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Ethiopia is a second populous country in Africa with a total population of 82.8 million, birth rate
of 39 and death rate of 12 per 1000 population. Ethiopia is the least develop country and has
poor health status as dictated by low per capita income and high infant mortality rate 1.

The health policy of the Federal Government of Ethiopia uses decentralization and
democratization as a tool to address the problem of under privileged rural people 2. The Policy
has been realized after formulation of health sector development program. The 1st health sector
development program HSDP-I (1997/8 to 2002) and the 2nd health sector development program
HSDP-II (2003-2005) had been completed with encouraging results and potential experiences
gained which was an in put for the development of HSDP. HSDP- II took a stock of experiences
from HSDP-I and further aimed to the delivery of cost effective preventive and promotive health
care services through an integrated and articulated plan of health extension program (HEP)
which will be implemented almost through HSDP-III (2005/6- 2009/10) 3.

HEP is a new initiative, and defined package of basic and essential promotive, preventive and
selected high impact curative health services targeting households which had been started in
HSDP-II in response to HSDP-I findings. It is an initiative community based health care delivery
system aimed at creating healthy environment as well as healthy living using cadres of health
extension workers 4. It was introduced in recognition of failure of essential services to reach
communities in remote areas. HEP services have been customized to meet the needs, demands
and expectations of the pastoralist, agrarian and urban population. It is considered as the most
important institutional framework for achieving the Millennium Development Goals (MDGs) 5.

HEP is based on the concept and principles of PHC. It is designed to improve the health status of
families, with their full participation, using local technologies and the community's skill and
wisdom. HEP is similar to PHC in concept and principle, except HEP focuses on households at
the community level, and it involves fewer facility-based services. The philosophy of HEP is that
if the right knowledge and skill is transferred to households they can take responsibility for
producing and maintaining their own health. The HEP is the main vehicle for bringing key
maternal, neonatal and child health interventions to the community. It is expected that almost all

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of the activities listed in the National Child Survival Strategies are to be implemented through
the HEP 6.

The main objectives of HEP are shifting health care resources from predominantly urban to rural
areas; improving access and equity of essential health services at the village and household
levels; ensuring ownership and participation among community members; promoting gender
equality; improving the utilization of peripheral health services by bridging the gap between
communities and health facilities through Health Extension Workers (HEWs); reducing maternal
5,7
and child mortality and to promote an overall healthy lifestyle . HEP is designed to achieve
significant basic health care coverage in Ethiopia through the provision of a staffed health post to
serve every 5000 people. Every health post is being staffed by two female HEWs who had been
under gone one year training and receive salary from the government at the end of the month in
order to provide 16 major packages under four components 6, 8, 9, 10, 11. These are:

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 (HIV/AIDS and other sexually transmitted infections (STIs)
and TB prevention and control, Malaria prevention and control, and First Aid emergency
measures)



 (Maternal and child health, Family planning, Immunization, Nutrition, and
Adolescent reproductive health)












(Excreta disposal, Solid and liquid waste disposal,
Water supply and safety measures, Food hygiene and safety measures, Healthy home
environment, Control of insects and rodents, and Personal hygiene)



 





(Health education and communication).

The word health extension worker is not common in many countries other than Ethiopia.
Therefore, in this literature review other terms like community health workers, community health
agents, community health representatives, community health volunteers, nurses, doctors and
health workers/health professional are used for reviewing the literature on issues related to health
extension workers. And it is a timely issue to assess the motivation of health extension workers
who are the most important cadre for the implementation of health services extension program,
the utilization of health extension program and the impact of the program.

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Motivation is an internal psychological process that can be defined as an individual¶s degree of

willingness to exert and maintain an effort towards organizational goals. People cannot be
motivated directly; it needs to create an environment conducive to high degrees of motivation.
Motivation by itself is not an observable phenomenon; it is only possible to observe either the
results of the motivational process (such as improved performance) or perhaps, some of the
determinants of motivation. The results of the internal process of motivation reflect the specific
individual¶s situation and environment. Thus it is often said that motivation is a 



process: it depends upon the relationship between the individual and the organizational context
within which they work, and the broader societal context. Worker motivation is critical issue in
the health sector since health care delivery is highly labor-intensive and service quality,
efficiency and equity is directly affected by worker motivation 12, 13.

Work motivation is often mentioned as a major problem to health systems performance in

developing and middle-income countries. Motivational determinants of health worker motivation
14
at several levels can be seen as : individual level (goals, self-concept, and expectations for
consequences of work behavior); work context or organizational level (organizational structure
and processes, organizational culture, and human resource management inputs); and broad socio-
cultural factors (community expectations, peer pressure, societal values). Generally, as a
specialty in the broader field of human motivation, work motivation refers to the psychological
processes that have direct implications for individual behavior in the context of work, and in
particular those processes that influence the individual¶s achievement of workplace goals and
tasks. Emphasis is placed on a narrower set of person and situational factors than is considered in
broader theories of human motivation.

Different studies have been conducted by different researchers on motivation of health workers
and factors influencing motivation especially on community health workers, nurses, doctors and
other health workers. The findings of motivational studies can be seen as incentives versus
disincentives, and also motivating factors versus de-motivating factors.

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 ‘‘ 
 ‘

Motivation can be influenced by different factors. These motivating factors can be generally
classified in to two: incentives and disincentives.


 
‘ atisfactory remuneration: material incentives, financial incentives, possibility of
future paid employment; community recognition and respect, acquisition of valued skills,
personal growth and development, accomplishment, peer support, and clear role; community
involvement in selection; visible change; policies or legislation that support health workers are
some incentives that could lead to motivation of health workers 15. ‘


 
‘ on the other hand, inconsistent remuneration financial; change in tangible
incentives; inequitable distribution of incentives among different and community workers;
CHWs from outside community; inadequate refresher training, inadequate supervision; lack of
respect from health facility staff; inappropriate selection of CHWs, lack of community
involvement in CHW selection, training, and support, and unclear role and, failure to take
community needs into account; and inadequate staff and supplies can lead health workers to
dissatisfaction 15.‘

  ‘
 ‘‘   ‘
 ‘

Motivation can also be influenced by motivating and demotivating factors.

  ‘
 
Altruism, prestige, professionalism, job security, commitment of managers
16, 17
to improve staff conditions, recognition and appreciation . For example, A survey done on‘
work satisfaction of professional nurses in South Africa indicated that overall, professional
nurses in South Africa expressed greatest satisfaction in their relationship with patients and the
gratification they obtained from patient care, their relationship with their nursing colleagues, and
doctors and their sense of belonging in the communities within which they work 16.
‘
  ‘ 
 
Unmet expectations, challenged by the demands of clients, lack of
fairness, lack of incentives, poor inter-professional relations poor communication system, poor
salaries, lack of promotions, and poor access to training opportunities17, low salary, working
conditions and inadequate facilities for performing expected duties, lack of concern by


employers for staff welfare, lack of participation in decision making, poor information flow to
18
and from hospital management .The same study in South Africa indicated that professional
nurses and doctors were most dissatisfied with their pay, the workload, their career development
opportunities and the resources available to them 16.

A systematic review of motivation and retention of health workers in developing countries

(Africa and Asia) 19 revealed seven major themes regarding motivational factors were identified:
financial in terms of salary or allowances (90%); career development in regards to the possibility
to specialize or be promoted (85%); continuing education - having the opportunity to take classes
and attend seminars (80%); hospital infrastructure (the physical condition of the health facility,
in papers often described as 'work environment' (5%); resource availability (refers to equipment
and medical supplies that are necessary for health workers to perform their job (75%); hospital
management - refers to having a positive working relationship with the management with whom
the health workers work (70%); and personal recognition or appreciation - either from managers,
colleagues of the community (45%).

A study conducted to examine experiences with various incentives for CHWs and their impact
on retention and sustainability of CHW programs indicated that the motivation and retention of
CHWs is influenced by who they are in the community context. The inherent characteristics of
CHWs, such as their age, gender, ethnicity, and even economic status, will affect how they are
perceived by community members and their ability to work effectively. Monetary incentives can
increase retention. But monetary incentives often bring a host of problems because the money
may not be enough, may not be paid regularly, or may stop altogether. Non-monetary incentives
such as supportive supervision, appropriate training and relatively small things, such as an
identification badge, appropriate job aides such as counseling cards and regular replenishment of
supplies, peer support, and refresher training are critical to the success of any CHWs and are
very crucial to motivate CHWs 15.

In other study in Kenya, factors that appear to influence the motivation and work of CORPs
include: hopes for better life through continuous development of life skills and opportunities;
personal interests (values, characteristics), giving reason for volunteerism; administrative
environment (government regulations, laws, procedures, conditions, support, logistics supplies

º
available for the work leading to motivation); community factors (acceptance, understanding and
involvement); political and policy environment (creation of supportive structure); the strength of
the governing structures linking the community with the health system; training of the health
workers, supervisors, and mangers in participatory skills; and supportive supervision by a
multidisciplinary team of professionals 20.

A study conducted to assess the role of non-financial incentives and human resource
management tools on health worker motivation in Africa showed health workers in Benin
strongly referred to vocation and professional conscience, i.e. their personal professional values.
Among Kenyan respondents, vocation was equally very dominant. Also, healing patients,
professional satisfaction and recognition were considered important. These aspects nurture health
workers' goals. Both dimensions ± values and goals ± indicate a strong professional ethos and
commitment and strongly appear to translate into the "will-do" component of the motivation
process. Likewise, the wish to help patients and professional satisfaction were frequently
mentioned 21.

A study on retention of health workers in Malawi indicated that health workers were encouraged
to take jobs as health professionals within the districts because of the opportunity and ability to
assist mankind, coupled with a spirit of patriotism. They were specifically motivated to remain in
the districts because of the lower cost of living, the significant impact they made within the
communities they served and the fact that they learnt faster on their jobs in the districts compared
to their other colleagues in the urban areas. One major demotivating factor mentioned by all
cadres of health workers was monetary. Other demotivating factors mentioned were lack of
proper assistance from the Ministry of Health and poor human resource management practices,
including lack of supervision and continuous education. In addition, poor housing and the
absence of basic amenities such as water and electricity were considered to negatively affect
work performance 22.

A study on the match between motivation and performance management of health sector workers
in Mali on 370 health workers identified motivating and demotivating factors. The motivating
factors include: feeling responsible, salary increment, receiving training, holding responsibility,
appreciation, receiving recognition, receiving promotion, receiving incentives, working within a
team spirit, receiving financial benefits from user fees, having your partner, living near the

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workplace, and having good colleagues. Factors that de-motivate health workers include: lack of
material, lack of recognition, difficult living conditions, lack of a job description, subjective
performance appraisal, poor management, partner living far away, poor functioning of the health
committee, living far away from an urban centre and living far away from places where decisions
are being made 23.

Overall, in the above literature, it can be concluded that incentives and disincentives or
motivating and demotivating factors are mostly similar for different categories of health workers
though majority of motivational studies are qualitative. These factors can be categorized under
work-itself, co-workers, management, work load, promotion, organizational structure, working
conditions, and payment and benefits 24. Other noteworthy points emerged from this literature is
that a person can be relatively satisfied with some aspect of his or her job and dissatisfied with
others, either because they fail to fulfill his or her needs and values or because they do not meet
his or her expectations; and there is a clear understanding that improving management,
workload, promotion opportunities, organizational structure, working conditions, and pay and
benefits are factors that can motivate or demotivate health workers.

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Health Service Utilization denotes an individual demand and use of health care resources and
services and indicates the way‘ customers (patients) interaction with health care providers.
Therefore health service utilization (utilization of‘health care services) is a proxy of health status
of a population and use of health care services. Health care‘service utilizations are provided by
public, private or public-private facilities 25.

Studies in Uganda, Ecuador and Pakistan identified different factors that influence healthcare
utilization. The studies indicated that service acceptability depended on the health worker
attitudes and practices, perceived gender discrimination, local illness and treatment perceptions.
Fear and stigma were also identified as barriers in the health seeking process. Availability,
adequacy, acceptability and affordability of services; and ownership of material, human and
social resources were reported as determinants of health care service use 26, 27, 28.

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In Uganda barriers to healthcare utilization were reported for all the wealth categories (poor,
medium, and rich) along three different axes (the health seeking process; health services
delivery; and the ownership of livelihood assets) regardless of wealth category. Income source,
ownership of means of transport, and health literacy were reported as centrally useful in
facilitating use of healthcare utilization for the 'least poor' and 'medium' wealth categories.
However, the lack of these was a barrier for the poorest wealth category. The poorest' wealth
category were keen to utilize public health services which are provided free of charge. This study
suggests that in addition to income, physical resources and free public health services, social
resources were perceived as important in overcoming some of the existing barriers 25.

A study conducted focusing on developing countries revealed that utilization of health service
can be influenced by the type and mix of health professional working in the health care facilities.
For example, higher doctor concentration was significantly associated with greater use of
measles immunization and higher nurse concentration was associated with greater use of skilled
birth attendants. Aggregate health worker concentration was positively and significantly
associated with use of skilled birth attendants and measles immunization 29.

A study on Utilisation of Health Care in North Bengal, India indicated that demographic factors
like age and family size have been important determinants of utilization of care. The regression
analyses indicate that children in the 5-14 age groups are by and large neglected. Probability of
utilisation is seen higher in small families. As of µnormal out-of-door trips¶, those households
whose heads make frequent trips, have a tendency to utilise care more 30.

The demand for public health facilities is tremendously high as compared to that of private
health facilities in rural areas of the districts. The effect is too strong to hold well in the area as a
whole (combined category) also. Probability of utilisation is very high in rural areas when the
preference for the system of medicine is Homeopathy. Availability of health facilities is seen to
have negative impact towards utilisation of a care. The underlying assumption was that in the
urban areas health facilities are available. However, the result indicates that as compared to the
people of the rural areas, urban dwellers are likely to avoid utilizing a care from modern source.
Cost of treatment seems to affect utilisation of care positively. The question of financing of

×
health care is, therefore, drawing attention 30. Cost sharing overall reduces utilization of services
i.e., after the introduction of cost sharing reduction of service utilization amounts to 21.3% for all
31,
cases and 12% for malaria cases and insurance system also affect utilization of health care
32
services .

A study on determinants of health care utilization by immigrants in Portugal, in Lisbon indicated

that barriers to appropriate and timely access were identified as waiting times (50.2%), providers'
attitudes (17.9%), cost (3.4%), distance and transportation (2.2%), and language (1.3%). The
logistic regression analysis allowed the identification of age, length of stay, legal status and
economic situation as positively associated with the use of health services. More than 10 years of
school education or being born in Eastern European or South American countries were
significantly associated with a lower probability of using health services, both for males and
females33.

