ConcernWorldwide_Endline_HEWs_Capacity_Assessment_RCT_Study_Final

INDEX CoNsult
IMPROVING CAPACITY AND SKILLS OF HEALTH EXTENSION WORKERS
THROUGH MODULE-BASED TRAINING IN TIGRAY REGION, ETHIOPIA:
Randomised Control Trial
Asrade Abate (MD, MSc)
December, 2013

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IMPROVINGCAPACITY ANDSKILLS OFHEALTH EXTENSIONWORKERSTHROUGHMODULE-BASEDTRAINING INTIGRAYREGION,ETHIOPIA:RANDOMISED CONTROLTRIAL
Acknowledgment
I acknowledge the valuable assistance of Tigray Regional Health Bureau, Concern Worldwide staff and
experts who helped in the review of this document.
I am also grateful to health post staff involved in the study and gave generously of their time in
completing the survey questions and data clerks who continued to deliver the data.

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CONTENTS
TABLES, FIGURES 4
ABBREVIATIONS 5
EXECUTIVE SUMMARY 6
1. INTRODUCTION 9
1.1. Ethiopia - Country Information 9
1.2. The Health Extension Programme 10
1.3. Infant and Young Child Feeding Practice 12
1.4. Piloting the CMAM Intervention 12
2. OBJECTIVES OF THE STUDY 13
3. METHODS AND MATERIALS 14
3.1. Study settings 14
3.2. Sample size 14
3.3. Data Collection 15
3.4. Data Management and Statistical Analysis 15
3.5. Limitations 16
3.6. Ethical considerations 16
4. RESULTS 17
4.1. Characteristics of the respondents 17
4.2. Provision of Training to HEWs 18
4.3. Assessment of Knowledge of HEWs 19
4.4. Assessment of Skills of HEWs 20
4.5. Medical Equipment, Supplies and Reference Materials 23
4.6. Service Delivery Activities (Health Post and Outreach) 24
4.7. Patient Screening and Referral 26
4.8. Data Compiling and Reporting 27
4.9. Community perception and Challenges 27
5. DISCUSSION 29
ANNEX I: References 31
ANNEX II: Health Posts/HEWs interviewed during end-line 32
ANNEX III: Informed Consent Form 34
ANNEX IV: Questionnaire 01 (HEWs Interview) 35
ANNEX V: Questionnaire 02 (Household Interview) 47
ANNEX VI: FGD Guideline 48

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TABLES, FIGURES
Table 1: Health Extension Programme packages, FMOH 2009 9
Table 2: Minimum Standard of Medical Equipment, Drugs and Supplies at HPs, FMHACA 10
Table 3: Number of Staff per Health Post 16
Table 4: Place of residence of HEWs and distance from HPs 16
Table 5: Socio-demographic characteristics of respondents, training and population 17
Table 6: Overview of the training provide to HEWs in 2013 17
Table 7: Knowledge of HEWs about breastfeeding of infants 18
Table 8: Knowledge of HEWs about complementary feeding of infants 19
Table 9: Knowledge of HEWs about micronutrient feeding of infants 19
Table 10: Number of HEWs grouped by the total score attained 20
Table 11: Number of HEWs who were able to identify malnutrition using clinical signs 20
Table 12: Number of HEWs who are able to apply MUAC measurement techniques 20
Table 13: Number of HEWs who can apply the appropriate methods to measure weight 21
Table 14: Number of HEWs who can spot difficulties of mothers and conduct counseling 21
Table 15: Number of HEWs who demonstrated correct positioning & attachment during BF 21
Table 16: Possession of various Medical Equipment, Furniture, Supplies and materials by HEWs 22
Table 17: Routine and periodic tasks performed by HEWs and time allocation 23
Table 18: List of important tasks identified and ranked by HEWs as per level of priority given. 24
Table 19: Nutrition and related tasks performed by HEWs and time allocation 25
Table 20: Top five referral diseases by HEWs 25
Table 21: Patient screening and referral activity by HEWs 25
Table 22: Report preparation activities by HEWs 26
Figure 1: The administrative divisions within Tigray Region and study Woredas 11

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ABBREVIATIONS
CMAM: Community Management of Acute Malnutrition
CSA: Central Statistical Agency
DHS: Demographic and Health Survey
FMHACA: Food, Medicine, Health Care Administration and Control Authority
FMOH: Federal Ministry of Health
HC: Health Centre
HEP: Health Extension Programme
HEW: Health Extension Worker
HSDP: Health Service Development Programme
ICCM Integrated Community-Case Management
IYCF: Infant and Young Child Feeding
MDG: Millennium Development Goal
MUAC: Mid Upper Arm Circumference
NGO: Non-Governmental Organization
NSU: Nutrition Stabilization Unit
ORS: Oral Rehydration Salts
ORT: Oral Rehydration Therapy
RHB: Regional Health Bureau
RUTF: Ready to Use Therapeutic Food
SNNPR: Southern Nations, Nationalities and People’s Region
TB: Tuberculosis
VAD: Vitamin A Deficiency
VCT: Voluntary Counseling and Testing
WFP: World Food Programme
WHO: World Health Organization

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EXCUTIVE SUMMARY
This study was conducted as part of the Community based Management of Acute Malnutrition (CMAM)
project piloted in Tigray Region, Ethiopia. The Piloting of CMAM project, funded by World Bank via the
Japanese Social Development Fund (JSDF) and implemented by Concern Worldwide Ethiopia aimed to
support the Ethiopian government in the effective implementation of CMAM in the Tigray region. The
project supported the Regional Health Bureau (TRHB) in 5 Woredas which was later expanded to a total
of 24 Woredas. An integral part of the project was building the capacity of HEWs to recognise and
treat/refer children suffering from SAM using the CMAM. For this, Concern produced training guides;
provided on-the-job training; job-aids; and also supplied logistic and material support. In this respect,
two studies were conducted which evaluated the effectiveness of the capacity building activity
provided for HEWs.
The studies were randomized, controlled, pre and post-test intervention studies investigating the
knowledge, attitude and skill of HEWs towards CMAM/IYCF practices. The studies focused on collecting
comparable information to assess the achievements before and after the intervention. The studies
were carried out in four selected Woredas in Tigray Region, namely: Alaje, Endamehone, Ofla and Raya
Azebo. Health Posts were used as a unit of randomization. The sample size was calculated on the basis
of achieving at least a 40% difference between groups using 5% significance, 95% power and also taking
into account a 20% drop-out of participants. Following the baseline evaluation of the HEWs, several
capacity building measures were implemented in HPs designated as an intervention group but not the
control group. The intervention package included theoretical and practical trainings, on-job trainings
and logistic support. The study applied structured questionnaires and checklists administered to HEWs
and households. To obtain comparable information, the mean scores of the pre-test were weighed
against the post-test for each study group, significance set at p<0.05. Descriptive frequencies;
independent-test; and ANOVA were applied during analysis. Qualitative data obtained from the FGDs
and household in-depth interviews was organised under different thematic areas and triangulation of
data from different sources was applied to verify the findings.
At baseline, the total number of HEWs invited to the study was 98 (in 64 HPs) which were also invited
for the end-line study; however, some of the HEWs were not available and a total 13 HEWs were
missing. As a result four HPs were dropped from the study (accommodated within the dropout quota).
The distribution of HEWs varied between 1 and 3 (mean = 1.88 per health post) and a higher proportion
(78.6%) of HPs has 2 HEWs. The end-line study revealed an increase in the number and distribution of
HEWs per Health Post compared to the baseline. Various health services were delivered at the
HP/household by a team of HEWs but majority of the activities were delivered at the household. None
of the HEWs/WDAs mentioned utilization of vehicle transport during their household visits. In all cases,
the only means of travel was on foot. On average, 26 household visits were made by WDAs on a
monthly basis, slightly increased during the post-intervention assessment.
The number of trainings received by HEWs during the baseline was 2.43 and no statistical significant
differences between study groups. Nevertheless, the post-test assessment revealed that the number of
trainings received by HEWs and total training hours in the intervention groups was increased in contrast
to the control group where the number of trainings received showed a slight drop. The number of
trainings attended by HEWs during the intervention period varied between 1 and 5 (mean = 2.45), an
increased mean value compared to the baseline results. On average, HEWs in the intervention group
received 1.19 hours of training on nutrition. This was a reflection of the targeted training, delivered
through the special intervention package. As a result, an improved level of knowledge and acquisition
of skills by HEWs was observed in the intervention group in contrast to the control group. In addition,
the end-line results demonstrated that the level of knowledge was directly correlated to the total
number of trainings and the association was revealed by statistically significant correlation (p <0.05)
suggesting induction of the intervention package was associated with an increased knowledge, skill and
implementation capacity.

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In the baseline assessment, knowledge of HEWs in the intervention group averaged 18.26 out of out of
30 points, while the control group averaged 18.60 points. Statistical test verified that the knowledge
was the same across the study groups (p>0.05). The end-line assessment showed results: 19.67 for the
control group averaged 23.62 the intervention group. Baseline results showed that knowledge about
complementary feeding and essential minerals was low; particularly knowledge about breastfeeding
was the lowest for both study groups. In contrast, the post-intervention results concluded substantial
boost for all knowledge assessment variables which were statistically significant. The intervention
package applied enabled the HEWs to deliver an extensive health education, promoting IYCF practices,
household level screening, follow-up throughout the community and they also applied a good level of
effort through defaulter tracing thereby actively supporting the progress of CMAM.
More than half of the HEWs interviewed scored below average and the skills and performances of HEWs
were more or less similar at baseline. However, the post-intervention assessment revealed statistically
significant differences between the intervention and control groups for all items analysed. In the
intervention group, more than 90% of HEWs scored above the mean they demonstrated their skills
correctly. The skills in applying MUAC technique, was the best learned. This is a reflection of the fact
that malnutrition-focused trainings were delivered resulting in overall improvement of skills; hence
reinforcing the need for widespread training of similar pattern to HEWs who didn’t receive the
intervention package. Score for positioning and attachment of baby during breastfeeding had the
lowest score: an area of recommendation in the upcoming trainings. In the control group, the scores
remained constant or even declined.
Unlike the baseline results, where 30% or more of the HPs were in short of various equipment and
supplies, the end-line assessment revealed an improved logistics support. Important supplies provided
to those HEWs in the intervention group included: Weighting Scale; Lockable RUTF storage shelf; ORS
synthesis utensils, porridge preparation and demonstration tools; and stationary materials (OTP Chart
and various reporting forms). In addition, other supports were also given including quick reference
materials, demonstration charts and various IEC/BCC materials. End-line assessment showed
availability of a complete list of reference materials in all of those HPs and zero requests for additional
reference materials. The post-intervention results showed statistically significant improvement but not
for the control group.
Both studies showed that HEWs systematically shared HP as well as outreach tasks by applying rotation
method: one assured routine HP operations and the other visited households and vise-versa.
Considering a 40hrs/week working time for a government employee, mean working hours per week
were 25.77 for health post activities and 33.75 for outreach activities. In addition, compared to
baseline results, the post-intervention study detected a new task practiced by HEWs, the Outpatient
Therapeutic Programme (OTP). Screening, Treatment, RUTF distribution, Referral and Follow-up of
SAM cases were activities under the umbrella of the OTP. Clearly the post-intervention data shows the
number of tasks carried out had been increased, perhaps due to the addition of OTP and related tasks,
attrition of HEWs, increased catchment, or reallocation of extra time for other demanding activities at
the HP.
Among the list of important activities, nutrition and related activities were widespread and also
regarded as one of the top priority tasks carried out by the HEWs. About 48.5% of the overall time was
allocated for nutrition and related activities. On average 3.88 hours/day and 8.19 days/ month were
spent on nutrition tasks. Post-intervention results revealed more time spent on nutrition and related
activities across all items analysed. Furthermore, post-intervention results indicated improved
allocation of time for nutrition tasks including screening, treatment and referral; and also enhanced
outreach case detection through community involvement The HEWs were able to screen and refer
significant number of patients to health centres particularly, increased quarterly malnutrition
referrals. The changes were observed only in the intervention group and were statistically significant
and conclusions can be made that it was due to the intervention. On average, a consistent number of
HEWs produce 6 to 7 types of reports, one weekly report and five or more monthly reports and in
extreme cases, as high as 17. Few HEWs were also found engaged in daily reporting tasks.

