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Abstract
Introduction Health development army is a network of women volunteers organised to promote health and prevent disease through community empowerment and participation.
Objective To assess the level of motivation and associated factors of the health development army in the implementation of health extension packages in Northwest Ethiopia.
Design Data were from a community-based cross-sectional study.
Setting This study was conducted in Mecha district, Northwest Ethiopia. The district is located around 30 km from Bahir Dar, the capital city of Amhara National Regional State, Ethiopia.
Participants A total of 624 health development army members were interviewed using a structured questionnaire from 20 April 2020 to 20 May 2020.
Outcome measures Motivation was assessed using a five-item Likert scale statement ranging from 1 to 5. Data were collected using a structured questionnaire and analysed using a binary logistic regression model.
Results The proportion of health development army members, who had motivation in the implementation of the health extension package, was 47.8% (95% CI (43.90 to 51.80)). The odds of having motivation were higher among health development army members who lived in urban areas ((adjusted OR, AOR 2.47; 95% CI (1.21 to 5.03)), were less than 30 years ((AOR 2.42; 95% CI (1.22 to 4.78)), had more than 4 years work experience ((AOR 4.72; 95% CI (2.54 to 8.76)), had high intrinsic job satisfaction ((AOR 2.31; 95% CI (1.51 to 3.55)), had good community support ((AOR 2.46; 95% CI (1.34 to 4.51)), received supportive supervision ((AOR 1.85; 95% CI (1.24 to 2.77)) and were recognised for their efforts ((AOR 1.52; 95% CI (1.01 to 2.30)).
Conclusion The proportion of motivation among health development army members was low. To increase the motivation of health development army members in the implementation of the health extension package, measures or strategies may consider targeting members who live in rural areas, are older than 30 years, have less than 4 years of work experience, report low job satisfaction, have low community support, do not have supportive supervision and are not recognised.
- Health Education
- PUBLIC HEALTH
- Primary Health Care
Data availability statement
Data are available on reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
We used cross-sectional studies for large sample sizes which improves generalisability and statistical power.
Questions were phrased in both positive and negative ways to minimise response bias.
Due to the cross-sectional nature of these data, it was not possible to establish a temporal relationship between exposure variables and motivations; thus causation was not demonstrated. Due to limitations in time and resources, only a quantitative method based on previously tested questions was used.
All the outcome measures were dichotomised.
Background
Several countries have been implementing community health programmes to deliver basic health and medical care to the public.1 The ‘Health Extension Programme’ and the ‘Health Extension Packages’ are both key components of Ethiopia’s primary healthcare system. In Ethiopia, the Health Extension Programme was launched in 2004 to deliver primary healthcare services.2 Health Extension Programme is a community-based programme that trains and deploys health extension workers to provide essential health services at the grassroots level. The health extension workers are selected from within their communities and undergo a 1-year training programme to acquire skills in preventive, promotive and basic curative healthcare. On the other hand, the Health Extension Packages refer to a set of essential health interventions provided by the health extension workers as part of the Health Extension Programme. These packages include a range of services such as maternal and child health, family planning, immunisation, hygiene promotion, disease prevention and control, and health education.1
One of the Health Extension Programmes is the ‘women’s development army’ or the health development army. Women development army members are a network of women volunteers who are organised to provide disease prevention and health promotion services to the community through community empowerment and active participation.3 4 Furthermore, health development army members are essential in improving community health and health equity, particularly in the context of low-income and middle-income countries.5
Health development army members are different from other health professionals. They are working without salary and are serving in linking the community with formal healthcare.6 Health development army members are representative of the community, and they are suitable to implement the Health Extension Programme packages.7 Retention of health development armies can be an effective way of improving health service delivery and the continuum of care to the community. The major activity of health development army members is supporting the primary healthcare intervention under the Health Extension Programme. Women’s development army members have contributed towards the improvement of maternal and child health, and health service use.8 On the other hand, poor motivation of health development army members can lead to absenteeism, high turnover, poor work performance and failure to fulfil responsibilities.9
Health extension workers and health development army members typically work together in a collaborative and coordinated manner to improve community health outcomes. Health extension workers provide training to health development army members, equipping them with the necessary knowledge and skills to promote health within their communities. This includes training on various health topics such as hygiene, nutrition, family planning and disease prevention. They work together to mobilise the community for health-related activities such as immunisation campaigns, health screenings and awareness programmes. Health extension workers often rely on health development army members to assist in delivering health education messages at the grassroots level. Their combined efforts help improve access to healthcare services, promote preventive measures, raise awareness about key health issues and empower communities to take charge of their well-being.8 10
Implementation of the health extension packages has several challenges, for instance, lack of resources, poor skills and competencies of the health extension workers, demotivation of health extension workers, absence of supportive supervision, poor referral and lack of implementation research.10 By providing updated knowledge and skills, health extension workers can deliver better quality services to the community. This includes improving their understanding of various health issues, enhancing their communication and counselling skills, and keeping them up-to-date with new developments in healthcare.10
Motivation is an individual’s degree of willingness to exert and support an effort towards certain goals.11 Previous studies have identified factors associated with motivation among voluntary community health workers.6 12–18 However, different levels of motivational status were observed.14 16 The contributing factors for lower levels of motivation among voluntary community health workers vary in different settings and different populations.6 16–18 This study may contribute by generating and providing knowledge about factors associated with motivation among the health development army members in the Mecha district, Northwest Ethiopia. These findings may help fill the information gap to improve the level of care delivered by the health development army.
