A community survey on maternal and child health services utilization in rural Ethiopia

A household health interview survey on MCH services utilization was carried out in 22 villages of a rural district of Arsi region, Ethiopia, before the launching of an integrated MCH programme. Coverage of antenatal services was 26%, and 61% of the women who received antenatal care reported having had 3 or more visits.Antenatal care was positively associated with living within 10 km of the Health Centre. Twenty-eight percent of the mothers attended the under-5 clinic and most returned for 3 or more visits. In addition, 99% reported having breast-fed their last child but more than 25% started weaning only after the seventh month of age. Differences in practice of treating diarrhoea according to knowledge of ORS were found. Of the 33% of those with knowledge of ORS, almost 90% reported use of ORS for treating child's dirrhoea, showing a positive attitude towards modern health care. The proportion of women using family planning was 5%, with no difference found between Christians and Muslims. Results on EPI coverage validated data from routine reporting. Integration of MCH services including out-reach activities may increase access and coverage of MCH services.     

Referral revisited: community financing schemes and emergency transport in rural Africa.

Referral between first and second levels of care in rural African health systems is an extremely complex problem. Problems that have plagued the process of referral include poor service quality, low availability of trained personnel, inadequate supplies of drugs and medical diagnostic equipment and inadequate communication infrastructure. In this paper, the authors analyse the role of transport costs in the utilization of referral and how community health insurance schemes can help reduce the economic burden of transport costs, thereby improving referral utilization and health outcomes. Following the introduction, the authors provide a conceptual framework of the individual-, household- and community-level factors that affect referral in the rural African context, with particular emphasis on the role of the time and monetary costs of transport and the potential role of community risk-sharing schemes. The paper then presents a detailed case study from Kenya where a community has been experimenting with a health insurance scheme which provides emergency transport for emergency referral. Data from the past eight years of experience in northern Kenya suggests that support for the insurance scheme has depended on the reliability of the health system, as well as the seasons and various external problems, such as political interference, drought and insecurity. Conclusions drawn support the idea of community financing schemes for transport, not merely as a life-saving strategy in remote and resource-poor health infrastructures, but also as a means to help build trust in the health system itself and thus improve sustainability through local institutional support.     

A one-year community study of under-fives in rural Ethiopia: health andbehavioural determinants of morbidity

Based on a one-year weekly home surveillance study, morbidity patterns of 1,304 children under five years ofage in a rural Ethiopian community were measured, together with nutritional and health behavioural determinants. Using Poisson regression models, the study showed that nutritional and health care factors make a significant impact on under-five morbidity. Gastroenteritis was particularly associated with child care factors, while acute respiratory infections were particularly associated with nutritional factors. Lack of immunization, low birthweight and pre-term delivery (more than one month early) were not found to have any independent effect on morbidity. Breast feeding was universal, but the introduction of supplementary foods was found to protect from excess morbidity. The study concludes by discussing possible applications of the results in inter vention programmes.     

Determining the differential preferences of users of two fluoride-free water options in rural Ethiopia

Aim

In the Ethiopian Rift Valley, 8.5 million people depend on water sources with excessive fluoride. In one rural village, a fluoride-removal community filter was implemented; a personalized reminder was distributed to change people’s behavior and increase the usage of the in-village community filter. During this promotion phase, an alternative fluoride-removal option was installed in a neighboring village. This study examines psychological factors that explain the differences in preference between the two options and their influence on the usage of the different sources. In addition, the effectiveness of the applied behavior change technique, a personalized reminder, on the use of the in-village community filter was analyzed.

Subject and methods

In a complete longitudinal survey, 180 households, with access to both mitigation options, were interviewed through structured, face-to-face interviews. Logistic regressions were carried out to reveal factors predicting the usage of the two mitigation options and the effect of the implemented behavior change intervention.

Results

The results showed that the better the taste, the lower the effort and the lower the costs for using the in-village community filter are perceived; in addition, the lower the perceived vulnerability to contract disease, the more the in-village community filter is used. Moreover, it was found that the personalized reminder also had a positive effect on the usage of the in-village mitigation option.

Conclusion

Based on the results, possible recommendations for practitioners and researchers are made to help plan and implement mitigation options.     

