title: Factors shaping interactions among community health workers in rural Ethiopia: rethinking workplace trust and teamwork.
abstract: BACKGROUND
  Worldwide, a shortage of skilled health workers has prompted a shift toward community-based health workers taking on greater responsibility in the provision of select maternal and newborn health services. Research in mid- and high-income settings suggests that coworker collaboration increases productivity and performance. A major gap in this research, however, is the exploration of factors that influence teamwork among diverse community health worker cadres in rural, low-resource settings. The purpose of this study is to examine how sociodemographic and structural factors shape teamwork among community-based maternal and newborn health workers in Ethiopia.
  
  
  METHODS
  A cross-sectional survey was conducted with health extension workers, community health development agents, and traditional birth attendants in 3 districts of the West Gojam Zone in the Amhara region of Ethiopia. Communities were randomly selected from Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) sites; health worker participants were recruited using a snowball sampling strategy. Fractional logit modeling and average marginal effects analyses were carried out to identify the influential factors for frequency of work interactions with each cadre.
  
  
  RESULTS
  One hundred and ninety-four health workers participated in the study. A core set of factors-trust in coworkers, gender, and cadre-were influential for teamwork across groups. Greater geographic distance and perception of self-interested motivations were barriers to interactions with health extension workers, while greater food insecurity (a proxy for wealth) was associated with increased interactions with traditional birth attendants.
  
  
  CONCLUSIONS
  Interventions that promote trust and gender sensitivity and improve perceptions of health worker motivations may help bridge the gap in health services delivery between low- and high-resource settings. Inter-cadre training may be one mechanism to increase trust and respect among diverse health workers, thereby increasing collaboration. Large-scale, longitudinal research is needed to understand how changes in trust, gender norms, and perceptions of motivations influence teamwork over time.
authors.forename: Michelle M
authors.initials: MM
authors.lastname: Dynes
authors.forename: Rob
authors.initials: R
authors.lastname: Stephenson
authors.forename: Craig
authors.initials: C
authors.lastname: Hadley
authors.forename: Lynn M
authors.initials: LM
authors.lastname: Sibley
mesh_terms: D000328:Adult; D000368:Aged; D003150:Community Health Workers; D003299:Cooperative Behavior; D003430:Cross-Sectional Studies; D003625:Data Collection; D003695:Delivery of Health Care; D005002:Ethiopia; D005260:Female; D006801:Humans; D007231:Infant, Newborn; D008297:Male; D008427:Maternal Health Services; D008875:Middle Aged; D008880:Midwifery; D009042:Motivation; D011247:Pregnancy; D019035:Rural Health Services; D012424:Rural Population; D063507:Sexism; D012923:Social Class; D035502:Trust; D017132:Workplace; D055815:Young Adult
keywords: Ethiopia; community health workers; health services; maternal health; motivations; teamwork; trust