Health postservice readiness and use of preventive and curative services for suspected childhood pneumonia in Ethiopia: A cross-sectional study

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Study Justification:
– Pneumonia is the leading cause of infectious disease deaths in children under 5 in Ethiopia.
– Despite this, the utilization of preventive and curative child health services remains low.
– This study aims to investigate the association between health post service readiness and caregivers’ awareness of pneumonia services, care-seeking behavior, and utilization of pneumonia-relevant immunization.
Highlights:
– Only 62.8% of health posts were ready to provide sick child care services.
– One-quarter of caregivers were aware of pneumonia services.
– 56.8% of caregivers sought appropriate care for suspected pneumonia.
– 49.3% of children (12-23 months) had received pentavalent-3 immunization.
– General health post readiness was not associated with caregivers’ awareness of pneumonia treatment and utilization of pentavalent-3 immunization.
– Health post readiness was negatively associated with care-seeking for childhood illnesses.
Recommendations:
– Enhance facility preparedness to provide high-quality care for childhood illnesses, including pneumonia.
– Intensify efforts to generate awareness among caregivers about pneumonia-related services.
– Strengthen demand generation activities to encourage caregivers to seek appropriate care for childhood illnesses, including pneumonia.
Key Role Players:
– Ethiopian Ministry of Health
– Health extension workers (community health workers)
– District health services
– Women’s development group leaders
Cost Items for Planning Recommendations:
– Training and capacity building for health extension workers and women’s development group leaders.
– Strengthening district health services’ ownership and accountability of primary newborn and child health services.
– Community engagement activities.
– Health post infrastructure improvement.
– Provision of essential medicines and diagnostic equipment.
– Supportive supervision for health extension workers.
– Maternal and child health education through community forums.
Please note that the cost items provided are general categories and not actual cost estimates.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a cross-sectional study conducted in four regions of Ethiopia. The study used the WHO Health Service Availability and Readiness Assessment tool to assess health post readiness and collected data on caregivers’ awareness and utilization of pneumonia services. The study found that only 62.8% of health posts were ready to provide sick child care services, and there were significant deficiencies in health post preparedness. However, the study did not find an association between facility readiness and awareness or utilization of child health services. The study provides valuable insights into the challenges faced by the Ethiopian primary healthcare system in delivering preventive and curative services for childhood pneumonia. To improve the strength of the evidence, future research could consider using a longitudinal study design to assess the impact of interventions aimed at improving health post readiness and caregivers’ awareness and utilization of pneumonia services.

Objective Pneumonia is the single-leading cause of infectious disease deaths in children under-5. Despite this challenge, the utilisation of preventive and curative child health services remains low in Ethiopia. We investigated the association between health post service readiness and caregivers’ awareness of pneumonia services, care-seeking and utilisation of pneumonia-relevant immunisation in four Ethiopian regions. Design and setting This cross-sectional study was conducted in 52 districts of four regions of Ethiopia from December 2018 to February 2019. The health posts preparedness for sick child care was assessed using the WHO Health Service Availability and Readiness Assessment tool. Multilevel analyses were employed to examine the associations between health post readiness and household-level awareness and utilisation of services. Participants We included 165 health posts, 274 health extension workers (community health workers) and 4729 caregivers with 5787 children 2-59 months. Outcome measures Awareness of pneumonia treatment, care-seeking behaviour and coverage of pentavalent-3 immunisation. Results Only 62.8% of health posts were ready to provide sick child care services. One-quarter of caregivers were aware of pneumonia services, and 56.8% sought an appropriate care provider for suspected pneumonia. Nearly half (49.3%) of children (12-23 months) had received pentavalent-3 immunisation. General health post readiness was not associated with caregivers’ awareness of pneumonia treatment (adjusted OR, AOR 0.9, 95% CI 0.7 to 1.1) and utilisation of pentavalent-3 immunisation (AOR=1.2, 95% CI 0.8 to 1.6), but negatively associated with care-seeking for childhood illnesses (AOR=0.6, 95% CI 0.4 to 0.8). Conclusion We found no association between facility readiness and awareness or utilisation of child health services. There were significant deficiencies in health post preparedness for services. Caregivers had low awareness and utilisation of pneumonia-related services. The results underline the importance of enhancing facility preparedness, providing high-quality care and intensifying demand generation efforts to prevent and treat pneumonia.

