Satisfaction of Caretakers on Community Based Newborn Care and Its Predictors in Boloso Sore District, Southern Ethiopia

Background: A community based newborn care was very important to the survival of newborns. The program is primarily provided by Health Extension Workers. However, the quality of the care in relation to caretakers’ satisfaction has not been adequately documented. Therefore the aim of this study was to assess satisfaction of caretakers on Community-Based Newborn Care and its predictors in Boloso Sore District in South Ethiopia. Methods : A community based cross-sectional study design was done on 426 caretakers with infants’ age less than 6 months. The outcome measure was satisfaction of caretakers. Socio-demographic characteristics and service utilization of respondents, and institutional and provider-related factors were predictors of caretakers’ satisfaction on the service. Structured questionnaire developed from relevant literatures and pretested before in use. The outcome was measured by using a 5-point Likert scale of seven questions (items). The seven items were also assessed for overall reliability (Chronbach’s alpha=0.94). A multivariate logistic regression was used to identify predictors of satisfaction of care takers by controlling potential confounders. Results : Based on this study 48.8 % of caretakers who received the Community Based Newborn Care from health extension workers were satisfied. Factors associated with their satisfaction were, educational status (AOR: 3.38, 95%CI: 1.02-11.27), postnatal care given by HEWs (AOR: 0.61, 95%CI: 0.39-0.98), recent child birth at home (AOR: 1.95, 95%CI: 0.99-3.86). Conclusions: More than half of caretakers who received CBNC from health extension workers in the study area were dissatisfied with the service. Public health interventions focusing on postnatal care and promoting institutional delivery might contribute to improve caretakers’ satisfaction.

About 90% of neonatal deaths in Low Income Countries (LICs) are caused by asphyxia, neonatal infections and prematurity [7][8][9][10]. Whereas, in such settings, the neediest have less access to essential newborn care augmented with community's poor health seeking practice to newborns [11][12][13]. Studies disclose that about 15-32% of neonatal deaths in LICs could be reduced through achieving a high coverage of a few key and essential practices [14][15][16]. These include hygienic cord care, thermal care, optimal breast breastfeeding, community-based newborn care (CBNC) and improved health care seeking for illnesses [17,18].
Ethiopia is one of the six high burden countries in neonatal mortality in the World. Estimated 37 of Ethiopian newborns die out of 1,000 live births. Whereas, the SDG targets to make it lesser than 12 per 1000 live births.The SDG's target entails achieving all pregnant mothers give birth at health facilities to attain its target for the burden of neonates. Nonetheless, estimated 80% of Ethiopian babies are born at home each year [19,20]. Accordingly, the decline in neonatal death in Ethiopia was less than 2% per annum [21].
Community Based Newborn Care (CBNC) is a national program in Ethiopia. The program was intended to improve newborn survival through the Health Extension Program (HEP). It has been implemented in Ethiopia since 2013. The approaches in the program are both preventive and curative services during antenatal, child birth and the postpartum period, for mothers and their babies. It focuses on active case identification, timely provision of care, and treatment [22,23]. The strategy in the CBNC is integrating community based health care system as an effective approach. The preventive packages such as behavioral change communication campaigns, health education through home visits, and participatory campaigns to reduce delays in health care seeking.
Improved health care seeking for newborns is said to be beneficial for both the newborns and their mothers. Caretakers' (mainly mothers) satisfaction influences the optimal use of the services; and their experiences while obtaining the care is supposed to be an important predictor of future use of such services and thus influence care-seeking behavior among others [24,25]. Therefore, this study was aimed to assess the level of satisfaction of caretakers on CBNC and factors associated with it among rural women in Boloso Sore District, Wolaita zone, Southern Ethiopia, 2017.

Study Setting and Study period
This study was conducted in rural Boloso Sore district in Wolaita zone administration in southern Ethiopia from August to September 2017. Boloso Sore District is one of the twelve rural districts in Wolaita Zone. The district is estimated to be 306,636 square kilometers and a projected total population of 201,334 people lives in the district in 2017. The district is located in about 329 kilometers to south direction from Addis Ababa (Ethiopia's capital) and 162 kilometers southwest of Hawassa (a regional capital for southern Ethiopia). Eight health centers and 32 HPs in the district provide primary health services to the population; of the HPs 29 are in rural settings. The CBNC services are provided in rural HPs in the study area.

Study design
A community-based cross sectional study design was conducted among mothers who received CBNC to their newborns in the last six months.

Source Population
All mothers who have infants less than 6 months of age who are registered in the CBNC log book in rural Kebeles in Boloso Sore District were included.

Study population
Mothers who received CBNC for their newborn in the last 6 months prior to the survey were included from source population until having the required sample size. We used 426 mothers who were selected through systematic random sampling from lower administrative units in Boloso Sore district as a sample population.

Sample Size Determination
The required sample size of 426 caretakers was calculated by using OpenEpi software with assumptions of a single population proportion: 10,000 minimum population size, 95% level of confidence, 50% anticipated proportion of the outcome (mothers̕ satisfaction) was used due to we didn't access similar study, 5% desired margin of error and 10% non-response rate.

