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Daka DW, Wordofa MA, Woldie M. Know-do gap for sick child care and drivers of knowledge and practice among health extension workers in four regions of Ethiopia: a cross-sectional study. BMJ Open 2023; 13:e069698. [PMID: 37612100 PMCID: PMC10450039 DOI: 10.1136/bmjopen-2022-069698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 08/15/2023] [Indexed: 08/25/2023] Open
Abstract
OBJECTIVE Though efforts were made to expand community-based sick child healthcare in Ethiopia, the quality of care provided remained low. Improving quality of care requires understanding providers' knowledge of appropriate care and their actual execution of tasks. This study examined gap between what health extension workers (HEWs) knew and did during the management of sick children in Ethiopia. DESIGN Facility-based cross-sectional study was conducted. SETTING The study was carried out in 52 districts across 4 regions in Ethiopia. PARTICIPANTS We interviewed 274 HEWs and performed observations of consultations done by 150 HEWs supplemented with facility assessment from December 2018 to February 2019. OUTCOME We compared providers' knowledge and performance in the management of childhood pneumonia and diarrhoea. Know-do gap implies the difference in proportion between knowledge and actual practice of HEWs. Logistic regression was used to identify predictors of knowledge and actual practice. RESULTS Providers' correct knowledge ranged from 27.8% to 76.0% for signs and symptoms of pneumonia, and 32.0% to 84% for dehydration signs. Their actual practices ranged from 15.1% to 47.3% for pneumonia and 27.0% to 42.6% for dehydration. The correct knowledge and actual practices for pneumonia and dehydration management were 88.3% vs 15.6% and 93.9% vs 51.3%, respectively. There was significant know-do gap in assessments (16.7%, p=0.002) and management of childhood conditions (68.5%, p<0.0001). Mentorships were associated with providers' knowledge of clinical management, while medicines availability was associated with their actual management practice. CONCLUSIONS While knowledge and actual practice for assessment and management of pneumonia and dehydration ranged from very low to high, what is more concerning is the huge know-do gap among HEWs. Our findings suggest that knowledge-based training is necessary but not sufficient for ensuring correct assessment and management of sick children by HEWs. Continuous support through mentorships and the supply of commodities are critically needed.
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Affiliation(s)
- Dawit Wolde Daka
- Department of Health Policy and Management, Jimma University, Jimma, Ethiopia
| | | | - Mirkuzie Woldie
- Department of Health Policy and Management, Jimma University, Jimma, Ethiopia
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Daka DW, Wordofa MA, Berhanu D, Persson LÅ, Woldie M. Quality of sick child management by health extension workers: role of a complex improvement intervention. BMC Health Serv Res 2023; 23:165. [PMID: 36797722 PMCID: PMC9933397 DOI: 10.1186/s12913-023-09131-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 01/31/2023] [Indexed: 02/18/2023] Open
Abstract
BACKGROUND Despite the expansion of the Integrated Community Case Management services for childhood illness, quality and utilization of services have remained low. To address the problem, the Government of Ethiopia introduced a complex intervention that included community engagement, capacity building of health workers and enhanced district-level ownership of sick child management. We examined whether this complex intervention was associated with improved management of sick children by health extension workers. METHODS The study was conducted in four Ethiopian regions. A baseline survey was conducted in 26 intervention and 26 comparison districts from December 2016 to February 2017, followed by an end-line survey 24 months later. We observed health extension workers' consultations of sick 2-59 months old children. The analysis has evaluated if children with pneumonia, diarrhoea and malnutrition were assessed, classified and treated according to guidelines, and included difference-in-difference analyses. RESULTS We observed 1325 consultations of sick children. At baseline, 86% of the sick children with cough in the intervention areas and 85% in comparison areas were assessed according to the guidelines, without any change at end-line associated with the intervention (difference-in-difference = -21%, p = 0.55). Sixty-two percent of children were assessed for dehydration at baseline in intervention and 47% in comparison areas, with no improvement associated with the intervention. Similarly, 87% of sick children in intervention and 91% in comparison areas were assessed for malnutrition, with no change over time associated with the intervention (difference-in-difference = 5%, p = 0.16). Appropriate pneumonia treatment with antibiotics declined and diarrhea treatment increased in both areas. Half of the malnourished children received ready-to-use therapeutic foods without any improvement associated with the intervention. CONCLUSION The intervention was not associated with improved quality of the health extension workers' management of sick children. The lack of association may be linked to low fidelity in the implementation of the intervention. Our findings suggest that training healthcare providers without continued clinical mentoring and support does not improve the quality of care. Community-based programs can be strengthened by ensuring high coverage and continued clinical mentorships, supportive supervision, and supply of medicines and other essential commodities. TRIAL REGISTRATION NUMBER ISRCTN12040912, retrospectively registered on 19/12/ 2017.
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Affiliation(s)
- Dawit Wolde Daka
- Faculty of Public Health, Department of Health Policy and Management, Jimma University, Jimma, Ethiopia.
