Elsevier

Public Health

Volume 136, July 2016, Pages 166-171
Public Health

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

https://doi.org/10.1016/j.puhe.2016.01.010Get rights and content

Highlights

  • Integrating full-time CHWs into health systems is an accepted goal of many countries but the role of CHVs is less well defined.

  • CHVs, if trained by CHWs can potentially increase the CHWs reach and scope helping to overcome barriers to preventative and curative health care uptake.

  • Knowledge acquisition, development of relationships in the community and action were important motivators for the CHVs.

Abstract

Objectives

In some countries, full-time Community Health Workers (CHWs) have contributed to improvements in under-5 morbidity and mortality. Based on these successes, other low- and middle-income countries are in the process of reconsidering their current health care delivery systems and integrating CHWs as a means by which to fill the gaps. It may be important to make the distinction between CHWs and Community Health Volunteers (CHVs), both of which have a unique but complementary role. While remuneration in motivation of CHWs has been extensively discussed in the literature, other motivators that may prevent high attrition rates amongst volunteers have gained less attention. The objective of this study was to understand whether full-time professional CHWs can potentially work with volunteers in the community to widen their reach and scope and if so what motivators might be of key importance to the CHVs remaining active in the field.

Study design

CHVs were selected and trained in eight villages in East Uganda as part of a mixed-method trial conducted between March 2014 and February 2015.

Methods

Eight to twelve CHVs from each village were trained by CHWs to make home-visits to pregnant women and newborn babies and to improve hygiene. This paper reports on a) demographic data about CHVs (n = 81) and; b) in-depth interviews with retained CHVs (n = 81).

Results

There was a 95% retention rate amongst CHVs. In-depth interviews showed that acquisition and sharing of knowledge, relationship building and seeing health-related knowledge put into action were more important motivators than the transport allowances or the hope of gaining employment. Additionally, CHVs put what they learnt into practice by building tippy taps, having dish-racks and purifying water in their homes and as such were role models in the community.

Conclusion

CHVs can be retained and motivated by factors other than remuneration. Gaining and sharing of knowledge with community members, relationship building and community action were inter-related and ranked higher by CHVs as motivators than the hope of employment or the transport allowance.

Introduction

Many Community Health Workers (CHWs) in low- and middle-income countries have been self-supporting volunteers with incomes that may be supplemented by small stipends, the sale of health commodities or by receiving incentives for the health work they undertake.1, 2, 3, 4, 5, 6, 7, 8 Both voluntary and paid CHWs have been effective in improving under 5-mortality through community education and circumscribed provision of preventative and curative care such as Integrated Community Case Management (iCCM), particularly when supported by a well-functioning health care system.1, 9, 10, 11, 12, 13 Experiences in countries such as Ethiopia, Brazil and Iran have shown that CHWs can be most effective when they are full-time and remunerated.1, 9, 10, 11, 12, 13, 14, 15, 16 This strategy has been successful in attracting and retaining younger individuals who are then accountable for the hours they serve.9, 10, 11, 12, 13 Based on these experiences, in order to improve CHW effectiveness and retention, the current trend is to select individuals with higher basic education to receive systematic, professional training and to be integrated into the existing health system.1, 9, 10, 11, 12, 13 With supportive supervision, these CHWs can potentially deliver well-circumscribed services closer to where the majority of people in predominantly rural populations live.1, 7, 9, 10, 11, 12, 13, 14, 15, 16

With this trend it is useful to make a distinction between the more professional CHW and the Community Health Volunteer (CHV) whose profile is likely to differ from the CHW described above, but who still has an important role to play. The CHV is likely to be older and more established and respected in the community, despite less formal education and health training.14, 15, 16 As mature and respected members, CHVs can effectively engage the community in transformative processes that address the social determinants of health, and the cultural and societal perceptions and beliefs that effect health care uptake. An example of the relationship between CHWs and CHVs can be found in Ethiopia where the Ministry of Health consciously selected young women as their Health Extension Workers (HEW) – or full-time CHWs. In order that two HEWs can serve a population of 5000 they offer training in preventative care to model families and CHVs, some of which constitute Health Development Armies.14, 15, 16 These volunteers help facilitate the acceptability of the young female CHWs and create a ripple effect in the villages as increasing numbers of people engage in health care improvement.9, 10, 11, 12

The need for remuneration of CHWs has been extensively discussed in the literature1, 2, 5, 13, 17 as it became the focal explanation for attrition. The value of other motivators, which may be important for retaining CHVs, have received less attention.8, 13, 18, 19, 20, 21, 22, 23 Some of the authors that have investigated other sources of motivation for CHVs, have identified that knowledge, community appreciation and respect or personal development rate equally with the desire for financial support.8, 21, 22, 23 Engagement with or connection to community, are crucial factors. Behavioural economic theories propose various models to explain these findings that include altruistic capital, positive emotions from being helpful and development of skills, networking and experience.22, 23, 24

The research in Uganda that is described in this paper seeks to add to the body of knowledge about the non-financial motivations of CHVs that would help them to make a meaningful contribution to health improvement in their communities. The aims of this study were to understand how regular training and supervision might contribute to retaining CHVs and this paper examines 1. The motivation and retention of CHVs; 2. CHV engagement of communities to improve health; and 3. Translation of new knowledge by CHVs into behaviour change.

Section snippets

Study setting

The current study was undertaken in Budondo, a sub-county of the Jinja district in East Uganda. Situated near the Nile River, the majority of the population work as subsistence farmers, homemakers, shopkeepers and fishermen. Food insecurity has recently emerged due to cash crops and population pressures on the land. Budondo has had various government initiated CHV programs since 1996. Village Health Teams – made up of groups of CHVs – were introduced in 2005, however many members have not been

Research ethics

Our study protocol was approved by the Institutional Review Board at the School of Public Health at Makerere University, Uganda and the Uganda National Council for Science and Technology and the Human Research Ethics Committee at the University of Sydney, Australia.

Materials used in the study

The materials that were used were developed by Healthy Child Uganda and Ministry of Health in Uganda and were in-line with the priorities of the Ministry of Health for care of pregnant women and newborn babies and improved hygiene in

Demographic data about CHVs

Demographic information for the CHVs is provided in Table 1.

Amongst the 81 CHVs there were 43 females (53%) and 38 (47%) males. The average age was 40 years. Twenty-seven (33%) had primary level education, 47 (58%) had attended secondary school and seven (9%) had higher education. Thirty-eight (48%) of the 81 had no prior experience as a CHV and the average number of years of experience in the others was 4.5 years.

The motivation and retention of CHVs

Questions relating to motivation included: 1. Why did you want to be trained as a

Discussion

Volunteers have played an important role in the improvement of health in communities over many years. With the trend toward increasing the number of systematically and professionally trained CHWs, it is possible that this additional group of human resources will be overlooked or continue to receive little training and supervision. The purpose of this study was to add to the body of knowledge about what motivates CHVs and how they can best be retained if they are to complement and expand the

Ethical approval

The study protocol was approved by the Institutional Review Board at the School of Public Health at Makerere University, Uganda and the Uganda National Council for Science and Technology and the Human Research Ethics Committee at the University of Sydney, Australia.

Funding

None.

Conflicting interests

Nil.

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