Background
Globally, there were an estimated number of 2.5 million newborn deaths in 2018, mostly from preterm birth, intrapartum complications, and bacterial infection [
1]. The bacterial infection, named possible serious bacterial infection [PSBI], is defined as a clinical syndrome used in the Integrated Management of Childhood Illness [IMNCI] package referring to a sick young infant (0–59 months) who requires urgent referral to hospital. The signs are unable to feed or stopped feeding well, convulsions, fast breathing, severe chest in-drawing, fever, low body temperature, movement only when stimulated, or no movement at all [
2,
3]. It was caused an estimated number of 6.9 million newborn morbidities [
4], and 600,000 newborn deaths per year [
3], which is roughly 23% of neonatal deaths, still the proportion is as high as 50% in low-income settings [
5,
6]. The incidence ranges from 5.5 to 170 cases/1000 live births for blood culture-confirmed infections and clinically diagnosed cases, respectively [
7]. In Ethiopia, it is also a cause for newborn mortality [
8]. A prospective study conducted in Ethiopia from 2012 to 2013 showed that 34.3% of neonatal deaths were caused as a result of a neonatal infection [
9].
It is most prevalent in low- and middle-income countries particularly in sub-Saharan Africa and Southern Asia [
4]. This is because these countries have conditions such as poor quality of care around the time of birth [
4], limited attention given for newborns on critical first few days, low institutional delivery and giving birth in settings with suboptimal hygiene and non-sterile techniques [
10], premature birth, low coverage of maternal immunization [
11], and poor preventive measures [
5,
6]. Also, almost 98% of deaths due to this infection occur at these countries [
3] due to presence of poor timely care-seeking, limited treatment with appropriate antibiotics or follow up [
5,
6], lack of receiving the recommended inpatient treatment due to accessibility, acceptability or affordability problems resulting in unnecessary, potentially preventable infection-related newborn death [
3].
To overcome such challenges, the world health organization [WHO] developed a guideline that provides programmatic and clinical guidance and recommends the provision of effective treatment for young infants with severe infection at first-level health facilities to increase access to potentially lifesaving care for these infants when families do not accept or cannot access referral [
2,
3]. Besides these, studies indicated that interventions like management of newborn PSBI at the community level by is associated with reduced newborn mortality [
6,
12]. Our country, Ethiopia, also adapted the WHO guideline developing the implementation strategies that fit the local context to accelerate the MDG4 achievement and the subsequent agendas to reduce newborn mortality [
13,
14]. The country had made remarkable achievements in Millennium Development Goal 4 [MDG4] by reducing under-5 mortality from 205 deaths per 1000 live births in 1990 to 64 deaths per 1000 live births in 2013. However, despite this remarkable progress, newborn mortality was decreased much slower; 55 deaths per 1000 live births in 1990 to 28 deaths 1000 live births in 2013, which accounted for 45% of under-5 mortality [
15], and also increased to 30 deaths per 1000 live births in 2019 [
16]. Thus, to reduce newborn mortality, Ethiopia piloted the guideline from 2008 and 2013 evaluating the impact of a regimen of intramuscular gentamicin and oral amoxicillin given by HEWs to newborns and young infants with signs of PSBI when a referral is not possible and launched the project on March 2013 [
12].
Currently, the service is being delivered as a CBNC package and high impact newborn and child survival intervention focusing on 0–2 month newborns [
13,
17]. Under the supervision of primary health care unit [PHCU], trained health extension workers are the frontline service promoters and providers for sick newborns at the community level (both at home and health post [
18]. The program also utilizes health developmental armies [HDA] and other existing effective community mobilization mechanisms to scale up the service and to improve maternal and newborn care practices and care-seeking [
13]. There is also evidence that showed community-based service utilization is being provided for newborn PSBI management [
12,
19,
20]. But, the study findings also showed that there were newborns that did not get treatment service besides the presence of signs or symptoms suggestive to PSBI [
12,
19]. Nevertheless, limited information was available on what factors deter or facilitate its service utilization. Addressing the facilitators and barriers for its service utilization at the community level is imperative. Therefore, to address this knowledge gap, the study was utilized descriptive qualitative study to explore potential barriers and facilitators for the community-based service utilization for newborn PSBI management.