A one-year community study of under-fives in rural Ethiopia: patterns of morbidity and public health risk factors

A prospective weekly home surveillance study was undertaken to determine morbiditypatterns within the Butajira Rural Health project in central Ethiopia. Overall prevalence of illness was 5.8% in 1216 person-years observed among rural Ethiopian children aged under 5 years. Acute respiratory infections (ARI) (prevalence 2.8%) and acute diarrhoea (2.4%) were the commonest conditions. Episodes of illness were distributed unequally among children, with a mean of 2.34 episodes per child. These included an average of 1.13 episodes of ARI (of which 0.16 had lower respiratory symptoms [ALRI]) and 1.17 episodes of acute diarrhoea. Sanitation factors were the principal risks for gastroenteritis, while living in rural areas predisposed children to ARI. Parental factors such as illiteracy were also linked to morbidity.     

Determinants of exclusive consumption of fluoride-free water: a cross-sectional household study in rural Ethiopia

Aim

The occurrence of high fluoride concentrations in the ground- and surface water all over the world leads to the risk of developing dental and skeletal fluorosis. In Ethiopia, 8 million people depend on water sources with excessive fluoride. In four project areas in the Ethiopian Rift Valley, fluoride removal household filters based on bone char media have been implemented. This study examines possible predictors of consuming filtered water derived from various behavior change theories.

Subject and methods

In a complete cross-sectional survey, 160 filter users were interviewed through structured face-to-face interviews. A logistic regression was carried out to reveal factors predicting consumption of filtered water.

Results

The results show that the consumption of fluoride-free water is mainly related to people’s pride in offering filtered water to guests (status norm) and the feeling of being able to produce enough water with the filter (perceived behavioral control). Moreover, the study showed that the more filter users like the taste of filtered water and the more expensive they perceive the filter media, the more likely users will exclusively consume filtered water (attitudinal beliefs). Furthermore, perceiving the act of filling as a matter of habit (perceived habit) enhances filtered water consumption.

Conclusion

Based on the results, possible intervention strategies to change the influential psychological factors and, hence, increase the consumption of treated water can be designed.     

The epidemiology of burns in rural Ethiopia.

STUDY OBJECTIVE--The aims were (1) to review inpatient burn records of Attat Hospital (Ethiopia) for the years 1983-1989, and (2) to determine the prevalence of burns and knowledge of first aid for burns in 16 communities served by Attat Hospital in rural Ethiopia. DESIGN--A retrospective review of all records was used to describe characteristics of the inpatient with burns and cost of the service. Adult members of a systematic random sample (20%) of households from 16 communities (total population = 10,183) were interviewed. Questions focused on what to do to put out the fire, what to do for first aid for a burn, the major cause of adult and childhood burns, and a history of burn in any household member. SETTING--The study was conducted at Attat Hospital and in the surrounding Gurage-Chaha Region of West Shoa Province of Ethiopia. STUDY SUBJECTS--There were 271 burn inpatients during the 7 year period from 1983-1989; 163 households were selected for interview; there were no refusals. MAIN RESULTS--During the 7 year period the cost of tertiary inpatient burn treatment at Attat Hospital has been estimated to be US$86,366.72, of which the hospital absorbed 66%. From community based information the cumulative incidence of burns in this population was found to be 5-11%. The absence of a cumulative increase in burns over time in men suggests that female respondents may not fully recall burn histories in adult male household members. The study population possess inadequate knowledge regarding burn prevention and burn first aid. Deleterious traditional compounds were used on 32% of burn patients in the villages. CONCLUSIONS--Since most burns are related to household fires, generally in the domain of women in rural Ethiopia, women's groups may be the most appropriate setting for education on burn prevention and first aid. Burn prevention and first aid education should also be recognised as a priority in schools and in the training of community health workers.     

