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IntroductionHomelessness among women of reproductive age is a global problem. Several unique gender-based issues affect homeless women’s well-being, including reproductive health issues, their homelessness experiences, and a high rate of sexual violence. In this study, we aimed to describe women’s experiences of street homelessness in their own terms and their suggestions to address their unmet needs.MethodsThis photovoice study draws on photos, focus group discussions, and semi-structured interviews. We conducted the study in collaboration with women in their reproductive years experiencing homelessness (n = 9). A total of 80 photos were taken, and 40 were chosen to be discussed in interviews and further focus group discussions. The participating women selected photographs, explained their significance, and codified them based on how they related to their lives. Data from these discussions were then analysed using a reflexive thematic approach.ResultsFour themes were developed from the data: (a) deprivation of basic needs; (b) experiencing dependency, shame, and seclusion while dealing with the burden of street life; (c) the vulnerability and neglect of children; and (d) being resilient to harsh conditions. In this study, women’s street life was characterised by numerous unfavourable aspects, including unmet needs, human rights violations, social exclusions, substance use, and child protection issues. Participants provided suggestions for change and confirmed their belief that adequate housing represents one of the most urgent unmet basic needs of people experiencing homelessness. They also emphasised the critical need for employment opportunities, non-discriminatory provision of social support, treatment programs for substance misuse, and legal and social protection.ConclusionThis study contributes to understanding how women experiencing homelessness describe and articulate their living circumstances and what they perceive needs to be addressed. Based on participants’ proposal for change, comprehensive services are needed to address women’s multifaceted issues. However, the mitigation strategies and long-term effects of women’s homelessness require further research.

Background: In low-income countries, social norms play a significant role in intrahousehold food allocation practices. These norms can sometimes lead to discrimination against specific groups, posing a public health concern. This study focuses on the social norm surrounding food allocation within households and food taboos affecting adolescent girls in rural Ethiopia. Method: A qualitative study was conducted using vignettes as prompts for 20 focus group discussions and 32 in-depth interviews. The vignettes were tailored to the local context. Participants were chosen purposefully, and data were collected in a comfortable setting. All sessions were recorded and transcribed verbatim. Data analysis was done using Open Code qualitative analysis software with a thematic framework approach. Findings: In the community, adolescent girls were expected to eat after serving the male family members. Those who did not follow this expectation faced sanctions such as being labeled as disrespectful and could even be insulted or beaten by their spouses and siblings. However, there were some exceptions to this rule, such as when girls were giving birth, breastfeeding, sick, or when male family members were traveling. Certain foods were also prohibited for adolescent girls, including spicy foods like chili, animal products such as meat and milk, and nuts. These foods were believed to increase girls' sexual desire, potentially leading them to engage in premarital or extramarital sex. Additionally, eating outside of the house was not considered appropriate behavior for adolescent girls in this community. Conclusion: In many households, social norms dictate that adolescent girls are not given enough food or are denied essential nutrients for their health. It is important to challenge these norms to ensure fair food distribution within households and support the healthy development of adolescent girls.

Photo elicitation interviewing (PEI), as a visual qualitative research methodology, has been used widely in various fields with different participants. However, little has been written about using the method in public health research, especially involving men in low-income settings. In this paper, the authors reflect upon the use of PEI in a study that explored fathers’ experiences in child care and feeding in a low-income neighbourhood of Addis Ababa city in Ethiopia. The reflections focus on two overarching themes; (1) how PEI worked well as an effective technique in terms of addressing the research questions posed in this low-resourced setting and (2) how it served to enhance phenomenology in qualitative public health research. The researchers also discuss the limitations and lessons from employing this methodology through continuous reflexivity, which is valuable to qualitative work.

