The motivation of health workers involved in the distribution of ivermectin: a study from the Republic of Benin

WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTE ONCHOCERCIASIS CONTROL PROGRAMME IN WEST AFRICA PROGRAMME DE LUTTE CONTRE L'ONCHOCERCOSE EN AFRIQUE DE L'OUEST EXPERT AD\/ISORY COMMITTEE Ad hoc Session 11 - 15 e EAC.AD.5 Original : English Dccernber 2001J The motivation of health workers involved in the distribution of ivermectin (A study from the Republic of Benin) ! .l World Health Organisation Onchocerciasis Control Programme in West Africa The motivation of health workers involved in the distribution of ivermectin a study from the Republic of Benin The planning for the study was jointly undertaken by: t AWEDOBA, K.A. DEDY, F.Seri PROZESKY, D.R. PROZESKY, D.R SINTONDJI, F The system for data analysis was developed by: lnstitute of African Studies University of Ghana, LEGON, Ghana I nstitut d'Ethno-sociologie Universite de Cocody, ABIDJAN, COte d'lvoire Faculty of Health Sciences University of Pretoria, PRETORIA, South Africa Faculty of Health Sciences University of Pretoria, PRETORIA, South Africa Ministere de le Sant6 Publique et de la Condition F6minine CONTONOU, Benin { Report author: PROZESKY, D.R. Faculty of Health Sciences University of Pretoria, PRETORIA, South Africa December 2001 Acknowledgements The researchers would like to thank the following persons for their help: . At OCP Headquarters Ouagadougou: * Dr Boakye Boatin * Dr Komla Siam6vi * Dr William Soumbey Alley . ln Benin: * Dr Julius Gaba, national onchocerciasis co-ordinator * Messrs Abibou and Sikirou, drivers for OCP * Health service staff, CDs and villagers in the health districts of K6tou, Dassa-Zoum6, Nikki and Djougou. , lt INDEX Page no Abbreviations, acronyms, conventions Executive summary iv 1 Chapter 1 Background .1 .2 .3 Background to the study Literature survey Conceptual basis for the research 2 2 2 8 Chapter 2 Methodology 2.1 2.2 2.3 2.4 2.5 Study aim, research question, study design Population and sampling lnformation sources and instruments Enhancing trustworthiness Data analysis I II 10 11 11 Chapter 3 Findings: nurses 3.1 Nurses' level of motivation for CDTI 3.2 Factors influencing nurses' motivation for CDTI 12 1 1 2 3 Chapter 4 Findings: community distributors 4.1 CDs' level of motivation for CDTI 4.2 Factors influencing CDs' motivation for CDTI 4.3 Applying the knowledge gained: a case study 22 22 23 34 Chapter 5 Discussion and recommendations 5.1 Dealing with low motivation for CDTI in nurses 5.2 Dealing with low motivation for CDTI in CDs 5.3 Practical considerations 5.4 The way forward 35 35 40 45 46 Appendices Appendix A Appendix B Appendix C Appendix D Appendix E Plan for field work in Benin Data collection instruments Applying the instruments Case analysis form: health centre nurses Case analysis form: distributors 48 48 50 60 62 65 lll CD CDTI CHW 'E' Abbreviations and acronyms EPI FCFA MCH OCP PHC TBA WHO community distributor of ivermectin community directed treatment with ivermectin community health worker the effort, energy, excitement, expenditure etc. that someone decides to expend on a certain course of action expanded programme of immunisation CFA franc maternal and child health Onchocerciasis Control Programme in West Africa Primary Health Care traditional birth attendant World Health Orgtanisation Conventions Each case (nurses and CDs) was given a master number. ln the qualitative findings and discussions data drawn from a particular case are identified by that number given in square brackets, as follows: [13] lv EXECUTIVE SUMMARY The study was the result of deliberations at the Expert Advisory Committee of OCP, in 1999. When OCP comes to an end at the end of 2002, the only strategy left to combat onchocerciasis in the 11 member countries will be community directed treatment with ivermectin (CDTI). ln this activity there are two key players: community distributors of ivermectin (CDs), and the nurses at health centre/ sub-district level who supervise and train the CDs. Evidence from the field points to the fact that there are problems in maintaining the motivation of these two groups of workers. A study was therefore required to investigate the level of motivation for CDTI, and factors influencing it. A literature study was undertaken, and Handy's model of motivation (1976) identified. ln this model motivation is seen to be specific, for particular activities. This model was used as the conceptual basis for the study. An exploratory; descriptive, cross-sectional study was carried out. Field work took place over a period of two weeks in three countries: Benin, Ghana and COte d'lvoire. A case study methodology was developed, where semi-structured interviews and discussions provided data from multiple sources. This made it possible to identify the level of motivation of CDs and sub- district nurses with respect to CDTI, as well as the factors influencing such motivation. ln all 14 nurses and 58 CDs from Benin were studied in depth. For various reasons the data from Ghana and Cote d'lvoire have not been analysed in depth to date. The applicability of the present findings to all OCP countries is therefore limited. It was found that a significant proportion of nurses and CDs had levels of motivation for CDTI that were medium or low - 58% and 53% respectively. lt was also found that CDTI was a relatively low priority in their working lives. Six groups of factors were found to influence their level of motivation, either positively (as facilitators of motivation) or negatively (as obstacles to it). These were found to be operating in the following order of importance: , For the nurses: community; health service; personality of the worker; biographical details of the worker; the nature of the job; financial. . For the CDs: the nature of the job; personality of the worker; financial; community; biographical details of the worker; health service. These factors were analysed in detail, quantitatively and qualitatively, thus clarifying the nature of motivation for CDTI in these two categories of worker in Benin. Based on these findings, the following instruments were developed for use in the field: . A checklist to assess the level of motivation of nurses and CDs. . An instrument to diagnose the reasons for this level of motivation. . A schematic plan for remedial action, in case of unsatisfactory levels of motivation. It is suggested that these instruments be tested in the field, particularly to establish whether they can be used to improve the level of motivation for CDTI among sub-district nurse and CDs. It is further suggested that similar research be carried out in other OCP or APOC countries. The applicability of the findings to other disease control programmes at community level is also briefly discussed. Cha r 1 BACKGROUND 1.1 Background to the study OCP ends in December 2002. Responsibility for all residual activities will by then have been transferred to the 11 member countries. These residual activities will include epidemiological surveillance, entomological surveillance and community directed treatment with ivermectin (CDTI). Several levels of health worker will be implicated in performing these tasks. There is evidence (anecdotal mostly, but also in terms of poorer coverage than was expected) of problems with the motivation of these workers. Accordingly all parties - OCP and the national teams - would benefit by a greater understanding of what drives people to participate in onchocerciasis control activities. Only activities surrounding CDTI were to be studied, and not other onchocerciasis control activities like epidemiological surveillance. lt is noted that the problems surrounding CDTI implementation are likely to be generic. For example low salaries, and the need to earn an extra income, are also a problem in sectors other than health care. There is an urgent need to come to grips with these problems, since the sustain ability of onchocerciasis control is at stake. 1.2 Literature survey ln this survey an effort is made to gain a deeper understanding of the lives of individuals working in organisations. This brief overview is taken directly from Handy's book "Understanding organisations", and focuses on motivation theory; role theory; and the sociology of people within organisations. 1.2.1 About the motivation to act or work Early work on motivation focused on ways in which people could be influenced to do something that the authority/ employer wanted - to employ more of their talent and effort for the benefit or the organisation (or the shareholders) (Vroom and Deci, '1970): Satisfaction theories (Porter and Lawler, 1968) Satisfaction depends on conditions of work, on morale (which is the expectation that the future will fulfil expectations). While satisfaction promotes job stability, there is little evidence that it improves productivity. lncreased productivity however may lead to increased satisfaction. lncentive theories The incentive most studied is money (but it is by no means the only one). lncentive theory works if an individual perceives the effort to be worth the reward; if the additional output can be measured and attributed to the individual; and if the individual wants that kind of reward. lntrinsic theories (based on Maslow, 1954) * Humans experience needs at different levels (physiological -, self-actualisation). lf needs are unsatisfied they motivate people to action. ln the present situation these needs may be at any level (e.9. actual hunger, to the need for self-actualisation). 2 I Theory X and Theory Y (McGregor 1960): - X: Most workers are lazy and lack ambition - so they need to be organised by a ruling class of managers. - Y: Organisations tend to make workers passive, but they naturally have some potential for initiative, responsibility etc. - managers have to unlock this. These theories depend on underlying assumptions about man (Schein's classification, 1965): . Rational-economic man: underlies Theory X - 2 types of people. ' Socia/ man'. we gain our sense of identity primarily from our relationships with others - so an understanding of these is of great importance in the work situation. . Se/f-actualising man: underlies Theory Y. ' Complex man'. man's needs and motives vary with time and situation, and he can often select them at will. ' Psychologicalman (Levinson1972): every person develops an'ego ideal'- strives towards this, as far as circumstances allow. Work is an important part of the 'ego ideal' - if opportunities are provided to approach the ideal, motivation follows. Further research shows more clearly how the individual makes decisions on how to appropriate/ allocate his/ her time, energy, talents. ln Handy's model (1976) 'motivation'should be regarded as the way in which individuals deal with individual decisions, to do or not to do something. This decision can be modelled like this: *( the individual's needs the'motivation calculus' - the individual decides how much'E'the to invest the results the individual wantsfeedback all of this takes place within a 'psychological contract' as well as 'circumstances of life and work' . 'E' refers to effort, energy, excitement, expenditure etc. ' This model assumes that people have some control over their destiny/ freedom of choice 'Needs'i n the model These can be classified in different ways: * Maslow's hierarchy: physiological, safety, belonging, esteem, self-actualisation. * Roethlisberger and Dickson (1951): physiological, safety, fair treatment, independence, achievement. * Herzberg (1966): in work situations there are factors which - dissatisfy (hygiene factors) - related to working conditions: 'why work here?' - satisfy (motivators) - related to achievement, recognition etc.: 'why work harder?' * McClelland (1961): people think according to their needs for power; for affiliation; for achievement. 3 r* Ardrey (1967): need for identity, security, stimulation. Each person has her/ his own set of needs; these change over time. There is a lot of evidence that people need to work, even if the rewards are very low. The oriqin of these needs - the factors that influence them x Heredity and early environment. * Education: changes models, and therefore needs. * Self-concept: an individuals' assessment of his/ her capacities, place aspirations (see also below). * Experience: clearly affects how needs develop. in society, The'Motivation calculus' in the model This is the mechanism by which we decide how much 'E' to spend. There are three elements to the calculation: * The strength of the need * The expectancy that the 'E'will lead to the desired result * The usefulness of the result - that it really will address/ reduce the need. Note here that. * The calculation can be unconscious or deliberate; it can take account of immediate or long-term results. * lf the individualjudges any of the three (strength of need, expectancy, usefulness) to be zero, motivation collapses. * Most decisions are not made this way but by precedent - but at some stage the decisions are made which set the precedents, and then the calculus probably operates at that stage. 'Resu/ts'in the model These must be specified, since without knowledge of the intended results it is not possible to complete the calculus. There must also be feedback about whether they have been achieved, or the calculus stops operating. The 'Psvcholoqical contract'in lhe mOdel This is a set of mutual expectations between the employer and the worker - what each expects from the other, and will give in return. lt is a kind of contract. Note in this regard: * Most individuals belong to different organisations, and fulfil some of their needs in one and some in another. * lf the contract is perceived too differently by the two parties conflict results. * lf they view the contract in the same way the 'motivation' becomes clear to both. There are different types of contract (Handy, 1976): x Coercive - the 'E' appears through fear of punishment, and will not last. * Calculafive - the most common form, usually used in industry (and the health service). Since the contract is voluntary, 'E' has to be paid for by the organisation in some way. * Cooperafive - the worker gets more say in goals and how to achieve them, which elicits 'E'. lt has to be voluntary though. Often more than one type of contract operates in an organisation at the same time. The implicafions of all of this are: . 'Motivation' happens when the psychological contract as viewed by the employer and employee is the same. . There is no one 'right' theory of motivation - each case is unique, for an individual in a given set of circumstances. . Changes pushed through in organisations involve changes in the psychological contract - and may therefore affect motivation. 4 I ' lf a calculation does not provide the desired results, the individual experiences drssonance, which brings with it stress. The individual copes by increasing 'E'; or lowering expectations; or deciding s/he doesn't need the result after all. Irrloney has a specific place as a motivating agent: ' lt operates within the calculus ('E' is expected to bring more money, which it is hopes will meet a specific need). , Money is all-embracing - it can meet a great many needs (but not all). ' Money is the basis for comparison. There is much evidence that equity (for which money is the evidence) is the need/ motivator here, rather than money itself. ' Money is a reinforcement: but only if it is tied to specific additional work, over a specific(short) time. ' ln the long run money is probably the simplest (and cheapest) way of rewarding people - rather than status, security or job satisfaction. Motivation theory helps one to understand how most individuals, given who they are, make decisions about their lives. So the nature of the person making the decision is crucial - but also very hard to understand. What makes him/ her to be what s/he is? ' The notion of self-concept (Mead '1 934, Horney 1951 ) is useful here - our needs are rooted in our self-concept. The way in which a self-concept is formed is not well understood: * lt comes largely from our selection of models early in life (at adolescence). ln today's society the choice of models is much wider than before.x The process of forming a self-concept is often traumatic (during adolescence). * As we grow older we fix on a self-concept - which we then protect, e.g. by having as friends those who accept it as valid. * DifferenU traumatic experiences can change our self-concept, always an uncomfortable process. * Commitments (to a specific role of job) shape and stabilise self-concepts (Becker 1960). ' Another useful notion here is psychological success (Argyris 1964). People seek to enhance their self-concepU increase their self-esteem by setting goals which enhance their self-concept, and achieving those goals usrng their own methods: * Experiences of success lead to feelings of competence, willingness to take risks in areas in which the person feels are important. * Experiences of failure tend to make an individual 'draw inward' to protect him/ herself, and breed low achievement. * The theory is that 'psychological success' becomes the main need for an individual - it is the way the other needs operate, since if they are met 'psychological success' is achieved. A person will only spend 'E' on an activity if it enhances her/ his self-concept, if it will bring her/ him 'psychological success'. Also, if s/he has not chosen the way to achieve the goal, less 'psychological success' results, and so less 'E'will be allocated. 