Role of health extension workers in the relationship between vector control interventions and malaria in Ethiopia

Background Despite a tremendous decline in the burden of malaria through public health interventions, it is yet remains a critical parasitic health problem in Ethiopia. Insecticide-treated nets and indoor residual spray are considered as the most effective preventive interventions against malaria. This study intended to determine the role of health extension workers in influencing the relationship between vector control strategies and malaria prevalence in Ethiopia. Methods The study adopted a descriptive study based on panel data collected from 10 regions of Ethiopia from 2010 to 2018. The data collected were analyzed using STATA version 13.0. Structural equation modelling was used to assess the mediating effect of health extension workers in the relationship. Further, the random effect model was employed to investigate the direct relationship among the study variables. Results We observed a strong mediating role of health extension workers to the relationship between strategic interventions and malaria prevalence, where the direct path is (β = 0.64, p < 0.05), and the indirect path (β = 0.72, p < 0.001) and (β = 0.98, p < 0.001) confirming the mediation condition to appear. Our analysis revealed that, insecticide-treated nets and indoor residual spray significantly impacts the malaria prevalence (β = 0.20, p < 0.05) and (β = 0.70, p < 0.001) respectively. Further, our analysis suggests that the cumulative effect of indoor residual spray and insecticide-treated mosquito nets have helped better avert malaria prevalence (β = 81.3%, P < 0.05). Moreover, the finding demonstrates the incremental rate of 30.2%, which is the indirect effect of the research [(β = 0.813) - (β1 = 0.511)]. Conclusion The findings are potentially useful for the health sector in charge of infectious disease prevention and control, particularly in developing countries explaining how these group provided support to reduce malaria ensuring the provision of proper health message about the program.

The implementation and impact of a pilot hydrocele surgery camp for LF-endemic communities in Ethiopia

Background Ethiopia aims to eliminate lymphatic filariasis by 2020, through a dual approach of mass drug administration to interrupt transmission and morbidity control which includes making hydrocele surgery available in all endemic areas. Locating patients requiring surgery, providing high quality surgeries, and following up patients are all formidable challenges for many resource-challenged or difficult-to-reach communities. To date, hydrocele surgery in Ethiopia has only occurred when a patient has the knowledge, time and resources to travel to regional hospitals. Ethiopia tested the novel approach of using a surgical camp, defined as mobilizing, transporting, providing surgery at a static site, and following up of a large cohort of hydrocele patients within a hospital’s catchment area, to address delays in seeking and receiving care. Methodology and results Health extension workers mobilized 252 patients with scrotal swelling from a list of 385 suspected hydrocele cases from seven endemic districts in the region of Beneshangul-Gumuz. Clinical health workers and surgeons confirmed 119 as eligible for surgery. Of 70 additional patients who self-referred, 56 were eligible for surgery. Over a two-week period at a regional hospital, 175 hydrocele excision surgeries were conducted. After discharge three days after surgery, trained clinical health workers followed up with the patients on Day 5, Day 8, Day 14 and 1st-month benchmarks with a randomized follow-up of a selection of patients conducted at 9–12 months. There were no post-operative complications upon discharge at Day 3 and 22, while minor complications occurred (12.6%) between Day 3 and one month. The 9–12 month follow-up found patients self-reported an improvement in quality of life, health and economic status. Conclusion A hydrocele surgery camp was effective at providing a large number of quality surgeries in a short time. Using peripheral health workers to mobilize and follow up patients helped address delays in seeking and receiving quality care. Mainstreaming patient mobilization and follow-up into a community health system could be effective in other countries. The camp’s results also influenced two regions in Ethiopia to change their policies in order to offer free hydrocele surgery (including patient transport, consultation, surgery, diagnostic tests and necessary medications).

Towards elimination of Lymphatic Filariasis in Kenya: Improving advocacy, communication and social mobilization activities for mass drug administration, a qualitative study.

IntroductionA major pillar in the Kenya Neglected Tropical Diseases (NTD) breaking transmission strategy of 2019 -2023 is that of intensifying advocacy, coordination and partnerships in NTD control and elimination. The purpose of this study was to explore views and experiences of stakeholders and health workers on ways of improving Advocacy, Communication and Social Mobilization (ACSM) activities of MDA for LF programmes through participatory approaches in Kilifi County, Kenya.Methods: Two wards were purposely selected in Kaloleni sub county, Kilifi County where there was average treatment coverage of 56% in 2015, 50.5% in 2016. Qualitative data collection methods were employed which included participatory meetings with county stakeholders to understand their views, experiences and suggestions on how ACSM strategies can be improved in MDA for LF. 12 In-Depth Interviews (IDI) were conducted (six with opinion leaders and six with Community Health Extension Workers (CHEWs) and two Semi structured interviews (SSIs) were held with county and sub-county coordinators involved in MDA administration. The aim was better understanding their perceptions of the NTD program about ACSM, challenges to ACSM strategies, and ways to improve the strategies for ACSM in MDA for LF. Data was organized and classified into codes and themes using QSR NVIVO version 12.Results: The study observed a low participation of stakeholders in ACSM activities of MDA for LF and identified potential areas for stakeholders’ involvement to strengthen the activities. Challenges hindering effective implementation of ACSM activities included late delivery of Information Educational and Communication (IEC) and few IEC materials, insufficient funding, inadequate time allocated to reach to the assigned households with messages, messaging and packaging of information for dissemination and vastness of the area. The stakeholders recommended innovative strategies and techniques to improve ACSM activities.Discussion and Conclusion: The results of this study show key challenges to ACSM implementation of MDA for LF. Implementers need to pay attention to these challenges to enhance effectiveness of MDA in accordance to the Kenya NTD breaking transmission Strategy. ACSM efforts in MDA for LF control and elimination should be linked with overarching efforts to mainstream partnerships and coordination in control and elimination.

