Retention, attrition and motivation of voluntary workers in community-based programs

Retention, attrition and motivation of voluntary workers in community-based programs
Peter Winch and Anne Palaia
Social and Behavioral Interventions Program
Department of International Health

Session objectives
List factors that have been found to affect the retention, attrition and motivation of unpaid or minimally paid workers in community-based programs.
Identify implications of these findings for the design of more effective and sustainable community-based programs.
Explain the steps in carrying out a systematic review on programmatic experiences with unpaid or minimally paid workers.
Describe methods appropriate for the study of retention, attrition and motivation in community-based programs.

Attrition/retention of voluntary workers
For salaried health workers, attention tends to be on performance and motivation
For voluntary workers e.g. community health workers (CHWs), much attention currently on attrition/retention
Voluntary workers have expanding range of tasks, e.g.
Mass treatment for trachoma, onchocerciasis, malaria (IPT, IPTI)
Voluntary counseling and testing
Ensuring compliance with AIDS and TB treatment
Management of sick newborns
Program cost-effectiveness threatened by high attrition, need to recruit & train replacements

Multilevel perspective on CHW attrition/retention
Developed this during BASICS II Project
Factors affecting attrition/retention act at different levels
Individual education, motivation etc.
Family
Community
District or Program
National

Bhattacharyya K, Winch P, LeBan K, Tien M. Community health workers incentives and disincentives: How they affect motivation, retention and sustainability. BASICS II Project, Arlington VA, October 2001.

Multilevel perspective on CHW Incentives and Disincentives
Individual
Monetary factors
Non-monetary factors
Community
Factors that Motivate the Individual CHW
Factors that Motivate Communities to Support and Sustain CHWs
District/Health facility
Factors that Motivate MOH Staff to Support and Sustain CHWs

Building on this work
We have been building on this work, applying the multi-level perspective to CHW programs
In different settings: Bangladesh, Tanzania and others
For different health problems: Newborn health, HIV/AIDS etc.

This session: 4 parts
Sources of volunteer motivation to serve as HIV VCT outreach workers in rural Tanzania.
Systematic review of experience with volunteer motivation and attrition in HIV/AIDS programs
Analysis of factors affecting attrition of community health workers in a newborn care intervention study in Sylhet District, Bangladesh
Examples from participants

Part I
Examining Sources of Motivation & Expectations of Remuneration Among HIV VCT Community Outreach Volunteers in Rural Tanzania

Authors
Anne Palaia
Michael Sweat
Irene Mashasi
IddaMosha
Jessie Mbwambo
Peter Winch

Community Health Workers: Issues in the field
How effective are HIV interventions that rely on CHWs?
Adequate Training?
Motivation?
Expectations?
Attrition?
Sustainability?

HIV/AIDS Programs in Tanzania
Coordinated by Tanzania National AIDS Control Programme (NACP)
Main Funders:
PEPFAR/USAID
Global Fund
Activities:
ARV Scale Up
Clinical and home-based care for people living with AIDS
Care for orphans and other vulnerable children
Expansion of VCT Services
Prevention of Mother to Child Transmission Initiatives
Other Prevention/behavior change interventions

Services Provided by HIV/AIDS Community Health Workers
HIV/AIDS Prevention
Peer Outreach and Education
Condom Distribution
HIV risk reduction counseling
Promote adherence to AIDS treatment regimens
Provide support for VCT
Provide home-based care for PLWHA
Care for OVC

Project ACCEPT: A Three Pronged Intervention for HIV
Community Mobilization
Paid Sociologists, ethnographers, qualitative researchers, drivers, unpaid community outreach volunteers
Community Based Voluntary Counseling and Testing for HIV
Paid nursing staff
Post Test Support Services
Paid trained counseling staff

Project ACCEPT Community Outreach Volunteers
Provide HIV / AIDS Education
Organize Discussions about HIV and VCT with local peer groups and social clubs
Distribute Condoms and HIV Education Materials
Notify Community Members About Mobile VCT Testing Sites in Their Area
Provide Support to Mobile VCT Staff when Necessary

Survey Questionnaire
24 volunteers
206 Community Members
Sources of Motivation
Expectations of Remuneration
Barriers to the Conduct of Outreach
Facilitators to the Conduct of Outreach

Sources of Volunteer Motivation: Altruistic and Pro-Social Factors
“When you want to help someone, you should not look at the benefits, you should just do it an you will see that you have helped the nation in one way or another.”
-VCT Outreach Volunteer

Sources of Volunteer Motivation: Relational factors
Prominence in the community
Family values volunteer work
Support Friends / Family with HIV
Loyalty to chairman who “appointed” the VCT outreach volunteer

Sources of Volunteer Motivation: Training & Education
Training and Education Highly Valued
92% of volunteers reported that access to additional training would motivate him/her to work harder.
Type of Training is Important:
79% of community members surveyed agreed that they believed training was only valuable if it would bring income to their families in the future.