| | - Muluemebet Abera Wordofa
- grid.411903.e0000 0001 2034 9160Faculty of Public Health, Department of Population and Family Health, Jimma University, Jimma, Ethiopia
| | - Della Berhanu
- grid.452387.f0000 0001 0508 7211Ethiopian Public Health Institute, Addis Ababa, Ethiopia ,grid.8991.90000 0004 0425 469XThe London School of Hygiene & Tropical Medicine, London, UK
| | - Lars Åke Persson
- grid.452387.f0000 0001 0508 7211Ethiopian Public Health Institute, Addis Ababa, Ethiopia ,grid.8991.90000 0004 0425 469XThe London School of Hygiene & Tropical Medicine, London, UK
| | - Mirkuzie Woldie
- grid.411903.e0000 0001 2034 9160Faculty of Public Health, Department of Health Policy and Management, Jimma University, Jimma, Ethiopia ,Fenot Project, University of British Columbia, School of Public Health and Population, Addis Ababa, Ethiopia
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Dada S, Cocoman O, Portela A, De Brún A, Bhattacharyya S, Tunçalp Ö, Jackson D, Gilmore B. What's in a name? Unpacking 'Community Blank' terminology in reproductive, maternal, newborn and child health: a scoping review. BMJ Glob Health 2023; 8:bmjgh-2022-009423. [PMID: 36750272 PMCID: PMC9906186 DOI: 10.1136/bmjgh-2022-009423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 01/09/2023] [Indexed: 02/09/2023] Open
Abstract
INTRODUCTION Engaging the community as actors within reproductive, maternal, newborn and child health (RMNCH) programmes (referred to as 'community blank') has seen increased implementation in recent years. While evidence suggests these approaches are effective, terminology (such as 'community engagement,' 'community participation,' 'community mobilisation,' and 'social accountability') is often used interchangeably across published literature, contributing to a lack of conceptual clarity in practice. The purpose of this review was to describe and clarify varying uses of these terms in the literature by documenting what authors and implementers report they are doing when they use these terms. METHODS Seven academic databases (PubMed/MEDLINE, Embase, CINAHL, PsycINFO, Scopus, Web of Science, Global Health), two grey literature databases (OAIster, OpenGrey) and relevant organisation websites were searched for documents that described 'community blank' terms in RMNCH interventions. Eligibility criteria included being published between 1975 and 1 October 2021 and reports or studies detailing the activities used in 'community blank.' RESULTS: A total of 9779 unique documents were retrieved and screened, with 173 included for analysis. Twenty-four distinct 'community blank' terms were used across the documents, falling into 11 broader terms. Use of these terms was distributed across time and all six WHO regions, with 'community mobilisation', 'community engagement' and 'community participation' being the most frequently used terms. While 48 unique activities were described, only 25 activities were mentioned more than twice and 19 of these were attributed to at least three different 'community blank' terms. CONCLUSION Across the literature, there is inconsistency in the usage of 'community blank' terms for RMNCH. There is an observed interchangeable use of terms and a lack of descriptions of these terms provided in the literature. There is a need for RMNCH researchers and practitioners to clarify the descriptions reported and improve the documentation of 'community blank' implementation. This can contribute to a better sharing of learning within and across communities and to bringing evidence-based practices to scale. Efforts to improve reporting can be supported with the use of standardised monitoring and evaluation processes and indicators. Therefore, it is recommended that future research endeavours clarify the operational definitions of 'community blank' and improve the documentation of its implementation.
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Affiliation(s)
- Sara Dada
- School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland .,UCD Centre for Interdisciplinary Research, Education and Innovation in Health Systems (UCD IRIS), School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland
| | - Olive Cocoman
- London School of Hygiene & Tropical Medicine, London, UK
| | - Anayda Portela
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Aoife De Brún
- School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland,UCD Centre for Interdisciplinary Research, Education and Innovation in Health Systems (UCD IRIS), School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland
| | | | - Özge Tunçalp
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneve, Switzerland
| | - Debra Jackson
- London School of Hygiene and Tropical Medicine Faculty of Epidemiology and Population Health, London, UK
| | - Brynne Gilmore
- School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland,UCD Centre for Interdisciplinary Research, Education and Innovation in Health Systems (UCD IRIS), School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland
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Gebregizabher FA, Medhanyie AA, Bezabih AM, Persson LÅ, Abegaz DB. Is Women's Engagement in Women's Development Groups Associated with Enhanced Utilization of Maternal and Neonatal Health Services? A Cross-Sectional Study in Ethiopia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1351. [PMID: 36674107 PMCID: PMC9858998 DOI: 10.3390/ijerph20021351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 01/02/2023] [Accepted: 01/03/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND In Ethiopia, the Women Development Group program is a community mobilization initiative aimed at enhancing Universal Health Coverage through supporting the primary healthcare services for mothers and newborns. This study aimed to assess the association between engagement in women's groups and the utilization of maternal and neonatal health services. METHOD A cluster-sampled community-based survey was conducted in Oromia, Amhara, Southern Nations, Nationalities and Peoples, and Tigray regions of Ethiopia from mid-December 2018 to mid-February 2019. Descriptive and logistic regression analyses were performed, considering the cluster character of the sample. RESULTS A total of 6296 women (13 to 49 years) from 181 clusters were interviewed. Of these, 896 women delivered in the 12 months prior to the survey. Only 79 (9%) of these women including Women Development Group leaders reported contact with Women Development Groups in the last 12 months preceding the survey. Women who had educations and greater economic status had more frequent contact with Women Development Group leaders. Women who had contact with Women Development Groups had better knowledge on pregnancy danger signs. Being a Women Development Group leader or having contact with Women Development Groups in the last 12 months were associated with antenatal care utilization (AOR 2.82, 95% CI (1.23, 6.45)) but not with the use of facility delivery and utilization of postnatal care services. CONCLUSIONS There is a need to improve the organization and management of the Women Development Group program as well as a need to strengthen the Women Development Group leaders' engagement in group activities to promote the utilization of maternal and neonatal health services.
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Affiliation(s)
- Fisseha Ashebir Gebregizabher
- Tigray Regional Health Bureau, Mekelle P.O. Box 07, Ethiopia
- School of Public Health, College of Health Sciences, Mekelle University, Mekelle P.O. Box 1871, Ethiopia
| | - Araya Abrha Medhanyie
- School of Public Health, College of Health Sciences, Mekelle University, Mekelle P.O. Box 1871, Ethiopia
| | - Afework Mulugeta Bezabih
- School of Public Health, College of Health Sciences, Mekelle University, Mekelle P.O. Box 1871, Ethiopia
| | - Lars Åke Persson
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK
- Ethiopian Public Health Institute, Addis Ababa P.O. Box 1242, Ethiopia
| | - Della Berhanu Abegaz
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK
- Ethiopian Public Health Institute, Addis Ababa P.O. Box 1242, Ethiopia
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Mielke J, Brunkert T, Zúñiga F, Simon M, Zullig LL, De Geest S. Methodological approaches to study context in intervention implementation studies: an evidence gap map. BMC Med Res Methodol 2022; 22:320. [PMID: 36517765 PMCID: PMC9749183 DOI: 10.1186/s12874-022-01772-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 10/25/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Within implementation science studies, contextual analysis is increasingly recognized as foundational to interventions' successful and sustainable implementation. However, inconsistencies between methodological approaches currently limit progress in studying context and guidance to standardize the use of those approaches is scant. Therefore, this study's objective was to systematically review and map current methodological approaches to contextual analysis in intervention implementation studies. The results would help us both to systematize the process of contextual analysis and identify gaps in the current evidence. METHODS We conducted an evidence gap map (EGM) based on literature data via a stepwise approach. First, using an empirically developed search string, we randomly sampled 20% of all intervention implementation studies available from PubMed per year (2015-2020). Second, we assessed included studies that conducted a contextual analysis. Data extraction and evaluation followed the Basel Approach for CoNtextual ANAlysis (BANANA), using a color-coded rating scheme. Also based on BANANA and on the Context and Implementation of Complex Interventions (CICI) framework-an implementation framework that pays ample attention to context- we created visual maps of various approaches to contextual analysis. RESULTS Of 15, 286 identified intervention implementation studies and study protocols, 3017 were screened for inclusion. Of those, 110 warranted close examination, revealing 22% that reported on contextual analysis. Only one study explicitly applied a framework for contextual analysis. Data were most commonly collected via surveys (n = 15) and individual interviews (n = 13). Ten studies reported mixed-methods analyses. Twenty-two assessed meso-level contextual and setting factors, with socio-cultural aspects most commonly studied. Eighteen described the use of contextual information for subsequent project phases (e.g., intervention development/adaption, selecting implementation strategies). Nine reported contextual factors' influences on implementation and/or effectiveness outcomes. CONCLUSIONS This study describes current approaches to contextual analysis in implementation science and provides a novel framework for evaluating and mapping it. By synthesizing our findings graphically in figures, we provide an initial evidence base framework that can incorporate new findings as necessary. We strongly recommend further development of methodological approaches both to conduct contextual analysis and to systematize the reporting of it. These actions will increase the quality and consistency of implementation science research.
