Motivation of Community Health Volunteers in rural Uganda: the interconnectedness of knowledge, relationship and action

Building the capacity of community health volunteers for non-communicable disease prevention in low-income urban communities in Malaysia

Background

To address the rising non-communicable diseases (NCDs) in Malaysia, the Better Health Programme Malaysia (BHP MYS) engaged and trained community health volunteers (CHVs) to undertake health promotion activities with poor urban communities in Kuala Lumpur to reduce their NCD risk. This study evaluates the extent that the capacity-building programme achieved the objectives of increasing knowledge and confidence in NCD prevention and adopting personal lifestyle changes.

Methods

A capacity-building programme was designed to emphasise active learning approaches and blended learning (in-person and digital) and was delivered between January to December 2021 (during the Malaysian Government “Movement Control Orders” in response to the COVID-19 pandemic). Thirty CHVs participated in the capacity-building programme. A mixed methods evaluation approach was used, including quantitative surveys and routine data, focus group discussions, and semi-structured interviews.

Findings

Community Health Volunteers increased their NCD knowledge (85.2% provided correct answers in post-programme assessment compared to 43.3% at pre-programme assessment), made changes to their dietary and physical activity practices (100%), and adopted new engagement techniques, particularly a digital social influencer role for NCD behaviour change. The most important factors for sustaining participation were individual motivation and a supportive environment. CHVs were satisfied with the blended in-person-digital approach and perceived that the usefulness and applicability of the health information received was the primary benefit across all delivery modes. Cohort-based, active learning approaches and actionable messages can encourage learning retention and facilitate application. Dedicated technical support and ‘job aid’ tools are required for CHVs to perform and sustain NCD prevention roles effectively.

Conclusions

The capacity-building programme effectively increased CHV capacities to address NCDs in their own lives and communities and was acceptable to CHVs. The findings suggest the value of cohort-based, active learning approaches in building capacity. Expanding on capacity-building and sustaining involvement are important considerations for this cohort and, in general, for health volunteer capacity-building in Malaysia and elsewhere.

Is respectful care provided by community health workers associated with infant feeding practices? A cross sectional analysis from India

Objectives

Breastfeeding and complementary feeding practices in India do not meet recommendations. Community health care workers (CHWs) are often the primary source of information for pregnant and postpartum women about Infant and Young Child Feeding (IYCF) practices. While existing research has evaluated the effectiveness of content and delivery of information through CHWs, little is known about the quality of the interpersonal communication (respectful care). We analyzed the effect of respectful interactions on recommended IYCF practices.

Methods

We use data from evaluation of an at-scale mHealth intervention in India that serves as a job aid to the CHWs (n = 3266 mothers of children < 12 m from 841 villages in 2 Indian states). The binary indicator variable for respectful care is constructed using a set of 7 questions related to trust, respect, friendliness during these interactions. The binary outcomes variables are exclusive breastfeeding, timely introduction of complimentary feeding, and minimum diet diversity for infants. We also explore if most of the pathway from respectful care to improved behaviors is through better recall of messages (mediation analysis). All models controlled for socio-economic-demographic characteristics and number of interactions with the CHW.

Results

About half of women reported positive, respectful interactions with CHWs. Interactions that are more respectful were associated with better recall of appropriate health messages. Interactions that are more respectful were associated with a greater likelihood of adopting all child-feeding behaviors except timely initiation of breastfeeding. After including recall in the model, the effect of respectful interactions alone reduced.

Conclusions

Respectful care from CHWs appears to be significantly associated with some behaviors around infant feeding, with the primary pathway being through better recall of messages. Focusing on improving social and soft skills of CHWs that can translate into better CHW-beneficiary interactions can pay rich dividends.

