Motivation Of Community Health Workers Research Articles

Utilizing Group Model Building to Identify Barriers and Facilitators of Hypertension Management in Primary Health Care, China.

Group Model Building (GMB) is a qualitative method that refers to a participatory process. This project aims to identify barriers and facilitators of hypertension management in primary health care in China, through which, the leverage point for intervention may be found. The GMB was used to identify the factors influencing hypertension management. Graphs over time and causal loop diagram (CLD) were main tools of GMB. To propose the influencing factors, key stakeholders were invited to participate in a workshop. During the workshop, stakeholders were encouraged to plot the graphs over time of the variables about research issues and give a descriptive explanation. And based on this, a CLD was initially developed to establish a model of the interaction of factors. After the workshop, the research group further improved the CLD through repeated mutual discussions, and gave feedback to the participants. The Vensim PLE 9.0 software package was used to build CLD. A total of 14 key stakeholders were invited to participate in the workshop. Finally, 26 influencing factors were identified, which were divided into three dimensions, including the institutional, the community health workers (CHWs), and the patient level. And 5 reinforcing loops and 4 balancing loops were formed in the CLD. Promoting the building of the Medical Community/Regional Medical Association, implementing the family doctor contract service (FDCS), and enhancing the motivation of CHWs may be potential leverage points for hypertension management in China. By using GMB, we have identified key factors in the management of hypertension in primary health care and provided comprehensive suggestions to overcome the obstacles.

Community Health Workers’ experiences of an intervention to provide them with increased support and supervision: a qualitative study of a home visiting model in rural South Africa

Deploying Community Health Workers (CHWs) is a crucial strategy to improve health at a community level in low- and middle-income countries. While there is substantial evidence for CHW effectiveness, there is a need for more research on the mechanisms through which these programs work. Understanding CHWs experiences of how programmes function is important. This article examines CHW’s experiences of three key programmatic domains; training, logistical support and supervision. Data were gathered using through qualitative descriptive study drawing from semi-structured interviews. The study was embedded within a cluster randomized controlled trial, testing the effectiveness of an enhanced supervision package delivered to government-employed CHWs in the rural Eastern Cape, South Africa, on maternal and child health outcomes We conducted individual semi structured interviews with CHWs (n = 16) and two supervisors. Data were coded deductively and overall, three overarching areas and five sub-themes emerged from our interviews, the overarching teams were; 1) CHW knowledge and confidence increased through additional training, 2) CHW motivation and community acceptance improved because of added logistical support, and 3) CHW supervision led to improved sense of accountability, feelings of respect, and sense of being supported. Our findings highlight the importance of a functional support system within which CHWs can operate, in a context where most CHWs operate in isolation and without support. CHWs receiving supportive supervision reported positive impacts on their motivation and ability to carry out their work effectively. Clinicaltrials.gov, NCT02957799, 2016-11-08.

Female community health volunteers' experience in navigating social context while providing basic diabetes services in western Nepal: Social capital and beyond from systems thinking.

The global burden of non-communicable diseases (NCDs) has led to an increased mobilization of community health workers (CHWs) in the prevention and management of NCDs, particularly in resource-poor settings. However, little is known about the experiences of CHWs as they navigate the complex social context while proving home-based NCD management. This study aims to explore the experiences of female community health volunteers (FCHVs) in a community-based pilot project in western Nepal, specially regarding the social challenges they face while delivering basic type 2 diabetes (T2D) services. Using a qualitative phenomenological approach, the study conducted two focus group discussions and nine in-depth interviews with a total of 14 and 9 FCHVs, respectively. Social Capital theory was employed to understand the sociological aspects. The findings shed light on the challenges encountered by FCHVs in expanding their social networks, building trust, and fostering reciprocity among T2D intervention recepients. Notably, social trust was a significant challenge, compounded by power dynamics related to gender and socioeconomic status. FCHVs managed to overcome these challenges through their perseverance, self-motivation, and leaveraging their strong bonding and linking social capital. The recognition they received from the community played a crucial role in sustaining their motivation. The study highlights the importance of FCHVs' strong social capital, supported by available resources and personal motivation, in overcoming social obstacles. It is imperative for community health interventions to anticipate challenges across various elements of social capital to ensure the long-term retention and motivation of CHWs. Establishing appropriate support systems that address personal motivating factors and the strengthen social capital is essential.

