Five demand-side barriers that contributed to low uptake of iCCM and CBNC services were identified. These include myths and misconceptions around the cause of childhood illnesses including low risk perception, preference for traditional healers or home remedies, lack of awareness of iCCM and CBNC services, perceived poor quality of care and lack of transport and distance to health post.
Myths and misconceptions around the causes of childhood illness
Although recognition of the symptoms of childhood illnesses was found to be high, there were important misconceptions on the causes which had implications on care-seeking practices. This included attributing illnesses to ‘mich’ (exposure to sunlight while breastfeeding or eating or exposure to a dirty environment or bad smell), cold weather and ‘evil eye’. An FGD participant mother who did not seek healthcare from Tigray explained:
“Some diseases, like diarrhea, cough and fever are caused as a result of exposing our children to direct sunlight.”
In Oromia, newborn illnesses were thought to be caused by the shadow of a bird flying over the mother when she was pregnant: “A bird (‘allati’) flying over a pregnant mother will make her malnourished, and her newborn baby will be weak,” a community leader explained in FGD.
Misconceptions were also shared by the WDA leaders.
“If children are breastfed from a pregnant mother, the clots from the milk will cause generalized body swelling.” (WDA leader, Oromia)
If a malevolent spirit or evil eye were believed to be the cause of an illness, biomedical treatment was not seen as appropriate.
“If a person assumes the child got the illness due to ancestral spirits, he will not bring the child to the health post. That child should be treated at home. This is called ‘ye bet tenk’ (ancestral problem).” (Community leader, Amhara)
Similarly, some illnesses such as ‘yewof beshita’ (disease characterized by yellowish discoloration of the skin) and measles were widely believed to have unknown causes that could not be treated with allopathic medicine. In fact, these illnesses were considered to get worse with biomedical treatment.
Low risk perception
Most participants indicated that perceived severity of an illness determined the level of urgency with which they sought care for their children. Few mothers sought care for their sick children immediately after the onset of the illness, while most sought care only after the disease persisted for two to three days. This was attributed to the belief that childhood illnesses were generally self-limiting.
Preference for traditional healers or home remedies
Closely related with the misconception of causes of illness, the preference for traditional healers and use of home remedies were demand-side barriers in all four regions. Most participants in this study indicated that they use home remedies and/or traditional medicine as their first choice of care, prior to seeking care at the health post.
Failure to breastfeed among newborns was thought to be caused by a problem in the “tonsils” (uvula), for which the uvula was removed by traditional healers.
“When a newborn is unable to suck breast milk or has vomiting and fever, we will take the newborn to a well-known traditional practitioner. Once the tonsil is cut, the child will regain his health and will start sucking.” (Mother who did not seek care, FGD participant, Oromia)
Caregivers reported using herbs and plant leaves to treat their children. Delays in seeking care were reported as a result of caregivers’ habit of trying different treatments from different sources of care.
“When children are sick, parents try traditional treatment first, such as taking them to a ‘tenkway’ [witch] … or use of ‘damakese’ [Chenopodium-herbal treatment for ‘mich’] ...These are the most common practices in our community.” (Kebele cabinet member, Amhara)
Commonly reported home remedies included the juice of a herb known locally as ‘damakese’ for ‘mich’; garlic and ginger boiled together for presumed throat problems; a mix of salt with water along with burning the abdomen with hot metal for diarrhea; and lemon, salt and ‘tenadam’ (Rue/Ruta graveolens) for malaria. Self-medication with a single dose of antibiotics was also reported.
“My child had a cough and was vomiting. I did not take her to a health facility. I have never taken her to a health facility. I always use traditional medicine. I gave her boiled garlic and ginger with sugar, and she got better." (Mother who did not seek care, FGD participant, SNNP)
Participants in all the four regions indicated that slaughtering animals with certain rituals was used as a healing practice when a newborn or a child was sick.