Methods
Study design, setting and period
This is a descriptive qualitative study that was conducted in Debre Libanos District, North Shoa, Oromia regional state, Ethiopia from March 11– April 7, 2019. It is located 90 km away from Addis Ababa in North direction. There was an estimated number of 64, 305 populations within the District [
21] where 77.1 and 22.9% of the population lives in rural and urban, respectively and about 99.29% of them follow the Ethiopian Orthodox Christianity religion [
22]. There were also four Health officers, one-degree nurse, twenty clinical nurses, one public nurse, four laboratory technicians, two druggists, five midwifery nurses, fourteen rural health extension workers [HEWs], and five urban HEWs who provide health care service for the populations, and two health centers [HC], ten health posts [HP] and three private primary clinics are there from which the populations of this setting utilize health care service [
21].
Sampling
The study participants were recruited purposively from six kebeles. The kebeles were selected considering the number of catchment kebeles per health center [HC], diversity in distance from health center [HC], rural versus urban residence, and performance of health extension workers [HEWs]. Women who gave birth within 2 months before data collection, women whose newborn died within 2 months of life, parents of a child who got treatment service at HP and HC within the last 2–3 years; care-givers [husbands, mothers and fathers] of women who delivered within 2 months before the data collection, pregnant mothers, mothers-in-law, fathers-in-law, and other reproductive age group peoples, religious leader, and kebele chairman were involved on the study from the community members. Also, from health facilities, health care providers like midwife nurses, clinical nurses who work at under-five clinics, and director of the health center; District Health Office Maternal, Neonatal, and Child health [MNCH] expert, and health extension worker were recruited. Participants from the health facility and community level were recruited based on their role on the implementation of the program activities [i.e. as a monitor or direct implementer], and having rich information on newborn illnesses or their role as a caregiver of newborns, respectively.
Data collection procedures (instrument, personnel, data collection)
A total of five in-depth interviews, seven key informant interviews, and four focused group discussions [FGDs] were conducted with a total of fifty-two participants. Four women who gave birth within 2 months before data collection and a woman whose newborn was died within 2 months of life participated in an in-depth interview [IDI] face to face. The key informants were religious leader, HEW, kebele chairman, midwife-nurse, U-5 clinic focal, director of the health center, and District health office Maternal, Neonatal, and Child health care [MNCH] expert. A total of 7–12 individuals participated, seated circular, in each FGD with a total of ten women who gave birth within 2 months before data collection and thirty other participants mentioned above.
Data were collected using a semi-structured guide (6–10 open-ended questions customized as per the respondent type) which was developed first in the English language and then translated into Afan Oromo and Amharic languages and back-translated into English by an independent translator. The guide was prepared concerning the research question starting from general and moving to specific taking into consideration the local knowledge and cultural sensitivities. The guide developed to cover topics related to a) communities’ perception and experience in health-seeking behavior towards newborn illnesses, b) community-related barriers and facilitators (cultural and religious beliefs, awareness related to service availability, etc.), c) Health facility related barriers and facilitators; d) health extension-related barriers and facilitators of community-based management of possible serious bacterial infection.
All in-depth and key informant interview participants were communicated one before the data collection day. But, to FGD participants, they were recruited before 1 week, and communication was made before 3 days of data collection to select a suitable and comfortable setting for the discussion. Then, the interviews and FGDs were conducted at the participant’s natural setting. In-depth interviews with women who gave birth within 2 months before data collection and whose newborn was died were conducted at their home; interviews conducted with health workers, HEW, kebele chairman, and religious leader were conducted at their office, and FGDs were conducted within their community. The interviews were conducted only with the principal investigator while FGDs were conducted; the research assistant was used as note-taker and an audio-recorder. The principal investigator has used the guide during modulating the interviews and FGDs to cover all relevant topics. At the beginning of each FGD and IDI, the purpose of the study and topic of the discussions was mentioned to study participants, and then individual-based written informed consent was taken for their willingness to participate and also for recording their voice. On average, the FGDs lasted from 1:15 to 1:41 h and the interviews with community members lasted from 21:33 to 43:51 min and interviews with health workers lasted from 0:39:40 to 1:12 h.
