Use of bed nets to prevent malaria

The objective of this study was to characterize the pattern related to ITN use in one village in south Ethiopia. A huge discrepancy was reported between ownership versus utilization of insecticide-treated bed nets (ITNs). To acquire the benefits of ITNs, households need to use and not merely own them.

Eskindir Loha, Kebede Tefera and Bernt Lindtjørn. Freely distributed bed-net use among Chano Mille residents, south Ethiopia: a longitudinal study. Malaria Journal 2013, 12:23 doi:10.1186/1475-2875-12-23

Background:  A huge discrepancy was reported between ownership versus utilization of insecticide-treated bed nets (ITNs). To acquire the benefits of ITNs, households need to use and not merely own them. The objective of this study was to characterize the pattern of, and assess factors related to ITN use in one village in south Ethiopia.

Methods:  A prospective cohort study involving 8,121 residents (in 1,388 households) was carried out from April 2009 to April 2011 (101 weeks). Every week, individuals were asked whether they slept under an ITN the night before the interview. Descriptive statistics was used to report the availability and use of ITN. A negative, binomial, probability, distribution model was fitted to find out significant predictors of ITN use. Reasons for not using ITN were summarized.

Results:  The total number of ITNs available at the beginning of the study was 1,631 (1.68 ITNs per household). On week 48, 3,099 new ITNs (PermaNet2.0) were distributed freely (2.3 ITNs per household). The number of households who received at least one new ITN was 1,309 (98.4%). The percentage of children <5 years and pregnant women not using ITNs exceeded that of other adults. The mean (range; SD) ITN use fraction before and after mass distribution was 0.20 (0.15-0.27; 0.03) and 0.62 (0.47-0.69; 0.04), respectively. Before mass ITN distribution, the most frequent reason for not using ITN was having worn out bed nets (most complained the bed nets were torn by rats); and after mass ITN distribution, it was lack of convenient space to hang more than one ITN. Males, younger age groups (mainly 15–24 years) and those living away from the vector-breeding site were less likely to use ITN.

Conclusions:  The ITN use fraction reached to a maximum of 69% despite near universal coverage (98.4%) was achieved. Gender, age differences and distance from vector breeding site were associated with ITN use. Strategies may need to be designed addressing disproportions in ITN use, lack of convenient space to hang more than one ITN (for those receiving more than one), and measures to prolong usable life of ITNs.

Podoconiosis: a form of elephantiasis

Recently I read the following text in a new and good website about Podo:

“Podoconiosis (or simply ‘podo’) is a form of elephantiasis or swelling of the lower leg triggered by prolonged exposure to irritant minerals in red clay soils. There is no infectious or contagious agent: no parasite, no bacterium, no virus is involved. It was classified as a Neglected Tropical Disease by the World Health Organisation in 2011.

An estimated 4 million people in highland tropical Africa are affected with podoconiosis, and evidence suggests widespread endemicity in more than 15 countries throughout the world.

Although the disease is both preventable (by avoiding contact with irritant soil) and treatable (through simple, inexpensive foot hygiene and protection), there are as yet no government-backed assistance programs for addressing prevention and treatment of podoconiosis.

Individuals afflicted with podoconiosis suffer debilitating physical effects, including attacks when the leg becomes warm, painful and even more swollen, and are ostracised from their communities because of misconceptions about the cause of podoconiosis”.

You can read more about this important public health problem at:

Excellent for Centre for International Health

Recently, The Research Council of  Norway evaluated health research in Norway.

The core research groups at Centre for International Health both received the grade “Excellent” by an international expert panel which evaluated medicine and health research in Norway.

The evaluation panel concludes that “the Centre for International Health is the leading research centre within international and global health in the Nordic countries, and one of the leading centres in Europe”.

CIH combines biomedical and public-health research. Both the Child Health and Nutrition, and the HIV and TB Research group received “excellent” grades. Both research groups address important research questions, and base their research on long-term collaboration with universities in Asia and Africa. The research also addresses  the needs of the population, and translates research findings into improved treatment and better control of diseases.

Read the full evaluation report here.


Can we improve health policy?

This is a central question in public health research. Epidemiological research aims to improve our understanding of diseases, or to improve health. Improving health often needs policy changes, either at institutional, regional or national level.

