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Original Articles
Open Access

Keeping community health workers in Uganda motivated: key challenges, facilitators, and preferred program inputs

Aurélie Brunie, Patricia Wamala-Mucheri, Conrad Otterness, Angela Akol, Mario Chen, Leonard Bufumbo and Mark Weaver
Global Health: Science and Practice February 2014, 2(1):103-116; https://doi.org/10.9745/GHSP-D-13-00140
Aurélie Brunie
aFHI 360, Washington, DC, USA
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  • For correspondence: abrunie@fhi360.org
Patricia Wamala-Mucheri
bFHI 360, Kampala, Uganda. Now with the Clinton Health Access Initiative, Kampala, Uganda
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Conrad Otterness
cFHI 360, Durham, NC, USA. Now with Community Partners International, Mae Sot, Thailand
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Angela Akol
dFHI 360, Kampala, Uganda
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Mario Chen
eFHI 360, Durham, NC, USA
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Leonard Bufumbo
dFHI 360, Kampala, Uganda
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Mark Weaver
fFHI 360, Durham, NC, USA. Now with the University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Figures & Tables

Tables

    • View popup
    TABLE 1. Program Inputs and Levels Used in the Discrete Choice Experiment (DCE)
    Program InputsLevel 1Level 2Level 3
    Training5-day initial training and 3-day supervised practicum at health centerSame as Level 1 + 3-day refresher training once a yearN/A
    SupervisionMonthly CHW meetings at health centerSame as Level 1 + quarterly visit by health center staff in the communityN/A
    IncentivesCHW kit with gumboots, raincoat, job aids, and stationeryCHW kit + T-shirt + badgeCHW kit + T-shirt + badge + bicycle
    Transportation refund5,000 UGX for each meeting10,000 UGX for each meetingN/A
    CommunicationNo mobile phoneMobile phone without airtimeN/A
    • Abbreviations: CHW, community health worker; N/A, not applicable; UGX, Ugandan Shilling.

    • View popup
    TABLE 2. Program Characteristics and Number of Interviews Conducted, by Program Type
    Active CHWsFormer CHWs
    Program TypeNo. of SurveysaNo. of IDIsTotal No. Interviewed/ Total No. in ProgramNo. of IDIs
    Public sector (2 districts)351348/483
    Former NGO (3 districts)821496/1120
    NGO (2 districts)661682/2032
    Total18343226/3635
    • Abbreviations: CHWs, community health workers; IDIs, in-depth interviews; NGO, nongovernmental organization.

    • ↵a Surveys included a Discrete Choice Experiment (DCE).

    • View popup
    TABLE 3. Item Means, Grouped by Factor, by CHW Level of Activity
    Total (N = 183)Highly Active (n = 88)Less Active (n = 69)
    Motivational Outcomes
    Overall, I am very satisfied with being an FP CHW.3.783.733.85
    I would recommend to my children that they become CHWs.3.503.573.48
    I am glad to be working as an FP CHW rather than in some other volunteer position in the community.3.203.133.40
    I feel very little commitment to the FP CHW program.a1.351.391.33
    I enjoy working in my community to make it better, even if it is without pay.3.773.813.74
    I do not think that it makes good sense to spend any time working in my community without payment.a1.551.461.57
    I have no intention to keep doing my FP CHW work without pay.a1.421.361.40
    Motivational Determinants
    Barriers
    My FP CHW work takes so much time that I am worried about how to support myself and my family.a2.132.032.07
    My family complains about the demands of my FP CHW work.a1.531.651.39
    Serving as an FP CHW will not help my chances of getting a better job in the future.a1.451.511.47
    Talking about FP with my clients is very embarrassing.a1.271.241.33
    It is difficult to help clients find the method that is right for them.a1.541.371.59
    Contraceptive use often makes people sick.a2.162.212.05
    Facilitators
    Overall, my supervisors provide helpful feedback and support.3.773.723.74
    I can probably perform most of my activities without additional training.2.512.502.58
    The FP CHW program provides all the equipment and material I need to do my job well.3.193.123.35
    It is easy to find women who are interested in receiving an FP method in this community.3.673.643.75
    • Abbreviations: CHW, community health worker; FP, family planning.

    • Level of activity of CHWs was based on data from service statistics, which were available for 157 CHWs.

    • Items were scored from 1 = “Disagree a lot” to 4 = “Agree a lot.” Nonresponses varied across items. Weighted means are reported.

    • ↵a Item was reverse-scored before factor analysis.

