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Table S1. Expenditure categories for consumption by depression group. (DOCX 13 kb)

Background. Health workers are one of the most important building blocks of the health system. High turnover rate contribute to the shortfalls and unbalanced distribution of health personnel in the health workforce. Turnover intention is the strongest predictor of actual turnover.Objective. To assess the magnitude of turnover intention and associated factors among health professionals working in public health institutions of North Shoa Zone, Amhara region, Ethiopia.Methods. A health facility based cross-sectional study was conducted from March to April 2016, on 612 health professionals working in public health institutions of North Shoa Zone, Amhara region, Ethiopia, using a multistage stratified sampling technique. Data were collected using a pretested self-administered structured questionnaire. The data were entered using Epidata version 3.1 and analyzed using SPSS version 22 software. Descriptive statistics were conducted to summarize the sample characteristics. Backward stepwise logistic regression model was fitted and AOR with 95% CI was calculated to identify the associated factors. P-value Results. Among the 568 health professionals who responded to the questionnaire, 348 (61.3%) of them reported to have the intention to leave their current workplaces. The results showed that being a male [AOR = 1.496 (95% CI: 1.016, 2.204)], medical doctor [AOR = 0.318 (95% CI: 0.122, 0.824)], unsatisfied with the work nature [AOR = 1.822 (95% CI: 1.206, 2.753)], unsatisfied with the incentives [AOR = 1.668 (95% CI: 1.105, 2.517)], and unsatisfied with the supervision [AOR = 1.916 (95% CI: 1.274, 2.881)] and having low normative commitment [AOR = 2.176 (95% CI: 1.482, 3.196)] were significantly associated with turnover intention of the health professionals.Conclusions. The magnitude of turnover intention was high among health professionals working in public health institutions of North Shoa Zone. Health service managers and policymakers should develop evidence based retention strategies considering the determinants of health professionals’ intention to leave. more...

A comparative case-control study to assess the determinants of Community Health Agent (CHA) functionality was done in two Arsi districts, in mid-southern Ethiopia. This was a census study which was conducted by interviewing 347 CHAs from a structured questionnaire. The objectives were to describe the situation of the CHAs trained up to the end of 1987, and to elucidate determinants of CHA functionality by comparing the attributes of functional CHAs (cases) with that of the nonfunctional ones (controls). The findings revealed that only 25.8% of the CHAs interviewed were performing 50% or more of the activities mentioned in their job description. It also revealed a point prevalence attrition rate of 45%. Comparing cases and controls showed a strong association between functionality and community support for the CHAs (RR = 72.4 with 95% CI 35 - 153). Association was also found between functionality and supervision by health institutions, presence of health posts, provision of stationary drugs and to the CHA, and establishment of an active health committee. These findings emphasize the importance of provision of proper community and health system support for the success of the community health services program. more...

Aims: To describe the epidemiological development of a rural Ethiopian population from 1987 to 2004 in terms of mortality and associated sociodemographic factors. Methods: A rural population comprising 10 communities was defined in 1987 and has since been followed by means of regular household visits. After an initial census, births, deaths and migration events were recorded, together with key background factors, on an open cohort basis. Over 97,000 individuals were observed during a total of over 700,000 person years. Results: The initial population of 28,614 increased by an average of 3.64% annually to 54,426 from 1987 to 2004, and also grew older on average. Birth and mortality rates fell, but were still subject to short-term variation due to external factors. Overall mortality was 13.5 per 1000 person years. Increasing mortality in some adult age groups was consistent with increasing AIDS-related deaths, but a new local hospital in 2002 may have contributed to later falls in overall mortality. Sex, age group, time period, literacy, water source, house ownership and distance to town were all significantly associated with mortality differentials. Conclusions: This population has undergone a complex epidemiological transition during a generation. Detailed long-term surveillance of this kind is essential for describing such processes. Many factors that significantly affect mortality cannot be directly controlled by the health sector and will only improve with general development. more...

The objective was to estimate the direct and indirect costs of malaria morbidity among communities in an epidemic area in rural Southcentral Ethiopia. The method used was a community-based cross-sectional study of 2195 households in Adami Tulu district from October to November 2003. Treatment-seeking behaviour expenditure on treatment and transportation interruption of normal activities time lost from working and household expenditure on preventive methods were ascertained through interview. Of 12 225 surveyed individuals 1748 (14.3%) reported perceived malaria during the preceding 2 weeks. 77.1% sought any form of care and 70% had recovered at the time of interview. The average treatment cost per patient at private clinics was Birr 24.00 ($2.76) and Birr 12.50 ($1.44) at public facilities. The average estimated direct cost of malaria per patient was Birr 14.00 ($1.60); the average indirect cost Birr 35.26 ($4.08). Only 5% of all households reported any preventive expenditure in the precedingmonth with a mean of Birr 0.76 ($0.09). Malaria poses a significant economic burden on rural households and individuals both through out-of-pocket payment and person-days lost. The promotion and implementation of insecticide-treated nets would alleviate the economic consequences of the disease. (authors) more...

