Retention, attrition and motivation of voluntary

workers in community-based programs

Peter Winch and Anne Palaia

Social and Behavioral Interventions Program

Department of International Health

Session objectives List factors that have been found to affect the

retention, attrition and motivation of unpaid or minimally paid workers in community-based programs.

Identify implications of these findings for the design of more effective and sustainable community-based programs.

Explain the steps in carrying out a systematic review on programmatic experiences with unpaid or minimally paid workers.

Describe methods appropriate for the study of retention, attrition and motivation in community-based programs.

Attrition/retention of voluntary workers

For salaried health workers, attention tends to be on performance and motivation

For voluntary workers e.g. community health workers (CHWs), much attention currently on attrition/retention

Voluntary workers have expanding range of tasks, e.g.– Mass treatment for trachoma,

onchocerciasis, malaria (IPT, IPTI)– Voluntary counseling and testing– Ensuring compliance with AIDS and TB

treatment– Management of sick newborns

Program cost-effectiveness threatened by high attrition, need to recruit & train replacements

Multilevel perspective on CHW attrition/retention

Developed this during BASICS II Project

Factors affecting attrition/retention act at different levels– Individual education, motivation

etc.– Family– Community– District or Program– National

Bhattacharyya K, Winch P, LeBan K, Tien M. Community health workers incentives and disincentives: How they affect motivation, retention and sustainability. BASICS II Project, Arlington VA, October 2001.

Multilevel perspective on CHW Incentives and Disincentives

Individual– Monetary factors– Non-monetary factors

Community– Factors that Motivate the Individual CHW– Factors that Motivate Communities to

Support and Sustain CHWs District/Health facility

– Factors that Motivate MOH Staff to Support and Sustain CHWs

Building on this work

We have been building on this work, applying the multi-level perspective to CHW programs– In different settings: Bangladesh,

Tanzania and others– For different health problems:

Newborn health, HIV/AIDS etc.

This session: 4 parts

1. Sources of volunteer motivation to serve as HIV VCT outreach workers in rural Tanzania.

2. Systematic review of experience with volunteer motivation and attrition in HIV/AIDS programs

3. Analysis of factors affecting attrition of community health workers in a newborn care intervention study in Sylhet District, Bangladesh

4. Examples from participants

Part I

Examining Sources of Motivation & Expectations of Remuneration Among

HIV VCT Community Outreach Volunteers in

Rural Tanzania

Authors

Anne Palaia Michael Sweat Irene Mashasi

Idda Mosha Jessie Mbwambo Peter Winch

Community Health Workers: Issues in the field

How effective are HIV interventions that rely on CHWs?

Adequate Training? Motivation? Expectations? Attrition? Sustainability?

HIV/AIDS Programs in Tanzania

Coordinated by Tanzania National AIDS Control Programme (NACP)

Main Funders:– PEPFAR/USAID– Global Fund

Activities:– ARV Scale Up– Clinical and home-based care for people living with

AIDS– Care for orphans and other vulnerable children– Expansion of VCT Services– Prevention of Mother to Child Transmission Initiatives– Other Prevention/behavior change interventions

Services Provided by HIV/AIDS Community Health Workers

HIV/AIDS Prevention– Peer Outreach and Education– Condom Distribution– HIV risk reduction counseling

Promote adherence to AIDS treatment regimens

Provide support for VCT Provide home-based care for PLWHA Care for OVC

Project ACCEPT: A Three Pronged Intervention for HIV

I. Community Mobilization• Paid Sociologists, ethnographers,

qualitative researchers, drivers, unpaid community outreach volunteers

II. Community Based Voluntary Counseling and Testing for HIV

• Paid nursing staff

III. Post Test Support Services• Paid trained counseling staff

Project ACCEPT Community Outreach Volunteers

Provide HIV / AIDS Education– Organize Discussions about HIV and VCT with

local peer groups and social clubs– Distribute Condoms and HIV Education

Materials

Notify Community Members About Mobile VCT Testing Sites in Their Area

Provide Support to Mobile VCT Staff when Necessary

Domains of Interest by Qualitative Method

KII FGD IDI

Community Perceptions About Volunteer Remuneration

Community Perceptions About Work vs. Volunteerism

Perceived Sources of Motivation for Volunteer Outreach Participation

Volunteer Expectations of Remuneration

Perceived Barriers to Outreach Work

Perceived Facilitators to Outreach Work

Survey Questionnaire

24 volunteers206 Community Members

– Sources of Motivation– Expectations of Remuneration– Barriers to the Conduct of Outreach– Facilitators to the Conduct of

Outreach

Sources of Volunteer Motivation:

Altruistic and Pro-Social Factors

“When you want to help someone, you should not look at the benefits, you should just do it an you will see that you have helped the nation in one

way or another.” -VCT Outreach Volunteer

Sources of Volunteer Motivation: Relational factors

Prominence in the community Family values volunteer work Support Friends / Family with HIV Loyalty to chairman who “appointed”

the VCT outreach volunteer

Sources of Volunteer Motivation: Training & Education

Training and Education Highly Valued– 92% of volunteers reported that

access to additional training would motivate him/her to work harder.