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The community verified that HPs were key in health service provision and through time they witnessed
the service delivery was getting closer to their home, particularly since the start of house-to-house
services provided through WDAs in collaboration with HEWs. Various services were sought by the
community at large and also confirmed adequate and all-time access to these service including
emergency situations. Community members asserted that they regularly received health education by
HEWs/WDAs and most attended various sessions despite circumstances. Majority of the community
respondents confirmed that the education delivery method was clearly understandable as it was
assisted by demonstrations. As a results, most appreciated the benefits they acquired from the health
education and they were also able to mention methods how they recognize illnesses particularly, cases
with malnutrition.
Both studies concluded that insufficient resource and time; focus on other demanding activities (as in
farming); arguments among family member to practice advices; and also shortage of medical supplies
needed at the health post were prominent challenges faced by HEWs in promoting nutrition. HEWs
were also asked to specify main challenges they confronted in relation to their activity. Prominent
challenges raised by most HEWs were: inadequate salary compared to the work load; lengthy, tiresome
travel and absence of transport for household visit; inadequate staff; lack of office stationary, forms
and registers; insufficient attention and priority given to health service provision by Woreda
administration; loose supervision and support; lack of access to education & training; duplication of
reports; and also availability of other competing and appealing jobs in the market that draws their
attention.
In conclusion, the intervention package was well received by the HEWs and improvements could be
directly attributed to the capacity building intervention. Besides, the intervention resulted in a
substantial acquisition of knowledge and skills, thereby effectively increased HEWs activity in support
of CMAM implementation. It is recommended that the time allocated for similar capacity building
intervention be increased. On the hand, the bulk of tasks assigned to HEWs are continually increasing;
thus, some of the burdens including reporting should be alleviated.

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1 INTRODUCTION
1.1 Ethiopia - Country Information
Ethiopia has the second largest population in sub-Saharan Africa, with a population of about
84 million people. The country introduced a federal government structure in 1994 composed
of nine Regional States: Tigray, Afar, Amhara, Oromia, Somali, Benishangul Gumuz, Southern
Nations Nationalities and Peoples Region, Gambella and Harrari and two city Administrations
(Addis Ababa and Dire Dawa). The Regional States are administratively divided into 78 Zones
and 710 Woredas [1]
. Woreda is the basic decentralized administrative unit which is further
divided into Kebeles (about 15,000 Kebeles countrywide) organised under peasant associations
(10,000 Kebeles) and urban dwellers associations (5,000 Kebeles). Kebele is the lowest
administrative unit and a geographically defined area within a Woreda. On average, each
Kebele has a population of about 5,000[1]
.
Ethiopia lies within the tropics and experiences a heavy burden of disease mainly attributed
to communicable, infectious diseases and nutritional deficiencies. Limited healthcare
infrastructure, shortage and high turnover of human resource and inadequacy of essential
drugs and supplies have also contributed to the burden. However, there has been encouraging
improvements in the coverage and utilization of the health services and improved access to
and quality of rural primary health care over the periods of implementation of Health Sector
Development Plan (HSDP) [2]
. One of the success stories of implementation of the HSDP is
improved access to and quality of rural primary healthcare through the Health Extension
Programme (HEP).
1.2 The Health Extension Programme
Ethiopia launched the Health Extension Programme (HEP) in 2003. The programme’s
objectives were to reach the poor and deliver preventive and basic curative, high-impact
interventions to the population. The introduction of HEP in Ethiopia was a government-led
community health service delivery programme, with innovative and cost effective
approaches, designed to improve access and utilization of preventive, wellness and basic
curative services.
The HEP basically consists of a health post which is operated by front-line community health
personnel, called Health Extension Workers (HEW). On average, a health post has a
catchment population of 5,000. The health post is under the supervision of the Woreda
(equivalent of district) health office and Kebele administration and receives technical and
practical support from the nearby health centre. A health centre is the primary Health Care
Unit that serves 25,000 people and functions as a referral centre and logistic hub for a health
post and also offers technical support.
The HEP focuses on four major areas of preventive healthcare and provides 16 different
packages to reach rural community at large and to address inequity (Table 1). In a short
period, the government deployed more than 30,000 HEWs. These Health Extension Workers
are posted to rural communities across Ethiopia, where they provide better and more
equitable access to health services for the population in a sustainable manner [8].

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Health extension workers are recruited using a specific criteria from the same communities in
which they will work. The criteria include: female, at least 18 years old, have at least
completed secondary school education and speak the local language. Females are selected
because most of the HEP packages relate to issues affecting mothers and children; thus
communication is thought to be easier between mothers and a female HEW and more
culturally acceptable. Upon completion of one year training, pairs of HEWs are assigned as
salaried government employees in each Kebele, where they staff health posts and work
directly with individual households. Each Kebele has a health post that serves 5,000 people
and functions as an operational centre for the health extension workers.
In general, the HEWs are expected to conduct household visits to deliver the 16 different
packages of healthcare prevention and promotion messages. The promotion of appropriate
breastfeeding and infant and young children feeding practices IYCF) is one of the packages
within the nutrition category. In addition, HEWs identify cases, refer cases to health centres,
perform home-based follow-up on referrals, manage the operation of health posts and submit
regular reports to Woreda Health Offices [8]
. They are also expected to identify, train and
collaborate with voluntary community health workers called Women’s Development Army.
Table 1: Health Extension Programme packages, FMOH 2009
Hygiene & environmental
sanitation
Disease prevention
& control
Family health
services
Health education
& communication
Proper and safe excreta
disposal system
Family planning
Health education
& communication
Proper and safe solid and liquid
waste management
Prevention and control
of malaria
Maternal & child
health
Water supply safety measures
Prevention and control
of tuberculosis &
HIV/AIDS
Adolescent
reproductive health
Food hygiene and safety
measures
First aid Nutrition
Healthy home environment Immunization
Arthropod and rodent control
Personal hygiene
Upon assignment, health extension workers conduct a baseline survey of the Kebele, using a
standardized tool. They map households and the population by age category. They also
prioritize health problems, set targets with respect to the 16 packages of services and draft a
plan of action for the year. The draft plan of action is then submitted to the village council
for approval.
In terms of medical equipment and supplies, each Health Post is equipped as per the standard
of level of provision of health care services. For this, a standard document has been
developed that states the minimum standards and requirements for the establishment and
maintenance of a health post in order to protect the public interest by promoting the health,
welfare and safety of individuals. Accordingly, health posts shall be staffed by at least two
HEWs and provided with the necessary logistics, medical equipment and supplies (Table 2).

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Table 2: Minimum Standard of Medical Equipment, Drugs and Supplies at HPs, FMHACA
1 Stethoscope
2 Sphygmomanometer
3 Thermometer
4 Kidney Basin
5 Delivery Set
6 Delivery Couch
7 Examination Coach
8 Storage Shelves (Medical Equipment, Supplies, Documents)
9 Cold Box
10 Adult & Child Weighing Scale
11 Autoclave or equipment with similar purpose
12 IEC Materials
13 Drug Lists and Supplies
1.3 Infant and Young Child Feeding Practice
Children constitute a very large percentage of the population in Ethiopia: 44.7% are under 15
years of age, 17.8% are under 5 years of age and 3.6% are under 1 year of age [1]
. According to
the Ethiopian DHS (2011), the infant mortality rate was 59 deaths per 1,000 live births. The
estimate of child mortality is 31 deaths per 1,000 children surviving to 12 months of age,
while the overall under-5 mortality rate for the same period is 88 deaths per 1,000 live births.
Sixty-seven percent of all deaths to children under-5 children in Ethiopia take place before
the child’s first birthday and the contribution of malnutrition is thought to underlie about 57%
of all under-5 deaths [9]
.
In recent years however, there has been significant progress in addressing these problems.
The government, in collaboration with development partners, has applied considerable effort
directed at improving access and use of primary care services, particularly among women and
children in rural settings, through the HEP. In addition, several policies and strategies are
being undertaken by the Federal Ministry of Health and stakeholders to accelerate the
promotion of breastfeeding and strengthen community outreach mechanisms to improve
infant and young child feeding practices. Community-based interventions to promote and
support IYCF practices, through HEP, are emphasized in the IYCF strategy.
The Health Extension Programme, nutrition being one component of the package, features
monthly growth monitoring and a community discussion forum. It also offers an integrated
package promoting optimal breastfeeding (especially early and exclusive breastfeeding),
adequate complementary feeding, control of anaemia, vitamin A deficiency and iodine
deficiency disorders and feeding of the sick child. In addition, the HEP also promotes
improved dietary practices during pregnancy and lactation as part of the package. Recently,
there are additions to the list of tasks including CMAM/IYCF.
Recognizing that the HEWs must address many health topics and cover a sizable area, the
significance of improving the capacity of these health workers through training should be an
important focus area. In this respect, studies were conducted in several countries which
evaluated the effectiveness of training for health workers in the promotion of nutrition and
health interventions. Several found evidence of significant improvement after the training.

