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menstruation significantly affects schoolgirls' academic attendance and performance. This study aims to explore the relationship between monthly menstruation along with the availability of water, sanitation and hygiene services, and school attendance among schoolgirls. a mixed-method cross-sectional study was conducted between March 2022 and August 2023. Study participants were selected using systematic random and purposive sampling techniques for quantitative and qualitative, respectively. A self-administered questionnaire was used to collect information from students. Focus group discussions were conducted among mothers of schoolgirls and interreligious council members, and in-depth and key informant interviews were used to gather information from parent-teacher-student association chairpersons and the vice head and head of the Education and Health department offices, respectively. Quantitative data were analyzed using SPSS version 27, and qualitative data used ATLAS.ti. The Chi-square test and binary logistic regression were used to assess the statistical significance of the relationship among variables, ensuring the thoroughness and validity of the research. in this study, more than half of the schoolgirls, 389 (55.50%), missed school days due to menstruation and related factors, and on average, the schoolgirls missed 2.08 (±0.87) days per month. Factors such as WASH facilities (χ = 46.78, p<0.0001; OR= 0.350, p<0,0001), accessibility with menstrual absorbent materials (χ =5.42, p=0.02; OR=0.634, p=0.012), menstrual hygiene management rooms (OR=0.669, p=0.029), socio-cultural constraints (χ = 22.08, p<0.0001; OR=0.539, p=<0.0001), menstrual-related pain (χ =5.9, p=0.015), fear (χ =36.32, p<0.0001; OR=2.505, p<0.0001), and teasing (χ =13.66, p-<0.0001; OR=1.754, p<0.0001), were significantly associated with school absenteeism. A qualitative study identified four themes that influence school attendance: inadequate water and sanitation facilities, lack of access to menstrual absorbent materials, sociocultural constraints, menstrual-related pain, and fear. in the study area, a significant number (55.50%) of schoolgirls missed school days due to menstrual-related factors. The identified factors in the quantitative study were also supported by the themes emerging from the qualitative study. The identified modifiable factors are the areas of intervention that can increase schoolgirls´ school attendance.

It is common in a number of disciplines such as economics, sociology, psychology and clinical trials that researchers are interested to test treatment effects among several of the outcomes in the same direction. Such tests can be performed by using equi-directional test statistics for multivariate data. If on the other hand, treatment effects with respect to one or more of the outcomes differ in direction, the power of equi-directional tests is compromised. Thus, we interchanged the signs of different outcomes by multiplying the values with - 1 and made the anticipated direction similar. Following this, we employed a recently proposed test statistic which handles equi-directional alternatives since the direction of treatment effects is made uniform through interchanging the signs. Once monotonic trend, that is, monotonic increasing for some of the outcomes and monotonic decreasing for others is demonstrated through the global test statistic, an investigator may be further interested in which specific outcomes or sets of outcomes actually these trends are observed. To address this issue, we adapted a closed testing principle. The whole procedure is illustrated by data sets from a toxicology study carried out by the National Toxicology Program, and a cost of transporting milk from farms to dairy plants per mile by different trucks.

Diarrhoeal diseases in children aged <5 years require immediate medical attention. However, previous studies conducted on treatment-seeking practices of caregivers for children aged <5 years with diarrhoea in low- and middle-income countries (LMICs) were inconsistent and inconclusive. We aimed to estimate the pooled treatment-seeking practice of caregivers for children aged <5 years with diarrhoea in LMICs. We used the 2020 PRISMA guidelines to conduct this systematic review and meta-analysis. We included both published and unpublished articles in English that reported treatment-seeking practices from health facilities in LMICs between 2010-22. We searched CINAHL, Medline/PubMed, Web of Science, Embase, and grey literature sources. We assessed the eligible articles using the Newcastle-Ottawa Scale quality appraisal checklist and Begg's test for the presence of publication bias. Further, we used the regression-based Egger test to test for a small study effect. Moreover, we used a narrative synthesis to characterise the studies. We estimated the pooled treatment-seeking practice using a random-effect model. We conducted a subgroup analysis considering the articles' publication status, residence, World Bank income category, study design and approach, and study setting. We presented the results using tables, figures, forest plots, and funnel plots. We included 76 articles in the analysis. The overall treatment-seeking practices of caregivers were 52.84% (95% confidence interval (CI) = 47.51-58.17). Healthcare-seeking practices in low-income countries (58.12%), lower-middle-income countries (48.41%), and upper-middle-income countries (51.44%) were not statistically different. The pooled treatment-seeking practice for diarrhoea varied by study site: 29.80% (95% CI = 25.00-34.60) in peri-urban, 54.20% (95% CI = 44.71-63.70) in rural, and 47.76% (95% CI = 34.47-61.06) in urban settings. A cross-sectional design was employed in 72 studies, and 71 were quantitative. Treatment-seeking practice for diarrhoea among children aged <5 years in LMICs remained low. There was no statistically significant difference in treatment-seeking practice for children with diarrhoea by the country's income classification. We recommend further studies to identify factors affecting treatment-seeking practices for diarrhoea among children aged <5 years in LMICs and to act on findings and recommendations. PROSPERO: CRD42022290180.