“If a newborn cry continuously, they move a red colored chicken around the newborn’s head and throw it...or they give him traditional medicine for evil eye or religious leaders pray for the newborn continuously for 15 days.” (Mother who did not seek care, FGD participant, SNNP)
Participants from Awi, Amhara indicated that the communicable nature of ‘ema wetete’ (local term for measles) necessitated traditional ritual. A mother described this ritual healing process during an FGD:
“We make coffee, boil some cereals, and bake bread and ‘injera’ [the local staple food]. Once ‘ema wetete’ tastes the food and coffee, she will leave our neighborhood … We do not need to take the child to a health facility.” (Mother who did not seek care, FGD participant, Amhara)
Additionally, some personal and spiritual beliefs indicated that the consumption of medicine was contradictory to their belief systems. Moreover, some illnesses were assumed to have ‘permanent cure’ only with traditional medicine or rituals.
“It is different from any other diarrhea, where the child had offensive diarrhea and he cried when peeing...When we take such children to health facilities, they may get relief for a few days and then they would get sick again. But if they are treated with traditional treatment called ‘arek’ [dried root of a plant locally known as ‘arek’] they will never get sick again with the same problem.” (Father who did not seek care, SNNP)
Lack of awareness of iCCM and CBNC services
Lack of awareness of the availability of curative child health services at the health post was a top demand-side barrier in all regions. Most caregivers considered HEWs as providers of preventive services only. Those who knew of the availability of curative services did not know that the services were free of charge. In particular, availability of treatment for sick young infants and for pneumonia were not well known by the participants. A mother whose child was sick, but did not seek care from the health post, indicated the following:
“I do not know the services given at this health post … I have taken children [to the health post] for vaccination and for nutritional supplements only.” (IDI with mother who did not seek care, Oromia)
The functionality of the WDA structure which was expected to increase awareness of iCCM and CBNC services in the community was mostly questionable. Most of the respondent mothers were unable to identify the WDA leader in their community and some of the WDA leaders revealed that they did not have regular meetings with the HEWs. Furthermore, many WDA leaders were not aware of the spectrum of HEWs’ services.
“There is no treatment for cough [at the health post]. The HEWs refer mothers who come to this health post to the health center immediately.” (WDA leader, Amhara)
Respondents also noted concerns about costs in seeking care as they were not aware that these services were provided for free at the health post.
“Yes, my children are sick even today...I cannot take them to the health center. I have no money.” (FGD participant mother who did not seek care, Oromia)
Perceived poor quality of care
Even though most community participants attributed the children’s improved health to immunization services and health education provided by HEWs, their curative skills were not well recognized. The perception that HEWs delivered poor-quality care emerged either from an assumption that HEWs were not qualified enough to provide curative services or from past negative experiences. Mothers who took their children to a health post and did not get appropriate care or faced stockouts reported that they decided not to go back to the health post again. In addition, mothers who were referred by HEWs to a health center without clear explanation, or who were mistreated, reported that they did not want to go back to that health post:
“HEWs do not know how to treat childhood illnesses. For example, I was told by health educators to take my children to the health post if they get sick. But when I took my baby because of fever and vomiting, they said they have no medication. I think it is not only lack of medication; they may not know how to treat babies.” (Mother who did not seek care, FGD participant, Oromia)
Problems related to physical structures were also raised as important deterrents to care seeking. For example, lack of furniture, poor physical structures and the untidiness of the health post contributed to the perceived poor quality of care at the health post by some caregivers.
Lack of transport and distance to health posts
Distance to health posts and lack of transportation were found to affect caregivers’ ability to access health posts. In almost all the districts, participants reported that the catchment area was large, and villages were dispersed, making access to the health posts difficult for people living on the outskirts of the kebeles. Difficult topography and terrain were also reported to be barriers.
“The topography of the area is very bad. The road is hilly and stony. The river divides the villagers and the health post. It is difficult for parents to bring their children to the health post because of the river and the difficult topography.” (WDA leader, Oromia)
The four supply side barriers identified in this study include drug stockouts, health post closure, HEWs’ lack of skill and confidence in treating sick young infants and poorly equipped health posts.
