Measuring and understanding motivation among community health workers in rural health facilities in India-a mixed method study

Motivation and associated factors of health development army in the implementation of health extension packages in Northwest Ethiopia: a cross-sectional study

INTRODUCTION

Health development army is a network of women volunteers organised to promote health and prevent disease through community empowerment and participation.

OBJECTIVE

To assess the level of motivation and associated factors of the health development army in the implementation of health extension packages in Northwest Ethiopia.

DESIGN

Data were from a community-based cross-sectional study.

SETTING

This study was conducted in Mecha district, Northwest Ethiopia. The district is located around 30 km from Bahir Dar, the capital city of Amhara National Regional State, Ethiopia.

PARTICIPANTS

A total of 624 health development army members were interviewed using a structured questionnaire from 20 April 2020 to 20 May 2020.

OUTCOME MEASURES

Motivation was assessed using a five-item Likert scale statement ranging from 1 to 5. Data were collected using a structured questionnaire and analysed using a binary logistic regression model.

RESULTS

The proportion of health development army members, who had motivation in the implementation of the health extension package, was 47.8% (95% CI (43.90 to 51.80)). The odds of having motivation were higher among health development army members who lived in urban areas ((adjusted OR, AOR 2.47; 95% CI (1.21 to 5.03)), were less than 30 years ((AOR 2.42; 95% CI (1.22 to 4.78)), had more than 4 years work experience ((AOR 4.72; 95% CI (2.54 to 8.76)), had high intrinsic job satisfaction ((AOR 2.31; 95% CI (1.51 to 3.55)), had good community support ((AOR 2.46; 95% CI (1.34 to 4.51)), received supportive supervision ((AOR 1.85; 95% CI (1.24 to 2.77)) and were recognised for their efforts ((AOR 1.52; 95% CI (1.01 to 2.30)).

CONCLUSION

The proportion of motivation among health development army members was low. To increase the motivation of health development army members in the implementation of the health extension package, measures or strategies may consider targeting members who live in rural areas, are older than 30 years, have less than 4 years of work experience, report low job satisfaction, have low community support, do not have supportive supervision and are not recognised.

"We are everyone's ASHAs but who's there for us?" a qualitative exploration of perceptions of work stress and coping among rural frontline workers in Madhya Pradesh, India

OBJECTIVE

More than a million female village-level lay providers called 'Accredited Social Health Activists (ASHAs)', who deliver primary care, face high levels of stress due to work demands and low compensation, within the context of poverty and gender inequality. Evidence on ASHAs has focused on workplace challenges from a system perspective, without sufficient probing into individual-level stress. This study aims to gain perspectives into the experiences of work stress, the related health symptoms, and the responses to stress among ASHAs in India.

METHODS

Focus group discussions (FGDs) conducted with ASHAs in Sehore district, Madhya Pradesh, were audio-recorded and transcribed. Grounded theory was used to generate themes under the various domains of ASHAs' work and domestic life. We identified pathways between the conditions that trigger stressful events, experiences of these events, resulting perceptions, effects on health and wellbeing, and approaches used by ASHAs to respond to stress.

RESULTS

Six FGDs with 59 ASHAs generated the following themes: (a) Facility: Workload, undue pressures, unstructured work; ASHAs' relationships with seniors (e.g., feelings of being disrespected, blamed, or targeted), and low access to physical and administrative resources; (b) Home: Feelings of guilt for putting less time for family/child care; disrespect by the elderly for a poorly incentivised job; (c) Community: Low acceptance by the villagers; caste- and gender-bias; difficult community-level relationships (emotional labour, fear/stigma towards her services); (d) Somatic and psychological symptoms: headache, exhaustion, depressive symptoms (to cite a few); and (e) Responses to stress: Motivation (support from peers, family, a sense of identity/pride, incentives), Individual strengths (e.g., social responsibility), and spiritual recourse mechanisms.

CONCLUSIONS

This study will inform the development of a strengths-based coaching intervention to address work stress among ASHAs. The findings are relevant to building the evidence on alleviation of work stress among female frontline cadres in low-resource settings globally.

How different incentives influence reported motivation and perceptions of performance in Ghanaian community-based health planning and services zones

BACKGROUND

Maternal mortality is still a burden worldwide, and Ghana's maternal and child mortalities are still high. Incentive schemes have been effective in improving health workers' performance thereby reducing maternal and child deaths. The efficiency of public health services in most developing countries has been linked to the provision of incentives. Thus, financial packages for Community Health Volunteers (CHVs) serve as enablers for them to be focused and committed to their work. However, the poor performance of CHVs is still a challenge in health service delivery in many developing countries. Although the reasons for these persistent problems are understood, we need to find out how to implement what works in the face of political will and financial constraints. This study assesses how different incentives influence reported motivation and perceptions of performance in Community-based Health Planning and Services Program (CHPS) zones in the Upper East region.

METHODS

A quasi-experimental study design with post-intervention measurement was used. Performance-based interventions were implemented for 1 year in the Upper East region. The different interventions were rolled out in 55 of 120 CHPS zones. The 55 CHPS zones were randomly assigned to four groups: three groups of 14 CHPS zones with the last group containing 13 CHPS zones. Several alternative types of financial and non-financial incentives as well as their sustainability were explored. The financial incentive was a small monthly performance-based Stipend. The non-financial incentives were: Community recognition; paying for National Health Insurance Scheme (NHIS) premiums and fees for CHV, one spouse, and up to two children below 18 years, and; quarterly performance-based Awards for best-performing CHVs. The four groups represent the four different incentive schemes. We conducted 31 In-depth interviews (IDIs) and 31 Focus Group Discussions (FGDs) with health professionals and community members.

RESULTS

Community members and the CHVs wanted the stipend as the first incentive but requested that it be increased from the current level. The Community Health Officers (CHOs) prioritized the Awards over the Stipend because they felt it was too small to generate the required motivation in the CHVs. The second incentive was the National Health Insurance Scheme (NHIS) registration. Community recognition was also considered by health professionals as effective in motiving CHVs and work support inputs and CHVs training helped in improving output. The various incentives have helped increase health education and facilitated the work of the volunteers leading to increased outputs: Household visits and Antenatal Care and Postnatal Care coverage improved. The incentives have also influenced the initiative of volunteers. Work support inputs were also regarded as motivators by CHVs, but the challenges with the incentives included the size of the stipend and delays in disbursement.

