ANC: Antenatal Care; AOR: Adjusted Odds Ratio; COR: Crude Odds Ratio; DC: Delivery Care; EDHS: Ethiopia Demographic Health Survey; FP: Family Planning; HEP: Health Extension Program; HEWs: Health Extension Workers; HC: Health Center; HP: Health Post; PNC: Postnatal Care; MCH: Maternal and Child Health; MFs: Model Families; NMFs: Non-model Families; OR: Odds Ratio; OSZSF: Oromia Special Zone Surrounding Finfine; PHCU: Primary Health Care Unit

Since Alma-Ata declaration, nearly for the last four decades, Primary Health Care (PHC) services have become major global health and economic concern [1]. Based on PHC approach, Ethiopia ministry of health (MOH) has formulated four consecutive phases of comprehensive Health Sector Development Plans (HSDPs) to be implemented within 20 years. The first phase was implemented between 1996/97 and 2001/2. Subsequently, the HSDP II, III and IV consecutively took their next five years of implementation till now. Over these periods, the federal MOH has formulated and implemented a number of policies and strategies that afforded an effective framework for improving health in the country including the recent addition of maternal and neonatal health. One of the focused strategies under implementation starting from the HSDP II has been the training and deployment of new health workforce at grass root levels–the female Health Extension workers (HEWs) who provide health services at village settings [2-6].

The Health Extension Program (HEP) is an innovative health service delivery approach with defined package health services targeting households (HHs) through Primary Health Care Unit (PHCU) platform that comprises of one health center with 5 satellite health posts within the radius of 10 KMs [4,5]. It was first launched in 2002/3 in five regions of the country. It was designed to improve the health status of families by providing healthy living knowledge and skills that empower the HHs to take responsibility that lead them to healthy life styles. Accordingly, each village (locally named as ganda) will have one health post serving 16 HEP packages under 4 thematic areas. Theme 1: Disease Prevention and Control (Prevention and control of HIV/ AIDS & other sexually transmitted infections (STIs), TB and Malaria and First Aid emergency measures). Theme 2: Family Health (MCHMaternal and child health, Family planning, Immunization, Nutrition, Adolescent reproductive health). Theme 3: Hygiene & Environmental Sanitation (Excreta disposal, Solid and liquid waste disposal, Water supply and safety measures, Food hygiene and safety measures, Healthy home environment, Control of insects & rodents, Personal hygiene) and Theme 4: Health Education and Communication (cross cutting) [6]. The program packages have been rendered by the HEWs, through outreach (like home visits) and in-the-health post activities. Creating model families (MFs) for HEP packages has been one of the strategies to enhance adoption of the HEP packages into the social system and healthy behaviors [4-6].

This study focused on MCH (ANC, PNC, delivery services, FP and immunization) services utilization, of the HEP packages [6]. It was well noted that MCH packages had direct effect in achieving global goals by reducing maternal and child Mortality. One of the targets of the sustainable Development Goals (SDGs) has been to reduce the underfive mortality rate by two-thirds within 1990-2015 [7-12]. In fact, under-five mortality was declined by 47 % (166 to 88 deaths per 1,000 live births) over the last decade in Ethiopia (2000-2011, EDHS). So do maternal mortality reduced by 72% [13-16]. Now, the HEP can be taken as the main vehicle for bringing key maternal, neonatal and child health interventions into effect in Ethiopian community, especially in rural contexts. Additionally, evidences indicate MCH services use has been a critical challenge in numerous African countries, needing improvement for achievement of the SDGs [17-25]. Many studies conducted in various settings in Ethiopia showed MCH aspects: family planning, antenatal care, delivery care, post-natal care, and immunization were low and needed improvement expectedly through the new program, the HEP strategies [26-31].

One of the approach in HEP is identification and training of model families that have acceptance and credibility by the community, as early adopters of desirable health practices to become role models in line with the packages. Model families help to diffuse health messages leading to the adoption of the desired practices and behaviors by the community. In fact, one of the strategies for improved health behavior at individual, family and community level is working on selected units of individuals, families or community, empowering them and using them as advocate. Once these targets fulfill some features for effective models, they can be utilized for expansion of healthy living knowledge, principles and actions. However, the modalities through which these models were produced/selected, named and used in HEP strategies, determine the level of effectiveness on production of healthy behaviors among targeted groups or community [32].

According to the HEP, some families who received some forms of education and brought some improvement at household (HH) levels: kept sanitation, hygiene, properly disposed wastes, built toilets and the like becomes graduated as models families [6]. Formally speaking, model families were those households who received certificate from district health office that declared them as model family. And, nonmodel families were those households living in the same setting who didn’t receive any certificate that claimed so. Once the families were declared model, the HEWs use them as models for the rest of the HEP packages. In fact, the mechanisms for selection of the model families looked inconsistent sometimes when checked against observable changes in the HHs. Plus; these models were not produced at least for each HEP theme separately. It seems some of them were getting the names that they did not deserve.

Therefore, the researchers question if families named as model really exhibit variations in MCH service knowledge and use. And, to look if they can at least act as early adopters by providing some features of models for the rest of the women in their surroundings. Therefore, it is timely and appropriate to compare MCH services knowledge and utilization between mothers from model and non-model families in Sebeta Hawas district Oromia special zone surrounding Finfine and suggest strategies to go for effective health behavior expansion in community for family health theme and beyond.

