Disparities in mothers’ healthcare seeking behavior for common childhood morbidities in Ethiopia: based on nationally representative data

Background: Childhood morbidities such as diarrhea and pneumonia are the leading causes of death in Ethiopia. Appropriate healthcare-seeking behavior of mothers for common childhood illnesses could prevent a significant number of these early deaths; however, little nation-wide research has been conducted in Ethiopia to assess mothers’ healthcare-seeking behavior for their under five children. Methods: The study used the Ethiopian Demographic and Health Surveys (EDHS) data. The EDHS is a cross sectional survey conducted in 2016 on a nationally representative sample of 10,641 respondents. The main determinants of care-seeking during diarrhea and acute respiratory infection (ARI) episodes were assessed using multiple logistic regression analyses while adjusting for complex survey design. Results: Only 43% and 35% of households sought medical attention for their children in episodes of diarrhea and ARI, respectively, during a reference period of 2 weeks before the survey. The odds of seeking care for diarrhea are lower for non-working mothers versus working mothers. The likelihood of seeking care for diarrhea or ARI is higher for literate fathers compared to those with no education. The place of delivery for the child, receiving postnatal checkup and getting at least one immunization in the past determined the likelihood of seeking care for ARI, but not for diarrhea. The odds of seeking care are higher for both diarrhea and ARI among households that are headed by females and where mothers experienced Intimate Partner Violence (IPV) violence. Religion and types of family structure are also significant factors of seeking care for diarrhea episodes, but not for ARI. Conclusions: The findings call for more coordinated efforts to ensure equitable access to health care services focusing on mothers living in deprived household environment. Strengthening partnerships with public facilities, private health care practitioners, and community-based organizations in rural areas would help further improve access to the services.

The conceptual framework (Fig. 1) for factors of health seeking behaviors for mothers of children with diarrhea and ARI conditions is based on Anderson’s behavioral model [15]. The model assumes that health-seeking behavior is a function of three sets of characteristics: predisposing, enabling, and need. The actual seeking of health services is assumed to be a sequential and conditional function of the individual’s predisposition to use health services, their perceived need to use them, and their ability to obtain the services [5]. Conceptual framework of the study developed based on Anderson’s behavioral model of health service utilization [15] The present study was conducted using a nationally representative data of the most recent Ethiopian Demographic and Health Survey (EDHS, 2016). The data were collected from 10,641 ever-married women (15–49 years), who had given birth in the last three years prior to the survey. The EDHS is a cross-sectional study which collected demographic and socioeconomic data at a specific point in the life of the respondents. It employed a two-stage stratified cluster sampling [6]. The first stage of sampling selected 645 enumeration areas (EAs) randomly from all administrative regions. In the second stage, households, within the selected EAs,were drawn using systematic random sampling [6]. For the present analysis, only those who reported episodes of ARI (n = 1280) and diarrhea illness (n = 1227) during the two weeks preceding the survey date were considered. The EDHS data collection used a standardized questionnaire, that has been used in more than 100 countries. Information on child’s experience of diarrhea/ARI episodes and care seeking was collected from closest caregiver of the child, mostly the biological mother. The data collection followed a standard procedure with adequate field staff training, pretesting, filed supervision and data quality maintenance. The detailed description of methods, design, instruments, participants, and sampling frame have been published by the Central Statistics Authority of Ethiopia and Macro International [6]. Permission to use the data for the purposes of the present study was granted by ORC Macro International and Central Statistics Authority. Ethical approval for this study was obtained from the University of Saskatchewan, Canada. Two dichotomous outcome variables were considered in the current analysis: appropriate seeking of treatment for diarrhea and ARI, respectively, constructed based on mothers’ responses to questions on recent episodes of various forms of morbidities. Appropriate healthcare-seeking behavior was defined as situations when mothers visited any health facility/institution during episodes of childhood illnesses for diarrhea or ARI. Information on the diarrhea episode during the reference period of two weeks was used. Diarrhea is described as an abnormal increase in the frequency, volume, or liquidity of stools, lasting from a few hours to several days [16, 17]. ARI is derived based on mothers’ responses to questions if their child had a fever, cough, chest congestion, or short rapid breaths in the two weeks preceding the survey [6]. The WHO referred these symptoms as “suspected pneumonia” [6]. The EDHS survey considered them as a proxy measure of pneumonia [16]. In a follow-up question, mothers who reported the occurrence of these symptoms were asked if the child required medical attention for any episode during the reference period. Health care seeking behavior was coded as “1” if mothers sought care during such episodes and “0” if no care was sought. The choice of potential explanatory variables was guided by literature reviews and model fitting procedures. To capture the key determinants of care-seeking, a wide range of explanatory variables were included. For the purpose of this analysis, the explanatory variables were divided into three major categories: (1) Predisposing factors (sex of household head, birth order, parity, religion, paternal education, maternal education, Intimate Partner Violence (IPV)); (2) enabling factors (wealth at household level, work status, community-level wealth status, overall community level education and residence); and (3) need factors includes behavioral variables (utilization of ANC, delivery care, postnatal care, and immunization). Most of the background variables such as child’s sex, age, parental literacy status, type of family structure, parity was used the way they were coded in the original data. The remaining variables were constructed by combining certain items. Of importance are those measured using indices such as IPV, household wealth index, community-level wealth, and community-level maternal education. IPV was constructed from mother’s binary response for five sets of questions about her experiences of violence by her partner (beating, insulting, causing physical assault, chasing from home, and slapping). The variable was dichotomized into no IPV and at least one IPV experience during a reference period of one year prior to the survey. Household wealth was estimated in the EDHS with an asset-based index that combined information about ownership of consumer goods, housing quality, and water and sanitation facilities [6]. This is a combined measure of the cumulative living standard. Community-level wealth was measured based on the mean of the wealth index of each household in a cluster. Similarly, mean maternal education at the community level was measured based on information on the highest education achieved by each individual woman. These two variables were used in the analysis as continuous variables. Data were analyzed using SPSS, version 20 [18]. Percentage and frequency were used to describe the distribution of child morbidity status and care-seeking by selected socio-demographic characteristics. Multicollinearity among the explanatory variables was checked using the Variance Inflation Factor (VIF). Bivariate logistic regression was conducted to select the variables with p-values < 0.2. Multiple logistic regression analyses were then conducted to examine the association between selected explanatory variables and the two-health care seeking variables. Both crude odds ratio (COR) and adjusted odds ratio (AOR) with 95% confidence interval (CI) were computed. A backward model selection method was employed. We used a p-value ≤ 0.05 to ascertain statistical significance [19]. Two-way interactions were assessed by entering the product of two hypothesized variables. The final multivariable model contained only statistically significant variables. All analyses were weighted per DHS guideline [6].

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• regassa, nigatu
• feng, cindy xin
• whiting, susan j.
• lepnurm, rein
• henry, carol j.
• janzen, bonnie