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Does a complex intervention targeting communities, health facilities and district health managers increase the utilisation of community-based child health services? A before and after study in intervention and comparison areas of Ethiopia

  • Berhanu, Della1, 2
  • Okwaraji, Yemisrach Behailu1
  • Defar, Atkure2, 3
  • Bekele, Abebe2
  • Lemango, Ephrem Tekle4
  • Medhanyie, Araya Abrha5
  • Wordofa, Muluemebet Abera6
  • Yitayal, Mezgebu3
  • W/Gebriel, Fitsum7
  • Desta, Alem5
  • Gebregizabher, Fisseha Ashebir5, 8
  • Daka, Dawit Wolde6
  • Hunduma, Alemayehu6, 9
  • Beyene, Habtamu7, 10
  • Getahun, Tigist3, 11
  • Getachew, Theodros2, 3
  • Woldemariam, Amare Tariku3
  • Wolassa, Desta2
  • Persson, Lars Åke1, 2
  • Schellenberg, Joanna1
  • 1 Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK , London
  • 2 Ethiopian Public Health Institute, Addis Ababa, Ethiopia , Addis Ababa (Ethiopia)
  • 3 University of Gondar, Gondar, Ethiopia , Gondar (Ethiopia)
  • 4 Ethiopia Ministry of Health, Addis Ababa, Ethiopia , Addis Ababa (Ethiopia)
  • 5 Mekelle University, Mekelle, Ethiopia , Mekelle (Ethiopia)
  • 6 Jimma University, Jimma, Ethiopia , Jimma (Ethiopia)
  • 7 Hawassa University, Hawassa, Ethiopia , Hawassa (Ethiopia)
  • 8 Tigray Regional Health Bureau, Mekelle, Ethiopia , Mekelle (Ethiopia)
  • 9 Oromia Regional Health Bureau, Addis Ababa, Ethiopia , Addis Ababa (Ethiopia)
  • 10 Southern Nations, Nationalities & Peoples Regional Health Bureau, Hawassa, Ethiopia , Hawassa (Ethiopia)
  • 11 Amhara Regional Health Bureau, Baher Dar, Ethiopia , Baher Dar (Ethiopia)
Published Article
BMJ Open
Publication Date
Sep 15, 2020
DOI: 10.1136/bmjopen-2020-040868
PMID: 32933966
PMCID: PMC7493123
PubMed Central


Introduction Ethiopia successfully reduced mortality in children below 5 years of age during the past few decades, but the utilisation of child health services was still low. Optimising the Health Extension Programme was a 2-year intervention in 26 districts, focusing on community engagement, capacity strengthening of primary care workers and reinforcement of district accountability of child health services. We report the intervention’s effectiveness on care utilisation for common childhood illnesses. Methods We included a representative sample of 5773 households with 2874 under-five children at baseline (December 2016 to February 2017) and 10 788 households and 5639 under-five children at endline surveys (December 2018 to February 2019) in intervention and comparison areas. Health facilities were also included. We assessed the effect of the intervention using difference-in-differences analyses. Results There were 31 intervention activities; many were one-off and implemented late. In eight districts, activities were interrupted for 4 months. Care-seeking for any illness in the 2 weeks before the survey for children aged 2–59 months at baseline was 58% (95% CI 47 to 68) in intervention and 49% (95% CI 39 to 60) in comparison areas. At end-line it was 39% (95% CI 32 to 45) in intervention and 34% (95% CI 27 to 41) in comparison areas (difference-in-differences −4 percentage points, adjusted OR 0.49, 95% CI 0.12 to 1.95). The intervention neither had an effect on care-seeking among sick neonates, nor on household participation in community engagement forums, supportive supervision of primary care workers, nor on indicators of district accountability for child health services. Conclusion We found no evidence to suggest that the intervention increased the utilisation of care for sick children. The lack of effect could partly be attributed to the short implementation period of a complex intervention and implementation interruption. Future funding schemes should take into consideration that complex interventions that include behaviour change may need an extended implementation period. Trial registration number ISRCTN12040912 .

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