Funding

This study is funded by Grant No. OPP1158231 from Bill and Melinda Gates Foundation. Trial registration number: 10.1186/ISRCTN83902145

Five-year Retention of Volunteer Community Health Workers in Rural Uganda: A Population-Based Retrospective Cohort

Community health workers (CHWs) effectively improve maternal, newborn and child health (MNCH) outcomes in low-to-middle-income countries. However, CHW retention remains a challenge. This retrospective registry analysis evaluated medium-term retention of volunteer CHWs in two rural Ugandan districts, trained during a district-wide MNCH initiative. From 2012 to 2014, the Healthy Child Uganda partnership facilitated district-led CHW programme scale-up. CHW retention was tracked prospectively from the start of the intervention up to 2 years. Additional follow-up occurred at 5 years to confirm retention status. Database analysis assessed CHW demographic characteristics, retention rates and exit reasons 5 years post-intervention. A multivariable logistic regression model examined 5-year retention-associated characteristics. Of the original cohort of 2317 CHWs, 70% were female. The mean age was 38.8 years (standard deviation, SD: 10.0). Sixty months (5 years) after the start of the intervention, 84% of CHWs remained active. Of those exiting (n = 377), 63% reported a ‘logistical’ reason, such as relocation (n = 96), new job (n = 51) or death (n = 30). Sex [male, female; odds ratio (OR) = 1.53; 95% confidence interval (CI): 1 · 20–1 · 96] and age group (<25 years, 30–59; OR = 0.40; 95% CI: 0.25–0.62) were significantly associated with 5-year retention in multivariable modelling. Education completion (secondary school, primary) was not significantly associated with retention in adjusted analyses. CHWs in this relatively large cohort, trained and supervised within a national CHW programme and district-wide MNCH initiative, were retained over the medium term. Importantly, high 5-year retention in this intervention counters findings from other studies suggesting low retention in government-led and volunteer CHW programmes. Encouragingly, findings from our study suggest that retention was high, not significantly associated with timing of external partner support and largely not attributed to the CHW role i.e. workload and programme factors. Our study showcases the potential for sustainable volunteer CHW programming at scale and can inform planners and policymakers considering programme design, including selection and replacement planning for CHW networks.

Trained Volunteers With Type 2 Diabetes Experience Significant Health Benefits When Providing Peer Support

Trained lay volunteers may have value in supporting lifestyle change programs in the prevention of type 2 diabetes, but the potential health benefits (or harms) experienced by these lay volunteers have not been well described. This is important, as this is an appealing model in terms of workforce planning. The aim of the prespecified quantitative study reported here, was to examine the possible health benefits or harms experienced by these trained lay volunteers with type 2 diabetes. In a large type 2 diabetes prevention program, we recruited and trained 104 lay volunteers with type 2 diabetes themselves, to act as diabetes prevention mentors and codeliver the lifestyle intervention. Mentors made motivational telephone calls to 461 participants randomized to one of the trial arms to encourage lifestyle changes. Weight, diet, physical activity, well-being, quality of life, diabetes-specific self-efficacy, and glycaemic control were measured at baseline, 12 and 24 months. Average mentor age was 62.0 years, 57 (54.8%) were male, 92 (88.5%) were overweight or obese (BMI>30 kg/m²). At 12 months, mentor dietary behaviors (fat and fiber intake) improved significantly, sedentary time spent fell significantly, and diabetes specific self-efficacy scores significantly increased. These significant improvements, with no evidence of harms, suggest lay volunteers with type 2 diabetes codelivering a lifestyle intervention, may themselves experience health benefits from volunteering.

An Investigation of Healthcare Professionals' Motivation in Public and Mission Hospitals in Meru County, Kenya

Strengthening health systems in developing countries such as Kenya is required to achieve the third United Nations’ Sustainable Development Goal of health for all, at all ages. However, Kenya is experiencing a “brain drain” and a critical shortage of healthcare professionals. There is a need to identify the factors that motivate healthcare workers to work in the health sector in rural and marginalized areas. This cross-sectional study aims to investigate the factors associated with the level and types of motivation among healthcare professionals in public and mission hospitals in Meru county, Kenya. Data were collected from 24 public and mission hospitals using a self-administered structured questionnaire. A total of 553 healthcare professionals participated in this study; 78.48% from public hospitals and 21.52% from mission hospitals. Hospital ownership was statistically nonsignificant in healthcare professionals’ overall motivation (p > 0.05). The results showed that sociodemographic and work-environment factors explained 29.95% of the variation in overall motivation scores among participants. Findings indicate there are more similarities than disparities among healthcare professionals’ motivation factors, regardless of hospital ownership; therefore, motivation strategies should be developed and applied in both public and private not-for-profit hospitals to ensure an effective healthcare workforce and strengthen healthcare systems in Kenya.