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Affiliation(s)
- Juliane Mielke
- Institute of Nursing Science, Department Public Health, University of Basel, Bernoullistrasse 28, CH-4056 Basel, Switzerland
| | - Thekla Brunkert
- Institute of Nursing Science, Department Public Health, University of Basel, Bernoullistrasse 28, CH-4056 Basel, Switzerland
- University Department of Geriatric Medicine FELIX PLATTER, Basel, Switzerland
| | - Franziska Zúñiga
- Institute of Nursing Science, Department Public Health, University of Basel, Bernoullistrasse 28, CH-4056 Basel, Switzerland
| | - Michael Simon
- Institute of Nursing Science, Department Public Health, University of Basel, Bernoullistrasse 28, CH-4056 Basel, Switzerland
| | - Leah L. Zullig
- Center for Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System and Department of Population Health Sciences, Duke University Medical Center, Durham, NC USA
| | - Sabina De Geest
- Institute of Nursing Science, Department Public Health, University of Basel, Bernoullistrasse 28, CH-4056 Basel, Switzerland
- Department of Public Health and Primary Care, KU Leuven, Academic Center for Nursing and Midwifery, Louvain, Belgium
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Amouzou A, Bryce J, Walker N. Strengthening effectiveness evaluations to improve programs for women, children and adolescents. Glob Health Action 2022; 15:2006423. [PMID: 36098952 PMCID: PMC9481099 DOI: 10.1080/16549716.2021.2006423] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A full understanding of the pathways from efficacious interventions to population impact requires rigorous effectiveness evaluations conducted under realistic scale-up conditions at country level. In this paper, we introduce a deductive framework that underpins effectiveness evaluations. This framework forms the theoretical and conceptual basis for the 'Real Accountability: Data Analysis for Results' (RADAR) project, intended to address gaps in guidance and tools for the evaluation of projects being implemented at scale to reduce mortality among women and children. These gaps include needs for a framework to guide decisions about evaluations and practical measurement tools, as well as increased capacity in evaluation practice among donors and program planners at global, national and project levels. RADAR aimed to improve the evidence base for program and policy decisions in reproductive, maternal, newborn and child health and nutrition (RMNCH&N). We focus on five linked methodological steps - presented as core evaluation questions - for designing and implementing effectiveness evaluation of large-scale programs that support both the needs of program managers to improve their programs and the needs of donors to meet their accountability responsibilities. RADAR has operationalized each step with a tool to facilitate its application. We also describe cross-cutting methodological issues and broader contextual factors that affect the planning and implementation of such evaluations. We conclude with proposals for how the global RMNCH&N community can support rigorous program evaluations and make better use of the resulting evidence.
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Affiliation(s)
- Agbessi Amouzou
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jennifer Bryce
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Neff Walker
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
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Wuneh AD, Bezabih AM, Okwaraji YB, Persson LÅ, Medhanyie AA. Wealth and Education Inequities in Maternal and Child Health Services Utilization in Rural Ethiopia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:5421. [PMID: 35564817 PMCID: PMC9099508 DOI: 10.3390/ijerph19095421] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 04/21/2022] [Accepted: 04/25/2022] [Indexed: 12/04/2022]
Abstract
As part of the 2030 maternal and child health targets, Ethiopia strives for universal and equitable use of health services. We aimed to examine the association between household wealth, maternal education, and the interplay between these in utilization of maternal and child health services. Data emanating from the evaluation of the Optimizing of Health Extension Program intervention. Women in the reproductive age of 15 to 49 years and children aged 12-23 months were included in the study. We used logistic regression with marginal effects to examine the association between household wealth, women's educational level, four or more antenatal care visits, skilled assistance at delivery, and full immunization of children. Further, we analyzed the interactions between household wealth and education on these outcomes. Household wealth was positively associated with skilled assistance at delivery and full child immunization. Women's education had a positive association only with skilled assistance at delivery. Educated women had skilled attendance at delivery, especially in the better-off households. Our results show the importance of poverty alleviation and girls' education for universal health coverage.
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Affiliation(s)
- Alem Desta Wuneh
- School of Public Health, College of Health Sciences, Mekelle University, Mekelle P.O. Box 1871, Ethiopia; (A.M.B.); (A.A.M.)
| | - Afework Mulugeta Bezabih
- School of Public Health, College of Health Sciences, Mekelle University, Mekelle P.O. Box 1871, Ethiopia; (A.M.B.); (A.A.M.)
| | - Yemisrach Behailu Okwaraji
- London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK; (Y.B.O.); (L.Å.P.)
- Ethiopian Public Health Institute, Addis Ababa P.O. Box 1242, Ethiopia
| | - Lars Åke Persson
- London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK; (Y.B.O.); (L.Å.P.)
- Ethiopian Public Health Institute, Addis Ababa P.O. Box 1242, Ethiopia
| | - Araya Abrha Medhanyie
- School of Public Health, College of Health Sciences, Mekelle University, Mekelle P.O. Box 1871, Ethiopia; (A.M.B.); (A.A.M.)
