Knowledge of neonatal danger signs and associated factors among mothers who gave birth the last four months attending immunization services in Harar town public health facilities, Ethiopia

Objective The purpose of this study was to assess knowledge about neonatal danger signs and associated factors among mothers that gave birth in the last 4 months attending immunization services.Result The study allowed 432 mothers to participate in the study. The knowledge score of neonatal danger signs was found 32.9% (95% CI: 28.9%, 37%). Mothers educated to secondary level were 4.9 times more likely to know about neonatal danger signs [(AOR=4.9, 95% CI: (1.15, 21). Similarly, mothers whose husband educated to college and above AOR=4.95, 95% CI: (1.15, 21), and being multipara mother (AOR=2.59, 95% CI: (1.05, 6.6), were significantly associated factors of good knowledge of mothers about neonatal danger signs.


Introduction
Parenthood of a new life is a responsibility for protection and crucial to the health and safety of the little, immune suppressed newborn. Although the symptoms of illness in the newborn baby are difficult to recognize, mothers always needed to notice at their newborn for any signs of illness arose in their neonate early. Majority of parent's lucks awareness about how a sick baby reacts compared to a healthy baby. Thus, they lack experience in recognizing what is normal signs and what is evil [1]. Neonatal danger signs that arose in the first month of life are multiple and can be a manifestation of almost any fatal diseases [2]. The integrated Management of Newborn and Childhood Illness (IMNCI), which is developed by World Health Organization (WHO) introduces around ten general danger signs which determines illness of a neonate.
The critical period in newborn survival is often during the first week of life, when most neonatal deaths occur at home and without any contact with the formal health professional. These unable to seek care related problems are managed if mothers are aware of newborn danger signs through routine counseling by health professionals to help them develop the experience of early recognition. Thus, it is found necessary to assess mothers' knowledge and associated factors hindering and promoting awareness of neonatal danger signs.

Methods (level 2 heading)
The quantitative institutional based cross-sectional study design was applied to study a total of 433 mothers at immunization ward in different health facilities. Mothers with health problems like deafness, and caregivers (Maidservant) who immunize their employer's baby were excluded from the study for the purpose of increasing quality of data.
The required sample size was determined from the literature using a double population proportion formula by assuming 95% level of confidence, 5% margin of error. 80% power and the ratio of exposed to unexposed equivalent to 1. The highest number of sample was taken from the scenario at which mothers exposed to primary education to that of not taking formal education (18% vs. 8%) which yields 394. Adding 10% non-response rate, it becomes 433 samples. A total of six public health facilities (four health centers and two hospitals) were included in the study. Thus, systematic sampling technique was used from their registration frame to get a total 433 samples after proportionally allocate to size for every health facilities.
A structured, questionnaire developed by the principal investigator was used for study. The questionnaire was first prepared in English language, translated to local languages and pretested on 5% of population out of the study area. Finally, samples were interviewed face-to-face using the checked and pretested questionnaires.

Operational definition Knowledge
A mother who mentions three of the ten WHO recognized danger signs of a neonate without prior prompt, or three and greater danger signs with a prior prompt are said to be had good knowledge.
But, mothers capable of mentioning two and less key danger signs of neonate with and without prior prompt are said to be having poor knowledge [10].
The collected data was entered in to epi data and exported to SPSS version 20. All variables with pvalue ≤ 0.2, on bivariate logistic regression analysis were taken in to multivariate model to control the possible confounders. The odds ratio (OR) was used as a measure of strength and level of statistical significance was declared at p-value < 0.05.
Finally, before the data collection process started, ethical clearance was secured from Haramaya University Institutional Health Research Ethics Review Committee (IHRERC). Official letter was disseminated from Haramaya University College of health and medical sciences to each selected health facilities.

Results
A total of 432 mothers of babies aged up to 4 months were included in the study. The median age of the mothers was 25 years with a range of 15-45 years (Table S1).
Out of the 432 recruited mothers, 130 (30.1%) didn't know about neonatal danger signs totally, but the remaining 302(69.9%) mothers were aware about the following number of mentioned neonatal dangers sign, one, 60(13.9%), two, 100(23.1%) and 142(32.9%) three & above. Mothers who full fill the WHO criteria for good knowledge was found 142 (32.9% with 95% CI: 28.9%, 37%). Among the prompted neonatal danger signs cord bleeding, redness followed by pus, and fever mentioned by 95.8%, while Hypothermia, convulsion, and vomiting are the least mentioned neonatal danger signs accounted for 45.8%, 63.4%, and 68.3% respectively ( Figure 1). Regarding to the source of information 253 (83.8%) mothers from those who were aware of neonatal danger signs got informed from different sources. Among these 81 (31%) received information from health professionals, while the remaining 49 (16.2%) mothers were not informed (Figure 2). The multi-variable analysis result showed that educated mothers to the level of college and above as well as secondary level were more likely to recognize neonatal danger signs (Table 1).  [20] and with the study conducted in Gondar (2012), by which mothers got their first information about neonatal danger sign from health professionals and media were significantly resulted good knowledge [17].
This study showed mothers who knew the exact breastfeeding initiation, as less than one hour (78%) were found more knowledgeable compared to those who reported as later than one hours. This is consistent with the study in Nepal, Chitwan district (2011) even though the number of mothers who reported as less than one hour differs (78% vs. 52%) [21], this consistency might because more emphasis is given by the government upon counseling breastfeeding habit of mothers, which increases bonding and identifying the possible newborn illness.

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