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IMPROVINGCAPACITY ANDSKILLS OFHEALTH EXTENSIONWORKERSTHROUGHMODULE-BASEDTRAINING INTIGRAYREGION,ETHIOPIA:RANDOMISEDCONTROLTRIAL
1.4 Piloting the CMAM Intervention
The Piloting Community Based Management of Acute Malnutrition Project, funded by World
Bank-Japanese Social Development Fund (JSDF) and implemented by Concern Worldwide
Ethiopia, began in August 2009 and aims to support the Ethiopian Government in its efforts to
improve nutrition outcomes in Tigray. Concern has been supporting the Regional Health
Bureau (RHB) in five Woredas in Tigray to integrate community-based management of acute
malnutrition (CMAM) into routine health services. In June 2011, the project was expanded to
24 Woredas. The goal of the programme was to contribute to the reduction in morbidity and
mortality due to severe acute malnutrition (SAM) amongst children less than five years of age.
Figure 1: The administrative divisions within Tigray Region and study Woredas.
Before the piloting of CMAM, linkages between treatment of SAM and promotion of optimal
nutrition practices at community and HP level are not well defined. Training materials and
job aids to help HEWs effectively treat and prevent SAM and promote optimal infant and
young child feeding (IYCF) practices were lacking and fragmented. As a result, opportunities
to promote improved nutrition at key contact points at community level were missed. In
order to strengthen the CMAM programme, it was believed that new training materials which
include community mobilisation techniques, CMAM processes and IYCF messages could
improve the nutrition knowledge, capacity and actions of HEWs. For this, Concern worked to
produce training guides and job aids to improve knowledge regarding CMAM and IYCF
practices. An integral part of the project was building the capacity of HEWs to recognise and
treat/refer children suffering from SAM using the CMAM approach and also prevent chronic
malnutrition through promotion of improved and optimal IYCF practices.
This study tested whether an extended, module-based training, conducted over 12 months,
resulted in improved community health outreach workers’ knowledge, motivation and
retention, thereby reducing staff attrition and increasing the number of contact points
households had with them. In addition, the study assessed the use of HEWs’ time to
determine if a cascaded approach to community outreach results in improved motivation and
availability of time for HEWs.

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2 OBJECTIVES OF THE STUDY
The overall objective of the study was to determine if the extended, module-based training
improved the knowledge, motivation and retention of community health outreach workers in
Tigray Region, Ethiopia. The specific objectives of the study were to:
1. Measure the extent to which enhanced CMAM and IYCF job aides and training lead to
changes in the knowledge of HEWs.
2. Assess the quality of care provided by HEWs through quality assessment tools which
measure the skill of workers.
3. Identify primary factors influencing job satisfaction and motivation of HEWs and their
supervisors and analyse the relative importance of such factors.
4. Assess the perceptions of HEWs and their supervisors regarding supervision and identify
opportunities to improve supervision.
5. Assess how HEWs and their supervisors prioritize work-related activities and allocate
their time.
6. Determine the coverage of community health outreach interventions by identifying the
percentage of caregivers visited by a member of the Women’s’ Development Army
(trained and encouraged by HEWs) in the past 30 days.

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3 METHODS AND MATERIALS
The baseline survey was conducted in September 2012 and assessed the capacity of health
extension workers (HEWs). The study was conducted in four project Woredas in Tigray region.
The design of the baseline survey was a randomized, controlled, pre and post-test
intervention study covering a total of 64 health posts. The baseline investigated knowledge,
attitude and skill of HEWs towards IYCF practices. In the same context, the major objective
of the end-line survey was to collect comparable information that can be used to assess the
programme achievements. Thus, sample sites, the survey technique and the survey tools that
were used during the baseline survey will be replicated in the end-line survey to avoid
statistical bias in the methodology and to facilitate comparative analysis of each round.
3.1 Study Period
The overall study was designed allocating 12 months of intervention period between the pre-
test and post-test studies and the end-line study was undertaken between November 20, 2013
and December 06, 2013.
3.2 Study settings
The end-line study applied the same approach as the baseline. Thus, a randomized,
controlled, post–intervention study was carried out. The study was carried out in four
selected Woredas in Tigray Region, namely: Alaje, Endamehone, Ofla and Raya Azebo (Figure
1).The Region is divided into seven Zones, which are further sub-divided in 47 rural Woredas
and 10 towns. But additional qualitative data was collected at the household level to obtain a
deeper understanding of the perception of the community towards service delivery by HEWs
thereby supplement the quantitative analysis. Hence, both qualitative and quantitative data
will be collected through interviews of HEWs, in-depth interviews of selected households and
focus group discussions (FGDs).
3.3 Sample size
The baseline study applied HPs as a unit of randomization and the number of participants
required in each group (intervention and control) was calculated on the basis of achieving at
least a 40% difference between groups. The sample size was calculated using 5% significance,
95% power and also taking into account a 20% drop-out of participants. Overall, 64 health
posts were randomly picked and equal number of health posts was assigned to each group,
the intervention and control group. At baseline, the total number of HEWs found working
within these HPs was 98 and all of them were invited to participate in the study (*1)
. Similarly,
the study participants of the end-line study were the same group of HEWs who participated in
the baseline study. However, some of the HEWs were not available or transferred to other
HPs for various reasons and a total 13 HEWs were missing. In four HPs selected for the study,
all the study participants were replaced by new staffs; therefore, these HPs were dropped
from the study. The dropouts hardly affected the analysis since it was anticipated from the
beginning and the sample size was consciously inflated to compensate for drop-outs.
*[The baseline study revealed that allocation of HEWs varied between 1 and 3 (mean= 1.76) per HP]

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3.4 Data Collection
Desk Review of documents including baseline study results, project reports, records of
intervention efforts, training materials and guidelines, and supervision checklists were
reviewed. The setup, equipment, medical supplies and furniture provided to HPs were also
inspected using checklists. Moreover, overall service delivery activity of HEWs at HPs was
observed.
The study applied structured questionnaires and checklists which were administered to HEWs
and households. Two different questionnaires were used during the interview: interview with
HEWs and interview with households. The interview with HEWs applied an exact replica of the
10-page questionnaire that was administered during the baseline study (see Annex IV). The
questionnaire consisted of institutional profile of the facilities, demographic/personal data of
HEWs and standard assessment questions to test IYCF knowledge, attitude and practice of
HEWs. In addition, questions about guidance and monitoring by supervisors; work
performance of HEWs; trainings conducted; availability of supplies and other resources,
equipment and manuals; and HEWs’ job satisfaction and challenges were included in the
questionnaire. The second questionnaire used for interview with selected households
consisted of demographic data, knowledge, and attitude of individuals towards service
delivery (see Annex V).
In addition, more qualitative data was also collected through focus group discussions (FGD).
The FGDs were valuable in eliciting, thereby generating, broad overviews of issues and
concern; level of involvement, cultural norms/barriers and challenges within the community
represented. A total of four FGDs were conducted, two in each study group: two FGDs were
held with a group of WDAs, and the other two FGDs with mixed groups from the community.
The participants were selected using a purposive sampling method. Participants of the FGDs
included model families, mother support groups, and caregivers of children under 2 years of
age, WDAs and key influential community leaders. The interviews were conducted by field
data enumerators aided by the field supervisor. All the data collectors and supervisors were
exhaustively trained to carry out these tasks properly. FGDs were conducted by data
collectors with a direct supervision by the Researcher. The data quality was verified through
onsite supervision by ensuring proper data collection, organization, transcription and
reporting. Throughout the whole process, the Researcher conducted close supervision and on-
site mentoring ensuring smooth workflow.
3.5 Data Management and Statistical Analysis
The data was entered into SPSS for Windows (version 20.0) using a double entry method and
answers to questions were coded using appropriate methods. Finally data cleaning was
carried out to ensure entry of valid data. The statistical analysis examined the socio-
demographic variables (age, gender, level of education, and marital status); work-related
activities (routine and periodic tasks, planning, prioritization and division of tasks,
performance evaluation, reporting and supervision); implementation challenges (medical
supplies and logistics, job satisfaction and desire to stay in the current job, and incentives
required and career upgrade intentions); and nutrition promotion (adequacy of training,
availability of quick reference materials, attitude and motivation towards IYCF
implementation, and level of knowledge and skills in IYCF).
The knowledge, attitude and skill of HEWs were categorized using recommended quality
assessment tools for IYCF practices4,7
. The level of participants' knowledge and attitude were
evaluated by means of a standardized test consisting 13 questions organised in three

15
assessment categories: breastfeeding assessment category, complementary feeding
assessment category and essential minerals assessment category. Each category consists of
five questions for which individual ratings were tabulated that added up to a total score of 10
points. In a similar fashion, skills of participants were assessed by observing the
demonstrations and clinical practices of the participants. The skill assessment applied a
standardized test consisting 30 questions organised under six assessment categories: clinical
signs of malnutrition, MUAC performance, weight measurement, height measurement,
negotiation and counseling skills, and positioning; and attachment of baby during
breastfeeding. Individual assessment tests under each assessment category valued a maximum
of 1 point which added up to give a total score of 5 points. The total scores under each
assessment category were used as absolute scores to perform various statistical
computations.
Descriptive frequencies; comparison of mean values; significance statistical test;
independent-test; and ANOVA were applied during analysis. To obtain comparable information
in the assessment of programme achievements, the mean scores of the pre-test were weighed
against the post-test for each study group. The significance level was set at p<0.05.
Qualitative data obtained from the FGDs and household in-depth interviews was organised
under different thematic areas and ideas were sorted out and systematically pooled in to
those themes. Triangulation of data from different sources was applied to verify the findings
and their programmatic implications.
3.6 Limitations
Since the survey was mainly focused on the themes as outlined in the objectives, the analysis
was limited to the information collected in the survey. The study was conducted in Tigray
Region, a small section of the nationwide HP service; hence, the results are specific to local
study setting and are not necessarily conclusive of the HP activities countrywide.
Furthermore, information collected from households and FGDs was qualitative data, not
supported or verified by statistical computations and cannot be generalized.
3.7 Ethical considerations
Ethical approvals were granted by the Tigray Regional Health Bureau, local Ethics and
Research Committee and relevant Woreda administration review committees. Standard
ethical procedures were followed to acquire informed consents.