CONCLUSION

Incentives are effective in motivating CHVs to improve their performance, thereby improving access to and use of health services by community members. The Stipend, NHIS, Community recognition and Awards, and the work support inputs all appeared to be effective in improving CHVs' performance and outcomes. Therefore, if health professionals implement these financial and non-financial incentives, it could bring a positive impact on health service delivery and use. Also, building the capacities of CHVs and providing them with the necessary inputs could improve output.

Family Adoption Programme for Medical Undergraduates in India - The Way Ahead: A Qualitative Exploration of Stakeholders' Perceptions

Introduction

Community engagement in medical education gives the students an insight into the living conditions of the public and how they influence their health. Community Medicine departments accomplish this through field practice and family health studies. The Family Adoption Programme, newly mandated for all medical undergraduate students, brings its own set of challenges and opportunities. The study aims to understand the perceptions of various stakeholders regarding this program.

Material and Methods

A qualitative exploratory study was conducted. The faculty, undergraduate and postgraduate students, and field workers were purposively invited to participate. Thematic analysis was done on qualitative inputs obtained by Key Informant Interviews and Focussed Group Discussions.

Results

The participants felt that FAP will provide a good insight into the patient's living conditions and also motivate the students for the kind of career they have to prepare for. The major challenges were the lack of transport and logistics in government colleges and the faculty shortage in private colleges. There was a difference of opinion regarding the right time to initiate the student into FAP. Gaining the trust and cooperation of the family and reducing the expectations were also felt important. While more field involvement by faculty was advocated, increased workload and reduced faculty requirement specifications were a matter of concern.

Conclusion

While there was mixed response regarding the utility and long-term sustainability of FAP, it was hoped that with proper motivation and supervision, this program can create a significant difference in medical education and also the lives of adopted families.

Factors affecting motivation of close-to-community sexual and reproductive health workers in low-income urban settlements in Bangladesh: A qualitative study

Close-to-community (CTC) health workers play a vital role in providing sexual and reproductive health services in low-income urban settlements in Bangladesh. Retention of CTC health workers is a challenge, and work motivation plays a vital role in this regard. Here, we explored the factors which affect their work motivation. We conducted 22 in-depth interviews in two phases with purposively selected CTC health workers operating in low-income urban settlements in Dhaka, Bangladesh. We analyzed our data using the framework technique which involved identifying, abstracting, charting, and matching themes across the interviews following the two-factor theory on work motivation suggested by Herzberg and colleagues. Our results suggest that factors affecting CTC sexual and reproductive health workers' work motivation include both extrinsic and intrinsic factors. Extrinsic or hygiene factors include financial incentives, job security, community attitude, relationship with the stakeholders, supportive and regular supervision, monitoring, and physical safety and security. While, the intrinsic factors or motivators are the perceived quality of the services provided, witnessing the positive impact of the work in the community, the opportunity to serve vulnerable clients, professional development opportunities, recognition, and clients' compliance. In the context of a high unemployment rate, people might take a CTC health worker's job temporarily to earn a living or to use it as a pathway move to more secure employment. To maintain and improve the work motivation of the CTC sexual and reproductive health workers serving in low-income urban settlements, organizations should provide adequate financial incentives, job security, and professional development opportunities in addition to supportive and regular supervision.

Human Resources for Health in Haryana, India: What can be Done Better?

Introduction

Health systems in developing countries suffers from both input and productivity issues. We examined the status of three domains of human resources for health, i.e., availability and distribution, capacity and productivity, and motivation and job-satisfaction, of the health-care workforce employed in the public health system of Haryana, a North Indian state.

Methodology

The primary data were collected from 377 public health facilities and 1749 healthcare providers across 21 districts. The secondary data were obtained from government reports in the public domain. Bivariate and multivariate statistical techniques were used for evaluating district performances, making inter-district comparisons and identifying determinants of motivation and job-satisfaction of the clinical cadres.

Results

We found 3.6 core health-care workers (doctors, staff nurses, and auxiliary nurses-midwives) employed in the public health-care system per 10,000 population, ranging from 1.35 in Faridabad district to 6.57 in Panchkula district. Around 78% of the sanctioned positions were occupied. A number of inpatient hospitalizations per doctor/nurses per month were 17 at the community health center level and 29 at the district hospital level; however, significant differences were observed among districts. Motivation levels of community health workers (85%) were higher than clinical workforce (78%), while health system administrators had lowest motivation and job satisfaction levels. Posting at primary healthcare facility, contractual employment, and co-habitation with family at the place of posting were found to be the significant motivating factors.

Conclusions

A revamp of governance strategies is required to improve health-care worker availability and equitable distribution in the public health system to address the observed geographic variations. Efforts are also needed to improve the motivation levels of health system administrators, especially in poorly performing districts and reduce the wide gap with better-off districts.

'You say you are a TB doctor, but actually, you do not have any power': health worker (de)motivation in the context of integrated, hospital-based tuberculosis care in eastern China

BACKGROUND

In China, tuberculosis (TB) care, traditionally provided through the Centre for Disease Control (CDC), has been integrated into 'designated' public hospitals at County level, with hospital staff taking on delivery of TB services supported by CDC staff. Little is known about the impact of this initiative on the hospital-based health workers who were delegated to manage TB. Drawing on a case study of two TB 'designated' hospitals in Zhejiang province, we explored factors influencing hospital-based health workers' motivation in the context of integrated TB service delivery.

METHODS

We conducted 47 in-depth interviews with health officials, TB/hospital managers, clinicians, radiologists, laboratory staff and nurses involved in the integrated model of hospital-based TB care. Thematic analysis was used to develop and refine themes, code the data and assist in interpretation.

RESULTS

Health workers tasked with TB care in 'designated' hospitals perceived their professional status to be low, related to their assessment of TB treatment as lacking need for professional skills, their limited opportunities for professional development, and the social stigma surrounding TB. In both sites, the integrated TB clinics were under-staffed: health workers providing TB care reported heavy workloads, and expressed dissatisfaction with a perceived gap in their salaries compared with other clinical staff. In both sites, health workers were concerned about poor infection control and weak risk management assessment systems.

CONCLUSIONS

Inadequate attention to workforce issues for TB control in China, specifically the professional status, welfare, and development as well as incentivization of infectious disease control workers has contributed to dissatisfaction and consequently poor motivation to serve TB patients within the integrated model of TB care. It is important to address the failure to motivate health workers and maximize public good-oriented TB service provision through improved government funding and attention to the professional welfare of health workers providing TB care in hospitals.

