Community health worker motivation to perform systematic household contact tuberculosis investigation in a high burden metropolitan district in South Africa
Abstract Background South Africa faces a chronic shortage of professional health workers. Accordingly, community health workers (CHWs) are being employed to mitigate the ongoing health workforce deficiencies. In addition to facilitating linkages between communities and primary health care (PHC) facilities, CHWs are entrusted with a range of crucial tuberculosis (TB), HIV/AIDS and maternal health services. As increased access to quality service delivery hinges upon their motivation, this study explored CHWs’ motivation to deliver systematic household contact TB investigation (SHCI). Methods In 2017, a cross-sectional survey was conducted among CHWs enrolled in the ward-based PHC outreach teams in the Mangaung Metropolitan District in the Free State Province. Exploratory factor analysis (EFA) was performed on a 30-item scale to determine the dimensions underlying CHW motivation. Items with factor loadings of 0.4 and above were retained. Descriptive and inferential analyses were used to determine CHW motivation levels. Multiple linear regression analysis was used investigate the determinants of CHW motivation. Statistical significance was determined at p ≤ 0.05. Results Out of 235 participants, the majority were female (89.2%). Participants’ median age was 39 (inter-quartile range: 33-45) years. CHW motivation was defined by 16 items across three dimensions — intrinsic job satisfaction, burnout and team commitment, together explaining 56.04% of the total variance. The derived 16-item scale showed satisfactory internal consistency (Cronbach’s α: 0.81), with a mean motivation score of 51.29 (sd: 5.14) out of 64. Formal CHWs — with at least phase 1 of standardised training scored statistically significantly higher than informal CHWs – with non-standardised training on the team commitment sub-scale (mean: 17.82; sd: 2.48) vs. 17.07; sd: 2.82; t(233) = 2.157; p = 0.013). CHW age (β = 0.117, p = 0.030), location (β = 1.759, p = 0.038), length of service (β = -0.505, p <0.001), attendance of TB SHCI training (B = 1.833, p = 0.33), and TB SHCI competence (β = 0.713, p <0.001), contributed statistically significantly to CHW motivation. Conclusion CHW motivation to perform TB SHCI was both intrinsic and extrinsic. The high overall mean score implies that the CHWs were well-motivated to perform TB SHCI. To ensure sustained improved access to quality TB SHCI service provision, the tool derived from this study could potentially be used by TB programme managers in the Free State and similar settings to monitor and inform CHW motivation interventions. Interventions should especially pay close attention to the CHWs’ formalisation, competence and training.