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Abstract

Background:

Essential newborn care (ENC) encompasses a range of evidence-based interventions aimed at improving neonatal health outcomes and reducing mortality. Despite global efforts to improve neonatal survival, newborn deaths still account for approximately half of all under-five mortality cases, especially in low-resource settings. Adherence to recommended infant care practices remains a difficulty, contributing to avoidable neonatal mortality. In Ethiopia, newborn mortality is a serious public health issue, with an estimated rate of 33 fatalities for every 1000 live births. Therefore, this study seeks to assess essential newborn care practices and their associated factors among postpartum mothers in Tembaro Zone, Southern Ethiopia.

Methods:

A community-based cross-sectional study was conducted in, involving 390 postnatal mothers. Participants were selected using multistage simple random sampling. Data were entered into EpiData version 3.1 and exported to STATA version 16.0 for analysis. We performed binary and multiple logistic regression analysis to find factors related to the outcome variable. To determine the presence of association, an adjusted odd ratio was generated along with its 95% confidence interval. A P-value of less than .05 was used to indicate statistically significant.

Results:

The overall practice of essential newborn care was 57.7% (95% CI: 52.6-62.6). Significant factors of ENC included maternal educational status (AOR = 3.2; 95% CI: 1.45-6.98), absence of home visits by health extension workers (AOR = 0.32; 95% CI: 0.19-0.54), having 2 or fewer live births (AOR = 0.34; 95% CI: 0.20-0.57), lack of antenatal care visits (AOR = 0.48; 95% CI: 0.28-0.81), and insufficient knowledge (AOR = 0.24; 95% CI: 0.12-0.48).

Conclusion:

Approximately half of postnatal mothers practiced essential newborn care. The absence of health extension worker visits, having 2 or fewer live births, lack of antenatal care visits, and insufficient knowledge were negatively associated with essential newborn care practices. Conversely, educational level was positively correlated with essential newborn care practices.

Keywords

essential newborn practice newborn care practice neonatal health postpartum mothers maternal and child health

Introduction

Essential newborn care (ENC) is a strategic approach to improving the health of newborns through interventions before, during, and after pregnancy, immediately after birth, and during the postnatal period. Enhanced newborn care practices, particularly during the early neonatal period, are critical in reducing neonatal mortality rates.^1,2 It’s vital for all newborns, regardless of their birth location or size. Globally, approximately 2.4 million newborns die within the first 28 days of life, and an additional 3 million are stillborn each year. Every minute, 11 newborns die before their fifth birthday. Sub-Saharan Africa accounts for approximately 90% of neonatal deaths (27 deaths per 1000 live births [LBs] in 2017), with approximately half of these deaths occurring at home.³ Neonatal mortality accounts for approximately two-thirds of all infant mortality and 33% of the deaths of children aged less than 5 years.^4,5 Ethiopia also faces a significant neonatal mortality burden, with a reported rate of 48 per 1000 live births⁶

The high death and morbidity rates among newborns are attributed to improper the community practices that now exist throughout the region among home-delivered women.⁷ Studies in several African countries, including Uganda, Ghana, and Cameroon, indicate that newborn care practices are often inadequate, contributing to high neonatal mortality rates. Common practices such as applying substances to the umbilical cord and early bathing may pose health risks.⁸ Similar suboptimal practices are observed across Sub-Saharan Africa.⁹ In Ethiopia, 92% of mothers who had a live birth in the past 5 years did not receive postnatal care. Only 7% of women received postnatal care within the recommended 3 days.¹⁰

The predominant cause of neonatal mortality in developing countries is related to conditions of labor, intra-partum, and poor immediate newborn child care practices.¹¹ According to various studies, several variables have been identified as factors influencing newborn care practices, including maternal occupation, educational attainment, socioeconomic status, home-to-home visits by health extension workers (HEW), maternal knowledge of newborn care, antenatal care (ANC) visits, and place of delivery.¹² Ethiopia is among the Sub-Saharan countries where neonatal care practices are considered substandard or inadequate.¹³ The majority of neonatal deaths take place at home and are regularly not documented. Due to a lack of postnatal health care and traditional practices such as delayed breastfeeding initiation, early bathing, and improper cord care contributed to high newborn mortality rates.¹⁴

Although standard newborn care practices are well-established and widely promoted, there is limited data on the prevalence and factors of essential newborn care practices in Ethiopia. Therefore this study aimed to assess magnitude of essential new born care practices and identify key factors affecting the implementation of essential newborn care practices among postnatal mothers in the Kembata Tembaro zone.