"My motivation was to save": a qualitative study exploring factors influencing motivation of community healthcare workers in a cervical cancer screening program in Dschang, Cameroon

Background

Cervical cancer is a major public health issue among women in Cameroon and uptake of screening programs remains a challenge in many low- and middle-income countries. Community healthcare workers can play an important role in promoting cervical cancer services. This study aimed to explore factors affecting the motivation of community healthcare workers in a cervical cancer screening program in Dschang, Cameroon.

Methods

A qualitative approach including 11 in-depth individual interviews with community healthcare workers was used. The interviews were audio-recorded, transcribed and coded using thematic analysis assisted by ATLAS.ti software.

Results

Four women and seven men aged between 21 and 77 years old were interviewed. Community healthcare workers had high motivation. Factors affecting motivation were divided into individual and environmental level, based on a theoretical framework. Factors with a positive influence on motivation were mainly on the individual side while impeding factors were mainly associated with the environmental level.

Conclusions

Key interventions to improve motivation among community healthcare workers include: (i) more training and supportive supervision; (ii) evaluation of remuneration systems by workload; and (iii) provision of job-enabling resources such as uniforms, cellphone cards and transport.

Trial registration: Geneva Cantonal Ethics Committee on Human Research (No. 2017-01110) and the Cameroonian National Ethics Committee for Human Health Research (No. 2018/07/1083/CE/CNERSH/SP).

Cervical cancer is the second leading cause of cancer-related death among women in Cameroon. This is mainly due to the absence of routine cervical cancer screening programs and the lack of treatment. However, even in case of availability of cervical cancer screening programs, barriers exist. Therefore, community healthcare workers have been involved successfully to increase the screening coverage. As retention of these actors remains a challenge, the main objective of this study was to identify key factors affecting their motivation aiming to suggest interventions to address motivational factors. 11 qualitative interviews with individual community healthcare workers were conducted at a cervical cancer screening program in Dschang, Cameroon. Motivation was generally high and affecting factors were divided into the individual and the environmental level. Factors with a positive influence on motivation were mainly on the individual side while impeding factors were mainly associated with the environmental level. Ongoing collaboration with community healthcare workers is beneficial for cervical cancer screening programs, and key interventions should therefore include: (i) more training and supportive supervision; (ii) evaluation of remuneration systems by workload; and (iii) provision of job-enabling resources such as uniforms, cellphone cards and transport.

Incentives management among health workers in primary health-care facilities: addressing important issues in rural Ghana

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.

MS. Assessment of Workload of ASHAs: A Multi-stakeholder Perspective Study for Task-sharing and Task-shifting

The Accredited Social Health Activist (ASHA) programme has proven to be cost-effective and successful in addressing the growing shortage of health workers and reaching the vulnerable. ASHA’s contribution towards the improvement in maternal and child health and other health programmes at the community level is reported and acknowledged widely in literature. However, nearly 16 years into the introduction of ASHA, challenges in terms of workload, fatigue, poor work–life balance and low levels of compensation have emerged.

Aim:

To assess the workload on ASHAs, impact of their responsibilities on their quality of life and the potential for structured task sharing/shifting among other healthcare workers.

Methodology:

The study used a mixed-method approach with data and source triangulation. A multi-stage random sampling method was used to collect the data. Qualitative research was carried out to explore ASHAs’ and stakeholders’ perspectives, and a thematic analysis was undertaken using NVivo-12. ASHAs’ quality of life was also measured using the World Health Organization Quality of Life (WHO QOL)-BREF. The study was carried out in three districts of Karnataka: Mysuru, Raichur and Koppala.

Results:

The majority of ASHAs reported that they experience work burden in terms of population coverage, extended hours of work and additional tasks. Lack of access to transportation, inadequate support from other healthcare personnel and delayed payment of incentives add to them often feeling overworked and underpaid. The research also elicited perspectives on ASHAs’ work from different stakeholders. Findings from the study emphasise the necessity for sharing/shifting of selected tasks among other frontline health workers based on complexity and capabilities.

Understanding the factors affecting attrition and intention to leave of health extension workers: a mixed methods study in Ethiopia

BACKGROUND

The Health Extension Program (HEP) is Ethiopia's flagship community health program, launched in 2003. Health Extension Workers (HEWs) are key vehicles for the delivery of the HEP. While it is believed that there is high attrition among HEWs, the magnitude of or reasons for attrition is unknown. Their intention to leave their jobs in the next 5 years has also never been investigated on a national scale. This study aimed to assess the magnitude of, and factors affecting HEWs' attrition and intention to leave in Ethiopia.

METHODS

The study used mixed methods to address the research objectives. Using stratified random sampling and regions as strata, 85 districts from nine regions were randomly selected in Ethiopia. Within each study district, six kebeles (village clusters) were randomly selected, and all HEWs working in these kebeles were interviewed to capture their 5-year intention to leave. The study team developed a data-extraction tool for a rapid review of district-level documents covering the period June 30, 2004 through June 30, 2019 to gather their attrition figures. We used survival analysis to model attrition data and checked model goodness-of-fit using the Cox-Snell residual test. We additionally collected qualitative data from HEWs who had left their positions.

RESULTS

The attrition of HEWS over the lifespan of the HEP was 21.1% (95% CI 17.5-25.3%), and the median time to exit from HEWs workforce was 5.8 years. The incidence rate was 3.1% [95% CI 2.8-3.4]. The risk of attrition was lower amongst HEWs with level four certifications, with children, and among those working in urban settings. By contrast, HEWs who were not certified with a certificate of competency (COC), who were deployed after 2008, and those who were diploma/degree holders were more likely to exit the HEWs workforce. The magnitude of intention to leave was 39.5% (95% CI 32.5-47%) and the primary reasons to leave were low incentives, dearth of career development opportunities (50.8%), high workload (24.2%), and other psychosocial factors (25%).

CONCLUSION

Although the magnitude of attrition is not worryingly high, we see high magnitude in HEWs' intention to leave, indicating a dissatisfied workforce. Multiple factors have contributed to attrition and intention to leave, the prevalence of many of which can be reduced to fit the needs of this workforce and to retain them for the sustained delivery of primary healthcare in the country. Ensuring HEWs' job satisfaction is important and linked with their career development and potentially higher rates of retention.

