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Hailemariam T, Atnafu A, Gezie L, Kaasbøll J, Klein J, Tilahun B. Intention to Use an Electronic Community Health Information System Among Health Extension Workers in Rural Northwest Ethiopia: Cross-Sectional Study Using the Unified Theory of Acceptance and Use of Technology 2 Model. JMIR Hum Factors 2024; 11:e47081. [PMID: 38437008 PMCID: PMC10949131 DOI: 10.2196/47081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 08/31/2023] [Accepted: 10/05/2023] [Indexed: 03/05/2024] Open
Abstract
BACKGROUND IT has brought remarkable change in bridging the digital gap in resource-constrained regions and advancing the health care system worldwide. Community-based information systems and mobile apps have been extensively developed and deployed to quantify and support health services delivered by community health workers. The success and failure of a digital health information system depends on whether and how it is used. Ethiopia is scaling up its electronic community health information system (eCHIS) to support the work of health extension workers (HEWs). For successful implementation, more evidence was required about the factors that may affect the willingness of HEWs to use the eCHIS. OBJECTIVE This study aimed to assess HEWs' intentions to use the eCHIS for health data management and service provision. METHODS A cross-sectional study design was conducted among 456 HEWs in 6 pilot districts of the Central Gondar zone, Northwest Ethiopia. A Unified Theory of Acceptance and Use of Technology model was used to investigate HEWs' intention to use the eCHIS. Data were cleaned, entered into Epi-data (version 4.02; EpiData Association), and exported to SPSS (version 26; IBM Corp) for analysis using the AMOS 23 Structural Equation Model. The statistical significance of dependent and independent variables in the model was reported using a 95% CI with a corresponding P value of <.05. RESULTS A total of 456 HEWs participated in the study, with a response rate of 99%. The mean age of the study participants was 28 (SD 4.8) years. Our study revealed that about 179 (39.3%; 95% CI 34.7%-43.9%) participants intended to use the eCHIS for community health data generation, use, and service provision. Effort expectancy (β=0.256; P=.007), self-expectancy (β=0.096; P=.04), social influence (β=0.203; P=.02), and hedonic motivation (β=0.217; P=.03) were significantly associated with HEWs' intention to use the eCHIS. CONCLUSIONS HEWs need to be computer literate and understand their role with the eCHIS. Ensuring that the system is easy and enjoyable for them to use is important for implementation and effective health data management.
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Affiliation(s)
- Tesfahun Hailemariam
- Department of Health Informatics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Asmamaw Atnafu
- Department of Health System and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Lemma Gezie
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Jens Kaasbøll
- Department of Informatics, University of Oslo, Oslo, Norway
| | - Jorn Klein
- Department of Nursing and Health Sciences Campus Porsgrunn, University of South-Eastern Norway, Porsgrunn, Norway
| | - Binyam Tilahun
- Department of Health Informatics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Gurara MK, Draulans V, Jacquemyn Y, Van Geertruyden JP. Evaluation of a community-based intervention package to improve knowledge of obstetric danger signs, birth preparedness, and institutional delivery care utilization in Arba Minch Zuria District, Ethiopia: a cluster-randomized trial. Reprod Health 2023; 20:169. [PMID: 37980484 PMCID: PMC10657004 DOI: 10.1186/s12978-023-01713-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 11/10/2023] [Indexed: 11/20/2023] Open
Abstract
INTRODUCTION Maternal healthcare utilization, particularly the institutional delivery, is disproportionately low in rural Ethiopia. This study aimed to evaluate the effectiveness of an integrated package of community-based interventions on the improved knowledge of obstetric danger signs, birth preparedness, and institutional delivery services utilization in rural areas of Gamo zone, southern Ethiopia. METHODS We conducted cluster-randomized controlled trial (NCT05385380) from 2019 to 2021 at the Arba Minch Health and Demographic Surveillance System site. We randomly assigned the 10 kebele clusters to intervention and control arm. We used a package of interventions, which included providing information on safe motherhood via video and/or audio with a birth preparedness card for pregnant women, training for community volunteers and health extension workers, and improving maternity waiting home services. Women in the control arm received routine services only. We used generalized mixed-effects logistic regression models to evaluate the effectiveness of the intervention on the outcome variables. RESULTS The study enrolled 727 pregnant women across the 10 clusters, with a 617 (84.9%) successful follow-up rate. The proportion of institutional delivery in the intervention arm was increased by 16.1% from 36.4% (174/478) at the baseline to 52.5% (224/427) at the endline (Adjusted odds ratio [AOR] for McNemar's Test = 1.5; 95% confidence interval [CI]: 1.1 to 2; p < 0.001). In the control arm, however, there was a 10.3% fall in the proportion of institutional delivery (from 164/249 to 105/190). Pregnant women who received the intervention were significantly more likely to give birth in a health institution than those who did not (AOR 2.8; 95% CI: 1.2, 6.4). CONCLUSION The study demonstrates that an integrated community-based intervention package that included video-based storytelling and upgrading maternity waiting homes increased institutional delivery care utilization among rural women. We recommend that audio-visual storytelling, starting during pregnancy and continuing postpartum, be incorporated into routine maternal healthcare services to address access to care inequalities in rural settings. TRIAL REGISTRATION The study protocol was registered in the clinicaltrials.gov with registry number NCT05385380.
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Affiliation(s)
- Mekdes Kondale Gurara
- Department of Public Health, College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Ethiopia.
- Global Health Institute, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.
| | - Veerle Draulans
- Faculty of Social Sciences, Centre for Sociological Research, KU Leuven, Louvain, Belgium
| | - Yves Jacquemyn
- Global Health Institute, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
- Department of Obstetrics and Gynaecology, Antwerp University Hospital, UZA, Edegem, Belgium
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Mupara LM, Mogaka JJ, Brieger WR, Tsoka-Gwegweni JM. Community Health Worker programmes’ integration into national health systems: Scoping review. Afr J Prim Health Care Fam Med 2022. [DOI: 10.4102/phcfm.v14i1.3204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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Mupara DLM, Mogaka DJJO, Brieger DWR, Tsoka-Gwegweni PJM. The Extent of Integration of Community Health Worker Programs Into National Health Systems: Case Study of Botswana. INQUIRY: THE JOURNAL OF HEALTH CARE ORGANIZATION, PROVISION, AND FINANCING 2022; 59:469580221093170. [PMID: 35946905 PMCID: PMC9373171 DOI: 10.1177/00469580221093170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background The paucity of Human Resources for Health (HRH) is a major global health challenge. The World Health Organization (WHO) recognizes the potentials that Community Health Workers (CHWs) have in closing the gap of an inadequate supply of human resources for health (HRH). However, weak CHW integration into national health systems curtails effective implementation of CHW delivered high impact interventions in resource constrained settings. This study assessed the extent of integration of the CHW Recruitment, Education, and Certification (REC) component into the national health system’s HRH building block, using Botswana’s CHW program as a case study. Methods The study used mixed methods. Data collated from CHW training program documentary abstraction, five key informant interviews were analyzed thematically. Data collected through the survey with 123 CHWs were analyzed quantitatively. A recently developed Community Health Workers Program Integration Scorecard Metrics (CHWP-ISM) that comprises of the WHO building blocks and corresponding CHW integration metrics, with process, evidence, and status of integration parameters, was used to determine the extent of integration. Results An analysis of Botswana’s CHW REC component using the CHWP-ISM scale showed that the component was 80% integrated into the national HS. Whereas the CHW training program was fully government sponsored and accredited, some aspects of the program’s selection and recruitment criteria and training modalities were lacking integration. Although CHW training was exclusively offered at a local private training institute, findings from documentation reviews, interviewed KIIs and the survey show that the training accreditation, regulation and funding was the responsibility of the central government. Conclusion The application of the CHWP-ISM scale to assess extent of CHW program integration into HS identified important CHW human resource integration gaps in CHW selection criteria and recruitment process as well non-inclusion of CHWs post-training accreditation by national accreditation board in government policy documents.
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Affiliation(s)
- Dr. Lucia M. Mupara
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu Natal, South Africa
| | - Dr. John J. O. Mogaka
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu Natal, South Africa
| | - Dr. William R. Brieger
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Prof Joyce M. Tsoka-Gwegweni
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu Natal, South Africa
- Faculty of Health Sciences, University of the Free State, South Africa
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Dadi TL, Medhin G, Kasaye HK, Kassie GM, Jebena MG, Gobezie WA, Alemayehu YK, Teklu AM. Continuum of maternity care among rural women in Ethiopia: does place and frequency of antenatal care visit matter? Reprod Health 2021; 18:220. [PMID: 34742315 PMCID: PMC8572478 DOI: 10.1186/s12978-021-01265-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 10/13/2021] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION The ministry of health (MOH) of Ethiopia recommends 4 or more focused antenatal care (ANC) visits at health centre (HC) or at a higher level of health facility (HF). In Ethiopia, few studies investigated time dimension of maternal health continuum of care but lack data regarding place dimension and its effect on continuum of care. The aim of this study is to estimate effect of place of ANC-1 visit and adherence to MOH's recommendations of MOH for ANC visits on continuum of care rural in Ethiopia. METHODS We used data collected from 1431 eligible women included in the National Health Extension Program (HEP) assessment survey that covered 6324 households from 62 woredas in nine regions. The main outcome variable is continuum of care (CoC), which is the uptake of all recommended ANC visits, institutional delivery and postnatal care services. Following descriptive analysis, Propensity Score Matching was used to estimate the effect of place of ANC-1 visit on completion of CoC. Zero inflated Poisson regression was used to model the effect of adherence to MOH recommendation of ANC visits on intensity of maternal health continuum of care. RESULT Only 13.9% of eligible women completed the continuum of care, and place of first antenatal care (ANC) visit was not significantly associated with the completion of continuum of care (β = 0.04, 95% CI = -0.02, 0.09). Adherence of ANC visit to the MOH recommendation (at least 4 ANC visits at higher HFs than health posts (HPs)) increased the likelihood of higher intensity of continuum of care (aIRR = 1.29, 95% CI: 1.26, 1.33). Moreover, the intensity of continuum of care was positively associated with being in agrarian areas (aIRR = 1.17, 95% CI: 1.06, 1.29), exposed to HEP (IRR = 1.22, 95% CI: 1.16, 1.28), being informed about danger signs (aIRR = 1.14, 95% CI: 1.11, 1.18) and delivery of second youngest child at HF (IRR = 1.16, 95% CI: 1.13, 1.20). Increasing age of women was negatively associated with use of services (IRR = 0.90, 95% CI: 0.87, 0.94). CONCLUSION Completion of maternal health continuum of care is very low in Ethiopia, however most of the women use at least one of the services. Completion of continuum of care was not affected by place of first ANC visit. Adherence to MOH recommendation of ANC visit increased the intensity of continuum of care. Intensity of continuum of care was positively associated with residing in agrarian areas, HEP exposure, danger sign told, delivery of second youngest child at health facility. To boost the uptake of all maternal health services, it is crucial to work on quality of health facilities, upgrading the infrastructures of HPs and promoting adherence to MOH recommendations of ANC visit.
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Affiliation(s)
- Tegene Legese Dadi
- College of Medicine & Health Science, School of Public Health, Hawassa University, Hawassa, Ethiopia. .,MERQ Consultancy PLC, Addis Ababa, Ethiopia.
| | - Girmay Medhin
- MERQ Consultancy PLC, Addis Ababa, Ethiopia.,Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Habtamu Kebebe Kasaye
- College of Medicine & Health Science, Department of Midwifery, Wollega University, Nekemte, Ethiopia
| | - Getnet Mitike Kassie
- International Institute for Primary Health Care - Ethiopia, Addis Ababa, Ethiopia
| | | | - Wasihun Adualem Gobezie
- MERQ Consultancy PLC, Addis Ababa, Ethiopia.,Averting Maternal Death and Disability (AMDD), Columbia University, New York, NY, USA
| | - Yibeltal Kiflie Alemayehu
- MERQ Consultancy PLC, Addis Ababa, Ethiopia.,Institute of Health Science, Jimma University, Jimma, Ethiopia
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Umeta B, Girma B. Health Extension Workers Knowledge and Associated Factors on Child Immunization in Bako Tibe, West Shewa, Oromia, Ethiopia: A Cross-Sectional Study. J Multidiscip Healthc 2021; 14:2827-2832. [PMID: 34675530 PMCID: PMC8520477 DOI: 10.2147/jmdh.s334230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 09/23/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose To assess health extension workers knowledge of child immunization schedules and associated factors. Methods A cross-sectional study design was conducted among health extension workers working in Bako Tibe Woreda. The data were collected by using semi-structured questionnaires, and descriptive statistics were used to summarize the data. Chi-square (χ 2) was used to identify factors associated with the knowledge of health extension workers on the immunization schedules. Results The response rate of the study was 92.1% (58/63). All of the health extension workers included in the study were females. The majority of health extension workers 45 (77.59%) had satisfactory knowledge of the child immunization schedule. Educational status (χ 2 = 11.05; P= 0.001), work experience of as health extension workers (χ 2 = 6.22; P= 0.045), on job training on immunization (χ 2 = 11.12; P= 0.002), marital status (χ 2 = 6.30; P= 0.019) were factors associated with health extension workers knowledge. Conclusion The majority of health extension workers had satisfactory knowledge of the child immunization schedule. Educational status, work experience as health extension worker, on job training on immunization, and marital status were factors associated with the knowledge of health extension workers on the child immunization schedule.