Background The Ethiopian health system has been undergoing through reforms. One of the reforms stipulated in policy documents is the introduction of health insurance at national level. Having the majority of the population without any experience of health insurance, investigating preferences and knowledge of the essence of health insurance among potential enrolees will provide vital information for policy makers. This formative study seeks to explore the knowledge and the preference for health insurance among formal sector employees in Addis Ababa. Methods Six focus group discussions with formal sector employees and five key informant interviews were conducted in Addis Ababa. A thematic analysis is used to analyse the results. Results The findings suggest that there is little knowledge about the concept and elements of health insurance. Some concepts such as, risk pooling and sharing are not well understood. The participants of the study considered health insurance as only a prepayment mechanism without risk sharing among members of the scheme. Regarding preference for health insurance, they have revealed quality of care as the most important factor. Comprehensiveness of benefit packages and the amount of premium level are also found to be concerns related to health insurance. However, a trade-off is also observed among premium level, comprehensive benefit packages, and healthcare facilities. Conclusions Improvements on availability and quality of services need to precede the introduction of social health insurance. There is also a need to work on awareness creation regarding concepts of health insurance. Further studies may explore if the knowledge gap is real or appeared due to reservations of the participants on the introduction of health insurance. more...

BACKGROUND: Antiretroviral treatment (ART) programs in many resource-limited settings have expanded treatment toward universal access. Ethiopia is one of the countries that has been scaling up ART toward universal access, but with very few data on long-term outcomes and their determinants. The objective of this study was to identify the level of long-term outcomes and their determinants in patients on ART in Ethiopia. METHODS: A retrospective cohort study was conducted in 3 health facilities (2 hospitals and 1 health center) between July and September, 2014. Loss to follow-up, death, attrition, and retention were the primary outcomes. Data were collected from patient registers and medical records for the period 2005/6-2011/12. RESULTS: A total of 11,731 patients were included in the study. The overall retention rate was 78 per 100 person-months. Retention rates were 82%, 74%, and 72% at 24, 60, and 84 months on ART, respectively. Retention was associated with male sex, adolescent age, marital status, advanced HIV disease, illiteracy, and peer-support services; however, long-term retention was associated independently with only male sex [with adjusted hazard ratio (aHR) 0.68 (0.56 to 0.77)], married patients [with aHR 0.62 (0.54 to 0.72)], and peer-support services [with aHR 1.62 (1.58 to 1.66)]. DISCUSSION AND CONCLUSIONS: ART programs have lost most of their patients during the first 24 months on ART. It is, therefore, imperative that HIV/ART programs ensure people are tested, linked to care, and initiated on ART early. ART programs should also design and implement interventions, including peer-support services, which are targeted to male, adolescent, unmarried, and illiterate patients. more...

Background Human immunodeficiency virus (HIV), multi-drug resistant tuberculosis (MDR) is emerging as major challenge facing tuberculosis control programs worldwide particularly in Asia and Africa. Findings from different studies on associations of HIV co-infection and drug resistance among patients with TB have been contradictory (discordant). Some institution based studies found strongly increased risks for multi-drug resistant TB (MDR TB) among patients co-infected with TB and HIV, whereas other studies found no increased risk (it remains less clear in community based studies. The aim was to conduct a systematic review and meta-analysis of the association between multi-drug resistant tuberculosis and HIV infection. Methods and findings Systematic review of the published literature of observational studies was conducted. Original studies were identified using databases of Medline/Pubmed, Google Scholar and HINARI. The descriptions of original studies were made using frequency and forest plot. Publication bias was assessed using Funnel plot graphically and Egger weighted and Begg rank regression tests statistically. Heterogeneity across studies was checked using Cochrane Q test statistic and I2. Pool risk estimates of MDR-TB and sub-grouping analysis were computed to analyze associations with HIV. Random effects of the meta-analysis of all 24 observational studies showed that HIV is associated with a marginal increased risk of multi-drug resistant tuberculosis (estimated Pooled OR 1.24; 95%, 1.04–1.43). Subgroup analyses showed that effect estimates were higher (Pooled OR 2.28; 95%, 1.52–3.04) for primary multi-drug resistance tuberculosis and moderate association between HIV/AIDS and MDR-TB among population based studies and no significant association in institution settings. Conclusions This study demonstrated that there is association between MDR-TB and HIV. Capacity for diagnosis of MDR-TB and initiating and scale up of antiretroviral treatment, and collaborations between HIV and TB control programs need to be considered and strengthened. more...

Background. Intimate partner violence is a global health issue and is associated with a range of health problems for women. Nurses, as the largest health workforce globally, are well positioned to provide care for abused women. Objectives. This nursing-led interdisciplinary project was conducted to understand the current state of knowledge about intimate partner violence in Ethiopia and make recommendations for country-specific activities to improve response to intimate partner violence through practice changes, education, and research. Methods. The project involved two phases: review of relevant literature and an interdisciplinary stakeholder forum and a meeting with nurse educators. Findings. The literature review identified the pervasiveness and complexity of intimate partner violence and its sociocultural determinants in the Ethiopian context. Two significant themes emerged from the forum and the meeting: the value of bringing multiple disciplines together to address the complex issue of intimate partner violence and the need for health care professionals to better understand their roles and responsibilities in actively addressing intimate partner violence. Conclusions. Further research on the topic is needed, including studies of prevention and resilience and “best practices” for education and intervention. Interdisciplinary and international research networks can support local efforts to address and prevent intimate partner violence. more...

