Health extension program as innovative health care service : The socio-cultural factors affecting its implementation in Jimma Zone , South Western Oromia

Ethiopia’s Health Extension Program is an innovative community-based health care service delivery system that emphasizes the construction of health posts at village level and assignment of trained Health Extension Workersto improve the prevailing high disease burden and mortality that Ethiopians suffer from. The main objective of the study was to assess the socio-cultural factors that affect the implementation of HEP in rural communities focusing on Family Health and Hygiene and Environmental sanitation packages of HEP. A cross sectional survey was conducted in randomly selected 416 households of rural kebeles found in Jimma Zone. Even though 57% of the mothers did ANC follow-up in health posts, none of them reported for delivery in health posts. Home delivery was practiced by 82.5% of the mothers. From the 61.5% FP service beneficiaries only 15% were clients of health posts. TT coverage was 90% and 87% of the under 5 children have vaccination cards. Though 90% of the households have constructed pit latrines, 49% lackedshading and 10% have practiced open field defecation. Wash-hand basin and soap or mud was not seen around 95% of the latrines. Unprotected streams were sources of water supply for about 10% of the households. Almost half of the households studied disposed solid wastes in open fields. Generally, health posts were underutilized by the community. Above all, attention was not given to the cultural assets of the community that are suggested in the HEP guidelines as a means to increase community’s participation.


INTRODUCTION
Access to health services is one of the major problems in most African Countries.The available health institutions especially in rural Sub-Saharan Africa (SSA) including Ethiopia are inaccessible to the majority of the population due to weak infrastructure and the limited health services are organized in urban centers.
Furthermore, the health systems in these countries often suffer from lack of qualified human resources, and poor management systems.The quality of health service in rural areas is also constrained by uneven distribution of health workers (Tekle-Ab, 2007;Nejmudin et al., n. d.).Though there are some changes recently, the Ethiopian population continued to suffer from a high disease burden, of which 60% is believed to be preventable.*Corresponding author.E-mail: negajibat@gmail.com;nega.jibat@yahoo.com. Tel: 251913157105.Authors agree that this article remain permanently open access under the terms of the Creative Commons Attribution License 4.0 International License Researches indicate that the Health Status indicators of Ethiopia are among the poorest even compared to other low-income countries and Sub Saharan Africa (SSA) indicators.According to the Ethiopian Demographic and Health Survey (2011) estimate, the maternal mortality rate was 676 deaths per 100,000 live births, which is among the highest in Africa.The under-five child mortality has shown marked decline from 123 per 1000 live births in 2004/05, to 88 per 1000 in 2009.However, it is still too high amongst the poorest households: 137/1000 lives compared to 86/1000 lives for children from richest quintile (EDHS, 2011;MoFED, 2011).
A series of Health Sector Development programs (HSDPI, II andIII 1997-2010) has been formulated by the Ethiopian Government with the aim of addressing such enormous health problems prevailing in the country (FMoH, 2007).The Health Sector development program is a component of the government's plan for Accelerated and Sustained Development to End Poverty (PASDEP) and to achieve the health-related MDG (Alula, 2008).Health extension program (HEP) is an innovative programme, which is introduced in 2003 by the Ethiopian Government as envisaged in HSDP III's plan that aims to address the service coverage problem of the health system through an accelerated expansion and strengthening of primary health care services (Dawit, 2009).The program is designed to provide services at kebele level, which is the lowest administrative unit (with an average of 5000 people) covering sixteen essential health service packages (EHSP) categorized under three major areas -Disease Prevention and Control, Family Health Service, Hygiene and Environmental Sanitation and a cross cutting component Health Education and Communication (FMoH, 2007).
The implementation of HEP has been preceded by the recruitment and training of Health Extension Workers (HEWs).The HEWS were recruited from the communities in which they will work according to specific criteria.The criteria include being female in sex (except in pastoralist areas), at least 18 years old, have at least a 10th grade education, and speak the local language.The reasons suggested why females are preferred to males were the emphasis of most of the HEP packages to issues affecting mothers and children, the assumption that communication is thought to be easier between mothers and female health extension workers and female workers are thought to be more culturally acceptable.Moreover, their selection is seen as empowering women (Nejmudin et al., n.d).
The HEP has envisioned training of 30,000 female HEWs on the health extension packages for one year in different phases, and cover the whole country by 2009 (CNHD-E, 2005;FMoH, 2007).As a result, 30,578 HEWs have been trained and were deployed (two HEWs per kebele) in almost all villages in rural areas by the year 2010 (Hailom, 2011).Trainings were also provided to other health care services staff, particularly at the Health Center level, to aid in the accelerated implementation of the HEP (CNHD-E, 2005;MoH, 2007).
Additionally, given that HEP is an expression of the government's far reaching commitment regarding health service provision at all levels, all government sectors and local leaders are expected to actively collaborate in the implementation of HEP programs.The collaboration can be realized through the selection of CHWs and model families; health post construction; mobilization of communities during immunization campaigns; and construction of sanitary facilities (FMoH, 2007).
HEP is designed to improve the health status of families, with their full participation, using local technologies and the community's skill and wisdom.Hence, the program is participatory with Community Based Health Packages in that HEWs communicate health messages by involving the community from the planning stage all the way through evaluation.As a strategy, HEWs are expected to involve civic organizations like Women and Youth Associations, community associations (indigenous associations) such as Idir, Mahaer, Ekub, as well as other social structures in disseminating HEP messages and promoting good health practices (FMoH, 2007).Additionally, applying Local Rules and Regulations is suggested as a means of enhancing the diffusion, adoption and sustainability of HEP by the community.
Though the program has given such a huge emphasis to sociocultural aspects of the society, studies done on the influence of social organizational networks and indigenous knowledge on the implementation of HEP are lacking or are not handy.The available studies done on HEP are focused mainly on the assessment of problems associated with trainings and working conditions of health extension (Awash et al., 2007).
The objective of this study was to explore the sociocultural factors that facilitate or impede the implementation of health extension program in rural communities of Mana Woreda, Jimma Zone, Oromia Region.Specifically, the focus of the study was to acquire data/information pertaining to the community's opinion about the benefit of HEP, cultural factors that were supportive or deterrents to the diffusion and adoption of HEP and the extent of community-based approach followed in the implementation process.
Selected HEP packages under Family Health Service, Hygiene and Environmental Sanitation such as maternal and child health, family planning, immunization, proper and safe excreta disposal system, proper and safe solid and liquid waste management and healthy home environment were the focus of this study.
Finally, the findings of this research will help Health Extension Workers, Woreda Health Office Administration and Zonal Health Departments to fill the gaps identified in this study by paying attention to the sociocultural factors that are hindrances to the enhancement of HEP implementation.

