Health extension service utilization and associated factors in East Gojjam zone, Northwest Ethiopia: A community-based cross-sectional study.

INTRODUCTION: Health Extension Program is a preventive, promotive, and basic curative service targeting households to improve the health status of families with the effective implementation of 16 health extension packages. We, therefore, did this study to assess health extension package utilization and associated factors in the East Gojjam zone, Northwest Ethiopia.
METHODS: A community-based mixed cross-sectional study was conducted on households of East Gojjam Zone, from January 1 to April 30, 2020. A multistage sampling procedure was used to select 806 study participants in this study. We used EPI info version 7 for data entry and SPSS version 24 software for cleaning and analysis. Variables having a P-value of less than 0.25 in the bivariate logistic regression analysis were fitted into the multivariable logistic regression model. The 95% confidence interval of odds ratio was computed and a variable having P-value less than 0.05 in the multivariable logistic regression analysis was considered as statistically significant.
RESULTS: The study showed that 119 (14.8%) respondents have utilized health extension packages. Knowledge health extension package (AOR = 1.84, 95% CI: 1.22, 2.79), residence (AOR = 3.55, 95% CI: 1.99,6.33),visited health post(AOR = 1.63, 95% CI: 1.054,2.50), home visited by health extension worker (AOR = 1,68, 95% CI: 1.025,2.74) and involving in model family training(AOR = 2.10, 95% CI: 1.38,3.215) were significant factors for health extension service utilization.
CONCLUSION: The magnitude of health extension service utilization was low since the Ethiopian government recommends 100% health extension service utilization coverage. Knowledge of health extension package, residence, health post-visit, home visit, and model family training were significant factors for health extension service utilization. So expanding the model family training and strict home-to-home visit especially in rural areas may increase the health extension package utilization.

Introduction

Establishing an effective and responsive health service delivery system is an integral part of the overall development that aims to reduce poverty and achieve economic growth and development [1, 2]. The Health Extension Program (HEP) is a package of preventive, promotive, and basic curative services targeting households to improve the health status of families with their full participation [3]. HEPs include disease prevention and control, family health service, hygiene, and environmental sanitation, health education, and communication [1]. The former Frontline Health workers or traditional birth attendants (TBAs) are incorporated into the system by serving as volunteers that work under the supervision of the health extension worker (HEW) [4]. Thus, HEP will serve as a primary vehicle for prevention, health promotion, behavioral change communication, and basic curative care [5]. Globally many countries, especially developing countries are striving to achieve universal health coverage starting from the “Health for All” movement of 1978 by the World Health Organization (WHO) or the Almata declaration [6]. The Government of Ethiopia has implemented the Health Extension package (HEP) since 2003 to improve primary health coverage at the grassroots level [7] and also agreed to this movement and tried to address universal health coverage mainly primary health care (PHC) throughout the country [8].

The center for the HEP activity is a health post (HP) located in each smallest administrative unit of the country and is staffed by two female Health Extension Workers (HEWs) who receive one year’s training and a regular salary from the government [9, 10]. HEP was published to have public sector facilities provide a minimum standard of care that fosters an integrated service delivery approach [11]. And it delivers cost-effective basic services to all Ethiopians, mainly women, and children [12]. More than 75% of the health problem in Ethiopia is largely attributed to preventable communicable diseases and under-nutrition. The prevalence of these diseases is mainly due to poor socio-economic conditions, a low level of awareness about health, and inadequate health service delivery across the country [13]. Concerning this, the Ethiopian government designed a sound able plan to achieve universal access to primary health care by preparing a health sector development program (HSDP). This plan was aimed to address the service coverage problem of the health system through an accelerated expansion and strengthening of primary health care services [1, 12].

There are some factors associated with health extension service utilization in the previous study: these are knowledge of community on health extension service, age, occupation, community participation in the planning of health extension activities, and graduation of model family [18].

According to the Ethiopian Demographic and Health Survey of 2016, 38% of children under the age of five years suffered from stunting due to malnutrition; the Amhara region accounts for the highest proportion (46%) and the prevalence of water-borne and water-washed diseases were high. The Mini EDHS 2019 report also indicates under 5 mortality 30%, maternal mortality 412 per100,000 live births, and unmet need for family planning is 22% [14]. Therefore, this study aims to assess HEP utilization and its factors in East Gojjam Zone.

