Village health worker motivation for better performance in a maternal and child health programme in Nigeria: A realist evaluation

Abstract

Background Community health workers play an important role in linking communities with formal health service providers, thereby improving access to and utilization of health care. A novel cadre of community health workers known as village health workers (VHWs) were recruited to create demand for maternal health services in the Nigerian Subsidy Reinvestment Programme (SURE-P/MCH). In this study, we investigated the role of contextual factors and underlying mechanisms motivating VHWs. Methods We used realist evaluation to understand the impact of a multi-intervention maternal and child health programme on VHW motivation using Anambra State as a case study. Initial working theories and logic maps were developed through literature review and stakeholder engagement; programme theories were developed and tested using focus group discussions and in-depth interviews with various stakeholder groups. Interview transcripts were analysed through an integrated approach of Context, Mechanism and Outcomes (CMO) categorisation and connecting, and matching of patterns of CMO configurations. Motivation theories were used to explain factors that influence VHW motivation. Explanatory configurations are reported in line with RAMESES reporting standards. Results The performance of VHWs in the SURE-P maternal and child health programme was linked to four main mechanisms of motivation: feelings of confidence, sense of identity or feeling of acceptance, feeling of happiness and hopefulness/expectation of valued outcome. These mechanisms were triggered by interactions of programme-specific contexts and resources such as training and supervision of VHWs by skilled health workers, provision of first aid kits and uniforms, and payments of a monthly stipend. The monthly payment was considered to be the most important motivational factor by VHWs. VHWs used a combination of innovative approaches to create demand for maternity services among pregnant women, and their performance was influenced by health system factors such as organisational capacity and culture, and societal factors such as relationship with the community and community support. Conclusion This paper highlights important contextual factors and mechanisms for VHW motivation that can be applied to other interventions that seek to strengthen community engagement and demand creation in primary health care. Future research on how to sustain VHW motivation is also required.

Participatory Health Cadre Model to Improve Exclusive Breastfeeding Coverage with King’s Conceptual System

“…Additionally, they play an advocacy role, participating in representing the voice of the community in policy debates. 89 , 93 Expected behaviors in these roles are often related to the values and culture of the organization or community. Meanwhile, rules are often based on values and principles considered important by the community.…”

Demand and supply analysis for maternal and child health services at the primary healthcare level in Nigeria

“…This paper was developed from a wider REVAMP (DeteRminants of Effectiveness and sustainability of a noVel community heAlth workers programMe in imProving MCH in Nigeria) study ( 21) which used realist evaluation to examine the effectiveness of the SURE-P programme in Nigeria. It builds on, and complements, analyses of further speci c aspects such as security, trust, health worker and VHW motivations, costs and utilisation (10,(22)(23)(24) as well as methodological lessons from the research (10, 21, 25).…”

Financial incentive for community health workers, a necessity for achieving universal health coverage: integrated literature review

“…Financial incentives have been linked to CHWs' motivation and retention and has become more necessary especially as expectations in the form of tasks and workload expand. 10,14,[23][24][25] Reichenbach and Shimul reported that 86% of the respondents in their study claimed they had become CHWs "to contribute to the income of their households". 26 Several studies on CHWs motivation in LMICs highlighted monetary incentives as valued income on which they could depend on to support their households especially in situations in which CHWs have no other source of income and a significant portion of the day is needed to meet the job requirements.…”