16
4 RESULTS
4.1 Characteristics of the respondents
In this study, unlike the baseline study, 84 questionnaires completed by HEWs were analyzed.
Thirteen participants from both groups were missing, but their absence didn’t affect the
analysis since the loss was accommodated within the dropout quota allocated for the study.
The overall response rate was 86.6% because some of the HEWs who took part during the
baseline study were not available. Various factors were associated with the missing HEWs.
Some of the HEWs were transferred to other HPs, a few joined an upgrade class and others
left their job for good. Finally, equal number of respondents, 42 HEWs in each group,
participated in the post-intervention study.
In general, the number of HEWs in those HPs enrolled for the study varied between 1 and 3
and a mean value of 1.88 per health post. A higher proportion (78.6%) of HPs has 2 HEWs
followed by HPs with only one HEW (16.7%). The end-line study revealed an increase in the
number and distribution of HEWs per HP compared to the baseline. Table 3 presents
allocation of HEWs per HP. It is a standard criterion upon employment that all HEWs should be
female; hence, zero male respondents were enrolled.
Table 3: Number of Staffs per Health Post
Number of HEWs per Health Post Number of Health Posts Percent
Health Posts with One HEW 14 16.7%
Health Posts with Two HEWs 66 78.6%
Health Posts with Three HEWs 4 4.8%
The average catchment population of a Health Post was 5,503 and on average, 44 WDAs were
found supporting the various activities implemented by HEWs from within the community.
Mean age distribution of HEWs in the intervention and control group were 25.1 (SD±0.436) and
28.24 (SD± 0.877) years respectively with median age of 27. Most respondents (85.7%) aged
between 20 and 35. The rest evenly distributed between the over-36 age groups. No
significant difference of age, level of education, service year and status of marriage were
detected among HEWs enrolled for the study.
Table 4: Place of residence of HEWs and distance from HPs
Place of residence of HEWs Number of HEWs Percent (%)
Residence within the HP Compound 71 79.8
Residence within the HP surrounding 81 91
Residence within 5km radius of the HP 8 9
In terms of years of experience, majority (79.8%) of HEWs had more than 5 years of
experience and the mean service year was 5.18 (SD±0.398) with an academic background of
10+1 certificate in both study groups. Majority of the HEWs (65%) in both study groups were
found to be married. Table 5 presents socio-demographic characteristics, distance and
population information. The mean distance of a HP from Woreda Health Office and residence
of HEW was 24.4 km and 0.58 km respectively. Majority of HEWs (71.1%) had 6-8 years of work

17
experience positioned around a mean value of 5.17 years. The mean distribution for all items
listed in tables were the same across the study groups during the baseline (P>0.05). During
post-intervention study, only slight changes were observed.
Table 5: Socio-demographic characteristics of respondents, training and population
Socio-demographic variables Minimum Maximum Mean (±SD)
Age 20 43 26.6 (SD4.69)
Service years 0 15 5.17 (SD3.64)
Level of education 11 14 11.1 (SD0.50)
HP distance from Woreda (km) 2 75 24.4 (SD18.0)
HP distance from HEW's residence(km) 0 7 0.58 (SD1.45)
Travel time to furthest household (hrs) 1 8 3.04 (SD1.09)
Catchment population (per HP) 849 11,881 5503 (SD2251)
4.2 Provision of Training to HEWs
On average, the number of trainings received by HEWs during the baseline was 2.43 and
statistical tests showed that there were no significant differences between study groups in
terms of number of trainings received by HEWs. Nevertheless, the post-test assessment
revealed that the number of trainings received by HEWs and total training hours in the
intervention groups were increased. The number of trainings attended by HEWs during the
intervention period varied between 1 and 5 with a mean value of 2.45, an increased mean
value compared to the baseline results. Notable improvements were observed in the delivery
of various types of trainings particularly, in the area of nutrition. On average, HEWs in the
intervention group received 1.19 hours of training on nutrition. In the control group; however,
the number of trainings received showed a slight drop.
Table 6: Overview of the training provide to HEWs in 2013
Control Group
Provision of Trainings
Baseline End-line
Min/Max Mean (±SD) Min/Max Mean (±SD)
# of Trainings (All types) 1 / 8 2.57(±1.34) 0 / 4 2.07(±1.06)
# of Trainings (Specific to Nutrition) 0 / 3 0.54(±0.66) 0 / 3 0.45(±0.63)
Intervention Group
Baseline End-line
Provision of Trainings Min/Max Mean (±SD) Min/Max Mean (±SD)
# of Trainings (All types) 1 / 5 2.42 (±0.96) 0 / 5 2.45 (±1.5)
# of Trainings (Specific to Nutrition) 0 / 2 0.85 (±0.64) 0 / 4 1.19 (±0.96)
As a matter of fact, more training was given to those HEWs in the intervention group
compared to the control group because the intervention packages were exclusively provided
to participants of the intervention group. This was confirmed by the results from the
comparison of the pre- and post-test data and statistically significant differences were
detected between the intervention and control groups. As a result, an improved level of
knowledge and acquisition of skills by HEWs was observed in the intervention group.

18
4.3 Assessment of Knowledge of HEWs
Changes in the participants' knowledge, attitudes and skills were evaluated twice, before and
after the implementation of the intervention package. The impact of the intervention
package on the participants' knowledge and skill was evaluated by means of a standardized
test. Following the baseline evaluation of the HEWs, several capacity building measures were
implemented in HPs designated as an intervention group during the study period. The
intervention package included theoretical and practical trainings, on-job trainings and logistic
support. On the other hand, HPs designated as control groups did not receive any direct
support from the intervention package. In the baseline assessment, knowledge of HEWs in the
intervention group averaged 18.26 out of out of 30 points, while the control group averaged
18.60 points. Statistical test verified that the knowledge of the HEWs, for each assessment
category compared, was the same across the study groups (p>0.05). This was evidence that
the process of dividing the study participants into two groups resulted in groups that were
initially homogeneous in terms of their knowledge.
In the end-line assessment, held one year after the implementation of the capacity building
measures, the control group averaged 19.67 and the intervention group 23.62 (P<0.05). Thus,
although the control group slightly changed compared to their baseline score, the study
participants in the intervention group maintained a statistically significant increase in
knowledge compared to their baseline results. Cross-contamination between study groups,
exchange programmes between HPs, and trainings provided outside of the intervention
package could be possible explanations for the small change in the control group. Results of
the end-line study showed, the overall average knowledge score for all the 84 participants
was 20.9.
Tables 7 to 9 show the level of knowledge and attitude of HEWs across assessment categories
and study groups. The level of knowledge of HEWs was highest for the knowledge on
breastfeeding followed by essential minerals category. However, knowledge in the
complementary feeding category was the lowest for both study groups.
Table 7: Knowledge of HEWs about Breastfeeding of infants
#
Knowledge of HEWs on
Breastfeeding (BF)
Control, Mean(±SD) Intervention, Mean(±SD)
Baseline End-line Baseline End-line
1 Early initiation of BF 1.62(±0.9) 1.83(±0.37) 1.83(±0.98) 2.36(±0.48)
2 Water feeding (<6 infant) 0.9(±0.29) 2 ((±0.22) 0.90(±0.29) 1.00
3 On demand Feeding 1.00 0.98(±0.15) 0.98(±0.15) 0.93(±0.26)
4 Frequency of BF 0.69 (±0.71) 0.86(±0.56) 0.40(±0.54) 1.52(±0.55)
5 BF by a working mother 0.74 (±0.44) 0.5(±0.5) 0.67(±0.47) 0.71(±0.45)
6 Technique to confirm optimal BF 1.14(±0.71) 1.36(±0.57) 0.79(±0.41) 1.95(±0.21)
7 Sum of Scores 6.09(±1.44) 6.52(±1.01) 5.57(±1.41) 8.48(±0.94)

19
Table 8: Knowledge of HEWs about Complementary Feeding of infants
#
Knowledge about Complementary
Feeding (CF)
1 Time of initiation of CF 1.00 1.00 0.95(±0.21) 1.00
2 Justifies the need for CF 1.19(±0.99) 1.14(±0.47) 1.45(±0.88) 1.69(±0.46)
3 Knows number of meals/day for infants 0.98(±0.15) 0.76(±0.69) 0.81(±0.39) 1.05(±0.85)
4 Identifies minimum number of food groups 0.43(±0.50) 0.57(±0.73) 0.31(±0.46) 0.40(±0.49)
5 Explains the consistency of porridge 1.81(±0.45) 1.86(±0.52) 1.76(±0.43) 2.00
6 The need for extra food by BF mother 1.00 0.98(±0.15) 0.95(±0.21) 1.00
7 Sum of Scores 6.4(±1.25) 6.31(±1.2) 6.24(±1.2) 7.14(±1.09)
Table 9: Knowledge of HEWs about Micronutrient feeding of infants
#
Knowledge about Micronutrient
Feeding (MF)
1 List of important micronutrients 0.86(±1.15) 1.86(±0.78) 0.83(±1.16) 2.07(±0.94)
2 Need for all micronutrients 0.29(±0.45) 0.31(±0.46) 0.29(±0.45) 0.40 (±0.49)
3 Local food source of Iron 1.57(±0.83) 1.57(±0.73) 1.71(±0.70) 1.81(±0.55)
4 Local food source of Iodine 1.62(±0.79) 1.76(±0.65) 1.67(±0.75) 1.86(±0.52)
5 Local food source of Vitamin A 1.76(±0.65) 1.33(±0.68) 1.95(±0.30) 1.86(±0.52)
6 Sum of Scores 6.09(±2.18) 6.83(±2.08) 6.45(±1.96) 8.00
4.4 Assessment of Skills of HEWs
The skills and performances of HEWs, as measured by the mean of the aggregate scores
attained in each skill assessment category, were more or less similar at baseline. In addition,
statistical tests also revealed that there were no significant differences between the average
pre-intervention scores of the intervention or control groups for any of the five skill
assessment categories and also individual items within each category. However, the post-
intervention assessment revealed statistically significant differences between the
intervention and control groups for all items analysed.
Table 10 shows the average scores obtained for each skill assessment category (cumulative of
the individual items) by HEWs in the exposed and control groups. Comparison of the means
achieved by each of the two groups before and after the intervention period reveals that the
averages of all items improved for the intervention group. In the control group, the scores
remained constant or even declined.