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Affiliation(s)
- Belachew Umeta
- School of Pharmacy, Department of Pharmaceutical Sciences, Institute of Health, Jimma University, Jimma, Oromia, Ethiopia
| | - Biniyam Girma
- School of Pharmacy, Department of Pharmacology, Institute of Health, Jimma University, Jimma, Oromia, Ethiopia
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Viljoen L, Mainga T, Casper R, Mubekapi-Musadaidzwa C, Wademan DT, Bond VA, Pliakas T, Bwalya C, Stangl A, Phiri M, Yang B, Shanaube K, Bock P, Fidler S, Hayes R, Ayles H, Hargreaves JR, Hoddinott G, Seeley J, Donnell D, Floyd S, Mandla N, Bwalya J, Sabapathy K, Eshleman SH, Macleod D, Moore A, Vermund SH, Hauck K, Shanaube K. Community-based health workers implementing universal access to HIV testing and treatment: lessons from South Africa and Zambia-HPTN 071 (PopART). Health Policy Plan 2021; 36:881-890. [PMID: 33963387 PMCID: PMC8227454 DOI: 10.1093/heapol/czab019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2021] [Indexed: 01/20/2023] Open
Abstract
The global expansion of HIV testing, prevention and treatment services is necessary to achieve HIV epidemic control and promote individual and population health benefits for people living with HIV (PLHIV) in sub-Saharan Africa. Community-based health workers (CHWs) could play a key role in supporting implementation at scale. In the HPTN 071 (PopART) trial in Zambia and South Africa, a cadre of 737 study-specific CHWs, working closely with government-employed CHW, were deployed to deliver a ‘universal’ door-to-door HIV prevention package, including an annual offer of HIV testing and referral services for all households in 14 study communities. We conducted a process evaluation using qualitative and quantitative data collected during the trial (2013–2018) to document the implementation of the CHW intervention in practice. We focused on the recruitment, retention, training and support of CHWs, as they delivered study-specific services. We then used these descriptions to: (i) analyse the fidelity to design of the delivery of the intervention package, and (ii) suggest key insights for the transferability of the intervention to other settings. The data included baseline quantitative data collected with the study-specific CHWs (2014–2018); and qualitative data from key informant interviews with study management (n = 91), observations of CHW training events (n = 12) and annual observations of and group discussions (GD) with intervention staff (n = 68). We show that it was feasible for newly recruited CHWs to implement the PopART intervention with good fidelity, supporting the interpretation of the trial outcome findings. This was despite some challenges in managing service quality and CHW retention in the early years of the programme. We suggest that by prioritizing the adoption of key elements of the in-home HIV services delivery intervention model—including training, emotional support to workers, monitoring and appropriate remuneration for CHWs—these services could be successfully transferred to new settings.
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Affiliation(s)
- Lario Viljoen
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Stellenbosch University, Lower Level Clinical Building, Francie van Zijl Drive, Cape Town 7505, South Africa.,Department of Sociology and Social Anthropology, Stellenbosch University, Stellenbosch, South Africa
| | - Tila Mainga
- Zambart, School of Public Health, Ridgeway Campus, University of Zambia, Lusaka, Zambia
| | - Rozanne Casper
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Stellenbosch University, Lower Level Clinical Building, Francie van Zijl Drive, Cape Town 7505, South Africa
| | - Constance Mubekapi-Musadaidzwa
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Stellenbosch University, Lower Level Clinical Building, Francie van Zijl Drive, Cape Town 7505, South Africa
| | - Dillon T Wademan
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Stellenbosch University, Lower Level Clinical Building, Francie van Zijl Drive, Cape Town 7505, South Africa
| | - Virginia A Bond
- Zambart, School of Public Health, Ridgeway Campus, University of Zambia, Lusaka, Zambia.,Global Health and Development Department, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Triantafyllos Pliakas
- Department of Public Health, Environments and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Chiti Bwalya
- Zambart, School of Public Health, Ridgeway Campus, University of Zambia, Lusaka, Zambia
| | - Anne Stangl
- International Center for Research on Women, Washington, DC, USA.,Hera Solutions, Baltimore, MD, USA
| | - Mwelwa Phiri
- Zambart, School of Public Health, Ridgeway Campus, University of Zambia, Lusaka, Zambia
| | - Blia Yang
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Stellenbosch University, Lower Level Clinical Building, Francie van Zijl Drive, Cape Town 7505, South Africa
| | - Kwame Shanaube
- Zambart, School of Public Health, Ridgeway Campus, University of Zambia, Lusaka, Zambia
| | - Peter Bock
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Stellenbosch University, Lower Level Clinical Building, Francie van Zijl Drive, Cape Town 7505, South Africa
| | - Sarah Fidler
- Department of Infectious Disease, Imperial College NIHR BRC, Imperial College London, UK
| | - Richard Hayes
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Helen Ayles
- Zambart, School of Public Health, Ridgeway Campus, University of Zambia, Lusaka, Zambia.,Department of Public Health, Environments and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - James R Hargreaves
- Department of Public Health, Environments and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Graeme Hoddinott
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Stellenbosch University, Lower Level Clinical Building, Francie van Zijl Drive, Cape Town 7505, South Africa
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Arora N, Hanson K, Spicer N, Estifanos AS, Keraga DW, Welearegay AT, Tela FG, Hussen YA, Mandefro YS, Quaife M. Understanding the importance of non-material factors in retaining community health workers in low-income settings: a qualitative case-study in Ethiopia. BMJ Open 2020; 10:e037989. [PMID: 33033092 PMCID: PMC7545659 DOI: 10.1136/bmjopen-2020-037989] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 08/28/2020] [Accepted: 09/01/2020] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES The motivation and retention of community health workers (CHWs) is a challenge and inadequately addressed in research and policy. We sought to identify factors influencing the retention of CHWs in Ethiopia and ways to avert their exit. DESIGN A qualitative study was undertaken using in-depth interviews with the study participants. Interviews were audio-recorded, and then simultaneously translated into English and transcribed for analysis. Data were analysed in NVivo 12 using an iterative inductive-deductive approach. SETTING The study was conducted in two districts each in the Tigray and Southern Nations, Nationalities and People's Republic (SNNPR) regions in Ethiopia. Respondents were located in a mix of rural and urban settings. PARTICIPANTS Leavers of health extension worker (HEW) positions (n=20), active HEWs (n=16) and key informants (n=11) in the form of policymakers were interviewed. RESULTS We identified several extrinsic and intrinsic motivational factors affecting the retention and labour market choices of HEWs. While financial incentives in the form of salaries and material incentives in the form of improvements to health facility infrastructure, provision of childcare were reported to be important, non-material factors like HEWs' self-image, acceptance and validation by the community and their supervisors were found to be critical. A reduction or loss of these non-material factors proved to be the catalyst for many HEWs to leave their jobs. CONCLUSION Our study contributes new empirical evidence to the global debate on factors influencing the motivation and retention of CHWs, by being the first to include job leavers in the analysis. Our findings suggest that policy interventions that appeal to the social needs of CHWs can prove to be more acceptable and potentially cost-effective in improving their retention in the long run. This is important for government policymakers in resource constrained settings like Ethiopia that rely heavily on lay workers for primary healthcare delivery.
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Affiliation(s)
- Nikita Arora
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Kara Hanson
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Neil Spicer
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | | | | | | | | | - Matthew Quaife
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Teklu AM, Litch JA, Tesfahun A, Wolka E, Tuamay BD, Gidey H, Cheru WA, Senturia K, Gezahegn W. Referral systems for preterm, low birth weight, and sick newborns in Ethiopia: a qualitative assessment. BMC Pediatr 2020; 20:409. [PMID: 32861246 PMCID: PMC7456368 DOI: 10.1186/s12887-020-02311-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 08/21/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND A responsive and well-functioning newborn referral system is a cornerstone to the continuum of child health care; however, health system and client-related barriers negatively impact the referral system. Due to the complexity and multifaceted nature of newborn referral processes, studies on newborn referral systems have been limited. The objective of this study was to assess the barriers for effective functioning of the referral system for preterm, low birth weight, and sick newborns across the primary health care units in 3 contrasting regions of Ethiopia. METHODS A qualitative assessment using interviews with mothers of preterm, low birth weight, and sick newborns, interviews with facility leaders, and focus group discussions with health care providers was conducted in selected health facilities. Data were coded using an iteratively developed codebook and synthesized using thematic content analysis. RESULTS Gaps and barriers in the newborn referral system were identified in 3 areas: transport and referral communication; availability of, and adherence to newborn referral protocols; and family reluctance or refusal of newborn referral. Specifically, the most commonly noted barriers in both urban and rural settings were lack of ambulance, uncoordinated referral and return referral communications between providers and between facilities, unavailability or non-adherence to newborn referral protocols, family fear of the unknown, expectation of infant death despite referral, and patient costs related to referral. CONCLUSIONS As the Ethiopian Federal Ministry of Health focuses on averting early child deaths, government investments in newborn referral systems and standardizing referral and return referral communication are urgently needed. A complimentary approach is to lessen referral overload at higher-level facilities through improvements in the scope and quality of services at lower health system tiers to provide basic and advanced newborn care.
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Affiliation(s)
- Alula M. Teklu
- St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - James A. Litch
- Global Alliance to Prevent Prematurity and Stillbirth (GAPPS), 19009 33rd Avenue W, Suite 200, Lynnwood, Seattle, WA 98036 USA
| | - Alemu Tesfahun
- Defence University, College of Health Sciences, Addis Ababa, Ethiopia
| | | | | | | | | | - Kirsten Senturia
- Global Alliance to Prevent Prematurity and Stillbirth (GAPPS), 19009 33rd Avenue W, Suite 200, Lynnwood, Seattle, WA 98036 USA
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Sabot K, Blanchet K, Berhanu D, Spicer N, Schellenberg J. Professional advice for primary healthcare workers in Ethiopia: a social network analysis. BMC Health Serv Res 2020; 20:551. [PMID: 32552727 PMCID: PMC7302001 DOI: 10.1186/s12913-020-05367-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 05/26/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In an era of increasingly competitive funding, governments and donors will be looking for creative ways to extend and maximise resources. One such means can include building upon professional advice networks to more efficiently introduce, scale up, or change programmes and healthcare provider practices. This cross-sectional, mixed-methods, observational study compared professional advice networks of healthcare workers in eight primary healthcare units across four regions of Ethiopia. Primary healthcare units include a health centre and typically five satellite health posts. METHODS One hundred sixty staff at eight primary healthcare units were interviewed using a structured tool. Quantitative data captured the frequency of healthcare worker advice seeking and giving on providing antenatal, childbirth, postnatal and newborn care. Network and actor-level metrics were calculated including density (ratio of ties between actors to all possible ties), centrality (number of ties incident to an actor), distance (average number of steps between actors) and size (number of actors within the network). Following quantitative network analyses, 20 qualitative interviews were conducted with network study participants from four primary healthcare units. Qualitative interviews aimed to interpret and explain network properties observed. Data were entered, analysed or visualised using Excel 6.0, UCINET 6.0, Netdraw, Adobe InDesign and MaxQDA10 software packages. RESULTS The following average network level metrics were observed: density .26 (SD.11), degree centrality .45 (SD.08), distance 1.94 (SD.26), number of ties 95.63 (SD 35.46), size of network 20.25 (SD 3.65). Advice networks for antenatal or maternity care were more utilised than advice networks for post-natal or newborn care. Advice networks were typically limited to primary healthcare unit staff, but not necessarily to supervisors. In seeking advice, a colleague's level of training and knowledge were valued over experience. Advice exchange primarily took place in person or over the phone rather than over email or online fora. There were few barriers to seeking advice. CONCLUSION Informal, inter-and intra-cadre advice networks existed. Fellow primary healthcare unit staff were preferred, particularly midwives, but networks were not limited to the primary healthcare unit. Additional research is needed to associate network properties with outcomes and pilot network interventions with central actors.
