Introduction
The principle of Primary Health Care (PHC) was introduced in the Declaration of Alma-Ata in 1978 (World Health Organization, 1978). PHC had already been promulgated for over three decades as a global strategy for ensuring essential health care for all people.
Community Health Workers (CHWs) play a key role in the functioning of PHC, especially in a resource-limited setting. Some studies have documented that CHWs can help reduce childhood mortality (Pandey et al., Reference Pandey, Daulaire, Starbuck, Houston and Mcpherson1991; Sazawal and Black, Reference Sazawal and Black1992; Kidane and Morrow, Reference Kidane and Morrow2000; Jones et al., Reference Jones, Steketee, Black, Bhutta and Morris2003), particularly in terms of the early detection and treatment of pneumonia (Shann et al., Reference Shann, Hart and Thomas1984; Deming et al., Reference Deming, Gayibor, Murphy, Jones and Karsa1989; Zeitz et al., Reference Zeitz, Harrison, López and Cornale1993; Fagbule et al., Reference Fagbule, Parakoyi and Spiegel1994), malaria (Ruebush et al., Reference Ruebush, Kern, Campbell and Oloo1995), and dehydration resulting from diarrhea (Kumar et al., Reference Kumar, Kumar and Khurana1989) and increased immunization coverage (Patel and Nowalk, Reference Patel and Nowalk2010).
However, it was also reported that CHWs had not played a significant role in decreasing childhood mortality (Menon, Reference Menon1991) in terms of child health (Bryce et al., Reference Bryce, El Arifeen, Pariyo, Lanata, Gwatkin and Habicht2003), injuries (Bickler and Rode, Reference Bickler and Rode2002), mental disorder (Abas et al., Reference Abas, Baingana, Broadhead, Iacoponi and Vanderpyl2003), sexually transmitted diseases (Bitera et al., Reference Bitera, Alary, Mâsse, Viens, Lowndes, Baganizi, Kamuragiye, Kane, Kintin, Sylla and Zerbo2002), and diabetes (Whiting et al., Reference Whiting, Hayes and Unwin2003). It was also reported that, as the performance of CHWs improves, the use of health services such as immunization (Elisabetta et al., Reference Pegurri, Fox Rushby and Damian2005) and treatment of dehydration (Kumar et al., Reference Kumar, Kumar and Khurana1989) can potentially be increased.
In Kenya, CHWs in community units (CUs) were identified as Level One of the health systems in Kenya from 2006. They were nominated from community members. A criterion to select CHWs was literacy. They got standard training for one week, and some of them might have received additional training and identifications such as T-shirts depending on training partners. Their main activities were door-to-door canvassing to teach health-related preventive methods and collect data of each household. There is no monitoring and evaluation tool to measure CHWs’ performance except for their monthly report in Kenya.
There were four training partners in the research area to support the establishment of CUs: Global Alliance for Vaccines and Immunization (GAVI), government agency, international NGO, and community-based organization (CBO). GAVI and international NGO supported government standard training. The GAVI foundation was managed by government officers only. The CUs supported by government agency were conducted government standard training and some additional training in terms of nutrition, and maternal and child health. In addition, the government agency supported monthly meetings, T-shirts, name tags, and reporting tools. The CBO also provided government standard training and continuous demand-based trainings.
The strategic plan for 2008–2012 (Ministry of health systems in Kenya in 2006) stated that the scaling up of community strategy was indispensable, meaning that more well-performed CHWs were required to improve the delivery of health-care services at the community level. However, little research has been conducted in Kenya on the performance of CHWs in improving health services.
This study aimed to describe their performance in terms of the reporting rate and to determine which factors impacted the performance of CHWs in Kenya.
Methods
Study site
This study was conducted in Kisumu West district, Nyanza Province, Kenya in July 2010. This area is mainly inhabited by subsistence farmers and fishermen. This district has about 144 907 residents and the population density per km2 is 404 according to the national census of 2009 (Kenya Demographic and Health Survey, 2010). The District Health Systems were composed of a district hospital, two sub-district hospitals, three health centers, and 12 dispensaries (Ministry of Health, 2010). Moreover, there were 15 CUs established at Level One of the health system. One CU covers one sub-location, which has a population of around 5000. Each CU theoretically has 50 CHWs and two Community Health Extension Workers who supervise CHWs and collect their monthly reports.
