Urban health extension program model housing and household visits improved the utilization of health Services in Urban Ethiopia: a community-based cross-sectional study

The government of Ethiopia launched an innovative program called Urban Health Extension Program (UHEP) in 2009, intended to produce good health status to the urban populations using urban health extension professionals (UHE-ps)as lead implementer of the program [1]. The purpose of the program is to ensure access and quality of services for the urban community. With 15 UHEP packages, the UHEP was initiated in seven regions of the country (Tigray, Amhara, Oromia, SNNPR (southern nation, nationalities people’s region) Harari, DD (Diredawa) and (AA) (Addis Ababa) [2]. The site of work for the (UHE-ps) is in the health centers serving 40, 000 community members.

The ultimate aim of the UHEP is to produce model households. The health service extension program contains 16 rural extension program packages, since there is separate health education and communication package (in contrast to the UHEP packages, of which there are 15 because it is thought that this package can serve as a tool for all the packages of the UHEP (Table 1). Households that attend at least 75% of the training and put at least 75% of the UHEP packages into practice will be graduated and certified by the catchment UHE-ps [2].

A number of factors have been identified as the leading causes of poor health service utilization such as inaccessibility of the health care facility, low socioeconomic status, low educational status of the mothers and cultural views and insights of the community. A number of studies showed that these factors categorized as sociodemographic status, autonomy of women’s, cultural insights, trends of diseases and health service utilizations, and physical and economic accessibility issues [3‐5].

According to Anderson behavioral model risk factors associated to health service utilization can be categorized in to need, enabling and predisposing factors [6]. Health service characteristics can also have impacts on utilization of health services. These characteristics include the health service relevance (tertiary, secondary, or primary care); classification (drugs and medications, hospital, physicians and others); unit of measurements (episode, contact and volume); characteristics of provision, such as the intensity (amount) and time frame (acute or chronic); and frequency of household visits by the health workers [7, 8](Fig. 1).

During the implementation period of the UHEP (particularly between 2012 and 2013 regarding child and maternal health services, an increase was observed for antenatal and postnatal care coverage (from 89.1 to 97.4% and from 44.5 to 50.5%, respectively) as well as for the percentage of deliveries attended by skilled health personnel (from 20.4 to 23.1%), while the percentage of clean and safe deliveries (by health extension workers) declined from 13.2 to 11.6% in the same period [9]. A report from a miniature demographic release in 2014 showed promising results in Addis Ababa, for example, in terms of utilization of any modern contraceptive method (57%), antenatal care (94), child mortality (53 per 1000 live births) and the rate of diarrhea in children under five (9.4%) [10].

This achievement logically links the launch of the UHEP to improvement of the health status of the urban community of Addis Ababa. However, investigation of the determinants and impacts of the program interventions would facilitate further progress toward sustaining development goals. Therefore, the aim of this study was to assess the utilization of the UHEP by the urban community and associated factors.

A total of 1086 households were sampled in the survey, and 1078 females participated in this study, corresponding to a response rate of 99.1%. Additionally, 954 of the study participants visited the health center during the year (89.1, 95% CI = 87.1, 90.9).

The results of showed being a model household, hearing (having information) about the UHEP, receiving home visits from UHE-ps, having under-five children, being a mother in the reproductive age group and having a sustainable source of income were independent determinants of HC utilization. However, HC visits exhibited no significant association with mothers’ occupations, the frequency of visits, understanding the UHEP packages, the quality of the health centers, or referrals of community members by UHE-ps.

Receiving household visits by UHE-ps and being model households exhibited significant associations with HC visits made by members of the community. The results of this study is in line with a study conducted in Ethiopia indicating that HEW (health extension worker) home visits and after becoming model households exhibited significant positive associations with health service utilization [13]. Other related study showed the potential of preventive home visits for reducing the disability burden, despite the fact that this depends on a number of risk factors and health facility infrastructure [14]. Another systematic review suggested that home visits can reduce chronic cares and mortality [15]. In contrast, a study by Van Haastregt and Diederiks (2000) showed that there was no any studies indicating the effectiveness of household visiting [16]. Another related study suggested that instant community involvements would have maximum benefit [17]. Nevertheless, some systematic reviews of home visiting programs have showed differences related to outcomes associated with the average intensities and durations of the programs [17, 18].

This study explored the hypothesis that model households increase the potential to utilize health centers. This hypothesis is in line with a related findings in Ethiopia showing that women who are model families of an HEP (health extension program) are more likely to exhibit good utilization of maternal health services [19].

Solid and liquid waste management, latrine construction and utilization, personal and environmental hygiene and healthy housing were the packages that were most frequently recalled. The moderately recalled packages included tuberculosis, leprosy and HIV control, water supply and food hygiene, family planning, non-communicable diseases and immunization. The least recalled packages were adolescent and reproductive health, health education, nutrition, first aid and accident prevention.

The packages that were least or moderately recalled could be due to the focus of UHE-ps on household-level services (even though the program implementation centers also include school and youth centers [1]), since most of the least-recalled packages were to be implemented among youths and adolescents. One exception to this trend was the malaria package, since the study area is not endemic for malaria.

