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.

Engaging communities as partners in health crisis response: a realist-informed scoping review for research and policy.

BACKGROUND: Health is increasingly affected by multiple types of crises. Community engagement is recognised as being a critical element in successful crisis response, and a number of conceptual frameworks and global guideline documents have been produced. However, little is known about the usefulness of such documents and whether they contain sufficient information to guide effective community engagement in crisis response. We undertake a scoping review to examine the usefulness of conceptual literature and official guidelines on community engagement in crisis response using a realist-informed analysis [exploring contexts, mechanisms, and outcomes(CMOs)]. Specifically, we assess the extent to which sufficient detail is provided on specific health crisis contexts, the range of mechanisms (actions) that are developed and employed to engage communities in crisis response and the outcomes achieved. We also consider the extent of analysis of interactions between the mechanisms and contexts which can explain whether successful outcomes are achieved or not. SCOPE AND FINDINGS: We retained 30 documents from a total of 10,780 initially identified. Our analysis found that available evidence on context, mechanism and outcomes on community engagement in crisis response, or some of their elements, was promising, but few documents provided details on all three and even fewer were able to show evidence of the interactions between these categories, thus leaving gaps in understanding how to successfully engage communities in crisis response to secure impactful outcomes. There is evidence that involving community members in all the steps of response increases community resilience and helps to build trust. Consistent communication with the communities in time of crisis is the key for effective responses and helps to improve health indicators by avoiding preventable deaths. CONCLUSIONS: Our analysis confirms the complexity of successful community engagement and the need for strategies that help to deal with this complexity to achieve good health outcomes. Further primary research is needed to answer questions of how and why specific mechanisms, in particular contexts, can lead to positive outcomes, including what works and what does not work and how to measure these processes.

Undernutrition in children under five associated with wealth-related inequality in 24 low- and middle-income countries from 2017 to 2022.

Undernourishment is a persistent public health problem contributing to increased mortality in children under five in low-income countries, likely exacerbated by socio-economic disparities within communities. This paper aimed to examine the effect of wealth-related inequality on undernutrition in children under five in low, lower-middle, and upper-middle-income countries (LMICs). We analyzed cross-sectional data from the demographic and health survey program collected between 2017 and 2022 from 24 LMICs. Children born within 5 years preceding the survey were included in the analysis. Child undernutrition was the dependent variable (measured by stunting, wasting, and underweight) and country-level wealth-based inequality was the independent variable assessed by concentration index values stratified by the World Bank's income categories. Within country inequality of child undernutrition was determined by concentration index (C) values with 95% confidence intervals (95% CI) and sub-group analysis by place of residence and sex of the child. We then fit bootstrapped meta-regression to check the variation in inequality of child undernutrition across different income category countries. The analysis was controlled by potential confounding variables. From the total sample size of 334,502 children included in the study, 35% were undernourished. Wealth-related inequality in child undernutrition was observed in 11 countries, consistently across income categories. Child undernutrition was highly concentrated among the poor households of Türkiye [C: - 0.26, 95% CI - 0.31 to - 0.20], and Cameroon [C: - 0.19, 95% CI - 0.22 to - 0.17], and relatively it was less concentrated among the poor in Liberia [C: - 0.07, 95% CI - 0.11 to - 0.04], and Gambia [C: - 0.07, 95% CI - 0.11 to - 0.04]. There is no difference in undernutrition associated with inequality between the three broad LMIC categories. The wealth-related inequality in child undernutrition within many of the included countries is still very significant. However, the economic category of countries made no difference in explaining wealth-related inequality in child undernutrition. Inter-sectoral collaboration to fight poverty and render special attention to the disadvantaged population segments would potentially help to address the observed inequity.

Trends in social determinants of inequality in child undernutrition from the Ethiopian Demographic and Health Surveys, 2005-2016.

