Dataset Information

Assessing community health workers' performance motivation: a mixed-methods approach on India's Accredited Social Health Activists (ASHA) programme.

ABSTRACT:

Objective

This study examined the performance motivation of community health workers (CHWs) and its determinants on India's Accredited Social Health Activist (ASHA) programme.

Design

Cross-sectional study employing mixed-methods approach involved survey and focus group discussions.

Setting

The state of Orissa.

Participants

386 CHWs representing 10% of the total CHWs in the chosen districts and from settings selected through a multi-stage stratified sampling.

Primary and secondary outcome measures

The level of performance motivation among the CHWs, its determinants and their current status as per the perceptions of the CHWs.

Results

The level of performance motivation was the highest for the individual and the community level factors (mean score 5.94-4.06), while the health system factors scored the least (2.70-3.279). Those ASHAs who felt having more community and system-level recognition also had higher levels of earning as CHWs (p=0.040, 95% CI 0.06 to 0.12), a sense of social responsibility (p=0.0005, 95% CI 0.12 to 0.25) and a feeling of self-efficacy (p=0.000, 95% CI 0.38 to 0.54) on their responsibilities. There was no association established between their level of dissatisfaction on the incentives (p=0.385) and the extent of motivation. The inadequate healthcare delivery status and certain working modalities reduced their motivation. Gender mainstreaming in the community health approach, especially on the demand-side and community participation were the positive externalities of the CHW programme.

Conclusions

The CHW programme could motivate and empower local lay women on community health largely. The desire to gain social recognition, a sense of social responsibility and self-efficacy motivated them to perform. The healthcare delivery system improvements might further motivate and enable them to gain the community trust. The CHW management needs amendments to ensure adequate supportive supervision, skill and knowledge enhancement and enabling working modalities.

SUBMITTER: Gopalan SS

PROVIDER: S-EPMC3488714 | biostudies-literature | 2012

REPOSITORIES: biostudies-literature

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Publications

Assessing community health workers' performance motivation: a mixed-methods approach on India's Accredited Social Health Activists (ASHA) programme.

Gopalan Saji Saraswathy SS Mohanty Satyanarayan S Das Ashis A

BMJ open 20120927 5

<h4>Objective</h4>This study examined the performance motivation of community health workers (CHWs) and its determinants on India's Accredited Social Health Activist (ASHA) programme.<h4>Design</h4>Cross-sectional study employing mixed-methods approach involved survey and focus group discussions.<h4>Setting</h4>The state of Orissa.<h4>Participants</h4>386 CHWs representing 10% of the total CHWs in the chosen districts and from settings selected through a multi-stage stratified sampling.<h4>Prima ...[more]

PMID: 23019208

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Project description:BackgroundHypertension is a major risk factor for cardiovascular disease, a leading cause of premature death and disability in India. Since access to health services is poor in rural India and Accredited Social Health Activists (ASHAs) are available throughout India for maternal and child health, a potential solution for improving hypertension control is by utilising this available workforce. We aimed to develop and implement a training package for ASHAs to identify and control hypertension in the community, and evaluate the effectiveness of the training program using the Kirkpatrick Evaluation Model.MethodsThe training program was part of a cluster randomised feasibility trial of a 3-month intervention to improve hypertension outcomes in South India. Training materials incorporated details on managing hypertension, goal setting, facilitating group meetings, and how to measure blood pressure and weight. The 15 ASHAs attended a five-day training workshop that was delivered using interactive instructional strategies. ASHAs then led community-based education support groups for 3 months. Training was evaluated using Kirkpatrick's evaluation model for measuring reactions, learning, behaviour and results using tests on knowledge at baseline, post-training and post-intervention, observation of performance during meetings and post-intervention interviews.ResultsThe ASHAs' knowledge of hypertension improved from a mean score of 64% at baseline to 76% post-training and 84% after the 3-month intervention. Research officers, who observed the community meetings, reported that ASHAs delivered the self-management content effectively without additional assistance. The ASHAs reported that the training materials were easy to understand and useful in educating community members.ConclusionASHAs can be trained to lead community-based group educational discussions and support individuals for the management of high blood pressure.Trial registrationThe feasibility trial is registered with the Clinical Trials Registry - India (CTRI) CTRI/2016/02/006678 (25/02/2016).