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Affiliation(s)
- Kate Sabot
- The Centre for Maternal, Adolescent, Reproductive and Child Health (MARCH), London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK. .,Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Karl Blanchet
- Department of Global Health, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Della Berhanu
- The Centre for Maternal, Adolescent, Reproductive and Child Health (MARCH), London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK.,Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Neil Spicer
- Department of Global Health, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Joanna Schellenberg
- The Centre for Maternal, Adolescent, Reproductive and Child Health (MARCH), London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK.,Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
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Befekadu A, Yitayal M. Knowledge and practice of health extension workers on drug provision for childhood illness in west Gojjam, Amhara, Northwest Ethiopia. BMC Public Health 2020; 20:496. [PMID: 32295548 PMCID: PMC7160904 DOI: 10.1186/s12889-020-08602-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 03/27/2020] [Indexed: 11/16/2022] Open
Abstract
Background The HEP was established decades ago to address preventive, promotive and selective curative services through Health Extension Workers (HEWs). However, knowledge and practice of HEWs on drug provision for childhood illnesses such as diarrhea, fever, and/or acute respiratory infection have not been well studied. This study aimed to assess the knowledge and practice of HEWs on drug provision for childhood illnesses. Methods An institutional-based cross-sectional study was conducted among 389 rural HEWs. The districts were selected by using simple random sampling technique, and all the HEWs in the districts were included in the study. Bivariable and multivariable logistic regressions were performed to see the association between knowledge and practice of HEWs on drug provision with the response variables. Results The study revealed that 57.5 and 66.8% of HEWs had good knowledge and practice on drug provision for childhood illnesses, respectively. Having college diploma (AOR = 5.59; 95% CI: 1.94, 16.11), 7–9 years (AOR = 2.7; 95% CI: 1.3, 5.5) and 10–12 years (AOR = 2.7; 95% CI: 1.4, 5.4) of experiences, being supervised quarterly (AOR = 0.24; 95% CI: 0.13, 0.47) and biannually (AOR = 0.11; 95% CI: 0.04, 0.30), and having national guideline (AOR = 0.22; 95% CI: 0.06, 0.90) were factors significantly associated with good knowledge. In addition, having college diploma (AOR =3.1; 95% CI: 1.1, 8.8), not receiving refreshment training (AOR = 0.31; 95% CI: 0.11, 0.91), being supervised biannually (AOR = 0.32, 95% CI: 0.13, 0.80), and not having national guideline (AOR = 0.16, 95% CI: 0.04, 0.60) were factors significantly associated with good practice. Conclusion The study indicated that a considerable number of HEWs had poor knowledge and practice on drug provision. Socio-demographic factors such as educational status, and work experience; and health systems and support related factors such as training, supervision, and availability of national guidelines, and training had a significant association with HEWs’ knowledge and practice on drug provision. Therefore, designing appropriate strategy and providing refreshment training, and improving supervision and availability of national guidelines for HEWs might improve the knowledge and practice of HEWs on drug provision.
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Affiliation(s)
- Ager Befekadu
- Felege Hiwot Referral Hospital, Bahir Dar, Amhara National Regional State, Ethiopia.,Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Science, University of Gondar, P. O. Box, 196, Gondar, Ethiopia
| | - Mezgebu Yitayal
- Felege Hiwot Referral Hospital, Bahir Dar, Amhara National Regional State, Ethiopia. .,Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Science, University of Gondar, P. O. Box, 196, Gondar, Ethiopia.
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12
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Keyes EB, Parker C, Zissette S, Bailey PE, Augusto O. Geographic access to emergency obstetric services: a model incorporating patient bypassing using data from Mozambique. BMJ Glob Health 2019; 4:e000772. [PMID: 31321090 PMCID: PMC6606078 DOI: 10.1136/bmjgh-2018-000772] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 05/14/2018] [Accepted: 05/28/2018] [Indexed: 11/04/2022] Open
Abstract
Introduction Targeted approaches to further reduce maternal mortality require thorough understanding of the geographic barriers that women face when seeking care. Common measures of geographic access do not account for the time needed to reach services, despite substantial evidence that links proximity with greater use of facility services. Further, methods for measuring access often ignore the evidence that women frequently bypass close facilities based on perceptions of service quality. This paper aims to adapt existing approaches for measuring geographic access to better reflect women's bypassing behaviour, using data from Mozambique. Methods Using multiple data sources and modelling within a geographic information system, we calculated two segments of a patient's time to care: (1) home to the first preferred facility, assuming a woman might travel longer to reach a facility she perceived to be of higher quality; and (2) referral between the first preferred facility and facilities providing the highest level of care (eg, surgery). Combined, these two segments are total travel time to highest care. We then modelled the impact of expanding services and emergency referral infrastructure. Results The combination of upgrading geographically strategic facilities to provide the highest level of care and providing transportation to midlevel facilities modestly increased the percentage of the population with 2-hour access to the highest level of care (from 41% to 45%). The mean transfer time between facilities would be reduced by 39% (from 2.9 to 1.8 hours), and the mean total journey time by 18% (from 2.5 to 2.0 hours). Conclusion This adapted methodology is an effective tool for health planners at all levels of the health system, particularly to identify areas of very poor access. The modelled changes indicate substantial improvements in access and identify populations outside timely access for whom more innovative interventions are needed.
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Affiliation(s)
- Emily B Keyes
- Reproductive, Maternal, Newborn and Child Health, FHI 360, Durham, North Carolina, USA
| | - Caleb Parker
- Behavioral, Epidemiological and Clinical Sciences, FHI 360, Durham, North Carolina, USA
| | - Seth Zissette
- Behavioral, Epidemiological and Clinical Sciences, FHI 360, Durham, North Carolina, USA
| | - Patricia E Bailey
- Averting Maternal Death and Disability Program (AMDD), Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, USA
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13
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Jackson R. "We Prefer the Friendly Approach and Not the Facility": On the Value of Qualitative Research in Ethiopia. Ethiop J Health Sci 2019; 28:555-562. [PMID: 30607070 PMCID: PMC6308781 DOI: 10.4314/ejhs.v28i5.6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Quantitative research is useful for answering 'how many' or 'how much' questions, while qualitative research helps answer 'why' and 'how' questions. Most research about health extension workers (HEWs) has been quantitative and few studies examine the experiences of HEWs themselves. This qualitative study draws attention to the gendered dynamics of human resources for health at the community level. Methods Focus Group Discussions (FGDs) with 14 HEWs (two FGDs in Afar Region and two in Southern Nations Nationality and Peoples Region), and interviews with 45 HEWs from Afar Region, SNNPR and Adwa (Tigray Region) were conducted to identify how gender issues affected their well-being. Questions were designed to explore personal safety, stress, autonomy, self-esteem, family, other social relationships, as we wanted to analyze the extent to which these gendered issues affected HEWs in their day-to-day work. Results By employing female HEWs, the Health Extension Program (HEP) has seen substantial gains in 'practical' gender needs by improving women's access to, and utilization of maternal and child health services. Although the HEP has the potential to be gender transformative by providing employment for HEWs, there is limited evidence that it 'strategically' advances women's position. Many HEWs had heavy workloads, received low pay relative to other public sector jobs and lacked opportunity to transfer or upgrade their skills and advance within the health workforce hierarchy. Conclusion Qualitative research can provide complex descriptions of the social world to better understand what people such as HEWs say and the meanings they give, thus providing explanations for some health problems outside disciplinary boundaries.
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Affiliation(s)
- Ruth Jackson
- Honorary Fellow, School of Humanities and Social Sciences, Faculty of Arts & Education, Deakin University
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14
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Assefa Y, Gelaw YA, Hill PS, Taye BW, Van Damme W. Community health extension program of Ethiopia, 2003-2018: successes and challenges toward universal coverage for primary healthcare services. Global Health 2019; 15:24. [PMID: 30914055 PMCID: PMC6434624 DOI: 10.1186/s12992-019-0470-1] [Citation(s) in RCA: 171] [Impact Index Per Article: 34.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 03/15/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ethiopia 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. METHODS We 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. FINDINGS The 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. CONCLUSION The 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.
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Affiliation(s)
- Yibeltal Assefa
- School of Public Health, the University of Queensland, Brisbane, Australia.
| | | | - Peter S Hill
- School of Public Health, the University of Queensland, Brisbane, Australia
| | | | - Wim Van Damme
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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15
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Aseyo RE, Mumma J, Scott K, Nelima D, Davis E, Baker KK, Cumming O, Dreibelbis R. Realities and experiences of community health volunteers as agents for behaviour change: evidence from an informal urban settlement in Kisumu, Kenya. HUMAN RESOURCES FOR HEALTH 2018; 16:53. [PMID: 30286763 PMCID: PMC6172748 DOI: 10.1186/s12960-018-0318-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 09/19/2018] [Indexed: 05/05/2023]
Abstract
BACKGROUND Community health workers play an important role in health service delivery and are increasingly involved in behaviour change interventions, including for hygiene-related behaviour change. However, their role and capacity to deliver behaviour change interventions, particularly in high-density urban settlements, remain under-researched. This study examines the behaviour change-related activities of community health volunteers (CHVs)-community health workers affiliated with the Kenyan Ministry of Health-in a peri-urban settlement in Kenya, in order to assess their capabilities, opportunities to work effectively, and sources of motivation. METHODS This mixed-methods study included a census of 16 CHVs who work in the study area. All CHVs participated in structured observations of their daily duties, structured questionnaires, in-depth interviews, and two focus group discussions. Structured data were analysed descriptively. Thematic content analysis was followed for qualitative data. Results were synthesized and interpreted using the capability, opportunity, motivation for behaviour change framework, COM-B. RESULTS In addition to their responsibilities with the Ministry of Health, CHVs partnered with a range of non-governmental organizations engaged in health and development programming, often receiving small stipends from these organizations. CHVs reported employing a limited number of behaviour change techniques when interacting with community members at the household level. Capability: While supervision and support from the MOH was robust, CHV training was inconsistent and inadequate with regard to behaviour change and CHVs often lacked material resources necessary for their work. Opportunity: CHVs spent very little time with the households in their allocated catchment area. The number of households contacted per day was insufficient to reach all assigned households within a given month as required and the brief time spent with households limited the quality of engagement. MOTIVATION Lack of compensation was noted as a demotivating factor for CHVs. This was compounded by the challenging social environment and CHVs' low motivation to encourage behaviour change in local communities. CONCLUSIONS In a complex urban environment, CHVs faced challenges that limited their capacity to be involved in behaviour change interventions. More resources, better coordination, and additional training in modern behaviour change approaches are needed to ensure their optimal performance in implementing health programmes.