BACKGROUND: While child undernutrition has been eliminated in some middle-income countries, it remains highly prevalent in sub-Sahara African (SSA) and South Asian regions, and is disproportionately concentrated among the poor. In this study, we estimated trends in child undernutrition by social determinants and related risks from wealth inequality in Ethiopia, from 2005 to 2016. METHOD: We analyzed data from three consecutive surveys (2005, 2011, and 2016) from the Ethiopian Demographic and Health Survey. First, we estimated trends in the prevalence of childhood undernutrition variables (stunting, underweight, and wasting) and social determinants (household wealth status, education level, place of residence, and administrative regions). Then we assessed evidence of undernutrition by wealth-related inequality with concentration curves (visual) and concentration indeces (quantitative). A multilevel mixed-effect Poisson regression model was used to identify predictors of undernutrition variables expressed as covariate-adjusted rate ratios, with 95% confidence intervals (RRs, 95%CI). RESULT: A total of 23,934 mother-child pairs were obtained from the three surveys. The average prevalence decreased by 12.4 percentage points for stunting (from 50.8 to 38.4%, P<0.01), 9.5 percentage points for underweight (33.2% to23.7%, P<0.01), and 2.1 percentage points for wasting (12.2% to10.1%, P<0.01). There was persistent and statistically evidence of wealth inequality in stunting, underweight, and wasting (concentration indeces of -0.2 to -0.04, all P values <0.05). Stunting, underweight, and wasting variables were associated with male sex of the child (RR 0.94, 0.95, 0.85, all P-values <0.01) recent diarrhea (RR 1.18, 1.27, 1.37, all P-values <0.01), secondary education status of the mother (RR 0.66, 0.57, 0.61, all P-values < 0.057), increasing wealth index (richest) (RR 0.73, 0.70, 0.50, all P-values < 0.05), and having no toilet facility (RR 1.16, 1.22, 1.18, all P-values < 0.05). CONCLUSION: Despite the decreased burden of stunting and underweight, the prevalence of wasting remained relatively unchanged in Ethiopia from 2005 to 2016. Moreover, wealth-related inequality in child undernutrition increased for most of the child undernutrition indicators during this period. Social determinants of child undernutrition warrant urgent implementation of strategies to reduce their health impacts in SSA.

Adherence to evidence-based implementation of antimicrobial treatment guidelines among prescribers in sub-Saharan Africa: a systematic review and meta-analysis.

BACKGROUND: Adherence to evidence-based standard treatment guidelines (STGs) enable healthcare providers to deliver consistently appropriate diagnosis and treatment. Irrational use of antimicrobials significantly contributes to antimicrobial resistance in sub-Saharan Africa (SSA).  The best available evidence is needed to guide healthcare providers on adherence to evidence-based implementation of STGs. This systematic review and meta-analysis aimed to determine the pooled prevalence of adherence to evidence-based implementation of antimicrobial treatment guidelines among prescribers in SSA. METHODS: The review followed the JBI methodology for systematic reviews of prevalence data. CINAHL, Embase, PubMed, Scopus, and Web of Science databases were searched with no language and publication year limitations. STATA version 17 were used for meta-analysis. The publication bias and heterogeneity were assessed using Egger's test and the I2 statistics. Heterogeneity and publication bias were validated using Duval and Tweedie's nonparametric trim and fill analysis using the random-effect analysis. The summary prevalence and the corresponding 95% confidence interval (CI) of healthcare professionals' compliance with evidence-based implementation of STG were estimated using random effect model. The review protocol has been registered with PROSPERO code CRD42023389011. The PRISMA flow diagram and checklist were used to report studies included, excluded and their corresponding section in the manuscript. RESULTS: Twenty-two studies with a total of 17,017 study participants from 14 countries in sub-Saharan Africa were included. The pooled prevalence of adherence to evidence-based implementation of antimicrobial treatment guidelines in SSA were 45%. The pooled prevalence of the most common clinical indications were respiratory tract (35%) and gastrointestinal infections (18%). Overall prescriptions per wards were inpatients (14,413) and outpatients (12,845). Only 391 prescribers accessed standard treatment guidelines during prescription of antimicrobials. CONCLUSIONS: Healthcare professionals' adherence to evidence-based implementation of STG for antimicrobial treatment were low in SSA. Healthcare systems in SSA must make concerted efforts to enhance prescribers access to STGs through optimization of mobile clinical decision support applications. Innovative, informative, and interactive strategies must be in place by the healthcare systems in SSA to empower healthcare providers to make evidence-based clinical decisions informed by the best available evidence and patient preferences, to ultimately improving patient outcomes and promoting appropriate antimicrobial use.

Evaluating equity across the continuum of care for maternal health services: analysis of national health surveys from 25 sub-Saharan African countries.

