National Assessment of the Health Extension Program in Ethiopia: Study Protocol and Key Outputs

BACKGROUND: The Health Extension Program (HEP) was introduced in 2003 to extend primary health care services by institutionalizing the former volunteer-based village health services.However, this program is not comprehensively evaluated.MATERIALS AND METHODS: The 2019 comprehensive national assessment of HEP involved (1) assessment through quantitative and qualitative primary data, (2) a thorough systematic review of the HEP literature, and (3) a synthesis of evidence from the two sources. The assessment included household survey(n=7122), a survey of health extension workers (HEWs) (n=584)_, and an assessment of health posts (HPs)(n=343) and their supervising health centers (HCs)(n=179)from 62 randomly selected woredas. As part of the comprehensive assessment.OUTPUT AND RESULTS: The outputs were (a) full and abridged reports, (b) 40 posters, (c) seven published, three under review scientific papers and (d) seven papers in this special issue. During the one-year period preceding the study, 54.8% of women, 32.1% of men, and 21.9% of female youths had at least a one-time interaction with HEWs. HPs and HEWs were universally available. There were critical gaps in the skills and motivation of HEWs and fulfillment of HP standards: 57.3% of HEWs were certified, average satisfaction score of HEWs was 48.6%, and 5.4% of HPs fulfilled equipment standards. CONCLUSIONS: The findings informed policy and program decisions of the Ministry of Health, including the design of the HEP Optimization Roadmap 2020­2035 and the development Health Sector Transformation Plan II. It is also shared with global community through published papers

Ethiopian Health Extension Workers' Training Status and Perceived Competency

BACKGROUND: Training and work experience are critical inputs for delivering quality health services. However, no nationwide assessment has been conducted on the status of training and the competency of Health Extension Workers (HEWs). Therefore, this study aimed to assess HEWs' pre service training status and perceived competency in Ethiopia. METHODS: The study was conducted in all regions and all HEWs training institutions in Ethiopia. We used cross sectional study design with a mixed method approach that included 585 HEWs, 1,245 HEW trainees, 192 instructors, and 43 key informants. Descriptive statistics and thematic analysis were used to analyse quantitative and quantitative data respectively. RESULT: Twenty-six percent of the HEWs said that they were competent to deliver all the HEP activities, and 73% of the HEWs said that they could confidently deliver 75% of the HEP activities. Receiving in-service training and having level III/IV qualifications are positively associated with the competency of HEWs. Similarly, HEP trainees perceived themselves as highly competent in executing their professional work, except in using computer and mobile health technology. Both instructors and trainees rated the quality of the curriculum and course materials positively. However, basic services and facilities in most training institutions were perceived to be inadequate. Additionally, individual learning, problem-solving, case-analysis, and assessment methods such as project work and portfolios were rarely practiced. CONCLUSIONS: Although the perceived competence of HEW trainees is high, the HEWs' training is not provided as per the curriculum because of limited resources. All the necessary resources should be made available to produce competent HEWs

Depression and Burnout among Health Extension Workers in Ethiopia: A Cross-Sectional Study

BACKGROUND: Depression and burnout are common among healthcare workers (HCWs) and negatively affect their well being and the quality of the service they provide. However, the burden of depression and burnout among health extension workers (HEWs) in Ethiopia and their relationship has not been documented well. The objective of this study was to estimate the prevalence of depression and burnout among HEWs in Ethiopia and to investigate the relationship between these conditions. MATERIALS AND METHODS: We used a cross-sectional study design and collected data from 584 rural and 581 urban HEWs in Ethiopia, as part of the 2019 national health extension program assessment. The Patient Health Questionnaire (PHQ-9) and Burnout Self-Test were used to screen HEWs for depression and burnout, respectively. We used descriptive statistics to estimate the magnitude of depression and burnout, and logistic regression to examine their relationship. RESULT: Based on PHQ-9 cutoff scores of 10, the prevalence of major depression was 16.5% among rural and 8.9% among urban HEWs, whereas burnout risk was 39.8% among rural and 12.6% among urban HEWs. The odds of having depression among HEWs with burnout risk was relatively higher compared to those without burnout risk [For rural HEWs, the adjusted odds ratio (AOR) is 11.88 at a 95% confidence interval (CI; 5.27, 26.80), and for urban HEWs, the AOR is 11.49 at a 95% CI (5.35, 24.63)]. CONCLUSION: The prevalence of depression and burnout is high among HEWs in Ethiopia, with a significant rural­urban difference, and burnout is a significant predictor of depression. Mental health interventions that enable prevention, early detection, and management are needed especially for rural HEWs who are in charge of preventive health service delivery for the disadvantaged rural communities