Unpacking the challenges of fragmentation in community-based maternal newborn and child health and health system in rural Ethiopia: A qualitative study.

In Ethiopia, country-wide community-based primary health programs have been in effect for about two decades. Despite the program's significant contribution to advancing Maternal Newborn and Child Health (MNCH), Ethiopia's maternal and child mortality is still one of the highest in the world. The aim of this manuscript is to critically examine the multifaceted fragmentation challenges of Ethiopia's Community Health Workers (CHWs) program to deliver optimum MNCH and build a resilient community health system. We conducted a qualitative case study in West Shewa Zone, rural Ethiopia. A purposive sampling technique was used to recruit participants. Data sources were two focus group discussions with sixteen CHWs, twelve key informant interviews with multilevel public health policy actors, and a policy document review related to the CHW program to triangulate the findings. Thematic analysis of the qualitative data was conducted. The World Health Organization's health systems framework and socio-ecological model guided the data collection, analysis, and interpretation. The CHWs program has been an extended arm of Ethiopia's primary health system and has contributed to improved health outcomes. However, the program has been facing unique systemic challenges that stem from the fragmentation of health finance; medical and equipment supply; working and living infrastructures; CHWs empowerment and motivation, monitoring, supervision, and information; coordination and governance; and community and stakeholder engagement. The ongoing COVID-19 and volatile political and security issues are exacerbating these fragmentation challenges. This study emphasized the gap between the macro (national) level policy and the challenge during implementation at the micro (district)level. Fragmentation is a blind spot for the community-based health system in rural Ethiopia. We argue that the fragmentation challenges of the community health program are exacerbating the fragility of the health system and fragmentation of MNCH health outcomes. This is a threat to sustain the MNCH outcome gains, the realization of national health goals, and the resilience of the primary health system in rural Ethiopia. We recommend that beyond the current business-as-usual approach, it is important to emphasize an evidence-based and systemic fragmentation monitoring and responsive approach and to better understand the complexity of the community-based health system fragmentation challenges to sustain and achieve better health outcomes. The challenges can be addressed through the adoption of transformative and innovative approaches including capitalizing on multi-stakeholder engagement and health in all policies in the framework of co-production.

From an interventional study to a national scale-up: lessons learned from the Malakit strategy at the French Guiana–Suriname border

Scaling-up an experimental intervention is always a challenge. On the border between French Guiana, Brazil and Suriname, an interventional study demonstrated the effectiveness of distributing self-diagnosis and self-treatment kits (Malakits) to control malaria in mobile and hard-to-reach populations. Its integration into the Suriname’s National Malaria Elimination Plan after a 2-year experiment faced numerous challenges, including human resources to cope with the additional workload of coordinators and to maintain the motivation of community health workers. The economic recession in Suriname, the Covid pandemic, and logistical issues also hampered the scale-up. Finally, thanks to the commitment of stakeholders in Suriname and French Guiana, the integration of Malakit distribution into the Surinamese national programme was proved possible.

'Community health workers are unable to work because they don't have supervisors' - mid-level providers' experiences of a CHW program in rural South Africa.

