Optimising scale-up for public health impact: a multimethod implementation science research protocol to improve infant health outcomes in Ethiopia.

INTRODUCTION: Child mortality rates remain high in sub-Saharan Africa, including Ethiopia. We are conducting a cluster randomised control trial in the Gondar zone of the Amhara region to determine the impact of pairing Orthodox priests with community health workers, known locally as the Health Development Army (HDA), on newborns' nutritional status, early illness identification and treatment, and vaccination completeness.Ensuring intervention efficacy with scientific rigour is essential, but there are often delays in adopting evidence into policy and programmes. Here, we present a protocol for conducting parallel implementation research alongside an efficacy study to understand intervention implementability and scalability. This will help develop a scale-up strategy for effective elements of the intervention to ensure rapid implementation at scale. METHODS AND ANALYSIS: We will conduct a stakeholder analysis of key implementation stakeholders and readiness surveys to assess their readiness to scale up the intervention. We will conduct semistructured interviews and focus group discussions with stakeholders, including HDA members, health workers, Orthodox priests, and caregivers, to determine the core intervention elements that need to be scaled, barriers and facilitators to scaling up the intervention in diverse sociocultural settings, as well as the human and technical requirements for national and regional implementation. Finally, to determine the financial resources necessary for sustaining and scaling the intervention, we will conduct activity-based costing to estimate implementation costs from the provider's perspective. ETHICS AND DISSEMINATION: The study received approval from the University of Gondar Institutional Review Board (approval no: VP/RTT/05/1030/2022) and the University of Washington Human Subjects Division (approval no: STUDY00015369). Participants will consent to participate. Results will be disseminated through workshops with stakeholders, local community meetings, presentations at local and international conferences, and journal publications. The study will provide evidence for factors to consider in developing a scale-up strategy to integrate the intervention into routine health system practices.

Partnering faith leaders with community health workers increases utilization of antenatal care and facility delivery services in Ethiopia: A cluster randomized trial.

BACKGROUND: Ethiopia and other countries continue to experience high rates of maternal mortality and neonatal deaths. Interventions are needed to increase utilization of antenatal care (ANC) and facility delivery services to improve outcomes. METHODS: A cluster-randomized trial was conducted in the Amhara Region of Ethiopia, with 6 communities randomly assigned to receive the intervention and 12 communities monitored as controls. Intervention teams provided outreach to pregnant women and their families. Registry data were used to measure utilization of services provided at health centers in intervention and control communities.The intervention consisted of trained pairs of community health workers and Ethiopian Orthodox priests who worked together to promote health messages around safe delivery. The pairs visited pregnant women and their families in their homes to provide counseling, discuss concerns, and answer questions about ANC and facility deliveries. Intervention impact was measured using facility-level data on monthly number of ANC visits and facility deliveries at the health centers that served the intervention and control communities. Intervention effect was measured using difference-in-difference analyses estimated by generalized estimating equation models. RESULTS: During the 12-month intervention period, intervention facilities (n = 6) recorded 14% more ANC1 visits (relative risk RR = 1.14; 95% confidence interval (CI) = 1.09-1.19; P < 0.001) and 26% more ANC4 visits (RR = 1.26; 95%CI = 1.18, 1.34; P < 0.001) compared to control health centers (n = 12). The intervention health centers experienced a 10% increase in facility deliveries over what would have been expected had the intervention not occurred (RR = 1.10; 95% CI = 1.05-1.16; P < 0.001). CONCLUSIONS: Promotion of safe delivery through home visits by community health workers paired with Ethiopian Orthodox priests increased utilization of ANC and facility delivery services. This approach could leverage the influential role of faith leaders and increase the impact of community health workers in Ethiopia. TRIAL REGISTRATION: NCT04039932.