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Affiliation(s)
| | - Jane Mumma
- Great Lakes University of Kisumu, P O Box 2224, Kisumu, 40100 Kenya
| | - Kerry Scott
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205 United States of America
- Bangalore, India
| | - Damaris Nelima
- Great Lakes University of Kisumu, P O Box 2224, Kisumu, 40100 Kenya
| | - Emily Davis
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205 United States of America
| | - Kelly K Baker
- Occupational and Environmental Health, University of Iowa College of Public Health, 145 N Riverside Dr, Iowa City, IA 52246 United States of America
| | - Oliver Cumming
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT United Kingdom
| | - Robert Dreibelbis
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT United Kingdom
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Kea AZ, Tulloch O, Datiko DG, Theobald S, Kok MC. Exploring barriers to the use of formal maternal health services and priority areas for action in Sidama zone, southern Ethiopia. BMC Pregnancy Childbirth 2018; 18:96. [PMID: 29649972 PMCID: PMC5897996 DOI: 10.1186/s12884-018-1721-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Accepted: 03/28/2018] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND In 2015 the maternal mortality ratio for Ethiopia was 353 per 100,000 live births. Large numbers of women do not use maternal health services. This study aimed to identify factors influencing the use of maternal health services at the primary health care unit (PHCU) level in rural communities in Sidama zone, south Ethiopia in order to design quality improvement interventions. METHODS We conducted a qualitative study in six woredas in 2013: 14 focus group discussions (FGDs) and 44 in-depth interviews with purposefully selected community members (women, male, traditional birth attendants, local kebele administrators), health professionals and health extension workers (HEWs) at PHCUs. We digitally recorded, transcribed and thematically analysed the interviews and FGDs using Nvivo. The 'three delay model' informed the analytical process and discussion of barriers to the use of maternal health services. RESULTS Lack of knowledge on danger signs and benefits of maternal health services; cultural and traditional beliefs; trust in TBAs; lack of decision making power of women, previous negative experiences with health facilities; fear of going to an unfamiliar setting; lack of privacy and perceived costs of maternal health services were the main factors causing the first delay in deciding to seek care. Transport problems in inaccessible areas were the main contributing factor for the second delay on reaching care facilities. Lack of logistic supplies and equipment, insufficient knowledge and skills and unprofessional behaviour of health workers were key factors for the third delay in accessing quality care. CONCLUSIONS Use of maternal health services at the PHCU level in Sidama zone is influenced by complex factors within the community and health system. PHCUs should continue to implement awareness creation activities to improve knowledge of the community on complications of pregnancy and benefits of maternal health services. The health system has to be responsive to community's cultural norms and practices. The mangers of the woreda health office and health centres should take into account the available budgets; work on ensuring the necessary logistics and supplies to be in place at PHCU.
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Affiliation(s)
| | | | - Daniel G. Datiko
- REACH Ethiopia, P.O. Box 303, Hawassa, Ethiopia
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Maryse C. Kok
- Royal Tropical Institute, P.O. Box 95001, 1090 HA Amsterdam, The Netherlands
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Jackson R, Hailemariam A. The Role of Health Extension Workers in Linking Pregnant Women With Health Facilities for Delivery in Rural and Pastoralist Areas of Ethiopia. Ethiop J Health Sci 2018; 26:471-478. [PMID: 28446853 PMCID: PMC5389062 DOI: 10.4314/ejhs.v26i5.9] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Women's preference to give birth at home is deeply embedded in Ethiopian culture. Many women only go to health facilities if they have complications during birth. Health Extension Workers (HEWs) have been deployed to improve the utilization of maternal health services by bridging the gap between communities and health facilities. This study examined the barriers and facilitators for HEWs as they refer women to mid-level health facilities for birth. Methods A qualitative study was conducted in three regions: Afar Region, Southern Nations Nationalities and People's Region and Tigray Region between March to December 2014. Interviews and focus group discussions were conducted with 45 HEWs, 14 women extension workers (employed by Afar Pastoralist Development Association, Afar Region) and 11 other health workers from health centers, hospitals or health offices. Data analysis was done based on collating the data and identifying key themes. Results Barriers to health facilities included distance, lack of transportation, sociocultural factors and disrespectful care. Facilitators for facility-based deliveries included liaising with Health Development Army (HDA) leaders to refer women before their expected due date or if labour starts at home; the introduction of ambulance services; and, provision of health services that are culturally more acceptable for women. Conclusion HEWs can effectively refer more women to give birth in health facilities when the HDA is well established, when health staff provide respectful care, and when ambulance is available at any time.
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Affiliation(s)
- Ruth Jackson
- Alfred Deakin Institute for Citizenship and Globalisation, Deakin University, Australia
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18
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Desta FA, Shifa GT, Dagoye DW, Carr C, Van Roosmalen J, Stekelenburg J, Nedi AB, Kols A, Kim YM. Identifying gaps in the practices of rural health extension workers in Ethiopia: a task analysis study. BMC Health Serv Res 2017; 17:839. [PMID: 29262806 PMCID: PMC5738923 DOI: 10.1186/s12913-017-2804-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 12/14/2017] [Indexed: 11/10/2022] Open
Abstract
Background Health extension workers (HEWs) are the frontline health workers for Ethiopia’s primary health care system. The Federal Ministry of Health is seeking to upgrade and increase the number of HEWs, particularly in remote areas, and address concerns about HEWs’ pre-service education and practices. The aim of this study was to identify gaps in HEWs’ practices and recommend changes in their training and scope of practice. Methods A cross-sectional descriptive task analysis was conducted to assess the work of rural HEWs who had been in practice for six months to five years. One hundred participants were invited from 100 health posts in five regions of Ethiopia. HEWs self-reported on 62 tasks on: frequency, criticality (importance), where the task was learned, and ability to perform the task. Descriptive statistics, including frequencies and percentages, were computed for each variable. Task combinations were examined to identify tasks performed infrequently or for which HEWs are inadequately prepared. Results A total of 82 rural HEWs participated in the study. Nearly all HEWs rated every task as highly critical to individual and public health outcomes. On average, most HEWs (51.5%–57.4%) reported learning hygiene and environmental sanitation tasks, disease prevention and control tasks, family health tasks, and health education and communication tasks outside of their pre-service education, primarily through in-service and on-the-job training. Over half of HEWs reported performing certain critical tasks infrequently, including management of supplies, stocks and maintenance at the facility and management of the cold chain system. Almost all HEWs (95.7–97.2%) perceived themselves as competent and proficient in performing tasks in all program areas. Conclusion HEWs were insufficiently prepared during pre-service education for all tasks that fall within their scope of practice. Many learned tasks through in-service or on-the-job training, and some tasks were not learned at all. Some tasks that are part of expected HEW practice were performed infrequently, potentially reducing the effectiveness of the Health Extension Program to provide preventive and basic curative health care services to communities. Findings should alert policy makers to the need to review HEWs’ scope of practice, update pre-service education curricula and prioritize in-service training modules.
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Affiliation(s)
| | | | | | | | | | - Jelle Stekelenburg
- Medical Centre Leeuwarden, University Medical Centre Groningen/University of Groningen, Groningen, The Netherlands
| | | | - Adrienne Kols
- Jhpiego, 1615 Thames Street, Baltimore, MD, 21231, USA
| | - Young Mi Kim
- Jhpiego, 1615 Thames Street, Baltimore, MD, 21231, USA
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Ballard M, Montgomery P. Systematic review of interventions for improving the performance of community health workers in low-income and middle-income countries. BMJ Open 2017; 7:e014216. [PMID: 29074507 PMCID: PMC5665298 DOI: 10.1136/bmjopen-2016-014216] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To systematically review and critically appraise the evidence for the effects of interventions to improve the performance of community health workers (CHWs) for community-based primary healthcare in low- and middle-income countries. DESIGN Systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. METHODS 19 electronic databases were searched with a highly sensitive prespecified strategy and the grey literature examined, completed July 2016. Randomised controlled trials evaluating interventions to improve CHW performance in low- and middle-income countries were included and appraised for risk of bias. Outcomes were biological and behavioural patient outcomes (primary), use of health services, quality of care provided by CHWs and CHW retention (secondary). RESULTS Two reviewers screened 8082 records; 14 evaluations were included. Due to heterogeneity and lack of clear outcome data, no meta-analysis was conducted. Results were presented in a narrative summary. The review found one study showing no effect on the biological outcomes of interest, though these moderate quality data may not be indicative of all biological outcomes. It also found moderate quality evidence of the efficacy of performance improvement interventions for (1) improving behavioural outcomes for patients, (2) improving use of services by increasing the absolute number of patients who access services and, perhaps, better identifying those who would benefit from such services and (3) improving CHW quality of care in terms of upstream measures like completion of prescribed activities and downstream measures like adherence to treatment protocols. Nearly half of studies were compound interventions, making it difficult to isolate the effects of individual performance improvement intervention components, though four specific strategies pertaining to recruitment, supervision, incentivisation and equipment were identified. CONCLUSIONS Variations in recruitment, supervision, incentivisation and equipment may improve CHW performance. Practitioners should, however, assess the relevance and feasibility of these strategies in their health setting prior to implementation. Component selection experiments on a greater range of interventions to improve performance ought to be conducted.
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Affiliation(s)
- Madeleine Ballard
- Centre for Evidence-Based Intervention, University of Oxford, Oxford, UK
| | - Paul Montgomery
- Department of Social Policy and Social Work, University of Birmingham, Birmingham, UK
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Tesfaye B, Mathewos T, Kebede M. Skilled delivery inequality in Ethiopia: to what extent are the poorest and uneducated mothers benefiting? Int J Equity Health 2017; 16:82. [PMID: 28511657 PMCID: PMC5434546 DOI: 10.1186/s12939-017-0579-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 05/08/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The fifth Millennium Development Goal (MDG) targeted at improving maternal health. In this regard, Ethiopia has shown substantial progresses in the past two decades. Nonetheless, these impressive gains are unevenly distributed among Ethiopian women with different socio-economic characteristics. This study aimed at investigating levels and trends of skilled delivery service, and wealth and education related inequalities from 2000 to 16. METHODS Longitudinal data analysis was conducted on Ethiopian Demographic and Health Survey (EDHS) data of 2000, 2005, 2011 and 2016. The outcome variable was skilled delivery, while data on economic status and education level were used as dimensions of inequality. Rate Ratio (RR) and Rate Difference (RD) inequality measures were applied. STATA for windows version 10.1 statistical software was utilized for data analysis and presentation. The strength of association of inequality dimensions with the outcome variable was assessed using a 95% confidence interval. RESULTS From total deliveries, 5.62%, 6.3%, 10.8% and 28% of them were attended by skilled birth attendant in 2000, 2005, 2011 and 2016 respectively. In the most recent survey (EDHS 2016), proportion of births attended by skilled birth attendance among women who completed secondary and above education was about 5.42 [95% CI (4.53, 6.09)] times more when compared to women with no formal education. Proportion of births attended by skilled birth attendance among women in the richest quintile was about 5.11 [95% CI (3.98, 6.12)] times higher than that of women in the poorest quintile. Moreover, gap of inequality on receiving skilled delivery service has increased substantially from 24.2 (2000) to 53.8 (2016) percentage points between women in the richest and poorest quintiles; and from 44.9 (2000) to 76.0 (2016) percentage points between women who completed secondary and above education and women with no formal education. CONCLUSIONS Skilled birth attendance remained low and virtually unchanged during the period 2000-2011, but increased substantially in 2016. Gap on wealth and education related inequalities increased linearly during 2000-16. Most pronounced inequalities were observed in women's level of education revealing women with no formal education were the most underserved subgroups. Encouraging women in education and economic development programs should be strengthened as part of the effort to attain Universal Health Coverage (UHC) of Sustainable Development Goals (SDGs) in Ethiopia.
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Affiliation(s)
- Brook Tesfaye
- Health Policy and Planning Directorate, Ethiopian Federal Ministry of Health, Sudan Street, Lideta Sub-city, Addis Ababa, Ethiopia
| | - Tsedeke Mathewos
- John Snow Incorporated Research and Training Institute, Health Management Information System Scale-up Project, Addis Ababa, Ethiopia
- Technical Assistant to Director of Health Policy and Planning Directorate, Ethiopian Federal Ministry of Health, Addis Ababa, Ethiopia
| | - Mihiretu Kebede
- Department of Health Informatics, College of Medicine and Health Sciences, Institute of Public Health, University of Gondar, Gondar, Ethiopia
- Leibniz Institute for Prevention Research and Epidemiology – BIPS, Achterstraße 30, Bremen, Germany
- University of Bremen, Health Sciences, Bremen, Germany
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Gudu W. Prodromal symptoms, health care seeking in response to symptoms and associated factors in eclamptic patients. BMC Pregnancy Childbirth 2017; 17:87. [PMID: 28288576 PMCID: PMC5348883 DOI: 10.1186/s12884-017-1272-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Accepted: 03/08/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Eclampsia is one of the leading causes of maternal death worldwide. Maternal catastrophe is made worse in developing countries by the high incidence coupled with delayed presentation of patients and health facility constraints in effective management of eclampsia and its complications. METHODS A prospective study of all 93 eclamptic women admitted to a general hospital in Somali regional state, Ethiopia was conducted between May 1, 2014 and April 30, 2015 using a structured questionnaire which included socio-demographic data, antenatal visit status, distance of nearest maternal health facility, timing of convulsions, questions related to symptoms preceding seizures; health care seeking for the symptoms and time interval from prodromal symptoms to the diagnosis of eclampsia. Descriptive statistics and multivariable logistic regression analyses were conducted. Statistical tests were done at a level of significance of P < 0.05. RESULTS There were 93 cases of eclampsia among 3500 deliveries with an incidence of 2.7%. The timing of Eclampsia was antepartum in 57 (61.3%); intrapartum in 26 (28.0%) and postpartum in 10 (10.7%). Most (63%) were not having any antenatal care (ANC) follow up. Precedent symptoms were reported in 73 (79.0%) of the mothers with severe head ache in 70 (75.0%); visual disturbance in 44 (47%) and epigastric pain in 17 (18.0%). The frequency of symptoms was not influenced by the timing of eclampsia and degree of hypertension and prodromal symptoms were reported in 80% of the patients with severe hypertension. The mean duration of prodromal symptoms before patients were diagnosed with eclampsia was 5.5 days. Only 19/73 (26.0%) of the patients with prodromal symptoms visited a health facility for their complaints prior to developing eclampsia. The diagnosis of hypertensive disorder of pregnancy was made in 8 (42.0%) of these patients. Independent predictors of failure to seek health care in response to preceding symptoms were: rural residence (p-value < 0.001) and distance of maternal health facility of > 5km (p-value < 0.01). CONCLUSIONS Precedent symptoms were reported in most women. But many patients present late in response to these warning signs of eclampsia. Improving awareness of prodromal symptoms of eclampsia and timely health care seeking; providing ANC advises on danger signs of eclampsia in the socio-cultural context of the community; ensuring access to ANC services for rural mothers, and administration of anticonvulsants for all women with prodromal symptoms are recommended.
