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Bao M, Wang H, Huang C, Wang L, Xie C, Chen G. Exploring employment preferences of nurses to improve retention in rural China. Int J Nurs Stud 2023; 141:104473. [PMID: 36934659 DOI: 10.1016/j.ijnurstu.2023.104473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 02/18/2023] [Accepted: 02/21/2023] [Indexed: 02/27/2023]
Abstract
BACKGROUND The scarcity of nurses in rural China deserves serious consideration in light of the widening gap in health outcomes between rural and urban populations. The outflow of primary care nurses suggests the value of examining their employment preferences to identify possible effective incentives for their retention. METHODS Our research used discrete choice experiment methodology designed to quantitatively measure the relative importance of various job attributes valued by primary care nurses using conditional logit and mixed logit models. Willingness to pay and uptake rates were also calculated. RESULTS A total of 1744 registered nurses in township health centres were surveyed. Participants considered all the job attributes included in the study to be significant, with pay increases demonstrating the greatest potential to improve the retention of nurses. Among the non-monetary aspects of work, nurse-patient relationships, bianzhi (positions allocated to each unit by the Chinese government with special benefits) and educational opportunities ranked highest in importance for respondents. Responses to hypothetical policy proposals suggest that incentive packages are also likely to be effective. CONCLUSIONS Policy making regarding rural nurses' retention is an important undertaking that requires an evidence-based approach. Our findings provide a range of policy options that shed light on effective retention strategies. Tailoring policy incentives to primary care nurses is also necessary.
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Affiliation(s)
- Meiling Bao
- School of Public Health, Guizhou Medical University, Guiyang, China; School of Public Health, Sun Yat-sen University, Guangzhou, China.
| | - Haoxiang Wang
- School of Public Health, Sun Yat-sen University, Guangzhou, China.
| | - Cunrui Huang
- Vanke School of Public Health, Tsinghua University, Beijing, China.
| | - Lei Wang
- Department of Primary Healthcare, Health Commission of Guizhou Province, Guiyang, China.
| | - Chun Xie
- School of Public Health, Guizhou Medical University, Guiyang, China.
| | - Gang Chen
- College of Medicine and Public Health, Flinders University, Adelaide, Australia.
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Gadsden T, Sujarwoto S, Purwaningtyas N, Maharani A, Tampubolon G, Oceandy D, Praveen D, Angell B, Jan S, Palagyi A. Understanding community health worker employment preferences in Malang district, Indonesia, using a discrete choice experiment. BMJ Glob Health 2022; 7:bmjgh-2022-008936. [PMID: 35953209 PMCID: PMC9379506 DOI: 10.1136/bmjgh-2022-008936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 07/28/2022] [Indexed: 11/04/2022] Open
Abstract
Background Community health workers (CHWs) play a critical role in supporting health systems, and in improving accessibility to primary healthcare. In many settings CHW programmes do not have formalised employment models and face issues of high attrition and poor performance. This study aims to determine the employment preferences of CHWs in Malang district, Indonesia, to inform policy interventions. Methods A discrete choice experiment was conducted with 471 CHWs across 28 villages. Attributes relevant to CHW employment were identified through a multistage process including literature review, focus group discussions and expert consultation. Respondents’ choices were analysed with a mixed multinomial logit model and latent class analyses. Results Five attributes were identified: (1) supervision; (2) training; (3) monthly financial benefit; (4) recognition; and (5) employment structure. The most important influence on choice of job was a low monthly financial benefit (US$~2) (β=0.53, 95% CI=0.43 to 0.63), followed by recognition in the form of a performance feedback report (β=0.13, 95% CI=0.07 to 0.20). A large monthly financial benefit (US$~20) was most unappealing to respondents (β=−0.13, 95% CI=−0.23 to −0.03). Latent class analysis identified two groups of CHWs who differed in their willingness to accept either job presented and preferences over specific attributes. Preferences diverged based on respondent characteristics including experience, hours’ worked per week and income. Conclusion CHWs in Malang district, Indonesia, favour a small monthly financial benefit which likely reflects the unique cultural values underpinning the programme and a desire for remuneration that is commensurate with the limited number of hours worked. CHWs also desire enhanced methods of performance feedback and greater structure around training and their rights and responsibilities. Fulfilling these conditions may become increasingly important should CHWs work longer hours.
