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

BMC Health Services Research, Volume 21, No. 1, Year 2021

Interpretação

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].

AI Digest

Study Justification:

– Childhood morbidities such as diarrhea and pneumonia are leading causes of death in Ethiopia.
– Appropriate healthcare-seeking behavior by mothers can prevent a significant number of these deaths.
– Little nationwide research has been conducted in Ethiopia to assess mothers’ healthcare-seeking behavior for their under five children.

Highlights:

– Only 43% and 35% of households sought medical attention for their children during episodes of diarrhea and acute respiratory infection (ARI), respectively.
– Non-working mothers were less likely to seek care for diarrhea, while literate fathers were more likely to seek care for both diarrhea and ARI.
– The place of delivery, postnatal checkup, and immunization history influenced the likelihood of seeking care for ARI, but not for diarrhea.
– Female-headed households and households where mothers experienced intimate partner violence (IPV) were more likely to seek care for both diarrhea and ARI.
– Religion and types of family structure were significant factors for seeking care for diarrhea, but not for ARI.

Recommendations:

– Coordinated efforts are needed to ensure equitable access to healthcare services for mothers living in deprived household environments.
– Strengthen partnerships with public facilities, private healthcare practitioners, and community-based organizations in rural areas to improve access to services.

Key Role Players:

– Public facilities
– Private healthcare practitioners
– Community-based organizations

Cost Items for Planning Recommendations:

– Training and capacity building for healthcare providers
– Infrastructure development and maintenance
– Outreach programs and community engagement
– Health education and awareness campaigns
– Monitoring and evaluation systems

Força da prova

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is rated 7 because it is based on a nationally representative survey and uses multiple logistic regression analyses to assess the determinants of care-seeking behavior for childhood morbidities in Ethiopia. However, the abstract does not provide specific details about the methodology, such as the sampling strategy or data collection procedures. To improve the evidence, the abstract could include more information about the study design and methodology, as well as the limitations of the study.

Resumo

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].

Materiais

N/A

Inovações

Based on the information provided, here are some potential innovations that could improve access to maternal health:

1. Mobile Health (mHealth) Solutions: Develop mobile applications or text messaging services to provide information and reminders to mothers about maternal health, including prenatal care, postnatal care, and immunizations. These services can also provide guidance on when to seek medical attention for common childhood illnesses like diarrhea and acute respiratory infections.

2. Community Health Workers: Train and deploy community health workers to provide education and support to mothers in rural areas. These workers can visit households, conduct health assessments, and provide guidance on when and where to seek medical care for maternal and child health issues.

3. Telemedicine: Establish telemedicine services to connect mothers in remote areas with healthcare providers. This can enable remote consultations, diagnosis, and treatment recommendations, reducing the need for mothers to travel long distances to access healthcare facilities.

4. Public-Private Partnerships: Foster collaborations between public healthcare facilities and private healthcare practitioners to improve access to maternal health services. This can involve sharing resources, expertise, and infrastructure to ensure that quality care is available and accessible to all mothers.

5. Financial Incentives: Implement financial incentives, such as conditional cash transfers or subsidies, to encourage mothers to seek timely and appropriate healthcare for themselves and their children. This can help alleviate financial barriers that may prevent some mothers from accessing necessary care.

6. Health Education Campaigns: Launch targeted health education campaigns to raise awareness among mothers about the importance of seeking medical care for common childhood illnesses. These campaigns can provide information on the signs and symptoms of these illnesses, as well as the benefits of early treatment.

7. Improving Infrastructure: Invest in improving healthcare infrastructure, particularly in rural areas, by building and equipping healthcare facilities. This can help ensure that mothers have access to quality healthcare services within a reasonable distance from their homes.

8. Addressing Socioeconomic Factors: Implement interventions that address socioeconomic factors, such as poverty and gender inequality, which may hinder access to maternal health services. This can involve initiatives to improve education, income generation, and empowerment of women.

It is important to note that these recommendations are based on the information provided and may need to be tailored to the specific context and needs of Ethiopia.

AI Innovations Description

Based on the information provided, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Strengthening Partnerships: Collaborate with public facilities, private healthcare practitioners, and community-based organizations in rural areas to improve access to maternal healthcare services. This can be done by establishing partnerships and creating referral systems to ensure that mothers have access to appropriate healthcare facilities and services.