MATERIAL AND METHODS
Study design: Community-Based cross-sectional study was conducted in 6 rural kebeles of Mana Woreda, Jimma Zone located 18 Km away from Jimma town.The research approach was mixed type employing qualitative and quantitative methods.

Study population:
Adult family members (mainly, female household heads), Health Extension Workers, Voluntary Community Health Workers and managers of health centers that were working under the randomly selected health centers and representatives of Woreda Health Office in rural kebeles of Mana Woreda.Even though information about Health Extension Program in general and Hygiene and Environmental Sanitation component in particular was collected from female household heads of all ages, only responses from women of child bearing age (15-49) were used in the analysis of data on the Family Health component of HEP.

Sample size and sampling procedure
Our approach to select health posts (one health post representing one kebele) was started by first identifying the number of health centers found in Mana Woreda.The main reason for such approach was to use the health posts under the randomly selected health centers as a center of the study and avoid geographical discrepancy that would affect the accessibility of health posts/kebeles and prolong data collection period.Accordingly, 2 health centers (Bilida and Qoree) were randomly selected from among the 3 functional rural health centers.Then, 4 rural health posts (2 from Bilida and 2 from Qoree) from the 7 more rural health posts were randomly selected through lottery method.
Cluster sampling, which is a probability sampling technique, was used to collect quantitative data from kebeles that were found in the catchment area of the selected health posts using zones of the kebeles as clusters.Hence, 6 zones (3 from Bilida and 3 from Qoree) were randomly selected out of the total 12 zones and used as clusters for house-to-house survey.As a result, data were collected from 416 households during the study period.
Additionally, qualitative information was secured through in-depth interviews with key-informants from Woreda Health Office, health center representatives, Health Extension Workers (HEWs), Voluntary Community Health Workers (VCHWs), and with heads of traditional associations.

