Assessment of non-financial incentives for volunteer community health workers - the case of Wukro district, Tigray, Ethiopia

Strategies for Sustained Empowerment of Community Health Workers: A Qualitative Analysis of the Comprehensive Rural Health Project in Jamkhed, India

To understand the core aspects of an empowerment-based Community Health Worker (CHW) training program, we studied the model of the Comprehensive Rural Health Project (CRHP) in Jamkhed, India-an organization known for facilitating empowerment of women as Village Health Workers (VHWs) and agents of community change. We define empowerment as a means by which individuals gain health and development-related skills and knowledge to facilitate positive change within their lives and communities. Using VHW training observations and semi-structured interviews with health workers and senior trainers, 6 themes were developed and applied in 4 focus group sessions with 18 multigenerational VHWs trained by the CRHP. Transcripts were qualitatively analyzed under 6 themes-selection, baseline training, continuing education and support, community participation, community empowerment, and commitment and longevity. Empowerment of VHWs was found to be an intentional process involving the creation of safe and supportive environments conducive to long-term participatory and experiential learning with professionals who facilitate and mentor. The impact of the baseline training is maintained through ongoing program-VHW interactions and knowledge reinforcement in both the field and training center. Importantly, these interactions reinforce VHWs' credibility and confidence in communities served. Community participation was found to be of key importance starting at the selection phase. The methods used for selection, training and ongoing support are critical to developing a cadre of competent, effective and motivated VHWs as well as fostering long-lasting self-development and leadership skills. Downstream effectiveness of community empowerment on health outcomes is demonstrated through indicators such as access to safe deliveries, declining child malnutrition rates, high vaccination rates as well as reductions in stigmatization of illness and caste discrimination.

Drivers of retention of the HIV workforce transitioned from PEPFAR support to the Uganda government payroll

BACKGROUND

Health worker (HW) retention in the public health sector in Uganda is an enduring health system constraint. Although previous studies have examined the retention of in-service HWs, there is little research focusing on donor-recruited HWs. The objective of this study was to explore drivers of retention of the HIV workforce transitioned from PEPFAR support to the Uganda government payroll between 2015 and 2017.

METHODS

We conducted ten focus group discussions with HWs (n = 87) transitioned from PEPFAR support to the public sector payroll in 10 purposively selected districts across Uganda. In-depth interviews were conducted with national-level stakeholders (n = 17), district health and personnel officers (n = 15) and facility in-charges (n = 22). Data were analyzed by a hybrid approach of inductive and deductive thematic development based on the analytical framework by Schaefer and Moos regarding individual-level and organizational-context drivers.

RESULTS

At the individual level, job security in the public sector was the most compelling driver of health worker retention. Community embeddedness of HWs in the study districts, opportunities for professional development and career growth and the ability to secure salary loans due to 'permanent and pensionable' terms of employment and the opportunity to work in 'home districts', where they could serve their 'kinsmen' were identified as enablers. HWs with prior private sector backgrounds perceived public facilities as offering more desirable challenging professional work. Organizational context enablers identified include perceptions that public facilities had relaxed supervision regimes and more flexible work environments. Work environment barriers to long-term retention include frequent stock-out of essential commodities, heavy workloads, low pay and scarcity of rental accommodation, particularly in rural Northern Uganda. Compared to mid-cadres (such as nurses and midwives), higher calibre cadres, such as physicians, pharmacists and laboratory technologists, expressed a higher affinity for seeking alternative employment in the private sector in the immediate future.

CONCLUSIONS

Overall, job security was the most compelling driver of retention in public service for the health workforce transitioned from PEPFAR support to the Uganda government payroll. Monetary and non-monetary policy strategies are needed to enhance the retention of upper cadre HWs, particularly physicians, pharmacists and laboratory technologists in rural districts of Uganda.

Social capital and its role to improve maternal and child health services in Northwest Ethiopia: A qualitative study

BACKGROUND

Social capital is a set of shared values that allows individuals or groups receive emotional, instrumental or financial resources flow. In Ethiopia, despite people commonly involved in social networks, there is a dearth of evidence exploring whether membership in these networks enhances uptake of maternal and child health (MCH) services. This study aimed to explore perspectives of women, religious leaders and community health workers (CHWs) on social capital to improve uptake of MCH services in Northwest Ethiopia.