5 1.2.2 About roles Role theory is a specific way of looking at the interaction the forces in a person: personality, skills the forces in her/ his surroundings Any person in any given situation occupies a role in relation to the other people in it The following well-known concepts in role theory form the background to any discussion: . Role sef: The other people in a given situation, around the 'focal person', with whom that person has a more than trivial relationship. . Role definition: A combination of the 'role expectations' that the members of the role set have of the 'focal role'. Role definition is often made clear by 'role signs': uniform, place, furniture etc. . Role ambiguity: When there is uncertainty in the minds of the members of the role set, or of the 'focal person', about her/ his role in a given situation: * For some 'focal persons' this is welcome - they like the space, the freedom. Others are stressed by it: uncertainty about responsibility, about others' expectations, about how one is to be evaluated, about advancement. * lf the role set is not clear about the role of the focal person, insecurity, irritation etc. may result. . Role incompatibility: When the 'role expectations' of the set are well known, but incompatible with the'focal role': * The focal person's boss and subordinates may have different expectations. x The focal person him/ herself may have different expectations from other members of the set. . Role conflict: The result of the need for a person to carry out more than one role (each of which is completely clear to all concerned) at the same time. lt is the differing nature of the roles that causes the conflict. . Role overload: A form of role conflict. Most people can handle some role conflict, but when it becomes too much role overload results (an inability to cope with the conflicting demands of the different roles). Note that this is not the same as 'work overload'. . Role underload: The role definition is out of line with a person's self-concept - s/he feels capable of handling a bigger role, or more roles. An important concept in role theory is role sfress - which may result from role ambiguity, role incompatibility, role conflict, role overload, role underload: Sometimes this stress is good, enhances performance - 'role pressure'. Sometimes it is harmful -' role strain''. * This has been shown to lead to the symptoms of tension (irritation, excessive attention to detail, excessive sickness etc.); to low morale; to difficulties in communication. * People use different mechanisms to dealwith role stress: - Unilateral strategies - redefining the role, without consultation. This may result in retaliation and an escalation of the problem. - Cooperative strategies - which require good relationships with colleagues (but note that role stress tend to undermine such relationships). 6 Three situations in particular have been shown to lead to role stress: * Respon sibility for the work of others: the higher the rank, the greater the stress. * lnnovative functions: power centres are conservative (even if they say they want innovation). * lntegrative/ boundary functions: the coordinator - becomes the focal point for the frustrations of others. Personality traits strongly influence people's ability to handle role stress: * Sociabilify: persons with deep-rooted work relationships handle stress better. * Emotional sensitivity: too much of it leads to more tension being experienced; too little of it produces bad relationships - and more stress. * Flexibility/ rigidity: the role set applies more pressure to people perceived to be flexible. ! I 1.2.3 About people within organisations A useful concept related to roles comes from organisational culture theory (Harrison 1972). Four basic organisational cultures are described: The pouzer culture It depends on a central power source, with influence spreading out from that figure; is highly political; puts faith in the individual; judges by results; is tolerant of means; thrives on insecurity and challenge. . The culture It develops pillars - departments with special functions and strengths; progression in each of these is possible; it is bureaucratic - the role is more important than the individual; rules are seen as crucial; it does well in a stable environment. The fask culture It is project or task oriented; groups of people get together to do jobs because they are skilled, not because of their place in a hierarchy; very adaptable; difficult to control; power lies where the stronger strands of the net intersect. The p culture This is rare. The individual is the starting point. lf there is a structure it exists only to support each individual in what s/he wants to do - a co-operative. The importance of these models is that particular individuals appear to be better suited to particular organisational cultures, and the roles that go with these. The questionof learning within an organisationis also relevant. Workers at all levels are going to have to learn to carry out new tasks. lt must be remembered that every vertical programme does this kind of training on a regular basis. ln connection with training: For learning to occur the individual must want to learn, must feel the need for it in her/ his work. ldeally s/he should volunteer to attend! Othenrvise s/he will comply (by attending) but not necessarily learn. Learning must be 'owned' - it must be seen to be close to the learner's work, in time and in content. lf learning is not immediately used it fades quickly. ! 7 ICompensafion within organisations is a central issue, since it is closely related to motivation However: Pay in most organisations is seen as compensation, not as incentive. Pay is what you get for doing something, rather than inspiring you towards greater achievements. lt only has that motivating effect when: * The reward follows closely on the improved/ additional performance, so the worker can see that the two are closely linked.x The differential (between the one who does the extra work and the one who doesn't) is considerable. Even if additional pay is offered, very soon the problem of equity comes in. Large differentials in pay for the same cadre are not tolerated in organisations - why should X get more pay because s/he happens to have this extra task, whereas I have other extra tasks for which I get nothing? Promotion (the other main method of compensation) - this is of relevance in the case of the nurses, but not the CDs. lf rewards such as promotion and more pay are not offered, the only remaining reward for effort is increased job satisfaction - but studies show that this effect, even if it exists, does not last beyond a short time. lt must be followed by a tangible reward. Praise in itself is also not an adequate reward. 1.3 Conceptual basis for the research It was decided to use Handy's model, as depicted in the diagram in Section 1.2, as the basis for coming to groups with the concept of 'motivation'for the present research. The findings of the present research led to a refinement of the model: adding the concept "circumstances of life and work" as a group of factors influencing motivation. 8 Chapter 2 METHODOLOGY 2.1 Study aim, research question, study design 2.1.1 Study aim To gain an in-depth understanding of the motivation of health care workers at different levels, to participate effectively in onchocerciasis control activities that have been assigned to them or for which they have volunteered. This understanding is necessary because local motivation will clearly play an important part in the successful continuation of control activities, when OCP has come to an end and is no longer a driving force and source of resources. 2.1.2 Research question The main research question is What a re the leve ls of motivation for CDT work n both comm un itv d stri buto rS (CDs ) and the h ea Ith cen tre eve n U rse S Wh o ta n and SE them? The following sub-questions follow: . What determines and influences this motivation? ' Are the levels of motivation sufficient for the work that needs to be done, to be carried out in the long term? 2.1.3 Study design Exploratory; descriptive, cross-sectional. Case studies: health centre nurses and community distributors 2.2 Population and sampling 2.2.1 Population The following persons concerned with implementing onchocerciasis control measures (especially CDTI), in the 11 OCP countries: r persons responsible for onchocerciasis control at district level ' persons undertaking CDTI activities at sub-districU health centre level . village level distributors. It was subsequently decided to focus on the last two groups. 2.2.2 Sampling The size of the sample was constrained by availability of finance for the study: ' 3 researchers, with an assistant each;2 vehicles for each team of 2. ' 1 month's work (in total), including planning (4 days) and analysis (1 week). This weeks for field work. 9 left about 2 The countries had to be sampled, giving a spectrum of: . Francophone-Anglophone health systems . Stronger/ weaker economies . Countries where CDTI is going well/ not going so well . Original programme areas/ extension areas Ghana Cote d'lvoire 86nin Within each country districts had to be sampled: those where CDTI is taking place - including ones: . Where the coverage is good, and where it is poor . Where CDTI is just starting, and where it has been going on for some time . Where the epidemiological situation is unsatisfactory (since CDTI will have to continue there for some time) . To represent different ethnic groups, if feasible. 1 district per team per week=4districtsper country Within each district sub-districts/ health centres had to be sampled: . Those with easy access, and those that are hard to get to/ far from the district or town . Those that have a small workload in terms of patient care and flllqgqs to visit, and those that have a large load. 4 sub-districts/ health centres per district (as many as can be done in a week) Within each sub-districU health centre catchment area villages with CDs had to be sampled: . A random sample (if villages are all more or less similar) . Taking into account access/ distance; compactness; population. 3 villages per sub- districU health centre (as many as can be done in one day) Practically speaking this meant a daily routine in the field of visiting:! one health centre/ sub-district (separate interviews with 1-2 staff members) . followed by 2-3 villages (interviews with CDs) At 4-5 working days per week (the rest taken up with travel) this gave a sample size of: . Per country: 4 district oncho. officers, 16 peripheral health workers, 48 CDs . Total: 16 district oncho. officers, 48 periphera! health workers, 150 CDs The number of CDs was eventually quite a bit higher, since many villages had two or more CDs 2.3 lnformation sources and instruments 2.3.1 Sources of information The following sources were used People involved in CDTI gave information about themselves and about others: * the district officers in charge of programmes (including onchocerciasis); the nurses/ technical officers a sub-districU health centre level, responsible for implementing CDTI in their areas; the village level CDs; the villagers who select the CDs * also the national onchocerciasis coordinator, the regional officer with responsibility for onchocerciasis, and the district medical officer. Documents and statistics related to the CDTI work in the districts concerned l0 2.3.2 Data collection instruments The principal instrument was a set of schedules for semi-structured interviews (see Appendix B). Data obtained were be recorded by hand, using patterned note taking where needed. lf more than one respondent of a level was present a focus group discussion was held, using the same instruments. 2.3.3 Pretesting the instruments The instruments were pretested in the L6o region of Burkina Faso, which is conveniently near Ouagadougou, and where there is a small CDTI programme operating. A few changes resulted. 2.4 Enhancing trustworthiness Steps were taken to enhance the trustworthiness of data collected, according to the accepted criteria in qualitative research: Criterion Step/ activity Credibility Triangulation: multiple sources, methods, investigations Analysis and discussion of differences between researchers and their find rngs Transferability I C lear reports of how the research process develops, how hypotheses were arrived at Confirmability Keeping a research journal Triangulation: multiple sources, methods, investiqationsa Qependability I Triangulation: multiple sources, methods, investiqations 2.5 Data analysis For each of the two levels of worker under consideration there were multiple sources of information(the interviews with themselves, and with the colleagues above and below them; also in some cases documentary evidence). ln each case: . The level of motivation for CDTI (= the amount of 'E' they were willing to spend on work related to CDTI) was determined, and categories of 'motivation' established (see Sections 3.1 and 4.1 ). ' The data from different sources were triangulated, to build up case studies for nurses and CDs. ' The factors influencing motivation were extracted from the stories of each case, counted, scored (on a scale of 1-3) and richly described. Qualitative data were entered and analysed using Word software. Biographical data and commonly recurring phenomena were analysed quantitatively using Excel software. ln the actual event only data from Benin were analysed (although they were collected in all three countries): . 14 health centre nurses . 58 community distributors. ll I Gha r 3 FINDINGS: NURSES 3.1 Nurses' level of motivation for CDTI As the data were being collected, a framework was developed to conceptualise nurses' motivation for cDTl, and then to assign a value to it. The following was the result: ln this model, 'achievement' was seen to consist of five elements: ' Coverage level: proportion of villages in the programme . Training of CDs: how well it was done . lvermectin supply: whether shortages happen . Supervision of CDs: how frequently, how well done ' Opinion of the community, the CDs, the district supervisor about the nurse's work Factors influencing motivation were similarly identified and classified as the field work proceeded(see Section 3.2 below). The model was tested and refined iteratively during the course of the research. For the 14 health centre nurses in the sample the following was found: Motivation level of nurses medium motivation levels high o -o E 7 6 5 4 3 2 1 0 low __) Fewer than half of the nurses were found to be highly motivated for CDTI - a finding with important implications for the sustainability of the CDTI programme. The five elements of achievement score high a vatedHiohlv factors and relativel few obsfac/esThere are man fa I nAveraoe Facilita factors and obsfac/es of moderate Average levels of achievement I vatedPoorlv Ail efive e entsm achieof entvem red low orone two be a e( may verag faThe cilita arefactors few and obsfac/esthe m r-Ir I-I II I t2 n 3.2 Factors influencing nurses' motivation for CDTI Using the methodology described in Chapter 2 above, the factors promoting or hindering motivation for CDTI were explored. The following should be noted: . The factors promoting and hindering motivation are termed 'facilitators' and 'obstacles' in the ensuing discussion. . Six groups of factors presented themselves from the data, for both facilitators and obstacles. These groups are related to: * The community within which the nurse worked * The personality of the nurse * The nature of the job (of a nurse, in implementing CDTI) * The health service within which the nurse worked * The nurse's biographical particulars (past life and experience) * The financial situation of the nurse. There is inevitably some degree of overlap between these categories. ln summary, their relative strength was found to be the following: Factors affecting motivation in nurses 6 4 3 2 o to G' o o o- o) '6 = 5 Efacilitators I obstacles 0 conmrnity health service personality biographical the job f inancial category of factor ln this diagram the term 'weight per case' is an indication of the strength with which that group of factors influences motivation for CDTI. The following scoring system was used: \)- z- l= the factor was one of the group that had the most powerful impact on motivation the factor had a lesser but definite impact on motivation the factor is but seems to have had little im ct on motivation r3 1 a These factors operate at different points in the motivation model of Section 1.2.1 above * Psychological contract Needs of/ results for the nurse Circumstances of life/ work. The data below make it possible to understand the motivation of nurses involved in CDTI at a deeper level. Only some of these factors are however realistically amenable to change. ln the discussion following each group of factors is dealt with. * Quantitatively: in the form of a table which illustrates the nature and relative strength of facilitators and obstacles related to that factor. * Qualitatively: in the form of a discussion, illuminating the facilitators and obstacles in more detail, and based on qualitative data obtained from the full range of sources. 3.2.1'Community' factors Table 3.1 'Community'factors influencing nurses' motivation for CDTI Factor Where it works Weightper case aL o o .