2. Education and Awareness: Implement educational programs and awareness campaigns targeting mothers and their families to increase knowledge about the importance of seeking timely healthcare for common childhood morbidities. This can include providing information on the signs and symptoms of common illnesses, the benefits of seeking medical attention, and the available healthcare services.

3. Addressing Socioeconomic Factors: Address socioeconomic factors that may hinder access to maternal healthcare, such as poverty and lack of education. This can be done by implementing programs that provide financial support for healthcare expenses, improving access to education for mothers, and addressing gender inequalities that may affect healthcare-seeking behavior.

4. Empowering Women: Empower women by addressing issues of intimate partner violence (IPV) and promoting gender equality. This can be achieved through community-based interventions that raise awareness about IPV, provide support services for victims, and promote gender equality in households and communities.

5. Improving Healthcare Infrastructure: Invest in improving healthcare infrastructure, particularly in rural areas, to ensure that healthcare facilities are accessible and equipped to provide quality maternal healthcare services. This can include building or upgrading healthcare facilities, providing necessary medical equipment and supplies, and training healthcare providers.

6. Data Collection and Analysis: Conduct regular national surveys, such as the Ethiopian Demographic and Health Surveys (EDHS), to collect data on maternal healthcare-seeking behavior and identify gaps and disparities. This data can be used to inform policy and program development, monitor progress, and evaluate the impact of interventions.

By implementing these recommendations, it is expected that access to maternal health services will be improved, leading to better health outcomes for mothers and their children in Ethiopia.

AI Innovations Methodology

Based on the information provided, here are some potential recommendations to improve access to maternal health:

1. Increase awareness and education: Implement comprehensive education programs to raise awareness among mothers about the importance of seeking healthcare for common childhood morbidities. This can include information on recognizing symptoms, understanding the benefits of seeking medical attention, and dispelling myths or misconceptions.

2. Strengthen healthcare infrastructure: Invest in improving healthcare infrastructure, particularly in rural areas where access to healthcare services may be limited. This can involve building or upgrading healthcare facilities, ensuring availability of essential medicines and equipment, and training healthcare providers to deliver quality maternal healthcare.

3. Enhance community-based healthcare services: Establish and strengthen community-based healthcare services, such as mobile clinics or community health workers, to provide accessible and affordable healthcare services to mothers and children in remote areas. This can help overcome geographical barriers and improve access to timely healthcare.

4. Address socio-economic barriers: Implement measures to address socio-economic barriers that prevent mothers from seeking healthcare, such as poverty, lack of transportation, and cultural beliefs. This can include providing financial assistance or subsidies for healthcare services, improving transportation infrastructure, and promoting culturally sensitive healthcare practices.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define indicators: Identify specific indicators that measure access to maternal health, such as the percentage of mothers seeking medical attention for common childhood morbidities, distance to the nearest healthcare facility, or availability of healthcare services in a given area.

2. Collect baseline data: Gather baseline data on the identified indicators before implementing the recommendations. This can be done through surveys, interviews, or analysis of existing data sources.

3. Implement interventions: Implement the recommended interventions, such as awareness campaigns, infrastructure improvements, or community-based healthcare services, in selected areas or communities.

4. Monitor and evaluate: Continuously monitor and evaluate the impact of the interventions on the identified indicators. This can involve collecting data on the indicators after the interventions have been implemented and comparing them to the baseline data.

5. Analyze and interpret data: Analyze the data collected to assess the impact of the interventions on improving access to maternal health. This can include statistical analysis, data visualization, and interpretation of the findings.

6. Adjust and refine interventions: Based on the findings, make adjustments and refinements to the interventions as needed. This can involve scaling up successful interventions, addressing any challenges or barriers identified, and continuously improving the strategies to maximize impact.

7. Repeat the process: Repeat the monitoring, evaluation, and adjustment process periodically to track progress and ensure continuous improvement in access to maternal health.

By following this methodology, policymakers and healthcare providers can assess the effectiveness of the recommendations and make informed decisions to further improve access to maternal health.

Autor

Dima Health

Statistics:

Citations: 1

Identifiers:

DOI: 10.1186/s12913-021-06704-w

Research Areas:

Community Interventions, Environmental, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Social Determinants, Violence and Injury

Study Countries:

Ethiopia

Study Design:

Case-Control Study, Cohort Study, Cross Sectional Study, Grounded Theory

Study Approach:

Quantitative

Participants Gender:

Female

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