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.

The Effect of Community Health Information System on Health Care Services Utilization in Rural Ethiopia.

Background: In Ethiopia, the community health information system (CHIS) is implemented at the health post (hp) level with the aim of improving service delivery and use. We conducted a national level assessment of CHIS utilization and explored the associations of CHIS utilization with use of antenatal care (ANC), postnatal care (PNC), institutional delivery and child immunization in rural Ethiopia. Methods: We conducted a cross-sectional study measuring community-based health service use and HP based CHIS assessment from March to May 2019. Data were collected from 343 HPs and 2,864 women who delivered in the last five years, and multistage sampling was used to select the study subjects. We used descriptive statistics for CHIS implementation and service utilization and multilevel logistic regression to investigate the association of CHIS implementation with maternal and child health care services use. Results: Fifty five percent of the HPs were implementing CHIS. These HPs were using a paper-based household data collection tool called family folder (FF). Of the HPs, one third implemented lot quality assurance sampling (LQAS) based data quality check and 60.4% documented and followed execution of decisions. Overall, among the eligible women, 40% used ANC, close to 50% of currently married women used ANC services; 28% of women that fall in the high wealth index category used PNC within 48 hours after delivery; and 86.1% of women who had at least a high school education delivered at a health facility. Implementation of CHIS and family folder utilization and conducting LQAS based data quality check in the HPs were significantly associated with increased odds of ANC, delivery, and vaccination services use. Conclusion: We found that better implementation of CHIS was associated with better maternal and child health service use which implies that increasing utilization of CHIS at HPs will improve mother and child health service use.

Willingness to pay for social health insurance among public civil servants: A cross-sectional study in Dessie City Administration, North-East Ethiopia.

Background: The readiness to pay for health insurance has an impact on universal health care. This study investigated the willingness of public civil servants in Dessie City Administration, North-East Ethiopia, to pay for social health insurance and associated factors. Methods: From April to May 2021, a cross-sectional study was undertaken. The sectors from which the samples were proportionately allocated were chosen using a multistage sampling procedure. Using their payroll list as a sampling frame, simple random sampling was done to recruit them. A semi-structured self-administered questionnaire was used to collect data. Epi Data version 3.1 was used to enter, code, and clean the data, which was then exported to SPSS version 23 for analysis. To determine relationships, bi-variable and multivariable analyses were utilized. Candidates for multivariable analysis were variables with a p-value ≤ 0.3 in bi-variable analysis. AOR with a 95% CI was used to determine the strength and direction of association. Statistical significance was defined at p-value < 0.05. Results: A total of 796 employees took part in the study, with a 94.42% response rate. Overall, 29.60% of them were willing to pay for the scheme (95% CI: 26.4, 33%). The decision to pay was influenced by favorable perception (AOR = 2.43, 95% CI: 1.72, 3.44), household income < Birr 5,000 (AOR = 0.26, 95% CI: 0.14, 0.48), acute illness (AOR = 0.48, 95% CI: 0.32, 0.72), bachelor level education (AOR = 0.44, 95% CI: 0.28, 0.70), master and above level education (AOR = 0.26, 95% CI: 0.14, 0.49), and age 25-29 years (AOR = 1.97, 95 % CI: 1.08, 3.57). Conclusion: The willingness of the civil servants to pay for social health insurance was low, and it was influenced by their attitudes toward the scheme, the occurrence of severe illness, income level, educational status, and age.

Exploring complementary and competitive relations between non-communicable disease services and other health extension programme services in Ethiopia: a multilevel analysis.

