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BACKGROUND: IT has brought remarkable change in bridging the digital gap in resource-constrained regions and advancing the health care system worldwide. Community-based information systems and mobile apps have been extensively developed and deployed to quantify and support health services delivered by community health workers. The success and failure of a digital health information system depends on whether and how it is used. Ethiopia is scaling up its electronic community health information system (eCHIS) to support the work of health extension workers (HEWs). For successful implementation, more evidence was required about the factors that may affect the willingness of HEWs to use the eCHIS. OBJECTIVE: This study aimed to assess HEWs' intentions to use the eCHIS for health data management and service provision. METHODS: A cross-sectional study design was conducted among 456 HEWs in 6 pilot districts of the Central Gondar zone, Northwest Ethiopia. A Unified Theory of Acceptance and Use of Technology model was used to investigate HEWs' intention to use the eCHIS. Data were cleaned, entered into Epi-data (version 4.02; EpiData Association), and exported to SPSS (version 26; IBM Corp) for analysis using the AMOS 23 Structural Equation Model. The statistical significance of dependent and independent variables in the model was reported using a 95% CI with a corresponding P value of <.05. RESULTS: A total of 456 HEWs participated in the study, with a response rate of 99%. The mean age of the study participants was 28 (SD 4.8) years. Our study revealed that about 179 (39.3%; 95% CI 34.7%-43.9%) participants intended to use the eCHIS for community health data generation, use, and service provision. Effort expectancy (ß=0.256; P=.007), self-expectancy (ß=0.096; P=.04), social influence (ß=0.203; P=.02), and hedonic motivation (ß=0.217; P=.03) were significantly associated with HEWs' intention to use the eCHIS. CONCLUSIONS: HEWs need to be computer literate and understand their role with the eCHIS. Ensuring that the system is easy and enjoyable for them to use is important for implementation and effective health data management.

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BACKGROUND: The electronic community health information system has been increasingly developed and deployed to quantify and support quality health service delivery by community health workers in Ethiopia. However, the success and failure of the electronic community health information system depend on the acceptability and use by its users. This study assessed the acceptability and use of the electronic community health information system and its determinants among health extension workers in Ethiopia. METHODS: A retrospective cross-sectional observational study was conducted among 587 randomly selected health extension workers from six regions of Ethiopia. The Revised Technology Acceptance Model was used as a theoretical framework for the study. Descriptive statistics, structural equation modeling, and principal component analysis techniques were used to analyze the data. For all significance tests, multiple comparison adjustments were made using the Bonferroni Correction Method. RESULTS: There was near universal acceptance of the electronic community health information system, ranging from 94.4 to 97.4% among health extension workers. However, actual use of the system was considerably lower, at 50%. Perceived usefulness of the electronic community health information system had a direct and positive effect on acceptability (ß3 = 0.415, p < 0.001). Perceived ease of use had both direct and indirect positive effects on electronic community health information system acceptability (ß2 = 0.340, p < 0.001 and ß1*ß3 = 0.289, p < 0.001, respectively), while acceptability had a direct and positive effect on the use of the electronic community health information system (ß3 = 0.297, p < 0.001). CONCLUSIONS: Despite the very high acceptability of the electronic community health information system among health extension workers, actual use of the system is considerably lower. Hence, an integrated and coordinated approach is required to close the acceptance-use gap.

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BACKGROUND: Training health extension workers on Implanon insertion offsite, or away from the workplace, can be cost-intensive, can depend on the human and financial resources of partners, and can compromise routine health services by taking health workers off the job. To address these limitations, the USAID Transform Primary Health Care Activity in Ethiopia designed an onsite Implanon insertion training at the primary health care level. This study compared and documented the implementation experience of onsite vs offsite Implanon insertion training for health extension workers. METHODS: In a mixed-method study conducted in March 2020, the team collected training data from 468 participants-half trained onsite and half offsite-and conducted key informant interviews with 20 purposively sampled individuals. The team analyzed this data, summarizing the data in tables and figures and performing a t test with p value < 0.05 using SPSS v.20. Qualitative data were analyzed manually in Excel and summarized in Word based on emerging themes. RESULTS: Health extension workers trained onsite were away from routine work an average of 3 days compared to 8 days for those trained offsite (P < 0.001). The difference in average per-trainee cost of onsite (2707 Birr = 87.3 USD) and offsite (6006 Birr = 193.7USD) training was significant (P < 0.001). There was no significant difference in mean scores of onsite and offsite trainees on the knowledge pre-test (P < 0.947) and post-test (P < 0.220) or in simulated practice on an arm model (p < 0.202). Onsite trainees, assigned to their own health post for clinical practice, performed Implanon insertions on an average of 10 clients: offsite trainees on an average of 5 clients. Most interview participants reported that the onsite Implanon training was better organized, conducted, followed up, and monitored by health centers to ensure community-level access to Implanon services, with quality and continuity. CONCLUSIONS: Onsite training is a promising approach and minimizes service interruption. It is a likely strategy for on-demand training of health extension workers and immediate assignment of skilled providers to ensure access to and continuity of quality community-level Implanon care. Trial registration N/A.