Sampling
Twelve rural kebeles were selected out of 29 kebeles in the study district through simple random sampling by using SPSS syntax. Sub-samples were determined for each HP catchments based on proportional to size of the population of infants in the specific kebeles. Finally women with infants who received the CBNC service within the last 6-months prior to data collection period were systematically selected from the registry of each selected HPs (Table 1).

Inclusion criteria
Women/parents with infants less than 6months of age who received the service at selected kebele during the study period were included.

Exclusion criteria
Among Women/parents within the selected households who received the service within 6-months prior to the data collection, but lost their infants were excluded.

Data collection
Data was collected by 8 diploma nurses who had experience on data collection by using structured and pretested questionnaire after giving one day intensive training for the data collectors by principal investigator. The overall data collection process was supervised by two health Officers who are trained on community-based newborn care. Principal investigators frequently followed entire data collection process with taking appropriate measures when any gaps identified.

Outcome variable
The main outcome variable of interest was satisfaction of caretakers on community-based newborn care. The overall satisfaction was defined as 'proportions of caretakers who are satisfied with the variables, representing dimension of their satisfaction [38].
We adapteda Likert scale questionnaire with seven questions previously used in some studies in Ethiopia and elsewhere. Each of the questions have five response options as very satisfied, satisfied, neutral, dissatisfied and very dissatisfied in ordinal categories. We determined dichotomous categories of the outcome in such a way that very satisfied and satisfied were re-coded to satisfied group and the other three responses were coded as to "dissatisfied". People who prefer neutral response were assumed that they would not like to disclose their dissatisfaction; thus it could be unlikely for the satisfied not to disclose their feelings or experiences. The overall satisfaction was calculated by using the median of the sum of the numeric codes of logically ordered response categories; median and below were classified as dissatisfied and above the median were grouped as satisfied [39].

Exposure variables
Scheduled home visits for PNC by HEW (within a day postpartum, third day and seventh day visits) was the main exposure variable of interest.

Operational definition
Satisfied: for each responses to seven satisfaction measurement items very satisfied and satisfied considered as satisfied, and above the median of the sum of the numeric codes of logically ordered response categories were taken as satisfied.
Dissatisfied: median and below the median of the sum of the numeric codes of logically ordered response categories were classified as dissatisfied and for each responses on seven items, 'very dissatisfied', 'dissatisfied' and 'neutral' as Dissatisfied.

Data quality assurance
Sample size was checked for adequacy and it was adequate enough by having the power of 92.2% by KMO & Bartlett's test. The tool was checked for face validity by using pre-test on 22 caretakers' (5%).
Throughout the progress of the data collection, interviewers were supervised at each site, regular meetings was held between the data collectors and the principal investigators together in which problematic issues arising from interviews which was conducted and mistakes found during editing was discussed and decisions was reached. The collected data was reviewed and checked for completeness before data entry; the incomplete data was discarded. Data entry format template was produced and programmed. Double entry was done on 10% questionnaires to check consistency by using Epi Data software.
Data was cleaned and coded, and entered into EpiData version 3.1 and then exported to SPSS version 20 for analysis. A standard codes were used for uniform answers such as yes, no, and not indicated by using a coding keys to make data entry more organized. The data was also checked for internal consistency by using Chronbach's alpha and was said to have the value of 0.94.

Statistical Analysis
Data analysis carried out on SPSS version 20. Descriptive statistics was used to determine satisfaction indices. Frequencies, percentages, and cross tabulations were computed. Cronbach's alpha was calculated to describe the reliability of the study tool. Exploratory analysis was done to look for loading of the seven questions to some characteristic components with a combined variance explained by the rotated components through varimax rotation (Horn's Parallel analysis). A dose response relationship of the exposure and outcome categories was assessed by using a chi-square test for trend. Multivariate logistic regression was applied to identify independent predictors for the outcome after controlling potential confounders. A summary statistics of proportions including Odds Ratios and 95% confidence intervals used, and statistical significance at p-value < 0.05.
During factor analysis, to measure the overall level of satisfaction with community based newborn care in this study, seven factors with Eigen value greater than one were entered into the model and were grouped into two components. Component one (provider-related aspect) contains four dimensions: "Care my child received from HEW", "Treatment given to my child", "Timely treatment or referral was considered by HEW", "Average time taken by HEW during assessment and treatment of newborn" and "Approach of HEW"; and institutional aspects were categorized under component two: "Working hours of HP" and "Cleanliness of the facility". The model showed that two components measured more than 84% of the overall satisfaction level of the respondents.

Results
Four hundred twenty-six caretakers participated in this study with overall response rate of 100%. Four hundred sixteen (97.7%) of study participants were females. The mean age of the respondents was 31.07± 5.4SD. Four hundred eight (95.8%) of the respondents were married. Three hundred forty-one (80%) were in the aged 25 -39 years. As to their educational status, 172 (40.4%) had no formal education, and the rest had some level of achieved education. With regard to occupation, 310 (72.8%) of their households live on farming as their main income (Table 2).