Methods
Study design and setting
We conducted a community-based cross-sectional study from 20 April 2020 to 20 May 2020, among health development army members in Mecha district (woreda), Northwest Ethiopia. In Mecha district, there are three urban and 39 rural subdistricts (Kebeles). A total of 9292 health development army members were working together with the health extension workers deployed in the woreda/district.19
Sample size determination
The sample size was calculated by using a single population proportion formula and calculated by using Epi-info V.7 with 50% proportion, 5% absolute precision, 1.5 design effect, 95% CI and a non-response rate of 10%. The calculated overall sample size was 634.
Sampling procedures
From 3 urban and 39 rural Kebeles in the Mecha district, 1 urban Kebele and 8 rural Kebeles were selected by using lottery methods. Of the 9292 health development army members, 634 were selected by using computer-generated random numbers. Of the 634 respondents, 624 respondents were responded to the questionnaire.
Data collection measurement
Motivation
was measured using five items. Each item was measured on a 5-point Likert scale ranging from 1 to 5. A score of 1 represents the statement ‘strongly disagree’ for positively worded questions. A score of 5 represents the statement ‘strongly agree’ for positively worded questions, while negative questions were recoded in the opposite direction so that a score of 5 represents ‘strongly disagree’ and a score of 1 represents ‘strongly agree’ for negatively worded questions. A score of 3 in both negatively and positively worded questions represented ‘neither agree nor disagree’. To assess motivation, the 5 items were summed (ranging from 5 to 25). Items for motivation included statements such as, ‘I am proud to be working for the community’ and ‘I enjoy the work itself’.
Sociodemographic factors
The eight sociodemographic variables were age, educational status, marital status, occupation, residence, religion, current functional status (continued/discontinued) and duration of service as a member.
Intrinsic job satisfaction
To assess intrinsic job satisfaction, the 4 items were summed (ranging from 4 to 16). Items for intrinsic job satisfaction included statements such as ‘I am satisfied with the opportunity to use my abilities in my job’ and ‘I am satisfied that I accomplished something worthwhile in this job for the community’.
Supportive supervision
To assess supportive supervision, the 4 items were summed (ranging from 4 to 16). Items for supportive supervision included statements such as ‘I get support from the health post (HP)/HEWs (Health Extension Workers) when problems arise’ and ‘there is fair treatment by the health post/HEWs’.
Recognition
To assess recognition, the 4 items were summed (ranging from 4 to 16). Items for recognition included statements such as ‘The recognition given to me is encouraging’, and ‘My effort is recognised and I get an appreciation for my accomplishment from the HEWs or Kebele leaders’.
Community support
To assess community support, the 4 items were summed (ranging from 4 to 16). Items for community support included questions such as ‘I get support from the community when problems arise’ and ‘the community acknowledges my contribution’.
Because the distribution of the data for this study was skewed, we used the median value as a cut-point for all measures.
Data collection procedure and analysis
Data were collected using interviewer-administered structured questionnaires prepared after reviewing the literature. The measuring tool was adapted from previous studies14 15 20 21 to understand the level of motivation and associated factors among health development armies (online supplemental file 1).