The study design and setting

We employed comparative cross-sectional study mixed with qualitative methods to compare model and non-model families against maternal and child health services in Sebeta Hawas district. In this study, model families were households who received certificate from district health office that they are model families. And, non-model families were those households living in the same setting who didn’t receive any certificate. Sebeta Hawas is one of the districts in Oromia special zone surrounding Finfine. It comprises of 40 gandas (villages); 3 urban and 37 rural. In the district, there were about 24,074 households with total population of 132,294 (66,133 men and 64,161 women) based on 2007 estimation. About 94.44% of the population resides in rural villages. The district is bounded by South west Showa in the south and West, Walmera and Addis Ababa in the North and Akaki district in the East [33]. A total of 6 health centers and 40 satellite health posts surrounding the health centers (one for every ganda/village) were present in the district providing Primary Health Care services at grass root level. Regarding health man power there were 74 HEWs and 82 advanced health professionals including nurses, health officers and few general practitioners. We conducted this study in seven selected rural villages of the district between November 20 and December 5, 2015.

Population

For this study we considered mothers from model and non-model households located in randomly selected rural villages. We included women from rural settings because the HEP was initially designed for rural areas and the urban programs had been introduced only recently. We included woman in a reproductive age range (15-49 years), lived in the locality for at least six months and who has at least one exposure for delivery (giving birth) in the last five years.

Sample size

We calculated the sample size using EpI-info applying two population proportions formula: [n=[Zα/2+Zβ]2*[P1(1- P1)+P2(1-P2)/(P1-P2)2]. We considered the following assumptions: proportion of non-model families who use ANC in rural Ethiopia (P1=0.34 [Ethiopian DHS, 2011)(We assumed the ANC figure as reported by EDHS-2011 for rural areas represent non-model families, ANC yielded higher sample size compared to other maternal health indicators), proportion of model families who use ANC was unknown and assumed to be (P2=50%), level of significance (α=5%), standard reliability coefficient at 95% confidence level (Z 1-α/2=1.96), the 80% power to detect significant difference when it happens (Zβ=0.84) and one to one ratio for MFs and NMFs. Finally considering 10% nonresponse rate the calculation yielded to a total of 322 sample size (each of 161 for MFs and NMFs). For the qualitative part of the study, four focused group discussions (FGDs) were conducted with mothers (two FGDs each for MFs and NMFs). In each FGD, 6–10 participants were participated. A total of 34 mothers were involved in all the FGDs. Additionally, we conducted four key informant interview (KIIs) with 1 health office head, 1 MCH head, 1 HEWs supervisor at district level and 1 HEWs at village level for data triangulation. The qualitative samples (both FGDs and KIIs) were stopped when we assumed idea saturation was achieved.

Sampling techniques

First we randomly selected 7 rural gandas in the district. Based on the finding from one published work on HEP in rural areas [25], we expected about 22% of the households (HHs) across all rural gandas in the district to be model families. Accordingly, we allocated equal proportion of samples to each of the 7 gandas i.e., a total of 46 HHs (with equal proportion for MFs and NMFs per ganda). Then, we further allocated equal samples of HHs to each of the three lowest area administrative structures (interchangeably named as goti or zoni) functioning under gandas i.e., 8, 7, 7 HHs. In order to facilitate random selection, we first established separate sampling frame for MFs and NMFs altogether with their specific ganda and zoni locations through the assistance of the HEWs. Then, we used computer generated simple random sampling from the sampling lists. Then, mothers who fulfilled the inclusion criteria were involved in the study. We tolerated one more visit for those closed houses that were randomly selected, otherwise we treated as non-response. For qualitative approach we selected the 4 KIIs because they were strategically positioned experts to provide adequate responses about mothers, including their model-status and possible variations against MCH services. We recruited the FGDs from four gandas relatively distantly located from health centers near to the study setting, where we expect more mothers from model families will deliver there compared to non-model ones. Here, we assumed place of delivery as best comparator that demarcate between mothers of model families from the non-model ones, as delivery service was not given at health post levels. We used purposive (criteria sampling) to select mothers whose age range was between 18-49 years (younger and older), who showed variation in number of children they have (limited and many) and from different gares under gandas to participate in the FGDs. The diversities of participants involved in the FGDs and mixing data from KIIs was aimed to maintain data triangulation.

Instrument and measurement

The instrument was adapted for this study through thorough review of documents and guidelines [6,13,14] and related literatures that are specific to MCH behaviors [17-25]. The questionnaire has three main parts (part 1 model status, part 2) background characteristics (age, marital status, religion, number of children etc.) part 2 utilization knowledge/ perception and practice for MCH services with five sub-sections: family planning, antenatal care, delivery, post-natal care and child immunization. Most of the questions elicited categorical responses on ‘yes’ or ‘no’ formats or more close ended options. The questionnaire was pretested among 16 mothers in two other villages in the same district. Then, we improved the appropriateness of the instrument to the level it was believed to be user and consumer friendly. We translated the questionnaire from English into Afan Oromo local language and back translated into English to keep the instrument internally consistent. We used the Afan Oromo version for data collection. Complimentarily, we used qualitative interview guides to engage our interviewees and discussants for prolonged time between 30 and 60 minutes. For KIIs, we used three main concepts: 1) overall weakness and strength for health extension program, 2) MCH services utilization status, reasons, challenges in general and 3) demarcation between model and nonmodel families in particular concerning MCH behaviors. Furthermore, for the FGDs we used guides that elicited discussion among mothers based on three main MCH related dimensions: 1) perceptions and knowledge, 2) experiences, reasons and utilization, and 3) forms and ranges of challenges and expected solutions.

