Volume 28, Special Issue, 2014, 1-43 ISSN 1021-6790

yx!T×ùÃ ---@Â L¥T m{/@T The Ethiopian Journal Of

Health Development

Joint Scholarly Publication of the Ethiopian Public Health Association and the School of Public Health, College of Health Sciences, Addis Ababa University

Editor-in-Chief Damen Haile Mariam

Special Issue

On Associate Editor Ahmed Ali Academic-Private Sector Collaboration in Public Health Operations Research (School of Public Health, Addis Ababa University & 1 the Integrated Family Health Program (IFHP))

1 These studies are made possible by the generous support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of the Integrated Family Health Program (IFHP) and do not necessarily reflect the views of USAID or the United States Government. http://www.etpha.org http://www.ajol.info/

Volume 28, Special Issue, 2014, 1-43 ISSN 1021-6790

1 Editorial: Academic-private sector collaboration in public health operations research (PHOR): The case of Addis Ababa University Scool of Public Health (AAU-SPH) and the Integrated Family Health Program (IFHP). Adamu Addisse, Seifu Hagos, Girma Kassie, Tariku Nigatu, Mengistu Asnake

6 Magnitude and factors that affect males’ involvement in deciding partners’ place of delivery in Tiyo District of Oromia Region, Ethiopia. Wassie Lingerh, Bekele Ababeye, Ismael Ali, Tariku Nigatu, Heran Abebe, Getnet Mitike, Mitike Molla

14 Identification of factors associated with method shift from short-acting to long-acting methods of contraception in Amhara Region of Ethiopia. Habtu Atnafu, Yigzaw Dires, Amare Yeshambaw, Seid Ali, Wondimu Gebeyehu,Shewangizaw Bereda, Fikre Enqusilassie, Alemayehu Mekonnen, Adamu Addissie, Seifu Hagos

20 Magnitude and predictors of skilled delivery service utilization: A health facility-based, cross- sectional study in Tigray. Tesfaye Gebru, Desta Gebre-Egziabher, Kelali Tsegay, Brhane Hadera, Mesfin Addisse, Worku Tefera, Adamu Addisse, Seifu Hagos

26 Utilization of Prevention of Mother to Child transmission (PMTCT) services and factors that affect knowledge and service uptake among pregnant women attending antenatal care in East Hararge Zone of Oromia Regional State. Megersa Gobena, Tariku Nigatu, Belay Ymam, Adeba Tasisa, Daniel Wagaw, Fufa Birmechu, Daniel Keba, Ahmed Ali, Wubgzier Makonnen, Adamu Addisse, Seifu Hagos

36 Assessment of health care seeking behavior of caregivers for common childhood illnesses in Shashogo Woreda , Southern Ethiopia. Bekele Demissie, Berhanu Ejie, Habtamu Zerihun, Zergu Tafese, Getu Gamo, Tilahun Tafese, Abera Kumie, Jemal Haider, Adamu Addisse, Seifu Hagos

http://www.etpha.org http://www.ajol.info/

The Ethiopian Journal of Health Development

Editorial Office Team Editor-in-Chief: Meskerem Bezuayehu (Publication Secretary) Azeb Mesfin (Administrative Assistant) Damen Haile Mariam Worku Sharew (Language Editor)

Copyright Ethiopian Public Health Association & the School of Public Associate Editor : Health, Addis Ababa University. All rights reserved. This Journal, or any Ahmed Ali parts thereof, may not be reproduced in any manner without written permission.

Editorial Board The Ethiopian Journal of Health Development is published three times a Abraham Aseffa year by the Ethiopian Public Health Association & the School of Public Adugna Woyessa Health, Addis Ababa University. Alemayehu Worku The Journal is jointly sponsored by the Ethiopian Public Health Getnet Mitike Association and the Addis Ababa University. Helmut Kloos Lukman Yusuf All articles published in the Journal, including editorials, represent the Mengistu Asnake opinion of the authors and do not necessarily reflect the official policy of Mesganaw Fantahun the Ethiopian Public Health Association, the Editorial Board of the Journal or the institution with which the author is affiliated, unless this is Solomon Shiferaw clearly specified. Tewabech Bishaw Address all correspondence to: The Ethiopian Journal of Health Development, Tikur Anbessa Hospital, P.O. Box 32812, Addis Ababa, Editorial Consultants Ethiopia; Telephone: +251 1 513628, or +251 1 157701; Fax: +251 1 Abeba Bekele (Ethiopia) 517701 or +251 1 5148 70. Abdulahamid Bedri (Ethiopia) Aberra Geyid (Ethiopia) Annual subscription rates: Ethiopia 60.00 Birr; outside Ethiopia 75.00 Arnaud Fontanet (France) US Dollars. Asfaw Desta (Ethiopia) Assefa Hailemariam (Ethiopia) All prices include postage payment arrangements are: Asrat Hailu (Ethiopia) 1. Check must be written to be payable to the Ethiopian Public Health Bernt Lindtjorn (Norway) Association; and Debrework Zewde (U.S.A) 2. The check must be mailed to the Ethiopia Journal of Health Derege Kebede (Zimbabwe) Development P.O. Box 32812, Addis Ababa, Ethiopia. Desta Alamerew (Namibia) Eligius Lyamuya (Tanzania) This Publication is made possible by the generous support of the Eshetu Lemma (Ethiopia) American people through the United States Agency for International Eyasu Mekonnen (Ethiopia) Development (USAID). The contents are the responsibility of the Fikre Enquselassie (Ethiopia) Integrated Family Health Program (IFHP) and do not necessarily reflect Gail Davey (UK) the views of USAID or the United States Government. Gebre-Emanuel Teka (Ethiopia) Getu Degu (Ethiopia) EPHA mission statement Hailu Negassa (Ethiopia) The Ethiopian Public Health Association is a legally registered national, Hailu Yeneneh (Ethiopia) autonomous, non-profit-making, voluntary professional organization, Lulu Muhe (Switzerland) established in 1989 to promote public health services and professional Maowia Mukhtar (Sudan) standards though advocacy, active involvement, and net working. Mekonnen Assefa (Ethiopia) Mogessie Ashenafi (Ethiopia) The Journal contributes to EPHA's mission thorough publishing of peer- Peter Byass (U.K) reviewed original articles, reviews and correspondences on the broad Redda Tekle Haimanot (Ethiopia) field of health development. Shabbir Ismail (Ethiopia) Stig Wall (Swiden) EPHA Executive Board Members list Tesfaye Shiferaw (Namibia) Filimona Bisrat (President) Tsige Gebremariam (Ethiopia) Fekerte Belete (Vice President) Yemane Berhane (Ethiopia) Hiwot Mengistu (Member) Yetnayet Asfaw (Ethiopia) Seifu Hagos (Member) Yoseph A. Mengesha (Ethiopia) Alemayehu Mekonnen (Member) Takele Geresu (Member) Afework Kassu (Member) Hailegnaw Eshete (Nonvoting member)

EDITORIAL

Academic-private sector collaboration in public health operations research (PHOR): The case of Addis Ababa University School of Public Health (AAU-SPH) and the Integrated Family Health Program (IFHP)

Adamu Addisse 1, Seifu Hagos 1, Girma Kassie 2, Tariku Nigatu 2, Mengistu Asnake 2

Background service has been emphasized and various forms Universities are recognized as sources of of collaborations have evolved. Various knowledge, innovation and technological collaborative models are documented in Africa advances. Across the globe, they are being between academic and public healthservice positioned as strategic assets in innovation and agencies in areas of training human resources and economic competitiveness, and as research (4, 5) as well as between the public problemsolvers for socio-economic issues health system and academic institutions such as affecting their societies. Synergies between higher schools of public health (4-12). education institutions and industry play a critical role in securing and leveraging additional The Ethiopian health system is in dynamic resources by promoting innovation and change all the time with relatively rapid technology transfer (1). Universities need to work developments especially in the last two decades to understand the factors that support or interms of new health policies, programs, and undermine human development and monitor growth. Therefore, public and private sectors ways whereby such development can be used to need to identify their challenges, the challenges, enhance the quality of life. For universities to be and come up with practical and viable solutions able to play this role effectively, it is vital that to adapt to the changing environment through they create a new equilibrium between education, operations research. This type of research in research, and service and define new strategies health care is crucial foridentifying health for assisting society in addressing the more priorities and operations problems by producing urgent problems of development. By forming evidence for planning and decision-making to coalitions with other institutions, government improve health care services. Although it is and society, they can, assist in creatinga national critical, operations research has not been pursued agenda fordevelopment issues (2, 3). in a coordinated manner during the first and second Health Sector Development Program Academic institutions such as schools of public (HSDP) period. However, improvements have healthhave traditionally focused mainly on been observed in HSDP III and IV. Research training and research–where academics focus on and technology transfer is one of the core training and research while service agencies processes redesigned as part of the business (governmental and non-governmental) focus on processing re-engineering during the last HSDP serving the public. There are various guiding (13). documents for engaging academic Institutions in service and industry including the Bayh-Dole Act The Deputy Prime Minister of the Federal of 1980 (4). That 1980 encourages technology Democratic Republic of Ethiopia, during a transfer from universities to industry, with meeting on university and industry collaboration, resources financial facilitated among academics, said that universities need to work closely with biomedical researchers, and the biotechnology industries in Ethiopia to identify and solve industry. Over the years, the basic the necessity operational problems of industries through for academic institutions in the provision of research and advisory so that Ethiopia would

1Addis Ababa University, School of Public Health; 2Integrated Family Health Program, Ethiopia. 2 Ethiop. J. Health Dev. soon join the middle income countries. This trained manpower, research, and community statement indicates that governments are services– the pillars of the university’s mission. increasingly acknowledging the importance of higher learning institutions as strategic actors in Addis Ababa University’s College of Health national economic development, given their Sciences houses the School Public Health, the potential in upgrading the knowledge and skill of School of Medicine, the School of Pharmacy, the the workforce and their contribution to process School of Allied Health Sciences, and the and product innovation (14). teaching hospital. The College of Health Sciences strives to be a center of excellence in health- Partnerships between academic institutions and related issues.The SPH, founded in 1964 as the private industryallow academicians and health Department of Community Health of the Faculty practitioners to exchange experiences and of Medicine, is the oldest national public health resources can lead to rapid development. training institution in Ethiopia. Over the years it Examples of such collaborations and has been providing both undergraduate training engagements of universities include the of medical students and post-graduate training in involvement of US universities as contractors and public health master’s (MPH) and doctorate sub-grantees to the PEPFAR grant/initiative in (PhD) levels. The Department of Community various African countries, including Ethiopia. Health transformed itself to the School of Public However, even such initiatives fail to be typical Health in October 2010. models of collaborations since the in-country programs of each initiative function as public The Integrated Family Health Program (IFHP) is health service agencies. Moreover, the existing a USAID-funded health program implemented collaborations have not reached expectations and, by Pathfinder International Ethiopia (PIE) and so far, there is no clear collaborative channel or John Snow, Inc. (JSI) in partnership with the mechanism between academia and service Consortium of Reproductive Health Associations institutions. (CORHA) and other local partners. The program operates within the framework of the Ethiopian The current collaboration between the School government’s Health Sector Development Public Health (SPH) of Addis Ababa University Program (HSDP) in general, and the Health and the Integrated Family Health Program Extension Programin particular, in 301 woredas. (IFHP) stared with the objective of enhancing The program focuses on family planning, the capacity of the IFHP staff to undertake reproductive health, and maternal, newborn, and operations research and to strengthen and child health. expand the school’s linkage, presence, and engagements in the community to solve The program has a mechanism to systematically problems that hinder better health outcomes. learn from its own program implementation in The partnership convened regional health order to promote evidence-based practices, bureaus (RHB) and IFHP staff from across four inform policy, and advise future program regions. The two partnersinitiated IFHP staff-led investments. IFHP’s strategies are designed to research studies with the expectation that benefit from adaptation to the differing socio- findings would inform the partnership’s own demographic and health systems contexts. The program implementation and guide its future program fosters the sharing of model practices direction. and success stories in addition to commissioning and collaborating with stakeholders in the The collaborating partners conduct of operations research projects. Through Addis Ababa University (website address: close partnership with the RHBs that oversee its http://www.aau.edu.et/ ), where the SPH is operations areas, IFHP draws upon the ability of housed, was established in 1950. It is the oldest its local implementers to identify and respond to and largest higher education institution in implementation challenges with solutions Ethiopia. The university has made remarkable relevant to their local contexts based on scientific contributions to the country by providing with evidence. Ethiop. J. Health Dev. 2014;(Special Issue 1) Academic agency, public health agency, collaboration, operations research 3

The collaboration process analysis and report writing. Following the The current collaborationbetween the two training, each research team entered and analyzed institutions wasinitiated by the request from data and produced reports with the support of IFHP. The phases in the collaboration their respective advisors. includedneed identification, planning, implementation, and monitoring. Need Outcome of the collaboration and lessons identification was carried out on two levels: first, learned building capacity of IFHP and RHB staff, and, As a result of the joint venture, more than 25 second, the identification of specific research IFHP and RHB personnel received training on problems. Once the needs were articulated, research methods. In addition, five operations communications between SPH and IFHP began. research projects were designed and successfully Each partner identified a leader who could carried out. In the process, the staff of IFHP facilitate the planning and consensus building obtained theoretical and practical knowledge and process, and, subsequently, the heads of the SPH skills in undertaking quantitative and qualitative and the IFHP signed a memorandum of research. They were involved in selecting understanding. research topics, developing research proposals, processing ethical reviews, training data Implementing and monitoring were other core collectors, supervising the data collection process, components, which included two week-long entering and cleaning the data, analyzing and training and field-work accompanied by interpreting the data, writing reports, and mentorship of advisors from the SPH. The first developing research manuscripts for publication training focused on problem identification and and to the wider public (Table 1). The proposal writing, giving the trainees the manuscripts of each have been issued in this opportunity to develop proposals in consultation volume and were jointly authored by the SPH withthe advisors, finalize ethical clearance, and advisors and IFHP staff. collect data. The second training focused on

Table 1: Research projects funded by USAID undertaken by the collaborative effort, including their objectives and the regions where the research wasconducted. Region Operations research titles Objective(s) (Team) Oromia Determinants of male involvement in To assess male partners’ involvement in (Country team) supporting partners to access institutional deciding their spouses’ place of delivery and delivery identified factors associated with it in Tiyo woreda of Arsi zone, Ethiopia Oromia Facilitators of uptake and use of prevention of To identify factors that influence utlization of (Regional team) mother-to-child transmission of HIV services services provided by health facilities to prevent the transmission of HIV from mothers to their children Tigray Factors that influence the use of delivery To assess advantages of skilled birth (Regional team) services with a skilled birth attendant attendant and associated factors Amhara Assessment of factors associated with To assess factors associated with method (Regional team) method change from short-acting to long- change from short-acting to long-acting and acting and permanent contraceptive methods permanent contraceptive methods in five zones of Amhara region. SNNPR Caregivers’ health-care-seeking behavior for To assess the status of health-care-seeking (Regional team) common childhood illnesses behavior of caregivers for childhood illnesses and associated factors

The SPH also used the opportunity to provide collaborative undertaking mutually benefited the support to the community, particularly in helping collaborators in many ways. The most important the IFHP identify health problems in the reasons why the collaboration worked and community in an effort to provide viable options produced results were: and solutions for improved health outcomes.The Ethiop. J. Health Dev. 2014;(Special Issue 1) 4 Ethiop. J. Health Dev.

1. Dynamics of science and research methods – accommodate the unforeseen delays. Moreover, universities are stronger in this aspect of unexpected negotiation and consensus were continuously updating knowledge and necessary before the five teams were able to agree sharpening research skills; on a common timeframe for the training 2. Service-providing agencies (government and workshops. Finally, the ethical review process for non-government) areatthe forefront of the proposals was not uniform among the providing service to the community.As a regions and the requirements for each varied result of their activities, they face various significantly. The regional health offices tried to challenges that need solutions based on facilitate this process to create uniformity among scientific evidence. Thus, fertile ground exists all of the participants. for the two parties to collaborate and take advantage of each other’s expertise; Conclusion 3. Collaboration provides synergy and fosters The IFHP SPH partnership in PHOR has bi-directional learning; and demonstrated the feasibility of this partnership 4. Joint efforts help to pool resources and model which can be further and better utilized to improve efficiency. address prevalent operational public health problem in the Ethiopian setting. Therefore, we An article published by The Lancet shows that recommend the adoption of similar approaches partnership between academic institutions and in Ethiopia and beyond in order to synergize service delivery systems help build effective efforts towards meeting the goals of delivering interfaces between the collaborating institutions quality public health services. and the community, andresults in more effective public-private partnership (15). Similarly, the collaboration between the SPH and the IFHP has References resulted in the transfer of knowledge and skills 1. Hernes G, Martin M. Management of that may lead to the achievement of the desired university industry linkages. Results from the health outcomes in the community, which is the policy forum held at IIEP. Paris; common goal shared by both institutions. IIEP/UNESCO, 2000. 2. UNESCO. International conference on According to Chika Charles et al. (16), education, 38th session, Geneva, 10-19 collaborative relationships and partnerships November 1981. Paris; UNESCO, 1982. between universities and the private sector, 3. UNESCO. Study service: A tool of particularly NGOs, alsoserve multiple purposes. innovation in higher education. Paris; For example, in helping expose and frame UNESCO, 1984. research questions, allowing interaction 4. The Bayh-Dole Act or Patent and Trademark throughout the research process, supporting data Law Amendments Act. Pub. L. 96-517, USA, collection and analysis, and providing outlets for December 12, 1980. sharing, feedback and dissemination. This has 5. Editorial. Universities in transition to also been reflected in the partnership between improve population health: A Tanzanian case SPH and IFHP. study. Journal of Public Health Policy 2012; 33: S1, S3-S12. Challenges 6. Beyes N, Academic program partnership for These achievements were not obtained without operational research: A TREAT TB initiative challenges. One main challenge was the busy in South Africa, 42nd Union World schedules of the participants and the academic Conference on Lung Health, 26-30, October mentors. This obstacle resulted in the various 2011, Lillie, France. regions keeping to different project schedules 7. Schieve LA, Handler A, Gordon AK, Ippoliti instead of the original one prescribed. Despite P, Turnock BJ. Public health practice linkages the coordinators’ repeated encouragement and between schools of public health and state reminders about deadlines to the partners, the health agencies: Results from a three-year process timeline was eventually adjusted to Ethiop. J. Health Dev. 2014;(Special Issue 1) Academic agency, public health agency, collaboration, operations research 5

survey. J Public Health Management Practice 13. Federal Ministry of Health (FMOH), 1997; 3(3):29 -36. Ethiopia. Health Sector Development 8. Gordon AK, Chung K, Handler A, Turnock Program IV (HSDP IV). FMOH; Addis BJ, Schivelve LA, Ippoloti P. Final report on Ababa, 2010. public health practice linkages between 14. Ethiopian Television. Ethiopian news [cited schools of public health and state health 09 December 2013]; Available at: agencies: 1992-1996. J Public Health URL: http://www.diretube.com/ethiopian- Management Practice 1999; (3):25-34. news/university-industry-linkage-to-be- 9. Keck CW. Lessons Learned from an assembled-video_a5dbd8776.html . academic health department. J Public Health 15. Dzau VJ, Ackerly DC, Sutton-Wallace P, Management Practice 2000; 6(1):47-52. Merson MH, Williams RS, Krishnan KR, 10. Livingood WC, Goldhagen J, Little WL, Taber RC, et al. The role of academic health Gornto J, Hou T. Assessing the status of science systems in the transformation of partnerships between academic institutions medicine. The Lancet 2010; 375(9718): 949 - and public health agencies. Framing health 953 . matters. Am J Public Health 2007;97(4):659- 16. Charles AC, Hayman R, Mdee A, Akuni J, 666. Lall P, Stevens D. Academic-NGO 11. Nolle KC. Nevada's academic practice collaboration in international development collaboration: Public health preparedness research: A reflection on the issues. Working possibilities outside an academic center. Paper. September 2012. Public Health Reports 2005; 120 (Supplement1):100-120,. 12. Mier N, Establishing successful binational academic collaborations in minority health research. Public Health Reports 2005; 120:471- 475.