Perception and Experience of Health Extension Workers on Facilitators and Barriers to Maternal and Newborn Health Service Utilization in Ethiopia: A Qualitative Study

Background: Health extension workers (HEWs) have substantial inputs to reduce maternal and newborn morbidity and mortality in Ethiopia. However, their perceptions and experiences were not well understood. Therefore, this study aimed to explore their perceptions and experiences on facilitators and barriers to maternal and newborn health services in Ethiopia. Methods: A descriptive qualitative study was conducted from 8–28 April 2021 in Oromia, Amhara and Southern Nation, Nationality, and People’s Regional State of Ethiopia. Focused group discussions were made with purposively selected 60 HEWs. The data were transcribed verbatim and translated into English. An inductive thematic analysis was carried out using Atlas ti.7.1. The findings were presented in major themes, categories, and sub-categories with supporting quote(s). Results: The findings were categorized into two major themes (i.e., facilitators and barriers) and seven sub-themes. Community-related facilitators encompass awareness and behavior at the individual, family, and community. Significant others such as traditional birth attendants, religious leaders, women developmental armies, and kebele chairman substantially contributed to service utilization. Availability/access to infrastructures such as telephone, transportation services, and solar energy systems facilitated the service utilization. Furthermore, health facility-related facilitators include the availability of HEWs; free services; supervision and monitoring; maternity waiting rooms; and access to ambulance services. Maternal and newborn health services were affected by community-related barriers (i.e., distance, topography, religious and socio-cultural beliefs/practices, unpleasant rumors, etc.,), health facility-related barriers (i.e., health worker’s behaviors; lack of logistics; lack of adequate ambulance service, and placement and quality of health post), and infrastructure (i.e., lack or poor quality of road and lack of water). Conclusions: The HEWs perceived and experienced a wide range of facilitators and barriers that affected maternal and newborn health services. The study findings warrant that there was a disparity in behavioral factors (awareness, beliefs, and behaviors) among community members, including pregnant women. This underscores the need to design health education programs and conduct social and behavioral change communication interventions to address individuals, families, and the broader community to enhance maternal and newborn health service utilization. On the other hand, the health sector should put into practice the available strategies, and health workers provide services with empathy, compassion, and respect.

Community risk perception and barriers for the practice of COVID-19 prevention measures in Northwest Ethiopia: A qualitative study

Background According to the World Health Organization, viral diseases continue to emerge and represent a serious issue for public health. The elderly and those with underlying chronic diseases are more likely to become severe cases. Our study sets out to present in-depth exploration and analyses of the community’s risk perception and barriers to the practice of COVID-19 prevention measures in South Gondar Zone, Northwest Ethiopia. Methods A qualitative study was done in three districts of South Gondar Zone. Community key informants and health extension workers were selected purposely for in-depth interviews and focus group discussion. The interviews were conducted by maintaining WHO recommendations for social distancing and use of appropriate personal protective equipment. The sample size for the study depended on the theoretical saturation of the data at the time of data collection. The qualitative data generated from in-depth interviews and focus group discussions was transcribed verbatim and translated into English language and thematically analyzed using open code software version 4.02. Results Three main themes and five categories emerged from the narrations of the participants regarding the perceived barriers for the practice of COVID-19 prevention measures. A total of 9 community key informants (5 women development armies (HDA), 2 health extension workers (HEW), and 2 religious leaders participated in the in-depth interview, while two focus group discussions (7 participants in each round) were conducted among purposely selected community members. The age of the participants ranged from 24 to 70 years with the median age of 48 years. The major identified barriers for practicing COVID-19 prevention measures were the presence of strong cultural and religious practices, perceiving that the disease does not affect the young, misinformation about the disease, and lack of trust in the prevention measures. Conclusions Socio-cultural, religious, and economic related barriers were identified from the participant’s narratives for the practice of COVID-19 prevention measures in south Gondar Zone. Our findings suggest the need to strengthen community awareness and education programs about the prevention measures of COVID-19 and increase diagnostic facilities with strong community-based surveillance to control the transmission of the pandemic.