Data collection methods and procedures
Quantitative data were collected through face-to-face interview with the female household heads using a semi-structured questionnaire with close-ended items as well as many open-ended questions.Additionally, qualitative research methods, such as in-depth interview with key-informants, and non-participant observation were used to get detailed information especially on the sociocultural factors influencing the diffusion and adoption of HEP in the community.
The data were collected by teaching staffs from Jimma University.Interviews with families/households and key-informants were held on face-to-face basis and all information was recorded by the data collectors themselves believing that self-administered questionnaire is difficult in rural settings where most of the residents are illiterate or of low educational status.Qualitative information from in-depth interview was collected by the 2 researchers alongside with the supervision of data collection process.

Data collection instruments
Pre-tested semi-structured questionnaire was used to collect Tesfa and Jibat 237 quantitative data from families/households.The questionnaire was originally prepared in English and then translated to Afan Oromo.FGD Guide was used to collect data from FGD discussants.

Method of data analysis:
Quantitative data from family/household respondents were analyzed using frequencies, percentiles and tables.Information generated from FGD, observation and interview with key-informants was analyzed by narrative analysis and triangulated with the quantitative information.

Ethical consideration:
In conducting this study, administrative ethical procedures were followed by first obtaining ethical clearance from Jimma University.Informed consent was obtained from each informant after explaining the purpose of the study and assuring about the confidentiality of the information given by the respondents.

RESULTS
This study attempted to assess the sociocultural factors affecting the dissemination and adoption of Health Extension Program (HEP) in rural kebeles found in Mana Woreda of Jimma Zone, Oromia Region.A total of 416 households were covered through the study with 97% response rate.The reason for 3% non-response rate was absence of adult family members during the study period.

Characteristics of respondents
As indicated in Table 1, all the women interviewed were married, belonging to Oromo ethnic group and were followers of Muslim religion.When we look at their educational status, almost half of the women respondents were unable to read and write.Moreover, among the mothers who have joined formal education the majority were found to be in the category of grades 1-8.On the other hand, more than 50% of the respondents were found to be without any formal education and out of this only 5% were able to read and write.Though not surprising in the context of rural settings, no women with educational level beyond 10 th grade were identified.

Family health service utilization
Ethiopia's HEP gives remarkable space for women as service providers (a cadre of HEWs) and customers in its particular emphasis on mothers, neonates and children.Moreover, breastfeeding, antenatal care, assisted delivery, contraceptive use, childhood and tetanus toxoid immunization are among the indicators of HEP status (FMOH, 2007;FMoH-HEEC, 2008).Hence, Family Health Service was one of the components of HEP included in this study in order to figure out the level of mothers of child bearing age (15-49) utilizing the selected packages at the health post level.