Ethiop. J. Health Dev. 2014;(Special Issue 1)

Magnitude and factors that affect males’ involvement in deciding partners’ place of delivery in Tiyo District of Oromia Region, Ethiopia

Wassie Lingerh 1, Bekele Ababeye 1, Ismael Ali 1, Tariku Nigatu 1, Heran Abebe 1, Getnet Mitike 2, Mitike Molla 2, Adamu Addisse 2, Seifu Hagos 2

Abstract Background: Skilled birth attendants at health facilities reduce the death toll on mothers and newborns significantly. To the knowledge of the investigators, male involvement in deciding on the partners’ place of delivery and factors that affect male involvement have not been studied adequately in the Ethiopian context. Objective: The study set out assess male partners’ involvement in deciding on their spouses’ place of delivery and to identify factors associated with this involvement in the Tiyo District ( Woreda ) of Arsi Zone, Ethiopia. Methods: A community-based cross-sectional survey was taken between January and February 2012 in Tiyo district of Oromia Region. The study involved both quantitative and qualitative methods. A list of males, whose partners gave birth within 12 months prior to the survey, was prepared. A total of 999 men were included in the study. In addition, separate male and female focus group discussions (FGDs) were need to obtain additional information and to triangulate the quantitative findings. Data were collected using interviewer-administered questionnaires and a FGD guide. Descriptive and analytical statistics were calculated to summarize the data and explore associations. Results: The majority of respondents were farmers (93.4%) and had some formal education (84.6). Joint partners’ source of income (OR=4.25, 95%CI: 1.77- 10.2), making joint decision on antenatal care (ANC) service uptake (OR=3.61,95% CI: 1.52-8.57), history of previous institutional delivery (OR=2.10, 95%CI: 1.15-3.85) and owning radio and tape-recorder (OR=1.77, 95%CI, 1.20-2.85) were significantly associated with male involvement in deciding their spouses’ place of delivery. Qualitative findings showed a low level of awareness of the benefit of health facility use for delivery, low level of knowledge of danger signs related to pregnancy and delivery, and traditional and cultural influences about perceptions. Conclusion: Girls and women should be empowered by education and income-generating activities and male-targeted messages should be applied through mass media to motivate male partners to be involved in jointly deciding their spouses’ place of delivery. Health care providers should design a mechanism to involve male partners during ANC to jointly counsel partners on danger signs, birth preparedness, and complication readiness. Traditional and cultural barriers need to be addressed and made related to local context in tailored activities based on evidence from research. [Ethiop. J. Health Dev. 2014; (Special Issue 1):6-13]

Background by SBAs in developed countries compared to only 33.7% Globally, more than 536,000 maternal and 8 million in eastern African countries (5).The rate is much lower in perinatal deaths occur every year (1). Maternal deaths are Ethiopia, where service uptake is expected to rise from the ‘tip of the iceberg’ of the potential dangers faced by the current level of 10% to 60% by the end of 2015 (6, childbearing women in many parts of the world. For 7). example, more than 1.4 million women survive severe life-threatening complications (maternal near-miss) and Involvement of males in reproductive health is an an additional 9.5 million women suffer from severe and important step in reducing maternal and newborn deaths debilitating conditions, such as fistula and infertility (2). and for achieving Millennium Development Goals Sub-Saharan African countries account for over 90% of (MDGs) 4 and 5 (8). According to most studies, male maternal and neonatal deaths. Ethiopia is one of the six partner involvement in maternal and child health care countries that account for 50% of maternal deaths remains low in many sub-Saharan African countries (9). globally (3). Though the role of men in maternity care is under-studied in Africa, open discussion between partners on where to Over 60% of maternal and newborn deaths occur during give birth improves skilled delivery service uptake at labor, delivery, and the first days of postnatal period. health facilities (10). Peer-led, culturally sensitive These deaths can be prevented by making skilled birth community education increases males’ involvement and attendants (SBAs) available for every delivery and by improves service uptake (11). Studies conducted in ensuring access to Basic Emergency Obstetrics and different countries indicate that social, cultural, and Newborn Care (BEm ONC) for all complications (4, 5). religious factors play a paramount role in SBA service The use of SBAs at health facilities varies widely among uptake. Gender inequality, harmful traditional practices, countries. As many as 99% of deliveries were attended the low social status of women, limited female

1Integrated Family Health Program, POBox 12655, Wassie Lingerih Tel:251911954141 Email: [email protected] Addis Ababa, Ethiopia; 2Addis Ababa University, School of Public Health, Addis Ababa, Ethiopia. Magnitude and factors that affect males’ involvement in deciding partners’ place of delivery in Tiyo 7 involvement in decision making, family members’ Sample size and sampling technique: The sample size influence and decisions, and women’s limited influence for the study was calculated using single population over their families are key factors in SBA service uptake proportion formula, taking p= 50 %, precision of 5% , at (12). In addition, religious reasons, poor attitude of health 95% confidence level, a design effect of 2 for cluster workers, and the poor quality of care are related to low sampling method and 30% for non-response gave a service uptake (13). Skilled antenatal care (ANC) sample size of 999. Tiyo Woreda was selected attendance declines from the first to the fourth visit, purposively because it is within IFHP’s support zone. resulting in low skilled delivery service uptake. The Among Tiyo Woredas ’ 16 kebeles, 8 were selected using reasons also include no-access-related ones, such as socio a simple random sampling technique. Households in each cultural and economic factors, which play an important kebele with men aged 18 years or above and whose role in women’s health-seeking behavior during spouses gave birth within 12 months prior to the survey childbirth (14). In rural Ethiopian, male partners are were listed. Then the number of households to be gatekeepers to the family including for health service use. selected from each kebele was determined using PPS. They usually prefer home delivery for their partners Finally, the required number of households from each because of cultural influences and fear of expenses kebele was selected using a simple random sampling associated with medical and transport services (15). technique.

The Integrated Family Health Program (IFHP) is a Six focus group discussions (FDGs) (3 male and 3 comprehensive maternal and newborn health intervention female) were conducted. The men and women with in 20 districts with the objective of improving access to partners were selected purposively to participate in the and utilization of skilled delivery services at health FGDs each consisting 6 to 12 participants. The FGDs facilities. The project has been implemented for the past were moderated by experienced facilitators using an FGD three years and has achieved varying degrees of guide. improvement across the districts. Service use did not increase uniformly across the sites and the findings of Operational definitions: this operational research will be utilized to address • Male partner : male who has a spouse, whether challenges. with formal marriage or informal union. • Male involvement : males who were involved in In the Ethiopian context, males are close to their partners, deciding their spouses’ delivery place alone or the owners of significant household resources, and the together with their spouses, family members, or primary decision makers. Therefore, understanding the another individual. This included deciding a factors that affect their involvement in selecting their health facility, a health post (HP), home, spouses’ place of delivery is important to inform the ortraditional birth attendant’s (TBA) home as a efforts of policy makers, program planners, and health place of birth. care providers to improve health facility delivery service • Joint partners’ source of income : households utilization. This study was made to assess male with incomes generated from both the man and involvement in selecting their spouses’ place of delivery the woman, in formal or informal union. and to identify factors that influence their involvement, with the intent of using the findings to improve the Data Management and Analysis : program, in designing and improving similar programs, Each questionnaire was checked for consistency and and to informrelevant policymaking. completeness during data collection. Then, the questionnaires were entered and cleaned before analysis. Methods Analysis of the cleaned data was done using SPSS Study Area, Study Design, Study Population, and Data version 20. The result of the study is presented using Collection : tables and graphs. Percentages and frequencies were A cross-sectional study was carried out in Tiyo Woreda calculated to describe the data and chi square tests and of Arsi Zone of Oromia Regional State of Ethiopia from logistic regression were used to explore associations January to February 2012. The study involved both between dependent and independent variables. The quantitative and qualitative methods sequentially. The qualitative data was analyzed using open code software quantitative data were collected during the first two package version 3.6.2.0, transcribed and summarized weeks of January 2012 followed by the qualitative data under each theme and presented textually. collection. A structured, pretested, interviewer administered questionnaire was used for the quantities Ethical Considerations : survey and focus group discussions were used to collect Ethical clearance was obtained from the Oromia the qualitative data. The study participants for the Regional State Health Bureau. Permissions were also quantitative survey cause men aged 18 years or more secured from local officials at data collection sites. The whose spouses gave birth within 12 months prior to the objectives of the study were explained to study survey and living in the selected kebeles. participants. Potential harms and benefits of the study were explained to each respondent and then informed

Ethiop. J. Health Dev. 2014;(Special Issue 1) 8 Ethiop. J. Health Dev. consent was obtained. The respondents were allowed to Table 1: Socio-demographic characteristics of withdraw from the interview at anytime they wished and respondents who participated in the survey in Tiyo, Arsi participation was completely voluntary. The data (n=999) obtained were handled with confidentiality. No personal Variable Respondents n (%) Age in years identifiers, such as names, were used during data 18-24 82 (8.2) collection, analysis, or report writing. 25-34 418 (41.8) 35-44 345 (34.5) Results 45 + 153 (15.3) The response rate for this study was 100%. Four hundred Ethnicity Oromo 812 (81.4) and eighteen (41.8%) of the respondents were between Amhara 177 (17.7) the ages 25 and 34 years. The median age was 34 years Gurage 9 (0.9) (IQR: 28 to 40 years). The majority (933 or 93.4%) of Religion them were farmers, had some formal education (845 or Orthodox 424 (42.5) 84.6%), and were married (743 or 74.4%). A quarter (255 Muslim 547 (54.8) or 25.6%) of the respondents cohabited with their female Catholic 5 (0.5) Protestant 19 (1.9) partners without formal marriage. Nearly all (987 or Other 3 (0.3) 98.9%) were currently living with their female spouses Type of union and 94 (9.4%) were in polygamous marital unions. About Married 743 (74.4) half of the respondents owned radios (569 or 57%) and Living together 255 (25.6) mobile phones (451 or 45.2%), (see Table 1). Currently living with spouse Yes 987 (98.9) No 11 (1.1) Similarly, the median age of male FGD participants was How many years have you been 39 years (IQR: 32 to 40 years) with two-thirds 17(68%) together of them being farmers and educated. All female FGD Less than 1 10 (1.0) participants were in the age range of 15 to 45 years, most 1-5 312 (31.3) (16 or 84.1%) were educated, more than half (11 or 6-10 244 (24.4) More than 10 432 (43.3) 57.8%) were housewives, and more than one-third (6 or Age in years at first marriage 31.6%) were farmers (see Table 2). 12-19 192 (19.2) 20-24 423 (42.4) 25-34 331 (33.2) 35 or more 52 (5.2) Do you have another marriage Yes 94 (9.4) No 904 (90.6) Ever attended formal school Yes 843 (84.6) No 154 (15.4) Educational status Up to grade 4 173 (20.5) Grade 5 to 8 457 (54.3) Grade 9 to 10 166 (19.7) Preparatory 29 (3.4) Preparatory plus 17 (2.0) Occupation Farmer 934 (93.4) Government employee 22 (2.2) Merchant(trader) 18 (1.8) Student 4 (0.4) Daily laborer 20 (2.0) Number of rooms in your house 1 451 ( 45.2) 2-3 487 (48.8) More than 3 60 (6.0) Possession of household/personal goods Radio and tape-recorder 206 (20.6) Radio 569 (57.0) Mobile phone 451 (45.2) Television(TV) 53 (5.3) No TV, radio, tape, or mobile phone 161 (16.1)

Ethiop. J. Health Dev. 2014;(Special Issue 1) Magnitude and factors that affect males’ involvement in deciding partners’ place of delivery in Tiyo 9

Table 2: Socio-demographic characteristics of In this study, male involvement is defined as decisions respondents who participated in FGD in Tiyo, Arsi made by men in choosing the place of delivery for their Zone female partners. This was ascertained by asking who Variable Respondents n (%) decided the place of delivery for the last pregnancy. The Age in years study showed high (903 or 90.4%) male involvement in Male deciding the place of delivery regardless of the place of 25-34 9 (36) 35-44 6 (24) delivery. The involvement was relatively higher among 45+ 10 (40) men whose spouse delivered at health facilities (Figure Type of union 1). In this study, 260 (26%) men responded that their Female spouses delivered at health facilities (hospital or health Married 18 (94.7) center) and the majority (725or 72.6%) responded that Not married 1 (5.3) their spouses gave birth at home (Figure 2). Among Educational status respondents, whose spouses gave birth at health facilities, Male most (252 or 97%) of them accompanied their spouses to Not educated 8 (32) the health facilities at the time of delivery (Figure 3). Primary level school 4 (16)

Secondary level school and 13 (52) above Male FGD participants agreed that attending ANC is Females important and one male group believe that permission Not educated 3 (15.7) from the husbands was needed to start ANC. As for place Primary level school 3 (15.7) of delivery place, most male FGD participants identified Secondary level school and 13 (68.4) home as the best place for giving birth. This finding is above similar to that of the quantitative study. Most male FGD Occupation participants were not able to identify danger signs Males (symptoms) related to pregnancy or delivery. In one male Farmer 17 (68) group, all agreed that pregnancy and childbirth are not Small business 3 (12) Teacher 1 (0.4) associated with dangerous health problems. The female Not working 4 (16) groups also could not adequately identify the dangerous Females health problems. Farmer 6 (31.6%) Housewife 11 (57.8) Self-employed 1 (5.3%) Daily laborer 1 (5.3%)

Figure1: Male involvement in deciding their spouses’ place of delivery in the last pregnancy by place of respondent’s spouse’s delivery place, Tiyo Wored a, January 2012

Ethiop. J. Health Dev. 2014;(Special Issue 1) 10 Ethiop. J. Health Dev.

hospital 3% 17%

health center 9% Yes health post No 1%

Home 73% 97%

Figure 2 : Spouse’s delivery place for the last Figure 3: Male partners accompanying their spouse pregnancy, Tiyo Woreda , January 2012 to facility during delivery

In this study, there was no statistical significant significantly higher in involvement in selecting the place difference in the median age of males who were involved of delivery compared to those who were not. Male in decision making and those who were not. Upon binary partners, whose spouses gave birth of their last pregnancy logistic regression, the odds of respondents, whose at a health facility (OR=2.10, 95%CI: 1.15- 3.85), joint spouses delivered their last baby at health facilities family income (OR=4.06, 95%CI, 1.63-10.1), joint (OR=2.20, 95%CI: 1.22-3.94), those whose family decision making on going for ANC service (OR=3.61, income came from both partners (OR=4.25, 95%CI:1.77- 95%CI, 1.52-8.57), and ownership of radio and tape- 10.2), those who decided jointly on ANC service uptake recorder (OR=1.77, 95%CI, 1.20-2.85) remained (OR=3.61,95%CI:1.52-8.57), and those with a radio and statistically significant in multivariate logistic regression tape-recorder (OR=1.77, 95%CI:1.20-2.85) were (Table 3).

Table 3: Determinants of male involvement in Tiyo Woreda, Arsi, 2012 (n=999) Variab le Male Involvement COR (CI) AOR (IC) Yes No Place of delivery of spouses last pregnancy Health facility 246 14 2.20 (1.22, 3.94)* 2.10 (1.15, 3.85)** Home or health post 657 82 1.0 1.0 Family source of income Own and spouse’s earnings 13 282 4.25 (1.77, 10.2)* 4.06 (1.63, 10.1)** Own earnings 73 566 1.52 (0.74, 3.12) 1.28 (0.60, 2.72) Others’ (relatives) 10 51 1.0 1.0 Decision maker on ANC attendance during last pregnancy Self with spouse jointly 723 56 3.83 (1.66, 8.81)* 3.61 (1.52, 8.57)** Spouse 81 16 1.50 (0.58, 3.89) 1.41 (0.53, 3.78) Self 68 16 1.26 (0.48, 3.26) 1.46 (0.43, 3.14) Other 27 8 1.0 1.0 Radio and Tape -recorder ownership Yes 196 10 2.39 (1.22,4.70)* 1.77 (1.20,2.85)** No 703 86 1.0 1.0 **Statistically significant.

