{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,10]],"date-time":"2026-04-10T01:06:13Z","timestamp":1775783173481,"version":"3.50.1"},"reference-count":47,"publisher":"BMJ","issue":"6","license":[{"start":{"date-parts":[[2021,6,8]],"date-time":"2021-06-08T00:00:00Z","timestamp":1623110400000},"content-version":"unspecified","delay-in-days":7,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000865","name":"Bill & Melinda Gates Foundation","doi-asserted-by":"crossref","award":["INV-009691"],"award-info":[{"award-number":["INV-009691"]}],"id":[{"id":"10.13039\/100000865","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2021,5,26]]},"published-print":{"date-parts":[[2021,6]]},"abstract":"<jats:sec><jats:title>Objective<\/jats:title><jats:p>The health system context influences the implementation of evidence-based practices and quality of healthcare services. Ethiopia aims at reaching universal health coverage but faces low primary care utilisation and substandard quality of care. We assessed the health extension workers\u2019 perceived context and the preparedness of health posts to provide services.<\/jats:p><\/jats:sec><jats:sec><jats:title>Setting<\/jats:title><jats:p>This study was part of evaluating a complex intervention in 52 districts of four regions of Ethiopia. This paper used the endline data collected from December 2018 to February 2019.<\/jats:p><\/jats:sec><jats:sec><jats:title>Participants<\/jats:title><jats:p>A total of 152 health posts and health extension workers serving selected enumeration areas were included.<\/jats:p><\/jats:sec><jats:sec><jats:title>Outcome measures<\/jats:title><jats:p>We used the Context Assessment for Community Health (COACH) tool and the Service Availability and Readiness Assessment tool.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>Internal reliability of COACH was satisfactory. The dimensions<jats:italic>community engagement<\/jats:italic>,<jats:italic>work culture<\/jats:italic>,<jats:italic>commitment to work<\/jats:italic>and<jats:italic>leadership<\/jats:italic>all scored high (mean 3.75\u20134.01 on a 1\u20135 scale), while<jats:italic>organisational resources, sources of knowledge<\/jats:italic>and<jats:italic>informal payments<\/jats:italic>scored low (1.78\u20132.71). The general service readiness index was 59%. On average, 67% of the health posts had basic amenities to provide services, 81% had basic equipment, 42% had standard precautions for infection prevention, 47% had test capacity for malaria and 58% had essential medicines.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p>The health extension workers had a good relationship with the local community, used data for planning, were highly committed to their work with positive perceptions of their work culture, a relatively positive attitude regarding their leaders, and reported no corruption or informal payments. In contrast, they had insufficient sources of information and a severe lack of resources. The health post preparedness confirmed the low level of resources and preparedness for services. These findings suggest a significant potential contribution by health extension workers to Ethiopia\u2019s primary healthcare, provided that they receive improved support, including new information and essential resources.<\/jats:p><\/jats:sec>","DOI":"10.1136\/bmjopen-2020-048517","type":"journal-article","created":{"date-parts":[[2021,6,9]],"date-time":"2021-06-09T16:26:54Z","timestamp":1623256014000},"page":"e048517","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":11,"title":["Health extension workers\u2019 perceived health system context and health post preparedness to provide services: a cross-sectional study in four Ethiopian regions"],"prefix":"10.1136","volume":"11","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-6486-0531","authenticated-orcid":false,"given":"Theodros","family":"Getachew","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1150-2319","authenticated-orcid":false,"given":"Solomon