Supplemental material
Questionnaires were first prepared in English and then translated into Amharic and back-translated to English. The validity of the questionnaire was assessed by consulting experts in the field of public health, and their constructive feedback was taken into account during the tool’s modification. To ensure consistency and completeness of data, a pretest was conducted on 31 (5%) health development armies in a selected Kebele who were not part of the study before the actual data collection period. Trained nurses conducted a face-to-face interview with health development army members by using a structured questionnaire. Data were collected on respondents’ level of motivation and associated factors. The data collection process was supervised by a trained public health officer.
Data processing and analysis
Descriptive statistics of the collected data were done for most variables in the study using statistical measurements. Binary logistic regression models were used to assess the association between dependent and independent variables. All the variables associated with the outcome variable with a p<0.2 in the bi-variable analysis were entered into the multivariable analysis. In unadjusted models, the following factors were associated with motivation among health development army members: age, place of residence, years of work experience, current functional status, interpersonal relationship, intrinsic job satisfaction, commitment, perceived self-efficacy, community support, community expectation, supportive supervision, recognition, interest in social activity and peer support. Then, these variables were taken and analysed together to control confounding factors. After adjustment, age, rural residence, working experience as health developmental army, intrinsic job satisfaction, community support, supportive supervision, and presence of recognition were found to have a statistically significant association with motivation among health development armies.
A p<0.05, 95% CI and adjusted OR (AOR) were considered to declare the variables significantly with the dependent variable. Model fitness was checked using the Hosmer and Lemeshow goodness-of-fit test. The p value of the Hosmer and Lemeshow goodness-of-fit test in this particular data set was greater than 0.05 which confirms that the model was correctly fitted. The collected data were coded and entered using Epi-Data V.3.1 and exported to SPSS V.25 for analysis.
Patient and public involvement
No patient involved.
Results
Sociodemographic characteristics of study participants
Of the 624 participants, the median age was 34 years (IQR=28–38) with a minimum of 20 years and a maximum of 52 years. Table 1 describes the sociodemographic characteristics of health developmental army members. Among the total study participants, 535 (85.4%) came from rural areas.
Sociodemographic characteristics of health development army members in Mecha district, Northwest Ethiopia, 2020
Level of motivation
In this study, of the total participants, 298 (47.80%) (95% CI (43.90 to 51.80)) reported a high level of motivation (table 2).
Provides the level of motivation of health developmental army members in Mecha district, Northwest Ethiopia, 2020
Factors associated with motivation
Table 3 shows factors for motivation. After adjustment, health development army members who were 30 years or younger were twice as likely to report being motivated compared with those over 40 years old ((AOR 2.42, 95% CI 1.22 to 4.78)). Urban residence was an independent factor of an increased level of motivation (AOR 2.47, 95% CI (1.2 to 5.03)). After adjustment, study subjects who had served for more than 4 years were more likely to be motivated to serve their community (AOR 4.72, 95% CI (2.54 to 8.76)). Participants with high intrinsic job satisfaction were more likely to be motivated ((AOR 2.31, 95% CI 1.51 to 3.55)).
Factors for motivation among health development army members in Mecha district, 2020
In addition, those who reported high community support were twice as likely to be motivated compared with those who reported low community support (AOR 2.46, 95% CI (1.34 to 4.51)). Study participants who had high supportive supervision were more likely to be motivated than study subjects who had low supportive supervision (AOR 1.85, 95% CI (1.24 to 2.77)). Recognition was an independent factor for an increased level of motivation ((AOR 1.52, 95% CI (1.01 to 2.30)).
Discussion
This study assessed the level of motivation among health development army members in the implementation of health extension packages. In addition, this study identified factors for motivation among health development army members. Just over half of the health development army members reported low motivation in implementing health extension packages. These findings have important implications for public health that can be used as baseline information to improve the motivation of health development army members in delivering health extension packages to the community. This is very important, particularly in low-income settings where trained health professionals are limited. The findings of this study should alert public health agencies as the level of motivation of health development army members is still unsatisfactory. Furthermore, as this study was a preliminary assessment, researchers should explore other strategies that can potentially enhance the level of motivation among health development army members.