Additional factors affecting male involvement in decision preventing skilled delivery service use. A 40-year-old making about spouses’ place of delivery identified male discussant said: through FGDs included the influence of TBAs in favor of home delivery and cultural influences preventing facility “From my clan, there are traditional believes that delivery. The male FGD participants unanimously ruled prohibit women from visiting health facilities. In my out religious belief or cost of services as factors opinion, my relatives are not willing to allow pregnant

Ethiop. J. Health Dev. 2014;(Special Issue 1) Magnitude and factors that affect males’ involvement in deciding partners’ place of delivery in Tiyo 11 women to visit health facility due to poor awareness of Among women, who gave birth at the health facilities, the benefits of health facilities”. this study showed a higher level (96.9%) of males accompanying their spouses compared to 43% in other Female FGD participants identified lack of awareness of studies (9, 17). The degree of male involvement ranges benefits of delivering in health facilities, cultural beliefs, from an absolute male decision to joint decision making, lack of privacy at health facilities, exposure to long as seen in a study in Tanzania (11). This survey identified procedures, lack of support from male partners, and lack important factors that have a significant influence on of money as factors that force pregnant women to give male partner involvement. The respondents’ spouses’ birth at home despite the fact that health facilities are place of last delivery was a factor; respondents, whose clean and provide better services. spouses delivered at a health facility, were twice as likely to be involved in selecting the delivery place as In contrast to the survey findings, male FGD participants respondents whose spouses delivered at home mentioned that young, educated males were more (OR=2.10,95% CI:1.15-3.85). This may be because of involved in selecting health facility as a place of delivery male partners’ awareness of the benefits of using than those who are elderly and less educated. They facilities. This finding is similar to a study of northern stated: Uganda that found that spouses’ prior skilled delivery service attendance is significantly associated with male “There is a problem of accepting maternal-related involvement at subsequent skilled ANC service (17). education by those male partners who have no education. This study showed that males, whose spouses utilized Those who are educated visit health facilities. There is no professional delivery care, provided emotional and difference in visiting health facilities because differences informational support to their partners during delivery. in economic status”. For example, a female FGD participant stated:

The female FGD participants identified the influence of “Those men who have a good reputation and acceptance in-laws’ preference for local TBAs for labor and delivery in communities are usually good in supporting their attendance over health facilities. The female FGD spouses to go for health facility ANC and delivery discussants expressed that male partners, who are services .” respected by the community members are involved in selecting health facilities for delivery. This may be because of relatively better behavioral, economic, and educational status of males preferring Female FGD discussants explained: health facilities for its better outcome, as found in a study in Bangladesh (18). “Those men who have good reputation and acceptance in communities, are usually good in supporting their The odds of male involvement in this decision in couples spouses to go to health facilities for ANC and delivery with a joint source of family income coming from both services. There are no socio-cultural barriers hindering partners is four times greater than those with an income males from participating in supporting their spouses to from only one of them (OR=4.06, 95%CI: 1.63-10.1). attend facility-based delivery”. This may be due to the fact that additional sources of income gave male partners the power to be able to cover Moreover, both male and female discussants stressed the related costs. It may also be due to male partners’ attitude importance of the health extension workers in improving towards economically supportive spouses, making them male involvement in selecting the health facility for more responsible and accountable as women with own delivery services. income practices their right. This study is similar to a study from Uganda that, showed males, whose spouses Discussion have formal occupation (employed) were significantly The study findings revealed a high proportion of male involved for their spouses’ birth preparedness and ready involvement (90.4%). This proportion is even higher to result to health facilities in the case of complication among respondents whose spouses gave birth at health readiness (BPCR) at health facilities (where identifying facilities (95%). Among respondents, whose spouses health facility for delivery service is among BPCR) than gave birth at home, 89% of males were involved in those with spouses of casual workers or housewives (9). selecting the home as the place for delivery. The male and female FGD participants could not identify most of Decision on ANC visit was a factor for male the danger signs associated with pregnancy, delivery, and involvement; respondents who decided jointly on the immediate postpartum period. attending ANC service for recent pregnancy were more than 3 times (OR=3.61, 95%CI: 1.52-8.57) more likely to This study showed a relatively higher level of male be involved in decision compared to respondents who did involvement than did other studies in Africa. In one study not decide jointly for ANC attendance. This shows male in Uganda, only about half (56%) of male partners were partners’ commitment and open discussion between involved in deciding spouses’ place of delivery (16). partners. It may be due to male partner’s knowledge on

Ethiop. J. Health Dev. 2014;(Special Issue 1) 12 Ethiop. J. Health Dev. the benefit of using health facilities use influencing for recorder were statistically significant after multivariate involvement also for delivery place. logistic regression. Among the respondents whose spouses gave birth at health facilities, 98.3% of them said This study showed that male partners, who own radios they were confident in the quality of the delivery service and tape-recorders were significantly more involved in provided at the facilities, but 16.5% of them said their deciding their spouses’ place of delivery place (OR=1.77, spouse waited for a long time to get the service after they 95% CI: 1.20-2.85) than those who did not. This may be arrived at the health facilities. due to the exposure to mass media and the new health information and knowledge from it and thus taking to Conclusions and Recommendations new practices. As an important health issue, maternal and There was high proportion of male partner involvement newborn health is among the main current topics of in deciding the location of delivery, both when the health education broadcasted over the radio. Hence, preference was for health facility delivery and for home exposure to radio makes male partners more likely to delivery. Empowering women, especially in terms of understand the extent of potential problems, which economic self-sufficiency, will increase male partners’ causes them to be involved in selecting health facilities involvement positively for facility use. Girls’ education for delivery. This finding is similar to a study conducted and targeting women with income-generating businesses in Uganda where ownership of household assets like a are among the mechanism of empowerment. Low levels radio was found to be correlated with a high level of SBA of knowledge and awareness of dangerous health uptake involving spouses (16). In another study also from problems associated with pregnancy and delivery, in- in Uganda, women, who resided in a place longer than a laws’ attitudes, and cultural practices are barriers to male one-hour walk or more than 5km from the nearest health involvement in selecting facility deliveries. facility, were less likely to use SBAs (16, 17). However, in this survey, distance to facilities from the residence The following were missed opportunities in ANC service (by foot) had no influence on male involvement. delivery for SBAs to include male partners and should be Educated women had better pregnancy outcomes than an area of focus: joint counseling of partners on danger uneducated ones, as the forms usually selected health signals, benefit of health facility use, birth preparedness, facilities for delivery service in consultation with their and complication readiness. There should be male partners (13). However, education level of male partners targeted health education and other behavior changing had no influence on male involvement in using skilled activities based on studies that identify cultural, maternity services (9, 17). Similarly, this survey showed traditional, and social barriers at the local levels. Mass no relationship between male involvement and male media should target males using tailored messages. partners’ or their spouses’ level of education. Awider study on male involvement in delivery service Paradoxically, the male and female FGDs in this study uptake should be conducted to understand other factors showed the level of male partner education influenced that are not addressed in this study. male partner involvement in deciding in favor of delivering at health facilities. References 1. WHO, UNICEF, UNFP and World Bank. Maternal The FGD result showed that husbands, who have respect mortality in 2005, Geneva; WHO, 2000. and recognition in their communities chose the health 2. Philippi V, Ronsmans C, Campbel O, Graham J.W, facilities for the place of delivery. A similar qualitative Mills A, Borgh JI, et al . Maternal health in poor study in Bangladesh showed male partners with good countries: The broader context and a call for action. social relationships and social norms and who consider The Lancet 2006; 368((9546):1535-41. taking care of their partners as a social norm were 3. Hogan MC, Foreman KJ, Naghavi M, Ahn SY, involved in selecting the place of delivery (18). This Wang M, Makela SM, et al. Maternal Mortality for study’s FGDs found that it was necessary for the come to 181 countries, 1980-2008: A systematic analysis of obtain male partners’ permission to attend skilled progress towards Millennium Development Goal 5. maternity services, which is similar to another study in The Lancet 2010; 375(9726):1609 – 1623. Ethiopia (19). 4. Ronsmans C, Graham JW. Maternal mortality: Who, when, where, and why. The Lancet 2006; The strength of the study is believed to be its 368(9542):1189-200. methodology with an adequate sample size and its being 5. Adegoke AA, Van den Broek N. Skilled birth supplement by a qualitative study. The limitations attendant lesson learnt. BJOG 2009; 116 include not having other studies with a similar (supplement):1033-30). methodology to compare it to. 6. Central Statistical Agency [Ethiopia] and ICF International. Ethiopia demographic and health This study found that jointly earned partners’ family survey 2011. Addis Ababa, Ethiopia and Calverton, income, joint partners’ decision making about attending Maryland, USA, 2012. ANC services, delivery at the health facilities for the previous pregnancy, and ownership of a radio and tape-

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7. Federal Ministry of Health (FMOH), Ethiopia. 14. Carter A. Factors that contribute to the low uptake of Health Sector Development Program IV. Addis skilled care during delivery in Malindi, Kenya Ababa; FMOH, 2010. (2010). Independent Study Project (ISP) Collection. 8. Berhane Y. Male involvement in reproductive Paper 821 [cited 2013]; Available at: URL: health . Ethiop J Health Dev 2006; 20 (3):135-136 . http://digitalcollections.sit.edu/isp_collection/821 9. Kakaire O, Kaye DK. Osinde MO. Male 2010. involvement in birth preparedness and complication 15. Warren C. Care seeking for maternal health: readiness for emergency obstetric referrals in rural Challenges remain for poor women. Ethiop. J. Uganda. Reproductive Health 2011; 8:12. doi: Health Dev 2010; 24 Special Issues 1:100-10 10.1186/1742-4755-8-12. 16. Kabakyenga JK, Ostergren PO, Turyakira E, 10. Mpembeni RNM, Killewo JZ, Leshabari MT, Pettersson KO. Influence of birth preparedness, Massawe SN, Jahn A, Mushi D, et al. Use pattern of decision-making on location of birth and assistance maternal health services and determinants of by skilled birth attendants among women in south- skilledcare during delivery in Southern Tanzania: western Uganda. PLoS ONE 2012; 7(4): e35747. Implications for achievement of MDG-5 targets. doi:10. 10.1371/journal.pone.0035747. BMC Pregnancy Childbirth 2007; 7:29. doi: 17. Tweheyo R, Konde-Lule J, Tumwesigye N, Sekandi 1086/1471-2393-7-29. J. Male partner attendance of skilled antenatal care 11. Magoma M, Requego J, Campbell OM, Cousens S, in peri-urban Gulu District, Northern Uganda. BMC Filippi V. High ANC coverage and low skilled Pregnancy and Childbirth 2010; 10:53 attendance in a rural Tanzanian district: A case for doi:10.1186/1471-2393-10-53. implementing a birth plan intervention. BMC 18. Story T.W., Burgard S.S., Lori R.J, Taleb F., Ali Pregnancy Childbirth 2010; 10:13. doi: A.N., Hoque E.D. Husbands’ involvement in 10.1186/1471-2393-10-13. delivery care utilization in rural Bangladesh: A 12. Baral YR, Lyons K, Skinner J, van Teijlingen ER. qualitative study. BMC Pregnancy Childbirth 2012 Determinants of skilled birth attendants for delivery 12:28. in Nepal, Kathmandu Univ Med J 2010; 8(31):325- 19. Biratu BT, Lindstrom DP. The influence of 32. husbands’ approval on women’s use of prenatal care: 13. Reuben K. Esena, Mary-Margaret Sappor. Factors Results from Yirgalem and Jimma Towns, associated with the utilization of skilled delivery Southwest Ethiopia. Ethiop J Health Dev 2006; services in the Ga East Municipality of Ghana Part 20(2):84-92. 2: Barriers to skilled delivery. International Journal of Scientific & Technology Research 2013; 2(8):195- 207.

Ethiop. J. Health Dev. 2014;(Special Issue 1)

Identification of factors associated with method shift from short-acting to long-acting methods of contraception in Amhara Region of Ethiopia

Habtu Atnafu 1, Yigzaw Dires 1, Amare Yeshambaw 1, Seid Ali 1, Wondimu Gebeyehu 1, Shewangizaw Bereda 1, Fikre Enqusilassie 2, Alemayehu Mekonnen 2, Adamu Addisse 2, Seifu Hagos 2

Abstract Backg round: Maternal and child death in developing countries is very high. Every year, an estimated 287,000 women die because of pregnancy-related complications worldwide. Family planning can prevent at least 25% of all maternal deaths by allowing women to delay motherhood, prevent unintended pregnancies, and avoid unsafe abortions family planning also protects women from sexually transmitted infections (STIs), including HIV, and allows them to stop childbearing when they have reached their reproductive goals. Objective: To identify factors associated with the change shift from short-acting to long-acting methods of contraception in Amhara Region of Ethiopia. Methods: A descriptive, cross-sectional, quantitative, facility-based study was carried out on 986 women of reproductive age who were currently using short-acting family planning methods in 17 health centers. Results: Out of the 986 short-acting family planning users interviewed, 18.2% explained their intention to shift from short-acting to long-acting methods of contraception. Among those had the intention to change to long-acting methods of contraception, 95.6 % preferred for implants. 4.4% of them had the intention to shift to the intrauterine contraceptive device (IUCD). The main reason for shifting to long-acting methods of contraception was delaying having their next child (88.9% of respondents). Fear of side effects and desire to have more children were mentioned by 69.3% and 16.6%, respectively, as the main reasons for not changing to long-acting methods. Conclusion and Recommendations : This study showed that a considerable proportion of women had the intention to change from short-acting to long-acting methods of contraception. Having information about long-acting methods and not planning to have children in the future were found to be the main factors in the intention to change from short- acting to long-acting methods. We recommend providing of comprehensive family planning counseling and services by health workers and health extension workers and strengthening behavioral change interventions to change negative attitudes at the community level. [ Ethiop. J. Health Dev. 2014; (Special Issue 1):14-19]

Introduction childbearing when they have attained their reproductive Ethiopia is one of the countries with the highest goals. By spacing births, family planning can prevent an maternal mortality ratio, estimated at 676/100,000 live average of one in four infant deaths in developing births and the lifetime risk of maternal death is 1 in 14 countries. Adequate birth spacing can also improve the (1). Additionally, contraceptive coverage is very low survival of the next older brother or sister (3). and reported at 29% among currently married women. The demand for contraception among currently married Most family planning users in Ethiopia prefer to use women is also high; the unmet demand for short-acting family planning methods. According to the contraception is reported at 25%. In the study area, the Ethiopian Demographic and Health Survey (EDHS) Amhara region, the contraceptive prevalence rate 2011 report, short-acting family planning methods (CPR) and total fertility rate (TFR) are 33.9% and accounted for 23.1% of use among the total modern 4.2%, respectively (2). contraceptive users. Similarly, in Amhara region, the magnitude of short-acting family planning methods use Family planning can prevent at least 25% of all maternal is 28%. On the other hand, the prevalence of use of deaths by allowing women to delay motherhood, prevent long-acting family planning (LAFP) methods is 4.3% unintended pregnancies, and avoid unsafe abortions. It (4% implant and 0.3% IUCD) (2). also protects women from sexually transmitted infections (STIs), including HIV, and allows them to stop

1Integrated Family Health Program, P.o.Box 1841, Bahir Dar, Ethiopia, Habtu Atnafu E-mail [email protected] , P.O. Box 1841; 2Addis Ababa University, School of Public Health, Addis Ababa, Ethiopia. Identification of factors associated with method shift from short-acting to long acting contraception 15

A study done elsewhere in Ethiopia among married Study sites were selected proportionally according to the women revealed that 67% of women were currently number of backup service providing health centers in using at least one family planning method and most each zone. A lottery method was then used to select the obtained the methods from the public health sector. study health centers in each zone. The required number Short-acting methods such as pills and injectables, were the most commonly used methods. Family planning of clients was allocated proportionally to each health practice was significantly associated with willingness to center according to the client flow taken from the sample use long-acting or permanent FP methods in the future health centers prior to the data collection period. Study and with spousal attitudes about family planning (4). participants were selected by using a systematic sampling Educational status was positively associated with higher technique. Every other short-acting family planning user awareness, favorable attitude, and practice of family was included in the study until the required sample size planning (5). was obtained.

Studies in the US and England indicated that in the choice of a long-acting method, the potential for Data were collected by using a structured questionnaire forgetting to take short-acting family planning methods which was translated from English to Amharic and back was an important factor in utilization long-acting family to English to ensure consistency. planning methods (6, 7). Similar studies from Turkey, Uganda, and England showed that provider bias, Data Collection: misconceptions and fears, gender, related power Seventeen female data collectors, who had diploma in relations, poor information, and incorrect beliefs about safety and side effects were reasons for poor utilization nursing and five supervisors with diplomas and above of long-acting and permanent family planning methods with experience in health related fields, were recruited. (8-10). Two-day training was provided to data collectors and Short-acting family planning use is high in Ethiopia, supervisors that focused on the objectives of the study, even though there are different methods and trained interview techniques, and contents of the questionnaire. health workers to provide the services. There are few studies examining the factors associated with the Data Analysis: relatively high usage of short-acting methods and the Data were coded and labeled with the SPSS statistical lower utilization of long-acting methods. Hence, this software version 15, and then entered into the pre-coded study tries to identify respondents’ main reasons for SPSS sheet. Data cleaning was done by running shifting from short-acting to long-acting methods of frequency tables in the SPSS to ensure uniformity with contraception in Amhara region. hard copy and its completeness.

Methods Data were compiled and summarized by using tables and Study Design: graphs. Odds ratio with 95% confidence intervals were A descriptive cross-sectional quantitative facility-based calculated using bivariate and multivariate logistic study was carried out. regression to assess associations between the independent

and the dependent variables. Study Area and Period : The study was done in five zones of Amhara Region: Results East Gojjam, North Gondar, South Gondar, North Wollo The majority (88.7%) of the respondents were married. and Waghimera. Seventeen health centers were selected The average family size per household was found to be among the 34 LAFP backup service health centers. The 4.4. Five hundred twenty-eight (53.6 %) respondents study was carried out in January 2012. were illiterate, 162 (16.4%) could read and write, and 95 (9.6 %) had above grade 10 schooling. The majority Sample Size and Sampling: (43.7%) were housewives and 23.5% were farmers. Sample size was determined using a single proportion formula. The following assumptions were used to Of the 986 mothers, 863 (87.5 %) were using inject able calculate the sample size: Magnitude of method shift was contraceptives, followed by pills (16.2%) at the time of taken as 70% from a study done in Addis Ababa, 3% the study. margin of error, and 95% confidence interval. Adding 10% of non-response rate, the total sample size was 986. Seven hundred thirty-nine (74.8%) said that the choice was made by themselves. Spouse’s and friends’ Ethiop. J. Health Dev. 2014;(Special Issue 1) 16 Ethiop. J. Health Dev. involvement in the choice of family planning method health workers, 15.7% from health extension workers, were 9.3% and 1.9%, respectively. Fifty-one respondents and 34.3% had information from other sources such as (5.2%) replied that health professionals (health workers spouse, friends, neighbors, and other people. and health extension workers) chose the method for them. One hundred eighty respondents (18.2%) had the intention to change from short-acting to long-acting Among the total respondents, 800 (81%) replied that they methods. Among the 180 respondents who wanted to had ever heard about long-acting methods of shift to long-acting methods of contraception, 68.9% contraception. Four hundred and sixty-four (58%) had preferred Implanon, 24.4% preferred Jadelle, and 4.4% information on Implanon compared to other methods. preferred IUCD (Figure1). Regarding the source of information: 41.8 %heard from

100 90 80 68.9 70 60 50 40 24.4 30 20 4.4 2.3 10 0 Implanon Jaddele IUCD Others Figure 1: Respondent’s preference for long-acting methods of contraception, Amhara Region, January 2012

Of those who stated a desire to change, the main reason Table 1: Intention and reasons given for method given for changing from short-acting to long-acting changing from short-acting to long-acting methods of methods of contraception was delaying having their next contraception, Amhara Region, January 2012 child (160 o r88.9%). Reasons for not changing to long- Characteristics Number Percent acting methods of were: fear of side effects (69.3%) such Intention to change N=986 Yes 180 18.2 as headache, interference with workload, irregular No 806 81.8 vaginal bleeding, and a desire to have more children Type of FP to change N=180 (16.6%) (Table 1). Implant 172 95.5 IUCD 8 4.5 Five hundred and two (50.8%) respondents said using Reason for intention to change N=180 long-acting methods of contraception for a long time Spacing 160 88.9 could have health risks. Seven hundred thirty-four Fear of side effects of the current (74.3%) said using long-acting methods will cause health method 20 11.1 problems during pregnancy and delivery, and 202 Reason for not to change N=795 Desire for more children 132 16.6 (20.4%) responded that it may cause infertility. Fear of side effects 552 69.4 Service unavailability 13 1.6 Two hundred seventy-three (27.7%) replied that some Fear of procedure 47 5.9 long-acting family planning methods of contraception Spouse/family pressure 26 3.3 like IUCD could cause uterine problem. On the other Peer pressure 4 0.5 hand, 100 (10.2%) women responded that long-acting Service free 4 0.5 methods of contraception could reduce women’s sexual Other 17 2.1 desire.