= o(! ll A qood relationship with the community Psycholoqical contract 1.3 5.1 Feels appreciated by/ integrated into the community ' Needs of/ results for the nurse . Psycholoqicalcontract 1.3 Villagers are keen on the treatment - expensive but free Psychological contract 1 1 Knows people in the community who can help Circumstances of life/ work 1 1 Afraid her/ his reputation will suffer if s/he doesn't do the distribution well Needs ofl results for nurse 0.3 a o o(! ott o CDs nag about payment, or are jealous of her/ his salary Psychological contract 1.4 5.4 CDs often not available - occupied with personal affairs . Circumstances of life/ work . Needs of/ results for the nurse 1.3 People in villages are illiterate - hard to persuade them ' Psychologicalcontract . Needs of/ results for the nurse 1.1 CDs need to be policed all the time, to do the work . Psychologicalcontract . Needs ofi results for the nurse 1.0 Problems with communication - doesn't speak the vernacular Circumstances of life/ work 0.4 Conflict with the community/ leaders won't cooperate freely . Psychologicalcontract . Circumstances of life/ work 0.2 The group of factors most commonly and strongly influencing motivation were those related to the community within which the nurse was working. The overall effect of the obstacles was only slightly more than that of the facilitators. Nurses'task was made easier by a good relationship with their local communities - thus improving their motivation for CDTI. This required nurses to work through accepted community authority l4 structures, both traditional and administrative [30]. They were rewarded with cooperation for taking trouble to get to know the leadership [41] and to make use of other influential persons [34; 35]. tt was noted that a situation of social peace made the work easier [33]. Even villages which were slow to cooperate at the beginning soon became involved [34]. lt helped if the nurse spoke the local language well [43] or was working in the place where s/he had been born and bred [42]. ln one or two situations the local authorities were not very helpful [34]. This was in one situation related to the rather isolationist culture of a local tribe [36], and in another to the fact that the community wanted more than one round of treatment per year [40]. A few nurses could not speak the local language, and had to rely on translators in their dealings with patients and communities [12, 35]. This naturally made their CDTI work more difficult. Communities noticed and appreciated nurses who liked 'mixing in with them, and acting the way they do' [33], or who were always available in the health centre - and responded with cooperation [36]; on the other hand nurses were aware of the need to succeed with the CDTI, for the sake of their reputations [37]. ln such situations the nurses felt accepted and appreciated[12;30; 40] and enjoyed living in the community concerned [36]. ln one case villagers even presented the nurse with harvest produce as a gesture of thanks [37]. The fact that the ivermectin was being supplied free of charge had a very positive effect as well. The cooperation of village leaders was fostered by it [35], and villagers even came to ask for it to be given more frequently [37]. The nurses felt good about offering something for free, so that everyone could benefit [29]. Finally many CDs themselves felt proud to be associated with offering this free benefit to their communities [37]. All of this made the task of the nurses that much easier. Concerning obstacles to motivation, by far the most powerful group in the entire study was the attitude and conduct of the CDs - a combined 'weight per case' of 3.7. The CDs wanted to be paid [41] and expect the nurses to be their advocate to achieve that [35]. CDs suspected nurses of getting extra money for the CDTI work [41] or of holding back fees due to them [42] - after all CDTI is a 'project' and other projects come with money [43]. Although the nurses appreciated the justice of the CDs' claims [a3] they got worn down by the constant nagging [a3]. They were equally frustrated by the need to police CDs constantly - e.g. regarding reports that were late, or ivermectin that was not fetched [37; 38]. The fact that many CDs were only available after hours(since they work in their fields by day) was also a frustration [34]. t5 3.2.2'Health service' factors Table 3.2 'Health service'factors influencing nurses' motivation for cDT! Factor Where it works Weightper case aL o(! E 'o G tL The health service provides her/ him with the necessa ry transport and fuel . Circumstances of life/ work . Psycholoqicalcontract 1.7 4.2 S/he is regularly supervised/ encouraged by her/ his superiors, with respect to CDTI . Circumstances of life/ work . Psycholoqicalcontract 0.8 The health centre/ district covers all expenses incurred in CDTI Circumstances of life/ work Psycholooical contract 0.6 Her/ his predecessor oriented her/ him well, handed on necessary documentation Circumstances of life/ work 0.6 CDTI is included in her/ his official 'basic package of activities' Circumstances of life/ work 0.5 o o E(E o o Lack of resources (transport, fuel) - late/ insufficient . Circumstances of life/ work . Psychologicalcontract 1.2 4.4 Poor means of long distance communication, so wastes time travellinq Circumstances of life/ work 1 1 Promises about per diems not kepU not reimbursed . Circumstances of life/ work . Psychologicalcontract 0.8 Supervision for nurses' CDTI activities is relatively poor . Circumstances of life/ work . Psycholoqicalcontract 0.7 CDTI not included in 'basic package of activities' Circumstances of life/ work 0.6 Aspects of the health service strongly affected nurse motivation regarding CDTI, facilitating and obstructing motivation in more or less equal measure. Among these factors the issue of transport stands out. ln situations where transport for CDTI was available and paid for there was generally a positive attitude [35; 37; 38]. The transport (usually a motorcycle) could be hired [35], or be provided by the health centre itself [37] or by the EPI programme [38]. Funding - i.e. money for fuel - could also be from a variety of sources. The health centre often had to top it up from its own revenue [35] since the funding from the district was almost always too little. Often funding was only available for one of the aspects of CDTI (e.9. training) and not for others (e.9. supervision) [12]. ln some cases the transport was either absent [29] or objectively too little - even though its was used in an integrated way, and planned in advance, it simply could not cope with all the programmes that had to be run [12]. Not surprisingly a constant battle to obtain transport had a negative effect on motivation. The lack of other resources needed for CDTI similarly had a negative effect on motivation, by making tasks more onerous. The staffing level at a health centre might be too low to cope with all the programmes that need to be run 112). A shortage of ivermectin could equally cause problems: 'l didn't have enough tablets, so the communities who weren't treated weren't pleased with me. lt was demotivating. And I can't help it, it's the fault of the higher levels' [30; also 36]. A related theme was the lack of telecommunications. Since the post was not dependable and in any case took too long [12], nurses had to spend a lot of time driving to meetings or delivering messages - up to 25% of their working time [34]. l6 Supervision of CDTI activities by district and national level staff was also important as a motivator [13; 36]. Such supervision worked by helping the nurses to solve problems in the field [30], or simply by encouraging the nurses in their work [42]. ln several cases supervisory visits to health centres did take place, but CDTI was not on the supervisors'agenda [34; 36]. Failure to supervise adequately was sometimes due to a lack of transport at district level [35]. The willingness of nurses to engage in CDTI activities was in some cases clearly linked to their perception that the programme had been officially approved [38; 39] and had become an integral part of health centre's activities [33]. As a result nurses felt obliged to work on it [39]. This waslhe case in spite of the fact that CDTI had not yet been officially included in the list of basic activities for health centres [34]. 3.2.3'Personality' factors Table 3.3 'Personality'factors influencing nurses' motivation for cDTt Factor Where it works Weightper case th L o G .= '6 (! LL S/he is interested in working with the commun and likes it Needs ofl results for the nurse 1.6 4.1 S/he is public-spirited, wishes to protect the commun Needs ofl results for the nurse 1.4 S/he takes ride in doi her/ his ob well Needs of/ results for the nurse 0.6 Her/ his family members have suffered from onchocerciasis Needs of/ results for the nurse 0.6 oI o(! a -oo S/he has too many interests outside her/ his work; s/he is often away from work Needs ofl results for the nurse Circumstances of life/ work 0.7 1.6 S/he is not interested in this aspect of her/ his work Needs of/ results for the nurse 0.6 Her/ his morale is low - feels the Ministry treats her/ him shabbi . Psychologicalcontract . Needs ofl results for the nurse 0.3 The personality of the nurses had a marked effect on their motivation - considerab ly more positive than negative A strong motivating factor was an interest that the nurse had in working with the community. Such persons enjoyed the community contact [40] or found the concept of 'prevention is better thin cure' attractive [30; 39]. Others however were simply not very interested in this aspect of their work -preferring MCH, for example [38]. As a result they might not undertake all the component activities of CDTI properly - e.g. neglecting to send reports 1251. Otners were perceived as being generally slow, this being ascribed for example to being near retirement age [a1]. yet others naO io .rnyinterests or activities outside their health centre work that this wai OounO to have a negative effect on their motivation for CDTI. This showed itself in absences of up to 30 days per yearLn family or community affairs [30; a1]. ln a related theme nurses spoke of pride in doing their work well: 'You have to love your job, that,s what makes a man' [39]. They spoke of it being a matter of pride to achieve high'coverage [33]and of the obligation they felt to make CDTI work, since it is a State programme and the Orr! idgiven free [37]. Supervisors spoke of the 'professional conscience' oi a particular nurse t3gli of t1 itv ly nurses being conscientious and meticulous l42land dedicated to the job [13]. There were however a few cases where nurses appeared to be suffering from low morale - expressing feelings of being exploited and underpaid [30; 41]. Several nurses showed clear signs of public spiritedness, which motivated them to be involved in CDTI - wishing to protect people from suffering [39], and more specifically from blindness [12; 13; 371; and in so doing feeling useful to society [41]. ln a few cases actual family members of the nurse had suffered from onchocerciasis [34]. 3.2.4'Biographical' factors Table 3.4 'Biographical'factors influencing nurses' motivation for CDTI Factor Where it works Weightper case aL o G .= '6 o tL S/he has general experience as a nurse in charqe of a health centre Circumstances of life/ work 1.4 3.4S/he knows CDTI, has been trained in it, has worked in it Circumstances of life/ work 1.4 S/he has previously taken part in mass distribution of ivermectin Circumstances of life/ work 0.5 oI o(! o -oo S/he knows nothing about CDTI, has never been trained in it Circumstances of life/ work 0.4 1.1 A woman - not respected by the CDs Circumstances of life/ work 0.4 S/he is new to the iob Circumstances of life/ work 0.3 Biographical factors, i.e. the nurses'life and work history, affected motivation much more positively than negatively. Having experience as a nurse in charge of a health centre made it easier to manage programmes such as CDTI [34; 40]; on the other hand a lack of experience made some nurses more tentative [33; 39]. The training that the majority of nurses received in CDTI gave them confidence [many examples]; others however had recently been transferred, had not yet been trained and didn't really know how to go about the job [29; 33]. One had been trained but had clearly not mastered the essentials of CDTI in spite of it [43]. The experience gained as member of a team undertaking mass distribution of ivermectin in previous years familiarised some nurses with many aspects of CDTI [13; 34]. ln one case a nurse had heard about the onchocerciasis control programme while still at school, and was therefore interested in it [33]. The fact that the nurse was a woman made it more difficult in some cases to command the respect of CDs, leading to lower motivation [38]. t8 3.2.5 'Job'factors Table 3.5 'Job'factors influencing nurses' motivation for CDTI Factor Where it works Weightper case o(! LL S/he is only responsible for a few villages Circumstances of life/ work 1.3 1.3 oI o(! o o Many villages, distant hamlets, access difficult, poor roads Circumstances of life/ work 1.4 2.6S/he is often away on official business, so too little time Circumstances of life/ work 0.9 S/he has a heavy administrative burden Circumstances of life/ work 0.3 The majority of nurses were reportedly undertaking the full range of CDTI activities expected of them. However the nature of the job in a number of cases affected the motivation of the nurses - negatively rather than positively. The most significant negative effect on motivation was due to the fact that there were too many villages in the area to visit (such as the encampments of nomads) [34] or that the roads to some of them were not suitable for motorcycles [36]. In a related theme, if villages were very diffuse CDs were continually complaining and asking for money 141)- a constant irritation to nurses, who could do nothing about it. Conversely nurses with few villages to cover naturally found the task easier t38l Another theme was that the nature of the nurses' job at the health centres in many cases required them to be away from the workplace for significant amounts of time - up to 80 or 90 days per year [36, 43]. The purpose of these absences might be to collect fuel (e.g. for the fridge); to fetch/ change expired vaccines; to bank monies; for special meetings; for any large-scale 'actions', e.g. the polio vaccination; to cope with sudden demands for information; for emergencies etc. t34]. lf more than one programme was on at a given time some CDTI activities might be left out - e.g. supervision of distribution [34]. The nurses' administrative burden could also be heavy at times - so 'if another job came on top of the usual load there is less motivation' [33]. The relative priority of CDTI in the job Nurses were asked to list the activities they regularly undertake as part of their work, and to prioritise them in terms of their importance, and the amount of time they take. The following was found: Average number of work-related activities undertaken: 4.0 t9 Table 3.6 Priority ratings for nurses'work-related activities Work-related Activity Priority rating out of 4.0 Curative care EPI Management Maternal health IEC CDTI Leprosy proqramme 1.0 1.5 2.0 2.1 2.2 2.9 3.1 ln spite of a likely amount of politeness bias (since it was known that the researchers were 'from the oncho programme')the priority given to CDTI is low. Nurses were also asked to give the reasons for prioritising their activities in the way they did. The following was found: Table 3.7 Reasons for assigning priorities to activities Activity Reasons for assigning a particular priority Hiqh oriority activities . Curative care . EPI . Management . Maternal health a a These are the common activities, which involve lots of patients These are the activities which keep me busy every day. These activities are the raison d'6tre of the health centre. Low prio ritv activities CDTI Leprosy programme These activities I carry out seldom - they take little time. These activities deal with conditions which are rare, even if they are serious. The reasons for assigning a low priority to CDTI are clear. lt took place infrequently, and was seen as rather peripheral to the core activities which are the raison d'6tre of the health centre: curative care, EPl, maternal health and management. 3.2.6'Financial' factors Tabte 3.8 'Financial'factors influencing nurses' motivation for CDTI Factor Where it works Weightper case o(E l! S/he has enough other sources of revenue (e.9. spouse works) . Needs ofi results for the nurse . Circumstances of life/ work 0.8 0.8 o -go G o o S/he has dayto-day problems in making ends meet . Needs of/ results for the nurse . Circumstances of life/ work 0.2 0.4S/he has a heavy family load/ responsibility . Needs of/ results for the nurse . Circumstances of life/ work 0.1 20 Salaries were regularly paid but they were low: an lnfirmier de Sant6 started at FCFA 34 000 a month ($ +S1, and an lnfirmier Diplome de l'Etat at FCFA 44 000 ($ SS). Thereafter an increment of only FCFA 2 000 ($ 2.S01 every two years was usual. lt is therefore contrary to expectations that financial factors appeared to have little effect on nurse motivation, and that the influence of this effect on motivation was more positive than negative. ln the health districts visited nurses were allowed to earn money in their spare time, as long as this didn't detract from their work [12]. Almost all nurses did this, usually in the field of agriculture, or sometimes commerce; more often than not they hired labour to do the work for them, and only became involved themselves after hours or on weekends [34; 39; 41; 42]. Their spouses also earned: in salaried jobs, by manual work, by trading etc. [33; 37; 42]. Most nurses therefore reported coping financially, generating an overall family income at a reasonably satisfactory level. There were cases however where failure of agricultural enterprises and heavy family commitments made it hard to make ends meet, resulting in a worrying level of personal debt [35; 37]. 2t Chapter 4 FINDINGS: COMMUNITY DISTRIBUTORS 4.1 Community distributors' level of motivation for CDTI As the data were being collected, a framework was developed to conceptualise CDs' motivation for CDTI, and then to assign a value to it. The following was the result: 5 Hiqhly motivated . The three elements of achievemenf score high. . There are many strong facilitating factors, and relatively few obsfac/es (of which the majority are objective). Difference between '4' and '5': '4' has slightly lower implementation levels, and a few more subjective obstacles than '5'. 4 3 Averaqe motivation . Average levels of achievement . Facilitating factors and obsfac/es of moderate strength 2 Poorly motivated . All three elements of achievement are low (one or two may be average). . The facilitating factors are few, and the obstac/es many (with several being subjective). Difference between '1' and '2': in'2' there is clearly some goodwill/ volunteerism. 