Health Extension Program Research Articles

National Healthcare System Development of Ethiopia: A Systematic Narrative Review

Objective: To describe the evidence on the development of the National Healthcare System in Ethiopia. Method: The databases Embase, Ovid Emcare, Ovid MEDLINE, and Scopus were searched, together with the reference lists of the identified articles, relevant reports and books were searched. Articles were included if they described health services development in Ethiopia. Results: In Ethiopia, medical care has historically been performed by traditional healers who use magic and superstition. Over time, modern medicine continued to develop, and by 2014, 5% of Ethiopia’s total Gross Domestic Product was spent on health. In 2017, nearly 1.26 healthcare workers per 1000 population provided services through 21,071 healthcare organizations, with the majority being rural health posts. There are shortages of healthcare workers and limited numbers of hospitals. However, the introduction of the Health Extension Program and Health Extension Workers has improved access to healthcare in the country and could be a model for other African nations. Conclusion: Although the health care strategies introduced by the Ethiopian government have improved some health issues, accessibility to healthcare institutions that provide curative services is limited.

Knowledge, Attitude, and Practices on Water, Sanitation, and Hygiene among Rural Residents in Tigray Region, Northern Ethiopia.

Background Poor hygienic practices, inadequate water supply, and poor sanitary conditions play a major role in the spread of infectious diseases. Lack of knowledge, attitude, and practices (KAP) on WASH is one of the most imperative causes for transmission of infectious diseases. Therefore, the aim of this study was to assess knowledge, attitude, and practice of rural residents on water, sanitation, and hygiene in Tigray, Ethiopia. Methods A community-based cross-sectional study was conducted from June to July 2018. Multistage cluster sampling technique was used to collect data from 759 households in Tigray region, Northern Ethiopia. A standardized questionnaire was used to collect data on knowledge, attitude, and practice on water, sanitation, and hygiene (WASH). Descriptive data analysis was done to present the study findings. Results The response rate was 99.6%, and 574 (75.9%) of the respondents were females. Good knowledge, favorable attitude, and good practice on WASH were observed in 42.2% (95% CI: 38.7%, 45.7%), 48.5% (95% CI: 44.9%, 52.0%), and 49.2% (95% CI: 45.6%, 52.7%) of the respondents, respectively. Conclusions Poor knowledge, unfavorable attitude, and poor practice on WASH were common amongst the residents in rural Tigray, Northern Ethiopia. Therefore, the health extension programs at primary health care should be revitalized in a way that can enhance the interventional measures to improve knowledge, attitude, and practice on WASH.

The Utilization of Health Service Packages Among Mothers of Children Less Than 1Year of Age in the Somali Region of Ethiopia.

Health Service Package is the package of services that the government is providing or is aspiring to provide to its citizens in an equitable manner. The Ethiopia Family Health Service Package is part of the health extension program consisting of antenatal care, delivery service, postnatal care, immunization, and family planning. This package facilitates the utilization of maternal, neonatal and child health services and contributes to the reduction of maternal and child mortality. However, there is no data on the utilization of this package in pastoralist societies. This study aimed to assess the utilization of the Family Health Service Package and associated factors among mothers of children less than 1-year-old. From February 18-March 6, 2017 we conducted a community-based cross-sectional study with 421 mothers who gave birth in the last year in the Afdem district of the Somali region in Ethiopia. Mothers who gave birth between January 1/2016 to January 1/2017 in the district were selected by systematic random sampling. The study analysis included descriptive and bivariate statistics and multivariate logistic regression model. The overall utilization of the package was 25.1% (95% CI of 21.1-29.5%). Factors associated significantly with family health service utilization were urban place of residence [(AOR 95% CI) = 3.8 (1.5-9.9)], mother visited by health extension workers [(AOR (95% CI) = 3.1 (1.6-6.3)] and mothers participation in health extension program activities [(AOR (95% CI) = 2.8 (1.5-5.4)]. The utilization of the Family Health Service Package was low. Mothers visited by health extension workers and participated in the health extension program were more likely to utilize family health services. It needs to expand services beyond urban areas and involve rural mothers in health extension program activities.

Prevalence of Vitamin A Deficiency among Preschool Children in Ethiopia: A Systematic Review and Meta-Analysis.

