Maternal social support and health facility delivery in Southwest Ethiopia.

BACKGROUND: Maternal mortality continues to decrease in the world but remain the most important health problems in low-income countries. Although evidence indicates that social support is an important factor influencing health facility delivery, it has not been extensively studied in Ethiopia. Therefore, this study aimed to assess the effect of maternal social support and related factors on health facility delivery in southwest Ethiopia. METHODS: A cross-sectional survey data on 3304 women aged 15-47 years in three districts of Ethiopia, were analyzed. Using multivariable logistic regression, we assessed the association between health facility birth, social support, and socio-demography variables. Adjusted odds ratios with 95% confidence intervals were used to identify statistically significant associations at 5% alpha level. RESULT: Overall, 46.9% of women delivered at health facility in their last pregnancy. Average travel time from closest health facility (AOR: 1.51, 95% CI 1.21 to 2.90), mean perception score of health facility use (AOR: 1.83, 95% CI 1.44 to 2.33), involvement in final decision to identify their place of childbirth (AOR: 2.12, 95% CI 1.73 to 2.58) had significantly higher odds of health facility childbirth. From social support variables, women who perceived there were family members and husband to help them during childbirth (AOR: 3.62, 95% CI 2.74 to 4.79), women who received continuous support (AOR: 1.97, 95% CI 1.20 to 3.23), women with companions for facility visits (AOR: 1.63, 95% CI 1.34 to 2.00) and women who received support from friends (AOR: 1.62, 95% CI 1.16 to 3.23) had significantly higher odds of health facility childbirth. CONCLUSIONS: Social support was critical to enhance health facility delivery, especially if women's close ties help facility delivery. An intervention to increase facility delivery uptake should target not only the women's general social supports, but also continuous support during childbirth from close ties including family members and close friends as these are influential in place of childbirth. Also actions that increase women's healthcare decision could be effective in improving health facility delivery.

Acceptability of peer learning and education approach on malaria prevention (PLEA-malaria) through primary schools communities in rural Ethiopia: peer educators' perspectives.

BACKGROUND: Evidence on peer educators' experiences of implementing the school-based educational interventions on malaria prevention would be used as inputs for malaria eliminating efforts. This study explored the acceptability of the school-based peer-learning and education approach on malaria prevention (PLEA-malaria) among peer educators in Ethiopia. METHODS: This process evaluation study was aimed to examine the success of the school-based PLEA-malaria that was implemented in 75 primary schools in Jimma from 2017 to 2019. A mixed research method was employed to collect post-intervention data from 404 peer educators and key stakeholders. Data were collected using a structured questionnaire and interview guide. Multivariable linear regression modelling was performed using SPSS software version 26.0. Atlas ti 7.5 for windows was used to analyse the qualitative data. The result was presented by triangulating the findings of the qualitative and quantitative methods. RESULTS: The mean score (M, range = R) of acceptability of PLEA-malaria was (M = 20.20, R = 6-30). The regression modelling showed that age; (ß = 0.264, 95% CI 0.266 to 0.632), GPA; (ß = 0.106, 95% CI 0.008 to 0.074), parental readiness for malaria education; (ß = 0.184, 95% CI 0.711 to 2.130), frequency of peer education; (ß = 0.232, 95% CI 1.087 to 2.514) and team spirit; (ß = 0.141, 95% CI 0.027 to 0.177) were positively associated with the acceptability while this relationship was negative for the number of ITN in the household; (ß = - 0.111, 95% CI - 1.182 to -0.13) and frequency of parent-student communication; (ß = - 0.149, 95% CI - 1.201 to - 0.293). The qualitative study identified facilitators of PLEA-malaria (e.g. team formation process, outcome efficacy, presence of schools' structures, schools priority, and support) and barriers (e.g. low commitments, threat appraisal, response efficacy, and PLEA-malaria implementation gaps). CONCLUSION: The results suggested that the acceptability of the school-based PLEA-malaria was higher implying the strategy is promising in promoting malaria prevention in primary schools. Considering factors related to personal, access to malaria preventive services, school system, and social support in education and behaviour change interventions would be important to improve the acceptability. The relationship about how an improvement in the level of acceptability would in turn influences malaria preventive behaviours among the students should be investigated.

Acceptability and feasibility of the school-engaged social and behavior change communication approach on malaria prevention in Ethiopia: implications for engagement, empowerment, and retention (EER) of education sectors in malaria elimination efforts.