1 ln this model, 'achievement' was seen to consist of three elements: . Coverage rate: for the village and associated hamlets . The future: how strongly the CD wants to continue in the job . The nurse's opinion: of the CD's work and dedication. Factors influencing motivation were similarly identified and classified as the field work proceeded (see Section 4.2 below). The model was tested and refined iteratively during the course of the research. For the 58 CDs in the sample the following was found: Motivation level of CDs 16 14 12 r- 10 oll E) I 6 4 2 0 tr low low-med medium med.-high motivation levels high III I II II I 22 There is clearly a significant proportion of CDs with low or medium levels of motivation for CDTI - an important factor to consider in planning for the sustainability of the programme. An analysis of the factors underlying this situation is clearly necessary, in order to be able to manage the problem. This analysis is undertaken in the following section. 4.2 Factors influencing community distributors' motivation for CDTI Using the methodology described in Chapter 2 above, the factors promoting or hindering motivation for CDTI were explored. The following should be noted: The factors promoting and hindering motivation are termed 'facilitators' and 'obstacles' in the ensuing discussion. Six groups of factors presented themselves from the data, for both facilitators and obstacles These groups are related to: * The community within which the CD worked * The personality of the CD * The nature of the job of implementing CDTI * The health service supporting the CD in her/ his efforts * The CD's biographical particulars (past life and experience) * The financial situation of the CD. There is inevitably some degree of overlap between these categories. ln summary, their relative strength was found to be the following: Factors affecting motivation in CDs 6 5 o o Go o CL .9, o 3 4 3 I facilitators r obstacles 2 1 0 brographrcal cornrnunity types of factor personalrty the job financial heatth servtce 23 rl 3 = the factor was one of the group that had the most powerful impact on motivation 2 = the factor had a lesser but definite impact on motivation resent, but seems to have had little im1 = the factor is act on motivation I ln this diagram the term 'weight per case' is an indication of the strength with which that group of factors influences motivation for CDTI. The followin scofln tem was used These factors erate at different ints in the motivation model of Section 1.2.1 above The data below make it possible to understand the motivation of CDs involved in CDTI at a deeper level. Only some of these factors are however realistically amenable to change. ln the discussion following each group of factors is dealt with: * Quantitatively: in the form of a table which illustrates the nature and relative strength of facilitators and obstacles related to that factor. * Qualitatively: in the form of a discussion, illuminating the facilitators and obstacles in more detail, and based on qualitative data obtained from the full range of sources. 4.2.1 'Job'factors Table 4.1 'Job'factors influencing CDs'motivation for CDTI Factor Where it works Weightper case aL o G ='6 o LL Village small (<501 habitants) and/ or compact Circumstances of life/ work 1.2 2.8 S/he has been well trained Circumstances of life/ work 0.8 S/he has the transport s/he needs Circumstances of life/ work 0.4 Only one distribution done so far - still enthusiastic Needs of/ results for the CD 0.4 o o o G o -oo Village large (<1000 habitants) and/ or dispersed Circumstances of life/ work 2.5 4.6 S/he doesn't have the transport s/he needs Circumstances of life/ work 1.0 Several distributions done discouraqed getting Needs of/ results for the CD 0.5 S/he has too many commitments, so is not coprnq Circumstances of life/ work 0.4 The most important group of factors affecting motivation are those relating to the nature of the CDT|job. The overall effect is considerably more negative than positive. A very important obstacle to motivation was the magnitude and difficulty of the task. One element of this problem was the size and layout of the village and surrounding hamlets or encampments. One village had no less than 12 of these, at some distance - not surprisingly they were excluded from the distribution [95]. ln another the hamlets were up to 30 km away [69]. Some villages were l * * * Psychological contract Needs of/ results for the CD Circumstances of life/ work. 24 small and compact [71] but others large and dispersed, with a diameter of 5 km or more 11121. Geographical features compounded the problem: 'lt was in the season of floods, so we had to walk and go by boat - it was very difficult to walk, but we still tried't1061. Other irritants included difficulties with the community: 'Some people, although you make an appointment you find they've gone to the fields'[81]; also having to spend a lot of time persuading those who are reluctant to take the treatment [92]. lt was also hard personally: having to work at night (using one's own torch and batteries) [98] and ' When you get home from the fields you don't rest, you go to do the distribution, and then people give us trouble we well'1122). One reported that his health had been affected: 'You go far, you get tired, there's nothing to eat, you go on foot with the rod. I came home seriously sick'[110]. The situation got worse when CDs resigned, since that increased the work load of the remaining ones: 'He's alone - the second one gave up, and he is also the Guinea worm volunteer'[135]. As a result'..we haven't the time to work well'[112]. Not surprisingly CDs complained that'oncho takes us too much time and energy' [8g] and that they 'never knew it was going to be such a big task't1001. lnitial enthusiasm soon flagged in several cases: 'ln 1997 they were very good; in 1998 and 1999 - horrible. At the start there was goodwill, but at this time they are discouraged and unmotivated - not interested, so they don't wani to do it any more'[109]. CDs report that'you wear yourself out, nothing for transport, for the distance. Last year I borrowed a bike for it - but this year .' [111]. The absence of a reward also had its effect: 'The first distribution was well done because we thought something would follow. But when it didn't come we lost our enthusiasm for the work'[120]. As a result'l'm no longer prepared to wear myself out'[135]. On the other hand it appeared that repeat distributions were easier than the first ones: 'At the start it is hard. Now it's getting easier, the sensitisation has been done'[104], and: 'Some refused after the first round, due to the side-effects. These were better the second time around' [1 10]. This would have a positive effect on motivation. ln view of the distances to be covered the issue of transport strongly affected motivation. CDs who had access to bicycles [115] or motorbikes [114] found the task much easier - although sometimes 'a bicycle is not enough'[115]. ln some cases the motorbikes were the personal pioperty of the distributor [100; 107]; in others they were made available by a different programme, such as that for Guinea worm [106]. Far more commonly however CDs complained of difficulties with transport: 'l don't have a bicycle and it's difficult to go to treat the farms' 1123t. Many CDs had to meet transport expenses from their own pockets - to go to the health centre [g7] or for petrol for a motorbike 11121. This was bad for motivation: 'l don't have transport and I can't pay for it. lf it goes on like this we'll get tired' [73]. Training for the job was a smaller factor, generally positive in its impact. Training provided CDs with the confidence to tackle the job: 'The nurse taught me briefly . and gave me the rod. lt's not difficult'[100]. The duration of training varied a lot: from 15 minutes tO7] to one hourwith a family [96] to a short course with visual aids [101]. Much 'training'was 'on the job', working with the nurse [91] or simply learning from another CD: 'l follow the other one and I help him with what he does .. I wasn't trained' 1123).ln one case the nurse also left written instructions [91]. ln some cases there was no practical training at all: 'l got showed how to do the book, and was then given the pills and given_ a date by which to finish' [98]. Not surprisingly some CDs felt their tiaining had been insufficient: 'l didn't know that you have to keep tablets for people who are absent - no-one told me that'[128], and that they needed more training: 'We want to be retrained, we want to understand how to give, how to sensibilise the community so they understand what onchocerciasis is'[116]. These variations did not however appear to have a bad effect on performance (and motivationj. This may be because communities were already used to taking ivermectin, after the mass distribution campaigns. 25 4.2.2'Personality' factors Table 4.2 'Personality'factors influencing CDs' motivation for CDTI Factor Where it works Weightper case oL o o .= o G LL S/he feels respected, proud Needs of/ results for the CD 1.6 5.4 A track record of voluntary service Psychological contract 1.6 Feels bound by the decision to serve Needs of/ results for the CD 1 1 A feeling that it is right to serve ' Needs ofl results for the CD . Psychologicalcontract 1.0 og o o o -o o S/he wants money for what s/he is doing Needs of/ results for the CD 0.9 1.6S/he is not being paid, so will not exert him/ herself Needs ofl results for the CD 0.5 Factors within CDs' personalities strongly affected their motivation to perform the work required by CDTI. The overall effect was much more strongly positive than negative. An important source or motivation was the pride that CDs feel in doing the work. This already started at the time of selection: 'They applauded me in front of the public'[103]. The reasons for this feeling were many. CDs felt that this appointment gave them status and respect in the village: 'People take us like nurses in the village, it gave us a big name . I can even be offered a wife! .. lt gives me a name - that's the biggest thlng'[98]. Others felt proud to be helping their families [119]. The fact that'. people know the effectiveness of the product'[117] and that'.. the product is free, I can give it to all, without asking for money'. [93] contributed to the feeling of pride. ln one case this was linked to the fact that the CD felt inadequate, because of a physical handicap which made it impossible for him to work in the fields [115]. Villagers themselves report that: 'We are proud of what they do - it's only they who would do it'[101]. A further important element contributing to CDs' motivation to undertake CDTI, was the fact that CDs felt they had an obligation to carry out what they had undertaken to do: 'lf you said you're going to do it you'll do it correctly'['110]. This might have to do with an internal conviction or standard of behaviour '. because of the promise. I sometimes say to myself, I'm a fool. lf you've promised you have to deliver' [85]; or the need not to lose face: 'They do it despite themselves. They have been designated in public, so there is an obligation on them. The chief was there and the mayor'[105]; or the obligation of kinship: 'The villagers chose me; if I say no, they'll say, he doesn't want to do anything'1112); or an appreciation of the need: 'lf you've decided to do it you do it - if you regret it, it means there's no love' [92]. A further element of personal motivation was the moral conviction that some CDs clearly had, that CDTI in itself was a good thing to do. This feeling could have a religious basis: 'You work for God, on Gods' side' [97], or 'God forbids us to think only of ourselves' 1102). One CD stated that his Baha'i faith compelled him to do this work [103]. CDs clearly felt the moral obligation to love and serve their village community: 'We're here, we will do it for the wellbeing of the village' [107]; 'Why carry on really? lt's love of the village' [110]; 'For my village, always I'll sacrifice myself for them' [115]. This feeling could extend even more widely: 'We are for our commune, for our sous- pr6fecture, for our country' [1 16]. Another aspect was the ethical need to protect the community by 26 preventing the disease: 'The tablets help eye sickness. lf we use them people won't get sick't1091. This protection would prevent serious consequences: 'This is a good thing. I don't want the population to be blind, they must be saved'[104]; 'Blindness is something very serious because if you lose your vision you have lost everything'[125]. As a result of this conviction it happened that a CD'was attracted by the work and gave himself to it'[101], and was'very motivated and doesn't ask for anything' [1 31]. ln a related theme, many of the CDs were involved in a variety of voluntary activities, for the benefit of their communities. This general goodwill made it natural for them to accept the new task: 'lt didn'tworry me. lt's my kind of work, lwas in agreement'[107]. ln some cases the volunteerism was especially directed towards health related projects: 'They were already sacrificing themselves for PHC. She helps with all the programmes, that's whytheywere chosen with this one'[106]. One CD explained that'l'd like to do even more health work in the village - it pleases me to do it' [93]. Examples were volunteer work at the health centre [101]; membership of a health committee l1O2l;the Guinea worm programme 177) and EPI [87]. Other CDs were involved in a variety of community development programmes: secretary of the local agricultural union, literacy teaching [116], school and community development committee membership [92], working for the water pump committee, running a reading club [102]. Being involved in a number of activities meant that these might have different priorities in the lives of CDs. CDs were asked to list the voluntary activities in which they take part, and to prioritise them in terms of their importance for them. The following was found: Ave e number of tasks that CDs erform as volunteers: 2.5 Table 4.3 Priority ratings for CDs'voluntary activities Activity Priority rating out of 2.5 School committee Literacy programme Agriculture committee Community development group Guinea worm programme CHW/ TBA programme CDT! EPI/ polio immunisation Health cooperative/ committee .0 .1 .4 .5 .5 .6 .7 o .1 1 1 1 1 1 1 1 1 2 ln spite of a likely amount of politeness bias (since it was known that the researchers were 'from the oncho programme') the priority given to CDTI is relatively low. There are three main reasons for giving CDTI its particular priority level. Firstly CDTI is seen to deal with a serious disease 11261.Secondly it is a temporary yearly activity, whereas others go on all year t1271. Thirdly work in bOft is not rewarded financially: 'He is also president of the agricuttural union and the health insurance group, which positions bring in money, so he preferred to do it - this is voluntary'[99]. The issue of rewards being given for other programmes is discussed in detail in 4.2.3 below. On the negative side, a strongly recurring theme was the need expressed by many CDs, to be paid(or at least rewarded in some way) for their work. Most took a fairly balanced view: 'We need something to encourage us: training, money to make good the time you used. lt is voluntary work, but if there is also an encouragement we do it well. lt should be like other programmes'[104]. This 2l statement illustrates all the main issues raised by CDs in this regard. Economically valuable time was being used to perform CDTI: 'He's discouraged by the lack of remuneration. There's nothing in it. Time is lost there, others are in the field for that time, one week is lost'[104] (this issue is dealt with in more detail in Section 4.2.3 below). There is the question of recognition and encouragement, rather than a formal wage: 'You know it's voluntary work, but if they could find a present for us it's encouraging' 1117). lnterestingly the money that CDs ask for is often called 'a motivation' - '. you need encouragement - three days to do a job, with no "motivation"' [99]. The amount need not be much: '. a little bit of financial reward - not a lot' [103] and other forms of reward were also mentioned: T-shirts [102] or help with transport [1 1 1]. For some of these persons there was also the question of justice/ fairness: 'Now us, we get nothing - so we are slaves who will work and get nothing. lt's necessary for our life, to eat' 11121. ln a few cases the need to be paid was beginning to take the form of an ultimatum: 'He also demands payment' 1128);'He needs to be motivated otherwise there will be trouble . he won't continue long without "motivation"' 11221. Such CDs could be very insistent: 'They ask for money all the time, even write letters'[95]. ln spite of the moderate tone of most of these remarks one senses an underlying core of frustration and discouragement. ln some cases this resulted in a clear decision to spend less 'E' - for example by only doing part of the job: 'He fetches everything regularly; no pills are lost. But he has to be pushed to give his report'[110]. ln other instances the CDs from a village distributed in the village because it was easy - but decided not to bother with the surrounding Peulh hamlets [95]. Enthusiasm waned: 'He started out enthusiastic, but the job is too big for his available amount of goodwill, in the face of his great need of money for his family' [109] and in many reported cases CDs had decided to give up the job: 'He's not doing it because there's no money in it' [111]. 