Operational research is defined as: “The search for knowledge on interventions, strategies, or tools that can improve the quality, effectiveness, or coverage of programmes in which the research is being done” 1.

Operational research involves descriptive, case–control, and cohort analysis. Some say that basic science research and randomised controlled trials is not operational research. However, effectiveness trials show if an intervention works, and should in my view form an integral part of operational research. Results from such randomised trials can benefit in diverse settings of routine care.

Many researchers believe that doing good research and publishing the results in high-quality journals lead to policy change. Unfortunately, this is a naive view. Here I present a few examples showing that policy change is more that doing good research: it wants a close cooperation with policy-makers.

Improving tuberculosis control

Although tuberculosis treatment success rates have improved in Ethiopia, low case notification rate, mainly because of inability to access the health service, remains a challenge. Using community health workers, we enrolled health extension workers in providing health education, sputum collection and treatment. This improved treatment, case detection, occurs because of increased access to the diagnostic services 2. This approach also reduced costs by 63%, and is economically attractive to the health service and patients, caregivers and the community 3.

The Ministry of Health Ethiopia recently backed this approach, and Health Extension Workers now take part in tuberculosis control in Ethiopia.

The policy change was mainly brought about by close communication and involvement of key policy people in carrying out the research.

Antiretroviral treatment in district hospitals

About  ten years ago we started antiretroviral treatment in south Ethiopia. Our question was: Is antiretroviral treatment possible to do at rural hospitals? Our group showed that antiretroviral treatment in resource limited settings  is possible 4, and cost-effective 5.

It is important for HIV infected patients to take their drugs regularly. Interruptions in treatment lead to viral strains that are resistant to the cheapest medications, and to higher rates of illness and death. Unfortunately, many AIDS patients do not return to collect their antiretroviral medications (“lost to follow-up”).

In a recent review of 2191 adult HIV patients in south Ethiopia, we show that patients now start at earlier stages of their illness. Early treatment start improved survival 6. Unfortunately, 25 per cent were lost before they started treatment. This percentage has increased during recent years. Forty per cent of those lost to follow up had died.

This are examples of research that provides  information on how antiretroviral treatment programmes work in the country,

Health care financing

About 14 years ago we started a work to make the hospital sustainable managerially and financially. These were previous mission run hospitals. Over the years, the hospitals managed to become managerially and financially sustainable within a regional context.

And, this model of hospital finance formed a part of the evidence for health care financing in Ethiopia.  The evidence came from evaluations of the hospital services and accounts, as well as external independent audits. There were no formal peer-reviewed publications.

Reducing maternal deaths

In line with the Millennium Development Goal for maternal health (MDG-5), we have since 2008 been running a health programme to reduce maternal mortality in south-west Ethiopia. Based on experience from other countries, we aimed to develop a decentralised delivery of care. Staff at remote rural health centres should be able to carry out comprehensive emergency obstetric care, and these services should be available to and used by pregnant women.

Through this public health project we train staff from many rural hospitals and health centres to do comprehensive emergency obstetric care. We also equip the institutions, and regularly carry our supervision of the work. The project strengthens the antenatal services so the health extension workers can help normal deliveries and identify and refer women in need of help during delivery to health institutions. We enable these health institutions to practise safe delivery. As most maternal deaths occur with delivery, particular attention is on intrapartum care.

After four years, the number of the health care coverage has increased from 1 per 1,3 million people (2 hospitals  for  a population of 2,6 million people) to 1 per  270.000 people (11 institutions  for a population of 2,9 million). The future success of such a programme is that local hospitals start training staff, and supervise staff at the remote health centres and hospitals.

This project is mainly an education programme, and serves as a pilot model for the region. We have presented our experiences at several meetings, and publications will soon be available. But more important, representatives from other regions visit us, and plan to use our experiences in their efforts to reduce maternal deaths.


These examples from practical health work and research in Ethiopia show we should inform people in position to change policy. Engaging policy makers in the work is often more important than publications.


1. Zachariah R, Harries AD, Ishikawa N, et al. Operational research in low-income countries: what, why, and how? Lancet Infect Dis. 2010;9:711–717.

2. Datiko DG, Lindtjørn B. Health extension workers improve tuberculosis case detection and treatment success in southern Ethiopia: a community randomized trial. PLoS ONE. 2009;4(5):e5443.