Use, adoption, and effectiveness of tippy-tap handwashing station in promoting hand hygiene practices in resource-limited settings: a systematic review

BACKGROUND

Tippy-taps are locally made devices for washing hands with running water. They are simple and low-cost, enabling technology that provides adequate water sources, handwashing stations and motivation for people to prioritise handwashing. This systematic review aimed to establish the use, benefits, adoption and effectiveness of enabling technology; tippy-tap handwashing station, in resource-limited settings.

METHODS

We systematically searched for articles in the PubMed, EMBASE, PsycINFO, AMED, CINAHL, DOAJ and Google Scholar databases guided by the acceptable best practice developed by the PROSPERO and COCHRANE for systematic search and selection of articles. Search terms such as tippy-taps, enabling technology, hand-washing station, hand-washing behaviour, diarrhoea, respiratory infection, increase handwashing behaviour were used. In addition, a PRISMA flow diagram was used to elaborate on the number of articles retrieved, retained, excluded and reasons for every action. Studies that used tippy-tap hand washing station as a handwashing facility regardless of the design were included in this review. A mixed method appraisal tool was used to appraise studies.

RESULTS

Twenty articles met the eligibility criteria. The use of tippy-taps for handwashing by household members or school children was reported by authors of 16 studies, and it ranged from 2.7 to 80%. The availability of tippy-taps increased handwashing and use of soap among participants. Furthermore, the majority of people who were oriented to tippy-taps or recruited to tippy-tap studies built their tippy-tap stations even after the promotional activities or programs had ended. In one study, tippy-taps were reported by participant to be effective in preventing episodes of stomach pain among participants.

CONCLUSION

Tippy-tap handwashing station could help in promoting handwashing practice in resource constraint settings. Future studies are needed to evaluate the effectiveness of tippy-tap hand washing station on preventing water and hygiene-related infections.

Determinants of Motivation among Healthcare Workers in the East African Community between 2009-2019: A Systematic Review

Healthcare workers are an essential element in the functionality of the health system. However, the health workforce impact on health systems tends to be overlooked. Countries within the Sub-Saharan region such as the six in the East African Community (EAC) have weak and sub-optimally functioning health systems. As countries globally aim to attain Universal Health Coverage and the Sustainable Development Goal 3, it is crucial that the significant role of the health workforce in this achievement is recognized. In this systematic review, we aimed to synthesise the determinants of motivation as reported by healthcare workers in the EAC between 2009 and 2019. A systematic search was performed using four databases, namely Cochrane library, EBSCOhost, ProQuest and PubMed. The eligible articles were selected and reviewed based on the authors' selection criteria. A total of 30 studies were eligible for review. All six countries that are part of the EAC were represented in this systematic review. Determinants as reported by healthcare workers in six countries were synthesised. Individual-level-, organizational/structural- and societal-level determinants were reported, thus revealing the roles of the healthcare worker, health facilities and the government in terms of health systems and the community or society at large in promoting healthcare workers' motivation. Monetary and non-monetary determinants of healthcare workers' motivation reported are crucial for informing healthcare worker motivation policy and health workforce strengthening in East Africa.

Role-play versus lecture methods in community health volunteers

BACKGROUND

Considering the key role of health volunteers in promoting community's health, their effective training is of particular importance. Training can be more effective through cooperative and learner-centered methods. Role-play is among the cooperative methods with numerous advantages. Considering the positive impact of training via various methods, we aimed to compare training through role-play and lecture on health volunteers' health knowledge in selected comprehensive health centers of Shiraz, Iran.

METHODS

This quasi-experimental study was conducted on all health volunteers in four comprehensive health centers selected via random cluster sampling during the second half of 2017. The participants were divided into intervention and control groups and took part in the pretest based on the book entitled "Promotion of Breastfeeding". Based on the pretest results, health volunteers trained the participants in three educational sessions. The two groups were evaluated again immediately and two months after the intervention.

RESULTS

The mean age of the participants was 49.97 ± 8.1 and 46.52 ± 10.74 years in intervention and control groups, respectively. Most participants were married (94.8%) and had diplomas (92.1%).A significant difference was seen between both groups in knowledge scores at the three time points (P < 0.001). A significant difference was found between the two groups regarding knowledge scores immediately and two months after the intervention (P < 0.001), indicating the effectiveness of training through role-play.