Diarrhoea was the second leading cause of death among children aged <5 years in 2019. Most of these deaths occurred in low- and middle-income countries (LMICs). Summarising the available up-to-date evidence on the incidence of diarrhoeal disease among children could help track the effectiveness of diarrhoea prevention and control efforts. We summarised available evidence on the incidence of diarrhoea among children aged <5 years in LMICs. We included cross-sectional or cohort studies that reported diarrhoeal incidence among children aged <5 years in LMICs that were published between 2010-22 in English. Two authors searched, reviewed the quality of the selected articles, and extracted the data. We searched Medline/Pubmed, Web of Science, Scopus, CINHAL, EMBASE, WorldCat, OpenGrey, dissertations/theses, reports, and Google Scholar. We screened articles by title, abstract, and full text. We included 15 articles that met the inclusion criteria in the analysis. Four studies were from Africa, seven were from Asia, two were from Brazil, and two were from Nicaragua. Seven studies were conducted in urban settings, six in rural settings, and two in urban and rural areas. The highest incidence of diarrhoea was 5200 episodes of diarrhoea per 1000 child-years, and the lowest was 60.4 episodes of diarrhoea per 1000 child-years. There is limited evidence on the incidence of diarrhoea among children aged <5 years in LMICs. The available studies identified major differences in the incidence of diarrhoea by country, 60.4 in China, and 5200 episodes of diarrhoea per 1000 infants. We recommend more up-to-date primary studies on the incidence of diarrhoea among children aged <5 years in LMICs to monitor and evaluate the effectiveness of diarrhoea control and prevention policies and interventions. PROSPERO: CRD42022290180.

BackgroundCardiovascular disease poses a great financial risk on households in countries without universal health coverage like Ethiopia. This paper aims to estimate the magnitude and intensity of catastrophic health expenditure and factors associated with catastrophic health expenditure for prevention and treatment of cardiovascular disease in general and specialised cardiac hospitals in Addis Ababa.Methods and findingsWe conducted a cross-sectional cohort study among individuals who sought cardiovascular disease care in selected hospitals in Addis Ababa during February to March 2015 (n=589, response rate 94%). Out-of-pocket payments on direct medical costs and direct non-medical costs were accounted for. Descriptive statistics was used to estimate the magnitude and intensity of catastrophic health expenditure within households, while logistic regression models were used to assess the factors associated with it.About 27% (26 .7;95% CI 23.1 to 30.6) of the households experienced catastrophic health expenditure, defined as annual out-of-pocket payments above 10% of a household’s annual income. Family support was the the most common coping mechanism. Low income, residence outside Addis Ababa and hospitalisation increased the likelihood of experiencing catastrophic health expenditure. The bottom income quintile was about 60 times more likely to suffer catastrophic health expenditure compared with the top quintile (adjusted OR=58.6 (16.5–208.0), p value=0.00). Of those that experienced catastrophic health expenditure, the poorest and richest quintiles spent on average 34% and 15% of households’ annual income, respectively. Drug costs constitute about 50% of the outpatient care cost.ConclusionsSeeking prevention and treatment services for cardiovascular disease in Addis Ababa poses substantial financial burden on households, affecting the poorest and those who reside outside Addis Ababa more. Economic and geographical inequalities should also be considered when setting priorities for expanding coverage of these services. Expanded coverage has to go hand-in-hand with implementation of sound prepayment and risk pooling arrangements to ensure financial risk protection to the most needy.