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Affiliation(s)
- Wondimu Gudu
- Department of Obstetrics & Gynecology, Karamara General Hospital/Jigjiga University, P.O.Box: 238, Jigjiga, Somali Regional State, Ethiopia.
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Okoli H, Obembe T, Osungbade K, Adeniji F, Adewole D. Self-referral patterns among federal civil servants in oyo state, South-Western Nigeria. Pan Afr Med J 2017; 26:105. [PMID: 28491236 PMCID: PMC5409987 DOI: 10.11604/pamj.2017.26.105.11483] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 01/24/2017] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Primary health care is widely accepted as the first point of care; yet, individuals requiring healthcare engage in self-referrals to higher levels of care thereby by-passing primary care. Little is known of the extent to which self-referrals are carried out when care is needed. This study thus sought to determine the prevalence of self-referral, its patterns and factors influencing self-referrals amongst federal civil servants in Southwestern Nigeria. METHODS A cross-sectional study was carried out among 300 federal civil servants who were interviewed using validated and pre-tested interviewer-administered semi structured questionnaires. Data was analyzed using univariate and Chi-square test at level of significance set at P <0.05. RESULTS Mean age of the respondents was 39.96 ± 9.1 years with majority being married (80.7%); 90.7% completed tertiary education (and 76.7 % were middle grade (7-12) level officers. Most (60.0%) of the respondents had ever engaged in self-referral. Malaria was the commonest health problem (39.7%) for self-referral to secondary or tertiary facilities. Desire for quality service (35.7%) and competent staff (35.2%) were the commonest reasons for self-referral to a higher level of health care. More female respondents (76.0%) compared to male respondents (64.0%) significantly engaged in self-referral (p = 0.02, X2 = 5.14). Respondents having good knowledge of referral practices engaged less in self-referral compared to those with poor knowledge. (p = 0.02, X2 = 5.43). CONCLUSION Having good knowledge of referral practices and being male are positively associated with referral practices. Creating awareness and improving knowledge on referral practices with special emphasis on women population are desirable strategies for encouraging the use of primary health care as first of point of contact with health systems.
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Affiliation(s)
- Henry Okoli
- Department of Health Policy and Management, Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Taiwo Obembe
- Department of Health Policy and Management, Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Kayode Osungbade
- Department of Health Policy and Management, Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Folashayo Adeniji
- Department of Health Policy and Management, Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - David Adewole
- Department of Health Policy and Management, Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
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Tilahun D, Hanlon C, Araya M, Davey B, Hoekstra RA, Fekadu A. Training needs and perspectives of community health workers in relation to integrating child mental health care into primary health care in a rural setting in sub-Saharan Africa: a mixed methods study. Int J Ment Health Syst 2017; 11:15. [PMID: 28168004 PMCID: PMC5286789 DOI: 10.1186/s13033-017-0121-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 01/22/2017] [Indexed: 11/24/2022] Open
Abstract
Background Community health workers can help to address the substantial unmet need for child mental health care in low and middle income countries. However, little is known about their training needs for this potential role. The aim of this study was to examine training needs and perspectives of community health extension workers (HEWs) in relation to providing child mental health care in rural Ethiopia. Methods The study was conducted in the Southern Nations, Nationalities and Peoples’ Region of Ethiopia. A mixed methods approach was used. A total of 104 HEWs who had received training in child mental health using the Health Education and Training (HEAT) curriculum were interviewed using a structured survey. In-depth interviews were then conducted with 11 HEWs purposively selected on the basis of the administrative zone they had come from. A framework approach was used for qualitative data analysis. Results Most of the HEWs (88.5%; n = 93/104) reported that they were interested in the training provided and all respondents considered child mental health to be important. The perceived benefits of training included improved knowledge (n = 52), case identification (n = 14) and service provision (n = 22). While most of the participants had their training four months prior to the interview, over a third of them (35.6%; n = 37) had already organized mental health awareness-raising meetings. Participants in the qualitative interviews considered the problem of child mental disorders to be widespread and to cause a large burden to the family and the affected children. They reported that improving their competence and knowledge was important to address the problem and to tackle stigma and discrimination. Participants also listed some barriers for service provision, including lack of competence, stigma and institutional constraints. Opportunities mentioned included staff commitment, high levels of interest and a positive attitude towards providing the service. Conclusions Although the HEAT training on child mental health was brief, it appears to have had some impact in improving knowledge and care provision. If the key barriers to service provision are addressed and supported by policy guidance, community health workers may contribute substantially in addressing the treatment gap for children with mental health needs.
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Affiliation(s)
- Dejene Tilahun
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, PO 9086, Addis Ababa, Ethiopia.,Department of Health Education and Behavioural Sciences, College of Public Health and Medical Science, Jimma University, Jimma, Ethiopia
| | - Charlotte Hanlon
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, PO 9086, Addis Ababa, Ethiopia.,Health Services and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, Centre for Global Mental Health, King's College London, London, UK
| | - Mesfin Araya
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, PO 9086, Addis Ababa, Ethiopia
| | - Basiro Davey
- Department of Life, Health and Chemical Sciences, The Open University, Milton Keynes, UK
| | - Rosa A Hoekstra
- Department of Life, Health and Chemical Sciences, The Open University, Milton Keynes, UK.,Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Abebaw Fekadu
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, PO 9086, Addis Ababa, Ethiopia.,Centre for Innovative Drug Development and Therapeutic Trials for Africa, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.,Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, Centre for Affective Disorders, King's College London, London, UK
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Moosa S, Derese A, Peersman W. Insights of health district managers on the implementation of primary health care outreach teams in Johannesburg, South Africa: a descriptive study with focus group discussions. HUMAN RESOURCES FOR HEALTH 2017; 15:7. [PMID: 28109275 PMCID: PMC5251300 DOI: 10.1186/s12960-017-0183-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 01/12/2017] [Indexed: 05/28/2023]
Abstract
BACKGROUND Primary health care (PHC) outreach teams are part of a policy of PHC re-engineering in South Africa. It attempts to move the deployment of community health workers (CHWs) from vertical programmes into an integrated generalised team-based approach to care for defined populations in municipal wards. There has little evaluation of PHC outreach teams. Managers' insights are anecdotal. METHODS This is descriptive qualitative study with focus group discussions with health district managers of Johannesburg, the largest city in South Africa. This was conducted in a sequence of three meetings with questions around implementation, human resources, and integrated PHC teamwork. There was a thematic content analysis of validated transcripts using the framework method. RESULTS There were two major themes: leadership-management challenges and human resource challenges. Whilst there was some positive sentiment, leadership-management challenges loomed large: poor leadership and planning with an under-resourced centralised approach, poor communications both within the service and with community, concerns with its impact on current services and resistance to change, and poor integration, both with other streams of PHC re-engineering and current district programmes. Discussion by managers on human resources was mostly on the plight of CHWs and calls for formalisation of CHWs functioning and training and nurse challenges with inappropriate planning and deployment of the team structure, with brief mention of the extended team. CONCLUSIONS Whilst there is positive sentiment towards intent of the PHC outreach team, programme managers in Johannesburg were critical of management of the programme in their health district. Whilst the objective of PHC reform is people-centred health care, its implementation struggles with a centralising tendency amongst managers in the health service in South Africa. Managers in Johannesburg advocated for decentralisation. The implementation of PHC outreach teams is also limited by difficulties with formalisation and training of CHWs and appropriate task shifting to nurses. Change management is required to create true integrate PHC teamwork. Policy review requires addressing these issues.
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Affiliation(s)
- Shabir Moosa
- Department of Family Medicine, University of Witwatersrand, Johannesburg, South Africa
| | - Anselme Derese
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
| | - Wim Peersman
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
- Knowledge Centre Brussels Integrated Care, Erasmus University College Brussels, Brussels, Belgium
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Johns B, Yihdego YY, Kolyada L, Dengela D, Chibsa S, Dissanayake G, George K, Taffese HS, Lucas B. Indoor Residual Spraying Delivery Models to Prevent Malaria: Comparison of Community- and District-Based Approaches in Ethiopia. GLOBAL HEALTH: SCIENCE AND PRACTICE 2016; 4:529-541. [PMID: 27965266 PMCID: PMC5199172 DOI: 10.9745/ghsp-d-16-00165] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 10/21/2016] [Indexed: 12/02/2022]
Abstract
Integrating indoor residual spraying into the institutionalized community-based
health system in 5 districts was more efficient than the district-based model and did
not compromise quality or compliance with environmental standards. Background: Indoor residual spraying (IRS) for malaria prevention has traditionally been
implemented in Ethiopia by the district health office with technical and
operational inputs from regional, zonal, and central health offices. The United
States President's Malaria Initiative (PMI) in collaboration with the
Government of Ethiopia tested the effectiveness and efficiency of integrating IRS
into the government-funded community-based rural health services program. Methods: Between 2012 and 2014, PMI conducted a mixed-methods study in 11 districts of
Oromia region to compare district-based IRS (DB IRS) and community-based IRS (CB
IRS) models. In the DB IRS model, each district included 2 centrally located
operational sites where spray teams camped during the IRS campaign and from which
they traveled to the villages to conduct spraying. In the CB IRS model, spray team
members were hired from the communities in which they operated, thus eliminating
the need for transport and camping facilities. The study team evaluated spray
coverage, the quality of spraying, compliance with environmental and safety
standards, and cost and performance efficiency. Results: The average number of eligible structures found and sprayed in the CB IRS
districts increased by 19.6% and 20.3%, respectively, between 2012
(before CB IRS) and 2013 (during CB IRS). Between 2013 and 2014, the numbers
increased by about 14%. In contrast, in the DB IRS districts the number of
eligible structures found increased by only 8.1% between 2012 and 2013 and
by 0.4% between 2013 and 2014. The quality of CB IRS operations was good
and comparable to that in the DB IRS model, according to wall bioassay tests. Some
compliance issues in the first year of CB IRS implementation were corrected in the
second year, bringing compliance up to the level of the DB IRS model. The CB IRS
model had, on average, higher amortized costs per district than the DB IRS model
but lower unit costs per structure sprayed and per person protected because the
community-based model found and sprayed more structures. Conclusion: Established community-based service delivery systems can be adapted to include a
seasonal IRS campaign alongside the community-based health workers' routine
activities to improve performance efficiency. Further modifications of the
community-based IRS model may reduce the total cost of the intervention and
increase its financial sustainability.