CONCLUSION

The advantages of role-play, including development of communication skills and active listening, resulted in the learners' enthusiasm and motivation. This method was accompanied with higher educational output as well as longer knowledge persistence. Role-play increased cooperation and group discussions performed after the role-play promoted the transfer emotional experiences.

Motivational Factors Influencing Retention of Village Health Workers in Rural Communities of Bhutan

Village health workers (VHWs) are the first contact extending vital health services to unreached and underserved communities in Bhutan. VHWs truly embody the principles of primary health care and are effective catalysts in promoting community health. This study identifies and confirms factors motivating VHWs to remain in the health care system. This is a quantitative study with a cross-sectional survey design. Two-stage cluster sampling was used with VHWs from 12 districts representing 3 regions of Bhutan. Data were collected using pretested semistructured questionnaires. Confirmatory factor analysis was used for data analysis. Findings reveal a 4-factor model of motivations among VHWs that includes social, personal, job related, and organizational factors. Among these, the social factor most significantly motivates VHWs to remain in the health care system. VHW motivation can be further fostered by providing a holistic combination of financial and nonfinancial incentives that recognize intrinsic needs and empower innate altruism.

Exploring knowledge and attitudes toward non-communicable diseases among village health teams in Eastern Uganda: a cross-sectional study

BACKGROUND

Community health workers are essential personnel in resource-limited settings. In Uganda, they are organized into Village Health Teams (VHTs) and are focused on infectious diseases and maternal-child health; however, their skills could potentially be utilized in national efforts to reduce the growing burden of non-communicable diseases (NCDs). We sought to assess the knowledge of, and attitudes toward NCDs and NCD care among VHTs in Uganda as a step toward identifying their potential role in community NCD prevention and management.

METHODS

We administered a knowledge, attitudes and practices questionnaire to 68 VHT members from Iganga and Mayuge districts in Eastern Uganda. In addition, we conducted four focus group discussions with 33 VHT members. Discussions focused on NCD knowledge and facilitators of and barriers to incorporating NCD prevention and care into their role. A thematic qualitative analysis was conducted to identify salient themes in the data.

RESULTS

VHT members possessed some knowledge and awareness of NCDs but identified a lack of knowledge about NCDs in the communities they served. They were enthusiastic about incorporating NCD care into their role and thought that they could serve as effective conduits of knowledge about NCDs to their communities if empowered through NCD education, the availability of proper reporting and referral tools, and visible collaborations with medical personnel. The lack of financial remuneration for their role did not emerge as a major barrier to providing NCD services.

CONCLUSIONS

Ugandan VHTs saw themselves as having the potential to play an important role in improving community awareness of NCDs as well as monitoring and referral of community members for NCD-related health issues. In order to accomplish this, they anticipated requiring context-specific and culturally adapted training as well as strong partnerships with facility-based medical personnel. A lack of financial incentivization was not identified to be a major barrier to such role expansion. Developing a role for VHTs in NCD prevention and management should be a key consideration as local and national NCD initiatives are developed.

Supporting and retaining Village Health Teams: an assessment of a community health worker program in two Ugandan districts

BACKGROUND

Uganda's national community health worker program involves volunteer Village Health Teams (VHTs) delivering basic health services and education. Evidence demonstrates their positive impact on health outcomes, particularly for Ugandans who would otherwise lack access to health services. Despite their impact, VHTs are not optimally supported and attrition is a growing problem. In this study, we examined the support needs and existing challenges of VHTs in two Ugandan districts and evaluated specific factors associated with long-term retention. We report on findings from a standardized survey of VHTs and exploratory interviews with key stakeholders and draw conclusions that inform efforts to strengthen and sustain community health care delivery in Uganda.

METHODS

A mixed-methods approach was employed through a survey of 134 individual VHT members and semi-structured interviews with six key stakeholders. Descriptive and bivariate regression analysis of quantitative survey data was performed along with thematic analysis of qualitative data from surveys and interviews. In the regression analysis, the dependent variable is 10-year anticipated longevity among VHTs, which asked respondents if they anticipate continuing to volunteer as VHTs for at least 10 more years if their current situation remains unchanged.

