Introduction

Child malnutrition remains a pressing public health challenge in Ethiopia, particularly among
children under five years of age. Despite significant efforts to combat this issue through national
policies and health interventions, malnutrition continues to account for a substantial proportion
of child mortality and developmental delays (Federal Ministry of Health [FMOH], 2020). The
Oromia Regional State, specifically Eastern Hararge Zone and Haramaya Woreda, exhibits
unique socio-economic and agro-ecological characteristics that influence the prevalence and
determinants of child malnutrition (Central Statistical Agency [CSA], 2016). This study explores
the utilization of child care services for under-five nutrition and the factors associated with their
use among mothers in Haramaya Woreda.
Ethiopia has made strides in reducing under-five mortality rates, yet disparities persist across
regions and socio-economic groups (UNICEF, 2019). National initiatives such as the Health
Sector Transformation Plan (HSTP-II) aim to strengthen maternal and child health systems, but
localized studies are essential to address region-specific challenges (FMOH, 2020). Haramaya
Woreda, located in Eastern Hararge Zone, is characterized by rural settings where limited access
to healthcare services, food insecurity, and educational barriers exacerbate malnutrition among
children (Haramaya University, 2018).

Background of the Study

National Context
Ethiopia faces significant challenges in addressing child malnutrition due to recurrent droughts,
food insecurity, and inadequate healthcare infrastructure (World Food Programme [WFP], 2021).
Malnutrition among children under five manifests as stunting, wasting, and underweight
conditions, with national prevalence rates remaining alarmingly high (Ethiopian Public Health
Institute [EPHI], 2019). Studies estimate that 42% of Ethiopian children are stunted, 33% are
underweight, and 15% experience wasting (EPHI, 2019). These conditions are driven by factors
such as poor dietary diversity, maternal education levels, and socio-economic disparities (CSA,
2016).
The Ethiopian government has implemented various programs to combat malnutrition, including
the Health Extension Program launched in 2003 (FMOH, 2020). This program focuses on
improving access to healthcare in rural areas through community-based interventions. However,
fragmented approaches and insufficient multi-sectoral coordination have limited the
effectiveness of these initiatives (WFP, 2021).

Regional Context: Oromia Regional State

Oromia is Ethiopia's largest regional state and home to diverse agro-ecological zones that
influence nutritional outcomes (CSA, 2016). In Eastern Hararge Zone, communities face
challenges such as food scarcity, low maternal education levels, and limited access to healthcare
facilities (Oromia Health Bureau [OHB], 2019). These factors contribute to high rates of
malnutrition among children under five years old (OHB, 2019).
The region's reliance on subsistence farming makes households vulnerable to climatic shocks
that impact food availability (WFP, 2021). Additionally, cultural practices and beliefs
surrounding child feeding often hinder optimal nutritional outcomes (Haramaya University,
2018). Addressing these issues requires tailored interventions that consider the unique socio-
cultural dynamics of Oromia (OHB, 2019).

Local Context: Haramaya Woreda

Haramaya Woreda is situated within Eastern Hararge Zone and is predominantly rural (CSA,
2016). The area experiences high rates of undernutrition among children under five due to
factors such as poverty, inadequate maternal knowledge about nutrition, and limited access to
child care services (Haramaya University, 2018). A study conducted in Haramaya revealed that
undernutrition remains a major health problem despite national progress in reducing its
prevalence (Haramaya University, 2018).
Key determinants of malnutrition in Haramaya include poor dietary practices, lack of sanitation
facilities, and insufficient healthcare utilization (OHB, 2019). Mothers in this woreda often face
barriers such as financial constraints and limited awareness about available child care services
(FMOH, 2020). Understanding these local dynamics is crucial for designing effective
interventions (WFP, 2021).

Significance of the Study

This research aims to fill gaps in understanding the utilization of child care services for under-
five nutrition in Haramaya Woreda (Haramaya University, 2018). By identifying associated
factors such as maternal education levels, socio-economic status, and access to healthcare
facilities, the study will provide insights into targeted strategies for improving child nutritional
outcomes (EPHI, 2019).
Furthermore, findings from this study will contribute to regional planning efforts by highlighting
specific challenges faced by mothers in Haramaya Woreda (OHB, 2019). Policymakers can use
this information to enhance existing programs and ensure equitable access to child care services
across different socio-economic groups (FMOH, 2020).

Statement of the Problem

Child health care service utilization is a critical determinant of child survival and well-being,
particularly in low-income countries like Ethiopia, where under-five mortality remains a
significant public health challenge. Despite global efforts to reduce child mortality, Ethiopia
continues to face high rates of preventable deaths among children under five due to common
illnesses such as diarrhea, pneumonia, and fever. These illnesses are often exacerbated by
delayed or inadequate health care-seeking behavior among caregivers. In Haramaya Woreda,
Eastern Hararghe Zone, the situation is compounded by socio-economic, cultural, and systemic
barriers that hinder access to essential health services.

Low Utilization of Health Services

Nationally, the utilization of child health care services remains alarmingly low. According to the
2016 Ethiopian Demographic and Health Survey (EDHS), only 30% of children with symptoms
of acute respiratory infection (ARI), 35% with fever, and 44% with diarrhea received treatment
from health facilities. This trend is particularly pronounced in rural areas like Haramaya Woreda,
where geographic isolation, limited health infrastructure, and cultural practices further impede
access to care.

