Evaluation of the Ethiopian Millennium Rural Initiative: Impact on Mortality and Cost-Effectiveness

Main Objective

Few studies have examined the long-term, impact of large-scale interventions to strengthen primary care services for women and children in rural, low-income settings. We evaluated the impact of the Ethiopian Millennium Rural Initiative (EMRI), an 18-month systems-based intervention to improve the performance of 30 primary health care units in rural areas of Ethiopia.

Methods

We assessed the impact of EMRI on maternal and child survival using The Lives Saved Tool (LiST), Demography (DemProj) and AIDS Impact Model (AIM) tools in Spectrum software, inputting monthly data on 6 indicators 1) antenatal coverage (ANC), 2) skilled birth attendance coverage (SBA), 3) post-natal coverage (PNC), 4) HIV testing during ANC, 5) measles vaccination coverage, and 6) pentavalent 3 vaccination coverages. We calculated a cost-benefit ratio of the EMRI program including lives saved during implementation and lives saved during implementation and 5 year follow-up.

Results

A total of 134 lives (all children) were estimated to have been saved due to the EMRI interventions during the 18-month intervention in 30 health centers and their catchment areas, with an estimated additional 852 lives (820 children and 2 adults) saved during the 5-year post-EMRI period. For the 18-month intervention period, EMRI cost $37,313 per life saved ($42,366 per life if evaluation costs are included). Calculated over the 18-month intervention plus 5 years post-intervention, EMRI cost $5,875 per life saved ($6,671 per life if evaluation costs are included). The cost effectiveness of EMRI improves substantially if the performance achieved during the 18 months of the EMRI intervention is sustained for 5 years. Scaling up EMRI to operate for 5 years across the 4 major regions of Ethiopia could save as many as 34,908 lives.

Significance

A systems-based approach to improving primary care in low-income settings can have transformational impact on lives saved and be cost-effective.     

Assessment of woody species encroachment in the grasslands of Nechisar National Park,Ethiopia

Ecological survey was executed to assess woody species encroachment into the grassland plain of Nechisar National Park (NNP). Forty‐one woody species were recorded. Dichrostachys cinerea Wight & Arn., Acacia mellifera (Vahl) Benth., Acacia nilotica (L) Willd., Acacia senegal (L.) Willd., Acacia seyal Del. and Acacia tortilis (Forssk.) Hayne were among the major encroaching woody species. The majority of the woody species were found to be highly aggregated in their pattern of distribution, while only few species showed some degree of randomness. The mean woody species density was ca. 1995 woody plants ha^?1. Mean cover of woody, grass, unpalatable forbs and total herbaceous species were 31%, 58%, 68% and 121%, respectively. The woody species density and cover, unpalatable forbs and bare land cover were significantly higher in the highly grazed and fire‐suppressed part of the grassland plain. Pearson correlation coefficient matrix indicated that woody species cover and density were negatively correlated with total herbaceous and grass cover. The high woody, unpalatable forbs and bare land cover indicated the progressively increasing perennial grass species diversity deterioration in the grass plain of the Park. Decline in the grassland condition, unless reversed, will jeopardize the biological diversity as well as the aesthetic value of the NNP.     

The shrubland vegetation in western Shewa,Ethiopia and its possible recovery

Shrubland vegetation and environmental data in western Shewa, Ethiopia have been analysed. Vegetation data include cover-abundance values of vascular plant species; environmental data comprise physical and chemical properties of the soil, altitude, slope, grazing and browsing pressure. The vegetation data were subj ected to hierarchical and non-hierarchical classification and ordination with correspondence analysis. The classification resulted in seven different vegetation types, ranging from grassland with scattered shrubs to degenerated forest. Ordination of the data and biplot analysis showed that the vegetation is influenced by anthropogenic factors and altitudinal variation. Sand content is related to a low level of anthropogenic influence whereas silt content is related to a high level. This is explained by historical events rather than by the present situation. Total nitrogen, organic carbon, altitude and slope are positively correlated and these variables are negatively related to anthropogenic influences. The shrubland vegetation may have expanded from lower altitudes and drier sites as forests gradually disappeared. The recovery of an economically more rewarding vegetation type may be achieved through pro viding alternative sources of fuel and construction and through prohibiting cultivation and grazing in the shrublands on the hillsides. Regeneration can be accelerated by actively introducing seedlings of tree species that do not need a heavy canopy cover for establishment and growth.     