Methods

Study areas and period

East Gojjam zone is located in the Amhara region 300 km from Addis Ababa, a capital city of Ethiopia, and 265 km from Bihar Dar, the capital city of Amhara. It is bordered on the south by the Oromia Region, on the west by West Gojjam, on the north by South Gondar, and on the east by South Wollo. As the zonal health office report showed East Gojjam zone has a total population of 2,719,118 and 632,353 households. East Gojjam zone has also 21 Woreda, 480 Kebeles, 423 health posts, 102 health centers, 9 primary hospitals, and one referral hospital. The study was conducted from January 1, 2020, to April 30, 2020.

Study design

A community-based cross-sectional study design was conducted.

Study participants

The source population was all households who live in the East Gojjam zone. The study population was households in the east Gojjam zone during the study period in the selected Kebeles. Study participants age 18 and above who reside above six months in the study area were included and participants who were mentally ill during the data collection period were excluded.

Sample size determination

The sample size was determined based on a single population proportion formula assumption. The expected proportion of HEP utilization (39%) from the previous study in Ethiopia Abuna Gindeberet, West Shoa Zone [15], and a 5% confidence limit (margin of error) was used.

Considering design effect 2 since it had two stages and the sample size was calculated as 366*2 = 732. Then the non-response rate was also considered to be 10% and 732*0.10 = 74. Then the final sample size was 732+74 = 806.

Sampling techniques

A multistage sampling technique was used and firstly all the woreda found in the east Gojjam zone were listed in a frame. Then five out of the 21 woredas were selected by the lottery method. Again 4 kebeles, from Bibugn woreda, 5 kebeles from Debre Elias woreda, 5 kebeles from Dejen woreda, and 5 kebeles from Andede woreda were selected with the lottery method. The size of households consisting of the eligible population to be selected from each kebele was determined proportionally based on the size of the study units and the kth value was computed for each selected kebele. Any single individual age 18 and above of the selected household was interviewed. In the case of absenteeism, after three repeated visits the next eligible household was included in the study.

Study variables

Dependent variable

Health extension service utilization.

Independent variables

Age, marital status, religion, educational status, occupation, religion sex, residence, family size, knowledge, HP distance from home, HP visit, home visited by HEWs, model family training, model family graduation.

Operational definitions

Health extension service utilization

Anyone who implements at least 75% of the national health extension program packages [16].

Satisfactory knowledge

Respondents who scored 75% and above of the HEPs knowledge questions [15].

Model households

Households that attended at least 75% of the training and implemented at least 75% of the HEP and given certificates of completion [10].

Health extension package

Is a package of preventive, promotive, and basic curative services targeting households to improve the health status of families with their full participation [3].

Data collection and data quality control

To assure the data quality, data were collected with face-to-face interviews by three trained diploma nurses after two-day data collection training was given to them together with three BSc holder supervisors. The questionnaire was structured and pre-tested which was first prepared in English and translated to local (Amharic) language and then again translated back to English. A pretest was conducted on 40 households of the sample size other than the study area and the necessary correction on the tool was employed accordingly.

Data processing and analysis

Epi Info version 7 software was used for data entry and SPSS version 24 for used for analysis. Bivariate logistic regression was employed to identify an association between independent and dependent variables. Variables having a P-value of less than 0.25 in the bivariate logistic regression analysis were fitted into the multivariable logistic regression model. The 95% confidence interval of odds ratio was computed and a variable having P-value less than 0.05 in the multivariable logistic regression analysis was considered as statistically significant.

Ethical clearance

Ethical clearance was obtained from the research committee (Institutional Research Ethics Review Committee) of Debre Markos University with ethical approval number HSC/R/C/Ser/Co/341/06/12 and was submitted to the East Gojjam zone health bureau. Ethical clearance and formal letters were also obtained from the Debre Markos University and were submitted to the East Gojjam zone health bureau and permission was obtained. Finally, written informed consent was also obtained from each study participant in the sampled households.