Mekonnen","family":"Abebe","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mezgebu","family":"Yitayal","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Anna","family":"Bergstr\u00f6m","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0710-7954","authenticated-orcid":false,"given":"Lars-Ake","family":"Persson","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4984-893X","authenticated-orcid":false,"given":"Della","family":"Berhanu","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2021,6,9]]},"reference":[{"key":"2024112411551920000_11.6.e048517.1","doi-asserted-by":"publisher","DOI":"10.1186\/s12913-020-06001-y"},{"key":"2024112411551920000_11.6.e048517.2","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(18)31668-4"},{"key":"2024112411551920000_11.6.e048517.3","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pmed.1002990","article-title":"Estimating the global impact of poor quality of care on maternal and neonatal outcomes in 81 low- and middle-income countries: a modeling study","volume":"16","author":"Chou","year":"2019","journal-title":"PLoS Med"},{"key":"2024112411551920000_11.6.e048517.4","first-page":"210","article-title":"Factors affecting medical service quality","volume":"43","author":"Mosadeghrad","year":"2014","journal-title":"Iran J Public Health"},{"key":"2024112411551920000_11.6.e048517.5","doi-asserted-by":"publisher","DOI":"10.1016\/j.acap.2013.04.013"},{"key":"2024112411551920000_11.6.e048517.6","doi-asserted-by":"publisher","DOI":"10.2471\/BLT.16.180190"},{"key":"2024112411551920000_11.6.e048517.7","doi-asserted-by":"crossref","first-page":"e0214454","DOI":"10.1371\/journal.pone.0214454","article-title":"The role of context in implementation research for non-communicable diseases: Answering the 'how-to' dilemma","volume":"14","author":"Daivadanam","year":"2019","journal-title":"PLoS One"},{"key":"2024112411551920000_11.6.e048517.8","unstructured":"World Health Organization . Service availability and readiness assessment (SARA): an annual monitoring system for service delivery reference manual. In Geneva: World Health Organization, 2013."},{"key":"2024112411551920000_11.6.e048517.9","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pmed.1002464"},{"key":"2024112411551920000_11.6.e048517.10","doi-asserted-by":"publisher","DOI":"10.1136\/bmjopen-2013-004749"},{"key":"2024112411551920000_11.6.e048517.11","doi-asserted-by":"crossref","first-page":"120","DOI":"10.1186\/s13012-015-0305-2","article-title":"Health system context and implementation of evidence-based practices-development and validation of the context assessment for community health (COACH) tool for low- and middle-income settings","volume":"10","author":"Bergstr\u00f6m","year":"2015","journal-title":"Implement Sci"},{"key":"2024112411551920000_11.6.e048517.12","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0131080"},{"key":"2024112411551920000_11.6.e048517.13","doi-asserted-by":"crossref","first-page":"201","DOI":"10.2147\/JMDH.S62294","article-title":"The community-based health extension program significantly improved contraceptive utilization in West Gojjam zone, Ethiopia","volume":"7","author":"Yitayal","year":"2014","journal-title":"J Multidiscip Healthc"},{"key":"2024112411551920000_11.6.e048517.14","first-page":"320","article-title":"Ethiopia's health extension workers use of work time on duty: time and motion study","volume":"32","author":"Tilahun","year":"2017","journal-title":"Health Policy Plan"},{"key":"2024112411551920000_11.6.e048517.15","doi-asserted-by":"crossref","DOI":"10.1186\/1478-4491-12-61","article-title":"How do health extension workers in Ethiopia allocate their time?","volume":"12","author":"Mangham-Jefferies","year":"2014","journal-title":"Hum Resour Health"},{"key":"2024112411551920000_11.6.e048517.16","doi-asserted-by":"crossref","unstructured":"Wang H , Tesfaye R , Ramana GN . Ethiopia health extension program: an institutionalized community approach for universal health coverage 