Interrupted supply of iCCM/CBNC commodities was a major supply-side barrier that affected the utilization of services and contributed heavily to the perception of poor-quality services at the health post. Most interviewed HEWs also acknowledged that the frequent stockouts of iCCM/CBNC commodities led to service interruption:
“The majority of the people in the kebele have an interest in bringing their sick children to the health post, but the problem is the frequent service interruption due to inconsistent drug supply. When we get the supplies, we announce that we have the drugs, and the service is resumed. But after some time, we face drug stockouts and the service is interrupted again. As a result, the community is forced to look for other options.” (IDI with HEW, Oromia)
District stakeholders noted that the drug stockouts happened not only due to interrupted drug supply, but also due to the limited skill of HEWs in supply chain management, as they failed to forecast and request re-supplies on time. In addition, the distribution of drugs that were close to their expiry dates contributed to the problem, according to HEWs and the stakeholders.
Health post closure
Health post closure was another supply-side deterrent to care seeking. Parents noted their inability to locate HEWs for emergency care during weekends or after-hours.
"My four-year-old child was sick two weeks ago. He had diarrhea and vomiting, I gave him rice water, mixed with lemon and sugar. Unfortunately, he became unconscious...I wanted to go to the health post, but the HEWs do not work at night. So, I took him to the health center, around 7 kilometers away from my home, at night. Finally, my child recovered after taking treatment at the health center". (IDI with mother who did not seek care, SNNPR)
Lack of safe residential houses for the HEWs forced them to live far from the health post. This in turn prohibited HEWs from providing emergency services during the weekend or at night.
“The health post has no fence. There are no houses in the surrounding area, so we do not feel safe [to live close to the health post].” (IDI with HEW, SNNP)
Even in places where HEWs lived within the compound of the health posts, parents complained that some of the HEWs did not open their doors to provide emergency services outside of working hours. Parents disclosed their concern that the HEWs closed the health post without adequate reason.
Apart from weekends and after-hours closures, health posts were closed when the HEWs went to the community for home visits or when they were called for meetings or training. Such interruptions were reported to have negatively affected treatment-seeking behavior.
“It is difficult to get service in the health post, as the HEWs are sometimes not available. When we come here, they may be out in the villages...Sometimes they may go out for meetings.” (Mother who did not seek care, FGD participant, Amhara)
Some participants noted that based on their previous experience of health post closure, they resorted to traditional medicine or to cost-incurring options.
“We do not go to the health post as it is most of the time closed. We try home remedies. If there is no improvement, we go to private [providers], if we have the money.” (IDI with mother who did not seek care, Oromia)
HEWs, on the other hand, noted that their engagement went beyond the health sector, which overburdened them.
“Workload is our main challenge. When we are assigned for a political or agricultural mission out into the community, we are forced to close the health post and the mothers would not get us.” (IDI with HEW, SNNP)
Lack of confidence and skill among HEWs in treating sick young infants
Most HEWs were trained on iCCM, but some HEWs had not yet received training on CBNC. Even the trained HEWs felt that they lacked the skill and confidence needed to adequately treat sick young infants.
“It is very difficult to treat children under two months old. We need frequent refresher training and orientations.” (IDI with HEW, Oromia)
“HEWs can treat malnutrition, malaria, pneumonia and diarrheal diseases very well. However, they have gaps in treating sick young infants, as this is a newly acquired skill.” (Stakeholder, SNNP)
Poor physical structure or lack of essential equipment at the health post
HEWs indicated that the health posts were not well-equipped, which affected their work and their ability to provide high-quality care.
“We have no chairs [in our health post] for parents to sit on during examinations. We assess sick children while the mother is standing carrying her sick child. We also give injections and any treatment while she is standing carrying her child. We do not have benches for clients to sit on while waiting. This is challenging for us.” (IDI with HEW, Oromia)
Community members have raised the poor physical structure of the health post and its uncleanliness as an important deterrent to care seeking.
Suggested solutions to increase uptake of iCCM and CBNC services
The solutions suggested by the study participants are grouped into eight thematic areas.