The World Health Organization has called for more than 4 million community health workers (CHWs) globally; yet there are gaps in the evidence of CHWs' impact where studies have not had consistent results. South Africa is currently investing in CHW programs. However, there are significant concerns about the implementation and effectiveness of the program. We interviewed mid-level supervisors involved in eight rural clinics in a deeply rural South African municipality to identify the strengths and weaknesses of the CHW programs currently being implemented. Half of these clinics were part of a program providing enhanced supervision to CHWs, and the remainder were operating as usual. We hypothesized that stakeholders would provide valuable insights on how to improve the implementation of CHW programs. Fourteen interviews with supervisors from three levels of clinic and non-governmental organizations were conducted. Interviews were transcribed and translated from isiXhosa to English, and thematically analysed using ATLAS.ti. Two overarching themes emerged: challenges at the national CHW program level (loss of political support, inadequacy of supervision and access to resources, human resource considerations); and experiences of the enhanced-supervision model provided (engagement and buy-in, link between CHW program and healthcare facilities, improvements through the intervention). Our findings suggest that CHWs operate largely unsupported, with limited access to training, equipment and supervision. The enhanced-supervision intervention appeared to mitigate some of these shortfalls. To make CHW programs efficient, we need to recruit CHWs based on social and administrative competence (rather than network referrals), provide improved higher quality training, provide more resources, especially equipment and transport, and ensure that CHWs receive supportive supervision that goes beyond simply administrative supervision. Furthermore, our findings suggest that the intervention in this study has somewhat mitigated these challenges through a package of supportive supervision and additional resources, highlighting the importance of stakeholder engagement and buy-in. It is clear that the governmental CHW program has many challenges - a number of which were temporarily mitigated by the intervention tested in this research's parent study. A list of recommendations for practice was developed from this work. First, contracts and reimbursements are important for CHW motivation, and are seen as essential prerequisites for CHW program success. Second, CHWs and other stakeholders must be involved in the design and implementation of the CHW program. Third, good-quality training and refresher trainings for CHWs is critical. Fourth, access to equipment such as scales is needed. Fifth, transport is critical in rural areas to access patients in remote areas. Lastly, supportive supervision was described as of upmost importance. CHWs have the potential to provide invaluable support in communities, and in rural communities in particular - but they need to operate in a functional supportive system. More resources need to be allocated to training, equipment and supportive supervision.

Effects of community performance-based financing on community health workers’ service delivery in Kayanza health district, Burundi

Background: In many low- and middle-income countries, community services are often provided on a volunteer basis. To make their work more effective in the communities, some of them including Burundi adopted community performance-based financing as form of motivation of community health workers (CHWs). The study aimed to demonstrate the relationship between the community performance-based financing and health service delivery by the community health workers.Methods: It was a cross-sectional study using a comparative approach to assess the relationship with the performance-based financing scheme and the community services delivery. We used a stratified random sampling and inferential statistics used chi square and logistic regression.Results: The occupation of CHWs was significantly associated with counselling for early ANC (p=0.002), women attending early ANC and 4 ANC visits (p=0.000). Female were about 3 times likely to refer FP clients for FP methods uptake [p=0.043, CI= (1.030; 7.462), OR=2.773]. Farmers were 11 times as likely to perform this task as CHWs with other functions [p=0.000, CI= (3.890; 32.733), OR=11.284]. The CHWs who received 9 equipment and above [p=0.037, CI= (1.101)].Conclusions: The community performance-based financing has a significant relationship with the community health workers service delivery and should be enhanced by trainings, formative supervision, and provision of equipment. Occupation was identified as to predict this association. But further studies be conducted to establish other factors that complement the community performance-based financing in community services delivery.

The influence of incentives on community health worker motivation in the provision of family planning. A case of Msalala and Shinyanga Districts, Tanzania

Community health workers (CHWs) are essential in the provision of a wide range of services, including family planning. In Tanzania, deployment of CHWs has largely been supported by non-governmental organizations (NGOs) who often determine their incentives. A mix of incentives is required to increase CHW motivation and, ultimately, performance. This qualitative study aimed to explore how incentives influence CHW motivation in the provision of family planning services in Msalala and Shinyanga districts. The study included focus group discussions and in-depth interviews with 21 CHWs, 12 supervisors and eight policy makers and NGO representatives. Transcripts were coded and narratives were written on types of incentives, motivating and demotivating factors. The study revealed that although CHW motivation was related to feelings of accomplishment and respect from the community, financial incentives were found equally important for motivation. While most CHWs received non-financial incentives, CHWs had unequal access to financial incentives. Key informants confirmed that there was no coordination on incentives at district level. Some CHWs reported demotivation because of misconceptions and unacceptance of family planning in the community and irregular supply of contraceptives. Results from this study show that motivation of voluntary CHWs in Msalala and Shinyanga districts is currently sub-optimal, because of inequity in access to (financial) incentives. There is a need for better coordination and standardization of CHW incentives. Advocacy is needed to increase funding for CHWs’ deployment and remuneration. This would increase CHW motivation and ultimately performance, also in the field of family planning.

