering costs and outcomes of diabetic foot ulcer infections: A systematic review.

BACKGROUND: Diabetic foot ulcer (DFU) is a severe complication of diabetes and particularly susceptible to infection. DFU infection intervention efficacy is declining due to antimicrobial resistance and a systematic review of economic evaluations considering their economic feasibility is timely and required. AIM: To obtain and critically appraise all available full economic evaluations jointly considering costs and outcomes of infected DFUs. METHODS: A literature search was conducted across MedLine, CINAHL, Scopus and Cochrane Database seeking evaluations published from inception to 2019 using specific key concepts. Eligibility criteria were defined to guide study selection. Articles were identified by screening of titles and abstracts, followed by a full-text review before inclusion. We identified 352 papers that report economic analysis of the costs and outcomes of interventions aimed at diabetic foot ulcer infections. Key characteristics of eligible economic evaluations were extracted, and their quality assessed against the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. RESULTS: 542 records were screened and 39 full-texts assessed for eligibility. A total of 19 papers were included in the final analysis. All studies except one identified cost-saving or cost-effective interventions. The evaluations included in the final analysis were so heterogeneous that comparison of them was not possible. All studies were of "excellent", "very good" or "good" quality when assessed against the CHEERS checklist. CONCLUSIONS: Consistent identification of cost-effective and cost-saving interventions may help to reduce the DFU healthcare burden. Future research should involve clinical implementation of interventions with parallel economic evaluation rather than model-based evaluations.

Contextual and individual level factors influencing nutritional program effectiveness in HIV care setting in Tigray region, northern Ethiopia: Mixed methods study.

INTRODUCTION: Addressing malnutrition is one of the key components of HIV care among people living with HIV. Since 2010, a nutritional program has been implemented to address malnutrition amongst HIV patients in Ethiopia, with patients enrolled in the program for 3 months (for mild acute malnutrition) and 6 months (for severe acute malnutrition). However, utilisation and effectiveness of the nutritional programs remain unexplored. This study aimed to examine individual level determinants and contextual factors influencing the effectiveness of the nutritional program in the Tigray region of Ethiopia. METHODS AND SETTING: The study employed a mixed-methods approach involving quantitative and qualitative research methods. In the quantitative phase of the study, records from 1757 adult patients, including socio-demographic characteristics, clinical and nutritional program outcomes were retrieved from three selected hospitals in the Tigray region, Ethiopia. Logistic regression analysis was used to identify the individual demographic and socioeconomic, clinical and immunological, and anthropometric and nutritional determinants of nutritional outcomes. The qualitative study included 33 individual interviews with adult patients, health providers, and program managers. Interview data were analysed using a framework analysis approach. RESULTS: Amongst study participants, 55.3% (95% CI = 53.2‒57.4) recovered from malnutrition, 19% (95% CI, 17.3‒20.7) did not complete the program, and 21% (95% CI = 19.7‒23.4) completed the program but failed to recover from malnutrition. In the multivariable logistic regression analysis, those who were: living in urban areas (AOR = 1.44, 95% CI = 1.05‒1.97), employed (AOR = 1.39, 95% CI = 1.01‒1.93), attending Shul (AOR = 4.6, 95% CI = 3.15‒6.71) and Lemlem Karl (AOR = 2.5, 95% CI = 1.69‒3.71) hospitals, in clinical stages II (AOR = 2.49, 95% CI = 1.59‒3.91) and III (AOR = 1.46(1.02‒2.07), on ART for less than six months (AOR = 1.61, 95% CI = 1.09‒2.39), anaemic (AOR = 1.77, 95% = 1.29‒2.41), and diagnosed with severe acute malnutrition at enrolment (AOR = 6.43, 95% CI = 4.69‒8.3); were less likely to complete the program. Results for those who completed the program indicated that urban residence, (AOR = 1.46, 95% CI = 1.4‒2.91), attending Shul (AOR = 2.92, 95% CI = 2.04‒4.19) and Lemlem Karl (AOR = 1.49, 95% CI 1.05‒2.11) hospitals, having bedridden functional status (AOR = 0.36, 95% CI = 0.15‒0.83), advanced WHO clinical stage (WHO clinical stage IV) (AOR = 0.52, 95% CI = 0.28‒0.98) and severe malnutrition at enrolment (AOR = 4.25, 95% CI = 3.02‒5.98)) predicted non-response to the nutritional program. Qualitative interviews revealed that the taste and perceived side effects of the nutritional supplement provided as part of the nutritional program, sharing/selling practices, religious and sociocultural issues, distance and poor access to the health services were barriers to program utilisation. Nutritional counselling and health service-related factors such as a previous enrolment in the program and positive experience in the health service were enablers of program utilisation. CONCLUSION: There was a clear nexus between contextual factors such as distance, quality of health service and sociocultural factors, and individual patient characteristics with the effectiveness of the nutritional program. Taking individual and contextual factors into consideration in program design, planning and implementation is essential if the nutritional program in HIV care services is to achieve its goal in addressing malnutrition amongst people living with HIV.

