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

ABSTRACT: OBJECTIVES:The 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 Ethiopia and ways to avert their exit. DESIGN:A qualitative study was undertaken using in-depth interviews with the study participants. Interviews were audio-recorded, and then simultaneously translated into English and transcribed for analysis. Data were analysed in NVivo 12 using an iterative inductive-deductive approach. SETTING:The study was conducted in two districts each in the Tigray and Southern Nations, Nationalities and People's Republic (SNNPR) regions in Ethiopia. Respondents were located in a mix of rural and urban settings. PARTICIPANTS:Leavers of health extension worker (HEW) positions (n=20), active HEWs (n=16) and key informants (n=11) in the form of policymakers were interviewed. RESULTS:We identified several extrinsic and intrinsic motivational factors affecting the retention and labour market choices of HEWs. While financial incentives in the form of salaries and material incentives in the form of improvements to health facility infrastructure, provision of childcare were reported to be important, non-material factors like HEWs' self-image, acceptance and validation by the community and their supervisors were found to be critical. A reduction or loss of these non-material factors proved to be the catalyst for many HEWs to leave their jobs. CONCLUSION:Our study contributes new empirical evidence to the global debate on factors influencing the motivation and retention of CHWs, by being the first to include job leavers in the analysis. Our findings suggest that policy interventions that appeal to the social needs of CHWs can prove to be more acceptable and potentially cost-effective in improving their retention in the long run. This is important for government policymakers in resource constrained settings like Ethiopia that rely heavily on lay workers for primary healthcare delivery.

SUBMITTER: Arora N

PROVIDER: S-EPMC7545659 | biostudies-literature | 2020 Oct

REPOSITORIES: biostudies-literature

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

Arora Nikita N Hanson Kara K Spicer Neil N Estifanos Abiy Seifu AS Keraga Dorka Woldesenbet DW Welearegay Alemtsehay Tewele AT Tela Freweini Gebrearegay FG Hussen Yemisrach Ahmed YA Mandefro Yordanos Semu YS Quaife Matthew M

BMJ open 20201008 10

<h4>Objectives</h4>The 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 Ethiopia and ways to avert their exit.<h4>Design</h4>A qualitative study was undertaken using in-depth interviews with the study participants. Interviews were audio-recorded, and then simultaneously translated into English and transcribed for analysis. Data were analysed in NVivo 12 ...[more]

PMID: 33033092

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Project description:ObjectivesIn considering explanations for poor maternal and newborn health outcomes, many investigations have focused on the decision-making patterns and actions of expectant mothers and families, as opposed to exploring the 'supply side' (health service provider) barriers. Thus, we examined the health system factors impacting on access to and delivery of quality maternal and newborn healthcare in rural settings.DesignA semistructured qualitative study using face-to-face in-depth interviews with health professionals, and focus group sessions with community members, in eight project sites in two districts of Upper West Region, Ghana, was employed. Participants were purposively selected to generate relevant data to help address the study objective. The survey was guided by WHO standard procedures and Ghana Health Ministry's operational work plan for maternal and newborn care.SettingNadowli-Kaleo and Daffiama-Bussie-Issa districts in Upper West Region, Ghana.ParticipantsTwo hundred and fifty-three participants were engaged in the study through convenient and purposive sampling: healthcare professionals (pharmacist, medical doctor, two district directors of health services, midwives, community health and enrolled nurses) (n=13) and community members comprising opinion leaders, youth leaders and adult non-pregnant women (n=240 in 24 units of focus groups).ResultsResults show significant barriers affecting the quality and appropriateness of maternal and neonatal health services in the rural communities and the Nadowli District Hospital. The obstacles were inadequate medical equipment and essential medicines, infrastructural challenges, shortage of skilled staff, high informal costs of essential medicines and general limited capacities to provide care.ConclusionImplementation of the birth preparedness and complication readiness strategy is in its infancy at the health facility level in the study areas. Increasing the resources at the health provider level is essential to achieving international targets for maternal and neonatal health outcomes and for bridging inequities in access to essential maternal and newborn healthcare.