Study design and population
This study consisted of 750 CHWs (potential subjects) in total supported by several partners in this research area. Training partner is the partner who supported and assisted CU establishment and CHWs’ training. The training partners were categorized into four groups. The first is GAVI, the second is government agencies, the third is International NGO, and the fourth is the CBO. A total of 350 CHWs in seven CUs were trained by GAVI, and 200 CHWs in four CUs were trained by the International NGO. Government agencies and the CBO trained 100 CHWs in two CUs, respectively. All CHWs were informed of this study by their supervisors and were requested to participate. Out of 750 CHWs, 240 CHWs filled out a structured questionnaire about their socioeconomic characteristics and their job satisfaction/motivation. In addition, their supervisors provided us with information related to these subjects’ submission of monthly reports within the three months preceding the beginning of the study, as well as information regarding the subjects’ training partners. Data related to the submission of 35 CHWs were not recorded. Additional information about reporting rates and training partners was appended to the data gathered by structured questionnaire. The data of 33 CHWs were not appended, because their name as unique key was not written. Thus, 172 CHWs in total were involved in this study. An indicator of the subjects’ reporting rate during a three-month period was used to assess the performance of CHWs because submitting monthly reports is one of their main activities, as well as a clear way of measuring their job performance. In the present study, CHWs who submitted all of their required monthly reports in a three-month period were defined as CHWs displaying good performance (active CHWs), whereas the CHWs who did not do so were defined as CHWs lacking good performance (non-active CHWs).
Data analysis
Data were stored using Epi info (version 3.5) software. Statistical analysis was performed with STATA version 10 (STATA Corporation, Texas, USA). A χ 2-test was used to compare the differences in proportions for categorical data. If an expected value was lower than 5, a Fisher's exact test was performed. Socioeconomic characteristics were dichotomized and coded, except for those characteristics related to occupations and training partners. Moreover, these factors were analyzed using linear logistic models. Starting with a logistic model including all of these covariates, we selected the most appropriate model on the basis of Akaike's information criterion (Akaike, Reference Akaike1974). Once the most appropriate model was selected, a maximum likelihood estimation of the model parameters was conducted. Then, the odds ratio and the 95% confidence interval were calculated for each covariate in the model.
Ethical considerations
This research was approved by Gluk Ethical Review Board at the Great Lakes University of Kisumu in Kenya. Authorization to carry out the survey was obtained from the Ministry of Public Health and Sanitation in Nyanza province and the district health administrators.
Results
A total of 172 CHWs were respondents in this study. Eighty percent of them were women and 20% were men, as indicated in Table 1. Their mean age was 40 years, and their primary occupation was farming (62%). In all, 78% of them were married and 49% did not graduate from primary school; 52% of them visited fewer than 20 households as CHW. GAVI was the main training partner for 47% of the respondents. A total of 105 CHWs completely submitted their monthly reports within three months. This means that the number of active CHWs was 105 (61%) and non-active was 67 (39%).
Table 1 Basic characteristics of CHWs in Kisumu West district, Kenya
CHWs = community health workers; GAVI = global alliance for vaccines and immunization; NGO = non-governmental organization; CBO = community-based organization.
In Table 2, we compare active CHWs with non-active CHWs by using univariate analysis. Sixty-one percent of them were active CHWs. Active CHWs were significantly older (P < 0.001) and better off financially than non-active CHWs (P < 0.05). Moreover, between these two groups, there were few differences in their training partners (P < 0.06), as well as the CHWs’ occupations (P < 0.07). In addition, the proportion of satisfaction among subjects in the two groups was not different (P < 0.25).
Table 2 Comparison between CHWs with full reporting and CHWs without full reporting
CHWs = community health workers; GAVI = global alliance for vaccines and immunization; NGO = non-governmental organization; CBO = community-based organization.
aχ 2-test.
Furthermore, a logistic regression analysis revealed that CHWs over 40 years of age were likely to exhibit good performance (P < 0.001) (Table 3). In addition, the performance of CHWs was influenced by their training partners. On the basis of International NGO as base training partner, the CBO has a significantly good impact on the performance of CHWs (P < 0.03).
Table 3 Multivariate analysis of factors influencing performance of CHWs
CHWs = community health workers; CBO = community-based organization; GAVI = Global Alliance for Vaccines and Immunization; NGO = non-governmental organization.
aBase supporter: International NGO.