Beyond Institutionalization: Planning for Sustained Investments in Training, Supervision, and Support of Community Health Worker Programs in Bangladesh.

Bangladesh has a long history of mature and institutionalized community health worker (CHW) programs in primary health care. However, there is a lot of variability in the performance of the CHW programs in Bangladesh, as well as challenges associated with retention of CHWs. This study describes the challenges for CHWs, which in turn affect their motivation and performance. This study was conducted from December 2019 to January 2020 in 4 districts in Bangladesh: Cox's Bazar, Khulna, Rajshahi, and Sylhet. Twenty focus group discussions were conducted with 121 participants, including family welfare assistants (FWA), health assistants (HA), and their direct supervisors. Thirty in-depth interviews were conducted with upazila and district-level stakeholders. Data were analyzed using a thematic approach with a particular focus on CHW motivation, job satisfaction, and incentive preferences for improving morale and performance. Several nonmonetary and monetary factors affect CHWs' motivation, performance, and job satisfaction. Recognition by the community, availability of promotions and technical recognition, increased training opportunities, reduced workloads, identification as government employees, access to transportation, provision of working tools, and improvements in the workplace environment were identified as important nonmonetary incentives. CHWs also discussed the importance of sufficient salaries and allowances. Several factors impede the effectiveness of the CHW programs in Bangladesh. Changes to technical ranks and wages for the health care sector need to take a sector-wide lens to enable systematic calibration of wages for all health care workers. This study highlights that institutionalization of CHWs without adequate and sustained support for continued training, compensation, supervision, access to working tools, and recognition is insufficient to drive change. Identifying pragmatic strategies that can be supported through existing government budgets to address these factors is vital to sustaining the community health workforce in Bangladesh.

Community Health Workers' Experiences in Strengthening the Uptake of Childhood Immunization and Malaria Prevention Services in Urban Sierra Leone.

Introduction: Community health workers (CHWs) play an integral role in Sierra Leone's health systems strengthening efforts. Our goal was to understand CHWs' experiences of providing immunization and malaria prevention services in urban settings and explore opportunities to optimize their contributions to these services.Methods: In 2018, we conducted an exploratory qualitative assessment in the Western Area Urban district, which covers most of the capital city of Freetown. We purposively selected diverse health facilities (i.e., type, ownership, setting) and recruited CHWs through their supervisors. We conducted eight focus group discussions (FGD) with CHWs, which were audio-recorded. The topics explored included participants' background, responsibilities and priorities of urban CHWs, sources of motivation at work, barriers to CHWs' immunization and malaria prevention activities, and strategies used to address these barriers. The local research team transcribed and translated FGDs into English; then we used qualitative content analysis to identify themes.Results: Four themes emerged from the qualitative content analysis: (1) pride, compassion, recognition, and personal benefits are important motivating factors to keep working as CHWs; (2) diverse health responsibilities and competing priorities result in overburdening of CHWs; (3) health system- and community-level barriers negatively affect CHWs' activities and motivation; (4) CHWs use context-specific strategies to address challenges in their work but require further support.Conclusion: Focused support for CHWs is needed to optimize their contributions to immunization and malaria prevention activities. Such interventions should be coupled with systems-level efforts to address the structural barriers that negatively affect CHWs' overall work and motivation, such as the shortage of work supplies and the lack of promised financial support.

Performance-based incentives and community health workers' outputs, a systematic review.