In this study, less than half of the health development army members reported high motivation. The motivation levels in this study were found to be greater than a study conducted in Jimma, South West, Ethiopia health professionals (25%),16 however, lower than a study conducted in the central part of Ethiopia among health professionals (64%).14 This could be due to the employment nature of health development army members who are providing voluntary services whereas health professionals are hired for salary. Also, could be due to different motivator factors in different regional states. Furthermore, health development army members could have a lower workload. This could be due to health development army members typically focus on specific health promotion and community mobilisation activities, such as raising awareness about hygiene practices, promoting immunisations or encouraging antenatal care visits. They may have also less direct supervision or support from healthcare professionals due to the nature of their roles. This could result in a lower workload as they may not be responsible for providing direct healthcare services. This narrower scope of work may result in a lower overall workload.
Consistent with existing literature, this study identified that study participants whose age is less than 30 years have higher levels of motivation.17 In contrast, in Nepal health, a study identified that health workers aged 35 years and above were more motivated than health workers less than 35 years of age.13 Motivations of health workers in similar age categories could be different where their background such as culture, embodied health policy, and societal attitude towards younger professionals are different.
We found that the study subjects who lived in urban residences were more motivated than those who lived in rural residences. Studies conducted in another part of Ethiopia came up with different findings that voluntary health workers from rural areas are more motivated than their counterparts.6 This could be explained in the ways that in some parts of the country towns and cities are motivating health development army members more than rural settings. In the other parts of the region, courtside are more conducive for voluntary health workers to be inspired in their jobs than urban residents.
Health development army members who had served for more than 4 years had increased their level of motivation. This is consistent with other study findings.6 Employees with long work experience have a better opportunity for supportive supervision, training, appreciation and recognition.22–25 Furthermore, health development army members with longer work experience may be integrated well into the community.
The current study revealed that high intrinsic job satisfaction was a motivating factor for voluntary health development army members. Consistent with previous research,6 26 the current study revealed that high intrinsic job satisfaction was a motivating factor for voluntary health development army members. Job satisfaction and motivation are interconnected.26 Satisfied health professionals are often motivated and keep in the health programme on a sustainable basis.6 In addition, intrinsic job satisfaction allowed them to derive personal satisfaction from their roles.
We also found good community support was associated with motivation, this study result was similar to a study finding in India.17 Community support is linked with community-based and community-owned programmes; directions and decisions at least in the part determined by the community. Good community support reinforced the importance of their efforts and provided a sense of belonging. In turn, the communities become flexible and less resistant to the ideas generated by community health workers.27
This study found supportive supervision was associated with motivation. Consistent with previous studies, health workers who reported supportive supervision also reported high levels of motivation compared with those who did not.14 21 22 Supportive supervision helped them feel valued and guided in their work. In addition to this, training and supervision facilitate the workflow of voluntary health workers who have gaps in skills and knowledge.12 28 29
Recognition was a significant motivating factor for community health workers.30 31 Besides financial incentives,15 recognising staff through promotion and appreciation increases job motivation.18 Often the community, who do receive health services from voluntary health workers, has prejudice about the quality of health services that are provided by health volunteers that it is considered less valuable.32 While recognition validated their contributions and boosted their morale. Continuous development of unpaid community health workers and promotion into better job positions persuades society in the way that unpaid health services are not unimportant healthcare.33 34
Conclusion
Study results indicated that less than half the health development army members reported high motivation in the implementation of the health extension packages. These results suggest that programmes could aim to increase community support for the workers, more supportive supervision and provide additional recognition. In turn, these may help increase motivation among health development army members.
Data availability statement
Data are available on reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and ethical clearance was received from Bahir Dar University, College of Medicine and Health Sciences Institutional Review Board. Participants gave informed consent to participate in the study before taking part.
Acknowledgments
The authors gratefully acknowledge Bahir Dar University, College of Medicine and Health Sciences, School of Public Health, Amhara Regional Health Bureau, data collectors and study participants involved in the study.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Twitter @yihuno
Contributors HT led the study and had complete access to the data, taking the initiative to publish the article. Conceptualisation: HT. Data curation: HT. Formal analysis: HT, FAG and YMA. Investigation: HT, FAG and YMA. Methodology: HT, FAG and YMA. Resources: HT. Software: HT.Supervision: HT. Validation: HT, FAG and YMA. Visualisation: HT, FAG and YMA. Writing–original draft: HT, FAG and YMA. Writing–review and editing: HT, FAG and YMA.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.