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Affiliation(s)
- Benjamin Johns
- Abt Associates, Inc., The President's Malaria Initiative Africa Indoor Residual Spraying Project, Bethesda, MD, USA
| | - Yemane Yeebiyo Yihdego
- Abt Associates, Inc., The President's Malaria Initiative Africa Indoor Residual Spraying Project, Addis Ababa, Ethiopia
| | - Lena Kolyada
- Abt Associates, Inc., The President's Malaria Initiative Africa Indoor Residual Spraying Project, Bethesda, MD, USA.
| | - Dereje Dengela
- Abt Associates, Inc., The President's Malaria Initiative Africa Indoor Residual Spraying Project, Bethesda, MD, USA
| | - Sheleme Chibsa
- U.S. President's Malaria Initiative, U.S. Agency for International Development, Addis Ababa, Ethiopia
| | - Gunawardena Dissanayake
- U.S. President's Malaria Initiative, U.S. Agency for International Development, Addis Ababa, Ethiopia
| | - Kristen George
- U.S. President's Malaria Initiative, U.S. Agency for International Development, Bureau for Global Health, Office of Health, Infectious Disease & Nutrition, Arlington, VA, USA
| | | | - Bradford Lucas
- Abt Associates, Inc., The President's Malaria Initiative Africa Indoor Residual Spraying Project, Bethesda, MD, USA
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Fetene N, Linnander E, Fekadu B, Alemu H, Omer H, Canavan M, Smith J, Berman P, Bradley E. The Ethiopian Health Extension Program and Variation in Health Systems Performance: What Matters? PLoS One 2016; 11:e0156438. [PMID: 27227972 PMCID: PMC4882046 DOI: 10.1371/journal.pone.0156438] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Accepted: 05/14/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Primary health care services are fundamental to improving health and health equity, particularly in the context of low and middle-income settings where resources are scarce. During the past decade, Ethiopia undertook an ambitious investment in primary health care known as the Ethiopian Health Extension Program that recorded impressive gains in several health outcomes. Despite this progress, substantial disparities in health outcomes persist across the country. The objective of this study was to understand how variation in the implementation of the primary health care efforts may explain differences in key health outcomes. METHODS AND FINDINGS We conducted a qualitative study of higher-performing and lower-performing woredas using site visits and in-depth interviews undertaken in 7 woredas. We classified woredas as higher-performing or lower-performing based on data on 5 indicators. We conducted a total of 94 open-ended interviews; 12-15 from each woreda. The data were analyzed using the constant comparative method of qualitative data analysis. Substantial contrasts were apparent between higher-performing and lower-performing woredas in use of data for problem solving and performance improvement; collaboration and respectful relationships among health extension workers, community members, and health center staff; and coordination between the woreda health office and higher-level regulatory and financing bodies at the zonal and regional levels. We found similarities in what was reported to motivate or demotivate health extension workers and other staff. Additionally, higher-performing and lower-performing woredas shared concerns about hospitals being isolated from health centers and health posts. Participants from both woredas also highlighted a mismatch between the urban health extension program design and the urban-dwelling communities' expectations for primary health care. CONCLUSIONS Data-informed problem solving, respectful and supportive relationships with the community, and strong support from zonal and regional health bureaus contributed to woreda performance, suggesting avenues for achieving higher performance in primary health care.
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Affiliation(s)
- Netsanet Fetene
- Yale School of Public Health and Global Health Institute, New Haven, CT, United States of America
| | - Erika Linnander
- Yale School of Public Health and Global Health Institute, New Haven, CT, United States of America
| | - Binyam Fekadu
- JSI Research and Training Institute, Inc., Boston, MA, United States of America
| | - Hibret Alemu
- Harvard School of Public Health, Boston, MA, United States of America
| | - Halima Omer
- Yale School of Public Health and Global Health Institute, New Haven, CT, United States of America
| | - Maureen Canavan
- Yale School of Public Health and Global Health Institute, New Haven, CT, United States of America
| | - Janna Smith
- Yale School of Public Health and Global Health Institute, New Haven, CT, United States of America
| | - Peter Berman
- Harvard School of Public Health, Boston, MA, United States of America
| | - Elizabeth Bradley
- Yale School of Public Health and Global Health Institute, New Haven, CT, United States of America
- * E-mail:
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Acharya D, Paudel R, Gautam K, Gautam S, Upadhyaya T. Knowledge of Maternal and Newborn Care Among Primary Level Health Workers in Kapilvastu District of Nepal. Ann Med Health Sci Res 2016; 6:27-32. [PMID: 27144073 PMCID: PMC4849112 DOI: 10.4103/2141-9248.180266] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Higher maternal and neonatal deaths are common in low- and middle-income countries; due to less access to skilled help. Adequate knowledge and skills on maternal and newborn care (MNC) of community health workers can improve maternal and newborn health. AIMS To identify the knowledge of primary level health workers on some components of MNC. SUBJECTS AND METHODS Respondents were selected using simple random sampling method. For collecting the data, enumerators visited health institutions for 2 months from 1(st) October to 31(st) November 2012, and structured interview schedule was used to gather the information. A cross-sectional study was conducted in a total of one hundred and thirty-seven primary level health workers in Kapilvastu district, Nepal. The Chi-square test was employed to examine the association between the knowledge of health workers on MNC and designation and work experience. Data were analyzed using SPSS version 17. RESULTS In a total of 137 primary level health workers, more than half 53.2% (73/137) were senior auxiliary health workers/health assistant. Health workers having correct knowledge on contents of MNC were-registration 32.1% (44/137), major components of antenatal care 57.7% (79/137), danger signs of pregnancy 39.4% (54/137), five cleans 59.1% (81/137), postnatal health problems 54.0% (74/137), majority to health action to newborn care, newborn bath and meaning of exclusive breastfeeding. There was a statistical association between designation of health workers and above-mentioned components of MNC (P < 0.05). CONCLUSIONS The differentials in the knowledge of MNC among primary level health suggest improving knowledge of the grass root level health workers with appropriate training and development programs.
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Affiliation(s)
- D Acharya
- Department of Public Health, Sanjeevani College of Medical Sciences, Purbanchal University, Butwal, Rupandehi, Nepal
| | - R Paudel
- Department of Community Medicine and Public Health, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | - K Gautam
- Department of Public Health, Sanjeevani College of Medical Sciences, Purbanchal University, Butwal, Rupandehi, Nepal
| | - S Gautam
- Department of Public Health, Sanjeevani College of Medical Sciences, Purbanchal University, Butwal, Rupandehi, Nepal
| | - T Upadhyaya
- Ministry of Finance, Department of Inland Revenue, Taxpair Service Office, Maharajgunj, Kathmandu, Nepal
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Jackson R, Tesfay FH, Godefay H, Gebrehiwot TG. Health Extension Workers' and Mothers' Attitudes to Maternal Health Service Utilization and Acceptance in Adwa Woreda, Tigray Region, Ethiopia. PLoS One 2016; 11:e0150747. [PMID: 26963507 PMCID: PMC4786113 DOI: 10.1371/journal.pone.0150747] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 02/18/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The maternal health system in Ethiopia links health posts in rural communities (kebeles) with district (woreda) health centres, and health centres with primary hospitals. At each health post two Health Extension Workers (HEWs) assist women with birth preparedness, complication readiness, and mobilize communities to facilitate timely referral to mid-level service providers. This study explored HEWs' and mother's attitudes to maternal health services in Adwa Woreda, Tigray Region. METHODS In this qualitative study, we trained 16 HEWs to interview 45 women to gain a better understanding of the social context of maternal health related behaviours. Themes included barriers to health services; women's social status and mobility; and women's perceptions of skilled birth attendant's care. All data were analyzed thematically. FINDINGS There have been substantial efforts to improve maternal health and reduce maternal mortality in Adwa Woreda. Women identified barriers to healthcare including distance and lack of transportation due to geographical factors; the absence of many husbands due to off-woreda farming; traditional factors such as zwar (some pregnant women are afraid of meeting other pregnant women), and discouragement from mothers and mothers-in-law who delivered their children at home. Some women experienced disrespectful care at the hospital. Facilitators to skilled birth attendance included: identification of pregnant women through Women's Development Groups (WDGs), and referral by ambulance to health facilities either before a woman's Expected Due Date (EDD) or if labour started at home. CONCLUSION With the support of WDGs, HEWs have increased the rate of skilled birth attendance by calling ambulances to transfer women to health centres either before their EDD or when labour starts at home. These findings add to the growing body of evidence that health workers at the community level can work with women's groups to improve maternal health, thus reducing the need for emergency obstetric care in low-income countries.
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Affiliation(s)
- Ruth Jackson
- Alfred Deakin Institute for Citizenship and Globalisation, Deakin University, Geelong, Victoria, Australia
| | - Fisaha Haile Tesfay
- College of Health Sciences, Department of Public Health, Mekelle University, Mekelle, Tigray Region, Ethiopia
| | - Hagos Godefay
- Tigray Regional Health Bureau, Mekelle, Tigray Region, Ethiopia
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Kok MC, Kea AZ, Datiko DG, Broerse JEW, Dieleman M, Taegtmeyer M, Tulloch O. A qualitative assessment of health extension workers' relationships with the community and health sector in Ethiopia: opportunities for enhancing maternal health performance. HUMAN RESOURCES FOR HEALTH 2015; 13:80. [PMID: 26423049 PMCID: PMC4589131 DOI: 10.1186/s12960-015-0077-4] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Accepted: 09/17/2015] [Indexed: 05/28/2023]
Abstract
BACKGROUND Health extension workers (HEWs) in Ethiopia have a unique position, connecting communities to the health sector. This intermediary position requires strong interpersonal relationships with actors in both the community and health sector, in order to enhance HEW performance. This study aimed to understand how relationships between HEWs, the community and health sector were shaped, in order to inform policy on optimizing HEW performance in providing maternal health services. METHODS We conducted a qualitative study in six districts in the Sidama zone, which included focus group discussions (FGDs) with HEWs, women and men from the community and semi-structured interviews with HEWs; key informants working in programme management, health service delivery and supervision of HEWs; mothers; and traditional birth attendants. Respondents were asked about facilitators and barriers regarding HEWs' relationships with the community and health sector. Interviews and FGDs were recorded, transcribed, translated, coded and thematically analysed. RESULTS HEWs were selected by their communities, which enhanced trust and engagement between them. Relationships were facilitated by programme design elements related to support, referral, supervision, training, monitoring and accountability. Trust, communication and dialogue and expectations influenced the strength of relationships. From the community side, the health development army supported HEWs in liaising with community members. From the health sector side, top-down supervision and inadequate training possibilities hampered relationships and demotivated HEWs. Health professionals, administrators, HEWs and communities occasionally met to monitor HEW and programme performance. Expectations from the community and health sector regarding HEWs' tasks sometimes differed, negatively affecting motivation and satisfaction of HEWs. CONCLUSION HEWs' relationships with the community and health sector can be constrained as a result of inadequate support systems, lack of trust, communication and dialogue and differing expectations. Clearly defined roles at all levels and standardized support, monitoring and accountability, referral, supervision and training, which are executed regularly with clear communication lines, could improve dialogue and trust between HEWs and actors from the community and health sector. This is important to increase HEW performance and maximize the value of HEWs' unique position.
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Affiliation(s)
- Maryse C Kok
- Royal Tropical Institute, P.O. Box 95001, 1090 HA, Amsterdam, The Netherlands.
- VU University Amsterdam, Athena Institute for Research on Innovation and Communication in Health and Life Sciences, De Boelelaan 1081, 1081 HV, Amsterdam, The Netherlands.
| | | | - Daniel G Datiko
- REACH Ethiopia, P.O. Box 303, Hawassa, Ethiopia.
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
| | - Jacqueline E W Broerse
- VU University Amsterdam, Athena Institute for Research on Innovation and Communication in Health and Life Sciences, De Boelelaan 1081, 1081 HV, Amsterdam, The Netherlands.
| | - Marjolein Dieleman
- Royal Tropical Institute, P.O. Box 95001, 1090 HA, Amsterdam, The Netherlands.
| | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
| | - Olivia Tulloch
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
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Singh D, Negin J, Otim M, Orach CG, Cumming R. The effect of payment and incentives on motivation and focus of community health workers: five case studies from low- and middle-income countries. HUMAN RESOURCES FOR HEALTH 2015; 13:58. [PMID: 26169179 PMCID: PMC4501095 DOI: 10.1186/s12960-015-0051-1] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2014] [Accepted: 06/27/2015] [Indexed: 05/21/2023]
Abstract
INTRODUCTION Community health workers (CHWs) have been proposed as a means for bridging gaps in healthcare delivery in rural communities. Recent CHW programmes have been shown to improve child and neonatal health outcomes, and it is increasingly being suggested that paid CHWs become an integral part of health systems. Remuneration of CHWs can potentially effect their motivation and focus. Broadly, programmes follow a social, monetary or mixed market approach to remuneration. Conscious understanding of the differences, and of what each has to offer, is important in selecting the most appropriate approach according to the context. CASE DESCRIPTIONS The objective of this review is to identify and examine different remuneration models of CHWs that have been utilized in large-scale sustained programmes to gain insight into the effect that remuneration has on the motivation and focus of CHWs. A MEDLINE search using Ovid SP was undertaken and data collected from secondary sources about CHW programmes in Iran, Ethiopia, India, Bangladesh and Nepal. Five main approaches were identified: part-time volunteer CHWs without regular financial incentives, volunteers that sell health-related merchandise, volunteers with financial incentives, paid full-time CHWs and a mixed model of paid and volunteer CHWs. DISCUSSION AND EVALUATION Both volunteer and remunerated CHWs are potentially effective and can bring something to the health arena that the other may not. For example, well-trained, supervised volunteers and full-time CHWs who receive regular payment, or a combination of both, are more likely to engage the community in grass-roots health-related empowerment. Programmes that utilize minimal economic incentives to part-time CHWs tend to limit their focus, with financially incentivized activities becoming central. They can, however, improve outcomes in well-circumscribed areas. In order to maintain benefits from different approaches, there is a need to distinguish between CHWs that are trained and remunerated to be a part of an existing health system and those who, with little training, take on roles and are motivated by a range of contextual factors. Governments and planners can benefit from understanding the programme that can best be supported in their communities, thereby maximizing motivation and effectiveness.
