Rural health extension workers’ intention to leave their jobs and associated factors, North Wollo Zone, northeast Ethiopia

Background: The intention to leave primary jobs has risen in importance in the global dialogue on the health workforce. The related concept of staff turnover has also generated debate. This study was conducted to assess health extension workers’ intention to leave their jobs in North Wollo Zone, northeast Ethiopia. Methods: A cross-sectional study was conducted in North Wollo Zone from February to April 2016. Using a multi-stage stratified sampling technique, a total of 383 participants were selected. The data were entered into EpiData version 3.1 and exported to SPSS version 20 for analysis. Bivariable and multivariable logistic regression analyses were employed to identify significant factors. Odds ratios (ORs), 95% confidence intervals (CI), and p-values were used to measure the strength and presence of statistical associations. Results: The study showed that 64.1% (95% CI: 59.2, 69) of health extension workers had an intention to leave their jobs. Statistically significant factors were: low salary (AOR = 2.23; 95% CI: 1.98, 4.25); high workload (AOR = 2.78; 95% CI: 1.46, 5.31); dissatisfaction with educational opportunities (AOR = 3.74: 95% CI: 1.56, 8.27); dissatisfaction with payments and benefits (AOR = 3.32; 95% CI: 1.87, 6.68); dissatisfaction with the lack of recognition (AOR = 2.15; 95% CI: 1.18, 3.63); and dissatisfaction with working environments (AOR = 1.96; 95% CI: 1.18, 3.52). Conclusions: The proportion of participants who intended to leave their jobs was high. Hence, developing evidence-based retention strategies focusing on payments, educational opportunities, incentives, and work environment could help reduce the intention of health extension workers to leave their jobs. [Ethiop. J. Health Dev. 2020; 34(2):106-113] Keywords: Intention to leave, health extension workers, North Wollo Zone, Ethiopi

Risky Sexual Behavior and Associated Factors Among High School Students in Gondar City, Northwest Ethiopia

According to World Health Organization (WHO), youth are young people within 15-24 years old. Studies reported that more than half of all new HIV infections occur among people between the ages of 15 and 24 years. Institution based quantitative cross-sectional study was conducted among high school students in Gondar city. Multistage sampling technique was employed to recruit study participants. Data were collected using pretested structured self-administered questionnaire. Data were entered in Epi Info version 7 and analyzed using SPSS version 21. Descriptive statistics were computed to describe important variables in relation to the outcome variable, Binary and multivariable logistic regressions were used to identify independent predictors of the outcome variable. The overall prevalence of risky sexual behavior was 12.8%. Two out of five sexually active respondents ever had unprotected sexual intercourse. Ever used alcohol ((AOR, 3.53 95% CI (1.73-7.19)), had no parental monitor (AOR, 12.21 95% CI (6.55-22.78), ever watched pornographic film (AOR, 2.24 95% CI (1.15-4.35), had no parental discussion on sexual and reproductive health issues (AOR, 2.57 95% CI (1.36-4.85) and peer pressure (AOR,2.50, 95%CI (1.20-5.21), were factors which significantly increases the odds of risky sexual behavior among youth. Risky sexual behavior among high school students in Gondar city administration was very high and worrisome; so that collaborated effort is needed from parents, schools, health facilities and health policy makers to bring healthy sexual behavior among school youth

Effectiveness and impact of community-based health insurance on health service utilization in northwest Ethiopia: a quasi-experimental evaluation

BackgroundAddressing the health challenges of lower socioeconomic groups in Ethiopia is still a huge problem. In that regard, the government piloted the community-based health insurance (CBHI) in 2011 in a few districts and subsequently scaled up. However, the effectiveness of the program on the utilization of health services and its impact was not well explored. Thus, we aimed to evaluate the effectiveness of CBHI toward health services’ utilization and its impact in northwest Ethiopia.MethodsA quasi-experimental matched comparison group evaluation design with sequential explanatory mixed methods was employed. To evaluate the CBHI program, the effectiveness and impact dimensions from the Organization for Economic Cooperation and Development framework were used. A multistage sampling technique was used to select a total of 332 households enrolled in the CBHI program; 341 comparison households who did not enroll in the program were also randomly selected. A structured interviewer-administrated questionnaire was used to evaluate the effectiveness and impact of CBHI on health service utilization. The Propensity score matching model was employed for the estimation of the effect of the CBHI program on health service utilization. Challenges for program achievement toward health service utilization were explained through qualitative data and these were then analyzed thematically.ResultsThe evaluation showed 1.3 visits per capita per year of health service utilization among CBHI members. Households enrolled in CBHI increased health service utilization by 6.9 percentage points (ATT = 0.069; 95% CI: 0.034, 0.114). There was an improvement in health service utilization after the introduction of CBHI, however, there are challenges: (i) shortage of human resources, (ii) out-of-stock of drugs and medical supplies, and (iii) long waiting times for service and reimbursement claims. These issues limit the success of the program toward health service utilization.ConclusionThe CBHI program contributed to health service utilization improvement among CBHI members. However, the utilization rate of health services among CBHI members is still less than the target stated for the program and also the WHO recommendation. Therefore, the findings of this evaluation can be used by program implementers, policy makers, and other stakeholders to overcome the identified challenges and to increase the success of the program