3. Datiko DG, Lindtjørn B. Cost and cost-effectiveness of smear-positive tuberculosis treatment by Health Extension Workers in Southern Ethiopia: a community randomized trial. PLoS ONE. 2010;5(2):e9158.

4. Jerene D, Naess A, Lindtjørn B. Antiretroviral therapy at a district hospital in Ethiopia prevents death and tuberculosis in a …. AIDS Research and Therapy. 2006.

5. Bikilla AD, Jerene D, Robberstad B, Lindtjørn B. Cost-effectiveness of anti-retroviral therapy at a district hospital in southern Ethiopia. Cost effectiveness and resource allocation : C/E. 2009;7:13.

6. Mulissa Z, Jerene D, Lindtjørn B. Patients present earlier and survival has improved, but pre-ART attrition is high in a six-year HIV cohort data from Ethiopia. PLoS ONE. 2010;5(10):e13268.


PhD Reviews

Global Health Action (GHA) is an international, peer-reviewed Open Access journal, which was launched in 2008. It is affiliated with the Umeå Centre for Global Health Research (CGH) in Sweden.

The Journal is registered in PubMed, and reaches a global audience in 190 countries.

The journal has recently started a new area of editorial content called PhD Reviews.

They invite young researchers that have recently defended their PhDs within the field of global health to write a paper based on their cover stories. One background reason for this is that Scandinavian PhDs are usually based on a set of articles synthesized into a “cover story” of some 30-50 pages. Some of these syntheses provide excellent reviews of the research area but they seldom reach beyond the host institution or the close collaborators and examiners. Condensing them into a PhD Review may also serve as incentive for the young researcher to publish their first post doc paper as a sole author.

You may find a few examples at their website,, or by clicking here to find the section ‘PhD Reviews.

200 Countries, 200 Years, 4 Minutes

I have for many years known Hans Rosling. He is a professor in Stockholm. He started working in rural Africa, described the Konzo nutritional disorder, and is now a not only an excellent teacher, but also global educator.

Please visit his homepage and download some of the very good software that he has developed. This software is free, and the teaching materials are useful tools to learn both students and professionals.

Now, please watch the film from YouTube (BBC Four):

Statistics come to life when Swedish academic superstar Hans Rosling graphically illustrates global development over the last 200 years.

Ethiopian Journal of Health Development Vol 24 No 2

Volume 24, No 2, 2010, 87 – 153


pdf Bridging the divide: Linking training to services. Damen Haile Mariam
Original articles
pdf Assessing communication on sexual and reproductive health issues among high school students with their parents, Bullen Woreda, Benishangul Gumuz Region, North West Ethiopia. Desalegn Gebre Yesus, and Mesganaw Fantahun.
pdf Applicability of the theory of planned behavior in predicting intended use of Voluntary HIV Counseling and Testing services among teachers of Harari Region, Ethiopia. Shemsedin Omer, and Jemal Haidar
pdf Community based assessment on household management of waste and hygiene practices in Kersa Woreda, Eastern Ethiopia. Bizatu Mengistie, and Negga Baraki
pdf Assessment of the impact of latrine utilization on diarrhoeal diseases in the rural community of Hulet Ejju Enessie Woreda, East Gojjam Zone, Amhara Region. Andualem Anteneh, and Abera Kumie
pdf Healthcare waste generation and its management system: the case of health centers in West Gojjam Zone, Amhara Region, Ethiopia. Muluken Azage, and Abera Kumie
pdf The status of rabies in Ethiopia: A retrospective record review. Asefa Deressa, Abraham Ali, Mekoro Beyene, Bethelehem Newaye Selassie, Eshetu Yimer and Kedir Hussen
pdf Byssinosis and other respiratory symptoms among factory workers in Akaki textile factory, Ethiopia. Kassahun Alemu, Abera Kumie, Gail Davey
pdf Collective radiation dose from diagnostic x-ray examination in nine public hospitals in Addis Ababa, Ethiopia. Daniel Admassie, Seife Teferi and Kalkidan Hailegenaw
Bibliography on HIV/AIDS
Hypertension, obesity and central obesity in diabetics and non diabetics in Southern Ethiopia. Araya Giday, Mistire Wolde and Dawit Yihdego
pdf Comparison of formol-acetone concentration method with that of the direct iodine preparation and formol-ether concentration methods for examination of stool parasites. Feleke Moges, Yeshambel Belyhun, Moges Tiruneh, Yenew Kebede, Andargachew Mulu, Afework Kassu and Kahsay Huruy
Book review
pdf Water Resources Management in Ethiopia: Implications for the Nile Basin. Edited by: Helmut Kloos and Worku Legesse. Reviewed by: Abera Kumie
ISSN 1021-6790