METHODS

We employed a qualitative study through in-depth interviews with key informants, and focus group discussions. A maximum variation purposive sampling technique was used to select 41 study participants (11 in-depth interviews and 4 FGDs comprising 7-8 participants). Data were transcribed verbatim and thematic analysis was employed using ATLAS.ti software.

RESULTS

Four overarching themes and 13 sub-themes of social capital were identified as factors that improve uptake of MCH services. The identified themes were social networking, social norms, community support, and community cohesion. Most women, CHWs and religious leaders participated in social networks. These social networks enabled CHWs to create awareness on MCH services. Women, religious leaders and CHWs perceived that existing social capital improves the uptake of MCH services.

CONCLUSION

The community has an indigenous culture of providing emotional, instrumental and social support to women through social networks. So, it would be useful to consider the social capital of family, neighborhood and community as a tool to improve utilization of MCH services. Therefore, policymakers should design people-centered health programs to engage existing social networks, and religious leaders for improving MCH services.

The experiences and challenges of community health volunteers as agents for behaviour change programming in Africa: a scoping review

Community health volunteers are considered a vital part of the community health structure in Africa. Despite this vital role in African health systems, very little is known about the community health volunteers’ day-to-day lived experiences providing services in communities and supporting other health workers. This scoping review aims to advance understanding of the day-to-day experiences of community health volunteers in Africa. In doing so, this review draws attention to these under-considered actors in African health systems and identifies critical factors and conditions that represent challenges to community health volunteers’ work in this context. Ultimately, our goal is to provide a synthesis of key challenges and considerations that can inform efforts to reduce attrition and improve the sustainability of community health volunteers in Africa. This scoping review was conducted using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for scoping reviews checklist to achieve the objectives. A comprehensive search of six databases returned 2140 sources. After screening, 31 peer-reviewed studies were selected for final review. Analytical themes were generated based on the reviewers’ extraction of article data into descriptive themes using an inductive approach. In reviewing community health volunteers’ accounts of providing health services, five key challenges become apparent. These are: (1) challenges balancing work responsibilities with family obligations; (2) resource limitations; (3) exposure to stigma and harassment; (4) gendered benefits and risks; and (5) health-system level challenges. This scoping review highlights the extent of challenges community health volunteers must navigate to provide services in communities. Sustained commitment at the national and international level to understand the lived experiences of community health volunteers and mitigate common stressors these health actors face could improve their performance and inform future programs.

A light touch intervention with a heavy lift - gender, space and risk in a global vaccination programme

Frontline workers (FLWs) in the Global Polio Eradication Initiative go door-to-door delivering polio vaccine to children. They have played a pivotal role in eliminating wild polio from most countries on earth; at the same time, they face significant bodily risk. STRIPE, an international consortium, conducted a mixed-methods study exploring the knowledge and experiences of polio staff in seven countries (Afghanistan, Bangladesh, Democratic Republic of Congo, Ethiopia, India, Indonesia and Nigeria). We surveyed 826 polio FLWs and conducted semi-structured interviews with 22 of them. We used a body work framework to guide analysis. Polio workers perform a different kind of body work than many other FLWs. Delivering a few drops of oral vaccine takes a light touch, but gendered spaces can make the work physically dangerous. Polio's FLWs must bend or break gendered space norms as they move from house-to-house. Navigating male spaces carries risk for women, including lethal risk, particularly in conflict settings. Workers manoeuvre between skeptical community members and the demands of supervisors which generates emotional labour. Providing FLWs with more power to make operational decisions and providing them with robust teams and remuneration would improve the likelihood that they could act to improve their working conditions.

It is not all about salary: a discrete-choice experiment to determine community health workers' motivation for work in Nigeria

Introduction

Community health workers (CHWs) constitute the majority of primary healthcare (PHC) workers in Nigeria, yet little is understood about their motivations or the most effective interventions to meet their needs to ensure quality health coverage across the country. We aimed to identify factors that would motivate CHWs for quality service delivery.

Methods

A discrete-choice experiment was conducted among 300 CHWs across 44 PHC facilities in the Federal Capital Territory, Abuja Nigeria. Based on the literature review and qualitative research, five attributes, namely: salary, educational opportunities, career progression and in-service training, housing and transportation, were included in the experiment. CHWs were presented with 12 unlabelled choice sets, using tablet devices, and asked to choose which of two hypothetical jobs they would accept if offered to them, or whether they would take neither job. Mixed multinomial logistic models were used to estimate stated preferences for the attributes and the likely uptake of jobs under different policy packages was simulated.