Burden of disease attributable to suboptimal diet, metabolic risks and low physical activity in Ethiopia and comparison with Eastern sub-Saharan African countries, 1990-2015: findings from the Global Burden of Disease Study 2015.

BACKGROUND: Twelve of the 17 Sustainable Development Goals (SDGs) are related to malnutrition (both under- and overnutrition), other behavioral, and metabolic risk factors. However, comparative evidence on the impact of behavioral and metabolic risk factors on disease burden is limited in sub-Saharan Africa (SSA), including Ethiopia. Using data from the Global Burden of Disease (GBD) Study, we assessed mortality and disability-adjusted life years (DALYs) attributable to child and maternal undernutrition (CMU), dietary risks, metabolic risks and low physical activity for Ethiopia. The results were compared with 14 other Eastern SSA countries. METHODS: Databases from GBD 2015, that consist of data from 1990 to 2015, were used. A comparative risk assessment approach was utilized to estimate the burden of disease attributable to CMU, dietary risks, metabolic risks and low physical activity. Exposure levels of the risk factors were estimated using spatiotemporal Gaussian process regression (ST-GPR) and Bayesian meta-regression models. RESULTS: In 2015, there were 58,783 [95% uncertainty interval (UI): 43,653-76,020] or 8.9% [95% UI: 6.1-12.5] estimated all-cause deaths attributable to CMU, 66,269 [95% UI: 39,367-106,512] or 9.7% [95% UI: 7.4-12.3] to dietary risks, 105,057 [95% UI: 66,167-157,071] or 15.4% [95% UI: 12.8-17.6] to metabolic risks and 5808 [95% UI: 3449-9359] or 0.9% [95% UI: 0.6-1.1] to low physical activity in Ethiopia. While the age-adjusted proportion of all-cause mortality attributable to CMU decreased significantly between 1990 and 2015, it increased from 10.8% [95% UI: 8.8-13.3] to 14.5% [95% UI: 11.7-18.0] for dietary risks and from 17.0% [95% UI: 15.4-18.7] to 24.2% [95% UI: 22.2-26.1] for metabolic risks. In 2015, Ethiopia ranked among the top four countries (of 15 Eastern SSA countries) in terms of mortality and DALYs based on the age-standardized proportion of disease attributable to dietary and metabolic risks. CONCLUSIONS: In Ethiopia, while there was a decline in mortality and DALYs attributable to CMU over the last two and half decades, the burden attributable to dietary and metabolic risks have increased during the same period. Lifestyle and metabolic risks of NCDs require more attention by the primary health care system of the country.

Prevalence and predictors of implanon utilization among women of reproductive age group in Tigray Region, Northern Ethiopia.

BACKGROUND: The Ethiopian Federal Ministry of Health introduced provision of the contraceptive Implanon at community level by trained health extension workers in 2009. However, little is known regarding the utilization and factors associated with Implanon use among rural women since the introduction of the community based intervention. Thus, this study assessed the utilization of Implanon and associated factors among reproductive aged women in rural areas of Saesie-Tsaeda Emba and Ofla districts in Tigray, Northern Ethiopia. METHODS: A cross sectional community based survey was conducted in May and June 2014. A multistage sampling technique was used to randomly select 524 reproductive aged women (15-49 years). Data was collected through interview using a pre-tested and structured questionnaire. Univariate analysis was done to determine the prevalence for Implanon use, to assess general characteristics of respondents, and to produce summaries. Bivariate analysis was conducted to examine the relationship between each independent variable with the dependent variable. Multivariate logistic regression was conducted to identify factors influencing Implanon use by controlling effect of confounding variables. RESULTS: Of all the women, 444 (84.7%) had heard of Implanon. Health extension workers were the primary source of information on Implanon as mentioned by 376 (71.8%) of the respondents. Little more than seven women in every ten, 319 (71.8%), had good knowledge of Implanon and 248 (55.5%) of the women had supportive attitudes towards Implanon use. Among our sample, 10.1% women were using Implanon, 33 (62.3%) reported having received their Implanon at a health post from health extension worker. Women's employment (AOR: 2.73, 95% CI: 1.20-6.21), the number of modern contraceptive methods known (AOR: 2.24, 95% CI: 1.09-4.62), and the number of contraceptive methods ever used (AOR: 11.0, 95% CI: 5.06-23.90) were positively associated with Implanon use. CONCLUSION: Trained health extension workers played a major role in information and service provision of Implanon. However, this study revealed that a significant number of women had incorrect information regarding Implanon. Hence, health extension workers and other health professionals should provide appropriate counseling and education regarding Implanon and other contraceptives.