BACKGROUND: Ensuring access to the continuum of care for maternal, neonatal, and child health is an effective strategy for reducing maternal and child mortality. We investigated the extent of dropout, wealth-related inequalities, and drivers of inequality in the continuum of care for maternal health services in sub-Saharan Africa. METHODS: We analysed Demographic and Health Surveys (DHS) conducted between 2013 and 2019 across 25 sub-Saharan African countries. We defined the continuum of care for maternal health services as women who had received at least four ANC contacts (ANC 4 + contacts), skilled care at birth, and immediate postnatal care (PNC). We used concentration index to estimate wealth-related inequalities across the continuum of care. Multilevel logistic regression models were used to identify predictors of inequality in completing the continuum of care. RESULTS: We included data on 196,717 women with the most recent live birth. About 87% of women reported having at least one ANC contact, but only 30% of women received the recommended care package that includes ANC 4 + contacts, skilled care at birth, and PNC. The proportion of women who had completed the continuum of care ranged from 6.5% in Chad to 69.5% in Sierra Leone. Nearly 9% of women reported not having contact with the health system during pregnancy or childbirth; this ranged from 0.1% in Burundi to 34% in Chad. Disadvantaged women were more likely to have no contact with health systems and less likely to have the recommended care package than women from wealthier households. Women with higher education levels, higher exposure to mass media (radio and TV), and higher household wealth status had higher odds of completing the continuum of care. CONCLUSIONS: Persistent and increasing inequalities were observed along the continuum of care from pregnancy to the postnatal period, with socioeconomically disadvantaged women more likely to drop out of care. Improving access to and integration of services is required to improve maternal health. Initiatives and efforts to improve maternal health should prioritise and address the needs of communities and groups with low coverage of maternal health services.

Mapping the range of policies relevant to care of small and nutritionally at-risk infants under 6 months and their mothers in Ethiopia: a scoping review protocol.

INTRODUCTION: Evidence gaps limit management of small and/or nutritionally at-risk infants under 6 months and their mothers, who are at higher risk of death, illness, malnutrition and poor growth and development. These infants may be low birth weight, wasted, stunted and/or underweight. An integrated care model to guide their management (MAMI Care Pathway) is being tested in a randomised controlled trial in Ethiopia. Evaluating the extent to which an innovation is consistent with national policies and priorities will aid evidence uptake and plan for scale. METHODS AND ANALYSIS: This review will evaluate the extent to which the MAMI Care Pathway is consistent with national policies that relate to the care of at-risk infants under 6 months and their mothers in Ethiopia. The objectives are to describe the range and characteristics, concepts, strategic interventions, coherence and alignment of existing policies and identify opportunities and gaps. It will be conducted in accordance with the JBI methodology for scoping reviews (PRISMA-ScR). Eligible documents include infant and maternal health, nutrition, child development, food and social welfare-related policies publicly available in English and Amharic. The protocol was registered on the Open Science Framework Registry on 20 June 2022 (https://osf.io/m4jt6).Grey literature will be identified through government and agency websites, national and subnational contacts and Google Scholar, and published policies through electronic database searches (MEDLINE, EMBASE and Global and Health Information). The searches will take place between October 2023 and March 2024. A standardised data extraction tool will be used. Descriptive analysis of data will be undertaken. Data will be mapped visually and tabulated. Results will be described in narrative form. National stakeholder discussions will inform conclusions and recommendations. ETHICS AND DISSEMINATION: Ethical approval is not required as data consist solely of publicly available material. Findings will be used to evidence national and international policy and practice.

Know-do gap for sick child care and drivers of knowledge and practice among health extension workers in four regions of Ethiopia: a cross-sectional study.

OBJECTIVE: Though efforts were made to expand community-based sick child healthcare in Ethiopia, the quality of care provided remained low. Improving quality of care requires understanding providers' knowledge of appropriate care and their actual execution of tasks. This study examined gap between what health extension workers (HEWs) knew and did during the management of sick children in Ethiopia. DESIGN: Facility-based cross-sectional study was conducted. SETTING: The study was carried out in 52 districts across 4 regions in Ethiopia. PARTICIPANTS: We interviewed 274 HEWs and performed observations of consultations done by 150 HEWs supplemented with facility assessment from December 2018 to February 2019. OUTCOME: We compared providers' knowledge and performance in the management of childhood pneumonia and diarrhoea. Know-do gap implies the difference in proportion between knowledge and actual practice of HEWs. Logistic regression was used to identify predictors of knowledge and actual practice. RESULTS: Providers' correct knowledge ranged from 27.8% to 76.0% for signs and symptoms of pneumonia, and 32.0% to 84% for dehydration signs. Their actual practices ranged from 15.1% to 47.3% for pneumonia and 27.0% to 42.6% for dehydration. The correct knowledge and actual practices for pneumonia and dehydration management were 88.3% vs 15.6% and 93.9% vs 51.3%, respectively. There was significant know-do gap in assessments (16.7%, p=0.002) and management of childhood conditions (68.5%, p<0.0001). Mentorships were associated with providers' knowledge of clinical management, while medicines availability was associated with their actual management practice. CONCLUSIONS: While knowledge and actual practice for assessment and management of pneumonia and dehydration ranged from very low to high, what is more concerning is the huge know-do gap among HEWs. Our findings suggest that knowledge-based training is necessary but not sufficient for ensuring correct assessment and management of sick children by HEWs. Continuous support through mentorships and the supply of commodities are critically needed.