Community health workers' job satisfaction in Ebola-stricken areas of Sierra Leone and its implication for COVID-19 containment: a cross-sectional mixed-methods study

OBJECTIVES

Community health workers (CHWs) played important roles in supplementing scarce healthcare workforce in Sierra Leone during the Ebola outbreak, causing the government to launch the National Community Health Worker Policy 2016-2020. This study evaluated this ambitious policy and examined CHWs' sustainability through their job satisfaction and the underlying factors to inform new policy recommendations, especially the implication for COVID-19 containment.

DESIGN

A mixed-methods approach applying structured questionnaires and semistructured interviews.

SETTING AND PARTICIPANTS

188 CHWs in Bombali District (key Ebola-stricken areas) of Sierra Leone, 184 of them participated in follow-up interviews.

PRIMARY AND SECONDARY OUTCOME MEASURES

Quantitative and qualitative elements were triangulated to improve robustness of investigation: job satisfaction was measured by the Minnesota Satisfaction Questionnaire (MSQ), and factors associated with job satisfaction were identified through thematic analysis and multivariable logistic regression.

RESULTS

The MSQ score of CHWs in Sierra Leone was 65.09, extremely low even among low-income and middle-income countries. Five themes (grouped from 16 subthemes) emerged through the semistructured interviews and were tested quantitatively. Payment was CHWs' top concern. Low stipend and payment tardiness were significantly associated with dissatisfaction. Those with Ebola experience were 5.20 times (95% CI 1.51 to 17.95, p=0.009) more likely to be dissatisfied. This study also found that working conditions, medical material supplies and career development were far from what the CHW policy promised. CHWs' commitment was the only 'positive' theme, and their intrinsic job satisfaction (mean=3.61) was much higher than the extrinsic job satisfaction (mean=2.72).

CONCLUSIONS

Some critical components of the 2016 National Community Health Worker Policy, aiming to promote CHWs and strengthen primary healthcare, have severe shortfalls in practice. The Sierra Leone government should address the underlying factors that have impaired CHWs' job satisfaction to ensure sustainability of its CHW network, especially during the combat against COVID-19.

Burnout among primary health care workers in Brazil: results of a multilevel analysis

PURPOSE

Burnout among health care workers may hamper the quality of care and effectiveness of health systems. Hence, we examined the prevalence of burnout in primary care teams, including community health workers; and investigated associations between individuals' characteristics, team and primary care center factors, and burnout.

METHODS

We carried out a cross-sectional study among primary care teams in the city of São Paulo, Brazil (n = 2940). We randomly selected 66 primary care centers. The Maslach burnout inventory was used to investigate burnout. We used multilevel modelling to examine the associations between individuals' characteristics, team and primary care center variables with burnout.

RESULTS

We addressed 351 primary care teams, with 11.4% of participants presenting severe burnout. The variance in burnout among primary care workers was partially explained by individuals' characteristics, and by team and primary care center factors. Severe burnout was associated with the following: (1) individuals' characteristics: being black, being younger, a higher length of employment in primary care, and presenting a lack of feedback from supervisors; (2) team factors: working in deprived areas and not receiving the support of a multidisciplinary team; and (3) primary care center factors: inadequate infrastructure (less than one office available per team), and having a bad/very bad relationship with the community council.

CONCLUSIONS

To reduce burnout among primary care teams, stakeholders should: (1) train managers/supervisors on leadership styles that prioritize performance feedback, support, and communication skills; (2) allocate catchment areas to teams according to each community's vulnerability; (3) provide a multidisciplinary team to support primary care workers; and (4) offer suitable facilities and infra-structure.

Stakeholder perspectives on the integration of oral health into national health schemes: A mixed-method study research design in Delhi, India

Aim and Objectives:

To assess the factors and perception of various stakeholders on the integration of oral health into the national health schemes using a mixed-method research design.

Materials and Method:

A mixed-method study was carried out in 2018 in two phases. In the first phase of the study, a pretested and prevalidated self-designed close-ended questionnaire was used to assess the knowledge, attitude, perception, barriers, myths, and feasibility of the integration of oral health in national health schemes. This questionnaire was administered to 96 stakeholders consisting of a medical officer (MO), accredited social health activists (ASHA), auxiliary nurse midwifery (ANM), and dental surgeon in nine Delhi Government dispensaries. The questionnaire consisted of 42 close-ended questions and four open-ended questions. The domains and themes were identified along with the challenges and opportunities of integration for focus group discussion (FGD) after analyzing the results of the first phase. The FGD consisted of seven members representing each of the above stakeholders along with one moderator and one recorder.

Results:

88.3% of the ASHA workers and 85.7% of the ANM accepted that oral screening should be incorporated in their routine practice. The major barrier to the incorporation of oral health in general health was the lack of training and insufficient provision of monetary incentives. Job burnout, work situation, inadequate pay, opportunities, workload, and limited carrier development were the demotivators, whereas respect, goodwill, and recognition from the general public were the inducers.

Conclusion:

There was a strong agreement for National Oral Health schemes to be given space and priority in India. The majority agreed that they can be used as a medium for imparting oral health education. The majority of the stakeholders believed that oral health should be a part of general health and they are open to any scheme or program which would add an oral health component.

Prevalence and associated factors of the career plateau of primary care providers in Heilongjiang, China: a cross-sectional study

Background

Primary care providers are pillars of China’s medical and health sectors. However, due to the gap between career expectations and reality, they enter a career plateau phase through excessive pressure. This study aims to examine the prevalence and associated factors of the career plateau of primary care providers in Heilongjiang Province, China, and proposes strategies to improve and promote their career advancement.

Methods

Based on city-level GDP growth in the province, a questionnaire survey was conducted among 1500 primary care providers (effective response rate = 85.8%). Pearson’s chi-square analysis and binary logistic regression were used to analyse the factors associated with their career plateau.

Results

The prevalence rate of career plateau was 61.8% among primary care provider respondents. The factors associated with a career plateau included having a spouse (OR = 1.394, 95%CI = 1.056–1.839), working more than 40 h per week (OR = 1.473, 95%CI = 1.146–1.893); working for 11–20 years (OR = 1.607, 95%CI = 1.150–2.246); working for more than 20 years (OR = 2.818, 95%CI = 1.938–4.097); having an average monthly income of 3001–4000 yuan (OR = 1.886, 95%CI = 1.197–2.969) or 4001–5000 yuan (OR = 2.104, 95%CI = 1.256–3.524); and reporting unsatisfactory or very unsatisfactory sleep quality (OR = 1.838, 95%CI = 1.317–2.567).

Conclusions

Primary care providers in Heilongjiang Province face a high career plateau, with marital status, weekly working hours, number of years employed, monthly average income, and sleep quality considered associated factors. To eliminate negative factors of the career plateau, it is necessary to provide support to primary care providers in four domains: individual, organisation, society, and policy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01389-w.

