Spatiotemporal dynamics of cholera epidemics in Ethiopia: 2015-2021

Since the onset of the seventh cholera pandemic, Ethiopia has been affected by recurrent epidemics. However, the epidemiology of cholera in this country remains poorly understood. This study aimed to describe cholera outbreak characteristics in Ethiopia from 2015 to 2021. During this period, Ethiopia experienced four epidemic waves. The first wave involved nationwide outbreaks during the second half of 2016 followed by outbreaks predominantly affecting Somali Region in 2017. The second wave primarily affected Tigray and Afar Regions. During the third wave, multiple smaller-scale outbreaks occurred during 2019. The fourth wave was limited to Bale Zone (Oromia Region) in 2021. Overall, a north to south shift was observed over the course of the study period. Major cholera transmission factors included limited access to safe water and sanitation facilities. Severe weather events (drought and flooding) appear to aggravate cholera diffusion. Cholera transmission between Ethiopia and nearby countries (Kenya and Somalia), likely plays a major role in regional cholera dynamics. Overall, this study provides the first understanding of recent spatiotemporal cholera dynamics in Ethiopia to inform cholera control and elimination strategies.

Comparison of analysis methods to classify cholera hotspots in Ethiopia from 2015 to 2021

Cholera continues to represent a major public health concern in Ethiopia. The country has developed a Multi-sectoral National Cholera Elimination Plan in 2022, which targets prevention and control interventions in cholera hotspots. Multiple methods to classify cholera hotspots have been used in several countries. Since 2014, a classification method developed by United Nations Children's Fund has been applied to guide water, sanitation and hygiene interventions throughout Sub-Saharan Africa based on three outbreak parameters: frequency, duration and standardized attack rate. In 2019, the Global Task Force on Cholera Control (GTFCC) proposed a method based on two parameters: average annual cholera incidence and persistence. In 2023, an updated GTFCC method for multisectoral interventions considers three epidemiological indicators (cumulative incidence, cumulative mortality and persistence,) and a cholera-case confirmation indicator. The current study aimed to classify cholera hotspots in Ethiopia at the woreda level (equivalent to district level) applying the three methods and comparing the results to optimize the hotspot targeting strategy. From 2015 to 2021, cholera hotspots were located along major routes between Addis Ababa and woredas adjacent to the Kenya and Somalia borders, throughout Tigray Region, around Lake Tana, and in Afar Region. The multi-method comparison enables decision makers to prioritize interventions according to a sub-classification of the highest-priority areas.

Social and behavior change communication competency among front-line healthcare system actors in Ethiopia: a cross-sectional study

INTRODUCTION

Social and Behavior Change Communication (SBCC) plays a critical role in improving behavior and health outcomes across the continuum of healthcare. Failing to implement tailored SBCC strategies continues to pose a risk of ill health, increase disease burden, and impact the quality life of people. In Ethiopia, front-line healthcare system actors' knowledge and skills about SBCC have not been rigorously assessed. Thus, the current study aimed to assess healthcare system actors' competencies in designing, implementing, monitoring, and evaluating SBCC interventions in Ethiopia.

METHODS

A cross-sectional study was conducted between 01 August and 31 October, 2020. Five hundred twenty-eight frontline healthcare system actors in SBCC in Ethiopia were included using simple random sampling technique. Data was collected using a self-administered structured questionnaire adopted from Communication for Change; SBCC capacity assessment tool. Descriptive analysis frequencies, percentages, mean, median, standard deviation (SD), interquartile range (IQR) were employed. Besides correlations and linear regression with robust standard errors were carried out. A 95% confidence interval and a p-value of less than 0.05 were used to declare significant statistical association.

RESULTS

A total of 488 frontline workers participated in the study, with a response rate of 92.4%. The mean SBCC knowledge score was 13.2 ± standard deviation (SD) 3.99 and 59.2% scored below 60% of the expected maximum score. The standard mean score of overall skill in SBCC intervention was 2.36 (SD ± 0.98) and 52.6% of them scored below mean score. The SBCC knowledge was significantly predicted by the service year and the regional variation. On the other hand, SBCC skills was significantly predicted by sex, service year, profession, regional variation, and SBCC knowledge. The regional variation was the main predictor of both knowledge and skill on SBCC. The regression models explained 23.1% and 50.2% of the variance in knowledge and skill of SBCC, respectively.

CONCLUSION

Front-line healthcare system actors in Ethiopia has low knowledge and skills in SBCC. Variations in SBCC knowledge and skill were observed based on demographic and professionals experience related characteristics. Hence, continuous capacity building activities need to be given to frontline healthcare system actors to enhance their knowledge and skill on SBCC program and achieve the intended health results.

Complementary feeding and food-group level inequality among Ethiopian children 6-23 months of age (2011-2019)

Ensuring diet quality in the first 2 years of life is critical to preventing malnutrition and instilling healthy food preferences. Children's diet quality has changed little over time and inequalities by socioeconomic status, rural-urban residence, but also by food group may exist. Using data from the 2011, 2016 and 2019 demographic and health surveys (DHS), we estimated the prevalence and inequalities in the minimum diet diversity (MDD), minimum meal frequency (MMF) and minimum acceptable diet (MAD). We further assessed food group-level inequities. In 2019, only 13.5% of children 6-23 months of age met the MDD, 55% met the MMF and only 11% met the MAD indicator. Absolute and relative measures of inequality were calculated. Modest increases in MDD, MMF and MAD were observed over the past decade (2011-2019). These modest improvements were concentrated in limited geographical areas, among children in wealthier households, and urban residents. Unhealthy practices such as bottle-feeding and zero fruit and vegetables have been increasing; whereas, inequities in the consumption of nutrient-dense foods have widened. Nevertheless, children from the wealthiest quintile also failed to meet the MDD. Multisectoral efforts that span from diversifying the food supply, regulating the marketing of unhealthy foods, and promoting minimal processing of perishables (i.e., to extend shelf-life) are needed. Context-adapted behavioural change communication along with nutrition-sensitive social protection schemes are also needed to equitably improve the diet quality of children in Ethiopia.

