Implementation Science Protocol for a participatory, theory-informed implementation research programme in the context of health system strengthening in sub-Saharan Africa (ASSET-ImplementER)

Background ASSET (Health System Strengthening in Sub-Saharan Africa) is a health system strengthening (HSS) programme that aims to develop and evaluate effective and sustainable solutions that support high-quality care that involve eight work packages across four sub-Saharan African countries. Here we present the protocol for the implementation science (IS) theme within ASSET that aims to (1) understand what HSS interventions work, for whom and how; and (2) how implementation science methodologies can be adapted to improve the design and evaluation of HSS interventions within resource-poor contexts.

Pre-implementation phase The IS theme, jointly with ASSET work-packages, applies IS determinant frameworks to identify factors that influence the effectiveness of delivering evidence-informed care. Determinants are used to select a set of HSS interventions for further evaluation, where work packages also theorise selective mechanisms to achieve the expected outcomes.

Piloting phase and rolling implementation phase Work-packages pilot the HSS interventions. An iterative process then begins involving evaluation, refection and adaptation. Throughout this phase, IS determinant frameworks are applied to monitor and identify barriers and enablers to implementation in a series of workshops, surveys and interviews. Selective mechanisms of action are also investigated. In a final workshop, ASSET teams come together, to reflect and explore the utility of the selected IS methods and provide suggestions for future use.

Structured templates are used to organise and analyse common and heterogeneous patterns across work-packages. Qualitative data are analysed using thematic analysis and quantitative data is analysed using means and proportions.

Conclusions We use a novel combination of implementation science methods at a programmatic level to facilitate comparisons of determinants and mechanisms that influence the effectiveness of HSS interventions in achieving implementation outcomes across different contexts. The study will also contribute conceptual development and clarification at the underdeveloped interface of implementation science, HSS and global health.

Surgical data strengthening in Ethiopia: results of a Kirkpatrick framework evaluation of a data quality intervention

Background: One key challenge in improving surgical care in resource-limited settings is the lack of high-quality and informative data. In Ethiopia, the Safe Surgery 2020 (SS2020) project developed surgical key performance indicators (KPIs) to evaluate surgical care within the country. New data collection methods were developed and piloted in 10 SS2020 intervention hospitals in the Amhara and Tigray regions of Ethiopia.

Objective: To assess the feasibility of collecting and reporting new surgical indicators and measure the impact of a surgical Data Quality Intervention (DQI) in rural Ethiopian hospitals.

Methods: An 8-week DQI was implemented to roll-out new data collection tools in SS2020 hospitals. The Kirkpatrick Method, a widely used mixed-method evaluation framework for training programs, was used to assess the impact of the DQI. Feedback surveys and focus groups at various timepoints evaluated the impact of the intervention on surgical data quality, the feasibility of a new data collection system, and the potential for national scale-up.

Results: Results of the evaluation are largely positive and promising. DQI participants reported knowledge gain, behavior change, and improved surgical data quality, as well as greater teamwork, communication, leadership, and accountability among surgical staff. Barriers remained in collection of high-quality data, such as lack of adequate human resources and electronic data reporting infrastructure.

Conclusions: Study results are largely positive and make evident that surgical data capture is feasible in low-resource settings and warrants more investment in global surgery efforts. This type of training and mentorship model can be successful in changing individual behavior and institutional culture regarding surgical data collection and reporting. Use of the Kirkpatrick Framework for evaluation of a surgical DQI is an innovative contribution to literature and can be easily adapted and expanded for use within global surgery.

Survival and Predictors of Mortality among Breast Cancer Patients Diagnosed at Hawassa Comprehensive Specialized and Teaching Hospital and Private Oncology Clinic in Southern Ethiopia: A Retrospective Cohort Study

Background: Breast cancer is the most frequently diagnosed cancer and the leading cause of cancer death in over 100 countries. Despite the high burden of the problem, the survival status and the predictors for mortality are not yet determined well in Ethiopia. Therefore, we aimed to determine the survival and predictors of mortality among breast cancer patients diagnosed from 2013-2018 at Hawassa comprehensive specialized and teaching hospital and private oncology clinic in Southern Ethiopia.

Methods: Hospital-based retrospective cohort study of 302 patients was conducted. Data was collected on breast cancer patients diagnosed from January, 1st, 2013 to December, 30th, 2018 using a data extraction checklist and by telephone interview. The median survival was estimated by Kaplan- Meier. Log Rank test was used to compare survival among groups. Cox proportional hazards model was used to identify predictors. Results were repaired as hazard ratio (HR) along with the corresponding 95% CI. Sensitivity analysis was done with the assumption of loss to follow-ups (LTF) might die 3 months after the last hospital visit.