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Getahun T, Azale T, Alemayehu M, Yitayal M, Persson LÅ, Berhanu D. Management of bacterial infections in young infants in Ethiopia: Facility preparedness, health workers' knowledge and quality of care. Acta Paediatr 2022; 111:2178-2187. [PMID: 35445443 DOI: 10.1111/apa.16364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 03/24/2022] [Accepted: 04/19/2022] [Indexed: 12/23/2022]
Abstract
AIM We assessed primary care facility preparedness, health workers' knowledge and their classification and treatment of possible serious bacterial infection and local bacterial infection in young infants aged 0-59 days. METHOD A cross-sectional survey was conducted in four regions of Ethiopia, including 169 health posts with 276 health extension workers and 155 health centres with 175 staff. Registers of 1058 sick young infants were reviewed. RESULT Antibiotics to treat possible serious bacterial infection were available in 71% of the health centres and 38% of the health posts. Nine of ten health extension workers and eight of ten health centre staff mentioned at least one sign of possible serious bacterial infection and local bacterial infection. Among the registered cases with signs of bacterial infections, the health extension workers classified 49% as having a possible serious bacterial infection and 88% as local bacterial infection. The health centre staff classified 25% as possible serious bacterial infections and 86% as local bacterial infections. One-fourth (26%) of possible serious bacterial infection received the recommended treatment at health posts and 35% at health centres. CONCLUSION Many health posts lacked antibiotics. The classification and treatment of possible serious bacterial infection did not follow guidelines. The lack of medicines and poor adherence compromise the quality of care.
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Affiliation(s)
- Tigist Getahun
- Amhara Regional Health Bureau Bahir Dar Ethiopia
- College of Medicine and Health Science Institute of Public Health University of Gondar Gondar Ethiopia
| | - Telake Azale
- College of Medicine and Health Science Institute of Public Health University of Gondar Gondar Ethiopia
| | - Mekuriaw Alemayehu
- College of Medicine and Health Science Institute of Public Health University of Gondar Gondar Ethiopia
| | - Mezgebu Yitayal
- College of Medicine and Health Science Institute of Public Health University of Gondar Gondar Ethiopia
| | - Lars Åke Persson
- Health System and Reproductive Health Research Directorate Ethiopian Public Health Institute Addis Ababa Ethiopia
- London School of Hygiene and Tropical Medicine London UK
| | - Della Berhanu
- Health System and Reproductive Health Research Directorate Ethiopian Public Health Institute Addis Ababa Ethiopia
- London School of Hygiene and Tropical Medicine London UK
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“Mothers will be lucky if utmost receive a single scheduled postnatal home visit”: An exploratory qualitative study, Northern Ethiopia. PLoS One 2022; 17:e0265301. [PMID: 35353832 PMCID: PMC8967047 DOI: 10.1371/journal.pone.0265301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 03/01/2022] [Indexed: 11/19/2022] Open
Abstract
Background Postnatal home visits (PNHVs) have been endorsed as strategy for delivery of postnatal care (PNC) to reduce newborn mortality and improve maternal outcomes. Despite the important role of the Health Extension Workers (HEWs) in improving the overall healthcare coverage, PNHV remains as a missed opportunity in rural Ethiopia. Thus, this study aimed to explore the barriers and facilitators of scheduled postnatal home visits in Northern Ethiopia. Methods We conducted an exploratory qualitative study on a total of 16 in-depth interviews with HEWs and mothers who gave birth one year prior to the study. In addition, focus group discussions were conducted with HEWs and key informant interviews were conducted with women development group leaders, supervisors, and healthcare authorities from April to June 2019 in two rural districts of Northern Ethiopia. Discussions and interviews were audio recorded and transcribed verbatim in the local language (Tigrigna) and translated into English. The translated scripts were thematically coded using Atlas ti scientific software. Field notes were also taken during the discussion and while conducting the interviews. Results Health system factors, community context, and individual level factors were considered as the barriers and facilitators of scheduled PNHVs. Leadership, governance, management, support and supervision, referral linkages, overwhelming workload, capacity building, logistics and supplies are the major sub-themes identified as health system factors. Physical characteristics like geographical location and topography, distance, and coverage of the catchment; and community support and participation like support from women’s development groups (WDGs), awareness of the community on the presence of the service and cultural and traditional beliefs were community contexts that affect PNHVs. Self-motivation to support and intrinsic job satisfaction were individual level factors that were considered as barriers and facilitators. Conclusion The finding of this study suggested that the major barriers of postnatal home visits were poor attention of healthcare authorities of the government bodies, lack of effective supervision, poor functional linkages, inadequate logistics and supplies, unrealistic catchment area coverage, poor community participation and support, and lack of motivation of HEWs. Henceforth, to achieve the scheduled PNHV in rural Ethiopia, there should be strong political commitment and healthcare authorities should provide attention to postnatal care both at facility and home with a strong controlling system.
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Ashebir F, Medhanyie AA, Mulugeta A, Persson LÅ, Berhanu D. Exploring women's development group leaders' support to maternal, neonatal and child health care: A qualitative study in Tigray region, Ethiopia. PLoS One 2021; 16:e0257602. [PMID: 34555089 PMCID: PMC8460027 DOI: 10.1371/journal.pone.0257602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 09/06/2021] [Indexed: 11/18/2022] Open
Abstract
Background Community health workers and volunteers are vital for the achievement of Universal Health Coverage also in low-income countries. Ethiopia introduced community volunteers called women’s development group leaders in 2011. These women have responsibilities in multiple sectors, including promoting health and healthcare seeking. Objective We aimed to explore women’s development group leaders’ and health workers’ perceptions on these volunteers’ role in maternal, neonatal and child healthcare. Methods A qualitative study was conducted with in-depth interviews and focus group discussions with women’s development group leaders, health extension workers, health center staff, and woreda and regional health extension experts. We adapted a framework of community health worker performance, and explored perceptions of the women’s development group program: inputs, processes and performance. Interviews were recorded, transcribed, and coded prior to translation and thematic analysis. Results The women’s development group leaders were committed to their health-related work. However, many were illiterate, recruited in a sub-optimal process, had weak supervision and feedback, lacked training and incentives and had weak knowledge on danger signs and care of neonates. These problems demotivated these volunteers from engaging in maternal, neonatal and child health promotion activities. Health extension workers faced difficulties in managing the numerous women’s development group leaders in the catchment area. Conclusion The women’s development group leaders showed a willingness to contribute to maternal and child healthcare but lacked support and incentives. The program requires some redesign, effective management, and should offer enhanced recruitment, training, supervision, and incentives. The program should also consider continued training to develop the leaders’ knowledge, factor contextual influences, and be open for local variations.
