Implementation of the 'Optimising the Health Extension Program' Intervention in Ethiopia: A Process Evaluation Using Mixed Methods

Challenges and experience of the Ethiopian rural health extension program: implications for reform and revitalization

BACKGROUND

Despite remarkable gains over the past decade, mounting evidence suggests that Ethiopia's rural health extension program (HEP) is facing serious implementation challenges. We investigated the current and potential future program design and implementation challenges of Ethiopia's rural HEP based on the lived experiences of health extension workers (HEW) implementing the program at the grassroots level.

METHODS

We employed a longitudinal qualitative exploration linked to a larger cluster-randomized trial (RCT) which was implemented in 282 villages randomly selected from 18 Kebeles of the Gedeo zone, southern Ethiopia. Data were collected using in-depth interviews with key informants, focus group discussion, and passive observation of program implementation. The data were analyzed manually using a thematic framework analysis approach. Themes and sub-themes were generated by condensing, summarizing, and synthesizing data collected in the field in the form of extended notes and field observation checklists.

FINDINGS

Despite considerable gains in availing basic health services to the rural population, HEP seems to suffer serious design and implementation flaws that demand thoughtful and immediate adjustment. The design constraints span from the number and type of intervention packages to the means of dissemination (vehicle) as well as the target population emphasized. As such, some low-cost high-impact interventions that were strongly desired by the community were overlooked, while others were inappropriately packed. The means of distribution - female health extension workers trained with basic prevention skills, were lacking essential skills. They also had high burnout rates and with little engagement with men, were repeatedly mentioned flaws of the program demanding revitalization. Furthermore, the sheer structure of HEP precluded adult and adolescent men, non-reproductive women, and the elderly.

CONCLUSION

Despite significant gains over the last couple of months, Ethiopia's rural HEP appears to have reached a tipping point that requires a comprehensive revamp of the program package, means of distribution, and target beneficiaries rather than the "usual" tweaks to reap maximum benefits.

Care-seeking behaviours of mothers and associated factors for possible serious bacterial infection in young infants during COVID-19 pandemic in Ethiopia: mixed-methods formative research

OBJECTIVES

Implementation research was employed to examine rates and contextual factors associated with mothers' care-seeking for their sick neonates and identify challenges for community-based possible serious bacterial infection (PSBI) services access and implementation during the COVID-19 pandemic.

DESIGN

We conducted formative research involving household survey and programmatic qualitative study.

SETTING

This formative study was conducted in Dembecha and Lume woredas of Amhara and Oromia regions.

PARTICIPANTS

Data were captured from 4262 mothers aged 15-49 years who gave live birth 2-14 months before data collection, and interviews with 18 programme managers and 16 service providers in April to May 2021.

ANALYSIS

A multilevel regression model was employed to identify predictors of maternal care-seeking for PSBI and thematic qualitative analysis to inform strategy development to strengthen PSBI implementation.

RESULTS

Overall, 12% (95% CI 11.0% to 12.9%) and 8% (95% CI 7.9% to 9.6%) of mothers reported any newborn illness and severe neonatal infection (PSBI), respectively. More than half of mothers sought formal medical care, 56% (95% CI 50.7% to 60.8%) for PSBI. Women who received postnatal care within 6 weeks (adjusted OR (AOR) 2.08; 95% CI 1.12 to 3.87) and complete antenatal care (ie, weight measured, blood pressure taken, urine and blood tested) (AOR 2.04; 95% CI 1.12 to 3.75) had higher odds of care-seeking for PSBI. Conversely, fear of COVID-19 (AOR 0.27; 95% CI 0.15 to 0.47) and residing more than 2 hours of walking distance from the health centre (AOR 0.39; 95% CI 0.16 to 0.93) were negatively associated with care-seeking for severe newborn infection. Multiple pre-existing health system bottlenecks were identified from interviews as barriers to PSBI service delivery and exacerbated by the COVID-19 pandemic.

CONCLUSION

We found gaps in and factors associated with care-seeking behaviour of mothers for their sick young infants including fear of COVID-19 and pre-existing health system-level barriers. The findings of the study were used to design and implement strategies to mitigate COVID-19 impacts on management of PSBI.

Quality of sick child management by health extension workers: role of a complex improvement intervention

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.

