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 <br />Peter Winch and Anne Palaia<br />Social and Behavioral Interventions Program<br />Department of International Health<br />
Session objectives<br />List factors that have been found to affect the retention, attrition and motivation of unpaid or minimally paid workers in community-based programs.<br />Identify implications of these findings for the design of more effective and sustainable community-based programs.<br />Explain the steps in carrying out a systematic review on programmatic experiences with unpaid or minimally paid workers.<br />Describe methods appropriate for the study of retention, attrition and motivation in community-based programs.<br />
Attrition/retention of voluntary workers<br />For salaried health workers, attention tends to be on performance and motivation<br />For voluntary workers e.g. community health workers (CHWs), much attention currently on attrition/retention<br />Voluntary workers have expanding range of tasks, e.g.<br />Mass treatment for trachoma, onchocerciasis, malaria (IPT, IPTI)<br />Voluntary counseling and testing<br />Ensuring compliance with AIDS and TB treatment<br />Management of sick newborns<br />Program cost-effectiveness threatened by high attrition, need to recruit & train replacements<br />
Multilevel perspective on CHW attrition/retention<br />Developed this during BASICS II Project<br />Factors affecting attrition/retention act at different levels<br />Individual education, motivation etc.<br />Family<br />Community<br />District or Program<br />National<br />
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. <br />
Multilevel perspective on CHW Incentives and Disincentives<br />Individual<br />Monetary factors<br />Non-monetary factors<br />Community<br />Factors that Motivate the Individual CHW<br />Factors that Motivate Communities to Support and Sustain CHWs <br />District/Health facility<br />Factors that Motivate MOH Staff to Support and Sustain CHWs <br />
Building on this work<br />We have been building on this work, applying the multi-level perspective to CHW programs<br />In different settings: Bangladesh, Tanzania and others<br />For different health problems: Newborn health, HIV/AIDS etc.<br />
This session: 4 parts<br />Sources of volunteer motivation to serve as HIV VCT outreach workers in rural Tanzania.<br />Systematic review of experience with volunteer motivation and attrition in HIV/AIDS programs<br />Analysis of factors affecting attrition of community health workers in a newborn care intervention study in Sylhet District, Bangladesh<br />Examples from participants <br />
Part I<br />Examining Sources of Motivation & Expectations of Remuneration Among HIV VCT Community Outreach Volunteers in Rural Tanzania<br />
Community Health Workers: Issues in the field<br />How effective are HIV interventions that rely on CHWs?<br />Adequate Training?<br />Motivation?<br />Expectations?<br />Attrition?<br />Sustainability?<br />
HIV/AIDS Programs in Tanzania<br />Coordinated by Tanzania National AIDS Control Programme (NACP)<br />Main Funders:<br />PEPFAR/USAID<br />Global Fund<br />Activities:<br />ARV Scale Up<br />Clinical and home-based care for people living with AIDS<br />Care for orphans and other vulnerable children<br />Expansion of VCT Services<br />Prevention of Mother to Child Transmission Initiatives<br />Other Prevention/behavior change interventions<br />
Services Provided by HIV/AIDS Community Health Workers<br />HIV/AIDS Prevention<br />Peer Outreach and Education<br />Condom Distribution<br />HIV risk reduction counseling<br />Promote adherence to AIDS treatment regimens<br />Provide support for VCT<br />Provide home-based care for PLWHA<br />Care for OVC<br />
Project ACCEPT: A Three Pronged Intervention for HIV<br />Community Mobilization<br />Paid Sociologists, ethnographers, qualitative researchers, drivers, unpaid community outreach volunteers<br />Community Based Voluntary Counseling and Testing for HIV<br />Paid nursing staff<br />Post Test Support Services <br />Paid trained counseling staff<br />
Project ACCEPT Community Outreach Volunteers<br />Provide HIV / AIDS Education<br />Organize Discussions about HIV and VCT with local peer groups and social clubs<br />Distribute Condoms and HIV Education Materials<br />Notify Community Members About Mobile VCT Testing Sites in Their Area<br />Provide Support to Mobile VCT Staff when Necessary<br />
Survey Questionnaire<br />24 volunteers<br />206 Community Members<br />Sources of Motivation<br />Expectations of Remuneration<br />Barriers to the Conduct of Outreach<br />Facilitators to the Conduct of Outreach<br />
Sources of Volunteer Motivation: Altruistic and Pro-Social Factors<br />“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.” <br />-VCT Outreach Volunteer<br />
Sources of Volunteer Motivation: Relational factors<br />Prominence in the community<br />Family values volunteer work<br />Support Friends / Family with HIV<br />Loyalty to chairman who “appointed” the VCT outreach volunteer<br />
Sources of Volunteer Motivation: Training & Education<br />Training and Education Highly Valued<br />92% of volunteers reported that access to additional training would motivate him/her to work harder. <br />Type of Training is Important:<br />79% of community members surveyed agreed that they believed training was only valuable if it would bring income to their families in the future.<br />
Sources of Volunteer Motivation:Community Resources & Services<br />Volunteers reported being motivated by the promise of goods and services for their community, including:<br />Medical Services<br />Food & Clothing <br />Sports Programs<br />
Desired Remuneration Described by Survey Respondents <br />
Remuneration & Attrition<br />“After seeing that there is nothing or there is no payment of some kind, their work morale faded away a little bit…” <br />–ACCEPT Community Mobilization Staff (1)<br />“Half of the outreach volunteers work, half don’t… They don’t get paid, so they will do farm work over outreach work.” <br />–ACCEPT Community Mobilization Staff (2)<br />