Methods

Study Setting, Period, and Design

A community-based cross-sectional study was conducted in Kembata Tembaro zone between May to June 2022. The Kembata Tembaro zone is one of the administrative zones in South Ethiopia. Tembaro district is one of a districts found in Kembata Tembaro zone, which is located in SNNPR, and its administrative town is Mudulla. It has 21 rural and 3 urban kebeles. It is found 320 km South of Addis Ababa, the capital of Ethiopia. There are 1 primary hospital, 4 health centers (HC), and 22 health posts serving the total population in the district. The study was conducted in selected 9 kebeles of Tembaro district. The lists of selected kebeles has shown in sampling procedure.

Population

Source Population

All postnatal mothers of newborn age less than or equal to 42 days after delivery in Tembaro district.

Study Population

The study population comprised postnatal mothers with newborns aged 42 days or less, selected from the designated Kebeles during the data collection period.

Eligibility Criteria

Postnatal mothers with an alive newborn within 42 days after delivery before study period and residents for at least 6 months in the study area was included in this study. Those mothers who did not able to communicate with the interviewer, seriously ill, and mothers who delivered a baby died before the data collection period were excluded.

Sample Size Determination

The sample size for the study was calculated using a single population proportion formula with the assumptions of 95% confidence interval, 5% of marginal error and considering 40.7% mothers had good essential new born care practices from related study done in Enderta, Northen Ethiopia¹⁵ and adding 10% non-response rate, a total of 408 study participants were estimated for this study.

Accordingly to the sample size calculation the result is 408. Since, the source population (N) is less than 10,000 we used finite population correction formula:

nf = \frac{n}{1 + (n / N)} where n = 408 N = 8680

nf = \frac{408}{1 + (0.047)} = \frac{408}{1.047} = 390

So finally, a total of 390 study participants were used for this study.

Sampling Procedure

A survey was conducted among 390 postnatal mothers with newborns aged 42 days or less, from randomly selected kebeles in the Tembaro Zone. A multistage sampling technique was employed to select the study participants. To obtain the required sample from 9 selected Kebeles, all postnatal women who had given birth within 42 days of the study period were registered to establish a sampling frame. This sampling frame was then used to list the study units within the health posts of the selected Kebeles. The total determined sample size was proportionally allocated based on the population size of each Kebele. Finally, a simple random sampling method was employed to select the participants. In households with more than 1 eligible respondent, 1 was randomly chosen using the lottery method (Figure 1).

Figure 1.

Schematic presentation of sampling procedure.

Data Collection Tools and Procedure

The questionnaire was first developed in English and subsequently translated into Ahmaric to improve comprehension for both data collectors and responders. A pre-tested, structured questionnaire was used to collect data. The tool was developed after an exhaustive review of relevant literature.^16
-18 The questionnaire included sections on socio-demographic characteristics, health service utilization (such as antenatal care, delivery, and essential newborn care), postnatal care for both mother and newborn, and the mother’s knowledge of newborn care and neonatal danger signs.

Study Variables

The dependent variable was newborn care practices. The independent variables included the following:

Sociodemographic characteristics: age of the mother, marital status, religion, educational level of the mother, educational level of the husband, occupation of the mother, husband’s occupation, and household monthly income.

Obstetric characteristics: gravidity, parity, antenatal care (ANC) visits, number of ANC visits, age at first delivery, home visits by health extension workers (HEWs), counseling by health workers, place of birth, postnatal follow-up, and gestational age at the first ANC visit.

