Health Extension Program Research Articles

Community participation and maternal health service utilization: lessons from the health extension programme in rural southern Ethiopia

Community participation and maternal health service utilization: lessons from the health extension programme in rural southern Ethiopia

Community health extension program of Ethiopia, 2003\u20132018: successes and challenges toward universal coverage for primary healthcare services

BackgroundEthiopia has been implementing a community health extension program (HEP) since 2003. We aimed to assess the successes and challenges of the HEP over time, and develop a framework that may assist the implementation of the program toward universal primary healthcare services.MethodsWe conducted a systematic review and synthesis of the literature on the HEP in Ethiopia between 2003 and 2018. Literature search was accomplished in PubMed, Embase and Google scholar databases. Literature search strategies were developed using medical subject headings (MeSH) and text words related to the aim of the review. We used a three-stage screening process to select the publications. Data extraction was conducted by three reviewers using pre-prepared data extraction form. We conducted an interpretive (not aggregative) synthesis of studies.FindingsThe HEP enabled Ethiopia to achieve significant improvements in maternal and child health, communicable diseases, hygiene and sanitation, knowledge and health care seeking. The HEP has been a learning organization that adapts itself to community demands. The program is also dynamic enough to shift tasks between health centers and community. The community has been a key player in the successful implementation of the HEP. In spite of these successes, the program is currently facing challenges that remain to be addressed. These challenges are related to productivity and efficiency of health extension workers (HEWs); working and living conditions of HEWs; capacity of health posts; and, social determinants of health. These require a systemic approach that involves the wider health system, community, and sectors responsible for social determinants of health. We developed a framework that may assist in the implementation of the HEP.ConclusionThe HEP has enabled Ethiopia to achieve significant improvements. However, several challenges remain to be addressed. The framework can be utilized to improve community health programs toward universal coverage for primary healthcare services.

Urban health extension service utilization and associated factors in the community of Gullele sub-city administration, Addis Ababa, Ethiopia

Background: In Addis Ababa, the capital of Ethiopia, the urban health extension program was started in 2009. Its approach is based on the assumption that access to and quality of primary health care in urban communities can be improved through transfer of health knowledge and skills to households. The study was conducted to assess the status of urban health extension service utilization and associated factors.Methods: A community based cross–sectional study was conducted to collect data from 628 participants. Sample size was determined by using a single population proportion formula. Binary logistic regression was used for data analysis.Results: The proportion of community utilization of the urban health extension program was found to be 86%. Respondents’ odds of utilizing urban health extension services among those who participated in the planning of urban health extension program activities were 2.8 (AOR=2.8; 95% CI: 1.43-3.70) times the odds of those who did not participate. The household respondents who utilized toilet with hand washing facilities had odds of utilizing urban health extension services that are higher by 2.62 (AOR=2.62 with 95% CI: 1.70-9.77) compared to those not utilizing toilet with hand washing facilities.Conclusions: The study provided important information regarding to the status of community utilization of urban health extension services. Respondents who utilized toilet with hand washing facilities were higher among the respondents who utilized and implemented the urban health extension packages. Respondents who participated in the planning of urban health extension program activities were those who significantly utilized and implemented the urban health extension program.

Vaccination and adolescent knowledge: health education and disease prevention.

A cross-sectional study in conjunction with a health extension program was conducted with 605 adolescents aged between 13 and 18 years from 22 public schools in Divinópolis, Brazil. The aim of the study was to determine the vaccination status of the adolescents and their level of knowledge of communicable and vaccine-preventable diseases. Three-stage cluster sampling was used comprising schools, classes, and students. The findings show that vaccination coverage among adolescents was 45.1% and yellow fever was shown to have the lowest coverage rate (64%). The most mentioned diseases when the adolescents were asked which vaccinations they had had were infantile paralysis (60.7%), yellow fever (56%), tetanus (34%), and measles (28.6%). Extension activities were conducted with 6,650 people, comprising vaccination (2,334 doses administered), aimed at expanding vaccination coverage, and health education activities with 2,839 adolescents directed at sexually transmitted diseases, family planning; and licit and illicit drugs. The study had a positive impact in terms of the expansion of vaccination coverage and the extension activities played an essential role in increasing the adolescents' knowledge of the themes addressed.

