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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.
The study formed part of a larger project that evaluated the impacts of the SURE-P/MCH programme using realist evaluation, 11 a theory-driven evaluation approach that builds, tests, validates and refines theories, with a specific focus on VHW motivation. Realist evaluation provides a means to understand the resources or opportunities presented by a given intervention that enable actors (e.g. policymakers, implementers and service users) to make it work. 12 The projected effectiveness of an intervention is described in Context-Mechanism-Outcome (C-M-O) configurations, including explanation(s) of (i) why intervention outcomes turned out as they did and (ii) how the intervention/s responded to underlying mechanisms and in what contexts. 13 We drew on Herzberg’s two-factor theory and Vroom’s expectancy theory to understand how VHWs were motivated to carry out their duties, and the (group of) factors acting at macro, meso and micro levels that influenced their motivation. Herzberg’s two-factor theory considers motivational factors that lead to job ‘satisfaction’ (e.g. educational opportunities, sense of achievement, intrinsic interest in the work and involvement in decision-making) and hygiene factors that cause job ‘dissatisfaction’ when they are absent (e.g. salary, good working conditions, recruitment policies and administrative practices).14, 15 Motivational factors can be intrinsic or extrinsic to the individual whereas factors linked to job dissatisfaction (i.e. hygiene factors) are contextual and extrinsic to the individual. The theory stipulates that improving motivational factors increases job satisfaction while of hygiene factors decrease job dissatisfaction. Vroom’s expectancy theory is a process theory which focuses on outcomes, defined as an action-outcome estimate. People choose their behaviours (effort level) based on their perceptions of whether the behaviour is likely to lead to valued outcomes. 16 Vroom introduced the concepts of expectancy (increased effort will lead to increased results), instrumentality (if you perform well, you will receive a valued outcome) and valence (value placed on the expected outcome). The evaluation was carried out in Anambra State, one of the 36 states in Nigeria, with a population of about 4.1 million and a mix of urban and rural areas. Maternal and child health services are primarily accessed from PHC facilities, each of which covering a given catchment population. The SURE-P intervention was first implemented in 12 PHC facilities, with another 12 facilities included in a second phase of the intervention. In this paper, we only report on first phase health facilities as they had a longer experience of the programme. The realist evaluation comprised three interrelated steps. 13 We first developed an initial working theory based on a CMO configuration: In a context where pregnant women are incentivised (free drugs, free ANC services, mama kits, CCT) to access MCH care and where VHWs are trained, paid a regular stipend and provided with resources (VHW kits) to enable them to sensitise and mobilise pregnant women and support them to access facilities (C), these VHWs will feel more recognised by communities and will be motivated to encourage and accompany pregnant women to facilities for MCH services (M). This will contribute towards increased and sustained utilisation of MCH services by the pregnant women (O). In the second step, we used information from 16 in-depth interviews (IDIs) and 32 focus group discussions (FGDs) to build an initial programme theory for VHW motivation. Finally, the initial programme theory on VHWs was tested and refined alongside the CMO configurations developed in steps 1 and 2 above, using information from nine IDIs. Focus group discussions were conducted with all VHWs in eight first phase facilities. FGDs were also conducted with service users, their family members and representatives of ward development committees (WDC) in eight first phase facilities. In step 2, we additionally carried out IDIs with six health facility managers and ten health facility workers, followed by IDIs with nine VHWs in step 3 to allow for in-depth exploration of identified themes identified in step 2, in which all the VHWs participated. The IDIs focused on the factors that motivated the VHWs to carry out their duties, and how and in what combinations (if any) these factors worked to trigger mechanisms. We then used this information to develop a C-M-O template which consolidated patterns of explanations. Study participants were provided with a study information sheet and those that expressed a willingness to participate were invited to a PHC centre or to the village hall, depending of their preference, for the interview. Interviews were conducted by three pairs of qualitative researchers who had received training in realist interviewing, with each lasting 45–60 minutes. Data collection tools for this study are presented in the Online supplement. Table 1 summarises the data collection methods across the study steps. Summary of the steps in the study and methods of data collection. Data were analysed using a realist reduction approach consisting of iterations of inductive and deductive analysis. The analysis was performed by four authors (CM, EE, BE and AM), one of whom is skilled and experienced in realist evaluation. Analysis was guided by our overarching theory which centres on the presence or absence of resources given (by the programme) and/or existing resources and how the VHWs interacted with these resources to produce behaviours which manifested in their actions. 17 Varying explanatory configurations identified from the data are reported in line with the Realist And Meta‐narrative Evidence Syntheses Evolving Standards II (RAMESES). 16 Interviews were transcribed verbatim and each transcript was read by two researchers to identify themes and sort them into context, mechanisms and outcomes. Identified themes were compared and synthesised across transcripts, using the CMO categories. This was followed by connecting and matching patterns of CMO configurations across transcripts to determine how the causal mechanisms played out and produced similar or distinct outcomes. Step 2 interviews were used to build and record initial relationships and linkages between contexts (resources), mechanisms and outcomes, and to generate proposed CMO configurations. Then, step 3 interviews were used to explore the proposed CMO configurations; that is, the effect of context, the proposed enabling mechanisms and the extent to which the outcomes had been achieved or not, and if not, why. Ethical approval was granted by the School of Medicine Research Ethics Committee at the Faculty of Medicine and Health at the University of Leeds (ref: SoMREC/14/097) and the Health Research Ethics Committee at the University of Nigeria Teaching Hospital (ref: NHREC/05/02/2008B-FWA00002458-1RB00002323). Respondents were informed about the purpose of the study and their roles and rights as participants. Voluntary written consent was obtained from all the participants prior to the interviews.
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