Outcome variables

We considered MCH service utilization by mothers as outcome variable of interest to see variations between MFs and NMFs. These include use of FP, ANC, DC, PNC and child immunization. We expected more mothers from MFs exhibit MCH behaviors than mothers from NMFs. No variation means MFs cannot help to diffuse MCH behaviors that have been promoted by the HEP through model HHs production strategies. And, more importantly suggest devise new approach for formation of the models.

Data collection procedures

The data were collected by three trained diploma holder nurses. The randomly selected houses were traced by the assistance of the HEWs as local guiders. Three trained bachelor degree holder health professionals supervised the data collection. We arranged discussion about challenges during data collection period. The data were cleaned every day before submission to immediate supervisors. The investigators conducted the KIIs and FGDs by themselves face to face at the health posts that were located in each ganda. The investigators are one PhD in international health and two masters of public health holders. They were experienced with qualitative research designs, methods and implementations. All of them were ever involved conduct on in-depth interviews and focus group discussions. The FGDs and KIIs were done at private and quite place and audiotaped.

Data analysis

We used SPSS version 16 software for data analysis. Data cleaning and editing was carried out regularly through the course of the survey and after data entry. Missing data were excluded during analysis. Mothers who mentioned more than half of the HEP services were considered as knowledgeable about HEP. Mothers who were using any FP methods were taken as FP users. Mothers who visited HF at least once during last pregnancy were treated as ANC users. In fact, a minimum of four visits were also used for further analysis. Mothers who gave their last delivery at health institutions within the last five years were considered utilized skilled delivery services. Mothers who visited HF for checkup within 6 weeks after delivery were PNC users. And, mothers who immunized their last child were immunization users. Mothers who claimed knowing and using FP, ANC, PNC, and skilled delivery places and immunization were asked for details to display possible further variations. We used frequency tables, percentages to describe MCH services use both for MFs and NMFs. We executed binary logistic regression analysis to compare mothers based on model status. Variables with zero values in any of the comparison cells were excluded during logistic regression analysis. The finding was interpreted consistently by comparing NMFs against MFs i.e., we used a code value of ‘1’ for non-model and ‘0’ for model mothers. . We used adjusted Odds Ratio (OR) with 95% confidence interval (CI), and P-values (<5%) to declare predictors of model status (MFs or NMFs) in the contexts of socio-demographic features, MCH related knowledge and utilization. Audio taped qualitative data was first transcribed into text data. Then, texts were coded by the three investigators who worked altogether to give any possible meaningful interpretation against the objectives of the study. Then, the codes were made up to build higher level categories or themes. Finally, the thematically analyzed findings from qualitative data were mixed to support the quantitative findings.

Ethical considerations

The approval for this study was secured from Jimma University Public health and medical science ethical review committee. Then, we communicated with Zonal health office through the support letter we received from the ethical review committee. Finally, we obtained further support letter from zone to Sebeta Hawas district. The participants were adequately informed about the purpose of, potential risk and benefits, and right to withdraw from the study. We mentioned no direct risks and benefits were involved for participants because of their involvement in the study. In fact, we informed them that their responses are very important to inform the HEP strategies. The participants declared they understood information sheet read out for them before giving their consent. The involvement in the study was entirely based on oral informed consent. Privacy was kept during the study. The responses were kept confidential, as we did not use personal identifiers anywhere in the report.

Socio-demographic characteristics of the respondents

From a total of 322 households approached, 305 (146 MFs and 159 NMFs) were participated in the study, producing a response rate of 94.7%. For qualitative data 4 FGDs (34 participants involved and 6 invited persons did not come for discussion) and 4 KIIs were involved in the study. In fact, the response rates for MFs and NMFs were 90.9% and 98.8% respectively. Table 1 presents the details of the background for respondents. Accordingly, 108 (35.4%) of respondents were within 25- 29 years age ranges. The respondents were predominantly, 264 (86.6%), Orthodox Christianity followers. More than half, 168 (55.1%), of the respondents were not attended formal education. In fact, nearly onein- three attended the first primary education cycle (1-4 graders). The Oromo ethnic group contributed to 262 (85.9%) of the respondents. With regard to marital status, 283 (92.8%) of them were married. More than two-fifth, 133 (43.6%) of respondents had more than four live births. In fact, slightly lower number, 125 (41%) of children were alive at the time of the study. It seems slight variations were present between mothers from model and non-models based on religion and number of children they had (those who have 4-6 children tend to be models) (p<0.05).

Table 1: Background characteristics of respondents, Sebeta Hawas district, OSZSF, December 2015 (N=305).