Tuberculosis case-finding through a village outreach programme in a rural setting in southern Ethiopia: community randomized trial

OBJECTIVE: To ascertain whether case-finding through community outreach in a rural setting has an effect on case-notification rate, symptom duration, and treatment outcome of smear-positive tuberculosis (TB). METHODS: We randomly allocated 32 rural communities to intervention or control groups. In intervention communities, health workers from seven health centres held monthly diagnostic outreach clinics at which they obtained sputum samples for sputum microscopy from symptomatic TB suspects. In addition, trained community promoters distributed leaflets and discussed symptoms of TB during house visits and at popular gatherings. Symptomatic individuals were encouraged to visit the outreach team or a nearby health facility. In control communities, cases were detected through passive case-finding among symptomatic suspects reporting to health facilities. Smear-positive TB patients from the intervention and control communities diagnosed during the study period were prospectively enrolled. FINDINGS: In the 1-year study period, 159 and 221 cases of smear-positive TB were detected in the intervention and control groups, respectively. Case-notification rates in all age groups were 124.6/10(5) and 98.1/10(5) person-years, respectively (P = 0.12). The corresponding rates in adults older than 14 years were 207/10(5) and 158/10(5) person-years, respectively (P = 0.09). The proportion of patients with >3 months' symptom duration was 41% in the intervention group compared with 63% in the control group (P<0.001). Pre-treatment symptom duration in the intervention group fell by 55-60% compared with 3-20% in the control group. In the intervention and control groups, 81% and 75%, respectively of patients successfully completed treatment (P = 0.12). CONCLUSION: The intervention was effective in improving the speed but not the extent of case finding for smear-positive TB in this setting. Both groups had comparable treatment outcomes.     

Pesticide pollution in water systems in a small rural community in Southeast Brazil

Recent advances in analytical techniques allow identifying pesticide pollution in water systems. In small rural communities, the negative effects of pesticide pollution can be aggravated by the lack of infrastructure and adverse socioeconomic conditions. This study investigated pesticide pollution in potential water supply sources in a tomato growing area in Paty do Alferes, Rio de Janeiro State, Brazil. The study selected 27 points where five monthly samples were collected. Pesticide pollution was determined by analyzing acetyl-cholinesterase inhibition. In 19 of the 27 sample points, some pesticide pollution was detected, and in two points the pesticide pollution was above the permitted limits. The results thus proved the incidence of pesticide pollution in water sources in Paty do Alferes that could jeopardize the local population's health.     

Determinants of mothers' treatment of diarrhea in rural Ethiopia

A total of 6414 mothers in a rural Ethiopian district were sampled and interviewed about the presence of under-5 yr children and the prevalence of diarrhea in the previous 2 weeks. There were 707 cases of diarrhea among the 6384 under-5 yr children, yielding a period prevalence of 11.07%. The diarrhea associated mortality rate was 11.4/1000 children. A structured questionnaire on home and professional treatment as well as knowledge about diarrhea was completed by the mothers of 619 of these cases. Over 50% of the mothers restricted the child's fluid intake and 70% stopped or decreased food intake; only 20% used ORS or cereal based ORT. The major factor associated with adequate home treatment was the mother's knowledge about the causes and treatment of diarrhea. Only 26.8% of the mothers had sufficient knowledge. Many of the mothers believed that teething and accidental falls caused diarrhea and that diarrhea helped to clean out the bowels. They also believed that only water should be given to the child, but that too much fluid worsened diarrhea. Half of the mothers did not seek professional treatment; 20% went to a traditional healer and only 7.3% took the child to a health institution. The outcome of the diarrhea was positively associated with having sought modern treatment and negatively associated with having gone to a traditional healer.     

Attitudes of rural people in central Ethiopia towards epilepsy

In the farming community of the sub-district of Meskan and Mareko in central Ethiopia, where the prevalence of epilepsy is known to be 5.2/1000, a door-to-door survey was undertaken in 1546 sampled households to find out public attitudes to epilepsy. Nearly 64% of the respondents were in the age group of 14-50 years, and 58.6% were women. The majority (86%) were illiterate, and 94% had incomes of a subsistence level; 89% had heard or witnessed seizures. Traditional views on the association of evil spirits and superstition was prevalent. By 45% of the interviewees, the disease was believed to be contagious through physical contacts during an attack. Although there was sympathetic concern in the community for the person suffering from epilepsy, negative attitudes were strong on matrimonial associations, sharing of accommodation and physical contacts with affected persons, particularly when there were obvious signs and frequent attacks by seizures. The study demonstrates that the rural community has very poor knowledge of the causes and nature of epilepsy, and this has resulted in social deprivations and at times, rejection of the sufferers.     

