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Asrade Abate (MD, MSc)
BACKGROUND: Within the Ethiopian Health Extension Program (HEP), the Health Extension Workers (HEW) are posted to rural communities across Ethiopia, where they provide better and more equitable access to health services for the population in a sustainable manner. OBJECTIVES: The overall objective of the study was to determine if the extended, module-based training improved the knowledge, motivation and retention of community health outreach workers. METHODS AND MATERIALS: The study was conducted in Tigray region. The design of the baseline survey was a randomized, controlled, pre and post-test intervention study. The overall study was designed allocating 12 months of intervention period between the pre-test and post-test studies. Both quantitative and qualitative data was collected. The sample size was calculated using 5% significance, 95% power. Overall, 64 health posts were randomly picked and equally distributed to each group. CONCLUSION: The assessment of implementation of the intervention package indicated that it was well received by the HEWs and improvements could be directly attributed to the capacity building intervention.
Ethiopia - Country Information
Ethiopia has the second largest population in sub-Saharan Africa, with a population of about 84 million people. The country introduced a federal government structure in 1994 composed of nine Regional States: Tigray, Afar, Amhara, Oromia, Somali, Benishangul Gumuz, Southern Nations Nationalities and Peoples Region, Gambella and Harrari and two city Administrations (Addis Ababa and Dire Dawa). The Regional States are administratively divided into 78 Zones and 710 Woredas . Woreda is the basic decentralized administrative unit which is further divided into Kebeles (about 15,000 Kebeles countrywide) organised under peasant associations (10,000 Kebeles) and urban dwellers associations (5,000 Kebeles). Kebele is the lowest administrative unit and a geographically defined area within a Woreda. On average, each Kebele has a population of about 5,000.
Ethiopia lies within the tropics and experiences a heavy burden of disease mainly attributed to communicable, infectious diseases and nutritional deficiencies. Limited healthcare infrastructure, shortage and high turnover of human resource and inadequacy of essential drugs and supplies have also contributed to the burden. However, there has been encouraging improvements in the coverage and utilization of the health services and improved access to and quality of rural primary health care over the periods of implementation of Health Sector Development Plan (HSDP) . One of the success stories of implementation of the HSDP is improved access to and quality of rural primary healthcare through the Health Extension Programme (HEP).
Ethiopia launched the Health Extension Programme (HEP) in 2003. The programme’s objectives were to reach the poor and deliver preventive and basic curative, high-impact interventions to the population. The introduction of HEP in Ethiopia was a government-led community health service delivery programme, with innovative and cost effective approaches, designed to improve access and utilization of preventive, wellness and basic curative services.
The HEP basically consists of a health post which is operated by front-line community health personnel, called Health Extension Workers (HEW). On average, a health post has a catchment population of 5,000. The health post is under the supervision of the Woreda (equivalent of district) health office and Kebele administration and receives technical and practical support from the nearby health centre. A health centre is the primary Health Care Unit that serves 25,000 people and functions as a referral centre and logistic hub for a health post and also offers technical support.
The HEP focuses on four major areas of preventive healthcare and provides 16 different packages to reach rural community at large and to address inequity (Table 1). In a short period, the government deployed more than 30,000 HEWs. These Health Extension Workers are posted to rural communities across Ethiopia, where they provide better and more equitable access to health services for the population in a sustainable manner .
Health extension workers are recruited using a specific criteria from the same communities in which they will work. The criteria include: female, at least 18 years old, have at least completed secondary school education and speak the local language. Females are selected because most of the HEP packages relate to issues affecting mothers and children; thus communication is thought to be easier between mothers and a female HEW and more culturally acceptable. Upon completion of one year training, pairs of HEWs are assigned as salaried government employees in each Kebele, where they staff health posts and work directly with individual households. Each Kebele has a health post that serves 5,000 people and functions as an operational centre for the health extension workers.
In general, the HEWs are expected to conduct household visits to deliver the 16 different packages of healthcare prevention and promotion messages. The promotion of appropriate breastfeeding and infant and young children feeding practices IYCF) is one of the packages within the nutrition category. In addition, HEWs identify cases, refer cases to health centres, perform home-based follow-up on referrals, manage the operation of health posts and submit regular reports to Woreda Health Offices . They are also expected to identify, train and collaborate with voluntary community health workers called Women’s Development Army.
Table 1: Health Extension Programme packages, FMOH 2009
Upon assignment, health extension workers conduct a baseline survey of the Kebele, using a standardized tool. They map households and the population by age category. They also prioritize health problems, set targets with respect to the 16 packages of services and draft a plan of action for the year. The draft plan of action is then submitted to the village council for approval.