International collaboration in nursing and other health disciplines is vital for addressing global health issues. While the results and processes of such collaborations have been reported, few publications have addressed their philosophical or theoretical underpinnings, particularly with respect to collaboration between those in low- and high-income countries. Piaget's notion of social relations of cooperation and constraint and Habermas's notion of "lifeworld" provide a theoretical lens through which to examine international collaboration as a construction of knowledge. This article is an exploration of these ideas as seen in the collective experience of Canadians and Ethiopians organizing an interdisciplinary forum on intimate partner violence in Ethiopia. The project is presented as a case study for reflecting on international collaboration as a manifestation of social relations. Such re-visioning of international collaboration may be useful for improving collaborative processes and their outcomes. more...

Objective : to explain comparatively how economic and family caregiver burden in families with bipolar disorder patients change overtime. Method : one year follow-up of economic and family caregiver burden was carried out on family caregivers of 190 bipolar, 55 diabetes, hypertension and asthma patients and 659 sick controls in the community. Population average generalized estimating equation was used to make longitudinal comparative analysis. Results : bipolar patient family caregivers were found to be more burdened, for about 8 to 10 months of the year of study, than family caregivers of diabetes, hypertension and asthma and sick controls in the community. The average difference in family caregiver burden score between bipolar and diabetes, hypertension and asthma patient family caregivers was 4.36 (z = -8.75, P > |z| = 0.001); while the difference due to time between the two groups was 3.42 (z = -4.27, P > |z| = 0.001). Similarly, the average difference in family caregiver burden score between family caregivers of bipolar patient and sick controls in the community was 3.7 (z = -4.88, P > |z| 0.001). In terms of longitudinal caregiver burden difference, bipolar patients family caregivers were found to be more burdened than family caregivers of sick controls in the community with a burden score difference of 2.97 (z = -5.17, P > |z| = 0.001). Conclusion : more should be done to lessen the economic and family caregiver burden due to bipolar disorder. more...

To estimate the direct and indirect costs of malaria morbidity among communities in an epidemic area in rural Southcentral Ethiopia.Community-based cross-sectional study of 2195 households in Adami Tulu district from October to November 2003. Treatment-seeking behaviour, expenditure on treatment and transportation, interruption of normal activities, time lost from working and household expenditure on preventive methods were ascertained through interview.Of 12,225 surveyed individuals, 1748 (14.3%) reported perceived malaria during the preceding 2 weeks. 77.1% sought any form of care and 70% had recovered at the time of interview. The average treatment cost per patient at private clinics was Birr 24.00 ($2.76) and Birr 12.50 ($1.44) at public facilities. The average estimated direct cost of malaria per patient was Birr 14.00 ($1.60); the average indirect cost, Birr 35.26 ($4.08). Only 5% of all households reported any preventive expenditure in the preceding month, with a mean of Birr 0.76 ($0.09).Malaria poses a significant economic burden on rural households and individuals both through out-of-pocket payment and person-days lost. The promotion and implementation of insecticide-treated nets would alleviate the economic consequences of the disease. more...

SummaryA range of activities are currently underway to improve access to malaria prevention and control interventions. As disease control strategies change over time, it is crucial to understand the health-seeking behaviour and the local socio-cultural context in which the changes in interventions operate. This paper reflects on how people in an area of seasonal malaria perceive the causes and transmission of the disease, and what prevention and treatment measures they practise to cope with the disease. It also highlights some of the challenges of malaria treatment for health care providers. The study was undertaken in 2003 in Adami Tulu District in south-central Ethiopia, where malaria is a major health problem. Pre-tested structured questionnaires and focus group discussions were conducted among men and women. Malaria, locally known as busa, was perceived as the most important cause of ill health in the area. Respondent’s perception and knowledge about the cause and transmission of the disease were relatively high. The newly introduced insecticide-treated nets were not popular in the area, and only 6·4% of households possessed at least one. The results showed that patients use multiple sources of health care for malaria treatment. Public health facilities, private clinics and community health workers were the main providers of malaria treatment. Despite higher treatment costs, people preferred to use private health care providers for malaria treatment due to the higher perceived quality of care they offer. In conclusion, effort in the prevention and control of malaria should be intensified through addressing not only public facilities, but also the private sector and community-based control interventions. Appropriate and relevant information on malaria should be disseminated to the local community. The authors propose the provision of effective antimalarial drugs and malaria prevention tools such as subsidized or free insecticide-treated nets. more...

Additional file 2. Literature search terms.

Additional file 2. Literature search terms.

Additional file 3. PRISMA flow diagram.

Additional file 3. PRISMA flow diagram.