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Assessing community health workers' performance motivation: A mixed-methods approach on India's Accredited Social Health Activists (ASHA) programme

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This study examined the performance motivation of community health workers (CHWs) and its determinants on India's Accredited Social Health Activist (ASHA) programme. Cross-sectional study employing mixed-methods approach involved survey and focus group discussions. The state of Orissa. 386 CHWs representing 10% of the total CHWs in the chosen districts and from settings selected through a multi-stage stratified sampling. PRIMARY AND SECONDARY OUTCOME MEASURES: The level of performance motivation among the CHWs, its determinants and their current status as per the perceptions of the CHWs. The level of performance motivation was the highest for the individual and the community level factors (mean score 5.94-4.06), while the health system factors scored the least (2.70-3.279). Those ASHAs who felt having more community and system-level recognition also had higher levels of earning as CHWs (p=0.040, 95% CI 0.06 to 0.12), a sense of social responsibility (p=0.0005, 95% CI 0.12 to 0.25) and a feeling of self-efficacy (p=0.000, 95% CI 0.38 to 0.54) on their responsibilities. There was no association established between their level of dissatisfaction on the incentives (p=0.385) and the extent of motivation. The inadequate healthcare delivery status and certain working modalities reduced their motivation. Gender mainstreaming in the community health approach, especially on the demand-side and community participation were the positive externalities of the CHW programme. The CHW programme could motivate and empower local lay women on community health largely. The desire to gain social recognition, a sense of social responsibility and self-efficacy motivated them to perform. The healthcare delivery system improvements might further motivate and enable them to gain the community trust. The CHW management needs amendments to ensure adequate supportive supervision, skill and knowledge enhancement and enabling working modalities.
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Assessing community health
workersperformance motivation: a
mixed-methods approach on Indias
Accredited Social Health Activists
(ASHA) programme
Saji Saraswathy Gopalan,
Satyanarayan Mohanty,
Ashis Das
To cite: Gopalan SS,
Mohanty S, Das A. Assessing
community health
motivation: a mixed-methods
approach on Indias
Accredited Social Health
Activists (ASHA) programme.
BMJ Open 2012;2:e001557.
Prepublication history and
additional material for this
paper are available online. To
view these files please visit
the journal online (http://
Received 24 May 2012
Accepted 15 August 2012
This final article is available
for use under the terms of
the Creative Commons
Attribution Non-Commercial
2.0 Licence; see
The World Bank, NW
Washington DC, USA
DCOR Consulting Pvt Ltd,
Bhubaneswar, Orissa, India
Correspondence to
Dr Saji Saraswathy Gopalan;
Objective: This study examined the performance
motivation of community health workers (CHWs) and
its determinants on Indias Accredited Social Health
Activist (ASHA) programme.
Design: Cross-sectional study employing mixed-
methods approach involved survey and focus group
Setting: The state of Orissa.
Participants: 386 CHWs representing 10% of the total
CHWs in the chosen districts and from settings selected
through a multi-stage stratified sampling.
Primary and secondary outcome measures: The
level of performance motivation among the CHWs, its
determinants and their current status as per the
perceptions of the CHWs.
Results: The level of performance motivation was the
highest for the individual and the community level factors
(mean score 5.944.06), while the health system factors
scored the least (2.703.279).Those ASHAs who felt
having more community and system-level recognition
also had higher levels of earning as CHWs (p=0.040,
95% CI 0.06 to 0.12), a sense of social responsibility
(p=0.0005, 95% CI 0.12 to 0.25) and a feeling of self-
efficacy (p=0.000, 95% CI 0.38 to 0.54) on their
responsibilities. There was no association established
between their level of dissatisfaction on the incentives
(p=0.385) and the extent of motivation. The inadequate
healthcare delivery status and certain working modalities
reduced their motivation. Gender mainstreaming in the
community health approach, especially on the demand-
side and community participation were the positive
externalities of the CHW programme.
Conclusions: The CHW programme could motivate and
empower local lay women on community health largely.
The desire to gain social recognition, a sense of social
responsibility and self-efficacy motivated them to perform.
The healthcare delivery system improvements might
further motivate and enable them to gain the community
trust. The CHW management needs amendments to
ensure adequate supportive supervision, skill and
knowledge enhancement and enabling working
Article focus
What is the current level of the performance
motivation of the community health workers?
What are the determinants of their performance
What are the community health workers(CHWs)
perceptions and experiences on the current status
of the factors affecting their performance
Key messages
The CHWs are more motivated on the individual
and the community level factors than the health
system determinants.
The qualitative findings also support the survey out-
comes that the healthcare delivery status and the
human resource management modalities for CHW
are not satisfactory for them.
This study recommends that the CHW management
needs changes to ensure adequate supportive
supervision, skill and knowledge enhancement and
enabling working modalities.
Strengths and limitations of this study
This is a unique study exploring the performance
motivation of the public sector CHW on one of the
largest CHW programmes in the world. The evi-
dence on CHWsperformance motivation and that
of public sector CHW programmes are limited. The
unique application of the mixed-methods approach
will enhance the generalisability of the study find-
ings. It helped in finding the causality between the
level of CHWs motivation and its each determinant
along with an understanding of how and why a
CHW is motivated or demotivated. The study dis-
cussions are centred on comparable global experi-
ences for relevant policy changes.
Among the study limitations, there could be a pos-
sibility of CHWsresponses complying with percep-
tions of what should be an acceptable answer. We
did not assess the actual level of performance of
the CHWs and its effectiveness from the commu-
nitys or the supervisorsperspectives.
Gopalan SS, Mohanty S, Das A. BMJ Open 2012;2:e001557. doi:10.1136/bmjopen-2012-001557 1
Open Access Research
Globally, the intermediation of community health workers
(CHWs) in healthcare delivery is widening as they are inev-
itable to meet the universal healthcare provision and the
millennium development goals.
The term community
health workerencompasses a wide variety of local health-
care providers ranging from nurse-midwives to home-based
care givers and salaried-staffs to volunteers.
The CHWs
enable access to and utilisation of health services, and
inculcate healthy behaviours among the communities.
They are preponderantly deployed to cater to underutilised
services, unmet health behaviours and underserved popu-
The CHWs contributions to disease control,
immunisation and family planning programmes are
already established.
In the public sector, though the
CHWs are primarily link-workers or motivators, yet they do
undertake curative services for malaria, tuberculosis and
elderly care.
The spectrum of the CHW programmes
varies across countries on their objectives, rollout and man-
agement. Their larger penetration and sustainability are
more observed with the public sector.
Having identied
the potential of women in community mediation, predom-
inantly females constitute CHWs universally.
The existing literature on CHWsperformance motivation
and its determinants are scanty. Similar to any other
health cadre, the performance of CHWs depends on
their job satisfaction derived from certain intrinsic and
extrinsic motivators.
