• Share
  • Email
  • Embed
  • Like
  • Save
  • Private Content
Retention, attrition and motivation of voluntary workers in community-based programs
 

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

on

  • 5,070 views

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, Johns Hopkins Bloomberg School of Public Health

CORE Group Spring Meeting, April 29, 2010

Statistics

Views

Total Views
5,070
Views on SlideShare
5,066
Embed Views
4

Actions

Likes
0
Downloads
74
Comments
0

1 Embed 4

http://www.slideshare.net 4

Accessibility

Categories

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment
  • The diversity of CHW interventions is enormous. However, in low income countries like TZ, CHWs often serve as substitute health care providers in rural areas. Some are formally trained according to government standards in first aid and basic nursing , others by NGOs, and in some cases, may be individuals informally nominated by their villages, based on a history of service as a traditional healer, some previous health experience or other reasons. Does this diversity affect motivation for some differently than others? What do we know about community health worker attrition and the sustainability of these interventions? I’ll touch on several of these questions in my research discussion.
  • In a community based intervention for HIV, community health workers in Tanzania may serve to: HIV/AIDS PreventionPeer Outreach and EducationCondom DistributionHIV risk reduction counsellingPromote adherence to AIDS treatment regimensProvide support for VCTProvide home-based care for PLWHACare for OVC
  • Located about 40 miles from Dar es Salaam Kisarawe cuts through the center of the Pwani region. Kisarawe is about 4.45 square km with a population of 95,000. It’s landscape is mountainous, situated on the Pugu Hills. The main road into Kisarawe, from Dar es Salaam is partially paved, however the remaining travel surfaces consist of red soil, rock and forest.
  • Research was conducted in 4 Phased. The first three consisted of qualitative methods, the final instrument involved a quantitative survey questionnaire.Key informant Interviews: 10, 1 man & 1 woman from each of 5 intervention communities/ Key informants selected by the village leadership for their knowledge of the community, involvement in activities and willingness to communicate ideas. Focus Group Discussions: 10, each consisting of 6-12 informants selected by the village leadership…. 2 groups from each of the 5 communities. Grouped by age and gender for facilitate free-flowing discussionIn Depth Interviews. All 30 volunteers 10 Project Accept Staff Community Mobilization Team Coordinator VCT Nurses Drivers / Community Mobilizers Post-test support counselors 10 ACCEPT staff serving in various capacities
  • I don’t like this slide…. (ap)Field guides based on information gleaned from previous qualitative methods. 24 volunteers and 206 Community Members were surveyed to were surveyed to assess Volunteer and Community perceptions related to the volunteer HIV VCT outreach work, and volunteerism in general.Volunteer MotivationExpectations of RemunerationBarriers to the Conduct of OutreachFacilitators to the Conduct of Outreach TotalMissingValid Total Volunteers30624Community 23024206Combined Sample Size 230 (Valid Total)
  • National Development : Nyrere, the socialist leader in governing Tanzania in the 1960’s and ‘70s presented the Arusha Declaration at the 1967 Conference that restructured rural areas into self-governed villages and sub-villages. National and local leadership began to collaborate to establish more accessible health systems and a culture of volunteerism was born. This attitude was more common among men and women 35 and over who would have had more exposure to the socialist establishment. This attitude was more common among men and women 35 and over who would have had more exposure to the socialist establishment. ???This may have also contributed to their broad definition of volunteerism. The swahili words for work, “kazi” and volunteer “kujitolea” are used interchangeably. One volunteer exemplified this in an interview: “Volunteering is like one of the rules in Tanzania, because a large portion of things are voluntary, you see!...maybe people from the government will happen to come here and present a certain law that involves the participation of the whole village. Maybe he will say, ‘We will bring the cement and all the necessary building materials, but we need some people.’ Now we will just have to volunteer in that village. The chairmen will know where to get the people. The community members are the ones who will do that voluntary work.” –VCT Outreach Volunteer????This may have also contributed to their broad definition of volunteerism. The swahili words for work, “kazi” and volunteer “kujitolea” are used interchangeably. One volunteer exemplified this in an interview: “Volunteering is like one of the rules in Tanzania, because a large portion of things are voluntary, you see!...maybe people from the government will happen to come here and present a certain law that involves the participation of the whole village. Maybe he will say, ‘We will bring the cement and all the necessary building materials, but we need some people.’ Now we will just have to volunteer in that village. The chairmen will know where to get the people. The community members are the ones who will do that voluntary work.” –VCT Outreach Volunteer
  • Training and education are revered among the people of Kisarawe. However training that results in some sort of licensure or technical certification – training that will lead to a vocation or higher pay are most desirable.
  • 109 of 230 Respondents believed volunteers should receive some type of remuneration. Among these respondents, they provided the following suggestions. What is interesting is that previous interviews with volunteers, community members and Project Staff suggested provision of badges and condoms would motivate a person to volunteer, and yet no one reported these items in the quantitative survey. Also, Project staff suggested that the status associated with being a volunteer and wearing hats, shirts and badges, along with intrinsic motivation were enough to satisfy volunteers. Here we can see that these items are insignificant to most survey respondents.Multiple rewards were described by volunteers and community members as expected for VCT outreach work, from small items such as work material and food, to larger, such as money and employment. A list was made based on qualitative findings and developed for the survey, however respondents were unable to view it and the question remained open-ended. Some respondents provided multiple suggestions.
  • ACCEPT staff members observed and reported the desire for remuneration by volunteers. When remuneration was not received over time, observing decreased motivation, effort and morale among the volunteers she interacted with.
  • We adapted the PRISMA model for systematic Review for our research. 2620 Records identified using the Inclusion Criteria + Investigator Identified Articles.All but 94 Excluded – Reviewed in Full Text for Meeting Inclusion Criteria 8 studies Included2 Qualitative Only3 Quantitative Only3 Mixed Methods
  • Among the 8 Studies included, 2 contained attritiondata drawn from the Methods Section of the Published Articles b/c not available in the Results. None of the studies defined attrition.
  • Half of the programs provided volunteers with some kind of remuneration. In these cases private funding was always available. The lowest attrition rates were most often associated with lowest attrition rates.

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

  • 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
    Program & Policy Recommendations from the 2 studies
  • 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)
    Program & Policy Recommendations from the 2 studies
  • 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