Knowledge of and access to frontline workers among poor, rural households in Amhara region, Ethiopia: a mixed-methods study
Authors: Quinones Sarah , Palermo Tia , Gavrilovic Maja , Vinci Vincenzo , Otchere Frank , Mussa Essa Chanie ,   the ISNP Evaluation Team, Angeles Gustavo , Valli Elsa , Waidler Jennifer , Tadele Getinet , Adamu Sewareg , Abebe Teketel , Tadesse Yenenesh , Nega Feredu , Kebede Mesay , Muluye Fekadu , Matsentu Alene , Aklilu Daniel , Serdan Ana Gabriela Guerrero , Ouedraogo Lisa-Marie , Kebede Getachew Berhanu 
Published: November 2022

Abstract
Background
Social protection programmes have effectively reduced poverty and improved food security. However, the effects of poverty require an intersectoral approach to adequately address poor nutrition and health. Identifying gaps in knowledge and access to frontline workers who oversee these integrations is critical for understanding the potential for integrated social protection programming to improve these outcomes. We measured levels of social protection programme participants’ knowledge of and interaction with social workers (SWs) and health extension workers (HEWs) in rural Ethiopia.

Methods
This mixed-methods study uses cross-sectional data from the baseline survey of a quasi-experimental impact evaluation among a sample of 5,036 households participating in Ethiopia’s Productive Safety Net Programme. Qualitative interviews include key informant interviews, in depth interviews and focus group discussions with caregivers, community members, frontline agents, and stakeholders. Using data from household questionnaires administered to household heads, quantitative analyses include univariate and bivariate descriptive statistics as well as mutually-adjusted multivariable logistic regression analyses to estimate adjusted odds ratios and 95% confidence intervals for household sociodemographic characteristics associated with 1) knowledge of SWs and HEWs and 2) interaction with SWs and HEWs in their communities. Qualitative data were analysed using thematic analysis combining both a fluid and more structured coding processes to unpack the important topics within the data supported by illustrative quotes.

Results
Our results show that knowledge of and interaction with SWs is limited while many knew of and interacted with HEWs quite regularly. Interactions with SWs were negatively associated with increased household size and living in Dewa Chefa. Factors associated with increased knowledge of and interaction with HEWs include having children under the age of 5 years in the household, having health insurance, and having a formal education. Qualitative analyses suggest that SWs are limited by overwhelming caseloads, limited resources to carry out their work, and high staff turnover. However, SWs are considered highly valuable in the communities where they work.

Conclusions
While most of the participants reported knowing their HEW, there is room for improvement, especially around household engagement with HEWs. Although SWs support the ISNP in the treatment districts only and not formally incorporated into the structure in the region, our findings highlight a need to provide greater support to SWs to effectively facilitate improvements in health and nutritional outcomes among vulnerable households.

Trial registration
Pan African Clinical Trial Registry (PACTR201902876946874) and the Registry for International Development Impact Evaluations (RIDIE-STUDY-ID-5bf27eb0404a0).