Background Vitamin A deficiency is a major nutritional concern in lower-income countries. The aim of this systematic review and meta-analysis was to show the magnitude of vitamin A deficiency among preschoolers in Ethiopia. Objective The present study was aimed at synthesizing qualitatively and quantitatively the existing literature on the prevalence of VAD in preschool children in Ethiopia. Methods Studies were searched through the search engine of Google Scholar, Hinari, MEDLINE/PubMed, Cochrane Library, and Africa-Wide Information. Searching was made using the keywords/MeSH of vitamin A deficiency, xerophthalmia, night blindness, Bitot's spot, retinol, children, and Ethiopia. Data were analyzed and compared with the WHO threshold criteria to declare a public health problem. Heterogeneity among studies was assessed using a Cochran Q test and I2 statistics. A random-effects model with 95% confidence interval was used for prevalence estimations. Results Of the 13 studies included in clinical analysis, 12 of them reported the prevalence of night blindness and/or Bitot's spot among preschool children in Ethiopia which was above WHO cutoff point for the public health problem 1% and 0.5%, respectively. The prevalence of night blindness significantly decreased from moderate public health problem 4.2% (95% CI: 2.8%-5.7%) in a period from 1990 to 2004 to mild public health problem 0.8% (95% CI: 0.6%-1.0%) in a period from 2005 to 2019. Furthermore, statistically insignificant reduction was observed in the prevalence of Bitot's spot in a period from 1990 to 2004, 2.2% (95% CI: 1.3%-3.2%) to 1.8% (95% CI: 1.2%-2.3%) in a period from 2005 to 2019. Among 8 studies on subclinical vitamin A deficiency, 7 of them indicated a severe public health problem (>20%). The prevalence of subclinical vitamin A deficiency decreased from 55.7% (95% CI: 39.8%-71.6%) in a period from 1990 to 2004 to 28.3% (95% CI: 9.8%-46.7%) in a period from 2005 to 2019, but not statistically significant. Conclusions Despite the reduced proportion of night blindness and Bitot's spot, still both clinical and subclinical vitamin A deficiencies remain a public health problem in Ethiopia requiring strengthen intervention through the newly initiated health extension program.

Effectiveness of Checklist-Based Box System Interventions (CBBSI) versus routine care on improving utilization of maternal health services in Northwest Ethiopia: study protocol for a cluster randomized controlled trial

BackgroundMaternal mortality is still high in Ethiopia. Antenatal care, the use of skilled delivery and postnatal care are key maternal health care services that can significantly reduce maternal mortality. However, in low- and middle-income countries, including Ethiopia, utilization of these key services is limited, and preventive, promotive and curative services are not provided as per the recommendations. The aim of this study is to examine the effectiveness of checklist-based box system interventions on improving maternal health service utilization.MethodsA community-level, cluster-randomized controlled trial will be conducted to compare the effectiveness of checklist-based box system interventions over the routine standard of care as a control arm. The intervention will use a health-extension program provided by health extension workers and midwives using a special type of health education scheduling box placed at health posts and a service utilization monitoring box placed at health centers. For this, 1200 pregnant mothers at below 16 weeks of gestation will be recruited from 30 clusters. Suspected pregnant mothers will be identified through a community survey and linked to the nearby health center. With effective communication between health centers and health posts, dropout-tracing mechanisms are implemented to help mothers resume service utilization. Data will be collected using an open data kit and analyzed using STATA version 13.0. Data will be analyzed by the intention-to-treat analysis. Risk ratios will be computed at the cluster level and the summary will be compared using t tests. Outcomes between intervention and control groups will be compared with random effects logistic regression models. Achieving four antenatal care visits, health facility delivery, and postnatal care visits at 6 weeks after delivery were treated as primary outcomes for this study.DiscussionWe expect that the study will generate evidence on the effectiveness of checklist-based box system interventions on improving utilization of maternal health care service that will produce inputs for related policies in Ethiopia.Trial registrationClinicalTrials.gov, NCT03891030. Retrospectively registered on 26 March 2019.

Promoting equity in maternal, newborn and child health – how does gender factor in? Perceptions of public servants in the Ethiopian health sector