However, the yardstick for their per-
formance motivation assessment should be different from
usual health staffs particularly on three grounds; (1) many
CHWs are volunteers and not salaried staff, (2) they are lay
workers without prior training on community health and
(3) CHWs constitute the outreach workforce directly
linking the community with the formal healthcare.
Further, the approach to assess the public sector CHWs
work motivation could be different from the private sector
since they are more integrated with the formal healthcare
system and have wider responsibilities. The existing few
studies from Kenya, Vietnam, Bangladesh, Taiwan, etc
have largely catered to the latter or omitted a mixed
-methods approachby mostly employing the qualitative
This paper explores one of the largest public
sector community health worker initiatives in the world,
namely the Accredited Social Health Activist (ASHA)
programme in India. This study had three objectives:
(1) assessing the current level of performance motivation
among the ASHAs, (2) understanding the factors affecting
their level of motivation and (3) their perceptions and
experiences on the current status of the motivational
ASHA programme: an overview
The ASHA is a female volunteer selected by the commu-
nity, deployed in her own village (one in every 1000
Figure 1 Responsibilities of the Accredited Social Health Activist.
2Gopalan SS, Mohanty S, Das A. BMJ Open 2012;2:e001557. doi:10.1136/bmjopen-2012-001557
CHWsperformance motivation and its determinants
population) after a short training on community
She is preferred to be between 25 and 45 years
old, with a minimum formal education of 8 years and
demonstrable leadership qualities.
ASHAs are not salar-
ied and they belong to the voluntary cadre of health staffs
as they get xed activity-based incentives. Started in 2006,
currently the ASHA programme has spread across the
country with 820 000 women trained and deployed.
Their responsibilities range from health education to
diagnosis of health conditions (gure 1). Each state over-
sees the programme conning to the guidelines of the
National Rural Health Mission (NRHM).
Conceptual framework
The concept of performance motivationis complex and
can be dened contextually. The study dened it as the
CHWs degree of interest and willingness to undertake
and improve upon an allotted responsibility towards com-
munity health.
We used a customised framework adapted
from the existing literature.
812 15 16
The motivation
factors were broadly classied into individual and environ-
mental. The latter was further divided into health system and
community level factors (gure 2). Further, 16 parameters
were considered (identied from the literature and self-
validated by the CHWs through group discussions)
together under the above broad classications, that is, indi-
vidual,health system and community levels (table 2).
Assessment tools
This cross-sectional study conducted during 2010
employed a mixed-methods approach, that is, a combin-
ation of qualitative and quantitative techniques. It
employed both survey and focus groups discussions
among the CHWs. The survey tool constituted 16
parameters and under each a set of questions explored
their level of motivation on a Likert scale of 1 (strongly
disagree) to 5 (strongly agree). The construct of the
questions were balanced with both positive and negative
directions to prevent similar responses. The composite
score of all questions decided the level of motivation
under each parameter. A CHW was considered as moti-
vated on a particular parameter if her mean score was
above 3. At the health system level, the exploration was on
the organisation and management of the healthcare
delivery system (eg, availability of services and commod-
ities, incentives, monitoring and training of CHWs,
interaction with supervisors, peers and grass roots non-
governmental organisations (NGOs)). The community
level parameters consisted of community response, recog-
nition of CHW and participation in activities. At the indi-
vidual level, abilities, inducements to perform, job
satisfaction, family support, etc were explored. The
focus group discussions (FGDs) explored CHWscurrent
experiences and perceptions on the factors affecting
their performance motivation. Their suggestions to
improve upon the existing situations were also probed.
Sampling and recruitment
The study settings were selected through a multistage
stratied sampling. First, Orissa was selected randomly
among the high-focus states of NRHM. Then, the dis-
tricts of Angul and Mayurbhanj were selected represent-
ing the state based on its administrative division. Finally,
25% of the rural administrative blocks from each district
were randomly selected.
The survey purposively targeted 10% (n=434) of the
existing number of ASHAs (n=4342) together from both
the districts.
Thus, it planned to interview 55 ASHAs
from each of the eight rural administrative blocks.
Figure 2 Community health workers performance motivation assessment framework.
Gopalan SS, Mohanty S, Das A. BMJ Open 2012;2:e001557. doi:10.1136/bmjopen-2012-001557 3
CHWsperformance motivation and its determinants
However, only 386 ASHAs could be interviewed consid-
ering their availability and willingness during the study
period. Each survey on an average took about
3045 min.
There were 11 FGDs for 78 CHWs and each consti-
tuted 710 participants. There were mixed groups of
ASHAs from different socio-economic and demographic
backgrounds. Each FGD took between 45 and 60 min
and interviews were conducted till the data saturation.
An FGD guide with broad themes and specic probes
directed the discussions. The FGDs were conducted rst,
followed by the survey.
The local womens groups mobilised the CHWs for
the surveys and the FGDs. The interviews were
conducted in the local language Oriya. The participants
were informed about this study through local village
leaders and womens groups a week prior to the study.
A written informed consent was obtained from each
CHW after explaining the study objectives and the
intended use of the information. The participation was
completely voluntary and the respondents had the
choice of not answering any question or withdrawal
from the study at any time. The condentiality of the
participants was maintained throughout the study. The
interviews were conducted at a convenient location and
refreshments were provided to the participants. In each
district, the survey and the FGDs were performed by ve
locally based researchers, who were social science bache-
lors. The entire data collection process took 3 months.
A predesigned protocol guided the conduct of the data
collection and further, it was supervised by one of the
coauthors. We could not initiate for ethical approval as
there was no such specic entity in the state providing
ethical approval on this kind of research.
Data analysis
The quantitative information was analysed through
STATA. Linear and multivariate regression tests
explored the association between the level of perform-
ance motivation and the predictors at different levels
along with the CHWsbackground characteristics. The
qualitative data were transcribed verbatim and trans-
lated to English by the researchers themselves who con-
ducted the interviews. These translations were veried
by the coauthors who are procient in the local lan-
guage. The translated transcripts were coded and ana-
lysed through NVivo. The analysis was both inductive
and deductive and relevant themes were indexed
under the individual, health system and community-level
aspects. They were further classied as the enabling
and the demotivating factors for the CHWsperform-
ance. The qualitative ndings were triangulated with
the survey ndings conning to the conceptual frame-
work of the study.
The survey consisted of 386 CHWs (table 1), of which
the majority were below poverty line (71%), married
(70.47%) and scheduled tribes (36%). Most of them
had 8 years of formal education (85.75%), experience of
25 years as CHW (82.9%). The majority had under-
gone a minimum ve trainings (73.06%), earned US
$22.2433.33/month as a CHW (83.16%). Further, most
of them did not have any other personal sources of
earning (91.97%).
