At this stage, you have identified your key barriers to CHW motivation, identified your intended audience(s), defined your objectives and the general strategic approach you plan to use.
This step pulls together resources, toolkits and guidelines that guide the development of SBCC approaches that will help you address the identified barriers to CHW motivation. These can be adapted to your context and intended audience as you see fit.
The tools and resources have been organized around the five main categories of CHW motivation discussed previously:
- Perceived Status and Social Support
- Level of Connectedness
- Incentives and Personal Rewards
- Supportive Social and Gender Norms
- Personal Attitudes and Beliefs
Review your findings from your situation, root cause and audience analyses to remind yourself of the motivation barriers your CHW audience faces. Consider the approaches you have chosen to address those barriers. Then, read the relevant sections below and access the resources that will help you in designing your SBCC intervention.
Perceived Status and Social Support
Some examples include: using mass media to publicly praise CHWs (used in Indonesia); designing branding strategies to help identify and recognize high quality CHWs; providing CHWs with bags, badges and high-quality counseling materials with identifying logos; providing identification cards to secure preferential treatment in health clinics (used in Ghana); and securing letters of appreciation from government officials. In Bangladesh, one CHW noted that simply being seen in the community on a periodic basis with a headquarters-based supervisor, which demonstrates support from the larger system, is a boost to one’s status among community members.
Providing CHWs with tablets and mobile phones that include SBCC materials and electronic guidelines has been used not only to improve CHW capacity in interpersonal counseling but also to improve their status in the communities in which they work. SBCC can also be used to advocate for improved government policy to raise the social status and support of CHWs. In India, for example, CHWs are given access to credit programs for income generating projects and are prioritized for literacy classes.
Regardless of the approach, it is important to ground techniques to improve social status in an understanding of the CHWs working in the community. What may be desired by one CHW may not be the same for another. These preferences are often influenced by age, gender, current social status within the community and level of education.
The Motivation Resource Table to the right details some documented programs and approaches, which have used various techniques to improve CHW social support and status.
Level of Connectedness
Community Connectedness – CHW programs integrated with the Primary Health Care system and managed well can help ensure quality continuum of care. A well-run CHW program directly engages with the community, which includes but is not limited to: enabling community members to help define CHW roles and job descriptions, selecting and recruiting CHWs, and helping to monitor CHW performance and resulting health outcomes. Community-led advocacy can also ensure that the appropriate structures are in place to select and monitor CHWs and ensure their activities provide efficient links to health services. SBCC plays an important role in all of these activities.
The Communication for Healthy Living Project in Egypt developed its Community Health Program through a multi-step process, which sought to ensure community health workers were linked to the community management structures. The process included:
- Mobilizing the community to establish a village health committee based on identified community needs together with the Village Council and Primary Health Care Unit
- Conducting village assessments to identify community needs and presenting to the Village Council through community meetings
- Revitalizing the Primary Healthcare Unit Board to help review proposed activities
- Identifying community health volunteers and leaders through the Village Health Committee to conduct group discussions for men and women, implement family health interventions, and facilitate health clinic discussions
Peer Connectedness – SBCC approaches can help address the loneliness and lack of support CHWs feel by connecting them to their peers. Some examples include bringing peer educators together for award ceremonies or refresher trainings, developing and distributing newsletters or conducting routine meetings for status updates.
The Care Community Hub (CCH) project's Community Health Nurse (CHN) on the Go developed a mobile app to improve motivation and job satisfaction among frontline health workers working in maternal, newborn and child health in rural Ghana. By providing this mobile phone app to community health officers, community health nurses and their supervisors, CNH on the Go will combine virtual peer-to-peer support with improved connectedness to a professional network and supervisors. The Community Health Nurse on the Go app aims to improve motivation among frontline health workers through a mobile technology application.
Connectedness to Supervisor – Some programs have employed SBCC approaches that allow supervisors to use interpersonal communication to counsel CHWs to discuss problems and exchange information. One example is PSI’s Provider Behavior Change Communication approach, which has applied an interpersonal-based coaching and support supervision approach, which helps build CHW capacity, improves self-efficacy and reduces CHWs feelings of isolation.
In Zambia, the Malaria Communities Program partners implemented a variety of supervision systems, including conducting joint supervision visits with MOH staff and holding monthly meetings with volunteers. Supervisory visits were tremendously motivating to volunteers, providing opportunities to recognize their efforts and reinforce their credibility in communities. Monthly or quarterly meetings encouraged a cohesive spirit of teamwork and motivated volunteers to continue their work.
Connectedness to Health Facilities – SBCC approaches can be used to help advocate for improved CHW connectedness to health facilities and stimulate community support and demand for CHW led health services as an extension of facility based health services. It can also be used to develop training and support materials to help them in their work.
As a means of addressing poor motivation tied to increased demand for CHW services in Kailahun District in Sierra Leone, in 2012 the Innovations Project and Catholic Relief Services implemented the Quality Circles Project. Quality Circles consisted of regular quality improvement group meetings with health volunteers and health facility staff to address peer learning, foster peer support and develop joint problem solving strategies to improve health services and health worker morale. Many “change ideas” sought to improve Traditional Birth Attendants' (TBAs) relationships with their communities and with health workers, such as training TBAs to assist with non-clinical tasks in the health facility. Issues that could not be resolved by health workers and TBAs themselves were presented as part of an advocacy strategy to the District Health Management Teams for their action, enhancing communication on health system issues in the district.