Mothers’ knowledge about HEP and MCH services and model status

This study assessed distribution of knowledge or awareness related HEP, HEWs and MCH services among respondents aimed to see variations in proportion based on model status. Table 2 conveys the details. About four in five mothers claimed to be oriented about the activities of the HEWs as community HEP workers. 137/245 (55.9%) of them were model families (p<0.001). 237 out 245 (96.7%) mothers who claimed knowing the roles of HEWs, could mention <6 activities in connection with HEWs’ role from the following lists: nutrition, family planning, antenatal care, immunization, institutional delivery, breast feeding, latrine use, housing condition (how to keep house clean), personal hygiene, environmental sanitation, HIV/AIDs, Tuberculosis and Malaria). Though 296 (97%) of mothers mentioned at least one FP methods, only 221 (72.5%) confidently declared they about FP. 122/221 (55.2%) were from model families (p=0.12). Overwhelmingly, 300 (98.4%) were claimed to be aware of ANC services. In fact, 139/300 (46.3%) mentioned ANC package involves other services like immunization for healthy pregnancy not just checkup. 76/139 (54.7%) were model families (pv <0.05). Predominantly, 286 (94.4%) mothers perceived skilled birth attendances as beneficial.11/17 (64.7%) who perceived institutional delivery as not beneficial were from nonmodel families (pv=0.3). Minority, 36/222 (16.7%), of the respondents who ever visited health post for ANC reported they were informed about pregnancy-delivery complications. However, greater proportion (28=77.8%) of those informed were MFs (pv<0.001). The FGDs also showed that mothers from both groups had no objection about the benefit of delivering at HF but conceived invulnerability to complication; they perceived it as rare occasion. For example, one woman from NMFs who delivered her five children at home said, “it is good to deliver at HF. No objection for that. Women could be best supported at HF if complication is present. But, I delivered all my children at home without encountering any problem. Saint Merry made easy my labor easy”. Another woman from MFs said, “…...I have attended ANC services both with HEWs at health post and nurses at health center. Though, they told me to deliver at health institution, I delivered my baby at home with support of traditional birth attendant without complication, difficulty and soon”. And, 303 (99.3%) respondents were aware of child immunization services in HEP. On the contrary, mothers who did not know about the need to visit HF(starting from day 1 through 6 weeks) after delivery takes on the major share, 276(90.8%).21/28 (75%) of mothers who were aware of PNC were from model families (pv <0.002). Pertaining to source of information about MCH services, majority of the respondents, 186 (62.0%) heard from the HEWs. But, greater proportion of those mothers who claimed hearing from other health professionals and media were significantly from NMFs (Pv<0.001). Overall, report of knowing activities of HEWs as community worker for HEP, knowledge of ANC packages, awareness about PNC and source of information showed significant variation in proportions between mothers from MFs and NMFs (pv <0.005).

Table 2: Awareness and Knowledge about HEP and MCH services, Sebeta Hawas district, OSZSF, December 2015 (N=305).

Mothers’ MCH service utilization and model status

Table 3 displayed distribution of mothers’ use of FP, ANC, DC, PNC and Immunization among model and non-model families. 201 (65.9%) of the respondents were using FP. 114/201 (56.7%) and 87 (43.3%) were MFs and NMFs respectively (pv<0.001). Majority of, 164/201 (81.6%), the respondents used injectable contraceptive. Though MFs seems to use pills and IUD (intrauterine device) more than NMFs, percentage variation was not significant (pv=0.83). 222 (73%) of the respondents used ANC during their last pregnancy, 120/222 (54.1%) and 102 (45.9%) of them were MFs and NMFs respectively (pv<0.001). 82/222 (36.9%) of the ANC users visited HF at least four times, of whom 56 (68.3%) and 26 (31.7%) MFs and NMFs respectively (pv<0.001). Overwhelmingly, 233 (76%), the respondents were delivered their last deliveries they made within the past five years. 37/72 (51.4%) and 35 (48.6%) of the deliveries made at HF were MFs and NMFs respectively. (pv=0.29). Seventy (23%) of the respondents were used PNC services at HF, of them 38 (54.3%) and 35 (45.7%) were MFs and NMFs respectively (pv=0.14). And, 287 (94.1%) used child vaccination service. 13/18 (72.2%) of mothers who did not immunize their children were from NMFs compared to 5/13 (27.8%) MFs (pv=0.06).

Table 3: Maternal and child health services utilization, Sebeta Hawas, OSZSF, Ethiopia, December 2015 (No=305).

Predictors of mothers’ model status: were the models really exhibited differences?

Table 1-3 described variations in percentages over some of the socio-demographic characteristics, knowledge/awareness related to HEP&MCH services, and utilization of MCH behaviors (pv <0.05). Religion, having 4-6 and 7-9 alive children, being oriented about the activities of HEWs, awareness for ANC packages, getting informed about delivery complication, awareness for PNC visit within 6 weeks after delivery, source of MCH information, FP utilization, ANC ever visit and ANC visit frequency were variables that initially produced variation in proportions between the MFs and NMFs. Utilization of delivery care, PNC and child immunization services, perceived benefit of institutional delivery, awareness about child immunization, age, and educational level were not demarcated between NMFs and MFs (Table 2). Accordingly, these variables were pulled into further adjustment analysis to identify the variables that strongly demarcated between NMFs and MFs. Table 4 displayed predictors for being MCH model. After adjustment; MFs were found to be different from NMFs based on number of alive children they had, orientation with HEW activities, utilization of FP, frequency of ANC visits, knowledge of ANC packages, awareness of PNC service, perceived informed level of pregnancy/ delivery complication and media as source of MCH information. Details were put as follows:

Table 4: Predictors of being model for MCH behaviors, Sebeta Hawas district, OSZSF, December 2015 (N=305).

