Socio-Contextual Determinants of Community-Level Care Seeking for Neonatal Possible Severe Bacterial Infection (PSBI) in Amhara, Ethiopia Open Access

Abstract

Background: Approximately 25% of neonatal deaths occur globally due to infections. In Ethiopia, neonatal mortality accounts for 42% of under-five deaths with the majority of these deaths driven by infections. Possible Severe Bacterial Infection (PSBI) in neonates is a syndromic diagnosis that non-clinical health providers use to identify newborns with likely sepsis outside of health facilities. In low- and middle–income countries, referral to a hospital may not be feasible due to transportation, distance or finances. Growing evidence suggests health extension workers (HEWs) can identify and manage PSBI at the community level when referral to a hospital is not possible. However, community-based PSBI care strategies have not been widely scaled-up.

Methods: We conducted eleven focus group discussions (FGDs) and six in-depth interviews (IDIs) to analyze illness recognition and care seeking intentions from four rural kebeles in Amhara, Ethiopia. FGDs were conducted among mothers, fathers and households with recruitment stratified among households that have had a newborn with at least one symptom of PSBI (Symptomatic Group), and households that have had a newborn regardless of the child’s health status (Community Group). IDIs were further conducted among peripheral family members. Data were then thematically analyzed using MAXQDA software.

Results: Mothers were described as primary caretakers of the newborn and were often appreciated for making decisions for treatment, even when the father was not present. Type of care accessed was often dependent on conceptualization of the illness as simple or complex. When symptoms were not relieved with clinical care, or treatments at facilities were perceived as ineffective, alternative methods were sought. Most participants identified the health center as a reliable facility. While designed to be the first point of access for primary care, health posts were not mentioned as locations where families seek clinical treatment.

Conclusions: This study describes socio-contextual drivers for PSBI treatment at the community level. Future programming should consider the role community members have in planning interventions to increase demand for care at primary facilities. Encouragement of health post utilization could further allow for heightened accessibility-acceptability of a simplified PSBI regimen.

Table of Contents

CHAPTER 1: INTRODUCTION 1

Problem Statement 4

Theoretical Framework 5

Purpose Statement 6

Research Question(s) 6

Significance Statement 6

CHAPTER 2: LITERATURE REVIEW 8

Neonatal Mortality in Ethiopia 8

Possible Severe Bacterial Infection 9

Treatment Practices 10

Determinants of Neonatal Mortality 10

Care Seeking Behaviors 11

CHAPTER 3: STUDENT CONTRIBUTION 13

CHAPTER 4: MANUSCRIPT SUBMISSION 16

ABSTRACT 17

KEYWORDS 17

BACKGROUND 18

METHODS 20

Study setting 20

Study design 21

Recruitment 22

Data collection 23

Analysis 25

Ethics 26

RESULTS 26

Participant characteristics 26

Key themes 27

DISCUSSION 36

LIMITATIONS 38

CONCLUSIONS 39

ABBREVIATIONS 40

DECLARATIONS 40

Acknowledgements 40

Funding 40

Availability of data and materials 40

Authors’ contributions 41

Competing Interests 41

Ethics approval and consent to participate 41

Consent for publication 41

REFERENCES 41

CHAPTER 5: PUBLIC HEALTH IMPLICATIONS 44

REFERENCES 48

LIST OF APPENDICES

Appendix A. Data Collection Tools 53

Appendix B. Emory IRB Determination Letter 89

Appendix C. APHI Ethical Review Letter 91

Appendix D. Final Codebook 92

LIST OF FIGURES

Figure 1. Sampling Frame 96

Figure 2. Care Trajectory diagram 97

LIST OF TABLES

Table 1. Characteristics of Woreda and Kebele Sites 98

Table 2. Sampling Strategy per Woreda 99

About this Master's Thesis

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School	Rollins School of Public Health
Department	Behavioral Sciences and Health Education
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health
Keyword	sepsis Ethiopia Possible Severe Bacterial Infection (PSBI) care seeking community-based care neonatal mortality
Committee Chair / Thesis Advisor	Comeau, Dawn , Emory University
Committee Members	Spangler, Sydney, Emory University Cranmer, John, Emory University

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