Level of performance motivation among the CHWs
The level of motivation was the highest on the intrinsic
job satisfaction on various job-related achievements (mean
4.30; 68.4% of CHWs). The self-efcacy or the perceived
abilities on job scored a mean score of 4.27 (69.7%).
Table 1 Background characteristics of the CHWs
Characteristics Percentage (n/386)
Age (years)
2530 45.60 (176)
3135 32.64 (126)
3640 17.88 (69)
>41 3.88 (15)
Education (years)
57 14.25 (55)
810 85.75 (331)
Marital status
Married 70.47 (272)
Widowed 17.88 (69)
Separated 3.88 (15)
Unmarried 4.92 (19)
Divorced 2.85 (11)
Poverty status
Below poverty line 70.98 (274)
Above poverty line 29.02 (112)
Monthly household income in INR (US$)
10002000 (22.2144.44) 21.51 (83)
20013000 (44.4666.65) 43.26 (167)
>3000 (66.67) 35.23 (136)
Scheduled caste* 29.02 (112)
Scheduled tribe* 36.01 (139)
Others 34.97 (135)
Monthly earning as CHW in INR (US$)
<500 (11.13) 2.07 (8)
5001000 (11.1322.21) 14.77 (57)
10011500 (22.2433.33) 83.16 (321)
Sources of earning
Only as CHW 91.97 (355)
Other sources 8.03 (31)
Years of experience as ASHA
<2 17.10 (66)
25 82.90 (320)
Number of trainings undergone
<5 73.06 (282)
610 26.94 (104)
*Scheduled caste and tribe are communities that receive special
privileges from the Government of India based on relatively
weaker socio-economic status.
ASHA, Accredited Social Health Activist; CHWs, community
health workers; INR, Indian rupees.
4Gopalan SS, Mohanty S, Das A. BMJ Open 2012;2:e001557. doi:10.1136/bmjopen-2012-001557
CHWsperformance motivation and its determinants
The nature of the job responsibilities positioned at the
third with a mean score of 4.18 (66.3%), followed by the
social responsibility and altruism (4.12; 66.1%). The mean
scores were 4.07 for the self-motivation (84.7%), 4.06 for
the community participation in activities (63.2%) and 4.04
for the peer support (77.2%).
The degree of motivation was the least on the commu-
nity opinion on the healthcare delivery system (2.7; 1%), fol-
lowed by their satisfaction on the level of healthcare
infrastructure (2.83; 6.7%). The ASHAs were also less
motivated on their work load (2.96; 8.8%). They had a
moderate level of motivation (mean 34) on enjoying
the autonomy to move, express opinions and execute the
responsibilities (3.96; 60.4%). The recognition from the
community, family and health system scored moderately
(3.96; 55.4%). The training (3.78; 72.8%), the type of
supportive supervision received (3.28; 12.2%), the work
modality (3.18; 17.6%) and the incentives (3.07; 16.6%)
also scored a moderate mean.
A large proportion of the ASHAs (n=327; 84.72%)
were self-motivated. If we look at the individual scores
for each parameter, the question on community
acceptance, that is, the community accepts my activities as
Iintendtosecured the highest mean score at 4.64
(n=366). Second, a self-efcacy-related question (Ican
always manage to solve difcult problems if I try hard
enough) scored at 4.58 (n=350). Further, the probe on
the intrinsic job satisfaction (I am satised that I accomplish
something worthwhile in this job) received a mean score
of 4.54 (n=336).
As per the Cronbachsαtest, the internal consistency
of the scale was adequate. The consistency coefcient
was 0.78, 0.79 and 0.84 for the community, health system
and the individual scales, respectively.
Table 2 Level of performance motivation among the community health workers (CHWs) (N=386)
Variable Mean 95% CI
n (%)
Health system level
Nature of responsibilities: level of interest in the responsibilities
and confidence to execute them
4.18 4.09 to 4.27 256 (66.3)
Workload: time to complete daily tasks, able to spend time with f
amily and flexibility in work schedule
2.96 2.90 to 3.02 34 (8.8)
Incentive: adequacy of financial and non-financial incentives and their
pattern of payment
3.07 2.97 to 3.17 64 (16.6)
Healthcare infrastructure: satisfaction on the quality of existing infrastructure,
communication options and commodities
2.83 2.78 to 2.89 26 (6.7)
Work modality: satisfaction on hierarchy, participatory approach,
recording and reporting
3.18 3.13 to 3.24 68(17.6)
Training: level of knowledge and skills imparted through trainings, and timing and
organisation of training
3.78 3.72 to 3.85 281 (72.8)
Supportive supervision: help, monitoring, and supervision to execute r
esponsibilities and solve issues
3.28 3.23 to 3.32 47 (12.2)
Peer support: moral support, advice and learning from peers 4.04 3.95 to 4.14 298 (77.2)
Community level
Community participation: level of communitys interest, acceptance and
participation in activities
4.05 3.96 to 4.16 244 (63.2)
Community opinion on public healthcare system: on quality of care, availability of
healthcare and community programmes
2.70 2.65 to 2.75 4 (1.0)
Individual level
Social responsibility and altruism: interest in social work when existing
social norms adversely impact community health, and sense of social responsibility
4.12 4.04 to 4.20 255 (66.1)
Intrinsic job satisfaction: chance for better use of abilities and time, feeling of
accomplishment, awards, career enhancement, advancement in employability,
knowledge, communication skills, managerial skills and overall happiness being on job
4.30 4.24 to 4.36 264 (68.4)
Self-efficacy: able to handle tough situations, solve problems, feel emotionally and
physically perfect on work
4.27 4.20 to 4.33 269 (69.7)
Self-motivation: working with a sense that the job is important and is not for
avoiding blame from others and gaining money alone
4.07 4.05 to 4.10 327(84.7)
Individual+community+health system level
Recognition: acceptance of CHWsperformance, its value, and talents by family,
community and system
3.96 3.90 to 4.02 214 (55.4)
Autonomy: freedom to move in the community, express opinion and execute
3.96 3.90 to 4.02 233 (60.4)
*Motivated if mean score >3.
Gopalan SS, Mohanty S, Das A. BMJ Open 2012;2:e001557. doi:10.1136/bmjopen-2012-001557 5
CHWsperformance motivation and its determinants
Determinants of the level of performance motivation
The ASHAsearning as a CHW (p<0.05, 95% CI 0.06 to
0.12), sense of social responsibility and altruism ( p<0.01,
95% CI 0.12 to 0.25) and feeling of self-efcacy (p<0.01,
95% CI 0.38 to 0.54) in undertaking responsibilities
inuenced her recognition at the health system, commu-
nity and family (not mentioned in the tables). Other
socio-economic characteristics were not signicant in
this regard.
How does the healthcare delivery system impact on the
CHWs level of motivation?