Socio-Economic and Educational Barriers

Socio-economic factors such as household wealth and parental education significantly influence
health care-seeking behaviors. Studies have shown that mothers from wealthier households and
those with higher educational attainment are more likely to seek medical treatment for their
children. Conversely, poverty and illiteracy among mothers in Haramaya Woreda limit their
ability to recognize the severity of illnesses and access timely medical care. Additionally,
harmful cultural norms and gender inequalities often restrict women's decision-making power
regarding their children's health.

Systemic Challenges

The availability and quality of health services in rural Ethiopia are often inadequate. Challenges
include insufficient health facilities, poorly trained staff, and a lack of essential medicines.
Furthermore, the expansion of primary health care (PHC) facilities has not sufficiently bridged
the urban-rural gap in service utilization. Geographic disparities persist, with rural residents less
likely to access immunization services or institutional deliveries compared to their urban
counterparts. In Haramaya Woreda, these systemic issues are exacerbated by a lack of
community awareness about the importance of skilled health care for childhood illnesses.

Knowledge Gaps
While national-level studies have identified key determinants of child health service utilization,
there is limited research specifically addressing the unique socio-cultural and economic context
of Haramaya Woreda. Understanding local barriers and facilitators is essential for designing
targeted interventions that can improve service uptake among mothers with children under five
years.
Public Health Implications
The low utilization of child health services in Haramaya Woreda contributes to preventable
morbidity and mortality among children under five years old. Addressing this issue requires a
multi-faceted approach that includes improving maternal education, enhancing the quality and
accessibility of health services, and addressing socio-cultural barriers. Without targeted
interventions, the region will continue to experience high rates of child mortality from
preventable causes.
In summary, this study aims to explore the factors influencing child health care service
utilization in Haramaya Woreda to inform evidence-based strategies for improving access and
reducing under-five mortality in the region.

CHAPTER TWO: REVIEW OF RELATED LITERATURE

2.1 Introduction

Child nutrition and proper child care services during the early years of life are vital for optimal
growth, cognitive development, and long-term health. Globally, undernutrition contributes to
nearly half of deaths in children under five. In Ethiopia, despite policy efforts, undernutrition and
limited utilization of child care services remain significant public health concerns. This chapter
reviews relevant literature on child care service utilization, the nutritional status of under-five
children, and the associated factors influencing service use among mothers, particularly in rural
areas like Haramaya Woreda.

2.2 Concept of Child Care Services and Nutritional Utilization

Child care services for children under five generally include growth monitoring, immunization,
nutrition education, supplementary feeding, and treatment of common childhood illnesses.
Nutritional utilization, in this context, refers to the uptake and proper use of these services aimed
at enhancing child nutritional outcomes. The World Health Organization (WHO) emphasizes
integrated approaches such as Infant and Young Child Feeding (IYCF) practices and community-
based nutrition programs to improve outcomes.
2.3 Global Perspective on Under-Five Nutrition and Child Care Services

Globally, malnutrition remains a critical issue. According to the UNICEF (2023) report,
approximately 149 million children under five are stunted, and 45 million are wasted. In sub-
Saharan Africa, the situation is even more dire due to poverty, food insecurity, inadequate health
services, and lack of maternal education. Various studies have demonstrated that countries with
strong primary health care systems and better maternal education show higher rates of child care
service utilization.

2.4 Under-Five Nutritional Status in Ethiopia

Ethiopia has made significant strides in reducing child malnutrition over the past two decades.
The 2019 Ethiopia Mini Demographic and Health Survey (EMDHS) reported that 37% of
children under five were stunted, 7% were wasted, and 21% were underweight. Despite this
progress, regional disparities remain, with areas like Eastern Hararghe experiencing higher rates
of malnutrition due to socio-economic and cultural barriers.

2.5 Child Care Service Utilization in Ethiopia

Utilization of child care services in Ethiopia remains suboptimal, especially in rural areas.
Factors contributing to low utilization include lack of awareness, inadequate health
infrastructure, cultural beliefs, and gender roles. According to a study by Yalew et al. (2020),
less than 50% of mothers in rural settings regularly attend growth monitoring and nutrition
counseling sessions.

2.6 Determinants of Child Care Service Utilization

Numerous factors influence the use of child care services:

2.6.1 Maternal Education

Education enhances mothers’ knowledge about child health and nutrition. Several studies,
including one by Fekadu et al. (2021), found a positive association between maternal education
and regular use of nutrition services.

2.6.2 Household Income

Low-income households often struggle to access health facilities due to transportation costs or
competing financial demands. Studies in Oromia have shown that mothers from wealthier
households are more likely to utilize child care services.

2.6.3 Cultural Beliefs and Practices

Traditional beliefs regarding child feeding and treatment can deter mothers from seeking formal
care. For example, some communities in Eastern Hararghe prefer herbal remedies over modern
medicine.

2.6.4 Health Facility Accessibility

Distance to health facilities and the availability of trained personnel affect utilization. Mothers in
remote kebeles are less likely to attend monthly child care services.

2.6.5 Knowledge and Awareness

Awareness campaigns significantly influence service uptake. Research shows that community
health workers and local media play a critical role in disseminating information.
References
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Ethiopian Public Health Institute [EPHI]. (2019). National nutrition program baseline survey
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Federal Ministry of Health [FMOH]. (2020). Health sector transformation plan II (2020/21–
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Haramaya University. (2018). Assessment of child nutrition practices in Haramaya Woreda.
Haramaya, Ethiopia: College of Health and Medical Sciences.
Oromia Health Bureau [OHB]. (2019). Annual performance report on maternal and child health
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UNICEF. (2019). The state of the world’s children 2019: Children, food, and nutrition. New
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