The Ethiopian primary healthcare system typically consists of a primary hospital, a health centre and five satellite health posts. A health post is the lowest service delivery point staffed by two health extension workers serving around 5000 rural residents. Since 2003, Ethiopia has implemented the health extension programme to achieve universal coverage of primary healthcare for the rural population. This national programme is implemented by health extension workers, and they provide basic promotive, preventive and curative services through outreach and health post-based approaches. In 2010, after a change in policy that allowed the health extension workers to treat child pneumonia, the Ethiopian Ministry of Health and partners initiated the implementation of iCCM of childhood illnesses as part of the health extension programme. Under the iCCM programme, the health extension workers examine, classify and treat pneumonia.34 35 The OHEP intervention had three components, that is, community engagement activities, capacity building of health extension workers and women’s development group leaders, and strengthening of the district health services’ ownership and accountability of the primary newborn and child health services. The intervention was conducted in 26 intervention districts with 26 comparison districts spread in four regions of Ethiopia, namely Tigray, Amhara, Oromia and Southern Nations, Nationalities and Peoples Regions. The intervention started in 2016 and was completed in 2018. For the evaluation, baseline and end line surveys were performed. This paper reports a secondary analysis of end line cross-sectional data.33 This study included all caregivers and children aged 2–59 months, who resided in 52 study districts. It also includes all health posts with one or two health extension workers per health post serving these families. This study was based on secondary analysis of data from the endline survey that was part of the evaluation of the OHEP intervention. Sample size for the end line survey was estimated to measure changes in care-seeking and appropriate treatment for childhood illnesses between intervention and comparison areas at baseline and endline. Assumptions considered for the sample size calculation for the main OHEP evaluation36 were 80% power to detect differences of 15% for the reported level of care-seeking (55%) and 20% for appropriate treatment for childhood illnesses (47%) at the baseline, design effect of 1.001% and 90% completeness. Accordingly, a sample size of 12 000 households was obtained. With this number of households, 6532 children below the age of 5 years were expected to be reached by the survey, of whom 368 were assumed to have any illnesses and 308 to have suspected pneumonia within 2 weeks before the survey. The parent study used a sampling frame generated based on the 2007 Ethiopian Central Statistical Agency housing and population survey. Two hundred enumeration areas, that is, clusters, were selected from 52 study districts with probability proportional to size. A two-staged cluster sampling followed by systematic sampling to select 60 representative households from each study cluster. All caregivers of children aged 2–59 months living in the selected households were interviewed. Moreover, all health posts and one or two health extension workers from each health post serving the population of the study clusters were included.37 Data were collected using structured and pre-tested interviewer-administered questionnaires through an electronic data collection software (CSpro survey software). The questionnaires were translated into local languages (Amharic, Tigrigna and Oromiffa) and back-translated into English. They comprised three main modules; household, healthcare provider and health facility modules (see online supplemental files 1–3). Data collectors and supervisors, who had bachelor’s degree or above, were trained for 2 weeks on data collection techniques, procedures, quality assurance and ethical considerations of the study. Further detailed information about data collection and quality control is available in the published study protocol.33 bmjopen-2021-058055supp001.pdf bmjopen-2021-058055supp002.pdf bmjopen-2021-058055supp003.pdf The outcomes of this study are caregivers’ awareness of pneumonia treatment, care-seeking behaviour and coverage of pentavalent-3 immunisation as defined in the Demographic and Health Surveys.28 The awareness of availability of pneumonia treatment was calculated as the proportion of caregivers who had heard messages regarding pneumonia treatment. Suspected pneumonia was ascertained by asking the caregiver if the child had cough combined with either fast or difficult breathing due to chest problems within 2 weeks before the survey. Care-seeking was defined as children with suspected pneumonia for whom advice or treatment was sought from an appropriate care provider, that is, either government or private providers. The vaccination status of children aged 12–23 months was primarily assessed by reviewing immunisation cards. When cards were not available at home, the caregivers were requested to report the type of vaccines their children had received. Hence, coverage of pentavalent vaccination was estimated as the proportion of children 12–23 months who had received three doses of pentavalent vaccine. The readiness of health posts for sick child care was assessed using the WHO Service Availability and Readiness Assessment tool.38 Using 23 tracer items, the preparedness of facilities was shown in five domains or indices, that is, basic amenities, basic equipment, standard precaution equipment for infection prevention, diagnostic capacity and essential medicines. The mean availability of items across the four domains of readiness was estimated by assigning equal weight to each of the items, and was expressed as a proportion. Health posts’ diagnostic capacity was shown as the proportion of facilities having rapid diagnostic test for malaria. The general service readiness was calculated as the average of percentages depicting mean availability of tracer items in five indices.38 The availability of vaccination card at the health posts was also estimated. The number of health extension workers working at the health post and the percentage of these workers trained in iCCM and who had received supportive supervision during 6 months before the survey were also calculated. The health post demand generation activities were recorded as the proportion of health posts showing opening days or that used community forums to deliver maternal and child health education. The household socioeconomic status was constructed through principal component analysis of household assets, ownership of house, livestock, agricultural land and access to utilities and infrastructures. The factor scores were summed and ranked into quintiles from the poorest to the least poor. The study linked the household, health facility and care provider information. Our analysis was based on linked samples for outcome variables, that is, caregivers’ awareness of pneumonia treatment (n=4934), care-seeking when the child was sick (n=613) and vaccination of 12–23 months old children with a third dose of pentavalent immunisation (n=860). Care-seeking was assessed for all childhood illness episodes, including symptoms of suspected pneumonia as reported by caregivers for the 2 weeks prior to the survey. The effect of clustering on three of the study outcomes was examined by estimating intracluster correlation coefficients (ICC). A multilevel binary logistic regression model was fitted to examine the association between health post readiness and household level awareness, care-seeking and utilisation of three doses of pentavalent vaccinations. We checked for potential household-level confounders. The fitness of the model was checked through Likelihood Ratio Test. Data were analysed using Stata V.14. Patients or the public were not involved in the design or conduct or reporting or dissemination plans of this research.