We explored how signicantly the level of motivation on
the health system factors inuenced their motivation at
the individual and the community levels. This exploration
was prompted by the fact that the CHWs were more
demotivated on the status of the former (table 2 and
gure 3). The peer support induced for a higher level of
satisfaction on the community participation,recognition,self-
efcacy and intrinsic job satisfaction. On the contrary, the
dissatisfaction on the workload also led to a higher level
of dissatisfaction on the above aspects. The dissatised
CHWs on the supportive supervision had reported a lesser
community recognition and intrinsic job satisfaction. The
demotivation on the work modality and the healthcare infra-
structure were positively related to a lesser intrinsic job sat-
isfaction. Their perceptions on the incentives did not
affect the level of motivation on any of the community,
individual or health system parameters (table 3).
Prevailing scenario of the factors affecting the
performance motivations: experiences of the ASHAs
Enabling factors
The better use of time (91%), lack of alternative job
opportunities (76%) and a sense of social responsibility
(68%) were the reasons to become a CHW and everyone
wanted to continue as ASHA. They considered perform-
ance motivation as an encouragement (45%) or some-
thing which makes their performance better (62%).
Their prior involvement in womens groups improved
their sense of altruism. Working with the community as
CHW and empowering them, especially women, inspired
many. They felt women to be more receptive to their
health advices and engage in community activities com-
pared to men.
Figure 3 Healthcare delivery system vis-à-vis the community health workersperformance motivation.
6Gopalan SS, Mohanty S, Das A. BMJ Open 2012;2:e001557. doi:10.1136/bmjopen-2012-001557
CHWsperformance motivation and its determinants
We have more support from our Didis and womens
groups are now more enthusiastic and capable in com-
munity activities. Our social cohesion is improving
further. [CHW, #4]
Supporting the survey data, many reported enhance-
ment in their family and social status, and personal
autonomy attributing to the role of CHW. They felt
empowered through the acquisition of knowledge and
skills on community health through training, designated
stature in the community and the personal autonomy to
work. Peer support and healthy competition among the
ASHAs seemed to have enhanced their enthusiasm to
perform well and achieve progressive community health.
They enjoyed the job autonomy to perform the desig-
nated duties.
Now I have a say in my neighborhood. I am being invited
to sit in community meetings and I represent my village
in health centre meetings. [CHW# 28]
We meet during trainings and meetings and share a lot
with each other. Since we have the same kind of work,
learning from each other has increased our problem-
solving skills. [CHW # 41]
Demotivating factors
On the contrary, the CHWs had certain dissatisfactions
on certain health system aspects limiting their perform-
ance motivation at the individual and the community
levels. Excessive workload, frequent refresher trainings
and meetings at health centres and travel to remote
habitations took away their personal time. They some-
times felt having limited autonomy at work to perform
their social responsibilities beyond the specied guide-
lines. The CHWs solicited their active involvement in
the planning of service delivery to incorporate commu-
nitys felt needs, as often they were given only the
options to deliver services than planning.
Very often what the programme wants and people want
from me are different. I feel whatever issues I raise on
behalf of the community during the health centre meet-
ings are not addressed timely. [CHW# 74]
Many posed concern on the communitys lack of trust
on the public healthcare system. There were instances of
care seeking from the private informal providers, despite
the availability of drugs with the CHWs. This community
behaviour was built on the instances of them not getting
drugs from the CHWs due to unavailability. Their activ-
ities were limited by the frequent stock-out of drugs and
commodities and the communication gap at different
levels of their supervision.
They also reported to have an inadequate level of
knowledge, skills and supportive supervision to perform
optimally. Their performances were monitored through
the self-recording of activities, supplemented with
random visits by the multipurpose female health
workers and other supervisors. They found it difcult to
monitor community health through surveys as it was
time consuming and tricky to record, with their low level
of education. Most of them expected to have routine
supportive supervision of their activities and the
grass-roots level organisationscooperation to enable
improved performances.
We would like to have an integrated approach with the
womens group, the NGOs and the village health com-
mittee to share and solve local issues. [CHW# 13]
Table 3 Influence of the healthcare delivery system on the community health workers(CHWs) performance motivation
Dependent variable Independent variable Coefficient SE p Value 95% CI R
Community participation Work load 0.065 0.028 <0.05 0.12 to 0.01 0.069
Work autonomy 0.062 0.026 <0.01 0.01 to 0.11
Peer support 0.139 0.049 <0.001 0.04 to 0.24
Community recognition Work load 0.215 0.077 <0.001 0.37 to 0.06 0.223
Work autonomy 0.165 0.039 <0.001 0.08 to 0.24
Peer support 0.089 0.040 <0.05 0.01 to 0.17
Supportive supervision 0.19 0.096 <0.05 0.38 to 0.00
Social prestige Work autonomy 0.153 0.032 <0.001 0.09 to 0.22 0.124
Self-efficacy Workload 0.204 0.082 <0.01 0.37 to 0.04 0.436
Work autonomy 0.185 0.042 <0.001 0.10 to 0.27
Peer support 0.089 0.040 <0.05 0.01 to 0.17
Relatedness Work autonomy 0.238 0.036 <0.001 0.17 to 0.31 0.276
Intrinsic job satisfaction Workload 0.097 0.039 <0.01 0.18 to 0.02 0.510
Work autonomy 0.215 0.020 <0.001 0.17 to 0.25
Healthcare infrastructure 0.145 0.049 <0.001 0.24 to 0.05
Work modality 0.063 0.030 <0.05 0.12 to 0.05
Training 0.327 0.038 <0.001 0.25 to 0.40
Supportive supervision 0.229 0.079 <0.001 0.38 to 0.07
Peer support 0.131 0.045 <0.001 0.04 to 0.22
Gopalan SS, Mohanty S, Das A. BMJ Open 2012;2:e001557. doi:10.1136/bmjopen-2012-001557 7
CHWsperformance motivation and its determinants
Often, I communicate timely on drug stock-outs to sub-
centre, but the primary health centres tell that they are
not aware of this. I feel my concerns and issues are not
spelled out at the higher level properly, though I share
everything with my supervisors. I am also not given timely
instruction on my roles on many activities [CHW #53]
They demanded for more exibility in organising
meetings at convenient locations to give more time for
the community and their personal life. Although CHWs
received honorarium for trainings and meetings, they
did not prefer frequently attending them. They were
condent to execute the responsibilities, still desired
knowledge and skill enhancement to convince the com-
munity and gain community acceptance. They seemed
to be less condent on curative skills and urged for
more system thrust and training in this regard.