Ethiop. J. Health Dev. 2014;(Special Issue 1) Identification of factors associated with method shift from short-acting to long acting contraception 17

In the bivariate analysis, socio-demographic variables Respondents’ perception of not having health risks when such as education, income, family size, and occupation using long-acting methods for a longer time was found to did not have a statistically significant association with the be positively associated with intention to use with COR intention to change from short-acting to long-acting (95%CI = 2.74 (1.94, 3.87)). Those respondents who methods of contraception. believed that using long-acting methods would not cause Those who had ever heard about long-acting methods health risks were 2.74 times more likely to use them than were 1.93 times more likely to use the methods COR those who expected them to cause health risks. (95%CI = 1.93 (1.18, 3.12)) than those without such In the multivariate analysis, among the respondents’ information. A plan not to have children in the future had conditions of knowledge and perception characteristics, a positive and statistically significant association with a ever having heard about long-acting methods no, plan to intention to use long-acting methods of contraception have children sometime in the future, and a belief that with COR (95%CI = 1.62 (1.17, 2.24)). using long-acting contraception would not cause health There was no significant statistical difference between problems remained statistically significantly associated respondents’ expectation of health problems during with the intention to use them. In their order they are pregnancy and delivery and their intention to use long- significantly associated with intention to use long-acting acting methods COR (95%CI =1.09 (0.76, 1.57)). methods of contraception with an adjusted AOR (95%CI = of 2.31(1.40, 3.81), 1.93(1.37, 2.72) and 2.58 (1.73, 3.83)) (Table 2).

Table 2: Factors associated with intention to use long-acting family planning methods, Amhara, January 2012. Characteristics Number Intention to use LAFP Methods COR (95% CI) AOR (95% CI) Education Illiterate 92 1 Primary school completed 48 0.77 (0.51, 1.17) Secondary and above 40 0.78 (0.48, 1.24) Family size 1-4 105 1 5 and above 75 1.15 (0.83, 1.6) Ever heard about LAFP Yes 159 1.93 (1.18, 3.12) 2.31 (1.4, 3.81) No 21 1 1 Plan for having children in the future Yes 97 1 1 No 83 1.62 (1.17, 2.24) 1.93 (1.37, 2.72) Expectatio n of any health problem Yes 56 1 No 124 2.74 (1.94, 3.87) 2.58 (1.73, 3.83) Using LAFP causes sterility Yes 30 1 No 150 1.35 (0.88, 2.07) Using LAFP causes permanent health problem Yes 56 1 No 124 2.41 (1.59, 3.64) 1.65 (1.00, 2.72) Using LAFP could cause cancer Yes 22 1 No 156 1.21 (0.74, 1.97)

Discussion A considerable proportion of women had the intention to Many previous studies had shown that women’s change from short-acting to long-acting methods of education is an important predictor of the use of long- contraception. Information about long-acting methods of acting methods of contraception, as it increases contraception and limiting births were the main factors awareness and decision-making abilities (5, 13). In this influencing intention to the change from short-acting to study, however, education was not found to be long-acting methods. significantly associated with the intention to method for Ethiop. J. Health Dev. 2014;(Special Issue 1) 18 Ethiop. J. Health Dev. choosing long-acting methods of contraception. A References possible explanation for this is the similar educational 1. Population Action International (FAI). How family level of respondents. Respondents’ family size was not planning protects the health of women, men and associated with the change to long-acting methods. children . 2006. 2. Central Statistics Authority (CSA) and ORC Marco.

Ethiopian Demographic and Health Survey (DHS). The findings of the EDHS 2011 and those of our study on 1996: Addis Ababa, 2005. the use of long-acting methods of contraception in 3. Barbara S. Family Planning Saves Lives, Third Amhara region are different. The difference may be, in Edition. Washington DC; USA, 1996. this study, respondents were short-acting of using of 4. International Nursing Research (INR). Family methods during the interview period and the findings planning practice and related factors of married from EDHS 2011 were collected from main women of women in Ethiopia. Seoul; Korea. 2010. reproductive age. 5. Ismail S. Men's knowledge, attitude and practices of

family planning in North Gondar. The intention to change to long-acting methods among Ethiopia Med J 1998; 36(4):261-71. women who are currently using short-acting ones was 6. Grimes D. Forgettable contraception. Family Health lower than in a similar study done in Rwanda (16). The International, Research Triangle Park, NC; USA, difference may be due to socio-demographic differences 2009. between the family planning users in the two countries. 7. Rai K, Gupta S, Cotter S. Experience with Implanon The current study’s findings also differed from those of a in a Northeast London family planning clinic. study done in Addis Ababa (17). Different study periods Eur J 2004; 9(1):39- and the study set-ups may be the reasons for the Contraceptive Reprod Health Care. 46. differences in the results. 8. Finger W. Method choice involves many factors.

Network . 1994 Dec; 15(2):14-7. Consistent with other studies done in different places, 9. Nalwadda G, Mirembe F, Byamugisha J, Faxelid E. perception of health problems during pregnancy and Persistent high fertility in young people recount delivery, a plan to have children in the future, and having obstacles and enabling factors to the use of information about long-acting methods were statistically contraceptives. BMC Public Health 2010 Sep 3; significant factors(15). 10:530. 10. Glasier A, Scorer J, Bigrigg A. Attitudes of women in Scotland to contraception: A qualitative study to This study attempted to answer questions related to the explore the acceptability of long-acting methods. J use of long-acting methods in Ethiopia. Hence, we Fam Plann Reprod Health Care 2008 Oct; believe the study adds to the limited amount of 34(4):213-7. information available in our country. 11. Balaiah D, Naik DD, Ghule M, Tapase P. Determinants of spacing contraceptive use among This study was facility-based and the respondents were couples in Mumbai: A male perspective. J Biosoc current users of family planning services who came to the Sci 2005 Nov; 37(6):689-704. 12. China. Zhang XJ, Wang GY, Shen Q. Current status health facility. Therefore, the study findings may not be of contraceptive use among rural married women in generalizable to women in the community, which is a Anhui Province. BJOG 2009; 116(12):1640-5. limitation of the study. 13. Tuladhar H, Marahatta R. Awareness and practice of family planning methods in women attending gynecology outpatient clinics Nepal Medical College Teaching Hospital. 2008; Conclusion Nepal Med Coll J 10(3):184-91. In conclusion, the intention to change to long-acting 14. Weldegerima B, Denekew A. Women's knowledge, methods of contraception was considerably high. preferences, and practices of modern contraceptive Information on long-acting methods perception of not methods in Woreta, Ethiopia. Res Social Adm Pharm having risks, and a positive attitude towards long-acting 2008; 4(3):302-7. methods were the main reasons for changing to the long- 15. Chigbu B, Onwere S, Aluka C, Kamanu C, Okoro O, acting methods. Feyi-Waboso P. Contraceptive choices of women in rural Southeastern of Obstetrics and Gynecology, Abia State University Teaching Hospital Aba, Proving comprehensive family planning counseling and Nigeria. Niger J Clin Pract. 2010;13(2):195-9. services by health can providers and health extension 16. Dhont N, Ndayisaba GF, Peltier CA, Nzabonimpa A, workers and strengthening behavioral change Temmerman M, van de Wijgert J. Improved access interventions to change negative attitudes at the increases postpartum uptake of contraceptive community level are recommended. implants among HIV-positive women in Rwanda.

Ethiop. J. Health Dev. 2014;(Special Issue 1) Identification of factors associated with method shift from short-acting to long acting contraception 19

The European Journal of Contraception and Reproductive Health Care 2009; 14(6):420-5. 17. Argina H, Lukman HY. Norplant implants in Ethiopia. Gandhi Memorial Hospital, Addis Ababa. East Afr Med J 1997; 74(4):258-62.

Ethiop. J. Health Dev. 2014;(Special Issue 1)

Magnitude and predictors of skilled delivery service utilization: A health facility-based, cross-sectional study in Tigray

Tesfaye Gebru 1, Desta Gebre-Egziabher 1, Kelali Tsegay 1, Brhane Hadera 1, Mesfin Addisse2, Worku Tefera 2, Adamu Addisse 2,Seifu Hagos 2

Abstract Background : A skilled birth attendant for every pregnant woman during childbirth is the most crucial intervention for improving maternal and child health. Ethiopia has a maternal mortality ratio of 676 per 100,000 live births. The majority of births are delivered at home and the proportion of deliveries assisted by a skilled attendant is very low at 10%. Objective : To assess utilization of skilled delivery service and associated factors. Methodology : A facility-based, cross-sectional survey was taken in 35 randomly selected health centers in March 2012, targeting women who had delivered 12 months prior to the survey and had come for EPI services for their children under the age of one. A total of 911 women were interviewed using a pretested, structured questionnaire. Result: Among the study subjects, 46.8% used skilled delivery service, and mothers’ level of education, knowledge on delivery complications, family monthly income, and distance to health facility were significantly related to the used of the delivery service. Women with at least primary education were two times more likely (AOR=2.19 and 95%CI=1.33-3.61) to utilize skilled delivery service. Women who have knowledge of delivery complication were greater than three times more likely to have skilled delivery (AOR =3.577 and 95%CI=1.50-11.121). Women with monthly family income greater than ETB 500 were two times more likely (AOR=2.438 and 95%CI= 1.256-4730) to use skilled delivery service. Women whose had to travel to a health facility less than an hour were four times more likely to have a skilled birth attendant (AOR=4.01, 95% CI=2.30-7.00). Conclusion and Recommendations: This study revealed a very high proportion of mothers had skilled birth attendant (46.8%). Knowledge about delivery complications, education level, household income, and distance from health facility were linked to skilled-delivery attendance of mothers. Convenient availability and accessibility of health facilities and promotion of antenatal care follow-up with maternal and child health information particularly on delivery complications or danger signs were vital for the increased utilization of a skilled delivery attendance. [ Ethiop. J. Health Dev. 2014; (Special Issue 1):20-25]

Introduction Skilled birth attendance refers to professionally trained Ethiopia has a maternal mortality ratio (MMR) of 676 per health workers with the skills necessary to manage a 100,000 live births. Moreover, the majority of births are normal delivery and diagnosis incase complications. This delivered at home without any supervision by skilled usually refers to a doctor, midwife or health officer and health workers. National estimates indicate that only 10 nurse. Skilled attendants must be able to manage a percent of deliveries were assisted by health normal labor and delivery and recognize complications professionals. In the study area, Tigray region, only 10.8 early on. Should a problem arise, the skilled attendant percent of deliveries were assisted by skilled service should be able to perform essential interventions, start providers (4). Therefore, this study was carried out to treatment, and supervise the referral of the mother to the measure the proportion of women who delivered with the next level of care, if necessary (1, 2). assistance of a skilled birth attendant and to identify factors that influence utilization of the service. The World Health Organization (WHO) estimates that globally only 43 percent of women have access to skilled Methods care during deliveries and the rest are exposed to Study Setting : unskilled delivery service (2). The organization has The study was done in Tigray region, which is one of the identified lack of access to skilled delivery services as a northern regional states of Ethiopia, administratively hindrance to efforts in improving the health of women divided into seven zones, 46 woredas, and 710 kebeles especially during delivery. In this regard, the United with a total population of 4,541,724. In the region, there Nations has identified the necessity to reduce maternal are one referral, five zonal and six district hospitals, mortality by three quarters by 2015. Even though this about 200 health centers, including recently upgraded objective of the Millennium Development Goals has been ones, and 590 health posts (5).The Tigray Region IFHP well promoted, relatively little progress given the (MMR operates in all woredas of the southern and eastern zones, 676/100.000) has been made so far (3). in seven sub-cities of Mekelle Special Zone, in nine

1Integrated Family Health Program, P.O. Box 428, Mekelle, Ethiopia; 2Addis Ababa University, School of Public Health, Addis Ababa, Ethiopia. Magnitude and predictors of skilled delivery service utilization 21 woredas in the central zone and two woredas of the recommended to use a health professional during their southeast zone of the region. These 35 woredas consist of delivery. 546 kebeles and 2,945,034 people (65 percent of the region’s population). The people who live here may Actual Delivery Practices : receive primary health care services in 127 health centers The proportion of SBA was 46.8%, which is a very high (HCs) and 320 health posts (HPs) (5). in comparisons with national and regional averages with

most (95.4%) being attended by skilled health Study Design and Sampling : professionals. This high proportion of SBA is attributed We used a facility-based cross-sectional study design. to by the referral linkage of the primary health care unit The study took place in March 2012. (PHCU) and the work of the health development army.

The sample size was calculated using the single- Table 1: proportion formula with the following assumptions: Selected socio-demographic characteristics skilled birth attendant (SBA) utilization in the region: of respondents in Tigray Region, March 2012, (n=911) Variable Count Percent 10.8% (4); 95% level of confidence; 3% margin of error; Age of respondent and with a design effect of 2. The total sample size 15-19 88 9.7 calculated was thus 911. 20-24 272 29.9 25-29 221 24.3 We used simple random sampling technique to select 30-34 171 18.8 HCs. All mothers who gave birth 12 months prior to the 35+ 158 17.3 study period and, who did visit the selected health Marital Status centers’ child immunizations service during the data Married 834 92.1 collection period, were included. Data were collected Divorced 51 5.6 Single 17 1.9 using a pre-tested, structured questionnaire written in the Widowed 4 0.4 local language (Tigrigna). We used trained health Religion professionals as data collectors. Orthodox 877 96.4 Muslim 32 3.5 Data Analysis : Catholic 1 0.1 Data were entered in MS Access. We used SPSS version Women educational status 16 for data analysis. Bivariate analysis was employed to Illiterate 426 46.9 determine crude associations and multivariate regression Non-formal Education 45 5 analysis to determine predictors while adjusting for other Grade 1-4 105 11.6 factors. Grade 5-8 181 19.9 High school (9-10) 102 11.2 Results Preparatory (11-12) 50 5.5 Socio-demographic characteristics : Family size For this study, a total of 911 women were interviewed 3 256 28.1 with 100% response rate. The mean (SD) age of 4-6 466 51.2 respondents was 27.04 (6.29 years). The majority of the ≥7 188 20.7 respondents were illiterate (53.2 percent), married (92.1 Women occupational status percent) and followers of Orthodox Christianity (96.4 Housewife 508 55.8 Government percent).The mean (SD) family size of the study Employee 48 5.3 respondents was 4.8+ 1.922 (Table 1). Private employee 311 34.1 Unemployed 24 2.6 Obstetric History and ANC Experience : Students 11 1.2 The mean (SD) mothers’ age at first pregnancy was Family mo nthly income (Birr) ≤250 280 31.5 19.34+2.99 years. Among the respondent mothers, 50% 251-500 308 34.7 of them had 2-4 live births, 30 percent a single live birth, >501 300 33.8 while the rest had >5 live births. The mean (SD) parity was 2.98 (1.89). Nine out of ten of the respondents Reasons given by those who delivered at home include attended antenatal care (ANC) at least once, while a usual practice, 166 (34.2%); feel more comfortable, 21 greater proportion (52.8 percent) attended at least four percent; missing expected date of delivery, 19.2%; close times for the last pregnancy (Table 2). All of the mothers attention from relatives, 15.5% ;“I dislike the service in (99.9%) were informed to deliver in a health facility the health facility”, 2.3%; and long distance and during their ANC follow up, while 89.7% of them were unwelcoming health workers, 8.8%. In contrast, reasons for institutional delivery include better service in the Ethiop. J. Health Dev. 2014;(Special Issue 1)