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

1. Mobile Health (mHealth) Solutions: Implementing mobile health technologies, such as mobile apps or SMS messaging, to provide information and reminders about maternal health services, prenatal care, and postnatal care. This can help increase awareness and encourage timely care-seeking behavior.

2. Telemedicine: Introducing telemedicine services that allow pregnant women to consult with healthcare providers remotely, reducing the need for travel and improving access to prenatal care, especially in remote or underserved areas.

3. Community Health Worker Training and Support: Enhancing the training and support provided to health extension workers and community health workers who play a crucial role in delivering maternal health services at the community level. This can include additional training on maternal health topics, regular supervision and mentoring, and access to job aids and resources.

4. Strengthening Health Post Readiness: Addressing the deficiencies in health post preparedness for services by improving the availability of basic amenities, equipment, diagnostic capacity, and essential medicines. This can ensure that health posts are adequately equipped to provide quality maternal health services.

5. Demand Generation Efforts: Intensifying efforts to generate demand for maternal health services through community engagement activities, health education forums, and awareness campaigns. This can help increase caregivers’ awareness of available services and encourage them to seek care when needed.

6. Integration of Services: Integrating maternal health services with other primary healthcare services, such as family planning, immunization, and child health services. This can improve the efficiency and accessibility of care by providing comprehensive services in one location.

7. Strengthening Health Information Systems: Improving the collection, analysis, and use of data on maternal health indicators to inform decision-making and resource allocation. This can help identify gaps in service delivery and monitor progress towards improving access to maternal health services.