20
Table 10: Number of HEWs grouped by the total score attained
Control Intervention
No Skill assessment categories Baseline End-line Baseline End-line
1 Clinical signs of malnutrition 3.23(SD±1.2) 3.54(SD±1.2) 3.62(SD±1.1) 4.09(SD±0.6)
2 MUAC performance 3.83(SD±1.0) 3.09(SD±0.9) 3.35(SD±1.3) 3.95(SD±0.6)
3 Weight measurement 3.78(SD±1.1) 3.43(SD±1.1) 4.09(SD±1.1) 4.28(SD±0.6)
4 Height measurement 1.85(SD±1.7) 0.93(SD±1.4) 1.47(SD±1.5) 1.66(SD±1.9)
5 Positioning & attachment 3.83(SD±1.1) 3.83(SD±0.5) 4.14(SD±0.8) 4.33(SD±0.4)
6 Counseling & Negotiation 3.83(SD±1.0) 3.83(SD±1.3) 3.93(SD±0.9) 4.35(SD±0.7)
Each skill assessment category was scored out of 5 point, adding up to a total of 25 points
In the intervention group, more than 90% of HEWs scored above the mean score of individual
skill assessment categories and they were able to demonstrate their skills correctly.
Conversely, in the case of height measurement, low scores were detected and only half of the
HEWs (52.4%) were found practicing height measurement though not formally trained on
measurement techniques. Tables 11 to 15 shows post-intervention results for each study
group, layered by individual assessment items of each skill assessment category.
Table 11: Number of HEWs who were able to identify malnutrition using clinical signs
Skill assessment category
(Clinical signs of malnutrition)
1 Prominent bones or ribs 0.642(SD±0.4) 0.785(SD±0.4) 0.69(SD±0.4) 0.904(SD±0.2)
2 Skinny limbs 0.857(SD±0.3) 0.738(SD±0.4) 0.857(SD±0.3) 0.976(SD±0.1)
3 Loose skin on lifting 0.547(SD±0.5) 0.714(SD±0.4) 0.642(SD±0.4) 0.785(SD±0.4)
4 Presence edema 0.571(SD±0.5) 0.785(SD±0.4) 0.761(SD±0.4) 0.809(SD±0.3)
5 A protuberant belly 0.595(SD±0.4) 0.523(SD±0.5) 0.666(SD±0.4) 0.619(SD±0.4)
Each Clinical Sign scored out of 1 point, adding up to a total of 5 points
Table 12: Number of HEWs who were able to apply MUAC measurement techniques
(MUAC performance)
1 Tip of the shoulder technique 0.880(SD±0.3) 0.666(SD±0.4) 0.738(SD±0.4) 0.904(SD±0.2)
2 Mid-point marking technique 0.928(SD±0.2) 0.571(SD±0.5) 0.714(SD±0.4) 0.88(SD±0.3)
3 Hanging arm technique 0.928(SD±0.2) 0.976(SD±0.1) 0.976(SD±0.1) 0.976(SD±0.1)
4 Tape placement & measuring 0.809(SD±0.3) 0.595(SD±0.4) 0.666(SD±0.4) 0.69(SD±0.4)
5 Measurement & interpretation 0.261(SD±0.4) 0.285(SD±0.4) 0.261(SD±0.4) 0.5(SD±0.5)
Each MUAC technique scored out of 1 point, adding up to a total of 5 points

21
Table 13: Number of HEWs who can apply the appropriate methods to measure weight
(Weight measurement)
1 Using Salter spring scale 0.952(SD±0.2) 0.833(SD±0.3) 0.928(SD±0.2) 0.904(SD±0.2)
2 Measure weight in mother's arms 0.333(SD±0.4) 0.428(SD±0.5) 0.571(SD±0.5) 0.761(SD±0.4)
3 Apply routine-check for scales 0.809(SD±0.3) 0.690(SD±0.4) 0.857(SD±0.3) 0.833(SD±0.3)
4 Measure weight without shoes 0.809(SD±0.3) 0.690(SD±0.4) 0.88(SD±0.3) 0.904(SD±0.2)
5 Measure with minimum clothing 0.880(SD±0.3) 0.785(SD±0.4) 0.857(SD±0.3) 0.88(SD±0.3)
Each measurement technique scored out of 1 point, adding up to a total of 5 points
Table 14: Number of HEWs who can spot difficulties of mothers and conduct counselling
(Counseling & Negotiation)
1 Verifying current practice 0.904(SD±0.2) 0.785(SD±0.4) 0.833(SD±0.3) 0.88(SD±0.3)
2 Identify difficulties of mother 0.642(SD±0.4) 0.738(SD±0.4) 0.809(SD±0.3) 0.88(SD±0.3)
3 Make recommendation to mother 0.880(SD±0.3) 0.904(SD±0.2) 0.857(SD±0.3) 0.928(SD±0.2)
4 Encourage mother to try out 0.714(SD±0.4) 0.738(SD±0.4) 0.69(SD±0.4) 0.857(SD±0.3)
5 Follow up of mother’s practice 0.761(SD±0.4) 0.666(SD±0.4) 0.738(SD±0.4) 0.809(SD±0.3)
Each Counselling & Negotiation technique scored out of 1 point, adding up to a total of 5 points
Table 15: Number of HEWs who demonstrated correct positioning & attachment during BF
(positioning & attachment)
1 Sitting position during BF 0.928(SD±0.2) 0.928(SD±0.2) 0.904(SD±0.2) 0.976(SD±0.1)
2 Support child’s head with hand 0.857(SD±0.3) 1(SD±0) 0.785(SD±0.4) 0.952(SD±0.2)
3 Support child’s head with arm 0.809(SD±0.3) 0.928(SD±0.2) 0.857(SD±0.3) 0.976(SD±0.1)
4 Sleeping position during BF 0.452(SD±0.5) 0.428(SD±0.5) 0.619(SD±0.4) 0.476(SD±0.5)
5 Attachment to the breast 0.785(SD±0.4) 0.595(SD±0.4) 0.976(SD±0.1) 0.952(SD±0.2)
Each Positioning & Attachment technique was scored out of 1 point, adding up to a total of 5 points

22
4.5 Medical Equipment, Supplies and Reference Materials
According to the minimum standard for health post, each health post should be equipped as
per the level of provision of health care services. During the post-intervention study, almost
all HEWs in the intervention group claimed adequacy of equipment and supplies as compared
to baseline results. The distribution of various logistic materials, as part of the intervention
package, enhanced the capacity of HEWs and also improved their performance.
The baseline study concluded that about 30% or more of the HPs were either poorly furnished,
equipped or were in short of various supplies. However, unlike the baseline results, the end-
line assessment revealed an improved logistics support that addressed the needs of the HEWs.
Important equipment and supplies provided to those HEWs in the intervention group included:
Weighting Scale (metallic Hanging scale); Lockable RUTF storage shelf; ORS synthesis utensils,
porridge preparation and demonstration tools; and stationary materials (OTP Chart and
various reporting forms). Table 16 show the list of equipment, furniture and supplies claimed
available and functional by HEWs (intervention group). Comparison of mean values of baseline
and end-line studies showed a statistically significant post-intervention increment of
availability of those items listed in the table below. The control group; however, showed no
change or in some cases a decline.
Table 16: Possession of various Medical Equipment, Furniture, Supplies and materials by HEWs
Medical Equipment, Supplies and Furniture
Intervention Group
Baseline End-line
Number of HPs Percent Number of HPs Percent
1. Weight Scale (Metallic Hanging) 26 61.9% 40 95.2%
2. Lockable shelves for storage
 Medical Supplies 32 76.2% 34 81.0%
 Documents 33 78.6% 38 90.5%
 RUTFs 19 45.2% 42 100.0%
3. Demonstration Materials
 Pot 30 71.4% 36 85.7%
 Glass 32 76.2% 42 100.0%
 Spoon 35 83.3% 41 97.6%
 ReSolMal 10 23.8% 40 95.2%
4. Reporting Forms 38 90.5% 41 97.6%
5. Family Folder 28 66.7% 33 78.6%
6. Quick Reference Books and IEC/BCC Materials 33 79% 42 100%
One of the components of the intervention package delivered to HEWs (intervention groups)
was the provision of quick reference materials, demonstration charts and various IEC/BCC
materials. As a result, the end-line assessment showed availability of a complete list of
reference materials in all HPs of the intervention group and also zero requests were detected
for additional references materials. Besides, statistical tests confirmed that the post-
intervention results for intervention group were increased and significant. The control group
shows no significant changes.

23
4.6 Service Delivery Activities (Health Post and Outreach)
In general, various health services were delivered at the HP operated by a team of HEWs.
Unlike other primary health care facilities, the delivery of services by health extension
workers is not restricted within the premises of the HP. In fact, majority of the activities
should be delivered at the household level. Hence, the activities of HEWs was categorized
using their work plan as daily, weekly and monthly activities or by place and service delivery
as health post and outreach tasks.
In the former category, the commonest daily tasks were: Antenatal Screening, Follow-up and
Delivery; Family Planning Services; Diagnosis & Treatment Under-Five Children; Hygiene &
Environmental Sanitation; and Nutrition Education, Malnutrition Screening, OTP Follow-up.
HEWs did also perform tasks on a weekly or monthly basis depending on the nature of the job.
Report Compiling and Sending; Activity Planning and Performance Evaluation; WDAs Training,
Support and Performance Evaluation; and Household Follow-up of Various Cases were common
weekly tasks for all participants of the study. Among the monthly tasks identified were
Monthly Maternal & Child Vaccination; Presentation & Discussion of Performance with
Supervisors; and Monthly OTP & Screening. Additional activities identified include: household
visits (for various purposes); outpatient diagnosis, treatment and referral; various under 5
services; school-based health education, HIV/AIDS counseling and screening, and WDA training
and support.
Table 17: Routine and periodic tasks performed by HEWs and time allocation
Tasks performed by HEWs and time allocation Baseline End-line
Number of Tasks performed by HEWs Min/Max Mean Min/Max Mean
Daily Tasks 1 / 6 3.31 1 / 7 3.90
‡
Weekly Tasks 0 / 4 2.07 1 / 4 2.14
Monthly Tasks 0 / 5 2.36 1 / 6 2.45
Number of Hours or Days Spend at Work
Hours/Day Spend at the HP 0 / 12 8.02 2 / 12 8.19
Days/Week Spend at the HP 0 / 4 2.26 2 / 7 2.95
‡
Hours/Week Spend at the HP (Weekly total) 0 / 36 20.00 6 / 56 23.19
Number of Hours or Days Spend in Outreach
Hours/Day Spent in Outreach 2 / 13 8.79 4 / 12 9.52
Days/Week Spent in Outreach 2 / 6 3.62 2 / 7 3.45
Hours/Week Spent in Outreach (Weekly total) 8 / 50 31.36 12 / 70 32.98
Number of Households Visited by HEWs
Households visited per day 4 / 70 14.86 0 / 30 13.17
Households visited per week 8 / 210 50.88 1 / 125 44.43
Households visited per month 32 / 840 213.67 4 / 500 181.50
Number of Weekly Emergency calls attained 0 / 4 2.05 0 / 10 2.69
‡
‡
Comparison of mean values showed statistically significant increment.

