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Bridging gaps in under-five child health: a comprehensive assessment of their social determinants and the health system performance in Tigray, Ethiopia
Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
2024 (English)Doctoral thesis, comprehensive summary (Other academic)Alternative title
Att överbrygga klyftor inom barnhälsa för barn under fem år : En omfattande bedömning av deras sociala determinanter och hälsosystemets prestanda i Tigray, Etiopien (Swedish)
Abstract [en]

Background: Achieving the Sustainable Development targets related to child health necessitates a deep understanding of the multifaceted factors influencing their health.

Aim: To comprehensively examine the social determinants of the access to, and quality of, child health services, and the performance of the health system in the region of Tigray.

Methods: The study was conducted in six randomly selected rural districts of Tigray. The study employed focus group discussions and interviews (sub-study I), a retrospective case-control study (sub-study-II), a capture recapture method (sub-study III), and a two-stage mortality survey (sub-study IV).

Results: Sub-study I: underscored a good knowledge on the causes and management of common childhood morbidity, and that the health posts were conveniently located and provided trusted services. However, several barriers to using health services were identified. These included cultural beliefs, seasonal mobility, economic constraints, limited decision-making power for women, and accessibility challenges.Sub-study II: Revealed that only 76% of eligible children born to HIV-positive mothers were tested, with 17% testing positive for HIV, and only 29% of them linked to anti-retroviral treatment.Sub-study III showed that the concordance correlation coefficient between the Family Folder data and the household survey for the total population, reproductive age women, and under-five year child population were all above 0.73, while they were close to zero for other child health parameters. Tracing and recording neonatal deaths, and the aggregation of data at various levels were the major operational challanges.Sub-study IV identified infectious diseases (52.9%), neonatal causes (35.6%), nutritional disorders (6.6%) and external causes (4.3%) as the major causes of child death. The cause for 76 (16.2%) children was indeterminate. Tracing neonatal deaths and logistical challenges, especially in remote areas were the major operational issues of conducting the mortality survey.

Conclusion: In spite of the improvements in health literacy, access to cost-free reproductive, maternal, neonatal and child health services and improved utilization, various interrelated social determinants, including cultural beliefs, financial barriers and health system-related factors continue to hinder the optimal utilization of essential child health services. Moreover, the health system’s performance in the prevention of mother-to-child transmission of HIV and its effect in reducing mortality among exposed children is generally poor. Policymakers in the region should focus on tackling those social determinants, including the health system, to improve children´s health. The community health information system showed promising potential. However, the operational issue of capturing neonatal deaths adequately and the process by which community data can be aggregated upwards through the health system has to be improved. The study underscored the viability of implementing a cause-specific mortality survey using health extension workers, and the need to standardize data collection tools and logistics before implementation on a larger scale.

Place, publisher, year, edition, pages
Umeå: Umeå University, 2024. , p. 94
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 2307
Keywords [en]
Under-five children, family folder, community, health information, verbal autopsy, health extension program, health system, Tigray, Ethiopia
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
URN: urn:nbn:se:umu:diva-224584ISBN: 978-91-8070-404-5 (electronic)ISBN: 978-91-8070-403-8 (print)OAI: oai:DiVA.org:umu-224584DiVA, id: diva2:1859054
Public defence
2024-08-30, NUS By 5B. plan 3, Umeå universitetssjukhus Rum Alicante, 09:00 (English)
Opponent
Supervisors
Note

Paper III listed in thesis with title "Assessing the performance of the FF system for collecting community-based health information In Tigray Region, North Ethiopia: A capture-recapture study". Correct title of publication: Assessing the performance of the family folder system for collecting community-based health information in Tigray Region, North Ethiopia: a capture-recapture study".