BACKGROUND: Evidence on process outcomes such as acceptability, and feasibility of behavior change communication interventions are important in program evaluation to understand how, and why such a program works. However; documented evidence on the issue is not available as far as the social and behavior change communication (SBCC) on malaria is concerned. Enrolling the frontline providers this study measured the acceptability and feasibility of the school-engaged SBCC strategy on malaria prevention in malaria-endemic settings of Ethiopia. METHODS: A school-engaged SBCC strategy involving various communication and capacity-building interventions aimed to advance malaria preventive practices in primary schools in Jimma were implemented from 2017 to 2019. A cross-sectional study was conducted with 205 key stakeholders at the end of the intervention. Both acceptability and feasibility were measured using standardized tools. Data were collected using a structured questionnaire and filled by the study participants. The SPSS version 26 was used to analyze the data. Multivariate general linear modeling was performed to identify the predictors of acceptability and feasibility of the program. P-value < 5% was considered to decide statistical significance. RESULTS: The result showed the mean scores (M, range = R) of acceptability and feasibility of the program were (M = 25.63, R = 6 to 30) and (M = 19.35, R = 5 to 25) respectively. The multivariate linear modeling showed acceptability was affected by self-efficacy; (ß = 0.438, P < 0.001), community support; (ß = 0.417, P < 0.001), school climate; (ß = - 0.16; P = 0.003), perceived malaria threat; (ß = 0.40, P < 0.001) and knowledge; (ß = 0.229, P = 0.013). Similarly, feasibility was influenced by self-efficacy; (ß = 0.352, P < 0.001), community support; (ß = 0.591, P < 0.001), school climate; (ß = - 0.099, P-value < 0.030) and perceived malaria threat; (ß = 0.172, P = 0.002). CONCLUSION: With a considerably high level of acceptability, the school-engaged SBCC strategy to enhance malaria preventive practices seems feasible. The SBCC strategy targeting personal factors such as malaria threat perceptions, knowledge and skills on the program, and contextual factors that include school social climate and community support would be fruitful to facilitate the implementation of the program. The result implicates the benefit of intensifying such a strategy to engage, empower, and retain the education sectors in malaria elimination efforts and beyond.

Primary school students' poetic malaria messages from Jimma zone, Oromia, Ethiopia: a qualitative content analysis.

BACKGROUND: The engagement of schools in malaria control is an emerging strategy. Little is known about the involvement of students in the development of malaria messages. This study evaluated the message content of primary school students' malaria poems. METHODS: A qualitative content analysis was conducted to explore malaria messages conveyed in poems produced by students. Twenty poems were purposively selected from twenty schools across rural villages in five districts of the Jimma Zone. Data were analyzed using Atlas.ti version 7.1.4 software. The message contents were quantified in terms of frequency, and including metaphors, presented using central themes, categories, and supportive quotations. RESULTS: A total of 602 malarial contents were generated, and organized into 21 categories under five central themes. 1) Malaria-related knowledge (causation and modes of transmission, mosquito breeding and biting behavior, signs and symptoms, care for insecticide-treated nets (ITNs), and prevention methods), 2) Perceived threats from malaria, 3)The effectiveness of prevention methods (i.e., related to the adaption of ITNs, environmental cleaning, indoor residual spray (IRS), treatment for fever, and drug adherence practices), 4) Misconceptions, beliefs, and malpractices regarding the cause of malaria and drug use) and 5) Direct calls to the adopt ITN, IRS, clean surroundings, treatment, and drug use. The most commonly conveyed message contents were about the severity of malaria, distinguishable signs and symptoms, calls for community participation for malaria elimination, knowledge of preventive methods, and effectiveness of ITN use. Metaphoric expressions (war and death) were used to convey messages about the severity and the need to manage the prognosis of malaria through the active ITN use, which itself was metaphorically represented as 'a trap' to mosquitoes. CONCLUSIONS: The poetic analysis indicated that the students developed and disseminated rich malarial messages, especially on malarial knowledge, and perceptions, beliefs, norms and practices of the local community to prevent and control malaria. Therefore, primary school students can be a source of information and would effectively communicate knowledge, perceptions, and promote malaria related practices, particularly in rural settings.

Comparing insecticide-treated nets access-use based on universal household and population indicators vis-a-vis measures adapted to sleeping spaces in Ethiopia.

BACKGROUND: Insecticide-treated nets (ITNs) access-use has been pivotal monitoring indicator for malaria prevention and control, particularly in resource limited settings. The objective of the study was to compare ITN access-use based on universal household and population indicators and measures adapted to sleeping spaces. METHODS: A cross-sectional study was conducted in five districts of Jimma Zone, Ethiopia, March, 2019. 762 HHs were sampled for the survey. Multi-stage followed by simple random sampling used. Monitoring and evaluation reference group's (MERG's) indicators were used for measuring ITN access-use. MERG's indicators are each adapted ITN access-use to sleeping spaces. Household (ownership, saturation and sufficiency) and population access and household members' status of last night sleeping under ITN compared based on the two models. Differences of estimates of ITN access-use based on the two methods reported as magnitude of over/under estimations, at p-value < 0.05. RESULTS: Based on MERG's approach, the study revealed household (HH) based indicators as such: HH ownership of at least 1 ITN (92.6%), sufficiency of ITN for every two people in HH (50.3%), and saturation of ITN for every 2 people in HHs with any ITN (54.6%). Moreover, population based indicators were: population with ITN access (P3 = 78.6%), people who slept under ITN previous night (63.0%), people who slept under ITN among who accessed it (73.1%), ITN use-gap (26.9%). Equivalent indicators of HH ownership, sufficiency, saturation, and people accessed at where they actually slept, and people slept under ITN among those accessed at where they slept estimated at 71.3%, 49.4%, 69.3%, 66.3%, and 92.1%, respectively. MERG's approach over-estimated ownership, people's access, and behaviour-failures by 21.3%, 12.3%, 19.0%, respectively. Over-estimation occurred for reasons such as many sleeping spaces lack ITN and > 2 people actually slept per sleeping space. CONCLUSIONS: MERG's universal indicators over estimated households and populations ITN access-use as a result of absence of measures capturing access-use values at spaces where people actually slept. Consequently, measures adapted to sleeping contexts revealed potential misdistributions practiced when the existing indicators are in use. Insertion of sleeping spaces into existing approach will be worthwhile and needs to be promoted as it improves curiosity in ITN distribution, produces closer estimates and prevents malaria prevention and control programmes from overlooking access-use challenges.