Results

About 70% of the respondents were women and 39% worked as volunteers. Jobs that offered career progression were the strongest motivators among the formally employed CHWs (β=0.33) while the ‘opportunity to convert from CHW to another cadre of health workers, such as nursing’ was the most important motivator among the volunteers’ CHWs (β=0.53). CHWs also strongly preferred jobs that would offer educational opportunities, including scholarship (β=0.31) and provision of transport allowances (β=0.26). Policy scenario modelling predicted combined educational opportunities, career progression opportunities and an additional 10% of salary as incentives was the employment package that would be most appealing to CHWs.

Conclusion

CHWs are motivated by a mix of non-financial and financial incentives. Policy interventions that would improve motivation should be adequate to address various contexts facing different CHWs and be flexible enough to meet their differing needs.

Occupational health research beyond the work setting: inclusive inquiry with ethnic minority and immigrant workers

Ethnic minority and immigrant workers comprise a sizable proportion of the low-wage workforce. They are surprisingly understudied despite their workplace prominence. Factors such as workplace policies, structures, worker-related characteristics, and research designs preclude their comprehensive research participation when studies are conducted in work settings. Consequently, ethnic minority and immigrant workers continue to be under-represented in inquiry and simultaneously over-represented with compromising occupational health risks. The purpose of this paper is to provide strategies to promote the inclusion of ethnic minority and immigrant workers in occupational health research. Using three different research-based examples, we illustrate the benefit of conducting occupational health research in non-workplace settings as a way to ensure research representation of ethnic minority and immigrant workers.

Exploring women's development group leaders' support to maternal, neonatal and child health care: A qualitative study in Tigray region, Ethiopia

Background

Community health workers and volunteers are vital for the achievement of Universal Health Coverage also in low-income countries. Ethiopia introduced community volunteers called women’s development group leaders in 2011. These women have responsibilities in multiple sectors, including promoting health and healthcare seeking.

Objective

We aimed to explore women’s development group leaders’ and health workers’ perceptions on these volunteers’ role in maternal, neonatal and child healthcare.

Methods

A qualitative study was conducted with in-depth interviews and focus group discussions with women’s development group leaders, health extension workers, health center staff, and woreda and regional health extension experts. We adapted a framework of community health worker performance, and explored perceptions of the women’s development group program: inputs, processes and performance. Interviews were recorded, transcribed, and coded prior to translation and thematic analysis.

Results

The women’s development group leaders were committed to their health-related work. However, many were illiterate, recruited in a sub-optimal process, had weak supervision and feedback, lacked training and incentives and had weak knowledge on danger signs and care of neonates. These problems demotivated these volunteers from engaging in maternal, neonatal and child health promotion activities. Health extension workers faced difficulties in managing the numerous women’s development group leaders in the catchment area.

Conclusion

The women’s development group leaders showed a willingness to contribute to maternal and child healthcare but lacked support and incentives. The program requires some redesign, effective management, and should offer enhanced recruitment, training, supervision, and incentives. The program should also consider continued training to develop the leaders’ knowledge, factor contextual influences, and be open for local variations.

Understanding community health worker incentive preferences in Uganda using a discrete choice experiment

Background

Community health workers (CHWs) play a critical role in supporting health systems, and in improving the availability and accessibility to health care. However, CHW programs globally continue to face challenges with poor performance and high levels of CHW attrition. CHW programs are often underfunded and poorly planned, which can lead to loss of motivation by CHWs. The study aims to determine preferences of CHWs for job incentives with the goal of furthering their motivation and success.

Methods

Relevant incentive attributes were identified through focus group discussions and in-depth interviews with CHWs, non-governmental organization CHWs, CHW supervisors, and policy-level stakeholders. Based on seven attributes (eg, training, workload, stipend) we developed a discrete choice experiment (DCE) that was administered to 399 CHWs across eight districts in Uganda. We used conditional and mixed multinomial logit models to estimate the utility of each job attribute. We calculated the marginal willingness to accept as the trade-off the CHWs were willing to make for a change in salary.

