Mother’s Level of Knowledge on Neonatal Danger Signs and Its Predictors in Chencha District, Southern Ethiopia

Introduction: Neonates and young infants often present with non-specific symptoms and signs of severe illness that indicate presence of severe infection which may require immediate care. So, mother’s knowledge is very important to recognize those symptoms to prevent further complications even dealth. But there is a gap in assessing mothers knowledge in neonatal danger signs. Because, almost all studies in Ethiopia assessed mother’s knowledge based on only one danger sign out of nine WHO recognized danger signs. So, the main aim of this study was to assess level of knowledge about neonatal danger signs based on 10 WHO recognized danger signs in Chencha District, Southern Ethiopia. Methods: Community based cross sectional study was conducted in 630 mothers from February 828, 2017 by using one-stage cluster sampling method. Structured interviewer administered pre-tested questionnaire was used to collect the data. The collected data were entered into Epi data version 3.1 and then exported into SPSS window version 22 for analysis. Bivariate and multivariate analysis was done by using binary logistic regression to see the association between each independent variable and the outcome variable. The goodness of fit was tested by Hosmer-Lemeshow statistic and Omnibus tests. Multi co-linearity test was carried out to see the correlation between independent variables using standard error and collinearity statistics. Variables with P<0.2 in the bivariate analysis were included in to final model and statistical significance were declared at P< 0.05. Result: In this study 50.3% (95%CI: 46.4%, 54.2%) of mothers had good level of knowledge who knows three or more neonatal danger signs out of WHO stated 10 neonatal danger signs. Place of residence, presence of radio in the household and knowledge about essential newborn care were statistically significant association with knowledge about neonatal danger signs with odds (AOR=1.58, 95%CI: 1.05, 2.37), (AOR=1.67, 95%CI: 1.13, 2.49) and (AOR=5.29, 95%CI: 3.61, 7.78) respectively. Conclusion/recommendations: This study revealed that mothers level of knowledge about neonatal danger signs were low. Therefore, strengthening the provision of health information and ENC by designing appropriate strategies like Information Education Communication and Behavioural Change Communications both at facility and community level and advocate to use media as source of information should be promoted.


Introduction
Neonates and young infants often present with non-specific symptoms and signs of severe illness. These signs might be present at or after delivery or in a newborn presenting to hospital or develop during hospital stay. Neonates are more prone to show subtle signs of illness. This signs indicate severe infection and require immediate care [1][2][3].
Newborns that experienced danger signs after delivery were two times more likely to die compared to those who never experienced any danger sign [4]. The study result which was conducted in Indonesia stated that neonatal illness during the first month of life and knowledge of neonatal danger signs were identified as the second major risk factors for neonatal death [5]. Study concluded that the health seeking behavior of mothers has been found appropriate, however, their knowledge regarding the danger signs and illness of their children was reported low [6].
Evidence from different studies which was conducted in Ethiopia and other parties of world stated that mother's knowledge about neonatal danger signs were low [7][8][9][10]. Studies done in four regions of Ethiopia, Enugu state, South-East of Nigeria, Nakuru Central District, Kenya and Gondar town, North West of Ethiopia showed that mothers knowledge of three or more danger signs were 29.3%, 30.3%, 15.5% and 18.2% respectively [8,9,11,12]. Recent studies identified that predictors for knowledge about neonatal danger signs were educational status, socio-economic status, the consumption of maternal and child health (MCH) services and source of information [9,[11][12][13][14][15].
As stated above some studies in Ethiopia assessed mother's knowledge about neonatal danger signs and identified some factors that affect the knowledge. But, most studies assessed mother's knowledge based on only one danger sign out of nine WHO recognized danger signs. So, the main aim of this study was to assess level of knowledge about neonatal danger signs based on 10 WHO recognized danger signs among mother's who gave birth within the last six months in Chencha District, Southern Ethiopia.

Population
The source population for this study was all mothers who delivered within the past six months prior to the study period in the study area and study population was all mothers who found in selected clusters. The sampling unit was households and the study unit was mothers.

Eligibility Criteria
All mothers who delivered within the past six months prior to the study period and resident at least for 6 month in the study area was included in this study whereas mothers who were not mentally competent or any psychiatric disorders, seriously ill or known medical problems, whose delivered baby was died prior to data collection period were excluded from this study.