Client retention in the continuum of maternal health services in Ethiopia.

BACKGROUND: Even though the global maternal mortality has shown an impressive decline over the last three decades, the problem is still pressing in low-income countries. To bring this to an end, women in a continuum of maternity care should be retained. This study aimed to assess the status of Ethiopian women's retention in the continuum of maternity care with their possible predictors. METHODS: We used data from the 2019 Ethiopian Mini-Demographic and Health Survey. The outcome variable in this study was retention in the continuum of maternity care, which consists of at least four ANC contacts, delivery in a health facility, and postnatal check within 48 h of delivery. We analyzed the data using STATA version 14 and a binary logistic regression model was used. In the multiple logistic regression model, variables with a p-value ≤ 0.05 were considered as significantly associated with the outcome variable. A weighted analysis was also done. RESULTS: Of the 3917 women included in this study, only 20.8% of women completed all of the recommended services. Besides, the use of maternal health services favors women living in the biggest city administrations, followed by women living in agrarian regions; however, those living in the pastoralist area were disadvantaged. Having four or more ANC was explained by the maternal secondary level of education [AOR: 2.54; 95% CI: 1.42, 4.54], wealth status [AOR: 2.59; 95% CI: 1.45, 4.62], early initiation of ANC [AOR: 3.29; 95% CI: 2.55, 4.24], and being in a union [AOR: 1.95; 95% CI: 1.16,3.29]. After having four ANC, factor-affecting delivery in a health facility was wealth status [AOR: 8.64; 95% CI: 4.07, 18.36]. The overall completion of care was associated with women's higher level of education [AOR: 2.12; 95% CI: 1.08, 4.25], richest wealth status [AOR: 5.16; 95% CI: 2.65, 10.07], timeliness of the first ANC visit [AOR: 2.17; 95% CI: 1.66, 2.85], and third birth order [AOR: 0.58; 95% CI: 0.35, 0.97]. CONCLUSIONS: Despite the efforts by the Ethiopian government and other stakeholders, the overall completion of care was quite low. There is also a clear inequality because of women's background characteristics and regional variation. Strategies aiming to empower women through improved educational experience and economic standing have to be implemented in collaboration with other relevant sectors.

Escalating spread of SARS-CoV-2 infection after school reopening among students in hotspot districts of Oromia Region in Ethiopia: Longitudinal study.

BACKGROUND: COVID-19 pandemic caused by extended variants of SARS-CoV-2 has infected more than 350 million people, resulting in over 5.5 million deaths globally. However, the actual burden of the pandemic in Africa, particularly among children, remains largely unknown. We aimed to assess the seroepidemiological changes of SARS-CoV-2 infection after school reopening among school children in Oromia, Ethiopia. METHODS: A prospective cohort study involving students aged 10 years and older were used. A serological survey was performed twice, at school reopening in December 2020 and four months later in April 2021. Participants were selected from 60 schools located in 15 COVID-19 hotspot districts in Oromia Region. Serology tests were performed by Elecsys anti-SARS-CoV-2 nucleocapsid assay. Data were collected using CSentry CSProData Entry 7.2.1 and exported to STATA version 14.2 for data cleaning and analysis. RESULTS: A total of 1884 students were recruited at baseline, and 1271 completed the follow-up. SARS-CoV-2 seroprevalence almost doubled in four months from 25.7% at baseline to 46.3% in the second round, with a corresponding seroincidence of 1910 per 100,000 person-week. Seroincidence was found to be higher among secondary school students (grade 9-12) compared to primary school students (grade 4-8) (RR = 1.6, 95% CI 1.21-2.22) and among those with large family size (> = 5) than those with a family size of <3 (RR = 2.1, 95% CI 1.09-4.17). The increase in SARS-CoV-2 seroprevalence among the students corresponded with Ethiopia's second wave of the COVID-19 outbreak. CONCLUSION: SARS-CoV-2 seroprevalence among students in hotspot districts of the Oromia Region was high even at baseline and almost doubled within four months of school recommencement. The high seroincidence coincided with the second wave of the COVID-19 outbreak in Ethiopia, indicating a possible contribution to school opening for the new outbreak wave.