Gender exploitative and gender transformative aspects of employing Health Extension Workers under Ethiopia's Health Extension Program.

To apply a gender lens to Ethiopia's Health Extension Program and the role of Health Extension Workers (HEWs). Interviews with 45 HEWs and four focus group discussions with 14 of the same HEWS from three regions in rural Ethiopia: Afar Region; Tigray Region (Adwa Woreda); and two locations in Southern Nations, Nationalities and People's Region (Aleta Wondo Woreda and Kafa Zone). Two focus group discussions were conducted in Afar Region with 17 Women Extension Workers employed by Afar Pastoralist Development Association. Using the Gender Equality Continuum as a gender analysis tool, we found that Ethiopia's Health Extension Program is gender aware by directly linking improved health outcomes for women and their empowerment. However, for HEWs who inhabit a gendered space and place from home to district health centres, there can be unexpected consequences that accommodate existing gender inequalities, are blind to them and perhaps even generate new forms of exploitation. The Health Extension Program could have more transformative outcomes for HEWs and also for communities if changing gender norms was given more attention and constraints to gender equality were reduced. Community Health Worker (CHW) programs should focus on better understanding on the role of gender for CHWs across health systems.

Urban health extension program model housing and household visits improved the utilization of health Services in Urban Ethiopia: a community-based cross-sectional study

BackgroundThe government of Ethiopia launched an innovative program called Urban Health Extension Program (UHEP) in 2009, aims to produce better health outcomes to the urban populations using urban health extension professionals (UHE-ps) by enabling households to implement most health intervention packages designed by the government, which is referred to as model households (practice and implement at least 75% of the training provided by UHE-ps on UHEP packages). The objective of this study was to assess health service use and its associated factors.MethodsA community-based cross-sectional study was conducted to assess the health service use in Addis Ababa. Structured questionnaires were filled out by 1086 women, and a binary logistic regression was performed.ResultsUrban health extension professionals performed home visits to 57.1% (95% CI (confidence interval) =54.2 to 59.8%) of the households. Mothers who had heard of the program (had information about UHEP) were 2.13 times more likely to visit the health center (HC) (AOR (adjusted odds ratio) =2.13, 95% CI = 1.36 to 3.32) than mothers who had not heard of the program. Mothers from model households were 2.12 times more likely to visit the HC (AOR = 2.12, 95% CI = 1.16 to 3.88) than mothers from non-model households. Mothers whose households were visited by the UHE-ps were 1.89 times more likely to visit the HC (AOR = 1.89, 95% CI = 1.22 to 2.94) than mothers whose households were not visited. Similarly, mothers who were in the reproductive age group (18 to 49 years) were 1.74 times more likely to visit the HC (AOR = 1.74, 95%CI = 1.12 to 2.71) than mothers above 49 years old.ConclusionsModel households and mothers in the reproductive age group exhibited significant associations with health service use. Sustaining the practices of graduated and certified model households is essential to maximize the benefits of the UHEP’s activities regarding health service use. Regular home visits to both model and non-model households are essential to scale up health service use and design re-graduation or other sustainable options for already graduated households.

Factors Associated with Health Extension Service Utilization in Dera District, Oromia, Ethiopia: A Multi Level Analysis

Introduction: Health Extension Program is implemented in Ethiopia since 2004 as a flagship of preventive, promotive, and basic curative services for poor and rural community, especially for children and mother. The purpose of this study is to examine the determinants and variations in health extension service utilization in Dera district, Oromia, Ethiopia. Methodology: Three-stage cluster sampling was used to select a random sample of 534 households from 10 kebeles of the district. The study used both descriptive and inferential statistics to identify the determinants of Health extension service utilization and variations. Result: The descriptive result revealed that out of 534 respondents, 223 (41.8%) of them utilized and 311 (58.2) of them not utilized health extension service given at the health post and outreach level. The random intercept binary logistic regression analysis identified that mother's age, mother educational level, mothers' employment status, knowledge on Health Extension Program, being model in Health Extension Program implementation, frequency of home visited by Health Extension Workers, number of students in a family and perception about conduct of Health Extension Workers were significant determinants of Health Extension Program utilization. Conclusion: Comparison between multilevel models has done and random intercept binary logistic model was found to have a better fit for utilization of health extension program and the district health office has to work to reduce the variance and factors that affect Health Extension Program utilization for each kebeles of the district.

