Utilization of urban health extension services
Three hundred and eight (72.8%) households reported they had service related contact with Urban Health Extension Professionals at least once in the previous 6 months prior to the study period. The mean frequency of service related contact with Urban Health Extension Professionals was found to be 2.24 (±1) contacts per 6 months. Among those who reported a contact, the majority, 279 (90.6%), reported that they were visited by the Urban Health Extension Professionals at their home (Table
2).
Table 2
Location of service related contact with urban health extension professionals in Bishoftu town, central Ethiopia, March 2012 (n = 418)
Place of contact |
Home | 279 | 66.7 |
Public places (School/working place) | 14 | 3.3 |
Health post | 11 | 2.6 |
Community meetings | 4 | 0.9 |
Never had contact | 110 | 26.3 |
Frequency of total contact in the last 6 months |
Five times or more | 23 | 5.5 |
Four times | 85 | 20.3 |
Three times | 115 | 27.5 |
Twice | 51 | 12.2 |
Once | 34 | 8.1 |
Never had contact | 110 | 26.3 |
Data on the use of other health services has also been collected in household surveys to compare how often UHES is used relative to the other existing health services. Two hundred ninety one (69.61%) households had visited other health facilities at least once in the previous 6 months prior to study period.
By categorizing the contents of service related contacts in core UHES areas (disease prevention and control, family health, personal hygiene and environmental sanitation, and first aid and emergency services) the following results were obtained. Model family graduation requests will be presented separately.
Of all the households in the study area, Urban Health Extension Professionals reported that 3974 (14.3%) households had been trained and certified as model households. In comparison, the household survey data indicates that only 99 (23.7%) of the respondent households reported that they had been invited by Urban Health Extension Professionals to participate in model family training. From the 99 households who were asked to participate in model family training, 48 (48.5%) of them were willing to participate in the training and forty (83.3%) of these finished and graduated from their training. On the other hand, four households discontinued the training and four are actively still in training. Fifty one (51.5%) households were not willing to train as a model family. The reasons given by the household respondents included shortage of time 40 (78.4) and lack of interest to train 6 (11.8%).
Urban Health Extension Professionals participants complained most that the urban people work through the week and have no time for participation. Urban Health Extension Professionals tried to solve this problem by giving trainings on weekends, after work hours. All service related contacts included some element of health education (Table
3).
Table 3
Themes addressed by the urban health extension professionals in Bishoftu town, Central Ethiopia, March 2012 (n = 308)
Personal hygiene and environmental sanitation |
Housing and environmental sanitation | 238 | 77.3 |
Solid and liquid waste management | 194 | 63.0 |
Excreta disposal/latrine utilization | 181 | 58.8 |
Water and food safety | 146 | 47.4 |
Disease prevention and control |
Prevention of Malaria | 107 | 34.7 |
Prevention of diarrhoea | 73 | 19.5 |
Prevention of HIV/AIDS/TB | 30 | 9.7 |
Non communicable disease | 46 | 15.0 |
Mental health | 59 | 19.2 |
Family health |
Vaccination advice | 207 | 67.2 |
Nutrition counselling | 60 | 19.4 |
Family planning | 59 | 19.2 |
Pregnancy and delivery care | 42 | 13.6 |
Adolescent reproductive health | 24 | 7.8 |
Discussions were conducted with Urban Health Extension Professionals to explore the reasons why some topics are covered in some households, but not in others. The discussions indicate that the Urban Health Extension Professionals select the topics based on their perceived assessment of the household’s need.
In all of the kebeles, Urban Health Extension Professionals reported they were delivering health education related to disease prevention (both communicable and non-communicable). However, for HIV/AIDS they provided services in addition to disease prevention including HIV/AIDS counselling and testing.
From 308 households who had contacted Urban Health Extension Professionals in the previous 6 months, 205 (66.55%) reported receiving health education and/or advice related to disease prevention and control. Urban Health Extension Professionals indicate that the knowledge and behavioural practices of households towards prevention of both communicable and non-communicable disease was improved. Community members participated in the FGD reported they learned very important information about disease prevention. A female community discussant explained, “We learned from Urban Health Extension Professionals how much we are affecting our health and our children by simply affecting our environment”.
Regarding the lessons in family health, in all of the kebeles, Urban Health Extension Professionals reported they are providing family planning services (provision of oral contraceptives orinjectables) regularly. Regarding the other services on family health sessions, Urban Health Extension Professionals reported teaching the promotion and the utilization of maternal and child health services. Moreover, teachings about healthy behaviours like proper feeding habits (such as breast feeding, and supplements for babies), nutrition for pregnant women and adolescent reproductive health counselling were also reported.
From 308 households who had contacted Urban Health Extension Professionals, 252 (81.81%) reported they received health education on at least one of the packages included in family health. One hundred twenty six (40.90%) interviewees reported they received at least one service found in the family health package. The sessionsteaching about personal hygiene and environmental sanitation were planned to provide adequate information in seven areas. These include proper and safe excreta disposal, proper and safe solid and liquid waste management, water supply safety measures, food hygiene and safety measure, healthy home environment and personal hygiene.
