Study area, study design and study population
The institution based case control study was conducted in Public Health Facilities of Arba Minch Town from March 4 to April 30, 2019. Arba Minch Town is one of the city administrations found in Gamo Zone of SNNPR, Ethiopia. Arba Minch Town is located at a distance of 495 km south from Addis Ababa, capital of Ethiopia, and 275 km south west away from Hawassa, the regional capital. The town administration has an estimated total population of 115, 639 with Male = 58,051, Female = 57, 588, a total of 18,051under-five children in 2018/2019 G.C. It also has 1 general public hospital which is serving as referral hospital for the patients from surrounding districts in the zone as well as surrounding zones, and 2 public Health Centers (14).Arba Minch General Hospital has emergency pediatric, OPD pediatric and Inpatient pediatrics to provide health care service for children. Pediatric and child health OPD and wards has 4 pediatricians, 1from Hospital and 3 from Arba Minch University and 4 GP, 6 Health Officer, 5 BSc Nurses, 7 Clinical Nurses, 1 IMNCI trained professional. Arba Minch Health Center and Shecha Health Center have 2 and 1 IMNCI trained professionals, respectively who provide the care for under-five children. All Mothers/Caregivers of under-five children with diarrheal illness who utilize health care services from Public Health Facilities of Arba Minch Town were source population, and those Mothers/Caregivers of under-five children with diarrheal disease who were visited Public Health Facilities during data collection period were study population. Cases were under-five children with signs/symptoms of diarrhea whose mothers sought treatment after 24-hours of the recognition of diarrhea(15, 16). Controls were under-five children with signs/symptoms of diarrhea whose mothers sought treatment within 24-hours of the recognition of diarrhea(15, 16). The inclusion criteria’s considered for the study subjects was all mothers/caregivers of under-five children seeking care for any type of diarrhea and visiting Pediatric/IMNCI clinic of Public Health Facilities of Arba Minch Town.
Sample size determination and sampling technique
Sample size was determined using Epi Info Version 7 software by using sample size calculation formula for unmatched case control study. Sample size was calculated for maternal educational status, presence of severity signs and child’s age in months. Finally, we have taken child’s age in months as main exposure variable, with proportion of exposure among cases and controls was 74.1% and 60.1%, respectively, 80% of power, 95% confidence level, OR of 1.9, 1 to 1 case to control ratio, since it yields larger sample size, 380(15). Considering 5% nonresponse rate, the final total sample size was 400.
All the Public Health facilities found in Arba Minch Town were included in the study. last year, 2010 EFY, same quarter 2-month report data was used to estimate number of participants from each health facility. Then, depending on that number, i.e. out of total 844 patients received care last year, sampling interval, K, was calculated, which was 2.11≈2. Proportional allocation of respondents to three public health facilities was done. So, cases were selected by systematic random sampling technique where every other person was included and controls were patients who came to the same health facility following the cases. The first participant of the case group was selected by lottery method while the control was under-five child with diarrheal illness who come to the health facility following the cases but within the 24 hours of onset of diarrheal illness. When Mothers/Caregivers complained of diarrhea in their child completed their consultation with a health care professional, they were moved to a private room for an interview until the total required sample size obtained.
Data collection procedure
Data was collected using semi-structured interviewer administered questionnaire which was adapted from EDHS_2016(17) and it includes predisposing, enabling, need/disease factors, promptness of treatment seeking, client perception towards pharmacy service, client satisfaction by the health facility service and client perception towards respect of health care professionals. Two diploma nurses in Heath Centers and 1 BSc Nurse in the Arba Minch General Hospital who were not assigned in Under-five clinic to provide the service for children presenting with medical case were collected the data. Two BSc Nurses supervised data collectors on daily bases to maintain the quality of data. Cases and Controls were recruited from Hospital and Health Centers after they came to the facilities and are diagnosed with diarrhea and they were moved to private room to provide information.
Data Quality Control
The questionnaire was initially prepared in English and it was translated into Amharic, local language, and back into English by language experts, to check the consistency. Two-day training was given for data collectors and supervisors about the way of selecting study participants, way of interviewing and checking the already filled questionnaire by the principal investigator. Pretesting was performed at Shelle Health Center of Arba Minch Zuria district on 5% of sample size to check consistency and any ambiguity of the questionnaire a week back of actual data collection, then necessary revisions like some of the skipping pattern was modified. Data completeness was checked by the supervisor daily and weekly by the Principal Investigator for completeness and missing values.
Data Processing and Analysis
Data was entered into EpiData Version 4.4.2.1 and exported to SPSS version 23 for further analysis. Data cleaning and coding was conducted. Descriptive analysis was carried out and summarized by frequency tables, graphs and charts. Study participants’ household wealth status was assessed by Principal component analysis. Then, participants were ranked into 3 groups, Poor, Middle, and Rich, based on the factor that explains largest variance in the included variables. The Hosmer Lemeshow statistics and deviance coefficient was used to check goodness of fit of the model and the model was good fit. No multicollinearity and outliers as it was checked by standard error of coefficients>2 and standardized residuals of >1.96 at 0.05 significance level respectively. Both bivariable and multivariable logistic regression was done to identify candidate variables and determinants of delay in seeking timely care, respectively. Statistical significance of variables at final model was declared at p-value <0.05 and 95% CI of adjusted odds ratio.
Operational definitions
Caregiver: -Any person above 18 years of age who is directly responsible for the care of the child at the time of the study(11, 18).
Delay in seeking Care: - Care that was sought from health facilities after 24 hours from the recognition of the presence of diarrhea in under-five children(15).
Client perception towards pharmacy service: - the perception of patients towards the pharmaceutical services provided in the health facility by pharmacy professionals were measured by 10 questions. The questions were organized to be responded in the Likert scale, ranging from 1(strongly disagree) to 5(strongly agree). Then, the mean score was calculated, and the scores above the mean were considered to have positive perception towards the pharmacy service and those who score below the mean were considered to have negative perception toward the pharmacy services(19).
Client satisfaction: -the satisfaction of patients with the service provided in the health facility by health professionals were measured with 12 questions. They were organized to be responded in the Likert scale, ranging from 1(Poor) to 5(Excellent). The, the mean value was calculated and those who score above the mean were considered to have good satisfaction and those who score below the mean were considered to have poor satisfaction(19).
Client perception towards respect of health workers: - the respect of health workers was measured in terms of patient’s response on the 5 questions provided. The questions were organized in Likert scale, ranging from 1(strongly disagree) to 5(strongly agree). Then, the mean score was calculated and those who score above the mean were considered as they got respect from health workers and those who score below the mean were considered that as they did not get respect from health workers(20).