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Affiliation(s)
- Thomas Gadsden
- Health Systems Science, George Institute for Global Health, Sydney, New South Wales, Australia
| | | | | | - Asri Maharani
- Faculty of Health and Education, Manchester Metropolitan University, Manchester, UK
| | - Gindo Tampubolon
- Global Development Institute, The University of Manchester, Manchester, UK
| | - Delvac Oceandy
- Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
| | - Devarsetty Praveen
- Better Care India, The George Institute for Global Health India, Hyderabad, India.,Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
| | - Blake Angell
- Health Systems Science, George Institute for Global Health, Sydney, New South Wales, Australia
| | - Stephen Jan
- Health Systems Science, George Institute for Global Health, Sydney, New South Wales, Australia
| | - Anna Palagyi
- Health Systems Science, George Institute for Global Health, Sydney, New South Wales, Australia
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Okyere E, Ward PR, Marfoh K, Mwanri L. Incentives management among health workers in primary health-care facilities: addressing important issues in rural Ghana. J Health Organ Manag 2022; ahead-of-print. [PMID: 35443126 DOI: 10.1108/jhom-08-2021-0322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE This study seeks to explore health workers' perceptions and experiences on incentives for motivating and retaining them in primary health-care facilities in rural Ghana. DESIGN/METHODOLOGY/APPROACH Phenomenological research design was used to explore health workers' experiences and perceptions on their incentive packages. Sixty-eight in-depth interviews were conducted with health-care workers in primary health-care facilities and analyzed using thematic analysis approach. FINDINGS The findings show health-care workers' perceptions on their incentives, ranging from low awareness, unfair distribution, favoritism, means of punishment and incentives regarded unattractive. The preferred incentive packages identified were salary increase, housing availability, recognition, adequate supplies, and risk and responsibility allowances. Health-care workers suggested for the modification of incentives including vehicle importation waiver, reduction in study leave years and opportunity to pursue desired courses. ORIGINALITY/VALUE The findings suggest that incentives that align with health-care workers' preferences can potentially improve their motivation and influence retention. Health-care workers' concern on incentives having been used as favors and punishment as well as unfair distribution should be addressed by health managers and policymakers, to achieve the desired purpose of motivating and retaining them in rural areas. Appropriate internal monitoring mechanisms are needed for incentives regulation and to improve health workers' retention in rural Ghana.
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Affiliation(s)
- Eunice Okyere
- Department of Public Health, College of Medicine Nursing and Health Sciences-Tamavua Campus, Fiji National University, Suva, Fiji
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Nyanja N, Nyamu N, Nyaga L, Chabeda S, Lusambili A, Temmerman M, Mantel M, Ngugi A. Application of the Ultra-Poverty Graduation Model in understanding community health volunteers' preferences for socio-economic empowerment strategies to enhance retention: a qualitative study in Kilifi, Kenya. HUMAN RESOURCES FOR HEALTH 2021; 19:104. [PMID: 34454506 PMCID: PMC8400398 DOI: 10.1186/s12960-021-00645-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 08/14/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND A significant shortage of healthcare workforce exists globally. To achieve Universal Healthcare coverage, governments need to enhance their community-based health programmes. Community health volunteers (CHVs) are essential personnel in achieving this objective. However, their ability to earn a livelihood is compromised by the voluntary nature of their work; hence, the high attrition rates from community-based health programmes. There is an urgent need to support CHVs become economically self-reliant. We report here on the application of the Ultra-Poverty Graduation (UPG) Model to map CHVs' preferences for socio-economic empowerment strategies that could enhance their retention in a rural area in Kenya. METHODS This study adopted an exploratory qualitative approach. Using a semi-structured questionnaire, we conducted 10 Focus Group Discussions with the CHVs and 10 Key Informant Interviews with County and Sub-county Ministry of Health and Ministry of Agriculture officials including multi-lateral stakeholders' representatives from two sub-counties in the area. Data were audio-recorded and transcribed verbatim and transcripts analysed in NVivo. Researcher triangulation supported the first round of analysis. Findings were mapped and interpreted using a theory-driven analysis based on the six-step Ultra-Poverty Graduation Model. RESULTS We mapped the UPG Model's six steps onto the results of our analyses as follows: (1) initial asset transfer of in-kind goods like poultry or livestock, mentioned by the CHVs as a necessary step; (2) weekly stipends with consumption support to stabilise consumption; (3) hands-on training on how to care for assets, start and run a business based on the assets transferred; (4) training on and facilitation for savings and financial support to build assets and instil financial discipline; (5) healthcare provision and access and finally (6) social integration. These strategies were proposed by the CHVs to enhance economic empowerment and aligned with the UPG Model. CONCLUSION These results provide a user-defined approach to identify and assess strategic needs of and approaches to CHVs' socio-economic empowerment using the UPG model. This model was useful in mapping the findings of our qualitative study and in enhancing our understanding on how these needs can be addressed in order to economically empower CHVs and enhance their retention in our setting.