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Affiliation(s)
- Fisseha Ashebir
- Tigray Regional Health Bureau, Mekelle, Tigray, Ethiopia.,School of Public Health, College of Health Sciences, Mekelle University, Mekelle, Tigray, Ethiopia
| | - Araya Abrha Medhanyie
- School of Public Health, College of Health Sciences, Mekelle University, Mekelle, Tigray, Ethiopia
| | - Afework Mulugeta
- School of Public Health, College of Health Sciences, Mekelle University, Mekelle, Tigray, Ethiopia
| | - Lars Åke Persson
- London School of Hygiene & Tropical Medicine, London, United Kingdom.,Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Della Berhanu
- London School of Hygiene & Tropical Medicine, London, United Kingdom.,Ethiopian Public Health Institute, Addis Ababa, Ethiopia
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Beyene H, Kassa DH, Tadele HD, Persson L, Defar A, Berhanu D. Factors associated with the referral of children with severe illnesses at primary care level in Ethiopia: a cross-sectional study. BMJ Open 2021; 11:e047640. [PMID: 34112644 PMCID: PMC8194336 DOI: 10.1136/bmjopen-2020-047640] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
CONTEXT AND OBJECTIVE Ethiopia's primary care has a weak referral system for sick children. We aimed to identify health post and child factors associated with referrals of sick children 0-59 months of age and evaluate the healthcare providers' adherence to referral guidelines. DESIGN A cross-sectional facility-based survey. SETTING This study included data from 165 health posts in 52 districts in four Ethiopian regions collected from December 2018 to February 2019. The data included interviews with health extension workers, assessment of health post preparedness, recording of global positioning system (GPS)-coordinates of the health post and the referral health centre, and reviewing registers of sick children treated during the last 3 months at the health posts. We analysed the association between the sick child's characteristics, health post preparedness and distance to the health centre with referral of sick children by multivariable logistic regressions. OUTCOME MEASURE Referral to the nearest health centre of sick young infants aged 0-59 days and sick children 2-59 months. RESULTS The health extension workers referred 39/229 (17%) of the sick young infants and 78/1123 (7%) of the older children to the next level of care. Only 18 (37%) sick young infants and 22 (50%) 2-59 months children that deserved urgent referral according to guidelines were referred. The leading causes of referral were possible serious bacterial infection and pneumonia. Those being classified as a severe disease were referred more frequently. The availability of basic amenities (adjusted OR, AOR=0.38, 95% CI 0.15 to 0.96), amoxicillin (AOR=0.41, 95% CI 0.19 to 0.88) and rapid diagnostic test (AOR=0.18, 95% CI 0.07 to 0.46) were associated with less referral in the older age group. CONCLUSION Few children with severe illness were referred from health posts to health centres. Improving the health posts' medicine and diagnostic supplies may enhance adherence to referral guidelines and ultimately reduce child mortality.
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Affiliation(s)
- Habtamu Beyene
- Regional Health Bureau, Southern Nations Nationalities and Peoples' Region, Hawassa, Ethiopia
- College of Medicine and Health Sciences, School of Public Health, Hawassa University, Hawassa, Sidama, Ethiopia
| | - Dejene Hailu Kassa
- College of Medicine and Health Sciences, School of Public Health, Hawassa University, Hawassa, Sidama, Ethiopia
| | - Henok Dangiso Tadele
- College of Health Sciences, Department of Paediatrics and Child Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Lars Persson
- London School of Hygiene and Tropical Medicine, Faculty of Infectious and Tropical Diseases, London, UK
- Health System and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Atkure Defar
- Health System and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
- Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Della Berhanu
- London School of Hygiene and Tropical Medicine, Faculty of Infectious and Tropical Diseases, London, UK
- Health System and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
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Getachew T, Abebe SM, Yitayal M, Bergström A, Persson LA, Berhanu D. Health extension workers' perceived health system context and health post preparedness to provide services: a cross-sectional study in four Ethiopian regions. BMJ Open 2021; 11:e048517. [PMID: 34108171 PMCID: PMC8191611 DOI: 10.1136/bmjopen-2020-048517] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE The health system context influences the implementation of evidence-based practices and quality of healthcare services. Ethiopia aims at reaching universal health coverage but faces low primary care utilisation and substandard quality of care. We assessed the health extension workers' perceived context and the preparedness of health posts to provide services. SETTING This study was part of evaluating a complex intervention in 52 districts of four regions of Ethiopia. This paper used the endline data collected from December 2018 to February 2019. PARTICIPANTS A total of 152 health posts and health extension workers serving selected enumeration areas were included. OUTCOME MEASURES We used the Context Assessment for Community Health (COACH) tool and the Service Availability and Readiness Assessment tool. RESULTS Internal reliability of COACH was satisfactory. The dimensions community engagement, work culture, commitment to work and leadership all scored high (mean 3.75-4.01 on a 1-5 scale), while organisational resources, sources of knowledge and informal payments scored low (1.78-2.71). The general service readiness index was 59%. On average, 67% of the health posts had basic amenities to provide services, 81% had basic equipment, 42% had standard precautions for infection prevention, 47% had test capacity for malaria and 58% had essential medicines. CONCLUSION The health extension workers had a good relationship with the local community, used data for planning, were highly committed to their work with positive perceptions of their work culture, a relatively positive attitude regarding their leaders, and reported no corruption or informal payments. In contrast, they had insufficient sources of information and a severe lack of resources. The health post preparedness confirmed the low level of resources and preparedness for services. These findings suggest a significant potential contribution by health extension workers to Ethiopia's primary healthcare, provided that they receive improved support, including new information and essential resources.