Results

Socio-demographic characteristics

All 806 study participants responded to the questionnaire, giving a response rate of 100%. All of the participants were Amhara in ethnicity and 758 (94.1%) of the participants are orthodox Christian. Five hundred thirteen (63.6%) were living in a rural area with agriculture as a source of income (Table 1).

Table 1

Sociodemographic characteristics of respondents (n = 806) in East Gojjam Zone, Northwest Ethiopia, 2019.

Variable	Frequency	Percent
Age(in years)
18–24	30	3.7
25–39	357	44.3
≥40	419	52
Marital status
Single	48	5.9
Married	696	86.4
Widowed	20	2.5
Divorced	42	5.2
Religion
Orthodox	758	94.1
Muslim	38	4.7
Protestant	10	1.2
Educational status
No formal education	485	60.2
Primary education	126	15.6
Secondary education	90	11.2
College and above	105	13
Occupation
Housewife	46	5.7
Self-employee (doing own small business)	138	17.6
Private employee(salaried in the nongovernmental sector)	44	5.5
Government employee	65	8.1
Farmer	513	63.6
Residence
Rural	513	63.6
Urban	293	36.4
Source of income
Agriculture	513	63.6
Other*	293	36.4
Sex
Male	152	18.9
Female	654	81.1
Family size
1–4	316	39.2
4+	490	60.8

Service-related characteristics

Less than half (37%) of the study participants have transport access to the health post. Two hundred-one (90.5%) of the participants got a good approach from HEWs. Again around 208 (93.7%) participants got participants needed (Table 2).

Table 2

Service related issues among respondents (n = 806) in East Gojjam Zone, Northwest Ethiopia, 2019.

Variable	Frequency	Percent
Transport access to the health post
Yes	298	37
No	508	63
Visited health post
Yes	222	27.5
No	584	72.5
Reasons for visiting health post
For antenatal care	116	48.7
For family planning	91	38.2
For other services	31	13.1
health extension worker approach
Good	201	90.5
Bad	21	9.5
Returned without getting the service needed
Yes	14	6.3
No	208	93.7
Reasons returned without getting the service
Absence of health extension workers	8	57.1
Unavailability of the service	6	42.9
Home visited by a health extension worker
Yes	544	67.5
No	262	32.5

Knowledge and modeling related characters

Among the respondents, only 311(38.6%) had satisfactory knowledge of HEPs. About 259(32.1%) of respondents have participated in model family training of HEPs. Of these 249 (96.1%) had been graduated. One hundred ten (44.2%) of these had 1–2 years, 122(49%) had 3 years and 17(6.8%) had greater than 4 years after model family graduation.

Utilization of the health extension package and its associated factors

One hundred nineteen (14.8%) of the study population have utilized health extension packages [95% CI: 12.4, 17.2] (Table 3). Bivariate logistic regression was used to identify an association between independent and outcome variables. Variables with P-values <0.25 in binary logistic regression (educational status, residence, knowledge, health post-visit, home visited by HEW, and model family training) continued to be fitted into the multivariable logistic regression.

Table 3

Utilization of health extension package (n = 806) in East Gojjam Zone, Northwest Ethiopia, 2019.

Package	Frequency	percent
A: Hygiene and sanitation
Proper and safe excreta disposal
Yes	366	45.4
No	440	54.6
Proper and safe solid and liquid management
Yes	268	33.3
No	538	66.7
Personal hygiene
Yes	310	38.5
No	496	61.5
Water supply and hygiene
Yes	142	17.6
No	664	82.4
Proper and safe home environment
Yes	469	58.2
No	337	41.8
Insects and rodents control
Yes	592	73.4
No	214	26.6
Food hygiene
Yes	471	58.4
No	335	41.6
B: Communicable disease prevention and control
HIV/AIDS and TB prevention and control
Yes	610	75.7
No	196	24.3
Malaria prevention and control
Yes	461	57.2
No	345	42.8
First aid
Yes	77	9.6
No	729	90.4
Youth reproductive health care
Yes	179	22.2
No	627	77.8
Child and maternal health care
Yes	481	59.7
No	325	40.3
Maternal and child nutrition
Yes	387	48
No	419	52
Immunization
Yes	583	72.3
No	223	27.7
Family planning
Yes	518	64.3
No	288	35.7
C: Communication
Communication and health education
Yes	577	71.6
No	229	28.4
Over all utilization
Yes	119	14.8
No	687	85.2