Client-related factors: mothers’ knowledge about newborn care and awareness of neonatal danger signs.

Operational and Term Definitions

Newborn care practices: A set of practices by mothers to newborn which includes delay bathing, thermal care, safe cord care, early initiation of breast feeding, immunization, and eye care.²

Those mothers who reported 4 and above out of 6 of mentioned practices were categorized as “good newborn care practice” and those who reported 3 or less of the above practices were categorized as “poor newborn care practice” ¹⁹

Early initiation of breast feeding: Mothers initiating breast feeding to newborn following delivery within 1 hour of life² Safe cord care: Keeping the cord clean and dry without application of any foreign substances until the umbilical stump falls off (until 7 days of old).²

Bathing: Avoidance of bathing before 24 hours of delivery.

Thermal care: Drying and wrapping whole body of newborn and covered whole body including legs and head.²

Immunization: BCG and OPV-0 vaccines given at recommended time for newborn.

Eye care: applying of eye medication (TTC) and keep cleanness.

Good knowledge on newborn care practice: Those mothers who respond correctly above 50% of knowledge related questions and Poor knowledge on newborn care practice: Those mothers who respond less than 50% of knowledge related questions.¹⁹

With regard to knowledge related to neonatal danger signs, those mothers who identified at least 4 and above among the 6 listed danger signs categorized as good knowledge on neonatal danger sign and for those who mentioned 3 or less of danger signs categorized as poor /knowledge on neonatal danger sign.¹⁹

Data Quality Control

To ensure uniformity, the questionnaire was translated back into English by a bilingual professional. Finally, the Ahmaric version was employed for gather data. Two days of training were given to supervisors and data collectors on data collection methods, participant approaches, ethical concerns, data quality, and the benefit of gathering real data, as well as their roles and duties as supervisors and data collectors. A pretest of the questionnaire was also conducted. Data collectors conducted a pre-test on 5% of the overall sample size outside of the study’s selected kebeles, which shared the same socio-demographic characteristics as the selected kebeles. Cronbach’s alpha was checked for questionnaires, and the value was .75. The data was reviewed for consistency, clarity, and accuracy before being entered into the software. Proper coding and categorization were maintained to ensure data quality. Additionally, double data entry was performed to validate the data and ensure consistency with the original entries. Cross-questions and pretest questions were utilized to reduce bias.

Data Analysis and Processing

After coding, updating, cleaning, and entering the data into Epi Data version 3.1, it was exported to STATA Version 16 for analysis. Binary logistic regression was used to evaluate the relationship between each independent variable and the outcome variable. Model fitness was assessed using the Hosmer–Lemeshow goodness-of-fit test. All variables with a P-value of less than .25 in the bivariate analysis were included in the final multivariable analysis to control for potential confounders. A variance inflation factor (VIF) greater than 10 was considered evidence of multicollinearity. Statistical significance was determined by a P-value of less than .05, with a 95% confidence interval.

Ethical Approval and Consent to Participate

The study was approved by the Ethics Review Committee (Ref no: ERC/670/2022) School of graduate Study, Wachemo University, Ethiopia. The informed consent with a written signature was obtained upon the agreement from participants after purpose of study had been explained. There were informed to withdraw at any time and/or to refrain from responding to questions. Study participants were also informed that all the data obtained from them could be kept confidential using code instead of any personal identifiers. Furthermore, the research procedures were conducted in accordance with the principle expressed in The World Medical Association’s Declaration of Helsinki.

Results

Socio-Demographic Characteristics

In this study, 388 participants responded to the questionnaire with a total responses rate of 99.5%. The majority of participants, 227 (58.5%), were between the ages of 25 and 34 and the mean age of study participants were 29.5 (±4.9 SD). Approximately two-thirds of the respondents, 270 (69.6%) had received formal education. In regard to occupation, 357 (92%) of the participants were housewives. More than two-thirds 344(89.8%) of husbands have a formal education (Table 1).

Table 1.

Socio Demographic and Economic Characteristics of Women in Postnatal Period, in Tembaro District Southern Ethiopia, May to June 2022 (n = 388).