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Background: The equitable distribution of a skilled health workforce is critical to health service delivery. Kaduna state has taken significant steps to revamp the primary health care system to ensure access to health care for its populace. However, these investments are yet to yield the desired outcomes due to health workforce shortages and the inequitable distribution of those available. Methods: A Workload Indicator for Staffing Need (WISN) study was conducted at Kaduna state's primary health care level. The study focused on estimating staffing requirements; Nurses/Midwives and Community Health Worker practitioners, Community Health Officers, Community Health Extension Workers, and Junior Community Health Extension Workers in all government-prioritised primary health care facilities. A total of ten focal primary health care facilities in Kaduna North Local Government Area (LGA) were included in the study. Results: Findings from the study revealed a shortage of Nurses/Midwives and Community Health Workers across the study facilities. For the Nurse/Midwife staffing category, nine of the ten PHCs have a WISN ratio < 1, indicating that the number of staff in the Nurse/Midwife category is insufficient to cope with the workload. In two of the ten primary health care facilities, there is an excess in the number of CHWs available; a WISN ratio > 1 was calculated. Conclusion: The WISN study highlights staffing needs in Kaduna State's government-prioritised primary health care facilities. This evidence establishes the basis for applying an evidence-based approach to determining staffing needs across the primary health care sector in the State to guide workforce planning strategies and future investments in the health sector. The World Health Organisation (WHO) WISN tool is useful for estimating staffing needs required to cope with workload pressures, particularly in a resource-constrained environment like Kaduna State.

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Background: High TB mortality is increasingly understood as an indicator of different problems in the health system and community. Limited awareness of TB in the community, restricted accessibility and/or quality of health services can hamper survival. Exploration and analysis of death among TB patients can lead to a clearer and specific understanding of why the deaths happened and where interventions are likely to make a difference in a specific context. Objective: The study aimed to assess why people die of active tuberculosis in the era of effective chemotherapy. Methods: The study was conducted from October to December 2020 in Arba Minch Health and Demographic Surveillance System (AM-HDSS) by applying phenomenological study design. A total of 27 family members of people who had died of TB, 9 health extension workers (HEW) and 8 health care professionals working in TB clinics were participated in open in-depth interview. A total of 130 individuals participated in 16 focus group discussion which composed of patient survived from TB, religious leader, health development army (HAD) and HEWs. Adequacy of information (saturation) was considered as an adequate sample size to create the intended qualitative product. All the interviews and FGD were tape recorded and recordings were transcribed immediately. ATLAS TI 9 software was used to analyse and process qualitative data. From data set codes were created then by identifying pattern among them themes were created. Then, generated themes were compared and some of them were split, combined, discarded and new ones created after returning to data set. Finally, themes were defined and a concise and easily understandable name was given for each theme. Result: Luck of sufficient knowledge about TB was considered to be a reason for cause of death. Most of the time, TB patients underestimate and ignore when the symptoms first emerge and will not relate it with any diseases. The low level of community awareness about the cause, transmission, treatment and prevention highly contributed to increased transmission rate and death due to TB. The study identified misconceptions in the community; they prefer traditional medicine to the scientific way. First, they try different herbal medicine to get relief from their illness. At the end, if the disease is getting worse, they visit health facilities. Participants mentioned high transportation cost, poor health seeking behaviours, inadequate food consumption and lack of TB awareness as reasons for low treatment adherence. The health facilities were inaccessible for the community. Most of them indicated that health facilities were too far to reach. In some health institution, right amount and combination of medication were not delivery on time and Diagnostic facilities for TB were reported to be inadequate. Conclusion: Poor treatment adherence, lack of TB awareness, stigma, inadequate food consumption, poor health care seeking behaviour and inaccessibility of health facility were identified as major reasons for death. To prevent death of TB patients all sectors such as education, health, and agriculture should work to address health education, infrastructures, nutritional supplementation needs of TB patients, caregivers and the community as a whole.

