Application of the Ultra-Poverty Graduation Model in understanding community health volunteers’ preferences for socio-economic empowerment strategies to enhance retention: a qualitative study in Kilifi, Kenya

Background: A significant shortage of healthcare workforce exists globally. To achieve Universal Healthcare coverage, governments need to enhance their community-based health programmes. Community health volunteers (CHVs) are essential personnel in achieving this objective. However, their ability to earn a livelihood is compromised by the voluntary nature of their work; hence, the high attrition rates from community-based health programmes. There is an urgent need to support CHVs become economically self-reliant. We report here on the application of the Ultra-Poverty Graduation (UPG) Model to map CHVs’ preferences for socio-economic empowerment strategies that could enhance their retention in a rural area in Kenya. Methods: This study adopted an exploratory qualitative approach. Using a semi-structured questionnaire, we conducted 10 Focus Group Discussions with the CHVs and 10 Key Informant Interviews with County and Sub-county Ministry of Health and Ministry of Agriculture officials including multi-lateral stakeholders’ representatives from two sub-counties in the area. Data were audio-recorded and transcribed verbatim and transcripts analysed in NVivo. Researcher triangulation supported the first round of analysis. Findings were mapped and interpreted using a theory-driven analysis based on the six-step Ultra-Poverty Graduation Model. Results: We mapped the UPG Model’s six steps onto the results of our analyses as follows: (1) initial asset transfer of in-kind goods like poultry or livestock, mentioned by the CHVs as a necessary step; (2) weekly stipends with consumption support to stabilise consumption; (3) hands-on training on how to care for assets, start and run a business based on the assets transferred; (4) training on and facilitation for savings and financial support to build assets and instil financial discipline; (5) healthcare provision and access and finally (6) social integration. These strategies were proposed by the CHVs to enhance economic empowerment and aligned with the UPG Model. Conclusion: These results provide a user-defined approach to identify and assess strategic needs of and approaches to CHVs’ socio-economic empowerment using the UPG model. This model was useful in mapping the findings of our qualitative study and in enhancing our understanding on how these needs can be addressed in order to economically empower CHVs and enhance their retention in our setting. The current study was conducted in Kaloleni and Rabai sub-counties in Kilifi county in the coast of Kenya. The two sub-counties cover an area of 909 km2 and have a population of about 290,000 living in about 44,000 households [30]. Children under 5 years of age comprise one-fifth of the Kilifi population and women of reproductive age account for a quarter [30]. Maternal, neonatal and child health indicators are poorer than the national averages [30, 31]. Fifty-seven percent of the population are Christian, 19% are Muslim and the remainder are traditionalists [30]. Kaloleni and Rabai sub-counties are among the poorest parts in Kenya [32]. Approximately 70% of the population lives below the poverty line [31]. Forty health facilities serve these sub-counties: 20 public/government health facilities (16 dispensaries, one health centre, one sub-district hospital, one district hospital, one military health centre), three faith-based facilities (one hospital and two dispensaries), three NGO dispensaries, and 14 privately owned dispensaries [33]. The physician-to-population ratio 10:100,000 in this area is below the national average of 19:100,000 while the nurse-to-population ratio is 40:100,000 against a national average of 166:100,000 [34]. Trained CHVs visit households for data collection, health promotion and education during their own free time, making at least one visit per month [24]. The main study adopted an exploratory multi-method qualitative approach including Key Informant Interviews (KIIs) and Focus Group Discussions (FGDs). Study participants included CHVs and key stakeholders. These included County and Sub-county Ministry of Health and Ministry of Agriculture officials as well as multi-lateral stakeholders’ representatives from Kaloleni and Rabai sub-counties. We conducted focus group discussions (FGDs) with CHVs from 10 out of the 17 Community Health Units (CHU) within the two sub-counties. The FGDs had an average of 6–10 participants sampled proportionately by gender distribution within the CHU. Participants were purposively identified by recruitment liaisons and included more experienced CHVs conversant with the Kaloleni and Rabai area. Eight Key Informant Interviews (KIIs) were conducted with participants purposively identified as able to provide rich contextual information. Table ​Table11 summarises the KII population. Demographics for the CHVs interviewed using focus group discussions (FGDs) Total 64 female CHVs interviewed Total 17 males CHVs interviewed Interview process To ensure the validity and reliability of the data collection tool, the principal investigator (PI) developed semi-structured questionnaires, one for the FGDs and another for the KIIs. An expert panel consisting of social scientists and an epidemiologist validated the content and construct of the semi-structured questionnaires. Originally developed in English, questionnaires were translated to Kiswahili (a national language in Kenya and the language commonly used in the Coast) and then back translated by an expert linguist. A team of research assistants underwent a 2-day training by the PI on data collection and interviewing techniques. The tools were further piloted in two FGDs using 16 CHVs who were excluded from the study. Interviews lasted between 40 and 100 min and were conducted in either English or Kiswahili based on participants’ preference. Participants in FGDs were given equal opportunity to respond to the questions as moderated by the facilitator. At the end of the interviews, the moderator and the note taker conducted debriefs and included their discussions as part of the notes. Data collected included socio-demographic information; current income source; challenges faced while earning income; effect of CHV work on livelihood; engagement in other income-generating activities (IGAs); preference of IGAs and proposed sponsors or supporters of these engagements. For the KIIs, information was collected on; their role in engaging CHVs; challenges they perceived attributed to CHVs attrition; their sentiments on financial remuneration of CHVs; awareness of IGAs; policies in place for sustainability of IGAs and identification of key players within their institution; access to support and any ongoing or previous IGAs (Additional file 1: Appendices 1–3). The qualitative analyses and findings of the main study are published elsewhere [25]. These findings were mapped and contextualised using UPG model, which highlighted important factors that could be considered in the implementation of the preferred IGAs.