Abstract Background Private health care facilities working in partnership with the public health sector is one option to create sustainable health systems and ensure health and well-being for all in low-income countries. As the second-most populous country in Africa with a rapidly growing economy, demand for health services in Ethiopia is increasing and one-quarter of its health facilities are privately owned. The Private Health Sector Program (PHSP), funded by the United States Agency for International Development, implemented a series of public–private partnership in health projects from 2004 to 2020 to address several public health priorities, including tuberculosis, malaria, HIV/AIDS, and family planning. We assessed PHSP’s performance in leadership and governance, access to medicines, health management information systems, human resources, service provision, and finance. Methods The World Health Organization’s health systems strengthening framework, which is organized around six health system building blocks, guided the assessment. We conducted 50 key informant interviews and a health facility assessment at 106 private health facilities supported by the PHSP to evaluate its performance. Results All six building blocks were addressed by the program and key informants shared that several policy and strategic changes were conducive to supporting the functioning of private health facilities. The provision of free medicines from the public pharmaceutical logistics system, relaxation of strict regulatory policies that restricted service provision through the private sector, training of private providers, and public–private mix guidelines developed for tuberculosis, malaria, and reproductive, maternal, newborn, child, and adolescent health helped increase the use of services at health facilities. Conclusions Some challenges and threats to sustainability remain, including fragile partnerships between public and private bodies, resource constraints, mistrust between the public and private sectors, limited incentives for the private sector, and oversight of the quality of services. To continue with gains in the policy environment, service accessibility, and other aspects of the health system, the government and international communities must work collaboratively to address public–private partnerships in health areas that can be strengthened. Future efforts should emphasize a mechanism to ensure that the private sector is capable, incentivized, and supervised to deliver continuous, high-quality and equitable services.

Plain Language Summary In Ethiopia, married girls are a particularly vulnerable adolescent population because of the many health risks associated with early marriage. Peer-based approaches are a common strategy to improve sexual and reproductive health knowledge and behaviours for marginalized groups. Critiques of these approaches are that they lack sustainability without ongoing investment and have no lasting impact on health behaviours. CARE’s TESFA programme, a peer-based approach with married adolescent girls in South Gondar, was found to be effective in creating long-term behavior change related to uptake of family planning and rates of institutional delivery. Some 88% of groups who received the TESFA curriculum were still meeting 4 years after the programme had concluded. Some participants even created groups of their own, scaling TESFA beyond the original audience, suggesting a potential approach to wider scale-up. To explore lessons learned around scale and sustainability, this study interviewed TESFA participants and stakeholders. Improvements in behaviours related to contraceptive use, institutional delivery, and girls’ agency in reproductive decision-making were sustained over time regardless of group status. Factors that affected the sustainability and scale-up of groups included solidarity among group members, support from husbands and community members, ongoing savings and loan structures, flexibility of group processes, and availability of relevant curriculum topics. Through an analysis of these findings, this paper discusses recommendations for sustainable and scalable peer-based programme design via existing Ethiopian community structures. Using TESFA principles as a model, practitioners could design and implement scalable and sustainable peer-based programming for adolescents sexual and reproductive health.

Abstract Small-scale chicken production holds great potential as a nutrition-sensitive strategy in low-income settings, due to its potential for improving income, increasing the consumption of nutritious foods (including eggs and meat), and empowering women. This study sought to evaluate the impacts of and to identify challenges and solutions for a nutrition-sensitive chicken production intervention in rural Ethiopia. We conducted a qualitative study following the endline evaluation of the African Chicken Genetic Gains and Agriculture to Nutrition project in the Amhara and Oromia regions of Ethiopia. Using semi-structured interviews, we held twelve Focus Group Discussions with woman project participants and six Key Informant Interviews with project staff. Data were analyzed using thematic analysis. Six Focus Group Discussions were with participants in the African Chicken Genetic Gains intervention, through which women received 25 high-yielding chickens. The other six Focus Group Discussions were held with participants who (in addition to the African Chicken Genetic Gains intervention) also received the Agriculture to Nutrition intervention, which focused on nutrition-sensitive behavior change communication related to child feeding, water, sanitation and hygiene, and home gardening. The African Chicken Genetic Gains and the Agriculture to Nutrition interventions benefited participants through improved income, nutrition, and child caregiving knowledge. Nutrition and child feeding benefits were emphasized more in the nutrition-sensitive behavior change arm, while income benefits were emphasized more in the arm that did not receive behavior change. The primary challenges of the project included death and disease of chickens and implementation issues at both the project and household levels. Recommendations to address these challenges included improved chicken housing designs, access to inputs, access to veterinary care (including vaccines and medication), and project logistics. The nutrition-sensitive and chicken production interventions were largely well-received by participants. Most participants agreed that the benefits of the project outweighed the challenges. Future projects would benefit from logistical and infrastructural improvements to improve implementation and impacts on nutrition, health, and livelihoods.