RESULTS

VHTs desire additional support primarily in the forms of money (e.g. transportation allowance) and material supplies (e.g. rubber boots). VHTs commonly report difficult working conditions and describe a lack of respect from their communities and other health workers. If their current situation remains unchanged, 57% of VHTs anticipate remaining in their posts for at least 10 years. Anticipated 10-year longevity was positively associated with stronger partnerships with local health center staff and greater ease in home visiting.

CONCLUSIONS

Supporting and retaining Uganda's VHTs would be enhanced by building stronger partnerships between VHTs and other health workers and regularly providing supplies and transportation allowances. Pursuing such measures would likely improve equity in access to healthcare for all Ugandans.

Community Health Volunteers in Primary Healthcare in Rural Uganda: Factors Influencing Performance

Introduction

Community health volunteers (CHVs) play an integral role in primary healthcare. Several countries rely on CHV programs as a major element in improving access to care and attaining universal health coverage. However, their performance has been heterogeneous and at times context-specific, and influenced by multiple factors. We describe the socio-demographic and workplace characteristics affecting CHVs’ performance in a public health program in rural western Uganda.

Methods

This was a cross-sectional study based on routine program data of CHVs serving the catchment of Bwindi Community Hospital, Kanungu District, South Western Uganda, in 2014 and 2015. Information was collected on individual socio-demographic and workplace characteristics of the CHVs. To assess their work output, we defined study-specific targets in terms of attendance at monthly CHVs’ meetings with community health nurses, households followed-up and reported, children screened for malnutrition, immunization coverage, and health facility deliveries. Frequencies and proportions are reported for characteristics and outputs and odds ratios for study-specific factors associated with overall performance.

Results

Of the 508 CHVs, 65% were women, 48% were aged 35 years and below, and 37% took care of more than the recommended 20–30 households. Seventy-eight percent of the CHVs had ≥80% of pregnant women under their care delivering in health units, 71% had ≥95% of the children on schedule for routine immunization, while 27% screened ≥75% of the children under 5 years for malnutrition. More refresher trainings was associated with better overall performance [adjusted odds ratio (aOR): 12.2, 95% confidence interval (CI): 1.6–93.6, P = 0.02] while overseeing more than the recommended 20–30 households reduced overall performance (aOR: 0.6, 95% CI: 0.4–0.9, P = 0.02).

Conclusion

Being in-charge of more than the recommended households was associated with reduced performance of CHVs, while more refresher trainings were associated with improved performance. If the CHVs are to remain a strategic pillar in universal health coverage, it is imperative to address those factors known to impact on their performance.

Supportive supervision for volunteers to deliver reproductive health education: a cluster randomized trial

Background

Community Health Volunteers (CHVs) can be effective in improving pregnancy and newborn outcomes through community education. Inadequate supervision of CHVs, whether due to poor planning, irregular visits, or ineffective supervisory methods, is, however, recognized as a weakness in many programs. There has been little research on best practice supervisory or accompaniment models.

Methods

From March 2014 to February 2015 a proof of concept study was conducted to compare training alone versus training and supportive supervision by paid CHWs (n = 4) on the effectiveness of CHVs (n = 82) to deliver education about pregnancy, newborn care, family planning and hygiene. The pair-matched cluster randomized trial was conducted in eight villages (four intervention and four control) in Budondo sub-county in Jinja, Uganda.

Results

Increases in desired behaviors were seen in both the intervention and control arms over the study period. Both arms showed high retention rates of CHVs (95 %). At 1 year follow-up there was a significantly higher prevalence of installed and functioning tippy taps for hand washing (p < 0.002) in the intervention villages (47 %) than control villages (35 %). All outcome and process measures related to home-visits to homes with pregnant women and newborn babies favored the intervention villages. The CHVs in both groups implemented what they learnt and were role models in the community.

Conclusions

A team of CHVs and CHWs can facilitate families accessing reproductive health care by addressing cultural norms and scientific misconceptions. Having a team of 2 CHWs to 40 CHVs enables close to community access to information, conversation and services. Supportive supervision involves creating a non-threatening, empowering environment in which both the CHV and the supervising CHW learn together and overcome obstacles that might otherwise demotivate the CHV. While the results seem promising for added value with supportive supervision for CHVs undertaking reproductive health activities, further research on a larger scale will be needed to substantiate the effect.