Care Seeking for Common Childhood Illnesses in the Context of Integrated Community Case Management Scale up in Rural Ethiopia
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CARE SEEKING FOR COMMON CHILDHOOD ILLNESSES IN THE CONTEXT OF INTEGRATED COMMUNITY CASE MANAGEMENT SCALE UP IN RURAL ETHIOPIA by Bryan C. Shaw A dissertation submitted to Johns Hopkins University in conformity with the requirements for the degree of Doctor of Philosophy Baltimore, Maryland August 2014 ©2014 Bryan C. Shaw All Rights Reserved Abstract Problem statement: Diarrhea, Malaria and Pneumonia are the major causes of under- five mortality (U5M) in sub-Saharan Africa. These illnesses can be prevented with provision of child health interventions delivered at the community level. Ethiopia is currently scaling up integrated community case management (iCCM) of common childhood illnesses through health extension workers (HEWs) in rural community health posts to improve access to evidence-based treatments. However, utilization of HEWs at the health post for child illness has been found to be very low. Little is known about reasons for low utilization of HEWs and care seeking behaviors for this population. Methods: Qualitative methods, including focus group discussions and in-depth interviews, were conducted among caregivers of U5 children and community health workers/volunteers in eight rural health post catchment areas. Paper 1 documents community-based sources of care, describes care seeking behaviors and strategies and explores sociocultural factors influential in care seeking for child illnesses. Paper 2 explores influential access barriers for utilizing HEWs delivering iCCM services at the health post. Quantitative analysis was conducted on data from a household cluster survey (12,000 households) evaluating differences in coverage and mortality between areas providing iCCM and routine community case management (CCM) services. Paper 3 assesses differences in utilization of HEWs for caregivers of sick children in iCCM areas those in routine CCM areas, determinants of utilization of HEW and health post services for child illness and reasons for non-use of HEW/health post services. Results: Paper 1: Caregivers of sick children sought care from multiple sources within the landscape of available care and treatment options. The majority of care was sought ii from informal sources. Choice of care provider was influenced by illness perceptions, perceptions of provider characteristics, influential social others and social networks, perceptions of medicines and caregiver autonomy. Paper 2: Participants noted a wide range of barriers for using HEWs delivering iCCM services at the health post. These barriers reflected both demand- and supply-side challenges. Participants noted that these services were often not: available, geographically accessible and acceptable for their child’s illness. Additional influences included sociocultural factors which were reported to both aid and hinder utilization of HEWs at the health post. Paper 3: Caregivers in iCCM areas are marginally more likely to use the health post for child illnesses compared to caregivers residing in areas only with access to routine CCM services. Determinants for utilization of HEWs at the health post differed between the areas, with iCCM services reaching groups typically marginalized in service utilization studies. The primary reason given for not utilizing the HEW/health post related to caregivers perceptions of low severity for their child’s illness. Conclusions: Despite increases in coverage and quality of child health services delivered by HEWs through the strategy of iCCM, utilization remains very low. Many of the reasons for low utilization related to barriers to access and limited demand. In order to achieve the full potential of iCCM, efforts to minimize these remaining barriers and incorporate demand-generation activities need to be integrated within iCCM actions. Advisor: Pamela Surkan, ScD, PhD Thesis readers: Amy Tsui, PhD, MA; Jennifer Bryce, EdD, MEd; Jill Owczarzak, PhD, MA Alternates: Peter Winch, MD, MPH; Ronald Gray, MD iii Acknowledgements The completion of this work would not have been possible without the assistance of many individuals. First, I would like to thank my advisor, Dr. Pamela Surkan, for her valuable insight and guidance throughout the PhD and dissertation process. Special thanks are also due to Dr. Peter Winch who encouraged my many interests and creativity along this path. I would like to express my appreciation for the Institute for International Programs and especially Dr. Agbessi Amouzou and Dr. Jennifer Bryce, both of whom were invaluable for providing me the opportunity to take part in a significant research opportunity, expand my public health skills and complete the dissertation process. Finally, I would like to thank my friend and colleague Dr. Nate Miller for providing consistent advice and feedback. I would also like to express my gratitude to other colleagues including Elizabeth Hazel, Dr. Bob Black, Dr. Cesar Victora, Eeva Sallinen, Verna Scheeler, Joe Agostino and Syreeta Hubbard, for their assistance and support. I am grateful for the advice and support received by other faculty and staff at JHSPH. In particular, I would like to thank Dr. Amy Tsui, Dr. Jill Owczarzak and Dr. Ron Gray for acting as my thesis readers and on my defense committee. I would also like to thank Dr. Henry Perry, Dr. Asha George, Dr. Abdullah Baqui and Dr. Caitlin Kennedy for guidance through key questions. I greatly appreciate the assistance of both Cristina Salazar and Carol Buckley for going above and beyond in navigating the bureaucracy of JHSPH. A number of individuals in Ethiopia made important contributions to this research. I am indebted to Dr. Luwei Pearson, Dr. Tedbabe Degefie and Dr. Hailemariam iv Legesse of UNICEF Ethiopia who provided important feedback and insight into the Ethiopian health context. I would also like to thank Dr. Markos Feleke, Dr. Mengistu Tafesse and Eyob Kifle from ABH Services, PLC, whose hard work and commitment helped me to overcome several logistic barriers to conducting research in Ethiopia. I would like to thank my qualitative research team Yosef Adinew, Tolessa Dekebe, Getinet Kaba and Fitsum Workneh and the many members of the quantitative research team for the long hours committed to collecting data, and discussing key issues with me. As well the many Ethiopian mothers, fathers and health workers that participated in this study were remarkably generous with their time, and I appreciate their willingness to share their views and lives with me. I would like to thank all of my family and friends, many of them fellow PhD students who acted as more than a support group at times during this program and research. I would like to thank my mother and father who challenged me in explaining my research to those unacquainted with the public health world. Most importantly, I would like to thank my wife, Alexandria Appah. I never could have done it without you. v Support Support for this research was provided by the United Nations Children’s Fund (award 1000017212) and the Canadian International Development Agency (award 7056791) as part of their support for the independent impact evaluation of the scale up of integrated community case management of childhood illness in Ethiopia. Additional support was provided by the Institute for International Programs at the Johns Hopkins Bloomberg School of Public Health. vi Table of Contents Introduction ......................................................................................................................... 1 1. Background .................................................................................................................. 1 1.1 Child survival in sub-Saharan Africa ................................................................... 1 1.2 Access to health care and community-based child health programs .................... 1 1.3 Community case management of common childhood illnesses........................... 5 1.4 Integrated community case management of common childhood illnesses .......... 7 2. Study Site ..................................................................................................................... 9 2.1 Ethiopia ................................................................................................................ 9 2.2 Oromia region .................................................................................................... 10 2.3 Ethiopia Health Extension Program ................................................................... 11 2.4 Ethiopia iCCM evaluation .................................................................................. 14 3. Literature Review ...................................................................................................... 16 3.1 Qualitative studies on care-seeking behaviors ................................................... 16 3.2 Quantitative studies on determinants of health services utilization ................... 20 4. Conceptual Framework .............................................................................................. 23 5. Rationale for Study .................................................................................................... 25 6. Knowledge Gaps Addressed ...................................................................................... 27 7. Methods ..................................................................................................................... 29 7.1 Objectives ........................................................................................................... 29 7.2 Study organization.............................................................................................