Model and Non-Model Mothers Are Similar Over Significant Aspects of Maternal-Child Health Behaviors in Rural Contexts of Central Ethiopia: Diffusing Healthy Behaviors

Background: Health Extension Program (HEP) was launched-innovative community health service since 2002 in Ethiopia. Since then, families were graduated as models for the HEP. Maternal and child Health (MCH) was one of the major packages in HEP. This study intended to compare model and non-model families (MFs and NMFs) on MCH behaviors. Method: Correlational study was conducted between mothers' model status and MCH service use in Sebeta Hawas district, Oromia special zone surrounding Finfine. A total of 305 samples were involved in the study from both MFs and NMFs. We applied simple random sampling. A pretested and structured questionnaire adopted from literatures together with discussion guides was used. It mainly composed of utilization of Family Planning (FP), antenatal care (ANC), delivery care (DC), postnatal care (PNC) and immunization. Quantitative data was analyzed using Statistical Package for Social Sciences (SPSS) version 16. We used frequency tables to describe model status. Odds Ratio (OR) was used to identify demarcations between MFs and NMFs. Finally, quantitative and qualitative findings was triangulated. Result: The study showed statistically significant key variations between MFs and NMFs over family size, knowledge of (ANC, delivery complications and PNC) and utilization of (FP and ANC visits). These variables were positively linked with being from MFs. For example, 114/201 (56.7%) current FP users, 120/222 (54.1%) any ANC visitors, and 56/82 (68.3%) repeated (>=4) ANC visitors were from MFs compared to NMFs (PV<0.001). However, mothers from MFs & NMFs had no variation on delivery, PNC & immunization utilization. Closure of health posts at work time, inaccessible institutional delivery service (for MFs) and perceived invulnerability to delivery complications (for NMFs) hampered the MCH behaviors. Conclusion: Though MFs and NMF were similar over some MCH service knowledge and utilization, they vary over FP and ANC. MFs can be advocate for enhancing adoption and diffusion of earlier stage MCH behaviors. However, beyond the control contexts hindered MFs from playing their role of modeling late stages MCH behaviors (DC/ PNC/immunization).Therefore, HEP designers and implementers shall work on system challenges and create separate models for those behaviors and assign new name.

Role of Health Extension Worker in Tuberculosis Prevention and Control in Ethiopia: Systematic Review

Background: Health Extension Program was designed to serve the rural community of Ethiopia and has brought significant change in improving utilization of family planning, antenatal care, postnatal care, birth preparedness, initiating breast feeding immediately after birth and HIV testing. In relation to Tuberculosis (TB) prevention and control, TB patients believe that they learnt about TB from HEWs and some patients stated that they could not have been diagnosed without the work of HEWs. HEWs focus on Education of the community, Identification of suspects, referral of suspects to health Facilities, Support for adherence to treatment, retrieval of absentees and contact tracing. Objective: The objective of this review was to assess the role of Ethiopian health extension workers in prevention and control of TB. Method: Computerized systematic search was conducted through PubMed, Google Scholar, and Science direct databases. After reviewing for relevance of articles based on title, abstract and eliminating for redundancies five articles were included for this review. Studies presented to the original article, studies that examine contribution of HEWs to TB prevention, studies conducted in Ethiopia; studies written in English were included in the review. Results: Large number of people with TB symptom which is the base for TB prevention and elimination strategy was identified by the HEWs. The health extension workers identified not only new patients but also the retreatment (defaulters) which are the major contributors to (multi drug resistant TB (MDR-TB). From the identified TB suspects by HEWs, majority of them were found to be positive for the disease. Health extension worker remain the health worker who identify TB suspects and refer patient to health facilities. They were also the source of community health educator in relation to TB.

