This study aimed to identify factors associated with motivation and satisfaction among a recently trained and deployed volunteer cadre of CHWs in Morogoro Region, Tanzania. CHWs were more likely to be motivated to become CHWs due to altruism (work on MNCH, desire to serve God, work hard) and intrinsic needs (help community, improve health, pride) than due to external stimuli (monetary incentives, skill utilization, community respect or lack of professional alternatives). Factors strongly associated with CHW satisfaction included relationships with health workers and communities, the availability of job aides and the capacity to provide services and with the training. On the other hand, CHWs were highly dissatisfied with the unavailability of transportation for carrying out their tasks and the lack of allowances or financial incentives. Factors associated with motivation and satisfaction did not substantially differ across socio-demographic CHW characteristics, although CHWs who were older and less educated were more likely to report motivation and job satisfaction.
Findings of this study pertaining to motivation behind becoming a CHW corroborate those previously reported from Morogoro. Qualitative research found that strong altruistic motivation was not incompatible with the importance of financial compensation of some kind, particularly considering the vulnerable livelihoods among these communities [25]. In other settings, for example, in Bangladesh, the reasons respondents chose to become CHWs included a desire to improve community health and to serve women and children and not aspirations for financial independence [26]. Trust-based relationships with rural communities, an altruistic motivation to serve rural people and sound health knowledge and skills were reported to facilitate successful implementation of CHW programmes in Iran [27].
The strongest satisfaction factor for CHWs was related to work relations with varied CHW stakeholders and training. Similarly, a study conducted in Nepal found that one of the most enabling factors for the sustainability and scaling up of CHW programmes was integration of CHWs with the health system and existing healthcare providers [28]. Community support has been found to be critical for making CHWs feel welcome, acceptable and appreciated in the communities where they provide services in various settings [8, 29]. With regard to training, technically strong and relevant training valued by CHWs and respected by communities has been reported to be an important factor for satisfaction, retention and motivation of CHWs in other low- and middle-income countries as well [8, 30–32]. Increased training corresponding to a broader scope of work and, in particular, having more curative tasks may too increase motivation, service delivery time and time spent working [12].
Another strong factor for satisfaction, the availability of job aids and registers, indicated the importance CHWs attach to having necessary supplies to carry out their tasks effectively. Other studies have also reported the availability of job aids as critical, whether in improving the efficiency of their tasks and in supporting communication with beneficiaries [8, 17, 33]. The capacity to provide services and receive support was also a strong satisfaction factor. Studies have documented similar findings reflecting “personal satisfaction about their contribution to the work”, self-efficacy (able to handle tough situations, solve problems, feel emotionally and physically perfect on work) and self-esteem as factors influencing satisfaction [25, 30, 31, 34].
While CHWs reported to be highly satisfied by their capacity to meet needs of the community, they were dissatisfied by the specific types of support that had not been adequately provided to them (allowances, supply of communication devices and transportation). Dissatisfaction with support received, particularly financial compensation, has been found in other low-resource settings [25, 33–37] as well as in the same region in Tanzania in a prior study [38]. Financial incentives have also been reported as dominant motivating factors for retention of these providers [26, 39].
Similar to other settings [39], lack of availability of transport for travelling to households and health facilities also appeared to have caused discontentment among CHWs. This can be attributed to the fact that CHWs in Morogoro Region have to travel across an expansive and difficult terrain, making it both strenuous and time-consuming to complete scheduled household visits without readily available transportation. The programme had promised to give the CHW bicycles to facilitate movement during care provision. However, it was not possible to follow through on this promise in a timely manner, and the survey was conducted before they received them.
Limitations of the study
The study was conducted as part of a larger study to evaluate the Integrated Programme and the CHWs who worked with it. There is therefore a possibility of desirability bias in the responses received, particularly around altruistic motivations for being a CHW. Attempts were made to reduce this by assuring respondents of confidentiality and by using investigators external to the programme. The study did not interview community members to share their experiences about the performance of CHWs. This could have helped to better understand community perceptions of CHWs’ performance and hence assess strengths and weaknesses of the Integrated Programme. Although scale items for both job satisfaction and motivation were selected based on discussions with key stakeholders and an extensive literature review, additional qualitative approaches to check face and content validity were not carried out. Although these results closely match those obtained from a qualitative study conducted in the same setting previously [38], concurrent qualitative research or further field testing of the items could have resulted in increasing the total variance explained by the scale.
In addition, a global or overall item of motivation or satisfaction was not included in the scale, limiting the ability to measure correlations between different facets of these constructs with an overall score. The grouping of a few items resulting from factor analysis, for example, the fifth factor for job satisfaction, included heterogeneous items, which collectively did not necessarily represent a composite factor. This could provide a possible explanation for the low value of Cronbach’s alpha for this particular factor. Similarly, the fourth factor of motivation (intrinsic needs) determinants also includes unrelated factors. Testing the psychometric properties of the reduced scales obtained for both job satisfaction and motivation in this study could improve further research inquiry in similar settings.
Implications
This study has significant policy and programmatic implications for the current CHW programme in Morogoro Region, as well as its scale up to other parts of Tanzania and other low- and middle-income countries. The fact that the CHWs were selected from and by their own communities may have contributed to high levels of satisfaction with relations with co-workers and community members. The importance of interpersonal relations with health workers for CHWs is also an important finding, pointing to the importance of elements such as trust in health worker performance [40, 41].
The CHWs interviewed during this study were from a government programme supported by external technical assistance and had access to essential working tools such as job aides and registers to record patient information. The importance CHWs attached to training in this programme, by highly qualified trainers, instilled performance confidence among the trainees. Sustained availability of working tools and training will ensure high satisfaction among the current cadre of CHWs and is likely to attract others into the workforce in the future.
On the other hand, this study suggests that the current programme did not at the time of the survey provide adequate transportation and monetary compensation to CHWs. In order to improve coverage of visits to target households as per the recommended schedule, given the large catchment area under each CHW, the current and future programmes should strive towards ensuring means of transport or equivalent monetary resources to CHWs. While findings suggest that CHWs were more likely to join this profession due to altruism and to meet their intrinsic needs, they became dissatisfied by the lack of financial incentives offered to them. This result could be due to the growing demands on their time, comparisons that may be drawn with other community level cadres that are paid and/or the desire to contribute to their household income – an activity that programme engagement may detract from. Thus, CHW programmes should also advocate for financial incentives for this cadre either in the form of a salary or stipends to influence both job satisfaction and motivation and consequently the attrition rate [38, 42].
Further research
In 2015, it is anticipated that the government of Tanzania will initiate a national CHW programme. While this study highlights several key determinants of motivation and satisfaction that need to be considered, additional research is warranted to better understand nuances regarding intrinsic vs extrinsic motivations to enlist as a CHW and levels of monetary compensation to ensure their job satisfaction. The relationship between job satisfaction and performance should also be studied in greater detail for this specific context. Future research should also consider further scale refinement and larger sample sizes to support subgroup analyses of interest.