Quality of sick child management by health extension workers: role of a complex improvement intervention.

BACKGROUND: Despite the expansion of the Integrated Community Case Management services for childhood illness, quality and utilization of services have remained low. To address the problem, the Government of Ethiopia introduced a complex intervention that included community engagement, capacity building of health workers and enhanced district-level ownership of sick child management. We examined whether this complex intervention was associated with improved management of sick children by health extension workers. METHODS: The study was conducted in four Ethiopian regions. A baseline survey was conducted in 26 intervention and 26 comparison districts from December 2016 to February 2017, followed by an end-line survey 24 months later. We observed health extension workers' consultations of sick 2-59 months old children. The analysis has evaluated if children with pneumonia, diarrhoea and malnutrition were assessed, classified and treated according to guidelines, and included difference-in-difference analyses. RESULTS: We observed 1325 consultations of sick children. At baseline, 86% of the sick children with cough in the intervention areas and 85% in comparison areas were assessed according to the guidelines, without any change at end-line associated with the intervention (difference-in-difference = -21%, p = 0.55). Sixty-two percent of children were assessed for dehydration at baseline in intervention and 47% in comparison areas, with no improvement associated with the intervention. Similarly, 87% of sick children in intervention and 91% in comparison areas were assessed for malnutrition, with no change over time associated with the intervention (difference-in-difference = 5%, p = 0.16). Appropriate pneumonia treatment with antibiotics declined and diarrhea treatment increased in both areas. Half of the malnourished children received ready-to-use therapeutic foods without any improvement associated with the intervention. CONCLUSION: The intervention was not associated with improved quality of the health extension workers' management of sick children. The lack of association may be linked to low fidelity in the implementation of the intervention. Our findings suggest that training healthcare providers without continued clinical mentoring and support does not improve the quality of care. Community-based programs can be strengthened by ensuring high coverage and continued clinical mentorships, supportive supervision, and supply of medicines and other essential commodities. TRIAL REGISTRATION NUMBER: ISRCTN12040912, retrospectively registered on 19/12/ 2017.

Assessment of Implementation Outcome Measures for Positive Deviance Approach as a New Strategy to Promote Exclusive Breastfeeding: A Psychometric Follow-Up Study.

Background: Implementation outcomes are the effects of deliberate actions while implementing new interventions which explain the process and are preconditions to achieve the desired outcomes. Positive Deviance Approach (PDA) was implemented as a new strategy to mitigate the gaps of exclusive breastfeeding (EBF) practice in Jimma, Ethiopia. However, there was no evidence to what extent intervention participants' perceive/rate these outcomes. In addition, psychometric outcome measures lack conceptual clarity, have unknown reliability and validity to the context. Therefore, we aimed to assess implementation outcomes, determine valid and reliable scales and analyze their correlation and variation explained. Methods: A post-implementation follow-up study was conducted between August 28, 2020 and September 30, 2020 among the intervention participants of an earlier trial. A sample of 384 participants was invited to respond to an interviewer (or self)-administered structured questionnaire. The developed tool was refined through experts' comment, pre-test, and using Exploratory Factor Analysis (EFA) to determine the measurement scales, and Total Variability Explained (TVE). The reliability test was done. The mean scores were determined which indicates the extent of each scale's rate. Pearson's correlation, independent sample t-test/One-way ANOVA were used as needed. The explained variation (interdependency) of scales was checked using coefficient of determination (r2). Level of significance was declared at 95% CI and p-value of <0.05. Results: This study identified nine implementation outcomes of PDA as a new strategy to promote EBF with a TVE 72.1%. 52 valid and reliable items were developed to measure these outcomes. The maximum mean score was for "appropriateness scale" - 27.81 (6.5SD), while the minimum was for "implementation cost scale" - 11.37 (5.2SD). The overall mean score was 164.18 (26.8SD). The emerged scales explained 72.1% of the total variability in implementation outcomes. Majority (6) of outcomes of PDA were highly rated. Implementation fidelity, penetration, organizational readiness, and sustainability scores were positively and significantly correlated with acceptability of the approach. Conclusion: This study identified nine valid, reliable, well explained and correlated implementation outcomes which help to understand the success of PDA as a new strategy to promote EBF. Majority of outcome measures were highly rated by intervention participants, which suggests it is a promising approach in promoting EBF in urban community by PDs.