ABSTRACT Background: Advancing gender equality and health equity are concurrent priorities of the Ethiopian health sector. While gender is regarded as an important determinant of health, there is a paucity of literature that considers the interface between how these two priorities are pursued. Objective: This article explores how government stakeholders understand gender issues (gender barriers and roles) in the promotion of maternal, newborn and child health equity in Ethiopia. Methods: Adopting an exploratory qualitative case study design, we conducted semi-structured interviews with 17 purposively-selected stakeholders working in leadership positions with the Federal Ministry of Health and Federal Ministry of Women and Children Affairs as part of a larger study regarding the promotion of health equity in maternal, newborn and child health. A post hoc content and thematic sub-analysis was done to explore how participants raised gender issues in conversations about health equity. Results: Efforts to address gender inequalities were synonymous with the promotion of a women’s health agenda, which was largely oriented towards promoting health service use. Men were predominant decision makers with regards to women’s health and health care seeking in both public and private spheres. Participants reported persisting gender-related barriers to health stemming from traditional gender roles, and noted the increased inclusion of women in the health workforce since the introduction of the Health Extension Program. Conclusions: The framing of gender as a women’s health issue, advanced through patriarchal structures, does little to elevate the status of women, or promote power differentials that contribute to health inequity. Encouraging leadership roles for women as health decision makers and redressing certain gender-based norms, attitudes, practices and discrimination are possible ways forward in re-orienting gender equality efforts to align with the promotion of health equity.

Assessing satisfaction and motivation of health extension workers (Hews) and factors associated with it in gambella region, Gambella, southwest Ethiopia, 2019: A cross-sectional study

Background: Health extension workers (HEWs) are the frontline health workers for Ethiopia’s primary health care system. The Health Extension Program (HEP) is one of the most innovative community- based health programs launched by the Ethiopian Federal Ministry of Health (FMOH) to make health services accessible to rural communities by setting out women health extension workers (HEWs) in rural health posts. Ethiopia has initiated a nationwide community health program (referred to as Health Extension Program) that is primarily staffed with health extension workers; however, data on their satisfaction and motivation and related factors were not studied and scanty in the country. Thus, this study was aimed to assess measure the satisfaction of health extension workers and to identify factors affecting their satisfaction in the study setting in particular and the country in general. Materials and Methods: A cross-sectional descriptive study analysis was conducted to collect relevant data on satisfaction from health extension workers who had been from three districts in Southwest Ethiopia. Items included in the questionnaires include values, organizational cultures, work place conditions, personality, motivating and satisfaction. They also included reasons for satisfaction and dissatisfaction; motivating and de-motivating from future perspectives using Likert scale. Mean and standard deviation were used to describe satisfaction level. Multiple linear regression model was used for identifying associated factors. Result: The overall mean satisfaction score was 43.0 out of the 60 total score. Organizational culture, personal recognition and appreciation, job descriptions and criteria career structure and for promotion salary have been identified by rural HEWs as major were mentioned as a reason for satisfaction and motivating; while low salaries, insufficient training and lack of capacity among others, absence of transportation, poor supervision, and absence of housing living conditions were mentioned as reasons for dissatisfaction and de-motivating. Conclusion: HEWs play a pivotal role in Ethiopia’s HEP. As such, their motivations require special consideration to support them to continue doing their health care activities in a productive way. The HEWs were least satisfied with Salary pay, education, and benefits which require high level decision for strategies to improve the pay and benefits, and opportunities for education. They were also least satisfied with management and working conditions that can be addressed at organization level by supportive supervision and management, participatory decision making, clear job descriptions, merit based recognition and appreciation and balanced workload.

Modern Contraceptive Utilization and Its Associated Factors Among Women Beggars in Bahir Dar Town, North West Ethiopia

In Ethiopia the health extension packages as Ethiopia’s Health Extension Programs primarily targets to address maternal and child health problems specifically in addressing family planning services at household level. However women living on street, around churches and mosques living by begging cannot be addressed by health extension packages, only those beggars who have rented houses can be addressed by health extension packages, though modern contraceptive use among women beggars is scarce and not well known in the study area. This study aims to assess modern contraceptive utilization and associated factors among women beggars in Bahir Dar town, North Western Ethiopia. A quantitative cross-sectional study was conducted in March 2019 from Bahir Dar town, Northwestern Ethiopia on 238 women beggars using consecutive sampling technique with an interviewer administered structured questionnaire. Data was entered in to Epi-Info version 7 then, exported to SPSS version 23 for cleaning and analysis. Binary logistic regression analysis was used to determine the association between different factors and modern contraceptive service utilization. Those variables which had significant association with modern contraceptive service utilization were entered to multivariable logistic regression analysis. Finally odds ratio with 95% confidence intervals were used to identify the independent predictors of modern contraceptive utilization by women beggars. One hundred fifteen (48.9%) have ever used and seventy three (31.1%) with (95%CI=25.1-37.4%) were currently using modern contraceptives, 44 (60.3%) use injectable followed by implant 11 (15.1%). Being married (AOR=4.850 & 95%CI 2.285-6.971), being educated (AOR=5.771 & 95%CI 3.173-6.564), currently living in a rented house (AOR=2.155 & 95%CI 1.523-3.623), having a history of sexual assault/rape (AOR=3.846 & 95%CI 2.133-5.448) and having discussion with a HEW (AOR=3.173 95%CI 2.154-3.889) were more likely to be modern contraception users than their counter parts. The current contraceptive use among women beggars in Bahir Dar town Northwestern Ethiopia is lower considering the natures of their life styles and living conditions though working by including them in urban health extension program by targeting the identified factors is more helpful.