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Affiliation(s)
- Njeri Nyanja
- Department of Family Medicine, Aga Khan University, Nairobi, Kenya.
| | - Nelson Nyamu
- Department of Family Medicine, Aga Khan University, Nairobi, Kenya
| | - Lucy Nyaga
- Centre of Excellence for Women and Child Health, Aga Khan University, Nairobi, Kenya
| | | | | | - Marleen Temmerman
- Centre of Excellence for Women and Child Health, Aga Khan University, Nairobi, Kenya
- Department of Obstetrics and Gynaecology, Aga Khan University, Nairobi, Kenya
- Department of Public Health and Primary Care, International Centre for Reproductive Health, Ghent University, Ghent, Belgium
| | - Michaela Mantel
- Centre of Excellence for Women and Child Health, Aga Khan University, Nairobi, Kenya
| | - Anthony Ngugi
- Department of Population Health, Aga Khan University, Nairobi, Kenya
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Evaluation of a package of continuum of care interventions for improved maternal, newborn, and child health outcomes and service coverage in Ghana: A cluster-randomized trial. PLoS Med 2021; 18:e1003663. [PMID: 34170904 PMCID: PMC8232410 DOI: 10.1371/journal.pmed.1003663] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 05/20/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In low- and middle-income countries (LMICs), the continuum of care (CoC) for maternal, newborn, and child health (MNCH) is not always complete. This study aimed to evaluate the effectiveness of an integrated package of CoC interventions on the CoC completion, morbidity, and mortality outcomes of woman-child pairs in Ghana. METHODS AND FINDINGS This cluster-randomized controlled trial (ISRCTN: 90618993) was conducted at 3 Health and Demographic Surveillance System (HDSS) sites in Ghana. The primary outcome was CoC completion by a woman-child pair, defined as receiving antenatal care (ANC) 4 times or more, delivery assistance from a skilled birth attendant (SBA), and postnatal care (PNC) 3 times or more. Other outcomes were the morbidity and mortality of women and children. Women received a package of interventions and routine services at health facilities (October 2014 to December 2015). The package comprised providing a CoC card for women, CoC orientation for health workers, and offering women with 24-hour stay at a health facility or a home visit within 48 hours after delivery. In the control arm, women received routine services only. Eligibility criteria were as follows: women who gave birth or had a stillbirth from September 1, 2012 to September 30, 2014 (before the trial period), from October 1, 2014 to December 31, 2015 (during the trial period), or from January 1, 2016 to December 31, 2016 (after the trial period). Health service and morbidity outcomes were assessed before and during the trial periods through face-to-face interviews. Mortality was assessed using demographic surveillance data for the 3 periods above. Mixed-effects logistic regression models were used to evaluate the effectiveness as difference in differences (DiD). For health service and morbidity outcomes, 2,970 woman-child pairs were assessed: 1,480 from the baseline survey and 1,490 from the follow-up survey. Additionally, 33,819 cases were assessed for perinatal mortality, 33,322 for neonatal mortality, and 39,205 for maternal mortality. The intervention arm had higher proportions of completed CoC (410/870 [47.1%]) than the control arm (246/620 [39.7%]; adjusted odds ratio [AOR] for DiD = 1.77; 95% confidence interval [CI]: 1.08 to 2.92; p = 0.024). Maternal complications that required hospitalization during pregnancy were lower in the intervention (95/870 [10.9%]) than in the control arm (83/620 [13.4%]) (AOR for DiD = 0.49; 95% CI: 0.29 to 0.83; p = 0.008). Maternal mortality was 8/6,163 live births (intervention arm) and 4/4,068 live births during the trial period (AOR for DiD = 1.60; 95% CI: 0.40 to 6.34; p = 0.507) and 1/4,626 (intervention arm) and 9/3,937 (control arm) after the trial period (AOR for DiD = 0.11; 95% CI: 0.11 to 1.00; p = 0.050). Perinatal and neonatal mortality was not significantly reduced. As this study was conducted in a real-world setting, possible limitations included differences in the type and scale of health facilities and the size of subdistricts, contamination for intervention effectiveness due to the geographic proximity of the arms, and insufficient number of cases for the mortality assessment. CONCLUSIONS This study found that an integrated package of CoC interventions increased CoC completion and decreased maternal complications requiring hospitalization during pregnancy and maternal mortality after the trial period. It did not find evidence of reduced perinatal and neonatal mortality. TRIAL REGISTRATION The study protocol was registered in the International Standard Randomised Controlled Trial Number Registry (90618993).