Perceived sustainability of the school-based social and behavior change communication (SBCC) approach on malaria prevention in rural Ethiopia: stakeholders' perspectives.

BACKGROUND: Evidence on what makes the school-engaged social and behavior change communication (SBCC) interventions on malaria prevention more sustainable are limited in literature partly due to its recent emergence. Enrolling the key stakeholders, this study explored the perceived sustainability of the SBCC interventions on malaria prevention through primary school communities in rural Ethiopia. METHODS: The SBCC interventions were implemented from 2017 to 2019 in 75 primary schools and villages in rural Jimma to promote malaria preventive practices. As a part of program evaluation, this study employed a mixed-method to collect qualitative and quantitative data from 205 stakeholders following the end of the program. Data were collected using interview guides and structured questionnaires. The SPSS version 26 and Atlas ti7.1 software were used to analyze the data. Multivariable linear regression modeling was used to identify predictors of the perceived sustainability of the program (SOP). RESULTS: The mean score of SOP was 25.93 (SD = 4.32; range 6-30). Multivariable linear regression modeling showed that the perceived risk to malaria (ß = 0.150; P = 0.029), self-efficacy (ß = 0.192; P = 0.003), and perceived fidelity of implementation (ß = 0.292; P = 0.000) and degree of adoption (ß = 0.286; P = 0.000) were positively predicted the perceived SOP. The qualitative result identified various barriers and opportunities to sustaining the program that summarized under three themes which include perceptions about the quality of program delivery (e.g inadequate involvement of stakeholders and staffs, concerns over short project life, immature sustainability efforts), school settings (e.g schools' malaria priority, schools' climate and quality of coaching) and the outer settings (e.g existing structures in the health and education systems). CONCLUSION: The study identified key predictive variables such as stakeholders' perceived risk to malaria, self-efficacy, perceived fidelity of implementation and degree of adoption that could help to improve the sustainment of the school-based SBCC approach on malaria prevention and control. Further longitudinal study should be conducted to examine the rate of decline in program components over time and how improved sustainability would contribute to the effectiveness on malaria preventive behaviors among students.

Effectiveness of the school-based social and behaviour change communication interventions on insecticide-treated nets utilization among primary school children in rural Ethiopia: a controlled quasi-experimental design.

BACKGROUND: School-based behaviour change communication interventions could help to achieve behavioural changes in the school and enhance the enrollment of the students and teachers as health messengers to local communities. Evidence on the impacts of the school-engaged malaria preventive interventions are limited as far as the social and behaviour change communication (SBCC) is concerned. This study examined the effectiveness of the school-based SBCC approach on insecticide-treated nets (ITNs) utilization among primary school students in malaria-endemic settings of Ethiopia. METHODS: Various participatory, educational, and communication interventions were implemented from 2017 to 2019 in 75 primary schools and respective villages in Jimma to promote malaria preventive practices. A quasi-experimental design was conducted with randomly selected 798 students (i.e. 399 intervention and 399 control groups). Data were collected by trained interviewers using structured questionnaires. The SPSS version 26 software was used to analyse the data. Propensity score matching analysis was performed to control for possible confounding biases. The average effects of the intervention were estimated using multivariate general linear modelling to estimate for mean differences and odds ratio based on the nature of data. RESULTS: The result showed that the ITNs utilization was 6.857 folds in the intervention groups compared to the counterpart; (OR = 6.857; 95% CI: (4.636, 10.1430); effect size = 39%). A mean differences (MD) of self-efficacy (MD = 15.34; 95% CI: 13.73 to 16.95), knowledge (MD = 5.83; 95% CI: 5.12 to 6.55), attitude (MD = 6.01; 95% CI: 5.26 to 6.77), perceived malaria risk (MD = 2.14; 95% CI: 1.53 to 2.76), and perceived family supports (MD = 6.39; 95% CI: 5.57 to 7.22) were observed favoring the intervention. Multivariable logistic regression modelling results showed that knowledge (ß = 0.194, 95% CI: 1.09 to 1.35) and perceived family supports (ß = 0.165, 95% CI: 1.11 to 1.25) and self-efficacy (ß = 0.10, 95% CI: 1.22 to 2.32) predicted the ITN utilization among the school children. CONCLUSIONS: The finding of this study suggested that the school-based SBCC approach combined with peer education activities advanced the malaria-related knowledge, attitude, self-efficacy, risk perceptions, and family supports and ultimately improved the sustained use of ITNs among school-going children. Further research should be conducted to understand the mechanism of these effects given the influences of social, health services, and school systems are considered.