Results

CHWs preferred higher salaries, though salary was not the most important attribute. There was a preference for reliable transportation, such as a bicycle (β = 1.86, 95% CI = 1.06, 2.67), motorcycle (β = 1.81, 95% CI = 1.27, 2.34) or transport allowance (β = 1.37, 95% CI = 0.65, 2.10) to no transport. Formal identification including identity badges (β = 1.61, 95% CI = 0.72, 2.49), branded uniforms (β = 1.04, 95% CI = 0.45, 1.63) and protective branded gear (β = 0.76, 95% CI = 0.32, 1.21) were preferred compared to no identification. CHWs also preferred more regular refresher trainings, the use of mobile phones as job-aids and a lesser workload. The relative importance estimates suggested that transport was the most important attribute, followed by identification, refresher training, salary, workload, recognition, and availability of tools. CHWs were willing to accept a decrease in salary of USH 31 240 (US$8.5) for identity badges, and a decrease of USH85 300 (US$23) for branded uniforms to no identification.

Conclusions

This study utilized CHW and policymaker perspectives to identify realistic and pragmatic incentives to improve CHW working conditions, which is instrumental in improving their retention. Non-monetary incentives (eg, identification, transportation) are crucial motivators for CHWs and should be considered as part of the compensation package to facilitate improved performance of CHW programs.

Factors determining job satisfaction of malaria community microscopists in Palawan, the Philippines: a cross-sectional mixed-methods study

BACKGROUND

This study was conducted to investigate the overall job satisfaction and its associated factors among microscopists as community health workers who specialize in malaria microscopic diagnosis and treatment in Palawan, the Philippines. The study offered new insights to further lessen the burden of malaria and improve treatment by enhancing their commitment and satisfaction.

METHODS

A quantitative study was conducted with 217 microscopists who were asked about their sociodemographic characteristics, ability as microscopists (service quality, knowledge of malaria and ability to diagnose malaria by microscopy [malaria microscopy]) and job satisfaction. Structural equation modelling (SEM) was conducted to analyse these factors. A qualitative study was also conducted and four focus group discussions (FGDs) were carried out.

RESULTS

SEM identified that the job satisfaction of microscopists was enhanced by ability in malaria microscopy, the annual parasite index and belonging to ethnic minorities. In the FGDs, high job satisfaction was seen in their devotion to the community and increasing knowledge about malaria.

CONCLUSIONS

Providing opportunities to improve malaria microscopy ability would increase the overall job satisfaction of microscopists and eventually improve the quality of care.

Salaried and voluntary community health workers: exploring how incentives and expectation gaps influence motivation

BACKGROUND

The recent publication of the WHO guideline on support to optimise community health worker (CHW) programmes illustrates the renewed attention for the need to strengthen the performance of CHWs. Performance partly depends on motivation, which in turn is influenced by incentives. This paper aims to critically analyse the use of incentives and their link with improving CHW motivation.

METHODS

We undertook a comparative analysis on the linkages between incentives and motivation based on existing datasets of qualitative studies in six countries. These studies had used a conceptual framework on factors influencing CHW performance, where motivational factors were defined as financial, material, non-material and intrinsic and had undertaken semi-structured interviews and focus group discussions with CHWs, supervisors, health managers and selected community members.

RESULTS

We found that (a mix of) incentives influence motivation in a similar and sometimes different way across contexts. The mode of CHW engagement (employed vs. volunteering) influenced how various forms of incentives affect each other as well as motivation. Motivation was negatively influenced by incentive-related "expectation gaps", including lower than expected financial incentives, later than expected payments, fewer than expected material incentives and job enablers, and unequally distributed incentives across groups of CHWs. Furthermore, we found that incentives could cause friction for the interface role of CHWs between communities and the health sector.

CONCLUSIONS

Whether CHWs are employed or engaged as volunteers has implications for the way incentives influence motivation. Intrinsic motivational factors are important to and experienced by both types of CHWs, yet for many salaried CHWs, they do not compensate for the demotivation derived from the perceived low level of financial reward. Overall, introducing and/or sustaining a form of financial incentive seems key towards strengthening CHW motivation. Adequate expectation management regarding financial and material incentives is essential to prevent frustration about expectation gaps or "broken promises", which negatively affect motivation. Consistently receiving the type and amount of incentives promised appears as important to sustain motivation as raising the absolute level of incentives.

