Under-Five Child Health Service Quality and its Determinants in Goncha Siso Enessie District, Northwest Ethiopia, 2016

Methods: A facility based cross sectional quantitative and qualitative study design was employed from JanuaryMay 2016 on 396 guardians of under five children. The data were collected using structured exit interviews, facility assessment checklists and record reviews. Data was cleaned and entered Microsoft office Access, EPI info and analyzed by Statistical Package for the Social Science. Binary and multivariate logistic regression was used to identify factors of guardians’ satisfaction and odds ratios, 95% CI and p-value was computed to measure the presence and strength of associations.


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its risks [2]. Willy De Geyndt also define that quality of health care as a multidimensional and multifaceted concept interwoven with value judgments about what constitutes good quality and proposed a conceptual model based on three basic elements-structure, process, and outcome [3]. A review of Integrated Management of Childhood Illness (IMCI) implementation in developing countries and elsewhere indicated the positive impact of IMCI on child health, quality of care and referrals of sick children from firstlevel and community care to higher units [4]. The Government of Ethiopia adopted the Integrated Management of Childhood Illness (IMCI) strategy in 1996 as a key strategy to improve quality of child health care at all levels in order to reduce child mortality and improve child health development [5]. It also adopts Integrated Community Case Management (ICCM) for common child hood illness in 2005 to complement facility-based management and used as a strategy to deliver antibiotics outside of health facilities where access to treatment is poor [6,7]. Pneumonia and diarrhea remain major killers of young children that account for 29% of all deaths of children less than 5 years of age but only 60% of children with suspected pneumonia access appropriate care; only 31% of children with suspected pneumonia receive antibiotics and only 35% of children with diarrhea receive oral rehydration therapy [8].
Most health professionals were experienced and well trained, but they perform 77% of adequate diagnosis established in consultations and triage and attention to danger signs were poor.
An antibiotic was prescribed in almost half of the consultations, but antibiotic use was unwarranted in one-third of these cases. Growth Monitoring and Promotion (GMP) and nutritional counseling were consistently ignored during sick child visits and HIV status was seldom asked about or investigated, for the mother or for the child [9,10]. Quality of care provided at a tertiary hospital in South-Eastern Nigeria indicates that the overall satisfaction score of the respondents was 66.8%. Specifically, the respondents expressed satisfaction with patient-provider relationship, patient-provider communication, accessibility, hospital environment, dissatisfaction with hospital bureaucracy and patient waiting time was 81.5%, 79.9%, 74.2%, 68.2% ,48.8% and 48.3% respectively [11]. Lack on job-based training, poor performance of health workers, shortage of staffs, shortage of proper equipment at the periphery centers, lack of organization of care in the peripheral facilities and lack of timely referrals were the major determinants for quality of neonatal care in Tanzania [12].
Most of the reported studies had been done in hospitals and the majority has been in industrialized countries. A great deal of this work had focused on the care of patients with specific diagnosis and data had been collected on relatively easy points of diagnosis or therapy and the results of these actions. Even though patient satisfaction is higher in Ethiopia compared to other countries; there are intertwined problems that affect quality of health service at all levels. There is no growing interest to assess quality of integrated under-five child health service at levels of the country as compared to its access. There for, the present study is planned to address the prevailing knowledge gap [13,14]. To the best of the knowledge of the researcher, studies addressing the quality of health care rendered to under-five children on diarrhea, pneumonia and malnutrition management are virtually absent. The result of this study was will address the prevailing knowledge gap and had paramount importance for district health managers, practitioners, and researchers. It had also suggested points of difficulties at the service utilization and focused on the weak parts of activities that will contributed to define the conditions for implementing any policies and oriented towards the attainment of "Quality Health for All".

Methods
This study was a facility based cross-sectional study by using quantitative and qualitative data collection methods that was reviews and checklist-based assessments. Data was collected using exit structured interview questionnaire adopted from review of different literatures [15,16], observation checklists and documentary review of selected diseases and then compared with standards [17][18][19]. Seven data collectors who completed 10/12 grades and speaks Amharic fluently collected the data under supervision of four senior public health professionals.
The sample size was calculated using a single population proportion formula by taking previous prevalence from the study done on the assessment of quality of health care in Jimma zone, Ethiopia [16] with 95 % confidence interval and a precision of +5% plus 10% non-response rate. Accordingly, 396 guardians and their children were included in the study and allocated proportionally to the health facilities based on the size of patients'/client's flow.
The collected data were coded, cleaned and entered by Microsoft Responses of patients to the 11 statements of questionnaire were put in a 5-points Likert Scale including; very satisfactory (5 scores), satisfactory (4 scores), neutral (3 scores), dissatisfactory (2 scores) and very dissatisfactory (1 score). Then the mean score was calculated from 11 satisfaction questions to determine cut off point for satisfaction level of this study and was 38 points.
A client who had scores above 38 points from 11 question having 5 Likert-like scale points was labeled as satisfied by the service and client/patient below 38 points was categorized as dissatisfied by health service. Bivariate and multivariate analyses were done using logistic regression analysis. Odds Ratio with 95% Confidence Interval was determined to see the association between the dependent and independent variables. P < 0.2 was considered and included to multivariate analysis to get more variables for analysis.
Independent variables with p-values less than 0.05 in multivariate analysis were considered as significant association with dependent variable. The study protocol was reviewed and approved by health research Ethics Review Committee of the College of Medicine and Health Sciences from Debre Markos University and GAMBY.
Moreover, an informed oral consent was obtained from each study subject and the confidentiality and privacy of participants was maintained during data collection.  (Table 1).    (Table 3).     (Table 6).