Project description:BackgroundGlobally, community health workers (CHWs) are integral contributors to many health systems. In India, Accredited Social Health Activists (ASHAs) have been deployed since 2005. Engaged in multiple health care activities, they are a key link between the health system and population. ASHAs are expected to participate in new health programmes prompting interest in their current workload from the perspective of the health system, community and their family.MethodsThis mixed-methods design study was conducted in rural and tribal Primary Health Centers (PHCs), in Pune district, Western Maharashtra, India. All ASHAs affiliated with these PHCs were invited to participate in the quantitative study, those agreeing to contribute in-depth interviews (IDI) were enrolled in an additional qualitative study. Key informants' interviews were conducted with the Auxiliary Nurse Midwife (ANM), Block Facilitators (BFF) and Medical Officers (MO) of the same PHCs. Quantitative data were analysed using descriptive statistics. Qualitative data were analysed thematically.ResultsWe recruited 67 ASHAs from the two PHCs. ASHAs worked up to 20 h/week in their village of residence, serving populations of approximately 800-1200, embracing an increasing range of activities, despite a workload that contributed to feelings of being rushed and tiredness. They juggled household work, other paid jobs and their ASHA activities. Practical problems with travel added to time involved, especially in tribal areas where transport is lacking. Their sense of benefiting the community coupled with respect and recognition gained in village brought happiness and job satisfaction. They were willing to take on new tasks. ASHAs perceived themselves as 'voluntary community health workers' rather than as 'health activists".ConclusionsASHAs were struggling to balance their significant ASHA work and domestic tasks. They were proud of their role as CHWs and willing to take on new activities. Strategies to recruit, train, skills enhancement, incentivise, and retain ASHAs, need to be prioritised. Evolving attitudes to the advantages/disadvantages of current voluntary status and role of ASHAs need to be understood and addressed if ASHAs are to be remain a key component in achieving universal health coverage in India.

Project description:BackgroundAs India's accredited social health activist (ASHA) community health worker (CHW) programme enters its second decade, we take stock of the research undertaken and whether it examines the health systems interfaces required to sustain the programme at scale.MethodsWe systematically searched three databases for articles on ASHAs published between 2005 and 2016. Articles that met the inclusion criteria underwent analysis using an inductive CHW-health systems interface framework.ResultsA total of 122 academic articles were identified (56 quantitative, 29 mixed methods, 28 qualitative, and 9 commentary or synthesis); 44 articles reported on special interventions and 78 on the routine ASHA program. Findings on special interventions were overwhelmingly positive, with few negative or mixed results. In contrast, 55% of articles on the routine ASHA programme showed mixed findings and 23% negative, with few indicating overall positive findings, reflecting broader system constraints. Over half the articles had a health system perspective, including almost all those on general ASHA work, but only a third of those with a health condition focus. The most extensively researched health systems topics were ASHA performance, training and capacity-building, with very little research done on programme financing and reporting, ASHA grievance redressal or peer communication. Research tended to be descriptive, with fewer influence, explanatory or exploratory articles, and no predictive or emancipatory studies. Indian institutions and authors led and partnered on most of the research, wrote all the critical commentaries, and published more studies with negative results.ConclusionPublished work on ASHAs highlights a range of small-scale innovations, but also showcases the challenges faced by a programme at massive scale, situated in the broader health system. As the programme continues to evolve, critical comparative research that constructively feeds back into programme reforms is needed, particularly related to governance, intersectoral linkages, ASHA solidarity, and community capacity to provide support and oversight.

Project description:Community health workers (CHWs) in Mozambique (known as Agentes Polivalentes Elementares (APEs)) are key actors in providing health services in rural communities. Supervision of CHWs has been shown to improve their work, although details of how it is implemented are scarce. In Mozambique, APE supervision structures and scope of work are clearly outlined in policy and rely on supervisors at the health facility of reference. The aim of this study was to understand how and which aspects of supervision impact on APE motivation and programme implementation.Qualitative research methodologies were used. Twenty-nine in-depth interviews were conducted to capture experiences and perceptions of purposefully selected participants. These included APEs, health facility supervisors, district APE supervisors and community leaders. Interviews were recorded, translated and transcribed, prior to the development of a thematic framework.Supervision was structured as dictated by policy but in practice was irregular and infrequent, which participants identified as affecting APE's motivation. When it did occur, supervision was felt to focus more on fault-finding than being supportive in nature and did not address all areas of APE's work - factors that APEs identified as demotivating. Supervisors, in turn, felt unsupported and felt this negatively impacted performance. They had a high workload in health facilities, where they had multiple roles, including provision of health services, taking care of administrative issues and supervising APEs in communities. A lack of resources for supervision activities was identified, and supervisors felt caught up in administrative issues around APE allowances that they were unable to solve. Many supervisors were not trained in providing supportive supervision. Community governance and accountability mechanisms were only partially able to fill the gaps left by the supervision provided by the health system.The findings indicate the need for an improved supervision system to enhance support and motivation and ultimately performance of APEs. Our study found disconnections between the APE programme policy and its implementation, with gaps in skills, training and support of supervisors leading to sub-optimal supervision. Improved methods of supervision could be implemented including those that maximize the opportunities during face-to-face meetings and through community-monitoring mechanisms.