Data analysis
Inductive thematic analysis through which codes, categories, and themes are generated from the data was employed to analyze the data. The analysis was carried out simultaneously with data collection. After each data collection, debriefing of data was conducted with a research assistant to ensure data completeness and consistency with field notes. Simultaneously, data were analyzed to extract major themes, to plan for the next data collection, and discussions were also conducted with a research assistant to ensure data saturation. The data were begun to saturate after seven interviews and three FGDs were conducted. Then, the data were transcribed verbatim (in Afan Oromo and Amharic languages) from audio-recorded material. Ensuring the completeness and consistency of transcriptions, the data were translated to the English language by the principal investigator.
Then, important concepts that are related to the research question were extracted from the data after reading and re-reading the translations, and the codebook was developed. To develop the codebook, line by line coding was conducted separately by the principal investigator on ATLAS.Ti.7.1 software package, and one other peer who acts as a second research assistant on Microsoft word starting with richest data. After checking the inter-coder consistency, the codebook manual was developed to ensure code consistency, and credibility. Then, using the developed codebook, the whole data were coded by principal investigator coded the whole translations with simultaneous checking of intra-coder consistency. The potential categories and themes were developed by clustering sub-categories and categories, respectively, which answers the research question. Coding was repeated four times while refining the codebook, categories, and themes. Finally, findings were presented with two major themes, thirteen categories and quotations derived from the data concerning critical steps in the pathway: (a) community-related barriers and facilitators (b) health system-related barriers and facilitators.
Trustworthiness (rigor)
To keep the trustworthiness of this study, different techniques were used. First, the guide was pre-tested with three women who gave birth 2 months before data collection and three health workers [two HEW and one under-five clinic focal] who reside at the neighboring district. Second, diversified study participants who have adequate experience in the area of interest/issue were recruited. Third, data were triangulated by collecting through interviews and focused group discussions from those diversified study participants. Forth, peer debriefing was done with a research assistant and research team. Fifth, at the end of each data collection period, a summary of major themes was raised for study participants, and discussion was conducted to clarify unclear concepts. Sixth, the transcriptions, translation, and findings were shared with key informants such as HEWs, focal persons of under-5 clinics, director of a health center and district health office, and MNCH expert to check the interpretations and to provide their comments, critiques, clarification, and confirmation. Seventh, through negative case analysis, contradicting ideas or deviant cases that emerged in the data was analyzed by enquiring deep information from potential study participants on the consecutive data collection periods. Eight, to ensure transferability, the whole research process, participant’s diverse perspectives and experiences, methodology, interpretation of results, and contributions of research assistants were thickly described. Professionals interested to apply the findings reported in this study may consider the transferability of the results after careful consideration of contextual information described earlier in the study setting section. Furthermore, the findings of the current study suit for the current Ethiopian primary health care structure and training system for health extension workers. Hence, analysis of contextual similarities is needed before taking up of the results of the current study to other contexts.
Ninth, to ensure dependability, the participant’s recruitment process, data collection methods, and the analysis process were clearly described. A detailed chronology of research activities and processes [data collection and analysis, emerging themes, categories or quotations] were audited by advisors, colleagues and other experts having good experience of qualitative research to confirm the procedures and verify whether they were used appropriately, and to make both the process and the study output consistent. Thus, with these activities, the process through which findings were derived was made explicit enough.
Tenth, confirmability of the study was ensured through different techniques. The first technique was the research team’s self-reflectivity and bracketing. The principal investigator is a public health officer in his background that has experience in working at a health center with different departments including under-5 clinics. Also, he had attended different pieces of training related to Community-Based Newborn Care, including management of newborn possible serious bacterial infection, had worked as CBNC project coordinator, and participated in different supportive supervisions, and performance review, and clinical mentoring meeting (PRCMM). Currently, he has a Master of Public Health in Health Promotion and Human Behavior. Besides this, he has also good experience in qualitative research. This preconception, knowledge, and skills benefited the principal investigator to set and focus on research questions. Other research teams have educational backgrounds in the health disciplines and have philosophical Degree [GTF] and Master of Public Health in Health Promotion and Human Behavior [YKL] and both have good experience of qualitative researches.