22 Ethiop. Health Dev. health facility, 351 (82.4%); better outcomes from health courtesy and respect offered, measures taken to ensure institution, 224 (52.6%); poor outcomes from home privacy and comfort, and professional competency and delivery, 202 (47.4%); informed to deliver in a health skill of the health worker (ranging from 99.1-97.9%). facility, 146 (34.3%); and facility being close to where I Table 3: Predisposing, enabling, and reinforcing live, 26 (6.1%). factors in utilization of SBA in Tigray Region, March 2012, ( n=426) Table 2: Obstetric history and ANC experience of the Variables Frequency Percent respondents in Tigray Region, March 2012, (n=911) Availability of HF which Variable s Count Percent gives SBA Live births Yes 797 87.6 1 263 29.1 No 37 4.1 2-4 445 49.2 Don’t know 76 8.4 ≥5 195 21.5 Heard about referral to ANC Visit higher health facilities Yes 829 91 Yes 780 90 No 82 9 No 87 10 ANC visits Husband preference for 1 4 4.8 delivery attendant 2-3 350 42.4 Delivery with health 4 342 41.4 professional 621 69.3 >4 94 11.3 Delivery without health Age at fir st pregnancy professional support 290 30.7 ≤20 549 60.4 Family preference for 21-29 353 38.8 delivery attendant ≥30 6 0.7 Delivery with health Received information on professional 543 60.7 pregnancy and delivery- Delivery without health related complication professional 368 39.3 Yes 790 95.5 No 36 4.4 Socio-demographic factors influencing utilization of skilled delivery service: Binary logistic regression was Mothers’ knowledge, attitude on places of delivery and applied to determine predictors of utilization of skilled perceptions of family, relatives, and community during delivery services. The result showed that socio- the last delivery: Among mothers who delivered at a demographic variables, women’s education, and monthly health facilities (HF), nearly all 424 (99.8%) had good family income were significantly associated with SBA attitude towards SBA. Out of the total 829 (91%) women (p-values<0.05). Women with secondary education and who visited a HF for ANC during their pregnancy only monthly income greater than 500 ETB were more likely half, 426 (51.4%), of them had attended skilled delivery to utilize SBA [OR=3.173 (95%CI: 1.151-8.742)] and and about two-thirds of the respondents, 602 (66.1%), [OR=2.438 (21.256-4.734)] respectively (Table 4). were knowledgeable on the danger signs that can occur during pregnancy. Nine of the ten, 780 (90%), Obstetric factors influencing utilization of skilled respondents had information that HFs referred mothers to delivery service : When the obstetric factors, ANC visit, higher HF in case of emergency during delivery. Two- age at first pregnancy, presence of pregnancy and thirds of the respondents expressed that their husbands delivery complications (danger signs), distance to HFs preferred the use of SBAs (69.3%), while 3 out of 5 that provide skilled delivery service, and knowledge reported other family members and relatives (60.7%) about referral to higher HFs were adjusted, women’s preferred SBAs. However, a number of husbands, 275 knowledge of delivery complications and distance to HF (30.7%) and family members and relatives, 352 (39.4%) remained significantly associated; women, who knew still preferred to use traditional birth attendants (TBA) or about delivery complications or danger signs are three family members and neighbors (Table 3). times more likely to utilize SBA [AOR=3.577 95%CI=1.150-11.121)]. While ANC visit was highly Client satisfaction with institutional delivery: Among the associated during bivariate logistic regression, no clients who facilities to delivery (n=426), there was high significant association with SBA was observed during satisfaction with the time the health worker spent with multivariate regression when the interest was to find the the client, cleanliness of the delivery place, cleanliness of

frequency of ANC visits (Table 4). instruments and equipment used by the health worker, the

Ethiop. J. Health Dev. 2014;(Special Issue 1) Magnitude and predictors of skilled delivery service utilization 23

Table 4: Socio-demographic factors influencing utilization of skilled delivery service in Tigray Region, March 2012, (n=426) Variables Utilization of SBA Crude ORs (95%CI) AORs (95%CI) P-value Yes No Educational status Non-formal education 16 29 1 1 0.018** 1-4 50 55 1.648 (.802-3.387) 1.372 (.538-3.502) 5-8 92 89 1.874 (.953-3.685) .971 (.402-2.343) 3.173 (1.151- 9-10 77 25 5.582 (2.613-11.925)** 8.742)** >10 42 8 9.516 (3.601-25.144)** 2.698 (.645-11.291) Occupation Farmer 89 168 1 Government employee 41 7 11.056 (4.765-5.654)** 1 0.314 Private /petty trade 44 18 4.614 (2.518-8.455)** 1.219 (.294-5.058) Housewife 226 282 1.513 (1.109-2.064)** 2.955 (.974-8.967) Student /unemployed 25 10 4.719 (2.170-10.264)** 1.117 (.571-2.184) 2.046 (.582-7.195) Family monthly income <=250 121 159 1 1 0.026** 251-500 107 201 .700 (0.501-0.967)** 1.394 (.726-2.677) 2.438 (1.256- >=501 188 112 2.206 (1.562-3.076)** 4.730)** Family size <=3 145 111 1 1 0.651 4_6 217 249 2.531 (1.714-3.783)** 0.633 (.085-4.694) >=7 64 124 1.689 (1.187-2.402)** 0.484 (.085-2.772) Total number of live births 1 149 114 2.941 (1.991-4.343)** 2.072 (.256-16.784) 2_4 213 232 2.066 (1.446-2.950)** 2.987(.483-18.479) >=5 60 135 1 1 0.414 Number of ANC visit 1 8 32 1 1 0.139 2_3 343 349 3.931 (1.786-8.653)** 4.559 (.758-27.440) >=4 67 30 8.933 (3.682-21.675)** 6.877 (.996-47.463) Distance to HF 4.017 (2.302- <=1 hour 82 274 5.731 (4.221-7.781)** 7.009)** >1 hour 319 186 1 1 0.000** Knowledge on referral Yes 382 398 3.952 (2.284-6.838)** 1.586 (.566-4.444) No 17 70 1 1 0.38 Knowledge of pregnancy danger signs mentioned None 109 198 1 1 0.206 One 137 118 2.109 (1.502-2.961)** 1.736 (0.866-3.479) Two – three 154 149 1.877 (1.357-2.597)** 1.702 (.851-3404) More than three 26 20 2.361 (1.260-4.425)** .727(.198-2.671) Knowledge of delivery danger signs mentioned None 62 157 1 1 0.044** One 125 101 3.134 (2.114-4.647)** 1.044 (.465-2.341) 2.163 (1.002- Two – three 188 189 2.519 (1.763-3.598)** 4.665)** 3.577 (1.150- More than three 51 38 3.399 (2.035-5.675)** 11.121)**

Discussion health development army. The study revealed that From the results of this study, the proportion of utilization of SBA is very close to the national level in institutional delivery was far more common than the urban settings (49.8%), while it is less than that of Addis country’s average. This high proportion of SBA use Ababa (82.3%) it is more than that of Dire Dawa attributes contributed by the referral linkage of the (39.7%). However, the finding on the primary health care unit (PHCU) and the role played the utilizationSBAfrom this study is by far higher than the

Ethiop. J. Health Dev. 2014;(Special Issue 1)

24 Ethiop. Health Dev. national average for rural settings, which is 4.1%, representativeness of total population, and those of a according to the Central Statistics Authority (4). cross-sectional nature, havinga one-time view and weaker evidence, and others of a cross-sectional From the result of this study, better service in HF, better nation. outcomes from institutional delivery, information . The study falls short of providing client-provider received from health professionals to deliver in HF, and interaction to address the effect of skilled delivery the closeness of HF were the reasons mentioned by the attendant on utilization, especially from the respondents for using skilled delivery service. A study provider’s perspective. done in Addis Ababa also revealed that the reasons for . It would have been more appropriate to use non- preferring to deliver in services in HFs were the high health worker data collectors to avoid the possibility quality of service, followed by a closeness of health of bias. institution, and the approach of good health workers (6). Conclusion and Recommendations The significant associated factors from the study Based on the study being facility-based it can be including women’s education, family monthly income, concluded that institutional delivery in Tigray is far distance to HFs, and knowledge about possible delivery common than the country’s average.Distances to HFs and complication or danger signs were consistent with Women’s knowledge about delivery complications or findings of other similar studies (4, 6). danger signs are the two most relevant factors affecting SBA in Tigray. Women’s educational status and family Women with secondary and above educational level were monthly income are also found to be important predictors more likely to use to go for skilled delivery. The reason for SBA utilization. Based on this, the following for education being such an important a predictor for recommendations are made: utilization of skilled delivery services could be explained . Access to HFshould be improved for better by the power education gives women tomake decisions utilization of skilled delivery services. about their own health (4, 7). . Health professionals should promote ANC follow up and provide information on the problems of Those who know the presence of delivery complication pregnancy and delivery complications; health were more likely to use SBA. Similarly, a study from promotion on the importance of SBA at every child Ghana also stated that 64 percent of women who died of birth for every woman who came to HF in general delivery complications had sought help from a traditional and at ANC visit in particular. birth medication going to HF (8). Studies from India and . Community health activities such as community Iraq showed that lack of recognition of seriousness of awareness programs, home visit, and community- health problems related to delivery complications based delivery systems must focus on those who are wereamong the reason for not using available health care illiterate, who do not get MCH information and who that accounts for half of maternal deaths (9). A do not come for ANC. community-based study done in Addis Ababa on . Community-based (health-facility linked) maternal mortality also found that one of the reason for prospective cohort studies to identify predictors of not having ANC was a low level of awareness about the SBA are recommended for the future. problems of child bearing (6). With regard to family influence on SBA, the husbands and family members of a Acknowledgements large proportion of women in this study did not We are grateful to the Addis Ababa University School of recommend the women go to HF for SBA, at least as a Public Health for the technical assistance provided during first preference. the process of the research design and implementation. We are also grateful for the staff members from woreda With regard to access to HFs, those who were traveling health offices and health centers who diligently less than an hour (walking) were four times more likely participated in the data collection process. Thank you to to utilize SBA. Improving access to services has been a the women who participated in the study and to the primary strategy for increasing health-service utilization Integrated Family Health Program (IFHP) for its in developing countries, including Ethiopia (HSDP IV). financial support to conduct the research. Several studies have stressed the importance of access to HF as a factor affecting their utilization. Studies indicate References that one of the reasons for choosing not to use available 1. World Health Organization (WHO)> Statement. SBA is poor access to HFs because of long and poor road Geneva; WHO, 1999. conditions both in dry and wet seasons, as well as the 2. World Health Organization (WHO). Reduction of shortages of vehicles. maternal mortality: A joint WHO/UNFPA/UNICEF/World Bank Report. Limitations Geneva; WHO, 2011. . As a facility-based cross-sectional study it shares the limitation of both facility-based studies, lack of

Ethiop. J. Health Dev. 2014;(Special Issue 1) Magnitude and predictors of skilled delivery service utilization 25

3. Federal Ministry of Health (FMOH), Ethiopia. 15. Yared M. Patterns of maternal care service Health and health related indicators for 2008/2009. utilization in southern Ethiopia: Evidence from a Addis Ababa; FMOH MOH, 2010. community and family survey. Ethiop J Health Dev 4. Central statistics Authority (CSA), Ethiopia. 2003; 17(1):27-33. Demographic and health survey, 2011. Addis Ababa; 16. Esena RK, Sappor MM. Factors associated with the CSA, 2012. utilization of skilled delivery services in the Ga East 5. Tigray Regional Health Bureau (TRHB), Ethiopia. Municipality of Ghana Part 2: Barriers to skilled Tigray health profile 2011. Mekele; TRHB, 2012. delivery. International Journal of Scientific & 6. Fantahun M, Olwit G, Shamebo D. A determinant of Technology Research 2013 ; 2(8): 195-207. antenatal care attendance and preference of site of 17. Baral YR, Lyons K, Skinner J, van Teijlingen ER. delivery in Addis Ababa. Ethiop J Health Dev 1992; Determinants of skilled birth attendants for delivery 1(2): 17-22. in Nepal. Kathmandu Univ Med J 2010; 8(31):325- 7. Safe Motherhood. Safe motherhood non-technical 32. fact sheet: Maternal Mortality. New York, NY: 18. Fikrie AA, Demissie M. Prevalence of institutional Family Care International, 2001. delivery and associated factors in Dodota Woreda 8. UNFPA. Delivering into good hands. Maternal (district), Oromia Regional State, Ethiopia. mortality updates. UNFPA; 2004. Reproductive Health 2012; 9:33. doi:10.1186/1742- 9. Ayele B. Factors influencing utilization of skill birth 4755-9-33. attendant delivery? [MPH Thesis]; Addis Ababa 19. Gebeyehu A, Worku A, Fantahun M. Availability University, 2005. and components of maternity services according to 10. Berhane Y. Women’s health and reproductive providers and users perspectives in North Gondar, outcome in rural Ethiopia. [MPH Thesis]; Jimma Northwest Ethiopia. Reproductive Health 2013; University, 2008. 10:43. doi:10.1186/1742-4755-10-43. 11. Mesfin M, Farrow J. Determinants of antental care 20. Satoko Y, Sophal O, Susumu W. Determinants of utilization in Arsi Zone, Central Ethiopia. Ethiop J skilled birth attendance in rural Cambodia. Trop Med Health Dev 1996; 10(3):171-178. Int Health 2006; 11(2):238–251. 12. Family Care International, Inc. Skilled Care during 21. Kristen C, Mark H, Marleen T. Low use of skilled Childbirth: Policy Brief, 2002. attendants’ delivery services in rural Kenya. J Health 13. Hussein, J, Bell J, Nazzar A, Abbey M, Adjei S, Popul Nutr 2006; 24(4):467-471. Graham W. The skilled attendance index: Proposal 22. Mabel NA. Factors contributing to the low for a new measure of skilled attendance at delivery. utilization of skilled delivery in Ano South District, Reprod Health Matters 2004; 12(24):160-70. Ashanti Region, Ghana. November 2008 [cited 14. Stock R. Distance and the utilization of health 2013]; Available at: facilities in rural Nigeria. Soc Sci Med 1983; 17: URL: http://hdl.handle.net/123456789/115 . 563-570.

Ethiop. J. Health Dev. 2014;(Special Issue 1)

Utilization of Prevention of Mother to Child transmission (PMTCT) services and factors that affect knowledge and service uptake among pregnant women attending antenatal care in East Hararge Zone of Oromia Reginal State

Megersa Gobena 1, Tariku Nigatu 1, Belay Yimam, Adeba Tasisa, Daniel Wagaw, Fufa Birmechu, Daniel Keba 3, Ahmed Ali 4, Wubegzier Makonnen 4, Adamu Addisse 4, Seifu Hagos 4

Abstract Background: Prevention of Mother-to-Child Transmission of HIV (PMTCT) which is provided as part of antenatal care (ANC) is one of the most effective strategies in HIV prevention. However, there is a huge descrepancy between levels of ANCattendance and utilization of PMTCT services in Ethiopia. Objective: This study aims at assessing the utilization of PMTCT services and factors that affect knowledge and service uptake among women attending ANC in East Herarghe Zone of Oromia Region. Methodology: A cross-sectional, facility-based study was conducted in March 2012 among 605women following ANC in16 randomly selected health facilities (15 health centers and 1 district hospital). The sample size was equally divided among the health facilities and every third pregnant woman was selected for an exit interview. Quantitative data were collected and analyzed statistically. Descriptive statistics including frequencies and associations using appropriate statistical tests were applied. Multiple logistic regression technique was also used to control for confounding variables. SPSS version 17 was used for data analysis. Results: The response rate was 99.5%. Of the total women, 76% and 79% of them never attended school and were from rural areas, respectivelly. The average duration of pregnancy was 6.32 months (+1.86). Utilization of PMTCT was 72.8%. Previous ANC visits and prior Information on HIV transmission routes were associated with knowledge on both MTCT and PMTCT. However, reading IEC materials and occupation of respondents were associated only with knowledge on MTCT while school attendance was limited only to PMTCT. Utilization of PMTCT was also related to prior information on HIV transmission routes and knowledge on MTCT and PMTCT. Conclusion: Knowledge on MTCT and PMTCT directly or indirectly depended on having the necessary information.Utilization of PMTCT was also suboptimal compared to the national direction of providng the service to all ANC attendants. [Ethiop. J. Health Dev. 2014; (Special Issue 1):26-35]

Introduction implementation of Prevention of Mother to Child The World Health Organization (WHO) in its 2011 Transmission (PMTCT) intervention (5, 6). epidemic update indicated that at the end of 2010, an estimated 34 million people were living with Human To prevent the transmission of HIV from mother to baby, Immuno-Deficiency Virus (HIV) globally, including 3.4 WHO promotes a comprehensive strategic approach that million children aged below 15 years. Of the 2.7 million includes four components; namely: the prevention of new new HIV infections in 2010, 390, 000 of them were infections in parents, avoiding unwanted pregnancies in among children less than 15 years down from 500,000 in HIV infected women, preventing transmission of HIV 2001 (1). The majority of the HIV infections in children from an infected mother to her infant, and care, treatment occur due to mother to child transmission of the virus. A & support for mothers living with HIV, their children and woman infected with HIV can pass the virus to her baby families. It primarily includes the provision of during pregnancy, labor and delivery, or breastfeeding antiretroviral prophylaxis to the mother to reduce the risk even though the rate of transmission varies (2). of MTCT (Mother to child transmission) through rigorous PMTCT programs (7). Mother-to-child transmission of HIV is associated with up to 90% of all infections in children up to six years (3, According to a 2010 WHO report significant progress 4). It is estimated that without any intervention about has been made in the area of PMTCT during the past 35% of children born to HIV infected mothers will be several years. In 2009, 53% of the estimated HIV- infected with the virus. This percentage has reportedly infected pregnant women worldwide received at least been reduced to levels as low as 2% in developed some antiretroviral (ARV) drugs to prevent HIV countries with the advent of antiretroviral drugs and the transmission to their children. However, there are still