    • View popup
    TABLE 4. Selected Characteristics of Survey Respondents, by Level of Activity
    CharacteristicsTotalHighly ActiveLess ActiveP Value
    (N = 183)(n = 88)(n = 69)
    Age, y, mean (SE)41.3 (0.8)41.1 (1.1)40.9 (1.2).89
    No. of living children, mean (SE)5.5 (0.2)5.2 (0.2)6.0 (0.5).23
    Education, %
     Primary27.426.137.4.17
     Secondary or higher72.673.962.6
    Sex, %
     Female49.859.148.8.47
     Male50.240.951.2
    No. of years as an FP CHW, mean (SE)5.6 (0.4)5.5 (0.4)5.3 (0.4).83
    Provides other services besides FP, %
     No7.34.89.4.31
     Yes92.795.290.6
    Prior volunteer experience, %
     No10.912.25.3.05
     Yes89.187.894.7
    Received refresher training in past year, %
     No26.127.232.9.50
     Yes73.972.867.1
    Ever received supervision from HC staff, %
     Never34.039.436.7.82
     Ever66.060.963.3
    Received supervisory visits in community in the past year, %
     No41.336.050.8.23
     Yes58.764.049.2
    Problems with supplies, %
     No36.126.741.2.01
     Yes63.973.358.8
    Received recognition/support from community in the past year, %
     No10.910.012.0.75
     Yes89.190.088.0
    Received incentive from NGO or district in the past year, %
     No46.245.247.4.81
     Yes53.854.852.3
    Collaboration with other CHWs, %
     No37.146.824.7.03
     Yes62.953.275.3
    Time to HC, h, mean (SE)1.2 (0.1)1.3 (0.1)1.3 (0.1).88
    Motivation, mean (SE)-0.08 (0.1)-0.05 (0.1)-0.04 (0.1).95
    Barriers, mean (SE)-0.05 (0.1)-0.04 (0.1)-0.04 (0.1).96
    Facilitators, mean (SE)-0.02 (0.1)-0.05 (0.1)0.07 (0.1).41
    • Abbreviations: CHW, community health worker; FP, family planning; HC, health center; NGO, nongovernmental organization; SE, standard error.

    • Level of activity of CHWs was based on data from service statistics, which were available for 157 CHWs.

    • Nonresponses varied across items. Weighted percentages and means are reported.

    • View popup
    TABLE 5. Factors Associated With CHW Level of Activity in Logistic Regression Analysis (N = 156)
    CharacteristicsaOdds Ratio (95% CI)
    Demographic
     Maleb0.63 (0.23–1.76)
     Secondary or higher educationb2.30 (0.75–7.01)
     Age, y1.04 (0.99–1.08)
    Situational
     Prior volunteer experienceb0.67 (0.26–1.72)
     Travel time to health center, h0.98 (0.68–1.43)
    Work
     Problems with suppliesb2.22 (1.32–3.75)
     Collaboration with other CHWsb0.33 (0.13–0.86)
    Motivational outcomes and determinants
     Motivation1.25 (0.70–2.23)
     Barriers1.07 (0.67–1.72)
     Facilitators0.67 (0.40–1.14)
    • Abbreviations: CHW, community health worker; CI, confidence interval.

    • ↵a Control variables were education, sex, age, time to health center, motivation, barriers, and facilitators.

    • ↵b Indicator variable. For male/sex, the reference is female. For education, the reference is primary education. Other variables are yes/no binary variables, with “no” as the reference level.

    • View popup
    TABLE 6. Mixed Logit Model Results for Program Inputs Influencing CHW Preferences in the Discrete Choice Experiment (N = 182)
    Program InputModel Coefficients
    Mean Estimate (SE)Standard Deviation Estimate (SE)
    T-shirt, badge, and bicycle3.90a (1.41)1.24 (1.45)
    Mobile phone, no airtime0.99b (0.41)…
    10,000 UGX transport refund0.77b (0.35)1.06 (0.77)
    Yearly refresher training0.73b (0.34)1.22 (0.63)
    T-shirt and badge1.97 (1.02)1.51 (0.86)
    Quarterly supervisory visits in community0.70 (0.38)1.15 (0.70)
    • Abbreviations: CHW, community health worker; SE, standard error; UGX, Ugandan Shilling.

    • Number of observations = 1,092.

    • ↵a P < .01.

    • ↵b P < .05.

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Global Health: Science and Practice: 2 (1)
Global Health: Science and Practice
Vol. 2, No. 1
February 01, 2014
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Keeping community health workers in Uganda motivated: key challenges, facilitators, and preferred program inputs
Aurélie Brunie, Patricia Wamala-Mucheri, Conrad Otterness, Angela Akol, Mario Chen, Leonard Bufumbo, Mark Weaver
Global Health: Science and Practice Feb 2014, 2 (1) 103-116; DOI: 10.9745/GHSP-D-13-00140

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Keeping community health workers in Uganda motivated: key challenges, facilitators, and preferred program inputs
Aurélie Brunie, Patricia Wamala-Mucheri, Conrad Otterness, Angela Akol, Mario Chen, Leonard Bufumbo, Mark Weaver
Global Health: Science and Practice Feb 2014, 2 (1) 103-116; DOI: 10.9745/GHSP-D-13-00140
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