BACKGROUND: Ethiopia has recently revitalised its health extension programme (HEP) to address the rising burden of non-communicable diseases (NCDs). We examined the effects of existing essential HEP services on the uptake of NCD preventive services. METHODS: We applied a mixed-effect non-linear model with a logit link function to identify factors associated with a community resident's probability of receiving NCD prevention services through the HEP. The data were drawn from the Ethiopian HEP assessment Survey conducted in all regions. The analysis included 9680 community residents, 261 health extension workers (HEWs), 153 health posts, 119 health centres, 55 districts and 9 regions, which we combined hierarchically into a single database. RESULTS: In the 12 months before the survey, 22% of the sample population reported receiving NCD preventive service at least once. The probability of receiving NCD prevention service increased by up to 25% (OR=1.25, CI 1.01 to 1.53) if health centres routinely gathered NCD data from health posts and by up to 48% (OR=.48, CI 1.24 to 1.78) if they provided general (ie, non-NCD specific) training to HEWs. NCD preventive service uptake also increased if the HEW held level IV qualification (OR=1.32, CI 1.06 to 1.65) and lived in the community (OR=1.24, CI 1.03 to 1.49). Conversely, if facilities delayed general performance reviews of HEWs by a month, uptake of NCD prevention services decreased by 6% (OR=0.94, CI 0.91 to 0.97). We observed that better HIV/AIDS programme performance was associated with a lower uptake of NCD preventive services (OR=0.15, CI 0.03 to 0.85). CONCLUSION: Despite efforts to improve NCD services through the HEP, the coverage remains limited. A strong HEP is good for the uptake of NCD preventive services. However, integration requires a careful balance, so that the success already recorded for some existing programmes is not lost.

Disparities in the implementation of the Health Extension Program in Ethiopia: Doing more and better towards universal health coverage.

Introduction: Large-scale implementation of the Health Extension Program (HEP) has enabled Ethiopia to make significant progress in health services coverage and health outcomes. However, evidence on equity and disparities in the implementation of the HEP is limited. The aim of this study was to examine disparities in the implementation of the HEP in Ethiopia. Methods: We used data from the 2019 National HEP assessment which was conducted between Oct 2018 and Sept 2019 in nine regions in the country. Data were collected from 62 districts, 343 Health posts, 179 Health centres, 584 Health Extension Workers (HEWs), and 7043 women from 7122 Households. This study focused on selected input, service delivery, and coverage indicators. We used rate differences, rate ratios and index of disparity to assess disparities in HEP implementation across regions. Results: We found wide inter-regional disparities in HEP implementation. Developing regional states (DRS) had significantly lower availability of qualified HEWs (Rate Ratio (RR) = 0.54), proportion of households visited by Health Extension workers (RR = 0.40), and proportion of mothers who received education on child nutrition (RR = 0.45) as compared national average. There were also significant disparities in HEP implementation among DRS in the proportion of households visited by HEWs in the past 12 months (Index of disparity = 1.58) and proportion of adolescents who interacted with HEWs (Index of disparity = 1.43). Despite low overall coverage of health services in DRS, the contribution of the HEP for maternal health services was relatively high. Conclusion: There were significant inter-regional disparities in the implementation HEP in Ethiopia. The level of disparity among DRS was also remarkable. To achieve Universal Health Coverage, it is important that these disparities are addressed systematically and strategically. We recommend a tailored approach in HEP implementation in DRS.

The Intersection of Gender-Based Violence and Risky Sexual Behaviour among University Students in Ethiopia: A Qualitative Study.

Women who experience gender-based violence (GBV) are at risk for adverse sexual health outcomes, as they may be unable to fully negotiate sexual encounters. This may be especially true for females at universities in Ethiopia, where women are the minority and patriarchal norms prevail. This study explored students' experiences and faculty's perceptions of GBV and sexual risk behaviours at two Ethiopian universities. Individual interviews were conducted with male and female students, and focus group discussions were held with students and faculty/staff. Qualitative thematic analysis was used to explore the relationship between GBV and sexual risk and identify intervention points. Data revealed that female students at both universities are regularly exposed to GBV, which in combination with risky sexual behaviours may threaten their health. Participants (n = 126) reported a belief that women who violate traditional gender norms are more prone to violence. Substance use was reported to contribute to risky behaviours, particularly for women. Participants reported male students sometimes encourage female intoxication in order to achieve sexual encounters, resulting in coercive situations. Sexual health and GBV-related services are provided on campus, but participants highlighted ways they can be improved. In order for females to safely pursue higher education in Ethiopia, campus-based interventions focused on the intersection of GBV and sexual risk are greatly needed.