Level of Health Extension Service Utilization and Associated Factors Among Community of Merti Woreda Arsi Zone, Oromia Regional State, Ethiopia

Introduction: To address health problem of the rural community, Ethiopia launched Health Extension Program in 2003. Mother and child have been facing different problems and due to poor access to modern health care facilities. Lack of effective demands to utilize the available service also has its own contribution to the problems. Objective: The aim of this study was to assess the status of Health Extension Service Utilization and Associated Factors among Community of Merti Woreda Arsi Zone, Oromia Regional State, Ethiopia. Methodology: Community based, quantitative cross-sectional study using structured questionnaires were carried out. A total of 604 households were selected from each kebeles through systematic sampling from random starting point from household registration book using a number between one and sampling interval. The data was entered to Epi Info version 7computer software and transferred to SPSS version 21 computer software programs. Descriptive statistics was done for each variables, bivariate analysis between dependent and independent variables was performed. Multivariate analysis was done to control for possible confounding variable finally P-Value < 0.05 with CI was used as level of significance. Results: The level of community utilization of health extension service was 92.4%. Even though the health extension service is high, the implementation is found to be low in some packages such as women’s immunization service, delivery, postnatal care service, community conversation, and model family. Age, educational status, religion, language, and knowledge about health extension service were identified as the independent factors affecting community health extension services utilization. Further studies should be undertaken to determine the level and factors affecting utilization of health extension service from the perspective of health extension workers on a wider scale. Conclusion: The level of community utilization of health extension service has registered relatively higher results as compared to the previous studies. Age, educational status, religion, language, and knowledge about health extension service were identified as the independent factors affecting community health extension services utilization.

Prevalence and Intensity of Soil-Transmitted Helminth Infection among Rural Community of Southwest Ethiopia: A Community-Based Study.

Background Helminths are significant contributors to global health problems. Subgroup soil-transmitted helminths are among the listed neglected tropical diseases. The rural inhabitants often suffer from heavy infection, particularly children and pregnant women. Objective The study aimed at determining the magnitude and intensity of soil-transmitted helminth infection and associated risk factors in the study area where the prevalence and intensity of the infection are yet unknown at the community level. Method A community-based cross-sectional study was conducted between April and June 2016 on 377 individuals. Systematic random sampling was utilized to select the households. Lottery method was used for study subject selection in the households. Sociodemographic and risk factor data were collected using a pretested questionnaire. Parasitological tests were processed using Kato-Katz thick smear and duplicate direct wet mount analysis of the stool sample. Results A total of 377 subjects aged from 2 to 55 years were enrolled in the study, of which 211 were female (56%) and 166 were male (44%). The overall prevalence of soil-transmitted helminths was 265 (70.3%). The females shared more (36.6%, 138) as compared to males (33.7%, 127) at P < 0.05. Of all identified soil-transmitted helminths, Trichuris trichiura was the predominant infectious agent (66.8%, 252) followed by Ascaris lumbricoides (16.4%, 62) and hookworm (14.1%, 53). Gender (AOR: 1.67 (95% CI: 1.034–2.706)), lack of fruit washing before consumption (AOR: 1.7 (95% CI: 1.1–2.6)), open defecation habit (AOR: 1.75 (95% CI: 0.921–3.338)), and drinking untreated water (AOR: 1.994 (95% CI: 1.019–3.90)) were significantly associated with soil-transmitted helminth infection. Conclusion High prevalence of STH infection was still an important health issue of the community even after the implementation of the health extension program. Hence, intervention considering all population of the residents as eligible to deworm and health education are mandatory.