It’s 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’s healthcare system.
AI Innovations Description
Based on the study, here is a recommendation that can be developed into an innovation to improve access to maternal health:

1. Enhance health post readiness: The study found that only 62.8% of health posts were ready to provide sick child care services. Improving the readiness of health posts by ensuring they have basic amenities, equipment, diagnostic capacity, and essential medicines can contribute to improving access to maternal health. This can be achieved through targeted investments in infrastructure, equipment, and training of health workers.

2. Strengthen caregiver awareness: The study found that only one-quarter of caregivers were aware of pneumonia services. Increasing caregiver awareness about maternal health services, including prenatal care, postnatal care, and family planning, can help improve access to these services. This can be done through community engagement activities, health education campaigns, and the use of various communication channels such as radio, television, and mobile phones.

3. Improve care-seeking behavior: The study found that 56.8% of caregivers sought appropriate care providers for suspected pneumonia. Encouraging caregivers to seek timely and appropriate care for maternal health issues is crucial. This can be achieved by providing information on the importance of seeking care, addressing cultural and social barriers, and improving the quality and accessibility of healthcare services.

4. Strengthen immunization coverage: The study found that only 49.3% of children aged 12-23 months had received pentavalent-3 immunization. Improving immunization coverage can contribute to reducing maternal and child mortality. This can be achieved through targeted immunization campaigns, outreach programs, and ensuring the availability of vaccines at health posts.

Overall, the recommendation is to focus on improving health post readiness, increasing caregiver awareness, promoting care-seeking behavior, and strengthening immunization coverage to improve access to maternal health services in Ethiopia.
AI Innovations Methodology
Based on the provided description, here are some potential recommendations to improve access to maternal health in Ethiopia:

1. Strengthen Health Post Readiness: Enhance the preparedness of health posts to provide comprehensive maternal health services. This can include improving basic amenities, equipment, diagnostic capacity, and essential medicines at health posts.

2. Increase Awareness: Implement targeted awareness campaigns to increase caregivers’ knowledge and awareness of maternal health services, including prenatal care, safe delivery practices, and postnatal care.

3. Improve Care-Seeking Behavior: Promote and encourage caregivers to seek appropriate care for maternal health issues by providing information on the importance of timely and skilled care during pregnancy, childbirth, and the postpartum period.

4. Enhance Health Extension Worker Training: Provide comprehensive training to health extension workers on maternal health topics, including antenatal care, delivery assistance, and postnatal care. This can help ensure that health extension workers are equipped with the necessary skills and knowledge to provide quality maternal health services.

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

1. Define Key Indicators: Identify key indicators that reflect access to maternal health, such as the percentage of pregnant women receiving antenatal care, the percentage of deliveries attended by skilled birth attendants, and the percentage of postpartum women receiving postnatal care.

2. Collect Baseline Data: Gather baseline data on the identified indicators from a representative sample of health facilities and communities in Ethiopia. This can be done through surveys, interviews, and data collection from health records.

3. Implement Innovations: Implement the recommended innovations, such as strengthening health post readiness, increasing awareness, improving care-seeking behavior, and enhancing health extension worker training.

4. Monitor and Evaluate: Continuously monitor and evaluate the implementation of the innovations. Collect data on the indicators identified in step 1 to assess the impact of the innovations on improving access to maternal health.

5. Analyze Data: Analyze the collected data to determine the changes in the identified indicators before and after the implementation of the innovations. This can be done using statistical analysis techniques to measure the significance of the changes.

6. Assess Impact: Assess the impact of the innovations on improving access to maternal health by comparing the baseline data with the data collected after the implementation of the innovations. This will provide insights into the effectiveness of the recommendations.

7. Refine and Scale-Up: Based on the findings from the impact assessment, refine the innovations as needed and develop strategies for scaling up successful interventions to a larger population.

By following this methodology, policymakers and healthcare providers can gain valuable insights into the potential impact of the recommended innovations on improving access to maternal health in Ethiopia.

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