title: Access to integrated community case management of childhood illnesses services in rural Ethiopia: a qualitative study of the perspectives and experiences of caregivers.
abstract: BACKGROUND
  In 2010, Ethiopia began scaling up the integrated community case management (iCCM) of childhood illness strategy throughout the country allowing health extension workers (HEWs) to treat children in rural health posts. After 2 years of iCCM scale up, utilization of HEWs remains low. Little is known about factors related to the use of health services in this setting. This research aimed to elicit perceptions and experiences of caregivers to better understand reasons for low utilization of iCCM services.
  
  
  METHODS
  A rapid ethnographic assessment was conducted in eight rural health post catchment areas in two zones: Jimma and West Hararghe. In total, 16 focus group discussions and 78 in-depth interviews were completed with mothers, fathers, HEWs and community health volunteers.
  
  
  RESULTS
  In spite of the HEW being a core component of iCCM, we found that the lack of availability of HEWs at the health post was one of the most common barriers to the utilization of iCCM services mentioned by caregivers. Financial and geographic challenges continue to influence caregiver decisions despite extension of free child health services in communities. Acceptability of HEWs was often low due to a perceived lack of sensitivity of HEWs and concerns about medicines given at the health post. Social networks acted both to facilitate and hinder use of HEWs. Many mothers stated a preference for using the health post, but some were unable to do so due to objections or alternative care-seeking preferences of gatekeepers, often mothers-in-law and husbands.
  
  
  CONCLUSIONS
  Caregivers in Ethiopia face many challenges in using HEWs at the health post, potentially resulting in low demand for iCCM services. Efforts to minimize barriers to care seeking and to improve demand should be incorporated into the iCCM strategy in order to achieve reductions in child mortality and promote equity in access and child health outcomes.
authors.affiliation: Institute for International Programs, Johns Hopkins Bloomberg School of Public Health 615 N. Wolfe St., Baltimore, MD 21205, USA, bshaw@jhsph.edu.
authors.forename: Bryan
authors.initials: B
authors.lastname: Shaw
authors.affiliation: Institute for International Programs, Johns Hopkins Bloomberg School of Public Health 615 N. Wolfe St., Baltimore, MD 21205, USA.
authors.forename: Agbessi
authors.initials: A
authors.lastname: Amouzou
authors.affiliation: Institute for International Programs, Johns Hopkins Bloomberg School of Public Health 615 N. Wolfe St., Baltimore, MD 21205, USA.
authors.forename: Nathan P
authors.initials: NP
authors.lastname: Miller
authors.affiliation: ABH Services, PLC, Addis Ababa, Ethiopia and.
authors.forename: Mengistu
authors.initials: M
authors.lastname: Tafesse
authors.affiliation: Institute for International Programs, Johns Hopkins Bloomberg School of Public Health 615 N. Wolfe St., Baltimore, MD 21205, USA.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Bryce
authors.affiliation: Department of International Health,Johns Hopkins Bloomberg School of Public Health 615 N. Wolfe St.,10 Baltimore, MD 21205, USA.
authors.forename: Pamela J
authors.initials: PJ
authors.lastname: Surkan
mesh_terms: D000884:Anthropology, Cultural; D017028:Caregivers / Q000523:psychology*; D019090:Case Management / Q000706:statistics & numerical data*; D002662:Child Health Services / Q000600:supply & distribution*; D002675:Child, Preschool; D003153:Community Health Services / Q000706:statistics & numerical data* / Q000600:supply & distribution; D003150:Community Health Workers / Q000523:psychology / Q000600:supply & distribution*; D005002:Ethiopia; D017144:Focus Groups; D006801:Humans; D007223:Infant; D036301:Qualitative Research
keywords: Diarrhoea; Ethiopia; healthcare access; healthcare seeking behaviour; iCCM; malaria; pneumonia