Community engagement and mobilisation of local resources to support integrated Community Case Management of childhood illnesses in Niger State, Nigeria

Background

Despite strong evidence of integrated community case management (iCCM) of childhood illnesses being a proven intervention for reducing childhood morbidity and mortality, sustainability remains a challenge in most settings. Community ownership and contribution are important factors in sustainability. The purpose of this study was to document the process and scale achieved for community engagement and mobilisation to foster ownership, service uptake and sustainability of iCCM activities.

Methods

A review of data collected by the RAcE project was conducted to describe the scale and achievement of leveraging community resources to support the community-oriented resource persons (CORPs). The Rapid Access Expansion (RAcE)-supported iCCM programme in Niger state (2014-2017), aimed at improving coverage of case management services for malaria, pneumonia, and diarrhoea, among children aged 2–59 months. Resources donated were documented and costed based on the market value of goods and services at the time of donation. These monetary valuations were validated at community dialogue meetings. Descriptive statistics were used to summarise quantitative variables. The mean of the number of CORPs in active service and the percentages of the mobilised resources received by CORPs were calculated.

Results

The community engagement activities included 143 engagement and advocacy visits, and meetings, 300 community dialogues, reactivation of 60 ward development committees, and 3000 radio messages in support of iCCM. 79.5% of 1659 trained CORPs were still in active iCCM service at the end of the project. We estimated the costs of all support provided by the community to CORPs in cash and kind as US$ 123 062. Types of support included cash; building materials; farming support; fuel for motorcycles, and transport fares.

Conclusions

The achievements of community engagement, mobilisation, and the resources leveraged, demonstrated acceptability of the project to the beneficiaries and their willingness to contribute to uninterrupted service provision by CORPs.

Evaluating Equity and Inclusion in Access to Water and Sanitation for Persons Living with HIV/AIDS in Wukro, Ethiopia

For more than a decade, foreign aid-supported water interventions focusing on an increase in household private connections have been implemented in the small urban center of Wukro. However, little has been investigated about the effectiveness of these interventions in achieving equitable and inclusive access to water and sanitation for all, including the most vulnerable. With this purpose, a cross-sectional comparative analysis of service provision between the HIV-infected population (n = 199) and non-infected population (n = 199) was undertaken. Findings suggest significant inequalities regarding the primary water source, monthly expenditure in water, water consumption, and time employed to fetch water, as well as the type of toilet facility, number of users, and the time employed to access it. Results also show a reported feeling of discrimination with regard to service provision within the HIV-positive population. This study provides evidence on local-scale interventions increasing the number of household water connections but overlooking the pursuit of equity and inclusion for the most vulnerable. The study also presents recommendations on how to specifically target the needs of persons living with HIV/AIDS in order to achieve equitable and inclusive access to water and sanitation for all.

Prevalence, incidence and predictors of volunteer community health worker attrition in Kwale County, Kenya

Introduction

In underserved populations, the contribution of community health workers (CHWs) is vital to the healthcare systems. Attrition of these workers causes critical breakdowns in the delivery of essential services to these populations. Literature on reasons for attrition is limited, although some have been identified in studies on sustainability of CHW programmes. These factors are, however, likely to be influenced by context. We measured CHW attrition and its predictors in a rural area in Kenya.

Methods

We conducted a nested case–control study and focus group discussions among CHWs involved in a maternal and child health project. A training register of 1005 CHWs was used to sample and follow CHWs for attrition. Incidence of CHW attrition was calculated using a Poisson model. Separately, we used logistic regression to determine predictors of CHW attrition.

Results

Of the 1005 CHWs, 498 (49.6%) had left the project by the time of the study. The incidence of attrition was 46.8/1000 person-years (95% CI 38.7 to 56.5). In the case–control study, lack of interest in peer organisation membership (OR 5.3; 95% CI 1.3 to 20.6) was associated with attrition. Absence of refresher training (OR 4.0; 95% CI 2.2 to 7.1) and receiving no feedback from supervisors (OR 2.0; 95% CI 1.0 to 3.9) were also associated with attrition. Discordance in expectations and perceived heavy workload were also identified as key reasons for attrition in the qualitative study.

Conclusion

This study estimates high prevalence and incidence of CHW attrition in Kwale County, Kenya. Ongoing training, feedback and peer support are also important in enhancing retention of CHWs. Additionally, expectations regarding the roles and benefits of involvement in CHW work should be communicated clearly, and workload should be kept reasonable or negotiated with the CHWs.