Results: Advanced stage diagnosis of breast cancer was found on 83.4 % of patients with breast cancer. The study participants were followed for a total of 4685.62 person-months. Their median survival was 50.61 months (IQR=18.38-50.80) which declined to 30.57 months in the worst-case analysis (WCA). The overall survival of patients at two years was 73.2% and it declines to 51.3 % in the worst-case analysis. Rural residence (AHR=2.71, 95% CI: 1.44, 5.09), travel time >7 hours (AHR=3.42, 95% CI: 1.05, 11.10), duration of symptom 7-23 months (AHR=2.63, 95% CI: 1.22, 5.64), > 23 months (AHR=2.37, 95% CI: 1.00, 5.59), advanced stage (AHR=3.01, 95% CI: 1.05, 8.59) and not taking chemotherapy (AHR=6.69, 95% CI: 2.20, 20.30) were independent predictors of death.

Conclusion: Above two-third of the patients have two years of overall survival in south Ethiopia. Rural residence, advanced stage, and poor adherence to chemotherapy were independent predictors of death. Thus, Improving early detection, diagnosis, and treatment capacity of breast cancer patients are an important way-outs to avert the problem with appropriate intervention means.

Magnitude of Surgical Site Infection and Its Associated Factors Among Patients Who Underwent a Surgical Procedure at Debre Tabor General Hospital, Northwest Ethiopia

Background: Surgical site infections are the commonest nosocomial infections and responsible for considerable morbidity and mortality as well as increased hospitalizations and treatment cost related to surgical operations. The aim of this study was to determine the magnitude and factors associated with surgical site infections at the surgical ward of Debre Tabor General Hospital, Northwest Ethiopia.

Method: Institution based cross-sectional study was conducted on patients who underwent a surgical procedure at Debre Tabor General Hospital in 2020. The sample size was determined using the single population proportion formula. Data were entered and analyzed using SPSS version 21 software. Bivariate and multivariate logistic regressions analysis were employed. The odds ratio and its 95% confidence interval were taken to test the association between the dependent and independent variables. A P-value of less than 0.05 will be considered statistically significant.

Result: In this study, a total of 191 patients have participated in the study yielding a response rate of 100%. The mean age of the respondents was 2.5 (SD ±0.68) years. The most age group 115(60.2%) resides at the age group greater than 40 years. More than one half(62.3) of the surgical clients were females. Most of the clients were farmers(32.5%) and unable to read and write(41.9) based on the occupation. The magnitude of surgical site infection in this study was found to be 11.5% (95% CI: 7.8%, 15.9%). The factors existence of comorbidity and antibiotic prophylaxis was given were found to be significantly associated with the magnitude of surgical site infection.

Conclusion: The magnitude of surgical site infection in this study was high. Proper management of patients with co-morbidity especially those with diabetes mellitus, proper administration of anesthesia, and delivering intravenous antimicrobial prophylaxis before surgery as ordered would significantly reduce the incidence of surgical site infection.

Neural Tube Defects and Associated Factors among Neonates Admitted to the Neonatal Intensive Care Units in Hiwot Fana Specialized University Hospital, Harar, Ethiopia

Neural tube defects are a major public health problem and substantially contribute to morbidity and mortality, particularly in low-income countries, including Ethiopia. There are a paucity of data on the magnitude and associated factors of neural tube defects in Ethiopia, particularly in the study setting.

This study aimed to assess the magnitude of neural tube defects and associated factors among neonates admitted to the neonatal intensive care unit in Hiwot Fana Specialized University Hospital, Harar, Ethiopia.

A hospital-based cross-sectional study was employed from October 2019 to January 2020. A total of 420 newborn-mother pairs were included consecutively. Data were collected using a face-to-face interviewer-administered questionnaire and clinical examination. Data were entered into Epi Data version 3.1 and analyzed using the statistical package for Social Sciences version 20.0 software. An adjusted odds ratio (AOR) with 95% confidence interval (CI) was used to identify the associated factors. A p-value <.05 was considered statistically significant.

The magnitude of neural tube defects was 5.71% (95% CI: 3.5-7.9). Approximately 83.5% of infants had spinal bifida and 16.5% anencephaly. In multivariable logistic regression analyses, preterm birth (32-34 weeks) (AOR= 3.84; 95% CI: 2.1,10.7), low birth weight (1000-1500 g) (AOR = 4.74; 95% CI: 1.8, 9.1), 1500-2500 g (AOR = 3.01; 95% CI: 2. 1, 13.2), maternal coffee consumption (AOR = 11.2; 95% CI: 3.1, 23.7), a history of abortion or stillbirth (AOR = 9.6; 95% CI:7.6,19.4), radiation exposure (AOR = 5.0; 95% CI:1.6,14.3), and intake of anticonvulsant drugs during pregnancy (AOR = 4.75; 95% CI: 1.5,16.2) were factors associated with neural tube defects.