Messenger students' engagement scale: Community perspectives on school-based malaria education in Ethiopia.

A two-year school-based malaria education intervention was developed to engage students as implementers in malaria prevention and control in the Oromia region, Ethiopia. The current study aimed to validate messenger students' engagement scale (MSES) in malaria education. The scale development process was done stepwise. Multiple behavioural theories were examined to derive possible domains of engagement. Next, a pool of items was developed by linking the domains with malaria target behaviours. The items critically reviewed, pretested and refined for clarity and appropriateness. A cross-sectional survey of 451 sample households with school-going children was conducted in five districts of the Jimma-Zone in March-2019. Exploratory factor analysis (EFA)/principal component analysis (PCA) was executed to evaluate the construct validity of the scale. Rotated factor loading coefficients of ≥0.4 were retained. Items loaded on multiple factors were retained on the factor with a higher loading score. Cronbach's alpha of 0.7 was used as the cutoff point for reliability. Discriminative validity was declared based on Pearson correlation (between the extracted factors) coefficients that were moderate (r < 0.7), and less than the respective variance explained (VE) by each factor. The validity of convergence of domains with the overall MSES assessed (0.4 < r < 0.9). Logistic regression for key malaria preventive practices was conducted to assess predictive validity. The study explored a 24-item MSES in six domains of malaria education: reminding, supporting, monitoring, messenger credibility, role modelling and norm setting. The domains explained 67.82% variance of MSES, with a reliability of 93.3%. The factors were convergent with the overall scale (r = 0.764-0.834). Most factors were discriminative, with moderate correlation to each other. Adjusted odds ratios showed engaging credible students in reminding malaria preventive messages and modelling practices predicted exposure to message, insecticide-treated net (ITN) utilisation and cleaning surrounding. The current MSES is reliable, valid and predictive of malaria preventive practices.

Characterizing 'health equity' as a national health sector priority for maternal, newborn, and child health in Ethiopia.

Background: The pursuit of health equity is a priority in Ethiopia, especially with regards to maternal, newborn, and child health (MNCH). To date, there has been little characterization of the 'problem' of health inequity, and the normative assumptions implicit in the representation of the problem. Yet, such insights have implications for shaping the framing, incentivization, and implementation of health policies and their wider impact. Objective: In this article, we characterize how health (in)equity is represented as a policy issue, how this representation came about, and the underlying assumptions. Methods: We draw from Bacchi's 'what is the problem represented to be' approach to explore how national-level actors in the health sector constitute the problem. The data for our analysis encompass 23 key informant interviews with national health sector actors working in leadership positions on MNCH in Ethiopia, and six policy documents. Findings were derived from thematic and content analysis. Results: Health inequity is a normalized and inevitable concern that is regarded as actionable (can be altered) but not fully resolvable (can never be fully achieved). Operationally, health equity is viewed as a technocratic matter, reflected in the widespread use of metrics to motivate and measure progress. These representations are shaped by Ethiopia's rapid expansion of health services into rural areas during the 2000s leading to the positive international attention and funding the country received for improved MNCH indicators. Expanding the coverage and efficiency of health service provision, especially in rural areas, is associated with economic productivity. Conclusion: The metrication of health equity may detract from the fairness, justice, and morality underpinnings of the concept. The findings of this study point to the implications of global pressures in terms of maximizing health investments, and call into question how social, political, and economic determinants of health are addressed through broader development agendas.

Effectiveness of peer-learning assisted primary school students educating the rural community on insecticide-treated nets utilization in Jimma-zone Ethiopia.

