Abstract
BackgroundIn the last decade, the proportion of Ethiopian women using contraceptive methods has increased substantially (from 14% in 2005 to 35% in 2016 among married women). Numerous factors have contributed to the increased uptake. An important one is the implementation of the Health Extension Program, a government-led health service delivery strategy that has deployed more than 38,000 health extension workers (HEWs) throughout the country. Key mechanisms underlying the success of this program are not well understood. Using a case study approach, the goal of this study is to describe how key features of local contexts, community perceptions, and messaging by HEWs have contributed to the increased use of modern contraception in one community in Ethiopia.MethodsWe conducted focus groups and individual interviews with men, women, adolescents, and key informants, including (HEWs), in Oromia, Ethiopia. We used a random sampling protocol to recruit all participants except key informants, with whom purposive sampling was used to ensure participants were knowledgeable on family planning in the village. Interviews were audio recorded, translated, transcribed, and then analyzed using applied thematic analysis and NVivo v.11 qualitative research software.ResultsWe identified four themes that may explain uptake of contraception: (1) HEWs are seen as trusted and valued community members who raised awareness about family planning; (2) the HEW messaging that contraception is useful to space pregnancies among married women was effective; (3) the message that spacing is healthy for mother and child was also effective; and (4) communicating to the entire community (including men, women, adolescents, and religious leaders), contributed to changing attitudes around contraception.ConclusionThe four aspects of the Health Extension Program approach increased uptake of contraception in our sample. In contexts where community health workers are valued by the health systems and local communities they serve, this type of approach to widening modern contraception use could help increase uptake and address unmet need. Understanding these granular aspects of the program in one local context may help explain how use of contraception increased in the country as a whole.
Highlights
In the last decade, the proportion of Ethiopian women using contraceptive methods has increased substantially
We found four main themes: (1) Health extension worker (HEW) are seen as trusted and valued community members who raised awareness about family planning; (2) the message that contraception is useful to space pregnancies was effective; (3) the message that spacing is healthy for mother and child was effective; and (4) communicating to the entire community, contributed to changing attitudes around contraception
We identified four main themes that may help explain uptake of modern contraception in Oromia: (1) high acceptance of and impact on uptake of family planning services provided by HEWs in the community; (2) a focus on changing behaviors to increase spacing between births; (3) framing the spacing message as “healthy” for mother and baby but only targeting married women who have already given birth; and (4) delivering the message to everyone in the community, including men, women, adolescents, and religious leaders
Summary
The proportion of Ethiopian women using contraceptive methods has increased substantially (from 14% in 2005 to 35% in 2016 among married women). An important one is the implementation of the Health Extension Program, a government-led health service delivery strategy that has deployed more than 38,000 health extension workers (HEWs) throughout the country. Using a case study approach, the goal of this study is to describe how key features of local contexts, community perceptions, and messaging by HEWs have contributed to the increased use of modern contraception in one community in Ethiopia. Between 2005 and 2016, total fertility in Ethiopia dropped and contraceptive use increased significantly. Various factors have been proposed to explain this increase in contraceptive use, including growing political will, substantial external funding, non-governmental and public-private partnerships, and implementation of the Health Extension Program (HEP) to train health extension workers (HEWs) to work at community health posts [5]. The HEWs are recruited from within their own community to ensure delivery of locally needed care and to facilitate trust between the community and the HEWs [9]
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