Children's health and wellbeing studies focus mainly on mothers' roles while very little is known about the experiences/challenges that fathers face in fulfilling their responsibilities. Therefore, this study aims to explore the fathers' lived experiences of childcare and feeding in an urban low-income setting. This qualitative study was conducted in Addis Ababa, Ethiopia. Photo-elicitation was used to facilitate the in-depth interviews with fathers of children below the age of five years. All interviews were audio-recorded, transcribed and translated verbatim, followed by a thematic analysis approach. The overarching theme of this study was "Fatherhood as an enduring identity", which comprised of three sub-themes: 1) Blessings of fatherhood, 2) Adjusting to fathering roles, and 3) Struggles/demands of fatherhood in a low-resource setting. Fathers expressed that having children or becoming parents was a blessing. They expressed their love, devotion, and attachment to their children. Some used the term "my second chance in life" underscoring the importance. Although fathers strived relentlessly to spend time and care for their children, they faced challenges such as internal struggles adjusting to and fatherhood whilst maintaining a sense of their former self. As well, providing for their families amidst added pressures imposed by the external environment, such as poor housing conditions, a lack of employment opportunities, the then COVID-19 pandemic, further increased their stressors. Most fathers were engaged in child care and feeding, suggesting that like mothers, fathers should be viewed as potential agents for implementing nutrition interventions in this setting. However, if interventions are to be successful, they need to incorporate components that boost fathers' livelihoods and general wellbeing.

Abstract Background Household chicken production presents an opportunity to promote child nutrition, but the benefits might be offset by increased environmental contamination. Using household surveys, direct observations, and in-depth interviews with woman caregivers, we sought to describe the relationship between chicken management practices and household exposure to environmental contamination, and assess barriers to adopting improved husbandry practices. Methods First, we analyzed baseline data from 973 households raising chickens in the two interventions arms from the Agriculture-to-Nutrition (ATONU) study in Ethiopia to assess the relationship between animal management practices and environmental exposures. Second, we conducted six-hour direct observations of children’s environmental exposures in 18 households. Among these households, we analyzed in-depth interviews with child caregivers. Results Quantitative analyses showed that households raised approximately 11 chickens, had animal feces visible on the property 67% of the time, and children’s hands were visibly dirty 38% of the time. Households with more chickens had lower exposure to animal feces. Having a chicken coop increased the risk of observing animal feces on the property by 30%, but among those with a coop, having an enclosed coop reduced that risk by 83%. Coops that were enclosed, had fencing, and were located further from homes were associated with a reduced risk of observing animal feces and an increased likelihood of children having clean hands. Direct observations showed that chicken coops were often poorly designed or not used. On average, 3 to 5 chickens were inside homes at a time, and livestock and domestic animals were frequently inside of houses and interacting with young children. In-depth interviews revealed that protection of animals, maintenance of household cleanliness and health, type of chicken (local versus improved) and resource constraints influenced management decisions. Conclusions Improvements in chicken management practices could mitigate the exposure of household members to environmental contamination. Our findings highlight the need for training and resources to promote safe animal husbandry practices and optimal child health in nutrition-sensitive livestock projects. Trial registration Clinical trials number: NCT03152227 ; Retrospectively registered at ClinicalTrials.gov on May 12, 2012.