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Affiliation(s)
- Debra Singh
- Research and Collaboration, Kimanya-Ngeyo Foundation for Science and Education, Jinja, Uganda.
| | - Joel Negin
- School of Public Health, University of Sydney, Sydney, Australia.
| | - Michael Otim
- School of Allied Health | Faculty of Health Sciences, Australian Catholic University, Sydney, Australia.
| | | | - Robert Cumming
- School of Public Health, University of Sydney, Sydney, Australia.
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Edward A, Branchini C, Aitken I, Roach M, Osei-Bonsu K, Arwal SH. Toward universal coverage in Afghanistan: A multi-stakeholder assessment of capacity investments in the community health worker system. Soc Sci Med 2015; 145:173-83. [PMID: 26141453 DOI: 10.1016/j.socscimed.2015.06.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Global efforts to scale-up the community health workforce have accelerated as a result of the growing evidence of their effectiveness to enhance coverage and health outcomes. Reconstruction efforts in Afghanistan integrated capacity investments for community based service delivery, including the deployment of over 28,000 community health workers (CHWs) to ensure access to basic preventive and curative services. The study aimed to conduct capacity assessments of the CHW system and determine stakeholder perspectives of CHW performance. Structured interviews were conducted on a national sample from 33 provinces and included supervisors, facility providers, patients, and CHWs. Formative assessments were also conducted with national policymakers, community members and health councils in two provinces. Results indicate that more than 70% of the NGO's provide comprehensive training for CHWs, 95% CHWs reported regular supervision, and more than 60% of the health posts had adequate infrastructure and essential commodities. Innovative strategies of paired male and female CHWs, institution of a special cadre of community health supervisors, and community health councils were introduced as systems strengthening mechanisms. Reported barriers included unrealistic and expanding task expectations (14%), unsatisfactory compensation mechanisms (75%), inadequate transport (69%), and lack of commodities (40%). Formative assessments evidenced that CHWs were highly valued as they provided equitable, accessible and affordable 24-h care. Their loyalty, dedication and the ability for women to access care without male family escorts was appreciated by communities. With rising concerns of workforce deficits, insecurity and budget constraints, the health system must enhance the capacity of these frontline workers to improve the continuum of care. The study provides critical insight into the strengths and constraints of Afghanistan's CHW system, warranting further efforts to contextualize service delivery and mechanisms for their support and motivation.
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Affiliation(s)
- Anbrasi Edward
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Casey Branchini
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Iain Aitken
- Management Sciences for Health, Arlington, VA, USA
| | - Melissa Roach
- Texas Department of State Health Services, Austin, TX, USA
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Medhanyie AA, Little A, Yebyo H, Spigt M, Tadesse K, Blanco R, Dinant GJ. Health workers' experiences, barriers, preferences and motivating factors in using mHealth forms in Ethiopia. HUMAN RESOURCES FOR HEALTH 2015; 13:2. [PMID: 25588973 PMCID: PMC4325949 DOI: 10.1186/1478-4491-13-2] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Accepted: 12/20/2014] [Indexed: 05/24/2023]
Abstract
BACKGROUND Mobile health (mHealth) applications, such as innovative electronic forms on smartphones, could potentially improve the performance of health care workers and health systems in developing countries. However, contextual evidence on health workers' barriers and motivating factors that may influence large-scale implementation of such interfaces for health care delivery is scarce. METHODS A pretested semistructured questionnaire was used to assess health workers' experiences, barriers, preferences, and motivating factors in using mobile health forms on smartphones in the context of maternal health care in Ethiopia. Twenty-five health extension workers (HEWs) and midwives, working in 13 primary health care facilities in Tigray region, Ethiopia, participated in this study. RESULTS Over a 6-month period, a total of 2,893 electronic health records of 1,122 women were submitted to a central computer through the Internet. Sixteen (69.6%) workers believed the forms were good reminders on what to do and what questions needed to be asked. Twelve (52.2%) workers said electronic forms were comprehensive and 9 (39.1%) workers saw electronic forms as learning tools. All workers preferred unrestricted use of the smartphones and believed it helped them adapt to the smartphones and electronic forms for work purposes. With regards to language preference, 18 (78.3%) preferred using the local language (Tigrinya) version of the forms to English. Indentified barriers for not using electronic forms consistently include challenges related to electronic forms (for example, problem with username and password setting as reported by 5 (21.7%), smartphones (for example, smartphone froze or locked up as reported by 9 (39.1%) and health system (for example, frequent movement of health workers as reported by 19 (82.6%)). CONCLUSIONS Both HEWs and midwives found the electronic forms on smartphones useful for their day-to-day maternal health care services delivery. However, sustainable use and implementation of such work tools at scale would be daunting without providing technical support to health workers, securing mobile network airtime and improving key functions of the larger health system.
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Affiliation(s)
- Araya Abrha Medhanyie
- />Department of Public Health, College of Health Sciences, Mekelle University, PO Box 1871, Mekelle, Ethiopia
| | - Alex Little
- />Digital Campus, 21 North Drive, Littletown, Winchester, Winchester, S022 6QA England, UK
| | - Henock Yebyo
- />Department of Public Health, College of Health Sciences, Mekelle University, PO Box 1871, Mekelle, Ethiopia
| | - Mark Spigt
- />Department of Public Health, College of Health Sciences, Mekelle University, PO Box 1871, Mekelle, Ethiopia
- />Department of Family Medicine, CAPHRI, School for Public Health and Primary Care, Maastricht University, PO Box 616, 6200 MD Maastricht, Netherlands
- />General Practice Research Unit, Department of Community Medicine, The Arctic University of Norway, Tromsø, Norway
| | - Kidane Tadesse
- />Department of Public Health, College of Health Sciences, Mekelle University, PO Box 1871, Mekelle, Ethiopia
| | - Roman Blanco
- />Department of Surgery, School of Medicine, University of Alcala, 28871 Alcala de Henares, Madrid, Spain
- />Digital Campus, 21 North Drive, Littletown, Winchester, Winchester, S022 6QA England, UK
| | - Geert-Jan Dinant
- />Department of Family Medicine, CAPHRI, School for Public Health and Primary Care, Maastricht University, PO Box 616, 6200 MD Maastricht, Netherlands
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Mangham-Jefferies L, Mathewos B, Russell J, Bekele A. How do health extension workers in Ethiopia allocate their time? HUMAN RESOURCES FOR HEALTH 2014; 12:61. [PMID: 25315425 PMCID: PMC4209031 DOI: 10.1186/1478-4491-12-61] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 09/29/2014] [Indexed: 05/23/2023]
Abstract
BACKGROUND Governments are increasingly reliant on community health workers to undertake health promotion and provide essential curative care. In 2003, the Government of Ethiopia launched the Health Extension Programme and introduced a new cadre, health extension workers (HEWs), to improve access to care in rural communities. In 2013, to inform the government's plans for HEWs to take on an enhanced role in community-based newborn care, a time and motion study was conducted to understand the range of HEW responsibilities and how they allocate their time across health and non-health activities. METHODS The study was administered in 69 rural kebeles in the Southern Nations Nationalities and People's Region and Oromia Region that were intervention areas of a trial to evaluate a package of community-based interventions for newborns. Over 4 consecutive weeks, HEWs completed a diary and recorded all activities undertaken during each working day. HEWs were also surveyed to collect data on seasonal activities and details of the health post and kebele in which they work. The average proportion of productive time (excluding breaks) that HEWs spent on an activity, at a location, or with a recipient each week, was calculated. RESULTS The self-reported diary was completed by 131 HEWs. Over the course of a week, HEWs divided their time between the health post (51%) and the community (37%), with the remaining 11% of their time spent elsewhere. Curative health activities represented 16% of HEWs' time each week and 43% of their time was spent on health promotion and prevention. The remaining time included travel, training and supervision, administration, and community meetings. HEWs spent the majority (70%) of their time with individuals, families, and community members. CONCLUSIONS HEWs have wide-ranging responsibilities for community-based health promotion and curative care. Their workload is diverse and they spend time on activities relating to family health, disease prevention and control, hygiene and sanitation, as well as other community-based activities. Reproductive, maternal, newborn, and child health activities represent a major component of the HEW's work and, as such, they can have a critically important role in improving the health outcomes of mothers and children in Ethiopia.
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Affiliation(s)
- Lindsay Mangham-Jefferies
- />Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
| | - Bereket Mathewos
- />Department of Health and Nutrition, Save the Children, P. O. Box 387, Nefas Silk Lafto, Addis Ababa, Ethiopia
| | - Jeanne Russell
- />Department of Health and Nutrition, Save the Children, 2000 L St NW # 500, Washington, DC, 20036 USA
| | - Abeba Bekele
- />Department of Health and Nutrition, Save the Children, P. O. Box 387, Nefas Silk Lafto, Addis Ababa, Ethiopia
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Gopinathan U, Lewin S, Glenton C. Implementing large-scale programmes to optimise the health workforce in low- and middle-income settings: a multicountry case study synthesis. Trop Med Int Health 2014; 19:1437-56. [PMID: 25255908 DOI: 10.1111/tmi.12381] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To identify factors affecting the implementation of large-scale programmes to optimise the health workforce in low- and middle-income countries. METHODS We conducted a multicountry case study synthesis. Eligible programmes were identified through consultation with experts and using Internet searches. Programmes were selected purposively to match the inclusion criteria. Programme documents were gathered via Google Scholar and PubMed and from key informants. The SURE Framework - a comprehensive list of factors that may influence the implementation of health system interventions - was used to organise the data. Thematic analysis was used to identify the key issues that emerged from the case studies. RESULTS Programmes from Brazil, Ethiopia, India, Iran, Malawi, Venezuela and Zimbabwe were selected. Key system-level factors affecting the implementation of the programmes were related to health worker training and continuing education, management and programme support structures, the organisation and delivery of services, community participation, and the sociopolitical environment. CONCLUSIONS Existing weaknesses in health systems may undermine the implementation of large-scale programmes to optimise the health workforce. Changes in the roles and responsibilities of cadres may also, in turn, impact the health system throughout.
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Affiliation(s)
- Unni Gopinathan
- Norwegian Knowledge Centre for the Health Services, Oslo, Norway
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Zulu JM, Kinsman J, Michelo C, Hurtig AK. Integrating national community-based health worker programmes into health systems: a systematic review identifying lessons learned from low-and middle-income countries. BMC Public Health 2014; 14:987. [PMID: 25245825 PMCID: PMC4192351 DOI: 10.1186/1471-2458-14-987] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 09/15/2014] [Indexed: 11/23/2022] Open
Abstract
Background Despite the development of national community-based health worker (CBHW) programmes in several low- and middle-income countries, their integration into health systems has not been optimal. Studies have been conducted to investigate the factors influencing the integration processes, but systematic reviews to provide a more comprehensive understanding are lacking. Methods We conducted a systematic review of published research to understand factors that may influence the integration of national CBHW programmes into health systems in low- and middle-income countries. To be included in the study, CBHW programmes should have been developed by the government and have standardised training, supervision and incentive structures. A conceptual framework on the integration of health innovations into health systems guided the review. We identified 3410 records, of which 36 were finally selected, and on which an analysis was conducted concerning the themes and pathways associated with different factors that may influence the integration process. Results Four programmes from Brazil, Ethiopia, India and Pakistan met the inclusion criteria. Different aspects of each of these programmes were integrated in different ways into their respective health systems. Factors that facilitated the integration process included the magnitude of countries’ human resources for health problems and the associated discourses about how to address these problems; the perceived relative advantage of national CBHWs with regard to delivering health services over training and retaining highly skilled health workers; and the participation of some politicians and community members in programme processes, with the result that they viewed the programmes as legitimate, credible and relevant. Finally, integration of programmes within the existing health systems enhanced programme compatibility with the health systems’ governance, financing and training functions. Factors that inhibited the integration process included a rapid scale-up process; resistance from other health workers; discrimination of CBHWs based on social, gender and economic status; ineffective incentive structures; inadequate infrastructure and supplies; and hierarchical and parallel communication structures. Conclusions CBHW programmes should design their scale-up strategy differently based on current contextual factors. Further, adoption of a stepwise approach to the scale-up and integration process may positively shape the integration process of CBHW programmes into health systems.