MCH service utilization
As indicated in Table 2, from the 412 mothers of child bearing age, closer to 90% of the mothers responded "Yes" when asked whether they are beneficiaries of MCH service or not while the remaining 10% replied "No".Though 57% of the mothers reported that they were getting the service from health posts, the remaining considerable proportion (43%) of the mothers reported health centers as their place of service utilization.Concerning the reasons for not utilizing MCH service at health post level, the mothers gave multiple responses.Most responses are related to lack of satisfactory service in the health posts.For instance, the majority of mothers (87.8%) raised issues such as absence of medications; laboratory and other medical equipment in health posts.Moreover, many mothers were questioning or doubting the skill of HEWs to deliver appropriate service.Lack of information about family health services (5%) and that these mothers rely on God's help (2.6%) and / or some biological factors like any menopause were additional reasons suggested.Scholars see ANC as a big pillar of safe motherhood and suggest that the ideal time for the first ANC visit is in the 1 st trimester, around or preferably before week 12 of pregnancy.Hence, mothers were asked about the time at which they have started their first ANC visit.Among the 370 women who were utilizing ANC service, 217 (58.6%) reported at the 3 rd month whereas 142 (38.4%) reported after 3 rd month.The rest 11 (3%) women made their first visit before 3 rd month of their pregnancy due to pregnancy related problems and other health problems.
The other point of inquiry was the place where mothers were giving birth for their last pregnancy.None of the mothers reported for delivery in a health post.Hence, 340 (82.5%) of the mothers reported for home delivery while only 72 (17.5%) have given birth in other health institutions (health center and hospital).The reasons for home delivery specifically include: no need to go to health institutions without having serious problem (21.4%), being assisted by TBAs (19%), spontaneous delivery/night time delivery (16.7%), relying on God's help (15%), financial problem for transport to health center (9.5%) since women depend on the willingness of males to pay transport, fear of surgery/operation (7%), lack of awareness (5.4%) and unwillingness of husband (2.4%).Additionally some cultural beliefs such as reliance on God and were among the constraints to seek birth attendance at HIs.
The qualitative finding from Woreda Health Office and health center representatives and FGD participants stresses the importance of HEP in improving the health service delivery system including MCH services.However, they raised their concerns on issues that affect ANC and PNC follow-ups as well as delivery in health institutions, lack of training on labour attendance by many HEWs, shortage of examination/delivery beds, delivery kits and preoccupation of HEWs by home visits that makes them inaccessible for clients were some of the factors mentioned during in-depth interviews.Moreover, they stated that the problem is exacerbated when HEWs leave the area for further training and during maternal leave.One of the informants underscored the problem associated with the sex of HEPs saying, "The reservation of HEP work only for females has its own impact since some of them leave for Arab countries and there are times when both HEWs working in one health post become pregnant simultaneously and stay at home for months when they give birth."In this respect, another informant said: "Women HEWs face hardships to move to distant places and areas with demanding topographies.On the other hand, a woman health center head emphasized the preference of male HEWs over the males justifying her stand as follows: HEP is mainly based on outreach activities focusing on home visits where they mostly encounter women household members.So, women will be ideal to discuss on HEP packages that are domestic oriented and related to Family Health service utilization by participating in home activities.Moreover, husbands will be suspicious if the HEWs were males." To conclude, based on the findings from the quantitative and qualitative data it can be understood that MCH service utilization is affected both by the socio-economic situation of the mothers and problems inherent in the health institutions including the health posts.

Family planning service utilization
From the mothers of child bearing age found in the households surveyed, about 4 mothers out of 10 were not beneficiaries of contraceptive methods.Among the beneficiaries of FP service, most of the mothers reported that their sources of contraceptive methods are health centers since there is no supply from health posts.However, few mothers mentioned access from health posts and private clinics.See Table 3 for the main reasons given by the mothers for not utilizing FP service.
The key-informants from health centers believe that there is dramatic change in respect to family planning service utilization.Nevertheless, they pointed out that some mothers are refraining from seeking contraceptive methods due to religious reasons.In sharp contrast to the qualitative finding that portrays shortage of contraceptives in health posts that forced mothers to depend on health centers (Table 3), the officials interviewed unanimously reported the presence of enough contraceptive supply in health posts.However, a group of women (living in one compound) were complaining about absence of contraceptives for months even from health centers.For example one women residing closer to a health center explained the seriousness of the problem in this way: "we are not getting contraceptives from health posts at all and there are times where injectable types of FP methods are not available for 3-4 months in health center.As a result, we have no option except purchasing the drugs from Finally, the above inconsistency of ideas from the keyinformants on family planning service utilization implies lack of uniformity and regularity on the distribution and unmet need on the type of methods available in health institutions in the study area rendering the service unsatisfactory to the mothers.

Immunization service utilization
Immunization was the only service provided efficiently in the health posts.As a result, the study revealed that approximately 9 out of 10 women were vaccinated for TAT either in health posts or health centers and almost similar proportion of the children has been vaccinated for childhood diseases.However, about 8 out of 10 children have started vaccination lately in their 6 week postdelivery (Table 4).
There was high consistency between the quantitative findings and the qualitative information from the keyinformants and FGD participants.The health center heads and the HEWs were reporting up to 95% immunization coverage.Outreach immunization programs carried out by HEWs' was the main reason given for such achievement.Of course, even mothers who were expres-sing their dissatisfaction with the services available in health posts during the survey were reacting positively about the immunization service given in health posts.
For that matter, it was common to hear respondents saying: "only immunization service is given in health posts." To generalize the findings on Family Health component of HEP, the finding on immunization coverage is encouraging since immunization (childhood and tetanus toxoid immunization for mothers) is an indicator of HEP.However, the other HEP indicators such as antenatal care, assisted delivery and contraceptive use are highly constrained by different factors stated above.