After controlling the effect of other variables with multivariable logistic regression analysis, residence [AOR: 3.549(95% CI: 1.99, 6.33)], knowledge [AOR: 1.84(95% CI: 1.216, 2.796)] health post-visit [AOR: 1.63(95% CI: 1.054, 2.50)], home visited by HEW [AOR: 1.68(95% CI: 1.03,2.740)] and Graduated from model family training [AOR: 2.10(95% CI: 1.38,3.22)] were significant factors for health extension package utilization (Table 4).

Table 4

Bivariable and multivariable analysis of factors associated with utilization of health extension package in East Gojjam Zone, Northwest Ethiopia, 2019.

Variable	Utilized		Crude OR[95%CI]	AOR[95%CI]
	No	Yes
Age
18–24	26	4	1
25–39	307	50	0.94 (.35, 3.16)
≥40	354	65	1.194(.403,3.53)
Marital status
Single	41	7	1
Married	590	106	1.50 (.46,2.41)
Widowed	18	2	.651(.12, 3.44)
Divorced	38	4	.617(.17,2.27)
Religion
Orthodox	644	114	1
Muslim	35	3	.48 (.15,1.60)
Protestant	8	2	1.412(.29, 6.74)
Educational status
No formal education	434	51	1	1
Primary education	99	27	3.32 (1.39,3.88)	1.126(.60,2.09)
Secondary education	74	16	1.84 (.99, 3.39)	.64 (.302,1.39)
College and above	80	25	2.66(1.56,45)	.774(.370,1.615)
Sex
Female	564	90	1
Male	123	29	1.48(.93, 2.35)
Residence
Rural	466	47	1	1
Urban	221	72	3.23 (2.16, 4.82)	3.55(1.99,6.33) **
Family size
1–4	269	47	1
Above 4	418	72	.99(.66,1.47)
Knowledge
Unsatisfactory	437	58	1	1
Satisfactory	250	61	1.84(1.24, 2.72)	1.84 (1.22, 2.79) **
Visited health post
No	511	73	1	1
Yes	176	46	1.83 (1.22, 2.75)	1.63(1.05, 2.50)
Home visited by HEW
No	237	25	1	1
Yes	450	94	1.98(1.24,316)	1.68(1.03, 2.74)
Participated in model family training
No	484	63	1	1
Yes	203	56	2.12(1.43,3.15)	2.10 (1.38, 3.22)
Graduated from model family training
No	9	1	1
Yes	194	55	2.55 (.32, 20.56)

** P value< 0.001, 1reference,

*housewife self-employee, private employee, and government employee.

Discussion

The study finding of health extension package utilization (14.8%) in the current study was higher than the study done in Hosanna, Hadya Zone, Southern Ethiopia (2.352%) [17]. The possible explanation for this difference might be the difference in socio-economic status and cultural aspects and differences in the level of awareness about health extension packages.

But the result of this study is lower than the study conducted in Abuna Gindeberet district, West Shoa Zone, Ethiopia (39%) [18]. The possible reasons for this difference could be the difference in study area coverage. This study was done at a zonal level that covers a wide area that might have great variation in health extension package utilization across the zone and leads to low coverage of HEP utilization. Again this finding is lower than the study done in Gulelle sub-city Administration, Addis Ababa, Ethiopia (86%) [15]. The possible explanation for this difference can be the study setting, socio-economic status of the community, and living standards. Our study was conducted in areas including the rural community which is unthinkable to be comparable with a community living in Addis Ababa. People in the Gulelle sub-city administration utilize the health extension packages on their own since they understand the importance of these packages whereas the rural community considers the importance of these packages is not for them rather either for the health extension workers or for the government. The other possible reason may be a limitation in basic infrastructures in rural communities relative to the Gulelle sub-city administration community.