In this study, the only socio-demographic characteristics that predicted mothers’ model status were number of live children. NMFs were averagely 11% less likely [(AOR (95% CI):0.89 (0.45-0.94)] to have higher [4-6] children compared MFs i.e., mothers whose number of live children ranges from 4-6 had more chance of being MFs than NMFs compared to mothers who have fewer or higher number of live children. The study found out that there were variations between NMF and MFs concerning knowledge/ awareness about HEP and MCH services. For example, mothers who were from NMFs were averagely about five folds more likely [(AOR (95% CI): 4.83(1.99-11.69)] to report they were not well oriented about the activities/roles of HEWs as HEP implementers compared to mothers from MFs. However, the MFs and NMFs did not mention statistically significant different number of lists of HEWs’ activities (Table 2). NMFs were averagely about 1.5 times more likely [(AOR (95% CI):1.56 (1.19-2.86)] to report media as their source of MCH information compared to MFs though generally major source of information for respondents was HEWs. Additionally, NMFs were averagely 74% less likely [(AOR (95% CI): 0.26 (0.10-0.67)] to be informed by the HEWs about pregnancy/delivery complications compared to MFs. When, knowledge of ANC was checked, NMFs were averagely 18% less likely [(AOR (95% CI): 0.82(0.68, 0.93)] to know that ANC has extra packages (like immunization for safer motherhood and fetal health) apart from checkup of pregnancy status compared to MFs. Regarding awareness of PNC, NMFs were averagely nearly three folds more likely [(AOR (95% CI): 2.75(1.41, 6.75)] to report not aware of the need to visit for PNC within 6 weeks after delivery compared to mothers from MFs. Therefore, the above facts summarizes that NMFs seemingly had lesser attachment with HEWs, their activities and communication they were making than do the NMFs (Table 4). In fact, it was unknown whether model status facilitated the attachment or vice versa.

NMFs and MFs had also shown differences in MCH service utilization. To begin with family planning; NMFs were averagely four folds more likely [(AOR (95% CI): 3.89 (1.98, 7.63)] not to use FP service at the time of the study. Mothers from NMFs, at their earlier stage of continuum of MCH behaviors, i.e., early in pregnancy, were averagely two times more likely [(AOR (95% CI): 2.22 (1.24-4.67)] to claim missing any visit for ANC compared to MFs. Furthermore, the NMFs were averagely 67% less likely [(AOR (95% CI): 0.33(0.17, 0.64)] to report making at least four ANC visits compared mothers from MFs (Table 4). In congruent to quantitative findings, the FGDs showed mothers from both groups were not using delivery, PNC and immunization services i.e. they were similar on those MCH outcome behaviors. In fact, the IDIs and FGDs expressed variation points between MFs and NMFs on each of later stages MCH behaviors: DC, PNC and immunization service utilization. Accordingly, we discuss each behavior as follows (Table 5).

Table 5: Matrix of qualitative findings, from across the FGDs and IDI, Sebeta Hawas, OSZSF, Ethiopia, December, 2015 (N= 38 individuals across 4 FGDs and 4 IDIs).

Delivery service utilization

Across the FGDs women were found to be none- user of delivery service for some reasons. One is they had no intention/plan to go for HF as they 1) perceived the TBAs were enough, 2) health workers lack respectful/caring support during past deliveries at HF and 3) perceived no need to deliver at HF unless complication was present. The second reason was they perceived no vulnerability i.e., rare chance of experiencing delivery complication. The third reason was inaccessibility of the service for those who intended to get it. However, the FGDs were also clearly conveyed the points of departure between the two groups. The first two features more or less characterized the NMFs and the third aspect mostly characterized the MFs. The nonmodel mothers were not yet perceived the relevance of delivering at HF. The model mothers lacked enabling environments (inaccessibility) to realize their intention. Therefore, the MFs and NMFs were slightly different on mechanisms through which they ended up not delivered at HF.

Less perceived relevance of HF for delivery (more common mentioned by NMFs) was facilitated by two main reasons. First, perceived adequacy of TBAs to manage deliveries: the TBAs were perceived as wise women, blessed handed, healer with just a touch, pain killer, child position and status assurer, long-lived experts with accumulated generational credentials, and more importantly still relied on especially by the non-model families. In fact, the model families were more likely to manifest a sort of modesty against the skills of TBAs, and tend to deny their use anymore. The second was perceived invulnerability to delivery complications: the use of HF seemed to happen only when delivery process gets complicated i.e., no anticipated complication- no institutional delivery. Closely linked with this idea and more importantly, most discussants perceived minimal chances of experiencing delivery complications (especially among NMFs). This idea was emanated from two relevant sources: past safe delivery experiences of their own (giving births without complications) and generational experiences (of getting safe assistance from local expertsthe TBAs and storyline that their grandpas were giving births so safely). In fact, HF was believed to be more effective to manage complication than TBAs, even by the non-model families, if that happened at all. Accordingly, seemingly one of the good opportunities to deal with women for improved MCH behaviors was the non-objection of HF as a potential place for skilled birth attendances, because of perceived skill to manage complications by health workers.