ObjectiveTo review the evidence on the impact on measurable outcomes of performance-based incentives for community health workers (CHWs) in low- and middle-income countries.MethodsWe conducted a systematic review of intervention studies published before November 2020 that evaluated the impact of financial and non-financial performance-based incentives for CHWs. Outcomes included patient health indicators; quality, utilization or delivery of health-care services; and CHW motivation or satisfaction. We assessed risk of bias for all included studies using the Cochrane tool. We based our narrative synthesis on a framework for measuring the performance of CHW programmes, comprising inputs, processes, performance outputs and health outcomes.FindingsTwo reviewers screened 2811 records; we included 12 studies, 11 of which were randomized controlled trials and one a non-randomized trial. We found that non-financial, publicly displayed recognition of CHWs’ efforts was effective in improved service delivery outcomes. While large financial incentives were more effective than small ones in bringing about improved performance, they often resulted in the reallocation of effort away from other, non-incentivized tasks. We found no studies that tested a combined package of financial and non-financial incentives. The rationale for the design of performance-based incentives or explanation of how incentives interacted with contextual factors were rarely reported.ConclusionFinancial performance-based incentives alone can improve CHW service delivery outcomes, but at the risk of unincentivized tasks being neglected. As calls to professionalize CHW programmes gain momentum, research that explores the interactions among different forms of incentives, context and sustainability is needed.

What is the impact of removing performance-based financial incentives on community health worker motivation? A qualitative study from an infant and young child feeding program in Bangladesh

BackgroundCommunity health worker (CHW) motivation is an important factor related to health service quality and CHW program sustainability in low- and middle-income countries. Financial and non-financial motivators may influence CHW behavior through two dimensions of motivation: desire to perform and effort expended. The aim of this study was to explore how the removal of performance-based financial incentives impacted CHW motivation after formal funding ceased for Alive and Thrive (A&T), an infant and young child feeding (IYCF) program in Bangladesh.MethodsThis qualitative study included seven focus groups (n = 43 respondents) with paid supervisors of volunteer CHWs tasked with delivering interpersonal IYCF counseling services. Data were transcribed, translated into English, and then analyzed using both a priori themes and a grounded theory approach.ResultsResults suggest the removal of financial incentives was perceived to have negatively impacted CHWs’ desire to perform in three primary ways: 1) a decreased desire to work without financial compensation, 2) changes in pre- and post-intervention motivation, and 3) household income challenges due to dependence on incentives. Removal of financial incentives was perceived to have negatively impacted CHWs’ level of effort expended in four primary ways: 1) a reduction in CHW visits, 2) a reduction in quality of care, 3) CHW attrition, and 4) substitution of other income-generating activities.ConclusionsThis study provides new evidence regarding how removing performance-based financial incentives from a CHW program can negatively impact CHW motivation. The findings suggest that program decision makers should consider how to construct community health work programs such that CHWs may continue to receive performance-based compensation after the original funding ceases.

Barriers and facilitators in implementing population based common cancer screening through community health workers.

Population based cancer screening was initiated in India in 2016 owing to an increased burden of cancers. A feasibility health system study was done by utilising community health workers (CHWs) to conduct the cancer screening. The current study is a qualitative study to elicit the barriers and facilitators in implementing population based cancer screening through CHWs. The study was conducted at three subcentres of Dholai block of Cachar district, Assam, India and Cachar Cancer Hospital and Research Center, Silchar. The participants of the study were CHWs, master trainer nurses and women from community. Three focus group discussions (FGDs) and one in-depth interview (IDI) were conducted at the provider level and seven IDIs of women from the community. The FGDs and IDIs were audio recorded after taking verbal consent from the participants. The verbatims were prepared following translation and transcription and data analysis using ATLAS ti ver 8. The major barrier faced by the community was a lack of motivation to get screened which stemmed from various factors such as personal beliefs, attitudes and fear. The major facilitators were accessibility of tests, family support and CHWs as screening service providers. The major barriers for CHWs were difficulty in motivating the community, lack of support from supervisors and lack of motivation to work. The major facilitators were convenience of screening during home visits, empowerment, skill enhancement and teamwork. Population based cancer screening was a new concept for the community under study. Cancer screening by CHWs was well accepted by the community. Awareness generation among the community was a major factor in improving screening coverage. The study highlights that training and motivation of CHWs can improve the uptake of cancer screening services. CHWs felt empowered with the new skills imparted and were able to carry out screening.