Wealth-based equity in maternal, neonatal, and child health services utilization: a cross-sectional study from Ethiopia

BackgroundDespite the pro-poor health policies in Ethiopia, the utilization of maternal, neonatal, and child health services remains a challenge for the country. Health equity became central in the post-2015 Sustainable Development Goals globally and is a priority for Ethiopia. The aim of this study was to assess equity in utilization of a range of maternal and child health services by applying absolute and relative equity indices.MethodsData on maternal and child health utilization emanated from a baseline survey conducted for a large project ‘Optimizing the Health Extension Program from December 2016 to February 2017 in four regions of Ethiopia. The utilization of four or more antenatal care visits; skilled birth attendance; postnatal care within 2 days after childbirth; immunization with BCG, polio 3, pentavalent 3, measles and full immunization of children aged 12–23 months; and vitamin A supplementation for 6–23 months old children were stratified by wealth quintiles. The socioeconomic status of the household was assessed by household assets and measured by constructing a wealth index using principal component analysis. Equity was assessed by applying two absolute inequity indices (Wealth index [quintile 5- quintile 1] and slope index of inequality) and two relative inequity indices (Wealth index [quintile5: quintile1] and concentration index).ResultsThe maternal health services utilization was low and inequitably distributed favoring the better-off women. About 44, 71, and 18% of women from the better-off households had four or more antenatal visits, utilized skilled birth attendance and postnatal care within two days compared to 20, 29, and 8% of women from the poorest households, respectively. Skilled birth attendance was the most inequitably distributed maternal health service. All basic immunizations: BCG, polio 3, pentavalent 3, measles, and full immunization in children aged 12–23 months and vitamin A supplementation were equitably distributed.ConclusionUtilization of maternal health services was low, inequitable, and skewed against women from the poorest households. In contrast, preventive child health services were equitably distributed. Efforts to increase utilization and reinforcement of pro-poor and pro-rural strategies for maternal, newborn and immunization services in Ethiopia should be strengthened.

Get Smart: Learning and partnership with Ethiopia’s Health Extension Programme to re-envision contraceptive service delivery to young couples

Background: Adolescents 360 (A360) implements the Smart Start (SS) programme through Ethiopia’s Health Extension Programme (HEP). SS is premised on financial planning as an entry point to discuss family planning (FP) with newly married couples and central to its delivery are the health extension workers (HEW). This article evaluates the A360 experience and learning from the process evaluation implemented by Itad to understand contextual barriers and enablers from the perspective of the HEW. Methods: A purposive sampling strategy was employed whereby 27 key stakeholders were identified from Oromia, Addis Ababa and Amhara, based on exposure to the SS programme. Findings from the action research were shared with A360 through a one day sounding workshop. Results: Findings revealed that many local government and communal respondents do not view adolescent pregnancy as a problem, unless out of wedlock, and adolescent pregnancy is closely linked to early marriage. As a result, some providers, including HEWs, acknowledged that married adolescent girls were previously ‘neglected’ by them, while husbands indicated that they had not previously been included in FP counselling. Findings also revealed some challenges with SS implementation as HEWs were ‘deprioritizing’ the intervention and many HEWs had been in situ for several years and were overworked and frustrated. Against this backdrop, A360 was viewed as adding to the HEW workload. While the programme design was focused on adolescent users, there was increasing recognition that HEWs also needed to be at the centre of solution design. Conclusions: Despite challenges associated with the HEP, Ethiopia FP2020 plans to support the ‘next generation’ of HEWs, including a focus on adolescents and youth. To gain deeper insight and put the HEW at the centre of design, A360 will continue to work with the process evaluation to understand contextual barriers and enablers from the perspective of the HEW.

Application of behavioral economics principles to reduce injectable contraceptive discontinuation in rural Ethiopia: A stratified-pair, cluster-randomized field trial.

Background: Contraceptive prevalence in Ethiopia jumped from 6% in 2000 to 36% in 2016, mainly due to increased injectable method use. However, discontinuation rates among injectable users were high (38%). Given that the public sector is the major source for injectable contraceptives, John Snow Inc. (JSI) in collaboration with ideas42 worked with Ethiopia's flagship Health Extension Program to apply behavioral design to mitigate discontinuation of injectable contraceptives. Methods: We applied behavioral economics insights to mitigate the discontinuation of injectable contraceptives. This process created an intervention package, consisting of a health worker planning calendar, a client counseling job aid, and client appointment cards. A stratified-pair cluster-randomized field trial tested the effectiveness of the intervention. The study area included two districts from the four regions where JSI was implementing a family planning program. One district from each region was randomly allocated to the intervention arm. Women visiting health posts to use injectable contraceptives were enrolled in the study. Regression methods, adjusted for study design, participants' backgrounds, and contextual factors, estimated the intervention's effect on discontinuation rates. Results: A behavioral design methodology was feasibly implemented in a rural, low-resource setting in Ethiopia. The resultant intervention package was successfully delivered in 19 satellite health posts in four districts. Intervention adherence was high for the appointment cards and counseling job aid, but not for the planning calendar. The injectable discontinuation rate was 10.8 % (95% confidence interval: 2.2, 19.3) points lower in the intervention area compared to the control area during the post-intervention follow-up survey. Conclusion: The use of two tools informed by behavioral economics -the appointment card and counseling job aid-effectively decreased injectable discontinuation even with the presence of other health system bottlenecks. Behavioral economics insights and the behavioral design methodology have the potential to enhance family planning programs in Ethiopia and elsewhere.

