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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.
Tigray region is located in the northern part of Ethiopia. The study was conducted in two woredas (districts) of Tigray region: Enderta woreda, located in the South East zone of Tigray, and Kilte-Awlaelo woreda, located in the East zone of Tigray. Enderta has a population of 125,739 and six primary healthcare units with 12 satellite health posts. Kilte-Awlaelo has a population of 111,993 (2017/18: CSA, projected from 2007 census) and five primary healthcare units with 18 satellite health posts [23]. Like most rural communities in Ethiopia, the populations of the study areas live on subsistence farming and have limited access to basic healthcare. This study was part of a broader project to evaluate the Optimization of the Health Extension Program Intervention [24]. The intervention aimed to increase service utilization by under-five children. A baseline survey that was part of the evaluation was conducted from December 2016-February 2017 in 52 districts of which eight were rural woredas in Tigray. We have previously reported on WDG leaders based on that survey [16]. In order to capture a range of factors that may affect WDG leaders’ performance, we used data from that survey to select one woreda where WDG leaders had good knowledge on the promotion of maternal, neonatal, and child health, and one woreda with low knowledge. Fieldwork was done from July 2018 to August, 2018. We used purposive sampling to select study participants. With the assistance of health extension workers, 1–30 and 1 to 5 WDG leaders were selected from the two districts of Tigray region that were included in the previous survey. To be included in the study, the WDG leaders had to serve a large number of women, be active in their role, and be able to explain their ideas. In addition, we included health extension workers who supported the selected WDG leaders, health extension worker supervisors at health centers serving them, woreda maternal, neonatal and child health and Health Extension Program experts from study woredas, and a Health Extension Program coordinator from the regional health bureau (Table 1). WDG = women’s development group; HEW = health extension worker The first author (FA) and three research assistants with Masters in Public Health from the School of Public health, College of Health Science, Mekelle University, who were experienced in qualitative data collection, were trained for one day by the first author (FA). The training included a detailed review of the study protocol, topic guide and mock interviews. The topic guides were developed in English (S1 File), translated into the local language, Tigrigna (S2 File), pre-tested and modified. Data were collected in key informant interviews, in-depth interviews, and focus group discussions (Table 1). The topic guides included exploration of the participants’ experiences and opinions on WDG inputs, programmatic processes, and contribution to the primary healthcare system, especially maternal neonatal, and child health. The tools were continuously revised based on emerging themes during data collection. Seven key informant interviews, 15 in-depth interviews, and four focus group discussions were carried out. Each interview took on average one hour. Every focus group included 7–9 participants with a mean duration of one and a half hours. The interviews were conducted in Scheduled areas to provide privacy and avoid noise. All interviews were conducted in Tigrigna and were audio recorded with the permission from study participants. Audio recordings were transcribed verbatim and, after that, translated from Tigrigna into English. During data collection, interview notes were read and re-read. This provided an iterative process to reflect and be immersed in the details and specifics of the data, allowing for the discovery of important patterns, themes, and interrelationships, which were followed up in subsequent interviews. All transcripts were imported into ATLAS.TI 7.5.4 software for coding and analysis. Inductive data analysis was guided by three broad tasks: data reduction, data display and conclusion drawing or verification [25]. The transcripts were re-read, and coded until saturation of the emerging themes was achieved. Text searches were also carried out for pertinent key words and quotations. After debriefing sessions to compare findings by the study team members, interpretations were confirmed and related to the adapted framework for measuring community health workforce performance within primary health care systems [22] with the following thematic areas: 1) Inputs (logistics and commodities); 2) Programmatic processes (supportive systems, WDG development, support from community based groups); and 3) Community health systems performance outputs (WDG competency and WDG well-being) (Fig 1) and revision of the national guidelines to the WDG program [16]. The final outcome, improved maternal, neonatal, and child health, was beyond the scope of this study. Ethical approval was obtained from the Institutional Review Board (IRB) of Mekelle University, College of Health Sciences (protocol number 1433/2018). Support letters were also obtained from the Tigray regional health bureau and woreda health offices. Verbal consent was obtained from all participants, and the use of verbal consent was approved by the ethical committee. Privacy and confidentiality was maintained during interviews and discussions. Participants were also given identification numbers to conceal their identities. All audio recordings and translated notes were stored on password-protected files accessed only by the researcher.