Maternal continuum of care (MCC) is the utilisation of maternal health care services, including 4+ antenatal care (ANC) visits, skilled birth attendants (SBAs), and postnatal care (PNC). This systematic review and meta-analysis assessed the pooled proportion of MCC utilisation among women in sub-Saharan Africa (SSA) and its association with selected sociodemographic factors. We identified keywords and MeSH terms related to the condition (MCC), the context (SSA), and population (women with history of childbirth) to search for published or unpublished observational studies. We used the Joanna Briggs Institute tool to extract data and the Newcastle Ottawa Scale for quality assessment. Meta-analysis was used to compute pooled estimates (MCC utilisation and odds ratio (OR) associates) with 95% confidence intervals (CI) using Stata 17. Of 45 402 studies identified, we included 23 involving 320 353 women. The pooled estimate of MCC utilisation across SSA was 18.72% (95% CI = 14.51, 22.93), showing a significant increase (P < 0.05) from 2015 to 2022. Southern Africa had the highest MCC utilisation (38%; 95% CI = 36.59, 39.41), while East Africa had the lowest (17.5%; 95% CI = 12.22, 22.75). Maternal continuum of care utilisation was associated with maternal age 25-34 years (pooled odds ratio (POR) = 1.27), urban residence (POR = 2.69), richer/richest wealth status (POR = 1.68), as well as higher level of education and employment (POR = 1.32). MCC utilisation in SSA remains low, with significant variation across the sub-regions and sociodemographic strata. Context-specific interventions targeting identified factors are essential to enhance MCC utilisation in SSA. PROSPERO: CRD42021272708.

Estimating the proportion of children with diarrhoea and those who are taken in as inpatients or outpatients is important for policy planning, resource allocation, and to evaluate the effectiveness of diarrhoea prevention and control interventions. We aimed to estimate the proportion of children <2 years of age with diarrhoea, explore their treatment-seeking practices, and identify factors associated with both diarrhoea and treatment seeking. We designed a longitudinal study based on a sample of children <2 years of age in the Birhan field site from September 2018 to September 2019. The study site collected data on child mortality and morbidity and treatment-seeking practice for those with a history of illness every three months. Mothers/caregivers were asked about signs or symptoms of illnesses for a two-week period prior to each study visit. We estimated the proportion of children <2 years of age with diarrhoea and treatment-seeking practices for each of the four rounds of data collection and identified associated factors through bivariable and multivariable logistic regression. We enrolled 4678 children <2 years of age. The proportion of children with diarrhoea was the highest from 11 September 2018 to 9 December 2018 (4.47%; 95% confidence interval (CI) = 3.70-5.35) and the lowest from 10 December 2018 to 9 March 2019 (2.48%; 95% CI = 1.90-3.19). Children from households with chlorinated drinking water had a 50% (adjusted odds ratio (aOR) = 0.50; 95% CI = 0.28-0.88) lower odds of developing diarrhoea compared to those who did not. Among 339 children with diarrhoea, 275 (81.12%; 95% CI = 76.54-85.15) were taken to health facilities for treatment. Female children had lower odds of being taken to health facilities for treatment (aOR = 0.37; 95% CI = 0.17-0.80) compared to males. While the proportion of children with diarrhoea in our study was lower than that observed in prior research conducted in Ethiopia, treatment-seeking practices were higher. Female children and children from the poorest families had lower odds of treatment. We recommend more studies to explore gender-based and socioeconomic differences affecting treatment-seeking practices.

IntroductionDespite the progress in reducing child mortality, the rate remains high, particularly in sub-Saharan African countries. Limited data exist on child survival and other birth outcomes by sex. This study compared survival rates and birth outcomes by sex among neonates and children under 2 in Ethiopia.MethodsWomen who gave birth after 28 weeks of gestation and their newborns were included in the analysis. Survival probabilities were estimated for males and females in the neonatal period as well as the 2-year period following birth using Kaplan-Meier curves. HRs and 95% CIs were compared between males and females under 2. Descriptive statistics and χ2 tests were used to determine the sex-disaggregated variation in the birth outcomes of preterm birth, low birth weight (LBW), stillbirth, small for gestational age (SGA) and large for gestational age (LGA).ResultsThe study included a total of 3904 women and child pairs. The neonatal mortality rate for males (3.4%, 95% CI 2.6% to 4.2%) was higher compared with females (1.7%, 95% CI 1.1% to 2.3%). The hazard of death during the first 28 days of life was approximately two times higher for males compared with females (HR 1.99, 95% CI 1.30 to 3.06) but was not significantly different after this period. While there was a non-significant difference between males and females in the proportion of preterm, LBW and LGA births, we found a significantly higher proportion of stillbirth (2.7% vs 1.3%, p=0.003) and SGA (20.5% vs 15.6%, p<0.001) for males compared with females.ConclusionsThis study identified a significant sex difference in mortality and birth outcomes. We recommend focusing future research on the mechanisms of these sex differences in order to better design intervention programmes to reduce disparities and improve outcomes for neonates.