In this study, the burden of neural tube defects was 5.71% among neonates admitted to the neonatal intensive care unit, which was a public health concern. Increased attention to the monitoring of neural tube defects in eastern Ethiopia is crucial to improve birth outcomes in the study setting.

Patient Delay and Contributing Factors Among Breast Cancer Patients at Two Cancer Referral Centres in Ethiopia: A Cross-Sectional Study

Background: Unlike developed countries, there is high mortality of breast cancer in low- and middle-income countries associated with prolonged patient delays and advanced stage presentations. However, evidence-based information about patient delay in presentation and contributing factors to diagnosis of breast cancer in Ethiopia is scarce.
Methods: Institution-based cross-sectional study was conducted at oncology units of the University of Gondar and Felege Hiwot specialized hospitals. A total of 371 female breast cancer patients who were newly diagnosed from September 2019 to April 30, 2020 were included. Data were entered using EPI info version 7.2 and analyzed in SPSS version 23. Descriptive statistics was used to summarize socio-demographic and clinical characteristic of the patients. Multivariable logistic regression at a P-value< 0.05 significance level was used to identify predictors of patient delay.
Results: A total of 281 (75.7%) patients had long patient delay of ≥ 90 days (3 months) with the average patient delay time of 8 months, and advanced stage diagnosis was found on 264 (71.2%) of patients. The median age of patients was 40 years. Rural residence (AOR=3.72; 95% CI=1.82– 7.61), illiterate (AOR=3.8; 95% CI=1.71– 8.64), having a painless wound (AOR=3.32; 95% CI=1.93, 5.72), travel distance ≥ 5 km (AOR=1.66; 95% CI=1.09– 3.00), having no lump/swelling in the armpit (AOR=6.16; 95% CI=2.80– 13.54), and no history of any breast problem before (AOR=2.46; 95% CI=(1.43– 4.22) were predictors for long patient delay.
Conclusion: Long patient delay and advanced stage diagnosis of breast cancer are higher in our study. Travel distance ≥ 5 km, rural residence, no history of any breast problem before, having no lump/swelling in the arm pit, a painless lump in the breast, and being illiterate were important predictors for patient delay. Therefore, public awareness programs about breast cancer should be designed to prevent patient delay in presentation and to promote early detection of cases before advancement.

Surgical Site Infections and Prophylaxis Antibiotic Use in the Surgical Ward of Public Hospital in Western Ethiopia: A Hospital-Based Retrospective Cross-Sectional Study

Surgical site infection (SSI) is one of the leading causes of hospital-acquired infection among hospitalized patients. It causes significant health problems and results in an extended length of hospital stay, increased cost, and increased patient morbidity and mortality. To prevent the development of SSI, surgical antibiotic prophylaxis (SAP) administration before surgery is an evidence-based practice. Therefore, this study aimed to assess the prevalence of SSIs and surgical antibiotic prophylaxis practice, and identifying the gap in practicing prophylactic surgical antibiotic use.

A retrospective cross-sectional study design was conducted on randomly selected 281 participants who fulfilled the inclusion criteria. Appropriateness of surgical antibiotic prophylaxis was assessed by clinical pharmacists based on the standard treatment guideline. Descriptive and multivariate logistic regression analyses were performed in SPSS version 25. Statistical significance was set at p <0.05.

The overall prevalence of SSI was 19.6% (95% CI: 19–20.2). Majority of surgical patients (88.6%) got surgical antibiotic prophylaxis. Ceftriaxone and metronidazole (45.4%), and ceftriaxone (33.3%) were the most frequently used prophylactic antibiotics. Presence of comorbidity (AOR=9.18, 95% CI: 5.17–17.9, p<0.001), contaminated (AOR=6.01, 95% CI: 1.77–16.8, p=0.019) and dirty (AOR=7.20, 95% CI: 1.23–12.1, p=0.029) wound classes, devoid of prophylactic antibiotics (AOR=6.63, 95% CI: 0.89–19.3, p=0.006), the timing of prophylactic antibiotic administration between 1 hour and 2 hours before incision (AOR=8.2, 95% CI: 4.34–18.1, p=0.001), and 48 hours duration of surgical antimicrobial prophylaxis (AOR=7.20, 95% CI: 1.23–28.17, p=0.027) were significantly associated with the development of SSIs.