1Integrated Family Health Program; E-mail [email protected] or mgobena @ifhp-e.org; 2East Hararge Zone Health Office; 3Oromia Regional Health Bureau; 4 School of Public Health, Addis Ababa University. Utilization of PMTCT services and factors that affect knowlede and service uptake in East Hararge Zone 27 challenges and huge gaps to scale up PMTCT Another study conducted in Southern Ethiopia among interventions (8). 1,325 ANC attending women indicated that all interviewed pregnant women were aware of HIV/AIDS Several papers studied the determinants of PMTCT transmission, but only 60.7% were aware of the risk of services uptake. Evidence suggests that factors operate at MTCT. The proportion of women who were fully both the micro and macro levels in getting PMTCT knowledgeable on the timing of MTCT was 11.5%. services. Micro-level factors include health seeking Women’s knowledge on MTCT was associated with behavior (9, 10), adherence (11, 12), home delivery and maternal education and occupation (e. g. being non-attendance of Antenatal Care (ANC) (13), lack of government employee). knowledge & stigma and discrimination (14), trust in the hospital (15), while the macro level includes factors such Whereas, there was a negative association between as underlying inequities in healthcare quality (16), health knowledge of women on MTCT and absence of services and health policy (10) and distance and information provision on MTCT/PMTCT by ANC transport cost (16). service provider, lack of discussion on ANC and HIV/AIDS (22). A study conducted in South Africa indicated that utilization of PMTCT (that is the provision of ARV to It is believed that there are common and contextual HIV positive women, facility-based delivery, and factors that affect utilization of service utilization. The adherence to "take-home" ART), depended on HIV objective of this study was therefore to assess utilization counseling by health care staff, physical access to a of PMTCT services and factors that influence health facility, family and community support, stigma, knowledge, and service uptake among pregnant women delivery preference (facility vs. Home) and infant feeding attending antenatal care in East Hararge Zone of Oromia preferences (17). Another study conducted in Uganda Region. showed that access to PMTCT services (family planning, HIV counseling and testing, and delivery at a health Methods facility) was influenced by various socio-economic Study Area, Study design and Study Population : factors that include, among others, wealth quintiles, age, The study was conducted in East Hararge Zone of institutional practices and educational level. In addition, Oromia region in March 2012. It has an area of 24,247.66 the study showed that joint decision making (husband square kilometers and is subdivided into 19 Woredas and and wife) was also associated with higher HIV test 3 town administrations. The zone’s total projected uptakes during ANC (18). population was over 3.3 million in 2012 based on the 2007 population and housing census (23). The estimated Although Ethiopia has made progress in the provision of number of pregnant women in the zone was 126,824 services to reduce MTCT by increasing the proportion of during the same year. The zone has 4 district hospitals, women getting tested and knowing their results through 116 health centers and over 530 health posts. Except the expanding rapid testing at many PMTCT sites, there is health posts, the rest of the health facilities provide still a huge gap between the national ANC coverage PMTCT services. (34%) and the percentage of women who were counseled, tested and received the test result during ANC The study employed facility-based cross sectional study (11%). The national skilled birth attendance also stands design. Quantitative data were collected from pregnant at 10% (19). women attending ANC through exit interviews conducted at randomly selected health facilities in the A study in North West Ethiopia that involved 400 Zone. The source population for the study included all pregnant women showed that acceptance of provider pregnant women who were attending ANC at the health initiated HIV testing and counselling is facilities in the Zone. The study population included 82.5%.Acceptance of provider-initiated HIV testing and those pregnant women who came for ANC visits in the counselling was also associated with number of ANC selected health facilities. visits, residence (urban vs. rural), comprehensive knowledge on HIV, partners reaction for HIV positive Sample Size and Sampling Technique : results, knowledge on PMTCT, maternal age and The sample size for this study was calculated using the educational level (20). standard formula for single population proportion; 2 2 n = [(Z α/2 ) x p (1-p) ]/ d , where: A multilevel model study in Tigray region of Ethiopia n = the sample size for the study, that involved 220 HIV positive post-partum women Zα/2 = the value of Z at the 95%CI, attending child immunization services at 50 health p = the proportion of women who utilize facilities in 46 districts showed that uptake of PMTCT PMTCT during ANC, services among mothers was 79%. The study found out d = the margin of error. that mothers who delivered at a health facility were 18 times more likely to receive PMTCT services, compared Taking the following statistical assumption: to mothers delivering at home (21). Zα/2 = 1.96, Ethiop. J. Health Dev. 2014;(Special Issue 1) 28 Ethiop. J. Health Dev.

p = 50%, those questionnaires which were found to be grossly d = 0.05, incomplete or inconsistent were replaced by interviewing Non-response rate = 5% and another client. Microsoft Access software was used for A design effect = 1.5. entering the data into the computer. Then, the entered Accordingly, the final sample size was calculated to be data were further cleaned by running frequencies. 605 ANC attendants. To select the study subjects, first, 15 health centers and Data was exported to and analyzed using SPSS version one hospital (a total of 16 health facilities) were 17 . Data cleaning and outlier checks were done. randomly selected from the lists of health centers and Descriptive statistics including frequencies and hospitals in the zone using a lottery method. Then, the associations using appropriate statistical tests were used total sample size was equally divided among the 16 during analysis. Odds ratios with 95% CI were used to health facilities. The sample size was equally divided measure the strength of associations. Multiple logistic based on the observation that ANC and PMTCT service regression was used to control for confounding factors utilization in each selected health facilities was not during multivariate analysis. significantly different from one other. Ethical Considerations : Then, the average number of ANC visits per day in the Before the commencement of the study, ethical clearance selected health facilities was calculated to be 10 clients. was secured from the Oromia Regional Health Bureau. Based on the calculated average, it was estimated that Permissions were obtained from zonal and local 120 pregnant women come for ANC visits during the authorities. During the training of supervisors and data data collection period (12 days). Then, dividing the collectors, ethics of data collection was addressed in expected number of visits in 12 days (120 women per detail emphasizing on voluntary participation, privacy facility) by the number of pregnant women allocated to and confidentiality. All interviews were conducted in be sampled from each facility (605/12=37.8) places where the privacy of the study participants was approximately yields 3, which is the sampling fraction maintained. Each participant was briefed about the for the study. Thus, every third ANC client, irrespective purpose and importance of the study before the initiation of the number of previous ANC visit, was selected for of interviews. The respondents were told that their exit interview until the required sample size was participation was entirely voluntary and that whether they achieved. choose to participate or not, all the services they would normally receive will continue. Written consent was Operational Definitions : obtained from all respondents before the interview was In this study, a respondent is said to be knowledgeable on conducted. MTCT if she mentioned the three routes of MTCT; namely: during pregnancy, delivery and breastfeeding. Results Similarly, if a respondent answered that there is at least Socio-demographic Characteristics : one way to prevent MTCT of HIV, then, she is regarded A total of 605 pregnant women who come for ANC visit as knowledgeable on PMTCT. Negative attitude towards were invited and 602 of them volunteered to participate HIV/AIDS is defined in this study as the presence of at in the study making the response rate 99.5%. The mean least one stigmatizing attitude towards HIV/AIDS (+ SD) and median (IQR) ages of the respondents were: victims. Finally, a respondent is said to have used 25.7 (+5.52) and 25 (9) years, respectively. The majority PMTCT services if she was counseled and tested in her of the respondents, 476 (79%), came from rural areas. previous or current ANC visit for the current pregnancy. 571 of the participants (95.2%) of them were Muslims and 597(99.2%) were currently married. School Data Management and Analysis : attendance among the respondents was very low in the Quantitative data were collected from the selected health study area. About 455(76%) of all the respondents never facilities using a standard structured questionnaire from attended formal schooling (Table1). the Ethiopian Demographic and Health Survey, 2011 (EDHS, 2011) (19). Additional questions were included Reproductive Characteristics: to enrich the questionnaire. The questionnaire was first The average duration of pregnancy for the study translated into Afan Oromo. Then, it was back translated participants was 6.32 months (SD=1.86). Four hundred into English by a different translator to check for nine (67%) of the women had children with an average of consistency of the translation.Then, it was pretested 2.95 children (SD=2.45). Health Extension Workers outside the study area and relevant corrections were were the primary source of information about ANC. Of made. the total study participants, 279 (46.3%) of them came for their first ANC. Three hundred sixty three (60.3%) of Sixteen data collectors (new nursing BSc graduates), who the women reported that they either wanted to delay the had been recruited in collaboration with the Zonal Health current pregnancy or did not want it at all. Four hundred Office, were trained for two days before deployment. fifty seven (75.9%) of them had intentions to use family Completed questionnaires were checked for planning in the future. Of all the women that came for completeness and consistency by the investigators and Ethiop. J. Health Dev. 2014;(Special Issue 1) Utilization of PMTCT services and factors that affect knowlede and service uptake in East Hararge Zone 29

ANC, 450 (74.8%) and 438 (72.8%) of them were tested Factors Affecting PMTCT Knowledge among ANC and counseled for HIV, respectively (Table 2). Attendants: Close to 7 in 10 of the respondents did not know about Table 1 : Socio-demographic characteristics of women the possibility of MTCT prevention. During bivariate attending ANC, East Hararge analysis, except religion and husbands’ literacy, all the Factors Number Percent other variables were associated with knowledge on Age of respondents PMTCT. During multivariate analysis, only three 17-25 222 24.5 variables namely; school attendance [AOR (95%CI) 26-34 492 54.2 =2.013 (1.148, 3.529)], previous ANC attendance [AOR 35-43 161 17.8 (95%CI) = 1.775 (1.125, 2.801)] and prior information ≥44 32 3.5 Relationship to the sick child on HIV transmission routes [AOR (95%CI) Mother 876 96.6 =3.410(2.143, 5.426)] were found to be associated with Grandmother 19 2.1 knowledge on PMTCT (Table4). Others* 12 1.3 Educational Level Table 2: Reproductive and other characteristics of No formal education 485 53.5 women attending ANC, East Hararge Zone, March 1-4 238 26.2 5-8 160 17.6 2012, (N= 602) 9 and above 24 2.6 Characteristics Number % Marital status (n=602) Not currently married 34 3.7 Have Children Currently married 873 96.3 Yes 409 67.9 Religion No 191 31.7 Muslim 384 42.3 Missing 2 0.3 Christian 523 57.7

Occupation Source of info about ANC (n= Farmer 873 96.3 Self- knowledge 219 36.4 Merchant 118 13.0 HEW 255 42.4 Other** 25 2.8 VCHW 14 2.3 Number of live children Husband/partner 19 3.2 <5 544 60.0 Health worker 84 14.0 5 363 40.0 ≥ Other 1 0.2 Number of <5 childr en <3 847 93.4 Missing 10 1.7 ≥3 60 6.6 Number of ANC Visits +In walking distance 1st 279 46.3 *others includes father, grand mother and sister 2nd 141 23.4 **others includes daily labourer and employees 3rd 132 21.9 4th or above 45 7.5 Factors Affecting MTCT Knowledge among ANC Missing 5 0.9 Attendants: Pregnancy Wanted The majority, 341 (57 %) of the ANC attendants did not Yes, then 239 39.7 know that MTCT of HIV exists. During a bivariate Yes, but later 217 36.0 analysis, it was found that urban women, Christians, Not at all 146 24.3 those who attended formal education (elementary and Future Intension to us e FP above), who listened to radios, had previous ANC Yes 457 75.9 attendance, read IEC materials, had information on HIV No 144 23.9 transmission routes, whose husbands could read and Missing 1 0.2 write and those who earned their income from non- Tested for HIV farming sectors had at least 1.5 times more chance of Yes 450 74.8 knowing MTCT compared to the other groups. However, No 152 25.2 after controlling for potential confounding variables, Counseled for HIV Yes 438 72.8 previous ANC attendance [AOR(95%CI) = 1.552 (1.000, No 164 27.2 2.408)], reading IEC materials [AOR (95%CI) = 3.018 (1.403,6.4960], previous information on HIV transmission routes [AOR (95%CI)=2.109 (1.357,3.278)] and occupation of respondents [AOR (95%CI)= 2.369 (1.122,5.0010] were found to be associated with knowledge on MTCT (Table 3).

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Table 3: Factors that affect MTCT knowledge among women attending ANC, East Hararge Zone, March 2012 MTCT Knowledge Factors Crude OR (95% CI) Adjusted OR (95% CI) Know Do not know Residence (n=602) Rural 183 292 1 Urban 78 49 2.540 (1.699, 3.798) School Attendance (n=602) No 164 291 1 Yes 97 50 3.442 (2.328, 5.090) Religio n (n=602) Muslims 240 331 1 Christians 21 10 2.896 (1.339, 6.262) Listening to the radio (n=602) Non-listeners 148 261 1 Listeners 113 80 2.491 (1.755, 3.536) Previous ANC attendance (n=470) Did not attend 69 142 1 1 Attended 125 134 1.920 (1.317,2.799) 1.552 (1.000,2.408) Reading IEC materials (n=602) Did not read 181 317 1 1 Read 80 24 5.838 (3.572, 9.542) 3.018 (1.403,6.496)

Information on HIV transmission routes (n=496) Not informed 106 153 1 1 Informed 122 115 1.531 (1.073, 2.185) 2.109 (1.357,3.278) Husband’s literacy (n=602) Unable to read and write 122 216 1 Read, write and above 139 125 1.969 (1.418, 2.733) Occupation of respondent (n=602) Farmer 184 309 1 1 Non-farmer 77 32 4.041 (2.574, 6.343) 2.369 (1.122,5.001)

Attitude towards People Living With HIV/AIDS and provide care for a family member with HIV in their Factors Associated with It: households. One hundred three (17.1%) of the ANC clients had never heard of AIDS. One hundred twenty eight (25.8%) of Urban residence, school attendance, radio listening, 496 respondents, 260 (52.4%) of 496, 40 (8.1%) of 495, previous ANC attendance, reading IEC materials, respondents believed that HIV can be transmitted through respondents’ occupation and husbands’ education were food sharing, mosquito bite and witchcraft. While, 177 strongly associated with positive attitude towards (35.5%) of 498 believed that a healthy looking person HIV/AIDS victims during bivariate analysis. However, can’t have HIV. listening to radio [AOR (95%CI) =1.775 (1.1080, 2.844)], previous ANC attendance [AOR (95%CI) = One hundred sixty five (33.2%) of 497 women said they 1.958 (1.281, 2.992)], and reading IEC materials [AOR don’t buy fresh vegetables should they know that the (95%CI) = 3.754 (1.962, 7.984)] were found to be shopkeeper has HIV, 316 (63.5%) of 498 respondents associated with positive attitude towards HIV/AIDS after said they won’t keep secret if they know someone in the controlling confounding variables (Table 5). family has HIV, while 288 (52.5%) said they will not

Ethiop. J. Health Dev. 2014;(Special Issue 1) Utilization of PMTCT services and factors that affect knowlede and service uptake in East Hararge Zone 31

Table 4: Factors that affect knowledge on PMTCT among women attending ANC, East Hararge, March 2012 PMTCT Knowledge Factors Crude OR (95% CI) Adjusted OR (95% CI) Know Do not know Residence (n=602) Rural 139 336 1 Urban 53 74 1.731 (1.156,2.594) School Attendance (n=602) No 125 330 1 1 Yes 67 80 2.211 (1.505,3.247) 2.013 (1.148, 3.529) Religion (n=602) Muslims 178 393 1 Christians 14 17 1.818 (0.877,3.770) Listening to the radio (n=602) Non-listeners 115 294 1 Listeners 77 116 1.697 (1.184,2.432) Previous ANC attendance (n=470) Did not attend 51 160 1 1 Attended 102 157 2.038 (1.364,3.046) 1.775 (1.125,2.801) Reading IEC materials (n=602) Don’t read 143 355 1 Read 49 55 2.212 (1.437, 3.404) Information on HIV transmission routes (n=496)* Not informed 65 194 1 1 Informed 108 129 2.499 (1.709, 3.653) 3.410 (2.143,5.426) Husband’s literacy (n=602) Unable to read and write 99 239 1 Read, write and above 93 171 1.313 (.930,1.853) Occupation of respondent (n=602) Farmer 145 348 1 Non-farmer 47 62 1.819 (1.189, 2.785)

Utilization and factors that Affect PMTCT Service Except religion, radio listening, attitude towards Utilization among ANC Attendants: HIV/AIDS, and husbands education, all other variables Only 86 (14.3 %) of the women surveyed came to the plus the composite variables of MTCT and PMTCT health facilities for their first ANC during their first knowledge were entered in to a multiple logistic trimester. Two hundred sixty-two (43.5 %) came in their regression model and only three variables namely; prior second trimester. A substantial proportion, 254 (42.2 %), information on HIV transmission routes [AOR (95%CI) came during their last trimester. Overall, the utilization of = 2.601 (1.520, 4.450)], MTCT knowledge [AOR PMTCT among ANC attendants was 72.8% (438 of the (95%CI) = 2.096 (1.129,3.892) and PMTCT knowledge 602). [AOR (95%CI) = 2.659 (1.284,5.506)] were found to be associated with PMTCT service utilization (Table 6).

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Table 5: Factors that affect attitude toward HIV/AIDS victims among women attending ANC, East Hararge March 2012 HIV/AIDS Attitude Adjusted OR Factors Crude OR (95%CI) Positive Negative (95 %CI) Residence (n=549) Rural 148 283 1 Urban 72 46 2.993 (1.967,4.555) School attendance (n=549) No 127 280 1 Yes 93 49 4.184 (2.792,6.271) Religion (n=549) Muslims 206 315 1 Christians 14 14 1.529 (0.714,3.274) Listening to the radio (n=549) Non-listeners 114 253 1 1 Listeners 106 76 3.095 (2.142,4.474) 1.775 (1.108,2.844) Previous ANC attendance (n=433) Did not attend 52 141 1 1 Attended 110 130 2.294 (1.527,3.447) 1.958 (1.281,2.992) Reading IEC materials (n=549) Don’t read 147 299 1 1 Read 73 30 4.4949 (3.098,7.909) 3.754 (1.962,7.984) Occ upation of respondent (n=549) Farmer 150 296 1 Non-farmer 70 33 4.186 (2.647,6.618) Husband’s literacy (n=549) Unable to read and write 89 219 1 Read, write and above 131 110 2.930 (2.058,4.173) Information on HIV transmissio n routes (n=496)* Not informed 93 145 1 Informed 91 126 1.126 (.774,1.638)

Ethiop. J. Health Dev. 2014;(Special Issue 1) Utilization of PMTCT services and factors that affect knowlede and service uptake in East Hararge Zone 33

Table 6: Factors that affect PMTCT services utilization among pregnant women following ANC, East Hararge, March 2012 Factors PMTCT service utilization Crude OR (CI) Adjusted OR (95 %) Utilizers Non -Utilizers Residence (n=602) Rural 346 129 1 Urban 104 23 1.686 (1.028,2.765) School attendance (n=602) No 330 125 1 Yes 120 27 1.684 (1.057,2.681) Religion (602) Muslims 422 149 1 Christians 28 3 3.295 (0.987,10.998) Listening to the radio (n=602) Non-listeners 310 99 1 Listeners 140 53 .844 (.572,1.244) Previous ANC attendance (n=470) Did not attend 142 69 1 Attended 206 53 1.889 (1.245,2.866) Reading IEC materials (n=602) Don’t read 362 136 1 Read 88 56 2.066 (1.171,3.646) Information on HIV transmission routes (n=496) Not informed 193 66 1 1 Informed 207 30 2.360 (1.469,3.791) 2.601 (1.520,4.450) Husband’s literacy (n=602) Unable to read and write 251 87 1 Read, write and above 199 65 1.061 (.732,1.538) Occupation of respondent (n=602) Farmer 358 135 1 Non-farmer 92 17 2.041 (1.173,3.551) Attitude towa rds HIV/AIDS Negative 238 91 1 Positive 171 49 1.334 (.895,1.989) MTCT knowledge Don’t know 225 116 1 1 Know 225 36 3.22 (2.123,4.890) 2.096 (1.129,3.892) PMTCT Knowledge Don’t know 273 137 1 1 know 177 15 5.922 (3.364,10,425) 2.659 (1.284,5.506)

Discussion to reduce pediatric infection. According to a study, The WHO recommends and emphasizes that PMTCT is increasing contraceptive use to prevent unintended the most effective intervention in combating new HIV pregnancies in the general population (regardless of HIV infections among pediatrics (24). PMTCT is a status) prevents more HIV-positive births than does multifaceted intervention. It is not only just a way to stop increasing services that promote and provide nevi rapine vertical transmission of HIV but also to provide access to in ANC programs (27). treatment, care and support for women who would otherwise not get the chance to know their HIV status Of all the women included in the study, 72.8% of them (25). were tested and counseled for HIV during the current ANC visits. The HIV testing and counseling uptake in The primary sources of information about ANC for this study is low compared to the national direction of respondents in this study were health extension workers providing testing and counseling for all pregnant women (HEWs). This could be partly because majority of the coming for ANC to eliminate new pediatric infection by respondents (79%) were from rural areas and had access 2015 (28). It is also lower than the uptake of provider to HEWs. This is also in accordance with the priority initiated HIV testing and counselling reported in a study given to maternal health, child health and health in North West Ethiopia that involved 400 pregnant education by the Health Extension Program as part of the women. According to the study, 82.5% of the pregnant 16 program packages (26). women were willing to take HIV testing and counselling (20). Three fourth of the study participants expressed interest to use FP services in the future, which is a huge potential Ethiop. J. Health Dev. 2014;(Special Issue 1) 34 Ethiop. J. Health Dev.