As shown in this study, residence was one of the significant factors for the utilization of health extension package utilization. Urban dwellers were 3.55 times more likely to utilize the health extension packages as compared with rural households (AOR = 3.55, 95% CI: 1.99, 6.33). This finding was supported by the studies done in Kombolcha town district, East Hararghe Zone, Eastern Ethiopia, and Esera district of Southern Ethiopia [19, 20]. The possible explanation for this might be urban residents might have higher information access about health extension packages than the rural dwellers and there might have infrastructure assess to utilize these package.

Participants with a satisfactory knowledge of health extension packages were 1.84 times more likely to utilize these packages than respondents with their counterparts (AOR = 1.84, 95% CI: 1.22, 2.79). This result is supported by other studies conducted in Ethiopia as nationwide, Abuna Gindeberet District, West Shoa Zone, Ethiopia, and Hadya Zone, Southern Ethiopia [17, 18, 21, 22]. knowledge is the entry point for any activity, so respondents who know the health extension package could utilize those packages than their counterparts. Again participants who got the opportunity to know about health extension packages may have an effort to utilize it than those who do not have.

The other variable which was significantly associated with the health extension service utilization was health post-visit. Respondents who had visited the health post were 1.63 times more likely to utilize the health extension packages than those who did not visit the health post (AOR = 1.63, 95% CI: 1.054, 2.50). This finding was supported by a nationwide finding of Ethiopia [23]. The possible explanation for this difference might be as the respondents visit the HP they may have the opportunity to be familiar with the HEWs and get enough information about the HEP utilization than those who did not visit. When the respondents visit the HP, they can access the HEWs to talk frankly about HEP utilization with the aid of demonstration in addition to the home to home visit than those who do not visit. Visiting the HP by itself is using the HEP like ANC follow-up, HIV/AIDS counseling, family planning access, malaria prophylaxis, and prevention access, getting health education, and other packages. Therefore, respondents who visit HP may easily utilize HEP than those who did not.

Respondents from the household which is visited by the HEW were 1.676 times more likely to utilize the HEP than from not visited households (AOR = 1.68, 95% CI: 1.03, 2.74). This result was supported by a study done in Akaki district, Addis Ababa, and nationwide studies conducted in Ethiopia [23-25]. Visiting the households by the HEWs is the key factor for HEP utilization by the community. During the HEWs home to home visit, they perform lots of activities concerning HEP like registering pregnant women with their expected date of delivery, proper utilization of latrine, kitchen, insect acid-treated net, family planning, diagnose ill individuals in the household, and refer to health institution, provide health education and proper disposal of waste materials. So study participants whose houses are visited by the HEWs can utilize HEP than which is not visited.

Participants who had been involved in model family training were 2.10 times more likely to implement the health extension packages than those who had not participated (AOR = 2.10, 95% CI:1.377, 3.22). This result was supported by a study conducted in Nefas Silk Lafto Sub-city, Addis Ababa, Ethiopia [26]. The possible explanation might be involving the model family training regarding the health extension package increases awareness about these packages utilization than those who did not participate. The other reason could be when participants are involved in the model family training; they may have inspired to utilize the HEP than those who do not participate.

Conclusion

The magnitude of health extension service utilization was low as compared to other studies. Knowledge, residence, health post-visit, home visit, and model family training were significant factors for health extension service utilization. So expanding the model family training and strict home-to-home visit especially in rural areas may increase the health extension package utilization.

Limitation and strength

The strength of this study was the data source which was primary data collected directly from the community that makes it more accurate and representative for the study population. Difficulty of data collection from the community due to COVID-19 in terms of cost (availing sanitizer, face masks and transport) and the nature of study design (cross sectional study design) which cannot show the cause and effect relationship between the independent and the outcome variables were the limitation of this study.

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15 Apr 2021

PONE-D-20-30163

Health extension service utilization and associated factors in east Gojjam zone, North West Ethiopia: community based cross-sectional study

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Reviewer #1: Reviewer comment to author’s

Title: - Health extension service utilization and associated factors in east Gojjam zone, North

West Ethiopia: community based cross-sectional study.