The prevalence of SSI was relatively high despite most surgical patients were given prophylactic antibiotics. The presence of comorbidity, contaminated and dirty wound classes, devoid of prophylactic antibiotics, administering prophylactic antibiotics between 1 hour and 2 hours before incision, and 48 hours duration of surgical antibiotic prophylaxis were significantly associated with SSIs.

Case series of hyena bite injuries and their surgical management in a resource-limited setup: 1-year experience

Animal bites are a significant cause of morbidity and mortality and pose a major public health problem worldwide. Children are reportedly the most common victims of animal bites. Bites may be limited to superficial tissues or lead to extensive disfiguring injuries, fractures, infections and rarely result in death. Recently, human injuries caused by non-domesticated animals are increasingly common as ecosystems change and humans encroach on previously wild land. Wild animals like hyenas have been reported to prey on humans and cattle in parts of Africa. Discussed here are four children out of 11 patients that presented with hyena bites-the children had severe bites to the face and head with extensive soft tissue loss, fractures and concomitant severe infections that led to high mortality, indicating the necessity for advanced intensive care and multidisciplinary treatment needed in such situations.

One Health Approach and Antimicrobial Resistance: From Global to Ethiopian Context

Recently, antimicrobial resistance is considered as a global health crisis. Some are thought that we are now in post-antibiotic era. Despite data gaps are largest; it creates particularly significant intimidation to low- and middle-income countries. Many factors are responsible for the development of resistance to antimicrobials by microorganisms. Weak regulations and usage inaccuracies are the major causes for the occurrence of antibiotic resistance. In the last three decades, greater than thirty new infectious diseases, most originated from animals, have been emerged. There is also rising of antimicrobial consumption across the world. The growth
of human populations and an increase in contact with wildlife contribute to the spread of resistance and making it a global health concern. Since there are many routes by which drug metabolites and resistant microbes can disseminate among humans, animals and the environment, One Health Approach is urgently required to address antimicrobial resistance in global, national and local level, including Ethiopia. Internationally, the worst threat comes from the emergence and rapid spread of multi-drug resistant Gramnegative bacteria. Once again, an intercontinental, interdisciplinary and multiple approaches should be taken to combat this problem among worldwide nations with special emphasis in developing countries encompassing Africa and Ethiopia.

Cost-effectiveness of inhaled oxytocin for prevention of postpartum haemorrhage: a modelling study applied to two high burden settings

Background: Access to oxytocin for prevention of postpartum haemorrhage (PPH) in resource-poor settings is limited by the requirement for a consistent cold chain and for a skilled attendant to administer the injection. To overcome these barriers, heat-stable, non-injectable formulations of oxytocin are under development, including oxytocin for inhalation. This study modelled the cost-effectiveness of an inhaled oxytocin product (IHO) in Bangladesh and Ethiopia.

Methods: A decision analytic model was developed to assess the cost-effectiveness of IHO for the prevention of PPH compared to the standard of care in Bangladesh and Ethiopia. In Bangladesh, introduction of IHO was modelled in all public facilities and home deliveries with or without a skilled attendant. In Ethiopia, IHO was modelled in all public facilities and home deliveries with health extension workers. Costs (costs of introduction, PPH prevention and PPH treatment) and effects (PPH cases averted, deaths averted) were modelled over a 12-month program. Life years gained were modelled over a lifetime horizon (discounted at 3%). Cost of maintaining the cold chain or effects of compromised oxytocin quality (in the absence of a cold chain) were not modelled.

Results: In Bangladesh, IHO was estimated to avert 18,644 cases of PPH, 76 maternal deaths and 1954 maternal life years lost. This also yielded a cost-saving, with the majority of gains occurring among home deliveries where IHO would replace misoprostol. In Ethiopia, IHO averted 3111 PPH cases, 30 maternal deaths and 767 maternal life years lost. The full IHO introduction program bears an incremental cost-effectiveness ratio (ICER) of between 2 and 3 times the per-capita Gross Domestic Product (GDP) ($1880 USD per maternal life year lost) and thus is unlikely to be considered cost-effective in Ethiopia. However, the ICER of routine IHO administration considering recurring cost alone falls under 25% of per-capita GDP ($175 USD per maternal life-year saved).

Conclusions: IHO has the potential to expand access to uterotonics and reduce PPH-associated morbidity and mortality in high burden settings. This can facilitate reduced spending on PPH management, making the product highly cost-effective in settings where coverage of institutional delivery is lagging.