Hygiene and environmental sanitation
According to FMoH (2007) document, facilities for liquid/solid waste disposal, safe drinking water and safe extra disposal are among the indicators of HEP.Hence, measures taken by the households as regards these packages were assessed in this study.As indicated in Table 5, though about 9 out of 10 households have pit latrines, almost half of the households were using latrines that have no shading.Moreover around 1 out of 10 households were practicing open field defecation.Remarkably enough, the proportion of households who prepared wash-hand basin and soap/mud near the latrines for hand washing after defecation was very low.However, the majority of the respondents stated that they are using water from their homes to clean themselves after defecation.
In respect to access to safe water and enough supply, the majority of the respondents replied "Yes" though they have complained of drying of water sources in dry seasons that forced them to move long distance to fetch clean water.Exactly two-third of the households reported collecting and preserving water in clean Jerri cans as safety method while the remaining one-third pointed out for shortage of safe and enough supply and was obliged to fetch water from unprotected streams.
Furthermore, the study showed that the share of households practicing safe and unsafe solid waste disposal was somewhat equal, 49 and 51% respectively.When asked why they are disposing garbage in open fields, the majority of households reasoned out that it serves as a fertilizer.
Additionally, availability of ITN (utilization of insecticide treated net) in the households was assessed with checkup (observation).The study indicated that 320 (77%) of the households were having a Bed-Net while a quarter (23%) of the households were not having Bed-Net.The reason that the respondents gave for not utilizing Bed-Net were worn out of previously given Bed-Nets and absence of Bed-Net distribution/supply by concerned government offices.
Diversity of views was observed among the keyinformants that participated in the qualitative part of this study concerning the status of latrine construction by the community.One of the health center heads mentioned that almost all of the households in his area have constructed latrines.He also said: "the community in our catchment area has prepared latrines around markets and beside roads so that persons from distant places can use them.Now, our focus is on standardizing the latrines by working with an NGO in this area."To the contrary, the other head of a health center expressed his disappointment in winning the cooperation of the community saying: "they are always promising that they will construct their latrines within few days.However, we are always getting them without taking any action when we go to their home after a month or more."As to a proper solid and liquid waste disposal practices, there is no different finding from what is attained quantitatively.Nevertheless, the problem of safe and enough water supply was seen as a serious problem by CHWs and health center heads.All the key-informants complained that the health centers and health posts are devoid of water supply for years.They also mentioned that the delay of water supply projects in the area is worsening the problem.Except one of the heads of health centers who reported the presence of enough source of water supply in her catchment area with 88 protected streams and 44 hand pump wells, the other informants have articulated that the protected streams that the communities use have lost their purity and are becoming waterless during dry seasons.
To sum up, from the above findings and the observation made by the researchers on some water sources ("protected streams"), it is possible to generalize that inaccessibility of pure and enough water supply in the kebeles studied outweighs its accessibility.

Health education and communication
With the aim of identifying the HEP dissemination process household members were asked whether they have gotenough training on HEP or not, level of satisfaction with the training, if they have graduated as a model family and the more suitable source of HEP information they prefer.As a result, 306 (74%) mentioned that they have got training by HEWs within the last 2 years.However, 110 (26%) household members suggested that they were not trained on HEP except the information they got from HEWs during home visit.Most of the trained informants articulated their satisfaction with the training.For the question 'are you a model family?'only 10% of the household members reacted "Yes".
Household members were also asked to prioritize the suitable sources of information on HEP.Health information by the HEWs was the first preference followed by discussion with peers.Discussion with Garee (group of 5 persons in the village) was their second preference.Insignificant number of respondents preferred Radio and support by model families as medium of knowledge transfer.
To finalize, the above findings suggest that HEWs have made considerable effort to disseminate information on HEP to the community through organized trainings and during home visits.However, their effort on the identification and training of model families that have acceptance and credibility by the community was minimal.In fact, socially notable model families would have enhanced the diffusion of health messages and facilitated 'the adoption of the desired practices and behaviors by the community.'