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Introduction: Optimal breast-feeding practices make a major contribution to the promotion of healthy growth and development through much prevention of diarrheal and respiratory diseases which majorly cause morbidity and mortality in under-five children. However, breast-feeding practices remain suboptimality in Ethiopia. Objective: The study objective was to determine the effect of maternal nutrition education on early initiation and exclusive breast-feeding practice in the Hawela Tulla sub-city. Methods: A cluster randomised, parallel-group, single-blinded trial was used. About 310 pregnant women (155 for the intervention group and 155 for the control group) were included. Result: An early initiation of breast-feeding was significantly higher among women who received breast-feeding education than those who did not receive (104(72·7 %) v. 85(59·9 %), P = 0·022) and exclusive breast-feeding practice was also significantly higher among women who received breast-feeding education than those who did not receive (106(74·1 %) v. 86(60·6 %), P = 0·015). Breast-feeding education [AORs 1·55, 95 % CI (1·02, 2·36)], institutional delivery [AOR 2·29, 95 % CI (1·21, 4·35)], vaginal delivery [AOR 2·85, 95 % CI (1·61, 5·41)] and pre-lacteal feeding [AOR 0·47, 95 % CI (0·25, 0·85)] were predictors of early initiation of breast-feeding. Breast-feeding education [AOR 1·72, 95 % CI (1·12, 2·64)] and institutional delivery [AOR 2·36, 95 % CI (1·28, 4·33)] were also determinants of exclusive breast-feeding practices. Conclusion: Breast-feeding education improved early initiation of breast-feeding and exclusive breast-feeding practices. Providing sustained education to women regarding early initiation and exclusive breast-feeding practice should be strengthened.

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BACKGROUND: Although the existing evidence suggests that the implementation of the health, developmental army (HDA) brought promising successes towards the delivery of Health Extension Programs (HEPs), pieces of evidence have shown that there are problems related to its functionality. Therefore, this study explored barriers to the functionality of HDAs. METHODS: A descriptive qualitative study was conducted from March 11 to April 7, 2019, in the Debre Libanos District, Oromia, Ethiopia. The study participants were purposively recruited from six kebeles. They were recently delivered mothers, pregnant women, other reproductive age group community members, health workers, kebele chairman, HDA team leaders, and religious leaders. Five in-depth interviews, seven key informant interviews, and four focus group discussions were conducted with a total of 52 participants. Data were audio-recorded, transcribed verbatim, and translated. The inductive thematic analysis approach was used and the data were coded, categorized, and themes were developed using Atlas ti.7.1. software package. RESULTS: The barriers to the functionality of HDAs were organized into four major themes. First, it was affected by structure, monitoring, or supervision-related challenges. Second, community-related barriers such as perceptions and attitudes towards HDAs, and the need for incentives or compensation from the HDAs affected the functionality. Third, it was affected by the lack of multi-sectoral collaboration to strengthen, monitor, or supervise the HDAs. Lastly, behavior, residence, or shortage of health extension workers affected its implementation. In addition, the study found that, as a result of poor functionality of HDAs, service utilization was decreased, especially antenatal care, postnatal care, sick newborn treatment, etc. CONCLUSION: The functionality of HDAs was affected by a variety of barriers. Therefore, there is a need to develop different strategies and take action to address the explored barriers to improve their capacity and implementation status for increasing health care service utilization.

