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Background: In 2010, Ethiopia began scaling up the integrated community case management (iCCM) of childhood illness strategy throughout the country allowing health extension workers (HEWs) to treat children in rural health posts. After 2 years of iCCM scale up, utilization of HEWs remains low. Little is known about factors related to the use of health services in this setting. This research aimed to elicit perceptions and experiences of caregivers to better understand reasons for low utilization of iCCM services. Methods: A rapid ethnographic assessment was conducted in eight rural health post catchment areas in two zones: Jimma and West Hararghe. In total, 16 focus group discussions and 78 indepth interviews were completed with mothers, fathers, HEWs and community health volunteers. Results: In spite of the HEW being a core component of iCCM, we found that the lack of availability of HEWs at the health post was one of the most common barriers to the utilization of iCCM services mentioned by caregivers. Financial and geographic challenges continue to influence caregiver decisions despite extension of free child health services in communities. Acceptability of HEWs was often low due to a perceived lack of sensitivity of HEWs and concerns about medicines given at the health post. Social networks acted both to facilitate and hinder use of HEWs. Many mothers stated a preference for using the health post, but some were unable to do so due to objections or alternative care-seeking preferences of gatekeepers, often mothers-in-law and husbands. Conclusion: Caregivers in Ethiopia face many challenges in using HEWs at the health post, potentially resulting in low demand for iCCM services. Efforts to minimize barriers to care seeking and to improve demand should be incorporated into the iCCM strategy in order to achieve reductions in child mortality and promote equity in access and child health outcomes.
Qualitative research was conducted as part of a series of studies evaluating Ethiopia’s scale-up of iCCM in the Oromia Region. Fieldwork was conducted for 30 days from December 2012 to January 2013. Eight rural sites, each corresponding to a kebele or one health post catchment area servicing ∼5000 people, were selected from sites where iCCM implementation and scale-up had been occurring for at least 18 months in the predominantly rural zones of Jimma and West Hararghe. Purposive selection of sites was based on existing information about health post utilization (number of sick child consultations) obtained from a quality of care survey conducted 4 months prior to the qualitative study (Miller et al. 2014). Sites were selected to achieve maximum variation for this factor of health post utilization. Table 3 presents key characteristics for selected kebele sites. Characteristics of selected kebele sites aSource: Miller et al. (2014). bSites were selected from among the lowest (low) 20% and highest (high) 20% of average sick child consultations from April through June 2012. All sites in the low category had an average of 40 sick child consultations. The study design was informed by rapid ethnographic assessments developed as part of applied anthropological research methods for child health and care-seeking behaviours (Scrimshaw and Hurtado 1987; Pelto and Pelto 1997). One team of four college-educated, Afan Oromo-speaking investigators with experience in qualitative research methods was trained and conducted the research under the supervision of the first author. Qualitative methods consisted of focus group discussions (FGDs) and in-depth interviews (IDIs). Following recommendations of Pelto and Pelto (1997), FGDs focused on social norms of care seeking and community perceptions of HEWs and iCCM services; IDIs focused on care-seeking experiences over the course of the most recent illness of a caregiver’s child, including perceptions relating to barriers and facilitators to utilizing HEWs delivering iCCM services at the health post. Sixteen FGDs were held and were stratified into eight with mothers who were identified as previously using iCCM services and eight with mothers identified as never using iCCM services. Forty IDIs were held with mothers of children under the age of five screened for having experienced a child illness over the previous month. For additional context, 16 IDIs were held with a subset of these women’s husbands and 22 IDIs were held with HEWs and members of the HDA (including VCHWs). Tables 4 and and55 provide the sample size and selected demographic characteristics of participants, respectively. Respondent groups by district and data collection method Selected demographic characteristics of maternal caregiversa aBased on self-report. bInformation not collected from FGDs participants. Data were analysed using Atlas.ti software (1997). Hierarchical codes were created after reading through a sub-sample of transcripts by the primary investigator and validated by independent analysts. A priori codes were also included based on Penchansky and Thomas’s (1981) study, while additional themes were identified that emerged from the data. All transcripts were then coded for thematic analysis. During analysis, data were compared across sites, methods and participant groups to triangulate findings. The study received ethical approval from the Oromia Region Health Bureau and Johns Hopkins Bloomberg School of Public Health. All participants gave oral consent for involvement in IDIs and FGDs and no individuals selected for this study refused participation. The research consent process stressed the independence of the research from federal or regional government affiliation. Nevertheless, some participants may have biased their participation and responses due to perceived affiliations.
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