title: Low contribution of health extension workers in identification of persons with presumptive pulmonary tuberculosis in Ethiopian Somali Region pastoralists.
abstract: To accelerate the expansion of primary healthcare coverage, the Ethiopian government started deploying specially trained community health workers named Health Extension Workers (HEWs) in 2003. HEWs work on sixteen health service packages; one being tuberculosis (TB) control and prevention. However, their contribution to TB care and prevention services among pastoralist communities has not been evaluated. Thus, this study has assessed their contribution in identification of persons with presumptive pulmonary TB in Ethiopian Somali Pastoralist Region.
  
  
  
  A cross sectional study with mixed approach of quantitative and qualitative methods was applied. A randomly selected cross-sectional sample of 380 pulmonary TB cases from 20 health facilities was selected to obtain information on the role of HEWs in the identification of persons with presumptive TB, and their referral. Purposively selected HEWs were also interviewed individually to obtain in-depth information on their in-service training and experiences with referring TB cases. SPSS version20 was used to summarize the quantitative data and test statistical significance using chi-square test and logistic regression model. The qualitative data was analyzed under the principles of thematic analysis.
  
  
  
  Overall, 20.3% [95% CI = 16.6-24.5] of pulmonary TB patients were referred by HEWs; while the majority were referred by healthcare workers (52.6%), family members (13.4%), neighbours/friends (2.4%) and self-referred (11.3%). Out of all, 66.1% and 53.4% had neither received community TB health education nor home visit from HEW respectively. Multivariate analysis indicated that provision of community health education [AOR = 14.0, 95% CI = 6.6-29.5], being model household [AOR = 21.2, 95% CI = 9.5-47.3], home visit from HEW [AOR = 2.8, 95% CI = 1.2-9.6] and rural residence [AOR = 3.0, 95% CI = 1.2-7.7] were significantly associated with referral by HEW. The qualitative findings supported that HEWs' involvement in referral of persons with presumptive TB was limited. Communities' low confidence in HEWs, inaccessibility of TB services at nearest health centers and lack of in-service trainings for HEWs were identified by the interviewee HEWs as underlying factors for their limited involvement.
  
  
  
  The contribution of health extension workers in identifying and referring presumptive TB cases is limited in Ethiopian Somali pastoralist region. Increased community health education and home visits by HEWs could contribute to increased identification and referral of persons with presumed TB. HEW should be properly trained on TB through in-service refreshment trainings and supported by routine supervision. Further expansion of TB diagnostic services would benefit to increasing case detection.
authors.affiliation: College of Medical and Health Sciences, Jigjiga University, P.O. Box: 1020, Jigjiga, Ethiopia. b.infen4ever@gmail.com.
authors.forename: Fentabil
authors.initials: F
authors.lastname: Getnet
authors.affiliation: College of Medical and Health Sciences, Jigjiga University, P.O. Box: 1020, Jigjiga, Ethiopia.
authors.forename: Abdiwahab
authors.initials: A
authors.lastname: Hashi
authors.affiliation: Ethiopian Somali Regional Health Bureau, Jigjiga, Ethiopia.
authors.forename: Sahardid
authors.initials: S
authors.lastname: Mohamud
authors.affiliation: Ethiopian Somali Regional Health Bureau, Jigjiga, Ethiopia.
authors.forename: Hassen
authors.initials: H
authors.lastname: Mowlid
authors.affiliation: KNCV Tuberculosis Foundation, The Hague, The Netherlands.|Department of Global Health, Academic Medical Centre, University of Amsterdam, Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands.
authors.forename: Eveline
authors.initials: E
authors.lastname: Klinkenberg
mesh_terms: D000293:Adolescent; D000328:Adult; D003150:Community Health Workers / Q000193:education; D003430:Cross-Sectional Studies; D005002:Ethiopia; D005260:Female; D006801:Humans; D007318:Inservice Training; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D012017:Referral and Consultation; D012424:Rural Population; D014397:Tuberculosis, Pulmonary / Q000175:diagnosis* / Q000628:therapy; D055815:Young Adult
keywords: Ethiopia; Health extension worker; Identification; Pastoralist; Presumptive; Referral; Somali region; Tuberculosis