BACKGROUND: Making insecticide-treated nets (ITNs) utilization a social norm would support the global goal of malaria eradication and Ethiopian national aim of its elimination by 2030. Jimma zone is one of the endemic settings in Ethiopia. This study aimed to report effects of malaria education, delivered by students, on community behaviours; particularly ITNs. METHODS: In pre-posttest, cross-sectional household surveys conducted in rural villages of 5 districts in Jimma Zone, Ethiopia, 762 households were sampled. The intervention engaged students from primary schools in participatory peer education within small groups, followed by exposing parents with malaria messages aimed at influencing perceptions and practices. The data were analysed using SPSS version 20.0. Proportions/means differences were computed to compare changes in exposure, knowledge, perceptions, and practices using 95% CI at p < 0.05. Regression analyses were conducted to assess exposures to school-based education, content intensity, perception, and access related predictors of ITN utilization over the intervention periods. RESULTS: Over the intervention periods, the findings showed significant improvement in exposure to and content intensity of malaria messages delivered by students, effect size (ES) = 44.5% and 19.3%, p < 0.001, respectively. ITN utilization (ES = 25.8%), and the reported behaviour of giving ITN priority to children under 5 years old and pregnant women increased by ES = 16.3% and 24.8%, respectively. The exposure status or content intensity of malaria education, in turn, significantly improved comprehensive knowledge about malaria (ß = +1.82), misconceptions about causes (ß = - 11.46), awareness of caring for ITN (ß = +24.79), identifying ITN as effective preventive methods (OR = 1.93), attitude towards ITN (ß = +0.20), perceived efficacy of ITN (OR = 1.04), acceptance of ITN as a means to control the danger of malaria (ß = +8.08%), and ITN utilization (OR = 1.85). Nonetheless, perceived threat (ß = - 0.19) significantly negatively correlated with exposure to students' messages. Socio-demography, access, exposures to messages, and parental perception that students were good reminders predicted ITN utilization over the intervention periods with some changing patterns. CONCLUSIONS: Exposing the community to malaria education through students effectively supports behaviour change, particularly ITN usage, to be more positive towards desired malaria control practices. A school-based strategy is recommended to the national effort to combat malaria.

School-based social and behavior change communication (SBCC) advances community exposure to malaria messages, acceptance, and preventive practices in Ethiopia: A pre-posttest study.

BACKGROUND: Ethiopia has shown incredible success in malaria morbidity, mortality, and control. Community empowerment is a milestone to meet the ambitious plans of eliminating malaria by 2030. OBJECTIVES: This study aimed to evaluate school-based malaria social behavior change communication (SBCC) in terms of community message exposure, acceptance, knowledge, and practices. METHODS: A community-based pre-posttest study was conducted in five districts of the Jimma Zone, Ethiopia. 762 and 759 households were sampled for baseline and end-line, respectively. The intervention engaged students from primary schools on participatory peer education within small groups, followed by exposing parents with malaria messages aimed to influencing ideation and preventive practices. The data were analyzed using Statistical Package for Social Sciences (SPSS) version 20.0. Proportion/mean differences were computed to compare both surveys on exposure, knowledge, perceptions, and practices at p <0.05. Finally, a regression analysis was conducted between key changes and school-based exposure. RESULTS: The study revealed a sharp increase in exposure to malaria messages with effect size (ES) of 65.7%, p <0.001. School specific exposure has grown to 57.8% (ES = 44.5%). Comprehensive knowledge about malaria increased to 39.1% (ES = 14.8%). Identifying mosquito bites as a cause of malaria was increased by ES = 20.8%. A slight reduction in risk perception (ES = 3.3%) and attitude (ES = 3.8%) and a higher rise in self-efficacy (ES = 8.5%) were observed. Community message acceptance in favor of malaria danger control was significantly improved by 10% i.e. an increase in rational decision making to uptake preventive practices. Consistently, insecticide-treated nets (ITNs) usage was improved to 63.0% (ES = 25.8%). Giving priority to use ITNs for under five years old children and pregnant women grew by 16.3% and 24.8%, respectively. Significant improvements were observed in treatment-seeking for fever (ES = 16.3%) and early treatment-seeking (ES = 15.5%). Not painting or plastering walls 6 months within spraying changed by ES = 61%. No significant change was observed in drug adherence. The school-based content intensity of exposure had effects on comprehensive knowledge, message acceptance, and ITN utilization. CONCLUSIONS: Engaging school-aged children effectively advances community exposure, perception, and behaviors. We recommend the inclusion of school-based SBCC in the national malaria control programs.

Formula-feeding practice and associated factors among urban and rural mothers with infants 0-6 months of age: a comparative study in Jimma zone Western Ethiopia.

BACKGROUND: Infants are in a state of rapid development and maturation; the growth rate is most rapid during the first 4 to 6 months of life. Few studies indicated that in developing countries including Ethiopia the prevalence and duration of breastfeeding is declining and being replaced by formula milk. Therefore, this study aimed to assess the formula-feeding practice and its associated factors among urban and rural mothers with infants 0-6 months of age in the Jimma Zone, Western Ethiopia. METHODS: A community-based cross-sectional study was conducted from November 7, 2015, to January 10, 2016, in the Jimma Zone. The quantitative data were collected from a sample of 714 respondents using a multistage sampling technique. Data were collected through a structured questionnaire and the multivariate logistic regression model was used to show predictors of the formula-feeding practice among mothers with infants 0-6 months of age. RESULT: The proportion of mothers who feed their baby formula-based was 47.2%, of which 34.5% were living in rural areas and 65.5% were living in urban areas. Among the mothers living in urban areas, the likelihood of formula-feeding was significantly associated with maternal educational status and attitude towards formula-feeding. On the other hand, being attended by relatives/friends and the traditional birth attendant was significantly associated with the formula-feeding practice among mothers who live in rural areas. CONCLUSION: Nearly half of the mothers in the study area practice formula-feeding for their infant. Therefore, sustained community based nutritional health education is recommended for pregnant and lactating mothers to reduce the practice of formula-feeding for infants.

