Background Community Health Workers (CHWs) have a positive impact on the provision of community-based primary health care through screening, treatment, referral, psychosocial support, and accompaniment. With a broad scope of work, CHW programs must balance the breadth and depth of tasks to maintain CHW motivation for high-quality care delivery. Few studies have described the CHW perspective on intrinsic and extrinsic motivation to enhance their programmatic activities. Methods We utilized an exploratory qualitative study design with CHWs employed in the household model in Neno District, Malawi, to explore their perspectives on intrinsic and extrinsic motivators and dissatisfiers in their work. Data was collected in 8 focus group discussions with 90 CHWs in October 2018 and March–April 2019 in seven purposively selected catchment areas. All interviews were audiotaped, transcribed verbatim, coded, and analyzed using Dedoose. Results Themes of complex intrinsic and extrinsic factors were generated from the perspectives of the CHWs in the focus group discussions. Study results indicate that enabling factors are primarily intrinsic factors such as positive patient outcomes, community respect, and recognition by the formal health care system but can lead to the challenge of increased scope and workload. Extrinsic factors can provide challenges, including an increased scope and workload from original expectations, lack of resources to utilize in their work, and rugged geography. However, a positive work environment through supportive relationships between CHWs and supervisors enables the CHWs. Conclusion This study demonstrated enabling factors and challenges for CHW performance from their perspective within the dual-factor theory. We can mitigate challenges through focused efforts to limit geographical distance, manage workload, and strengthen CHW support to reinforce their recognition and trust. Such programmatic emphasis can  focus on enhancing motivational factors found in this study to improve the CHWs’ experience in their role. The engagement of CHWs, the communities, and the formal health care system is critical to improving the care provided to the patients and communities, along with building supportive systems to recognize the work done by CHWs for the primary health care systems.

BackgroundChoosing who should be recruited as a community health worker (CHW) is an important task, for their future performance partly depends on their ability to learn the required knowledge and skills, and their personal attributes. Developing a fair and effective selection process for CHWs is a challenging task, and reports of attempts to do so are rare. This paper describes a five-stage process of development and initial testing of a CHW selection process in two CHW programmes, one in Malawi and one in Ghana, highlighting the lessons learned at each stage and offering recommendations to other CHW programme providers seeking to develop their own selection processes.Case presentationThe five stages of selection process development were as follows: (1) review an existing selection process, (2) conduct a job analysis, (3) elicit stakeholder opinions, (4) co-design the selection process and (5) test the selection process. Good practice in selection process development from the human resource literature and the principles of co-design were considered throughout. Validity, reliability, fairness, acceptability and feasibility—the determinants of selection process utility—were considered as appropriate during stages 1 to 4 and used to guide the testing in stage 5. The selection methods used by each local team were a written test and a short interview.ConclusionsWorking with stakeholders, including CHWs, helped to ensure the acceptability of the selection processes developed. Expectations of intensiveness—in particular the number of interviewers—needed to be managed as resources for selection are limited, and CHWs reported that any form of interview may be stressful. Testing highlighted the importance of piloting with CHWs to ensure clarity of wording of questions, interviewer training to maximise inter-rater reliability and the provision of guidance to applicants in advance of any selection events. Trade-offs between the different components of selection process utility are also likely to be required. Further refinements and evaluation of predictive validity (i.e. a sixth stage of development) would be recommended before roll-out.

Background Obesity is increasingly a public health concern in low- and middle-income countries, including Malawi where 36% of women have body mass index in overweight/obese categories in urban areas. Eating behaviors, attitudes, and beliefs are associated with body size, but have not been studied in-depth in sub-Saharan African countries. This study therefore, explored eating behaviors, attitudes, and beliefs of women in Lilongwe, Malawi. Methods This was a descriptive ancillary qualitative study utilising in-depth interviews with 27 women (13 in normal weight range and 14 in overweight/obesity ranges) puporsively selected in Lilongwe City, Malawi from October to November 2017. The concept of data saturation guided data collection, and it was reached with the 27 interviewed participants when there was no new information coming from the participants. All interviews were conducted in the local language, transcribed verbatim, and translated into English. The transcripts were analysed manually using thematic content analysis. Results Majority of participants perceived overweight as an indication of good health such that with food affordability, women deliberately gain weight to demonstrate their good health. Most normal weight respondents said they ate less food than they wanted to because of financial constraints. Most women in overweight/obese ranges in our sample reported that they eat large portions and eat frequently due to the desire to portray a good image of their marital life since there is a societal expectation that when a woman is married, her weight should increase to show that the marriage is successful. The perceived contributors to weight gain include eating behaviors, feelings about weight gain, and gender roles and social expectations to gain weight. Conclusion Beliefs and attitudes related to eating behaviors may have contributed to women being in overweight range and should be considered in designing obesity prevention interventions targeting women in Malawi.

