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

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Abstract

Objective

This study examined the performance motivation of community health workers (CHWs) and its determinants on India's Accredited Social Health Activist (ASHA) programme.

Design

Cross-sectional study employing mixed-methods approach involved survey and focus group discussions.

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 5.94–4.06), 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.

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 modalities.

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Most cited references 12

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Identifying factors for job motivation of rural health workers in North Viet Nam

Marjolein Dieleman, Pham Viet Cuong, Le Vu Anh … (2003)

Background In Viet Nam, most of the public health staff (84%) currently works in rural areas, where 80% of the people live. To provide good quality health care services, it is important to develop strategies influencing staff motivation for better performance. Method An exploratory qualitative research was carried out among health workers in two provinces in North Viet Nam so as to identify entry points for developing strategies that improve staff performance in rural areas. The study aimed to determine the major motivating factors and it is the first in Viet Nam that looks at health workers' job perception and motivation. Apart from health workers, managers at national and at provincial level were interviewed as well as some community representatives. Results The study showed that motivation is influenced by both financial and non-financial incentives. The main motivating factors for health workers were appreciation by managers, colleagues and the community, a stable job and income and training. The main discouraging factors were related to low salaries and difficult working conditions. Conclusion Activities associated with appreciation such as performance management are currently not optimally implemented, as health workers perceive supervision as control, selection for training as unclear and unequal, and performance appraisal as not useful. The kind of non-financial incentives identified should be taken into consideration when developing HRM strategies. Areas for further studies are identified.

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Going to scale with community-based primary care: an analysis of the family health program and infant mortality in Brazil, 1999-2004.

Maria Souza, Ismael D. C. G. da Silva, Frederico Guanais … (2007)

This article assesses the effects of an integrated community-based primary care program (Brazil's Family Health Program, known as the PSF) on microregional variations in infant mortality (IMR), neonatal mortality, and post-neonatal mortality rates from 1999 to 2004. The study utilized a pooled cross-sectional ecological analysis using panel data from Brazilian microregions, and controlled for measures of physicians and hospital beds per 1000 population, Hepatitis B coverage, the proportion of women without prenatal care and with no formal education, low birth weight births, population size, and poverty rates. The data covered all the 557 Brazilian microregions over a 6-year period (1999-2004). Results show that IMR declined about 13 percent from 1999 to 2004, while Family Health Program coverage increased from an average of about 14 to nearly 60 percent. Controlling for other health determinants, a 10 percent increase in Family Health Program coverage was associated with a 0.45 percent decrease in IMR, a 0.6 percent decline in post-neonatal mortality, and a 1 percent decline in diarrhea mortality (p<0.05). PSF program coverage was not associated with neonatal mortality rates. Lessons learned from the Brazilian experience may be helpful as other countries consider adopting community-based primary care approaches.

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Lay health workers in primary and community health care.

Wenda B Veen, X Bosch-Capblanch, G Aja … (2004)

Lay health workers (LHWs) are widely used to provide care for a broad range of health issues. However, little is known about the effectiveness of LHW interventions. To assess the effects of LHW interventions in primary and community health care on health care behaviours, patients' health and wellbeing, and patients' satisfaction with care. We searched the Cochrane Effective Practice and Organisation of Care and Consumers and Communication specialised registers (to August 2001); the Cochrane Central Register of Controlled Trials (to August 2001); MEDLINE (1966- August 2001); EMBASE (1966-August 2001); Science Citations (to August 2001); CINAHL (1966-June 2001); Healthstar (1975-2000); AMED (1966-August 2001); the Leeds Health Education Effectiveness Database and the reference lists of articles. Randomised controlled trials of any intervention delivered by LHWs (paid or voluntary) in primary or community health care and intended to promote health, manage illness or provide support to patients. A 'lay health worker' was defined as any health worker carrying out functions related to health care delivery; trained in some way in the context of the intervention; and having no formal professional or paraprofessional certificated or degreed tertiary education. There were no restrictions on the types of consumers. Two reviewers independently extracted data onto a standard form and assessed study quality. Studies that compared broadly similar types of interventions were grouped together. Where feasible, the results of included studies were combined and an estimate of effect obtained. Forty three studies met the inclusion criteria, involving more than 210,110 consumers. These showed considerable diversity in the targeted health issue and the aims, content and outcomes of interventions. Most were conducted in high income countries (n=35), but nearly half of these focused on low income and minority populations (n=15). Study diversity limited meta-analysis to outcomes for five subgroups (n=15 studies) (LHW interventions to promote the uptake of breast cancer screening, immunisation and breastfeeding promotion [before two weeks and between two weeks and six months post partum] and to improve diagnosis and treatment for selected infectious diseases). Promising benefits in comparison with usual care were shown for LHW interventions to promote immunisation uptake in children and adults (RR=1.30 [95% CI 1.14, 1.48] p=0.0001) and LHW interventions to improve outcomes for selected infectious diseases (RR=0.74 [95% CI 0.58, 0.93) p=0.01). LHWs also appear promising for breastfeeding promotion. They appear to have a small effect in promoting breast cancer screening uptake when compared with usual care. For the remaining subgroups (n=29 studies), the outcomes were too diverse to allow statistical pooling. We can therefore draw no general conclusions on the effectiveness of these subgroups of interventions. LHWs show promising benefits in promoting immunisation uptake and improving outcomes for acute respiratory infections and malaria, when compared to usual care. For other health issues, evidence is insufficient to justify recommendations for policy and practice. There is also insufficient evidence to assess which LHW training or intervention strategies are likely to be most effective. Further research is needed in these areas.

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Author and article information

Journal

Journal ID (nlm-ta): BMJ Open

Journal ID (iso-abbrev): BMJ Open

Journal ID (hwp): bmjopen

Journal ID (publisher-id): bmjopen

Title: BMJ Open

Publisher: BMJ Group (BMA House, Tavistock Square, London, WC1H 9JR )

ISSN (Electronic): 2044-6055

Publication date (Print): 2012

Publication date Collection: 2012

Publication date (Electronic): 27 September 2012

Volume: 2

Issue: 5

Electronic Location Identifier: e001557

Affiliations

[1 ]The World Bank, NW Washington DC, USA

[2 ]DCOR Consulting Pvt Ltd, Bhubaneswar, Orissa, India

Author notes

[Correspondence to ] Dr Saji Saraswathy Gopalan; sajisaraswathyg@ 123456gmail.com

Article

Publisher ID: bmjopen-2012-001557

DOI: 10.1136/bmjopen-2012-001557

PMC ID: 3488714

PubMed ID: 23019208

SO-VID: 0d5c8d2a-02b4-432f-aa9c-a81b725f2d67

Copyright © © 2012, Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

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This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode.

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

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Abstract

Objective

Design

Setting

Participants

Primary and secondary outcome measures

Results

Conclusions

Related collections

Global Health Next Generation Network

Most cited references 12

Identifying factors for job motivation of rural health workers in North Viet Nam

Going to scale with community-based primary care: an analysis of the family health program and infant mortality in Brazil, 1999-2004.

Lay health workers in primary and community health care.

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