Who could be One Health Activist at the community level?: A case for India

BACKGROUND

Community health workers (CHWs) are the mainstay of the public health system, serving for decades in low-resource countries. Their multi-dimensional work in various health care services, including the prevention of communicable diseases and health promotion of non-communicable diseases, makes CHWs, the frontline workers in their respective communities in India. As India is heading towards the development of One Health (OH), this study attempted to provide an insight into potential OH activists (OHA) at the community level. Thus, this case study in one of India's western cities, Ahmedabad, targeted identifying OHA by exploring the feasibility and the motivation of CHWs in a local setting.

METHODS

This case study explores two major CHWs, i.e., female (Accredited Social Health Activists/ASHA) health workers (FHWs) and male (multipurpose) health workers (MHWs), on their experience and motivation for becoming an OHA. The data were collected between September 2018 and August 2019 through a mixed design, i.e., quantitative data (cross-sectional structured questionnaire) followed by qualitative data (focus group discussion with a semi-structured interview guide).

RESULTS

The motivation of the CHWs for liaisoning as OHA was found to be low; however, the FHWs have a higher mean motivation score [40 (36-43)] as compared to MHWs [37 (35-40)] out of a maximum score of 92. Although most CHWs have received zoonoses training or contributed to zoonoses prevention campaigns, their awareness level was found to be different among male and female health workers. Comparing the female and male health workers to act as OHA, higher motivational score, multidisciplinary collaborative work experience, and way for incentive generation documented among the female health workers.

CONCLUSION

ASHAs were willing to accept the additional new liaison role of OHAs if measures like financial incentives and improved recognition are provided. Although this study documented various systemic factors at the individual, community, and health system level, which might, directly and indirectly, impact the acceptance level to act as OHA, they need to be accounted for in the policy regime.

Evaluation of a training program for life skills education and financial literacy to community health workers in India: a quasi-experimental study

Background

Accredited Social Health Activists (ASHA) are community health workers responsible for improving the health status of people by facilitating their access to healthcare services. The life skills of ASHA are known to be effective in negotiating behaviour change in the community; however, there has been a meagre focus towards improving them. Considering this gap, we adopted a comprehensive training program, known as Personal Advancement and Career Enhancement (P.A.C.E.), to empower ASHAs on life skills and financial literacy. The present study intends to assess the training program in two districts of Uttar Pradesh, India, by examining changes in knowledge, perceptions, and practices of ASHAs about life skills and financial literacy.

Methods

We conducted a quasi-experimental, non-randomized, controlled study with pre-and post-test assessments. Data were collected on socio-demographic characteristics, knowledge, and practices related to life skills (communication skills, self-confidence, problem–solving and decision-making skills, time and stress management skills) and financial literacy. Additionally, change perceptions on gender-, life skills-, and savings-related practices at the personal, community, and workplace levels were assessed in the intervention group. Factor analysis was performed to obtain the change patterns by assessing the degree to which the four life skills, financial literacy, and change perceptions on practices were correlated. A general linear regression model was performed to assess associations among change pattern scores and socio-demographic variables.

Results

We analyzed the data of 171 ASHAs (intervention group:86 and control group:85). There was a significant improvement in the average post-test scores of all the life skills and financial literacy in the intervention group (p < 0.001). Three distinct change patterns were found post-training in the intervention group. Factor 1 (high loadings for change perceptions on practices) was positively associated with ASHAs aged 38 and above and with experience of ≤12 years. On the contrary, the change in financial literacy and self-confidence scores was common among ASHAs with more than 12 years of experience.

Conclusions

The P.A.C.E training program was found effective in improving the life skills and financial literacy of ASHAs in India.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-06025-4.

Digital training for non-specialist health workers to deliver a brief psychological treatment for depression in India: Protocol for a three-arm randomized controlled trial

BACKGROUND

Training non-specialist health workers (NSHWs) at scale is a major barrier to increasing the coverage of depression care in India. This trial will test the effectiveness of two forms of digital training compared to conventional face-to-face training in changing the competence of NSHWs to deliver a brief evidence-based psychological treatment for depression.

METHODS

This protocol is for a three-arm, parallel group randomized controlled trial comparing three ways of training NSHWs to deliver the Healthy Activity Program (HAP), a brief manualized psychotherapy for depression, in primary care. The arms are: digital training (DGT); digital training combined with individualized coaching support (DGT+); and conventional face-to-face training (F2F). The target sample comprises N = 336 government contracted NSHWs in Madhya Pradesh, India. The primary outcome is change of competence to deliver HAP; secondary outcomes include cost-effectiveness of the training programs, change in participants' mental health knowledge, attitudes and behavior, and satisfaction with the training. Assessors blind to participant allocation status will collect outcomes pre- (baseline) and post- (endpoint) training to ascertain differences in outcomes between arms. Training program costs will be collected to calculate incremental costs of achieving one additional unit on the competency measure in the digital compared to face-to-face training programs. Health worker motivation, job satisfaction, and burnout will be collected as exploratory outcome variables.

DISCUSSION

This trial will determine whether digital training is an effective, cost-effective, and scalable approach for building workforce capacity to deliver a brief evidence-based psychological treatment for depression in primary care in a low-resource setting.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04157816.

An Investigation of Healthcare Professionals' Motivation in Public and Mission Hospitals in Meru County, Kenya

Strengthening health systems in developing countries such as Kenya is required to achieve the third United Nations’ Sustainable Development Goal of health for all, at all ages. However, Kenya is experiencing a “brain drain” and a critical shortage of healthcare professionals. There is a need to identify the factors that motivate healthcare workers to work in the health sector in rural and marginalized areas. This cross-sectional study aims to investigate the factors associated with the level and types of motivation among healthcare professionals in public and mission hospitals in Meru county, Kenya. Data were collected from 24 public and mission hospitals using a self-administered structured questionnaire. A total of 553 healthcare professionals participated in this study; 78.48% from public hospitals and 21.52% from mission hospitals. Hospital ownership was statistically nonsignificant in healthcare professionals’ overall motivation (p > 0.05). The results showed that sociodemographic and work-environment factors explained 29.95% of the variation in overall motivation scores among participants. Findings indicate there are more similarities than disparities among healthcare professionals’ motivation factors, regardless of hospital ownership; therefore, motivation strategies should be developed and applied in both public and private not-for-profit hospitals to ensure an effective healthcare workforce and strengthen healthcare systems in Kenya.