In Bangladesh, a cross-sectional study was conducted to investigate the pattern of utilization of

child health care services provided by the Thana Health Complex (THC) of Keraniganj and to
identify the factors that are affecting the use of Child Health care (CHC) services. The study
focuses on socio-economic factors, knowledge and attitude of people and demographic factors
that are affecting the use of CHC facilities at the THC level and information about the children
under 5 years of age. Family income and mother`s education was found to have positive effect
on the rate of child vaccination. The percentage of vaccinated children (97% approximately)
among sample population was found close to that of the recorded percentage (98.6%)) at the
Keraniganj. It was found in the study that higher level of knowledge of the respondents about the
CHC service provision of the use of the THC increases the use of THC 34.

A qualitative study on utilization of maternal health care services in the department of

Matagalpa, Nicaragua was conducted to investigate women¶s maternal health care- seeking
behaviors and perceptions using an analytic induction approach. The overwhelming majority of
women interviewed (31 out of 37, or 84%) reported seeking prenatal care at health facilities.
Though 31 women reported they accessed prenatal care services, only 19 (61%) of them
delivered in health facilities. The study identified different factors that affect for utilization of
35
maternal health care services : 






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A study conducted on health service utilization in Amhara Region of Ethiopia in 1998 showed
59% of the people who died in a period of 12 months preceding the survey were taken to health
institutions for the disease, which killed them while the rest 41% did not visit health institutions.
The two most frequent reasons for not taking patients who died for the disease was fast course of
the disease (34.1%) and the deceased would not benefit from the services of modern health
institutions (31.7%). Over the two weeks period preceding the survey, 995 (5.6%) people
claimed that they were sick. The number of sick people who visited health institutions for
treatment was 385 (38.7%) while the rest 610 (61.3%) did not visit health institutions for their
perceived sickness. The most important reasons were believed that the disease did not need
treatment in health institutions (31.9%), bought drugs from drug vendors (27.2) and visited
traditional healers (20.2%). Secondary education or above (OR =2.1, 95%CI 1.2, 3, 4) were
significantly related to utilization of modern health institutions.36.

From the above literature on service utilization we can conclude that 
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' (professional mix, training and conduct of workers towards the client), 
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( 
) such as family characteristics (age, gender, household size, marital
status), social structure (education, employment, ethnicity), assets / affordability (land, livestock,
cash income), and perceptions about modern health care services;



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such as

availability of health facilities, accessibility to health care, quality of care, and costs; and

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$intensity of illness and number of spells ) can affect utilisation of
health care services 26-29,31,33-36.



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Community health workers (CHWs) improve access to and increase utilization of primary health
care, reduce costs of care, improve quality of care, and reduce health disparities. They achieve
these goals by serving as the bridge between clients in need and needed health care and human
services 37, 38.

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In the United States of America, community health workers contributed to the delivery of
primary and preventive care by increasing access to health care, improving the quality of care,
reducing the costs of care, and by making broader social contributions. CHW programs can
enable low-skilled unemployed workers and welfare recipients to pursue a new occupation and
career advancement. These programs could also be tied to national service programs and high
school enrichment programs, allowing young people exposure to health careers. CHW programs
can also assist health profession schools in better preparing their graduates for the realities of
practice 38, 39.

In many Africa countries CHWs have fulfilled generalist health functions, specialist health roles,
in of areas as nutrition, reproductive health, and malaria control, and wider roles as community
advocates and change agents. Evidence suggests that these workers have increased coverage of a
40
range of services over the last 30 years . Yet the effectiveness of CHW programs on the
continent has often been constrained by a lack of government support, the inattention to primary
health care, and the reduced role of CHWs in national health care systems, particularly during
political transition. And also the key to successful community-based programs may lie in the
effective training and continuing education of its CHWs and their acceptance by the community.

The types of tasks where CHWs have been successful include (but are not limited to)
communication within communities, improving the health environment, supporting health
programs such as EPI, and diagnosis and/or treatment of diseases such as pneumonia and TB.
There is generally a clear consensus that in many aspects of health care, CHWs have a vital role
in the achievement of MDGs relating to health, that more CHWs are needed, and that they are
trained. It was believed that universal health coverage could be achieved through implementation
of health extension program 41.

Ideally, the CHW combines service function and developmental/promotional function that are
also ideally, not just in the field of health, perhaps the most important developmental or
promotional role of the CHW is to act as a bridge between the community and the formal health
services in all aspects of health development, the bridging activities of CHWs may provide
opportunities to increase both the effectiveness of curative and preventive services and, perhaps

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more importantly, community management and owner ship of health related program. CHWs
may be the only feasible and acceptable link between the health sector and the community that
can be developed to meet the goal of improved health in the near term 42.

As available literatures indicate community health worker programs have come about as a result
of dramatic political transformation, as part of health sector reform processes, as the initiative of
NGO and faith based organizations. Ghana and Niger are some of examples of countries that
introduce CHWs as part of health sector reform initiatives aiming to enhance accessibility and
affordability of health services to rural and poor communities with in a PHC approach 43.

A study done to assess the performance of CHWs in the promotion of basic child heath services
in rural Mali indicated that of the 401 households suppose to receive a visit by a CHW, 219
(54.6%) had received at least one visit in the last three months prior to the study period and of
these 162 (73.9%) had received a visit the month before the survey (April, 2006). Regarding
knowledge of the child caregiver on home management of child illness, 40% mentioned to have
treated fever with the correct regimen. Seventy-nine percent of the visited households had a bed
net. A high percentage of households had iodized salt (98.7%). Comparison between households
with and without CHWs showed no statistically significant difference concerning socio-
demographic characteristics. When compared on knowledge and practice, a positive influence of
CHWs on specific essential family health practices by the households was found, namely
knowledge on the management of child fever (p = < 0.001), use (p = < 0.001) of bed net and,
utilization of iodized salt (p = 0.05) 44.

A community-based intervention study was conducted using a pre-post comparison of the same
group; which was implemented in three phases: situational analysis June 2004; intervention
October 2004 to October 2006 and the post-intervention assessment in November 2006, showed
a significant improvement in the utilization of a skilled attendance with variation across the
villages. Deliveries with skilled attendants significantly increased from 34.1% to 51.4% in 2006
(r < 0.05). The proportion of women who were assisted by traditional birth attendants (TBAs)
decreased from 35.7% to 29.9% while those assisted with relatives went down from 30.2% to
17.3%. Some of the observed positive effects during the course of the study as expressed by

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community leaders, health providers, safe motherhood promoters (SMPs) and villagers during
45
monitoring and in the final assessment were the following : improved involvement of
community leaders at sub-village level in promoting safe motherhood; increased involvement of
religious leaders in community health activities; and the intervention has built linkages between
health providers, SMPs and pregnant women and TBAs.

Often performance is measured in terms of improvement in health status of the population that
CHWs serve, increase in the utilization of services provided by them, reduction in the wastage of
resources, the presence and accessibility of CHWs to the community members. Computing each
of these measures is data intensive and also requires careful effort in documentation and analysis
over a period of time. However, the degree of trust and confidence of the community members
that CHWs have gained over a period of time is important in sustaining the motivation of CHWs
to function with commitment and effectiveness 46.

In Papua New Guinea, an outcome evaluation was conducted to investigate the long-term impact
community intervention activities on maternal and child health and identified reduced incidence
of illness and improved physical health in families of those villagers who made behavioral and
environment changes to improve their health. Individuals reported experiencing benefits from
simple, small and inexpensive changes that motivated changing traditional ways. Positive
benefits from these changes have resulted in people accepting a more hygienic environment and
improved sanitation practices as the social norm. Changes in one community have influenced
nearby communities because they see the benefits to family health in their neighbours 47.

In the literature review, it was very difficult to get published researches on health extension
program and health extension workers and those researches done on health extension program
related issues such as health extension workers access to information, continuing education and
48
reference materials ; assessment of the training of the first intake of health extension workers
49 50
, and working conditions of health extension workers in Ethiopia did not assess the
motivation of health workers, utilization and impact of the health extension program. The
retention of health extension workers and the outcome of the health extension program are yet to
be evaluated 20.

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(*

Health service extension program is an innovative approach which is encompassed under the
Health Sector Development Program to meet the millennium Development Goals (MDGs).

While the program is innovative and is supposed to bring better health status of population
especially in peripheral areas, studies done concerning program are rare. This study will be
conducted with the aim of assessing motivation of health extension workers (HEWs), utilization
of health extension program (HEP) by the community and outcome of health extension program.

Therefore the findings of this study will have a substantial contribution in maximizing utilization
of health service, improving healthy practice, and enhancing motivation of HEWs and overall
reduction of morbidity and mortality. It will also give insight for health care planners and policy
makers whether the policy change is required or not.

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The general objective of this dissertation is to assess the Implementation of Health Extension
Program (HEP) in West Gojjam Zone, Amhara National Regional State, Ethiopia.


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l‘ To assess the motivation of Health Extension Workers‘‘
l‘ To assess the utilization of Health Extension Program by the community‘‘
l‘ To assess the outcome of being graduated households/kebeles on maternal
and child health, family planning and immunization‘‘

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Figure 1: Conceptual Framework for Motivation of HEWs, Utilization of HEP by the

Community and Outcome of HEP.

This conceptual framework is the modification of conceptual framework used in the research
done by Franco M., Kanfer R., Milburn L., Qarrain Reem., and Stubblebine P. (2000): An In-
depth Analysis of Individual Determinants and Outcomes of Health Worker Motivation in Two
Jordanian Hospitals14, and a conceptual framework used in the research done by Amlan
Majumder (2006): Utilisation of Health Care in North Bengal: A Study of Health Seeking
Patterns in an Interdisciplinary Framework30.

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Amhara National Regional State (ANRS) is one of the eleven regions of the country and is
administratively divided into 10 zones, 1 special zone and 1 special district. It is borderd by the
Tigray Region in the North, the Afar Region in the East, the Oromia Region in the South and the
Benshagul Gumuz Region and Sudan in the West. The region has 166 districts (128 rural
districts and 38 urban district administrations), 3,466 kebeles (3,157 rural kebeles and 309 urban
kebeles) with a total population of 17,221,976 (8,641,580 males and 8,580,396 females)
according to 2007 CSA survey 51.‘


The study area, West Gojjam Zone, is one of the 10 zones of Amhara National Regional State
and is bordered on the North by Lake Tana, on the Northwest by North Gondar Zone, on the
Northeast by Bahir Dar and Abay River which separates it from South Gondar Zone, on the
South by Abay River which separates it from Oromia Region, on the East by East Gojjam and on
the West by Agew Awi Zone. The zone has 18 districts (13 rural districts and 5 urban district
administrations), 397 kebeles (364 rural kebeles and 33 urban kebeles) with a total population of
2,106,596 (1,058,272 males and 1,048,324 females) according to 2007 CSA survey 51.

In the region, there are 6,530 health extension workers (6,401 rural and 129 urban health
extension workers) and there are 782 health extension workers (772 rural and 10 urban health
extension workers) in the Wesst Gojjam zone working in all districts and kebeles of the zone.
The coverage of graduate heads of households is 57% (2,069,610), 32% (150,914) for Amhara
Region and West Gojjam zone respectively 52.

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Across-sectional study design will be employed in which health
extension workers will be interviewed using structured questionnaire to assess motivation of
Health Extension Workers.

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‘  ‘  ‘ ‘ ·
A community based
cross-sectional study design will be used to
collect data for assessment of utilization of HEP services/packages by the community.

‘ ·
A multi-methods approach to collecting qualitative and quantitative data will be

employed
to assess outcome of being graduated households on maternal and child health, family
planning and immunization. For quantitative data, retrospective cohort study
design will be used,
in which graduated households will be compared with non-graduated households in terms of
maternal health, family planning and immunization services. Qualitative data will be collected
through in-depth interviews, and focus groups discussion.
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The source population for assessment of:
{‘ Motivation of health extension workers will be all health extension workers who are
currently working in West Gojjam Zone;
{‘ Utilization of health service extension program by the community will be all households
in West Gojjam Zone; and
{‘ Outcome of health extension program on maternal and child health, family planning and
immunization will be all households in West Gojjam Zone.

The study population for:

{‘ Measuring motivation of health extension workers will be all health extension workers in
each selected kebeles of West Gojjam Zone.
{‘ Assessing health service utilization of Health Service Extension Program by the
community will be heads of households from selected kebeles.
{‘ Assessing the outcome of Health Services Extension Program on maternal and child
health, family planning and immunization will be heads of households from randomly
selected kebeles; Officials of Regional Health Bureau, Zonal Health Department, and
District Health Offices and HEWs.

c×
ÿ 
(/
("

The number of health extension workers to be included in the study for measuring their
motivation will be determined using single population proportion formula. The assumption in the
calculation of the sample size is 95% confidence interval (CI), marginal error (d) of 5 %, and
50% of HEWs may be satisfied.
n = ZĮ 2 p (1-p)
d2
Where, n = sample size, p = proportion of HEWs who may be satisfied, and d = assumed
marginal error (5%)
n = (1.96)2 (0.50) (0.50) = 384 HEWs
(0.05)2
Since the total number of HEWs in West Gojjam Zone is less than 10,000, the correction formula
nf = ______n______ is used.
1+ n/N
Where, nf = sample size after correction, N = total HEWs
nf = ____384_______ = 256 HEWs
1+ 384/772
Ten percent non-response rate = 10% x 256 = 26 HEWs
Therefore, the final sample size will be 256 + 26 = î î HEWs.


!/
·
The number of heads of households to assess the utilization of HEP services/packages
by the community to be included in the study will be determined using single population
proportion formula. The assumption in the calculation of the sample size is 95% confidence
interval (CI), marginal error (d) of 5 %, and 50% utilization of HEP by the community.
n = ZĮ 2 p (1-p)
d2
Where, n = sample size, p = proportion of community HEP services utilization, and d = assumed
marginal error (5%)
n = (1.96)2 (0.50) (0.50) = 384
(0.05)2
In this case, a design effect of 3 is needed. n = 3 x 384 = 1152 heads of households.

ca
Ten percent non-response rate = 10% x 1152 = 116 heads of households.
Therefore, the final sample size will be 1152 + 116 = cîÿ heads of households.

!/
·
To assess the outcome of HEP on maternal and child health, family planning and
immunization, the number of heads of households to be included in the study will be determined
using "  ‘ ‘ 

‘  ‘  ‘ ‘ ‘  ‘  ‘   ‘  ‘
‘ ‘

 
 ‘!‘


" ‘
1 = the level of significance (Type I error) i.e., aº

& &

$c2 13
4 = the chance of not detecting the relative risk (Type II error) i.e., 

/5
$c2
43
!c = º
of immunization coverage for participants in non-graduated households
!î = ÿ
of immunization coverage in graduated house hold
 = unexposed: exposed = c·c


 (RR) = 1.20

The software produces an output of sample size  for unexposed (non graduated households)
and sample size of  for exposed (graduated households).

In this case, a design effect of 3 is needed. n = 3 x 407 = 1221 heads of households.

Ten percent non-response rate = 10% x 1221 = 123 heads of households.
Therefore, the final sample size will be 1221 + 123 = c%
for unexposed (non graduated
households) and sample size of c% for exposed (graduated households) i.e., a total of îÿ
households/ heads of households.