Application of behavioral economics principles to reduce injectable contraceptive discontinuation in rural Ethiopia: A stratified-pair, cluster-randomized field trial

Background: Contraceptive prevalence in Ethiopia jumped from 6% in 2000 to 36% in 2016, mainly due to increased injectable method use. However, discontinuation rates among injectable users were high (38%). Given that the public sector is the major source for injectable contraceptives, John Snow Inc. (JSI) in collaboration with ideas42 worked with Ethiopia’s flagship Health Extension Program to apply behavioral design to mitigate discontinuation of injectable contraceptives. Methods: We applied behavioral economics insights to mitigate the discontinuation of injectable contraceptives. This process created an intervention package, consisting of a health worker planning calendar, a client counseling job aid, and client appointment cards. A stratified-pair cluster-randomized field trial tested the effectiveness of the intervention. The study area included two districts from the four regions where JSI was implementing a family planning program. One district from each region was randomly allocated to the intervention arm. Women visiting health posts to use injectable contraceptives were enrolled in the study. Regression methods, adjusted for study design, participants’ backgrounds, and contextual factors, estimated the intervention’s effect on discontinuation rates. Results: A behavioral design methodology was feasibly implemented in a rural, low-resource setting in Ethiopia. The resultant intervention package was successfully delivered in 19 satellite health posts in four districts. Intervention adherence was high for the appointment cards and counseling job aid, but not for the planning calendar. The injectable discontinuation rate was 10.8 % (95% confidence interval: 2.2, 19.3) points lower in the intervention area compared to the control area during the post-intervention follow-up survey. Conclusion: The use of two tools informed by behavioral economics —the appointment card and counseling job aid—effectively decreased injectable discontinuation even with the presence of other health system bottlenecks. Behavioral economics insights and the behavioral design methodology have the potential to enhance family planning programs in Ethiopia and elsewhere.

Factors associated with the early termination of exclusive breastfeeding among mother-infant dyads in Samara-Logia, Northeastern Ethiopia

BackgroundThe World Health Organization recommends that mothers should exclusively breastfeed their infants until 6 months of age due to the benefits for the mother and the child. There is documented evidence on exclusive breastfeeding from Ethiopia, but not specifically from Samara-Logia city administration. This study aimed to assess the factors associated with early termination of exclusive breastfeeding among mother-infant dyads in Samara-Logia, Ethiopia.MethodsA cross-sectional study was conducted in March 2018. Data were collected on 484 randomly selected mother-infant dyads. The Kaplan Meier curve with the log-rank test was used to compare the survival difference. Cox regression models were used to identify the predictors of early termination of exclusive breastfeeding.ResultsThe cumulative proportion of survival probability of exclusive breastfeeding to 6 months was 64.5%, with the median duration of 6 months. Mothers having partners with formal education [Adjusted hazard ratio (AHR): 0.58; 95% confidence interval (CI): 0.39, 0.85], receiving counseling on exclusive breastfeeding at antenatal check-up [AHR: 0.62; 95% CI: 0.43, 0.91], giving birth in a health institution [AHR: 0.50; 95% CI: 0.28, 0.88], initiating breastfeeding within the first hour [AHR: 0.41; 95% CI: 0.24, 0.68], and perceiving breast milk adequate for the first 6 months [AHR: 0.17; 95% CI: 0.12, 0.25] were associated with lower hazard of discontinuing exclusive breastfeeding before 6 months.ConclusionThis study showed that the cumulative proportion of survival probability on exclusive breastfeeding was low in Samara-Logia city administration. Educating husbands to support their partners, strengthening infant feeding counseling, promoting institutional delivery, educating women about the benefit of early initiation of breastfeeding, and expanding urban health extension program are important to improve the duration of exclusive breastfeeding in Ethiopia.