Perception and Experience of Health Extension Workers on Facilitators and Barriers to Maternal and Newborn Health Service Utilization in Ethiopia: A Qualitative Study

Background: Health extension workers (HEWs) have substantial inputs to reduce maternal and newborn morbidity and mortality in Ethiopia. However, their perceptions and experiences were not well understood. Therefore, this study aimed to explore their perceptions and experiences on facilitators and barriers to maternal and newborn health services in Ethiopia. Methods: A descriptive qualitative study was conducted from 8–28 April 2021 in Oromia, Amhara and Southern Nation, Nationality, and People’s Regional State of Ethiopia. Focused group discussions were made with purposively selected 60 HEWs. The data were transcribed verbatim and translated into English. An inductive thematic analysis was carried out using Atlas ti.7.1. The findings were presented in major themes, categories, and sub-categories with supporting quote(s). Results: The findings were categorized into two major themes (i.e., facilitators and barriers) and seven sub-themes. Community-related facilitators encompass awareness and behavior at the individual, family, and community. Significant others such as traditional birth attendants, religious leaders, women developmental armies, and kebele chairman substantially contributed to service utilization. Availability/access to infrastructures such as telephone, transportation services, and solar energy systems facilitated the service utilization. Furthermore, health facility-related facilitators include the availability of HEWs; free services; supervision and monitoring; maternity waiting rooms; and access to ambulance services. Maternal and newborn health services were affected by community-related barriers (i.e., distance, topography, religious and socio-cultural beliefs/practices, unpleasant rumors, etc.,), health facility-related barriers (i.e., health worker’s behaviors; lack of logistics; lack of adequate ambulance service, and placement and quality of health post), and infrastructure (i.e., lack or poor quality of road and lack of water). Conclusions: The HEWs perceived and experienced a wide range of facilitators and barriers that affected maternal and newborn health services. The study findings warrant that there was a disparity in behavioral factors (awareness, beliefs, and behaviors) among community members, including pregnant women. This underscores the need to design health education programs and conduct social and behavioral change communication interventions to address individuals, families, and the broader community to enhance maternal and newborn health service utilization. On the other hand, the health sector should put into practice the available strategies, and health workers provide services with empathy, compassion, and respect.

Health extension workers' perceived health system context and health post preparedness to provide services: a cross-sectional study in four Ethiopian regions

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.

Age-appropriate vaccination practice and associated factors among mothers of children aged less than one year in the pastoral community of Afar region, Ethiopia

Achieving and maintaining high-level immunization coverage is the priority of the health-care delivery system. However, any delay in receiving the vaccine leaves youngsters inadequately protected. Timely vaccination has scarcely been reported and given little attention in developing nations like Ethiopia, which hinders effective interventions. Therefore, this study aimed to assess age-appropriate vaccination practice and associated factors among mothers of children aged less than one year in the pastoral community. A community-based cross-sectional study has conducted among 340 mothers/caregivers of children aged less than one year in Samara-logia city administration. A systematic random sampling technique was employed to identify and enroll mothers-child paired. The logistic regression analysis had done to identify the factors associated with age-appropriate vaccination practice. The statistical association had measured, and a p-value < 0.05 was considered statistically significant. In this study, a total of 331 mothers/caregivers-child pairs participated with a response rate of 97.3%. The age-appropriate vaccination practice was 43.7% (95% CI, 38%, 49.5%). Mothers who had higher educational level (Adjusted odds ratio (AOR)) = AOR = 2.89, 95% CI (1.14, 7.3), antenatal care follow-up (AOR = 2.1, 95% CI (1.04, 4.1)), and had good knowledge on vaccination (AOR = 3.1, 95% CI (1.4, 6.78)) were associated with increased odds of age-appropriate vaccination practice.

Barriers to the utilization of community-based child and newborn health services in Ethiopia: a scoping review

