Background: Uptake of services to treat newborns and children has been persistently low in Ethiopia, despite being provided free-of-charge by Health Extension Workers (HEWs). In order to increase the uptake of these services, the Optimizing the Health Extension Project was designed to be implemented in four regions in Ethiopia. This study was carried out to identify barriers to the uptake of these services and potential solutions to inform the project. Methods: Qualitative data were collected in October and November 2015 in 15 purposely selected districts in four regions. We conducted 90 focus group discussions and 60 in-depth interviews reaching a total of 664 participants. Thematic analysis was used to identify key barriers and potential solutions. Results: Five demand-side barriers to utilization of health services were identified. Misconceptions about illness causation, compounded with preference for traditional healers has affected service uptake. Limited awareness of the availability of free curative services for children at health posts; along with the prevailing perception that HEWs were providing preventive services only had constrained uptake. Geographic challenge that made access to the health post difficult was the other barrier. Four supply-side barriers were identified. Health post closure and drug stock-out led to inconsistent availability of services. Limited confidence and skill among HEWs and under-resourced physical facilities affected the service delivery. Study participants suggested demand creation solutions such as increasing community awareness on curative service availability and educating them on childhood illness causation. Maintaining consistent supplies and ensuring service availability; along with regular support to build HEWs’ confidence were the suggested supply-side solutions. Creating community feedback mechanisms was suggested as a way of addressing community concerns on the health services. Conclusion: This study explored nine demand- and supply-side barriers that decreased the uptake of community-based services. It indicated the importance of increasing awareness of new services and addressing prevailing barriers that deprioritize health services. At the same time, supply-side barriers would have to be tackled by strengthening the health system to uphold newly introduced services and harness sustainable impact.
Exploratory qualitative research was conducted to identify barriers to community-based curative newborn and child health service utilization and to identify potential solutions to these barriers. The study was conducted in Tigray, Amhara, Oromia and SNNP Regions,4 where 75% of the Ethiopian population resides and which are dominantly agrarian. The study was conducted in the Awi Zone of Amhara, Guji and the West Harerge Zones of Oromia, the South Eastern Zone of Tigray and the Gurage Zone of SNNP, which were selected as the project intervention zones by the regional health bureaus mainly for their relatively low performance within their regions. According to the 2007 census, the total population in the four zones was projected to be about 6 million in 2015. The study was conducted in 15 districts (Table 1). A mix of high (four) and low (11) performing districts were purposively included in the study to increase representativeness. High- and low-performing districts were identified based on their sick newborn and child caseload from the routine service data obtained through the health management information system and a performance ranking made by the respective zonal health offices. Four high performing districts, one from each region, were purposely selected to identify best practices that may have led to increased uptake of services. A kebele was selected from each district taking the highest-performing kebele from the higher-performing district and the lowest-performing kebele from the lower-performing district. Study area aHigher-performing districts bSouthern Nations, Nationalities and Peoples Region Study participants were purposively selected bearing in mind their positions and knowledge of the subject area under research. Parents whose under five children were sick in the preceding month were included to understand care-seeking patterns. To encourage openness during the FGDs, separate sessions were conducted with mothers and fathers. To validate the FGDs, additional three in-depth interviews (IDIs) were conducted with mothers, where one was with a mother who sought care for her sick child. Influential community members (religious leaders, traditional healers, clan leaders) were reached through FGDs as they are mostly engaged in treating sick children or in providing advice for parents. WDA leaders were included in the FGDs given their role in health promotion within the community. Kebele cabinet members were part of the FGDs as they oversee the service of HEWs and the WDA. HEWs were included in the study to understand their perspective on iCCM and CBNC services. In kebeles where there were two HEWs, one of the HEWs participated in an IDI, while the other participated in the FGD of the kebele cabinet members. District health stakeholders – including the district health office head, the health center directors, the district maternal and child health (MCH) coordinator, the district HEW coordinator, and developmental partners working in MCH in the district – were included at the district level. Six focus group discussions (FGDs) (with mothers, fathers, influential community members, WDAs and kebele cabinet members and district stakeholders) and four in-depth interviews (IDIs) with mothers and HEWs were performed per district (Table 2). A total of 90 FGDs and 60 IDIs were conducted, reaching 664 participants in 15 districts. Data collection methods and participants per districts Community-level sampling: To ensure objective recruitment of parents, agriculture extension workers were used to identify participants instead of HEWs or WDA leaders. HEWs and WDA leaders could be biased in selecting those that are closer to the health service than the general population. The agriculture extension workers had a relatively neutral position and since they live within the community, they were able to support the recruitment of participants for the data collectors. FGD and interview guides were developed specifically for each type of informant (Additional file 1) and translated into three local languages (Tigrigna, Afan Oromo and Amharic5). The discussion questions focused on the general health status of children, care seeking patterns, barriers to seeking care from the health post and potential solutions. Data collectors were experienced public health professionals with master’s degrees who spoke the respective local language. They received a two-day intensive training on the tools prior to collecting data. The instruments were pre-tested in the respective regions before data collection and appropriate corrections to the tools were made. Data were collected in October and November 2015. A data collection team with two data collectors was deployed in each of the study zones. In each zone, the two data collectors conducted IDIs independently. During FGDs, one served as a facilitator and the other as a note-taker. Consultants from HANDS ON Research and Training PLC, a private Ethiopian research firm, and project staff members from PATH and UNICEF carried out field supervision. All interviews were audio-recorded and additional notes were taken for documenting expressions, interesting quotes and main points. Audio recordings were transcribed by the data collectors and the transcripts were then translated into English by the data collectors. Transcripts were then exported to NVivo software, where they were coded and categorized into predetermined and emerging themes. Two researchers conducted the data analysis by ensuring consistency of the transcribed data with the audio recordings. They first categorized the data using deductive thematic analysis by using predetermined codes [16]. The predetermined codes were demand- and supply-side barriers and potential solutions. We used both the inductive and the deductive approach in our study. We had deductively set to identify the demand and supply side barriers and potential solutions as these were what we were looking for to answer from our study. Within these large and overarching categories, we then inductively determined the lower-level themes. When an emerging theme was identified, the two analysts discussed it thoroughly before reaching agreement on how to code and categorize it inductively [17].
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