Variables	Category	Frequency	Percent
Mothers age	18-24	91	23.5
	25-34	227	58.5
	≥35	70	18
Religion	Protestant	257	66.2
	Orthodox	60	15.5
	Catholic	58	14.9
	Muslim	13	3.4
Ethnic groups	Tembaro	346	89.2
	Hadiya	15	3.9
	Kembata	11	2.8
	Donga	7	1.8
	Others^a	9	2.3
Marital status	In union (married)	383	98.7
Marital status	Not in union^b	5	1.3
Educational level of mothers	No formal education	118	30.5
	Primary education	143	36.9
	Secondary education	57	14.6
	College and above	70	18
Educational level of husband	No formal education	39	10.1
	Primary education	163	42.6
	Secondary education	108	28.2
	College and above	73	19.1
Occupation of mothers	Housewives	357	92
	Merchants	18	4.6
	Government employee	7	1.8
	Students	6	1.5
Occupation of husbands	Farmers	241	62.9
	Merchants	108	28.2
	Government employee	9	2.3
	Self-employee	21	5.4
	Students	4	1.0
Monthly income	<500	84	21.6
	500-1000	117	30.2
	≥1000	187	48.2

Amhara, Dawuro, Wolayita.

Divorced, single.

Maternal and Child Health Services

Among the respondents, 342 (88%) had attended antenatal care (ANC) follow-up. Of these, 196 (57.3%) had fewer than 3 visits, 146 (42.7%) had 3 or more visits, and 36 (7.6%) had 5 or more visits. During ANC follow-up, the majority, 322 (53.0%), received advice on essential newborn care (ENC). A total of 364 (59.9%) delivered in a health institution, and 354 (58.2%) received immediate postnatal care. The majority of the newborns, 344 (56.6%), were male, and 516 (84.9%) of the mothers did not experience any complications during delivery. Sixty-four (16.5%) of the participants delivered at home, and 251 (64.7%) of the households were visited by health extension workers during the postnatal period. Additionally, 201 (51.8%) of the participants had given birth to 1 or 2 live children, while 187 (48.2%) had given birth to 3 or more children (Table 2).

Table 2.

Obstetrics Factors and Health Service Utilization of Women in Postnatal Period, in Tembaro District South Ethiopia, May to June 2022 (n = 388).

Variables	Category	Frequency	Percent
Antenatal follow up	Yes	342	88
Antenatal follow up	No	46	12
Place of ANC visit (n = 342)	Governmental hospital	90	26.3
	Health centers	245	71.6
	Non-governmental health centers	7	2.1
Gestational age of ANC visit start (n = 342)	<16 wk	201	58.8
	16-30 wk	112	32.7
	.≥30 wk	29	8.5
Number of ANC visit (=342)	≤3 times	196	57.3
Number of ANC visit (=342)	>3 time	146	42.7
Place of current delivery (n = 388)	Home	64	16.5
	Health centers	217	55.9
	Governmental hospital	99	25.5
	Non-governmental health centers	8	2.1
Number of live births (n = 388)	1-2 live births	201	51.8
Number of live births (n = 388)	3 & above live births	187	48.2

Knowledge of Respondents on Newborn Care Practice

There were about 6 knowledge related questions used to assess knowledge status of mothers toward essential newborn care practice. Mothers who correctly answer more than 50% of the knowledge-related questions are classified as having good knowledge of newborn care practices and accordingly majority, 83% of them have good knowledge on newborn care (Figure 2).

Figure 2.

Knowledge status of mothers in postnatal period on essential newborn care practice in Tembaro district, South Ethiopia, May to June 2022.

Out of the total 388 respondents, more than three-fourth, 337 (87%) of them stated that they had the information about newborn danger signs and mothers who have good knowledge on poor sucking, 275(75.7%) followed by fever, 246 (73%; Table 3).

Table 3.

Shows That the Knowledge Level of Mothers on Each Newborn Danger Sign in Tembaro District, South Ethiopia, May to June 2022.