In addition, for in-depth interviewing, c health officials and program coordinators (3 from
Regional Health Bureau, 3 from Zonal Health Department, 12 from District Health Offices) and
î HEWs will be included in the study. For focus group discussions, individuas from the
community which will consist of 8-12 individuals will be included.

î

ÿ º
(/#
!& 

The sampling technique for all the three papers will be multistage sampling with simpe random
sampling.

The sampling procedure for assessment of motivation of health extension workers will start with
random selection of districts in the zone. Six districts will be randomly selected among the 13
rural districts of West Gojjam Zone. All (282) HEWs in 141 kebeles of those 6 districts will be
included in the study.

For utilization of HEP by the community and outcome of HEP on the community, the sampling
procedure again will start with random selection of districts in the zone. In this case, 6 districts
will be randomly selected and from these 6 districts 141 kebeles will be selected. The study
participants for assessment of utilization (1268 households) and outcome of HEP (2688
households i.e., 1344 graduated households and 1344 non-graduated households) will be selected
using simple random sampling technique from each selected kebele proportional to the number
of the households of each kebele.

îc


îî
ÿ ÿ

&
!& 


Individual HEWs questionnaire data will be collected during group sessions where health
extention workers hold monthly meeting at common place (usually one common site for three
kebeles i.e., six health extension workers). The questionnaire will be introduced by data
collection facilitator, and then self-administered. Sessions at the five study districts will be run
by data collection facilitator, in collaboration with district health office manager or district health
extension supervisor (if available). Participation in the study will be voluntary. Completing the
Individual HEWs questionnaire will take about 40 minutes.

For utilization of HEP by the community, an interview-administered face-to-face questionnaire

consisting mainly of close-ended questions will be applied. Trained interviewers who are trained
for this purpose will administer the questionnaire. Data collectors and supervisors will be
diploma and degree holder health professionals respectively and will be trained for two days by
the principal investigator. It will take approximately half an hour to complete the questionnaire.

Quantitative data for assessment of the outcome of HEP will be collected through administering
structured questionnaire to mothers or heads of households.The relationship between Health
Extension Program outcomes and being graduated (exposed) and non-graduated households is a
critical issue since it has been given emphasis by the Ministry of Health. A retrospective cohort
design will be used to examine the hypothesis that graduated households have better HEP
outcome in terms of immunization (fully immunized versus non-fully immunized), family
planning (family planning users versus non-users) and maternal and child health (institutional
deliveries versus home deliveries, and vitamin A supplementation versus no -supplementation).
In this study, a cohort of households who were given health extension program services between
2007 and 2010 will be selected from district health office reports/documents at six districts of
West Gojjam Zone, Amhara National Regional State.

In this cohort, 2688 households which will meet the selection criteria will be selected for the
study. Of these households, the HEP outcomes of 1344 graduated households will be compared
with 1344 non-graduated households.

îJ
Qualitative date for assessment of HEP outcomes will be collected by in-depth interviewing
officials of Regional Health Bureau, Zonal Health Department, and District Health Offices, who
are responsible for implementation of HEP, and HEWs; and by conducting focus group
discussions with community.

ÿ 

6

Before data collection, for qualitty purpose, the structured questionnaire will be pre-tested two
weeks before the study period in kebeles which will not be included again in the actual study.
The pre-test will be done on about 5% of the study participants and the questionnaire will be
assessed for its completeness, clarity and length.

During data collection, the data quality will be kept by using a structured questionnaire that has
been applied in other areas, performing a daily check-up of the questionnaires filled by data
collectors and by double entry. There will be strict supervision by the principal investigator and
supervisors. Five percent of questionnaire will be checked every day by the supervisors and
finally by principal investigator for its completence and consistency. Incomplete or incorrectly
filled questionnaires will be given to the data collectors so that they could correct it by revisiting
the respondent.

After data collection, double data entry will be used to see whether there is any inconsistency of
data and to avoid any problem through the data entry processes.

î
ÿ
-

-.&
/ 
 / 
-

-

‘‘ Motivation Age and sex;
of HEWs Expectations,
values/work ethic ,
personality factors related to work7

personality factors related to emotions,
and
individual differences;

Organizational culture,
and
organizational/task characteristics;

Resources, processes, and human resources management;

Community expectations, peer pressure, and societal values

‘‘ Utilization Age, gender, household size, marital status, education, employment,
of HEP religion, income, and perceptions about modern health care services;
HEWs` Training and conduct towards the community;
Type and severity of illness;
Availability, accessibility, affordability, quality and preference of
health care facilities/health posts
‘‘ Outcome Motivation of HEWs, Utilization of HEP, Age, gender, household
of HEP size, marital status, education, employment, religion, income, and
perceptions about modern health care services



ÿ a

#

(&


Quantitative data will be entered, edited; cleaned, and coded into computer using EPI Info 2002
and will be analyzed using SPSS 17. The analysis will be divided into two stages: a descriptive
analysis of the socio-economic characteristics of study participants, and multivariate analyses for
identifying factors associated to motivation of health extension workers, utilization of health
extension program by the community and outcome of health extension program in terms of
maternal and child health, family planning and immunization. For observational studies like this
PhD project, where total control is never possible, multivariate analysis is advantageous.
Multivariate analysis examines interactions and relations between a large number of
determinants and the esponse variable simultaneously.

îº
For paper I and II, multiple regression models will be used. The regression equation acts as a
compact summary of a complex state of affairs. In assessment of motivation of HEWs and
utilization of HEP by the community a variety of factors like demograghics, and socio-economic
factors interact with extraneous influences in causing an outcome, and regression modeling of
data will help provide an insight into a compex situation with this it is possiple to predict the
outcomes. Another advantage of multiple regression analysis is that by taking into account
simultaneously several explanatory variables it helps to correct for any possible confounding.
For paper III logistic regression method will be employed to describe how many times more
likely the outcome of HEP in graduated households compared to non-graduated households is in
terms of maternal and child health, immunization and family planning.

The analysis of qualitative data will be based on an inductive approach geared to identifying
patterns in the data by means of thematic codes i.e., themes, and categories of analysis come
from the data. The grounded theory method will be employed in this study. A grounded theory is
one that is inductively derived from the study of the phenomenon it represents.

In the analysis, verbatim transcript of the entire focus group discussion and in-depth interview
will be produced first, and secondly, the discussion and interview that are recorded in Amharic
will be translated to English, the language in which the analysis will be taken place. The
complete transcript should then be compared with the handwritten notes taken by the note-taker
to fill in the gaps. Once the transcribing is done, the next step will be coding the data in the
transcripts, which involves sorting the data and assigning them to categories. Open Code
software will be employed for coding data to categories and for analyzing qualitative data.

The actual data analysis process will be classified into two levels. The basic level of analysis i.e.,
a descriptive account of the data: explanation of what is said and no assumption is made. The
second level of analysis is interpretative, which will involve the comprehension of the themes (or
perspectives), creates links between the themes, demonstrates how those themes emerged and
generates a theory grounded in the data53.

îÿ
ÿ c

&
 

Ethical approval will be obtained from university of Gondar Ethical Review Board of School of
Public Health, College of Medicine and Health Sciences, University of Gondar. A written
consent will be requested from Amhara National Regional State Health Bureau. The West
Gojjam Zone Health Department and the selected Districts Health Offices will be communicated
through formal letter obtained from the Regional Health Bureau.

During field work, information sheets in Amharic about the study will be given out, explaining
why it will be done, by whom, and what it will involve. In the household survey, written and
verbal consent of all study participants will be sought. Privacy of study participants during data
collection time and confidentiality of their information to all study participants will be assured.
The right of the respondent to withdraw from the interview or not to participate will be
respected.

If participants and/or their family are in need of any medical care, they will be advised to visit
the nearest health institution. Results of the research will be communicated to government
offices and most importantly to the study subjects and members of the community through the
primary care assistant technicians at there local level. In this manner it is hoped that the
community can be educated so that health problems of the community can be alleviated and
study participants may benefit personally by being able to given emphasis by higher officials (for
HEWs) and by having improved health service strategies (for the community).

îu
 
0
!
)


(*

*
c

October, 2009 Enrolment
October-November, 2009 Confirmation of advisor and supervisor
&

&
5
January - May, 2010 Research thesis proposal preparation ‘#‘‘ ‘‘
‘
Assessment of Motivation of HEWs
‘
Assessment of Utilization of HEP by the Community
‘ 
‘Assessment of Outcome of HEP on Maternal and
Child Health, Family Planning and Immunization
June, 2010
June - July, 2010
July - August, 2010
September ± October, 2010
Research thesis proposal defence ‘#‘‘ ‘
Submission of research thesis proposal for consideration by
School of Public Health, University of Gondar
Working on research proposal and incorporating comments
*
î


5
&

Obtaining ethical clearance from School of Public Health,
University of Gondar
November - December, 2010 Data collection - ‘‘
Submission of Research Plan for the next 12 months
February, 2011 Submission of research progress report- ‘
March, 2011 Finalization - ‘
April - May , 2011 Data Collection - ‘‘
Manuscript Preparation for publication‘‘‘
July , 2011 Submission of research progress report- ‘
August, 2011 Finalization - ‘
*
%


5
&

October - December, 2011 Data collection - ‘‘
Submission of Research Plan for the next 12 months
Manuscript Preparation for publication‘‘‘
March, 2012 Submission of research progress report- ‘
June - August, 2012 Finalization - ‘‘
Manuscript Preparation for publication‘‘‘
*


September - October, 2012 Synthesis of the dissertation papers (Paper I, II, and III)
November, 2012 Identification of examiners
December, 2012 Submission of thesis for examination
December, 2012 Final dissertation defence

î×

(
)


!'


Cost Category Unit Total Unit Cost Total

Cost Cost Cost
 ‘ & ‘  ‘ š ‘ (‘ & ‘ (‘ & ‘ $%‘
'  ‘
Principal Investigator 1 PI for 4 days for 6 districts 100 00 2,400 00 Paper I
1 PI for 4 days for 6 district 100 00 2,400 00 Paper II
1 PI for 4 days for 6 districts 100 00 2,400 00 Paper III
Supervisors 6 supervisors for 2 days 80 00 960 00 Paper I
6 supervisors for 2 days 80 00 960 00 Paper II
6 supervisors for 2 days 80 00 960 00 Paper III
Data Collectors 12 data collectors for 2 days 80 00 1,920 00 Paper I
12 data collectors for 2 days 80 00 1,920 00 Paper II
12 data collectors for 2 days 80 00 1,920 00 Paper III
‘ )  *+#,-‘ ‘
 ‘& ‘ ‘ ‘ š ‘ (‘ & ‘ (‘ & ‘ $%‘
& 
 ‘
Advisors 2 advisors 4,000 00 8,000 00 All Papers
Principal Investigator 1 PI for 60 days 100 00 6,000 00 Paper I
1 PI for 60 days 100 00 6,000 00 Paper II
1 PI for 70 days 100 00 7,000 00 Paper III
Supervisors 6 supervisors for 10 days 80 00 4,800 00 Paper I
6 supervisors for 10 days 80 00 4,800 00 Paper II
6 supervisors for 20 days 80 00 9,600 00 Paper III
Data Collectors 12 data collectors for 10 days 80 00 9,600 00 Paper I
12 data collectors for 10 days 80 00 9,600 00 Paper II
12 data collectors for 20 days 80 00 19,200 00 Paper III
Data Clerks 282 questionnaires 6 00 1,692 00 Paper I
1268 questionnaires 6 00 7,608 00 Paper II
2688 questionnaires 6 00 16,128 00 Paper III
‘ )  **#,‘ ‘
'  ‘ š ‘ (‘ & ‘ (‘ & ‘ $%‘
Advisors 3 advisors 6,000 00 All Papers
Investigator 1 investigator 15,000 00
‘ ) ‘ ‘ ‘ ‘‘‘‘*#‘ ‘
"  .‘ š ‘ (‘ & ‘ (‘ & ‘ $%‘
Paper 25 rims 80 00 2,000 00 All Papers
Toner 8 pieces 1,000 00 8,000 00
Flash Disk 8 pieces(4 GB) 500 00 4,000 00
CD-R 25 pieces 4 00 100 00
CD-W 20 pieces 10 00 200 00
Binder/folder 15 pieces 30 00 450 00
Stapler 5 pieces 40 00 200 00
Notebook 15 pieces 30 00 450 00
Pen 45 pieces 4 00 180 00
Binding 36 bindings 10 00 360 00
‘ )  *+#/-‘ ‘

  ‘ š ‘ (‘ & ‘ (‘ & ‘ $%‘
Refreshments For 6 districts ‘ ‘ 12,000 00 All papers
‘ ) ‘ ‘ ‘ *#‘ ‘
' ‘ ‘ *0-#,,‘ ‘
&  
‘*1‘ ‘ *0#-,‘ ,‘
2 ‘' ‘ ‘ */#,,‘ ,‘

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Programming Department, 2005.
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for Health Reform, Abt Associates Inc., Major Applied Research 5, Working Paper 1, January
1999
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(2000); An In-depth Analysis of Individual Determinants and Outcomes of Health Worker
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Major Applied Research 5, Working Paper 8, September 2000
15.‘ Karabi Bhattacharyya, Peter Winch, Karen LeBan, and Marie Tien. 


*

+

 




 "
'
#
,!!
- 
.
/

.



.
Published by the Basic Support for Institutionalizing Child Survival Project (BASICS II) for the
United States Agency International Development. Arlington, Virginia, October 2001.
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analysis of the public and private sectors


/
!

2009, 7:15 doi:
10.1186/1478-4491-7-15
17.‘ Patrick Mbindyo, Lucy Gilson, Duane Blaau and Mike English(2009); Contextual influences on
health worker motivation in district hospitals in Kenya, +$




2009, 4:43
doi:10.1186/1748-5908-4-43
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(2008); Motivation of Healthcare Workers in Tanzania: A Case Study of Muhimbili National
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Prudence Ditlopo (2008); Motivation and retention of health workers in developing countries: a
systematic review
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2008, 8:247 doi:10.1186/1472-6963-8-247‘

J

20.‘ TICH (2006), Strengthening Community Based Kenya Essential care package for Health (CB-
KEPH) at the Community level, submitted to the Ministry of Health by Tropical Institute of
Community Health and Development (TICH) in Africa, March 2006
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financial incentives and human resource management tools, 

/
!

2006,
4:24 doi:10.1186/1478-4491-4-24
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Charles Normand (2009), Retention of health workers in Malawi: perspectives of health workers
and district management,


/
!

2009, :65 doi:10.1186/1478 4491-7-65
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!

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(2009), Inflation, Public Health Care and Utilization in Jamaica,
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perceptions and factors influencing utilization of health services in Uganda, +



1


!
2



2009, 8:25 doi:10.1186/1475-9276-8-25
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Waldo Hall, Corvallis, OR 97331; Tel. +1 541 908 0267; Fax. +1 541 737 4001; E-mail:
lopezced@onid.orst.edu
28.‘ Babar T. Shaikh and Juanita Hatcher(2004;Health seeking behaviour and health service
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nurses associated with coverage of essential health services in developing countries? A cross-
sectional study, 

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!