Background Early marriage is not uncommon in Ethiopia, particularly for adolescent girls in rural settings. Social norms are among the factors believed to perpetuate early marriage practices. This qualitative study explores social norms surrounding adolescent girls’ marriage practices in West Hararghe, Ethiopia. Methods This study used the qualitative inquiry method to explore social norms in rural Ethiopia. Focus group discussions were conducted with purposively sampled married and unmarried adolescent girls, adolescent boys, and parents. A total of 158 individuals participated in the study, comprising 95 adolescents and 63 parents. Data were collected using locally developed vignettes. A thematic framework analysis approach using the Social Norms Analysis Plot (SNAP) was employed to diagnose and understand social norms. Results Adolescent girls’ marriage was found to be mainly influenced by their peers who conform to prevailing social norms. Marrying one’s first suitor was considered an opportunity not to be missed and a symbol of good luck. Relatives, neighbors, and marriage brokers facilitate adolescent girls’ marriage in accordance with the local social norms. Girls usually accept the first marriage proposal regardless of their age, and they are highly expected to do so by their peers, parents, and influential others. Exceptions from the early marriage social norm include adolescent girls determined to continue their education and those having supportive teachers. Conclusions In this study context, social norms strongly encourage early marriage and are mainly perpetuated by peers of adolescent girls and influential adults. A strong determination to continue education on the part of girls, strong school performance, and supportive schoolteachers are important conditions for circumventing social norms on early marriage. As social norms evolve slowly, we recommend periodical assessment in order to develop locally appropriate interventions against early marriage.

Background. Antibiotic overprescribing is the major driving force for the emergence of antibiotics resistance. The aim of this study was to assess antibiotics prescribing at primary healthcare facilities in Addis Ababa, Ethiopia. Methods. The study was conducted in six public health centers found in Addis Ababa City. Data was collected retrospectively from a total of 900 prescriptions and selected medical charts of patients in the health centers in 2016. Data was entered and analyzed using EPI Info 7 and SPSS 20, respectively. Descriptive statistics and logistic regression analysis were used to analyze the data. Results. One or more antibiotics were prescribed in 56.0% of the prescriptions. Antibiotics accounted for 46.0% of the total cost of medicines prescribed. Amoxicillin was the most frequently (44.8%) prescribed antibiotic and upper respiratory tract infection was the most common (24.5%) diagnosis for prescribing antibiotics. Laboratory investigation was done for only about 27% of the cases for which antibiotics were prescribed. Conclusion. There was a high rate of antibiotics prescribing in the health centers often empirically which might exacerbate the antimicrobial resistance situation in the country. Large-scale study should be conducted to fully understand the prescribing pattern and identify the associated factors thereby design and implement appropriate interventions.

Self-care practices that include self-monitoring of blood sugar level, diet management, physical exercise, adherence to medications, and foot care are the cornerstones of diabetes management. However, very little is known about self-care in developing countries where the prevalence of diabetes is increasing.The objective of this study was to describe self-care practices among individuals with type II diabetes in Addis Ababa, Ethiopia.A qualitative method was used to gather data from type II diabetes patients. Patients were recruited from the outpatient diabetes clinics of two public hospitals in Addis Ababa. Data were collected using a semi structured interview guide. A thematic analysis approach was used to process the data.Overall self-care practices were not adequate. Most patients reported irregular self-monitoring of blood sugar. Dietary and physical exercise recommendations were inadequately practiced by most of the participants. Most patients better adhered to medication prescriptions. Patients generally lack proper information/knowledge regarding the importance of self-care and how it should be implemented. Based on reported behavior we identified three main categories of patients; which are those 'endeavor to be compliant', 'confused' and 'negligent'.Diabetes patients largely depend on prescribed medications to control their blood sugar level. The importance of proper self-care practices for effective management of diabetes is not adequately emphasized in diabetes care centers and patients lack sufficient knowledge for proper self-care.