Perceptions and experiences of community health workers on community-based child health interventions in the Maekel region, Eritrea

Background In 2015 alone, 5,9 million children under the age of five died. In an attempt to reduce child mortality in Eritrea, the government implemented community- based child health interventions by community health workers (CHWs). Despite progress, challenges remain. In Eritrea, few studies have examined CHWs and community perceptions of child health interventions. The aim of this study was to explore the perceptions of CHWs regarding benefits and challenges of community-based child health interventions in the Maekel region in Eritrea. Methods An explorative qualitative study was conducted employing focus group discussions. Data was analyzed using qualitative content analysis. Results The CHWs reported positive aspects such as easier access to health services, generated relationships and support and opportunities to give back to the community. Perceived challenges were: constraints in delivering services, resources and supervision, inadequate knowledge and awareness and juggling multiple roles with no pay. The ministry of health (MoH) in Eritrea prioritizes reducing child mortality but, is still in the process of building and stabilizing the healthcare system. The biggest challenge is to incorporate community level Integrated Management of Childhood Illnesses and Case Management (C-IMCI/iCCM), involving communities, families and CHWs into the current system of limited resources. Conclusions This study indicates the importance of focusing on identifying solutions to the challenges the CHWs faces and understanding factors associated with CHWs motivation. This with the hope of better effectiveness and sustainability of the C-IMCI/iCCM program.

Assessing the feasibility and acceptability of a financial versus behavioural incentive-based intervention for community health workers in rural Indonesia

BackgroundThe World Health Organization recommends that community health workers (CHWs) receive a mix of financial and non-financial incentives, yet notes that there is limited evidence to support the use of one type of incentive (i.e. financial or non-financial) over another. In preparation for a larger scale trial, we investigated the acceptability and feasibility of two different forms of incentives for CHWs in Malang District, Indonesia.MethodsCHWs working on a cardiovascular disease (CVD) risk screening and management programme in two villages were assigned to receive either a financial or non-financial incentive for 6 months. In the financial incentives village, CHWs (n = 20) received 16,000 IDR (USD 1.1) per patient followed up or 500,000 IDR (USD 34.1) if they followed up 100% of their assigned high-risk CVD patients each month. In the non-financial incentive village, CHWs (n = 20) were eligible to receive a Quality Care Certificate for following up the highest number of high-risk CVD patients each month, awarded in a public ceremony. At the end of the 6-month intervention period, focus group discussions were conducted with CHWs and semi-structured interviews with programme administrators to investigate acceptability, facilitators and barriers to implementation and feasibility of the incentive models. Data on monthly CHW follow-up activity were analysed using descriptive statistics to assess the preliminary impact of each incentive on service delivery outcomes, and CHW motivation levels were assessed pre- and post-implementation.ResultsFactors beyond the control of the study significantly interrupted the implementation of the financial incentive, particularly the threat of violence towards CHWs due to village government elections. Despite CHWs reporting that both the financial and non-financial incentives were acceptable, programme administrators questioned the sustainability of the non-financial incentive and reported CHWs were ambivalent towards them. CHW service delivery outcomes increased 17% for CHWs eligible for the non-financial incentive and 21% for CHWs eligible for the financial incentive. There was a statistically significant increase (p < 0.0001) in motivation scores for the performance domain in both villages.ConclusionIt was feasible to deliver both a performance-based financial and non-financial incentive to CHWs in Malang District, Indonesia, and both incentive types were acceptable to CHWs and programme administrators. Evidence of preliminary effectiveness also suggests that both the financial and non-financial incentives were associated with improved motivation and service delivery outcomes. These findings will inform the next phase of incentive design, in which incentive feasibility and preliminary effectiveness will need to be considered alongside their longer-term sustainability within the health system.