In terms of medical equipment and supplies, each Health Post is equipped as per the standard of level of provision of health care services. For this, a standard document has been developed that states the minimum standards and requirements for the establishment and maintenance of a health post in order to protect the public interest by promoting the health, welfare and safety of individuals. Accordingly, health posts shall be staffed by at least two HEWs and provided with the necessary logistics, medical equipment and supplies (Table 2).
Table 2: Minimum Standard of Medical Equipment, Drugs and Supplies at HPs, FMHACA
Children constitute a very large percentage of the population in Ethiopia: 44.7% are under 15 years of age, 17.8% are under 5 years of age and 3.6% are under 1 year of age . According to the Ethiopian DHS (2011), the infant mortality rate was 59 deaths per 1,000 live births. The estimate of child mortality is 31 deaths per 1,000 children surviving to 12 months of age, while the overall under-5 mortality rate for the same period is 88 deaths per 1,000 live births. Sixty-seven percent of all deaths to children under-5 children in Ethiopia take place before the child’s first birthday and the contribution of malnutrition is thought to underlie about 57% of all under-5 deaths .
In recent years however, there has been significant progress in addressing these problems. The government, in collaboration with development partners, has applied considerable effort directed at improving access and use of primary care services, particularly among women and children in rural settings, through the HEP. In addition, several policies and strategies are being undertaken by the Federal Ministry of Health and stakeholders to accelerate the promotion of breastfeeding and strengthen community outreach mechanisms to improve infant and young child feeding practices. Community-based interventions to promote and support IYCF practices, through HEP, are emphasized in the IYCF strategy.
The Health Extension Programme, nutrition being one component of the package, features monthly growth monitoring and a community discussion forum. It also offers an integrated package promoting optimal breastfeeding (especially early and exclusive breastfeeding), adequate complementary feeding, control of anaemia, vitamin A deficiency and iodine deficiency disorders and feeding of the sick child. In addition, the HEP also promotes improved dietary practices during pregnancy and lactation as part of the package. Recently, there are additions to the list of tasks including CMAM/IYCF.
Recognizing that the HEWs must address many health topics and cover a sizable area, the significance of improving the capacity of these health workers through training should be an important focus area. In this respect, studies were conducted in several countries which evaluated the effectiveness of training for health workers in the promotion of nutrition and health interventions. Several found evidence of significant improvement after the training.
The Piloting Community Based Management of Acute Malnutrition Project, funded by World Bank-Japanese Social Development Fund (JSDF) and implemented by Concern Worldwide Ethiopia, began in August 2009 and aims to support the Ethiopian Government in its efforts to improve nutrition outcomes in Tigray. Concern has been supporting the Regional Health Bureau (RHB) in five Woredas in Tigray to integrate community-based management of acute malnutrition (CMAM) into routine health services. In June 2011, the project was expanded to 24 Woredas. The goal of the programme was to contribute to the reduction in morbidity and mortality due to severe acute malnutrition (SAM) amongst children less than five years of age.
Figure 1: The administrative divisions within Tigray Region and study Woredas.
Before the piloting of CMAM, linkages between treatment of SAM and promotion of optimal nutrition practices at community and HP level are not well defined. Training materials and job aids to help HEWs effectively treat and prevent SAM and promote optimal infant and young child feeding (IYCF) practices were lacking and fragmented. As a result, opportunities to promote improved nutrition at key contact points at community level were missed. In order to strengthen the CMAM programme, it was believed that new training materials which include community mobilisation techniques, CMAM processes and IYCF messages could improve the nutrition knowledge, capacity and actions of HEWs. For this, Concern worked to produce training guides and job aids to improve knowledge regarding CMAM and IYCF practices. An integral part of the project was building the capacity of HEWs to recognise and treat/refer children suffering from SAM using the CMAM approach and also prevent chronic malnutrition through promotion of improved and optimal IYCF practices.
This study tested whether an extended, module-based training, conducted over 12 months, resulted in improved community health outreach workers’ knowledge, motivation and retention, thereby reducing staff attrition and increasing the number of contact points households had with them. In addition, the study assessed the use of HEWs’ time to determine if a cascaded approach to community outreach results in improved motivation and availability of time for HEWs.
The overall objective of the study was to determine if the extended, module-based training improved the knowledge, motivation and retention of community health outreach workers in Tigray Region, Ethiopia. The specific objectives of the study were to:
Measure the extent to which enhanced CMAM and IYCF job aides and training lead to changes in the knowledge of HEWs.