Exploring women’s development group leaders’ support to maternal, neonatal and child health care: A qualitative study in Tigray region, Ethiopia

Background Community health workers and volunteers are vital for the achievement of Universal Health Coverage also in low-income countries. Ethiopia introduced community volunteers called women’s development group leaders in 2011. These women have responsibilities in multiple sectors, including promoting health and healthcare seeking. Objective We aimed to explore women’s development group leaders’ and health workers’ perceptions on these volunteers’ role in maternal, neonatal and child healthcare. Methods A qualitative study was conducted with in-depth interviews and focus group discussions with women’s development group leaders, health extension workers, health center staff, and woreda and regional health extension experts. We adapted a framework of community health worker performance, and explored perceptions of the women’s development group program: inputs, processes and performance. Interviews were recorded, transcribed, and coded prior to translation and thematic analysis. Results The women’s development group leaders were committed to their health-related work. However, many were illiterate, recruited in a sub-optimal process, had weak supervision and feedback, lacked training and incentives and had weak knowledge on danger signs and care of neonates. These problems demotivated these volunteers from engaging in maternal, neonatal and child health promotion activities. Health extension workers faced difficulties in managing the numerous women’s development group leaders in the catchment area. Conclusion The women’s development group leaders showed a willingness to contribute to maternal and child healthcare but lacked support and incentives. The program requires some redesign, effective management, and should offer enhanced recruitment, training, supervision, and incentives. The program should also consider continued training to develop the leaders’ knowledge, factor contextual influences, and be open for local variations.

Effectiveness of task-sharing in providing comprehensive long-acting reversible contraceptives through Level IV health extension workers in rural Ethiopia

Background: Modern family planning uptake in Ethiopia, primarily short-acting injectables, has increased after the engagement of community health extension workers (HEWs). The aim of this study was to investigate the effectiveness of using Level IV health extension workers to deliver long-acting reversible contraceptives (LARCs) at the community level. Methods: A retrospective cohort study design was used to recruit 710 women who received LARC insertion services at pilot health posts within eight months before survey time. The interviewer administered a data collection tool to collect the required data through a house-to-house survey. The questionnaire had sections covering demographic and socioeconomic characteristics, reproductive history, use of family planning methods, knowledge about LARC methods (i.e., IUCD and Implanon), and service satisfaction. Descriptive statistics were used to analyze data. Chi-square test was used to identify the determinants of LARC use. Results: Out of 702 LARC users included in the study, 92.7% received services from Level IV HEWs. The median age of clients was 30 years (IQR: 25–35), 92.7% were married, and 22.6% were new family planning users (75% Implanon users and 19.4% Jaddelle users). Of the aggregated variables, 67.38% had good knowledge of LARC, 92.28% had positive attitudes in availing services at health posts, and 92.76% was the satisfaction score of clients. New users tended to be young, Muslim, less likely to want more children, and more likely to decide on contraception on their own. At eight months post insertion, LARC use was effective in preventing pregnancy (99.7%) with low removal (n = 36, 5.1%) and expulsion rates (n = 1, 0.1%). No infection was reported. The major reasons for removal were side effects and the desire to have children. Client knowledge, attitude, and satisfaction were found to be high. In conclusion, trained Level IV HEWs provided LARCs safely and effectively at the health post level as an alternative service delivery outlet.

Evidence for hidden leprosy in a high leprosy-endemic setting, Eastern Ethiopia: The application of active case-finding and contact screening

Leprosy or Hansen’s disease is a disabling infectious disease caused by Mycobacterium leprae. Reliance on the self-presentation of patients to the health services results in many numbers of leprosy cases remaining hidden in the community, which in turn results in a longer delay of presentation and therefore leading to more patients with disabilities. Although studies in Ethiopia show pockets of endemic leprosy, the extent of hidden leprosy in such pockets remains unexplored. This study determined the magnitude of hidden leprosy among the general population in Fedis District, eastern Ethiopia. A community-based cross-sectional study was conducted in six randomly selected leprosy-endemic villages in 2019. Health extension workers identified study participants from the selected villages through active case findings and household contact screening. All consenting individuals were enrolled and underwent a standardized physical examination for diagnosis of leprosy. Overall, 262 individuals (214 with skin lesions suspected for leprosy and 48 household contacts of newly diagnosed leprosy cases) were identified for confirmatory investigation. The slit skin smear technique was employed to perform a bacteriological examination. Data on socio-demographic characteristics and clinical profiles were obtained through a structured questionnaire. Descriptive statistics and binary logistic regression were used to assess the association between the outcome variable and predictor variables, and the P-value was set at 0.05. From the 268 individuals identified in the survey, 6 declined consent and 262 (97.8%) were investigated for leprosy. Fifteen cases were confirmed as leprosy, giving a detection rate of 5.7% (95%, CI: 3%, 9%). The prevalence of hidden leprosy cases was 9.3 per 10,000 of the population (15/16107). The majority (93.3%) of the cases were of the multi-bacillary type, and three cases were under 15 years of age. Three cases presented with grade II disability at initial diagnosis. The extent of hidden leprosy was not statistically different based on their sex and contact history difference (p > 0.05). High numbers of leprosy cases were hidden in the community. Active cases findings, and contact screening strategies, play an important role in discovering hidden leprosy. Therefore, targeting all populations living in leprosy pocket areas is required for achieving the leprosy elimination target.