Health Care service Utilization
Two hundred ninety (about seventy percentages) of the mothers (respondents) had Antennal care visit (ANC) during their last pregnancy. Two hundred fifty-seven (60.3%) mothers had recent child birth in health facility and 204 (49%) reported visiting health facilities for PNC. Three hundred sixtyseven (62.7%) respondents reported that they have visited health facilities other than HPs (Table 3)

Factors associated with caretakers' Satisfaction on Community Based Newborn Care
During bivariate analysis, variables that were associated with satisfaction of caretakers on CBNC were educational status, place of delivery, place of PNC service, and visiting other health facilities than the HP within 6 months prior to data collection. However, during multivariate logistics analysis, educational status, place of delivery and place of PNC service were predictors of caretakers' satisfaction.
Respondents who had educational status of secondary and above were three times (AOR = 3.38; 95% CI: 1.06-11.27) more likely to be satisfied on CBNC service compared with those who had primary level or below. Similarly, mothers who gave birth of their last child at home were 39% (AOR = 0.61, 95%CI; 0.39-0.98) less likely to be satisfied as compared to those who received institutional delivery service. This study also revealed that caretakers who received PNC service at health center were about 3.7 times (AOR = 3.71, 95% CI; 1.75-7.89) more likely to be satisfied as compared to those who received elsewhere or not (Table 5).
The proportion of caretakers satisfaction in current finding was lower than many other studies in Educational status was one of the main predictors for caretakers' satisfaction on CBNC. Those who completed at least secondary education were more likely to be satisfied as compared to those who had lower level education or did not have formal education. This was different from other studies done in and Senegal [44], and different parts of Ethiopia [42,],and in Tanzania [28] and rural Nigeria Province [43] in that educational status of respondents was not significantly associated with mothers' satisfaction. The difference might be due to the difference in methodology and disparities in socio- that mothers who had lower educational level were more likely to be satisfied compared to those with high level educated as indicated in this study. The difference might be due to inconsistency in level of facilities and quality of the services.
The result of this study shows that place of delivery was significantly associated with caretakers' satisfaction on Community-Based Newborn Care. Mothers who gave birth of their last child at home were less likely to be satisfied on the services when compared to those who had institutional delivery service. Literature review from many studies in different parts of Ethiopia indicated that mothers were more satisfied if they are assisted by TBAs during their home delivery because they share similar culture with TBAs [36].Similarly, study done in North West Ethiopia by Bekana Kebede, Abebaw Gebeyehu and Gashaw Andargie (2013) indicated that mothers who gave a birth of their last child at the health center were less likely to re-attend the facility for PNC follow-up. The expected reason for this, according to them, was that mothers who got institutional delivery service might not be satisfied on the services they received at health center, because their expectations on quality of care would remain unmet [37]. The results of these two were in contrary to this study result.
Current study finding also depicted that place of PNC follow-up visits was associated statistically.
Caretakers who received postnatal care at health centre were more likely to be satisfied as compared to those who did not received or received elsewhere. This might be due to the respondents' expectations. This result was somewhat similar with the study in Iran [33], Nepal [34] and rural India [35].

Strength
Efforts were exerted to minimize recall bias using different mechanisms such as asking caretakers whether they got the services or not to their infants, and by reviewing from HP CBNC register, and rounding decimal numbers down during calculation to get the K-value. And, we only included those caretakers with less than 1year infants who received the service within 6 months prior to data collection period. Attention was given to the study procedures, including the process of training the data collectors and supervisors, data cleaning and confounding factors to minimize the expected biases.

Limitation
Satisfaction was subjective to recall bias and social desirability bias due to that information was obtained from caretakers who got the services from HEWs. Mothers whose infants were with different clinical presentations might have different satisfaction rates, and also the severity of cases might influence degrees of satisfaction. It is difficult to measure causal-relationship with cross-sectional study design since data on exposure and outcome were collected simultaneously. In relation to caretakers' satisfaction, evidence based intervention can be implemented based on such assessment data. We believe that there may be potential confounding factors that we did not consider either in data collection tools preparation or in the analysis. We faced somewhat uncertainty to compare and contrast literatures because we were unable to find the literature conducted elsewhere which is directly related with our study title.

Conclusions
Less than half of the respondents participated in this study were satisfied with the services they Sore Woreda Health Office to co-operate during data collection. Then, Consent was gained from each interviewee by confirming them that all the data collected would be kept confidential, and won't be used for any other purposes than the stated research objective and which was approved by the ERC.

Availability of data and materials
The dataset analyzed for the findings of this study are available with the corresponding author and can accessed by reasonable request.

Competing interest
The authors declare that they have no competing interests       Figure 1 Satisfaction of caregivers towards care dimensions Shows that the median satisfaction of caregivers