Assess the quality of care provided by HEWs through quality assessment tools which measure the skill of workers.
Identify primary factors influencing job satisfaction and motivation of HEWs and their supervisors and analyse the relative importance of such factors.
Assess the perceptions of HEWs and their supervisors regarding supervision and identify opportunities to improve supervision.
Assess how HEWs and their supervisors prioritize work-related activities and allocate their time.
Determine the coverage of community health outreach interventions by identifying the percentage of caregivers visited by a member of the Women’s’ Development Army (trained and encouraged by HEWs) in the past 30 days.
The baseline survey was conducted in September 2012 and assessed the capacity of health extension workers (HEWs). The study was conducted in four project Woredas in Tigray region. The design of the baseline survey was a randomized, controlled, pre and post-test intervention study covering a total of 64 health posts. The baseline investigated knowledge, attitude and skill of HEWs towards IYCF practices. In the same context, the major objective of the end-line survey was to collect comparable information that can be used to assess the programme achievements. Thus, sample sites, the survey technique and the survey tools that were used during the baseline survey will be replicated in the end-line survey to avoid statistical bias in the methodology and to facilitate comparative analysis of each round.
The overall study was designed allocating 12 months of intervention period between the pre-test and post-test studies and the end-line study was undertaken between November 20, 2013 and December 06, 2013.
The end-line study applied the same approach as the baseline. Thus, a randomized, controlled, post–intervention study was carried out. The study was carried out in four selected Woredas in Tigray Region, namely: Alaje, Endamehone, Ofla and Raya Azebo (Figure 1).The Region is divided into seven Zones, which are further sub-divided in 47 rural Woredas and 10 towns. But additional qualitative data was collected at the household level to obtain a deeper understanding of the perception of the community towards service delivery by HEWs thereby supplement the quantitative analysis. Hence, both qualitative and quantitative data will be collected through interviews of HEWs, in-depth interviews of selected households and focus group discussions (FGDs).
The baseline study applied HPs as a unit of randomization and the number of participants required in each group (intervention and control) was calculated on the basis of achieving at least a 40% difference between groups. The sample size was calculated using 5% significance, 95% power and also taking into account a 20% drop-out of participants. Overall, 64 health posts were randomly picked and equal number of health posts was assigned to each group, the intervention and control group. At baseline, the total number of HEWs found working within these HPs was 98 and all of them were invited to participate in the study (*). Similarly, the study participants of the end-line study were the same group of HEWs who participated in the baseline study. However, some of the HEWs were not available or transferred to other HPs for various reasons and a total 13 HEWs were missing. In four HPs selected for the study, all the study participants were replaced by new staffs; therefore, these HPs were dropped from the study. The dropouts hardly affected the analysis since it was anticipated from the beginning and the sample size was consciously inflated to compensate for drop-outs.
Desk Review of documents including baseline study results, project reports, records of intervention efforts, training materials and guidelines, and supervision checklists were reviewed. The setup, equipment, medical supplies and furniture provided to HPs were also inspected using checklists. Moreover, overall service delivery activity of HEWs at HPs was observed.
The study applied structured questionnaires and checklists which were administered to HEWs and households. Two different questionnaires were used during the interview: interview with HEWs and interview with households. The interview with HEWs applied an exact replica of the 10-page questionnaire that was administered during the baseline study (see Annex IV). The questionnaire consisted of institutional profile of the facilities, demographic/personal data of HEWs and standard assessment questions to test IYCF knowledge, attitude and practice of HEWs. In addition, questions about guidance and monitoring by supervisors; work performance of HEWs; trainings conducted; availability of supplies and other resources, equipment and manuals; and HEWs’ job satisfaction and challenges were included in the questionnaire. The second questionnaire used for interview with selected households consisted of demographic data, knowledge, and attitude of individuals towards service delivery (see Annex V).
In addition, more qualitative data was also collected through focus group discussions (FGD). The FGDs were valuable in eliciting, thereby generating, broad overviews of issues and concern; level of involvement, cultural norms/barriers and challenges within the community represented. A total of four FGDs were conducted, two in each study group: two FGDs were held with a group of WDAs, and the other two FGDs with mixed groups from the community. The participants were selected using a purposive sampling method. Participants of the FGDs included model families, mother support groups, and caregivers of children under 2 years of age, WDAs and key influential community leaders. The interviews were conducted by field data enumerators aided by the field supervisor. All the data collectors and supervisors were exhaustively trained to carry out these tasks properly. FGDs were conducted by data collectors with a direct supervision by the Researcher. The data quality was verified through onsite supervision by ensuring proper data collection, organization, transcription and reporting. Throughout the whole process, the Researcher conducted close supervision and on-site mentoring ensuring smooth workflow.