Subnational mapping for targeting anaemia prevention in women of reproductive age in Ethiopia: A coverage-equity paradox

Anaemia in women of reproductive age (WRA) can be effectively addressed if supported by a better understanding of the spatial variations, magnitude, severity and distribution of anaemia. This study aimed to map the subnational spatial distribution of anaemia (any, moderate and severe forms) among WRA in Ethiopia. We identified and mapped (any, moderate and severe) anaemia hotspots in WRA (n = 14,923) at the subnational level and identified risk factors using multilevel logistic regression. Kulldorff scan statistics were used to identify hotspot regions. Ordinary kringing was used to predict the anaemia prevalence in unmeasured areas. The overall anaemia prevalence increased from 16.6% in 2011 to 23.6% in 2016, a rise that was mostly related to the widening of existing hotspot areas. The primary clusters of (any) anaemia were in Somali and Afar regions. The horn of the Somali region represented a cluster of 330 km where 10% of WRA were severely anaemic. The Oromia-Somali border represented a significant cluster covering 247 km, with 9% severe anaemia. Population-dense areas with low anaemia prevalence had high absolute number of cases. Women education, taking iron-folic-acid tablets during pregnancy and birth-delivery in health facilities reduced the risk of any anaemia (P < 0.05). The local-level mapping of anaemia helped identify clusters that require attention but also highlighted the urgent need to study the aetiology of anaemia to improve the effectiveness and safety of interventions. Both relative and absolute anaemia estimates are critical to determine where additional attention is needed.

Understanding delays in the introduction of complementary foods in rural Ethiopia

Age-appropriate breastfeeding and introduction to complementary foods can shape child feeding practices, ensure adequate energy and nutrient intake and prevent linear growth faltering. This study aimed to assess mothers' and health workers' knowledge of timely introduction to complementary foods and evaluate the relationship between delays in complementary feeding and subsequent linear growth. We conducted two rounds of surveys (March/August 2017) among 249 health workers (n = 249) and caregivers (n = 2635) of children 6-23 months of age. We collected information about socio-demographic characteristics, knowledge and practice related to timely introduction to complementary foods. The study was conducted in households from the Productive Safety Net Programme (PSNP) districts, in four highland regions of Ethiopia. Delays in the introduction to complementary feeding were widespread with 53% of children 6-8 months of age not consuming solid, semisolid or soft foods in the past 24 h. After controlling for child, caregiver and household characteristics, children not introduced to complementary foods by 6-8 months had a 0.48 SD lower length-for-age z-score at 12-15 months. Caregivers' knowledge was strongly and inversely correlated with untimely introduction of complementary foods in logistic regressions (OR = 0.55, p < 0.01). In turn, local health extension worker's knowledge was strongly correlated with caregiver's knowledge. Consequently, frequent and timely visits by health extension workers emphasising not only on what to feed but also when and how to feed a child are needed. Innovative ways of increasing reach, intensity and frequency of nutrition messaging by using the PSNP interactions as an additional point of contact would need to be explored further.

Barriers to utilize nutrition interventions among lactating women in rural communities of Tigray, northern Ethiopia: An exploratory study

Background

While lactation is a physiological process requiring high energy demand to fulfill the nutrient requirements of the mother and the breastfeeding child, many factors affecting maternal nutrient intake can lead to nutritional deficits. Previous studies in Ethiopia have reported the prevalence of maternal and child undernutrition and related complications. However, qualitative studies exploring potential barriers to utilizing available nutrition interventions are limited. This study, therefore, sought to qualitatively explore barriers hindering the uptake of nutrition services among lactating mothers from rural communities in Tigray, northern Ethiopia.

Methods

We conducted 6 in-depth interviews, 70 key informant interviews, and 13 focus group discussions among purposively selected community groups, experts, and lactating mothers between November- 2017 and January- 2018. Audio records of all interviews and focus group discussions were transcribed verbatim (word-to-word) and translated into English. Then, translated data were analyzed thematically using qualitative data analysis software Atlas ti-version 7.4.

Results

The participants in this study perceived that lactating mothers in their study area are not properly utilizing available and recommended nutrition interventions, and as a result, their nutrient intake was reported as inadequate. Participants identified inadequate accessibility and availability of foods, feeding practices, cultural and religious influences, focus on agricultural production and productivity, barriers related to health services and poor access to water, sanitation and hygiene as major barriers hindering the uptake of nutrition interventions by lactating women in Tigray, northern Ethiopia.

Conclusion

The uptake of nutrition intervention services was low among lactating mothers and was hindered by multiple socio-cultural and health service related factors requiring problem-specific interventions at community, health facility, and administrative levels to improve the nutritional status of lactating mothers in the study area.