On the other hand, the MFs were more critically challenged with past experience of disrespect by health workers during the past deliveries at HF, and inaccessibility. Perceived lack of concern and respect from health workers was adversely influencing MCH services. Experiences women faced during their or their relatives’ past deliveries at HF affected their preference of places for successive deliveries. Health workers who were not caring, respectful and responsive pushed even the MFs away from delivering at HF. Women reported they needed support, caring and encouraging words and actions at the moment of their delivery, not disgrace. The experiences of disgust at HF led the women to foster their reliance on TBAs-who were perceived to be caring, encouraging and respectful. And, on top of this, inaccessibility claims for institutional delivery had a sort of hierarchical aspects that affected use of MCH services: lack of readiness for delivery, urgent nature of labor, no road departure to wait for vehicle (beyond the control), no transportation and no finance.

The PNC and child immunization service utilization

3Both shared similar elements to display variations between the two groups, as they both happen after delivery. Across the FGDs with both groups: low level of awareness about PNC/immunization, postpartum social norms and closed health post occasions interacted with the services utilization. With regarding to awareness for the services; discussants from both groups confused immunization with PNC i.e., they perceived PNC visit was meant for child vaccination. And, PNC use was reported to happen after 45 days. In fact, this was commonly stated among women from NMFs. The post-delivery traditional practices were high likely to link with consecutive MCH services utilization: PNC and child immunization. Though both groups shared the practices and beliefs, the MFs claimed closed health occasions as reasons for not getting MCH services after delivery. Women approached believed to be powerful persons available in their locality, referred to as ‘hammachiisaa’-literary means the one who takes newborns up in arms, who were supposed to bless their newborns. They also were supposed to stay at home for forty days after delivery-this was to prevent ‘michii’- literary means allergy. The worst point was women might not have visited HF when they faced signs that sought medical consultation, like post-partum hemorrhage. Mostly, MFs claim that absence of the HEWs from their station: closure of HPs was a challenge to uptake of MCH services and products like child vaccines (including family planning), even after repeated visits.

One of the approaches of HEP was training of model families who were expected to help diffuse health messages leading to the adoption of the desired practices and behaviors by the community, mothers of reproductive age groups. The production of the model families starts with training and through close support and follow-up it achieves the goal of modeling MCH behaviors: FP, ANC, DC, PNC and child immunization. This study produced evidences about model and non-model families targeting to MCH utilization behaviors and that can inform achievement of the HEP strategies. In order to easily demonstrate variations between the two groups, we categorized FP/ ANC use as early stage utilization behaviors and the DC/PNC/Child immunization as later stage utilization behaviors on the continuum of MCH service utilization behaviors. This category was intended because this study found out that models had exhibited explicitly differently on behaviors that happen before or early in pregnancy and they didn’t on behaviors that were late in pregnancy or post. Major findings were discussed with closely related evidences, guidelines and behavior change theories to search for implications.

Accordingly, we first introduced major findings as follows. This study generally observed differences between MFs and NMFs against respondents’ background, knowledge or awareness of HEP/HEWs’ role/ MCH services and MCH utilization practices. The observed variations between MFs and NMFs were captured through both quantitative and qualitative findings. In fact, there were similarities between the two groups against some MCH relevant knowledge and practices. Number of live children the mothers had was the only background characteristics that demarcated the groups. The major demarcation between the two groups in terms of MCH practices was family planning and antenatal care utilization. Though qualitative aspects of the study observed variations in commitments to engage on the later MCH behaviors, practically no statistically significant differences were observed on DC, PNC and immunization between the groups. The study found out that the model families were more informed about role of HEW as HEP worker, ANC, pregnancy-delivery complications and PNC compared to non-models. The HEWs were significantly mentioned to be source of MCH information for model mothers compared to other sources; other health professionals and media which in turn were commonly mentioned by the non-models.

Variations with the level of awareness/ information about HEP/ HEW and MCH services between model and non-model groups could be attributed to particular training the models received about the HEP packages and strategies. The HEP working guide advises training to be given to model families [6]. As the qualitative findings also showed the model families had supposed to be trained for 3 months before they were graduated as models (refer to table 5). One relevant question, for this particular area of study, was about the characteristics of cohort of mothers who were models compared to non-model ones, and how they were selected to involve as trainees for being models? According to this study, no other socio-demographic characteristics significantly split up the mothers into model and non-model groups except the number of live children they had. Those mothers who had 4-6 live children were more of models compared to mothers that had <4 or >6 children. Perhaps, it seemed models were first selected for training based on their family size on one hand. And, on the other hand, the selection of women for initial investment as models so that they reach other mothers was not purposive. According to diffusion of innovation (DOI) theory (one of the most effective behavior change theories), new behaviors (in this case, MCH utilization) best diffuse quickly when program implementers work through purposively selected individuals, groups or other unit of adoption who potentially acts as advocates. In fact, these advocates are supposed to be well equipped, knowledgeable and adopt the behaviors themselves first before they reached others. Then, after significant proportion of these early adopters (advocates) were targeted by the program objectives, the behaviors will soon diffuse on its own through locally existing communication forms including interpersonal discussions [32]. Though variations in the level of knowledge most probably linked to the training the model families, both groups were not different in knowledge of family planning and child immunization awareness. This could be because of high magnitude of ever hearing about those services that could hide differences: only 9 (3%) of mothers were unable to mention any FP method and 2 (0.66%) of them mentioned never aware of child immunization.

