BackgroundTo address the shortfall in human resources for health, Ethiopia launched the Health Extension Program (HEP) in 2004, establishing a health post with two female health extension workers (HEWs) in every kebele (community). In 2011, the Women’s Development Army (WDA) strategy was added, using networks of neighboring women to increase the efficiency of HEWs in reaching every household, with one WDA team leader for every 30 households. Through the strategy, women in the community, in partnership with HEWs, share and learn about health practices and empower one another. This study assessed the association between the WDA strategy implementation strength and household reproductive, maternal, newborn and child health care behaviors and practices.MethodsUsing cross-sectional household surveys and community-level contextual data from 423 kebeles representing 145 rural districts, an internal comparison group design was applied to assess whether HEP outreach activity and household-level care practices were better in kebeles with a higher WDA density. The density of active WDA leaders was considered as WDA strategy implementation strength; higher WDA density in a kebele indicating relatively high implementation strength. Based on this, kebeles were classified as higher, moderate, or lower. Multilevel logit models, adjusted for respondents’ individual, household and contextual characteristics, were used to assess the associations of WDA strategy implementation strength with outcome indicators of interest.ResultsAverage numbers of households per active WDA team leader in the 25th, 50th and 75th percentiles of the kebeles studied were respectively 41, 50 and 73. WDA density was associated with better service for six of 13 indicators considered (p < 0.05). For example, kebeles with one active WDA team leader for up to 40 households (higher category) had respectively 7 (95% CI, 2, 13), 11 (5, 17) and 9 (1, 17) percentage-points higher contraceptive prevalence rate, coverage of four or more antenatal care visits, and coverage of institutional deliveries respectively, compared with kebeles with one active WDA team leader for 60 or more households (lower category).ConclusionHigher WDA strategy implementation strength was associated with better health care behaviors and practices, suggesting that the WDA strategy supported HEWs in improving health care services delivery.Electronic supplementary materialThe online version of this article (10.1186/s12884-018-1975-y) contains supplementary material, which is available to authorized users.
BackgroundCommunity participation and community health volunteer programs are an essential part of the health system so that health services are responsive and accountable to community needs. Information systems are necessary for community health volunteer programs to be effective, yet effectiveness evaluations of such information systems implemented at scale are rare. In October 2010, a network of female volunteers with little or no literacy, the Women’s Development Army (WDA), was added to extend Ethiopia’s Health Extension Program services to every household in the community. Between July 2013 and January 2015, a health management information system for the WDA’s Community-Based Data for Decision-Making (CBDDM) strategy was implemented in 115 rural districts to improve the demand for and utilization of maternal and newborn health services. Using the CBDDM strategy, Health Extension Workers (HEWs) fostered the WDA and community leaders to inform, lead, own, plan, and monitor the maternal and newborn health interventions in their kebeles (communities). This paper examines the effectiveness of the CBDDM strategy.MethodsUsing data from cross-sectional surveys in 2010–11 and 2014–15 from 177 kebeles, we estimated self-reported maternal and newborn care practices from women with children aged 0 to 11 months (2124 at baseline and 2113 at follow-up), and a CBDDM implementation strength score in each kebele. Using kebele-level random-effects models, we assessed dose-response relationships between changes over time in implementation strength score and changes in maternal and newborn care practices between the two surveys.ResultsKebeles with relatively high increases in CBDDM implementation strength score had larger improvements in the coverage of neonatal tetanus-protected childbirths, institutional deliveries, clean cord care for newborns, thermal care for newborns, and immediate initiation of breastfeeding. However, there was no evidence of any effect of the intervention on postnatal care within 2 days of childbirth.ConclusionsThis study shows the extent to which an information system for community health volunteers with low literacy was implemented at scale, and evidence of effectiveness at scale in improving maternal and newborn health care behaviors and practices.
Background: Contraceptive prevalence in Ethiopia jumped from 6% in 2000 to 36% in 2016, mainly due to increased injectable method use. However, discontinuation rates among injectable users were high (38%). Given that the public sector is the major source for injectable contraceptives, John Snow Inc. (JSI) in collaboration with ideas42 worked with Ethiopia’s flagship Health Extension Program to apply behavioral design to mitigate discontinuation of injectable contraceptives. Methods: We applied behavioral economics insights to mitigate the discontinuation of injectable contraceptives. This process created an intervention package, consisting of a health worker planning calendar, a client counseling job aid, and client appointment cards. A stratified-pair cluster-randomized field trial tested the effectiveness of the intervention. The study area included two districts from the four regions where JSI was implementing a family planning program. One district from each region was randomly allocated to the intervention arm. Women visiting health posts to use injectable contraceptives were enrolled in the study. Regression methods, adjusted for study design, participants’ backgrounds, and contextual factors, estimated the intervention’s effect on discontinuation rates. Results: A behavioral design methodology was feasibly implemented in a rural, low-resource setting in Ethiopia. The resultant intervention package was successfully delivered in 19 satellite health posts in four districts. Intervention adherence was high for the appointment cards and counseling job aid, but not for the planning calendar. The injectable discontinuation rate was 10.8 % (95% confidence interval: 2.2, 19.3) points lower in the intervention area compared to the control area during the post-intervention follow-up survey. Conclusion: The use of two tools informed by behavioral economics —the appointment card and counseling job aid—effectively decreased injectable discontinuation even with the presence of other health system bottlenecks. Behavioral economics insights and the behavioral design methodology have the potential to enhance family planning programs in Ethiopia and elsewhere.
Background: Contraceptive prevalence in Ethiopia jumped from 6% in 2000 to 36% in 2016, mainly due to increased injectable method use. However, discontinuation rates among injectable users were high (38%). Given that the public sector is the major source for injectable contraceptives, John Snow Inc. (JSI) in collaboration with ideas42 worked with Ethiopia’s flagship Health Extension Program to apply behavioral economics informed approaches to mitigate discontinuation of injectable contraceptives. Methods: Behavioral diagnosis was conducted to identify the primary drivers of discontinuation of injectable contraceptives. Using these insights, a user-centered behavioral design approach was implemented to create an intervention package, consisting of a health worker planning calendar, a client counseling job aid, and client appointment cards. The study area included two districts from the four regions where JSI was implementing a family planning program. One district from each region was randomly allocated to the intervention arm. Women visiting health posts to use injectable contraceptives were enrolled in the study. Regression methods adjusted for study design, participants’ backgrounds, and contextual factors, were used to estimate the intervention’s effect on discontinuation rates. Results: Intervention adherence was high for the appointment cards and counseling job aid, but not for the planning calendar. This was not surprising as using appointment cards and the job aid was within the routine workflow of health extension workers, but using the planner was not. The injectable discontinuation rate was 10.8 % points lower in the intervention area compared to the control area during the post intervention follow-up survey. Conclusion: The use of two behavioral economics informed tools—the appointment card and counseling job aid—effectively decreased injectable discontinuation even with the presence of other health system bottlenecks. Behavioral economics approaches have the potential to enhance family planning programs in Ethiopia and elsewhere. Trial registration: ISRCTN ISRCTN17390653 (10/04/2019)
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