Utilization of key preventive measures for pregnancy complications and malaria among women in Jimma Zone, Ethiopia.

BACKGROUND: In Ethiopia, malaria infections and other complications during pregnancy contribute to the high burden of maternal morbidity and mortality. Preventive measures are available, however little is known about the factors influencing the uptake of maternal health services and interventions by pregnant women in Ethiopia. METHODS: We analyzed data from a community-based cross-sectional survey conducted in 2016 in three rural districts of Jimma Zone, Ethiopia, with 3784 women who had a pregnancy outcome in the year preceding the survey. We used multivariable logistic regression models accounting for clustering to identify the determinants of antenatal care (ANC) attendance and insecticide-treated net (ITN) ownership and use, and the prevalence and predictors of malaria infection among pregnant women. RESULTS: Eighty-four percent of interviewed women reported receiving at least one ANC visit during their last pregnancy, while 47% reported attending four or more ANC visits. Common reasons for not attending ANC included women's lack of awareness of its importance (48%), distance to health facility (23%) and unavailability of transportation (14%). Important determinants of ANC attendance included higher education level and wealth status, woman's ability to make healthcare decisions, and pregnancy intendedness. An estimated 48% of women reported owning an ITN during their last pregnancy. Of these, 55% reported to have always slept under it during their last pregnancy. Analysis revealed that the odds of owning and using ITNs were respectively 2.07 (95% CI: 1.62-2.63) and 1.73 (95% CI: 1.32-2.27) times higher among women who attended at least one ANC visit. The self-reported prevalence of malaria infection during pregnancy was low (1.4%) across the three districts. We found that young, uneducated, and unemployed women presented higher odds of malaria infection during their last pregnancy. CONCLUSION: ANC and ITN uptake during pregnancy in Jimma Zone fall below the respective targets of 95 and 90% set in the Ethiopian Health Sector Transformation Plan for 2020, suggesting that more intensive programmatic efforts still need to be directed towards improving access to these health services. Reaching ANC non-users and ITN ownership and use as part of ANC services could be emphasized to address these gaps.

How do community health actors explain their roles? Exploring the roles of community health actors in promoting maternal health services in rural Ethiopia.

BACKGROUND: Maternal and child morbidity and mortality remains one of the most important public health challenges in developing countries. In rural settings, the promotion of household and community health practices through health extension workers in collaboration with other community members is among the key strategies to improve maternal and child health. Little has been studied on the actual roles and contributions of various individuals and groups to date, especially in the rural areas of Ethiopia. In this study, we explored the role played by different actors in promoting ANC, childbirth and early PNC services, and mainly designed to inform a community based Information, Education & Communication intervention in rural Ethiopia. METHODS: An exploratory qualitative study was conducted on 24 in-depth interviews with health extension workers, religious leaders, women developmental army leaders, and selected community members; and 12 focus group discussions, six with female and six with male community members. Data was captured using voice recorders and field notes and transcribed verbatim in English, and analyzed using Atlas.ti software. Ethical approval for the fieldwork was obtained from Jimma University and the University of Ottawa. RESULTS: Participants described different roles and responsibilities that individuals and groups have in promoting maternal/child health, as well as the perceived roles of family members/husband. Commonly identified roles included promotion of health care services; provision of continuous support during pregnancy, labour and postnatal care; and serving as a link between the community and the health system. Participants also felt unable to fully engage in their identified roles, describing several challenges existing within both the health system and the community. CONCLUSIONS: Involvement of different actors based on their areas of focus could contribute to community members receiving health information from people they trust more, which in turn is likely to increase use of services. Therefore, if our IEC interventions focus on overcoming challenges that limit actors' abilities to engage effectively in promoting use of MCH services, it will be feasible and effective in rural settings, and these actors can become an epicenter in providing community based intervention in using ANC, childbirth and early PNC services.

Promoting and delivering antenatal care in rural Jimma Zone, Ethiopia: a qualitative analysis of midwives' perceptions.