End-Users Satisfaction with Positive Deviance Approach as an Intervention to Promote Exclusive Breastfeeding in Jimma, Ethiopia: A Multi-Level Analysis.

BACKGROUND: Positive deviance approach (PDA) was implemented as an intervention strategy to address the poor practice of exclusive breastfeeding (EBF) in Jimma town, Ethiopia. Understanding the end-users satisfaction and its drivers is essential to determine whether this approach will be viable in the long run. Therefore, we determined the level of users' satisfaction with the intervention and identified multi-level predictors to explain variability. METHODS: The data for this follow-up study were collected from September 01 to 25, 2020 among the study participants who were living in the intervention clusters of an earlier trial. A sample of 260 participants were invited to respond to an interviewer-administered structured questionnaire that assessed both individual and community-level variables. The developed tool was refined using experts' view (face validity) and using factor analysis (FA) to validate the satisfaction measurement scales (construct validity). The mean scores were standardized using Percentages Scale Mean Score (PSMS) formulae. Two-level mixed-effects linear regression (linear mixed models) were performed to fit individual, community, and mixed-level variables. All assumptions were checked for each analysis as appropriate and ß-estimates at 95% CI and p-value of <0.05 were considered to declare a level of significance. RESULTS: The overall level of end-users' satisfaction (PSMS) with PDA as an intervention to improve EBF was 50.9% with a maximum score of 99% and a minimum of 8%. Of the emerged satisfaction measuring scales, the standardized mean score for the user empowerment scale was the highest (53.7%). Five scales were emerged with 84.2% of the total variability explained in users' satisfaction. The mixed-effect model revealed that age, occupation, experience of breastfeeding (BF), knowledge, attitude, self-efficacy, main source of BF information, previous home visit/support received from HEPs, participation in any social activities, and perceived community support for BF were independent two-level predictors of satisfaction. CONCLUSION: As an intermediate outcome, more than half of the end-users of the PDA intervention were satisfied. End-users' satisfaction with PDA as an intervention to promote EBF was predicted by multi-level factors. If they chose to use PDA as an intervention, Health program managers should be mindful of the two-level factors identified in this study.

Child vaccination in sub-Saharan Africa: Increasing coverage addresses inequalities.

BACKGROUND: Vaccines have substantially contributed to reducing morbidity and mortality among children, but inequality in coverage continues to persist. In this study, we aimed to examine inequalities in child vaccination coverage in sub-Saharan Africa. METHODS: We analysed Demographic and Health Survey data in 25 sub-Saharan African countries. We defined full vaccination coverage as a child who received one dose of bacille Calmette-Guérin vaccine (BCG), three doses of diphtheria, pertussis, and tetanus vaccine (DTP 3), three oral polio vaccine doses (OPV 3), and one dose of measles vaccine. We used the concentration index (CCI) to measure wealth-related inequality in full vaccination, incomplete vaccination, and zero-dose children within and between countries. We fitted a multilevel regression model to identify predictors of inequality in receipts of full vaccination. RESULTS: Overall, 56.5% (95% CI: 55.7% to 57.3%) of children received full vaccination, 35.1% (34.4% to 35.7%) had incomplete vaccination, while 8.4% (95% CI: 8.0% to 8.8%) of children remained unvaccinated. Full vaccination coverage across the 25 sub-Saharan African countries ranged from 24% in Guinea to 93% in Rwanda. We found pro-rich inequality in full vaccination coverage in 23 countries, except for Gambia and Namibia, where we found pro-poor vaccination coverage. Countries with lower vaccination coverage had higher inequalities suggesting pro-rich coverage, while inequality in unvaccinated children was disproportionately concentrated among disadvantaged subgroups. Four or more antenatal care contracts, childbirth at health facility, improved maternal education, higher household wealth, and frequently listening to the radio increased vaccine uptake. CONCLUSIONS: Continued efforts to improve access to vaccination services are required in sub-Saharan Africa. Improving vaccination coverage and reducing inequalities requires enhancing access to quality services that are accessible, affordable, and acceptable to all. Vaccination programs should target critical social determinants of health and address barriers to better maternal health-seeking behaviour.

Spatial patterns and inequalities in skilled birth attendance and caesarean delivery in sub-Saharan Africa.