Geospatial variations in trends of reproductive, maternal, newborn and child health and nutrition indicators at block level in Bihar, India, during scale-up of Ananya program interventions

BACKGROUND

Geographical variations in the levels and trajectory of health indicators at local level can inform the adaptation of interventions and development of targeted approaches for efficient scale-up of intervention impact. We examined the hypothesis that time trends of a set of reproductive, maternal, newborn, and child health and nutrition (RMNCHN) indicators varied at block-level during the statewide scale-up phase of the Ananya program in Bihar, India.

METHODS

We used data on 22 selected indicators from four rounds of the Community-based Household Survey carried out between 2014 and 2017. Indicator levels at each round were estimated for each block. We used hierarchical Bayesian spatiotemporal modelling to smooth the raw estimates for each block with the estimates from its neighbouring blocks, and to examine space-time interaction models for evidence of variations in trends of indicators across blocks. We expressed the uncertainty around the smoothed levels and the trends with 95% credible intervals.

RESULTS

There was evidence of variations in trends at block level in all but three indicators: facility delivery, public facility delivery, and age-appropriate initiation of complementary feeding. Fifteen indicators showed trends in opposite directions (increases in some blocks and declines in others). All blocks had at least 97.5% probability of a rise in immediate breastfeeding, early pregnancy registration, and having at least four antenatal care visits. All blocks had at least 97.5% probability of a decline in seeking care for pregnancy complications.

CONCLUSIONS

The findings underscore the value of monitoring and evaluation at local level for targeted implementation of RMNCHN interventions. There is a need for identifying systematic factors leading to universal trends, or variable contextual or implementation factors leading to variable trends, in order to optimise primary health care program impact.

STUDY REGISTRATION

ClinicalTrials.gov number NCT02726230.

Community health worker motivation to perform systematic household contact tuberculosis investigation in a high burden metropolitan district in South Africa

BACKGROUND

South Africa faces a chronic shortage of professional health workers. Accordingly, community health workers (CHWs) are being employed to mitigate the ongoing health workforce deficiencies. As increased access to quality service delivery hinges upon their motivation, this study explored CHWs' motivation to deliver systematic household contact tuberculosis (TB) investigation (SHCI).

METHODS

In 2017, a cross-sectional survey was conducted among CHWs in the Mangaung Metropolitan District, Free State Province. Exploratory factor analysis was performed on a 30-item scale to determine the dimensions underlying CHW motivation. Items with factor loadings of 0.4 and above were retained. Descriptive and inferential analyses were used to determine CHW motivation levels. Multiple linear regression analysis was used to investigate the determinants of CHW motivation.

RESULTS

Out of 235 participants, 89.2% were female. Participants' median age was 39 (inter-quartile range: 33-45) years. CHW motivation was defined by 16 items across three dimensions - intrinsic job satisfaction, burnout and team commitment, together explaining 56.04% of the total variance. The derived scale showed satisfactory internal consistency (Cronbach's alpha: 0.81), with a mean motivation score of 52.26 (standard deviation [sd]: 5.86) out of 64. Statistically significant differences were observed between formal CHWs - those with at least phase 1 standardised accredited training, and informal CHWs - those without such accredited training regarding team commitment scores (17.82 [sd: 2.48] vs. 17.07 [sd: 2.82]; t(233) = 2.157; p = 0.013). CHW age (β = 0.118, p = 0.029), location (β = 1.737, p = 0.041), length of service (β = - 0.495, p < 0.001), attendance of TB SHCI training (β = 1.809, p = 0.036), and TB SHCI competence (β = 0.706, p < 0.001), contributed statistically significantly to CHW motivation.

CONCLUSION

CHW motivation to perform TB SHCI was both intrinsic and extrinsic. The high overall mean score implies that the CHWs were well-motivated to perform TB SHCI. To ensure sustained improved access to quality TB SHCI service provision, programme managers in the Free State and similar settings could potentially use the tool derived from this study to monitor and inform CHW motivation interventions. Interventions should pay close attention to the CHWs' formalisation, competence and training.

Determinants of Motivation among Healthcare Workers in the East African Community between 2009-2019: A Systematic Review

Healthcare workers are an essential element in the functionality of the health system. However, the health workforce impact on health systems tends to be overlooked. Countries within the Sub-Saharan region such as the six in the East African Community (EAC) have weak and sub-optimally functioning health systems. As countries globally aim to attain Universal Health Coverage and the Sustainable Development Goal 3, it is crucial that the significant role of the health workforce in this achievement is recognized. In this systematic review, we aimed to synthesise the determinants of motivation as reported by healthcare workers in the EAC between 2009 and 2019. A systematic search was performed using four databases, namely Cochrane library, EBSCOhost, ProQuest and PubMed. The eligible articles were selected and reviewed based on the authors' selection criteria. A total of 30 studies were eligible for review. All six countries that are part of the EAC were represented in this systematic review. Determinants as reported by healthcare workers in six countries were synthesised. Individual-level-, organizational/structural- and societal-level determinants were reported, thus revealing the roles of the healthcare worker, health facilities and the government in terms of health systems and the community or society at large in promoting healthcare workers' motivation. Monetary and non-monetary determinants of healthcare workers' motivation reported are crucial for informing healthcare worker motivation policy and health workforce strengthening in East Africa.

Comprehensive measurement of health system performance at district level in India: Generation of a composite index

There have been limited attempts at measurement of health system performance at decentralized levels in low- and middle-income countries. This study was undertaken to develop a composite indicator to measure health system performance at district level in India. Primary data were collected from 377 public health facilities in 21 districts of Haryana state in India using health facility surveys. In addition, 1700 health care providers and 800 clients visiting health facilities were interviewed. Routine health management information system data at district and state level were also analyzed. These data were used for computing 67 input and process indicators covering six health system building blocks. Indicators were normalized and aggregated to generate domain-specific and overall composite health system performance index (HSPI) for each district. Several sensitivity analyses were performed to assess robustness of results. Overall, Panchkula and Ambala districts were found to be the best performing in the state (with HSPI scores of 0.64 and 0.62 out of 1), while Mewat, Faridabad, and Palwal districts had the poorest performance (with HSPI scores of 0.46, 0.49, and 0.48 out of 1). Significant variation in performance was observed for each health system building block. Sensitivity analyses results showed that study findings were robust to variations in methods of aggregation of indicators. Our study provides a framework and methods to measure health system performance at district level in a comprehensive manner. The composite indicator provides a summary snapshot to benchmark performance, while building block and domain scores provide critical information for programmatic action.