BACKGROUND: Despite improvements in recent years, Ethiopia faces a high burden of maternal morbidity and mortality. Antenatal care (ANC) may reduce maternal morbidity and mortality through the detection of pregnancy-related complications, and increased health facility-based deliveries. Midwives and community-based Health Extension Workers (HEWs) collaborate to promote and deliver ANC to women in these communities, but little research has been conducted on the professional working relationships between these two health providers. This study aims to generate a better understanding of the strength and quality of professional interaction between these two key actors, which is instrumental in improving healthcare performance, and thereby community health outcomes. METHODS: We conducted eleven in-depth interviews with midwives from three rural districts within Jimma Zone, Ethiopia (Gomma, Kersa, and Seka Chekorsa) as a part of the larger Safe Motherhood Project. Interviews explored midwives' perceptions of strengths and weaknesses in ANC provision, with a focus as well on their engagement with HEWs. Thematic content analysis using Atlas.ti software was used to analyse the data using an inductive approach. RESULTS: Midwives interacted with HEWs throughout three key aspects of ANC promotion and delivery: health promotion, community outreach, and provision of ANC services to women at the health centre and health posts. While HEWs had a larger role in promoting ANC services in the community, midwives functioned in a supervisory capacity and provided more clinical aspects of care. Midwives' ability to work with HEWs was hindered by shortages in human, material and financial resources, as well as infrastructure and training deficits. Nevertheless, midwives felt that closer collaboration with HEWs was worthwhile to enhance service provision. Improved communication channels, more professional training opportunities and better-defined roles and responsibilities were identified as ways to strengthen midwives' working relationships with HEWs. CONCLUSION: Enhancing the collaborative interactions between midwives and HEWs is important to increase the reach and impact of ANC services and improve maternal, newborn and child health outcomes more broadly. Steps to recognize and support this working relationship require multipronged approaches to address imminent training, resource and infrastructure deficits, as well as broader health system strengthening.

Subnational health management and the advancement of health equity: a case study of Ethiopia.

BACKGROUND: Health equity is a cross-cutting theme in the United Nations 2030 Agenda for Sustainable Development, and a priority in health sector planning in countries including Ethiopia. Subnational health managers in Ethiopia are uniquely positioned to advance health equity, given the coordination, planning, budgetary, and administration tasks that they are assigned. Yet, the nature of efforts to advance health equity by subnational levels of the health sector is poorly understood and rarely researched. This study assesses how subnational health managers in Ethiopia understand health equity issues and their role in promoting health equity and offers insight into how these roles can be harnessed to advance health equity. METHODS: A descriptive case study assessed perspectives and experiences of health equity among subnational health managers at regional, zonal, district and Primary Health Care Unit administrative levels. Twelve in-depth interviews were conducted with directors, vice-directors, coordinators and technical experts. Data were analyzed using thematic analysis. RESULTS: Subnational managers perceived geographical factors as a predominant concern in health service delivery inequities, especially when they intersected with poor infrastructure, patriarchal gender norms, unequal support from non-governmental organizations or challenging topography. Participants used ad hoc, context-specific strategies (such as resource-pooling with other sectors or groups and shaming-as-motivation) to improve health service delivery to remote populations and strengthen health system operations. Collaboration with other groups facilitated cost sharing and access to resources; however, the opportunities afforded by these collaborations, were not realized equally in all areas. Subnational health managers' efforts in promoting health equity are affected by inadequate resource availability, which restricts their ability to enact long-term and sustainable solutions. CONCLUSIONS: Advancing health equity in Ethiopia requires: extra support to communities in hard-to-reach areas; addressing patriarchal norms; and strategic aligning of the subnational health system with non-health government sectors, community groups, and non-governmental organizations. The findings call attention to the unrealized potential of effectively coordinating governance actors and processes to better align national priorities and resources with subnational governance actions to achieve health equity, and offer potentially useful knowledge for subnational health system administrators working in conditions similar to those in our Ethiopian case study.

Maternity waiting areas - serving all women? Barriers and enablers of an equity-oriented maternal health intervention in Jimma Zone, Ethiopia.

In Ethiopia, maternal waiting areas (MWAs) - residential areas near health facilities where women can stay while waiting to give birth - are community-based, equity-oriented interventions to improve maternal outcomes among rural populations. In this qualitative study we sought to explore the barriers and enablers that Health Extension Workers (HEWs) encounter when engaging with communities about MWAs. We conducted semi-structured interviews with HEWs across rural sites in Jimma Zone, Ethiopia. Drawing from an ecological model of social determinants of maternal and child health, we analysed data using thematic coding methods. HEWs reported a variety of factors that determined MWA use, including the number of children at home, previous childbirth experiences, community support networks, decision making practices within families, the availability and acceptability of health services, geographical access, and health beliefs. HEWs worked to increase the use of MWAs by engaging with husbands and communities, raising awareness in target groups of women, and managing community participation. Policies and practices that support enhanced training for HEWs, increased resources for communities, and greater opportunities for HEWs to liaise with decision makers at various levels of influence are possible ways forward to improve MWA use, specifically, and maternal and neonatal/child health outcomes more generally.

Talking health: trusted health messengers and effective ways of delivering health messages for rural mothers in Southwest Ethiopia.