The data was entered into SPSS for Windows (version 20.0) using a double entry method and answers to questions were coded using appropriate methods. Finally data cleaning was carried out to ensure entry of valid data. The statistical analysis examined the socio-demographic variables (age, gender, level of education, and marital status); work-related activities (routine and periodic tasks, planning, prioritization and division of tasks, performance evaluation, reporting and supervision); implementation challenges (medical supplies and logistics, job satisfaction and desire to stay in the current job, and incentives required and career upgrade intentions); and nutrition promotion (adequacy of training, availability of quick reference materials, attitude and motivation towards IYCF implementation, and level of knowledge and skills in IYCF).
The knowledge, attitude and skill of HEWs were categorized using recommended quality assessment tools for IYCF practices4,7. The level of participants' knowledge and attitude were evaluated by means of a standardized test consisting 13 questions organised in three assessment categories: breastfeeding assessment category, complementary feeding assessment category and essential minerals assessment category. Each category consists of five questions for which individual ratings were tabulated that added up to a total score of 10 points. In a similar fashion, skills of participants were assessed by observing the demonstrations and clinical practices of the participants. The skill assessment applied a standardized test consisting 30 questions organised under six assessment categories: clinical signs of malnutrition, MUAC performance, weight measurement, height measurement, negotiation and counseling skills, and positioning; and attachment of baby during breastfeeding. Individual assessment tests under each assessment category valued a maximum of 1 point which added up to give a total score of 5 points. The total scores under each assessment category were used as absolute scores to perform various statistical computations.
Descriptive frequencies; comparison of mean values; significance statistical test; independent-test; and ANOVA were applied during analysis. To obtain comparable information in the assessment of programme achievements, the mean scores of the pre-test were weighed against the post-test for each study group. The significance level was set at p<0.05. Qualitative data obtained from the FGDs and household in-depth interviews was organised under different thematic areas and ideas were sorted out and systematically pooled in to those themes. Triangulation of data from different sources was applied to verify the findings and their programmatic implications.
Since the survey was mainly focused on the themes as outlined in the objectives, the analysis was limited to the information collected in the survey. The study was conducted in Tigray Region, a small section of the nationwide HP service; hence, the results are specific to local study setting and are not necessarily conclusive of the HP activities countrywide. Furthermore, information collected from households and FGDs was qualitative data, not supported or verified by statistical computations and cannot be generalized.
Ethical approvals were granted by the Tigray Regional Health Bureau, local Ethics and Research Committee and relevant Woreda administration review committees. Standard ethical procedures were followed to acquire informed consents.
*[The baseline study revealed that allocation of HEWs varied between 1 and 3 (mean= 1.76) per HP]
In this study, unlike the baseline study, 84 questionnaires completed by HEWs were analyzed. Thirteen participants from both groups were missing, but their absence didn’t affect the analysis since the loss was accommodated within the dropout quota allocated for the study. The overall response rate was 86.6% because some of the HEWs who took part during the baseline study were not available. Various factors were associated with the missing HEWs. Some of the HEWs were transferred to other HPs, a few joined an upgrade class and others left their job for good. Finally, equal number of respondents, 42 HEWs in each group, participated in the post-intervention study.
In general, the number of HEWs in those HPs enrolled for the study varied between 1 and 3 and a mean value of 1.88 per health post. A higher proportion (78.6%) of HPs has 2 HEWs followed by HPs with only one HEW (16.7%). The end-line study revealed an increase in the number and distribution of HEWs per HP compared to the baseline. Table 3 presents allocation of HEWs per HP. It is a standard criterion upon employment that all HEWs should be female; hence, zero male respondents were enrolled.
Table 3: Number of Staffs per Health Post
The average catchment population of a Health Post was 5,503 and on average, 44 WDAs were found supporting the various activities implemented by HEWs from within the community. Mean age distribution of HEWs in the intervention and control group were 25.1 (SD±0.436) and 28.24 (SD± 0.877) years respectively with median age of 27. Most respondents (85.7%) aged between 20 and 35. The rest evenly distributed between the over-36 age groups. No significant difference of age, level of education, service year and status of marriage were detected among HEWs enrolled for the study.
