London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.
Mercy Corps Pakistan, Islamabad, Pakistan.
BMC Public Health. 2019 Jul 25;19(1):999. doi: 10.1186/s12889-019-7326-8.
Many interventions to motivate community health workers to perform better rely on financial incentives, even though it is not clear that monetary gain is the main motivational driver. In Pakistan, Lady Health Workers (LHW) are responsible for delivering community level primary healthcare, focusing on rural and urban slum populations. There is interest in introducing large-scale interventions to motivate LHW to be more actively involved in improving tuberculosis case-finding, which is low in Pakistan.
Our study investigated how to most effectively motivate LHW to engage more actively in tuberculosis case-finding. The study was embedded within a pilot intervention that provided financial and other incentives to LHW who refer the highest number of tuberculosis cases in three districts in Sindh province. We conducted semi-structured interviews with 20 LHW and 12 health programme managers and analysed these using a framework categorising internal and external sources of motivation.
Internal drivers of motivation, such as religious rewards and social recognition, were salient in our study setting. While monetary gain was identified as a motivator by all interviewees, programme managers expressed concerns about financial sustainability, and LHW indicated that financial incentives were less important than other sources of motivation. LHW emphasised that they typically used financial incentives provided to cover patient transport costs to health facilities, and therefore financial incentives were usually not perceived as rewards for their performance.
This study indicated that interventions in addition to, or instead of, financial incentives could be used to increase LHW engagement in tuberculosis case-finding. Our finding about the strong role of internal motivation (intrinsic, religious) in Pakistan suggests that developing context-specific strategies that tap into internal motivation could allow infectious disease control programmes to improve engagement of community health workers without being dependent on funding for financial incentives.
许多旨在激励社区卫生工作者表现更出色的干预措施依赖于经济激励，尽管尚不清楚金钱收益是否是主要的激励驱动因素。在巴基斯坦，妇女卫生工作者（LHW）负责提供社区一级的初级保健服务，重点关注农村和城市贫民窟人口。人们对引入大规模干预措施以激励 LHW 更积极地参与改善结核病发现工作感兴趣，因为巴基斯坦的结核病发现率较低。
我们的研究调查了如何最有效地激励 LHW 更积极地参与结核病发现工作。该研究嵌入在一项试点干预措施中，该措施为在信德省三个地区转诊最多结核病病例的 LHW 提供财务和其他激励措施。我们对 20 名 LHW 和 12 名卫生项目管理人员进行了半结构化访谈，并使用一种将内部和外部激励源分类的框架对这些访谈进行了分析。
在我们的研究环境中，内在激励因素，如宗教奖励和社会认可，非常突出。虽然所有受访者都认为金钱收益是一种激励因素，但项目管理人员对财务可持续性表示担忧，而 LHW 则表示经济激励因素不如其他激励源重要。LHW 强调，他们通常将提供给他们的用于支付患者前往医疗机构交通费用的经济激励用于此用途，因此，经济激励通常不会被视为对其工作表现的奖励。
本研究表明，可以使用除经济激励之外或代替经济激励的干预措施来增加 LHW 参与结核病发现工作。我们在巴基斯坦发现内在激励（内在的、宗教的）发挥着强大作用的这一发现表明，制定针对具体情况的策略，利用内在激励因素，可能使传染病控制项目能够在不依赖资金提供经济激励的情况下，提高社区卫生工作者的参与度。