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Affiliation(s)
- Theodros Getachew
- Health System and Reproductive Health Research Directtorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
- Institute of Public Health, University of Gondar College of Medicine and Health Sciences, Gondar, Ethiopia
| | - Solomon Mekonnen Abebe
- Institute of Public Health, University of Gondar College of Medicine and Health Sciences, Gondar, Ethiopia
| | - Mezgebu Yitayal
- Institute of Public Health, University of Gondar College of Medicine and Health Sciences, Gondar, Ethiopia
| | | | - Lars-Ake Persson
- Health System and Reproductive Health Research Directtorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
- London School of Hygiene and Tropical Medicine, London, UK
| | - Della Berhanu
- Health System and Reproductive Health Research Directtorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
- London School of Hygiene and Tropical Medicine, London, UK
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Defar A, Okwaraji YB, Tigabu Z, Persson LÅ, Alemu K. Distance, difference in altitude and socioeconomic determinants of utilisation of maternal and child health services in Ethiopia: a geographic and multilevel modelling analysis. BMJ Open 2021; 11:e042095. [PMID: 33602705 PMCID: PMC7896622 DOI: 10.1136/bmjopen-2020-042095] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 12/23/2020] [Accepted: 01/13/2021] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVE We assessed whether geographic distance and difference in altitude between home to health facility and household socioeconomic status were associated with utilisation of maternal and child health services in rural Ethiopia. DESIGN Household and health facility surveys were conducted from December 2018 to February 2019. SETTING Forty-six districts in the Ethiopian regions: Amhara, Oromia, Tigray and Southern Nations, Nationalities, and Peoples. PARTICIPANTS A total of 11 877 women aged 13-49 years and 5786 children aged 2-59 months were included. OUTCOME MEASURES The outcomes were four or more antenatal care visits, facility delivery, full child immunisation and utilisation of health services for sick children. A multilevel analysis was carried out with adjustments for potential confounding factors. RESULTS Overall, 39% (95% CI: 35 to 42) women had attended four or more antenatal care visits, and 55% (95% CI: 51 to 58) women delivered at health facilities. One in three (36%, 95% CI: 33 to 39) of children had received full immunisations and 35% (95% CI: 31 to 39) of sick children used health services. A long distance (adjusted OR (AOR)=0.57; 95% CI: 0.34 to 0.96) and larger difference in altitude (AOR=0.34; 95% CI: 0.19 to 0.59) were associated with fewer facility deliveries. Larger difference in altitude was associated with a lower proportion of antenatal care visits (AOR=0.46; 95% CI: 0.29 to 0.74). A higher wealth index was associated with a higher proportion of antenatal care visits (AOR=1.67; 95% CI: 1.02 to 2.75) and health facility deliveries (AOR=2.11; 95% CI: 2.11 to 6.48). There was no association between distance, difference in altitude or wealth index and children being fully immunised or seeking care when they were sick. CONCLUSION Achieving universal access to maternal and child health services will require not only strategies to increase coverage but also targeted efforts to address the geographic and socioeconomic differentials in care utilisation, especially for maternal health. TRIAL REGISTRATION NUMBER ISRCTN12040912.
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Affiliation(s)
- Atkure Defar
- Health System and Reproductive Health, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
- Institute of Public Health, Department of Epidemiology and Biostatistics, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Yemisrach B Okwaraji
- Health System and Reproductive Health, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
- Department of Disease Control, London School of Hygiene and Tropical Medicine Faculty of Infectious and Tropical Diseases, London, UK
| | - Zemene Tigabu
- Department of Paediatrics and Child Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Lars Åke Persson
- Health System and Reproductive Health, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
- Department of Disease Control, London School of Hygiene and Tropical Medicine Faculty of Infectious and Tropical Diseases, London, UK
| | - Kassahun Alemu
- Institute of Public Health, Department of Epidemiology and Biostatistics, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Tariku A, Okwaraji YB, Worku A, Biks GA, Åke Persson L, Berhane Y. Prevention and treatment of suspected pneumonia in Ethiopian children less than five years from household to primary care. Acta Paediatr 2021; 110:602-610. [PMID: 32478446 PMCID: PMC7891650 DOI: 10.1111/apa.15380] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 05/18/2020] [Accepted: 05/26/2020] [Indexed: 11/28/2022]
Abstract
Aim Ethiopia has implemented the integrated community case management to reduce mortality in childhood diseases. We analysed prevention, care seeking and treatment of suspected pneumonia from household to health facility in Ethiopia. Methods Analyses were based on a survey in four regions that included modules covering 5714 households, 169 health posts with 276 health extension workers and 155 health centres with 175 staff. Caregivers of children aged 2‐59 months responded to questions on awareness of services and care seeking for suspected pneumonia. Pneumonia‐related knowledge of health workers was assessed. Results When a child had suspected pneumonia, 46% (95% CI: 25,68) sought care at health facilities, and 27% (95% CI: 12,51) received antibiotics. Forty‐one per cent had received full immunisation. One‐fifth (21%, 95%: 19,22) of the caregivers were aware of pneumonia treatment. Sixty‐four per cent of the health extension workers correctly mentioned fast or difficult breathing as signs of suspected pneumonia, and 88% suggested antibiotics treatment. Conclusion The caregivers' awareness of suspected pneumonia treatment and the utilisation of these services were low. Some of the health extension workers were not knowledgeable about suspected pneumonia. Strengthening primary health care, including immunisation, and enhancing the utilisation of services are critical for further reduction of pneumonia mortality.