Type of Training is Important:– 79% of community members

surveyed agreed that they believed training was only valuable if it would bring income to their families in the future.

Sources of Volunteer Motivation:Community Resources & Services

Volunteers reported being motivated by the promise of goods and services for their community, including:

– Medical Services

– Food & Clothing

– Sports Programs

Desired Remuneration Described by Survey Respondents

Type of Remuneration

Described Percent NumberMoney 88.10% 96Food 9.20% 10Bicycles 9.20% 10Pens & Work Materials 7.30% 8Home 5.50% 6Future Employment 5.50% 6Car 2.80% 3Motorcycle 1.80% 2Hats 0.90% 1T-Shirts 0.90% 1Badge 0% 0Condoms 0% 0Other 2.80% 3

Remuneration & Attrition

“After seeing that there is nothing or there is no payment of some kind, their work morale faded away a little bit…”

–ACCEPT Community Mobilization Staff (1)

“Half of the outreach volunteers work, half don’t… They don’t get paid, so they will do farm work over outreach work.”

–ACCEPT Community Mobilization Staff (2)

Expectations of the CHWs

CHWs have a number of expectations and assumptions when they take on the position

These expectations and assumptions continue, even when program staff directly contradict them

Many decisions they make (e.g. how much effort to invest in the work) are influenced by these assumptions

Examples of expectations we encountered

CHWs will be paid eventually, after an initial period of proving themselves

After the project ends, the CHWs will take over the paid jobs of the project staff

CHWs will be provided with the same equipment and materials as the project staff– Perceived as issues of justice &

trust

“There is a time when we used to stay with our fellow mobilizers (project staff) from ACCEPT and we pitched up tents during the rainy period. The most surprising part was that they had gum boots and gloves, but we didn’t have any. I don’t know if it is because we are voluntary mobilizers that we were left like that without even rain coats. That hurt.”

-37 Year old Male Volunteer

Part II

Volunteer Attrition in HIV/AIDS Programs: A

Systematic Review

Authors

Anne Palaia Peter Winch

Inclusion Criteria for the systematic review

Low or Middle Income Country (According to World Bank Country Classification)

HIV Intervention Primary Data (Qualitative or Quantitative) 1980 – 2009 Peer Reviewed Sources Provides Data Related To Volunteer

Intervention Worker Retention / Attrition

Summary of the findings Many articles with some mention of

volunteers in HIV/AIDS prevention and control: 2659 records located in a search of key terms across five databases

Very few studies specifically on volunteer health worker attrition

What data there are on attrition are often presented in the methods section, rather than in the results section

Attrition is not defined in the papers

2620 Records Identified Through Database

Search

39 Additional Records Identified Through Alt

Sources

2659 Records Screened

2565 Records Excluded

94 Full Text Articles Assessed

for Eligibility

86 Full Text Articles Excluded

8 Studies Included in Synthesis2 Contained Qualitative Data Only3 Contained Quantitative Data Only3 Contained Qualitative and Quantitative Data

I NC

LUD

ED

EL

IGIB

ILIT

Y

S

CR

EE

NIN

G

ID

EN

TIF

ICAT

ION

*(Adapted from Moher, 2009)

Study

Attrition Data Obtained Primary

Results (vs. Secondary/ Descriptive)

Contains Clear

Definition of Attrition

Data Provides a Clear Time Frame For Attrition

1 Broadhead, 2006 Y N 6 MOS2 Hoy, 2008 Y N 6 YRS3 Ford, 2000 N* N 4-5 MOS4 Lakamm-Josten, 2000 N* N N5 Lee, 2002 Y N N6 Sanjana, 2009 Y N N7 Welsh, 2001 Y N 8 MOS8 Walden, 1999 Y N N

*In these instances, data was drawn from the Methods Section of Published Articles

Defining Attrition in the 8 included studies

Next slide:Observed relationship

between remuneration and attrition in the 8 studies

Volunteers

Received Remuner-

ation

StudySource of Project Funding Attrition

YES

Broadhead, 2006

PRIVATE (OSI) 55% (Standard PDI)

