Retention, attrition and motivation of voluntary workers in community-based programs Peter Winch and Anne Palaia, Johns Hopkins Bloomberg School of Public Health CORE Group Spring Meeting, April 29, 2010

1. 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

2. 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.

3. 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

4. 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

5. 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.

6. 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

7. 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.

8. This session: 4 parts Sources of volunteer motivation to serve as HIV VCT outreach workers in rural Tanzania. Systematic review of experience with volunteer motivation and attrition in HIV/AIDS programs Analysis of factors affecting attrition of community health workers in a newborn care intervention study in Sylhet District, Bangladesh Examples from participants

9. Part I Examining Sources of Motivation & Expectations of Remuneration Among HIV VCT Community Outreach Volunteers in Rural Tanzania

10. Authors Anne Palaia Michael Sweat Irene Mashasi IddaMosha Jessie Mbwambo Peter Winch

11. Community Health Workers: Issues in the field How effective are HIV interventions that rely on CHWs? Adequate Training? Motivation? Expectations? Attrition? Sustainability?

12. 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

13. 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

15. Project ACCEPT: A Three Pronged Intervention for HIV Community Mobilization Paid Sociologists, ethnographers, qualitative researchers, drivers, unpaid community outreach volunteers Community Based Voluntary Counseling and Testing for HIV Paid nursing staff Post Test Support Services Paid trained counseling staff

16. 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

19. Survey Questionnaire 24 volunteers 206 Community Members Sources of Motivation Expectations of Remuneration Barriers to the Conduct of Outreach Facilitators to the Conduct of Outreach

20. 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

21. 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

22. 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.

23. 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

24. Desired Remuneration Described by Survey Respondents

25. 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)

26. 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

27. 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

28. “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

29. Part II Volunteer Attrition in HIV/AIDS Programs: A Systematic Review

30. Authors Anne Palaia Peter Winch

31. 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

32. 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

34. Defining Attrition in the 8 included studies

35. Next slide:Observed relationship between remuneration and attrition in the 8 studies

37. 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

38. 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

39. 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

40. Part III Factors affecting recruitment and retention of community health workers in a newborn care intervention in Bangladesh

41. Authors Syed Moshfiqur Rahman Nabeel Ashraf Ali Larissa Jennings M. Habibur R. Seraji Ishtiaq Mannan Rasheduzzaman Shah ArifBillah Al-Mahmud Sanwarul Bari Daniel Hossain Milan Krishna Das, Abdullah H. Baqui Shams El Arifeen Peter J. Winch

42. 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

43. 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

44. 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

45. 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.

46. 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

47. Primary reasons for attrition Family reasons Work-related reasons Education opportunities Actions taken by the project

48. 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.”

49. CHW attrition during the project

50. 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

51. 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

52. Framework for decisions by CHW

53. 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