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BACKGROUND: Rural health extension workers (HEWs) are essential for the implementation of the promotion and prevention-based health care policy of Ethiopia. Job satisfaction is believed to be one of the key factors that influence their performance. Information regarding job satisfaction and associated factors are limited in the study area. Therefore, this study was aimed at assessing job satisfaction level and associated factors among rural Health Extension Workers of Sidama Region, Southern Ethiopia. METHOD: A facility-based cross-sectional study was conducted among 341 rural HEWs from 1 March to 30 April 2021. Data was collected using trained data collectors using pre-tested and self-administered questionnaires. SPSS version-25 was used for data analysis. Bi-variable and multi-variable logistic regressions were used to observe the association between the outcome variable and associated factors. The outputs are presented using an adjusted odds ratio (AOR) with a 95% confidence interval (CI). RESULT: This study revealed that 36.6% (95% CI: 31.6%-41.6%) of the rural HEWs were satisfied with their job. Increased odds of satisfaction were observed among rural HEWs who got training opportunities (AOR: 3.74, 95% CI: 2.01, 6.98), education opportunities (AOR: 3.06, 95% CI: 1.56, 7.46), management support (AOR: 4.59, 95% CI: 2.44, 8.67), supervisor support (AOR: 7.40, 95% CI: 3.84, 14.26), and a better salary/payment (AOR: 4.18, 95% CI: 2.19, 7.88) compared to their counterparts. CONCLUSION AND RECOMMENDATION: The job satisfaction level among rural HEWs in the study area was low. Strategies to stimulate and strengthen recognition of management, supportive supervision, performance-based regular salary increment, and career developments are recommended.

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Background: Absenteeism is widespread in Nigerian health facilities and is a major barrier to achievement of effective Universal Health Coverage. We have examined the role of internal (by managerial staff within facilities) and external (by managers at a higher level) supervision arrangements on health worker absenteeism. Specifically, we sought to determine whether these forms of supervision have any role to play in reducing health worker absenteeism in health facilities in Enugu State Nigeria. Methods: We conducted interviews with 412 health workers in urban and rural areas of Enugu State, in South-Eastern Nigeria. We used binary logistic regression to estimate the role of different types of supervision on health worker absenteeism in selected health facilities in Enugu State. Results: Internal supervision arrangements significantly reduce health worker absenteeism (odds ratio = 0.516, p = 0.03). In contrast, existing external supervision arrangements were associated with a small but significant increase in absenteeism (OR = 1.02, 0.043). Those reporting a better financial situation were more likely to report being absent (OR = 1.36, p < 0.01) but there was no association with age and marital status of respondents. Our findings also pointed to the potential for alternative forms of supervision, provided in a supportive rather than punitive way, for example by community groups monitoring the activities of health workers but trying to understand what support these workers may need, within or beyond the work environment. Conclusion: The existing system of external supervision of absenteeism in health facilities in Nigeria is not working but alternatives that take a more holistic approach to the lived experiences of health workers might offer an alternative.

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AIM: Pneumonia is the leading infectious cause of death among children under five globally. Many pneumonia deaths result from inappropriate treatment due to misdiagnosis of signs and symptoms. This study aims to identify whether health extension workers (HEWs) in Ethiopia, using an automated multimodal device (Masimo Rad-G), adhere to required guidelines while assessing and classifying under five children with cough or difficulty breathing and to understand device acceptability. METHODS: A cross-sectional study was conducted in three districts of Southern Nations, Nationalities, and Peoples' Region, Ethiopia. Between September and December 2018, 133 HEWs were directly observed using Rad-G while conducting 599 sick child consultations. Usability was measured as adherence to the World Health Organization requirements to assess fast breathing and device manufacturer instructions for use. Acceptability was assessed using semi-structured interviews with HEWs, first-level health facility workers and caregivers. RESULTS: Adherence using the Rad-G routinely for 2 months was 85.3% (95% CI 80.2, 89.3). Health workers and caregivers stated a preference for Rad-G. Users highlighted a number of device design issues. CONCLUSION: While demonstrating high levels of acceptability and usability, the device modifications to consider include better probe fit, improved user interface with exclusive age categories and simplified classification outcomes.

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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.