Community participation in HEP implementation
HEP guidelines on HEP advocate that HEP is a community-based health intervention that demands the HEWs to closely work with traditional associations in the society in communicating health messages.The keyinformants from the Woreda Health Office, HEWs and Voluntary Community Health Workers (VCHWs) have reported that the overall participation of the community is good.For example, the contribution of the community in the construction of health posts was reported to be high.As an example, following is the Woreda Health Manager's statement: In the past the community had no enough awareness about prevention of disease since they used to give attention for curative aspect of health services like getting injection.However, now the community is getting awareness form the health education being provided at grass root level.At the beginning, the community has perceived the health extension workers as laymen.Advocacy by elders is undertaken to all people pertaining to the health extension workers.So all people are now getting the awareness about them.The kebele structure, other nongovernmental organizations are helping the activities of these health extension workers.In the past we provide minimum support for the health extension workers however we started to recognize that strong support is needed from our side.
However, from the conversations with health center representatives and heads of the traditional associations, it was understood that the community was not involved in the selection of HEWs for training.Moreover, heads of indigenous associations, who were used as keyinformants, stated that they were not actively participating in the process of HEP program planning and implementation.Similar ideas were also raised by representatives of Idirs except the contribution of money and materials they made for Health Post construction.According to the responses of health office representatives and the keyinformants from local associations, the focus is on strengthening the organization of community in to Garees that are extensions of the formal administrative network.

Sociocultural factors affecting HEP implementation
Representatives from health institutions, Health Extension Workers, other key-informants were inquired if there are cultural factors that constraint community's adoption of HEP.Though the degree that the informants give for the issue varies, all of them believed that some HEP packages are not favored due to traditions.For instance, one of the key-informants expressed his doubt for the existence of hidden female circumcision in the area.The HEWs interviewed also stated that though mothers are not openly talking, it could be due to religious reason that many mothers refrain from utilizing FP services.In general terms, low educational status of women, delay to adopt health messages sticking to the traditional way of life (e.g.solid waste disposal system), religious orientation, etc. were the main factors mentioned as constraints to HEP implementation.

DISCUSSION
The study was carried out with the aim of assessing the socio-cultural factors that influence the execution of Ethiopia's Health Extension Program that is perceived as an important approach to health related Millennium Development Goals (MoFED, 2012, FMoH, 2010FMoH-HEEC, 2007).When the women were asked about the existence of Health Extension Program activity in the area, 363 (87%) of them replied "Yes".However, as discussed under the specific packages, most of the HEP packages are not reasonably adopted by the community.Hence, the findings of this study and the underlining problems are discussed in comparison with other studies done on the topic.