Table 4: Place of residence of HEWs and distance from HPs
In terms of years of experience, majority (79.8%) of HEWs had more than 5 years of experience and the mean service year was 5.18 (SD±0.398) with an academic background of 10+1 certificate in both study groups. Majority of the HEWs (65%) in both study groups were found to be married. Table 5 presents socio-demographic characteristics, distance and population information. The mean distance of a HP from Woreda Health Office and residence of HEW was 24.4 km and 0.58 km respectively. Majority of HEWs (71.1%) had 6-8 years of work experience positioned around a mean value of 5.17 years. The mean distribution for all items listed in tables were the same across the study groups during the baseline (P>0.05). During post-intervention study, only slight changes were observed.
Table 5: Socio-demographic characteristics of respondents, training and population
On average, the number of trainings received by HEWs during the baseline was 2.43 and statistical tests showed that there were no significant differences between study groups in terms of number of trainings received by HEWs. Nevertheless, the post-test assessment revealed that the number of trainings received by HEWs and total training hours in the intervention groups were increased. The number of trainings attended by HEWs during the intervention period varied between 1 and 5 with a mean value of 2.45, an increased mean value compared to the baseline results. Notable improvements were observed in the delivery of various types of trainings particularly, in the area of nutrition. On average, HEWs in the intervention group received 1.19 hours of training on nutrition. In the control group; however, the number of trainings received showed a slight drop.
Table 6: Overview of the training provide to HEWs in 2013
As a matter of fact, more training was given to those HEWs in the intervention group compared to the control group because the intervention packages were exclusively provided to participants of the intervention group. This was confirmed by the results from the comparison of the pre- and post-test data and statistically significant differences were detected between the intervention and control groups. As a result, an improved level of knowledge and acquisition of skills by HEWs was observed in the intervention group.
Changes in the participants' knowledge, attitudes and skills were evaluated twice, before and after the implementation of the intervention package. The impact of the intervention package on the participants' knowledge and skill was evaluated by means of a standardized test. Following the baseline evaluation of the HEWs, several capacity building measures were implemented in HPs designated as an intervention group during the study period. The intervention package included theoretical and practical trainings, on-job trainings and logistic support. On the other hand, HPs designated as control groups did not receive any direct support from the intervention package. In the baseline assessment, knowledge of HEWs in the intervention group averaged 18.26 out of out of 30 points, while the control group averaged 18.60 points. Statistical test verified that the knowledge of the HEWs, for each assessment category compared, was the same across the study groups (p>0.05). This was evidence that the process of dividing the study participants into two groups resulted in groups that were initially homogeneous in terms of their knowledge.
In the end-line assessment, held one year after the implementation of the capacity building measures, the control group averaged 19.67 and the intervention group 23.62 (P<0.05). Thus, although the control group slightly changed compared to their baseline score, the study participants in the intervention group maintained a statistically significant increase in knowledge compared to their baseline results. Cross-contamination between study groups, exchange programmes between HPs, and trainings provided outside of the intervention package could be possible explanations for the small change in the control group. Results of the end-line study showed, the overall average knowledge score for all the 84 participants was 20.9.
Tables 7 to 9 show the level of knowledge and attitude of HEWs across assessment categories and study groups. The level of knowledge of HEWs was highest for the knowledge on breastfeeding followed by essential minerals category. However, knowledge in the complementary feeding category was the lowest for both study groups.
Table 7: Knowledge of HEWs about Breastfeeding of infants
Table 8: Knowledge of HEWs about Complementary Feeding of infants
Table 9: Knowledge of HEWs about Micronutrient feeding of infants
The skills and performances of HEWs, as measured by the mean of the aggregate scores attained in each skill assessment category, were more or less similar at baseline. In addition, statistical tests also revealed that there were no significant differences between the average pre-intervention scores of the intervention or control groups for any of the five skill assessment categories and also individual items within each category. However, the post-intervention assessment revealed statistically significant differences between the intervention and control groups for all items analysed.
Table 10 shows the average scores obtained for each skill assessment category (cumulative of the individual items) by HEWs in the exposed and control groups. Comparison of the means achieved by each of the two groups before and after the intervention period reveals that the averages of all items improved for the intervention group. In the control group, the scores remained constant or even declined.
Table 10: Number of HEWs grouped by the total score attained
In the intervention group, more than 90% of HEWs scored above the mean score of individual skill assessment categories and they were able to demonstrate their skills correctly. Conversely, in the case of height measurement, low scores were detected and only half of the HEWs (52.4%) were found practicing height measurement though not formally trained on measurement techniques. Tables 11 to 15 shows post-intervention results for each study group, layered by individual assessment items of each skill assessment category.