Sources of Volunteer Motivation:Community Resources & Services
Volunteers reported being motivated by the promise of goods and services for their community, including:
Medical Services
Food & Clothing
Sports Programs

Desired Remuneration Described by Survey Respondents

Remuneration & Attrition
“After seeing that there is nothing or there is no payment of some kind, their work morale faded away a little bit…”
–ACCEPT Community Mobilization Staff (1)
“Half of the outreach volunteers work, half don’t… They don’t get paid, so they will do farm work over outreach work.”
–ACCEPT Community Mobilization Staff (2)

Expectations of the CHWs
CHWs have a number of expectations and assumptions when they take on the position
These expectations and assumptions continue, even when program staff directly contradict them
Many decisions they make (e.g. how much effort to invest in the work) are influenced by these assumptions

Examples of expectations we encountered
CHWs will be paid eventually, after an initial period of proving themselves
After the project ends, the CHWs will take over the paid jobs of the project staff
CHWs will be provided with the same equipment and materials as the project staff
Perceived as issues of justice & trust

“There is a time when we used to stay with our fellow mobilizers (project staff) from ACCEPT and we pitched up tents during the rainy period. The most surprising part was that they had gum boots and gloves, but we didn’t have any. I don’t know if it is because we are voluntary mobilizers that we were left like that without even rain coats. That hurt.”
-37 Year old Male Volunteer

Part II
Volunteer Attrition in HIV/AIDS Programs: A Systematic Review

Authors
Anne Palaia
Peter Winch

Inclusion Criteria for the systematic review
Low or Middle Income Country (According to World Bank Country Classification)
HIV Intervention
Primary Data (Qualitative or Quantitative)
1980 – 2009
Peer Reviewed Sources
Provides Data Related To Volunteer Intervention Worker Retention / Attrition

Summary of the findings
Many articles with some mention of volunteers in HIV/AIDS prevention and control: 2659 records located in a search of key terms across five databases
Very few studies specifically on volunteer health worker attrition
What data there are on attrition are often presented in the methods section, rather than in the results section
Attrition is not defined in the papers

Defining Attrition in the 8 included studies

Next slide:Observed relationship between remuneration and attrition in the 8 studies

Program & Policy Recommendations from the 2 studies
Formative Research
Volunteer Role Responsibilities
Volunteer and Program Expectations
Reasonable Exchange
Identify “Range” of Acceptable and Sufficient Rewards Prior to Recruitment - Compromise

Selection of Volunteers
Recruitment Should Exclude Chairman Nomination of Volunteers
Pre-Program Testing for Theory Based Recruitment
Community Involvement in Project Design & Implementation
Community Awareness Initiative Prior to Advent of Program Activities to Gain Community Support

Programmatic Support
Consistent and Frequent Training and Feedback
Research & Development
Expanded evaluation of interventions for volunteer attrition rates, causes and recommendations for program sustainability
Establishment of common indicators for comparison of attrition data is necessary for future literature reviews
(Eg: # LTFU Time t – deaths due to HIV in Time t)

Part III
Factors affecting recruitment and retention of community health workers in a newborn care intervention in Bangladesh

Authors
Syed Moshfiqur Rahman
Nabeel Ashraf Ali
Larissa Jennings
M. Habibur R. Seraji
Ishtiaq Mannan
Rasheduzzaman Shah
ArifBillah Al-Mahmud
Sanwarul Bari
Daniel Hossain
Milan Krishna Das,
Abdullah H. Baqui
Shams El Arifeen
Peter J. Winch

CHWs in Projahmo study in Sylhet District, Bangladesh(Home care arm)
CHWs serve population of 4000 ~ 800 households
Earn ~$45 per month
Responsibilities
Pregnancy surveillance
Antenatal home visits for birth and newborn care preparedness
Essential newborn care after birth
Coordination with TBAs
Management and referral of newborn sepsis
Counseling

Recruitment of CHWs
Advertisements in local paper and dialog with community leaders and groups
Criteria: Female, local resident, preferably married (this criterion was dropped), aged between 20 and 40, secondary school leaving certificate
Written examination

Trends in attrition
73 CHWs were recruited either initially (41 CHWs) or later on to replace CHWs who left the project
Total period of intervention was 36 months
32 CHWs left the project during this period, 15 left within one year, another 10 by the end of the second year
Training replacement CHWs had higher unit cost

Efforts to reduce attrition
Community advocacy meetings to explain the project and respond to community concerns
Dialogue with families of CHWs at the time of recruitment in order to explain the project and roles of the staff members.
Some CHWs given the opportunity to become supervisors based on exemplary performance.
Incentives for the CHWs to attend deliveries at night.

Data from three sources
Project monitoring system, including exit interviews with CHWs at time of leaving project
Questionnaire completed by 69 of 73 current and former CHWs
Qualitative interviews

Primary reasons for attrition
Family reasons
Work-related reasons
Education opportunities
Actions taken by the project

Family reasons
“They wonder what kind of job it is that requires women to stay out so long. If my brother was here in the country, then I wouldn’t be able to work as a CHW.”
“My father is the sufferer…He used to be the alternate imam of the village. Now half of the people do not want to stand behind him in the prayers. They say his daughters work for NGOs, which is not right for a religious person.”

CHW attrition during the project

Specific reasons for attrition
11 - Marriage
3 - Family opposed to her working as CHW
6 - Left to take other position
2 - Workload considered too heavy
2 - Wanted promotion but not granted
1 - Wanted to change to other service area
1 - CHW left to pursue higher education
4 - Promoted to higher position project
3 - Terminated due to poor performance

Factors found to influence retention
Job satisfaction: amount of work, work-home distance, incentives and costs to being a CHW, supervision and operational support
Alternative job opportunities
Significant life events: Marriage, childbirth, moving to another community, personal illness, illness or death in the family
Value community attributes to CHW work, and the existence of other options for health care in the community
Extent to which her pre-hire expectations were realized

Framework for decisions by CHW

Recommendations
Salary comparable with other similar positions
Hardship allowances to ensure newborn visits during holidays and beyond official work-hours
Sick leaves can be provided for unforeseen sicknesses and medical emergencies
Group discussions to engage the family whole to increase the sense of ownership of the project
Clear expectations roles and responsibilities
Frank discussions of less pleasant aspects of the job, such as late hours and holiday duties

Retention, attrition and motivation of voluntary workers in community-based programs

by jehill3 on May 04, 2010

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Retention, attrition and motivation of voluntary workers in community-based programs — Presentation Transcript