Thank you very much editor for give me a chance to review this interesting manuscript. I thank you for authors for your effort and interesting work. I think this work adds value for the scientific community and the community in which the study done after the following issues addressed. English language editing will benefit for improvement.

General comment

Before submitted any manuscript to journal you should give line number and follow the guideline of the journal. This manuscript does not have line number and it is difficult to give line-by-line comments. Anyways my comment given each session of the manuscript find it and address it.

Abstract

Introduction

The introduction section of the abstract does not show the gap. What is the reason to study this research? It needs rewriting explain the gap and reason to conduct this study needed. Before you talk about the significance of the study, you should tell the gap.

Method

The method session needs some modification. The model fitness and include the bivariable analysis variable selection p-value

Result

The abbreviation HEW did not explained before but written their it not write. The abstract session should be free and abbreviation

Conclusion: - In the first sentence, you said, “The magnitude of health extension service utilization was low.” What is your cutting point to say high/low? Such types of conclusion is blind and not informative.

Body of the manuscript

Introduction

In your introduction session, I did not see any factors associated with health extension service utilization what previous scholars explore. It needs one paragraph the reviews the associated factors of health extension service utilization in Ethiopia. Include it in your next revision part.

Method

In the study design session said” Community based mixed cross-sectional study design” what does it mean? I did not see any qualitative part. I need a justification such types of study design.

What your justification in your study participants session you included participants in age >=18 years?.

In your sample size calculation formula you only calculated for prevalence of health extension service utilization. Why not calculate for factors. You are expected to calculate for both the magnitude and the factor then you will take sample size which large. Why that not done?

In your sampling technique from 5/21 woredas why only 5? Justify it. Again the seleceted kebeles from total woredas ? how determine the number of kebele for each woreda? Justfy it.

In your data processing and analysis you used 0.25 as a variable screening but there is no any justification. Justify why that?

The model fitness issue is not presented. Why? Justify it. Include in the revision part

Did you check multicolleanity among explanatory variables? if not why justify it.

Did you check assumptions of binary logistic regression model?

What variable selection method you used? Forward/backward/stepwise?

Result

In the result section it said that “giving a response rate of 100%.” How it could be? Unbelievable result. justify it.

In the “Knowledge and modeling related characters” has no table citation? Why?

In the model interpretation session you said that “After controlling the effect of other variables

with binary logistic regression, educational status, residence, knowledge, health postvisit,

home visited by HEW, and model family training continued to be significantly associated with utilization of HEPs (P-values<0.25).” how other variables effect controlled in the bivariable analysis part? Justify it.

In the final model result interpretation section “After controlling the effect of other variables with multivariable logistic regressionanalysis, residence [AOR: 3.549(95% CI: 1.99, 6.328)], knowledge [AOR: 1.844(95%CI: 1.216, 2.796)] health post-visit [AOR: 1.625(95% CI: 1.054, 2.504)], home visited by HEW [AOR: 1.676(95% CI: 1.025,2.740)] and Graduated from model family training [AOR: 2.104(95% CI: 1.377,3.215)] were significant factors for health extension

package utilization (Table 4 ).”

Such type of writing should be in the abstract session, you are expected interpret the result explicitly. Correct it during the revision.

Discussion

I found your result and discussion section mixed. You should separate them. If the result is correctly, interpret in the result session no need to repeat it in the discussion session.

In the discussion section your speculation needs citation example “The other possible reason may be a limitation in basic infrastructures in rural communities relative to the Gulelle sub-city administration community.” Need to be supported by evidence…..works for all discussion session.

I did not see any strength and limitation of the study. Why ? justify it?

Conclusion

The conclusion and recommendation should be based on your findings.

Declaration session

No Abbreviations and Acronyms

Totally you did not follow the journal guideline please follow it and correct it accordingly.

Reviewer #2: Major revision is needed in terms of addressing the comments that are indicated in the methods section, results and discussion section.

The work is essential to inform policy makers. However, clarity on the further work to address comments is needed.

Please find my review attached.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Zemenu T.

