Abstract
BackgroundCommunity health workers (CHWs) are increasingly being used in low-income countries to address human resources shortages, yet there remain few effective, evidence-based strategies for addressing the enduring programmatic constraints of worker motivation, retention and performance. This paper describes how two interventions were designed by the Innovations at Scale for Community Access and Lasting Effects (inSCALE) project to address these constraints in Uganda and Mozambique drawing on behavioural theory and formative research results.MethodsA review of the work motivation and CHW motivation literature—incorporating influences on retention and performance—was conducted on articles sourced through electronic web searches. Formative research with a focus on the barriers and facilitators to CHW motivation, retention and performance was conducted with community health workers and key stakeholders in Uganda and Mozambique. An analytical induction approach to the thematic analysis of transcripts from 98 in-depth interviews and 26 focus group discussions was adopted across the country settings.ResultsFrom the theoretical review, it was determined that the interventions should promote CHWs as members of a collective by highlighting a sense of shared experience, focus on alignment between worker and programme goals, and emphasise the actions that lead to good performance. The Social Identity Approach was selected as the theory most likely to lead to the development of effective, scalable and sustainable interventions by addressing the identified gap in the literature of the influence of CHW working context. The formative research indicated that CHWs value feedback and feeling connected to the health system and their community, are motivated by status and community standing, and want to be provided with the necessary tools to perform. Two interventions based on these results were developed: a participatory, local community approach and an information communication technology (ICT) approach.ConclusionsDrawing on contextual data and theory that is sensitive to context can potentially lead to the development of appropriate and effective interventions when aiming to improve the motivation, retention and performance of CHWs in Uganda and Mozambique and other comparable settings. Evaluation of the developed interventions is crucial to assess this potential.
Highlights
Community health workers (CHWs) are increasingly being used in low-income countries to address human resources shortages, yet there remain few effective, evidence-based strategies for addressing the enduring programmatic constraints of worker motivation, retention and performance
Previous enquiry focusing on the motivation, retention and performance of cadres of CHWs has typically sought to determine the right incentives to elicit tangible improvements in these outcomes [10,11,16,17,18,19]
Guidelines for managers of CHW programmes often recommend an approach that incorporates health system and community level factors [9,10,19]; psychological explanation of how such approaches may or may not lead to improved motivation, retention and performance remains dominated by behavioural theories that focus on the individual [13,21]
Summary
Community health workers (CHWs) are being utilised in low-income countries to perform key health tasks and address human resources shortages in line with the WHO’s ‘task shifting’ agenda [1,2,3,4,5,6,7,8]. Despite this trend, the motivation, retention and performance of CHWs remain key reported constraints to the success of programmes in these settings [5,9]. From a social psychological perspective, the importance of understanding the role of community context and culture, as well as individual cognitions, has been emphasised when seeking insight into the factors influencing CHW motivation, retention and performance [4,9]
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