Available from: 2024-05-24 Created: 2024-05-20 Last updated: 2024-05-22Bibliographically approved
List of papers
1. Social determinants of under-5 child health: A qualitative study in Wolkayit Woreda, Tigray Region, Ethiopia
Open this publication in new window or tab >>Social determinants of under-5 child health: A qualitative study in Wolkayit Woreda, Tigray Region, Ethiopia
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2019 (English)In: PLOS ONE, E-ISSN 1932-6203, Vol. 14, no 6, article id e0218101Article in journal (Refereed) Published
Abstract [en]

Despite the significant reductions seen in under-5 child mortality in Ethiopia over the last two decades, more than 10,000 children still die each year in Tigray Region alone, of whom 75% die from preventable diseases. Using an equity lens, this study aimed to investigate the social determinants of child health in one particularly vulnerable district as a means of informing the health policy decision-making process. An exploratory qualitative study design was adopted, combining focus group discussions and qualitative interviews. Seven Focus Group Discussions with mothers of young children, and 21 qualitative interviews with health workers were conducted in Wolkayit district in May-June 2015. Data were subjected to thematic analysis. Mothers’ knowledge regarding the major causes of child mortality appeared to be good, and they also knew about and trusted the available child health interventions. However, utilization and practice of these interventions was limited by a range of issues, including cultural factors, financial shortages, limited female autonomy on financial resources, seasonal mobility, and inaccessible or unaffordable health services. Our findings pointed to the importance of a multi-sectoral strategy to improve child health equity and reduce under-5 mortality in Wolkayit. Recommendations include further decentralizing child health services to local-level Health Posts, and increasing the number of Health Facilities based on local topography and living conditions.

National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-160500 (URN)10.1371/journal.pone.0218101 (DOI)000471238300048 ()31194787 (PubMedID)2-s2.0-85067475600 (Scopus ID)
Funder
Swedish Research Council, C0615601
Available from: 2019-06-19 Created: 2019-06-19 Last updated: 2024-07-02Bibliographically approved
2. The effects of maternal and child HIV infection on health equity in Tigray Region, Ethiopia, and the implications for the health system: a case-control study
Open this publication in new window or tab >>The effects of maternal and child HIV infection on health equity in Tigray Region, Ethiopia, and the implications for the health system: a case-control study
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2019 (English)In: AIDS Care, ISSN 0954-0121, E-ISSN 1360-0451, Vol. 31, no 10, p. 1271-1281Article in journal (Refereed) Published
Abstract [en]

Services that aim to prevent mother-to-child HIV transmission (PMTCT) can simultaneously reduce the overall impact of HIV infection in a population while also improving maternal and child health outcomes. By taking a health equity perspective, this retrospective case control study aimed to compare the health status of under-5 children born to HIV-positive and HIV-negative mothers in Tigray Region, Ethiopia. Two hundred and thirteen HIV-positive women (cases), and 214 HIV-negative women (controls) participated through interviews regarding their oldest children. Of the children born to HIV-positive mothers, 24% had not been tested, and 17% of those who had been tested were HIV-positive themselves. Only 29% of the HIV-positive children were linked to an ART programme. Unexpectedly, exposed HIV-negative children had fewer reports of perceived poor health as compared to unexposed children. Over 90% of all the children, regardless of maternal HIV status, were breastfed and up-to-date with the recommended immunizations. The high rate of HIV infection among the babies of HIV-positive women along with their low rates of antiretroviral treatment raises serious concerns about the quality of outreach to pregnant women in Tigray Region, and of the follow-up for children who have been exposed to HIV via their mothers.

Place, publisher, year, edition, pages
Routledge, 2019
Keywords
Ethiopia, HIV, PMTCT, health equity, under-5 morbidity, under-5 mortality
National Category
Public Health, Global Health, Social Medicine and Epidemiology Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:umu:diva-158194 (URN)10.1080/09540121.2019.1601670 (DOI)000471385300001 ()30957540 (PubMedID)2-s2.0-85063992477 (Scopus ID)
Funder
Swedish Research Council, C0615601
Available from: 2019-04-16 Created: 2019-04-16 Last updated: 2024-07-02Bibliographically approved
3. Assessing the performance of the family folder system for collecting community-based health information in Tigray Region, North Ethiopia: a capture–recapture study
Open this publication in new window or tab >>Assessing the performance of the family folder system for collecting community-based health information in Tigray Region, North Ethiopia: a capture–recapture study
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2024 (English)In: BMJ Open, E-ISSN 2044-6055, Vol. 14, no 2, article id e067735Article in journal (Refereed) Published
Abstract [en]

Objectives: To assess completeness and accuracy of the family folder in terms of capturing community-level health data.