28 4.2.3'Financial' factors Table 4.4 'Financial'factors influencing CDs' motivation for GDTI Factor Where it works Weightper case aL o(! E '6 (o tL Hopes to earn money in future Needs of/ results for the CD 0.6 1.7Hopes to make a career of health work Needs of/ results for the CD 0.6 Other sources of revenue besides agriculture Circumstances of life/ work 0.5 og o G a -oo The work uses economically valuable time . Circumstances of life/ work ' Needs ofl results for the CD 1.1 2.9 Other programmes give financial rewards . Psychologicalcontract . Needs ofl results for the CD 0.7 A big family, income from agriculture only . Needs of/ results for the CD . Circumstances of life/ work 0.7 S/he has to go away at times to work Circumstances of life/ work 0.3 Financial considerations were the third most important group of factors influencing motivation - considerably more negatively than positively. A number of CDs reported being motivated by the prospect future reward for the work they were doing. This started from the time of being selected: 'At that moment I had nothing, I thought this might be a way for me' [111] - or as another CD put it, 'They may do something good for me - I'm a high school graduate without work. Something may come of it' [1 15]. Some soon accepted the fact that their expectations were misplaced: 'l was happy, I thought I was going to earn something, but I understood later that there was nothing' [122). Others kept hoping, almost despite themselves: 'He has the hope that for the good he does, one day he'll get something' [9S]. ln yet other cases the hope changed into disillusionment, when it became clear that the reward was not forthcoming: 'lt's bad because it was on the basis of that hope that we started' [85]. ln a few cases CDs had the wider hope of an eventual career in health work, stemming from their present involvement: 'He'd be happy to do other health projects, elsewhere - on a permanent basis; that's very important to him' [93]. ln a number of cases CDs were relatively secure financially, which afforded them the luxury of spare time for good works. ln one case the CD worked as a freelance photographer for all the villages around; he also had a small soap making business and a chicken farm, and as a result owned his own motorbike 11021. Another was a successful farmer and ran a village pharmacy, while his wife made good money from a small business t1101. In other cases however CDs' financial worries were great: being unable to make ends meet from agriculture, and with a large number of dependants - this resulting in poor performancetgg]. A young CD reported that: 'lt's difficult because even my parents don't like it when I leave the fields. They don't understand' 1121). A very significant obstacle to motivation was the perception that the job used up economically valuable time. From the data provided by the CDs it emerged that the time reportedly taken for distribution was much longer than expected: 14.4 days on the average (with a range of 3 - 60 days). ln 88.5% of cases the CD did house-to-house distribution; in only 11.SYo the villagers came 29 together in a central place. Following up of absentees by repeat visiting took a lot of time. All parties mentioned the economic loss repeatedly. CDs spoke about times '.. when there is no food because I've been out'[107], and'.. another difficulty is money. lt does take one away from work in the fields' [116]. A group of villagers reported that the CDs'. work for 3-4 days without going to their fields - it's amazing. They are peasants who work in the fields - they lose time to do the work well'[101]. A nurse reported that'.. you have to appreciate the work of the distributors because they lose by it'[117]. This led to CDs feeling that'l don't like the fact that you have to leave other things undone, and find nothing in it'[135], and the need for compensation: 'lt's good to fight against onchocerciasis, but we leave our fields and we have to be compensated for that' [130]. As a result the work was in some cases not fully done: a CD refused to complete the register, because he was going to miss time in the field and there was no reward, so he sent it to the nurse to do [103]. A particular irritant to CDs was the fact that many other health-related programmes provided tangible rewards to villagers involved in them. This affected their motivation to do CDTI work: 'l regret taking this on when others I know get something and I get nothing'[111]. A nurse reported that: '. it's the problem of the "motivation" - for projects which have that there isn't a problem' 1117). The feeling of injustice was exacerbated by the fact that CDTI is more onerous: 'The polio was easier, yet lgot something'[105]. Rumours of payment for CDs in other areas also did not help: 'There are those who say that in Zou the distributors get something. The day they told me that I said, they are encouraging those'1112). The Guinea worm programme was mentioned especially. 'The Guinea worm volunteers get: a yearly party; transport; per diem; some money too' [1 12]. This clearly affected the relative motivation of villagers towards the two programmes: 'When you look at remuneration Guinea worm is more important, but the two are really the same - blindness is a serious matter'[135]. The general feeling of CDs was well summarised as follows: 'We need something to encourage us: training, money to make good the time you used. lt is voluntary, but if there is also an encouragement we do it well. lt should be like other programmes' [104] 4.2.4'Community' factors Table 4.5 'Community'factors influencing CDs' motivation for CDTI Factor Where it works Weightper case oL o G' .= o(!tr Chosen by the community, or by a respected person Psychological contract 0.9 2.3A well organised, supportive community ' Psychologicalcontract . Circumstances of life/ work 0.7 The community has really suffered; reports of healing . Circumstances of life/ work . Needs of/ results for the CD 0.7 og o(I, o -oo Community not involved - s/he works alone Psychological contract 0.7 1.6 Community doesn't understand, doesn't co-operate ' Psychologicalcontract . Circumstances of life/ work 0.5 People think s/he earns money, which is hurtful . Needs of/ results for the CD ' Psychologicalcontract 0.3 30 CDs' motivation for CDTI was considerably affected by factors in the community. These tended to have more positive than negative effects. The fact that CDs were selected or appointed by people with authority appeared to motivate the CDs strongly. They felt that this made them recognised by the villagers: 'They applauded me in front of the public'[103]. ln some cases the process sanctioned by OCP was followed: 'The delegue asked for volunteers at a meeting, three volunteered, the villagers were happy'[104]. ln many other situations different processes were followed. CDs might be 'designated by the chief of the village'[119] or'appointed by the king and the sages, without his being there'(the CD being a member of the royal family) t981. As a result villagers might feel estranged: 'They were chosen by someone high, so they don't know us down here' 1112). Often the health centre nurse took the initiative: 'The nurse approached me and said, you are available, you are liked, it's for the good of the community, it's just a few weeks' work - so I agreed' [102]. Nurses made use of their contacts in the community for this purpose: one CD was chosen by the nurse because the nurse knew his father, and therefore the family [91]. Replacements were sometimes chosen in this way: 'The nurse called me when the first distributors left' [83]. lndividual villagers themselves might do the selection - another CD: 'One of the distributors is an asthmatic and doesn't get to do the work. So his deputy came to look for me' 11171 or a TBA: 'l was appointed by the midwife with the knowledge of the chief [75]. lt should be noted that many CDs who were appointed in these unorthodox ways still performed well. The attitude of and support from the local community directly influenced CDs' motivation to work in CDTI. Support from the village leadership was helpful: 'With us here there is no problem. The involvement of the "d6l6gu6" is enough to ensure a good job'[131]. A history of successful community development activity in the village was also helpful [102]. ln such cases villagers felt a common responsibility to help: 'You [the health service] don't need to do anything - you've put in an effort by supplying the drug. We have to do the rest'[116]. ln some instances community groups bore all or some of CDs'work-related expenses: 'The village co-operative gives him a litre of petrol when he goes to the Gandos. They paid for everything: the book, the pen, the rod' l1O2). ln another case a villager lent the CD his bicycle for the work [93]. One village even paid its CDs some money for each distribution [98]. The enthusiasm of the villagers was appreciated: 'We like those families who are all ready, who want to be first' [97]. Villagers themselves report following up their CD if he missed them [91]. On the other hand negative community attitudes had a bad effect on CDs' motivation. ln some cases the community appeared not to care, Ieaving the CDs to soldier on by themselves. This could begin at the time of selection: 'At the meeting to elect them many were there, many were not' [109]. This neglect could be benign:'They take the product but they are a bit indifferent'[87] but also destructive: 'They say: leave it, there's nothing in it, you have a job! The only encouragement is from the school principal'[115]. ln other cases people were slow to respond. Whole villages could refuse to cooperate, in spite of numerous meetings - giving as reasons that they were farmers and therefore too busy; that there was no-one literate; that they wanted money [108]. The same could be true of individuals: 'You have to be patient: to sensitise, to visit several times again'[101]. ln some cases people were suspicious: a distant hamlet with a different ethnic group seemed to think the CD was trying to poison them -'so it's hard, and therefore often doesn't get done't1131. Villagers also mocked CDs for their efforts, 'becoming "nurses" and earning no money'[116]. Such attitudes made the work more difficult. One CD tried to get everyone in the same place but it didn't work [102]. Another couldn't use the town crier to announce a distribution because he would ask for money [112]. CDs 3t complain that ' people are always doing other things, so you have to change your programme - it's a nuisance' [99]. There was trouble if the distribution took place during times of planting or harvest Ie5] ln several communities villagers thought that CDs earn money for the work: 'They think we are earning money for it - a lot, that's what they say'[105]. As a result'the people are envious, they think you're doing it because you earn something'11171. CDs find this particularly hurtful: 'At times when we go there they think we are paid, they insult us. You have to have sang froid, to explain to bring them to their senses't110]. ln some cases the villagers don't believe the explanation: 'The comhunity thinks that we get a large sum, and they don't believe our denial'[111]. The overall result was that'people discourage us' [109]. 4.2.5'Biographical' factors Table 4.6'Biographical' factors influencing CDs' motivation for CDTI Factor Where it works Weight per case a o o .= '6 o lJ- Previous experience of/ training in health work Circumstances of life/ work 1.2 2.6Secondary education easier makes the task Circumstances of life/ work 0.8 S/he has a smallfamily (<5) Circumstances of life/ work 0.6 thI o6 o -oo S/he has a physical handicaP Circumstances of life/ work 0.1 0.2 S/he is illiterate Circumstances of life/ work 0.1 Biographical factors had a smaller, and very largely positive, effect on CDs' motivation. Several CDs had previous experience of health work in the community. 'l'm interested in health - I'm involved in other programmes and activities. That's why the nurse had to take me for this work' [93]. Some had been previously trained as VHWs and TBAs: 'l'm already a VHW, and I'm used to i,rnOting medicines.'[120]; 'She was appointed long ago at a meeting with the mayor present, to be trained as a TBA;t10-61. Another was'a Guinea worm volunteer, that's why lwas chosen. I know the place, I know the hamlets, I do the work well' [112]. These experiences clearly made the work easier, and were therefore good for motivation. The level of CDs' education could affect the ease with which they were able to do the job, and consequenly their motivation. CDs who were completely or partly illiterate had particular difficulty: 'l'm heid Oact< Oy the fact that I can't read or write' [127), and:'They need the teacher to support them with writing - they can't do the reports properly' [95]. ln some cases this could not be helped: there were so few suitable candidates for DC in villages that more or less illiterate ones had to be taken t113]. This was not however an insuperable obstacle: 'His level of education is not really what is needed, but he tries hard' [71] and ' Although he can hardly read or write he's the enthusiast in their litle team't1131. -onversely a higher level of education generally made life easier. lt could be the reason why-particular persons were chosen: 'She was known as reliable; also they can read French and calculate'[106]. lnterestingly many villages were obliged to select young persons, even teenagers: 'Us young ones - we are well known, we can read and write, now 32 we work in the village, we do the public work'[105]. Such persons could become overloaded though. Finally a few smaller obstacles. One CD was reportedly 'held back by her status as a woman, and she is also timid by nature. This makes it difficult for her to confront some things' 11271. Others hadto resign for reasons of ill health: lameness [115] and asthma 1117). One was very late in completing the distribution because of a severe attack of malaria [116]. Yet another had a stammer, which made health education difficult [126] 4.2.6'Health seryice' factors Table 4.7 'Health seryice'factors influencing cDs' motivation for cDTl Factor Where it works Weightper case aL o(! =(.) o tJ- S/he feels the nurse appreciates and supports him/ her . Psychologicalcontract . Needs of/ results for the CD . Circumstances of life/ work 0.6 0.9 S/he is scared of the nurse, who is rather bossy ' Psychologicalsupport . Needs of/ results for the CD . Circumstances of life/ work 0.3 aI o(! o -oo Little appreciation/supporUsupervision from the nurse . Psychologicalcontract . Needs of/ results for the CD . Circumstances of life/ work 0.5 0.8 Ivermectin not available at times Circumstances of life/ work 0.3 Factors related to the interaction between the CD and the health service had a relatively small effect on CDs' motivation. Some CDs appreciated support given by the health service. This could be at the level of the State: 'The essential thing is that the State is supporting us in the matter of the struggle against this serious disease. Someone is taking trouble with our health, for free' [137]; or at the level of thehealth centre nurses - being 'close to them', and feeling that the training had been good [93].Others reported being happy that '. the side-effects are well and cheaply treated at the health centre'[116] and that they were supplied with a handout containing the necessary facts [98]. One was evidently in awe of the nurse, on whom he depended for his supplies as a CHW: 'lf he doesn't do that his boss can make life hard'[110]. On the other hand there were CDs who harboured negative feelings about the nurses who were supposed to be supporting them. Some reported not being supervised properly [95] and not receiving re-training as promised [91]. Others suspected that the nurses were holding back monies due to them [93; 129) or were upset because they had been promised'something'at the time of training, which never materialised [85; 113]. Others were angry because they were not asked to help with the polio campaign, which carried some financial reward [109]. ln one or two cases CDs reported some frustration at not receiving enough ivermectin tablets for the work they needed to do: 'Still people come and ask me, why didn't you give it to me? what's wrong? lsay, the pills are too few'[105]. -1J 4.3 Applying the knowledge gained: a case study The farmer from M'b6t6koukou . His only income is from the fields. He has some secondary education. . He has been working as a CD for three years. They do one distribution per year. ' The villagers know what it is to suffer from onchocerciasis. . The coverage is 65%, and the nurse is more or less happy with his performance His needs . He believes he's protecting his people from blindness. . He serves in other capacities: is a Guinea worm volunteer and a trained VHW . From past experience he knew it was going to be a big job. Results for him so far . Only the satisfaction of knowing he's helping, that he's keeping his word The circumstances of his life and work , There are hamlets - up to B km away. . People refuse to take the ivermectin. . He has to leave his work in the fields to do the distribution The psychological contract between him and the village , The villagers appointed him - but now appear indifferent, don't help him at all So what about his 'E'? . Moderate coverage only. . He won't do the report without being nagged. . He now seriously expects some reward: help with transport, and payment . His level of motivation: 'medium'. , He is still willing to carry on - so far .. The level of motivation for CDTI has now identified and clarified, for CDs and health centre nurses in Benin. The factors influencing such motivation have similarly been studied and clarified. ln the next chapter the ractical a lication of this knowled ts 34 Ghapter 5 DISCUSSION AND RECOMMENDATIONS The aim of the research is to gain sufficient insight into the question of motivation, to be able to manage it in a practical way. This insight has now been gained. Managing 'motivation' implies two processes: 1. Diagnosing situations where there is a problem with low motivation.2. Taking remedial action, based on the understanding gained of how motivation works. Once cases with low motivation have been identified, steps need to be taken to improve matters Such a plan needs to be governed by the following principles: ' Particular emphasis should be placed on factors which are known to be important - i.e. which have a higher'weight per case'. ' Factors which are known to facilitate motivation should be emphasised and strengthened. . Obstacles to motivation should be removed as far as possible. ' The realities of the situation have to be taken into account: personal characteristics, resource limitations, official regulations etc. 5.1 Dealing with low motivation for CDTI in nurses It is the responsibility of managers at the district level to manage motivation of nurses at health centre level. lf it is a widespread problem (which is likely to be the case) higher levels of staff(provincial and national) also need to be involved. lt should be noted that problems with motivation for CDTI may well be repeated in other programmes requiring the mobilisation of community action on a regular basis. 