Background Community health workers (CHWs) play a vital role in facilitating social connectedness, building trust, decrease stigma, and link communities to essential healthcare and social support services. More studies are needed to understand the factors facilitating these interactions among CHWs, clients, and community members. Objective This study examined the CHW role and relationships between CHWs, communities, and health facilities that promote trust, positive relationships, and social connectedness. Methods In 2016, the CHW program in Neno District, Malawi, was transitioned to a household-level assignment of CHWs to provide screening, linkage to care, and psychosocial and chronic disease support from a disease-based program. We employed an exploratory qualitative study with thematic analysis linked to Fredrickson’s broaden-and-build theory of positive emotions through focus group discussions (FGDs) and in-depth interviews (IDIs) to understand the impact of the household assignment. We purposively sampled community stakeholders, CHWs, health service providers, and clients (total N = 180) from October 2018 through March 2020. All interviews were audiotaped, transcribed verbatim, translated, coded, and analyzed. Results Participants reported decreased stigma and discrimination with increased trust and confidence in CHWs with household-level assignment. Positive relationships between CHWs in their households, community members, and health facility staff fostered health knowledge, individual agency, and personal resources for the community members to access health services. Community members’ personal resources of increased health knowledge, trust, gratitude, and social support improved social connectedness and subjective wellbeing. Areas to improve positive relationships include CHWs maintaining confidentiality and caring for pregnant women. Conclusion Our study findings demonstrate that by building solid relationships as a community chosen, well informed, and household-level workforce, CHWs can develop positive relationships with communities and the health-care facility staff through building knowledge, trust, gratitude, and hope. Further work is needed in maintaining CHW confidentiality and new ways to approach culturally sensitive health areas.

Introduction Community health workers (CHWs) are vital resources in delivering community-based primary health care, especially in low-and-middle-income countries (LMIC). However, few studies have investigated detailed time and task assessments of CHW's work. We conducted a time-motion study to evaluate CHWs' time on health conditions and specific tasks in Neno District, Malawi. Methods We conducted a descriptive quantitative study utilizing a time observation tracker to capture time spent by CHWs on focused health conditions and tasks performed during household visits. We observed 64 CHWs between 29 June and 20 August 2020. We computed counts and median to describe CHW distribution, visit type, and time spent per health condition and task. We utilized Mood’s median test to compare the median time spent at a household during monthly visits with the program design standard time. We used pairwise median test to test differences in median time duration for health conditions and assigned tasks. Results We observed 660 CHW visits from 64 CHWs, with 95.2% (n = 628) of the visits as monthly household visits. The median time for a monthly household visit was 34 min, statistically less than the program design time of 60 min (p < 0.001). While the CHW program focused on eight disease areas, pretesting with the observation tool showed that CHWs were engaged in additional health areas like COVID-19. Of the 3043 health area touches by CHWs observed, COVID-19, tuberculosis, and non-communicable diseases (NCDs) had the highest touches (19.3%, 17.6%, and 16.6%, respectively). The median time spent on sexually transmitted infections (STIs) and NCDs was statistically higher than in other health areas (p < 0.05). Of 3813 tasks completed by CHWs, 1640 (43%) were on health education and promotion. A significant difference was observed in the median time spent on health education, promotion, and screening compared to other tasks (p < 0.05). Conclusion This study demonstrates that CHWs spend the most time on health education, promotion, and screening per programmatic objectives but, overall, less time than program design. CHWs deliver care for a broader range of health conditions than the programmatic design indicates. Future studies should examine associations between time spent and quality of care delivery.