Salaried and voluntary community health workers: exploring how incentives and expectation gaps influence motivation

BACKGROUND

The recent publication of the WHO guideline on support to optimise community health worker (CHW) programmes illustrates the renewed attention for the need to strengthen the performance of CHWs. Performance partly depends on motivation, which in turn is influenced by incentives. This paper aims to critically analyse the use of incentives and their link with improving CHW motivation.

METHODS

We undertook a comparative analysis on the linkages between incentives and motivation based on existing datasets of qualitative studies in six countries. These studies had used a conceptual framework on factors influencing CHW performance, where motivational factors were defined as financial, material, non-material and intrinsic and had undertaken semi-structured interviews and focus group discussions with CHWs, supervisors, health managers and selected community members.

RESULTS

We found that (a mix of) incentives influence motivation in a similar and sometimes different way across contexts. The mode of CHW engagement (employed vs. volunteering) influenced how various forms of incentives affect each other as well as motivation. Motivation was negatively influenced by incentive-related "expectation gaps", including lower than expected financial incentives, later than expected payments, fewer than expected material incentives and job enablers, and unequally distributed incentives across groups of CHWs. Furthermore, we found that incentives could cause friction for the interface role of CHWs between communities and the health sector.

CONCLUSIONS

Whether CHWs are employed or engaged as volunteers has implications for the way incentives influence motivation. Intrinsic motivational factors are important to and experienced by both types of CHWs, yet for many salaried CHWs, they do not compensate for the demotivation derived from the perceived low level of financial reward. Overall, introducing and/or sustaining a form of financial incentive seems key towards strengthening CHW motivation. Adequate expectation management regarding financial and material incentives is essential to prevent frustration about expectation gaps or "broken promises", which negatively affect motivation. Consistently receiving the type and amount of incentives promised appears as important to sustain motivation as raising the absolute level of incentives.

Motivational Factors Influencing Retention of Village Health Workers in Rural Communities of Bhutan

Village health workers (VHWs) are the first contact extending vital health services to unreached and underserved communities in Bhutan. VHWs truly embody the principles of primary health care and are effective catalysts in promoting community health. This study identifies and confirms factors motivating VHWs to remain in the health care system. This is a quantitative study with a cross-sectional survey design. Two-stage cluster sampling was used with VHWs from 12 districts representing 3 regions of Bhutan. Data were collected using pretested semistructured questionnaires. Confirmatory factor analysis was used for data analysis. Findings reveal a 4-factor model of motivations among VHWs that includes social, personal, job related, and organizational factors. Among these, the social factor most significantly motivates VHWs to remain in the health care system. VHW motivation can be further fostered by providing a holistic combination of financial and nonfinancial incentives that recognize intrinsic needs and empower innate altruism.

What do community health workers want? Findings of a discrete choice experiment among Accredited Social Health Activists (ASHAs) in India

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.

Factors contributing to motivation of volunteer community health workers in Ethiopia: the case of four woredas (districts) in Oromia and Tigray regions

BACKGROUND

The use of community health workers (CHWs) has been considered as one of the strategies to address the growing shortage of health workers, predominantly in low-income countries. They are playing a pivotal role in lessening health disparities through improving health outcomes for underserved populations. Yet, little is known about what factors motivate and drive them to continue working as CHWs. In this study, we aimed to examine factors contributing to the motivation of volunteer CHWs (vCHWs) in Ethiopia currently known as one-to-five network leaders (1to5NLs) and explore variations between attributes of social and work-related determinants.

METHOD

We conducted a cross-sectional study in four selected woredas (the second lowest administrative structure in Ethiopia, and similar to a district) of Oromia and Tigray regions and interviewed 786 1to5NLs. The effects of each motivational factor were explored using percentage of respondents who agreed and strongly agreed to each of them and Mann-Whitney U test.

RESULTS

Individual, community, and health system factors contributed to the motivation of 1to5NLs in this study. Intrinsic desire to have a good status in the community as a result of their volunteer service (81.86%) followed by a commitment to serve the community (81.61%) and to gain satisfaction by accomplishing something worthwhile to the community (81.61%) were some of the factors motivating 1to5NLs in our study. Despite these motivational items, factors such as lack of career development (51.47%), unclear health development army guideline (59.26%), limited supervision and support (62.32%), and lack of recognition and appreciation of accomplishments (63.22%) were the factors negatively affecting motivation of 1to5NLs. Lack of career development, limited supervision and support, and lack of recognition and appreciation of accomplishments were significantly varied between attributes of educational level, marital status, service year as 1to5NLs, and previous volunteer engagement (at P < 0.05).

CONCLUSION

Findings of our study indicated that non-financial incentives such as the creation of career development models is the key to motivating and retaining CHWs where they are not receiving stipends. Sustainability of CHW program should consider exploring enhanced innovations to strengthen supportive supervision, development of better mechanisms to publicize the role of CHWs, and improvement of recognition and appreciation schemes for CHWs' efforts and accomplishments.

Identifying and confirming demotivating factors for village health workers in rural communities of Bhutan

BACKGROUND

Bhutan achieved over 95% of health coverage through its primary health care network and geared towards achieving and ensuring Universal Health Coverage. About 62.2% of the Bhutanese people are rural dwellers, living in villages. Village health workers (VHWs) are essential for primary health care delivery at the community level in order to bridge the gap between the health care system and the communities. However, increasing numbers of VHWs leaving the health care system remain a challenge for Bhutan. This study intends to find existing problems of motivation and retention among VHWs in Bhutan and to devise appropriate strategies for making effective policy interventions.

METHODS

This quantitative study with a cross-sectional survey design aims to determine demotivating factors. One stage cluster sampling technique was applied for VHWs from 12 districts in three regions. Data were collected by the trained enumerators using a pre-tested semi-structured questionnaire.

RESULTS

The Confirmatory factor analysis identified and confirmed a four-factor model of demotivation among VHWs in Bhutan. Among the four factors, the social factor was the main factor for VHWs leaving the health care system. However, the holistic combination of both financial and non-financial motivator needs to be taken into consideration. The content analysis revealed six areas of recommendation for improving motivation and retention among VHWs.

CONCLUSION

The study concluded that managers and policymakers must give more emphasis to non-financial motivators through the holistic approach to existing altruism and intrinsic needs.