The study context and actual location of the research setting were different from where the principal investigator and research team are working. Therefore, there was no potential bias that could be introduced if they would be from the same location. However, since biases are not inevitable, as much as possible, subjectivity was managed by balancing together with the data, analytic processes, and findings in such a way that the reader can confirm the adequacy of the findings. Besides, the research teams speak the local language well. The research assistant has a good orientation to the local culture. This background used to minimize interpretation bias. Moreover, the interpretation of the findings was cross-checked by other peers by reading direct quotations from study participants. The second technique used to ensure conformability was through an audit trail. The findings of this study were audited and verified by colleagues and other experts having experience in qualitative research. The findings were also verified by key informants like HEWs, village leaders /kebele chairman, and health workers who participated in the study. Each study process was documented and audio records were available for cross-checking.
The third technique was a prolonged engagement. By spending enough time in the study setting and through creating rapport with study participants, the principal investigator observed and confirmed the findings of the interviews and FGDs. He had observed and understood like the closure of health posts [HP] on working hours, the short-time stay of HEWs in the health posts, HEWs traveling to and from the district town, punctuality of HEWs, presence or absence of arrangements such as pregnant women conferences, presence or absence of supervision and mentoring for HEWs, etc. Besides, he was also carefully reviewed the 0–2 month sick newborn registration book at six health posts and verified that many sick newborns were registered, assessed, classified and managed from 2013 to 2017, but there were few from 2017 till the data collection time.
Discussion
This study found the availability of trained manpower, logistics [medical supply and job aids], and monthly performance review meetings as facilitators for community-based service utilization for newborn PSBI management. Also, barriers such as communities perception that newborn illnesses have no medical treatment, perception of non-severity and self-resolution, belief in the healing power of traditional medicines, socio-cultural and religious beliefs, lack of awareness on the availability of sick newborn treatment service at the health post, lack of program supervision, monitoring and evaluation, shortage of HEWs, shortage of trained health workers, the residence of HEWs, poor health workers and HEWs’ commitment and non-functionality of health developmental army were explored.
This study found that community members locally diagnose newborn illness as the sun or hot burn (‘mitch’), body dislocation or fracture (‘kichitat’), the evil eye (‘buda)’, ‘megagna’ (locally perceived as a newborn illness caused by demon-evil spirit), ‘berd’ (locally perceived as a newborn illness caused by exposure of coldness), common cold and tonsillitis (enlarged or dropped uvula) from perceived but misconceived causes of illnesses. This local illness diagnosis makes the community members perceive that newborn illnesses have no medical treatment from health facilities, and rely on the traditional medicines rather than seeking care from health facilities; developing misconception on treatment options. These findings are consistent with the findings of studies conducted in central and southern Ethiopia, Nigeria, and Bangladesh in that community members use herbal medicine to treat newborn illnesses [
23‐
28]. This study also found that community members perceive newborn illnesses as non-severe which resolve spontaneously within a few days. This finding is consistent with findings from different studies conducted at different settings in that community members in those settings delay sought health care from health facilities due to expectation of self-resolution [
28,
29] and considering the symptoms as minor that resolve within next few days [
28,
30]. This calls a need to conduct a behavioral change communication to change the behavior of the community members towards newborn illnesses and their treatment.
Lack of awareness on the availability of sick newborn treatment at a health post among the community members is one explored barrier in this study. This was because awareness creation or promotion of the availability of sick newborn service at health posts for the community members was not done due to lack of commitment, unavailability of HEWs at health posts on working hours, and non- functionality of health developmental armies in the study setting that facilitate service utilization. But, community empowerment and demand creation is one key objective to create awareness and promote service for effective use of newborn and child survival interventions in Ethiopian newborn and child survival programs [
17]. Therefore, this underscores the importance of conducting awareness creation activities for the community members to utilize the service for their sick newborns.