2016.","DOI":"10.1596\/978-1-4648-0815-9"},{"key":"2024112411551920000_11.6.e048517.17","doi-asserted-by":"publisher","DOI":"10.1186\/1472-6963-14-1"},{"key":"2024112411551920000_11.6.e048517.18","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0249644"},{"key":"2024112411551920000_11.6.e048517.19","first-page":"1","article-title":"Community health extension program of Ethiopia, 2003\u20132018: successes and challenges toward universal coverage for primary healthcare services","volume":"15","author":"Assefa","year":"2019","journal-title":"Global Health"},{"key":"2024112411551920000_11.6.e048517.20","doi-asserted-by":"publisher","DOI":"10.1186\/s12913-019-4537-8"},{"key":"2024112411551920000_11.6.e048517.21","unstructured":"Ministry of Health . Ethiopian Health Sector Transformation Plan.2015\/16 - 2019\/20. 20. Federal Democratic Republic of Ethiopia Ministry of Health, 2015."},{"key":"2024112411551920000_11.6.e048517.22","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0239361","article-title":"Quality of clinical assessment and management of sick children by health extension workers in four regions of Ethiopia: a cross-sectional survey","volume":"15","author":"Daka","year":"2020","journal-title":"PLoS One"},{"key":"2024112411551920000_11.6.e048517.23","doi-asserted-by":"crossref","first-page":"2100","DOI":"10.1111\/apa.14888","article-title":"Health extension workers' diagnostic accuracy for common childhood illnesses in four regions of Ethiopia: a cross-sectional study","volume":"108","author":"Getachew","year":"2019","journal-title":"Acta Paediatr"},{"key":"2024112411551920000_11.6.e048517.24","doi-asserted-by":"publisher","DOI":"10.1136\/bmjopen-2020-040868"},{"key":"2024112411551920000_11.6.e048517.25","doi-asserted-by":"crossref","first-page":"e0247474","DOI":"10.1371\/journal.pone.0247474","article-title":"Association between a complex community intervention and quality of health extension workers' performance to correctly classify common childhood illnesses in four regions of Ethiopia","volume":"16","author":"Getachew","year":"2021","journal-title":"PLoS One"},{"key":"2024112411551920000_11.6.e048517.26","doi-asserted-by":"crossref","first-page":"12","DOI":"10.1371\/journal.pmed.1002465","article-title":"Bridging the quality chasm in maternal, newborn, and child healthcare in low- and middle-income countries","volume":"14","author":"Persson","year":"2017","journal-title":"PLoS Med"},{"key":"2024112411551920000_11.6.e048517.27","doi-asserted-by":"publisher","DOI":"10.1186\/s12913-020-06001-y"},{"key":"2024112411551920000_11.6.e048517.28","doi-asserted-by":"crossref","DOI":"10.3402\/gha.v9.31572","article-title":"Response process and test\u2013retest reliability of the context assessment for community health tool in Vietnam","volume":"9","author":"Duc","year":"2016","journal-title":"Glob Health Action"},{"key":"2024112411551920000_11.6.e048517.29","doi-asserted-by":"publisher","DOI":"10.1177\/0193945903260554"},{"key":"2024112411551920000_11.6.e048517.30","first-page":"1","article-title":"From impressions to data: increasing the objectivity of cognitive interviews","volume":"1","author":"Conrad","year":"1996","journal-title":"Proc Sect Surv Res Methods, Annu Meet Stat Assoc"},{"key":"2024112411551920000_11.6.e048517.31","unstructured":"WHO . Service availability and readiness assessment (SARA) an annual monitoring system for service delivery reference manual 2013."},{"key":"2024112411551920000_11.6.e048517.32","unstructured":"Gliem JA , Gliem RR . Midwest research to practice conference in adult, continuing and community education 2003."