Learnings From a Pilot Study to Strengthen Primary Health Care Services: The Community-Clinic-Centered Health Service Model in Barishal District, Bangladesh.

Community clinics (CCs) staffed by community health workers (CHWs) represent an effort of the Government of Bangladesh to strengthen the grassroots provision of primary health care services and to accelerate progress in achieving universal health coverage. The Improving Community Health Workers (ICHWs) Project of Save the Children piloted a CC-centered health service (CCHS) model that strengthened community and local government engagement, harmonized the work of different CHW cadres who were working in the same catchment area of each CC, and improved the accountability of CHWs and the CC to the local community. We describe the process for developing and implementing the CCHS model in 6 unions in Barishal District where the model was piloted and provide some early qualitative and quantitative findings pertaining to the model's effectiveness. Data were collected from CCs in the 6 pilot unions and 6 other unions that served as a control. Qualitative data were collected from the intervention area during the pre-pilot (October 2017-September 2018) and pilot phase (October 2018-September 2019). Document review, key informant interviews, and focus group discussions were also conducted. Maternal and child health service utilization data were extracted from the government health information system in both the intervention and control areas. Community group meetings ensured engagement with local government authorities and supported resource mobilization. There was greater coordination of work among CHWs and increased motivation of CHWs to better serve their clients. The analysis showed that the increase in maternal health consultations was substantially greater in the intervention area than in the control area, as was the number of referrals for higher-level care. The CCHS model as applied in this pilot project is effective in engaging local key stakeholders, increasing CHW capacity, and improving client satisfaction. The model demonstrated that a community health system can be strengthened by a comprehensive approach that engages communities and local government officials and that harmonizes the work of CHWs.

Development and validation of a multi-dimensional scale to assess community health worker motivation.

BackgroundEnsuring that Community Health Workers (CHWs) are motivated is critical to their performance, retention and well-being – and ultimately to the effectiveness of community health systems worldwide. While CHW motivation is as multi-dimensional construct, there is no multi-dimensional measure available to guide programming. In this study, we developed and validated a pragmatic, multi-dimensional measure of CHW motivation.MethodsScale validation entailed qualitative and survey research in Mali and Bangladesh. We developed a pool of work satisfaction items as well as several items assessing the importance of hypothesized sub-dimensions of motivation, based on the literature and expert consultations. Qualitative research helped finalize scale sub-dimensions and items. We tested the scale in surveys with CHWs in Mali (n = 152, 40% female, mean age 32) and Bangladesh (n = 76 women, mean age 46). We applied a split-sample exploratory/confirmatory factor analysis (EFA/CFA) in Mali, and EFA in Bangladesh, then assessed reliability. We also gauged convergent/predictive validity, assessing associations between scale scores with conceptually related variables.ResultsThe final 22-item scale has four sub-dimensions: Quality of supervision, Feeling valued and capacitated in your work, Peer respect and support, and Compensation and workload. Model fit in CFAs was good, as were reliabilities for the full scale (alpha: 0.84 in Mali, 0.93 in Bangladesh) and all sub-dimensions. To construct scores for the final scale, we weighted the scores for each sub-dimension by CHW-reported importance of that sub-dimension. Final possible range was -6 to +6 (sub-dimensions), -24 to +24 (full scale). Mean (standard deviation) of full-scale scores were 5.0 (3.3) in Mali and 14.5 (5.3) in Bangladesh. In both countries, higher motivation was significantly associated with higher overall interest in their work, feeling able to improve health/well-being in their community, as well as indicators of higher performance and retention.ConclusionsWe found that the Multi-dimensional Motivation (MM) scale for CHWs is a valid and reliable measure that comprehensively assesses motivation. We recommend the scale be employed in future research around CHW performance and community health systems strengthening worldwide. The scale should be further evaluated within longitudinal studies assessing CHW performance and retention outcomes over time.

Understanding the importance of non-material factors in retaining community health workers in low-income settings: a qualitative case-study in Ethiopia

ObjectivesThe motivation and retention of community health workers (CHWs) is a challenge and inadequately addressed in research and policy. We sought to identify factors influencing the retention of CHWs in...

