The study revealed that only one-fourth of the households were graduated as model family for being adopters of services given by HEWs. This leaves a huge gap since all households were expected to be trained and graduated during the first three years of the program implementation. Previous studies also documented that the overall trend in the graduation of model families is far behind the expectation [3, 5, 6, 10, 20]. Literatures documented several reasons regarding low progress in graduating model families such as being overloaded with activities (HEWs), less involvement of community volunteers in the program, lack of incentives for community volunteers, less acceptance of and closed attitudes on the part of the community, uncomfortable working condition and living environment for HEWs, lack of commitment from HEWs, limited comprehensive and supportive supervision, shortage of supplies, poor transportation and communication facilities, lack of access to reference materials and other resources [9–15, 20]. However, nearly three-fourth of the respondents received information on some health extension packages during one year before the survey. This finding is found to be better compared to earlier reports [13, 16]. Better exposures to information observed for hygiene and environmental sanitation packages. However, consistent with some earlier reports [12, 16], community exposure to family health and communicable diseases control package was lower. This might be due to the higher attention laid on the outreach services as program expectations.
HEWs are required to spend 75% of their time conducting outreach activities by going from house-to- house while the remaining 25% at the HP  leaving less time for static services. The current finding is consistent with the expectations of the program as more than half of the respondents stated that HEWs were infrequently available at HPs. However, the scenario of 25–75% was a contentious agenda among the FGD participants. It is strongly criticized as it gave less attention to routine daily health services being rendered at HP. This is because, on most of the working days, the HP is closed as both of the HEWs are required to go out for outreach activities. Earlier study also reported similar findings . It was one of the unpleasant experiences mothers had as they could not access to HEWs when they need them, especially for time- sensitive cases such as family planning, illness, immunization and emergency conditions. Consequently, for a large number of respondents, it was not uncommon to return home without getting the service they wanted because of the closure of HPs. Another reflection of this reality was the fact that nearly three-fourth of the respondents preferred private clinics to HPs for family planning service. On the other hand, inconsistent with the expectation, most respondents did not agree with the claim that HEWs were spending most of their time on conducting outreach activities. The qualitative finding also revealed similar experiences: most discussants argued that they were not sure where HEWs spent most of their time. Thus, it is believed that the 25–75% scenario might facilitate absenteeism as it is easier to attribute reasons of absence from work either to static or outreach services. On the top of that, some literature reported that in most cases, HEWs live in uncomfortable environment  which may also contribute for absenteeism from work.
The involvement of female HEWs alone in HEP received higher attention, especially among FGD participants. The majority of the participants did not support that HEP shall be run only by female workers. It is believed that active involvement of both females and males is a necessary condition for HEP success. The involvement of female HEWs in the program was preferred on the grounds of degree of closeness, easier disclosure of personal problems and cultural norms. This might reflect the fact that most mothers tend to have better relationship with HEWs. However, the extent of reported relationship was lower compared to an earlier report  though higher proportions of respondents knew HEWs by their names as found out in this study.
On the other hand, males’ involvement in HEP was recommended for various reasons such as being more professional/expert and competent, ascribed status in the community and capacity to withstand challenging work conditions. Such preferences might be associated with gender roles and deep rooted cultural beliefs that portray men as more competent, active and brilliant than women. In fact, such beliefs would have a negative impact on the acceptance of HEWs as it was revealed in qualitative part of the study. Similar finding was reported in one previous study .
Though, curative health service is not part of HEP packages , the current study revealed higher unmeet demands for curative health services. Consistent with some earlier reports [10–12, 21], HEP was highly criticized in that it does not encompass curative health services and HEWs cannot deal with many of the health problems the community encounters. Although HEWs administer anti-malaria drugs, several participants complained that they were not given the drugs. Previous studies have also reported problems of anti-malaria drug supply at HP level [10, 12]. In addition, one study reported that, in some cases, HEWs are not competent enough to use the anti-malaria drugs even when these drugs are available . On the other hand, there might be over expectations regarding treatment of malaria as HEWs are providing only artemether/lumefantrine drug.
HEP was acknowledged though it has some perceived drawbacks. For instance, the existence of home visit was highly appreciated. Earlier studies also documented similar findings [9, 10, 13, 15, 16]. Nevertheless, there were concerns related to programmatic issues such as 25–75% scenario, absence of curative services and lower competency and skill of the HEWs. Limited access to information, resources and reference materials may be associated with the lower competency of HEWs as documented in earlier studies [10–12, 14]. Despite these concerns, the level of satisfaction was moderately high which was also documented in earlier researches [9, 16]. Finally, age, perceived HEWs’ skill to diagnose community problems, perceived respect, involvement of husband in HEP and being model families were significantly predicted respondents’ satisfactions with health extension service provisions. Older mothers tend to be more satisfied with HEP service. This might be due to difference of expectations between young and older women. The involvement of husbands, during home based health education also plays an important role to boost the level of satisfaction. This might be because the husband is a key decision makers in household matters in Ethiopia. Similarly, being a model family was associated with higher satisfaction implying that families tend to appreciate and give recognition to HEP as they fully pass through all packages of HEP. Some earlier studies also reported that respect and politeness, background characteristics of respondents such as education and age, perceived competency, interpersonal communications and information sharing were powerful predictors of satisfactions with health service [22–28]. However, it is difficult to compare the finding of the current study with earlier reports as earlier reports were based on populations who seek medical care and treatments which is totally incomparable with the service being provided at HP and community level. Nevertheless, there are some determinants of satisfaction which are also common in both settings such as interpersonal relationship, respect and perceived competency of providers.
Limitations of the study
It must be noted that the finding of this study represent only community perceptions. We did not study the reflection of HEWs and other stakeholders. In addition, the study did not cover large geographic areas which affect generalization of the finding. HEP is new to Ethiopian health care delivery system which limits the comparisons of the current findings with earlier studies on satisfactions with health services.