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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.
Neno district is a remote, rural, and impoverished district situated in Southwest Malawi with an estimated 144,442 people in 2020 [25]. The district hospital is not accessible by tarmac roads due to mountainous terrain and poor infrastructure. The majority of the population of Neno are subsistence farmers who live on less than 1.90 USD per day, and 95.5% do not have access to electricity [26]. At the inception of the CHW program in 2007, CHWs were positioned to support and accompany TB and HIV patients on clinical visits, treatment adherence, and psychosocial support that led to improved patient adherence and clinical outcomes [27, 28]. In 2016, the CHW program transitioned to the polyvalent household model. In this model, each household in the district is assigned a CHW regardless of disease for universal coverage. The household model focuses on eight major disease areas: 1) TB; 2) HIV; 3) STIs; 4) non-communicable diseases (NCDs); 5) family planning; 6) maternal and neonatal health; 7) child health, and 8) malnutrition screening in children under 5 years old [29]. Structurally, the household model is a three-tiered program with CHW, senior CHW (SCHW), and site supervisor (SS) roles designed in alignment with the national community health worker structure. Community health workers are called Health Surveillance Assistants (HSAs). HSAs are part of the Ministry of Health (MoH) Environmental Health Department. They are one of the most prominent cadres of the Ministry of Health workforce across Malawi, with over 9400 HSAs in service [30]. They support Village Clinics for preventive care for under-five children and pregnant women and manage care for pediatric malnutrition and tuberculosis cases [30, 31]. At the community level in Neno, one HSA serves approximately 540 households with case-finding, prevention, and essential case management. In terms of individuals, this translates to approximately a ratio of 1 HSA to 2300 people, which leads to poor coverage where households may go for long periods without interacting with their assigned HSAs [30, 32]. Thus, the household model was designed to complement the HSA program with a large cadre of > 1000 CHWs to act as foot soldiers to the HSAs. The HSAs frequently interact with SS to identify clients to follow up and other tasks for the CHW and SCHW and coordinate on village clinics and activities. The Neno district population has 14 catchment areas, each served by a health facility – 12 primary health facilities and 2 hospitals – Neno District Hospital and Lisungwi Community Hospital. The household model recruits CHWs by catchment area with mapping to determine the overall number of households and the required CHWs to serve the community adequately. Then through engagement meetings with community leaders and structures, potential CHW candidates are nominated based on a designated selection criterion. Selected CHWs are assessed for literacy, and successful candidates are further taken through a five-day foundational training with subsequent quarterly one-day refresher training. Working materials are provided in the form of job cards, registers, and logbooks. Supervisory structures of senior CHWs and SSs receive further training and meet regularly with CHWs for ongoing supportive supervision and mentorship. The primary roles of the CHW are to monitor the health of their assigned households, conduct health education activities, screen and link community members to essential health services at the health facility, collect data for reporting, and support patients and community members in their assigned households. The CHW’s roles are summarized into five main categories, namely; 1) monitor/screen; 2) educate; 3) collect data and report; 4) accompany/refer; and 5) support. Each CHW is assigned 20–40 households within their community, depending on village size and geography. They are expected to visit each household at least once a month with frequent visits to households with members who have active disease or need of follow-up or support. CHWs receive a monthly stipend of approximately USD 22. CHWs are supervised by senior CHWs and SSs within the 14 catchment areas in the district who work closely with the facility-based MoH community health care workers – the health surveillance assistants (HSAs). They meet regularly in a month at the community and facility level to review and validate data, receive program updates and plan their work. SCHWs work as CHWs attending to ~ 15 assigned households as above and have an advising and supervisory role. They support village-level monitoring and supervision of 10–15 CHWs with verifying data and troubleshooting household challenges—the SCHWs complete spot checks with mentorship and coaching with the assigned CHWs each quarter. Additionally, the SCHW serves as a community TB sputum collection agent, where sputum is collected from presumptive TB clients