In this study, though mothers from model families and nonmodel families had shown differences on early stage MCH utilization behaviors, they did not on later MCH utilization behaviors. This means utilization of FP and ANC services were significantly better attached to mothers from model family than non-model ones while utilization of DC, PNC and child vaccination were not significantly explicitly attached to being model. The variations on early stage MCH utilization behaviors between the two groups were perhaps because of two things: the trainings the model families received and the utilization of these services did not require too much resource: time, money, and access to the service outlet points-health posts unlike services in late pregnancy period-delivery or post. Mothers from model families converted their knowledge into commitments and actual utilizations of FP and ANC services compared to the non-models. Therefore, they can help diffuse the utilization of those services. Similarities of both groups on later stage MCH utilization behaviors could be because these services required too much resource to access the services: time, money, vehicles infrastructures needed for delivery services including facility and roads. In fact, similarities on PNC and immunization services may be attributed to competing traditional practices like forbidden going out after giving births and closure of health posts as of workload, unplanned tasks and meetings the HEWs attended. Many studies conducted on MCH services utilization behaviors (FP, ANC, DC, immunization services utilization) documented that knowledge, commitments/ intention; traditional beliefs and accessibility of services determine use of MCH services [17-24]. Another study identified limited number of HEWs, often closed health posts were critical challenges to MCH service utilization [25]. Basically FP and ANC can be utilized at health post level i.e., at ganda closer to where the mothers live while skilled institutional delivery services were rendered at health center level i.e., located at more distant settings away from where rural mothers live. The HSDP I-IV and HEP guidelines clearly specified that health posts and HEWs were not well equipped and skilled for rendering skilled birth attendance services. Mothers were expected to travel to health centers where the skilled/institutional delivery services were rendered [3-6]. Qualitative findings clearly put hierarchical inaccessibility aspects that hidden possible demarcations between the two groups though model families seemed be better committed to use the services. Plus to that there were challenging multi-level contexts through which MCH service were delivered and within which frame the model families were expected to carry out their modelling tasks (Table 5). Therefore, health system contexts handicapped mothers from modeling especially the later stage MCH utilization behaviors. Model families were challenged with contexts beyond their control.

The findings carried relevant messages for HEP designers and implementers that deemed further discussion over its implications for improvement of MCH practices among mothers. The study portrayed that women from model families were having practices that can be observed and adopted by other women around at times before or early in pregnancy. They can be used for enhancing FP and ANC utilization. According to DOI theory, Social cognitive theory (SCT) and other behavioral theories, models (in this case, model families) were intended to exhibit healthier roles, practices, experiences that we needed others to give attention to, observe, adopt and later become advocate themselves. In this case, we purposely were supposed to invest resources over these models in a way we like others will most probably follow either because the target behavior has overtly conveyed benefits to the target audiences or become a new social norms to comply with [32]. Nonetheless, system challenges were significantly responsible for similarities between the two groups though variations were expected. The above theories (DOI and SCT) clearly specified complexity of the systems and incompatibility of service delivery outlets and mechanisms can pose critical hindrances to adoption of service (MCH) utilization and its further diffusion among members of target population in a given community [32,33]. Finally, this study was not without limitations. Firstly, findings in this study were not thoroughly compared with other studies because of limited access to similar literatures. Up to our knowledge there were deficit of comparative studies that focused on variations in health service use based on model status and similar contexts. Therefore, we used general evidences that did not compare both groups. Secondly, the scope of this study was limited to look at MCH service utilization demarcation between model and non-model families. It was not aimed to determine factors that influenced specific MCH behaviors separately for both groups. Thirdly, this study was limited to one district of OSZSF, though it included many villages. Regarding potential source of bias, this study could have been exposed to – that may hide variations through misclassification as any mother needs to be positively evaluated against MCH services utilization.

Modeling MCH behaviors within the context of HEP delivery for rural community was in its infantile stage. Mothers from model families had practices that can be observed by other women in their surroundings. Family planning and repeated antenatal care utilization were some of the areas where HEP can be effective in using them as advocates to prevent or care for pregnancy in its early stage. Nonetheless, model mothers did not exhibit practices that can set examples for others to observe regarding utilization of MCH services in late pregnancy- to the point of institutional delivery including post-natal care and child immunization. Model mothers did not keep on acting their model role across all relevant stages on the continuum of maternity: before, early and late in pregnancy. There were contexts beyond the control of the mothers leaving hindrances for exhibiting model practices for late stage MCH behaviors. MCH service delivery system had bottleneck features that disabled conversion of commitments and intentions model mothers had in order to use delivery, PNC and immunization services. Hierarchical inaccessibility aspects: services outlets, distance, transport and finance were critical challenges for modelling specifically delivery service utilization. Closure of health posts at work time because of factors related health system and health extension workers were challenges especially for post-natal care and child immunization utilizations. Thereof, we claim the findings of this study as urgent given that MCH behaviors, particularly skilled birth attendances, has been identified by different stakeholders as relevant strategy to reduce maternal and child mortality rates. Therefore, this study calls for earnest work to improve late stage maternity service utilization behaviors in general and facilitating modelling strategies that can enhance the services utilization in particular. Furthermore, the HEP designers and implementers should work on aiming to produce model mothers distinctly for delivery care, postnatal care and child immunization services and provide them reinforcing names.