},{"key":"2024112411551920000_11.6.e048517.33","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1186\/s13643-017-0566-8","article-title":"The influence of contextual factors on healthcare quality improvement initiatives: what works, for whom and in what setting? protocol for a realist review","volume":"6","author":"Coles","year":"2017","journal-title":"Syst Rev"},{"key":"2024112411551920000_11.6.e048517.34","doi-asserted-by":"publisher","DOI":"10.1111\/j.1468-0009.2010.00611.x"},{"key":"2024112411551920000_11.6.e048517.35","doi-asserted-by":"crossref","DOI":"10.1080\/16549716.2018.1532631","article-title":"Ready to deliver maternal and newborn care? health providers' perceptions of their work context in rural Mozambique","volume":"11","author":"Mocumbi","year":"2018","journal-title":"Glob Health Action"},{"key":"2024112411551920000_11.6.e048517.36","first-page":"1","article-title":"Community participation and maternal health service utilization: lessons from the health extension programme in rural southern Ethiopia","volume":"3","author":"Datiko","year":"2019","journal-title":"J Glob Health Rep"},{"key":"2024112411551920000_11.6.e048517.37","doi-asserted-by":"publisher","DOI":"10.1186\/1478-4491-13-1"},{"key":"2024112411551920000_11.6.e048517.38","doi-asserted-by":"crossref","unstructured":"Teklehaimanot A , Kitaw Y , G\/Yohannes A , et al . Study of the working conditions of health extension workers in Ethiopia. Ethiop J Heal Dev 2008;21.doi:10.4314\/ejhd.v21i3.10055","DOI":"10.4314\/ejhd.v21i3.10055"},{"key":"2024112411551920000_11.6.e048517.39","doi-asserted-by":"publisher","DOI":"10.1186\/1478-4491-13-1"},{"key":"2024112411551920000_11.6.e048517.40","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1186\/s12960-018-0319-3","article-title":"Factors contributing to motivation of volunteer community health workers in Ethiopia: the case of four woredas (districts) in Oromia and Tigray regions","volume":"16","author":"Jigssa","year":"2018","journal-title":"Hum Resour Health"},{"key":"2024112411551920000_11.6.e048517.41","doi-asserted-by":"publisher","DOI":"10.1186\/s12913-020-06001-y"},{"key":"2024112411551920000_11.6.e048517.42","doi-asserted-by":"publisher","DOI":"10.1186\/1478-4491-7-1"},{"key":"2024112411551920000_11.6.e048517.43","doi-asserted-by":"crossref","first-page":"738","DOI":"10.2471\/BLT.17.191916","article-title":"Service readiness of health facilities in Bangladesh, Haiti, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Uganda and the United Republic of Tanzania","volume":"95","author":"Leslie","year":"2017","journal-title":"Bull World Health Organ"},{"key":"2024112411551920000_11.6.e048517.44","doi-asserted-by":"crossref","unstructured":"Acharya K , Paudel YR . General health service readiness and its association with the facility level indicators among primary health care centers and hospitals in Nepal. J Glob Health Rep 2019;3.doi:10.29392\/joghr.3.e2019057","DOI":"10.29392\/joghr.3.e2019057"},{"key":"2024112411551920000_11.6.e048517.45","doi-asserted-by":"crossref","first-page":"5803","DOI":"10.3390\/ijerph17165803","article-title":"Implementation of the \u2018optimising the health extension program\u2019 intervention in ethiopia: A process evaluation using mixed methods","volume":"17","author":"Okwaraji","year":"2020","journal-title":"Int J Environ Res Public Health"},{"key":"2024112411551920000_11.6.e048517.46","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0191962"},{"key":"2024112411551920000_11.6.e048517.47","doi-asserted-by":"crossref","DOI":"10.1186\/s12913-015-0906-0","article-title":"The influence of context on the effectiveness of hospital quality improvement strategies: a review of systematic reviews","volume":"15","author":"Kringos","year":"2015","journal-title":"BMC Health Serv Res"}],"container-title":["BMJ Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjopen-2020-048517","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,11,24]],"date-time":"2024-11-24T19:55:58Z","timestamp":1732478158000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmjopen.bmj.com\/lookup\/doi\/10.1136\/bmjopen-2020-048517"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,6]]},"references-count":47,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2021,6,9]]},"published-print":{"date-parts":[[2021,6]]}},"alternative-id":["10.1136\/bmjopen-2020-048517"],"URL":"https:\/\/doi.org\/10.1136\/bmjopen-2020-048517","relation":{},"ISSN":["2044-6055","2044-6055"],"issn-type":[{"value":"2044-6055","type":"print"},{"value":"2044-6055","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,6]]}}}