Autoradiographic localization of 3H-5-HTP and 3H-5-HT in the pineal organ and circumventricular areas in the rainbow trout,Salmo gairdneri Richardson

Summary The time course of incorporation and cellular localization of ³H-5-hydroxytryptophan (³H-5-HTP) and ³H-5-hydroxytryptamine (³H-5-HT) in the pineal and some brain regions in rainbow trout, Salmo gairdneri, were studied by quantitative and qualitative autoradiography.Among the tissues examined, the pineal shows the highest and most rapid uptake of the two isotopes. Maximum incorporation of ³H-5-HTP is achieved by 2 h and that of ³H-5-HT by 20 minutes post injection. At the end of the six-hour experimental period, a significantly high amount of radioactivity is still detectable in the pineal. The results indicate a much slower turnover of the two indoles, especially 5-HTP, in the trout than is known for mammalian tissues.Both the ependymal supporting cells and the receptor cells of the pineal localize these isotopes. In contrast, the intrapineal neurons remain unlabeled. This is taken to suggest lack of capacity of these cells to metabolize 5-HTP and 5-HT.In the circumventricular regions, the two indoles occur in the ependyma of the recessus lateralis and the recessus praeopticus. The label is also localized in the neuropil and the neurons of the nuclei recessus lateralis and praeopticus. Semiquantitative estimates reveal a significant labeling of these areas only 20 minutes after injection, although a weak but inconsistent labeling of the ependyma is evident at 5 minutes. The significance of these results is discussed in regard to (a) normal capacity of circumventricular areas to metabolize indoles and (b) a possible chemical interaction between the pineal and the brain involving a direct pineal-cerebrospinal fluid pathway.Supported in part by a grant to the senior author from the University of Kentucky Research FoundationThe authors wish to thank the Department of Fish and Game, Kentucky, for supplying rainbow trout. The technical assistance of Mrs. Munira Nasser is gratefully acknowledged     

Caspase-3-induced truncation of type 1 inositol trisphosphate receptor accelerates apoptotic cell death and induces inositol trisphosphate-independent calcium release during apoptosis

Inositol 1,4,5-trisphosphate receptor-deficient (IP3RKO) B-lymphocytes were used to investigate the functional relevance of type 1 inositol 1,4,5-trisphosphate receptor (IP3R1) and its cleavage by caspase-3 in apoptosis. We showed that inositol 1,4,5-trisphosphate receptor-deficient cells were largely resistant to apoptosis induced by both staurosporine (STS) and B-cell receptor (BCR) stimulation. Expression of either the wild-type IP3R1 or an N-terminal deletion mutant (Delta1-225) that lacks inositol 1,4,5-trisphosphate-induced Ca2+ release activity restored sensitivity to apoptosis and the consequent rise in free cytosolic Ca2+ concentration ([Ca2+]i). Expression of caspase-3-non-cleavable mutant receptor, however, dramatically slowed down the rate of apoptosis and prevented both Ca2+ overload and secondary necrosis. Conversely, expression of the "channel-only" domain of IP3R1, a fragment of the receptor generated by caspase-3 cleavage, strongly increased the propensity of the cells to undergo apoptosis. In agreement with these observations, caspase inhibitors impeded apoptosis and the associated rise in [Ca2+]i. Both the staurosporine- and B-cell receptor-induced apoptosis and increase in [Ca2+]i could be induced in nominally Ca2+-free and serum-free culture media, suggesting that the apoptosis-related rise in [Ca2+]i was primarily because of the release from internal stores rather than of influx through the plasma membrane. Altogether, our results suggest that IP3R1 plays a pivotal role in apoptosis and that the increase in [Ca2+]i during apoptosis is mainly the consequence of IP3R1 cleavage by caspase-3. These observations also indicate that expression of a functional IP3R1 per se is not enough to generate the significant levels of cytosolic Ca2+ needed for the rapid execution of apoptosis, but a prior activation of caspase-3 and the resulting truncation of the IP3R1 are required.     