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Agarwal S, Abuya T, Kintu R, Mwanga D, Obadha M, Pandya S, Warren CE. Understanding community health worker incentive preferences in Uganda using a discrete choice experiment. J Glob Health 2021; 11:07005. [PMID: 33763219 PMCID: PMC7956012 DOI: 10.7189/jogh.11.07005] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Smisha Agarwal
- Department of International Health, the Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | | | | | - Melvin Obadha
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom.,University College, Oxford, UK
| | - Shivani Pandya
- Department of International Health, the Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Bao M, Huang C. Job preferences of medical and nursing students seeking employment in rural China: a discrete choice experiment. BMC MEDICAL EDUCATION 2021; 21:146. [PMID: 33673842 PMCID: PMC7934374 DOI: 10.1186/s12909-021-02573-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 02/18/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND China has a shortage of health workers in rural areas, but little research exists on policies that attract qualified medical and nursing students to rural locations. We conducted a discrete choice experiment to determine how specific incentives would be valued by final-year students in a medical university in Guizhou Province, China. METHODS Attributes of potential jobs were developed through the literature review, semi-structured interviews, and a pilot survey. Forty choice sets were developed using a fractional factorial design. A mixed logit model was used to estimate the relative strength of the attributes. Willingness to pay and uptake rates for a defined job were also calculated based on the mixed logit estimates. RESULTS The final sample comprised 787 medical and nursing students. The statistically significant results indicated "Bianzhi" (the number of personnel allocated to each employer by the government) and physical conflicts between doctors and patients were two of the most important non-monetary job characteristics that incentivized both medical and nursing students. Policy simulation suggested that respondents were most sensitive to a salary increase, and the effect of incentive packages was stronger for students with a rural family background. CONCLUSIONS Strategies for patient-doctor relationships, Bianzhi and salary should be considered to attract final-year medical and nursing students to work in rural China. In addition, specific recruitment policy designs tailored for students with different majors and backgrounds should be taken into account.
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Affiliation(s)
- Meiling Bao
- School of Public Health, Sun Yat-sen University, Zhongshan Road #2, Guangzhou, 510080, China
- School of Public Health, Guizhou Medical University, Guiyang, China
| | - Cunrui Huang
- School of Public Health, Sun Yat-sen University, Zhongshan Road #2, Guangzhou, 510080, China.
- School of Public Health, Zhengzhou University, Zhengzhou, China.
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Arora N, Hanson K, Spicer N, Estifanos AS, Keraga DW, Welearegay AT, Tela FG, Hussen YA, Mandefro YS, Quaife M. Understanding the importance of non-material factors in retaining community health workers in low-income settings: a qualitative case-study in Ethiopia. BMJ Open 2020; 10:e037989. [PMID: 33033092 PMCID: PMC7545659 DOI: 10.1136/bmjopen-2020-037989] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 08/28/2020] [Accepted: 09/01/2020] [Indexed: 11/17/2022] Open
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.