24
The post-intervention study detected a new task practiced by HEWs, the Outpatient
Therapeutic Programme (OTP). The OTP task was not in the list of tasks recorded during the
baseline. Screening, Treatment, RUTF distribution, Referral and Follow-up of children
possessing malnutrition problems were regular activities under the umbrella of the OTP.
Table 17 shows the number of tasks performed and time allocation to those tasks. Clearly the
post-intervention data shows the number of tasks carried out had been increased. One
possible factor could be the addition of OTP and related tasks. Other possible factors could
be attrition of HEWs, increased catchment, or reallocation of extra time for demanding
activities at the HP.
The commonest routine task carried out was Antenatal Screening, Follow-up and Delivery
Service followed by Family Planning and Diagnosis & Treatment of Under-Five Children.
Activities related to nutrition ranked fourth in daily tasks category. In addition to the routine
and periodic activities, the HEWs were also available for emergency calls during off-duty
hours. On average, 2-3 emergency calls per week were attended by HEWs. The mean
comparison of the number of emergency calls attained showed a rise during the post-
intervention study. The study participants were also asked to list the most important
activities performed and also rank those tasks as per the level of priority they believe the
task deserves. Table 18 shows the top five most important tasks listed according to the
priority given.
Table 18: List of important tasks identified and ranked by HEWs as per level of priority given.
Task Item Priority Rank Voted in favor (%)
Antenatal Screening, Follow-up and Delivery 1 26.6%
Family Planning Services 2 15.1%
Under-Five Children Illness Diagnosis & Treatment 3 12.0%
Nutrition Education, Malnutrition Screening, OTP Follow-up 4 9.9%
Hygiene & Environmental Sanitation 5 9.6%
The post-intervention results, similar to the baseline study, showed that HEWs systematically
shared both the HPs as well as outreach tasks by applying rotation method: one assured
routine operations and continuity of care at the HP, whereas the other visited households and
vise-versa. Considering a 40hrs/week as standard working time for a government employee,
the mean working hours per week recorded during the end-line study were 25.77 for health
post activities and 33.75 for outreach activities. The mean values were increased both for the
intervention a control groups. Though the time allocated in the latter category appeared
more than the expected 50% share, perhaps those additional hours arose from the time spent
for travel to individual households.
About 48.5% of the overall time was allocated for nutrition and related activities. On average
3.88 hours/day and 8.19 days/ month were spent on nutrition tasks. During the baseline, the
distribution and time allocation for various activities was comparable across the study groups;
however, post-intervention results revealed more time spent on nutrition and related
activities across all items analysed, as shown in Table 19 below. Tests confirmed that
increment of total hours spent on nutrition was statistically significant.

25
Table 19: Nutrition and related tasks performed by HEWs and time allocation
Nutrition and related tasks Baseline End-line
Nutrition Related Tasks Performed by HEWs Min/Max Mean Min/Max Mean
Hours/Day Spent on Nutrition 0 / 10 2.76 2 / 10 3.88
‡
Days/Month Spent on Nutrition 2 / 20 6.88 2 / 30 8.19
Hours/Month spent Nutrition (monthly total) 0 / 120 18.79 4 / 120 28.57
‡
Nutrition Related Household visits by WDAs
Number of Household visits per month 0 / 125 25.55 10 / 30 26.31
‡
Comparison of mean values showed statistically significant increment.
On average, 26 household visits were made by WDAs on a monthly basis, slightly increased
during the post-intervention assessment. Table 19 shows the number of households visited
made by WDAs on a monthly basis. None of the HEWs/WDAs mentioned utilization of vehicle
transport during their household visits, even for trips that took hours of travel. In all cases,
the only means of travel was on foot.
4.7 Patient Screening and Referral
With regard to patient referral, the HEWs were able to screen and refer significant number of
patients to health centres. A monthly and quarterly average of 3.39 and 18.98 was recorded
in terms of patient referral by each HEW. Results of the post-intervention study revealed
increased number of quarterly patient referrals, particularly referrals related to malnutrition.
Table 20 below shows the top five referral diseases.
Table 20: Top five referral diseases by HEWs
Disease Type Referrals Percent
1. Antenatal Illness, PMTCT and Labor & Delivery 147 53.6%
2. Malnutrition 52 19.0%
3. Other Outpatient Cases 25 9.1%
4. Bloody Diarrhea 23 8.4%
5. Watery Diarrhea 20 7.3%
6. Pneumonia 7 2.6%
Table 21: Patient screening and referral activity by HEWs
Patient referral activity
Number of referrals (Baseline) Number of referrals (End-line)
Minimum Maximum Mean Minimum Maximum Mean
Monthly patient referrals 0 18 4.17 0 18 3.39
Quarterly patient referrals 0 45 13.83 0 48 18.98

26
4.8 Data Compiling and Reporting
On average, each HEW produces six types of reports, one weekly report and five monthly
reports. The average number of reports; however, was found increased to seven reports
during the post intervention study. The maximum number of reports monthly reports
prepared was as high as 17 in both studies (Table 22). A few cases were also engaged in daily
reporting tasks. In general, the task of synthesizing reports is time consuming, particularly in
the case of redundant reporting tasks. The variations among reports could be due to the type
of reporting forms, contents, organization of data or the time schedule for submission.
Reports with such kinds of variations were considered different, however small the
differences might be. Hence, the reporting activities were grouped into three by the
frequency of submission and, for each group, all reports prepared were counted. Table 22
shows the reporting activities for all types of reports prepared.
Table 22: Report preparation activities by HEWs
Reporting schedule
Min/Max Mean (SD) Mean (SD) Min/Max Mean (SD) Mean (SD)
# of daily reports by type 0/1 0.07(0.26) 0.07(0.26) 0/1 0 0.26(0.44)
# of weekly reports by type 0/5 1.21(0.78) 1.42(1.23) 0/5 1.04(0.43) 1.28(0.94)
# of monthly reports by type 1/15 5.71(3.49) 6.40(2.54) 1/16 5.35(3.32) 7.07(2.70)
# of reports (all durations) 2/17 6.30(4.19) 7.90(2.79) 2/17 5.52(3.92) 8.61(2.47)
4.9 Community perception and Challenges
The community verified that HPs were key in health service provision and through time they
witnessed the service delivery was getting closer to their home, particularly since the start of
house-to-house services provided through WDAs in collaboration with HEWs. They concluded
the presence of HPs is vital. Various services were sought by the community at large. Since
the HEWs are part of the community, they confirmed adequate and all-time access to the
service rendered at the HPs including emergency situations.
Community members were convinced about the health education provided by HEWs regarding
MNCH, Nutrition, Hygiene and Sanitation, and also others. They also explained that the
presentation was clearly understandable as it was assisted by demonstrations. Most
community respondents attended health education sessions despite circumstances. In some
cases; however, other demanding tasks didn’t allow them to attend all sessions. Majority of
the community respondents were able to clearly discuss the benefits they acquired from the
health education. They were also able to talk about methods how they recognize illness
particularly, cases of malnutrition.
With regard to challenges most community respondents complained about insufficient
resource and time; focus on other demanding activities (as in farming); arguments among
family member to practice advices; and also shortage of medical supplies needed at the
health post. Both assessments concluded that inadequate community participation and lack of
practice were prominent challenges faced by HEWs in promoting nutrition. Insufficiency of

27
resources, lack of confidence, as a result failure to accept and poor commitment were some
of the factors involved. The community was also not easily convinced to apply new
approaches; hence, advices provided by HEWs were not immediately put in to practice by the
community.
Among the challenges specified by HEWs with regard to their own activities were: inadequate
salary compared to the work load, tiresome household visits, and lengthy travel; lack of
transport for household visit; inadequate staff; lack of office stationary, forms, registers;
insufficient attention and priority given to health by Woreda administration, loose supervision
and support; lack of access to education & training; duplication of reports submitted; and also
availability of other competing and appealing jobs in the market that draws their attention.

28
5 DISCUSSION
The assessment of implementation of the intervention package indicated that it was well
received by the HEWs and improvements could be directly attributed to the capacity building
intervention. In fact, one of the criteria for choosing the controlled study was to evaluate if
the improvements were elicited through the intervention package. Indeed, there was no
significant change observed in the control group, rather a decline in most cases.
In general, the number of HEWs in those HPs enrolled for the study varied between 1 and 3
and a mean value of 1.88 per health post and results of the post-intervention study indicated
an increase in the number and distribution of HEWs per HP compared to the baseline. In
addition, the range of activities and type of service delivered at the HP level and the extent
to which the HEWs took assignments showed remarkable improvements. The changes were
observed only in the intervention group and were statistically significant. Thus, conclusions
can be made that the changes were due to intervention.
Among the list of important activities, ranked by level of priority, nutrition and related
activities were widespread and also regarded as one of the top priority tasks carried out by
the HEWs. Furthermore, post-intervention results indicated improved allocation of time for
nutrition tasks, increased level of malnutrition screening, treatment and referral; and also
enhanced outreach case detection through community involvement. Thus, emphasizing the
level of concern provided to CMAM implementation at the community level.
The HEWs in the intervention group were also confident, knowledgeable, skillful to put in
practice a widespread and improved IYCF practices at the community level. The intervention
package applied enabled the HEWs to deliver an extensive health education, promoting IYCF
practices, household level screening and follow-up throughout the community. In addition, a
good level of effort was applied through defaulter tracing and active support of the progress.
Baseline results showed that the level of knowledge about complementary feeding and
essential minerals was low, particularly knowledge about breastfeeding was the lowest for
both study groups, as less than 50% of each group had this knowledge. In contrast, the post-
intervention results concluded substantial boost for all knowledge assessment variables which
were statistically significant.
The end-line results demonstrated that the level of knowledge was directly correlated to the
total number of trainings. Moreover, a clear picture the association was revealed by
statistically significant correlation (p <0.05) suggesting induction of the intervention package
was associated with an increased knowledge, skill and implementation capacity. In contrast,
statistical tests of the baseline data showed that there were no significant differences
between study groups or correlation of the variables tested.
In terms of number of trainings received by all groups HEWs, no significant differences were
detected at baseline. Nevertheless, the post-test assessment revealed that the number of
trainings received by HEWs and total training hours in the intervention groups was increased
in contrast to the control group where the number of trainings received showed a slight drop.
This was a reflection of the targeted training, delivered through the special intervention
package, received by those HEWs in the intervention group. This implies that there was a
remarkable improvement in the delivery of various types of trainings particularly, in the area