I want to be with the community more than the meet-
ings. We wait for longer time, even for four hours at the
health centres for a one hour meeting [CHW# 29]
Some of them were disgruntled on the level of the
monetary and ours non-monetary incentives received,
yet they did not want to underperform. The ASHAs
often had to expend on mothers consumables and
spare on an average 30 hours on escorting mothers for
child birth. However what they receive was lesser consid-
ering their actual spending and the time cost. They
denied having any opportunity for informal payments,
but admitted to have received occasional incentives for
escorting mothers without actually doing so.
I often spend out-of-pocket on mothers consumables at
hospitals and what I receive is quite less in return. Still, I
want to support mothers as I feel they are like my sisters
and I am obliged to support them. [CHW#69]
What prompts the CHWs to perform and its externalities
on community health?
The rural women consider becoming a CHW as a mag-
nicent opportunity to empower themselves socially, per-
sonally and nancially.
Empowering rural women as
CHWs, who do not have alternate job opportunities can
be a replicable and sustainable model on community
health management.
In this study, the level of motiv-
ation was directly related to self-efcacy, yet socio-
economic status did not inuence the latter. This
implies that with proper selection, orientation and train-
ing, the lay women can be organised for community
health activities.
They displayed a strong commitment towards empower-
ing women as women were more receptive to their advices.
The higher level of health awareness and adherence to
healthy practices among women compared to men might
justify this village-level social network among women.
The identity with the government motivated them to
be a bridge between the community and the public
healthcare system. This will be relevant for those coun-
tries trying to reduce the poor peoples dependency on
the private sector.
Peer support and cross-learning from
peers were potential ways of inspiration, apart from the
support of many community-based organisations. The
involvement of locally based NGOs and community-
based organisations needs to be promoted to empower
and support the CHWs.
However, the NGOs need to
be a complimentary mechanism and should not under-
mine the CHWsefciency as health workers.
Above all, a sense of intrinsic motivation was the
underlying factor for the CHWsperformance. For
instance, their urge for community interactions pre-
vented them from attending the meetings and training,
despite the scope of receiving honoraria in such events.
The local cultural traits of solidarity, hospitality and pro-
viding social support lifted their enthusiasm.
behavioural traits could be exploited positively with
providing more public recognition to the CHWs. The
events of public honoring, involvement in public meet-
ings and appreciation in their group meetings would be
an impetus for their social commitment. Kenya also
reported on CHWsstrong preference for community
acceptance compared to the supervisors recognition.
In this study, the CHWsdissatisfaction on remuneration
was not associated with their level of earning. This implies
that remuneration through incentivising each activity
seems to have motivated performance despite their
feeling of under-remunerated. Yet, care should be taken to
ensure that the CHWs perform equally on all the responsi-
bilities despite the incentives varying on each responsibil-
ity. Further, they should be remunerated adequately
considering the time cost and the market rate.
What discourages the CHWs and the consequences?
The study found a strong nexus between the healthcare
delivery systems status and the CHWs level of perform-
ance motivation. As demonstrated in similar settings,
resource constraints such as limited transportation to
escort mothers and stock-outs of commodities hindered
the communitys trust on them.
The communication
gap among different actors led to delay in receiving the
stocks and non-clarity on the responsibilities among
CHWs. This weak supportive system to CHWs concerns
many other countries also as it might lead to the exclu-
sion of the poorest of the poor from appropriate health
The CHWs demanded for regular supportive supervi-
sion and streamlining of responsibilities. However, in
resource-constraint settings, identifying and training
more experienced volunteers for CHWs supervision will
be a challenge. This concern should be addressed
through leveraging some of the grass-roots level public
health managers or NGOs in a systematic manner. More
involvement of grass-roots entities like womens groups
could inculcate a sense of collective accountability and
learning. Nigeria reported village health committee
(VHC) supporting CHWs.
Since Indias VHCs are still
8Gopalan SS, Mohanty S, Das A. BMJ Open 2012;2:e001557. doi:10.1136/bmjopen-2012-001557
CHWsperformance motivation and its determinants
evolving, CHWs monitoring can be designed as one of
its roles in future.
The CHWsincreasing work load with more and more
community-based health programmes produced a
feeling of overburdened. Without proper orientation,
monitoring of many community health initiatives, espe-
cially surveys will be difcult for them, considering their
low level of formal education.
28 29
Though the current
pattern of incentivising does not appear to bring in less
performance, India could experiment with preferential
treatment on social securities and public privileges to
the CHWs and their households as demonstrated in
Guatemala and Nepal.
In India, the ASHAs are more indentied as link-
workersor facilitators for appropriate care and the com-
munity has less acceptance for their curative role.
CHWs are less condent on their curative care skills and
the supply constraints induce the communitys non-
condence on them.
In future, the CHWscould be
leveraged intensively on diagnosing health conditions to
promote a comprehensive community health manage-
ment approach. This will be relevant for elderly care
and settings with increasing chronic disease burden to
offer a cost-effective care.
19 3335
Strengths and limitations of the study
We employed a mixed-methods approach and it helped
us in two ways. First, to understand the extent of causal-
ity between the CHWs level of motivation and each of
its determinant. Second, to assess how, why and under
what condition a CHW is motivated or demotivated. The
study depended on a relativistapproach to trigger the
policy processes on streamlining the motivating factors
for the CHWs performance motivation. Further, the
FGD responses were used to verify the survey responses
and thereby enhance the generalisability of the study
outcomes. There could be a possibility of the CHWs
responses complying with the perceptions of what
should be an acceptable answer. We did not assess the
actual level of performance of the CHWs and its effect-
iveness from the communitys or supervisorsperspec-
tives. Despite this, these study revelations on the CHW
programme add to the rare global evidence base for
relevant policy changes, specically on the CHW man-
agement and the retention.
The CHW programme could motivate and empower the
local lay women on community health largely. The
desire to gain social recognition, a sense of social
responsibility and self-efcacy enhances their motivation.
Linking the incentive directly with each activity ensures
performances of the CHWs. The healthcare delivery
system improvement might further enhance their motiv-
ation and enable them to gain the community trust. The
CHW management needs to change with adequate
supportive supervision, skill and knowledge enhance-
ment and enabling working modalities.
Acknowledgements We are thankful to all the community health workers,
participated in the study. We also thank the womens groups, who mobilised
the study participants. We are grateful to the editorial board and the reviewers
for their comments on an earlier version of the manuscript.
Contributors All authors took part in the conceptualisation, design of tools
and writing of manuscript. SSG analysed the data and wrote the first draft of
the manuscript. SNM enabled the data collection. All authors read and
approved the final version.
Competing interests None.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement We declare that all the raw data are available with the
primary authors on the published information for public sharing.
Declaration The opinions expressed in this paper are exclusively of the
authors and not of their organizations they are currently affiliated with.