Partitioning an elevation gradient of vegetation from southeastern Ethiopia by probabilistic methods

Vegetation and environment have been analyzed along an altitudinal gradient in Harena Forest, Bale Mountains National Park, southeastern Ethiopia. Vegetation data include numbers of each tree and shrub species and cover-abundance values of each herbaceous species. Environmental data comprise edaphic factors, altitude and topography. The two vegetation layers data were analysed separately.Probabilistic similarity coefficients were computed between the relevés, and these values were used in subsequent computations for classification and ordination. Two sets of stratocoena, comprising 6 types each, derived on the basis of separate analyses of tree-shrub and herb layers of the forest were recognised. A combination of the two sets of stratocoena produced a total of 11 vegetation types. Environmental fuzzy set analysis was applied to determine the strength of the relationship of the relevés to the environmental factors. Autocorrelation analysis was applied to the eigenvectors of probabilistic similarity matrices and environmental data. Altitude appears to be more important thant the other environmental factors in controlling the zonation of the forest. Other important environmental influences on the vegetation include pH, organic matter content and texture of the soil. It is suggested that the whole forest be included in the National Park to create suitable conditions for adequate protection.Abbreviations EFS Environmental fuzzy sets - PROSIM Probability similarity index - PCA Principal components analysis     

‘If an Eye Is Washed Properly,It Means It Would See Clearly’: A Mixed Methods Study of Face Washing Knowledge,Attitudes, and Behaviors in Rural Ethiopia

BackgroundFace cleanliness is a core component of the SAFE (Surgery, Antibiotics, Facial cleanliness, and Environmental improvements) strategy for trachoma control. Understanding knowledge, attitudes, and behaviors related to face washing may be helpful for designing effective interventions for improving facial cleanliness.MethodsIn April 2014, a mixed methods study including focus groups and a quantitative cross-sectional study was conducted in the East Gojjam zone of the Amhara region of Ethiopia. Participants were asked about face washing practices, motivations for face washing, use of soap (which may reduce bacterial load), and fly control strategies.ResultsOverall, both knowledge and reported practice of face washing was high. Participants reported they knew that washing their own face and their children’s faces daily was important for hygiene and infection control. Although participants reported high knowledge of the importance of soap for face washing, quantitative data revealed strong variations by community in the use of soap for face washing, ranging from 4.4% to 82.2% of households reporting using soap for face washing. Cost and forgetfulness were cited as barriers to the use of soap for face washing. Keeping flies from landing on children was a commonly cited motivator for regular face washing, as was trachoma prevention.ConclusionsInterventions aiming to improve facial cleanliness for trachoma prevention should focus on habit formation (to address forgetfulness) and address barriers to the use of soap, such as reducing cost. Interventions that focus solely on improving knowledge may not be effective for changing face-washing behaviors.     

Patterns of Below- and Aboveground Biomass in Eucalyptus populnea Woodland Communities of Northeast Australia along a Rainfall Gradient