More than half of the respondents (57%) did not have studies in Uganda and North West Ethiopia showed that knowledge on MTCT. This is similar with the finding of education and residence are associated with PMTCT a study conducted in Southern Ethiopia that reported service uptake (18, 20). 60.7% awareness level of MTCT among pregnant women (22). Close to 70% of the women reported that Limitations of the Study: they don’t know at least one method of PMTCT. This study is a cross-sectional study. Because of the However, compared to the 2011 EDHS (which indicates nature of the study design, establishing causal that 44% of women know that PMTCT exits), the relationship between the explanatory variables and the PMTCT knowledge in our study is lower (19). In outcome vartiables is difficult. As this study is a facility- addition, the fact that 70 % of the women did not have based study, selection bias may also occur. Since a knowledge on PMTCT as compared to 57% in MTCT comparatively less proportion of pregnant women in the might suggest that there are women who know the study area come to health facilities for ANC, women presence of mother to child HIV transmission without found and interviewed at health facilities may not be true knowing the possibility of prevention. representatives.As the study heavily depended on quantitative data and was not complemented by Previous ANC visits and prior information on HIV qualitative information from different sources, there transmission routes were associated with knowledge on could be information gap. Because all the data collectors both MTCT and PMTCT. However, reading IEC were health personnel, they might have influenced the materials and occupation of respondents were associated respondents’ answers, thereby creating some interviewer only with knowledge on MTCT while school attendance biases. was related only to PMTCT. Similarly, the study in Southern Ethiopia indicated that education, occupation Conclusions and Recommendations: and prior information on MTCT affected knowledge on Utilization of PMTCT services was suboptimal compared MTCT (22). Another study conducted in Hawassa town to the national direction of providing the services to all also showed that age, marital status and religion are ANC attendants. Knowledge on MTCT and PMTCT and neither associated with MTCT knowledge nor with service utilization of PMTCT directly or indirectly PMTCT knowledge. The study further indicated that depended on information and knowledge. Individual education is associated with both MTCT and PMTCT characteristics such as: occupation and school attendace knowledge. However, contrary to our finding, the same were also found to be important for having knowledge on study also reported that occupation has no association MTCT and PMTCT. It is, therefore, very important to with knowledge on MTCT (29). strenghten health information provision and broaden the channels of communication to reach wider audience to Generally speaking, misconceptions and discriminatory convey the needed information about PMTCT and impart attitudes towards HIV/AIDS victims were reported in the knowledge. Educating women and girls is also significant portion of the study participants. The 2011 important to improve not only PMTCT services uptake EDHS indicated that despite high level of awareness on but also to imporve the overall health of mothers and HIV/AIDS among women (with wide regional their children. variations), there were still wide misconceptions concerning HIV/AIDS among women (19). Radio Acknowledgements listening, IEC materials reading and previous ANC We would like to express our appreciation to USAID, attendance were found to be associated with positive Oromia Regional Health Bureau, participants of the study attitude towards people living with HIV/AIDS. This participants, data collectors and the East Hararge Health could be because all the three factors could serve as office. sources of information for the women to develop positive attitude towards people living with HIV/AIDS. References 1. UNAIDS. Global Report on the AIDS The PMTCT service utilization in this study was found to epidemic/2011 Geneva 2011; page = 22 [cited be 72.8%, which is much higher than the 14% reported in 2013]; Available at: URL: www.unaids.org . the 2011 EDHS (19). The difference could be partly due 2. World Health Organization. PMTCT strategic tothe increased emphasis on maternal and newborn health decision 2010–2015: Preventing mother-to-child as part of Ethiopia’s effort to meet the millennium transmission of HIV [cited 2014]; Available at: development goals. URL: www.who.int/hiv . 3. Deribe K, Wolde Michael K, Wondafrash M, Haile Utilization of PMTCT services was associated with prior A, Amberbir A. Disclosure experience and information on HIV transmission routes, knowledge on associated factors among HIV positive men and MTCT and PMTCT. This is similar to the study women clinical service users in southwest Ethiopia. conducted in North West Ethiopia which showed BMC Publ Health 2008; 8:81. utilization of PMTCT is associated with comprehensive 4. United Nations Joint Program on AIDS (UNAIDS). : knowledge on HIV (including MTCT) and knowledge on International center for AIDS care and treatment PMTCT (20). Contrary to the findings of this study, the programs (ICAP). Columbia University’s mailman Ethiop. J. Health Dev. 2014;(Special Issue 1) Utilization of PMTCT services and factors that affect knowlede and service uptake in East Hararge Zone 35

School of Public Health [cited 2013]; Available at: 18. Mbonye AK, Hansen KS, Wamono F, Magnussen P. URL: http://www.Unaids.org . Barriers to prevention of mother to child 5. Joint United Nations Program on HIV/AIDS transmission of HIV services in Uganda Journal of (UNAIDS) and World Health Organization (WHO). Biosocial Science 2014; 42(02);271-283. AIDS epidemic update. Geneva; UNAIDS/WHO, 19. Central Statistical Agency and ICF International. 2006. Ethiopia Demographic and Health Survey. Addis 6. Medley A, Garcia-Moreno C, McGill S, Maman S. Ababa: CSA; 2011. Rates, barriers and outcomes of HIV sero-status 20. Tilahun M, Degu G. Assessment of utilization of disclosure among women in developing countries: provider-initiated HIV testing and counselling as an implications for prevention of mother-to-child intervention for prevention of mother to child transmission programs. Bull World Health Organ transmission of HIV and associated factors among 2004; 82:299-307. pregnant women in Gondar Town, Northwest 7. Ethiopia Ministry of Health (FMOH). Guidelines for Ethiopia. BMC Public Health 2012; 12:226. prevention of mother-to-child transmission of HIV in 21. Lerebo W, Callens S, Jackson D, Zarowsky C, Ethiopia. Addis Ababa; FMOH, 2007. Temmerman M. Identifying factors associated with 8. World Health Organization. Towards universal the uptake of prevention of mother to child HIV access progress 2010 [cited 2014]; Available at: transmission programme in Tigray Region, Ethiopia: URL:. http://www.who.int/hiv/pub A multilevel modelling approach. BMC Health /2009progressreport/en. Services Research 2014; 14:181 9. Sprague C. A capabilities approach to understanding 22. Asefa A, Beyene H. Awareness and knowledge on HIV prevention and treatment for pregnant women timing of mother-to-child transmission of HIV and children in South Africa. [PhD Dissertation]: among antenatal care attending women in Southern University of the Wit Water Strand; 2009. Ethiopia: A cross sectional study. Reproductive 10. Delva W, Draper B, Temmerman M. Health 2013; 10:66. Implementation of single-dose nevirapine for 23. Federal Democratic Republic of Ethiopia Population prevention of MTCT of HIV: Lessons from Cape and Housing Census Commission. Summary and Town. SAMJ 2006; 96(8):708-9 Statistical Report of the 2007 population and 11. Mirkuzie AM, Hin deraker SG, Mørkve O. Housing Census-Population size by Age and Sex. Promising outcomes of a national program for the Addis Ababa; UNFPA, 2008. prevention of mother-to-child HIV transmission in 24. WHO: Antiretroviral drugs for treating pregnant Addis Ababa: A retrospective study. BMC Health women and preventing HIV infection in infants: Serv Res 2010; 10:267. towards universal access: recommendations for a 12. Balcha TT, Lecerof SS, Jeppsson AR. Strategic public health approach. Geneva; WHO, 2006. challenges of PMTCT program implementation in 25. Mirkuzie AH, Hinderaker SG, Mørkve O. Promising Ethiopia. JIAPAC 2011; 10:187. outcomes of a national program for the prevention of 13. Temmerman M, Quaghebeur A, Mwanyumba F, mother-to-child HIV Transmission in Addis Ababa: Mandaliya K. Mother-to-child HIV transmission in A retrospective study. BMC Health Services resource poor settings: How to improve coverage? Research 2010; 10:267. AIDS 2003, 17:1239-1242 26. Federal Ministry of Health (FMOH), Ethiopia. 14. Nguyen T, Oosterhoff P, Ngoc Y, Wright P, Hardon Health Extension Program (HEP) in Ethiopia profile. A. Barriers to access prevention of mother-to-child Addis Ababa; FMOH, 2007. transmission for HIV positive women in a well- 27. Best K. Family planning and the prevention of resourced setting in Vietnam. AIDS Res Ther 2008; mother-to-child transmission of HIV: A review of 5:7. the literature. Family Health International (FHI) 15. O’Gorman D, Nyirenda L, Theobald S. Prevention Working Paper Series. No. WP04-01. North of mother-to-child transmission of HIV infection: Carolina; FHI, 2004. views and perceptions about swallowing nevirapine 28. Federal Ministry of Health (FMOH), Ethiopia. The in rural Lilongwe, Malawi. BMC Public Health national strategic plan for elimination of mother to 2010; 10:354. child transmission of HIV. Addis Ababa; FMOH, 16. Jackson D, Chopra M, Doherty T, Colvin M, Levin 2013. J, for the Good start study group: Operational 29. Abajobir AA, Zeleke AB. Knowledge, attitude, effectiveness and 36 week HIV-free survival in the practice and factors associated with prevention of South African program to prevent mother-to-child mother-to-child transmission of HIV/AIDS among transmission of HIV-1. AIDS 2007; 21:509-516. pregnant mothers attending antenatal clinic in 17. Peltzer K, Skinner D, Mfecane S, Shisana O, Hawassa Referral Hospital, South Ethiopia. J AIDS Nqeketo A, Mosala T. Factors influencing the Clin Res 2013; 4:215. doi:10.4172/2155- utilization of prevention of mother-to-child- 6113.1000215. transmission (PMTCT) services by pregnant women in the Eastern Cape, South Africa. Health SA Gesondheid 2005;10:26-40. Ethiop. J. Health Dev. 2014;(Special Issue 1)

Assessment of health care seeking behavior of caregivers for common childhood illnesses in Shashogo Woreda , Southern Ethiopia

Bekele Demissie 1, Berhanu Ejie 1, Habtamu Zerihun 2, Zergu Tafese 1, Getu Gamo 3, Tilahun Tafese 3, Abera Kumie 4, Jemal Haider 4, Adamu Addisse 4, Seifu Hagos 4

Abstract Introduction: Improving families' care-seeking behavior can contribute significantly to reduce child mortality. Studying status of care-seeking behavior and associated factors helps to curb trends in child morbidity and mortality. Objective: To assess status of health care-seeking behavior of caregivers for childhood illnesses and associated factors. Method: Descriptive cross-sectional study design was employed in Shashogo District during January 2012. Sample size of 908 was estimated using EPI info 3.5.1. Data were coded and entered into EPI info, and then exported to SPSS version 20 for analysis. The predictors of care-seeking behavior were estimated using OR, 95% CI and P-value. Results: The common symptoms reported were fever (91.0%), cough (66.5%), and diarrhea (38.5%). Care was sought from public (43.6%) and private (24.9%) facilities. Considerable proportion of caregivers (31%) did not seek care. Logistic regression analysis revealed that marriage AOR=3.16, 95% CI (1.33-7.51) and knowledge AOR=1.39,95% CI (1.04-1.87), sex of child AOR=1.49,95% CI (1.13-1.97), main symptoms of illness: cough OR=2.24, 95% CI (1.65- 3.04) and diarrhea OR=1.47, 95% CI (1.10-1.96) as predictors of health care-seeking behavior. Conclusion: Considerable proportion of caregivers did not seek care for childhood illness and most caregivers did not know where and when to seek care. Most often care sought was delayed after 24 hours of recognition of child’s illness. Basic health care services at community level should be strengthened. Information, Education, Communication/Behavior Change Communication (IEC/BCC) strategies should be strengthened toenhance appropriate and prompt healthcare-seeking practices. [Ethiop. J. Health Dev. 2014; (Special Issue 1):36-43]

Introduction Ethiopia is among the countries with poorest overall describe the factors affecting the family’s decision to health indicators in the world and has one of the highest seek care. These include background/predisposing factors under-five mortality rates, even among sub-Saharan like socio-economic and demographic variables; African countries (1). However, there has been a intermediate/enabling factors like knowledge of remarkable decline in all levels of childhood mortality childhood illness, perceived severity of illness, and time recently. Under-five and infant mortality rate has of health-seeking after onset of illness; and health care- decreased from 166 to 88 and 97 to 59 per 1000 live seeking behavior as outcome variables (11). births in the past 10 years respectively. These rates show that 1 in 17 children dies before the first birthday and 1 in Success in reducing childhood mortality involves 11 children dies before the fifth birthday (2, 3). Major availability of adequate health services with well-trained causes of mortality are pneumonia, malaria, diarrhea, health workers, effective management of childhood measles, and neonatal conditions. Malnutrition and HIV illness, and partnership between families and health are underlying causes for about 57 percent and 11% of workers. For sick children, families should seek these deaths, respectively (4). appropriate and timely assistance from health workers and give the recommended treatments appropriately (12). Appropriate care-seeking means that the need to take the Although progress has been made in Ethiopia for child for treatment outside the home is recognized, that universal access to standard case management of those the care is not delayed, and that the child is taken to an common childhood illnesses, healthcare-seeking appropriate health facility or provider (5, 6). Improving behaviors of caregivers for child illness has remained families' care-seeking behavior could contribute low. Some reports identified that healthcare was sought significantly to reducing child mortality in developing only for below half of the child illnesses. According to countries, where common childhood illnesses are a major the 2011 Ethiopian Demographic and Health Survey problem (7, 8). The prevalence of appropriate care- (EDHS 2011), treatment from a health facility or seeking for common childhood illness is low in most provider was sought for 27%, 24%, and 31% of children developing countries; only 26.4% of the mothers sought with Acute Respiratory Infection (ARI), fever, and appropriate care during the child illness (9, 10). A diarrhea, respectively (10-13). The end-line household conceptual framework for care-seeking behavior for survey report of Essential Health Service in Ethiopia childhood illness (modified from Anderson) was used to (ESHE), Southern Nations, Nationalities, and Peoples’

1JSI/ IFHP Southern Nations, Ethiopia, Email - [email protected]/[email protected]; 2Pathfinder/IFHP, Southern Nations, Ethiopia; 3Regional Health Bureau, Southern Nations, Ethiopia; 4School of Public Health, Addis Ababa University. Assessment of health care seeking behavior of caregivers for common childhood illness 37

Region (SNNPR), also indicated that of mothers with Sample Size and Sampling Method: sick children (55%) took their children to facilities for The sample size was determined using EPI Info statistical treatment (14). These findings demonstrated that software Windows version 3.5.1. Two sample sizes for healthcare-seeking behaviors of caregivers for those the two specific objectives were calculated. Proportion of common childhood illnesses still remain low (10, 13, 14). health care-seeking behavior for childhood illnesses (18%) was used for objective one and proportion of The decision to take a sick child to a health facility is part mothers with under-five children who had good of a complex care-seeking process that involves many knowledge of childhood illnesses and had taken a child to people. It has three identified components, which differ a health care facility (55%) (13, 14) was used for the in importance depending on the setting. Caregivers second objective to calculate for two population initially recognize that the child is ill and label the illness proportion equations. The larger sample size taken was (within local classification system and by severity), based 790. Considering non-response rate of 15%, the study on the recognized symptoms and illness context. Next, used a sample size of 908. they resort to care, influenced by the label among the barriers such as time and money constraints (15). All the 36 Kebeles of the Woreda were considered in the Appropriate care-seeking has the potential to sampling framework and the sample size per Kebele was substantially reduce child mortality and is of particular determined using probability proportional to size (PPS). importance in areas with limited access to health services Using the map of the Kebele, the spin pen technique was (16). used from the center of the Kebele to choose the direction and the first five households listed in that Some reports have estimated that seeking prompt and direction. The first sample household was randomly appropriate care could reduce child deaths due to ARI by chosen from the list, but if it was not eligible, the next 20% (15, 16). Only a few studies have been done on eligible household was taken. The study sample selection care-seeking behavior of caregivers for childhood illness continued by choosing every eligible household until the and its determinant factors in Ethiopia; yet, none has required sample size per Kebele found. If the boundary been conducted in SNNPR. Therefore, this study is of the Kebele was reached before the required sample important to know care-seeking behaviors of caregivers size, the opposite direction from the center was used to for common childhood illnesses and its determinant find the eligible households. factors in Shashogo District of Hadiya Zone, SNNPR. The information generated from this study will inform Data collection : policy makers and programmers about the potential Data were collected by interviewing a child’s primary impact of the existing interventions and help to set caretaker using structured questionnaires. The structured strategies to reduce child mortality in this area and questionnaires, which were in English, had been throughout Ethiopia. translated into Amharic (the official working language) and later back to English, to check its consistency. Methods Trained interviewers conducted the interviews in Study Design, Study Area, and Study Population : Amharic. Pre-testing and practical interviewing exercises A descriptive cross-sectional study was conducted in were conducted repeatedly among the research assistants Shashogo woreda, Hadiya Zone of SNNP Regional State, and mothers from the neighboring location before Ethiopia in January 2012. Bonosha is the capital of carrying out the actual survey. Since all the data Shashogo Woreda ; located about 340 km southwest of collectors were recruited from the local area, Hadiyegna Addis Ababa and 115 km west of Hawassa. The Woreda was used for those mothers who had difficulty to has 2 urban and 34 rural kebeles and it has 5 public understand Amharic. health centers, 36 health posts and 9 private clinics, providing health services in the woreda. The projected Data Management and Analysis : population of the woreda for 2012 (based on 2007 At the end of each day, the principal investigator went national census) was 118,208. All mothers in Shashogo through the completed questionnaires to check for woreda with children under five years old were completeness and accuracy. The data were coded and considered as source population, and those mothers with entered into the computer using EPI info 3.5.1.The data children under five years old who had illness within the were exported to SPSS Version 20 package for cleaning previous two weeks prior to the survey were considered and statistical analysis. Descriptive statistics were used as the study subjects. The inclusion criteria considered for data analysis. Cross-tabulations and logistic for the study subjects were households with children regression models were used in establishing relationships under five years old who had illness within the past two between variables at a significant level of (p<0.05). weeks prior to the study. If two or more children were Multi-collinearity among explanatory variables was sick within the given time interval, the latest sickness checked using Pearson correlation coefficients (r). The was considered and if the children were sick at the same correlation coefficient between explanatory variables was time, the youngest child was considered. small (r<0.07). There was no multi-collinearity effect on

the model.

