Department of International Development, University of Oxford, Oxford, United Kingdom.
Health and Nutrition Cluster, Institute of Development Studies, University of Sussex, Brighton, United Kingdom.
PLoS One. 2020 Nov 25;15(11):e0242460. doi: 10.1371/journal.pone.0242460. eCollection 2020.
Globally, there remain significant knowledge and evidence gaps around how to support Community Health Worker (CHW) programmes to achieve high coverage and quality of interventions. India's Integrated Child Development Services scheme employs the largest CHW cadre in the world-Anganwadi Workers (AWWs). However, factors influencing the performance of these workers remain under researched. Lessons from it have potential to impact on other large scale global CHW programmes. A qualitative study of AWWs in the Indian state of Bihar was conducted to identify key drivers of performance in 2015. In-depth interviews were conducted with 30 AWWs; data was analysed using both inductive and deductive thematic analysis. The study adapted and contextualised existing frameworks on CHW performance, finding that factors affecting performance occur at the individual, community, programme and organisational levels, including factors not previously identified in the literature. Individual factors include initial financial motives and family support; programme factors include beneficiaries' and AWWs' service preferences and work environment; community factors include caste dynamics and community and seasonal migration; and organisational factors include corruption. The initial motives of the worker (the need to retain a job for family financial needs) and community expectations (for product-oriented services) ensure continued efforts even when her motivation is low. The main constraints to performance remain factors outside of her control, including limited availability of programme resources and challenging relationships shaped by caste dynamics, seasonal migration, and corruption. Programme efforts to improve performance (such as incentives, working conditions and supportive management) need to consider these complex, inter-related multiple determinants of performance. Our findings, including new factors, contribute to the global literature on factors affecting the performance of CHWs and have wide application.
在全球范围内，关于如何支持社区卫生工作者（CHW）计划以实现干预措施的高覆盖率和高质量，仍然存在重大的知识和证据差距。印度的综合儿童发展服务计划雇用了世界上最大的 CHW 干部——安甘瓦迪工人（AWWs）。然而，影响这些工人绩效的因素仍在研究之中。从中吸取的经验教训有可能对其他大规模全球 CHW 计划产生影响。2015 年，在印度比哈尔邦对 AWWs 进行了一项定性研究，以确定影响绩效的关键驱动因素。对 30 名 AWWs 进行了深入访谈；使用归纳和演绎主题分析对数据进行了分析。该研究对 CHW 绩效的现有框架进行了调整和背景化，发现影响绩效的因素发生在个人、社区、计划和组织层面，包括文献中以前没有确定的因素。个人因素包括最初的财务动机和家庭支持；计划因素包括受益人和 AWWs 的服务偏好和工作环境；社区因素包括种姓动态以及社区和季节性移民；组织因素包括腐败。工人的最初动机（为家庭经济需求保留工作的需要）和社区期望（以产品为导向的服务）确保了即使她的动机较低，也会继续努力。绩效的主要制约因素仍然是她无法控制的因素，包括计划资源的有限可用性以及由种姓动态、季节性移民和腐败塑造的挑战性关系。提高绩效的计划努力（如激励措施、工作条件和支持性管理）需要考虑到这些复杂的、相互关联的绩效决定因素。我们的研究结果，包括新的因素，为全球 CHW 绩效影响因素的文献做出了贡献，并具有广泛的应用。