Motivation and satisfaction among community health workers administering rapid diagnostic tests for malaria in Western Kenya

Background

The continued success of community case management (CCM) programs in low-resource settings depends on the ability of these programs to retain the community health workers (CHWs), many of whom are volunteers, and maintain their high-quality performance. This study aims to identify factors related to the motivation and satisfaction of CHWs working in a malaria CCM program in two sub-counties in Western Kenya.

Methods

We interviewed 70 CHWs who were trained to administer malaria rapid diagnostic tests as part of a broader study evaluating a malaria CCM program. We identified factors related to CHWs' motivation and their satisfaction with participation in the program, as well as the feasibility of program scale-up. We used principal components analysis to develop an overall CHW satisfaction score and assessed associations between this score and individual CHW characteristics as well as their experiences in the program.

Results

The majority of CHWs reported that they were motivated to perform their role in this malaria CCM program by a personal desire to help their community (69%). The most common challenge CHWs reported was a lack of community understanding about malaria diagnostic testing and CHWs' role in the program (39%). Most CHWs (89%) reported that their involvement in the diagnostic testing intervention had either a neutral or a net positive effect on their other CHW activities, including improving skills applicable to other tasks. CHWs who said they strongly agreed with the statement that their work with the malaria program was appreciated by the community had a 0.76 standard deviation (SD) increase in their overall satisfaction score (95% confidence interval CI = 0.10-1.24, P = 0.03). Almost all CHWs (99%) strongly agreed that they wanted to continue their role in the malaria program.

Conclusions

Overall, CHWs reported high satisfaction with their role in community-based malaria diagnosis, though they faced challenges primarily related to community understanding and appreciation of the services they provided. CHWs' perceptions that the malaria program generally did not interfere with their other activities is encouraging for the sustainability and scale-up of similar CHW programs.

Implementing Community-based Health Planning and Services in impoverished urban communities: health workers' perspective

BACKGROUND

Three-quarters of sub-Saharan Africa's urban population currently live under slum conditions making them susceptible to ill health and diseases. Ghana characterizes the situation in many developing countries where the urban poor have become a group much afflicted by complex health problems associated with their living conditions, and the intra-city inequity between them and the more privileged urban dwellers with respect to health care accessibility. Adopting Ghana's rural Community-Based Health Planning and Service (CHPS) programme in urban areas is challenging due to the differences in social networks and health challenges thus making modifications necessary. The Community Health Officers (CHOs) and their supervisors are the frontline providers of health in the community and there is a need to analyze and document the health sector response to urban CHPS.

METHODS

The study was solely qualitative and 19 in-depth interviews were conducted with all the CHOs and key health sector individuals in supervisory/coordinating positions working in urban CHPS zones to elicit relevant issues concerning urban CHPS implementation. Thematic content data analysis was done using the NVivo 7 software.

RESULTS

Findings from this appraisal suggest that the implementation of this urban concept of the CHPS programme has been well undertaken by the health personnel involved in the process despite the challenges that they face in executing their duties. Several issues came to light including the lack of first aid drugs, as well as the need for the Integrated Management of Neonatal and Childhood Illnesses (IMNCI) programme and more indepth training for CHOs. In addition, the need to provide incentives for the volunteers and Community Health Committee members to sustain their motivation and the CHOs' apprehensions with regards to furthering their education and progression in their careers were key concerns raised.

CONCLUSION

The establishment of the CHPS concept in the urban environment albeit challenging has been fraught with several opportunities to introduce innovations which tailor the rural milestones to meet urban needs. Modifications such as adjusting timing of home visits and renting accommodation in the communities for the CHOs have been beneficial to the programme.

Community-based maternal, newborn, and child health surveillance: perceptions and attitudes of local stakeholders towards using mobile phone by village health volunteers in the Kenge Health Zone, Democratic Republic of Congo

BACKGROUND

In early 2016, we implemented a community-based maternal, newborn, and child health (MNCH) surveillance using mobile phones to collect, analyze, and use data by village health volunteers (VHV) in Kenge Health Zone (KHZ), in the Democratic Republic of Congo (DRC). The objective of this study was to determine the perceptions of households, attitudes of community health volunteers, and opinions of nurses in Health center and administrative authorities towards the use of mobile phones for MNCH surveillance in the rural KHZ in the DRC.