Risk Factors of Diarrhoea in Malnourished Children under Age of 5 Years

Abstract:&#x0D; Background: Acute infectious enteritis remains one of the commonest causes of death among infants and children in developing countries. Acute enteritis is defined as a loss of stool consistency with pasty or liquid stools, and/or an increase in stool frequency to more than three stools in 24 hours with or without fever or vomiting. Human survival depends on the secretion and reabsorption of fluid and electrolytes in the intestinal tract. The objective of the study is to evaluate the risk factors of diarrhoea in children under age of 5 years.&#x0D; Methodology: It was an observational study. Study was completed in about six months. Non-probability purposive sampling technique was used. In this study, 270 samples were taken from Diarrheal ward of The Children Hospital Lahore, Pakistan.&#x0D; Results: In this study, out of 270 patients, 58.52% were males and 41.48% were females. 90.37% patients were vaccinated. 54.81% had weaning history. 91.85% patients had feeding history. 29.26% had blood in stool. 96.67% patients were dehydrated. 95.56% patients had loose watery diarrhoea. 62.96% patients used boiled water. 58.52% patients consumed less than half litre of water, 30.00% patients consumed 1 litre of water and 11.48% patients consumed &gt; 1 litre of water. 49.18% patients had proper hygiene. 38.15% mothers of patients were well educated. 40.37% patients had model household condition. 57.41% patients lived in rural area and 42.59% patients lived in urban area.&#x0D; Conclusion: The variation in the level of diarrheal morbidity was well explained by maternal education, income, personal hygiene, refuse disposal system and the effect of health extension programme.

Health Extension Workers Involvement in the Utilization of Focused Antenatal Care Service in Rural Sidama Zone, Southern Ethiopia: A Cross-Sectional Study.

Background:Health extension workers (HEWs) are primarily been assigned in rural areas of Ethiopia to provide maternal and child health services. Few studies have been done to investigate HEWs’ contributions towards maternal health services. This study describes HEWs involvement in the utilization of focused antenatal care (FANC).Methods:A population-based cross-sectional survey was conducted between January 21 and February 4, 2017. Mothers (2300) who gave birth in the last 6 months (0-6 months) in randomly selected 30 kebeles in the rural Sidama zone, participated in the study. A face-to-face interview was done using a structured questionnaire adapted from the Saving Newborn Lives Program. The main outcome variable was FANC utilization. Descriptive statistics and multivariate logistic regression analysis were used using SPSS statistical software.Results:The FANC was used by 525 (24.36%; 95% confidence interval [CI]: 22.5%-26.2%) women. Health extension workers accounted for 244 (46.47%; 95% CI: 43.5-47.7%) of mothers. The FANC utilization was less likely among those who were illiterate (adjusted odds ratio [AOR]: .32; 95% CI: .18-.57) and those who attended first cycle (AOR: .41; 95% CI: .23-.74), those who attended secondary cycle (AOR: .47; 95% CI: .27-.82), primipara (AOR: 0.53; 95% CI: .35-.83), and those who gave birth at home (AOR: .66; 95% CI: .51-.84). Mothers who had knowledge of pregnancy danger signs (AOR: 1.42; 95% CI: 1.2-1.7) and exposure to mass media (AOR: 1.35; 95% CI: 1.1-1.66) were more likely to utilize FANC.Conclusions:FANC utilization in this study was low compared to other studies. The HEWs had a major contribution to the services. However, it is low when compared to the plan set by the state ministry of health. The existing health extension program could be strengthened by increasing the number of HEWs. Empowering rural mothers through continuous education program to enhance the utilization of maternal health services.

Can mHealth improve timeliness and quality of health data collected and used by health extension workers in rural Southern Ethiopia?

BackgroundHealth extension workers (HEWs) are the key cadre within the Ethiopian Health Extension Programme extending health care to rural communities. National policy guidance supports the use of mHealth to improve data quality and use. We report on a mobile Health Management Information system (HMIS) with HEWs and assess its impact on data use, community health service provision and HEWs’ experiences.MethodologyWe used a mixed methods approach, including an iterative process of intervention development for 2 out of 16 essential packages of health services, quantitative analysis of new registrations, and qualitative research with HEWs and their supervisors.ResultsThe iterative approach supported ownership of the intervention by health staff, and 8833 clients were registered onto the mobile HMIS by 62 trained HEWs. HEWs were positive about using mHealth and its impact on data quality, health service delivery, patient follow-up and skill acquisition. Challenges included tensions over who received a phone; worries about phone loss; poor connectivity and power failures in rural areas; and workload.DiscussionMobile HMIS developed through collaborative and locally embedded processes can support quality data collection, flow and better patient follow-up. Scale-up across other community health service packages and zones is encouraged together with appropriate training, support and distribution of phones to address health needs and avoid exacerbating existing inequalities.KeywordsCHWs, equity, ethics, Ethiopia, Health Management Information system, HEP, maternal health, mHealth, TB

