Using theory and formative research to design interventions to improve community health worker motivation, retention and performance in Mozambique and Uganda.
BACKGROUND
Community health workers (CHWs) are increasingly being used in low-income countries to address human resources shortages, yet there remain few effective, evidence-based strategies for addressing the enduring programmatic constraints of worker motivation, retention and performance. This paper describes how two interventions were designed by the Innovations at Scale for Community Access and Lasting Effects (inSCALE) project to address these constraints in Uganda and Mozambique drawing on behavioural theory and formative research results.


METHODS
A review of the work motivation and CHW motivation literature--incorporating influences on retention and performance--was conducted on articles sourced through electronic web searches. Formative research with a focus on the barriers and facilitators to CHW motivation, retention and performance was conducted with community health workers and key stakeholders in Uganda and Mozambique. An analytical induction approach to the thematic analysis of transcripts from 98 in-depth interviews and 26 focus group discussions was adopted across the country settings.


RESULTS
From the theoretical review, it was determined that the interventions should promote CHWs as members of a collective by highlighting a sense of shared experience, focus on alignment between worker and programme goals, and emphasise the actions that lead to good performance. The Social Identity Approach was selected as the theory most likely to lead to the development of effective, scalable and sustainable interventions by addressing the identified gap in the literature of the influence of CHW working context. The formative research indicated that CHWs value feedback and feeling connected to the health system and their community, are motivated by status and community standing, and want to be provided with the necessary tools to perform. Two interventions based on these results were developed: a participatory, local community approach and an information communication technology (ICT) approach.


CONCLUSIONS
Drawing on contextual data and theory that is sensitive to context can potentially lead to the development of appropriate and effective interventions when aiming to improve the motivation, retention and performance of CHWs in Uganda and Mozambique and other comparable settings. Evaluation of the developed interventions is crucial to assess this potential.
UCL Institute for Global Health, 30 Guilford St., London, WC1N 1EH, UK. d.strachan@ucl.ac.uk.
Daniel Llywelyn
DL
Strachan
Malaria Consortium, Development House, 56-64 Leonard Street, London, EC2A 4LT, UK. k.kallander@malariaconsortium.org.|Karolinska Institutet, Stockholm, Sweden. k.kallander@malariaconsortium.org.
Karin
K
Källander
Malaria Consortium Uganda, Plot 25 Upper Naguru East Road, P.O.Box 8045, Kampala, Uganda. m.nakirunda@malariaconsortium.org.
Maureen
M
Nakirunda
Malaria Consortium Mozambique, Rua Joseph Ki-Zerbo 191, PO Box 3655, Coop, Maputo, Mozambique. s.ndima@malariaconsortium.org.
Sozinho
S
Ndima
Malaria Consortium Mozambique, Rua Joseph Ki-Zerbo 191, PO Box 3655, Coop, Maputo, Mozambique. a.muiambo@malariaconsortium.org.
Abel
A
Muiambo
UCL Institute for Global Health, 30 Guilford St., London, WC1N 1EH, UK. z.hill@ucl.ac.uk.
Zelee
Z
Hill
D003153:Community Health Services; D003150:Community Health Workers; D017144:Focus Groups; D006801:Humans; D009042:Motivation; D009073:Mozambique; D010563:Personnel Turnover; D011361:Professional Competence; D011582:Psychological Theory; D036301:Qualitative Research; D012111:Residence Characteristics; D012933:Social Identification; D014454:Uganda; D014937:Work / Q000592:standards; D000078329:Workforce