Table 11: Number of HEWs who were able to identify malnutrition using clinical signs
Table 12: Number of HEWs who were able to apply MUAC measurement techniques
Table 13: Number of HEWs who can apply the appropriate methods to measure weight
Table 14: Number of HEWs who can spot difficulties of mothers and conduct counselling
Table 15: Number of HEWs who demonstrated correct positioning & attachment during BF
Medical Equipment, Supplies and Reference Materials
According to the minimum standard for health post, each health post should be equipped as per the level of provision of health care services. During the post-intervention study, almost all HEWs in the intervention group claimed adequacy of equipment and supplies as compared to baseline results. The distribution of various logistic materials, as part of the intervention package, enhanced the capacity of HEWs and also improved their performance.
The baseline study concluded that about 30% or more of the HPs were either poorly furnished, equipped or were in short of various supplies. However, unlike the baseline results, the end-line assessment revealed an improved logistics support that addressed the needs of the HEWs. Important equipment and supplies provided to those HEWs in the intervention group included: Weighting Scale (metallic Hanging scale); Lockable RUTF storage shelf; ORS synthesis utensils, porridge preparation and demonstration tools; and stationary materials (OTP Chart and various reporting forms). Table 16 show the list of equipment, furniture and supplies claimed available and functional by HEWs (intervention group). Comparison of mean values of baseline and end-line studies showed a statistically significant post-intervention increment of availability of those items listed in the table below. The control group; however, showed no change or in some cases a decline.
Table 16: Possession of various Medical Equipment, Furniture, Supplies and materials by HEWs
One of the components of the intervention package delivered to HEWs (intervention groups) was the provision of quick reference materials, demonstration charts and various IEC/BCC materials. As a result, the end-line assessment showed availability of a complete list of reference materials in all HPs of the intervention group and also zero requests were detected for additional references materials. Besides, statistical tests confirmed that the post-intervention results for intervention group were increased and significant. The control group shows no significant changes.
In general, various health services were delivered at the HP operated by a team of HEWs. Unlike other primary health care facilities, the delivery of services by health extension workers is not restricted within the premises of the HP. In fact, majority of the activities should be delivered at the household level. Hence, the activities of HEWs was categorized using their work plan as daily, weekly and monthly activities or by place and service delivery as health post and outreach tasks.
In the former category, the commonest daily tasks were: Antenatal Screening, Follow-up and Delivery; Family Planning Services; Diagnosis & Treatment Under-Five Children; Hygiene & Environmental Sanitation; and Nutrition Education, Malnutrition Screening, OTP Follow-up. HEWs did also perform tasks on a weekly or monthly basis depending on the nature of the job. Report Compiling and Sending; Activity Planning and Performance Evaluation; WDAs Training, Support and Performance Evaluation; and Household Follow-up of Various Cases were common weekly tasks for all participants of the study. Among the monthly tasks identified were Monthly Maternal & Child Vaccination; Presentation & Discussion of Performance with Supervisors; and Monthly OTP & Screening. Additional activities identified include: household visits (for various purposes); outpatient diagnosis, treatment and referral; various under 5 services; school-based health education, HIV/AIDS counseling and screening, and WDA training and support.
Table 17: Routine and periodic tasks performed by HEWs and time allocation
The post-intervention study detected a new task practiced by HEWs, the Outpatient Therapeutic Programme (OTP). The OTP task was not in the list of tasks recorded during the baseline. Screening, Treatment, RUTF distribution, Referral and Follow-up of children possessing malnutrition problems were regular activities under the umbrella of the OTP. Table 17 shows the number of tasks performed and time allocation to those tasks. Clearly the post-intervention data shows the number of tasks carried out had been increased. One possible factor could be the addition of OTP and related tasks. Other possible factors could be attrition of HEWs, increased catchment, or reallocation of extra time for demanding activities at the HP.
The commonest routine task carried out was Antenatal Screening, Follow-up and Delivery Service followed by Family Planning and Diagnosis & Treatment of Under-Five Children. Activities related to nutrition ranked fourth in daily tasks category. In addition to the routine and periodic activities, the HEWs were also available for emergency calls during off-duty hours. On average, 2-3 emergency calls per week were attended by HEWs. The mean comparison of the number of emergency calls attained showed a rise during the post-intervention study. The study participants were also asked to list the most important activities performed and also rank those tasks as per the level of priority they believe the task deserves. Table 18 shows the top five most important tasks listed according to the priority given.
Table 18: List of important tasks identified and ranked by HEWs as per level of priority given.