BACKGROUND: Improved access to and quality obstetric care in health facilities reduces maternal and neonatal morbidity and mortality. We examined spatial patterns, within-country wealth-related inequalities and predictors of inequality in skilled birth attendance and caesarean deliveries in sub-Saharan Africa. METHODS: We analysed the most recent Demographic and Health Survey data from 25 sub-Saharan African countries. We used the concentration index to measure within-country wealth-related inequality in skilled birth attendance and caesarean section. We fitted a multilevel Poisson regression model to identify predictors of inequality in having skilled attendant at birth and caesarean section. RESULTS: The rate of skilled birth attendance ranged from 24.3% in Chad to 96.7% in South Africa. The overall coverage of caesarean delivery was 5.4% (95% CI 5.2% to 5.6%), ranging from 1.4% in Chad to 24.2% in South Africa. The overall wealth-related absolute inequality in having a skilled attendant at birth was extremely high, with a difference of 46.2 percentage points between the poorest quintile (44.4%) and the richest quintile (90.6%). In 10 out of 25 countries, the caesarean section rate was less than 1% among the poorest quintile, but the rate was more than 15% among the richest quintile in nine countries. Four or more antenatal care contacts, improved maternal education, higher household wealth status and frequently listening to the radio increased the rates of having skilled attendant at birth and caesarean section. Women who reside in rural areas and those who have to travel long distances to access health facilities were less likely to have skilled attendant at birth or caesarean section. CONCLUSIONS: There were significant within-country wealth-related inequalities in having skilled attendant at birth and caesarean delivery. Efforts to improve access to birth at the facility should begin in areas with low coverage and directly consider the needs and experiences of vulnerable populations.

Effectiveness of Positive Deviance Approach to Promote Exclusive Breastfeeding Practice: A Cluster Randomized Controlled Trial.

BACKGROUND: Suboptimal breastfeeding (BF) contributes to a significant number of infant deaths. A positive deviance approach (PDA) was not studied in Ethiopia, whether it improve exclusive breastfeeding (EBF) practice. Therefore, we determined the effectiveness of positive deviant approached intervention in increasing the proportion of EBF practice. METHODS: A cluster-randomized controlled trial was employed in Jimma town from February 01 to September 30, 2018. Six randomly selected clusters (kebeles) were randomized into two arms. Then, 260 mothers who met the eligibility criteria were enrolled in either the intervention or control arm depending on where they lived. Women in the intervention group received counseling and social support in addition to the usual service to promote EBF, from women identified and trained as positive deviants in their community, while those in the control groups received the usual community-based services from urban health extension professionals. Data on primary and secondary outcome variables were collected at three points, and statistical difference was estimated using Chi-X 2 or Fisher exact test. The net effect of the intervention was calculated. The magnitude of the intervention effect was estimated using the relative risk. For all statistical tests, 95% CI with a P-value of <0.05 was used. RESULTS: The overall response rate at the endline was 98.8%. Exclusive BF was significantly different between the groups at mid and end points, while no difference at baseline. A higher proportion of mothers in the intervention group reported EBF compared to the control group at mid and end-line. The rate of EBF increased by 18.5% (P=0.01) in the intervention group while 0.2% in the counterparts, with a net effect of +18.2%. The probability of practicing EBF was significantly higher for the intervention group compared to the control group. At baseline, the relative risk of avoiding EBF (RR:1.112) was similar among the two groups. However, at follow-up, mothers in the intervention group were 2 times more likely to practice EBF (RR: 2.294) compared to those in the control group. CONCLUSION AND RECOMMENDATION: The PD approach is an effective intervention to promote EBF and also positively affected frequency and duration of BF. Therefore, we recommend the promotion and use of positive deviance approach as a strategy to improve EBF practice in urban settings. TRIAL REGISTRATION NUMBER: Clinical trial PACTR201805003379263, 23 May 2018.

Expanding Maternity Waiting Homes as an Approach to Improve Institutional Delivery in Southwest Ethiopia: A Community-Based Case-Control Study.