Study design: A capture–recapture method was applied in six randomly selected districts of Tigray Region, Ethiopia.

Participants: Child health data, abstracted from randomly selected 24 073 family folders from 99 health posts, were compared with similar data recaptured through household survey and routine health information made by these health posts.

Primary and secondary outcome measures: Completeness and accuracy of the family folder data; and coverage selected child health indicators, respectively.

Results: Demographic data captured by the family folders and household survey were highly concordant, concordance correlation for total population, women 15–49 years age and under 5-year child were 0.97 (95% CI 0.94 to 0.99, p<0.001), 0.73 (95% CI 0.67 to 0.88) and 0.91 (95% CI 0.85 to 0.96), respectively. However, the live births, child health service indicators and child health events were more erratically reported in the three data sources. The concordance correlation among the three sources, for live births and neonatal deaths was 0.094 (95% CI −0.232 to 0.420) and 0.092 (95% CI −0.230 to 0.423) respectively, and for the other parameters were close to 0.

Conclusion: The family folder system comprises a promising development. However, operational issues concerning the seamless capture and recording of events and merging community and facility data at the health centre level need improvement.

Place, publisher, year, edition, pages
BMJ Publishing Group Ltd, 2024
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-221656 (URN)10.1136/bmjopen-2022-067735 (DOI)001185044000061 ()38331856 (PubMedID)2-s2.0-85184682042 (Scopus ID)
Available from: 2024-03-04 Created: 2024-03-04 Last updated: 2024-05-20Bibliographically approved
4. Undertaking cause-specific mortality measurement in an unregistered population: an example from Tigray Region, Ethiopia
Open this publication in new window or tab >>Undertaking cause-specific mortality measurement in an unregistered population: an example from Tigray Region, Ethiopia
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2014 (English)In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 7, article id 25264Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: The lack of adequate documentation of deaths, and particularly their cause, is often noted in African and Asian settings, but practical solutions for addressing the problem are not always clear. Verbal autopsy methods (interviewing witnesses after a death) have developed rapidly, but there remains a lack of clarity as to how these methods can be effectively applied to large unregistered populations. This paper sets out practical details for undertaking a representative survey of cause-specific mortality in a population of several million, taking Tigray Region in Ethiopia as a prototype.

SAMPLING: Sampling was designed around an expected level of maternal mortality ratio of 400 per 100,000 live births, which needed measuring within a 95% confidence interval of approximately ±100. Taking a stratified cluster sample within the region at the district level for logistic reasons, and allowing for a design effect of 2, this required a population of around 900,000 people, equating to six typical districts. Since the region is administered in six geographic zones, one district per zone was randomly selected.

IMPLEMENTATION: The survey was implemented as a two-stage process: first, to trace deaths that occurred in the sampled districts within the preceding year, and second to follow them up with verbal autopsy interviews. The field work for both stages was undertaken by health extension workers, working in their normally assigned areas. Most of the work was associated with tracing the deaths, rather than undertaking the verbal autopsy interviews.

DISCUSSION: This approach to measuring cause-specific mortality in an unregistered Ethiopian population proved to be feasible and effective. Although it falls short of the ideal situation of continuous civil registration and vital statistics, a survey-based strategy of this kind may prove to be a useful intermediate step on the road towards full civil registration and vital statistics implementation.

Place, publisher, year, edition, pages
Co-Action publishing, 2014
Keywords
Ethiopia, mortality, verbal autopsy, population survey, civil registration and vital statistics, evidence-based decision making
National Category
Public Health, Global Health, Social Medicine and Epidemiology Occupational Health and Environmental Health
Identifiers
urn:nbn:se:umu:diva-93710 (URN)10.3402/gha.v7.25264 (DOI)000341393000001 ()25217254 (PubMedID)2-s2.0-84929512801 (Scopus ID)
Available from: 2014-09-30 Created: 2014-09-30 Last updated: 2024-07-02Bibliographically approved

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Abraha Derbew, Atakelti

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