METHODS

We used mixed methods combining phenomenological and descriptive cross-sectional study. Between 3 and 24 March 2016, we collected the data through focus group discussions (FGD) with households, and structured interviews with VHV, local health and administrative authority, and nurses to explore the perceptions on MNCH surveillance using mobile phone. Data from the FGD and interviews  were analyzed using thematic analysis techniques and descriptive statistics respectively.

RESULTS

Health issues and services for under-five children were well known by community; however, beliefs and cultural norms contributed to the practices of seeking behavior for households. Mobile phones were perceived as devices that render quick services for people who needed help; and the community's attitudes towards the mobile phone use for collection of data, analysis, and use activities were good. Although some of community members did not see a direct linkage between this surveillance approach and health benefits, majority believed that there would be better MNCH services with the use of mobile phone. In addition, VHV will benefit from free healthcare for households and some material benefits and training. The best time to undertake these activities were in the afternoon with mother of the child, being the best respondent at the household.

CONCLUSION

Health issues and services for under-five children are well known and MNCH surveillance using mobile phone by VHV in which the mother can be involved as respondent is accepted.

Exploring barriers and enablers for scaling up a community-based grain bank intervention for improved infant and young child feeding in Ethiopia: A qualitative process evaluation

Child malnutrition remains high in Ethiopia, and inadequate complementary feeding is a contributing factor. In this context, a community‐based intervention was designed to provide locally made complementary food for children 6–23 months, using a bartering system, in four Ethiopian regions. After a pilot phase, the intervention was scaled up from 8 to 180 localities. We conducted a process evaluation to determine enablers and barriers for the scaling up of this intervention. Eight study sites were selected to perform 52 key informant interviews and 31 focus group discussions with purposely selected informants. For analysis, we used a framework describing six elements of successful scaling up: socio‐political context, attributes of the intervention, attributes of the implementers, appropriate delivery strategy, the adopting community, and use of research to inform the scale‐up process. A strong political will, alignment of the intervention with national priorities, and integration with the health care system were instrumental in the scaling up. The participatory approach in decision‐making reinforced ownership at community level, and training about complementary feeding motivated mothers and women's groups to participate. However, the management of the complex intervention, limited human resources, and lack of incentives for female volunteers proved challenging. In the bartering model, the barter rate was accepted, but the bartering was hindered by unavailability of cereals and limited financial and material resources to contribute, threatening the project's sustainability. Scaling up strategies for nutrition interventions require sufficient time, thorough planning, and assessment of the community's capacity to contribute human, financial, and material resources.

The contribution of female community health volunteers (FCHVs) to maternity care in Nepal: a qualitative study

Background

In resource-poor settings, the provision of basic maternity care within health centres is often a challenge. Despite the difficulties, Nepal reduced its maternal mortality ratio by 80% from 850 to an estimated 170 per 100,000 live births between 1991 and 2011 to achieve Millennium Development Goal Five. One group that has been credited for this is community health workers, known as Female Community Health Volunteers (FCHVs), who form an integral part of the government healthcare system. This qualitative study explores the role of FCHVs in maternal healthcare provision in two regions: the Hill and Terai.

Methods

Between May 2014 and September 2014, 20 FCHVs, 11 health workers and 26 service users were purposefully selected and interviewed using semi-structured topic guides. In addition, four focus group discussions were held with 19 FCHVs. Data were analysed using thematic analysis.

Results

All study participants acknowledged the contribution of FCHVs in maternity care. All FCHVs reported that they shared key health messages through regularly held mothers’ group meetings and referred women for health checks. The main difference between the two study regions was the support available to FCHVs from the local health centres. With regular training and access to medical supplies, FCHVs in the hill villages reported activities such as assisting with childbirth, distributing medicines and administering pregnancy tests. They also reported use of innovative approaches to educate mothers. Such activities were not reported in Terai. In both regions, a lack of monetary incentives was reported as a major challenge for already overburdened volunteers followed by a lack of education for FCHVs.