"We are responsible for the violence, and prevention is up to us": a qualitative study of perceived risk factors for gender-based violence among Ethiopian university students.

BACKGROUND: There is a high prevalence of gender-based violence (GBV) victimization among young Ethiopian women, including in universities, where female enrollment is low but growing. Understanding factors contributing to GBV in this context and students' perspectives on gender, relationships, and interpersonal violence is essential to creating effective interventions to prevent GBV and support female students' rights and wellbeing. METHODS: In-depth interviews (IDIs) and focus group discussions (FGDs) were held with male and female students (male IDI n = 36, female IDI n = 34, male FGD n = 18, female FGD n = 19) and faculty and staff (FGD n = 19) at two Ethiopian universities. Audio recordings were transcribed and translated into English. Transcripts were coded thematically to identify key factors contributing to GBV and provide narratives of students' experiences. RESULTS: GBV against female students was a salient issue, including narrative accounts of harassment, intimidation, and physical and sexual violence on the university campuses and the towns in which they are located. Reported risks for GBV included receiving academic support from male peers, exercising agency in relationship decision-making, having a negative self-concept, belief in stereotypical gender expectations, and engaging in transactional sex and/or substance use. While students recognized these risk factors, they also suggested GBV may be the result of females' "improper" behavior, attire, use of males for personal gain, or personal failure to prevent violence. CONCLUSIONS: GBV is a serious issue in these two Ethiopian universities, creating a tenuous learning environment for female students. Programs are needed to address areas of vulnerability and negative attitudes toward female students in order to decrease female victimization.

Predictors of first-line antiretroviral therapy failure amongst HIV-infected adult clients at Woldia Hospital, Northeast Ethiopia.

BACKGROUND: Due to the limited availability of viral load testing for treatment outcome monitoring in resource limited settings, identifying predictive factors of antiretroviral treatment failure will help in selecting clients who will benefit most from the targeted use of viral load monitoring. Little is known about the predictors of treatment failure in the study area. This study was conducted to determine factors that predict first-line antiretroviral therapy failure among HIV-infected adult clients at Woldia Hospital, Northeast Ethiopia. For this study, antiretroviral therapy treatment failure was defined as the fulfillment of clinical and/or immunological criteria set by WHO. METHODS: Case-control study was carried out from November to December 2014. Cases were adult clients who were on failing first line regimen and on active follow up while controls were those adult clients on a non-failing first-line regimen for 36 months and above and on active follow up. Data was entered in to Epi Info version 7 and was exported to SPSS version 20 for analysis. Binary logistic regression model was used to identify predictors of ART failure. RESULTS: A total of 59 cases and 245 controls were included in the analysis. Sixty three percent of the participants were females and the median age at ART enrollment was 33 years (IQR; 28, 40). The median baseline CD4count was not significantly different among cases and controls (105 (IQR = 60-174)vs.131 (IQR = 72.5-189.0); p = 0.301). The median peak CD4 count in the failure group (230 (IQR = 123-387)) was significantly low compared to the non-failure group (463 (IQR = 348.5-577)) [p < 0.001]. High peak CD4count (AOR = 0.993; 95% CI 0.990, 0.996) and longer duration on ART (AOR = 0.923; 95% CI 0.893, 0.954) were protective of treatment failure. In addition stavudine based regimen (AOR = 3.47; 95% CI 1.343, 10.555), low baseline BMI (AOR = 2.75; 95% CI 1.012, 7.457), unemployment (AOR = 4.93; 95% CI 1.493, 16.305) and formal educational level (AOR = 5.15; 95% CI 1.534, 17.276) were independently significant predictors of treatment failure. CONCLUSIONS: In this setting low peak CD4count, shorter duration on first line ART, d4T based regimen, low baseline BMI, unemployment and formal educational level were significantly associated with increased treatment failure. Retaining patients on their initial first line regimen with appropriate follow up and improving their socioeconomic status through various livelihood initiatives should be strengthened.