Strengthening the WDA platform and enhancing awareness-raising by HEWs
Participants emphasized the importance of strengthening the WDA platform to bolster the link between communities and HEWs. They also highlighted the importance of creating awareness of iCCM and CBNC services and enhancing risk perception about childhood illnesses using HEWs and the WDA. These were effective strategies used in Degua Tembien, the best performing district in Tigray, where kebele cabinet members and WDA leaders worked closely with the HEWs. Their collaboration enhanced the link between the community and the health facilities, which in turn led to increased uptake of services.
“We have regular meetings with the HEWs to discuss about different health issues...When we visit the villages, we check and report to HEWs if there are children who are sick or malnourished.” (WDA leader, Degua Tembien, Tigray)
Mothers who were aware of the availability of iCCM and CBNC services reported that they received the information from HEWs. Some HEWs indicated that they promote the availability of services and how they can be reached by the community members when they are out for field work.
“We have prepared and posted a banner to show the services available in the health post. Most families have school age children who can read and tell them the available services. They can also get our phone numbers from the banner and call us.” (IDI with HEW, Meskan, SNNP)
Engaging religious leaders and using community structures
Gaining the support of religious leaders and traditional healers to address misconceptions about the causes of childhood illness was suggested to break the long-standing traditional beliefs that inhibit care-seeking. Organizing and utilizing community structures to change community perceptions and awareness was a common suggestion in all the districts. Community participants suggested several community platforms that could be used, such as churches, ‘idir’ (local term for community groups to help each other during funerals), ‘ekub’ (local term for a community savings groups) and ‘senbete’ (local term for gatherings of Orthodox Christian believers at church) to provide education and to mobilize the community.
“Our society has due respect toward religious leaders … If religious fathers tell the community to take their children to health posts when they are sick, they easily listen to them rather than the health professionals.” (Stakeholder, Amhara)
Using a multi-sectoral approach to create demand
Mobilizing different sectors to collaborate was suggested as an effective method to increase awareness of iCCM and CBNC programs. Participants recommended that political leaders become actively involved in championing iCCM and CBNC services to generate interest in their use.
“To enhance iCCM and CBNC service uptake, all government structures, including youth, women, and children affairs, should work in a coordinated way.” (Stakeholder, Amhara)
Establishing a feedback mechanism to address community concerns
Conducting consultative meetings with community members to identify and solve health service-related grievances was one of the strategies used by Meskan district health office.
“We have meetings with the community every three months to identify our strengths and weaknesses, so that we keep our strengths and work to improve our weaknesses. A community complaint about service interruption at health posts is the main one. We informed HEWs to give services for 24 hours, including weekends.” (Stakeholder, Meskan, Gurage, SNNP)
Ensuring the provision of iCCM and CBNC services during working hours
District managers reported several strategies to avoid service disruption when HEWs are out of the health posts. These included temporarily assigning health workers from health centers to health posts, temporarily re-assigning HEWs from places where there are two HEWs to cover for HEWs during training, and a better coordinated schedule during training or meetings, to ensure at least one of the HEWs would be available at the health post.
Providing iCCM/CBNC services during home visits
In Jawi, the highest-performing district in Amhara, HEWs carried iCCM and CBNC commodities during home visits, so they could carry out active case finding and treat sick children they identified.
“Whenever I go to the field, I carry my iCCM and CBNC kit. If a parent reports that a child is sick or if I find one myself, then I treat them.” (IDI with HEW, Jawi, Amhara)
Several participants suggested that all HEWs should adopt the practice of carrying out active case finding and treating sick children during their home visits to overcome problems related to access.
Building the capacity of HEWs
To increase HEWs’ capacity to provide respectful and compassionate care, stakeholders recommended that they should receive training on interpersonal communication. Stakeholder respondents also suggested training HEWs on drug supply chain management to mitigate stockouts. They also emphasized that HEWs need ongoing supportive supervision and review meetings to increase their confidence in treating newborns and children.
Ensuring the availability of child health commodities
Stakeholders emphasized the need to strengthen supply chain management to ensure adequate and timely provision of drugs and supplies to the health post.