Reviewer #2: Yes: Abera Kumie

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Submitted filename: Comments Health Extension Plos1_AK 12feb202112 Feb 2021.pdf

Click here for additional data file.

Submitted filename: Reviewer comment to author.docx

Click here for additional data file.

13 May 2021

all comments are addressed, please help me to publish this paper as soon as possible.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

28 Jun 2021

PONE-D-20-30163R1

Health extension service utilization and associated factors in east Gojjam zone, North West Ethiopia: community based cross-sectional study

PLOS ONE

Dear Dr. Aynalem,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Aug 12 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Ammal Mokhtar Metwally, Ph.D (MD)

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #3: (No Response)

Reviewer #4: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #3: (No Response)

Reviewer #4: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #3: (No Response)

Reviewer #4: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thanks authors to addressed all comments. This manuscript need to published and suitabl for publication in PLOS ONE.

Reviewer #3: I found this article very interesting, representing a well designed intervention. The report is totally satisfactory and I suggest to publish it in the present form

Reviewer #4: The authors identified factors associated to health extention service utilization in Noth West Ethipia. The research is original, the topic is relevant and of a high importance in its field. The statistical analysis been performed appropriately and rigorously. However, I have some suggestion to authors.

1. The formula for sample size calculation, W2 is the precision in the parameter estimation, it is different from the alpha (0.05) which is the margin of error (or 95% CI).

2. In the results section, page 7, the first paragraph. After controlling the effect of other variables with binary logistic regression, educational........continued to be significantly associated (p-values<0.25). there is contradiction we can't control in bivariate regression and p-values<0.25 is not sigificant. Please check this paragraph.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Zemenu Tadesse Tessema

Reviewer #3: Yes: Diego Serraino, MD

Reviewer #4: Yes: Hedia Bellali

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

28 Jun 2021

Dear reviewers, I would like to forward my gratitude to you for your constructive comments. I have learnt many things from your comments.

Dear 4th reviewer, I have accepted your comments and some correction are done based on your comments.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

21 Jul 2021

PONE-D-20-30163R2

Health extension service utilization and associated factors in east Gojjam zone, North West Ethiopia: community based cross-sectional study

PLOS ONE

Dear Dr. Aynalem,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Before accepting your manuscript, minor revision is required.

When submitting your revision, please consider addressing these requirements:

1. Please ensure including in the manuscript after the conclusion strengths and the limitation of your study

2. Please provide additional details regarding the ethical approval number  and the name of the ethical committee in the ethics statement in the Methods.

3. Add the authors contribution as per Plos1 Guidelines

Please submit your revised manuscript by Sep 04 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Ammal Mokhtar Metwally, Ph.D (MD)

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #3: (No Response)

Reviewer #4: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #3: Yes

Reviewer #4: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: Yes

Reviewer #4: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #3: Yes

Reviewer #4: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #3: Yes

Reviewer #4: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #3: I do not have further comments - in my opinion the paper is now ready to be published in the present form

Reviewer #4: (No Response)

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #3: Yes: Diego Serraino, MD, MSc

Reviewer #4: Yes: Hedia Bellali, MD, Associate professor in Epidemiology and Public Health

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

23 Jul 2021

all comments have been addressed.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

9 Aug 2021

Health extension service utilization and associated factors in east Gojjam zone, North West Ethiopia: community based cross-sectional study

PONE-D-20-30163R3

Dear Dr. Aynalem,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Ammal Mokhtar Metwally, Ph.D (MD)

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #3: All comments have been addressed

Reviewer #4: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #3: Yes

Reviewer #4: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: Yes

Reviewer #4: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #3: Yes

Reviewer #4: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #3: Yes

Reviewer #4: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #3: (No Response)

Reviewer #4: (No Response)

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #3: No

Reviewer #4: Yes: Dr Hedia Bellali, Associate professor in Epidemiology and Public Health, Medical Faculty of Tunis, Tunisia

11 Aug 2021

PONE-D-20-30163R3

Health extension service utilization and associated factors in east Gojjam zone, North West Ethiopia: a community-based cross-sectional study

Dear Dr. Aynalem:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Professor Ammal Mokhtar Metwally

Academic Editor

PLOS ONE