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Affiliation(s)
- Nikita Arora
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Kara Hanson
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Neil Spicer
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | | | | | | | | | - Matthew Quaife
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Agarwal S, Anaba U, Abuya T, Kintu R, Casseus A, Hossain S, Obadha M, Warren CE. Understanding incentive preferences of community health workers using discrete choice experiments: a multicountry protocol for Kenya, Uganda, Bangladesh and Haiti. BMJ Open 2019; 9:e033601. [PMID: 31831550 PMCID: PMC6924748 DOI: 10.1136/bmjopen-2019-033601] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION There is a renewed global interest in improving community health worker (CHW) programmes. For CHW programmes to be effective, key intervention design factors which contribute to the performance of CHWs need to be identified. The recent WHO guidelines recommends the combination of financial and non-financial incentives to improve CHW performance. However, evidence gaps remain as to what package of incentives will improve their performance in different country contexts. This study aims to evaluate CHW incentive preferences to improve performance and retention which will strengthen CHW programmes and help governments leverage limited resources appropriately. METHODS AND ANALYSIS A discrete choice experiment (DCE) will be conducted with CHWs in Bangladesh, Haiti, Kenya and Uganda with different levels of maturity of CHWs programmes. This will be carried out in two phases. Phase 1 will involve preliminary qualitative research including focus group discussions (FGDs) and key informant interviews to develop the DCE design which will include attributes relevant to the CHW country settings. Phase 2 will involve a DCE survey with CHWs, presenting them with a series of job choices with varying attribute levels. An orthogonal design will be used to generate the choice sets for the surveys. The surveys will be administered in locally-appropriate languages to at least 150 CHWs from each of the cadres in each country. Conditional and mixed multinomial logit (MMNL) models will be used for the estimation of stated preferences. ETHICS AND DISSEMINATION This study has been reviewed and approved by the Population Council's Institutional Review Board in New York, and appropriate ethics review boards in Kenya, Uganda, Bangladesh and Haiti. The results of the study will be disseminated through in-country dissemination workshops, meetings with country-level stakeholders and policy working groups, print media, online blogs and peer-reviewed journals.
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Affiliation(s)
- Smisha Agarwal
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Timothy Abuya
- Reproductive Health Program, Population Council, Nairobi, Kenya
| | | | | | | | - Melvin Obadha
- Health Economics Research Unit, KEMRI, Nairobi, Kenya
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Abdel-All M, Angell B, Jan S, Howell M, Howard K, Abimbola S, Joshi R. What do community health workers want? Findings of a discrete choice experiment among Accredited Social Health Activists (ASHAs) in India. BMJ Glob Health 2019; 4:e001509. [PMID: 31263591 PMCID: PMC6570975 DOI: 10.1136/bmjgh-2019-001509] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 04/24/2019] [Accepted: 04/29/2019] [Indexed: 01/06/2023] Open
Abstract
Introduction A number of factors contribute to the performance and motivation of India’s Accredited Social Health Activists (ASHAs). This study aims to identify the key motivational factors (and their relative importance) that may help retain ASHAs in service. Methods A discrete choice experiment (DCE) survey presented ASHAs with eight unlabelled choice sets, each describing two hypothetical jobs that varied based on five attributes, specifically salary, workload, travel allowance, supervision and other job benefits. Multinomial logit and latent class (LC) models were used to estimate stated preferences for the attributes. Result We invited 318 ASHAs from 53 primary health centres of Guntur, a district in south India. The DCE was completed by 299 ASHAs using Android tablets. ASHAs were found to exhibit a strong preference for jobs that incorporated training leading to promotion, a fixed salary and free family healthcare. ASHAs were willing to sacrifice 2530 Indian rupee (INR) from their monthly salary, for a job offering training leading to promotion opportunity and 879 INR for a free family health-check. However, there was significant heterogeneity in preferences across the respondents. The LC model identified three distinct groups (comprising 51%, 35% and 13% of our cohort, respectively). Group 1 and 2 preferences were dominated by the training and salary attributes with group 2 having higher preference for free family health-check while group 3 preferences were dominated by workload. Relative to group 3, ASHAs in groups 1 and 2 were more likely to have a higher level of education and less likely to be the main income earners for their families. Conclusion ASHAs are motivated by both non-financial and financial factors and there is significant heterogeneity between workers. Policy decisions aimed at overcoming workforce attrition should target those areas that are most valued by ASHAs to maximise the value of investments into these workers. Trial registration number CTRI/2018/03/012425.
