CARE SEEKING FOR COMMON CHILDHOOD ILLNESSES IN THE CONTEXT OF INTEGRATED COMMUNITY CASE MANAGEMENT SCALE UP IN RURAL ETHIOPIA
Shaw, Bryan Charles
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Problem statement: Diarrhea, Malaria and Pneumonia are the major causes of under-five mortality (U5M) in sub-Saharan Africa. These illnesses can be prevented with provision of child health interventions delivered at the community level. Ethiopia is currently scaling up integrated community case management (iCCM) of common childhood illnesses through health extension workers (HEWs) in rural community health posts to improve access to evidence-based treatments. However, utilization of HEWs at the health post for child illness has been found to be very low. Little is known about reasons for low utilization of HEWs and care seeking behaviors for this population. Methods: Qualitative methods, including focus group discussions and in-depth interviews, were conducted among caregivers of U5 children and community health workers/volunteers in eight rural health post catchment areas. Paper 1 documents community-based sources of care, describes care seeking behaviors and strategies and explores sociocultural factors influential in care seeking for child illnesses. Paper 2 explores influential access barriers for utilizing HEWs delivering iCCM services at the health post. Quantitative analysis was conducted on data from a household cluster survey (12,000 households) evaluating differences in coverage and mortality between areas providing iCCM and routine community case management (CCM) services. Paper 3 assesses differences in utilization of HEWs for caregivers of sick children in iCCM areas those in routine CCM areas, determinants of utilization of HEW and health post services for child illness and reasons for non-use of HEW/health post services. Results: Paper 1: Caregivers of sick children sought care from multiple sources within the landscape of available care and treatment options. The majority of care was sought from informal sources. Choice of care provider was influenced by illness perceptions, perceptions of provider characteristics, influential social others and social networks, perceptions of medicines and caregiver autonomy. Paper 2: Participants noted a wide range of barriers for using HEWs delivering iCCM services at the health post. These barriers reflected both demand- and supply-side challenges. Participants noted that these services were often not: available, geographically accessible and acceptable for their child’s illness. Additional influences included sociocultural factors which were reported to both aid and hinder utilization of HEWs at the health post. Paper 3: Caregivers in iCCM areas are marginally more likely to use the health post for child illnesses compared to caregivers residing in areas only with access to routine CCM services. Determinants for utilization of HEWs at the health post differed between the areas, with iCCM services reaching groups typically marginalized in service utilization studies. The primary reason given for not utilizing the HEW/health post related to caregivers perceptions of low severity for their child’s illness. Conclusions: Despite increases in coverage and quality of child health services delivered by HEWs through the strategy of iCCM, utilization remains very low. Many of the reasons for low utilization related to barriers to access and limited demand. In order to achieve the full potential of iCCM, efforts to minimize these remaining barriers and incorporate demand-generation activities need to be integrated within iCCM actions.