The Ethiopian Federal Ministry of Health and partners have scaled up integrated community case management (iCCM) and community-based newborn care (CBNC), allowing health extension workers (HEWs) to manage the major causes of child and newborn death at the community level. However, low service uptake remains a key challenge. We conducted a scoping review of peer-reviewed and grey literature to assess barriers to the utilization of HEW services and to explore potential solutions. The review, which was conducted to inform the Optimizing the Health Extension Program project, which aimed to increase the utilization of iCCM and CBNC services, included 24 peer-reviewed articles and 18 grey literature documents. Demand-side barriers to utilization included lack of knowledge about the signs and symptoms of childhood illnesses and danger signs; low awareness of curative services offered by HEWs; preference for home-based care, traditional care, or religious intervention; distance, lack of transportation and cost of care seeking; the need to obtain husband’s permission to seek care and opposition of traditional or religious leaders. Supply-side barriers included health post closures, drug stockouts, disrespectful care and limited skill and confidence of HEWs, particularly with regard to the management of newborn illnesses. Potential solutions included community education and demand generation activities, finding ways to facilitate and subsidize transportation to health facilities, engaging family members and traditional and religious leaders, ensuring consistent availability of services at health posts and strengthening supervision and supply chain management. Both demand generation and improvement of service delivery are necessary to achieve the expected impact of iCCM and CBNC. Key steps for improving utilization would be carrying out multifaceted demand generation activities, ensuring availability of HEWs in health posts and ensuring consistent supplies of essential commodities. The Women’s Development Army has the potential to improving linkages between HEWs and communities, but this strategy needs to be strengthened to be effective.

Caregivers' and Health Extension Workers' Perceptions and Experiences of Outreach Management of Childhood Illnesses in Ethiopia: A Qualitative Study

INTRODUCTION

Ethiopian Health Extension Workers provide facility-based and outreach services, including home visits to manage sick children, aiming to increase equity in service coverage. Little is known about the scope of the outreach services and caregivers' and health workers' perceptions of these services. We aimed at exploring mothers' and health extension workers' perceptions and experiences of the outreach services provided for the management of childhood illnesses.

METHODS

Four focus groups and eight key informant interviews were conducted. A total of 45 community members participated. Interviews were recorded, transcribed verbatim, and translated into English. We applied thematic content analysis, identified challenges in providing outreach services, and suggestions for improvement. We balanced the data collection by selecting half of the participants for interview and focus group discussions from remote areas and the other half from areas closer to the health posts.

RESULTS

Mothers reported that health extension workers visited their homes for preventive services but not for managing childhood illnesses. They showed lack of trust in the health workers' ability to treat children at home. The health extension workers reported that they provide sick children treatment during outreach services but also stated that in most cases, mothers visit the health posts when their child is sick. On the other hand, mothers considered distance from home to health post not to be a problem if the quality of services improved. Workload, long distances, and lack of incentives were perceived as demotivating factors for outreach services. The health workers called for support, incentives, and capacity development activities.

CONCLUSIONS

Mothers and health extension workers had partly divergent perceptions of whether outreach curative services for children were available. Mothers wanted improvements in the quality of services while health workers requested capacity development and more support for providing effective community-based child health services.

Association between a complex community intervention and quality of health extension workers' performance to correctly classify common childhood illnesses in four regions of Ethiopia

Background

Due to low care utilization, a complex intervention was done for two years to optimize the Ethiopian Health Extension Program. Improved quality of the integrated community case management services was an intermediate outcome of this intervention through community education and mobilization, capacity building of health workers, and strengthening of district ownership and accountability of sick child services. We evaluated the association between the intervention and the health extension workers’ ability to correctly classify common childhood illnesses in four regions of Ethiopia.

Methods

Baseline and endline assessments were done in 2016 and 2018 in intervention and comparison areas in four regions of Ethiopia. Ill children aged 2 to 59 months were mobilized to visit health posts for an assessment that was followed by re-examination. We analyzed sensitivity, specificity, and difference-in-difference of correct classification with multilevel mixed logistic regression in intervention and comparison areas at baseline and endline.

Results

Health extensions workers’ consultations with ill children were observed in intervention (n = 710) and comparison areas (n = 615). At baseline, re-examination of the children showed that in intervention areas, health extension workers’ sensitivity for fever or malaria was 54%, 68% for respiratory infections, 90% for diarrheal diseases, and 34% for malnutrition. At endline, it was 40% for fever or malaria, 49% for respiratory infections, 85% for diarrheal diseases, and 48% for malnutrition. Specificity was higher (89–100%) for all childhood illnesses. Difference-in-differences was 6% for correct classification of fever or malaria [aOR = 1.45 95% CI: 0.81–2.60], 4% for respiratory tract infection [aOR = 1.49 95% CI: 0.81–2.74], and 5% for diarrheal diseases [aOR = 1.74 95% CI: 0.77–3.92].

Conclusion

This study revealed that the Optimization of Health Extension Program intervention, which included training, supportive supervision, and performance reviews of health extension workers, was not associated with an improved classification of childhood illnesses by these Ethiopian primary health care workers.

Trial registration

ISRCTN12040912, http://www.isrctn.com/ISRCTN12040912.

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

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.