Pregnancy-related complications remain a global challenge, with low- and middle-income countries bearing the highest burden. Predicting the absolute risk of adverse birth outcomes will facilitate the delivery of early preventative and therapeutic interventions. We aimed to developed and internally validate a risk prediction model for low birth weight (LBW) in Ethiopia. We conducted a prognostic study using a prospective maternal and child health cohort in the Birhan field site, Amhara region, Ethiopia. We included all pregnant women with a live birth who had enrolled in the Birhan maternal and child health cohort between 2018 and 2021. We analysed data from 2076 live births. We first applied a multivariable logistic regression model to select variables for the risk prediction model, and used a classification and regression tree to select the most potent predictors. We presented the model with a nomogram suited to clinical use. We also calculated measures of risk prediction model accuracy, discrimination, and calibration, and used bootstrapping for internal validation. We assessed the clinical utility of the model using the decision curve analysis. The incidence of LBW was 9.44% (95% confidence interval (CI) = 8.2, 10.8). We identified seven predictors: previous maternal complication, previous foetal complication, pregnancy induced hypertension, average maternal body weight, average diastolic blood pressure, preterm delivery, and gravidity. The prediction model had an area under the curve (AUC) of 0.67 (95% CI = 0.63, 0.72). After internal validation, the corrected discrimination AUC value was 0.64 (95% CI = 0.59, 0.68). The classification and regression tree identified four predictors: preterm, gravidity, average maternal body weight, and previous foetal complication, with a discriminative ability of 0.65 (95% CI = 0.61, 0.69). The decision curve analysis showed that the prediction model had high net benefit at different threshold probabilities in both the nomogram and the classification and regression tree. We developed a modestly accurate risk prediction model to identify pregnancies leading to LBW babies that could aid in early decision-making for prevention. This model is a crucial first step towards developing a clinical decision support tool to prompt early referral of women who are at high risk of having a LBW infant.

Child mortality remains a concern in Ethiopia despite the significant achievements in the past three decades. Proper implementation of the existing low-cost interventions can prevent two-thirds of the deaths. Understanding illness recognition, care-seeking behaviours, and barriers that caregivers encounter during a child's illness along care pathways is imperative. We aimed to describe illness recognition and reactions of caregivers of children <2 years, and factors associated with severe illness or death related to the care pathways, including the child, caretaker, household, and health system. We conducted a prospective cohort study using an open birth cohort of Birhan field site, from December 2018 to November 2022. The analysis included newborns followed up to two years old who had an illness episode and for whom data were available for the mother-child dyad. We extracted and linked data on community follow-up and morbidity visits, clinical signs and symptoms of illness at health facility visits, verbal autopsy of deceased children, and maternal health and healthcare. We used descriptive and logistic regression analyses. Of 3969 eligible children enrolled in the Birhan Cohort, 1397 (37.8%) had at least one episode of illness during the first two years of life. Of those, 108 (8%) experienced a severe illness or died, of which the majority (n = 76; 70.4%) were newborns. Most sick children (n/N = 714/1187) did not get treatment from a formal source; 53.1% (n/N = 684/1289) of those with mild or moderate illness and 27.8% (n/N = 30/108) of the severely ill or deceased. The mean delay in care-seeking was 5.9 (standard deviation (SD) = 10.6) days for those with mild or moderate illness, and 1.7 (SD = 0.58) for the severely ill or deceased. Only 4.8% (n/N = 27/559) of children sought care from a health post (HP), and 68.1% (n/N = 94/138) of children were referred for further care. Only 68.4% (n/N = 13/19) of the severely ill or deceased children were referred, of which 3 (4.9%) accepted the referral. Compared to a newborn, being a young infant (adjusted odds ratio (aOR) = 0.05; 95% confidence interval (CI) = 0.008-0.27) and a child (aOR = 0.03; 95% CI = 0.005-0.17) were associated with a reduction in the odds of severe illness or death. Children who sought care from an HP had a higher risk of severe illness or death than those who consulted a government hospital (aOR = 19.6; 95% CI = 2.71-142.40). Belonging to a rich family resulted in a reduction in the odds of the outcome compared to a poor household (aOR = 0.15; 95% CI = 0.02-0.94). Illness recognition and care-seeking were low in the Birhan field site, and when care was sought, it was delayed. Care was sought from an HP in rare cases. Health workers did not refer about a third of severely ill or deceased children for further care. Being a newborn, consulting a HP rather than a hospital, and belonging to a poor family had a significantly higher risk of severe illness or death. Strategies should be devised targeting the modifiable factors identified at individual, family, or community and health facility levels to improve child survival.