2009, :27 doi: 10. 1186/1478-4491-7-27
30.‘ Amlan Majumder(2006): Utilisation of Health Care in North Bengal: A Study of Health Seeking
Patterns in an Interdisciplinary Framework, J. Soc. Sci., 13(1): 43-51 (2006)
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department of Matagalpa, Nicaragua. Rev Panam Salud Publica. 2008;24(2):75±84.
36.‘ Mesganaw Fantahun, and Getu Degu (2003); Health Service Utilization in Amhara Region of
Ethiopia, $
1


2003; 17(2):141-147
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Study of the Working Conditions of Health Extension Workers in Ethiopia; $ 1 

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Jî
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6

The Principal Investigator and University of Gondar and Addis Continental Institute of Public
Health are jointly conducting this study on health extension worker motivation, focusing on West
Gojjam Zone and Bahir Dar Special Zone of Amhara National Regional State.

This survey is part of a PhD dissertation aimed at better understanding the beliefs, attitudes, and
work conditions that contribute to employee motivation and job satisfaction. By gathering
information from many HEWs, we hope to learn what factors are most important in affecting
worker motivation, satisfaction, and job performance.

This booklet contains a series of brief questionnaires that take about 40 minutes to complete.
Please answer EVERY question in the booklet. Instructions for how to respond to the different
questionnaires in the booklet are provided at the top of each page. Please note that there is no
right or wrong answers, just what YOU think and how YOU perceive your work situation.

All the information that you provide in this session will be held in confidentiality. Your
responses will be kept by the researchers, and we will aggregate responses from all interviews so
that no one individual will be identifiable. The aggregated information we collect from these
interviews will be used to: (1) identify strengths and weaknesses in the current administrative
system with respect to enhancing worker motivation, (2) assist us in developing
recommendations to enhance motivation, satisfaction, and job performance among HEWs in
West Gojjam Zone and in particular and Amhara National Regional State in general.

Subject Number: ____________

ID.No.: ____________
Kebele: ____________

JJ
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6
$

3

District: ____________
Zone: _____________

+&#


For each question below, either write in your answer or put an ³X´ beside the best response
option.
1. How many years of experience do you have working in this profession? _____ yrs
2. Are you ____ Male or ____ Female?
3. How long have you been working for this health post? ____ Years and ____ months
4. How long have you been in your current job? ______ Years and ______ months
5. What is your age? _________ Years old
6. Do you supervise any other workers? ______ Yes _____ No
7. If the answer to question 6 is yes, approximately how many workers do you supervise?
______






 
use the scale below to indicate how much you agree or disagree with each statement
by placing the number that best corresponds to your answer in the space next to the question
number. Remember there are no right or wrong answers, only what is TRUE of you.
Scale: 1 = strongly disagree, 2 = disagree, 3 = neither agree nor disagree,
4 = sgree, 5 = strongly agree
Ser. Questions Scale
No.
1 Dedication to work is a virtue. 1 2 3 4 5
2 Cooperation is a virtue in work. 1 2 3 4 5
3 Work should be done with sufficient effort 1 2 3 4 5
4 One should strive to achieve better results. 1 2 3 4 5
5 Work is a source of self-respect. 1 2 3 4 5
6 Consultation allows one to overcome obstacles and avoid mistakes. 1 2 3 4 5
7 Work is not an end in itself but a means to foster personal growth. 1 2 3 4 5
8 Devotion to quality work is a virtue. 1 2 3 4 5
9 Progress on the job can be obtained through self-reliance. 1 2 3 4 5
10 A successful person is one who meets deadlines at work. 1 2 3 4 5
11 A person can overcome difficulties in life and better him/herself by doing 1 2 3 4 5
his/her job well.
12 A job is what you make of it. 1 2 3 4 5
13 On most jobs, people can pretty much accomplish whatever they set out to 1 2 3 4 5
accomplish.
14 If you know what you want out of a job, you can find a job that gives it to 1 2 3 4 5
you.
15 If employees are unhappy with a decision make by their boss, they should do 1 2 3 4 5
something about it.

J
16 Getting a job you want is mostly a matter of luck. 1 2 3 4 5
17 Making money is primarily a matter of good fortune. 1 2 3 4 5
18 Most people are capable of doing their jobs well if they make the effort. 1 2 3 4 5
19 In order to get a really good job you need to have family members or friends 1 2 3 4 5
in high places.
20 Promotions are usually a matter of good fortune. 1 2 3 4 5
21 When it comes to getting a really good job, who you know is more important 1 2 3 4 5
than what you know.
22 Promotions are given to employees who perform well on the job. 1 2 3 4 5
23 To make a lot of money you have to know the right people. 1 2 3 4 5
24 It takes a lot of luck to be an outstanding employee on most jobs. 1 2 3 4 5
25 People who perform their jobs well generally get rewarded for it. 1 2 3 4 5
26 Most employees have more influence on their supervisors than they think 1 2 3 4 5
they do.
27 The main difference between people who make a lot of money and people 1 2 3 4 5
who make a little money is luck
28 If I were known as a difficult worker, this would bring shame to my family. 1 2 3 4 5
29 If I do not put in a full day¶s work, I would feel bad even if no one else 1 2 3 4 5
notices.
30 If my supervisor told me I did a poor job, I would feel ashamed. 1 2 3 4 5
31 If co-workers had to redo my work, I would feel ashamed. 1 2 3 4 5
32 If everyone were to know that I was not reliable, it would bring shame to my 1 2 3 4 5
family.
33 If I do not do well, I feel bad, even if no one else notices. 1 2 3 4 5
34 If there were a goal I did not achieve at work, my family would feel shame. 1 2 3 4 5


#"


Directions: use the scale below to indicate how much you agree or disagree with each statement
by placing the number that best corresponds to your answer in the space next to the question
number. Remember there are no right or wrong answers, only what is TRUE of you.
Scale: 1 = strongly disagree, 2 = disagree, 3 = neither agree nor disagree,
4 = agree, 5 = strongly agree
Ser. Questions Scale
No.
35 I feel comfortable saying what I really think to health posts/ district health 1 2 3 4 5
management about how things are going at the health post.
36 It would be difficult for me to say something that my supervisor might 1 2 3 4 5
disagree with.
37 This health post has a good reputation in the community. 1 2 3 4 5
38 The majority of my co-workers in this health post are proud to work here. 1 2 3 4 5
39 Co-workers at this health post pride themselves in providing good services to 1 2 3 4 5
patients.
40 My co-workers in this health post regard their work as boring. 1 2 3 4 5
41 My co-workers help others if they fall behind in their work 1 2 3 4 5
42 My co-workers willingly ['
$
; share expertise and skills with 1 2 3 4 5
other members of the unit.

Jº
43 My co-workers try to act like peacemakers when co-workers have 1 2 3 4 5
disagreements.
44 My co-workers take steps to prevent problems with other co-workers. 1 2 3 4 5
45 My co-workers willingly give time to co-workers who have work-related 1 2 3 4 5
problems.
46 My co-workers talk to co-workers before taking action that might affect them. 1 2 3 4 5
47 My co-workers provide constructive suggestions about how the unit can 1 2 3 4 5
improve its effectiveness.
48 My co-workers are willing to risk disapproval in order to express beliefs 1 2 3 4 5
about what is best for the unit.
49 My co-workers attend and actively participate in (team) meetings [

1 2 3 4 5

';.
50 My co-workers find fault [3; with what other co-workers are doing. 1 2 3 4 5
51 My co-workers discourage co-workers from complaining about trivial 1 2 3 4 5
matters.
52 My co-workers focus on what is wrong with the situation, rather than the 1 2 3 4 5
positive side.
53 I feel comfortable saying what I really think [

$

; to my 1 2 3 4 5
supervisors about how things are happening in my work unit.


/&
 


 
use the scale below to indicate how much you agree or disagree with each statement
by placing the number that best corresponds to your answer in the space next to the question
number. Remember there are no right or wrong answers, only what is TRUE of you
Scale: 1 = strongly disagree, 2 = disagree, 3 = neither agree nor disagree,
4 = agree, 5 = strongly agree
Ser. Questions Scale
No.
54 The work I do provides me with direct feedback about the effectiveness (e.g., 1 2 3 4 5
quality and quantity) of my performance.
55 My managers and co-workers provide me with feedback about the 1 2 3 4 5
effectiveness (e.g., quality and quantity) of my performance.
56 My job provides the opportunity for social interaction such as teamwork or 1 2 3 4 5
co-worker assistance.
57 My job duties, requirements, and goals are clear and specific. 1 2 3 4 5
58 I have a variety of duties, tasks, and activities in my job. 1 2 3 4 5
59 My job requires a high level of knowledge and skills. 1 2 3 4 5
60 My job requires a variety of knowledge and skills. 1 2 3 4 5
61 My job permits me to get information and talk to people about things that 1 2 3 4 5
affect my work.
62 My job provides opportunities for advancement to higher level jobs. 1 2 3 4 5
63 My job gives me a feeling of achievement and accomplishment. 1 2 3 4 5
64 My job gives me the opportunity to participate in decisions that affect my job. 1 2 3 4 5
65 My job offers adequate pay compared with the job requirements and with pay 1 2 3 4 5
in similar jobs.
66 My job offers job security as long as I do a good job. 1 2 3 4 5
67 There is much variety in my job. 1 2 3 4 5
Jÿ
68 My duties are very repetitious. 1 2 3 4 5
69 I am left on my own to do my own work. [+




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'
+
'
.
1 2 3 4 5
'

!
;
70 I often see projects or jobs through to completion. 1 2 3 4 5
71 It is easy for me to find out how well I am doing on the job as I am working. 1 2 3 4 5
72 I am able to do my job independently of others. 1 2 3 4 5
73 I have freedom to do pretty much what I want on my job. 1 2 3 4 5
74 I receive frequent feedback from individuals other than my supervisor. 1 2 3 4 5
75 I usually have the opportunity to complete work I start. 1 2 3 4 5
76 I have control over the pace of my work. 1 2 3 4 5
77 I usually have the opportunity to do a job from the beginning to end (i.e., the 1 2 3 4 5
chance to do a whole job)
78 I have a lot of opportunity for independent thought and action. 1 2 3 4 5


 
use the scale below to indicate how much the following items are important or not
important for you in your work. Place the number that best corresponds to your response in the
space next to the question number.
Scale: 1 = very unimportant to me, 2 = unimportant, 3 = neither unimportant nor important
4 = important, 5 = very important
Ser. Questions Scale
No.
79 Being able to do a complete piece of work. [?$$




)
!
1 2 3 4 5






;
80 Have considerable freedom to adopt my own approach to the job. 1 2 3 4 5
81 Being able to judge my work performance, right away, when actually doing 1 2 3 4 5
the job.
82 Have a job that gives me a feeling of doing something really worthwhile. 1 2 3 4 5
83 Being able to achieve something that I really value. 1 2 3 4 5


!


 
‘use the scale below to indicate how much you agree or disagree with each statement
by placing the number that best corresponds to your answer in the space next to the question
number.
Remember there are no right or wrong answers, only what is TRUE of you.
Scale: 1 = strongly disagree, 2 = disagree, 3 = neither agree nor disagree,
4 = agree, 5 = strongly agree
Ser. Questions Scale
No.
84 I am confident about my ability to handle work problems. 1 2 3 4 5
85 I effectively cope with any important changes that occur in my work life 1 2 3 4 5
86 I feel that at work things are going the way I would like them to. 1 2 3 4 5
87 I feel that I have control of things concerning my work. 1 2 3 4 5
88 Even when my work is boring, I can keep focused on my tasks. 1 2 3 4 5

Ju
89 I consider myself to have self-control. 1 2 3 4 5
90 On difficult tasks, I check my progress frequently. 1 2 3 4 5
91 I am easily distracted in my job. 1 2 3 4 5
92 I like to set specific work goals for myself. 1 2 3 4 5
93 When I am worried about something, I can not do my work. 1 2 3 4 5
94 I do not let my emotions interfere with my work. 1 2 3 4 5
95 It is easy for me to keep myself from being distracted. 1 2 3 4 5
96 I prefer to put off more difficult tasks to the end. 1 2 3 4 5
97 I have a difficult time concentrating when I am upset (bothered by 1 2 3 4 5
something).
98 When I have a boring task to do, I make a game of it. 1 2 3 4 5
99 I do not like to quit a task until it¶s done. 1 2 3 4 5
100 It is important for me to do my work as well as I can even doing it well isn¶t 1 2 3 4 5
popular with my coworkers.
101 I find satisfaction in working as well as I can. 1 2 3 4 5
102 There is satisfaction in a job well done. 1 2 3 4 5
103 I find satisfaction in exceeding my previous performance even if I don't 1 2 3 4 5
outperform others.
104 I like to work hard. 1 2 3 4 5
105 Part of my enjoyment in doing things [
'; is improving my past 1 2 3 4 5
performance.


#"
:-&


 
use the scale below to indicate how much you agree or disagree with each statement
by placing the number that best corresponds to your answer in the space next to the question
number. Remember there are no right or wrong answers, only what is TRUE of you.
Scale: 1 = strongly disagree, 2 = disagree, 3 = neither agree nor disagree,
4 = agree, 5 = strongly agree
Ser. Questions Scale
No.
106 This health post provides everything I need to do my job effectively. 1 2 3 4 5
107 A fundamental reason I do not do my job properly is that I do not have the 1 2 3 4 5
equipment, supplies and/or materials I need.
108 I have the necessary materials, supplies and equipment to do a good job. 1 2 3 4 5
109 My work is rarely disrupted due to bureaucratic processes. 1 2 3 4 5
110 There are few instructions that obstruct and delay work. 1 2 3 4 5
111 I am often prevented from getting my work done effectively and efficiently 1 2 3 4 5
by bureaucracy and unneeded processes.