Get Smart: Learning and partnership with Ethiopia's Health Extension Programme to re-envision contraceptive service delivery to young couples.

Background: Adolescents 360 (A360) implements the Smart Start (SS) programme through Ethiopia's Health Extension Programme (HEP). SS is premised on financial planning as an entry point to discuss family planning (FP) with newly married couples and central to its delivery are the health extension workers (HEW). This article evaluates the A360 experience and learning from the process evaluation implemented by Itad to understand contextual barriers and enablers from the perspective of the HEW. Methods: A purposive sampling strategy was employed whereby 27 key stakeholders were identified from Oromia, Addis Ababa and Amhara, based on exposure to the SS programme. Findings from the action research were shared with A360 through a one day sounding workshop. Results: Findings revealed that many local government and communal respondents do not view adolescent pregnancy as a problem, unless out of wedlock, and adolescent pregnancy is closely linked to early marriage. As a result, some providers, including HEWs, acknowledged that married adolescent girls were previously 'neglected' by them, while husbands indicated that they had not previously been included in FP counselling. Findings also revealed some challenges with SS implementation as HEWs were 'deprioritizing' the intervention and many HEWs had been in situ for several years and were overworked and frustrated. Against this backdrop, A360 was viewed as adding to the HEW workload. While the programme design was focused on adolescent users, there was increasing recognition that HEWs also needed to be at the centre of solution design. Conclusions: Despite challenges associated with the HEP, Ethiopia FP2020 plans to support the 'next generation' of HEWs, including a focus on adolescents and youth. To gain deeper insight and put the HEW at the centre of design, A360 will continue to work with the process evaluation to understand contextual barriers and enablers from the perspective of the HEW.

Family Planning Utilization Among Model and Non Model Family Women Enrolled in Urban Health Extension Program in Addis Ababa, Ethiopia, 2015

Background : In 2003, the Ethiopian Federal Ministry of Health (FMOH) launched a new health care plan, the “Accelerated Expansion of Primary Health Care Coverage,” through a comprehensive Health Extension Program (HEP).Recognizing the huge gap between need and health care services available, the FMOH has focused on “providing quality promotive, preventive, and selected curative health care services in an accessible and equitable manner to reach all segments of the population, with special attention to mothers and children. Objective: To assess on family planning service utilization among model and non-model family women enrolled in urban health extension program of kirkos sub-city administration. Method: A cross sectional study design using a quantitative method was used .A total of 424 (212 model families and 212 non-model families) participated the study. Adjusted ORs that controls the confounding effects of other covariates were calculated using the multiple logistic regression models of SPSS version 16 statistical programs. Statistical significance was considered at P-value less than 0.05. Result: Large proportion study population 210(81.08%) [109(78.4%)) and 101 (84.1%),) model and non-model respectively] were they prefer to be informed by health professional and followed by other (like friend husband...) were 27(10.42%) [18(12.9%) and 9(7.5%) for model and non-model families respectively], media (radio and TV) were 15(5.79%) [5(3.59) and10 (8.33%) for model and non-model families respectively] with X2 =4.21, p value =0.000021. Conclusion : By this measurement the UHEP programs lacks the aspects expected to be done. FMOH should see the implementation strategies of UHEP on providing and upgrading family planning service. Keywords: Family planning, Urban Health Extension Program (UHEP), Model /Non-model Family DOI : 10.7176/JMPB/59-04 Publication date :September 30 th 2019

Design of a parallel cluster-randomized trial assessing the impact of a demand-side sanitation and hygiene intervention on sustained behavior change and mental well-being in rural and peri-urban Amhara, Ethiopia: Andilaye study protocol