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10 Gopalan SS, Mohanty S, Das A. BMJ Open 2012;2:e001557. doi:10.1136/bmjopen-2012-001557
CHWsperformance motivation and its determinants
... The BK project provided a CHW empowerment program and strengthened the CHW-nurse network activities with training. It included support, encouragement, and peer-to-peer learning, which inspire CHWs (Das, Gopalan, & Mohanty, 2012). Especially, the CHW nurse network activity was intended to revitalize the motivation to help villages through a sense of responsibility and mutual support while sharing activity experiences. ...
... CHWs' consciousness of benefiting the community, along with the respect and recognition gained from the village, may result in happiness and job satisfaction. Also, as with previous results, they gained confidence and happiness in realizing social responsibility through CHW activities (Gopalan et al., 2012). ...
Background: Community health workers (CHWs) have strong potential for conducting health initiatives in vulnerable countries. Their continuing activities are essential for positive outcomes. The purpose of this study is to understand CHW activities in Kyrgyzstan migrant villages and their impact on individuals and communities. Methods: This study used a mixed-method design. All active CHWs were invited to participate in the survey and the first reflection note regarding their experience and satisfaction with CHW activities. Respondents who agreed to participate in the second reflection notes wrote additional reflection notes. Participatory observational CHW activity report meeting data was collected for additional qualitative analysis. Quantitative data were analyzed using descriptive statistics, and qualitative data were analyzed thematically. Results: CHWs started their activities with altruistic and personal motives, such as social recognition and knowledge acquisition. Job-related satisfaction after the activity tended to be high. After performing home visits and resident participatory events, they experienced intrinsic motivation, resource mobilization efforts, increased autonomy, and social recognition. Although the material rewards were small as volunteers, they recognized their positive impact on individuals and communities and gained pride and happiness. Conclusions: CHWs participating in health promotion projects had training and CHW-nurse network activities and were gradually empowered in the process. When considering the sustainability of CHW activities, it is important to increase self-confidence and strengthen social recognition through empowerment.
... Unlike the 'motivation-demotivation' lens used in earlier mixed-methods studies with ASHAs (Gopalan et al., 2012;Tripathy et al., 2016) that touches upon a few work stress-related issues, our study is an early attempt to flesh out detailed narratives on the perceptions of ASHAs towards a multitude of conditions in their work environment that trigger stressful events, the nature of the ensuing experiences of these events, the effects on health, and the range of responses towards work stress. Therefore, we have centred on the individual (ASHA), and not only the inadequacies of the system in which she works. ...
... A study conducted in Uttarakhand, 79.2% reported spreading health awareness as one of their job responsibilities, a study in Orissa, reported that 48% of the ASHA knew that creating community awareness about various health determinants. 15,16 A study from Orissa reported that 81.3% of ASHA workers had knowledge about their responsibilities regarding counselling on antenatal care/postnatal care. 16 In present study nearly 73% of ASHAs were know the importance of Iron and calcium supplement during pregnancy. ...
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Background: Accredited social health activist (ASHA) forms the backbone of National Health Mission (NHM) as they are the important link between the community and the health system, her services become very crucial for the success of NHM. They are occupied by multiples roles, responsibilities and they are expected to perform at optimum level. Aim was to assess the knowledge and practice of ASHA workers regarding their work responsibilities and to explore the barriers and challenges faced by them while performing their multiple roles. Methods: An explanatory mixed-methods study was conducted among community health workers (ASHA) of having at least one years of experience at Uttarakhand, India with 150 ASHAs for quantitative and 14 for qualitative. Purposive sampling was employed for both the approaches. Results: Quantitative approach shown that almost 91% of ASHA are having the knowledge about the importance of colostrum milk followed by importance of Anganwadi center (83%), immunization (79%), general health (70%), and birth preparedness (69%). The core thematic areas in qualitative result represented as personal, psychological, economic, social and environmental factors. They showed a level of unhappiness and distress related to their work overload and incentives. Conclusions: In general, ASHAs are having adequate knowledge about their job responsibilities, there is more training needed about maintaining the records and documentation process. There is immediate need to overcome the barriers and challenges they are facing, which can hamper their performance level.
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Improving health literacy and diabetes education is essential for promoting self-care and obtaining the best results. This narrative review examines methods for enhancing educational initiatives as well as data on the current state of health literacy and diabetes-related knowledge across various Indian groups. Overall, there is a lack of awareness and literacy, which is worse in rural and lower socioeconomic areas. There are persistent knowledge gaps in prevention, diagnosis, monitoring techniques, and complications. Skills and motivation for illness management behaviours can be improved by multimodal education that makes use of a variety of media, straightforward messaging, and interpersonal training. Long-term retention and actual practise change, however, continue to be difficult. The concepts of peer collaboration and community health workers have promise for promoting context-appropriate education and enhancing self-efficacy. The effectiveness and reach of professional diabetes education services can be increased by high-quality training, user-centered design, and infrastructure upgrades. The need for policy measures promoting equity and community empowerment ultimately arises from the need to change the unfavourable surroundings and sociocultural norms that influence health literacy and behaviours.
Purpose: Despite the importance of trachomatous trichiasis (TT) case-finding activities in national trachoma elimination campaigns, the scientific literature on the determinants of good outcomes - finding and managing all TT cases - is still sparse. In Tanzania, we studied differences in case finding activities and outcomes between male and female case finders. Methods: This case study was conducted in two districts in Tanzania in 2021-2022. Quantitative data were extracted from case finder forms and outreach registers, and qualitative data were collected through direct observation, interviews, and focus group discussions. Results: Across both districts, more males were trained as case finders (68%). Productivity differences were minor, not statistically significant, between male and female case finders regarding the number of households visited and the number of adults examined. Whether identified by a male or female case finder, similar proportions of men and women suspected to have TT were subsequently managed. There is evidence that suggests that female case finders were more active in supporting suspected and confirmed TT cases to access follow-up services. Conclusion: The findings do not suggest that gender balance in the recruitment of TT case finders would have led to better TT campaign outcomes in the study districts. Programmes may benefit from integrating gender considerations in the design and implementation of case finding activities - e.g. in monitoring gender differences among case finders and the relationship with key outcomes. This study also highlights how women with TT face greater barriers to care.