Project description:BackgroundThere is a need for greater understanding of experiences implementing community-based primary health care in humanitarian settings and of the adjustments needed to ensure continuation of essential services and utilization of services by the population, and to contribute to effective emergency response. We reviewed the evidence base on community health workers (CHWs) in humanitarian settings, with the goal of improving delivery of essential services to the most vulnerable populations.MethodsWe conducted a scoping review of published and grey literature related to health and nutrition services provided by CHWs in humanitarian settings. Extracted data from retained documents were analyzed inductively for key themes.ResultsOf 3709 documents screened, 219 were included in the review. Key findings from the literature include: 1) CHWs were often able to continue providing services during acute and protracted crises, including prolonged periods of conflict and insecurity and during population displacement. 2) CHWs carried out critical emergency response activities during acute crises. 3) Flexible funding facilitated transitions between development and humanitarian programming. 4) Communities that did not have a locally-resident CHW experienced reduced access to services when travel was limited. 5) Community selection of CHWs and engagement of respected local leaders were crucial for community trust and acceptance and high utilization of services. 6) Selection of local supervisors and use of mobile phones facilitated continued supervision. 7) Actions taken to maintain supplies included creating parallel supply chains, providing buffer stocks to CHWs, and storing commodities in decentralized locations. 8) When travel was restricted, reporting and data collection were continued using mobile phones and use of local data collectors. 9) CHWs and supervisors faced security threats and psychological trauma as a result of their work.ConclusionsTo achieve impact, policy makers and program implementers will have to address the bottlenecks to CHW service delivery common in stable low-income settings as well as the additional challenges unique to humanitarian settings. Future interventions should take into account the lessons learned from years of experience with implementation of community-based primary health care in humanitarian settings. There is also a need for rigorous assessments of community-based primary health care interventions in humanitarian settings.

Project description:An estimated half of all mobile phone users in Kenya use WhatsApp, an instant messaging platform that provides users an affordable way to send and receive text messages, photos, and other media at the one-to-one, one-to-many, many-to-one, or many-to-many levels. A mobile learning intervention aimed at strengthening supervisory support for community health workers (CHWs) in Kibera and Makueni, Kenya, created a WhatsApp group for CHWs and their supervisors to support supervision, professional development, and team building. We analyzed 6 months of WhatsApp chat logs (from August 19, 2014, to March 1, 2015) and conducted interviews with CHWs and their supervisors to understand how they used this instant messaging tool. During the study period, 1,830 posts were made by 41participants. Photos were a key component of the communication among CHWs and their supervisors: 430 (23.4%) of all posts contained photos or other media. Of the remaining 1,400 text-based posts, 87.6% (n?=?1,227) related to at least 1 of 3 defined supervision objectives: (1) quality assurance, (2) communication and information, or (3) supportive environment. This supervision took place in the context of posts about the roll out of the new mobile learning intervention and the delivery of routine health care services, as well as team-building efforts and community development. Our preliminary investigation demonstrates that with minimal training, CHWs and their supervisors tailored the multi-way communication features of this mobile instant messaging technology to enact virtual one-to-one, group, and peer-to-peer forms of supervision and support, and they switched channels of communication depending on the supervisory objectives. We encourage additional research on how health workers incorporate mobile technologies into their practices to develop and implement effective supervisory systems that will safeguard patient privacy, strengthen the formal health system, and create innovative forms of community-based, digitally supported professional development for CHWs.

Project description:BackgroundDespite substantial reductions in perinatal deaths (stillbirths and early neonatal deaths), India's perinatal mortality rates remain high, both nationally and in individual states. Rates are highest among disadvantaged socio-economic groups. To address this, India's National Health Mission has trained community health workers called Accredited Social Health Activists (ASHAs) to counsel and support women by visiting them at home before and after childbirth. We conducted a qualitative study to explore the roles of ASHAs' home visits in improving equity in perinatal health between socio-economic position groups in rural Uttar Pradesh (UP), India.MethodsWe conducted social mapping in four villages of two districts in UP, followed by three focus group discussions in each village (12 in total) with ASHAs and women who had recently given birth belonging to 'higher' and 'lower' socio-economic position groups (n = 134 participants). We analysed the data in NVivo and Dedoose using a thematic framework approach.ResultsHome visits enabled ASHAs to build trusting relationships with women, offer information about health services, schemes and preventive care, and provide practical support for accessing maternity care. This helped many women and families prepare for birth and motivated them to deliver in health facilities. In particular, ASHAs encouraged women who were poorer, less educated or from lower caste groups to give birth in public Community Health Centres (CHCs). However, women who gave birth at CHCs often experienced insufficient emergency obstetric care, mistreatment from staff, indirect costs, lack of medicines, and referrals to higher-level facilities when complications occurred. Referrals often led to delays and higher fees that placed the greatest burden on families who were considered of lower socio-economic position or living in remote areas, and increased their risk of experiencing perinatal loss.ConclusionsThe study found that ASHAs built relationships, counselled and supported many pregnant women of lower socio-economic positions. Ongoing inequities in health facility births and perinatal mortality were perpetuated by overlapping contextual issues beyond the ASHAs' purview. Supporting ASHAs' integration with community organisations and health system strategies more broadly is needed to address these issues and optimise pathways between equity in intervention coverage, processes and perinatal health outcomes.