Planned social network change and modern contraceptive use in a rural Ethiopian community

# Background Over the last decade, Ethiopia has substantially increased uptake of modern contraception and experienced a decline in total fertility, coinciding with implementation of the national Health Extension Programme (HEP), involving an extensive deployment of health extension workers (HEWs), and a health development army (HDA) of volunteer families. The dynamics of such change are important. This multi-method qualitative study was conducted in a rural community in Oromia, Ethiopia, as part of a larger effort to understand the influence of social networks on modern contraceptive use. # Methods Data were collected in five focus groups and twelve individual interviews (n = 59) with men, women, adolescents and key informants in a rural area in Oromia, Ethiopia, together with participant observation. Analysis was conducted using NVivo qualitative research software. # Results We found two types of decision-making social networks for family planning: (i) one pertaining to basic decisions about having children *per se*, which remains the prerogative of traditional, patriarchal social structures; and (ii) a second network, which included HEWs, that applies after initial childbirth, concerning family size and spacing decisions for additional children. # Conclusions While this study supports other research on the effectiveness of the HEP, the study also identified limitations, and raised questions about the replicability of the Ethiopian model for reducing fertility. The level of government commitment and resources required for the HEP are linked to Ethiopia's key position among recipients of development assistance, likely connected to its history and geopolitical role. These circumstances may not be widely applicable.

Correlates of the Women\u2019s Development Army strategy implementation strength with household reproductive, maternal, newborn and child healthcare practices: a cross-sectional study in four regions of Ethiopia

BackgroundTo address the shortfall in human resources for health, Ethiopia launched the Health Extension Program (HEP) in 2004, establishing a health post with two female health extension workers (HEWs) in every kebele (community). In 2011, the Women’s Development Army (WDA) strategy was added, using networks of neighboring women to increase the efficiency of HEWs in reaching every household, with one WDA team leader for every 30 households. Through the strategy, women in the community, in partnership with HEWs, share and learn about health practices and empower one another. This study assessed the association between the WDA strategy implementation strength and household reproductive, maternal, newborn and child health care behaviors and practices.MethodsUsing cross-sectional household surveys and community-level contextual data from 423 kebeles representing 145 rural districts, an internal comparison group design was applied to assess whether HEP outreach activity and household-level care practices were better in kebeles with a higher WDA density. The density of active WDA leaders was considered as WDA strategy implementation strength; higher WDA density in a kebele indicating relatively high implementation strength. Based on this, kebeles were classified as higher, moderate, or lower. Multilevel logit models, adjusted for respondents’ individual, household and contextual characteristics, were used to assess the associations of WDA strategy implementation strength with outcome indicators of interest.ResultsAverage numbers of households per active WDA team leader in the 25th, 50th and 75th percentiles of the kebeles studied were respectively 41, 50 and 73. WDA density was associated with better service for six of 13 indicators considered (p < 0.05). For example, kebeles with one active WDA team leader for up to 40 households (higher category) had respectively 7 (95% CI, 2, 13), 11 (5, 17) and 9 (1, 17) percentage-points higher contraceptive prevalence rate, coverage of four or more antenatal care visits, and coverage of institutional deliveries respectively, compared with kebeles with one active WDA team leader for 60 or more households (lower category).ConclusionHigher WDA strategy implementation strength was associated with better health care behaviors and practices, suggesting that the WDA strategy supported HEWs in improving health care services delivery.