Ethiop. J. Health Dev. 2014;(Special Issue 1) 38 Ethiop. J. Health Dev.

Knowledge score was calculated by asking different Table 1: Demographic and socio-economic questions about the danger signs of child illness; what characteristics of the respondents, Shashogo actions to take when recognizing the danger signs; when Woreda , Southern Ethiopia; January 2012 (n=907) to seek medical care; and where to seek modern health Factors Num ber % care for the child illnesses. The responses were coded as Age of respondents 1 for correct and as 0 for incorrect answers and 17-25 222 24.5 26-34 492 54.2 eventually the response values were added. Respondents 35-43 161 17.8 who scored above or equal to the mean were labeled as ≥44 32 3.5 having good knowledge and those who scored below the Relationship to the sick mean were labeled as having poor knowledge about child childhood illnesses. Mother 876 96.6 Grandmother 19 2.1 Data Quality Assurance : Others* 12 1.3 In addition to training data collectors and supervisors, Educational Level No formal education 485 53.5 different methods of data quality assurance were used. 1-4 238 26.2 Data collectors and supervisors reviewed the data daily 5-8 160 17.6 and supervisors monitored the data collection process 9 and above 24 2.6 using an “interviewer control checklist.”In order to Marital status control for possible errors during data entry, data was Not currently married 34 3.7 cleaned using frequencies and cross-tabulations in Currently married 873 96.3 addition to customizing variables. Religion Muslim 384 42.3 Christian 523 57.7 Ethical Considerations : Occupation Ethical clearance was sought from the SNNPR Regional Farmer 873 96.3 Health Bureau Ethical Clearance Committee. Merchant 118 13.0 Additionally, a support letter was obtained from Hadiya Other ** 25 2.8 Zone Health Department and Shashogo Woreda Health Number of live children Office. Respondents were given complete information < 5 544 60.0 about the objective of the study and its potential ≥5 363 40.0 Number of < 5 children benefits/risks. Interviews were conducted after informed < 3 847 93.4 consent was obtained. All information was collected ≥3 60 6.6 anonymously, and all data was accumulated, organized, +In walking distances*others includes father, grand stored, analyzed, and retrieved guaranteeing mother and sister** others includes daily laborer and confidentiality. employees

Results Children’s median age was 24 months. The common A total of 907 caregivers were interviewed. Their ages symptoms of child illnesses reported by the respondents ranged from 17 to 70 years, with a median age of 30. were fever for 91%, cough for 66.5% and diarrhea for Almost all, 96.6%, of the respondents were mothers as 38.5% of those children who had illness. More than one primary caregivers and 96.3% of them were married at symptom was reported in 84% of them. The perceived the time of the interview. Only 2.6% had at least a seriousness of illness was reported as ‘severe’ for 68.2% secondary level education, and 53.5% did not have a of children, and 52.8% of the respondents reported formal education. About three in five (57.7%) of the “knowing those symptoms indicated the seriousness of respondents were Christians and the rest were Muslims. illness” as the main reason for the perceived severity. Five hundred forty-four (60%) of them had fewer than The public health facilities were accessible within 30 five live children and 93.4% of them had one or two minutes average walking distance to health posts for children of under five years of age in the household 86.4% and 60 minutes to health centers for 46.3% of the (Table 1). respondents. (Table 2).

Assessment of care giver knowledge revealed that 68.4% of them had poor knowledge about the childhood illnesses. Out of the 907 children under the age of five who had illnesses two weeks prior to the study, 51.2% were males and the remaining 48.8% were females.

Ethiop. J. Health Dev. 2014;(Special Issue 1) Assessment of health care seeking behavior of caregivers for common childhood illness 39

Table 2: Child’s illness-related characteristics, caretakers sought care after the third day. “Seeking better Shashogo Woreda , Southern Ethiopia; January 2012 care” was the main reason (57.9%) of caregivers for (n=907) preferring a health facility. The majority of caregivers Factors Number % received modern drugs for treatment from the health Mothers’ Knowledge of child facilities: anti-malaria (56%) and antibiotics (47.8%) for illnesses fever, antibiotics (93.7%) for cough and oral rehydration Poor 620 68.4 solution (ORS) (61.9%) for diarrhea. Good 287 31.6

Child’s sex A considerable number of caregivers did not seek care Female 443 48.8 from health facilities (31%): 7.8% purchased medicine Male 464 51.2 from drug shops; 7.2% taken to religious or traditional Child’s age ( in months ) healers; 10.0% given home treatment, and no care was <12 171 18.9 sought for 9% of children. The main reasons for 12-23 259 28.6 preference of treatment other than health facilities were 24-35 138 15.2 treatment expensiveness (41.1%), lack of money for 36-47 173 19.1 treatment (33.7%), thought the illness was not serious 48-59 166 18.3 (12.4%), and distance (3.6%) (Table 2 and 3). Main symptoms* Cough 605 66.5 Table 3: Care-seeking behavior of caregivers for Diarrhea 349 38.5 childhood illnesses, Shashogo Woreda , Southern Fever 825 91.0 Ethiopia; January 2012 Perceived severity Factors Numb % Severe 619 68.2 er Not severe 273 30.1 Care sought for the child illness Difficult to judge 15 1.7 (n= 907) Reasons for perceived Public HF 395 43.6 severity* Private clinic 226 24.9 Symptoms indicate 479 52.8 Purchased medicine 71 7.8 seriousness of the illness Taken to religious/traditional 65 7.2 Had more than one symptom 226 24.9 healer From experience, assuming it 206 22.7 Given home treatment 91 10.0 resolves by itself Waited for illness to subside 82 9.0 Fear of child dying of the 45 5.0 Time of care sought (n= 625) illness Immediately 37 5.9 Distance to HP (in walking On the first day 68 10.9 distances) (N=907) On the second day 171 27.4 < ½ hr 784 86.4 After third day 349 55.8 ≥ ½ hr 123 13.6 Types of visited facility (n= 625) Distance to HC (in walking Hospital 9 1.4 distances) (N=907) Health Center 391 62.6 < 1hr 420 46.3 Health Post 35 5.6 1-2 hrs 355 39.1 Private clinic 226 36.2 ≥2 hrs 132 14.6 Reason for preferring the HFs *Numbers do not add to 907 because of multiple (n= 625) illness and difference in reasons for perceived Seeking better treatment 362 57.9 seriousness Facility was nearby 134 21.5 People advised 59 9.5 Health care was sought for a total of 68.5% children with Fair treatment cost 29 4.6 illnesses; 43.6% and 24.9% sought care from public Fear illness was worsening 33 5.3 health facilities and private clinics respectively. The Reason for not taken to HFs (n= types of public health facilities visited by caregivers were 282) Treatment expensive 116 41.1 health centers, health posts, and hospitals by 62.6%, Lack of money 95 33.7 5.6% and 1.4% of respondents respectively. Moreover, The illness was not serious 35 12.4 more than one facility visit was reported for the same Distance of the health facility 10 3.6 episode of a child’s illness. Care was sought from health Others 67 23.8 facility for multiple symptoms than a single symptom. NB: Numbers do not sum up to n because all answers Only 5.9% of caregivers took their sick child within 24 are with multiple responses. hours from the recognition of illness, and most (55.8%)

Ethiop. J. Health Dev. 2014;(Special Issue 1) 40 Ethiop. J. Health Dev.

Table 4: Association of demographic, socio-economic characteristics and health-seeking behavior, Shashogo Woreda , Southern Ethiopia; January 2012 (n=907) Sick child taken to HF Factors COR (95%CI) Yes ( %) No ( %) Age of the respondents 17-25 94 (42.3) 128 (57.7) 0.65 (0.30, 1.36) 26-34 211 (42.9) 281 (57.1) 0.66 (0.32, 1.36) 35-43 73 (45.3) 88 (54.7) 0.73 (0.34, 1.57) ≥44 17 (53.1) 15 (46.9) 1.00 Number of Live children <5 237 (43.6) 307 (56.4) 1.00 (0.77, 1.31) 5 + 158 (43.5) 205 (56.5) 1.00 Number of < 5 children <3 366 (43.2) 481 (56.8) 0.81 (0.48, 1.37) 3 + 29 (48.3) 31 (51.7) 1.00 Marital status Not currently married 7 (20.6) 27 (79.4) 1.00 Currently married 388 (44.4) 485 (55.6) 3.09 (1.33, 7.16)** Religion Muslim 151 (39.3) 233 (60.7) 1.00 Christian 244 (46.7) 279 (53.3) 1.35 (1.03, 1.76)* Knowledge Poor 253 (40.8) 367 (59.2) 1.00 Good 142 (49.5) 145 (50.5) 1.42 (1.07, 1.88)* Occupation Farmer No 10 (29.4) 24 (70.6) 1.00 Yes 385 (44.1) 488 (55.9) 1.89 (0.89, 4.00) Merchant No 356 (45.5) 433 (54.9) 1.00 Yes 39 (33.1) 79 (66.9) 0.60 (0.39, 0.90)* Others+ No 388 (44.0) 494 (56.0) 1.00 Yes 7 (28.0) 18 (72.0) 0.49 (0.20, 1.19) + Others includes daily laborer and employees *p<0.05, **p<0.01, ***p<0.001

In the bivaraite analysis of the background and marriage (AOR= 3.16, 95% CI [1.33, 7.51]) and those intermediate variables; caregivers’ current marital status who had good knowledge about child illness (AOR=1.39, (OR=3.09, 95% CI [1.33, 7.16]), religion (OR=1.35, 95% CI [1.04, 1.87]) were more likely to seek care than 95% CI [1.03,1.76]), mothers’ knowledge for the child others. Similarly, male children (AOR= 1.49, 95%CI illness (OR=1.42, 95% CI [1.07, 1.88]), sex (OR=1.41 [1.13, 1.97]) and children with cough as main symptoms 95% CI [1.08, 1.83]) and, cough (OR=2.19 95% CI of illness (AOR= 2.24, 95% CI [1.65, 3.04]) and children [1.64, 2.93]) and diarrhea (OR=1.52 95% CI [1.16, 1.99]) with diarrhea as main symptoms of illness (AOR= 1.47, as main symptoms of the child illness had significant 95%CI [1.10, 1.96]) were more likely to be taken to a association with health care-seeking behavior. Moreover, health facility than others. However, perceived severity to identify the predictor variable of health care seeking of illness was not still significant after adjusted to the behavior, multivariate logistic regression analysis was other factors (Table 5 & 6). performed. The result revealed that mothers currently in

Table 5: Association of child-related factors and health-seeking behavior, Shashogo Woreda , Southern Ethiopia; January 2012 (n=907) Sick child taken to HF Crude Odds Factors Yes (%) No (%) Ratio/COR/ Main symptoms Cough No 94 (31.1) 208 (68.9) 1.00 Yes 301 (49.8) 304 (50.2) 2.19 (1.64, 2.93) *** Diarrhea No 221 (39.6) 337 (60.4) 1.00 Yes 174 (49.9) 175 (50.1) 1.52 (1.16, 1.99)** Fever No 32 (39.0) 50 (61.0) 1.00 Yes 363 (44.0) 462 (56.0) 1.23 (0.77, 1.95) Perceived severity of illness Severe 311 (50.2) 308 (49.8) 2.02 (0.68, 5.98) Not severe 79 (28.9) 194 (71.1) 0.81 (0.27, 2.46) Difficult to judge 5 (33.3) 10 (66.7) 1.00 Sex of sick child Female 174 (39.3) 269 (60.7) 1.00 Male 221 (47.6) 243 (52.4) 1.41 (1.08, 1.83)* *p<0.05, **p<0.01, ***p<0.001 Ethiop. J. Health Dev. 2014;(Special Issue 1) Assessment of health care seeking behavior of caregivers for common childhood illness 41

Table 6: Determinants of health care-seeking behavior for childhood illnesses, Shashogo Woreda , Southern Ethiopia; January 2012 Determinants Crude OR (C.I) Adjusted OR (C.I) Knowledge Poor 1.00 1.00 Good 1.42 (1.07, 1.88)* 1.39 (1.04, 1.87)* Perceived severity of illness Severe 2.02 (0.68, 5.98) 1.38 (0.45, 4.27) Not severe 0.81 (0.27, 2.46) 0.59 (0.19,1.87) Difficult to judge 1.00 1.00 Main symptoms of illness 1.00 1.00 Cough 2.19 (1.64, 2.93)*** 2.24 (1.65, 3.04)*** 1.00 1.00 Diarrhea 1.52 (1.16, 1.99)* 1.47 (1.10, 1.96)** 1.00 1.00 Fever 1.23 (0.77, 1.95) 0.96 (0.58, 1.58) Sex of sick child Female 1.00 1.00 Male 1.41 (1.08, 1.83)** 1.49 (1.13, 1.97)** Marital Status Not currently married 1.00 1.00 Currently married 3.09 (1.33, 7.16)** 3.16 (1.33, 7.51)** *p<0.05, **p<0.01, ***p<0.001

Discussion behavior, including both predisposing and enabling Prompt and appropriate care-seeking practices have the factors. This health care-seeking behavior is influenced potential to substantially reduce child mortality. For by multiple factors, such as age, gender, instance, timely care-seeking reduces under-five-aged occupation/income, education and marital status of child death by 20% from ARI (15), whereas caregivers as predisposing factors; and mothers’ inappropriate or delayed care-seeking contributed to 32% knowledge of the child illness, age and sex of the sick of deaths in Mexico (17). In Ethiopia, where common child, types of illness and perceived severity of the childhood illnesses are a major problem, it is vital to child’s illness, and proximity to health facility as decrease the number of deaths attributed to delays in enabling factors (23). In this study, mothers’ marital seeking health care and/or not seeking care at all (17-19). status, their knowledge about the child illness, sex of the sick child and presentation of main symptoms of the There had been an expansion of primary health care child illnesses were found as predictors of health care facilities in Ethiopia. As a result, public health facilities seeking behavior for childhood illnesses. Currently (both health centers and health posts) have been married women and those who had good knowledge accessible for the standard management of childhood about childhood illnesses were more likely to seek care illnesses (20). In this study, health care was sought from from health facilities than their counterparts. It is a health facility for 68.5% of children under five with comparable to other studies in Ethiopia and other illness, 43.6% from public and 24.9% from private health countries (13, 25, 26). Pokhrel et al. reported that the facilities. Even though about two third of caregivers took gender of a child not only affects illness reporting but their children with illness to health facilities, health care also the decision to choose a health care provider and was sought after three days by 55.8% and immediately how much to spend (33). This study found that health from the onset of the child illness only by 5.9% of them. care was sought 1.49 times more for male than females Although this finding was consistent with that found in children with illnesses which is consistent with trends Nigeria (65.7%) (21), better practices of health care- noted in Kenya, Ghana, and India (23, 24, 34, 35). In seeking behavior from health facilities has been revealed addition, children with main symptoms of cough and in this study than other studies in the country (less than diarrhea were more likely to be taken to health facilities 50 percent) (2, 13, 14) and in Kenya (34-42%) (22). This than with other symptoms, which was consistent with study also found that the major reasons reported for not reports from other studies (9, 27). seeking health care from health facilities were lack of money, expensiveness of the treatments and not However, some of the predisposing and enabling factors considering the illness as serious. The possible that were considered in this study did not show any explanation for this finding might be families with lower significant association with the health care seeking economic status have no resources and the limited behavior of mothers. These include: mother’s mothers’ ability to recognize when children need educational status, perceived severity of the child illness treatment. and distance of the available health facilities from their resident. Some studies reported that the parent's In most developing countries the health status of children schooling, particularly that of the mothers, is likely to is strongly associated with maternal health care-seeking influence their behavior in seeking health care services Ethiop. J. Health Dev. 2014;(Special Issue 1) 42 Ethiop. J. Health Dev. for their children. In a number of studies, the barriers to seek appropriate health care. Moreover, a educational level of mothers is associated with a greater large proportion of the mothers were not aware of the commitment to care their child and educated women danger signs of the childhood illness. Caregivers’ marital tend to provide better healthcare, hygiene and are more status, knowledge of childhood illnesses, sex of the child, likely to seek help when a child is ill (9, 30). However, as well as cough and diarrhea as main symptoms of the our finding was not in agreement to those studies. A child’s illness were predictors of health care-seeking possible explanation for such behavior could bemost of behavior. the respondents in our study had no formal education. The study team recommends that basic health care Few studies have considered caregivers’ perceived services should be strengthened at the community level. severity of illness as a factor influencing their response to Tailored IEC/BBC strategies should be considered to a child’s illness (13. 23, 27). However, caregivers’ enhance caregivers’ knowledge about child illnesses and perceived severity of illness is said to be unreliable in to promote health care-seeking practices. Caregivers’ terms of recognition and interpretation of severity of ability to recognize danger signs of childhood illness illness (9, 26). Therefore, both the number of symptoms should be addressed at each and every counseling session and the perception of severity of illness were considered during illness as well as child visits. There is a need to in this study to identify the predictors of care-seeking consider support and supervision of private health care behavior. However, we did not find significant providers, since caregivers seek their attention during association between perception of severity of illness and childhood illness too. health care seeking for a sick child. This might be due to the difference in the socioeconomic situation of the study Acknowledgements community. Accessibility of health facilities has a We are grateful to the study participants, SNNPR positive effect on the utilization of health services. In Regional Health Bureau, Hadiya Zonal Health other studies proximity to the health facility and Department, Shashogo Woreda Health Office, Addis availability of finance were factors that determine health Ababa University School of Public Health, JSI, care-seeking behavior (4, 13, 16, 31, 32). But findings of Pathfinder International, and USAID. 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