Discussion
The magnitude of the poor performance of almost half of the CHWs in this study was similar to that found in previous studies (Kelly et al., Reference Kelly, Osamba, Garg, Hamel, Lewis, Rowe, Rowe and Deming2001; Stekelenburg et al., Reference Stekelenburg, Kyanamina and Wolffers2003). That is, 40% of them were non-active CHWs, even though submitting monthly reports is one of the main duties for CHWs.
Although the performance indicator used in this study was related to literacy, all CHWs were literate, because one of the criteria to select CHWs is literacy. It means that the age is not related with literacy in this study.
Older CHWs in the present study were significantly likely to enhance their performance. There is some evidence that older CHWs are more respected in their communities than their younger counterparts (Ofosu Amaah, Reference Ofosu Amaah1983). Moreover, some cultures place greater emphasis on ascribed characteristics such as age than on achieved characteristics such as high education and special training (Bhattacharyya et al., Reference Bhattacharyya, Winch, Leban and Tien2001). Therefore, it may be relatively easy for older CHWs to conduct their duties at various households, and the respect they receive from community members may act as a form of peer pressure that facilitates their job performance. In addition, older people, especially women, may have more free time than younger persons because the duties of the former related to child care, housekeeping, and farming may decrease as their children grow up.
There were unique relationships between the initial training partners and CHWs’ performance, meaning that the subjects’ performance varied, depending on their training partners. It was also found in this study that CBOs were better training partners than International NGOs. Differences between training partners were equal in importance to differences in training methods, frequency of supervision and feedback, visual identification, and selection methods of CHWs. As other studies have reported, the complexities of guidelines (Kelly et al., Reference Kelly, Osamba, Garg, Hamel, Lewis, Rowe, Rowe and Deming2001), as well as the frequency of supervision and feedback (Rowe et al., Reference Rowe, de Savigny, Lanata and Victora2005), were key factors in the improvement of CHWs’ performance. In addition, visual means of identifications, such as bags and T-shirts (Haines et al., Reference Haines, Sanders, Lehmann, Rowe, Lawn, Jan, Walker and Bhutta2007), were related with the performance of CHWs in terms of their motivation. Selection criteria and selection methods for CHWs (Haines et al., Reference Haines, Sanders, Lehmann, Rowe, Lawn, Jan, Walker and Bhutta2007) were also influential factors in enhancing their performance because of increased identification as CHWs from community members and their own motivation. Although these factors were not assessed in this study, the ‘training partner’ variable may be representative of the aforementioned factors. In our opinion, CBOs were more likely to work with CHWs after CHWs had finished their standard training. Furthermore, one advantage of CBOs is that CHWs can easily contact them, which could make it relatively easy for CHWs’ supervisors, who are based in CBOs, to find problems related with the performance of CHWs.
As potential limitations of our study, one was the sampling method. In this inquiry, our subjects did not represent the entire population. The percentage of active CHWs may have been overestimated, because non-active CHWs may not have a desire to gather in order to participate in a study of this nature. Second, the performance indicator in this study was the reporting rate. The quality of the CHWs’ monthly reports was not assessed because of incidences whereby some CHWs lost these, as well as the lack of defined outcome indicators for measuring their performance. In addition, reporting rate was not enough to measure CHWs’ performance, further research focusing on not only reporting rate but also other performance indicators is necessary.
Furthermore, some of the key factors for improvement of CHWs' performance such as supervision and visual identification were not assessed. Although further research focusing on the details of the overall job performance of CHWs is needed, it was clear from the results of our study that immediate action needs to be taken in order to improve their performance, especially their reporting activity.
Conclusion
Older CHWs were likely to display a high level of job performance. Furthermore, the job performance of CHWs was influenced by the effectiveness of their training partners. Although further research on specific details of their job performance is necessary, the aforementioned factors may be important determinants of CHWs’ overall job performance.
Acknowledgments
The District Health Management Team in Kisumu West and JICA generously supported this study. We sincerely thank all of the people who participated in this study, including the respondents, as well as the staff who assisted with data collection and data entry, especially Dr Elizabeth Okoth, George S. Odhiambo, Nicholas Pule, and Lucas Ofwaya.