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Think about your job activities over the past six months. For each statement below, indicate how
YOU have performed your job. Place the number that best corresponds to your answer to the left of the statement.
Scale: 1 = very true of me, 2 = usually true of me 3 = sometimes true of me
4 = rarely true of me 5 = not at all true of me
Ser. Questions Scale
No.
112 I am punctual about coming to work. 1 2 3 4 5
113 I am reliable and dependable at work. 1 2 3 4 5
114 I always finish my work on time. 1 2 3 4 5
115 My work is of high quality. 1 2 3 4 5
116 I am a hard worker. 1 2 3 4 5
117 I do things that need doing without being asked or told. 1 2 3 4 5
118 I am very knowledgeable about my job. 1 2 3 4 5
119 I do not get defensive or upset when criticized. 1 2 3 4 5
120 I get upset at work. 1 2 3 4 5
121 I am careful not to make errors. 1 2 3 4 5
122 I keep updated on new equipment and procedures. 1 2 3 4 5
123 I get along well with my co-workers. 1 2 3 4 5
124 I get along well with my supervisor. 1 2 3 4 5
125 I maintain a positive attitude toward my work. 1 2 3 4 5
126 My work attendance record is very good. 1 2 3 4 5
127 I am rarely absent from work. 1 2 3 4 5
128 I am a fast worker. 1 2 3 4 5
129 I spend my time at work on work-related activities. 1 2 3 4 5


&
;&



Directions: Use the scale below to indicate how satisfied you are with the following aspects of your job; by placing
the number which best indicates your response in the space beside the question number.
Scale: 1 = very satisfied, 2 = moderately satisfied, 3 = neither satisfied nor dissatisfied
4 = moderately satisfied, 5 = very satisfied
Ser. Questions Scale
No.
130 All in all, how satisfied are you with your co-workers in your work unit? 1 2 3 4 5
131 All in all, how satisfied are you with your supervisor? 1 2 3 4 5
132 All in all, how satisfied are you with your job? 1 2 3 4 5
133 Considering your skills and the effort you put into your work, how satisfied are you 1 2 3 4 5
with your pay?
134 How satisfied are you with the management in your work unit? 1 2 3 4 5
135 How satisfied are you with your opportunity to use your abilities in your job? 1 2 3 4 5
136 How satisfied are you with the chances you have to learn new things? 1 2 3 4 5
137 How satisfied are you with the chances you have to accomplish something 1 2 3 4 5
worthwhile?
138 How satisfied are you with the chances you have to do something that makes you feel 1 2 3 4 5
good about yourself as a person?
139 How satisfied are you with the fringe benefits you receive? 1 2 3 4 5
140 How satisfied are you with the educational/training opportunities you get? 1 2 3 4 5
141 How satisfied are you with the physical working conditions (space, lighting, and 1 2 3 4 5
ventilation)?
‘

Ja
 
 
use the scale below to indicate how much you agree or disagree with each statement by placing the
number that best corresponds to your answer in the space next to the question number. Remember there are no right
or wrong answers, only what is TRUE of you.

Scale: 1 = strongly disagree 2 = disagree 3 = neither agree nor disagree

4 = agree 5 = strongly agree
Ser. Questions Scale
No.
142 I am willing to put in a great deal of effort beyond that normally expected in order to 1 2 3 4 5
ensure that our work at this health posts is successful.
143 I often tell my friends that this health post is a great organization to work for. 1 2 3 4 5
144 I feel very little commitment to this health post. 1 2 3 4 5
145 I find that my values and this health post¶s values are very similar. 1 2 3 4 5
146 I am proud to tell others that I am part of this health post. 1 2 3 4 5
147 This health post really inspires me to do my very best on the job. 1 2 3 4 5
148 I am extremely glad I work for this health post, as opposed to other health posts I 1 2 3 4 5
might have worked for.
149 It would take very little change in my present personal circumstances to cause me to 1 2 3 4 5
leave this health post.
150 There is not too much to be gained professionally by working for this health 1 2 3 4 5
post (indefinitely) [$

;.
151 Often, I find it difficult to agree with this health post¶s policies on important matters 1 2 3 4 5
relating to its employees.
152 For me, this is the best of all possible health posts to work for. 1 2 3 4 5
153 Accepting to work for this health posts was a definite mistake on my part. 1 2 3 4 5

8
#
;&




 
Use the scale below to indicate how satisfied you are with the following aspects of your job by placing
the number which best indicates your response in the space beside the question number.

Scale: 1 = very satisfied 2 = moderately satisfied 3 = neither satisfied nor dissatisfied

4 = moderately satisfied 5 = very satisfied
Ser. Questions Scale
No.
154 How satisfied are you that you have been given enough authority by your superiors to 1 2 3 4 5
do your job well?
155 How satisfied are you with your present job when you compare it to similar positions 1 2 3 4 5
in Ethiopia?
156 How satisfied are you with the progress you are making toward the goals which you 1 2 3 4 5
set for yourself in your present situation?
157 On the whole, how satisfied are you that your superior accepts you as a professional 1 2 3 4 5
expert to the degree which you are entitled by reason of your position, training and
experience?
158 On the whole, how satisfied are you with your present job when you consider the 1 2 3 4 5
expectations you had when you started working here?
159 How satisfied are you with your present job in light of (career) [!
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; 1 2 3 4 5
expectations?



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9


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!&3

Think about the performance of Health Extension workers in your district over the past six
months. For each statement below, indicate how each one has performed his/her job. Place the
number that best corresponds to your answer to the left of the statement.

Scale: 1 = always true of this person, 2 = usually true of this person

3 = sometimes true of this person, 4 = rarely true of this person
5 = not at all true of this person
Ser. Questions (Performance Component) Scale
No.
1 punctual about coming to work 1 2 3 4 5
2 reliable and dependable at work 1 2 3 4 5
3 always finish his/her work on time 1 2 3 4 5
4 work is of high quality 1 2 3 4 5
5 a hard worker 1 2 3 4 5
6 does things that need doing without being asked or told 1 2 3 4 5
7 very knowledgeable about his/her job 1 2 3 4 5
8 does not get defensive or upset when criticized 1 2 3 4 5
9 gets upset at work 1 2 3 4 5
10 Is careful not to make errors 1 2 3 4 5
11 keeps updated on new equipment and procedures 1 2 3 4 5
12 gets along well with co-workers 1 2 3 4 5
13 gets along well with supervisor 1 2 3 4 5
14 maintains a positive attitude toward his/her work 1 2 3 4 5
15 work attendance record is very good 1 2 3 4 5
16 rarely absent from work 1 2 3 4 5
17 a fast worker 1 2 3 4 5
18 Spends his/her time at work on work-related activities 1 2 3 4 5

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General Information

Name of Household Head ««««««««««««««««««««««««««««

Name of Kebele «««««««««...House No.««««««««««««««««««
Name District«««««««««««««««««««««««««««««««««
Zone««««««««««««. ««Region«««««««««««««««««««

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Hello. My name is _______________________________________. I am working with
University of Gondar/Addis Continental Institute of Public Health. We are doing a survey that is
part of a PhD research by the University of Gondar/Addis Continental Institute of Public Health
in West Gojjam, Amhara National Regional State. We study the Implementation of Health
Extension Program (Utilization of Health extension Program by the Community) which has been
implemented by the Government of Ethiopia. The information we collect will help the
government to plan health services. Your household was selected for the survey. The questions
usually take about %


minutes. All of the answers you give will be confidential and will not
be shared with anyone other than members of our survey team. You don't have to be in the
survey, but we hope you will agree to answer the questions since your views are important. If I
ask you any question you don't want to answer, just let me know and I will go on to the next
question or you can stop the interview at any time.

In case you need more information about the survey, you may contact the person listed on the
card that has already been given to your household.

Do you have any questions? May I begin the interview now?

Signature of interviewer: ««««««««««««.. Date: «««««««««.«

Respondent agrees to be interviewed . . . 1 respondent does not agree to be interviewed . . . 2 end

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No QUESTIONS AND FILTERS CODING CATEGORIES SKIP

101 How old are you? Years««««««««««««««..«..__ __
I don¶t know««««««««««««««98
Refused to tell««««««««««««.....99
102 What is your sex? Male«««««««««««««.««««...1
Female«««««««««««««.«««...2
103 What is your marital status? Single (never been married)««««««««...1
Married««««««««««««««««...2
Separated«««««««««««««««....3
Widowed«««««««««««««««....4
Divorced«««««««««««««««.....5
Other (specify)____________________________6
104 What is your educational status? Illiterate««««««««««««««««...1
Read and write only«««««««««««....2
Grade 1-6 (primary education)...«««««...«.3
Grade 7-8 (junior secondary education)««««.4
5. Grade 9-12 (senior secondary education)...........5
6. College, university«««««««««««..6
7. Other (specify)__________________________7
105 What is your main occupation (Past Unemployed««««««««««««««...1
twelve months)? Retired«««««««««««««««««2
Pupil/ student««««««««««««««..3
Disabled/ sick««««««««««««««.4
House wife«««««««««««««««..5
Merchant««««««««««««««««6
Daily laborer««««««««««««««..7
Employed by government«««««««««..8
Employed private for profit sector««««««9
Employed by NGO«««««««««««...10
Self-employed, business with employees«««.11
Self-employed, business no employees««««12
Self-employed, farmer/ fishing«««««««.13
Other (specify___________________________ 14
106 What is the monthly income of _______ Birr«««««««««««.........«.1
your family? I do not know««««««««««.«««..98
Refuse to tell«««««««««««««....99
107 Number of people living in your Number««««««««««..««««.__ __
family? Refused to tell««««««««««««...«99
108 What is your religion? Ethiopian Orthodox Tewahdo««««««««.1
Muslim««««««««««««««««....2
Catholic««««««««««««««««...3
Protestant««««««««««««««.«....4
Other (specify)«««««««««««««....5
109 What is your ethnicity? Amhara«««««««««««..«««.««.1

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110 How many rooms in this household
are used for sleeping?
111 Does any member of your
household own:
A watch?
A bicycle?
A motorcycle or motor scooter?
An animal-drawn cart?
A car or truck?
A boat with a motor?
112 How do you see the health services It is very good««««««««««««....«.1
given at the health post?
113 How do you see the conduct of
health extension workers towards
their client (you)?
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No QUESTIONS AND FILTERS
201 Have ever heard about health
extension program?
201 From where did you get the
information about HEP?
203 Have you had an understanding
about HEP components?
204 If you already know about HEP,
how many components do the
HEP have?
205 Which HEP you are familiar
with?
Agaw««««««««««««.««««......2
Tigrie««««««««««««.......................3
Oromo««««««««««««««««.....4
Other (specify)««««««««««««...«.5
Rooms . . . . . . . . . . . . . . . . . .
Yes No
Watch 1 2
Bicycle 1 2
Motorcycle/scooter 1 2
Animal-drawn cart 1 2
Car/truck 1 2
Boat with motor 1 2
It is good««««««««««««««««.2
Neither good nor bad««««««««««......3
It is bad««««««««««.««««««..4
It is very bad««««««««««««««...5
It is very good««««««««««..««..«.1
It is good««««««««««««..««..«.2
Neither good nor bad«««««««««..«....3
It is bad«««««««««««««««««4
It is very bad«««««««««««««...«.5
CODING CATEGORIES SKIP
Yes«««««««««««««««««««.1
No««««««««««««««««««.«..2
Health extension workers««««««««««..1
Other health workers««««««««««««.2
Community««««««««««««««««3
Radio««««««««««««««««««..4
Other (specify)____________________________98
Yes«««««««««««««««««««.1
No««««««««««««««««««.«..2
________ components«««««««««««...1
I do not know««««««««««««««...98
Refuse to tell«««««««««««««««99
HIV/AIDS and other sexually transmitted infections
(STIs) and TB prevention and control«««««.1
Malaria prevention and control««««.«.«......2
First Aid emergency measures«««««..«.......3
Maternal and child health«««««««.............4
Family planning««««««««.«««««...5
Immunization««««««««««.«.«..........6
Nutrition««««««««««««««............7
Adolescent reproductive health«««««.............8
Excreta disposal«««««««««.«««««9
Solid and liquid waste disposal««««..«««..10
Water supply and safety measures««««...........11


206 Which HEP component(s) have
you used (implemented)?
207 Which HEP component(s) have
not you used (implemented)?
208 For above question, what are the
major reasons for not using HEP
components?
Food hygiene and safety measures««««..........12
Healthy home environment««««««.............13
Control of insects and rodents«««««.............14
Personal hygiene«««««««««««..........15
Health education and communication«««««..16
HIV/AIDS and other sexually transmitted infections
(STIs) and TB prevention and control«««««...1
Malaria prevention and control««««.«.«........2
First Aid emergency measures«««««..«.........3
Maternal and child health«««««««...............4
Family planning««««««««.«««««....5
Immunization««««««««««.«.«...........6
Nutrition««««««««««««««.............7
Adolescent reproductive health«««««..............8
Excreta disposal«««««««««.«««««9
Solid and liquid waste disposal««««..«««..10
Water supply and safety measures««««...........11
Food hygiene and safety measures««««..........12
Healthy home environment««««««.............13
Control of insects and rodents«««««.............14
Personal hygiene«««««««««««..........15
Health education and communication«««««..16
HIV/AIDS and other sexually transmitted infections
(STIs) and TB prevention and control«««««...1
Malaria prevention and control««««.«.«.......2
First Aid emergency measures«««««..«........3
Maternal and child health«««««««..............4
Family planning««««««««.«««««....5
Immunization««««««««««.«.«...........6
Nutrition««««««««««««««.............7
Adolescent reproductive health«««««..............8
Excreta disposal«««««««««.«««««9
Solid and liquid waste disposal««««..«««..10
Water supply and safety measures««««...........11
Food hygiene and safety measures««««..........12
Healthy home environment««««««.............13
Control of insects and rodents«««««.............14
Personal hygiene«««««««««««..........15
Health education and communication«««««..16
We did not understand the benefit«««««««.1
The HEWs did not teach us«««««...««««2
Economic problem««««««««««««.«3
We are occupied by other business«««««««4
The health post is very far««««««««««..5
Very long waiting time in the health post««««..6
HEWs are not approachable«««««««««...7
Community perception is not good«««««««8
Previous experiences««««««««««««.9
Other(specify _____________________________
________________________________________
________________________________________98
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No QUESTIONS AND FILTERS
301 If you or a family member were
required to seek health services, Health Center«««««««««««««««.2
what would be your preferred
location?
302 Have HEWs ever visited you or
your home?
303 How often do HEWs visit you or
your home?
304 What do HEWs do when they
come to your home?
305 If HEWs visited you, what did
they teach and/or demonstrate
you about?
306 Have you ever visited a health
post?
307 How often do you have to travel
to Health Post for health
services/medical treatment?
CODING CATEGORIES SKIP
Health Post««««««««««««««««.1 «302
Hospital«««««««««««««««««..3
Private Health facilities«««««««««««.4
Traditional Healers««««....................................5
Others ___________________________________98
(Specify)
Yes«««««««««««««««««««.1
No««««««««««««««««««.«..2
More than once per week«««««««««..«.1
Once per week««««««««««««««....2
Once per fortnight««««««««««««..«3
Once per month«««««««««««««..«4
Once every six weeks««««««««««««.5
Other ____________________________________6
(Please specify)
Teach health extension packages«««««««...1
Demonstrate health extension packages«««««2
Other (specify) ____________________________
_________________________________________98
HIV/AIDS, STIs and TB ««««««««««...1
Malaria ««««.«.«............................................2
First Aid emergency measures«««««..«.........3
Maternal and child health«««««««...............4
Family planning««««««««.«««««....5
Immunization««««««««««.«.«...........6
Nutrition««««««««««««««.............7
Adolescent reproductive health«««««..............8
Excreta disposal«««««««««.«««««9
Solid and liquid waste disposal««««..«««..10
Water supply and safety measures««««...........11
Food hygiene and safety measures««««..........12
Healthy home environment««««««.............13
Control of insects and rodents«««««.............14
Personal hygiene«««««««««««..........15
Other (specify______________________________
_________________________________________98
Yes«««««««««««««««««««.1
No««««««««««««««««««.«..2
More than once per week«««««««««..«.1
Once per week««««««««««««««....2
Once per fortnight««««««««««««..«3
Once per month«««««««««««««..«4
Once every six weeks««««««««««««.5
Other ____________________________________6
(Please specify)
ÿ
308 How do you travel? Private vehicle«««««««««««««««1
Community Transport«««««.««««««...2
Public Transport««««««.«...««««««.3
On mule/horse back««««««..««««««.4
On foot««««««««««..«««««««.5
Other ____________________________________6
(Please specify)
309 How far do you travel (return Kilometers«««««««.««««««..__ __
trip)? I do not know««««««««««««««..98
310 What services did you get at the Immunization«««««««««««««.««1
health post provided by the Family planning««««««««««««««.2
HEWs? Antenatal care««««««...««««««««.3
Delivery«««««««««««««««««..4
Postnatal care«««««««««««««««.5
Diagnosis and treatment«««««««««««.6
Other (specify) _____________________________
___________________________________________
_________________________________________98
311 Do you think that the quality of Yes«««««««««««««««««««.1
care/services provided in the No««««««««««««««««««.«..2
health post is good enough?
312 If the answer to question X is No,
what are the problems? Probe.
313 Have you ever paid for health Yes«««««««««««««««««««.1
services you got from the health No««««««««««««««««««.«..2
post?
314 How do you see the cost you paid Very expensive««««««««««««««...1
for the health services you got? Expensive««««««««««««««««...2
Neither expensive nor cheap«««««««««..3
Cheap««««««««««««««««««.4
Very cheap««««««««««««««««.5
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No QUESTIONS AND FILTERS CODING CATEGORIES SKIP
401 For what type of illnesses, you usually visit health Child illness««««««««1
post or consult health extension workers? Family planning««««««..2
Pregnancy«««««««««3
Delivery«««««««««..4
Postnatal«««««««««..5
Family illness«««««««..6
Other (specify)««««««..98
402 At what stage of the illness do you usually visit the Soon after the illness stats««...1
health post when you or your family gets sick? If there is no improvement««..2
If the sick person unable to drink
and eat««««««««««.3
Other (specify)««««««..98