The post-intervention results, similar to the baseline study, showed that HEWs systematically shared both the HPs as well as outreach tasks by applying rotation method: one assured routine operations and continuity of care at the HP, whereas the other visited households and vise-versa. Considering a 40hrs/week as standard working time for a government employee, the mean working hours per week recorded during the end-line study were 25.77 for health post activities and 33.75 for outreach activities. The mean values were increased both for the intervention a control groups. Though the time allocated in the latter category appeared more than the expected 50% share, perhaps those additional hours arose from the time spent for travel to individual households.
About 48.5% of the overall time was allocated for nutrition and related activities. On average 3.88 hours/day and 8.19 days/ month were spent on nutrition tasks. During the baseline, the distribution and time allocation for various activities was comparable across the study groups; however, post-intervention results revealed more time spent on nutrition and related activities across all items analysed, as shown in Table 19 below. Tests confirmed that increment of total hours spent on nutrition was statistically significant.
Table 19: Nutrition and related tasks performed by HEWs and time allocation
On average, 26 household visits were made by WDAs on a monthly basis, slightly increased during the post-intervention assessment. Table 19 shows the number of households visited made by WDAs on a monthly basis. None of the HEWs/WDAs mentioned utilization of vehicle transport during their household visits, even for trips that took hours of travel. In all cases, the only means of travel was on foot.
With regard to patient referral, the HEWs were able to screen and refer significant number of patients to health centres. A monthly and quarterly average of 3.39 and 18.98 was recorded in terms of patient referral by each HEW. Results of the post-intervention study revealed increased number of quarterly patient referrals, particularly referrals related to malnutrition. Table 20 below shows the top five referral diseases.
Table 20: Top five referral diseases by HEWs
Table 21: Patient screening and referral activity by HEWs
On average, each HEW produces six types of reports, one weekly report and five monthly reports. The average number of reports; however, was found increased to seven reports during the post intervention study. The maximum number of reports monthly reports prepared was as high as 17 in both studies (Table 22). A few cases were also engaged in daily reporting tasks. In general, the task of synthesizing reports is time consuming, particularly in the case of redundant reporting tasks. The variations among reports could be due to the type of reporting forms, contents, organization of data or the time schedule for submission. Reports with such kinds of variations were considered different, however small the differences might be. Hence, the reporting activities were grouped into three by the frequency of submission and, for each group, all reports prepared were counted. Table 22 shows the reporting activities for all types of reports prepared.
Table 22: Report preparation activities by HEWs
The community verified that HPs were key in health service provision and through time they witnessed the service delivery was getting closer to their home, particularly since the start of house-to-house services provided through WDAs in collaboration with HEWs. They concluded the presence of HPs is vital. Various services were sought by the community at large. Since the HEWs are part of the community, they confirmed adequate and all-time access to the service rendered at the HPs including emergency situations.
Community members were convinced about the health education provided by HEWs regarding MNCH, Nutrition, Hygiene and Sanitation, and also others. They also explained that the presentation was clearly understandable as it was assisted by demonstrations. Most community respondents attended health education sessions despite circumstances. In some cases; however, other demanding tasks didn’t allow them to attend all sessions. Majority of the community respondents were able to clearly discuss the benefits they acquired from the health education. They were also able to talk about methods how they recognize illness particularly, cases of malnutrition.
With regard to challenges most community respondents complained about insufficient resource and time; focus on other demanding activities (as in farming); arguments among family member to practice advices; and also shortage of medical supplies needed at the health post. Both assessments concluded that inadequate community participation and lack of practice were prominent challenges faced by HEWs in promoting nutrition. Insufficiency of resources, lack of confidence, as a result failure to accept and poor commitment were some of the factors involved. The community was also not easily convinced to apply new approaches; hence, advices provided by HEWs were not immediately put in to practice by the community.
Among the challenges specified by HEWs with regard to their own activities were: inadequate salary compared to the work load, tiresome household visits, and lengthy travel; lack of transport for household visit; inadequate staff; lack of office stationary, forms, registers; insufficient attention and priority given to health by Woreda administration, loose supervision and support; lack of access to education & training; duplication of reports submitted; and also availability of other competing and appealing jobs in the market that draws their attention.
The assessment of implementation of the intervention package indicated that it was well received by the HEWs and improvements could be directly attributed to the capacity building intervention. In fact, one of the criteria for choosing the controlled study was to evaluate if the improvements were elicited through the intervention package. Indeed, there was no significant change observed in the control group, rather a decline in most cases.