Active case finding in tuberculosis

ResearchBlogging.orgEven if 36 million patients with tuberculosis were successfully treated, and up to 6 million lives were saved during the past 15 years, tuberculosis remains a major public health problem. More than 9 million cases occur every year.

Unfortunately, only a little more that half of the expected cases are identified yearly and receive proper care. We therefore need novel measures to diagnose, treat, and thus stop transmission of tuberculosis.

Many have previously questioned the role of active case finding in reducing tuberculosis prevalence. Recently, several active case-finding strategies for tuberculosis were tested and proved to be effective, both in urban (Corbett, Bandason et al. 2010) and rural settings (Datiko and Lindtjørn 2009). The Lancet study (Corbett, Bandason et al. 2010) also documented the effect on the prevalence of culture-positive tuberculosis. The study from Ethiopia also showed that active case finding is a cost-effective strategy (Datiko and Lindtjørn 2010).

These studies highlight active case-finding in tuberculosis control efforts, especially in settings where HIV is prevalent and in weak health systems.

Some of the research priorities for countries with weak health systems should include:

  • Evaluate tools for effective active case-finding so it reduces tuberculosis prevalence. To do this we should also set up good records on tuberculosis prevalence, and thus be able to document a future decline in tuberculosis prevalence.
  • We need to develop different models for active case finding in communities. By this, I mean practical tools on how to do this in a local community. We are starting a new research in Ethiopia to develop “tuberculosis suspect registries” in the communities as a tool to identify patients with tuberculosis.
  • In addition, we urgently need fast, accurate, and simple diagnostic test.

And, scaling up active case-finding outside health institutions needs to be paired with increased scientific interest, research investment, and political commitment for high-quality basic and operational research.

Corbett, E., Bandason, T., Duong, T., Dauya, E., Makamure, B., Churchyard, G., Williams, B., Munyati, S., Butterworth, A., & Mason, P. (2010). Comparison of two active case-finding strategies for community-based diagnosis of symptomatic smear-positive tuberculosis and control of infectious tuberculosis in Harare, Zimbabwe (DETECTB): a cluster-randomised trial The Lancet, 376 (9748), 1244-1253 DOI: 10.1016/S0140-6736(10)61425-0

Datiko DG, Lindtjorn B (2009) Health extension workers improve tuberculosis case detection and treatment success in southern Ethiopia: a community randomized trial. PLoS One 4: e5443.

Datiko DG, Lindtjorn B (2010) Cost and cost-effectiveness of smear-positive tuberculosis treatment by Health Extension Workers in Southern Ethiopia: a community randomized trial. PLoS One 5: e9158.

Achieving MDGs?

The United Nations recently discussed the achievements so far in achieving the Millennium Development Goals. The goals aim to:

  • Eradicate extreme poverty and hunger
  • Achieve universal primary education
  • Promote gender equality and empower women
  • Reduce child mortality
  • Improve maternal health
  • Combat HIV/Aids, malaria and other diseases
  • Ensure environmental sustainability
  • Develop a Global Partnership for Development

The Prime Minister of Norway, Jens Stoltenberg and the Gordon Brown, former PM of Great Britain, underline that governments of poorer nations have to put resources into education and health, and not into corruption.

As I have outlined previously, corruption is widespread at health institutions. Fighting corruption is necessary because corruption reduces the resources available for health. Corruption also lowers the quality, equity and effectiveness of health care services, and it decreases the volume and increases the cost of provided services. Corruption also discourages people to use and pay for health services.

It is encouraging that world leaders talk about broadening the tax base, and identify fighting corruption as a means of achieving the MDGs. The leading donors should encourage governments to put in place mechanisms at each institution to reduce corruption. This should include such basic functions and proper accounting systems and mechanisms for independent financial audits.