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Affiliation(s)
- Marwa Abdel-All
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,The George Institute for Global Health, Newtown, New South Wales, Australia
| | - Blake Angell
- The George Institute for Global Health, Newtown, New South Wales, Australia
| | - Stephen Jan
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,Health Economics and Process Evaluation Program, The George Institute for Global Health, Sydney, New South Wales, Australia.,Facultyof Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Martin Howell
- School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Kirsten Howard
- School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Seye Abimbola
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,The George Institute for Global Health, Newtown, New South Wales, Australia
| | - Rohina Joshi
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,The George Institute for Global Health, Newtown, New South Wales, Australia.,School of Public Health and Community Medicine, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
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Soekhai V, de Bekker-Grob EW, Ellis AR, Vass CM. Discrete Choice Experiments in Health Economics: Past, Present and Future. PHARMACOECONOMICS 2019; 37:201-226. [PMID: 30392040 PMCID: PMC6386055 DOI: 10.1007/s40273-018-0734-2] [Citation(s) in RCA: 407] [Impact Index Per Article: 81.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
OBJECTIVES Discrete choice experiments (DCEs) are increasingly advocated as a way to quantify preferences for health. However, increasing support does not necessarily result in increasing quality. Although specific reviews have been conducted in certain contexts, there exists no recent description of the general state of the science of health-related DCEs. The aim of this paper was to update prior reviews (1990-2012), to identify all health-related DCEs and to provide a description of trends, current practice and future challenges. METHODS A systematic literature review was conducted to identify health-related empirical DCEs published between 2013 and 2017. The search strategy and data extraction replicated prior reviews to allow the reporting of trends, although additional extraction fields were incorporated. RESULTS Of the 7877 abstracts generated, 301 studies met the inclusion criteria and underwent data extraction. In general, the total number of DCEs per year continued to increase, with broader areas of application and increased geographic scope. Studies reported using more sophisticated designs (e.g. D-efficient) with associated software (e.g. Ngene). The trend towards using more sophisticated econometric models also continued. However, many studies presented sophisticated methods with insufficient detail. Qualitative research methods continued to be a popular approach for identifying attributes and levels. CONCLUSIONS The use of empirical DCEs in health economics continues to grow. However, inadequate reporting of methodological details inhibits quality assessment. This may reduce decision-makers' confidence in results and their ability to act on the findings. How and when to integrate health-related DCE outcomes into decision-making remains an important area for future research.
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Affiliation(s)
- Vikas Soekhai
- Section of Health Technology Assessment (HTA) and Erasmus Choice Modelling Centre (ECMC), Erasmus School of Health Policy & Management (ESHPM), Erasmus University Rotterdam (EUR), P.O. Box 1738, Rotterdam, 3000 DR The Netherlands
- Department of Public Health, Erasmus MC, University Medical Center, P.O. Box 2040, Rotterdam, 3000 CA The Netherlands
| | - Esther W. de Bekker-Grob
- Section of Health Technology Assessment (HTA) and Erasmus Choice Modelling Centre (ECMC), Erasmus School of Health Policy & Management (ESHPM), Erasmus University Rotterdam (EUR), P.O. Box 1738, Rotterdam, 3000 DR The Netherlands
| | - Alan R. Ellis
- Department of Social Work, North Carolina State University, Raleigh, NC USA
| | - Caroline M. Vass
- Manchester Centre for Health Economics, The University of Manchester, Manchester, UK
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Salloum RG, Shenkman EA, Louviere JJ, Chambers DA. Application of discrete choice experiments to enhance stakeholder engagement as a strategy for advancing implementation: a systematic review. Implement Sci 2017; 12:140. [PMID: 29169397 PMCID: PMC5701380 DOI: 10.1186/s13012-017-0675-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 11/15/2017] [Indexed: 01/11/2023] Open
Abstract