Conclusions

Our findings suggest that the role of FCHVs varies according to the context in which they work. FCHVs, supported by government health centres with emphasis on the use of local approaches, have the potential to deliver basic maternity care and promote health-seeking behaviour so that serious delays in receiving healthcare can be minimised. However, FCHVs need to be reimbursed and provided with educational training to ensure that they can work effectively. The study underlines the relevance of community health workers in resource-poor settings.

Electronic supplementary material

The online version of this article (10.1186/s12913-017-2567-7) contains supplementary material, which is available to authorized users.

Perceptions of incentives offered in a community-based malaria diagnosis and treatment program in the Highlands of Papua New Guinea

What motivates community-based health workers to provide care in rural and remote areas, often on a voluntary or casual basis, is a key question for program managers and public health officials. This paper examines how a range of incentives offered as part of the Marasin Stoa Kipa program, a community-based malaria diagnosis and treatment program that has been implemented since 2007 within a major oil and gas development area in Papua New Guinea, are perceived and critiqued by community-based health workers. Nineteen interviews and seven focus group discussions with the workers who deliver services and members of the communities served by the program, conducted between November 4 and 25, 2015, reveal a pattern of mixed motivations and changes in motivation over time. This can be attributed partly to the unique social and economic circumstances in which the program is operating. Changes in the burden of disease as well as in global and national health services policy with implications for local level program operations also had an impact, as did the nature of relationships between program managers, community-based health workers, and program beneficiaries. Overall, the findings suggest that while financial and in-kind incentives can be a useful tool to motivate voluntary or minimally-compensated community-based health workers, they must be carefully structured to align with local social, economic, and epidemiological realities over the long-term.

Community health worker perspectives on a new primary health care initiative in the Eastern Cape of South Africa

BACKGROUND

In 2010, South Africa's National Department of Health launched a national primary health care (PHC) initiative to strengthen health promotion, disease prevention, and early disease detection. The strategy, called Re-engineering Primary Health Care (rPHC), aims to provide a preventive and health-promoting community-based PHC model. A key component of rPHC is the use of community-based outreach teams staffed by generalist community health workers (CHWs).

METHODS

We conducted focus group discussions and surveys on the knowledge and attitudes of 91 CHWs working on community-based rPHC teams in the King Sabata Dalindyebo (KSD) sub-district of Eastern Cape Province.

RESULTS

The CHWs we studied enjoyed their work and found it meaningful, as they saw themselves as agents of change. They also perceived weaknesses in the implementation of outreach team oversight, and desired field-based training and more supervision in the community.

CONCLUSIONS

There is a need to provide CHWs with basic resources like equipment, supplies and transport to improve their acceptability and credibility to the communities they serve.

Supporting close-to-community providers through a community health system approach: case examples from Ethiopia and Tanzania

INTRODUCTION

Close-to-community (CTC) providers, including community health workers or volunteers or health extension workers, can be effective in promoting access to and utilization of health services. Tasks are often shifted to these providers with limited resources and support from CTC programmes or communities. The Community Health System Strengthening (CHSS) model is part of an improvement approach which draws on existing formal and informal networks within a community, such as agricultural or women's groups, to support CTC providers and address gaps in community-based health services. The model offers a framework for bringing representatives from existing community networks, CTC providers, and health facility staff together to form a community team charged with identifying challenges in service delivery, testing solutions, and monitoring changes. CTC providers draw upon fellow community team members to disseminate health messages and refer community members in need of services.

CASES

Two cases are presented. In Ethiopia, the CHSS model was applied in 18 communities to increase HIV testing among pregnant women and antenatal care service utilization and improve sanitation. Prior to implementation, representatives from community groups were unaware of health extension workers or were uncomfortable making referrals. By participating on the community team, representatives became familiar with and comfortable referring people to health extension workers and spreading health messages. During implementation, more pregnant women registered for antenatal care and tested for HIV; health extension workers conducted more postnatal visits; and more households had functioning latrines and proper latrine use increased. In Tanzania, the CHSS model was applied in five communities to improve HIV testing and retention into care. Community team members talked to their families and social networks about HIV testing and, when they identified someone who had dropped out of treatment, they referred those individuals to the home-based care volunteer. Increases in HIV testing and a reduction in patients lost to follow-up were observed.

DISCUSSION AND CONCLUSION

The CHSS model brings together existing networks within communities to support and lend legitimacy to CTC providers. This approach may result in sustainable community-based programmes, especially in HIV where the continuum of care extends beyond the facility and into the community.