In this study, mothers with a stable source of income were less likely to visit private or highly advanced centers (expensive centers) than mothers with no stable source of income. This discrepancy might have occurred because those mothers who had stable sources of income (affluent) were more likely to visit a government health facility (relatively cheaper centers), similar to mothers with no stable source of income, possibly due to the global and the local economic crisis in Addis Ababa, Ethiopia. This inference is consistent with a study from the USA indicating that hospitalization rates are higher in limited-resource areas than in higher-income areas, where appropriate outpatient care is more readily available [20]. However, this possibility is not consistent with studies from Uganda and Bangladesh that have reported income as one of the most important factors in overcoming barriers to the utilization of health services [8, 12, 21].

Mothers in the reproductive age group as well as mothers having children under five were more likely to visit the HC, possibly because most of the packages of the UHEP are related to this group of mothers and children under five. This study showed that HC visits exhibited no significant association with mothers’ occupations, the frequency of visits, the understanding of UHEP packages, the quality of health centers and referrals of community members by UHE-ps.

The findings of this study indicated that mothers’ occupations exhibited no significant association with HC visits, which is consistent with another related study conducted in Ethiopia showing that a mother’s occupation is not a predictor of health service utilization within the community of West Gojam, Ethiopia [13]. Similarly, a study performed in South Asia and sub-Saharan Africa indicated that the likelihood of using health care for maternal services are similar for both working and non-working women in Tanzania, Bangladesh, India and Pakistan [22]. Similarly, other related study in South Korean showed there is no differences in mortality rates due to occupational differences (between manual versus non-manual labour) [23].

However, studies conducted in Nepal indicated that women who are not working are more likely to utilize health services than working women, which is justified, since most women in Nepal work for family responsibility in the agriculture [24, 25]. A study from Iran also showed that housewives are more likely to utilize health services than other working women [26].

In the present study, numbers of household visits by UHE- ps displayed no significant association with HC visits. Contrary to this finding, a study from Nepal demonstrated that health worker visits showed as significant association with the health service use [27]. Awareness on the elements of the UHEP in this study is not predictor for the health service use. Another study from Ethiopia showed contrary findings, suggesting that awareness of the components of the packages was positively associated with the health service use [13]. Other similarly contrary findings from greater Lansing showed a statistically significant association between knowledge and level of literacy associated with the health service utilization [28]. However, results from a similar study in Atlanta indicated no association between the literacy level and health service uses [29].

Community perception toward the conduct of UHE-ps and services quality provided in the HC showed significant association with HC visits, which might be due to the expansion of health centers in the catchment areas of the urban community. However, contrary results from Ethiopia indicated that community attitudes towards ethical practices of the HEWs and services quality provided in the health facility displayed no significant association with health service utilization [13]. Opposing results from Uganda revealed that the community perceived governmental health facilities substandard cares [30]. Referral of community members by UHE-ps was not found to be a significant predictor of HC visits in the present study, most likely due to the attitude of the community and UHE-ps themselves, as the UHE-ps were entirely responsible for handling cases at the household level.

According to the Anderson behavioral model initially designed in this study based on predisposing factors (age, hearing about the UHEP, understanding the UHEP (comprehending what the UHEP was)) and enabling factors (model households, home visits by UHE-ps), these factors show significant associations with health service use, which implies that predisposing and enabling factors are well illustrated by this model. However, need factors were not well represented in the model.

The UHEP related variable like home visit made by UHE-ps is the potential predictor in this study however similar related variable called frequency of visit by UHE-ps is not predictor variable for the health service utilization. Similarly hearing about UHEP (having information about the UHEP) is potential predictor, unfortunately understanding of the UHEP packages variable is not predictor for the health service utilization. This UHEP related variables expected to show causal ordering (but there is no casual ordering) so this needs further investigation.

The unique characteristics of this study included the use of a large sample size and a high response rate. Nevertheless, the two remaining limitations of this study were recall bias, the study participants might not have remembered all the UHEP services and associated factors, and a lack of baseline data with which to compare the findings of this study.

The determinants of UHEP factors, such as being model households and receiving home visits from UHE-ps, exhibited significant positive associations with the health services program. Having a sustainable source of income also displayed a significant positive association with health service utilization. Sustaining practices of graduated and certified model households are essential to maximize the benefits of the UHEP activities for health service utilization. Home visits to both model and non-model households on a regular basis are essential to advance health service utilization, in addition to designing re-graduation or other sustainability options for those in graduated model households.

The UHE-ps have diplomas in clinical nursing and work in promotive and preventive aspects of the UHEP. The professionals’ career structures in their own field have not yet been established, which makes them unmotivated to continue as UHE-ps. Instead, most of them teach in private colleges with the aim of changing their profession. Designing UHEP-based undergraduate and higher educational training is of paramount importance to utilize the benefits of an innovative UHEP through minimizing the turnover of UHE-ps.