Effects of a community-based data for decision-making intervention on maternal and newborn\xa0health care practices in Ethiopia: a dose-response study

BackgroundCommunity participation and community health volunteer programs are an essential part of the health system so that health services are responsive and accountable to community needs. Information systems are necessary for community health volunteer programs to be effective, yet effectiveness evaluations of such information systems implemented at scale are rare. In October 2010, a network of female volunteers with little or no literacy, the Women’s Development Army (WDA), was added to extend Ethiopia’s Health Extension Program services to every household in the community. Between July 2013 and January 2015, a health management information system for the WDA’s Community-Based Data for Decision-Making (CBDDM) strategy was implemented in 115 rural districts to improve the demand for and utilization of maternal and newborn health services. Using the CBDDM strategy, Health Extension Workers (HEWs) fostered the WDA and community leaders to inform, lead, own, plan, and monitor the maternal and newborn health interventions in their kebeles (communities). This paper examines the effectiveness of the CBDDM strategy.MethodsUsing data from cross-sectional surveys in 2010–11 and 2014–15 from 177 kebeles, we estimated self-reported maternal and newborn care practices from women with children aged 0 to 11 months (2124 at baseline and 2113 at follow-up), and a CBDDM implementation strength score in each kebele. Using kebele-level random-effects models, we assessed dose-response relationships between changes over time in implementation strength score and changes in maternal and newborn care practices between the two surveys.ResultsKebeles with relatively high increases in CBDDM implementation strength score had larger improvements in the coverage of neonatal tetanus-protected childbirths, institutional deliveries, clean cord care for newborns, thermal care for newborns, and immediate initiation of breastfeeding. However, there was no evidence of any effect of the intervention on postnatal care within 2 days of childbirth.ConclusionsThis study shows the extent to which an information system for community health volunteers with low literacy was implemented at scale, and evidence of effectiveness at scale in improving maternal and newborn health care behaviors and practices.

English

This study assesses the opportunities and challenges of implementing health extension program in Shiromeda Health Center, Addis Ababa, Ethiopia. It has three key objectives: to examine prospective and retrospective views of health extension workers towards health extension program; determine the challenges faced by clients in their health service utilization and examine the challenges extension workers face during provision of services. The study employed cross sectional research design and qualitative methods. Data were collected from health extension workers and residents using interview and focus group discussions, respectively. Accordingly, while four health extension workers were interviewed, two focus group discussions, each consisting of six discussants, were conducted with members of the community based on the objectives of the study. The study found that health extension program has become a hit- or- miss phenomenon for health extension workers are fed up with the routine, tiresome work of increasing health seeking behavior of people and keeping personal hygiene and environmental health with poor salary and other compensations. Though implementation of health extension program is considered as the right action for Ethiopia, except one, all interviewees have no interest to stay as health extension workers. It is also found that on top of limited number of toilets and other health promoting establishments, politicization of formation and implementation of community based health development army has severely limited the success of health extension program. Therefore, appropriate remuneration for health extension workers; establishment of health promoting infrastructures; deployment of senior and male health professionals as health extension workers should be considered. Key words: Health extension program, health development army, health extension workers, public health, opportunities, challenges.

The effect of SODIS water treatment intervention at the household level in reducing diarrheal incidence among children under 5 years of age: a cluster randomized controlled trial in Dabat district, northwest Ethiopia

BackgroundSolar Disinfection (SODIS) of water is an economical, user-friendly, and environmentally safe household water treatment method that has been advocated as a means of decreasing the burden of diarrhea among children under 5 years of age. Laboratory studies have consistently shown the efficacy of the SODIS method to destroy waterborne pathogens. However, the evidence-based health effect of a SODIS intervention at the household level is limited. The main aim of the study was to examine the effectiveness of a SODIS intervention in reducing the incidence of diarrhea among under-five children.MethodsA community-based, cluster randomized controlled trial was conducted, over 6 months from 10 January to 7 July 2016, in 28 rural villages of northwest Ethiopia. In the intervention group, 384 children in 279 households received polyethylene terephthalate (PET) bottles, and in the control group 394 children in 289 households who continued to use their usual drinking-water sources were included in the trial. The study compared diarrheal incidence among the intervention group children who were exposed to SODIS household water treatment and the control group children who were not exposed to such water treatment. A generalized estimating equation (GEE) model was used to compute the adjusted incidence rate ratio and the corresponding 95% confidence interval.ResultsIn this trial, the overall SODIS compliance was 90.6%. The incidence of diarrhea was 8.3 episodes/100 person-week observations in the intervention group compared to 15.3 episodes/100 person-week observations in the control group. A statistically significant reduction was observed in the incidence of diarrhea in the intervention group compared to the control (adjusted IRR 0.60 (95% CI 0.52, 0.70) with a corresponding prevention of 40% (95% CI: 34, 48).ConclusionThe SODIS intervention substantially reduced the incidence of diarrhea among under-five children in a rural community of northwest Ethiopia. This indicates that a SODIS intervention is an invaluable strategy that needs to be integrated with the National Health Extension Program to be addressed to rural communities.Trial registrationClinical Trial Registry India, ID: CTRI/2017/09/009640. Registered retrospectively on 5 September 2017.