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Affiliation(s)
- Amare Tariku
- Department of Human Nutrition Institute of Public Health College of Medicine and Health Sciences University of Gondar Gondar Ethiopia
- Addis Continental Institute of Public Health Addis Ababa Ethiopia
| | - Yemisrach B. Okwaraji
- Ethiopian Public Health Institute Addis Ababa Ethiopia
- London School of Hygiene & Tropical Medicine London UK
| | - Alemayehu Worku
- Addis Continental Institute of Public Health Addis Ababa Ethiopia
- School of Public Health Addis Ababa University Addis Ababa Ethiopia
| | - Gashaw Andargie Biks
- Department of Health System and Policy College of Medicine and Health Sciences Institute of Public Health University of Gondar Gondar Ethiopia
| | - Lars Åke Persson
- Ethiopian Public Health Institute Addis Ababa Ethiopia
- London School of Hygiene & Tropical Medicine London UK
| | - Yemane Berhane
- Addis Continental Institute of Public Health Addis Ababa Ethiopia
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Azaare J, Akweongo P, Aryeetey GC, Dwomoh D. Impact of free maternal health care policy on maternal health care utilization and perinatal mortality in Ghana: protocol design for historical cohort study. Reprod Health 2020; 17:169. [PMID: 33126906 PMCID: PMC7597017 DOI: 10.1186/s12978-020-01011-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 10/06/2020] [Indexed: 11/10/2022] Open
Abstract
Background Ghana introduced what has come to be known as the 'Free’ Maternal Health Care Policy (FMHCP) in 2008 via the free registration of pregnant women to the National Health Insurance Scheme to access healthcare free of charge. The policy targeted every pregnant woman in Ghana with a full benefits package covering comprehensive maternal healthcare. Purpose This study seeks to measure the contribution of the FMHCP to maternal healthcare utilization; antenatal care uptake, and facility delivery and determine the utilization impact on stillbirth, perinatal, and neonatal deaths using quasi-experimental methods. The study will also contextualize the findings against funding constraints and operational bottlenecks surrounding the policy operations in the Upper East Region of Ghana. Methods This study adopts a mixed-method design to estimate the treatment effect using variables generated from historical data of Ghana and Kenya Demographic and Health Survey data sets of 2008/2014, as treatment and comparison groups respectively. As DHS uses complex design, weighting will be applied to the data sets to cater for clustering and stratification at all stages of the analysis by setting the data in STATA and prefix Stata commands with ‘svy’. Thus, the policy impact will be determined using quasi-experimental designs; propensity score matching, and difference-in-differences methods. Prevalence, mean difference, and test of association between outcome and exposure variables will be achieved using the Rao Scot Chi-square. Confounding variables will be adjusted for using Poisson and multiple logistics regression models. Statistical results will be reported in proportions, regression coefficient, and risk ratios. This study then employs intrinsic-case study technique to explore the current operations of the ‘free’ policy in Ghana, using qualitative methods to obtain primary data from the Upper East Region of Ghana for an in-depth analysis. Discussion The study discussions will show the contributions of the ‘free’ policy towards maternal healthcare utilization and its performance towards stillbirth, perinatal and neonatal healthcare outcomes. The discussions will also centre on policy designs and implementation in resource constraints settings showing how SDG3 can be achievement or otherwise. Effectiveness of policy proxy and gains in the context of social health insurance within a broader concept of population health and economic burden will also be conferred. Protocol approval This study protocol is registered for implementation by the Ghana Health Service Ethical Review Committee, number: GHS-ERC 002/04/19.
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Affiliation(s)
- John Azaare
- Department of Health Policy Planning and Management, University of Ghana School of Public Health, Legon, Accra, Ghana.
| | - Patricia Akweongo
- Department of Health Policy Planning and Management, University of Ghana School of Public Health, Legon, Accra, Ghana
| | - Genevieve Cecilia Aryeetey
- Department of Health Policy Planning and Management, University of Ghana School of Public Health, Legon, Accra, Ghana
| | - Duah Dwomoh
- Department of Biostatistics, University of Ghana School Public Health, Legon, Accra, Ghana
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Daka DW, Wordofa MA, Woldie M, Persson LÅ, Berhanu D. Quality of clinical assessment and management of sick children by Health Extension Workers in four regions of Ethiopia: A cross-sectional survey. PLoS One 2020; 15:e0239361. [PMID: 32976508 PMCID: PMC7518593 DOI: 10.1371/journal.pone.0239361] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 09/06/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Care-seeking for sick children at the Ethiopian primary health care level is low. This problem may partly be due to unfavorable community perceptions of the quality of care provided. There is, however, limited knowledge on the quality of the clinical assessment and management provided by the health extension workers at the health posts. This study aimed to examine the quality of clinical assessment, classification and management provided to sick under-five children by health extension workers in four regions of Ethiopia. METHODS Clinical observations of 620 consultations of sick children by health extension workers were conducted from December 2016 to February 2017. A clinical pathway analysis was performed to analyze whether sick children were appropriately assessed, classified and managed according to the integrated Community Case Management guidelines. RESULTS Most sick children presented with complaints of cough (58%), diarrhea (36%), and fever (26%).Three quarters of children with respiratory complaints had their respiratory rate counted (74%, 95% CI 69-78), while a third (33%, 95% CI 27-40) of children with diarrhea were assessed for dehydration. Half (53%, 95% CI 49-57) of the sick children were assessed for general danger signs, while a majority (89%, 95% CI 86-92) had their arm circumference measured for malnutrition. Half of the sick children received some treatment and less than one-fifth were referred according to the integrated Community Case management guidelines. Comprehensive counseling was provided to 38% (95% CI 35-42) of the caregivers. CONCLUSION The Ethiopian health extension workers' clinical assessment, classification and management of sick children did to a large extent not follow the clinical guidelines. This lack of adherence could lead to misdiagnoses and lack of potentially life-saving treatments.
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Affiliation(s)
- Dawit Wolde Daka
- Faculty of Public Health, Department of Health Policy and Management, Jimma University, Jimma, Ethiopia
- * E-mail:
| | - Muluemebet Abera Wordofa
- Faculty of Public Health, Population and Family Health Department, Jimma University, Jimma, Ethiopia
| | - Mirkuzie Woldie
- Faculty of Public Health, Department of Health Policy and Management, Jimma University, Jimma, Ethiopia
- Fenot Project, Harvard T.H. Chan School of Public Health, Addis Ababa, Ethiopia
| | - Lars Åke Persson
- Ethiopian Public Health Institute, Addis Ababa, Ethiopia
- The London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Della Berhanu
- Ethiopian Public Health Institute, Addis Ababa, Ethiopia
- The London School of Hygiene & Tropical Medicine, London, United Kingdom
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Berhanu D, Okwaraji YB, Defar A, Bekele A, Lemango ET, Medhanyie AA, Wordofa MA, Yitayal M, W/Gebriel F, Desta A, Gebregizabher FA, Daka DW, Hunduma A, Beyene H, Getahun T, Getachew T, Woldemariam AT, Wolassa D, Persson LÅ, Schellenberg J. Does a complex intervention targeting communities, health facilities and district health managers increase the utilisation of community-based child health services? A before and after study in intervention and comparison areas of Ethiopia. BMJ Open 2020; 10:e040868. [PMID: 32933966 PMCID: PMC7493123 DOI: 10.1136/bmjopen-2020-040868] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Ethiopia successfully reduced mortality in children below 5 years of age during the past few decades, but the utilisation of child health services was still low. Optimising the Health Extension Programme was a 2-year intervention in 26 districts, focusing on community engagement, capacity strengthening of primary care workers and reinforcement of district accountability of child health services. We report the intervention's effectiveness on care utilisation for common childhood illnesses. METHODS We included a representative sample of 5773 households with 2874 under-five children at baseline (December 2016 to February 2017) and 10 788 households and 5639 under-five children at endline surveys (December 2018 to February 2019) in intervention and comparison areas. Health facilities were also included. We assessed the effect of the intervention using difference-in-differences analyses. RESULTS There were 31 intervention activities; many were one-off and implemented late. In eight districts, activities were interrupted for 4 months. Care-seeking for any illness in the 2 weeks before the survey for children aged 2-59 months at baseline was 58% (95% CI 47 to 68) in intervention and 49% (95% CI 39 to 60) in comparison areas. At end-line it was 39% (95% CI 32 to 45) in intervention and 34% (95% CI 27 to 41) in comparison areas (difference-in-differences -4 percentage points, adjusted OR 0.49, 95% CI 0.12 to 1.95). The intervention neither had an effect on care-seeking among sick neonates, nor on household participation in community engagement forums, supportive supervision of primary care workers, nor on indicators of district accountability for child health services. CONCLUSION We found no evidence to suggest that the intervention increased the utilisation of care for sick children. The lack of effect could partly be attributed to the short implementation period of a complex intervention and implementation interruption. Future funding schemes should take into consideration that complex interventions that include behaviour change may need an extended implementation period. TRIAL REGISTRATION NUMBER ISRCTN12040912.