BACKGROUND: Access to trusted health information has contribution to improve maternal and child health outcomes. However, limited research to date has explored the perceptions of communities regarding credible messenger and messaging in rural Ethiopia. Therefore, this study aimed to explore sources of trusted maternal health information and preferences for the mode of delivery of health information in Jimma Zone, Ethiopia; to inform safe motherhood implementation research project interventions. METHOD: An exploratory qualitative study was conducted in three districts of Jimma Zone, southwest of Ethiopia, in 2016. Twelve focus group discussions (FGDs) and twenty-four in-depth interviews (IDIs) were conducted among purposively selected study participants. FGDs and IDIs were conducted in the local language, and digital voice recordings were transcribed into English. All transcripts were read comprehensively, and a code book was developed to guide thematic analysis. Data were analyzed using Atlas.7.0.71 software. RESULT: Study Participants identified as Health Extension Workers (HEWs) and Health Development Army (HDA) as trusted health messengers. Regarding communication channels, participants primarily favored face-to-face/interpersonal communication channels, followed by mass media and traditional approaches like community conversation, traditional songs and role play.In particular, the HEW home-to-home outreach program for health communication helped them to build trusting relationships with community members; However, HEWs felt the program was not adequately supported by the government. CONCLUSION: Health knowledge transfer success depends on trusted messengers and adaptable modes. The findings of this study suggest that HEWs are a credible messenger for health messaging in rural Ethiopia, especially when using an interpersonal message delivery approach. Therefore, government initiatives should strengthen the existing health extension packages by providing in-service and refresher training to health extension workers.

A quality assessment of Health Management Information System (HMIS) data for maternal and child health in Jimma Zone, Ethiopia.

Health management information system (HMIS) data are important for guiding the attainment of health targets in low- and middle-income countries. However, the quality of HMIS data is often poor. High-quality information is especially important for populations experiencing high burdens of disease and mortality, such as pregnant women, newborns, and children. The purpose of this study was to assess the quality of maternal and child health (MCH) data collected through the Ethiopian Ministry of Health's HMIS in three districts of Jimma Zone, Oromiya Region, Ethiopia over a 12-month period from July 2014 to June 2015. Considering data quality constructs from the World Health Organization's data quality report card, we appraised the completeness, timeliness, and internal consistency of eight key MCH indicators collected for all the primary health care units (PHCUs) located within three districts of Jimma Zone (Gomma, Kersa and Seka Chekorsa). We further evaluated the agreement between MCH service coverage estimates from the HMIS and estimates obtained from a population-based cross-sectional survey conducted with 3,784 women who were pregnant in the year preceding the survey, using Pearson correlation coefficients, intraclass correlation coefficients (ICC), and Bland-Altman plots. We found that the completeness and timeliness of facility reporting were highest in Gomma (75% and 70%, respectively) and lowest in Kersa (34% and 32%, respectively), and observed very few zero/missing values and moderate/extreme outliers for each MCH indicator. We found that the reporting of MCH indicators improved over time for all PHCUs, however the internal consistency between MCH indicators was low for several PHCUs. We found poor agreement between MCH estimates obtained from the HMIS and the survey, indicating that the HMIS may over-report the coverage of key MCH services, namely, antenatal care, skilled birth attendance and postnatal care. The quality of MCH data within the HMIS at the zonal level in Jimma, Ethiopia, could be improved to inform MCH research and programmatic efforts.

"The sun keeps rising but darkness surrounds us": a qualitative exploration of the lived experiences of women with obstetric fistula in Ethiopia.

BACKGROUND: Obstetric fistula is a hole between the vagina and bladder, and/or between the vagina and rectum, triggered by prolonged obstructed labor. The World Health Organization has estimated that at least 50,000 to 100,000 cases of obstetric fistula occur every year, and that over two million women with obstetric fistula in developing countries remain untreated. Research on women's lived experiences of obstetric fistula is limited. This study aimed to explore the lived experience of women with obstetric fistula at Bahir Dar Hamlin Fistula Center, Amhara Regional State, Ethiopia. METHODS: A qualitative study design, drawing from a phenomenological approach, was employed to explore the lived experience of purposively-selected sample of ten women with obstetric fistula. In-depth interviews were conducted in the local language (Amharic) using an interview guide. Interviews were transcribed and translated into English, and transcripts were entered as primary documents into Atlas.ti 7 software. Thematic categories were identified, and transcripts were coded accordingly. RESULTS: Participants perceived that the contributing factors to obstetric fistula were: instrument-assisted delivery; inappropriate physical examination and care; early marriage; and long duration of labour. As a result of obstetric fistula, the patients suffered from uncontrolled dripping of urine and/or faeces (and associated offensive odours), ostracization by their family and community members, and feeling hopeless and isolation from the community. Patients used different coping mechanisms, including frequent washing of clothes and changing of underwear; they also expressed that they preferred to be alone. CONCLUSION: Women with obstetric fistula experienced urine incontinence and associated bad odour; social and psychological problems like isolation, divorce and fears were commonly reported. Our findings from perspectives of Ethiopian setting suggest that integrated services for women with obstetric fistula are warranted, including physical therapy, psychological support and social reintegration.