Assessing the quality of care in sick child services at health facilities in Ethiopia.

BACKGROUND: Quality of care depends on system, facility, provider, and client-level factors. We aimed at examining structural and process quality of services for sick children and its association with client satisfaction at health facilities in Ethiopia. METHODS: Data from the Ethiopia Service Provision Assessment Plus (SPA+) survey 2014 were used. Measures of quality were assessed based on the Donabedian framework: structure, process, and outcome. A total of 1908 mothers or caretakers were interviewed and their child consultations were observed. Principal component analysis was used to construct quality of care indices including a structural composite score, a process composite score, and a client satisfaction score. Multilevel mixed linear regression was used to analyze the association between structural and process factors with client satisfaction. RESULT: Among children diagnosed with suspected pneumonia, respiratory rate was counted in 56% and temperature was checked in 77% of the cases. A majority of children (92%) diagnosed with fever had their temperature taken. Only 3% of children with fever were either referred or admitted, and 60% received antibiotics. Among children diagnosed with malaria, 51% were assessed for all three Integrated Management of Childhood Illnesses (IMCI) main symptoms, and 4% were assessed for all three general danger signs. Providers assessed dehydration in 54% of children with diarrhea with dehydration, 17% of these children were admitted or referred to another facility, and Oral Rehydration Solution was prescribed for 67% while none received intravenous fluids. The number of basic amenities in the facility was negatively associated with the clients' satisfaction. Private facilities, when the providers had got training for care of sick children in the past 2 years, had higher client satisfaction. There was no statistical association between structure, process composite indicators and client satisfaction. CONCLUSION: The assessment of sick children was of low quality, with many missing procedures when comparing with IMCI guidelines. In spite of this, most clients were satisfied with the services they received. Structural and process composite indicators were not associated with client's satisfaction. These findings highlight the need to assess other dimensions of quality of care besides structure and process that may influence client satisfaction

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

BACKGROUND: Due to low care utilization, a complex intervention was done for two years to optimize the Ethiopian Health Extension Program. Improved quality of the integrated community case management services was an intermediate outcome of this intervention through community education and mobilization, capacity building of health workers, and strengthening of district ownership and accountability of sick child services. We evaluated the association between the intervention and the health extension workers' ability to correctly classify common childhood illnesses in four regions of Ethiopia. METHODS: Baseline and endline assessments were done in 2016 and 2018 in intervention and comparison areas in four regions of Ethiopia. Ill children aged 2 to 59 months were mobilized to visit health posts for an assessment that was followed by re-examination. We analyzed sensitivity, specificity, and difference-in-difference of correct classification with multilevel mixed logistic regression in intervention and comparison areas at baseline and endline. RESULTS: Health extensions workers' consultations with ill children were observed in intervention (n = 710) and comparison areas (n = 615). At baseline, re-examination of the children showed that in intervention areas, health extension workers' sensitivity for fever or malaria was 54%, 68% for respiratory infections, 90% for diarrheal diseases, and 34% for malnutrition. At endline, it was 40% for fever or malaria, 49% for respiratory infections, 85% for diarrheal diseases, and 48% for malnutrition. Specificity was higher (89-100%) for all childhood illnesses. Difference-in-differences was 6% for correct classification of fever or malaria [aOR = 1.45 95% CI: 0.81-2.60], 4% for respiratory tract infection [aOR = 1.49 95% CI: 0.81-2.74], and 5% for diarrheal diseases [aOR = 1.74 95% CI: 0.77-3.92]. CONCLUSION: This study revealed that the Optimization of Health Extension Program intervention, which included training, supportive supervision, and performance reviews of health extension workers, was not associated with an improved classification of childhood illnesses by these Ethiopian primary health care workers. TRIAL REGISTRATION: ISRCTN12040912, http://www.isrctn.com/ISRCTN12040912

Management of bacterial infections in young infants in Ethiopia: Facility preparedness, health workers' knowledge and quality of care.