Understanding modern contraception uptake in one Ethiopian community: a case study

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.

'We All Work Together to Vaccinate the Child': A Formative Evaluation of a Community-Engagement Strategy Aimed at Closing the Immunization Gap in North-West Ethiopia.

The role of community engagement (CE) in improving demand for immunization merits investigation. The International Rescue Committee developed a CE strategy to implement a vaccine defaulter-tracing tool and a color-coded health calendar aimed at increasing uptake of immunization services in north-west Ethiopia (‘The Fifth Child Project’). We report findings from a formative evaluation of this project. In May/June 2016 we conducted 18 participant observations of project activities, 46 semi-structured interviews and 6 focus groups with caregivers, health workers, community members/leaders. Audio-recordings and fieldnotes were transcribed, anonymized, translated and analyzed thematically using inductive and deductive coding. Additional data was collected in November 2016 to verify findings. The project was suitably integrated within the health extension program and established a practical system for defaulter-tracing. The calendar facilitated personalized interactions between health workers and caregivers and was a catalyst for health discussions within homes. At the community level, a regulation exercise of sanctions was observed, which served as a deterrent against vaccine default. Pre-existing community accountability mechanisms supported the CE, although varying levels of engagement between leaders and health workers were observed. The benefits of shared responsibility for immunization were evident; however, more transparency was required about community self-regulatory measures to ensure health-related discussions remain positive.

Determinants of childhood diarrhea in Medebay Zana District, Northwest Tigray, Ethiopia: a community based unmatched case\u2013control study

BackgroundGlobally, childhood diarrhea is amongst the most prevalent health problems and accounts for 9% of all deaths in children under-five. In Ethiopia, childhood diarrhea is a major public health problem in which the prevalence ranges from 13.5 to 30.5% and experienced by multiple factors. Although health extension program has been implementing for couples of years; diarrheal disease remains the second cause of morbidity and continues an important public health problem in the study district. Thus, this study assessed determinants of diarrheal disease among under-five children in the Medebay Zana district, northwest Tigray, Ethiopia, 2015.MethodA community based case-control study was used. A multistage sampling procedure was employed to enroll the study participants. Data were collected using face to face administered questionnaire. The collected data were entered into Epi Info version 3.5.4 and exported to SPSS Version 21 for analysis. Frequencies with percentages were computed using univariate analysis. Finally, logistic regression model was fitted to identify factors associated with childhood diarrhea where P-values of less than 0.05 were considered statistically significant.ResultsSocio-demographic factors such as low maternal educational level [AOR = 2.88, 95% CI (1.70, 4.88)], being index child of older age, households with ≥3 number of children under-five [AOR = 4.05, 95% CI (1.91, 8.60)] and maternal history of diarrhea [AOR = 2.10, 95% CI (1.09, 4.05)] were statistically associated with childhood diarrhea. This study also revealed that child feeding practice; not exclusively breastfed [AOR = 4.84, 95% CI (2.21, 10.60)] and initiation of complementary feeding above 6 months [AOR = 1.78, 95% CI (1.09, 2.92)] were statistically associated with outcome variable. Environmental and behavioral practices such as unavailability toilet facility [AOR = 2.10, 95% CI (1.34, 3.30)], improper solid waste disposal [AOR = 2.29, 95% CI (1.53, 3.44)] and unprotected drinking water [AOR = 1.83, 95% CI (1.12, 2.98)] were also found significant factors of childhood diarrhea.ConclusionMaternal educational status, age of index child, number of < 5 children, child feeding practices, maternal history of diarrhea, toilet facility, solid waste disposal and household drinking water were found determinants of childhood diarrhea. These findings have policy implications and insight the strengthening for health intervention programs.