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Affiliation(s)
- Joseph Mumba Zulu
- Department of Public Health, School of Medicine, University of Zambia, P,O, Box 50110, Lusaka, Zambia.
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Nwhator SO, Ijarogbe O, Agbaje O, Olojede CO, Olatunji AB. Nigerian dentists' knowledge of aggressive periodontitis. J Indian Soc Periodontol 2014; 18:78-81. [PMID: 24744550 PMCID: PMC3988650 DOI: 10.4103/0972-124x.128239] [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: 07/12/2013] [Accepted: 09/16/2013] [Indexed: 12/04/2022] Open
Abstract
Objective: To assess the general knowledge of Nigerian dentists on aggressive periodontitis (AgP) and specific knowledge of distinguishing between the clinical features of localized aggressive periodontitis (LAP) and generalized aggressive periodontitis (GAP). Materials and Methods: A cross-sectional, non-random convenience survey was done on 200 dentists, in three geopolitical zones of Nigeria, using pre-tested, closed question– type questionnaires. Eventually, only 133 questionnaires were analyzed. Relationships between six outcome variables namely clinical features of LAP, clinical features of GAP, LAP oral hygiene, GAP oral hygiene, laser therapy option and type of laser therapy, and the explanatory variables of gender and experience were analyzed. Results: A total of 33.8% of the dentists had poor general knowledge, 16.5% had fair knowledge, 31.9% had good knowledge, while 10.5% had excellent knowledge. Gender- and experience-related differences were found, but they were not statistically significant. Conclusion: Both the general and specific knowledge of aggressive periodontitis among Nigerian dentists is less than expected and needs improvement through targeted, continuing dental education.
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Affiliation(s)
| | - Olabode Ijarogbe
- Department of Oral and Restorative Dentistry, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Olayinka Agbaje
- Department of Child Dental Health, Lagos State University Teaching Hospital, Lagos, Nigeria
| | - Clement Olurotimi Olojede
- Department of Oral and Maxillofacial Surgery, College of Medicine, University of Lagos, Lagos, Nigeria
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Afework MF, Admassu K, Mekonnen A, Hagos S, Asegid M, Ahmed S. Effect of an innovative community based health program on maternal health service utilization in north and south central Ethiopia: a community based cross sectional study. Reprod Health 2014; 11:28. [PMID: 24708848 PMCID: PMC4041359 DOI: 10.1186/1742-4755-11-28] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Accepted: 03/28/2014] [Indexed: 11/10/2022] Open
Abstract
Background Among Millennium Development Goals, achieving the fifth goal (MDG-5) of reducing maternal mortality poses the greatest challenge in Sub-Saharan Africa. Ethiopia has one of the highest maternal mortality ratios in the world with unacceptably low maternal health service utilization. The Government of Ethiopia introduced an innovative community-based intervention as a national strategy under the Health Sector Development Program. This new approach, known as the Health Extension Program, aims to improve access to and equity in essential health services through community based Health Extension Workers. Objective The objective of the study is to assess the role of Health Extension Workers in improving women’s utilization of antenatal care, delivery at health facility and postnatal care services. Methods A cross sectional household survey was conducted in early 2012 in two districts of northern and south central parts of Ethiopia. Data were collected from 4949 women who had delivered in the two years preceding the survey. Logistic regression analysis was performed to determine the association between visit by Health Extension Workers during pregnancy and use of maternal health services, controlling for the effect of other confounding factors. Results The non–adjusted analysis showed that antenatal care attendance at least four times during pregnancy was significantly associated with visit by Health Extension Workers [Odds Ratio 3.46(95% CI 3.07,3.91)], whereas health facility delivery (skilled attendance at birth) was not significantly associated with visit by Health Extension Workers during pregnancy [Odds Ratio 0.87(95% CI 0.25,2.96)]. When adjusted for other factors the association of HEWs visit during pregnancy was weaker for antenatal care attendance [Adjusted Odds Ratio: 1.35(95% CI: 1.05, 1.72)] but positively and significantly associated with health facility delivery [Adjusted Odds Ratio 1.96(1.25,3.06)]. Conclusion In general HEWs visit during pregnancy improved utilization of maternal health services. Health facility delivery is heavily affected by other factors. Meaningful improvement in skilled attendance at birth (health facility delivery) should include addressing other factors on top of visits by HEWs during pregnancy and specific target oriented interventions during visits by HEWs to support skilled attendance at birth.
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Affiliation(s)
- Mesganaw Fantahun Afework
- Department of Reproductive Health and Health Service Management, School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
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Little A, Medhanyie A, Yebyo H, Spigt M, Dinant GJ, Blanco R. Meeting community health worker needs for maternal health care service delivery using appropriate mobile technologies in Ethiopia. PLoS One 2013; 8:e77563. [PMID: 24204872 PMCID: PMC3812262 DOI: 10.1371/journal.pone.0077563] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Accepted: 09/03/2013] [Indexed: 11/29/2022] Open
Abstract
Background Mobile health applications are complex interventions that essentially require changes to the behavior of health care professionals who will use them and changes to systems or processes in delivery of care. Our aim has been to meet the technical needs of Health Extension Workers (HEWs) and midwives for maternal health using appropriate mobile technologies tools. Methods We have developed and evaluated a set of appropriate smartphone health applications using open source components, including a local language adapted data collection tool, health worker and manager user-friendly dashboard analytics and maternal-newborn protocols. This is an eighteen month follow-up of an ongoing observational research study in the northern of Ethiopia involving two districts, twenty HEWs, and twelve midwives. Results Most health workers rapidly learned how to use and became comfortable with the touch screen devices so only limited technical support was needed. Unrestricted use of smartphones generated a strong sense of ownership and empowerment among the health workers. Ownership of the phones was a strong motivator for the health workers, who recognised the value and usefulness of the devices, so took care to look after them. A low level of smartphones breakage (8.3%,3 from 36) and loss (2.7%) were reported. Each health worker made an average of 160 mins of voice calls and downloaded 27Mb of data per month, however, we found very low usage of short message service (less than 3 per month). Conclusions Although it is too early to show a direct link between mobile technologies and health outcomes, mobile technologies allow health managers to more quickly and reliably have access to data which can help identify where there issues in the service delivery. Achieving a strong sense of ownership and empowerment among health workers is a prerequisite for a successful introduction of any mobile health program.
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Affiliation(s)
- Alex Little
- Digital Campus, Winchester, United Kingdom
- Department of Surgery, College of Health Sciences, University of Alcalá, Madrid, Spain
| | - Araya Medhanyie
- Department of Surgery, College of Health Sciences, University of Alcalá, Madrid, Spain
- Department of Public Health, Mekelle University, Mekelle, Ethiopia
- CAPHRI. School for Public Health and Primary Care, Maastricht University, Maastricht, Netherlands
| | - Henock Yebyo
- Department of Public Health, Mekelle University, Mekelle, Ethiopia
| | - Mark Spigt
- Department of Public Health, Mekelle University, Mekelle, Ethiopia
- CAPHRI. School for Public Health and Primary Care, Maastricht University, Maastricht, Netherlands
| | - Geert-Jan Dinant
- CAPHRI. School for Public Health and Primary Care, Maastricht University, Maastricht, Netherlands
| | - Roman Blanco
- Digital Campus, Winchester, United Kingdom
- Department of Surgery, College of Health Sciences, University of Alcalá, Madrid, Spain
- * E-mail:
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Developing the national community health assistant strategy in Zambia: a policy analysis. Health Res Policy Syst 2013; 11:24. [PMID: 23870454 PMCID: PMC3724745 DOI: 10.1186/1478-4505-11-24] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Accepted: 07/11/2013] [Indexed: 12/03/2022] Open
Abstract
Background In 2010, the Ministry of Health in Zambia developed the National Community Health Assistant strategy, aiming to integrate community health workers (CHWs) into national health plans by creating a new group of workers, called community health assistants (CHAs). The aim of the paper is to analyse the CHA policy development process and the factors that influenced its evolution and content. A policy analysis approach was used to analyse the policy reform process. Methodology Data were gathered through review of documents, participant observation and key informant interviews with CHA strategic team members in Lusaka district, and senior officials at the district level in Kapiri Mposhi district where some CHAs have been deployed. Results The strategy was developed in order to address the human resources for health shortage and the challenges facing the community-based health workforce in Zambia. However, some actors within the strategic team were more influential than others in informing the policy agenda, determining the process, and shaping the content. These actors negotiated with professional/statutory bodies and health unions on the need to develop the new cadre which resulted in compromises that enabled the policy process to move forward. International agencies also indirectly influenced the course as well as the content of the strategy. Some actors classified the process as both insufficiently consultative and rushed. Due to limited consultation, it was suggested that the policy content did not adequately address key policy content issues such as management of staff attrition, general professional development, and progression matters. Analysis of the process also showed that the strategy might create a new group of workers whose mandate is unclear to the existing group of health workers. Conclusions This paper highlights the complex nature of policy-making processes for integrating CHWs into the health system. It reiterates the need for recognising the fact that actors’ power or position in the political hierarchy may, more than their knowledge and understanding of the issue, play a disproportionate role in shaping the process as well as content of health policy reform.
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Tsegay Y, Gebrehiwot T, Goicolea I, Edin K, Lemma H, Sebastian MS. Determinants of antenatal and delivery care utilization in Tigray region, Ethiopia: a cross-sectional study. Int J Equity Health 2013; 12:30. [PMID: 23672203 PMCID: PMC3658893 DOI: 10.1186/1475-9276-12-30] [Citation(s) in RCA: 148] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Accepted: 05/07/2013] [Indexed: 11/28/2022] Open
Abstract
Introduction Despite the international emphasis in the last few years on the need to address the unmet health needs of pregnant women and children, progress in reducing maternal mortality has been slow. This is particularly worrying in sub-Saharan Africa where over 162,000 women still die each year during pregnancy and childbirth, most of them because of the lack of access to skilled delivery attendance and emergency care. With a maternal mortality ratio of 673 per 100,000 live births and 19,000 maternal deaths annually, Ethiopia is a major contributor to the worldwide death toll of mothers. While some studies have looked at different risk factors for antenatal care (ANC) and delivery service utilisation in the country, information coming from community-based studies related to the Health Extension Programme (HEP) in rural areas is limited. This study aims to determine the prevalence of maternal health care utilisation and explore its determinants among rural women aged 15–49 years in Tigray, Ethiopia. Methods The study was a community-based cross-sectional survey using a structured questionnaire. A cluster sampling technique was used to select women who had given birth at least once in the five years prior to the survey period. Univariable and multivariable logistic regression analyses were carried out to elicit the impact of each factor on ANC and institutional delivery service utilisation. Results The response rate was 99% (n=1113). The mean age of the participants was 30.4 years. The proportion of women who received ANC for their recent births was 54%; only 46 (4.1%) of women gave birth at a health facility. Factors associated with ANC utilisation were marital status, education, proximity of health facility to the village, and husband’s occupation, while use of institutional delivery was mainly associated with parity, education, having received ANC advice, a history of difficult/prolonged labour, and husbands’ occupation. Conclusions A relatively acceptable utilisation of ANC services but extremely low institutional delivery was observed. Classical socio-demographic factors were associated with both ANC and institutional delivery attendance. ANC advice can contribute to increase institutional delivery use. Different aspects of HEP need to be strengthened to improve maternal health in Tigray.
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Affiliation(s)
- Yalem Tsegay
- Department of Public Health, College of Health sciences, Mekelle University, Mekelle, Ethiopia
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