This study also explored socio-cultural and religious beliefs as a barrier for the community-based service utilization for newborn PSBI management. Community members who follow the Ethiopian Orthodox Christian religion do not take their newborns out of home for seeking care before the date of baptism even if the newborn is severely sick. On the other hand, community members who believe in ‘
hamachisa’ (a local culture through which the community members take their newborns to the witch and he or she blesses them). In both beliefs, if newborns are taken out of home for seeking treatment, PNC, or other issues before their date of baptism or taken to the witch for blessing, community members believe that newborns would face sickness from evil spirits or others. This finding is similar to the finding of a study conducted in Ethiopia which showed tradition recommends newborns to stay at home for 40 days because they are vulnerable to malevolent spirits [
27,
31]. This also underscores the need to conduct a behavioral change communication to change the behavior of the community members towards newborn illnesses and their treatment.
This study also found that there were no program-related supportive supervisions, monitoring, or evaluations conducted for the last 2–3 years after the implementing partner was phased-out. In contrast, the program is expected to be monitored through integrated supportive supervision twice a month, program-focused supervision once per month, and PRCMM twice a year [
18]. This happened from lack of giving attention to the program from health facilities and lack of commitment among health care providers. This implies that there are weak health center and health post linkage [
32]. This study also found that there are two health workers trained on IMNCI from each health center, and all rural HEWs who attended CBNC training which meet the expectation [
18].
This study found that two HPs have only one HEW, and one HP with no HEW which happened due to transfer and resigning. In contrast, according to the Health Extension Program, two health extension workers should be assigned per each health post [
31]. This makes difficult to conduct activities in static or outreach program. This calls a need to assign two health extension workers at these health posts. The finding this study also showed that except two HEWs, all other rural HEWs live at and travel from the district town due to lack of constructed home at assigned kebeles. In contrast, residence in the village is one of the HEW recruitment criteria [
33], and CBNC also acknowledges the importance of available HEWs close to the community to provide gentamycin injection for newborns with PSBI for 7 days [
18]. But, since the HEWs live at and traveling from the district town, health posts were not open all days of working hours or service is not given for sick newborns on working hours, weekends, holy days, or night time. The health posts are open for a maximum of 3 days per week and less than 5 hours per day. Therefore, this study finding is lower from the study findings which showed that approximately 15 % HPs were open less than 5 days of the week, and also over half of HEWs serve the community weekends or holidays [
18]. Similarly, this finding is lower when compared with the finding of an observational time-motion study conducted which showed that HEWs were on duty for an average of 15.5% and they stayed on duty for about 6 hours per day [
34].
A poor commitment of health extension workers to conduct post-natal care and pregnant women conferences also identified as a barrier for the community-based service utilization for newborn PSBI management. This is because both these activities are used as an entry point to promote the service, get sick newborns, and provide treatment service. Specifically, the postnatal care (PNC) is essential for teaching caregivers how to recognize sick newborns, screening or identifying sick newborns and provide care on the riskiest periods, first day, and the week of life. Thus, HEWs are responsible to provide a home to home PNC service on the first, third, and seventh day to identify and treat illnesses in newborns with amoxicillin and gentamycin [
9,
18,
27]. On the other hand, conducting pregnant women conference is used to promote the service and facilitates in developing health care seeking newborn illnesses [
28]. Nevertheless, the result from this study showed that there were no pregnant women conducted for the last 3 years, and HEWs did not provide PNC service on these critical days which might result in addressing sick newborns to screen for danger signs and sign and symptom of PSBI. This underscores the importance of providing attention to provide post-natal care to address sick newborns.
Lastly, this study found that there were non-functional health developmental armies from poor supervision or monitoring given by health extension workers. But, the implementation of the Health extension program is facilitated when HEWs are conducting activities in support of health developmental armies. This is because they play a substantial role in increasing the healthcare-seeking behavior of the community regarding MNCH services, promoting the availability of services delivered at the community and health facility level including ICCM, CBNC, skill birth, etc. [
17]. There were also evidences that health developmental armies made remarkable achievements concerning pregnant women identification, providing ANC and PNC counseling service, sick newborn identification, referring sick children to health posts, and promoting the service [
18]. Nevertheless, the result of this study showed that there the availability of non-functional health developmental armies. Due to these issues, study participants mentioned that community-based management of newborn PSBI was low.
Strength and limitation
The strength of this study is the involvement of participants from different socio-demographic backgrounds, the use of mixed data collection techniques and exploring barriers and facilitators at community, health facilities, and health care provider level have been explored. The potential limitation of this study is that there might be recall bias since it explored the participant’s experience.
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