BackgroundUnimproved water, sanitation, and hygiene (WASH) behaviors are key drivers of infectious disease transmission and influencers of mental well-being. While WASH is seen as a critical enabler of health, important knowledge gaps related to the content and delivery of effective, holistic WASH programming exist. Corresponding impacts of WASH on mental well-being are also underexplored. There is a need for more robust implementation research that yields information regarding whether and how community-based, demand-side interventions facilitate progressive and sustained adoption of improved sanitation and hygiene behaviors and downstream health impacts. The purpose of this protocol is to detail the rationale and design of a cluster-randomized trial evaluating the impact of a demand-side sanitation and hygiene intervention on sustained behavior change and mental well-being in rural and peri-urban Amhara, Ethiopia.MethodsTogether with partners, we developed a theoretically-informed, evidence-based behavioral intervention called Andilaye. We randomly selected and assigned 50 sub-districts (kebeles) from three purposively selected districts (woredas); half to receive the Andilaye intervention, and half the standard of care sanitation and hygiene programming (i.e., community-led total sanitation and hygiene [CLTSH]). During baseline, midline, and endline, we will collect data on an array of behavioral factors, potential moderators (e.g., water and sanitation insecurity, collective efficacy), and our primary study outcomes: sanitation and hygiene behaviors and mental well-being. We will perform a process evaluation to assess intervention fidelity and related attributes.DiscussionWhile CLTSH has fostered sanitation and hygiene improvements in Ethiopia, evidence of behavioral slippage, or regression to unimproved practices in communities previously declared open defecation free exists. Other limitations of CLTSH, such as its focus on disgust, poor triggering, and over-saturation of Health Extension Workers have been documented. We employed rigorous formative research and practically applied social and behavioral theory to develop Andilaye, a scalable intervention designed to address these issues and complement existing service delivery within Ethiopia’s Health Extension Program. Evidence from this trial may help address knowledge gaps related to scalable alternatives to CLTSH and inform sanitation and hygiene programming and policy in Ethiopia and beyond.Trial registrationThis trial was registered with clinicaltrials.gov (NCT03075436) on March 9, 2017.

Application of behavioral economics principles to reduce injectable contraceptive discontinuation in rural Ethiopia: A stratified-pair, cluster-randomized field trial.

Background: Contraceptive prevalence in Ethiopia jumped from 6% in 2000 to 36% in 2016, mainly due to increased injectable method use. However, discontinuation rates among injectable users were high (38%). Given that the public sector is the major source for injectable contraceptives, John Snow Inc. (JSI) in collaboration with ideas42 worked with Ethiopia's flagship Health Extension Program to apply behavioral economics informed approaches to mitigate discontinuation of injectable contraceptives. Methods: Behavioral diagnosis was conducted to identify the primary drivers of discontinuation of injectable contraceptives. Using these insights, a user-centered behavioral design approach was implemented to create an intervention package, consisting of a health worker planning calendar, a client counseling job aid, and client appointment cards. The study area included two districts from the four regions where JSI was implementing a family planning program. One district from each region was randomly allocated to the intervention arm. Women visiting health posts to use injectable contraceptives were enrolled in the study. Regression methods adjusted for study design, participants' backgrounds, and contextual factors, were used to estimate the intervention's effect on discontinuation rates. Results: Intervention adherence was high for the appointment cards and counseling job aid, but not for the planning calendar. This was not surprising as using appointment cards and the job aid was within the routine workflow of health extension workers, but using the planner was not. The injectable discontinuation rate was 10.8 % points lower in the intervention area compared to the control area during the post intervention follow-up survey. Conclusion: The use of two behavioral economics informed tools-the appointment card and counseling job aid-effectively decreased injectable discontinuation even with the presence of other health system bottlenecks. Behavioral economics approaches have the potential to enhance family planning programs in Ethiopia and elsewhere. Trial registration: ISRCTN ISRCTN17390653 (10/04/2019).

The impact of the Ethiopian health extension program and health development army on maternal mortality: A synthetic control approach

The Ethiopian government has implemented nationwide strategies to improve access to basic health services and enhance health outcomes. The Health Extension Program (HEP) launched in 2003, expanded basic health infrastructure and local human resources. In 2011, the government introduced the Health Development Army (HDA). HDA is a women-centered community movement inspired by military structures and discipline. Its special objective is to improve maternal health outcomes. This paper uses a synthetic control approach to assess the effects of HEP and HDA on maternal mortality ratios (MMR). The MMR data are from the Global Burden of Diseases (GBD) database. A pool of 42 Sub-Saharan African countries, covering the period 1990 to 2016, is used to construct a synthetic comparator which displays a mortality trajectory similar to Ethiopia prior to the interventions. On average, since 2004, maternal mortality in the control countries exhibits a moderate downward trend. In Ethiopia, the downward trend is considerably steeper as compared to its synthetic control. By 2016, maternal mortality in Ethiopia was lower by 171 (p-value 0.048) maternal deaths per 100,000 live births as compared to its synthetic control. Between 2003 and 2016, Ethiopia's maternal mortality ratio declined from 728 to 357. These estimates suggest that a substantial proportion of this decline may be attributed to HEP/HDA. The Ethiopian experience of enhancing nation-wide access to and use of maternal health services in a short time-span is remarkable. Whether such a model may be transplanted is an open question.