Family health service utilization
The MCH package is one of the strategies to implement the principles of safe motherhood since mothers are exposed to a number of risks during pregnancy, delivery and post-delivery periods.Hence, special care in the form of ANC, delivery with the assistance of competent professional and PNC are recommended to reduce the high maternal and child morbidity and mortality rates in Ethiopia (FMoH, 2003).Though it is encouraging that the majority of the mothers were beneficiaries of MCH service at different health institutions, 42 (10.2%)mothers of child bearing age were not having MCH service followup at all.Moreover, from those mothers that have attended MCH service, 43% were getting the service from health centers bypassing the health posts.Surprisingly enough, this study revealed that none of the mothers studied gave birth at health posts and more than 8 out of 10 (82.5%) mothers were practicing home delivery.Though the national percentage of deliveries attended by skilled birth attendants was 20.4% in 2011/12 (MoFED 2012), all births took place without the help of skilled professionals.Whatever personal reasons were suggested by the respondents why they were giving birth at home, mothers' hesitation to seek MCH service especially delivery service from health posts revolves around not being confident on the qualification of HEWs and shortage of examination beds.This was also confirmed during interview with health center heads and the HEWs themselves that the latter were mostly giving referral services to health centers.
The study area is not exceptional in this respect since a number of studies have also identified similar gaps on the provision of delivery service in health posts (Aschenaki et al., 2014;Medhanyie et al., 2012;Center for Health and Gender Equity, 2010;FMoH-HEEC, 2008).These studies have documented several factors contributing to and affecting performance of HEWs such as HEWs lacking adequate knowledge and skills to attend to women in labour and delivery, poor knowledge on contents of antenatal care counseling, danger signs and symptoms and complications in pregnancy, lack of supplies and equipment in the health posts including basic infrastructures like water supply, electricity, and waiting rooms for women in labor.Traditional influences such as religious beliefs, unwillingness to be examined by unfamiliar health workers were also mentioned.
Family planning package is one of the components of family health service intended to control the high fertility and rapid population growth that have an impact on the overall socio-economic development of the country in general and maternal and child health in particular.Hence, assessment of the level of contraceptive utilization by mothers (either for child spacing/delay pregnancy or avoid pregnancy) was made in this study in order to estimate to what extent HEP is adopted by the community.Though the study showed that high proportion (61.5%) of mothers of child bearing age were FP service utilizers, 83% of these mothers opted for health centers claiming that health posts failed to meet their needs.
The proportion of contraceptive utilization is slightly lower than FMoH-Health Extension and Education Center's (2008) 65.1% report in a study that covered 81 selected kebeles of four woredas of Amhara and SNNRP Regional States.On the other hand, the finding in the study area is somewhat higher compared to the 2009 Marie Stopes International Ethiopia's (MSIE) report of 49% modern FP usage by rural women in five regions of Ethiopia (Espeut et al., 2010).Generally, the FP usage by the study subjects is encouraging when equated with only 38.3% ever use of FP by women in Mojo town located at about 80 kilo meters from Addis Ababa, the country's capital (Abebe and Nigatu, 2011) and the 20% national contraceptive prevalence rate for Ethiopia (EDHS, 2011).
The main reasons given by the mothers for not benefiting from FP service were religious (22.5%), fear of the drugs impact on health (20.4%), need to have more children and child of other sex (10.2% each) among others.This finding is consistent with a national survey done on the availability of modern contraceptives and essential lifesaving maternal/RH medicines in service delivery points in Ethiopia that highlighted socio-cultural norms such as male/husband dominance and opposition to contraception, limited choices, worries of side effects and health concerns, lack of formal education for women as the determinants of family planning practice (Tedros, 2010).Many other studies undertaken at local/national level or rural/urban centers also state similar factors that are barriers to FP service utilization by eligible women (Abebe and Nigatu, 2011;Beekle and McCabe, 2006).
Immunization is among the most cost-effective childhood disease prevention interventions and immunization coverage also serves as a key indicator whether one country is on the track towards the achievement of MDG4 (FMoH, 2014;HEPCAPS1 Project Team. 2012).In this regard, representatives from Health Centers, HEWs and FGD participants from the community stated that community's awareness about immunization is very high.The study revealed that the majority of mothers were vaccinated for Tetanus (92.3%) and the 87% of the children have vaccination cards.Regarding the time of initiating the first vaccination for children, 79.4% were taking their children after 45 days and only 20.6% visited health institutions within the first week of delivery.When mothers were asked why they were not taking their children for immunization, most of them replied that they were informed by HEWs to bring their children after 45 days for vaccination.The immunization coverage in this study is very high compared to a similar study done in Tigray Region with 74% coverage in 2010 (Amare, 2013).

Hygiene and environmental sanitation
Excreta-borne diseases are wide spread in Ethiopia especially in rural areas where most of the population in many villages defecate in open fields or in any available spaces without any regard to the health risk that result from open field defecation practice (FMoH, 2004).
In this study, almost half proportion (40.7%) of the households surveyed was having pit latrines with shading and the rest (49%) of the households were using latrines that have no shading.The share of households that defecate in open fields was 10.3%.Moreover, 95% of the households have never prepared wash-hand basin and soap/mud near the latrines for hand washing after defecation.
The finding of this study shows lower latrines with shading compared to the result of another study conducted in Jimma Zone (Mirkuze (2009), in that 54% of the households have private pit latrines with shading.However, similar percentages of households dispose excreta on the open fields (10.3 and 10.2% respectively).Another, study undertaken in Damboya Woreda, Kembata Zone (SNNPR) indicates similar latrine coverage (93.8%) though it does not mention about use of shading.However, the study revealed that higher proportion of households (29.5%) had hand washing facilities near their toilets (Samuel, 2011).

Table 2 .
Level of MCH service utilization by respondents in rural kebeles of Jimma Zone, southwest Ethiopia.

Table 3 .
Level of FP service utilization by respondents from rural kebeles of Jimma Zone, Southwest Ethiopia (n = 412).

Table 4 .
Level of immunization service utilization in rural kebeles of Jimma Zone, southwest Ethiopia.

Table 5 .
Proper and safe excreta, solid and liquid waste disposal; safe water and enough supply and insect and rodent control in rural kebeles of Jimma Zone, southwestern Ethiopia (n=416 households).