The study showed that the number of years since a household graduated, frequency of HEWs household visits, understanding the components of HEP packages, and having higher family income were predictors of HP visits by the Community. However, mothers’ occupational status, hearing about HEP packages, perception of the community about the quality of services provided in the HP and the conduct of HEWs were not predictors of HP visits.
The frequency of HEWs household visits and the number of years after household graduation had a significant positive association with HP visits by the community. The findings regarding the effect of number of visits on the outcomes of home visit programs, such as the utilization of health services were mixed . A meta-analysis of home visiting programs for at-risk families to examine differences in the effects of programs on maternal behaviour, noted that the effectiveness of home visit programs was principally dependent upon the frequency of services, stating that programs with more frequent contact between home visitors and their clients were most successful . The same study suggested that the duration might be less important than the frequency of services, noting that short-term intensive interventions could be highly effective. In contrast to these findings, some systematic reviews of home visiting programs found no pattern of difference in the average intensity and duration of the program related to the outcomes measured [24, 25].
Understanding the components of the HEP had a significant positive association with the utilization of the HEP. This was consistent with studies done in Taiwan and Uganda that identified individual and community knowledge and acceptance of health services or health literacy had a significant positive association with health service utilization [18, 26]. Immunization, excreta disposal, family planning, solid and liquid waste disposal were packages most recalled by the participants, while first aid, insect and rodent control, adolescent reproductive health and nutrition were packages least recalled. This may be due to the focus of the HEWs on packages such as immunization and family planning which are now becoming more accepted by the community, and packages such as excreta disposal, and solid and liquid waste disposal which are considered as good signs of the HEP implementation by the community.
In this study, higher family income (Birr 961 and above) had a positive association with the HP visits by the community, which was consistent with the health service utilization studies in Uganda and Bangladesh that reported income as one of the important factors in overcoming barriers to utilization of health services [8, 11, 14, 21].
The study indicated that mothers’ occupation had no significant association with HP visits. This was consistent with a study on correlates of and barriers to the utilization of health services for delivery in South Asia and sub-Saharan Africa which reported the odds of using a health facility for delivery were about the same for both working and non-working women in Tanzania, Bangladesh, India and Pakistan . However, studies conducted in Nepal indicated that nonworking women were more likely to receive maternal health services than working women and reasoned out that most women in Nepal were working for family survival in the agriculture sector [28, 29]. Another study in Iran also revealed that housewives were more likely to seek outpatient care than other job holders .
The perception of the community about the conduct of HEWs, and the quality of services provided in the HP had no significant association with the HP visits. Although there was good perception about the quality of the services provided in the HPs by the majority of the study participants, lack of drugs and supplies, inability of the HEWs to diagnose, and poor services were the reasons mentioned by the other participants for having bad perception about the quality of services in the HPs. A study in India on the quality of healthcare services indicated that quality issues, such as healthcare delivery, health personnel conduct, and drug availability significantly impacted on the perception of women influencing the utilization of health services .
We also assessed the reasons for visiting HPs or consulting HEWs. Accordingly, family planning, immunization, child illness, and family illness were the most mentioned reasons while ANC, delivery, and PNC services were the least mentioned for visiting HPs and consulting HEWs. This might be due to the community perception that services like immunization and family planning could be provided at the HP level by HEWs and services like ANC, delivery, and PNC were better provided at health centers and hospitals by nurses or doctors. But this needs further investigation. In case of illness, most of the participants visited the HPs soon after the illness started, but still there were participants who visited the HP only if there was no improvement of the illness. This was consistent with previous studies that indicated that perceived morbidity and the presence of disabling health problem were predictors of health service utilization [16, 18].
Though the study was based on a large sample with a high response rate due to our effort to include 30 households from each kebele, it had the following limitations. Firstly, this cross sectional study provided only a snapshot (one point in time) of utilization of the HP visits by the community, and we could not ascertain a causal relationship but rather tendencies and associations. Secondly, recall bias was expected in this study since the study participants might not remember all the HEP services and associated factors. Lastly, there was lack of baseline information in the study area about basic health services before the implementation of the HEP, and we could not compare the results of this study with base line data.