29
of nutrition. As a result, an improved level of knowledge and acquisition of skills by HEWs was
observed in the intervention group in contrast to the control group.
In response to the skills assessment tests, more than half of the HEWs interviewed scored
below average at baseline. However, post intervention results were improved and significant
progresses were recorded for those HEWs who belonged to the intervention group. This is a
reflection of the fact that malnutrition-focused trainings were delivered resulting in overall
improvement of skills; hence reinforcing the need for widespread training of similar pattern
to HEWs who didn’t receive the intervention package.
Comparison of baseline and end-line results regarding report synthesis revealed a slight
increase of the mean values. On average, types of reports produced were 6 to 7 in both cases.
A consistent number of HEWs produce one weekly report and five or more monthly reports
and in extreme cases, the number of reports prepared were as high as 17. Few HEWs were
also found engaged in daily reporting tasks. This was probably due to additional tasks and
programmes implemented by the HEWs. Though each single data reported from the HPs is
deemed important, redundant reports make the task cumbersome and time consuming, as a
result compromising the quality of services rendered or, at worst, obstructing service
delivery. Similar recommendations were forwarded during publication of the baseline results.
The skills in applying MUAC technique, was the best learned and retained component of skills
assessment category. Skills to apply clinical signs of malnutrition; weight measurement
procedures; and also positioning and attachment of baby during breastfeeding were
adequately practiced by the participants (intervention group) after the intervention. A
component of the skills assessment for positioning and attachment of baby during
breastfeeding has the lowest score and was hardly retained by HEWs: an area of
recommendation in the upcoming trainings. Height measurement was not universally
practiced by all HEWs; hence, it will be impractical to compare mean values.
It is recommended that the time allocated for capacity building and similar intervention be
increased. In order for the training to be most effective, it should be followed up and HEWs
enabled, through refresher trainings, to continue practicing the skills they have acquired. On
the hand, the bulk of tasks assigned to HEWs are continually increasing; thus, some of the
burdens including reporting should be alleviated.
In conclusion, the capacity building intervention resulted in a substantial acquisition of both
knowledge and skills and there was substantial gain for any item evaluated, thereby
effectively increased HEWs' knowledge and skills in support of CMAM implementation.
However, adequate time, more practical exercises, clinical practice and continued support
should be provided in order for the HEWs to retain and apply the knowledge and skills
acquired.

30
Annex I: References
1. Central Statistical Agency. Population and Housing Census: Statistical Report. Addis Ababa: CSA;
2007.
2. Federal Ministry of Health, 2010. Health Sector Development Programme III. Annual Performance
Report. 2009/10.
3. Valdes V, Pugin E, Labbok MH, Perez A, Catalan S, Aravena R, et al. The effects on professional
practices of a three-day course on breastfeeding. J Hum Lact. 1995; 11:185-90. Medline: 7669237
doi:1 0.1177/089033449501100318.
4. M.F. Rea, S.I. Venancio, J.C. Martines, & F. Savage. Counselling on breastfeeding: assessing
knowledge and skills. Bulletin of the World Health Organization, 1999, 77 (6).
5. Health Extension Workers in Ethiopia: Improved Access and Coverage for the Rural Poor. Nejmudin
Kedir Bilal, Christopher H. Herbst, Feng Zhao, Agnes Soucat and Christophe Lemiere.
6. Central Statistical Agency. The Ethiopia Demographic and Health Survey (EDHS) 2011. Addis
Ababa: CSA; 2011.
7. Irena Zakarija-Grković, Tea. Burmaz2Effectiveness of the UNICEF/WHO 20-hour Course in
Improving Health Professionals’ Knowledge, Practices and Attitudes to Breastfeeding:
Before/After Study of 5 Maternity Facilities in Croatia. CMJ.2010.51.396, 2010
8. World Health Organization. Breastfeeding counselling: a training course. Geneva: WHO; 1994.
9. World Health Organization. Complementary feeding counselling: a training course. Geneva: WHO;
2004
10. World Health Organization. Infant and young child feeding counselling: an integrated course.
Geneva: WHO; 2006.

31
Annex II: Health Posts/HEWs interviewed during end-line
Health Post Number Of HEWs Intervention (0) / Control (1)
ABEDA 2 0
ADI GOLU 2 1
ADI NAQURA 1 1
ADISHUM BEREKET 1 1
ARENA 2 1
ATSELA 2 0
AYIBA 2 0
BASO 1 0
BESEBO 1 0
BETMARA 2 0
BEYRU 1 0
CHEKONE 1 0
DARA 1 1
DASUS 1 1
DEJEN BORA 2 0
DEJEN SELEWHA 2 0
DINKA ASHENA 1 1
DUME 1 1
EGRI ALEBA 2 0
EMBASAETI 2 1
EMBEGA 1 1
ENDODO 1 1
ERBA 2 0
FIKERE WOLDA 1 1
GELEWSA 2 1
GENETEYE 1 0
HADINET 1 1
HAWELTI 1 0
HAYALO 2 1
HEGUMBERDA 1 1
HOREDA 2 0
JA GEBRAEL 1 1
JEMMA 1 1
KEDANA 2 1
KILTO 1 0
MAARENET 1 0
MEBAL 1 0

32
MEKAN 2 1
MENKERE 1 1
MEWERA 1 1
QUORSEBE 1 0
SENAY 1 1
SERET 2 0
SESAT 2 0
SIMERET/Endamehone 2 1
SIMERET/Ofla 1 1
SOFIA 2 1
TAHTAH HAYA 2 1
TEKEA 1 0
TEKLEHAYMANOT 2 1
TEKLIWEYANE 2 0
TELEMA 1 0
TSAEDA MEDA 2 0
TSELIGO 1 1
TSIBAT 1 1
TSIGEA 1 0
WAEREB 1 0
WOREBAYU 2 0
WUHDET 1 1

33
Annex III: Informed Consent Form
EFFECTS OF A MODULE-BASED TRAINING ON KNOWLEDGE & CAPACITY OF HEALTH EXTENSION WORKERS:
A Pre-Post Test Randomized Controlled Trial, End-line Study
This Statement of Consent consists of two parts: Information Sheet and Certificate of Consent
Part I
Information Sheet
This study is intended to assess the Health Extension Workers’ knowledge, skills and attitudes towards
their work and the current implementation of nutrition promotion messages at the community level. If
you agree to take part in this research, you will be asked to complete a similar questionnaire which the
one you completed 12 months ago. This will take about 45 minutes.
Voluntariness
Your participation in this research is voluntary. You may refuse to participate or discontinue
participation at any time without penalty or loss of the benefits to which you are otherwise entitled.
Your decision will not affect your work or personal status.
Risks and Benefits
You may experience some mild, temporary discomfort relating to completing the questionnaire, about
your performance at work, feelings and attitudes. As a result of your participation, you will probably
not receive any direct benefits from participating in this research. However, your participation may
help researchers understand certain results.
Confidentiality
Only the principal researcher will have access to research results associated with your identity. In the
event of publication of this research, no personally identifying information will be disclosed. To make
sure your participation is confidential, please do not provide any personally identifying information on
the questionnaires. Questions about this research study should be directed to the primary investigator
and person in charge, Dr. Asrade Abate; (contact info: Index Consult, Addis Ababa, Ethiopia; Telephone
+251-911-377096)
Part II.
Certificate of Consent by Participant
I certify that I have read this form and volunteer to participate in this research study.
_________________________________
(Print) Name
_________________________________ Date: _________________
Signature
Statement by the person taking consent
I have accurately read out the information sheet to the potential participant, and to the best of my
ability made sure that the participant understands.
_________________________________
(Print) Name
_________________________________ Date: _________________
Signature

34
Annex IV: Questionnaire 01 (HEWs Interview)
A. General Profile (20 Questions)
i. Woreda Health Office
1) Name ______________________________
 የወረዳውስም
2) # of Kebele ______________________________
 የቀበሌቁጥር
3) # of Health Centers ______________________________
 የጤናጣቢያቁጥር
4) # of Health Posts ______________________________
 የጤናኬላቁጥር
5) # of Health Extension Workers ______________________________
 የጤናኤክስቴንሽንሰራተኞችቁጥር
6) # of Women's Development Army members____________________
 የልማትሰራዊትቁጥር
7) # of Health Extension Supervisors ___________________________
 የጤናኤክስቴንሽንተቆጣጣሪ
8) Nutrition Focal Person at Woreda level Yes No
 በወረዳውያለየስነ_ምግብኤክስፐርት
ii. Health Post
1) Name: ______________________________
 የጤናኬላውስም
2) Year of establishment of Health Post: ____________________
 ጤናኬላውየተመሰረተበትአመተምህረት
3) Number of HEWs: ______________________________
 የጤናኤክስቴንሽንሰራተኞችቁጥር
4) Number of WDAs: ______________________________
 የልማትሰራዊትቁጥር
5) Catchment population: ______________________________
 በጤናኬላውየተገልጋዩህብረተሰብቁጥር
6) Distance of the Health Post from the Woreda Office: ____________________
 የጤናኬላውከወረዳውጤናቢሮያለውርቀት
7) Distance of HEWs’ house from the Health Post:_______________________
iii. Health Extension Worker
1) Code: ______________(apply abbreviated Woreda & HP name followed by order of visit)
 የጤናኤክስቴንሽንሰራተኞችኮድ
2) Age: ____________
 እድሜ
3) Marital status: Married Not married
 የትዳርሁኔታ
4) Number of service years:____________
 ያገለገለችበትአመትብዛት
5) Level of Education: ________________
 የትምህርትደረጃ