Background One of the key strategies to successful implementation of effective health-related interventions is targeting improvements in stakeholder engagement. The discrete choice experiment (DCE) is a stated preference technique for eliciting individual preferences over hypothetical alternative scenarios that is increasingly being used in health-related applications. DCEs are a dynamic approach to systematically measure health preferences which can be applied in enhancing stakeholder engagement. However, a knowledge gap exists in characterizing the extent to which DCEs are used in implementation science. Methods We conducted a systematic literature search (up to December 2016) of the English literature to identify and describe the use of DCEs in engaging stakeholders as an implementation strategy. We searched the following electronic databases: MEDLINE, Econlit, PsychINFO, and the CINAHL using mesh terms. Studies were categorized according to application type, stakeholder(s), healthcare setting, and implementation outcome. Results Seventy-five publications were selected for analysis in this systematic review. Studies were categorized by application type: (1) characterizing demand for therapies and treatment technologies (n = 32), (2) comparing implementation strategies (n = 22), (3) incentivizing workforce participation (n = 11), and (4) prioritizing interventions (n = 10). Stakeholders included providers (n = 27), patients (n = 25), caregivers (n = 5), and administrators (n = 2). The remaining studies (n = 16) engaged multiple stakeholders (i.e., combination of patients, caregivers, providers, and/or administrators). The following implementation outcomes were discussed: acceptability (n = 75), appropriateness (n = 34), adoption (n = 19), feasibility (n = 16), and fidelity (n = 3). Conclusions The number of DCE studies engaging stakeholders as an implementation strategy has been increasing over the past decade. As DCEs are more widely used as a healthcare assessment tool, there is a wide range of applications for them in stakeholder engagement. The DCE approach could serve as a tool for engaging stakeholders in implementation science. Electronic supplementary material The online version of this article (10.1186/s13012-017-0675-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ramzi G Salloum
- Department of Health Outcomes and Policy, College of Medicine, University of Florida, 2004 Mowry Road, Gainesville, FL, 32610, USA.
| | - Elizabeth A Shenkman
- Department of Health Outcomes and Policy, College of Medicine, University of Florida, 2004 Mowry Road, Gainesville, FL, 32610, USA
| | - Jordan J Louviere
- Institute for Choice, School of Marketing, University of South Australia, Adelaide, SA, Australia
| | - David A Chambers
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
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Brown L, Lee TH, De Allegri M, Rao K, Bridges JF. Applying stated-preference methods to improve health systems in sub-Saharan Africa: a systematic review. Expert Rev Pharmacoecon Outcomes Res 2017; 17:441-458. [PMID: 28875767 DOI: 10.1080/14737167.2017.1375854] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Sub-Saharan African health systems must balance shifting disease burdens with desires for robust institutions. Stated-preference methods have been applied extensively to elicit health care workers' preferences and priorities for rural practice. This systematic review characterizes the range of their applications to African health systems problems. Areas covered: A PRISMA protocol was submitted to PROSPERO. Six databases were queried for peer-reviewed articles using quantitative stated-preference methods to evaluate a health systems-related trade-off. Quality was assessed using the PREFS checklist. Seventy-seven articles published between 1996 and 2017 met review criteria. Methods were primarily choice-based: discrete-choice experiments (n = 46), ranking/allocation techniques (n = 21), conjoint analyses (n = 7), and best-worst scaling (n = 3). Trade-offs fell into six 'building blocks': service features (n = 27), workforce incentives (n = 17), product features (n = 14), system priorities (n = 14), insurance features (n = 4), and research priorities (n = 1). Five countries dominated: South Africa (n = 11), Ghana (n = 9), Malawi (n = 9), Uganda (n = 9), and Tanzania (n = 8). Discrete-choice experiments were of highest quality (mean score: 3.36/5). Expert commentary: Stated-preference methods have been applied to many health systems contexts throughout sub-Saharan Africa. Studies examined established strategic areas, especially primary health care for women, prevention and treatment of infectious diseases, and workforce development. Studies have neglected the emerging areas of non-communicable diseases.
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Affiliation(s)
- Lauren Brown
- a Department of International Health , The Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | - Ting-Hsuan Lee
- b Department of International Health/Department of Health Policy and Management , The Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | - Manuela De Allegri
- c Institute of Public Health, Faculty of Medicine , Heidelberg University , Heidelberg , Germany
| | - Krishna Rao
- a Department of International Health , The Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | - John Fp Bridges
- b Department of International Health/Department of Health Policy and Management , The Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
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