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BACKGROUND: In the Tigray region of Ethiopia, Health Extension Workers (HEWs) conduct Tuberculosis (TB) screening for all household (HH) contacts. However, there is limited evidence on implementation status of HH contact TB screening by HEWs. The aim of this program assessment was to describe the implementation status and associated factors of HH contact TB screening by HEWs. METHODS: This programme assessment was conducted in three randomly selected districts from March to April 2018. Data was collected by using pre-tested structured questionnaire. Descriptive statistics was carried out using frequency tables. Logistic regression analysis was done to identify factors associated with HH contacts screening by HEWs. RESULTS: In this programme assessment a total of HHs of 411 index TB cases were included. One-fifth (21.7%) of index TB cases had at least one HH contact screened for TB by HEWs. Having TB treatment supporter (TTS) during intensive phase of index TB case (AOR = 2.55, 95% CI: 1.06-6.01), health education on TB to HH contacts by HEWs (AOR = 4.28, 95% CI: 2.04-9.00), HH visit by HEWs within 6 months prior to the programme assessment (AOR = 5.84, 95% CI: 2.81-12.17) and discussions about TB activities by HEWs with Women Development Army (WDA) leaders (AOR = 9.51, 95% CI: 1.49-60.75) were significantly associated with household contact TB screening by HEWs. CONCLUSIONS: Our finding revealed that the proportion of HH contact TB screened by HEWs was low. Therefore, HEWs should routinely visit HHs of index TB cases and provide regular health education to improve contact screening practice. In addition, it is highly recommended to strengthen HEWs regular discussion about TB activities with WDA leaders and TB TTS.

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AIM: Manually counting respiratory rate (RR) is commonly practiced by community health workers to detect fast breathing, an important sign of childhood pneumonia. Correctly counting and classifying breaths manually is challenging, often leading to inappropriate treatment. This study aimed to determine the usability of a new automated RR counter (ChARM) by health extension workers (HEWs), and its acceptability to HEWs, first-level health facility workers (FLHFWs) and caregivers in Ethiopia. METHODS: A cross-sectional study was conducted in one region of Ethiopia between May and August 2018. A total of 131 HEWs were directly observed conducting 262 sick child consultations after training and 337 after 2 months. Usability was measured as adherence to the WHO requirements to assess fast breathing and device manufacturer instructions for use (IFU). Acceptability was measured through semi-structured interviews. RESULTS: After 2 months, HEWs were shown to adhere to the requirements in 74.6% consultations; an increase of 18.6% after training (P < .001). ChARM is acceptable to users and caregivers, with HEWs suggesting that ChARM increased client flow and stating a willingness to use ChARM in future. CONCLUSION: Further research on the performance, cost-effectiveness and implementation of this device is warranted to inform policy decisions in countries with a high childhood pneumonia burden.

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AIM: The Ethiopian primary care of sick children is provided within the integrated Community Case Management of childhood illnesses by Health Extension Workers (HEW). There is limited knowledge whether this cadre correctly assess and classify common diseases. The aim was to study their ability to correctly classify common childhood illnesses. METHODS: A survey was conducted from December 2016 to February 2017 in four regions of Ethiopia. Observations of the HEWs' assessment and classification of sick children were followed by child re-examination by a trained health officer. RESULTS: The classification by the HEWs of 620 sick children as compared to the re-examiner had a sensitivity of 89% and specificity of 94% for diarrhoea, sensitivity 52% and specificity 91% for febrile disorders, and a sensitivity of 59% and specificity of 94% for acute respiratory tract infection. Malnutrition and ear infection had a sensitivity of 39 and 61%, and a specificity of 99 and 99%, respectively. CONCLUSION: Most cases of diarrhoea were correctly classified, while other illnesses were not frequently identified. The identification of malnutrition was especially at fault. These findings suggest that a significant number of sick children were undiagnosed that could lead to absent or incorrect management and treatment.

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BACKGROUND: Home-based neonatal care is associated with a reduction in neonatal mortality in settings with poor access to health facility-based care. The first day of a child's life is a day of unparalleled opportunity to spare lives and sets the level for a sound future. The aim of this study was to evaluate the prevalence and timing of home-based neonatal care by health extension workers (HEWs) in the rural Sidama Zone of southern Ethiopia. SUBJECTS AND METHODS: A community-based, cross-sectional study was conducted, and a total of 2,040 mothers who had a live birth in the last 6 months were studied from 1 to 31 January 2017. Interviewer-administered data were collected using a standard questionnaire developed by the Saving Newborn Lives Program. A descriptive analysis and logistic regression analyses were done. RESULTS: It was found that 252/2,040 (12.4%) mothers and their neonates were visited by the HEWs during the first month of birth. Out of all households who had a history of visits, 139 (55.2%) had a single visit. Of these, only 66/252 (26.2%) of the first visit were within the first 24 hours. Mothers who received postnatal home visit by the HEWs were at 1.35 times greater odds to have good postnatal practice compared to unvisited mothers (adjusted odds ratio [AOR] 1.35, 95% CI [1, 1.71]). Mothers who gave their last birth at home were 36% less likely to have good postnatal practice compared to those who gave birth in a health institution (AOR 0.64, 95% CI [0.53, 0.79]). CONCLUSION: Majority of the neonates did not get the recommended number and frequency of home visits. Postnatal home visit by HEWs had a great role in mothers having good postnatal practice. Therefore, all stakeholders should give attention on strengthening supportive supervision, proper implementation of community-based maternal and neonatal care is very crucial.