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Affiliation(s)
- Della Berhanu
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Health Systems and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Yemisrach Behailu Okwaraji
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Atkure Defar
- Health Systems and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Abebe Bekele
- Health Systems and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Ephrem Tekle Lemango
- Maternal and Child Health Directorate, Ethiopia Ministry of Health, Addis Ababa, Ethiopia
| | - Araya Abrha Medhanyie
- School of Public Health, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Muluemebet Abera Wordofa
- Department of Population and Family Health, Faculty of Public Health, Jimma University, Jimma, Ethiopia
| | - Mezgebu Yitayal
- Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Fitsum W/Gebriel
- College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
| | - Alem Desta
- School of Public Health, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Fisseha Ashebir Gebregizabher
- School of Public Health, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
- Tigray Regional Health Bureau, Mekelle, Ethiopia
| | - Dawit Wolde Daka
- Department of Health Policy and Management, Jimma University, Jimma, Ethiopia
| | - Alemayehu Hunduma
- Department of Population and Family Health, Faculty of Public Health, Jimma University, Jimma, Ethiopia
- Oromia Regional Health Bureau, Addis Ababa, Ethiopia
| | - Habtamu Beyene
- College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
- Southern Nations, Nationalities & Peoples Regional Health Bureau, Hawassa, Ethiopia
| | - Tigist Getahun
- Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
- Amhara Regional Health Bureau, Baher Dar, Ethiopia
| | - Theodros Getachew
- Health Systems and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
- Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Amare Tariku Woldemariam
- Department of Human Nutrition, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Desta Wolassa
- Health Systems and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Lars Åke Persson
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Health Systems and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Joanna Schellenberg
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
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Okwaraji YB, Hill Z, Defar A, Berhanu D, Wolassa D, Persson LÅ, Gonfa G, Schellenberg JA. Implementation of the 'Optimising the Health Extension Program' Intervention in Ethiopia: A Process Evaluation Using Mixed Methods. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E5803. [PMID: 32796574 PMCID: PMC7459764 DOI: 10.3390/ijerph17165803] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/07/2020] [Accepted: 08/09/2020] [Indexed: 01/10/2023]
Abstract
An intervention called 'Optimising the Health Extension Program', aiming to increase care-seeking for childhood illnesses in four regions of Ethiopia, was implemented between 2016 and 2018, and it included community engagement, capacity building, and district ownership and accountability. A pragmatic trial comparing 26 districts that received the intervention with 26 districts that did not found no evidence to suggest that the intervention increased utilisation of services. Here we used mixed methods to explore how the intervention was implemented. A fidelity analysis of each 31 intervention activities was performed, separately for the first phase and for the entire implementation period, to assess the extent to which what was planned was carried out. Qualitative interviews were undertaken with 39 implementers, to explore the successes and challenges of the implementation, and were analysed by using thematic analysis. Our findings show that the implementation was delayed, with only 19% (n = 6/31) activities having high fidelity in the first phase. Key challenges that presented barriers to timely implementation included the following: complexity both of the intervention itself and of administrative systems; inconsistent support from district health offices, partly due to competing priorities, such as the management of disease outbreaks; and infrequent supervision of health extension workers at the grassroots level. We conclude that, for sustainability, evidence-based interventions must be aligned with national health priorities and delivered within an existing health system. Strategies to overcome the resulting complexity include a realistic time frame and investment in district health teams, to support implementation at grassroots level.
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Affiliation(s)
- Yemisrach B. Okwaraji
- London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK; (D.B.); (L.Å.P.); (J.A.S.)
- Ethiopian Public Health Institute, Addis Ababa 5654, Ethiopia; (A.D.); (D.W.); (G.G.)
| | - Zelee Hill
- Institute for Global Health, University College London, London WC1E 6BT, UK;
| | - Atkure Defar
- Ethiopian Public Health Institute, Addis Ababa 5654, Ethiopia; (A.D.); (D.W.); (G.G.)
- Institute of Public Health, College of Medicine and Health Science, University of Gondar, Gondar 41822, Ethiopia
| | - Della Berhanu
- London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK; (D.B.); (L.Å.P.); (J.A.S.)
- Ethiopian Public Health Institute, Addis Ababa 5654, Ethiopia; (A.D.); (D.W.); (G.G.)
| | - Desta Wolassa
- Ethiopian Public Health Institute, Addis Ababa 5654, Ethiopia; (A.D.); (D.W.); (G.G.)
| | - Lars Åke Persson
- London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK; (D.B.); (L.Å.P.); (J.A.S.)
- Ethiopian Public Health Institute, Addis Ababa 5654, Ethiopia; (A.D.); (D.W.); (G.G.)
| | - Geremew Gonfa
- Ethiopian Public Health Institute, Addis Ababa 5654, Ethiopia; (A.D.); (D.W.); (G.G.)
| | - Joanna A. Schellenberg
- London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK; (D.B.); (L.Å.P.); (J.A.S.)
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