Variable	Category	Frequency	Percent
Do you know newborn danger signs? (n = 388)	Yes	337	86.9
Do you know newborn danger signs? (n = 388)	No	51	13.1
Which danger signs do you know (n = 337)
Poor sucking	Yes	255	75.7
Poor sucking	No	82	24.3
Fever	Yes	246	73
Fever	No	91	27
Hypothermia	Yes	160	47.5
Hypothermia	No	177	52.5
Fast breathing	Yes	155	46
Fast breathing	No	182	54
Unconscious	Yes	128	38
Unconscious	No	209	62
Cord infection	Yes	176	52.2
Cord infection	No	161	47.8

Essential Newborn Care Practice

In this study, 224 (57.7%; 95% CI: 52.6-62.6) of mothers practiced good essential newborn care. Of the responders, 324 (83.5%) reported early breast feeding, 303 (78%) safe cord care, 300 (77.3%) thermal care, 308 (79.4%) delayed bathing, 251 (64.7%) immunization, and 263 (67.8%) at-home eye care (Figure 3 and Table 4).

Figure 3.

Overall newborn care practice among mothers in postnatal period, in Tembaro district, south Ethiopia, May to June 2022.

Table 4.

Mothers Practice on Essential Newborn Care in in Tembaro District, South Ethiopia, May to June 2022.

Variables	Category	Frequency	Percent
Bathing initiating time	Immediately after birth	42	13.1
	Within 24 h of birth	80	24.8
	After 24 h of birth	200	62.1
Wiped with dry & soft close	Yes	321	82.7
Wiped with dry & soft close	No	67	17.3
Covered including legs & head	Yes	300	77.3
Covered including legs & head	No	88	22.7
Time of breast feeding initiation	Immediately after birth	324	83.5
Time of breast feeding initiation	After 24 h of birth	64	16.5
Apply something on the cord (n = 388)	Yes	85	22
Apply something on the cord (n = 388)	No	303	78
Substance to be applied to the cord(n = 85)	Butter	51	60
Substance to be applied to the cord(n = 85)	Vaseline	34	40
What do you do if cord bleeds?	Go to health institution	209	53.9
	Home medication	92	23.7
	Wait until heal by itself	87	22.4
Eye care at home	Yes	263	67.8
	No	125	32.2
	Face cleaning by water (n = 263)	220	83.6
	Apply eye medication (TTC; n = 263)	43	16.4
Immunized the newborn (n = 388)	Yes	251	64.7
	No	137	35.3
	Vaccinate only BCG (n = 251)	7	2.8
	Vaccinate only OPV₀ (n = 251)	155	61.8
	Vaccinate only BCG & OPV₀ (n = 251)	89	35.4

Factors Associated With Essential New-Born Care Practices

In this study, maternal educational level, health extension worker home visits during and after pregnancy, number of live births, number of antenatal care visits, and knowledge of newborn care practices were factors significantly associated with good essential newborn care practices.

Mothers who had completed college-level education or higher were found to have a statistically significant association with essential newborn care practices. Those who had completed college-level education or higher were 3.18 times more likely to practice newborn care when compared with mothers who had no formal education (AOR = 3.18, 95% CI: 1.45-6.98).

Mothers who had not been visited at home by health extension workers during and after pregnancy were 68% less likely, and mothers who had visited health institutions 3 times or fewer during their pregnancy were 52% less likely to practice essential newborn care, (AOR = 0.32, 95% CI: 0.19-0.54) and (AOR = 0.48, 95% CI: 0.28-0.81) respectively.

The odds of poor essential newborn care practice were 66% among mothers who had 2 or fewer live births and 76% among mothers who had poor knowledge about essential newborn care, (AOR = 0.34, 95% CI: 0.20-0.57) and (AOR = 0.24, 95% CI: 0.12-0.48) respectively (Table 5).

Table 5.

Factors Associated With Essential Newborns Care Practices of Women in Postnatal Period, in Tembaro district, South Ethiopia, May to June 2022.

