Table 2 Programme design and cross-cutting factors influencing HEWs’ relationships with the community and health sector

HEWs being selected from the community that they will serve generally enhanced community trust in HEWs, partly facilitated by good attitudes and high self-esteem of HEWs as a result of serving their own community

HEWs residing in their community of service facilitated ongoing communication and dialogue with community members

If HEWs served a community which they were not originating from, community trust in them could be hampered

Some HEWs were supported by TBAs, as both community and HEWs trusted the competencies of TBAs in child birth and related tasks above those of HEWs

Support from kebele administration, religious leaders and HDA leaders facilitated communication and dialogue between HEWs and community members, assisting HEWs in community mobilization, health education, identification of clients and referral; if this support was not present, communication and dialogue with community was hampered

Community expectations regarding TBA involvement were not always in line with the policy, and this created dilemmas, which could hamper HEWs’ relationships with community and TBAs

In some areas, support from TBAs to HEWs was ceased, because of lack of communication between HEWs and TBAs if TBAs were still conducting deliveries, which is not allowed by government

Quarterly facility or public forums, political gatherings, kebele cabinets, pregnant women’s forums and community-based review meetings were structures that facilitated communication and dialogue between HEWs and the community, including feedback on performance

Improper handling of referral cases hampered trust from HEWs and community in the health sector

Lack of referral forms and feedback after referral hindered communication between HEWs and the health sector

Community expectations with regard to payment of transport and higher level care did sometimes not match with the reality, hampering trusting relationships between HEWs (who made the referral) and community

Supervision with a fault-finding approach and without feedback, partly as a result of lack of resources and training of supervisors, hindered communication between HEWs and supervisors/management

HEWs’ expectations regarding trainings and career advancement were not met, hampering relationships between HEWs and health sector

Irregular held monitoring and evaluation meetings hampered communication between HEWs and the health sector

Regular support from health professionals at health centre level enhanced HEWs’ competencies and made them feel part of a team

Sometimes, expectations from the management level about tasks of HEWs interfered with HEWs’ work