Jimma University financially supported this study. Jimma University funds researches for academic purposes

1. John JH, Richard T (2013) Health for all beyond 2000: the demise of the Alma-Ata Declaration and primary health care in developing countries. Med J Aust 178: 17-20.
2. Ministry of Health (2006) Comprehensive Health Service Directory. Addis Ababa.
3. Ministry of Health (2005) Primary Health Care Review. Addis Ababa.
4. Federal Ministry of Health (2010) Ethiopian Health Sector Development Program IV 2010/11- 2014/15.
5. Health Extension and Education Center (2007) Federal Ministry of Health Addis Ababa, Ethiopia.
6. Federal Ministry of Health (2007) Health extension program in Ethiopia. Addis Ababa: Health Education Center.
7. World Health Organization (2005) World Health Report: Make Every Mother and Child Count. World Health Organization, Geneva.
8. World Health Organization (2008) Improved access to maternal health services. World Health Organization, Geneva.
9. World Bank (1994) Better health in Africa: Experience and lessons learned. World Bank Washington, DC.
10. World Health Organization (2010) Countdown to 2015 decade report (2000-10): taking stock of maternal, newborn and child survival.
11. The United Nations Children's Fund (UNICEF) (2012) Ethiopia Statistics. Basic Indicators 2012.
12. The Millennium Development Goals Report (2012) United Nations, New York.
13. Ethiopia Demographic and Health Survey (2005) Central Statistical Agency Addis Ababa, Ethiopia. ORC Macro Calverton, Maryland, USA September 2006.
14. Ethiopia Demographic and Health Survey (2011) Central Statistical Agency Addis Ababa, Ethiopia ICF International Calverton, Maryland, USA March 2012.
15. Ahmed A (2010) Maternal Mortality Trend in Ethiopia. Ethiop J Health Dev 24: 117-120.
16. Yalem TA, Tesfay GG, Isabel G, Kerstin EE, Hailemariam L, et al (2013) Determinants of Antenatal Care, Institutional Delivery and Skilled Birth Attendant Utilization in Samre Saharti District, Tigray, Ethiopia. Int J Equity Health 12: 30.
17. Bayou NB., Gacho YH (2013) Utilization of clean and safe delivery service package of health services extension program and associated factors in rural Kebeles of Kafa zone, southwest Ethiopia. Ethiop J Health Sci. 23: 79-89.
18. Zelalem B, Gashaw A, Tadesse A, Gizachew A, Digsu N (2013) Determinants of skilled attendance for delivery in Northwest Ethiopia: a community based nested case control study. BMC Public Health 13: 130.
19. Villadsen SF, Tersbøl BP, Negussie D, GebreMariam A, Tilahun A, et al (2014) Antenatal Care Strengthening in Jimma, Ethiopia: A Mixed Method Need Assessment. J Environ Public Health.
20. Yared M, Asnaketch M (2002) Utilization of Maternal Health Care Services in Ethiopia. Ethiopian Health and Nutrition Research Institute Addis Ababa, Ethiopia ORC Macro Calverton, Maryland, USA. November 2002.
21. Gurmesa T (2009) Antenatal care service utilization and associated factors in Metekel zone, Northwest Ethiopia Benishangul Gumuz Region, North West Ethiopia. Ethiop J Health Sci 9: 2.
22. Alemayehu ST, Fekadu MA, Solomon MW (2010) Institutional delivery service utilization and associated factors among mothers who gave birth in the last 12 months in Sekela District, North West of Ethiopia: A community - based cross sectional study. BMC Pregnancy and Childbirth 12: 74.
23. Addisalem F, Meaza D (2012) Prevalence of institutional delivery and associated factors in Dodota Woreda (district), Oromia regional state, Ethiopia. BMC Reproductive Health 9: 33.
24. Zewdie B, Ameyu G, Yohannes K, Mulusew G (2013) Mothers' experiences and satisfactions with health extension program in Jimma zone, Ethiopia: a cross sectional study. BMC Health Serv Res 13: 74.
25. Integrated Community-based Maternal (2011) Newborn and child health and Nutrition Intervention program in Senegal.
26. Rose NM, Japhet ZK, Melkzedeck T, Leshabari MT, Siriel NM, et al (2007) Use pattern of maternal health services and determinants of skilled care during delivery in Southern Tanzania: implications for achievement of MDG-5 targets. BMC Pregnancy Childbirth 7: 29.
27. Leslie J, Gupta GR (2008) Utilization of formal services for maternal nutrition and health care. Washington, DC. International Center for Research on Women.
28. Addai I (2000) Determinants of use of maternal-child health services in rural Ghana. J Biosoc Sci 32: 1-15.
29. Isaac A (1998) Demographic and sociocultural factors influencing use of maternal health services in Ghana. Afr J Reprod Health 2: 73-80.
30. Adetunji JA (1991) Response of parents to five killer diseases among children in a Yoruba community, Nigeria. Soc Sci Med 32: 1379-1387.
31. Rogers EM (2003) Diffusion of Innovations. (5th ed.) New York: Free Press.
32. 2007 Population and Housing Census of Ethiopia (2012) Results for Oromia Region Vol 1.
33. Karen G, Barbara K, Rimer K (2005) Health Behavior and Health Education: Theory, Research and Practice. 4th edition.