5.1.1 Diagnosing low motivation for CDTI in nurses It is suggested that the diagnosis of poor motivation be made on the basis of a nurse's performance in carrying out her/ his CDTI duties. The following adaptation of the model developed during the research could be used for this purpose: !g11e! of performance Performance area High=2 Medium=1 Low=0 Coverage level: Are all villages and hamlets lncluded in the proqramme? Ail included villages One or two not included More than two not included Training of CDs: Has this been done regularly and systematically? Allwelldone Some not well done Generally not welldone lvermectin supply: Have there been any shortages in the villages? No reported shortages Shortages once or twice Regular shortages Supervision of CDs: ls this done regularly and constructively? Several visits per year, supportive attitude One or two visits, only to scold No visits at all Opinion of other partners (community, CDs, district supervisor) about nurse's CDTI work S/he works well in all respects Some aspects of work not welldone Work generally not well done Overall score (out of 10) 3,s Scores of 7 or lower should give rise to concern, and point to the need for action. lf performance is poor it is likely that there is also a shortage of motivating factors, as well as too many obstacles to motivation. These then have to be dealt with in a systematic way, so that motivation may be improved. This is the subject of the next section. lt must be stressed that these suggestions are particularly relevant to the situation in Benin, and may be less so in other OCP countries. 5.1.2 Dealing with low motivation for CDTI in nurses The principles for planning an intervention have been stated above. Such interventions may be: . Specific, for a particular case. ln that case a specific diagnosis first has to be made, and the checklist in Section 5.1.2.1 may be used for this purpose. A specific intervention may then be planned, using the guidelines in Section 5.1.2.2. . General: lf motivation is a big problem managers may choose to skip the step of diagnosis, and implement the guidelines in Section 5.1.2.2 directly. 5.1.2.1 ldentifying factors causing problems with motivation The following checklist is closely based on the findings of the research (see Chapter 3). lt contains a selection of factors which affect motivation, which are both important and amenable to some form of management intervention. lt can be used as a diagnostic tool, to plan a specific/ targeted intervention to increase nurses'motivation for CDTI. The table leads into a list of specific activities that may be undertaken, in Section 5.1.2.2. a. 'Community' factors Yes/ Partly/ No Nurse has a good relationship with the community Nurse feels appreciated by/ integrated into the community Village rs are keen on treatment - the tablets are costly but free Nurse knows people in the community who can help Yes/ Partlyl No CDs naq about payment, or are jealous of the nurse's salary CDs are often not available, being occupied with perso nal affairs Villagers are resistant to CDTI - it is hard to pe rsuade them CDs need to be policed all the time, to do the work Are any of the following facilitators of motivation present? Are any of the following obstacles to motivation present? lf statements are marked 'Partly' or 'No' go to 5.1.2.2.4 below lf statements are marked 'Yes' or 'Partly' go to 5.',1.2.2.4 below 36 ? Yes/ Partly/ No Health service provides her/ him with the transport and fuel needed S/he is regularly supervised by superiors, regarding CDTI The health centre/ district covers all expenses incurred in CDTI Predecessor oriented her/ him well, qave relevant documentation CDTI is included in her/ his official 'basic package of activities' Yes/ Partly/ No Lack oI resources (transport, fuel) - late/ insufficient Poor means of long distance communication, - wastes time travelling Promises about per diems not kepV not reimbursed Supervision for nurses' CDTI activities is relatively poor CDTI not included in 'basic package of activities' b. 'Health service'factors Are any of the following facilitators of motivation present? Are any of the following obstacles to motivation present? c. 'Personality'factors Are any of the following facilitators of motivation present? Are any of the following obstacles to motivation present? d. 'Biographical'factors Are any of the following facilitators of motivation present? Are any of the following obstacles to motivation present? lf statements are marked 'Partly' or 'No' go to 5.1.2.2.8 below lf statements are marked 'Yes' or 'Paftly' go to 5.1.2.2.8 below lf statements are marked 'Partly' or 'No' go to 5.1.2.2.C below lf statements are marked 'Yes' or 'Partly' go to 5.1.2.2.C below lf statements are marked 'Partly' or 'No' go to 5.1.2.2.D below lf statements are marked 'Yes' or 'Partly' go to 5.1.2.2.D below Yes/ Partly/ No S/he is interested in worki with the communi and likes it S/he is public-spirited, wishes to protect the community S/he takes pride in doing her/ his job well Yes/ Parllyl No S/he has too many interests outside work; is often away from work S/he is not interested in this aspect of her/ his work Her/ his morale is low - feels the Ministry treats her/ him shabbily Yes/ Partlyl No S/he has ral experience as a nurse in charge of a health centre S/he knows CDTI has been trained in it, has worked in it Yes/ Partlyl No S/he knows nothin about CDTI has never been trained in it A woman - not cted the CDs S/he is new to the job Yes/ Partlyl No es, distant hamlets, access difficult oor roadsMan vill S/he is often on official business, so has too little time e. 'Job'factors Are any of the following obstacles to motivation present? lf statements are marked 'Yes' or 'Partly' go to 5.1.2.2.E below 5.1.2.2 Actions which are likely to improve nurse motivation for CDTI These suggestions are closely based on the findings in Chapter 3. They may be used selectively, as indicated by the checklist in Section 5.1.2.1 above, or as a whole. A. Action to imorove'Communitv' related motivation for nurses The following action on the part of the nurses is required: . Working at her/ his relationship with the community : * Being highly available for consultation in the health centre * Treating community members with respect at all times - avoiding seeming to feel superior to them. . Building up relationships with influential/ literate/ active people in the commuity, who can support the CDTI work. . Greater sensitisation of villagers about the benefits of CDTI. . Regular unhurried discussions with CDs about their problems. . Never promising CDs any reward (financial or otherwise) unless it is 100% guaranteed. DMT supervisors have to arrange a meeting with the nurses concerned, where they help nurses to make personal plans to brinq about these chanqes. B. Action likelv to improve 'Health service' related motivation for nurses The following action on the part of the DMT supervisors is required: . Making a specific transport plan for each health centre, in co-operation with the staff there: * Making sure that available transport is used in an integrated way. * Making provision for transport costs, for at least two visits per distribution - trying to get the health centre to agree to meet this expense . lmproving supervision of CDTI: * lncluding discussion on CDTI during in supervision visits to health centres: e.g. How was the coverage? Are there enough active CDs? ls more training/ sensitisation needed? * Making and using a supervision checklist which includes all preventive/ community based programmes (including CDTI of course). . Making sure newly transferred nurses are properly trained/ oriented about CDTI. . Making sure each health centre has an official document which states that CDTI is an essential part of the health centre's work. . Optimising communications between the district headquarters and the health centres. . Never making promises about money (e.9. per diems) unless the funds are guaranteed. . Making sure there is enough ivermectin for each distribution. 38 t DMT SU pe rViSO rS have to convene a meeting with n ursES, to devel op a )ot n t integ ra tedtransport p lan fo f comm un itv prog ra mm eS rU n by the hea Ith ce ntres n cl U ding costing a DMT SU pervrso rS have to COnVC ne th e IT own meeting h th plw ere ey a n mp roVEmen ts tn th e othe r activities sted above (S upervision o rienta tion of newly tra n S ferred nurs ES docum enta ry SU ppo rt for C DTI nicatiocom mu nS ith hea Ith CE n tres fu n d ng tve rm ecti nI S U The following action on the part of the DMT supervisors is required: ' lmproving nurses' morale, to make them feel more positiveiy about community work:* - Giving positive feedback to nurses about their wort</ efforts - praise where it is due, not onlyfor CDTI but for all preventive programmes. * Arranging a function once ayeat where nurses are thanked, with dignitaries present. The following action on the part of the cDs and viltagers is required: ' Thanking nurses periodically for what they do forlhem, in the preventive programmes DIMT supervisors have to convene activities listed above their own meeting, whe re they plan how to implement the C. Action to improve'Pe onalitv' motivation for NUTSES DMT Supe rviSO rS haVE to CONVEne th e ir own meeti ng Where they p lan a n a ch to CDs vi to pproa ES en CO e them to SU rt the health cent re n UTS ES n th e man n e I d ES C rI bed ba ove D. Actio to improve 'Bioqraoh I'related m ivation for UTSCS DMT supervisors have to con activities listed above vene their own meeting, where they plan improvements in the The following action on the part of the DMT superuisors is required: ' Making sure that newly transferred nurses are properly trained/ oriented towards CDTI - also lyrses newly promoted as nurse_in_charge ' Making sure thatthe training is really effective - that the nurses really understand CDTI. ' Boosting the credibility of female nuises, in their dealings with the community. The following action on the part of the nurses is required: ' Asking for training/ clarification if they are not sure about any aspect of the programme. The following action on the part of lhe DMT superuisors is required: ' ldentifying nurses who have a more difficult task: more villages/ villages difficult of access/ villages with few literate people/ groups resisting co-operation. ' ldentifying cases where the administrative burden of nurses is unnecessarily heavy. DMT SU perviso rS haVE to co nVE ne a meeti ng WI th nurse S where they plan togethe howI to roVE commu n ication abo ut ra mmES betwee n them E. im u 39 tVaking a plan to give these nurses extra help. DMT supervisors have to activities listed above convene their own meeting, where they plan improvements in the The following action on the part of the nurses is required: ' Asking for help from the district if the burden is too big for them - if they can see it,s greaterthan that of surrounding health centre areas ' Training more cDs in large villages, or for distanv larger hamlets DMT S upe rvi SO rS have to convene a meet ng with nursES, wh e re th lan toge the toim emen t th im ts ey p I e men S u sted d bove. 40 5.2 Dealing with low motivation for CDTI in CDs It is the responsibility of health centre nurses, as well as managers at the district level, to manage motivation of CDs. lf it is a widespread problem (which is likely to be the case) higher levels of stift(provincial and national) also need to be involved. lt should be noted that problems with motivation for CDTI may well be repeated in other programmes requiring the mobilisation of community action on a regular basis. 5.2.1 Diagnosing low motivation for CDTI in CDs It is suggested that the diagnosis of poor motivation be made on the basis of a CD's performance in carrying out her/ his CDTI duties. The following adaptation of the model developed during the research could be used for this purpose: Level of performance Performance area High=2 Medium=1 Low=0 Coverage level: ls the coverage rate for the vil e and hamlets satisfacto Over 70o/o 60 to 70% Less than 60% The future: Is the CD planning to continue with the work? S/he really wants to Yes, but S/he is likely to give up soon Opinion of nurse about CD's CDTI work S/he works well in all respects Some aspects of work not well done S/he needs to be changed Overall score (out of 6) Scores of 4 or lower should give rise to concern, and point to the need for action. lf performance ispoor it is likely that there is also a shortage of motivating factors, as well as too many obstacles to motivation. These then have to be dealt with in a systematic way, so that motiv'ation may be improved. This is the subject of the next section. lt must be stressed that these suggestions areparticularly relevant to the situation in Benin, and may be less so in other OCp countries. 5.2.2 Dealing with low motivation for CDTI in CDs The principles for planning an intervention have been stated at the beginning of the chapter. Such interventions may be: ' Specific, for a particular case. ln that case a specific diagnosis first has to be made, and the checklist in Section 5:2.2.1 may be used for this purpose. A specific intervention may then beplanned, using the guidelines in Section 5.2.2.2. ' General: lf motivation is a big problem managers may choose to skip the step of diagnosis, and implement the guidelines in Section 5.2.2.2 direcfly. 5.2-2.1 ldentifying factors causing probtems with motivation The following checklist is closely based on the findings of the research (see Chapter 4). lt contains a selection of factors which affect motivation, which are both important and amenable to someform of management intervention. lt can be used as a diagnostic iool, to plan a specific/ targeted intervention to increase CDs' motivation for CDTI. The table leads into a list of specific acti-vities that may be undertaken, in Section 5.2.2.2. 4l Yes/ Partly/ No The CD has been well trained The CD has the transport s/he needs Yes/ Partlyl No The village is large (<1000 habitants) and/ or dispersed The CD doesn't have the transport s/he needs The CD has too many commitments, so is not coping a. 'Job' factors Are any of the following facilitators of motivation present? Are any of the following obstacles to motivation present? b. 'Personality'factors Are any of the following facilitators of motivation present? Are any of the following obstacles to motivation present? c. 'Financial'factors Are any of the following facilitators of motivation present? Are any of the following obstacles to motivation present? lf statements are marked 'Partly' or 'No' go to 5.2.2.2.4 below lf statements are marked 'Yes' or 'Partly' go to 5.2.2.2.4 below lf statements are marked 'Partly' or 'No' go to 5.2.2.2.8 below lf statements are marked 'Yes' or 'Partly' go to 5.2.2.2.8 below lf statements are marked 'Partly' or 'No' go to 5.2.2.2.C below lf statements are marked 'Yes' or 'Partly' go to 5.2.2.2.C below Yes/ Partly/ No The CD feels respected, proud The CD has a track record of voluntary service The CD feels bound by the decision to serve The CD has a feelinq that it is morally riqht to serve Yes/ Partlyl No The CD wants money for what s/he is doinq The CD is not being paid, so will not exert him/ herself Yes/ Partly/ No The CD hopes to earn money from CDTI in future The CD hopes to make a career of health work Yes/ Parllyl No The work uses economically valuable time Other programmes give financial rewards 42 Yes/ Panlyl No The CD was chosen by the community, or by a respected person The CD has a well organised, supportive community Yes/ Parllyl No The community is not involved - the CD works alone The community doesn't understand, doesn't co-operate with the CD People think the CD earns money, which is hurtful d. 'Community'factors Are any of the following facilitators of motivation present? Are any of the following obstacles to motivation present? e, 'Biog ra ph i c a l' factors Are any of the following facilitators to motivation present? f. 