Variables	New born care practice		(95% CI)		P-value
Variables	Good	Poor	(95% CI)		P-value
Education level of mothers			COR	AOR
No formal education	55 (46.6%)	63 (53.4%)	1.00	1.00
Primary education	74 (51.7%)	69 (48.3%)	2.93 (1.48-5.80)	1.05 (0.58-1.93)	.854
Secondary education	41 (71.9%)	16 (28.1%)	3.86 (1.98-7.51)	1.86 (0.79-4.37)	.154
College and above	54 (77.1%)	16 (22.9%)	1.23 (0.75-2.00)	3.18 (1.45-6.98)	.004
HEWs home visit
No	56 (40.9%)	81 (59.1%)	0.34 (0.22-0.52)	0.32 (0.19-0.54)	.0001
Yes	168 (66.9%)	83 (33.1%)	1.00	1.00
Number of live birth
1-2	86 (42.8%)	115 (57.2%)	0.26 (0.17-0.40)	0.34 (0.20-0.57)	.0001
≥3	138 (73.8%)	49 (26.2%)	1.00	1.00
Number of ANC visits
≤3	108 (55.1%)	88 (44.9%)	0.12 (0.05-0.27)	0.43 (0.28-0.81)	.006
>3	108 (74%)	38 (26%)	1.00	1.00
Knowledge on NBC
Poor	23 (34.8%)	4 3(65.2%)	0.32 (0.18-0.56)	0.24 (0.12-0.48)	.0001
Good	201 (62.4%)	121 (37.6%)	1.00	1.00

1.00: reference category.

Discussion

The prevalence of essential newborn care (ENC) practices in this study was 57.7% (95% CI: 52.6-62.6). This is considerably higher than the rates reported in studies from Damot Pulasa Woreda (24%)²⁰ and the rural districts of the Gedeo Zone (24.1%).²¹ The observed differences may stem from variations in study settings, timeframes, and healthcare service availability, all of which can influence newborn care practices. Conversely, the ENC prevalence in this study is lower than the 81.1% reported in the Tigray Region, Northern Ethiopia (81.1%).¹⁹ This disparity may be due to differences in socioeconomic conditions, healthcare infrastructure, maternal education, and awareness levels between regions. Additionally, geographical factors may influence access to healthcare services and maternal health-seeking behaviors. These findings highlight the importance of context-specific interventions to enhance ENC practices and improve neonatal health outcomes. In this study, maternal education level was found to have a significant associated with newborn care practices among postnatal mothers. Women who had completed college or higher education were more likely to engage in essential newborn care practices compared to those with no formal education. This finding is consistent with research conducted in Uganda²² and in the rural district of Gedeo zone, Ethiopia.²¹ Educated women are likely to possess a better understanding and knowledge of essential newborn care, leading to increased confidence and improved caregiving practices.

Women who did not receive visits from health extension workers during and after pregnancy were less inclined to engage in proper newborn care practices compared to those who had such visits. This finding is consistent with research conducted in Ethiopia²³ and Nepal.²⁴ This correlation could be attributed to the potential impact of health extension worker visits in providing crucial guidance and support for newborn care practices to mothers.

Mothers who had 2 or fewer live births showed a lower likelihood of engaging in newborn care practices compared to those with 3 or more live births. This result aligns with studies carried out in Lawra District, Ghana, and Uganda, indicating that first-time mothers were less inclined to exhibit good newborn care practices in comparison to mothers with multiple children.^25,26 The consistency in these findings could be attributed to the fact that mothers with 3 or more children may prioritize their newborn care practices more due to their experience with caring for multiple children.

Additionally, frequency of ANC visits during pregnancy was associated with newborn care practices. Mothers who attended health institutions 3 times or fewer were less likely to engage in newborn care practices compared to those who had more than 3 visits²³ and in the Tigray Region of Northern Ethiopia.¹⁹ This is may be attributed to the likelihood of women receiving ongoing guidance on newborn care practices during ANC visits if they attended 3 or more times.