Project description:BackgroundRohingya refugees in Bangladesh are vulnerable to infectious diseases such as COVID-19 due to the crowded living conditions with fragile shelters, and limited water, sanitation and hygiene facilities and practices. While risk communication and community engagement (RCCE) is the cornerstone of outbreak control, there is limited evidence available on the effectiveness of the RCCE strategies in this setting.ObjectivesThe goal of this study is to evaluate the effectiveness of RCCE strategies and to explore the challenges and community recommendations in relation to COVID-19 preventive measures in the context of Rohingya refugee camps in Bangladesh.Materials and methodsIt was a qualitative study. Methods used were (a) observation of RCCE intervention by 3 clinical supervisors accompanying 25 Community Health Workers (CHWs) and (b) 5 focus group discussions engaging 60 community representatives. Data were analyzed using a thematic analysis approach, separately for observation and focus group discussions.ResultsThe study identified a number of good practices of RCCE, including selecting CHWs from the local community, engaging female CHWs, using local dialect, and collaborating with community/religious leaders. Certain good practices need scaling up, such as utilization of multiple communication methods and interpersonal communication skills. Some areas need improvement, such as CHWs being overburdened with multiple tasks, less effort to active listening, repeated delivery of same messages, inadequate linkage to culture, context, and resources, and less effort to empower the community. Engaging the community, five critical themes were identified in relation to poor COVID-19 preventive practices: culture, religion, and language; local context and resources; community trust and interaction with aid workers; communication methods; and gender and social inclusion. Religious misinterpretation, cultural barriers, physical barriers, lack of resources, breach of trust between the community and aid workers, inconsistent/complex messages, lack of gender and social inclusion, and stigmatization are among some key factors. Some key actions were recommended to improve COVID-19 RCCE strategy.ConclusionWe urge the RCCE partners to make use of the findings and recommendations to develop a robust RCCE strategy relevant to local culture and context, responsive to people's concerns and needs, and inclusive of gender, age and social vulnerabilities.

Project description:IntroductionWhile schools represent key venues for supporting health, they continue to experience gaps in health resources. The integration of community health workers (CHWs) into schools has the potential to supplement these resources but has been underexplored. This study is the first to examine perspectives of experienced CHWs about how CHWs can be applied in school settings to support student health.MethodsThis qualitative study involved conducting semi-structured interviews focused on implementation of CHWs in schools with individuals who held positions aligned with the CHW scope of work. De-identified transcripts were analyzed, and codes were organized into domains and themes.ResultsAmong 14 participants, seven domains emerged about the implementation of CHWs in schools: roles and responsibilities, collaborations, steps for integration, characteristics of successful CHWs, training, assessment, and potential challenges. Participants shared various potential responsibilities of school-based CHWs, including educating on health topics, addressing social determinants of health, and supporting chronic disease management. Participants emphasized the importance of CHWs building trusting relationships with the school community and identified internal and external collaborations integral to the success of CHWs. Specifically, participants indicated CHWs and schools should together determine CHWs' responsibilities, familiarize CHWs with the school population, introduce CHWs to the school community, and establish support systems for CHWs. Participants identified key characteristics of school-based CHWs, including having familiarity with the broader community, relevant work experience, essential professional skills, and specific personal qualities. Participants highlighted trainings relevant to school-based CHWs, including CHW core skills and health topics. To assess CHWs' impact, participants proposed utilizing evaluation tools, documenting interactions with students, and observing indicators of success within schools. Participants also identified challenges for school-based CHWs to overcome, including pushback from the school community and difficulties related to the scope of work.DiscussionThis study identified how CHWs can have a valuable role in supporting student health and the findings can help inform models to integrate CHWs to ensure healthy school environments.

Dataset Information

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

Publications

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

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