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General Information

Name of Household Head ««««««««««««««««««««««««««««

Name of Kebele «««««««««...House No.««««««««««««««««««
Name District«««««««««««««««««««««««««««««««««
Zone««««««««««««. ««Region«««««««««««««««««««

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Hello. My name is _______________________________________. I am working with
(University of Gondar/Addis Continental Institute of Public Health)). We are doing a survey that
is part of a PhD research by the University of Gondar/Addis Continental Institute of Public
Health in West Gojjam, Amhara National Regional State. We study the Implementation of
Health Extension Program which has been implemented by the Government of Ethiopia. The
information we collect will help the government to plan health services. Your household was
selected for the survey. The questions usually take about %


minutes. All of the answers
you give will be confidential and will not be shared with anyone other than members of our
survey team. You don't have to be in the survey, but we hope you will agree to answer the
questions since your views are important. If I ask you any question you don't want to answer, just
let me know and I will go on to the next question or you can stop the interview at any time.

In case you need more information about the survey, you may contact the person listed on the
card that has already been given to your household.

Do you have any questions? May I begin the interview now?

Signature of interviewer: ««««««««««««.. Date: «««««««««.«

Respondent agrees to be interviewed . . . 1 respondent does not agree to be interviewed . . . 2 end

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No QUESTIONS AND FILTERS
101 How old are you?
102 How old were you at your last
birthday?
103 What is your marital status?
104 What is your educational status?
105 What is your main occupation (Past Unemployed««««««««««««««...1
twelve months)?
106 Number of people living in your
family?
107 What is your religion?
108 What is your ethnicity?
CODING CATEGORIES SKIP
Years«««««««««««««..««..__ __
I don¶t know««««««««««.««««98
Refused to tell««««««««««.««.....99
Years««««««««««««.«««..__ __
I don¶t know«««««««««.«««««98
Refused to tell«««««««««.«««.....99
Single (never been married)«««««..«««..1
Married«««««««««««««..«««..2
Separated««««««««««««..«««...3
Widowed««««««««««««..««.«..4
Divorced«««««««««««««..««....5
Other (specify)____________________________6
Illiterate««««««««««««««««...1
Read and write only«««««««««««....2
Grade 1-6 (primary education)...«««««««3
Grade 7-8 (junior secondary education)««««.4
5. Grade 9-12 (senior secondary education)...........5
6. College, university«««««««««««..6
7. Other (specify)__________________________7
Retired«««««««««««««««««2
Pupil/ student««««««««««««««..3
Disabled/ sick««««««««««««««.4
House wife«««««««««««««««..5
Merchant««««««««««««««««6
Daily laborer««««««««««««««..7
Employed by government«««««««««..8
Employed private for profit sector««««««9
Employed by NGO«««««««««««...10
Self-employed, business with employees«««.11
Self-employed, business no employees««««12
Self-employed, farmer/ fishing«««««««.13
Other (specify__________________________ 14
Number««««««««««..««««__ __
Refused to tell««««««««««««...«99
Ethiopian Orthodox Tewahdo««««««««.1
Muslim«««««««««««........................2
Catholic««««««««««««««««...3
Protestant«««««««««««««««....4
Other (specify)««««««««........................5
Amhara«««««««««««««««««1
Agaw«««««««««««««««««...2
Tigrie«««««««««««««««««...3
Oromo«««««««««««««««««.4
Other (specify)«««««««««.5
a
109 How many rooms in this household Rooms . . . . . . . . . . . . . . . . . .
are used for sleeping?
110 Does any member of your Yes No
household own: Watch 1 2
A watch? Bicycle 1 2
A bicycle? Motorcycle/scooter 1 2
A motorcycle or motor scooter? Animal-drawn cart 1 2
An animal-drawn cart? Car/truck 1 2
A car or truck? Boat with motor 1 2
A boat with a motor?

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No QUESTIONS AND FILTERS CODING CATEGORIES SKIP
101 Now I would like to ask about all the births Yes «««««««««««««««1
you have had during your life. Have you No «««««««««««................ 2 106
ever given birth?
102 Do you have any sons or daughters to whom Yes «««««««««««..«««. 1
you have given birth who are now living No «««««««««««..«.......... 2 104
with you?
103 How many sons live with you? Sons at home . . . . . . . . . «««««........
And how many daughters live with you? Daughters at home . . . . «««««««.
IF NONE, RECORD '00'.
104 Do you have any sons or daughters to whom Yes «««««««««««««««1
you have given birth who are alive but do No «««««««««««.................2 106
not live with you?
105 How many sons are alive but do not live Sons elsewhere . . . . . . . «««««««.
with you? Daughters elsewhere««««««..««
And how many daughters are alive but do
not live with you?
IF NONE, RECORD '00'.
106 Have you ever given birth to a boy or girl Yes «««««««««««««««1
who was born alive but later died? No «««««««««««.................2 108
IF NO, PROBE: Any baby who cried or
showed signs of life but did not survive?
107 How many boys have died? Boys dead . . . . . . . . . . . . «««««.. .
And how many girls have died? Girls dead . . . . . . . . . . . . ««««««.
IF NONE, RECORD '00'.
108 Sum answers to 103, 105, and 107, and Total births . . . . . . . . . . . ««««««.
enter total.
If none, record '00'.
109 Check 108:
Just to make sure that i have this right: you
have had in total _____ births during your
life. Is that correct?
Yes«.. __ __
No«.. No correct 101-108 as necessary

º

110 Check 108:
One or more births«. __ __
No births«« 116
111. Now I would like to record the names of all your births, whether still alive or not, starting with the
first one you had. Record names of all the births in 212. Record twins and triplets on separate rows. (if
there are more than 12 births, use an additional questionnaire, starting with the second row).
112 What name was given to your (first/next) Last birth«««««««««««««.
baby? Next to last birth««««««««««..
Second to last birth«««««««.««
113 Is (NAME) a boy or a girl?
Last birth««««««««««««. Boy ««««..««««««««...«..1
Girl «««««..«««««................ 2
Next to last birth«««««««««.. Boy ««««..«««««««...««..1
Girl «««««..«««««.................2
Second to last birth««««««««. Boy ««««..««««««««««.1
Girl «««««..«««««.................2
114 In what month and year was (NAME) born?
Probe: When is his/her birthday?
Last birth««««««««««««.. Month ««««.«««.«««....__ __
Year..«««««................. __ __ __ __
Next to last birth«««««««««. Month ««««.«««««««..__ __
Year..«««««.................. __ __ __ __
Second to last birth««««««««. Month ««««.«««««««..__ __
Year..«««««.................. __ __ __ __
115 Is (NAME) still alive?
Last birth««««««««««««. Yes ««««..««««««««««..1
No.«««««..«««««.................. 2
Next to last birth«««««««««.. Yes ««««..««««««««««..1
No.«««««..«««««...................2
Second to last birth««««««««. Yes ««««..««««««««««..1
No.«««««..«««««...................2
116 Are you pregnant now? Yes «««««««««««««««1
No ««««««««««««.............2
Unsure ««««.«««««««««.8


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201 Now I would like to talk about family planning - the 202. Have you ever used (Method)?
various ways or methods that a couple can use to delay or
avoid a pregnancy. Have you ever heard of (method)?
01 )
(". Women can have an Yes«..1 Have you ever had an operation to
operation to avoid having any more children. No...... 2 avoid having any more children
Yes««.««««««««..........1
No«.«...........................................2
02 
(". Men can have an Yes«..1 Have you had a partner who had an
operation to avoid having any more children. No...... 2 operation to avoid having any more
children
Yes««.««««««««..........1
No«.«............................................2
03 !: Women can take a pill every day to Yes«..1 Yes««.««««««««..........1
avoid becoming pregnant. No...... 2 No«.«...........................................2

ºc
04 : Women can have a loop or coil placed
inside them by
a doctor or a nurse.
05 .&-: Women can have an injection by
a health provider that stops them from
becoming pregnant for one or more months.
06 /: Women can have one or more
small rods placed in their upper arm by a
doctor or nurse which can prevent pregnancy
for one or more years.
07  : Men can put a rubber sheath on
their penis before sexual intercourse.
08 )
 : Women can place a sheath
in their vagina before sexual intercourse.
09 &


(LAM)

10 
 : Every month that a woman
is sexually active she can avoid pregnancy by
not having sexual intercourse on the days of
the month she is most likely to get pregnant.
11
 5: Men can be careful and pull out
before climax.
12
#&
&/. As an
emergency measure, within three days after
they have unprotected sexual intercourse,
women can take special pills to prevent
pregnancy.
13 Have you heard of any other ways or methods
that women or men can use to avoid
pregnancy?
203 Check 202
Not a single µµyes¶¶ (never used) « go to 304
At least one used µµyes¶¶ (ever used)«««««««««. ««««««««««««.206
No QUESTIONS AND FILTERS
204 Have you ever used anything or tried in any
way to delay or avoid getting pregnant?
205 What have you used or done? Correct 202 and
203 (and 201 if necessary)
206 Check 202(01)
207 Check 116:
208 Are you currently doing something or using any Yes «««««..«««««««...1
method to delay or avoid getting pregnant?
209 Which method are you using?
Circle all mentioned
If more than one method mentioned, follow skip Pill......................................................C
instruction for highest method on list.
Yes«..1 Yes««.««««««««..........1
No...... 2 No«.«............................................2
Yes«..1 Yes««.««««««««..........1
No...... 2 No«.«...........................................2
Yes«..1 Yes««.««««««««..........1
No...... 2 No«.«...........................................2
Yes«..1 Yes««.««««««««..........1
No...... 2 No«.«...........................................2
Yes«..1 Yes««.««««««««..........1
No...... 2 No«.«...........................................2
Yes«..1 Yes««.««««««««..........1
No...... 2 No«.«...........................................2
Yes«..1 Yes««.««««««««.........1
No...... 2 No«.«...........................................2
Yes«..1 Yes««.««««««««..........1
No...... 2 No«.«...........................................2
Yes«..1 Yes««.««««««««..........1
No...... 2 No«.«...........................................2
Yes___1 Yes««.««««««««..........1
specify No«.«............................................2
No____2 Yes««.««««««««..........1
specify No«.«............................................2
CODING CATEGORIES SKIP
Yes «««««..«««««««...1
No ««««..«««««................2 «211
Woman not sterilized«««««««
Women sterilized«««««««...... .209A
Not pregnant or unsure«««««.«
Pregnant«.«««..««««««.... «211
No «««««««..««................2 «211
Female sterilization«««««««A
Male sterilization««««««««B
IUD«««««««««««........D
Injectables««««««««««..E
ºî
 Implants«««««««««««..F
Condom«««««««««««..G
Female condom««««««««..H
Lactational Amenorrhea Method««.I
Rhythm method««««««««...J «301
Withdrawal««««««««««.K «301
Other (specify)««««...«..««..X
210 Where did you obtain (current method) the last Public sector
time? Government Hospital«««««....11
Government Health center«««....12
If more than one method circled in 209, Ask Family planning clinic«««««..13
about method Public or private mobile clinic««..14
Fieldworker«««««««««...15
If unable to determine if public or private Other public ___________________16
sector, write the name of the place. (specify)
Private medical sector
Name of Place Private hospital/clinic«««««....21
Pharmacy««««««««««...22
If method is sterilization, do not circle code for Private doctor««««««««....23 «301
pharmacy, fieldworker, shop, friend /relative Mobile clinic«««««««««.24
Fieldworker«««««««««...25
Other private medical____________26
(specify)
Other source
Shop«««««««««««.«.31
Church«««««««««««..32
Friend/relative«««««««.«..33
Other ________________________96
(specify)
211 Do you know of a place where you can obtain a Yes «««««..«««««««...1
method of family planning? No ««««..«««««................2 «301
212 Where is that? Public sector
Government Hospital««««..«...A
Any other place? Government Health center«..««...B
Family planning clinic«««««....C
Probe to identify each type of source and circle the Public or private mobile clinic««...D
appropriate codes. Fieldworker««««««««.«...E
Other public ___________________ F
If unable to determine if public or private sector, (specify)
write the name of the place. Private medical sector
Private hospital/clinic«««««....G
Name of Place Pharmacy««««««««««...H
Private doctor«««««««««..I
Mobile clinic«««««««««...J
Fieldworker«««««««««....K
Other private medical ____________L
(specify)
Other source
Shop««««««««««««..M
Church«««««««««««....N
Friend/relative««««««««....O
Other ________________________ X
(specify)