In general, the number of HEWs in those HPs enrolled for the study varied between 1 and 3 and a mean value of 1.88 per health post and results of the post-intervention study indicated an increase in the number and distribution of HEWs per HP compared to the baseline. In addition, the range of activities and type of service delivered at the HP level and the extent to which the HEWs took assignments showed remarkable improvements. The changes were observed only in the intervention group and were statistically significant. Thus, conclusions can be made that the changes were due to intervention.
Among the list of important activities, ranked by level of priority, nutrition and related activities were widespread and also regarded as one of the top priority tasks carried out by the HEWs. Furthermore, post-intervention results indicated improved allocation of time for nutrition tasks, increased level of malnutrition screening, treatment and referral; and also enhanced outreach case detection through community involvement. Thus, emphasizing the level of concern provided to CMAM implementation at the community level.
The HEWs in the intervention group were also confident, knowledgeable, skillful to put in practice a widespread and improved IYCF practices at the community level. The intervention package applied enabled the HEWs to deliver an extensive health education, promoting IYCF practices, household level screening and follow-up throughout the community. In addition, a good level of effort was applied through defaulter tracing and active support of the progress.
Baseline results showed that the level of knowledge about complementary feeding and essential minerals was low, particularly knowledge about breastfeeding was the lowest for both study groups, as less than 50% of each group had this knowledge. In contrast, the post-intervention results concluded substantial boost for all knowledge assessment variables which were statistically significant.
The end-line results demonstrated that the level of knowledge was directly correlated to the total number of trainings. Moreover, a clear picture the association was revealed by statistically significant correlation (p <0.05) suggesting induction of the intervention package was associated with an increased knowledge, skill and implementation capacity. In contrast, statistical tests of the baseline data showed that there were no significant differences between study groups or correlation of the variables tested.
In terms of number of trainings received by all groups HEWs, no significant differences were detected at baseline. Nevertheless, the post-test assessment revealed that the number of trainings received by HEWs and total training hours in the intervention groups was increased in contrast to the control group where the number of trainings received showed a slight drop.
This was a reflection of the targeted training, delivered through the special intervention package, received by those HEWs in the intervention group. This implies that there was a remarkable improvement in the delivery of various types of trainings particularly, in the area of nutrition. As a result, an improved level of knowledge and acquisition of skills by HEWs was observed in the intervention group in contrast to the control group.
In response to the skills assessment tests, more than half of the HEWs interviewed scored below average at baseline. However, post intervention results were improved and significant progresses were recorded for those HEWs who belonged to the intervention group. This is a reflection of the fact that malnutrition-focused trainings were delivered resulting in overall improvement of skills; hence reinforcing the need for widespread training of similar pattern to HEWs who didn’t receive the intervention package.
Comparison of baseline and end-line results regarding report synthesis revealed a slight increase of the mean values. On average, types of reports produced were 6 to 7 in both cases. A consistent number of HEWs produce one weekly report and five or more monthly reports and in extreme cases, the number of reports prepared were as high as 17. Few HEWs were also found engaged in daily reporting tasks. This was probably due to additional tasks and programmes implemented by the HEWs. Though each single data reported from the HPs is deemed important, redundant reports make the task cumbersome and time consuming, as a result compromising the quality of services rendered or, at worst, obstructing service delivery. Similar recommendations were forwarded during publication of the baseline results.
The skills in applying MUAC technique, was the best learned and retained component of skills assessment category. Skills to apply clinical signs of malnutrition; weight measurement procedures; and also positioning and attachment of baby during breastfeeding were adequately practiced by the participants (intervention group) after the intervention. A component of the skills assessment for positioning and attachment of baby during breastfeeding has the lowest score and was hardly retained by HEWs: an area of recommendation in the upcoming trainings. Height measurement was not universally practiced by all HEWs; hence, it will be impractical to compare mean values.
It is recommended that the time allocated for capacity building and similar intervention be increased. In order for the training to be most effective, it should be followed up and HEWs enabled, through refresher trainings, to continue practicing the skills they have acquired. On the hand, the bulk of tasks assigned to HEWs are continually increasing; thus, some of the burdens including reporting should be alleviated.
In conclusion, the capacity building intervention resulted in a substantial acquisition of both knowledge and skills and there was substantial gain for any item evaluated, thereby effectively increased HEWs' knowledge and skills in support of CMAM implementation. However, adequate time, more practical exercises, clinical practice and continued support should be provided in order for the HEWs to retain and apply the knowledge and skills acquired.
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Asrade Abate (MD, MSc)
|Health Topic:||Child Health, Health Financing, Health Services & Policy, Maternal Health|
|Keywords||Health Extension Program , Ethiopia , Health extension workers , Capacity building , Module based training|
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