Project description:BackgroundEthiopia has been providing health care to its rural population since 2004 using female Community Health Workers called Health Extension Workers (HEWs). The HEWs are credited with several achievements in improving the country's health indicators. However, information about the HEWs' motivation and job satisfaction is limited. The aim of this study was to assess the HEWs' motivation and job satisfaction, as well as the factors that influence them.MethodsA mixed-methods study was nested within a national health extension program assessment conducted from March 01 to May 31, 2019. A structured questionnaire which looked at motivation and satisfaction with Likert type single-question and multiple-item measures was used to collect quantitative data from 584 HEWs. Focus group discussion and in-depth interviews were used to gather qualitative data. Means and percentages were used to descriptively summarize important variables. Linear regression was used to identify factors associated with job satisfaction. The qualitative data was analysed thematically.ResultsOverall, 48.6% of HEWs were satisfied with their job, with a mean score of 2.5 out of 4.0. The result showed a high level of satisfaction with autonomy (72%), relationships with co-workers (67%), and recognition (56%). Low level of satisfaction was linked to pay and benefits (13%), opportunities for promotion (29%), and education (34%). Regression analysis showed that HEWs in the age category of 30 years and older had lower satisfaction scores as compared to HEWs in the age category of 18-24 years (adjusted β = - 7.71, 95% CI: - 14.42, - 0.99). The qualitative result revealed that desire to help their community, recognition or respect gained from the community, and achievement were the major motivating factors. In contrast, inadequate pay and benefit, limited education and career advancement opportunities, workload, work environment, limited supportive supervision, and absence of opportunity to change workplace were the demotivating factors.ConclusionsThe overall job satisfaction of HEWs was low; extrinsic factors, such as inadequate pay, limited education and career advancement opportunities were the major sources of demotivation. Policy makers and human resource managers should revise their human resource policies and guidelines to address the main sources of low level of job satisfaction and demotivation.

Project description:BackgroundThe setting of realistic performance-based financing rewards necessitates not just knowledge of health workers' salaries, but of the revenue that accrues from their additional income-generating activities. This study examined the coping mechanisms of health workers in the public health sector of Nasarawa and Ondo states in Nigeria to supplement their salaries and benefits; it also estimated the proportionate value of the revenues from those coping mechanisms in relation to the health workers' official incomes.MethodsThis study adopted a mixed-methods approach, consisting of semi-structured interviews, a review of policy documents, a survey using self-administered questionnaires, and the randomized response technique (RRT). In all, 170 health workers (86 in Ondo, 84 in Nasarawa) participated in the survey. In-depth interviews were conducted with 24 health workers (12 per state) and nine policy makers from both states.ResultsThe health workers perceived their salaries as inadequate, though most policy makers differed in this assessment. There appeared to be a considerable expenditure-income disparity among the respondents. Approximately 56% (n?=?93) of the study population reported having additional earning arrangements: most reported non-medical activities such as farming and trading, but private practice was also frequently reported.Half of the respondents with additional earning arrangements stated that their income from those activities was the equivalent of half or more of their monthly salaries. Specifically, 35% (n?=?32) said that they earned about half of their official monthly salaries and 15% (n?=?14) reported earning the same or more than their monthly salaries from these activities. Other coping mechanisms used by the health workers included prioritizing activities that enabled the earning of per diems, collecting informal payments and gifts from patients, and pilfering drugs from facilities.ConclusionsPredatory and non-predatory mechanisms accounted for the health workers' additional income. It may be difficult for the health workers to meet their expenses with their salaries and financial incentives; this highlights the need for the regulation of additional earnings and to implement targeted accountability mechanisms. This study indicates the value of using mixed methods when investigating sensitive issues. Future studies of this type should employ mixed methods for triangulation purposes to provide better insight into health workers' responses.

Project description:INTRODUCTION:Well-trained, adequately skilled and motivated primary healthcare (PHC) workers are essential for attaining universal health coverage (UHC). While there is abundant literature on the drivers of workforce motivation, published knowledge on the mechanisms of motivation within different contexts is limited, particularly in resource-limited countries. This paper contributes to health workforce literature by reporting on how motivation works among PHC workers in a maternal and child health (MCH) programme in Nigeria. METHODS:We adopted a realist evaluation design combining document review with 56 in-depth interviews of PHC workers, facility managers and policy-makers to assess the impact of the MCH programme in Anambra State, Nigeria. A realist process of theory development, testing and consolidation was used to understand how and under what circumstances the MCH programme impacted on workers' motivation and which mechanisms explain how motivation works. We drew on Herzberg's two-factor and Adam's equity theories to unpack how context shapes worker motivation. RESULTS:A complex and dynamic interaction between the MCH programme and organisational and wider contexts triggered five mechanisms which explain PHC worker motivation: (1) feeling supported, (2) feeling comfortable with work environment, (3) feeling valued, (4) morale and confidence to perform tasks and (5) companionship. Some mechanisms were mutually reinforcing while others operated in parallel. Other conditions that enabled worker motivation were organisational values of fairness, recognition of workers' contributions and culture of task-sharing and teamwork. CONCLUSIONS:Policy designs and management strategies for improving workforce performance, particularly in resource-constrained settings should create working environments that foster feelings of being valued and supported while enabling workers to apply their knowledge and skills to improve healthcare delivery and promote UHC. Future research can test the explanatory framework generated by this study and explore differences in motivational mechanisms among different cadres of PHC workers to inform cadre-related motivational interventions.

Dataset Information

Assessing community health workers' performance motivation: a mixed-methods approach on India's Accredited Social Health Activists (ASHA) programme.

Objective

Design

Setting

Participants

Primary and secondary outcome measures

Results

Conclusions

Publications

Assessing community health workers' performance motivation: a mixed-methods approach on India's Accredited Social Health Activists (ASHA) programme.

Similar Datasets

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