'Health service'factors ls the following facilitator of motivation present? Are any of the following obstacles to motivation present? lf statements are marked 'Partly' or 'No' go to 5.2.2.2.D below lf statements are marked 'Yes' or 'Partly' go to 5.2.2.2.D below lf statements are marked 'Partly' or 'No' go to 5.2.2.2.E below lf statement is marked 'Partly' or 'No' go to 5.2.2.2.F below lf statements are marked 'Ygs' or 'Partly' go to 5.2.2.2.F below 5.2.2.2 Actions which are likely to improve GD motivation for CDTI These suggestions are closely based on the findings in Chapter 4. They may be used selectively, as indicated by the checklist in Section 5.2.2.1above, or as a whole. A. Action to improve'Job' related motivation for CDs The following action on the part of the nurses is required: . Ensuring that when new CDs are selected: * They are not already over-committed. * Help with their transport needs is negotiated right from the start. ' Ensuring that enough CDs are selected to cope with the workload in large villages, or villages with many hamlets - that additional ones are selected if necessary. Yes/ Parllyl No The CD has TEVIOUS rience ofl traini in health work The CD has seconda education which makes the task easier Yes/ Partly/ No The CD feels the nurse appreciates and supports him/ her Yes/ Partly/ No There is tittle reciation/su ervision from the nurse lvermectin is not available at times 43 DMT supervisors have to arrange a meeting with the nurses concerned, where they help nurses to make ersonal lans to about these chan Ensuring that new CDs are welltrained, using official training materials and procedures. Conducting refresher training for CDs who appear to lack knowledge and skills - negotiating with all parties (villagers, health centre committee, DMT) to obtain the resources for such training. The following action on the part of the CDs is required: . Negotiating with villagers to help them with the transport they need Nurses run a short course for CDs, to teach them negotiation skills. This may be done as part of initial training, or as refresher training. DMT supervisors may need to help nurses to plan such train B. Action to improve 'Personality' related motivation for CDs The following action on the parl of the CDs is required: . Negotiating with the villagers to provide them with the equipment they need and to help them cover the expenses they incur in the work. Nurses run a short course for CDs, to teach them negotiation skills. This may be done as Part of initial training, or as refresher training. DMT supervisors may need to help nurses to plan such trainin The following action on the part of lhe villagers is required: . providing COs with the equipment the need and helping to cover the expenses the CDs incur when they carry out the distribution. . providing CDs with some form of tangible reward on a yearly basis, for their CDTI work for the village. . Thanking CDs periodically for what they do for them, publicly and officially. Nurses enter into negotiations with village leadership a nd key figures, to discuss ways in which the vil ers can tm ment these actions The following action on the part of the nurses is required: . lmproving CDs' morale, to make them feel more positively about their work: * ' Giving positive feedback to CDs about their wor[</ efforts - praise where it is due. * tr4aking sure that CDs understand how much their community benefits by what they do. * Encouiaging villagers to provide some kind of tangible reward for CDs for their CDTI work, on a regular basis. * Negotiating with the DMT to provide some form of tangible reward for CDs for their work, on i yearly basis - e.g. in-service training, T shirts, an official letter of thanks. DMT supervisors have to arrange a meeting with the nurses con about these chanto make rsonal lans to bri es. cerned, where they help nurses 41 C. Action to improve 'Financial' related motivation for CDs The following action on the part of the CDs is required: . Negotiating with the villagers to provide them with the equipment they need and to help them cover the expenses they incur in the work. Nurses run a short course for CDs, to teach them negotiation skills. This may be done as part of initial training, or as refresher training. D[VT supervisors may need to help nurses to plan such trainin The following action on the parl of lhe villagers is required: . Providing CDs with the equipment the need and helping to cover the expenses the CDs incur when they carry out the distribution Nurses enter into negotiations with village leadership and key figures, to discuss ways in which the vill ers can im ment these actions The following action on the part of the nurses is required: . Encouraging villagers to provide some kind of tangible reward for CDs for their CDTI work, on a regular basis. . Taking care never to promise rewards for CDs, unless these are 100% guaranteed. DMT supervisors have to arrange a meeting with the nurses concerned, where they help nurses to make rsonal lans to bri about these ch ES The following action on the part of DMT superuisors is required: ' Giving priority for CDs with suitable qualifications, in allocating training places for auxiliary nurses. . Making an overall plan for the district, in which the rewards offered by different health programmes to community members are harmonised. DMT supervisors need to arrange a meeting, where they formulate policy regarding these two matters D. Action to improve'Community'related motivation for CDs The following action on the part of the CDs is required . Negotiating for better support form the community. N urses run a short course for CDs, to teach them negotiation skills. This may be done as part of initial training, or as refresher training. DMT supervisors may need to help nurses to plan such trainin The following action on the part of the villagers is required: . Supporting the CDs and their work as much as possible Nurses enter into negotiations with village leadership and key figures, to discuss ways in which the villa rs can i lement these actions 45 The following action on the part of the nurses is required: . Making clear to villagers that the CDs do not get paid by the State for carrying out CDTI . Ensuring that CDs are selected from as broad a base of support as possible. E. Action to imorove 'Bioqraphical' related motivation for CDs The following action on the part of the villagers is required: . Making sure that suitable persons are selected to be CDs: * Past experience of health work is helpful, but they should not be over-committed * Their educational standard should be sufficient for the tasks of CDTI. Whenever new CDs have been selected, nurses discuss these issues with the village leadership and the village at large, at public meetings. DMT supervisors need to discuss these criteria with nurses, durin initial or in-service traini F 'Health service' The following action on the part of the nurses is required: . Expressing appreciation for the CDs' work regularly. . Giving positive feedback to CDs about their wor[</ efforts - praise where it is due . Ensuring an adequate supply of ivermectin for the CDs. DMT supervisors have to arrange a meeting with the nurses concerned, where they help nurses to make rsonal lans to bri about these chan es. DMT supervisors have to arrange a meeting with the nurses concerned, where they help nurses to make I lans to brin about these chan 5.3 Practical considerations Regarding the way in which lt should be noted that there are two principal groups of actions that need to undertaken, at different levels in the CDTI programme: . Actions that make the programme work better, thus making the work easier and motivating workers in that way. This is why some of the actions designed to motivate CDs will also tend to motivate nurses. The actions operate on the level of 'Circumstances of life and work'. . Actions which directly motivate workers, by providing moral and material support. These actions operate on the levels of 'Needs ofl results for CDs and nurses' and 'The psychological contract'. The actions to be taken may also be divided into two main groups, from the practical point of view: . Training at different levels. The content is determined by the problems identified through the checklist. This content is valid not only for in-service training, but also for initial training in CDTI. . Meetings between managers and other levels. The agenda is determined by the problems identified through the checklist. The course of action set out above is based on findings in the field. lt will however have to be implemented and evaluated before it can be considered valid. This means setting up an experiment, in which the intervention is applied in one or more areas and the results compared with those of control areas. 46 5.4 The way forward This report deals with the situation in Benin only. The data for Ghana and Cote d'lvoire need to be analysed in the same way as the data for Benin, and the similarities and differences explored. lf the situation is not very different the findings and suggested interventions are probably applicable to the majority of OCP countries. lf not, the research will have to be repeated in other countries - not only to expand our understanding of motivation and its determinants, but also to develop the methodology further. It should be noted that this research and its findings are likely to have some application programmes which operate at village level, using village volunteers: . Onchocercrasis; CDTI programmes operating in APOC countries. . Cataracf: case finding and aphakic motivators ' Trachoma: azilhromycin administration and education for the SAFE strategy . Low vision due to refractive error: case finding . Lymphatic filariasis; administration of ivermectin and albend azole . Guinea worm: case finding, education and follow-up . HIV/AIDS: education and home-based care in other Many more could be added. The critical issue here is the need to understand the realities of the lives of village volunteers, and to negotiate their involvement with insight and respect. 4l APPENDICES Appendix A Plan for field work in Benin . NOTE: All data collection instruments, stationery, supplies etc. will be ready in advance. . OCP will inform the WR in advance that the research is going to take place. . Health districts and health centres in them to be sampled in advance, so that health centre staff and CDDs (community directed distributors) are prepared for the visit. This will happen through the OCP network. . Sufficient funds for subsistence will be brought from Ouagadougou. . Dr Gaba (national coordinator) is in The Hague from 4-12 December, so will not bsaround to help at the time of the research. Friday 3 December . travel to Cotonou Saturday 4 December . IRSP: meet with Prof d'Almeida and fellow researcher; discuss protocol and practical details Sunday 5 December . travel to Parakou Monday 6 December - Friday 10 December . Week for field work in health districts in two northern districts: * in two separate equal teams, each having a vehicle and consisting of a researcher and a driver * districts to be worked in selected in advance (having low CDTI coverage) Monday: visit regional directors and medical officers in charge of the two northern districts selected: interviews, and sampling of 4 health centres Tuesday to Friday: data collection * start day at a health centre, interviewing nurse who trains and supervises CDDs * then travel to 3 villages to interview CDDs and villagers; request staff member of health centre to accompany and guide * if possible travel on that same day to the health centre of the following day, so we can start bright and early * we will have to be opportunistic about places to eat and sleep (usually at the health centre of that day, or of the following day) The two researchers will work together on the first Tuesday, to coordinate methods and arrive at a standardised approach. This will mean one day's less data collected, which may be possible to make good on the weekend. 48 F Saturday 11 December - Sunday 12 December . Stay in Parakou. go through data, start developing categories, enter qualitative data into computer. . Also a spot of rest. . Travel to next region/ district in time for an early start on Monday. Monday 13 December - Friday 17 December . The same as the previous week, in two more districts (Centre and South). Saturday 18 December ' Meet in Parakou to go through data, compare notes, complete arrangements with research colleague. Sunday 19 December . Travel back to Ouagadougou. Monday 20 December, Tuesday 21 December ' Meet with Dr Dedy Seri in Ouagadougou to finalise categories, amalgamate qualitative data. Det Prozesky 27 November 1999 19 Appendix B Data collection instruments Country Date: District: Respondent code: 1. Biographical profile 1 13. Tell me about any other jobs you had in the past? 114. What is your present position exactly? 1 15. Why did you change to this job? 1 16. How long have you been in this job? 117. (tor CDDs only) How do you earn a living? What are your sources of income? 1 18. (for health workers only) ln addition to your current job as a health worker, what else do you do to supplement your income? 1 19. (for health workers only) How much of your time does this supplementary work take? 101. Full names 1 02. Age 103. Sex 104. Ethnic background 106. Number of children 107. Number of children undergoing education Primary: Secondary: Tertiary 108. Marital status 109. Number of other dependents 110. Educational (school) background 111. Professional qualifications (nature and dates) 1 12. Exposure to media (a) (b) (c) Do you read newspapers? Do you listen to the radio? Do you watch television? 1 = always 2 = sometimes 3 = never 50 Country: Date. District: Respondent code 2. Questionnaire about the motivation of other role players 2a. lf it is a about person known to the respondent Use a separate questionnaire for every person (X) about whom your respondent is talking 201. Name of respondent: 202. Administrative level of respondent. tick the appropriate box 203. Name of person about whom the respondent is talking (X) 204. Administrative level of person about whom respondent is talking: (tick the appropriate box) sub-district CDD district 205. For how long have you known him/ her? 206. What do you think is his/ her role in onchocerciasis control? 207. What do you think he/ she is doing well, or badly, in this role? well: badly: 208. What do you think are the reasons for this kind of performance? 209. What do you think could be done to improve her/ his performance? 210.For how long do you think he/she will continue in this role? 5l Country: Date District Respondent code 2. Questionnaire about the motivation of other people 2b. lf it is about a level of worker, not personally known to the respondent Use a separate questionnaire for every group (Y) about whom your respondent is talking 211. Name of respondent: 212. Administrative position of respondent (tick appropriate box) national region district 213. Group (Y) about which respondent is talking (tick appropriate box) district sub-district CDD 2'14. What do you think is the role of this group or level in onchocerciasis control? 215. What do you think they are doing well, or badly, in this role? well. badly. 216. What do you think are the reasons for this kind of performance? 217. What do you think could be done to improve their performance? 52 t Country Date District Respondent code 3. Questionnaire to villagers about their CDDs Use this instrument to interviewing a key informant in a village, and/ or a focus group discussion with a small group of villagers. 301. Name of village 302. Name and position of respondent: OR number of people in focus group 303. Who aski are your village distributors? (in case the wrong name is mentioned, carry on ng for more names): 1 2 304. For how long have they been the distributors? 1 2 305. Who chose them? 306. Why do you think they were chosen, and not someone else? 307. Do you think they like the work of a distributor? Why do you think that? 308. ls there anything you have against your CDDs? 309. Do you think there is anything the CDDs have against the villagers? 310. What do you thin k could be done to improve their performance? 31'1. For how long do you think they will continue this work? Why do you say that? ink a woman can be a CDD? Why do you think so?312. Do you th 53 t Country: Date 4. lnterview schedule for CDDs about their own motivation District Respondent code a a 401. CDD's full name 43. Name of health centre402. Name of village 405. Your own ethnic group:404. Ethnicity of village ue ?eth vi mads/ S pn fam s/ie C an gehof ma g roupsow406 v ef?the chiencla ASbem ofr eth same lagAre dU me740 yo e/ she volunteer or not?)408. How did You get into this job? (Probe: did h than someone else?409. Why were You selected, rather being selected as a distributor?410. How did You feel about cts you to do?411. About this job: what do You think the Government exPe noyes . ordering the right number of pills . fetching them at the right time; . doing the census of the families . informing the community when the date has come . handing out the right amount of pills to everyone . following up those who weren't there . dealing with side effects . filling in the report forms an' Do you think You are doing al to do the following412. Actually the ideal would have been for You d taking them to the health centre I of that, as you should? at you should be doing,doing, and wh413. lf there is a difference between what You are can you exPlain whY? work as a distributor?414. What do You think could be done to imProve Your 54 a415. What do you like about this job, and what don't you like? what l/ke: (Q.416) what I donl like: (O.416) 416. Why do you like/ dislike those parts of the job? 417. What do other people in the village think of yourwork as a village distributor? 422. Do you. see yourself continuing doing this job? and why? 423. For how long do you think you will continue in this job? 424. Do you sometimes regret having taken up the job? and why? 425. ln other areas some CDDs have given up the job, to do their own work. What do you think about that? 418. What other health programmes do you as a village health worker work for? PROGRAMME (0.418) BENEFTT (O.41e) RANK (o.420) 419. What benefits to you get from these activities (if any)? (goods, food, money, T-shirt etc.) 420. Which of these activities take up most of your time and attention? Prioritise them 421. Why have you arranged them in this order? 55 Country: Date District Respondent code 5. lnterview schedule for sub-district level workers about their own motivation 501. Your full name 502. Your ethnic group 503. Name of sub-district: 504. Ethnic groups in the CDTI villages 505. (a) How many villages are there in your sub-district? (b) How many of these villages ought to be in the CDTI programme? (c) ln how many of these villages have you already trained CDDs? 506. Do you experience problems with villagers in the CDTI programme ?(a) difficulties with language/ communication? (b) difficulties in obtaining collaboration? 