and submitted to the health facility. They receive a monthly stipend of approximately USD 33 and are supervised by the SS with quarterly visits at the household level and participate in the monthly data reviews. SSs serve as the primary link between the CHW program management and MoH’s facility-based community health team. SSs supervise and mentor SCHWs and CHWs through spot checks, data monitoring support, and supervisory meetings. They are responsible for data aggregation, record keeping, and monthly reporting. They jointly work with the HSAs to ensure CHW collaboration with specific emphasis on TB and malnutrition programs. We utilized an exploratory qualitative design of focus group discussions (FGDs) with CHWs and SCHWs to examine CHW perspectives on facilitating factors and challenges on their ability to perform their duties. FGDs were conducted in October 2018 and March–April 2019. Of the 14 catchment areas in the Neno district, seven catchment areas (Midzemba, Zalewa, Chifunga, Ligowe, Neno District Hospital, Nsambe, and Dambe) were purposively selected to take part in this study per topography. We purposively selected ninety (90) participants from these catchment areas with consideration of four criteria; 1) the type of CHW (CHW versus SCHW), 2) CHW age to include both young and old participants, 3) gender to include a balance of males and females, and 4) duration of work as CHWs (“new” to include those working 5 years) (Table 1). We chose this approach to recruit a diverse group of CHWs and SCHWs with different experiences to find diverse perspectives on their enabling factors and challenges that affect their performance. Demographic characteristics of CHW and SCHW focus group participants aNew = 5 years working In October 2018, four FGDs of CHWs and SCHWs were conducted. Each FGD comprised 9–12 participants, with one FGD in the catchment of Zalewa, Chifunga, Ligowe, and Dambe. In March – April 2019, an additional four FGDs were conducted with SCHWs only with 9–12 participants per group with one FGD in the catchments of Midzemba, Chifunga, Neno District Hospital, and Nsambe. The study team developed two question guides for this study (Appendix 1 and 2). One question guide was developed for the combined FGDs (CHWs and SCHWs), and the second question guide targeted SCHWs with a focus on their supervisory roles with overlapping question prompts. For the combined FGDs (CHWs and SCHWs), we asked participants on knowledge and perspective of CHW services, CHW’s influence on health care seeking and community trust, inter-program relationships, perceived differences between CHWs and other health cadres such as HSAs, and ideas for program improvement. The guides were developed in English, translated into the local language of Chichewa, and pretested with CHWs and SCHWs in the Neno District Hospital catchment area before use. We did not recruit CHWs and SCHWs who participated in pretesting for the main study. The content and translations were adjusted from feedback before formal data collection. The organization recruited the research fellow (MKN) and three research assistants for the evaluation study, with the research fellow facilitating data collection. These positions were not part of the implementation team and did not have prior knowledge of the household model in Neno, Malawi. The facilitator explained the study to participants and obtained signed written informed consent. The study was conducted by the Declaration of Helsinki guidelines and regulations [33]. Each FGD was recorded and took approximately 2 hours. Transcripts were transcribed verbatim in Chichewa and then translated to English and later uploaded in Dedoose version 8.3.17 for data management. Transcription was done by the research fellow (MKN) and double-checked by (BN), who listened to all audio recordings and verified the translation from Chichewa to English before loading them in Dedoose. The data were analyzed using qualitative content analysis [34]. The research fellow familiarized with the data set through immersion by the repeated and active reading of transcripts [35]. To ensure the reliability of coding and consistency, the research fellow, BN and EC independently read the first three transcripts line by line to deductively assign codes to similar concepts that repeatedly emerged from the data in line with study objectives [36]. The first codebook was generated from the first three transcripts through a consensus process by looking at commonalities and differences [36]. The research fellow then coded the rest of the transcripts, with feedback from the senior authors, deleted repeated codes, and added new ones until a final codebook was created. The final codebook was agreed upon by the joint consensus of all authors [36, 37]. We identified relationships between these codes, repeatedly identified codes were merged, and themes and sub-themes were generated from these codes. We chose quotes for each theme and sub-theme summarizing the main points [35, 36].