Sample Size Determination
Computer based Epi info 7 software Stat Cal was used to calculate the sample sizes for each objective. To assess mother's knowledge on neonatal danger signs single population proportion and to identify predictor's double population proportion was used. The final sample size was come up by adding non-response rate of 10% to the larger sample size which was 493. So, the final calculated sample size for this study was 543. But, because of cluster effect the final sample used for this study was 630. The design effect of 1.5 was used to calculate the sample size for each objective.

Sampling Procedure
One-stage cluster sampling method was used in order to draw the final sample size. The Chencha District has 50 kebeles/6 clusters based on topography and catchment area for health centers. First of all, those 6 clusters were clustered in to 17 smaller clusters. Secondly, from those 9 clusters were selected by simple random sampling method initially. But, to come up to calculated sample size one additional cluster was added again by simple random sampling from the residual clusters. So, the final clusters selected for this study were 10 out of 17.

Data Collection Methods
Structured interviewer administered pre-tested questionnaire was used. The data were collected by trained 7 diploma nurses and supervised by two BSc holder nurses who were fluent in local language "Gammogna". The data collectors were collected the information by face to face interview of mothers after going in to household level.

Variables
Knowledge on neonatal danger signs was the dependent variable and socio-demographic and socio-economic characteristics, knowledge about essential new care, MCH services, and source of information, birth preparedness and obstetric factors were independent variables for this study.

Operational Definitions
Good knowledge on neonatal danger signs: Mothers who were mentioned three from the ten key danger signs for neonate without prompt and three or more danger signs with prompt. Poor knowledge on neonatal danger signs: Mothers who were capable of mentioned two and less key danger signs of neonate with and without prompt [17,18]. Key danger signs: The key neonatal danger signs include: not feeding since birth or stopped feeding, convulsion, respiratory rate of 60 or more (fast breathing), severe chest in-drawing (difficulty in breathing), temperature of ≥ 37.5 degree centigrade (fever), temperature ≤ 35.5 degree centigrade (hypothermia), only moves when stimulated or not even when stimulated (weakness or lethargy), yellow soles (sign of jaundice), umbilicus redness or draining pus, skin boils, or eyes draining pus (sign of local infection) and vomiting [19].

Data Quality Control
To ensure quality, questionnaire was initially drafted in English language and then translated in to local language, "Gammogna" by experts and finally before data entry again re-translated back to English. Questionnaires were pre-tested in a local area with population having similar socio-demographic status. Data were checked for completeness, accuracy, clarity and consistency before data entry in to software. Proper coding and categorization of data were maintained for the quality of the data to be analyzed. Double data entry was done for its validity and compare to the original data.

Data Analysis and Processing
The data were coded, cleaned, edited and entered into Epi data version 3.1 and then exported to SPSS window version 22 for analysis. Wealth quintiles were determined by using Principal Component Analysis (PCA). Bi-variate analysis and multivariate analysis was done to see the association between each independent variable and the outcome variable by using binary logistic regression. The goodness of fit was tested by Hosmer-Lemeshow statistic and Omnibus tests. All variables with P<0.2 in the bivariate analysis were included in the final model of multivariate analysis in order to control all possible confounders. In addition, variables which were significant in previous studies and from context point of view included in the final model even if the above criteria was not meet. Multi co-linearity test was carried out to see the correlation between independent variables using standard error and collinearity statistics. The direction and strength of statistical association was measured by odds ratio with 95% CI. Adjusted odds ratio along with 95% CI was estimated to identify predictors for knowledge about neonatal danger signs by using multivariate analysis in the binary logistic regression. In this study P-value < 0.05 was considered to declare a result as statistically significant association.

Ethical Considerations
Ethical clearance was obtained from Haramaya University, College of Health and Medical Sciences, Institutional Health Research Ethics Review Committee (HU-IHRERC). All the study participants were informed about the purpose of the study, their right to refuse and written and signed voluntary consent was obtained from all study participants prior to the interview. The respondents were also been told that the information obtained from them was treated with complete confidentiality and do not cause any harm on them.

Source of Information about Neonatal Danger Signs
Out of the study participants 592(94%) were heard or counseled about neonatal danger signs and from them 312(52.7%) heard from health professionals and 342(57.8%) heard from health extension works (See figure 1 below). Three hundred nighty seven (63%) had radio and 184(29.2%) television in the household.