Relevance of the Health Extension Program to the current Health Needs and Evolving Demands of Rural Ethiopia: A Mixed-Method Analysi

BACKGROUND: Ethiopia has been implementing a health extension program (HEP) to respond to the high maternal and child mortality in rural communities. HEP has brought tremendous contributions to improved access and coverage of primary healthcare in the last 15 years. Despite its attributions, attention to HEP has declined in recent years due to several reasons. This study is designed to explore HEP's relevance to the current healthcare needs of the rural communities. METHODS: This study is a nested cross-sectional mixed method to the overall HEP's evaluation between March and May 2019. Descriptive statistics were used on qualitative and quantitative assessment. A literature review supplemented the assessment. A representative quantitative sample of 11,746 women, men, and young girls; a qualitative sample of 268 key informants from Kebele administrators, HEWs, program people in the health system and focus groups from community leaders, men and women from 185 Kebeles in 62 woredas were selected. A thematic approach was used for qualitative analysis. RESULTS: Rural communities and program managers asserted that HEP's service packages with the existing service delivery modalities were relevant. Eighty-two percent of men and women and 77% of young girls confirmed this relevance. Besides the existing packages, additional curative services for adults and children were recommended with emphasis on the pastoralist community. HEP's service uptake has declined as over 86% of targeted rural communities bypassed HPs due to unavailability of services and capacity problems of HEWs. CONCLUSION: The current HEP packages with the existing service delivery modalities are still relevant to the rural communities' health needs. However, on-going changes to address the evolving demands of the targeted rural communities are crucial

Perspectives of the Health Extension Program Enhancing Contraceptive Provision in Southern Ethiopia: A Qualitative Exploration

Aim: To uncover information gap on the health extension program contribution in improving access, the study explored the lived experiences towards creating enabling environments for contraceptive service provision and use in light of the health extension program.Methods: Interpretative phenomenological design was employed for the study. Data were collected using focus group discussions, individual in-depth interviews and key informant interviews. Analysiswas done using an interpretive phenomenological analysis framework including phases of data immersion, transcribing, coding, theme developmentand phenomenological interpretation through the hermeneutic circle.Results:The finding captures the contribution of the health extension program in accelerating/decelerating contraceptive use in the study area. Contraceptive services organization, access and extension in the era of the health extension program were presented. Since the beginning of the program, contraceptive use has alarmingly improved as witnessed by both the service users and providers. The linkage of primary health care with the community organization, a women development army and the one-to-five network are among the major contributed factors for the outcomes. Conclusion and Recommendation:The study concludes that the health extension program has given a special momentum in shaping the principles of PHC. The study revealed that women witnessed encouraging involvements in contraceptive service access and use. Hence, the study recommends that the experiences of women development armies and other networks have to be strengthened. Moreover, the existing community networks should be strengthened through proper evaluation and feedback.

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

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

Tendas do afeto como um 'coração' em pulsação popular na extensão em saúde / Tents of affection as a 'heart' with a popular beat in the Extension of Health

Na contemporaneidade, vivemos processos educativos com dificuldades de articulação do conhecimento acadê- mico com o saber popular, que pode ser e acontecer, de forma indissociada. Educadores e educadoras populares têm se ocupado de trabalhar nessa conexão, em que um transforme o outro. Para isso, podem usar de mecanismos na extensão, como tem sido as Tendas do Afeto Popular. Desse modo, objetiva-se compartilhar dos movimentos do afeto nas Tendas, como propulsor neste trabalho. A metodologia é de relato do vivido como uma experiência significativa, que apresenta a dinamicidade da Tenda do Afeto, como processo popular de extensão universitária e das Tendas na extensão como um 'coração' em pulsação popular. Por fim, considera-se que as Tendas de Afeto Popular têm sido um dispositivo com potência nas atividades de extensão em saúde.

In contemporary times we experience educational processes with difficulties in connecting academic knowledge with popular knowledge, which can happen in a dissociated form. Popular educators have been busy working on this connection, in which one transforms the other. In order to achieve that goal, they can use mechanisms of extension, like the Popular Affection Tents. Thus, the objective is to share the Affection in Tents movements, as a device for working and for encounters. The methodology works as an account of living as a meaningful experience, which shows the dynamism of Affection Tents as a popular university extension device and the extension of the Tents as a 'heart' with a popular beat. A final consideration is that Popular Affection Tents have been a powerful device in health outreach activities.