In vegetated terrestrial ecosystems, carbon in below- and aboveground biomass (BGB, AGB) often constitutes a significant component of total-ecosystem carbon stock. Because carbon in the BGB is difficult to measure, it is often estimated using BGB to AGB ratios. However, this ratio can change markedly along resource gradients, such as water availability, which can lead to substantial errors in BGB estimates. In this study, BGB and AGB sampling was carried out in Eucalyptus populnea-dominated woodland communities of northeast Australia to examine patterns of BGB to AGB ratio and vertical root distribution at three sites along a rainfall gradient (367, 602, and 1,101 mm). At each site, a vegetation inventory was undertaken on five transects (100 × 4 m), and trees representing the E. populnea vegetation structure were harvested and excavated to measure aboveground and coarse-root (diameter of at least 15 mm) biomass. Biomass of fine and small roots (diameter less than 15 mm) at each site was estimated from 40 cores sampled to 1 m depth. The BGB to AGB ratio of E. populnea-dominated woodland plant communities declined from 0.58 at the xeric end to 0.36 at the mesic end of the rainfall gradient. This was due to a marked decline in AGB with increased aridity whereas the BGB was relatively stable. The vertical distribution of fine roots in the top 1 m of soil varied along the rainfall gradient. The mesic sites had more fine-root biomass (FRB) in the upper soil profile and less at depth than the xeric site. Accordingly, at the xeric site, a much larger proportion of FRB was found at depth compared to the mesic sites. The vertical distribution patterns of small roots of the E. populnea woodland plant communities were consistently )-shaped, with the highest biomass occurring at 15–30-cm depth. The potential significance of such a rooting pattern for grass–tree and shrub–tree co-existence in these ecosystems is discussed. Overall, our results revealed marked changes in BGB to AGB ratio of E. populnea woodland communities along a rainfall gradient. Because E. populnea woodlands cover a large area (96 M ha), their contribution to continental-scale carbon sequestration and greenhouse gas emission can be substantial. Use of the rainfall-zone-specific ratios found in this study, in lieu of a single generic ratio for the entire region, will significantly improve estimates of BGB carbon stocks in these woodlands. In the absence of more specific data, our results will also be relevant in other regions with similar vegetation and rainfall gradients (that is, arid and semiarid woodland ecosystems).     

Antibiotic selection pressure and macrolide resistance in nasopharyngeal Streptococcus pneumoniae: a cluster-randomized clinical trial

Background

It is widely thought that widespread antibiotic use selects for community antibiotic resistance, though this has been difficult to prove in the setting of a community-randomized clinical trial. In this study, we used a randomized clinical trial design to assess whether macrolide resistance was higher in communities treated with mass azithromycin for trachoma, compared to untreated control communities.

Methods and Findings

In a cluster-randomized trial for trachoma control in Ethiopia, 12 communities were randomized to receive mass azithromycin treatment of children aged 1–10 years at months 0, 3, 6, and 9. Twelve control communities were randomized to receive no antibiotic treatments until the conclusion of the study. Nasopharyngeal swabs were collected from randomly selected children in the treated group at baseline and month 12, and in the control group at month 12. Antibiotic susceptibility testing was performed on Streptococcus pneumoniae isolated from the swabs using Etest strips. In the treated group, the mean prevalence of azithromycin resistance among all monitored children increased from 3.6% (95% confidence interval [CI] 0.8%–8.9%) at baseline, to 46.9% (37.5%–57.5%) at month 12 (p = 0.003). In control communities, azithromycin resistance was 9.2% (95% CI 6.7%–13.3%) at month 12, significantly lower than the treated group (p<0.0001). Penicillin resistance was identified in 0.8% (95% CI 0%–4.2%) of isolates in the control group at 1 year, and in no isolates in the children-treated group at baseline or 1 year.

Conclusions

This cluster-randomized clinical trial demonstrated that compared to untreated control communities, nasopharyngeal pneumococcal resistance to macrolides was significantly higher in communities randomized to intensive azithromycin treatment. Mass azithromycin distributions were given more frequently than currently recommended by the World Health Organization''s trachoma program. Azithromycin use in this setting did not select for resistance to penicillins, which remain the drug of choice for pneumococcal infections.

Trial registration

www.ClinicalTrials.gov {"type":"clinical-trial","attrs":{"text":"NCT00322972","term_id":"NCT00322972"}}NCT00322972 Please see later in the article for the Editors'' Summary