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No QUESTIONS AND FILTERS CODING CATEGORIES SKIP
301 Are you currently married or living together Yes, currently married «««««...1
with a man as if married? Yes, living with a man «««««...2 «304
No, not in union ««««««««.3
302 Have ever married or lived together with a man Yes, formally married «««.««...1
as if married? Yes, lived with a man «.««««...2
No, ««««... ««««««««.3 «304
303 What is your marital status now: are you Widowed«««««««««««1
married? Divorced? Separated? Divorced««««.............................2
Separated««««««««««....3
304 Check for presence of others. Before Continuing, make every effort to ensure privacy
305 Now I need to ask you some questions about
sexual activity in order to gain a better
understanding of some family life issues Never had sexual intercourse ««...00 «401
How old were you when you had sexual
intercourse for the very first time? Age in Years«««««««.... __ __
306 When was the last time you had sexual Days ago««««««««.«.__ __
intercourse? Weeks ago«««««««..«.__ __
If less than 12 months, answer must be recorded Months ago«««««««.__ __
in days, weeks or months. Years ago««««««...«.__ __
If 12 months (one year) or more, answer must
be recorded in years


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No QUESTIONS AND FILTERS CODING CATEGORIES SKIP
401 Check 104:
Neither sterilized ««««««««««««««««««««««««. Go to 402
He or she sterilized «««««««««««««««««««««««««««« «409
402 Check 116:
Not pregnant or unsure ______
Now I have some questions about the future:
Would you like to have (a/another) child, or Have (a/another) child««««««.1
would you prefer not to have any (more) No more/none«««««««««..2 «404
children? Says she cannot get pregnant«««..3 «409
Pregnant ______ Undecided/do not know:
Now I have some questions about the future: And pregnant«««««««««4 «405
After the child you are expecting now, would And not pregnant or unsure«««..5 «404
you like to have another child, or would you
prefer not to have any more children?
403 Check 116: Months«««.«««««.«1__ __
Not pregnant or unsure ______ Years««««..««««.«..2__ __
How long would you like to wait from now Soon/now««««««««««993
before the birth of (a/another) child? Says she can't get pregnant«««.994 «409
Pregnant__________ After marriage««««««««.995
After the birth of the child you are expecting Other _______________________ 996
now, how long would you like to wait before (specify)
the birth of another child? Don't know«««««««««.998

º
404 Check 203: using a contraceptive method? Not asked«.««««««go to 405
No, not currently««««..go to 405
Yes, currently using«««««««.. «409
405 Do you think you will use a contraceptive Yes «««««..««««««.«. 1
method to delay or avoid pregnancy at any time No ««««..«««««............... 2 «407
in the future? Do not know«««««««.««..8 «407
406 Which contraceptive method would you prefer Female sterilization«««««.«..01 «409
to use? Male sterilization«««««««...02 «409
Pill.....................................................03 «409
IUD««««««««««««....04 «409
Injectables««««««««.........05 «409
Implants««««««...««««.06 «409
Condom«««««««««.........07 «409
Female condom««««««««.08 «409
Lactational Amenorrhea Method«..09 «409
Rhythm method««««««««.10 «409
Withdrawal«««««««««....11 «409
Other (specify)________________ 96 «409
Unsure«««««««««««...98 «409
407 What is the main reason that you think you will Not Married««««««««..«11
not use a contraceptive method at any time in Fertility related reasons:
the future? Infrequent sex/no sex«««««.21
Menopausal/hysterectomy««.«22
Subfecund/infecund««««...«23
Wants as many children as
possible««««««««««.24
Opposition to use
Respondent opposed«««««..31
Husband/partner opposed«««..32
Other opposed««««««««33
Religious prohibition«««««.34
Lack of knowledge
Knows no method««««««..41 «409
Knows no source«««««««42
Method related reasons:
Health concerns«««««««..51
Fear of side-effects««««««.52
Lack of access/to far«««««..53
Costs too much«««««««..54
Inconvenient to use««««««55
Interferes with body`s normal
process ««««««««««.56
Other (specify)________________ 96
Unsure«««««««««««..98
408 Would you ever use a contraceptive method if Yes «««««..««««««.«. 1
you were married? No ««««..«««««............... 2
Do not know«««««««.««..8
409 Check 103 and 105:
Have living children __________ None ««««««««««.««00 «End
If you could go back to the time you did not Number«««««««««... __ __

ºº
 have any children and could choose exactly the Other(specify)«««««««..«.96 «End
number of children to have in your whole life,
how many would that be?

No living children ______________ None ««««««««««.««00 «End

If you could choose exactly the number of Number«««««««««.. __ __
children to have in your whole life, how many Other(specify)«««««««..«.96 «End
would that be?
 )‘ ‘‘ 
‘ ‘
410 How many of these children would you like to Boys Girls Either
be boys, to be girls and for how many would be Number««. _ _ __ __
the sex not matter? Other(specify)«««««««..«.96



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101 Check 114:
One or more births in 2005 ______....................................... go to 102
No births in 2005 ______________.............................................................. ««««««««..201
102 Check 114: Enter in the table the name of each birth in 2005
or later. Ask the questions about all of these
births. Begin with the last birth. Now I would like to ask some questions about your children born in the
last five years. (We will talk about each separately.)
103 From 212 (Reproduction Last Birth Next to Last Birth Second to Last Birth
Part) Name___________ Name___________ Name___________
104  ‘‘) ‘ ‘  ‘ ‘ ‘
Did you see anyone for Doctor««««««A ‘
antenatal are for this Nurse/Midwife««..B ‘
pregnancy? Aux. Midwife««....C ‘
6 ‘ ‘ ‘
If Yes: Whom did you TBAs««««««.D ‘
see?
Com. Heal. Worker..E ‘
Anyone else? 6  ___________ X ‘
Probe to identify each (specify) ‘
type of person and record | ‘ «««..««Y‘ ‘
all mentioned. ‘
105 Where did you receive  777777

‘
antenatal care for this 2   ‘
‘ ‘
pregnancy? Govt. Hospital«.......B ‘
Anywhere else? Govt. Health Center...C ‘
Govt. Health Post«..D ‘
Probe to identify each Other Public ‘
type(s) of source and Sector ____________E ‘
circle the appropriate (specify) ‘
code(s). ‘
‘
 ‘ ‘
Pvt. Hospital/Clinic...F ‘
If unable to determine if Other Private Medical ‘
public or private sector, Sector ___________ G ‘

ºÿ
 write the name of the (specify) ‘
place. Other ____________ X ‘
(specify) ‘
Name of Place ‘
106 How many months Months«««....__ __ ‘
pregnant were you when Don't know«««...98 ‘
you first received ‘
antenatal care for this ‘
pregnancy? ‘
107 How many times did you Number of ‘
receive antenatal care times««««...__ __ ‘
during this pregnancy? Don't know«««...98 ‘
‘
‘
‘
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|55555555555
|55555555555
|55555555555

108 As part of your antenatal Yes No ‘
care during this Weight««1 2
pregnancy, were any of
the following done at BP«««...1 2
least once:
Were you weighed? Urine« «..1 2
Was your blood pressure
measured? Blood«..«1 2
Did you give a urine
sample?
Did you give a blood
sample?
109 During (any of) your Yes ««««.««1
antenatal care visit(s), No ««««««..2
were you told about the Do not know««...8
signs of pregnancy
complications?
110 Were you told where to Yes ««««.««1
go if you had any of these No ««««««..2
complications? Do not know««...8

111 Who assisted with the  ‘ ‘  ‘ ‘  ‘ ‘
delivery of (NAME)? Doctor«««««A Doctor«««««A Doctor«««««A
Anyone else? Nurse/Midwife«...B Nurse/Midwife«...B Nurse/Midwife«...B
Probe for the type(s) of Aux. Midwife««.C Aux. Midwife««.C Aux. Midwife««.C
person(s) and record all 6 ‘ ‘ 6 ‘ ‘ 6 ‘ ‘
mentioned. If respondent TBAs«««««..D TBAs«««««..D TBAs«««««..D
says no one assisted, Relative/friend«....E Relative/friend«....E Relative/friend«....E
probe to determine 6  __________ X 6  __________ X 6  __________ X
whether any adults were (specify) (specify) (specify)
present at the delivery. | ‘ ‘«..Y | ‘ ‘«..Y | ‘ ‘«..Y
112 Where did you give birth  777777cc
 777777cc
 777777cc

to (NAME)?


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Probe to identify each 2   ‘
‘ 2   ‘
‘ 2   ‘
‘

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 type(s) of source and
circle the appropriate
code(s).
If unable to determine
if public or private sector,
write the name of the
‘ ‘
‘

‘ ‘
‘

‘
place.
Name of Place
113 Was (NAME) delivered
by Caesarean?
114 In the first two months
after delivery, did you
receive a vitamin A dose
like (this/any of these)?
Show vitamin A capsule


Govt. Hospital«.....21 Govt. Hospital«.....21 Govt. Hospital«.....21
Govt. Health Center.22 Govt. Health Center.22 Govt. Health Center.22
Govt. Health Post«.23 Govt. Health Post«.23 Govt. Health Post«.23
Other Public Other Public Other Public
Sector ___________26 Sector ___________26 Sector ___________26
(specify) (specify) (specify)
‘
‘

Pvt. Hospital/Clinic..31 Pvt. Hospital/Clinic..31 Pvt. Hospital/Clinic..31
Other Private Medical Other Private Medical Other Private Medical
Sector ___________36 Sector ___________36 Sector ___________36
(specify) (specify) (specify)
Other ___________ 96 Other ___________ 96 Other ___________ 96
(specify) (specify) (specify)
Yes ««««.««1 Yes ««««.««1 Yes ««««.««1
No ««««««..2 No ««««««..2 No ««««««..2
Yes ««««.««1
No ««««««..2
Do not know««...8



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No QUESTIONS AND FILTERS
101 I would like to ask you some questions
about (Name of child from cover page).
What is your relation ship to (Name of
Child)
102 What is (Name)`s date of birth?
103 How old is (Name)?
Compare and correct 102 and/or 103 if
necessary.
(&
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+ #
201 Was (Name of Child) ever breastfed?
202 Is (Name) still being breastfed?
CODING CATEGORIES SKIP
Biological Mother«««««««..«..01
Biological Father...«««««««..«02
Stepmother««««««««««..«.03
Stepfather«««««««««««.....04
Grandmother««««««««««....05
Grandfather«««««««««««..06
Adoptive Parent«««««««««...07
Sister/brother««««««««««...08
Other Relative«««««««««.«09
Not Related...««««««««««..10
Day«««««««««««««__ __
Don't know month«««««««.«.98
Month«««««««««««...__ __
Don't know month«««««««.«.98
Year««««««««««««...__ __
Don't know year««««««««..9998
Age in completed years««««__ __
Yes ««««.««««««««««...1
No «««««««««««.................2 «203
Yes «««««««««««««««1
No «««««««««««.................2

º×
203 Did (Name) drink anything from a bottle Yes «««««««««««««««1
with a nipple yesterday or last night? No «««««««««««.................2
Do not know... ««««««««««..8
204 Yesterday or last night, did (Name) eat or
drink Yes No DK
Plain water? Water««««««1 2 8
Baby formula or other milk? Milk««««««..1 2 8
Juice, soda, tea or rice water? Juice/soda/tea««...1 2 8
Any solid or mushy foods? Any food««««..1 2 8
(&
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No QUESTIONS AND FILTERS CODING CATEGORIES SKIP
301 Do you have a card where (NAME)'s vaccinations are Yes,
written down? Seen«.«««««««««1 ?
If yes: May I see it please? Yes, Not seen ««««...«..2 «305
No Card..««««««.««3
302 (1) Copy dates from the card.

(2) Write µ66' in µday' column if card shows that a dose was given, but no date is recorded.
(3) If more than two vitamin ³a¶ doses, record dates for most recent and second most recent doses.
DAY MONTH YEAR
BCG
POLIO 0 (POLIO
GIVEN AT BIRTH)
POLIO
1
POLIO
2
POLIO
3
DPT
1
DPT
2
DPT
3
MEASLES
VITAMIN A
(MOST RECENT)
VITAMIN A (2nd
MOST RECENT
303 Check 302
Not all from BCG to Measles recorded«««««««.«««««. Go to 304
BCG to Measles all recorded««««««««««««««««««««.. ...307
304 Has (NAME) had any vaccinations that are not Yes «««««««««««««..1 ...307
recorded on this card, including vaccinations No ««««.......................................2 ...307
given in a national immunization day Do not know... ...««««««««.8 ...307
campaign?

Record µyes¶ only if the respondent mentioned

BCG, Polio 0-3, DPT 1-3, and/or measles
vaccines.

ºa
 If yes write µ66¶ in question 302 in the day
column for the corresponding vaccine.
305 Did (NAME) ever have any vaccinations to Yes «««««««««««««..1
prevent him/her from getting diseases, No ««««.......................................2 «?
including vaccinations received in a national Do not know... ...««««««««.8 ..307
immunization day campaign?
306 Please tell me if (NAME) had any of
the following vaccinations:
06A A BCG vaccination against tuberculosis, which Yes «««««««««««««..1
is, an injection in the arm or shoulder that No ««««.......................................2
usually causes a scar? Do not know... ...««««««««.8


306B Polio vaccine, that is, drops in the mouth? Yes «««««««««««««..1
No ««««.......................................2 «?
Do not know... ...««««««««.8 306E

306C Did (Name) receive the first polio vaccine First two weeks«««««««««1
during the first two weeks after birth or later? Later«««««««««««««2

306D How many times was the polio vaccine given? Number of times«_ _

306E A DPT vaccination, that is, an injection given Yes «««««««««««««..1

in the thigh or buttocks, sometimes at the same No ««««.......................................2 «?
time as polio drops? Do not know... ...««««««««.8 306G

306F How many times did (Name) receive the DPT Number of times«_ _
vaccine?
306G A measles injection or an MMR injection - that Yes «««««««««««««..1
is, a shot in the arm at the age of 9 months or No ««««.......................................2
older ± to prevent him/her from getting Do not know... ...««««««««.8
measles?
307 Check 302, date for most recent vitamin A
dose recorded
No date for most recent vitamin A «««««««««««««««. ..310
dose...«««. Go to 308
Date for most recent vitamin A
dose«««««««««.
308 Has (Name) ever received vitamin A dose? Yes «««««««««««««.1
Show capsule No ««««...................................... 2 «?
Do not know... «««««««««8 ...310
309 Did (Name) receive vitamin A dose with in the Yes «««««««««««««. 1
last 6 months? No ««««...................................... 2
Do not know... «««««««««8
310 Has (Name) had diarrhea in the last two Yes «««««««««««««..1
weeks? No ««««.......................................2 «?
Do not know... «««««««««8 ..316
311 Now I would like to know how much (NAME) Much less«««««««««««.1
was given to drink during the diarrhea Somewhat less«««««««««.2
(including breast milk). About the same««............................3
Was he/she given less than usual to drink, More««««««............................4