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Objectives: The objective of the study was to assess the preparedness, perceptions and fears of the laboratory staff during the Coronavirus disease 2019 (COVID-19) pandemic. Methods: The questionnaire was designed in Akhtar Saeed Medical & Dental College, Lahore and this crosssectional study was conducted from 10th May 2020 to 30th May 2020 using google forms. Results: The age of most participants ranged from 20-30 years. A large number of respondents 28(51%) were government employees and qualified more as postgraduate, holding the designation of Consultant Pathologist 24(44%). The majority of respondents were given training on Personnel Protective Equipment (PPE) usage 51(93%), sample collection and processing 48(87%). However, many centres lacked approval for COVID-19 testing 24(44%). Subjects were also not satisfied with the Biosafety level 41(74.5%) and manpower for testing 29(53%). A bulk of laboratories had the provision of handwashing areas 53(96%) and used validated COVID-19 kits 41(74.5%) from competent authorities. Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) 51 (93%) with nasopharyngeal sampling 53 (96%) was the preferred method. Psychological effects included fear of carrying the infection to home 49(89%) and dealing with sample and reporting 36(65%). Conclusion: Our study concluded preparedness for an uncertain health crisis, provision of manpower, appropriate disinfectant use, collection, transport & handling of specimen and procedural equipment are the biggest workplace challenges faced by Pathology laboratories in our setup. Support and upgrading are needed so that the Pathology laboratories are strengthened to handle the diagnostic burden of any future outbreaks. Key words: COVID-19, Pandemic, Pathologists
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Background Cardiovascular disease (CVD) is the leading cause of death in women in India. Early identification is crucial to reducing deaths. Hypertensive disorders of pregnancy (HDP) and gestational diabetes mellitus (GDM) carry independent risks for future CVD, and antenatal care is a window to screen and counsel high-risk women. In rural India, community health workers (CHWs) deliver antenatal and postnatal care. We developed a complex intervention (SMARThealth Pregnancy) involving mobile clinical decision support for CHWs and evaluated it in a pilot cluster randomized controlled trial (cRCT). Objective The aim of the study is to co-design a theory-informed intervention for CHWs to screen, refer, and counsel pregnant women at high risk of future CVD in rural India and evaluate its feasibility and acceptability. Methods In phase 1, we used qualitative methods to explore community priorities for high-risk pregnant women in rural areas of 2 diverse states in India. In phase 2, informed by behavior change theory and human-centered design, we used these qualitative data to develop the intervention components and implementation strategies for SMARThealth Pregnancy in an iterative process with end users. In phase 3, using mixed methods, we evaluated the intervention in a cRCT with an embedded qualitative substudy across 4 primary health centres: 2 in Jhajjar district, Haryana, and 2 in Guntur district, Andhra Pradesh. Results SMARThealth Pregnancy embedded a total of 15 behavior change techniques and included (1) community awareness programs; (2) targeted training, including point-of-care blood pressure and hemoglobin measurement; and (3) mobile clinical decision support for CHWs to screen women in their homes. The intervention focused on 3 priority conditions: anemia, HDP, and GDM. The evaluation involved a total of 200 pregnant women, equally randomized to intervention or enhanced standard care (control). Recruitment was completed within 5 months, with minimal loss to follow-up (4/200, 2%) at 6 weeks postpartum. A total of 4 primary care doctors and 54 CHWs in the intervention clusters took part in the study. Fidelity to intervention practices was 100% prepandemic. Over half the study population was affected by moderate to severe anemia at baseline. The prevalence of HDP (2.5%) and GDM (2%) was low in our study population. Results suggest a possible improvement in mean hemoglobin (anemia) in the intervention group, although an adequately powered trial is needed. The model of home-based care was feasible and acceptable for pregnant or postpartum women and CHWs, who perceived improvements in quality of care, self-efficacy, and professional recognition. Conclusions SMARThealth Pregnancy is an innovative model of home-based care for high-risk pregnant women during the transitions between antenatal and postnatal care and adult health services. The use of theory and co-design during intervention development facilitated acceptability of the intervention and implementation strategies. Our experience has informed the decision to initiate a larger-scale cRCT. Trial Registration NCT03968952; International Registered Report Identifier (IRRID) RR2-10.3389/fgwh.2021.620759
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To discern how the public in four countries, each with unique health systems and cultures, feels about efforts to restrain healthcare costs by limiting the use of high-cost prescription drugs and medical/surgical treatments. Cross-sectional survey. Adult populations in Germany, Italy, the UK and the USA. 2517 adults in the four countries. A questionnaire survey conducted by telephone (landline and cell) with randomly selected adults in each of the four countries. Support for different rationales for not providing/paying for high-cost prescription drugs/medical or surgical treatments, measured in the aggregate and using four case examples derived from actual decisions. Measures of public attitudes about specific policies involving comparative effectiveness and cost-benefit decision making. The survey finds support among publics in four countries for decisions that limit the use of high-cost prescription drugs/treatments when some other drug/treatment is available that works equally well but costs less. The survey finds little public support, either in individual case examples or when asked in the aggregate, for decisions in which prescription drugs/treatments are denied on the basis of cost or various definitions of benefits. The main results are based on majorities of the public in each country supporting or opposing each measure. The survey findings indicate that the public distinguishes in practice between the concepts of comparative effectiveness and cost-effectiveness analysis. This suggests that public authorities engaged in decision-making activities will find much more public support if they are dealing with the first type of decision than with the second.
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To apply sociological theories to understand public trust in extended services provided by community pharmacists relative to those provided by general practitioners (GPs). Qualitative study involving focus groups with members of the public. The West of Scotland. 26 purposively sampled members of the public were involved in one of five focus groups. The groups were composed to represent known groups of users and non-users of community pharmacy, namely mothers with young children, seniors and men. Trust was seen as being crucial in healthcare settings. Focus group discussions revealed that participants were inclined to draw unfavourable comparisons between pharmacists and GPs. Importantly, participants' trust in GPs was greater than that in pharmacists. Participants considered pharmacists to be primarily involved in medicine supply, and awareness of the pharmacist's extended role was low. Participants were often reluctant to trust pharmacists to deliver unfamiliar services, particularly those perceived to be 'high risk'. Numerous system-based factors were identified, which reinforce patient trust and confidence in GPs, including GP registration and appointment systems, GPs' expert/gatekeeper role and practice environments. Our data indicate that the nature and context of public interactions with GPs fostered familiarity with a specific GP or practice, which allowed interpersonal trust to develop. By contrast, participants' exposure to community pharmacists was limited. Additionally, a good understanding of the GPs' level of training and role promoted confidence. Current UK initiatives, which aim to implement a range of pharmacist-led services, are undermined by lack of public trust. It seems improbable that the public will trust pharmacists to deliver unfamiliar services, which are perceived to be 'high risk', unless health systems change in a way that promotes trust in pharmacists. This may be achieved by increasing the quality and quantity of patient interactions with pharmacists and gaining GP support for extended pharmacy services.