Internal migrants' experiences with and perceptions of frontline health workers: A nationwide study in 13 Indian cities

The role of frontline health workers is crucial in strengthening primary health care in India. This paper reports on the extent of services provided by frontline health workers in migrants' experiences and perceptions of these services in 13 Indian cities. Cluster random sampling was used to sample 51 055 households for a quantitative survey through interviewer-administered questionnaires. Information was sought on the receipt of health workers' services for general health care overall (from the head/other adult member of the household) and maternal and immunization services in particular (from mothers of children <2 years old). Purposively, 240 key informants and 290 recently delivered mothers were selected for qualitative interviews. Only 31% of the total respondents were aware of the visits of frontline health workers, and 20% of households reported visits to their locality during past month. In 4 cities, approximately 90% of households never saw health workers in their locality. Only 20% of women and 22% of children received antenatal care and vaccination cards from frontline health workers. Qualitative data confirm that the frontline health workers' visits were not regular and that health workers limited their services to antenatal care and childhood immunization. It was further noted that health workers saw the migrants as"outsiders." These findings warrant developing migrant-specific health-care services that consider their vulnerability and living conditions. The present study has implications for India's National Urban Health Mission, which envisions addressing the health care needs of the urban population with a focus on the urban poor.

How do gender relations affect the working lives of close to community health service providers? Empirical research, a review and conceptual framework

Close-to-community (CTC) providers have been identified as a key cadre to progress universal health coverage and address inequities in health service provision due to their embedded position within communities. CTC providers both work within, and are subject to, the gender norms at community level but may also have the potential to alter them. This paper synthesises current evidence on gender and CTC providers and the services they deliver. This study uses a two-stage exploratory approach drawing upon qualitative research from the six countries (Bangladesh, Indonesia, Ethiopia, Kenya, Malawi, Mozambique) that were part of the REACHOUT consortium. This research took place from 2013 to 2014. This was followed by systematic review that took place from January-September 2017, using critical interpretive synthesis methodology. This review included 58 papers from the literature. The resulting findings from both stages informed the development of a conceptual framework. We present the holistic conceptual framework to show how gender roles and relations shape CTC provider experience at the individual, community, and health system levels. The evidence presented highlights the importance of safety and mobility at the community level. At the individual level, influence of family and intra-household dynamics are of importance. Important at the health systems level, are career progression and remuneration. We present suggestions for how the role of a CTC provider can, with the right support, be an empowering experience. Key priorities for policymakers to promote gender equity in this cadre include: safety and well-being, remuneration, and career progression opportunities. Gender roles and relations shape CTC provider experiences across multiple levels of the health system. To strengthen the equity and efficiency of CTC programmes gender dynamics should be considered by policymakers and implementers during both the conceptualisation and implementation of CTC programmes.

Increasing Full Child Immunization Rates by Government Using an Innovative Computerized Immunization Due List in Rural India

Increasing child vaccination coverage to 85% or more in rural India from the current level of 50% holds great promise for reducing infant and child mortality and improving health of children. We have tested a novel strategy called Rural Effective Affordable Comprehensive Health Care (REACH) in a rural population of more than 300 000 in Rajasthan and succeeded in achieving full immunization coverage of 88.7% among children aged 12 to 23 months in a short span of less than 2 years. The REACH strategy was first developed and successfully implemented in a demonstration project by SHARE INDIA in Medchal region of Andhra Pradesh, and was then replicated in Rajgarh block of Rajasthan in cooperation with Bhoruka Charitable Trust (private partners of Integrated Child Development Services and National Rural Health Mission health workers in Rajgarh). The success of the REACH strategy in both Andhra Pradesh and Rajasthan suggests that it could be successfully adopted as a model to enhance vaccination coverage dramatically in other areas of rural India.

A comparative study on the level of satisfaction among regular and contractual health-care workers in a Northern city of India

Introduction:

Job satisfaction greatly determines the productivity and efficiency of human resources for health. The current study aims to assess the level of satisfaction and factors influencing the job satisfaction among regular and contractual health-care workers.

Materials and Methods:

A cross-sectional quantitative study was conducted from January to June 2015 among health care workers (n = 354) at all levels of public health-care facilities of Chandigarh. The correlation between variables with overall level of satisfaction was computed for regular and contractual health-care workers. Stepwise multiple linear regression was done to elucidate the major factors influencing job satisfaction.

Results:

Majority of the regular health-care staff was highly satisfied (86.9%) as compared to contractual staff (10.5%), which however was moderately satisfied (55.9%). Stepwise regression model showed that work-related matters (β = 1.370, P < 0.01), organizational facilities (β = 1.586, P < 0.01), privileges attached to the job (β = 0.530, P < 0.01), attention to the suggestions (β = 0.515, P < 0.01), chance of promotion (β = 0.703, P < 0.01), and human resource issues (β = 1.0721, P < 0.01) are strong predictors of overall satisfaction level.

Conclusion:

Under the National Rural Health Mission, contract appointments have improved the overall availability of health-care staff at all levels of public health facilities. However, there are concerns regarding their level of motivation with various aspects related to the job, which need to be urgently addressed so as to improve the effectiveness and efficiency of health services.

Sharing Histories-a transformative learning/teaching method to empower community health workers to support health behavior change of mothers

BACKGROUND

One of the keys to improving health globally is promoting mothers' adoption of healthy home practices for improved nutrition and illness prevention in the first 1000 days of life from conception. Customarily, mothers are taught health messages which, even if simplified, are hard to remember. The challenge is how to promote learning and behavior change of mothers more effectively in low-resource settings where access to health information is poor, educational levels are low, and traditional beliefs are strong.

METHODS

In addressing that challenge, a new learning/teaching method called "Sharing Histories" is in development to improve the performance of female community health workers (CHWs) in promoting mothers' behaviors for maternal, neonatal and child health (MNCH).

RESULTS

This method builds self-confidence and empowerment of CHWs in learning sessions that are built on guided sharing of their own memories of childbearing and child care. CHWs can later share histories with the mother, building her trust and empowerment to change. For professional primary health care staff who are not educators, Sharing Histories is simple to learn and use so that the method can be easily incorporated into government health systems and ongoing CHW programs.

CONCLUSIONS

I present here the Sharing Histories method, describe how it differs from other social and behavior change methods, and discuss selected literature from psychology, communications, and neuroscience that helps to explain how and why this method works as a transformative tool to engage, teach, transform, and empower CHWs to be more effective change agents with other mothers in their communities, thereby contributing to the attainment of the Sustainable Development Goals.