ÿ

 about the same amount, or more than usual to Nothing to drink««««««««..5
drink? Don't know««««««««««..8
If less, Was he/she given much less than usual
to drink or somewhat less?
312 When (NAME) had diarrhea, was he/she given Much less«««««««.««.«...1
less than usual to eat, about the same amount, Somewhat less««««««.«.«...2
more than usual, or nothing to eat? About the same«««««««........3
If less, PROBE: Was he/she given much less More««««««««««««....4
than usual to eat or somewhat less? Stopped food«««««««««...5
Never gave food««««««««..6
Don't know««««««««««..8
313 Did you seek advice or treatment for the Yes «««««««««««««..1
diarrhea from any source? No ««««.......................................2 ..315

314 Where did you seek advice or treatment? )
‘
 ‘

Anywhere else? Govt. Hospital«................................A
If unable to determine Govt. Health Center«««««««B
If public or private sector, write the name of Govt. Health Post««««««........C
the place. Mobile Clinic««««««««......D
___________________________ Field Worker«««««««.««..E
Name of Place Other Public
Sector ________________________F
(specify)
‘
‘
 ‘
Pvt. Hospital/Clinic«««««.«...G
Pharmacy««««««««.««...H
Private Doctor«««««««««..I
Mobile Clinic«««««««.«......J
Field Worker««««««....««...K
Other Private
Medical Sector _________________L
(specify)
6 ‘ 
‘
Shop««««««««««««...M
Traditional Practitioner«««««.N
Other ________________________ X
(specify)
315 Was he/she given any of the following to drink at
any time since he/she started having the diarrhea: Yes No DK
a). A fluid made from a special packet called Fluid from ORS
(local name for ORS packet)? Packet«««««..«...1 2 8
b). A pre-packaged ORS liquid? ORS Liquid««««.......1 2 8
c). A government-recommended homemade Homemade Fluid«««...1 2 8
fluid?
316 The lat time (Name) passed stools, what was done Child used toilet or latrine.«««...01
to dispose of the stools? Put/rinsed into toilet or latrine««..02
Put/rinsed into drain or ditch«««03
Thrown into garbage...««««.«.04
Buried««««««««««.«...05
Left in the open...««««««..«06
Other ________________________96
(specify)

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I am __________. I will be moderating this discussion. ___________ will be recording the
discussion and taking notes. (Have each participant introduce him or herself by name.)
‘

 ‘ ‘
 
‘
Thank you for agreeing to help us with this PhD project. We appreciate your willingness to share
your time and expertise. We are with the University of Gondar/Addis Continental Institute of
Public Health and are working on a project entitled Implementation of Health Extension Program
(Outcome of Health Extension Program on Maternal and Child Health, Immunization and
Family Planning) in West Gojjam Zone, Amhara National Regional State, Ethiopia.

You are the experts on this topic: the information you give us will help us develop/improve
health extension programs to help you and others.

What you say here is confidential. We are interested in hearing your experiences: your name will
not be included in any reports. If you have any questions about this interview or the project after
we leave, you can call us at 8+*‘ /*,‘ +999,‘ 6$‘ 8+*‘ /‘ +09*, or you can talk to
!‘)‘:‘ ‘(the principal investigator), who can get in touch with us.

I want you to talk to each other rather than to me. I will start the conversation out with a
question, but after that I will just jump in to get us back on track if we have gotten off the topic,
or to bring up something we are interested in that you have not covered. Feel free to disagree
with what others have said or give another opinion: the more different ideas we hear, the more
information we will have to work with. Again, we are interested in hearing your experiences,
how you remember them.

I will let you know when we are near the end of our time. If you have to go to the bathroom, just
slip out quietly and come back as quickly as you can.

Are there any questions before we begin?

ÿî
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1.‘ What is health extension program to you? (PROBES: How do you see the program?
What does it look like in your village/community?)

2.‘ What were the key health problems in your community before the implementation of
health extension program? (PROBE: What were the main reasons that you had this health
problem?)

3.‘ What are the key health problems in your community currently (after the implementation
of health extension program)? (PROBE: What are the main reasons that you have this
health problem?)

4.‘ What changes are occurring regarding the health of the community? (Probes: what are the
changes on maternal and child health? What are the changes on immunization? And what
are the changes on family planning?)

5.‘ When is a household said to graduated?

6.‘ Are there differences between graduated households and non-graduated households?
(Probes: in terms of maternal and child health, immunization, and family planning?)

7.‘ Do graduated households continue to be a model for non- graduated households for a
long period of time? [sustainability;

8.‘ If graduated households fail to be a model for non-graduated households, in your view,
what are the major reasons?

9.‘ Could you tell me more about the health extension program benefits? Are there any
misconceptions about the program in the community?

ÿJ
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, 

I want to thank you for taking the time to meet with me today. I am __________. I will be in-
depth interviewing you, recording the interview and taking notes.
‘

 ‘ ‘
 
‘
Thank you for agreeing to help us with this project. We appreciate your willingness to share your
time and expertise. We are with the University of Gondar/Addis Continental Institute of Public
Health and are working on a project entitled Implementation of Health Extension Program
(Outcome of Health Extension Program on Maternal and Child Health, Immunization and
Family Planning) in West Gojjam Zone, Amhara National Regional State, Ethiopia.

I would like to talk to you about your experiences of health extension program (outcome of
health extension program). Specifically, as one of the objectives of our PhD project we are
assessing the program outcome on maternal and child health, immunization and family planning
in order to capture lessons that can be used in future interventions.

The interview should take less than an hour. I will be taping the session because I don¶t want to
miss any of your comments. Although I will be taking some notes during the session, I can¶t
possibly write fast enough to get it all down. Because we¶re on tape, please be sure to speak up
so that we don¶t miss your comments.

All responses will be kept confidential. This means that your interview responses will only be
shared with research team members and we will ensure that any information we include in our
report does not identify you as the respondent. Remember, you don¶t have to talk about anything
you don¶t want to and you may end the interview at any time.

Are there any questions about what I have just explained?

Are you willing to participate in this interview?

_____________________________ _______________________________ ________________

Interviewee Witness Date

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Interviewer code: _______________________________________________________________

Respondent Code: ______________________________________________________________

Region: ____________ Zone: _____________ District: _____________ Kebele: ___________

Name(s) and role(s) of respondent(s):
???????????????????????????????????????????????

??????????????????????????????????????????????????????????????????????????????
??????????????????????????????????????????????????????????????????????????????

??????????????????????????????????????????????????????????????????????????????

Interviewer Comments: __________________________________________________________

Date: ____________________Time: from: ____________________to_____________________

2 /
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This information sheet and consent form is prepared by the investigator whose main aim is to
study /



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/. The investigator is PhD student from University of Gondar
/Addis Continental Institute of Public Health..


!/·
The purpose of this research is to assess the implementation of health extension
program in relation to motivation of health extension workers (HEWs), utilization of health
extension program (HEP) services by the community and outcome of HEP on the community in
terms of family planning, immunization and Maternal and child health in West Gojjam, Amhara
national Regional State, Ethiopia.

Health service extension program is an innovative approach which is encompassed under the
Health Sector Development Program to meet the millennium Development Goals (MDGs).
While the program is innovative and is supposed to bring better health status of population
especially in peripheral areas, studies done concerning program are rare.

Therefore the findings of this study will contribute a substantial share in maximizing utilization
of health service, improving healthy practice, and enhancing motivation of HEWs and overall
reduction of morbidity and mortality.

!& ·
In order to assess the /



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/, we invite you to take part in our
project. If you are willing to participate in our project, you need to understand and sign the
consent form. Then, you will be asked to give your response by the data collectors.
For this
questionnaire based study, participants are health extension workers and all mothers (women
aged 15-49) during the study period. All the responses given by the participants and the results
obtained will be kept anonymous and confidential using coding system where by no one will
have access to your responses.




 :
&·
By participating in this research project you may feel that it has some
discomfort specially on wasting your time (-
%2
) but this may not be too much
as you are going to health institutions for you and your family health care and comparing its

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potential benefits it contributes to the overall improvement of the health status of the community.
There is no risk in participating in this research project.



+·
If you participate in this research project, you may not get direct benefit but your
participation is likely to help us in assessing the motivation of health extension workers,
utilization of health extension program and outcome of the health extension program and in
identifying factors affecting these issues in West Gojjam Zone, Amhara National Regional State,
Ethiopia.

Finally it will give an insight whether policy change is required or not based on the findings of
the study for improving the health status of the community.



&·
You will not be provided any incentives to take part in this project.

 

·
The information that we will collect from this research project
will be kept confidential. Information about you that will be collected from the study will be
stored in a file, which will not have your name on it, but a code number assigned to it. Which
number belongs to which name will be kept under lock and key, and it will not be revealed to
anyone except the principal investigator.

#



 5: You have the full right to refuse from participating in this
research (you can choose not to respond some or all of the questions) if you do not wish to
participate; and this will not affect your health services you get at from any health facilities. You
have also the full right to withdraw from this study at any time you wish to, without losing any of
your rights as a resident of this site.

!

&&·
If you have any question you can contact any of the following individuals
and you may ask at any time you want.

1.‘ )‘:‘  
University of Gondar/Addis Continental Institute of Public
Health
Tel: +251 581 116221/ +251 920 252761 OR +251 918 056668
E-mail: mezgebuy@yahoo.com OR mezgebuy@gmail.com

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 2.‘   ‘: ‘(  
‘Addis Continental Institute of Public Health,
Tel: +251 114 168207/ + 251 911219785
E-mail: yemaneberhane@ethionet.et OR yemane_b@hotmail.com
3.‘   ‘ :‘ >)
School of Public Health Sciences, College of Medicine and
Health University of Gondar
Tel: +251 581 116221/ +251 918 722268
E-mail: gkyigzaw@yahoo.com
‘

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· Mezgebu Yitayal Mengistu
(9· Male
!&

+· Addet, West Gojjam, Ethiopia


+· 10/07/1975
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Language Speak Read Write
Amharic :‘ :‘ :‘
English :‘ :‘ :‘

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Addis Ababa MPH- Health 2004-2006 Master of Public 3.52
University Management Health
Jimma University Environmental 1998-2001 Bachelor of Science 3.39
Health Science
University of Sanitary Science 1992-1994 Diploma 3.47
Gondar*
* University of Gondar was formerly known as Gondar College of Medical Sciences and it was
under Addis Ababa University

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{‘ Modular training on
!7
7



- organized and given by Gedeo
Zone Health Department at Dilla, Ethiopia from î::caaÿ2c:º:caaÿ
{‘ Training on 
#- organized and given by Gedeo Zone Health
Department at Dilla, Ethiopia from c%2c :º:caaÿ
{‘ Training on 
#

(- organized and conducted by
South Nations Nationalities and People` s Region Health Bureau in collaboration with
Gedeo Health Department and ESHE/JSI at Dilla, Ethiopia from %2ÿ::îî
{‘ Training on  &


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 &&- organized and
conducted by Health Education Center, Federal Ministry of Health of Ethiopia in
collaboration with Johns Hopkins University Center for Communication Programs and
United Nations Population Fund at Nazareth, Ethiopia from c2îÿ:î:î%
{‘ Ethiopian Public Health Training Initiative (EPHTI) Curriculum Development and Staff
Strengthening; )
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/- organized and conducted by
EPHTI, Carter Center-Ethiopia at Nazareth, Ethiopia from 2c::î%

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 {‘ Training on


&- organized and conducted by the Carter
Center/EPHTI in collaboration with the LINKAGES Project at Dilla College of Teacher
Education and Health Sciences from cÿ2ca:c:î
{‘ Training on &
#- organized and conducted by the LINKAGES
Project in Ethiopia in collaboration with the Carter Center/EPHTI, at Debub University
from îÿ2î::î




9/&

{‘ a:î:î

· Lecturer and Head at Department of Health Management and Health
Economics, School of Public Health, College of Medicine and Health sciences,
University of Gondar, Gondar, Ethiopia





/-· teaching health management, health economics and public health
courses for under graduate and graduate students and participating in extracurricular
activities of the university.

{‘ cc:a:î2 :î:î · Dean and Instructor at Abay Health College, Debre Markos,
Ethiopia






/-·
planning, implementing and evaluating curricular activities of the
college and teaching health science students.

{‘ cc:a:îÿ2c:a:î· Academic Vice Dean and Instructor at Abay Health College,

Debre Markos, Ethiopia






/-· planning, implementing and evaluating curricular activities of the
college and teaching health science students.

{‘ îî2î· Instructor and Department Head for Environmental Health department,

Faculty of Public Health, Health Sciences College, Hawassa University
/-· teaching environmental health and health sciences students; planning,
implementing and evaluating environmental health department activities; and receiving
assignments from the Head of the Public Health Faculty

{‘ îc2îî· District Environmental Health Expert at Yirgacheffe District Health office,

Gedeo Zone Health, Department, South Nations Nationalities and People` s Region
Health Bureau, Ethiopia
/-- planning, implementing and evaluating environmental health activities
of the district: carrying out supervision of food and drinking establishments, and health
care facilities of the district; and receiving assignments from the Head of the District
Health Office

{‘ caa2caa · District Sanitarian at Bulle and Yirgacheffe District Health offices, Gedeo
Zone Health, Department, South Nations Nationalities and People` s Region Health
Bureau, Ethiopia
Working for each districts for two years

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 /-- planning, implementing and evaluating environmental health activities
of the districts: carrying out supervision of food and drinking establishments, and health
care facilities of the districts; and receiving assignments from the Head of the District
Health Office

º
&

{‘ Economic Burden of Tuberculosis to Patients and Their Families: a Cross-sectional Study
at Addet Health Center, Yilmana Densa District, Amhara National Regional State,
2007(unpublished)
{‘ Economic Burden of Tuberculosis to Patients and Their Families: a Cross-sectional Study
at Felege Hiwot Referral Hospital, Bahir Dar , Amhara National Regional State,
2006(unpublished)
{‘ Review of literature on environmental and health to help the environmental economics
policy forum to identify possible research ideas for future contracted by Environmental
Economics Policy Forum for Ethiopia, 2004

ÿ
!-&

{‘ Yitayal M. and W/Cherkos A. (2004): Food Hygiene for Environmental Health Students,
carter center/USAID, Ethiopia


--


(

{‘ Browsing internet and communicating with peoples and organizations; watching TV
especially soccer match and athletics championship; and working ability of Microsoft
word, Microsoft power point and Microsoft excel




 






Mezgebu Yitayal
P.O. Box 628,
School of Public Health
College of Medicine and Health Sciences
University of Gondar, Gondar, Ethiopia
Tel: 0920 252761 OR 0918 056668 (mobile), +251 111 558386(Home):
E-mail: mezgebuy@yahoo.com OR mezgebuy@gmail.com


a
&

I.‘ Dr. Mesfin Addisse, Community Health Department, Faculty of Medicine, Addis Ababa
University
Tel: + 251 911 406790; E-mail: shewit91@yahoo.com
II.‘ Dr Abraham Aseffa, Armauer Hansen Research Institute (AHRI)
Tel: + 251 911 247525; E-mail: aseffaa@yahoo.com
III.‘ Dr. Belaynew Wassie, School of Public Health, University of Gondar
Tel: + 251 911 385423/+251 918 778268; E-mail: bewassie@yahoo.com

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