From 308 households, 293 (95.12%) reported they received health education on at least one of the packages included in personal hygiene and environmental sanitation. Two hundred eighty eight (93.50%) received support in construction of sanitation facilities. A total of 275 households reported using different kinds of liquid waste disposal mechanism. From this group, 177 (64.4%) reported receiving advise and/or support from Urban Health Extension Professionals. A total of 103 households reported availability of hand washing facility near to their latrine. From this group, 52 (50.5%) reported they received advice and/or support from Urban Health Extension Professionals.
Qualitative data also supported this finding. Participants across the group felt the program helped households use hand washing facility near to their latrines; separate liquid waste disposal pits; use clean cooking practices, keep drinking water free from contamination and mange clean environment.
The other key service areas were first aid, emergency and referral. According to the implementation guideline, first aid and emergency services include attending precipitatous deliveries, fever management in under 5 year old children, managing minor wounds, bleeding and allergy management. None of Urban Health Extension Professionals in the study area started providing first aid and emergency services due to lack of supplies. The only activity in this package the Urban Health Extension Professionals reported was referral.
From 308 households, 47 (15.25%) reported they received help from Urban Health Extension Professionals to care for a sick person at home. Two hundred ninety one households visited the health facility for a different reason. From this group, none of them mentioned a prior Urban Health Extension Professionals contact for referral. Based on these group discussions and interviews, the major factor affecting the ability for these households to adopt and utilize healthy practices is the acceptance of the Urban Health Extension Professional. Community acceptance was also reported to be the most difficult to achieve. There was also resistance of some community members to accept home visits from Urban Health Extension Professionals, and to train as a model family. These were important factors in the ability of these households to adopt healthy practices. Urban Health Extension Professionals discussants mentioned that in beginning there were many people who were hesitant to accept their services. The following quotes are cited as examples: A participant said, “When we go to houses of rich people, they tell us that they have personal doctors and they don’t need us. When we go to the poor, they will tell us they are busy with their livelihood earnings”. Another participant said, “When I go to some of the houses, I have to growth kebele security officers otherwise no one is willing to talk to me”.
Urban health extension professionals said that community resistance sometimes rose from lack of awareness about the service. They explained that the usual community perception of health extension services was derived from the practice of giving services to rural community. Urban Health Extension Professionals explained, “Most of urban people live in unsanitary conditions that are worse than rural communities, but they still tell us that they are not rural people, therefore, don’t need health extension service”.
Similarly, community members participated in FGD said that, “If the community basically understand the Urban Health Extension Professionals purpose, I don’t think there is any reason to resist their service”.
Most of the Urban Health Extension Professionals mentioned supply problems creating resistance for some community members. The Urban Health Extension Professionals reported that lack of some supplies found within the guidelines (first aid and emergency supplies) created a problem in the delivery services. For example, Urban Health Extension Professionals indicated that some households especially, the poor, ask Insecticide-Treated Net (ITN), treatment for their children and anti-pain for minor illness. However, these activities and requests are clearly outside the objectives and purpose of the educators.. Urban Health Extension Professionals also indicated that the inability to provide a wider range of services adversely affected their credibility and community interest.
Both the community discussants and Urban Health Extension Professionals believe that the Urban Health Extension Professionals service would be more acceptable if Urban Health Extension Professionals could treat some illnesses. However, the supervisors and health centre managers did not agree with this perspective. They believe Urban Health Extension Professionals should work more on raising community awareness on the importance of preventive and promotive services rather than play a curative role in the health care delivery.
The other factors mentioned were economic and educational status of the household members. Urban Health Extension Professionals participants claimed that the degree of behavioural change and adoption of healthy practices in the community were often dependent on other societal factors. Urban Health Extension Professionals explained that economic status of households, such as lack of materials to construct sanitation facilities, provided a significant barrier to adoption of healthy household practices.
From the in-depth interviews with health center managers and supervisors, an additional factor in the acceptance of the Urban Health Extension Professionals was identified. emerged The subjective attributes of the particular Urban Health Extension Professionals, such as interest in their work and ability to communicate well, were identified as factors affected the acceptability of Urban Health Extension Professionals and furthermore, theutilization of their services. Urban Health Extension Professionals with good communication and interaction skills were reported to have built stronger ties with their community members.
Similarly, kebele administrative heads and health committee discussants identified if the Urban Health Extension Professionals had good communication skills, there was a higher demand for their services.
During their interviews, Urban Health Extension Professionals reported that institutional support from kebele officials could serve as the bridge for enhancing relationships between them and their community members. This was especially important for community members who are refusing their service. An FGD discussant from Urban Health Extension Professionals reported, “Kebele council support is very important and without it we may not have been able to enter some houses”. She added “Council members influence reluctant families to apply for some packages”.
The important role of kebele support in mobilizing the community and managing reluctant households was acknowledged by the program supervisors and health centre managers.
All the participants across the groups reported that they are witnessing progress acceptance by the people. The increasing community members’ participation in meetings called by Urban Health Extension Professionals, and the decrease in number of resistant households were mentioned as a positive indicator of progress. Urban Health Extension Professionals discussant said, “At first, most people saw the government cadres and thought we were working for political ends, but now they have at least realized that we are working for the sake of the people’s health”.