Since 2003 the Government of Ethiopia has been implementing the Health Extension Program (HEP) which is an innovative approach initiated to meet the Millennium Development Goals (MDGs) [1]. HEP is designed to provide basic health care to an approximately 5000 people through a health post (HP). Every HP is staffed by two female health extension workers (HEWs) trained for one year and paid directly by the government [2, 3].

The HEP has 16 packages of preventive and curative health services that include 3 packages under disease prevention and control (HIV/AIDS and tuberculosis; malaria prevention and control; and first aid emergency measures); 5 packages under family health (maternal and child health, family planning, immunization, nutrition, and adolescent reproductive health); 7 packages under hygiene and 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 and rodents, and personal hygiene); and 1 package of health education and communication [2, 3].

Health service utilization is a result of multiple factors, such as health workers’ conduct, characteristics of the community (family characteristics, social structure, assets/affordability, and perceptions about modern health services). It is also influenced by enabling factors, such as the availability of health facilities, the accessibility to health services, the quality of services, and costs as well as the characteristics of disorder (intensity of illness and number of spells) [4–11]. According to Andersen, factors associated with the utilization of health services can be grouped into predisposing, enabling, and needs factors [12]. In addition, health service characteristics, such as type (hospital, physician, drugs and, medications, or other services); purpose (primary, secondary, or tertiary care), and unit of analysis (contact, volume or episode); health services provision, such as intensity (amount ) and duration (short or long); and frequency of house visits by health workers can have their own effect on health service utilization [13, 14].

Health service utilization studies in Ethiopia indicate that factors, such as awareness and perception, literacy, family size, educational status, perceived illness, family income, media exposure, perception of distance to health facilities, perceived transport, and treatment costs are some of the predictor factors [15–19]. The HEP is designed to increase the coverage of primary health care services in Ethiopia, mainly by producing model households using model-family training. The model family training comprises a total of 96 hours of training on basic hygiene and environmental sanitation (30 hours), family health care (42 hours), and disease prevention and control (24 hours). Households which attend at least 75% of the training and implement at least 75% of the HEP packages receive certificates of completion at a graduation ceremony and graduate as model households (families). The program also addresses health service utilization through the establishment of HP to serve 5000 people, and the deployment of two HEWs who conduct home visits in the community and give basic health services in each HP [2].

During the HEP implementation period, particularly from 2007 to 2011, the basic health services indicators such as, contraceptive acceptance (34.8 to 61.7%), antenatal care (52.1to 82.2%), and full immunization (56.4 to 74.5%) have indicated marked improvements. In 2011, in Amhara Region, the rates were 88.6% for contraceptive acceptance, 86.2% for antenatal care, and 82.5% for full immunization [20]. Though there are promising results of the HEP, conducting more studies on assessing the process and the effect has a paramount importance for its successful implementation. Therefore, this study was conducted with the aim of assessing the utilization of the HEP by the community and factors that might be associated with it.

A total of 1318 women participated in the study with a response rate of 99.85%, and 1034 (78.5%, 95% CI = 76.2 to 80.7%) study participants visited HPs during the year.

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 [22]. 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 [23]. 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 [27]. 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 [30].

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 [4].

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].

The study indicated that utilization of the HEP had a significant positive association with HEP implementation related factors, such as number of years after graduation, frequency of household visits by HEWs, and understanding the HEP. The utilization of the HEP also had a significant positive association with family income. Thus, conducting continuous home visits of non-model households and following up the existing model households, producing more model households by giving model-family training to non-model households, and strengthening the information, education, and communication package are crucial in the implementation of the HEP to increase basic health service utilization.

Unlike the conventional CHWs who train for a few months and get either incentives or per diem for their work, the HEWs get one year training and are full-time employees receiving regular monthly salary from the government to implement the HEP packages. This could trigger a sense of ownership and motivate the HEWs to implement the HEP. Other countries of similar context with Ethiopia may apply the HEP-like health programs that reach the community at the grass-roots level. The association of HEP related factors was evident in this study, but the fact that other factors, such as the availability of voluntary community health workers, agricultural development agents, and health promotion through the mass media could also affect service utilization and should be taken into consideration. Therefore, further studies which use more robust study designs and data analysis methods focusing on specific health services such as ANC and skilled delivery services are required for better understanding of HEP contribution to health services utilization.

MY is a lecturer of Health Service Management and Health Economics at the Institute of Public Health, the University of Gondar. He is also a PhD student at the University of Gondar and Addis Continental Institute of Public Health Joint PhD Program doing his dissertation on the implementation of the HEP in West Gojjam Zone, Amhara National Regional State, Ethiopia. YB is a Professor in Epidemiology and Public Health at the Addis Continental Institute of Public Health, Addis Ababa, Ethiopia. AW is Associate Professor of Biostatistics at Addis Ababa University, Addis Ababa, Ethiopia. YK is a Professor in Public Health at the University of Gondar and Director of Dabat Rural Health Research Center at the University, Gondar, Ethiopia.