Expectations of the CHWs<br />CHWs have a number of expectations and assumptions when they take on the position<br />These expectations and assumptions continue, even when program staff directly contradict them<br />Many decisions they make (e.g. how much effort to invest in the work) are influenced by these assumptions<br />
Examples of expectations we encountered<br />CHWs will be paid eventually, after an initial period of proving themselves<br />After the project ends, the CHWs will take over the paid jobs of the project staff<br />CHWs will be provided with the same equipment and materials as the project staff<br />Perceived as issues of justice & trust<br />
“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.” <br />-37 Year old Male Volunteer<br />
Part II<br />Volunteer Attrition in HIV/AIDS Programs: A Systematic Review<br />
Inclusion Criteria for the systematic review<br />Low or Middle Income Country (According to World Bank Country Classification)<br />HIV Intervention<br />Primary Data (Qualitative or Quantitative)<br />1980 – 2009<br />Peer Reviewed Sources<br />Provides Data Related To Volunteer Intervention Worker Retention / Attrition<br />
Summary of the findings<br />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<br />Very few studies specifically on volunteer health worker attrition<br />What data there are on attrition are often presented in the methods section, rather than in the results section<br />Attrition is not defined in the papers<br />
Program & Policy Recommendations from the 2 studies<br />Formative Research<br />Volunteer Role Responsibilities<br />Volunteer and Program Expectations<br />Reasonable Exchange<br />Identify “Range” of Acceptable and Sufficient Rewards Prior to Recruitment - Compromise<br />
Selection of Volunteers <br />Recruitment Should Exclude Chairman Nomination of Volunteers<br />Pre-Program Testing for Theory Based Recruitment <br />Community Involvement in Project Design & Implementation <br />Community Awareness Initiative Prior to Advent of Program Activities to Gain Community Support<br /> Program & Policy Recommendations from the 2 studies<br />
Programmatic Support <br />Consistent and Frequent Training and Feedback<br />Research & Development<br />Expanded evaluation of interventions for volunteer attrition rates, causes and recommendations for program sustainability<br />Establishment of common indicators for comparison of attrition data is necessary for future literature reviews<br />(Eg: # LTFU Time t – deaths due to HIV in Time t)<br /> Program & Policy Recommendations from the 2 studies<br />
Part III<br />Factors affecting recruitment and retention of community health workers in a newborn care intervention in Bangladesh<br />
Authors<br />Syed Moshfiqur Rahman<br />Nabeel Ashraf Ali<br />Larissa Jennings<br />M. Habibur R. Seraji<br />Ishtiaq Mannan<br />Rasheduzzaman Shah <br />ArifBillah Al-Mahmud<br />Sanwarul Bari<br />Daniel Hossain<br />Milan Krishna Das,<br />Abdullah H. Baqui<br />Shams El Arifeen<br />Peter J. Winch<br />
CHWs in Projahmo study in Sylhet District, Bangladesh(Home care arm)<br />CHWs serve population of 4000 ~ 800 households<br />Earn ~$45 per month<br />Responsibilities<br />Pregnancy surveillance<br />Antenatal home visits for birth and newborn care preparedness<br />Essential newborn care after birth<br />Coordination with TBAs<br />Management and referral of newborn sepsis<br />Counseling<br />
Recruitment of CHWs<br />Advertisements in local paper and dialog with community leaders and groups<br />Criteria: Female, local resident, preferably married (this criterion was dropped), aged between 20 and 40, secondary school leaving certificate<br />Written examination<br />
Trends in attrition<br />73 CHWs were recruited either initially (41 CHWs) or later on to replace CHWs who left the project<br />Total period of intervention was 36 months<br />32 CHWs left the project during this period, 15 left within one year, another 10 by the end of the second year <br />Training replacement CHWs had higher unit cost<br />
Efforts to reduce attrition<br />Community advocacy meetings to explain the project and respond to community concerns<br />Dialogue with families of CHWs at the time of recruitment in order to explain the project and roles of the staff members.<br />Some CHWs given the opportunity to become supervisors based on exemplary performance.<br />Incentives for the CHWs to attend deliveries at night. <br />
Data from three sources<br />Project monitoring system, including exit interviews with CHWs at time of leaving project<br />Questionnaire completed by 69 of 73 current and former CHWs<br />Qualitative interviews<br />
Primary reasons for attrition<br />Family reasons<br />Work-related reasons<br />Education opportunities<br />Actions taken by the project<br />
Family reasons<br />“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.”<br />“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.”<br />
Specific reasons for attrition<br />11 - Marriage<br />3 - Family opposed to her working as CHW<br />6 - Left to take other position <br />2 - Workload considered too heavy<br />2 - Wanted promotion but not granted<br />1 - Wanted to change to other service area<br />1 - CHW left to pursue higher education<br />4 - Promoted to higher position project<br />3 - Terminated due to poor performance<br />
Factors found to influence retention<br />Job satisfaction: amount of work, work-home distance, incentives and costs to being a CHW, supervision and operational support <br />Alternative job opportunities<br />Significant life events: Marriage, childbirth, moving to another community, personal illness, illness or death in the family<br />Value community attributes to CHW work, and the existence of other options for health care in the community<br />Extent to which her pre-hire expectations were realized<br />
Recommendations<br />Salary comparable with other similar positions <br />Hardship allowances to ensure newborn visits during holidays and beyond official work-hours<br />Sick leaves can be provided for unforeseen sicknesses and medical emergencies<br />Group discussions to engage the family whole to increase the sense of ownership of the project<br />Clear expectations roles and responsibilities <br />Frank discussions of less pleasant aspects of the job, such as late hours and holiday duties<br />