Community health worker motivation to perform systematic household contact tuberculosis investigation in a high burden metropolitan district in South Africa

BackgroundSouth Africa faces a chronic shortage of professional health workers. Accordingly, community health workers (CHWs) are being employed to mitigate the ongoing health workforce deficiencies. As increased access to quality service delivery hinges upon their motivation, this study explored CHWs’ motivation to deliver systematic household contact tuberculosis (TB) investigation (SHCI).MethodsIn 2017, a cross-sectional survey was conducted among CHWs in the Mangaung Metropolitan District, Free State Province. Exploratory factor analysis was performed on a 30-item scale to determine the dimensions underlying CHW motivation. Items with factor loadings of 0.4 and above were retained. Descriptive and inferential analyses were used to determine CHW motivation levels. Multiple linear regression analysis was used to investigate the determinants of CHW motivation.ResultsOut of 235 participants, 89.2% were female. Participants’ median age was 39 (inter-quartile range: 33–45) years. CHW motivation was defined by 16 items across three dimensions — intrinsic job satisfaction, burnout and team commitment, together explaining 56.04% of the total variance. The derived scale showed satisfactory internal consistency (Cronbach’s alpha: 0.81), with a mean motivation score of 52.26 (standard deviation [sd]: 5.86) out of 64. Statistically significant differences were observed between formal CHWs — those with at least phase 1 standardised accredited training, and informal CHWs — those without such accredited training regarding team commitment scores (17.82 [sd: 2.48] vs. 17.07 [sd: 2.82]; t(233) = 2.157; p = 0.013). CHW age (β = 0.118, p = 0.029), location (β = 1.737, p = 0.041), length of service (β = − 0.495, p < 0.001), attendance of TB SHCI training (β = 1.809, p = 0.036), and TB SHCI competence (β = 0.706, p < 0.001), contributed statistically significantly to CHW motivation.ConclusionCHW motivation to perform TB SHCI was both intrinsic and extrinsic. The high overall mean score implies that the CHWs were well-motivated to perform TB SHCI. To ensure sustained improved access to quality TB SHCI service provision, programme managers in the Free State and similar settings could potentially use the tool derived from this study to monitor and inform CHW motivation interventions. Interventions should pay close attention to the CHWs’ formalisation, competence and training.

Equity for health delivery: Opportunity costs and benefits among Community Health Workers in Rwanda.

Community Health Workers (CHWs) play a vital role delivering health services to vulnerable populations in low resource settings. In Rwanda, CHWs provide village-level care focused on maternal/child health, control of infectious diseases, and health education, but do not receive salaries for these services. CHWs make up the largest single group involved in health delivery in the country; however, limited information is available regarding the socio-economic circumstances and satisfaction levels of this workforce. Such information can support governments aiming to control infectious diseases and alleviate poverty through enhanced healthcare delivery. The objectives of this study were to (1) evaluate CHW opportunity costs, (2) identify drivers for CHW motivation, job satisfaction and care provision, and (3) report CHW ideas for improving retention and service delivery. In this mixed-methods study, our team conducted in-depth interviews with 145 CHWs from three districts (Kirehe, Kayonza, Burera) to collect information on household economics and experiences in delivering healthcare. Across the three districts, CHWs contributed approximately four hours of volunteer work per day (range: 0-12 hrs/day), which translated to 127 684 RWF per year (range: 2 359-2 247 807 RWF/yr) in lost personal income. CHW out-of-pocket expenditures (e.g. patient transportation) were estimated at 36 228 RWF per year (range: 3 600-364 800 RWF/yr). Participants identified many benefits to being CHWs, including free healthcare training, improved social status, and the satisfaction of helping others. They also identified challenges, such as aging equipment, discrepancies in financial reimbursements, poverty, and lack of formal workspaces or working hours. Lastly, CHWs provided perspectives on reasonable and feasible improvements to village-level health programming that could improve conditions and equity for those providing and using the CHW system.