title: A qualitative assessment of health extension workers' relationships with the community and health sector in Ethiopia: opportunities for enhancing maternal health performance.
abstract: BACKGROUND
  Health extension workers (HEWs) in Ethiopia have a unique position, connecting communities to the health sector. This intermediary position requires strong interpersonal relationships with actors in both the community and health sector, in order to enhance HEW performance. This study aimed to understand how relationships between HEWs, the community and health sector were shaped, in order to inform policy on optimizing HEW performance in providing maternal health services.
  
  
  METHODS
  We conducted a qualitative study in six districts in the Sidama zone, which included focus group discussions (FGDs) with HEWs, women and men from the community and semi-structured interviews with HEWs; key informants working in programme management, health service delivery and supervision of HEWs; mothers; and traditional birth attendants. Respondents were asked about facilitators and barriers regarding HEWs' relationships with the community and health sector. Interviews and FGDs were recorded, transcribed, translated, coded and thematically analysed.
  
  
  RESULTS
  HEWs were selected by their communities, which enhanced trust and engagement between them. Relationships were facilitated by programme design elements related to support, referral, supervision, training, monitoring and accountability. Trust, communication and dialogue and expectations influenced the strength of relationships. From the community side, the health development army supported HEWs in liaising with community members. From the health sector side, top-down supervision and inadequate training possibilities hampered relationships and demotivated HEWs. Health professionals, administrators, HEWs and communities occasionally met to monitor HEW and programme performance. Expectations from the community and health sector regarding HEWs' tasks sometimes differed, negatively affecting motivation and satisfaction of HEWs.
  
  
  CONCLUSIONS
  HEWs' relationships with the community and health sector can be constrained as a result of inadequate support systems, lack of trust, communication and dialogue and differing expectations. Clearly defined roles at all levels and standardized support, monitoring and accountability, referral, supervision and training, which are executed regularly with clear communication lines, could improve dialogue and trust between HEWs and actors from the community and health sector. This is important to increase HEW performance and maximize the value of HEWs' unique position.
authors.affiliation: Royal Tropical Institute, P.O. Box 95001, 1090 HA, Amsterdam, The Netherlands. Maryse.kok@kit.nl.|VU University Amsterdam, Athena Institute for Research on Innovation and Communication in Health and Life Sciences, De Boelelaan 1081, 1081 HV, Amsterdam, The Netherlands. Maryse.kok@kit.nl.
authors.forename: Maryse C
authors.initials: MC
authors.lastname: Kok
authors.affiliation: REACH Ethiopia, P.O. Box 303, Hawassa, Ethiopia. aschenakizer@yahoo.com.
authors.forename: Aschenaki Z
authors.initials: AZ
authors.lastname: Kea
authors.affiliation: REACH Ethiopia, P.O. Box 303, Hawassa, Ethiopia. danieljohn42@yahoo.com.|Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK. danieljohn42@yahoo.com.
authors.forename: Daniel G
authors.initials: DG
authors.lastname: Datiko
authors.affiliation: VU University Amsterdam, Athena Institute for Research on Innovation and Communication in Health and Life Sciences, De Boelelaan 1081, 1081 HV, Amsterdam, The Netherlands. j.e.w.broerse@vu.nl.
authors.forename: Jacqueline E W
authors.initials: JE
authors.lastname: Broerse
authors.affiliation: Royal Tropical Institute, P.O. Box 95001, 1090 HA, Amsterdam, The Netherlands. m.dieleman@kit.nl.
authors.forename: Marjolein
authors.initials: M
authors.lastname: Dieleman
authors.affiliation: Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK. Miriam.Taegtmeyer@lstmed.ac.uk.
authors.forename: Miriam
authors.initials: M
authors.lastname: Taegtmeyer
authors.affiliation: Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK. o.tulloch@odi.org.uk.
authors.forename: Olivia
authors.initials: O
authors.lastname: Tulloch
mesh_terms: D001290:Attitude; D003142:Communication; D003150:Community Health Workers; D003695:Delivery of Health Care; D005002:Ethiopia; D005260:Female; D019981:Health Care Sector; D006801:Humans; D008297:Male; D000068097:Maternal Health; D008427:Maternal Health Services; D008880:Midwifery; D011247:Pregnancy; D036301:Qualitative Research; D012111:Residence Characteristics; D035502:Trust