507. Do you feel accepted by these communities? Give reasons for your answer , 508. What are your routine activities at work? Let's make a list of them ACT|V|TY (O.508) BENEFtT (O.509) RANK(o.510) 509. Which benefits to you get from these activities (if any)? (motorbike, per diem, T-shirt, goods, fees etc. ) 510. Which of these activities take up most of your time and attention? Prioritise them 511. Why do you place these (name the first three) at the top? 512. Why do you place these (name the last three)at the bottom? 513. Why have you given this position (whatever it is)to CDTI? OR: why have you left out CDTI? 56 514. Do you also undertake family? Which ones? routine activities outside work, in the community or with your ACT|VtTY (O.514) BENEFTT (O.515) RANK (o.516) 515. Which be (financial, nefits do you get from these activities (if any)? goods, psychological etc.) 516. Which of these activities take up most of your time and attention? Prioritise them 517. Why have you arranged them in this order? 518. Which Expla are more important - these activities outside work, or those in your work? in why you say that. Tl, what do you think the Ministry of Health expects you to do?519. Concerning CD eal would have been for you to do all of the following . motivating every village in your sub-district to accept the programme . training the CDDs for every village . undertaking all aspects of ordering the ivermectin (receiving village estimates, checking them, putting them together in a yearly order) . receiving the yearly reports from the villages, and putting them together in your own yearly report to send to the district . visiting each village near distribution time to check that all is well . visiting villages which appear to have problems. Do you think you have managed to achieve all of that pro 520. Actually the id perly? yes no tf152 the re aS d ifference enbetwe isth ealid whand at au re rea ach evr n ca nyo v g you ex n Whit? at a WCrel therepla ems difficuand ti ?CSprobl 51 522. How have you dealt with these problems/ difficulties? 523. What do you think still needs to be done to strengthen CDTI activities in your area? 524. For how many days were you away from your work during the past year, for reasons which were officially authorised?(a) leave, training/ in-service training, planning meetings etc.(b) illness, funerals, family problems etc. 525. What do you like about this CDTI work? 526. Are there some parts of your CDTI work that people say you are not doing well? 527. Why do you think they find fault? 528. lt appears that in some areas nurses are leaving their positions to gain employment in the private health seryices, where they can earn more money. What do you think about that? 58 Country Date: Health district: Respondent code 6. General information to be collected At the level of the District At the level of the Sub-district 605. Quick evaluation of the training of the CDDs (check all relevant documentation): 606. An historical overview of each health centre: particular emphasis on community mobilisation for health, and the training of Village Health Workers (the process, numbers): 607. Details of local socio-political organisation 601. About national policy on Primary Health Care, from the Declaration of Alma-Ata to the Bamako lnitiative: how this policy was implemented in the district: 602. An historical overview of each health centre: particular emphasis on community mobilisation for health, and the training of Village Health Workers (the process, numbers): 603. Details of local socio-political organisation 604. Full particulars of the salaries of the sub-centre level health workers 59 a Appendix C Applying the instruments General Every interview/ discussion has to be properly introduced, more or less as follows: * The interviewed introduces him/ herself, and asks permission to conduct the interview. * The aim of the research is explained shortly: NOT 'We are studying your motivation', but rather'We need to understand your situation better'. * The person being interviewed is assured of confidentiality/ anonymity. The reason we are writing down her/ his name is that we may need to get back to her/ him, if there is something in the answers that we do not understand. lf there is not enough writing space, write on the back/ a separate sheet - which you have to number, staple, identify completely. Keep all data sheets from a district together in one folder. Summary of which instrument to use with whom person to interview sections to use regional director 1 (about him/ herself) 2a (about his 4 district level oncho. officers) 2b (about the workers responsible for CDTI at sub-district level) 2b (about CDDs) district medical officer 1 (about him/ herself) 2a (about his district level oncho. officer) district level oncho officer 1 (about him/ herself) 2a (about each of the workers responsible for CDTI at sub- district level) 2b (about CDDs) workers responsible for CDTI at sub-district level 1 (about him/ herself) 2a (about district level oncho. officer) 2a (about each CDD) 5 (about him/ herself) CDD 1 (about him/ herself) 2a (about the worker responsible for CDTI at sub-district level) 4 (about him/ herself) Villaqe 3 (about their CDDs) lnstrument 1 : Biographical profile This must be administered to the following t a level of respondent per country . regional directors of endemic diseases (1 per region) . district medical officers (1 per district) r p€rsorS in change of endemic diseases at district level (1 per district) . nurses/ technical officers at sub-districU health centre level, responsible for CDTI (1 per sub-district , 4 per district) . CDDs (2 oer villaqe, 6 per sub-district, 24 per district) 48 4 4 4 16 60 I alnstrument 2a: Questionnaire about the motivation of other role players (a person known to the respondent) this number (per country) of the following persons must be interviewed using form 2a they must each talk about this number of persons a. regional oncho. control officer b. the district medical officer c. district level oncho. control officers d. sub-district level health workers directly involved in organising CDTI e. village level CDDs 4 4 4 16 100 a. district level oncho. control officers b. district level oncho. control officers c. sub-district level health workers directly involved in organising CDTI d. CDDs, district level oncho. control Officers e. sub-district level health workers directly involved in organising CDTI 1 4 4 6 1 1 A separate questionnaire has to be completed for every person about whom we are enquiring from a particular respondent. lnstrument 2b: Questionnaire about the motivation of other people (a level of health worker not personally known to the respondent) this number (per country) of the following persons must be interviewed usinq form 2b they must each talk about this number of groups of worker a oncho. managers at national and regional level b. district level oncho. control officer 1 4 4 a. district level oncho. officer, sub- district level health worker directly involved in CDTI, CDDs b. the CDDs 1 1 1 1 lnstrument 3: Questionnaire to villagers about their CDD The tool can be used for individual interview (say with a key informant) or as a guide for a focus group discussion. ln each village either an interview or a FGD has to be conducted (3 villages per sub-district, 12 villages per district, 48 villages per country). lnstrument 4: lnterview schedule for c DDs about their own motivation This must be used with each CDD interviewed (usually 2 per village, 6 per sub-district, 24 per disgtrict, 96 per country). lnstrument 5: lnterview schedule for sub-district level workers about their own motivation This must be used with each such person (4 per health district, so 16 per country). lt should be done in the afternoon, after finishing, by which time a relationship will be established. 6l i] Appendix D Case analysis form: health centre nurses l. code no. ofnurse 2. age (years) 3. sex (M:1, F:2) 4. code no. of country (Benin:l, COte d'lvoire:2, Ghana:3) 5. code no. of district/ magistracy (B 1-4, CI 5-8, G 9-12) 6. code no. of health centre/ community (B 1-16, CI 17-32, G 33-48) 7 . qualification (SRN:1, enrolled nurse:2, nurse aide=3) Name of nurse being interviewed A. Biographical details B. Achievement/ performance E. Level of motivation (tick the appropriate block) NB: This section can only be judged/ filled in after completing sections B, C and D a 9. coverage level ( 1:all the village s;2=l-2 not covered; 3: >2 not covered) 10. training of DCs (l:all well done; 2:some not well done; 3: all not well done) 11. ivermectin supply (1:no shortages/ doesn't run out; 2:runs out at times) 12. supervision of DCs (1:several visits per year, supportive attitude;Z:few visits, or only to scold/ complain) 13. opinion of the community, the CDs, the district supervisor (0:new, no opinion; l:s/he works well; 2:some aspects not too good; 3:altogether not good) l4 J highly motivated: o The five elements of achievement score high. There are many strong factlitating factors, and relatively few obstacles. 2 average motrvatron: o Average levels of achievernent; facilitating factors and obstacles of moderate strength. 1 poorly motivated: . All five elements of achievement are low (one or two may be average) Thefacilitatingfactors are few, and the obstacles many. 62 I IC. Factors which promote/ facilitate motivation l:yes,Z:noY * 3:a major factor/ influence; 2:definite effect but not major; 1:trivial effect weightx bD 15. her/ his general experience as a nurse in charge of a HC 16. knows about CDTI, has been trained in it, has worked in it 17. has previously taken part in mass distribution of ivermectin 18. lias enough other sources of revenue (e.g. wife/ husband works) t) o 19. s/he is interested in working with the community, and likes it 20. takes pride in doing her/ his job well 21. public-spirited, wishes to protect the community against the disease 22. family members have suffered from onchocerciasis U () 23. a good relationship with the community/ is married to a villager 24. the villagers are keen on the treatment - get it for free although it's expensive 25. s/he knows people in the community who can help her/ him 26. slhe feels appreciated by and integrated into the community 27 . slhe is afraid that her/ his reputation will suffer, if s/he doesn't do arrange CDTI treatment correctly c)o c) U) cqq) 28. s/he is regularly supervised and encouraged by her/ his superiors, with respect to CDTI 29. CDTI is included in her/ his official 'minimum package of activities' 30. the health service provides her/ him with the necessary transport and fuel 31. the HC or district covers all expenses incurred in CDTI 32. her/ his predecessor oriented her/ him well, and passed on the necessary documentation 33. is only responsible for a few villages (<10) TOTAL 63 D. Obstacles to achievement l:yes, 2:no V * 3:a major obstacle/ influence; 2:definite effect but not major; weiglit* u0 34. s/lie is new to the job 35. s/he knows nothing about CDTI, has never been trained in it 36. a wornan - not respected by the CDs c) cq 31. a heavy family load./ responsibility (>8) 38. day-to-day problems in making ends meet c! (r) q) 39. s/he has too many interests outside her/ his work 40. s/he is not interested in this aspect of her/ his work (e.g. prefers curative work)/ not interested in the work at all (e.g. near retirement) 41. s/he is often absent from work, for family reasons (e.g. living away from home) ; because of illness; because of events like funerals 42. herlhis morale is low - feels the Ministry treats her/ him shabbily U oo 43 manv villages distant hamlets difficult of access poor roads) 44 conflict with the community/ leaders won't cooperate freely 45. the people in some villages are illiterate, through to them and it is hard to get 46. the CDs are often not available, being occupied with their personal affairs (agriculture, commerce, animal husbandry etc') 47 pro,blems wl th commun rcation doesn 't speak the vernacul ar 48. the CDs nag her/ him cons tantly about payment, or theY are J ealous ofher/ him because slhe gets a regular salary 49. the CDs need to be policed all the time, otherwise their work (e.g. bringing their reports in late) they don't do 0) c) q)(a 6 o) 50. lack of supervision from her/ his superiors in contrast to other Programmes with respect to CDTI - 51. CDTI is not included in her/ his 'minimum package of activities' 52. promises about per diems not kept, or does not get reimbursed when s/he uses her/ his own money to coverexpenses e) 53. many villages to cover (>20) 54. aheavy administrative burden 55. s/he is often away on offlcial business 56. lacks means of communication - wastes ttme because of travelling up and down (being the only one to have a vehicle) 57. lacks the necessary resources (transport, or are insufficient fuel) - these arrive late, TOTAL 1:trivial effect 64 Appendix E Case analysis form: distributors t Name of CDD being interviewed: A. Biographical details l. code no. ofCDD 2. age (years) I | : sex (M=1, F:2) 4. no. of years working as CD I I t no. of distributions per year 6. code no. of country (Benin:l, C0te d'Ivoire:2, Ghana:3) 7. code no. of district/ magistracy (B 1-4, CI 5-8, G 9-12) 8. code no. of health centre/ community (B l-16, CI 17-32, G 33-48) 9. code no. of village (see codification schedule, level E) B. Achievements 10. coverage rate (1 : >7)oh;2: 60-70%;3: <60Yo) I 1. the future ( l:s/he really wants to; 2:yes but..; 3:will probably give up) 12. the nurse's opinion (1:very good; 2:good but...; 3:s/he's got to be changed) E. Level of motivation (tick the appropriate block) NB: This section can only be judged/ filled in after completing sections B, C and D. NB: The obstacles are of two kinds: objective (e.g. size of the village) and subjective (e.g. how he eives not bein t3 5 4 highly motivated: . The three elements of achieventenl score high. There are many strong facilitating factors, and relatively few obstacles (of which the majority are objective). . The difference between '4' and '5' is that '4' has slightly lower implementation levels, and a few more subjective obstacles than'5'. J average motivation: . Average levels of achievement; facilitating factors and obstacles of moderate strength. 2 I poorly motivated: . All three elements of achievemenl are low (one or two may be average). The facilitating factors are few, and the obstacles many (with several being subjective). . The difference between'l'and'2'is that in the case of '2'there is clearly some goodwill and volunteerism. 65 { C. Factors rvhich promotc/ facilitate motivation 1:yes,2:no V * 3:a major factor/influence; 2:definite effect but not major; l:trivial effect weight* q, a0 FA 14. snrall family responsibility/ burden (<5) 15. educated to secondary level 16. lias undergone other health related training as well 17. has undergone other training in community development 18. previous experience of work for health programmes (CHW, TBA, Guinea wonr volunteer, village pharmacist etc.) e3 o 9 19. has several sourccs of income which supplement each other 20. s/he hopes to earn something from this sometime in the future 21 . s/he hopes to pursue a a career in health U) o 22. s/he feels proud, respected 23. an attitude of community service/ volunteerism/ self-sacrifice (with supporting evidence) 24. an attitude of service (without supporting evidence)/ spiritual reasons 25. slhe made a fimr commitment, feels good in doing this work 26. slhe is happy to have learnt some more about health U 27. elected by the community during a meeting, or by a respected authority figure (even the nurse) 28. the community supports the rvork (financial support etc.) 29. the community is well organised 30. the villagers have suffered a lot from the disease/ evidence of improvements in health q) (!n 31. s/he feels recognised and appreciated by the nurse, who supervises him/ her regularly 32. the nurse is bossy and keeps him/ her at it () l-r 33. small number of persons per CD (<501 inhabitants) 34. the village is compact, the hamlets are nearby 35. s/he works with another distributor who is very diligent 36. s/he knows his/ her job - was well trained 37. sftre has access to the transport he needs for the work 38. only one distribution so far - s/he is still enthusiastic , t 66 D Obstacles to achievement l:yes,2:noY * 3:a major obstacle/ influence; 2:definite effect but not major; l:trivial effect t a Weight* CD 39. s/he is illiterate 40. fernale 41. handicapped (e.g. s/he stutters) c! I tr 42. a heavy family burden/ responsibility (>8) 43. only one source of income, which is insufficient 44. the work costs liim/ her economically valuable time 45. false promises of remuneration 46. other programmes give financial incentives 47. goes away from time to time (or wants to) to work elsewhere q q) 48. no pay for the work, so s/he is not willing to put her/ himself out 49. demands to be paid - a rather calculating attitude 50. the inhabitants of the hamlets/ other village quarters are of a different clan/ tribe, so s/he doesn't feel responsible for them U 51. the community is not involved (they feel the contract is betrveen the CD and the health service, or that s/he is working by her/ himself) 52. the community suspects that s/he is earning something, which annoys her/ him 53. conflicts in the community make the work difficult 54. some villagers don't understand and refuse to take the drug 55. some villagers make fun of heri him, for working for nothing 56. feels inadequate because s/he can't treat other disease as well q) .r) 57 . a lack of recognition or appreciation from the nurse 58. a lack of supervision/ support from the nurse 59. the ivermectin supply is erratic - it runs out at times o F 60. large number of persons per CD (>1000 habitants) 61. village very dispersed, and/ or the hamlets are far away (>4 km) 62. too many other duties 63 . s/he lacks the necessary transport for the job 64. bad influence from another distributor 65. s/he isn't clear about what to do (was poorly trained) 66. several distributions have been done - sftre is getting discouraged 67