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BACKGROUND: In the last decade, the proportion of Ethiopian women using contraceptive methods has increased substantially (from 14% in 2005 to 35% in 2016 among married women). Numerous factors have contributed to the increased uptake. An important one is the implementation of the Health Extension Program, a government-led health service delivery strategy that has deployed more than 38,000 health extension workers (HEWs) throughout the country. Key mechanisms underlying the success of this program are not well understood. Using a case study approach, the goal of this study is to describe how key features of local contexts, community perceptions, and messaging by HEWs have contributed to the increased use of modern contraception in one community in Ethiopia. METHODS: We conducted focus groups and individual interviews with men, women, adolescents, and key informants, including (HEWs), in Oromia, Ethiopia. We used a random sampling protocol to recruit all participants except key informants, with whom purposive sampling was used to ensure participants were knowledgeable on family planning in the village. Interviews were audio recorded, translated, transcribed, and then analyzed using applied thematic analysis and NVivo v.11 qualitative research software. RESULTS: We identified four themes that may explain uptake of contraception: (1) HEWs are seen as trusted and valued community members who raised awareness about family planning; (2) the HEW messaging that contraception is useful to space pregnancies among married women was effective; (3) the message that spacing is healthy for mother and child was also effective; and (4) communicating to the entire community (including men, women, adolescents, and religious leaders), contributed to changing attitudes around contraception. CONCLUSION: The four aspects of the Health Extension Program approach increased uptake of contraception in our sample. In contexts where community health workers are valued by the health systems and local communities they serve, this type of approach to widening modern contraception use could help increase uptake and address unmet need. Understanding these granular aspects of the program in one local context may help explain how use of contraception increased in the country as a whole.

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Low intake of fruits and vegetables is a major cause of micronutrient deficiencies in the developing world. Since the 1980s, various non-governmental organizations have promoted homestead gardening (HG) programs, first in Asia, but now increasingly in Africa. Longstanding concerns with HG programs are: (1) they lack scalability, particularly for governments; (2) they only work in areas with/without good access to markets; and (3) they are only suitable for more water-abundant ecologies. We assess these concerns by analyzing a large and novel survey on the adoption of a nationwide HG program implemented by the Ethiopian government. We find that better market access encourages HG adoption; so too does greater public promotion of HGs, but only in more water-abundant ecologies.

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BACKGROUND: Health extension workers (HEWs) are the frontline health workers for Ethiopia's primary health care system. The Federal Ministry of Health is seeking to upgrade and increase the number of HEWs, particularly in remote areas, and address concerns about HEWs' pre-service education and practices. The aim of this study was to identify gaps in HEWs' practices and recommend changes in their training and scope of practice. METHODS: A cross-sectional descriptive task analysis was conducted to assess the work of rural HEWs who had been in practice for six months to five years. One hundred participants were invited from 100 health posts in five regions of Ethiopia. HEWs self-reported on 62 tasks on: frequency, criticality (importance), where the task was learned, and ability to perform the task. Descriptive statistics, including frequencies and percentages, were computed for each variable. Task combinations were examined to identify tasks performed infrequently or for which HEWs are inadequately prepared. RESULTS: A total of 82 rural HEWs participated in the study. Nearly all HEWs rated every task as highly critical to individual and public health outcomes. On average, most HEWs (51.5%-57.4%) reported learning hygiene and environmental sanitation tasks, disease prevention and control tasks, family health tasks, and health education and communication tasks outside of their pre-service education, primarily through in-service and on-the-job training. Over half of HEWs reported performing certain critical tasks infrequently, including management of supplies, stocks and maintenance at the facility and management of the cold chain system. Almost all HEWs (95.7-97.2%) perceived themselves as competent and proficient in performing tasks in all program areas. CONCLUSION: HEWs were insufficiently prepared during pre-service education for all tasks that fall within their scope of practice. Many learned tasks through in-service or on-the-job training, and some tasks were not learned at all. Some tasks that are part of expected HEW practice were performed infrequently, potentially reducing the effectiveness of the Health Extension Program to provide preventive and basic curative health care services to communities. Findings should alert policy makers to the need to review HEWs' scope of practice, update pre-service education curricula and prioritize in-service training modules.