With the promising efforts in increasing institutional delivery yet, maternal and child mortality is high in Ethiopia. One of the strategies used to minimize this problem was the introduction of Maternity Waiting Homes (MWH). MWHs are residential facilities for pregnant women near a qualified medical facility. The introduction of MWHs has improved institutional delivery in many countries. In Ethiopia however, the contribution of MWHs was rarely studied. To fill this gap, we have conducted a community-based unmatched case-control study from March 1 to April 20, 2016, in Southwestern Ethiopia. Mothers who delivered at a health facility within 1 year were considered as cases while mothers delivered at home were controls. We used simple random sampling to identify study participants from the pool of cases and controls who were identified by census. Data were analyzed using SPSS Version 20. Binary logistic regression was used to identify significant predictors. A total of 140 cases and 273 controls were included in the study. Among the case, 86 (61.4%) used MWHs during their last delivery. Variables like educational status of the mothers [AOR = 2.96, 95% CI: 1.41, 6.23], educational status of the husband [AOR = 5.19, 95% CI: 1.52, 17.76], and having antenatal care follow up [AOR = 3.22, 95% CI: 1.59, 6.54]. This study remarks, accessing MWHs, creating better awareness in utilizing them, and practicing antenatal follow-up have a crucial role in improving institutional delivery. Therefore, strengthening the existing and establishing new MWHs to deliver quality services is a good strategy in reducing home delivery.

Inequitable Utilization of Neonatal Health Services in Southwest Ethiopia: The Effects of Socioeconomic Disparities.

Low levels of neonatal health services utilization and high neonatal deaths are often concentrated among socially and economically disadvantaged groups, especially in low-income countries. Therefore the aim of this study was to assess inequity in the use of neonatal health services in Southwest Ethiopia. A community-based cross-sectional study was conducted in 8 districts located in Jimma Zone, Southwest Ethiopia from 19 March to 28 April 2018. A total of 835 mothers were included in the study with systematic random sampling. Principal component analysis was conducted to develop wealth quintiles of the households. Equity in neonatal health services was measured using rate-ratio, concentration curve, concentration index, and analyzed by binary logistic regression. Neonates from richer families were 1.25 times more likely to use neonatal health services than the poorer households with a concentration index value of 0.07. Neonates from highly educated mothers have better used the services and the corresponding concentration index value of 0.03. Neonatal service utilization was 1.32 times higher in the highest wealth quintile in rural settings. Similarly, services delivered at health posts and hospitals were used 2.4 and 2 times more by the wealthy, whereas services given at health centers are more utilized by the poorest. Outputs of binary logistic regression analysis indicated that neonates from middle quintile wealth households were found to be better neonatal health service users [AOR_1.72, 95% CI: 1.04, 2.82]. Neonate born from a secondary school attended mother [AOR_3.56, 95% CI: 1.90, 6.69] were more likely to use neonatal health services. Neonatal health service utilization in Southwest Ethiopia is more common among neonates from richer households and more educated mothers. There is a big difference among the wealthy and poorer in a rural setting and among those who used health posts. Working on the social-determinants of health will facilitate eliminating inequity.

Patient volume and quality of primary care in Ethiopia: findings from the routine health information system and the 2014 Service Provision Assessment survey.

BACKGROUND: Several studies have reported inadequate levels of quality of care in the Ethiopian health system. Facility characteristics associated with better quality remain unclear. Understanding associations between patient volumes and quality of care could help organize service delivery and potentially improve patient outcomes. METHODS: Using data from the routine health management information system (HMIS) and the 2014 Ethiopian Service Provision Assessment survey + we assessed associations between daily total outpatient volumes and quality of services. Quality of care at the facility level was estimated as the average of five measures of provider knowledge (clinical vignettes on malaria and tuberculosis) and competence (observations of family planning, antenatal care and sick child care consultations). We used linear regression models adjusted for several facility-level confounders and region fixed effects with log-transformed patient volume fitted as a linear spline. We repeated analyses for the association between volume of antenatal care visits and quality. RESULTS: Our analysis included 424 facilities including 270 health centers, 45 primary hospitals and 109 general hospitals in Ethiopia. Quality was low across all facilities ranging from only 18 to 56% with a mean score of 38%. Outpatient volume varied from less than one patient per day to 581. We found a small but statistically significant association between volume and quality which appeared non-linear, with an inverted U-shape. Among facilities seeing less than 90.6 outpatients per day, quality increased with greater patient volumes. Among facilities seeing 90.6 or more outpatients per day, quality decreased with greater patient volumes. We found a similar association between volume and quality of antenatal care visits. CONCLUSIONS: Health care utilization and quality must be improved throughout the health system in Ethiopia. Our results are suggestive of a potential U-shape association between volume and quality of primary care services. Understanding the links between volume of patients and quality of care may provide insights for organizing service delivery in Ethiopia and similar contexts.