35
B. Activity of the Health Extension Worker (18 Questions)
1) Do you think you have all the equipment you need at the Health Post?
(በጤናኬላውአስፈላጊናቸውብለሽየምታስቢያችውሁሉምየህክምናመሳሪያዎችአሉሽ?)
Yes No
 If no, what additional equipment do you need? (ተጨማሪየሚያስፈልጉሽአሉ?)
_________________________________________________________
Do you think you have all the supplies you need at the Health Post?
(በጤናኬላውአስፈላጊናቸውብለሽየምታስቢያችውሁሉምየህክምናአቅርቦቶችአሉሽ?)
Yes No
 If no, what additional supplies do you need? (ተጨማሪየሚያስፈልጉሽአሉ?)
____________________________________________________________
2) Do you think the Health Post is adequately furnished?
(በጤናኬላውአስፈላጊናቸውብለሽየምታስቢያችውሌሎችቁሳቁሶችተሟልተዋል?)
Yes No
 If no, what additional furniture do you need? (ተጨማሪየሚያስፈልጉሽአሉ?)
____________________________________________________________
3) Do you have the necessary Nutrition relevant Reference Guides you need?
(በጤናኬላውለአንችየሚያስፈልጉሽየማጣቀሻመጽሃፎችናሌሎችጽሁፎችአሉሽ?)
Yes No
 If no, what additional Reference Guides do you need? (ተጨማሪየሚያስፈልጉሽአሉ?)
____________________________________________________________
4) Do you think the staffing (number of HEWs /Health Post) is adequate? (በጤናኬላውያላችሁት •
የጤናኤክስቴንሽንሰራተኞችቁጥርበቂነውብለሽታስቢያለሽ?)
Yes No
5) How long does it take to reach the farthest household in your
catchment?በአንችየስራምድብውስጥበጣምሩቅየሚባለውቤተሰብጋርሄደሽለመስተማርምንያህልሰዐትይወስዳል?)_______
 How do you get there? ( እዚያለመድረስበምንትጓጓዣለሽ?) _______________________
6) Do you have a Uniform at work place? (በስራወቅትየምትለብሽውጋውን / ዩኒፎርምአለሽ?)
Yes No
 Do you think you need a Uniform? (ጋውን / ዩኒፎርምየሚያስፈልግይመስልሻል?)
Yes No
 If yes, what do you think is the added value? (ጋውን / ዩኒፎርምምንተጨማሪፋይዳአለው?)
____________________________________________________________

36
7) How do you divide tasks with your colleague HEW?
(ከስራባልደረባሽጋርየስራክፍፍልየምታደርጉትእንዴትነው?)
__________________________________________________________________________
____________
_______________________________________________________________________
8) Describe what you do: (ምን፡ምንእንደምትሰሪዘርዝሪልኝ)
 Daily (በየቀኑ )________________________________________________________
____________________________________________________________
 Weekly (በሳምንት)______________________________________________________
____________________________________________________________
 Monthly (በወር)______________________________________________________
____________________________________________________________
9) How do you schedule your daily work? (በየዕለቱየምትሰሪውንሰራእንዴትነውየምታቅጅው?)
____________________________________________________________
____________________________________________________________
____________________________________________________________
 List all the important tasks performed daily. Then, rank the tasks according to
priority) (በጣምአስፈላጊየምትያቸውንበየቀኑየሚከናወኑየስራዝርዝሮችንበቅደምተከተልንገሪኝ)
# List of important tasks (ዋናዋናየሚባሉትየስራዝርሮች) Rank (ደረጃ)
1
2
3
4
5
10) How do you manage your time to fulfill tasks at the HP or for outreach? ( በጤናኬላውና፡
ቤትለቤትየምትሰሪውንሰራበሰዕትናበሳምንትከፋፍለሽንገሪኝ)
# Task setup Health Post Outreach Other
1 # of hours per day
2 # of days per week
11) How many households do you visit per day/week/month? (ምንያህልየቤትለቤትጉብኝትታካሂጃለሽ፡
በቀን/በሳምንት/በወር?)_______________________________________________________________
____________________________

37
12) How frequently (# of calls/week) do you have emergency calls after work hours
(ከስራሰዕትውጭ፡ለድንገተኛየህክምናአገልግሎትበሳምንትምንያህልጊዜትጠሪያለሽ?
____________________________________________________________
13) How do you divide and assign tasks to each WDA/team of WDA?
(ለጤናልማትሰራዊትቡድንስራየምታከፋፍይውእንዴትነው?)
____________________________________________________________
____________________________________________________________
14) How many trainings do you have this year (2004 EC)? (በ2004
አመትምንያህልስልጠናወስደሻል?)_________________
 Mention the trainingsbelow
# Type or subject of training Provider #of days/hrs Place of training Remarks
የስልጠናውአይነት አዘጋጁ ምንያህልቀን/ሰዕት ቦታው
1
2
3
4
15) How many types of reports do you prepare? (ስንትአይነትሪፖርቶችታዘጋጃለሽ) _____________
16) What is the frequency/number of your reports ? (እያንዳንዱንሪፖርትበስንትጊዜነውየምታዘጋጅው)
 Daily______________; Weekly_____________; Monthly______________;
17) Are the reports complete (check reports of the last consecutive three months)
(የተከታታይ 3 ወርሪፖርትበማየት፡የሪፖርቱአስፈላጊመጠይቆችሙሉበሙሉመሞላታችውንአረጋግጥ)
#
Name of
Month
Report Completeness
Complet
e
Not
Complete
No
Report
Remark
1
2
3
18) How many referrals did you make in the last 3 months (include type of disease)?
((የተከታታይ 3 ወርሪፖርትበማየት፡በእያንዳንዱወር፡ወደጤናጣቢያየተላኩትንታካሚዎችመዝግብ/ቢ)
Month(ወር)
# of
Referrals(ቁጥር)
Type of Disease(የበሽታውአይነትዝርዝር)
1
2
3

38
C. Community Promotion Activities on Nutrition (6 Questions)
19) Do you think you have adequate training to implement nutrition promotion messages
(ህብረተሰቡንበአመጋገብዙሪያለማስተማርበቂየሆነስልጠናአግኝተሻል) ? Yes No
 If no, explain _______________________________________________________
___________________________________________________________________
20) Do you think you have adequate skills to execute the nutrition promotion
messages(ህብረተሰቡንበአመጋገብዙሪያለማስተማርና፡ለመተግበርበቂየሆነልምምድ / ሙያአካብተሻል?) Yes No
 If no, explain_________________________________________________________
____________________________________________________________________
21) How many hours/day and days/month do you spend on Nutrition
promotion(ህብረተሰቡንበአመጋገብዙሪያለማስተማርምንያህልጊዜትጠቀሚያለሽ)
 Hours/day (ምንያህልሰዐት /በቀን ) ___________________________
 Days/month (ምንያህልቀን/በወር) ___________________________
22) Do the WDAs perform household visits to promote nutrition?(ህብረተሰቡንበአመጋገብዙሪያለማስተማር፡
የልማትሰራዊትአባላትየቤትለቤትጉብኝትያደርጋሉ?) Yes No
 If yes, how many household visits/month are made by WDAs (explain the approach)
(የልማትሰራዊትአባላትበወርምንያህልየቤትለቤትጉብኝትያደርጋሉ?እንዴት?
_______________________________________________________________________
_______________________________________________________________________
23) Do you have all necessary CMAM and Infant and Young Child Feeding (IYCF)
modules(ህብረተሰቡንስለጨቀላዎችናህጻናትአመጋገብለማስተማርየሚያስፈልጉሽሁሉምአይነትየማጣቀሻመጽሃፎችናመረጃዎችአ
ሉሽ?)?
Yes No
 What additional materials do you need? (ተጨማሪየሚያስፈልጉሽአሉ?)
_______________________________________________________________________
24) Check if the following materials are available (read the title of the guide):
# List of Quick References Yes No
1 Initiation of Breastfeeding Quick Reference
2 Early Breast Feeding Quick Reference
3 Severe Acute Malnutrition (SAM) module
4 Severe Dehydration Quick Reference Guide
5 Quick reference (IYCF/ CMAM)
6 Counseling card flipchart_WB

39
D. Knowledge/Attitude of HEW on Nutrition (14 Questions)
25) When should a mother breastfeed her baby after birth?
(አንድእናትልጇከተወለደከምንያህልጊዜበኋላነውማጥባትያለባት?)
______________________________________________________________________________
_____
26) Does it have any harm to give water to a baby less than 6 months old?
(ስድስትወርላልሞላውህጻንውሃማጠጣትጉዳትአለው?) Yes No
27) Should the baby breastfeed on demand? (አንድህጻንመጥባትበፈለገጊዜሁሉመጥባትአለበት?)
Yes No
28) How often do you think baby be breastfed? (አንድህጻንበምንያህልጊዜልዩነትመጥባትአለበት?)
______________________________________________________________________________
_______________________________
29) Do you think a working mother is able to breastfeed her baby? (አንዲትስራያለባትእናት፡
የስራሰዐቷስይስተጓጎልልጇንበአግባቡጡትማጥባትትችላለች?) Yes No
30) When should the baby start supplementary feeding?
(አንድህጻንከጡትበተጨማሪምግብየሚያስፈልገውከስንትወርጀምሮነው?) _________________________
Why? (ለምን) _______________________________________________________________
31) How many meals per day should a child 12-23 months of age receive?
(እድሜውበ1አመትእናሁለትአመትመካከልየሆነህጻንበቀንስንትጊዜመመገብአለበት)
_________________________________________________
32) What is the minimum number of food groups a child should consume daily
(አንድጡትያቆመህጻንበቀንስንትየምግብአይነቶችመመገብአለበት? _______
33) What should the consistency of porridge be like for an infant of 7 months?((እድሜው7
ወርየሆነህጻንየሚበላውገንፎየሚሰራውከምንድንነው? ምን፡ምንነገሮችንስመያዝአለበት?)
______________________________________________________________________________
34) Does a breast feeding women need extra food?
(ልጅከመውለዷበፊትከነበረውአመጋገቧበተለየ(አንዲትእናትጡትስለምታጠባተጨማሪምግብመመገብአለባት? )
Yes No
35) What micronutrients do you think baby needs after 6 months (list below)
(እድሜውከ6ወርበላይየሆነህጻንበሚመገበውተጨማሪምግብውስጥመካተትያለባቸውንጥረ-ነገሮችምን፡ ምንናቸው? ዘርዝር)
______________________________________________________________________________
____
36) Of all mentioned, which micronutrient do you think is most needed by babies?
(ከነዚህከተጠቀሱትንጥረ-ነገሮችመካከልእጅግበጣምአስፈላጊነውየሚባለውየትኛውነው?)____________________
37) What local food do you recommend as a good source for each micronutrient listed below?
((ከዚህበታችየተጠቀሱትንንጥረ-ነገሮችበበቂመጠንሊሰጡንየሚችሉየምግብአይነቶችየትኞቹናቸው)
# Micronutrients Micronutrient source food (as recommended by HEW)
1 Iron

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