Lakamm-Josten, 2000

BOTH 14%

Lee, 2002 PRIVATE (FACT)“High Retention” – 1

Volunteer LostSanjana,

2009BOTH 21%

NO

Hoy, 2008 PUBLIC (LPDR)Regular outreach unlikely without

funds

Ford, 2000PUBLIC

(USNIMH)50%

Welsh, 2001 PRIVATE (FHI) 37% - 53%Walden, 1999 BOTH 52% - 59%

Program & Policy Recommendations from the 2 studies

Formative Research– Volunteer Role Responsibilities– Volunteer and Program

Expectations Reasonable Exchange

– Identify “Range” of Acceptable and Sufficient Rewards Prior to Recruitment - Compromise

Selection of Volunteers – Recruitment Should Exclude Chairman

Nomination of Volunteers– Pre-Program Testing for Theory Based

Recruitment Community Involvement in Project Design &

Implementation – Community Awareness Initiative Prior to

Advent of Program Activities to Gain Community Support

Program & Policy Recommendations from the 2 studies

Programmatic Support – Consistent and Frequent Training and

Feedback Research & Development

– Expanded evaluation of interventions for volunteer attrition rates, causes and recommendations for program sustainability

– Establishment of common indicators for comparison of attrition data is necessary for future literature reviews

(Eg: # LTFU Time t – deaths due to HIV in Time t)

Program & Policy Recommendations from the 2 studies

Part III

Factors affecting recruitment and retention

of community health workers in a newborn care intervention in Bangladesh

Authors

Syed Moshfiqur Rahman

Nabeel Ashraf Ali Larissa Jennings M. Habibur R. Seraji Ishtiaq Mannan Rasheduzzaman

Shah

Arif Billah Al-Mahmud

Sanwarul Bari Daniel Hossain Milan Krishna Das, Abdullah H. Baqui Shams El Arifeen Peter J. Winch

CHWs in Projahmo study in Sylhet District, Bangladesh

(Home care arm) CHWs serve population of 4000 ~ 800

households Earn ~$45 per month Responsibilities

– Pregnancy surveillance– Antenatal home visits for birth and

newborn care preparedness– Essential newborn care after birth– Coordination with TBAs– Management and referral of newborn

sepsis– Counseling

Recruitment of CHWs

Advertisements in local paper and dialog with community leaders and groups

Criteria: Female, local resident, preferably married (this criterion was dropped), aged between 20 and 40, secondary school leaving certificate

Written examination

Trends in attrition

73 CHWs were recruited either initially (41 CHWs) or later on to replace CHWs who left the project

Total period of intervention was 36 months

32 CHWs left the project during this period, 15 left within one year, another 10 by the end of the second year

Training replacement CHWs had higher unit cost

Efforts to reduce attrition

Community advocacy meetings to explain the project and respond to community concerns

Dialogue with families of CHWs at the time of recruitment in order to explain the project and roles of the staff members.

Some CHWs given the opportunity to become supervisors based on exemplary performance.

Incentives for the CHWs to attend deliveries at night.

Data from three sources

Project monitoring system, including exit interviews with CHWs at time of leaving project

Questionnaire completed by 69 of 73 current and former CHWs

Qualitative interviews

Primary reasons for attrition

Family reasons Work-related reasons Education opportunities Actions taken by the project

Family reasons

“They wonder what kind of job it is that requires women to stay out so long. If my brother was here in the country, then I wouldn’t be able to work as a CHW.”

“My father is the sufferer…He used to be the alternate imam of the village. Now half of the people do not want to stand behind him in the prayers. They say his daughters work for NGOs, which is not right for a religious person.”

CHW attrition during the project

No attrition: CHW worked until end

Attrition initiated by CHW and/or family

Attrition initiated by project

40

(54.8)

26

(35.6)

7 (9.6)

Specific reasons for attrition 11 - Marriage 3 - Family opposed to her working as

CHW 6 - Left to take other position 2 - Workload considered too heavy 2 - Wanted promotion but not granted 1 - Wanted to change to other service

area 1 - CHW left to pursue higher

education 4 - Promoted to higher position

project 3 - Terminated due to poor

performance

Factors found to influence retention

Job satisfaction: amount of work, work-home distance, incentives and costs to being a CHW, supervision and operational support

Alternative job opportunities Significant life events: Marriage, childbirth,

moving to another community, personal illness, illness or death in the family

Value community attributes to CHW work, and the existence of other options for health care in the community

Extent to which her pre-hire expectations were realized

Framework for decisions by CHW

Recommendations

Salary comparable with other similar positions

Hardship allowances to ensure newborn visits during holidays and beyond official work-hours

Sick leaves can be provided for unforeseen sicknesses and medical emergencies

Group discussions to engage the family whole to increase the sense of ownership of the project

Clear expectations roles and responsibilities Frank discussions of less pleasant aspects

of the job, such as late hours and holiday duties