Incentives and Personal Rewards
SBCC interventions can advocate for and use both financial and non-financial incentives to motivate CHWs. It is important to keep in mind that financial incentives alone are rarely sufficient. CHWs in Nepal, for example, are motivated to serve their communities due to the influence of religious customs that promote the importance of altruism and volunteering for the community good, and not as much by financial compensation. Financial rewards also come with a number of complicating issues, including:
- How to ensure sustainability
- How to manage inequity of distribution
- How to prevent the appearance of preferential treatment
For this reason, it is important to identify other ways to incentivize CHWs. Many programs use a combination of financial and non-financial incentives. The AIN-C Program in Honduras, for example, regularly provides non-financial incentives to their "monitoras" including publicly recognizing families who support the volunteers, letters of appreciation from government officials and community leaders and, community parties and events – all of which are seen as incentives.
Before designing any type of incentive structure, including one that offers non-material incentives, it is important to ensure the incentives offered match the needs of the selected CHWs and the environment and context in which they work. The situation analysis and audience analysis in the SBCC process are key steps to understanding these needs.
The table below summarizes the types of financial and non-financial incentives widely used in CHW programs. Many of the non-financial incentives can be addressed by SBCC techniques. Some have been mentioned earlier – support supervision, community recognition programs, branded giveaways and tokens of appreciation.
Terms and conditions of employment: salalry/stipend, pension, insurance, allowances and leave
Performance payments: performance-linked bonuses or incentives.
Other financial support: reimbursement of costs (travel, airtime), fellowships, loans and ad hoc
Job satisfaction/work environment: autonomy, role clarity, supportive/facilitative supervision and manageable workload
Preferential access to services: health care, housing and education
Professional development: continued training, effective supervision, study leave, career path that enables promotion and moving into new roles
Formal recognition: by colleagues, health system, community and wider society
Informal recognition: T-shirts, name tags, bicycles and access to supplies/equipment, etc.
|Well-functioning health systems: effective management, consistent M&E, prompt monthly payments, safe environment, adequate supplies and working equipment
|Community involvement in CHW selection and training
|Sustainable health systems: sustainable financing, job security
|Community organizations that support CHWs
|Responsive health systems: trust, transparency, fairness and consistency
|CHWs witnessing visible improvements in health of community members
|Health care workers witnessing and grateful for visible improvements in health of community members
|Community members witnessing and grateful for visible improvements in health of its members
|Policies and legislation that support CHWs
Funding for CHW activities from state or communities
Successful referral to health facilities
The table below summarizes some key questions programmers should consider before determining whether to employ indirect incentives as part of a program to increase CHW motivation.
Questions to Consider Regarding Indirect and Complementary Incentives*
|Clear roles, responsibilities and feedback
|Personal growth and professional development
|Day-to-day working relationships
|Accountability in the health system and community
|Role of civil society partners
|Community's relationship to the health system and government
The Incentives and Personal Rewards Motivation Resource Table in the box on the right presents a list of programs, toolkits and guides from recent programs that have incorporated incentives (direct or indirect) into their CHW programs.
Social and Gender Norms
Before employing an SBCC approach to improve provider motivation and performance, it is important to understand the most important prevailing social and gender norms and the underlying reasons as to why they exist. Some of this information may come out in the Situation Analysis, but you will likely need to conduct additional formative research to understand local norms. This can be done through key informant interviews, focus group discussions or other interactive research techniques.
Once you understand the social and gender norms that need to be addressed, you can design focused interventions. Normative change typically requires dialogue – between partners, families and communities. People often need to confront their values and openly discuss the impact of those values on their community. Social change also requires early adopters that others who are considering change can look to. SBCC effectively uses modeling to convey the sense that a certain behavior is widely acceptable, and to show others how that behavior can be carried out.
SBCC programs have successfully employed community dialogue, TV/radio listeners’ groups, community mobilization, mass media, peer-to-peer and other approaches to stimulate normative change.
In designing programs for CHWs that will target gender-related norms, consult the Gender Equality Continuum as a means of evaluating whether your program contributes to gender equity.
The Social and Gender Norms Motivation Resource Table (see box, right) presents a list of programs, toolkits and guides of recent programs that have addressed social and gender norms (direct or indirect) as part of their CHW performance improvement efforts.
Personal Attitudes and Beliefs
Changing attitudes, beliefs and values is central to SBCC efforts. SBCC can be used to influence how CHWs view their clients, the health topic or behavior, and the products and services they offer.
There are many SBCC interventions that can influence CHWs’ attitudes and beliefs. Included here are a few examples. One example involves using a positive deviance approach to identify CHWs with supportive attitudes and beliefs, then creating peer discussion or working groups to normalize those attitudes. Another approach involves using mass media to spark thinking on a topic, then allowing space (either formal or informal) for reflection. Values assessments can also help CHWs confront what they believe and how they act. Some CHWs are swayed by emotional or rational appeals where they are shown how their attitudes and actions impact the lives of their clients.
Defining quality services alongside community members can also help shift CHW perceptions. The Puentes project in Peru brought communities and health workers together to create participatory videos that identified barriers to utilization of services. Together, they defined what quality services looked like and came up with an action plan for improvements. Health workers saw issues in a new way and were able to shift attitudes about the services they offered and the community they served.
The table to the right contains examples of programs and guidance for addressing personal attitudes and beliefs.
Reflect on the examples and resources you have seen in this section. In the Step 7 section of the SBCC Strategy Template, write down ways you might adapt or use some of the ideas presented here in your own intervention.
Personal Attitudes and Beliefs