AIM: We assessed primary care facility preparedness, health workers' knowledge and their classification and treatment of possible serious bacterial infection and local bacterial infection in young infants aged 0-59 days. METHOD: A cross-sectional survey was conducted in four regions of Ethiopia, including 169 health posts with 276 health extension workers and 155 health centres with 175 staff. Registers of 1058 sick young infants were reviewed. RESULT: Antibiotics to treat possible serious bacterial infection were available in 71% of the health centres and 38% of the health posts. Nine of ten health extension workers and eight of ten health centre staff mentioned at least one sign of possible serious bacterial infection and local bacterial infection. Among the registered cases with signs of bacterial infections, the health extension workers classified 49% as having a possible serious bacterial infection and 88% as local bacterial infection. The health centre staff classified 25% as possible serious bacterial infections and 86% as local bacterial infections. One-fourth (26%) of possible serious bacterial infection received the recommended treatment at health posts and 35% at health centres. CONCLUSION: Many health posts lacked antibiotics. The classification and treatment of possible serious bacterial infection did not follow guidelines. The lack of medicines and poor adherence compromise the quality of care

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

OBJECTIVE: The health system context influences the implementation of evidence-based practices and quality of healthcare services. Ethiopia aims at reaching universal health coverage but faces low primary care utilisation and substandard quality of care. We assessed the health extension workers' perceived context and the preparedness of health posts to provide services. SETTING: This study was part of evaluating a complex intervention in 52 districts of four regions of Ethiopia. This paper used the endline data collected from December 2018 to February 2019. PARTICIPANTS: A total of 152 health posts and health extension workers serving selected enumeration areas were included. OUTCOME MEASURES: We used the Context Assessment for Community Health (COACH) tool and the Service Availability and Readiness Assessment tool. RESULTS: Internal reliability of COACH was satisfactory. The dimensions community engagement, work culture, commitment to work and leadership all scored high (mean 3.75-4.01 on a 1-5 scale), while organisational resources, sources of knowledge and informal payments scored low (1.78-2.71). The general service readiness index was 59%. On average, 67% of the health posts had basic amenities to provide services, 81% had basic equipment, 42% had standard precautions for infection prevention, 47% had test capacity for malaria and 58% had essential medicines. CONCLUSION: The health extension workers had a good relationship with the local community, used data for planning, were highly committed to their work with positive perceptions of their work culture, a relatively positive attitude regarding their leaders, and reported no corruption or informal payments. In contrast, they had insufficient sources of information and a severe lack of resources. The health post preparedness confirmed the low level of resources and preparedness for services. These findings suggest a significant potential contribution by health extension workers to Ethiopia's primary healthcare, provided that they receive improved support, including new information and essential resources

COVID 19 Epidemic Trajectory Modeling Results for Ethiopia

AbstractBackground: An outbreak of “pneumonia of unknown etiology" later renamed as Novel Corona Virus (COVID 19) was first reported from Hubei Province, China on 31 December 2019. The cases have increased exponentially; the pandemic has reached all countries in the world with 81.2 million confirmed cases and over 1.8 million by December 28, 2020. Ethiopia reported its first case on March 13, 2020, and as of December 28, 2020, the country had 122864 confirmed COVID-19 cases and 1909 deaths. Being a new pandemic its epidemiologic trajectories across regions and populations remains unknown. Mathematical models are widely used to understand and predict the possible courses of an outbreak, given a set of underlying assumptions. Objective: This study intends to model COVID 19 epidemic trajectory under different assumptions and to predict the likely timing of peak of the epidemic in Ethiopia. Methods: Standard Susceptible Exposed, Infected and Recovery (SEIR) compartmental epidemiological deterministic model was employed to estimate and predict COVID 19 in progression in Ethiopia and Addis Ababa at different points of time. Exhaustive literature reviews were carried out to contextualize COVID 19 pandemic epidemiological. Efficacy and coverage of face mask and social distancing were considered in the best and worst situation to run the model and estimate the number of infections after sustained local transmissions. Result. Without any intervention, the COVID 19 viruses spread will peak at 150 days from the first report, infecting 8.01million people given local/community transmission. As the compliance with face mask coverage increases by 25%, 50%, and 75%, the infection will be reduced by about 20%, 40%, and 60% respectively social distancing compliance by le 25% of the population alone will reduce above 60% of infections. Compliance of 40% face mask use and social distance combined effect will reduce 97% of the estimated number of cases. Conclusion: This predication indicated that compliance with combination of non-pharmaceutical intervention such as use of face mask use with physical distance averted significant number of COVID infection. For a county like Ethiopia with poor health systems resilience, mitigating the pandemic at an early stage through strong preventive measures is necessary. [Ethiop. J. Health Dev. 2021; 35(SI-1):25-32] Key word: COVID 19, Modelling, Non-Pharmaceutica intervention, Ethiopi

Protocol for the evaluation of a complex intervention aiming at increased utilisation of primary child health services in Ethiopia: a before and after study in intervention and comparison areas.