In this study, women with poor knowledge demonstrated lower likelihood of practicing essential newborn care compared to those with better knowledge. This finding aligns with studies in Sindh, Pakistan,²⁷ and Nepal,²⁸ which also showed a significant relationship between women’s knowledge of essential newborn care and their actual practices. This association may be due to the tendency of women with insufficient knowledge and awareness to be less inclined to engage in these practices.

Conclusion

This study showed that the level of good essential new-born care practices was found 57.7. Factors such as maternal education, home visits by health extension workers, number of live births, ANC visits, and maternal knowledge on newborn care were identified as independently associated with newborn care practices. It is imperative for primary healthcare providers to consistently deliver essential newborn care and educate mothers on this subject during pregnancy services and home visits.

Limitation of the Study

The cross-sectional design of this study was a limitation because it measured exposure and outcome at the same time. It does not demonstrate a cause-and-effect rela-tionship. Despite the implementation of standardized questionnaires and a shortened recall period to mitigate recall bias, it remains an unavoidable limitation in the study.

Footnotes

Acknowledgements

We would like to acknowledge Wachamo University College of medicine and health science for approving the research project. Furthermore, our special appreciation goes to data collectors for their genuine effort to bring reliable data. Finally, we would like to wholeheartedly acknowledge study participants without them this work could not be realized.

Acronyms and Abbreviations

ANC: Antenatal Care, BF: Breast Feeding, EDHS: Ethiopian Demographic and Health Survey, ENC: Essential Newborn Care, ENCP: Essential Newborn Care Practice HC: Health Center, HEWs: Health Extension Workers, LBs: Live births, MCH: Maternal and Child Health, NBC: Newborn Care Practice, NMRs: Neonatal Mortality Rates, SBAs : Skill Birth Attendants, SD: Standard deviation, SDG: Sustainable Developmental Goals, SNNPR: Southern Nations, Nationalities and People’s Region, SPSS: Statistical Package for Social Sciences WHO: World Health Organization

ORCID iD

Angefa Ayele

Ethical Considerations

The study was approved by the Ethics Review Committee (Ref no: ERC/670/2022) School of graduate Study, Wachemo University, Ethiopia.

Consent to Participate

The informed consent with a written signature was obtained upon the agreement from participants after purpose of study had been explained. There were informed to withdraw at any time and/ or to refrain from responding to questions. Study participants were also informed that all the data obtained from them could be kept confidential using code instead of any personal identifiers. Furthermore, the research procedures were conducted in accordance with the principle expressed in The World Medical Association’s Declaration of Helsinki.

Consent for Publication

Not applicable.

Author Contributions

AA: contributed to conception and design; contributed to acquisition, analysis, and interpretation; drafted manuscript; critically revised manuscript; gave final approval; agrees to be accountable for all aspects of work ensuring integrity and accuracy.

DD: contributed to conception and design; contributed to acquisition and analysis; drafted manuscript; critically revised manuscript; gave final approval; agrees to be accountable for all aspects of work ensuring integrity and accuracy.

TS: contributed to conception and design; contributed to acquisition, analysis, and interpretation; drafted manuscript; critically revised manuscript; gave final approval; agrees to be accountable for all aspects of work ensuring integrity and accuracy.

TL: contributed to conception and design; contributed to analysis and interpretation; drafted manuscript; critically revised manuscript; gave final approval; agrees to be accountable for all aspects of work ensuring integrity and accuracy.

AS: contributed to conception and design; contributed to acquisition and interpretation; drafted manuscript; critically revised manuscript; gave final approval; agrees to be accountable for all aspects of work ensuring integrity and accuracy.

FM: contributed to conception and design; contributed to analysis; drafted manuscript; critically revised manuscript; gave final approval; agrees to be accountable for all aspects of work ensuring integrity and accuracy.

AE: contributed to conception and design; contributed to acquisition, analysis, and interpretation; drafted manuscript; critically revised manuscript; gave final approval; agrees to be accountable for all aspects of work ensuring integrity and accuracy.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

All data analyzed during this study are included in the manuscript.

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