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BACKGROUND: To accelerate the expansion of primary healthcare coverage, the Ethiopian government started deploying specially trained community health workers named Health Extension Workers (HEWs) in 2003. HEWs work on sixteen health service packages; one being tuberculosis (TB) control and prevention. However, their contribution to TB care and prevention services among pastoralist communities has not been evaluated. Thus, this study has assessed their contribution in identification of persons with presumptive pulmonary TB in Ethiopian Somali Pastoralist Region. METHOD: A cross sectional study with mixed approach of quantitative and qualitative methods was applied. A randomly selected cross-sectional sample of 380 pulmonary TB cases from 20 health facilities was selected to obtain information on the role of HEWs in the identification of persons with presumptive TB, and their referral. Purposively selected HEWs were also interviewed individually to obtain in-depth information on their in-service training and experiences with referring TB cases. SPSS version20 was used to summarize the quantitative data and test statistical significance using chi-square test and logistic regression model. The qualitative data was analyzed under the principles of thematic analysis. RESULT: Overall, 20.3% [95% CI = 16.6-24.5] of pulmonary TB patients were referred by HEWs; while the majority were referred by healthcare workers (52.6%), family members (13.4%), neighbours/friends (2.4%) and self-referred (11.3%). Out of all, 66.1% and 53.4% had neither received community TB health education nor home visit from HEW respectively. Multivariate analysis indicated that provision of community health education [AOR = 14.0, 95% CI = 6.6-29.5], being model household [AOR = 21.2, 95% CI = 9.5-47.3], home visit from HEW [AOR = 2.8, 95% CI = 1.2-9.6] and rural residence [AOR = 3.0, 95% CI = 1.2-7.7] were significantly associated with referral by HEW. The qualitative findings supported that HEWs' involvement in referral of persons with presumptive TB was limited. Communities' low confidence in HEWs, inaccessibility of TB services at nearest health centers and lack of in-service trainings for HEWs were identified by the interviewee HEWs as underlying factors for their limited involvement. CONCLUSION: The contribution of health extension workers in identifying and referring presumptive TB cases is limited in Ethiopian Somali pastoralist region. Increased community health education and home visits by HEWs could contribute to increased identification and referral of persons with presumed TB. HEW should be properly trained on TB through in-service refreshment trainings and supported by routine supervision. Further expansion of TB diagnostic services would benefit to increasing case detection.

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Ethiopia implemented an innovative community-based health program, called the health extension program, to enhance access to basic health promotion, disease prevention and selected curative services by establishing health posts in every village, also called kebeles, with average of 5000 people, staffed with two health extension workers (HEWs). This time and motion study was done to estimate the amount of time that HEWs spend on various work duties and to explore differences in urban compared with rural settings and among regions. A total of 44 HEWs were observed for 21 consecutive days, and time and motion data were collected using tablet computers. On average, HEWs were on duty for 15.5 days out of the 21 days of observation period, and on average, they stayed on duty for about 6 hours per day. Out of the total observed work time, the percentages of total time spent on various activities were as follows: providing health education or services (12.8%); participating in meetings and giving trainings (9.3%); conducting community mapping and mobilization (0.8%); recordkeeping, reporting, managing family folders (13.2%); managing commodities and supplies (1.3%); receiving supervision (3.2%); receiving training (1.6%); travel between work activities (15.5%); waiting for clients in the health post (or health centre in urban settings) (24.9%); building relationships in the community (13.3%); and other activities that could not be meaningfully categorized (4%). The proportion of time spent on different activities and the total time worked varied significantly between rural and urban areas and among the regions (at P < 0.05). Findings of this study indicate that only a minority of HEW time is spent on providing health education and services, and substantial time is spent waiting for clients. The efficiency of the HEW model may be improved by creating more demand for services or by redesigning service delivery modalities.

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