BACKGROUND: By expanding primary health care services, Ethiopia has reduced under-five mor4tality. Utilisation of these services is still low, and concerted efforts are needed for continued improvements in newborn and child survival. "Optimizing the Health Extension Program" is a complex intervention based on a logic framework developed from an analysis of barriers to the utilisation of primary child health services. This intervention includes innovative components to engage the community, strengthen the capacity of primary health care workers, and reinforce the local ownership and accountability of the primary child health services. This paper presents a protocol for the process and outcome evaluation, using a pragmatic trial design including before-and-after assessments in both intervention and comparison areas across four Ethiopian regions. The study has an integrated research capacity building initiative, including ten Ph.D. students recruited from Ethiopian Regional Health Bureaus and universities. METHODS: Baseline and endline surveys 2 years apart include household, facility, health worker, and district health office modules in intervention and comparison areas across Amhara, Southern Nations Nationalities and Peoples, Oromia, and Tigray regions. The effectiveness of the intervention on the seeking and receiving of appropriate care will be estimated by difference-in-differences analysis, adjusting for clustering and for relevant confounders. The process evaluation follows the guidelines of the UK Medical Research Council. The implementation is monitored using data that we anticipate will be used to describe the fidelity, reach, dose, contextual factors and cost. The participating Ph.D. students plan to perform in-depth analyses on different topics including equity, referral, newborn care practices, quality-of-care, geographic differences, and other process evaluation components. DISCUSSION: This protocol describes an evaluation of a complex intervention that aims at increased utilisation of primary and child health services. This unique collaborative effort includes key stakeholders from the Ethiopian health system, the implementing non-governmental organisations and universities, and combines state-of-the art effectiveness estimates and process evaluation with capacity building. The lessons learned from the project will inform efforts to engage communities and increase utilisation of care for children in other parts of Ethiopia and beyond. TRIAL REGISTRATION: Current Controlled Trials ISRCTN12040912, retrospectively registered on 19 December, 2017

Does a complex intervention targeting communities, health facilities and district health managers increase the utilisation of community-based child health services? A before and after study in intervention and comparison areas of Ethiopia.

INTRODUCTION: Ethiopia successfully reduced mortality in children below 5 years of age during the past few decades, but the utilisation of child health services was still low. Optimising the Health Extension Programme was a 2-year intervention in 26 districts, focusing on community engagement, capacity strengthening of primary care workers and reinforcement of district accountability of child health services. We report the intervention's effectiveness on care utilisation for common childhood illnesses. METHODS: We included a representative sample of 5773 households with 2874 under-five children at baseline (December 2016 to February 2017) and 10 788 households and 5639 under-five children at endline surveys (December 2018 to February 2019) in intervention and comparison areas. Health facilities were also included. We assessed the effect of the intervention using difference-in-differences analyses. RESULTS: There were 31 intervention activities; many were one-off and implemented late. In eight districts, activities were interrupted for 4 months. Care-seeking for any illness in the 2 weeks before the survey for children aged 2-59 months at baseline was 58% (95% CI 47 to 68) in intervention and 49% (95% CI 39 to 60) in comparison areas. At end-line it was 39% (95% CI 32 to 45) in intervention and 34% (95% CI 27 to 41) in comparison areas (difference-in-differences -4 percentage points, adjusted OR 0.49, 95% CI 0.12 to 1.95). The intervention neither had an effect on care-seeking among sick neonates, nor on household participation in community engagement forums, supportive supervision of primary care workers, nor on indicators of district accountability for child health services. CONCLUSION: We found no evidence to suggest that the intervention increased the utilisation of care for sick children. The lack of effect could partly be attributed to the short implementation period of a complex intervention and implementation interruption. Future funding schemes should take into consideration that complex interventions that include behaviour change may need an extended implementation period. TRIAL REGISTRATION NUMBER: ISRCTN12040912