Epidemiological study on contamination of water and diarrheal diseases in a rural community in northeast Thailand

An epidemiological and bacteriological study of diarrheal diseases as well as the relation between domestic-use water and passage of enteric pathogens with stools of the villagers was performed in the northeastern rural area of Thailand on 4 different occasions during the 3 years from 1992-1994. The questionnaire study indicated that 93% of the residents used rain water stored in containers for drinking and other domestic uses, and that 28% of them filtrated and/or boiled the water before drinking it. About 90% of drinking water samples collected from the same residents showed positive responses for the preliminary test ofEscherichia coli contamination. Furthermore, a precise bacteriological survey indicated that more than half of the drinking water samples collected from containers storing rain water were contaminated with various enteropathogenic bacteria, includingE. coli, Vibrio spp. andShigella spp. The new serotype ofV. cholerae O139, synonym 'Bengal cholerae,' which could be isolated from different specimens, is replacing the traditional species ofVibrio. Forty-one per cent of the villagers carried enteropathogenic bacteria in their stools. Most of them were asymptomatic carriers and only a few of them showed clinical features of diarrhea. A few concrete propositions were discussed to supply safe water in these areas where drinkable underground water is not available.     

Illness and health behaviour in Addis Ababa and rural central Ethiopia

This paper examines the results of health surveys among 544 randomly selected households (2829 people) in seven kebele (urban dwellers' associations) in Addis Ababa and Kaliti, an industrial suburb of Addis Ababa, and in four rural villages in two peasant associations. The major objective was to study illness distribution and health behaviour among different socioeconomic and cultural groups in urban and rural communities within the context of available health resources, national health policy and planning. Results show that in spite of the rapid expansion of health services since the Ethiopian revolution serious problems of allocation and access persist. Higher illness prevalance rates were found in rural areas (23.2%), Kaliti (25.5%) and in the low socioeconomic kebele in Addis Ababa (23.9%) than in the high socioeconomic kebele (16.5%), but rural/urban and intraurban differences were greater than reported here due to underreporting. One-third of all illnesses were treated by modern services, 19.9% by self care and 26.0% by traditional medicine and transitional healers, with 21.5% of all illnesses not being treated. Utilization rates varied with type and duration of illness, socioeconomic level, age, sex and place of residence. The role of distance and other contact barriers, treatment outcome and availability of private clinics and alternative health resources in utilization is also evaluated. Coverage of the modern health services was associated with socioeconomic status and mobility of patients as well as availability of health services.     

Migration, community context, and child immunization in Ethiopia

This paper examines the relationship between parental migration status and child immunization in Southern Ethiopia, a region characterized by high mortality and morbidity. Using the 1997 Community and Family Survey and a multilevel modeling approach, we find that children born to rural-rural migrant mothers have significantly less chance of receiving full immunization coverage than children born to non-migrant mothers. The social mechanism that explains this huge disparity is that rural-rural migrant women have limited social networks in the host community. In addition, significant variation in receiving complete immunization is found by age of child (a likely period effect), mother's education, and distance to nearest health center. Marked child immunization differentials are also observed by ethnicity. The results from the multilevel analysis confirm the persistence of substantial community effects, even after controlling for a standard array of personal and household characteristics. Given the low levels of vaccination among children born to migrant women, health policy interventions and information campaigns might be effectively augmented to reach such migrant women and their children. Community and ethnic group effects suggest that further targeting of health activities could be efficient and effective.     

Feasibility of the randomized response technique in rural Ethiopia.

A multiple answer model of Randomized Response Technique (known as Hopkins RRT Model II) was tried in a rural area (Nekempte) in Ethiopia to estimate the incidence of induced abortion among currently married women of childbearing age. In the RRT adopted here, the question on abortion--sensitive as it is--was preceded by two innocuous "practice questions". Despite the very low literacy level of the women, nearly all of them cooperated. The RRT estimates in regard to the two innocuous "practice questions" were fairly reasonable, while the RRT estimate of the rate of induced abortion (35 per cent) was far higher than that derived from direct reporting. The differentials in abortion rates by age and parity were consistent with expectation. A post RRT survey indicated that more than one-half (58 per cent) of the women found RRT "easy" or "moderately easy" to understand, while nearly 80 per cent of them thought that there was no "trick" involved in it.