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According to guardians' assessment, the overall health service given for children, physical examination skills of health provider, cleanness of health institution, information provided by health provider found to be low with "Dissatisfaction" response rate  (Table 8).

Suggestion given to Improve Services
Guardians were asked to give suggestions for improving health services. Most of them were gave more than one suggestion and mainly focused on improvement of supply of drugs and equipment,

Discussion
This study assessed the quality of outpatient health service in Goncha Soso Enessie district using structure, process and outcome assessment tools to measure quality health service in seven respectively. 85.7 % of health center and 100% of health posts did not have enough budgets to fulfill necessary materials and drugs by themselves. This showed lower result compared with the study done on quality of health care at Jima Zone [16] and Health Extension Program Evaluation in Rural Ethiopia [17].
About 57.1% of health centers and 100% health posts had regular and outreach Expanded Program of Immunization (EPI).
Even though all health institutions had given diagnosis and treatments for dehydration, only 57.1% of health centers and 46.6% of health posts had Oral Rehydration (ORT) corner. Among them, there were only 14.3% functional ORT corner at health centers and 20% of health posts. This finding is much lower than other study done on health extension program evaluation in Rural Ethiopia [17]. Severe malnutrition was not treated according to standards.
All health institution discharged under five patients before they achieved the discharge criteria and didn't stay for 8 weeks. None of them followed children based on the OTP guidelines and 22.2% of children didn't specify their nutritional status on the registration book after discharge. Recovery rate, death rate and defaulter rate are 44.4%, 35.5% and 36.3% respectively. This result is far from sphere standard and a study done in low and middle-income couriers and Tigray region [14,18].
About 396 guardians who came to health center and health post for under-five child health service were interviewed for the measurements of satisfaction. 82.6% of the respondents were mothers as primary caregiver and 64.2% of them used farming as a means of livelihood, 75.8% didn't attend formal education but only 8.2% had secondary and above level of education. The overall satisfaction level (combined average response rate of "Very Satisfactory and Satisfactory" of guardians was 54.3%. This finding is lower than the study done at South-Eastern Nigeria, Central Ethiopia, Jimma University Specialized hospital and Jima zone [11][12][13][14][15][16]. The overall satisfaction level in this study decreased as one goes from health post to health center. This might be related lack of training for health professionals and negligence at health centers due to overburden in different tasks since the number and mix of health professionals were found below the standards. In this study, we found that participants had the mean waiting time of 33.5 (±23.6 SD) minutes for getting the required services. The

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This is lower waiting time compared with the reported study done at Johannesburg, Jimma University Specialized Hospital and Jima zone [10,16,19]. Guardians were satisfied with courtesy and respect given by health provider, consultation time with health provider; overall waiting time spent for health service, technical competence of health provider, and timely referrals of children to higher institution with overall satisfaction levels of 54.3%. But this finding is lower than other studies [9,11,13,15,16,19]. Analysis of overall satisfaction by socio demographic characteristics showed that educational status was associated with satisfaction, where respondents who were college and above group were more satisfied as compared to those who had lower educational level. This is disagreement with the study in Jimma Specialized Hospital in which satisfaction score was an in inverse relation to educational status. Guardians were dissatisfied with examination skills of health providers and cleanness of health institutions. This finding of this study was similar with finding from Eastern Ethiopia [16,19].

Conclusion
Although higher proportion of guardians were satisfied with health service given in the institutions, the courtesy and respect given to respondents by care providers was rated "poor" especially in the health centers. In addition, the patients' privacy keeping practice of care providers was poor at all levels. The strength of this study was that it involves different approaches of data collection such as exit interview, record review and checklists based on the Donabedian framework of health care quality. This study did not address observation methods of data collection during treatments of children at health institutions. The study includes only government health facilities in Goncha Siso Enessie district, so it may not represent all health facilities in the district and in Ethiopia in general. It was recommended that the management of respective health care institutions should take actions for improving institutional capacity and performance of care providers in order to improve quality of care in the study area.
District health office, health centers and health posts should work hard to solve problems related to shortage of drugs and supplies and look for different mechanisms to keep adequate stock of essential drugs and supplies. All concerned body is better to focus on fulfilling human resources, standard medical equipment, establish triage system to give priority for seriously sick child and avoid long waiting time. Training should be given on managements of child hood illness using IMCI guidelines. Concerned bodies should give special emphasis on the management of malnutrition that needs program interventions. Studies on health service quality should be done on specific diseases to solve specific problems related to the service given.