Knowledge about Essential Newborn Care
Regarding knowledge about essential newborn care 363 (57.6%) of study participants had good responded equal to median score whereas 267(42.4%) had poor knowledge responded below median score. Study participants were asked about instruments to cut the cord, material to tie the cord, breastfeeding initiation time, bathing time and knowledge about neonatal danger signs. 261(41.4%) stated new blade to cut the cord, 395(62.7%) stated cord tie to tie the cord and 389(61.7%) stated that breastfeeding initiation time was less than one hour (See table 3

Mother's Level of Knowledge about Neonatal Danger Signs
Based on summery scores 50.3% (95%CI: 46.4, 54.2%) had good knowledge about neonatal danger signs who had mentioned three and more neonatal danger signs out of ten World Health Organization (WHO) recognized neonatal danger signs with and without prompt. Out of the total respondents 360(57.1%) mentioned fever and 13(2.1) mentioned jaundice or yellowish discoloration of palms/soles (See table 4

Predictors for Mothers Level of Knowledge about Neonatal Danger Signs
In order to identify predictors for mother's level of knowledge about neonatal dangers signs binary logistic regression was done with assumptions. After controlling for cofounders in multivariate model place of residence, presence of radio in the household and knowledge about essential newborn care were significantly associated with knowledge about neonatal danger signs. Mothers who lived in urban were 1.58 times more likely knowledgeable as compare to mothers who lived in rural area (AOR=1.58, 95%CI: 1.05, 2.37). The odds of knowledge were 1.67 among mothers who had radio in the household (AOR: 1.67, 95%CI: 1.13, 2.49). Mothers who had knowledge about essential newborn care were 5.29 times more likely knowledge about neonatal danger signs with odds (AOR=5.29, 95%CI: 3.61, 7.78)(See table 5 below).

Discussion
In this study the overall mother's level of knowledge about neonatal danger signs was 50.3% (95%CI: 46.4%, 54.2%). Mothers who lived in urban were 58% and presence of radio in the household were 67% times more likely knowledgeable about neonatal danger signs. Mothers who had knowledge about essential newborn care were 5.29 times more likely knowledgeable about neonatal danger signs.
The prevalence of mother's level of knowledge about neonatal danger signs was higher than the studies conducted in four regions of Ethiopia (29.3%), Nigeria (30.3%), Kenya (15.5%) and North West of Ethiopia (18.2%) [8,9,11,20]. The reason for this difference is extensive work of HEWs in the community and different health care institution in awareness creation on neonatal danger signs in the study area and study period difference.
In this study age, parity and educational status of mother were not significantly associated with knowledge about neonatal dangers signs. This is incongruent with studies done in Nairobi, India and central Bangalore, Egypt, Sri -Lanka and Ethiopia [9,13,[21][22][23][24]. The reason for this difference may be due to the case that HEWs and other health care providers deliver health information or counseling about neonatal danger signs regardless of age, parity and educational status of mother. Place of residence was significantly associated with mother's level of neonatal danger signs. This is incongruent with study done in Egypt [23]. The reason for this difference is mothers who live in urban were more seek to health care and health information from different sources as compare to mothers who lived in rural parts.
Immediate postnatal care and antenatal care were not significantly associated with mother's level of knowledge on neonatal danger signs. This is inconsistent with studies done in Chewaka, Egypt and Ethiopia [9,23,25]. The reason for this is may be communiy based interventions of HEWs and other health care providers regarding community based newborn care and interventions for neonatal illnesses.
This study indicated that media exposure was significantly associated with mother's knowledge about neonatal danger signs especially radio because more people were more access radio than other media. The reason for this is mothers who access media more likely know about different information's. Mothers who were knowledge about essential newborn care practice had significant association with knowledge about neonatal danger signs. This is due to the case that recognition of neonatal danger signs is one of the components of essential newborn care. So, those mothers who have knowledge on essential newborn care practices are more likely knowledgeable.
The limitation of this study was it might not show cause and effect relationship because the study design was cross-sectional. It might be affected by recall bias. So, those things are considered during interpretation of findings of this study.

Conclusions and Recommendations
This study revealed that mothers level of knowledge about neonatal danger signs were low. In general, this study identified that place of residence, radio in the household and knowledge about ENC were the independent predictors for mother's level of knowledge about neonatal danger signs. Based on above finding the principal investigator would like to provide the following recommendations: Strengthening the provision of ENC by designing appropriate strategies like Information Education Communication (IEC) and Behavioural Change Communications (BCC) both at facility and community level. Advocating the mothers to use media's as source of information. Individual and community as well should actively involve in community based IEC and BCC regarding neonatal health issues and actively consume MCH services. The other researchers do further investigation to identify other factors by using other tools and other study design. data collectors and study participants. Last but not least, I would like to say thank you for all peoples who support directly or indirectly.