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Objective Hispanics in the USA are affected by the diabetes epidemic disproportionately, and they consistently have lower access to care, poorer control of the disease and higher risk of complications. This study evaluates whether a community health worker (CHW) intervention may improve clinically relevant markers of diabetes care in adult underserved Hispanics. Methods and analysis The Northern Manhattan Diabetes Community Outreach Project (NOCHOP) is a two-armed randomised controlled trial to be performed as a community-based participatory research study performed in a Primary Care Setting in Northern Manhattan (New York City). 360 Hispanic adults with poorly controlled type 2 diabetes mellitus (haemoglobin A1c >8%), aged 35–70 years, will be randomised at a 1:1 ratio, within Primary Care Provider clusters. The two study arms are (1) a 12-month CHW intervention and (2) enhanced usual care (educational materials mailed at 4-month intervals, preceded by phone calls). The end points, assessed after 12 months, are primary = haemoglobin A1c and secondary = blood pressure and low-density lipoprotein-cholesterol levels. In addition, the study will describe the CHW intervention in terms of components and intensity and will assess its effects on (1) medication adherence, (2) medication intensification, (3) diet and (4) physical activity. Ethics and dissemination All participants will provide informed consent; the study protocol has been approved by the Institutional Review Board of Columbia University Medical Center. CHW interventions hold great promise in improving the well-being of minority populations who suffer from diabetes mellitus. The NOCHOP study will provide valuable information about the efficacy of those interventions vis-à-vis clinically relevant end points and will inform policy makers through a detailed characterisation of the programme and its effects. Clinical trial registration number NCT00787475 at
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This review examines the experiences of nurses, community health workers, and home carers in health systems from a gender analysis. With respect to nursing, current discussions around delegation take place over layers of historical struggle that mark the evolution of nursing as a profession. Female community health workers also struggle to be recognized as skilled workers, in addition to defending at a personal level the legitimacy of their work, as it transgresses traditional norms proscribing morality and the place of women in society, at times with violent consequences. The review concludes by exploring the characteristics of, and challenges faced by, home carers, who fail to be recognized as workers at all. A key finding is that these mainly female frontline health workers compensate for the shortcomings of health systems through individual adjustments, at times to the detriment of their own health and livelihoods. So long as these shortcomings remain as private, individual concerns of women, rather than the collective responsibility of gender, requiring public acknowledgement and resolution, health systems will continue to function in a skewed manner, serving to replicate inequalities in the health labour force and in society more broadly.
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This paper is a contribution to the growing literature on how best to design and support community health worker (CHW) programmes to maximise their positive impact. CHWs are laypeople trained to promote health among their peers. To do so they are commonly tasked with providing basic curative services, promoting the use of existing health services, facilitating cultural mediation between communities and healthcare providers and encouraging critical reflection and dialogue on social health issues. This paper presents a case study of a CHW project in rural Uttarakhand, north India, called the Accredited Social Health Activist (ASHA) programme. While the ASHA programme is not specifically targeting HIV/AIDS, CHW programmes have been flagged as a key means of addressing health resource shortages in poor countries, especially in relation to HIV/AIDS. This study of the ASHA programme provides insights into how best to support CHW programmes in general, including those focused on HIV/AIDS. The research involved 25 interviews and five focus groups with ASHAs, health professionals and community members as well as over 100 hours of non-participant observation at public health centres. The research investigated contextual features of the programme that are hindering the ASHAs' capacity to increase quantitative health outcomes and act as cultural mediators and agents of social change. Research found that ASHAs were institutionally limited by: (1) the outcome-based remuneration structure; (2) poor institutional support; (3) the rigid hierarchical structure of the health system; and (4) a dearth of participation at the community level. The conclusion suggests that progressive policy on CHW programmes must be backed up by concrete institutional support structures to enable CHWs to fulfil their role.
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A key constraint to saturating coverage of interventions for reducing the burden of childhood illnesses in Low and Middle Income Countries (LMIC) is the lack of human resources. Community health workers (CHW) are potentially important actors in bridging this gap. Evidence exists on effectiveness of CHW in management of some childhood illnesses (IMCI). However, we need to know how and when this comes to be. We examine evidence from randomized control trials (RCT) on CHW interventions in IMCI in LMIC from a realist perspective with the aim to see if they can yield insight into the working of the interventions, when examined from a different perspective. The realist approach involves educing the mechanisms through which an intervention produced an outcome in a particular context. 'Mechanisms' are reactions, triggered by the interaction of the intervention and a certain context, which lead to change. These are often only implicit and are actually hypothesized by the reviewer. This review is limited to unravelling these from the RCTs; it is thus a hypothesis generating exercise. Interventions to improve CHW performance included 'Skills based training of CHW', 'Supervision and referral support from public health services', 'Positioning of CHW in the community'. When interventions were applied in context of CHW programs embedded in local health services, with beneficiaries who valued services and had unmet needs, the interventions worked if following mechanisms were triggered: anticipation of being valued by the community; perception of improvement in social status; sense of relatedness with beneficiaries and public services; increase in self esteem; sense of self efficacy and enactive mastery of tasks; sense of credibility, legitimacy and assurance that there was a system for back-up support. Studies also showed that if context differed, even with similar interventions, negative mechanisms could be triggered, compromising CHW performance. The aim of this review was to explore if RCTs could yield insight into the working of the interventions, when examined from a different, a realist perspective. We found that RCTs did yield some insight, but the hypotheses generated were very general and not well refined. These hypotheses need to be tested and refined in further studies.
A central component of the primary health care approach in developing countries has been the development and utilization of community-based health workers (CHWs) within the national health system. While the use of these front line workers has the potential to positively influence health behavior and health status in rural communities, there continues to be challenges to effective implementation of CHW programs. Reports of high turnover rates, absenteeism, poor quality of work, and low morale among CHWs have often been associated with weak organizational and managerial capacity of government health systems. However, no systematic research has examined the contribution of work-related factors to CHW job performance. The research reported in this paper examines the relative influence of reward and feedback factors associated with the community compared to those associated with the health system on the performance of CHWs. The data are drawn from a broader study of health promoters (CHWs) conducted in two departments (provinces) in Colombia in 1986. The research was based on a theoretical model of worker performance that focuses on job related sources of rewards and feedback. A survey research design was employed to obtain information from a random sample of rural health promoters (N = 179) and their auxiliary nurse supervisors about CHW performance and contributing factors. The findings indicate that feedback and rewards from the community have a greater influence on work performance (defined as degree of perceived goal attainment on job tasks) than do those stemming from the health system.(ABSTRACT TRUNCATED AT 250 WORDS)
Nigeria's primary health care program relies on village health workers (VHWs) to provide simple curative and preventive services to largely rural underserved communities. Despite the reported need for these services, there is increasing evidence that VHWs often take leave of their jobs as a result of low patient demand, competing time interests, and less than adequate supervision. This paper describes the use of a simple operations research (OR) approach [1] to assist rural health program managers design strategies for reducing VHW attrition. It illustrates the feasibility and potential utility of employing the Nominal Group Technique (NGT) to draw on the experience and judgment of a variety of health professionals in arriving at local program decisions. This OR approach to problem solving resulted in a feasible and acceptable strategy which is now being implemented in southern Gongola State, Nigeria.