Individual, community, and health system factors
The results of this study showed the degree to which a range of factors, individual, community, and health system factors, contributed to the motivation of vCHWs in Ethiopia. Health system factors were the most important deterrents of CHWs of which lack of career development was the primary discouraging factor. Consistent with this finding, a study in developing countries revealed that poor career paths and promotion opportunities lead health workers feeling stuck and demotivated [
24]. An astonishing relationship was also observed between volunteering and career motives in a study conducted in South Africa;
Akintola argued that the long-term sustainability of using poor and unemployed members of the community as volunteers in home-based care can be ensured through the creation of career paths [
25].
Unclear guideline was the second health system-level demotivating factor the participants highlighted. Evidence showed that a well-considered guideline and job description should help to avoid any misconceptions on what volunteers do and could lead to better management [
26]. Similarly, in a study conducted to assess the factors affecting the performance of community health workers in India, absence of clear guidelines and job descriptions among community health workers lead to greater noncompliance and poor performance [
27].
Kiangura and Nyambegera reported that about 90% of volunteers in their study agreed that clear job expectation and methods of evaluation would motivate them to perform better [
28].
Our study also showed that lack of frequent supervision and support from supervisors was another system-level demotivating factor. Evidence from different countries underlined the importance of supervision as a tool to motivate CHWs and reduce attrition. CHWs in Tanzania and Uganda mentioned that they were appreciative of the supervision made by their supervisors and that it increased their credibility and recognition in the community and found it to be highly motivating [
29,
30]. Consistently, participants of a study in Mozambique and Madagascar pointed out the negative effects of irregular supervision on their performance [
31,
32]. On the other hand, regular supportive supervision to CHWs was cited as a prerequisite for good quality care [
3,
13,
33,
34].
Another health system-level factor, lack of recognition and/or appreciation of accomplishments, was affirmed by participants of our study as a demotivating factor. Evidences showed that appreciation or recognition of good performance by employers and communities is one of the incentives motivating health workers [
35‐
39]. Consistently, WHO stated that financial incentives are not the only factors that cause lack of motivation but also non-financial incentives such as appreciation and recognition [
40].
On the other hand, this study showed that community-level factor, having a good status in the community, was the first factor motivating the 1to5NLs. Evidences showed that community acceptance affects performance and motivation of CHWs and is a significant predictor of retention [
23,
41]. Being identified as a CHW and affiliated with the health system is usually, though not always, considered as having a status that generates power and respect within a community [
42]. When CHWs in Nepal were asked why they continued their volunteer service, they said, “Our neighbors won’t let us resign; they insist we continue because their children’s health depends on us” [
43]. Public honoring, involvement in public meetings, more participation in community decision meetings, and more invitations in various events are some of the means to improve social prestige of CHWs [
13,
44]. vCHWs in Ethiopia said that an event organized to thank them in front of the community would strengthen their motivation [
22]. In Indonesia, a radio-based health communication campaign motivated the CHWs by publicly praising them as “volunteers who work without compensation for our children in our village for the sake of the future” [
45]. However, adverse sentiments from the community are a potential reason for poor retention of CHWs [
41].
Individual-level factors were also repeatedly mentioned by participants of our study as motivating factors. Commitment to serve the community as 1to5NLs rather than engaging in other businesses and accomplishing something worthwhile to the community were the second set of motivating factors of the respondents. Such compassion and commitment to serve the community may emanate from having acquainted with the existing health condition of their society. In Tanzania, CHWs were attracted to public services and find personal satisfaction and pride in helping their communities, as expressed by the desire to provide education and prevent common tragedies like the loss of a child [
7]. Similarly, a quantitative study on vCHWs in northwestern Tanzania found that more than three quarters of the CHWs continue to volunteer as they enjoy serving the community [
46]. According to a WHO report, health workers appear to be strongly motivated by observed reductions in burden of disease over time, and their own internal sense of purposefulness and honor about a job well done [
42,
47].
In general, participants of this study are motivated by individual- and community-level factors while they are more likely to be demotivated by system-level factors. As it is very difficult to sustain volunteers’ interest strictly with remuneration in low-income countries [
25], other ways of addressing motivation of vCHWs should be considered. Notwithstanding the intrinsic sources of motivation and community acceptance, long-term sustainability of volunteer CHW programs usually require supportive and responsive health system [
48] one of which is the creation of a platform that allows unemployed volunteers to fulfill their motives through skill training, thereby improving their employment opportunities in the labor market [
25]. Thus, given that 1to5NLs are not stipend, ensuring their satisfaction and consequently improving their motivation should be given due attention by the health system so that they can continue providing volunteer services.
Significance of selected demotivating factors
Despite insufficient evidence to draw conclusion on how each 1to5NL valued motivational factors, our study examined the effect of educational level, marital status, previous engagement on volunteer activities, and years of service on three of the identified de-motivational factors: lack of career path, lack of recognition and/or appreciation of accomplishments, and infrequent supervision and support. The current study found that the first demotivating factor, “I feel frustrated whenever I think I couldn’t develop my career”, was not significantly affected by educational level, marital status, and previous engagement in volunteer service. However, 1to5NLs with less than 2 years of service year felt the lack of career path more than those with more service years; the larger proportion (42%) in the former group were aged 30 years or less and another 41% between 30 to 40 years. Given the very high prevalence of youth unemployment in Ethiopia and globally [
49] and younger people tend to be literate [
42], the difference in the perception of lack of career path may be attributed to the desire to develop one’s career and to be employed in money-earning jobs is more pronounced by younger individuals than older ones.
Education was the only factor that had a significant effect on the perception of 1to5NLs about how frequently they received supervision and support. Comparing with volunteers with no formal education, network leaders who had a formal education are more likely to report dissatisfaction with the amount of supervision and support that they received when compared to those who had not received any formal education. HEWs are usually occupied with various tasks at the health post, house-to-house visit, collecting supplies from health centers, mobilizing the community for developmental activities, and training and supporting 1to5NLs. Moreover, there may be an average of 100+ 1to5NLs under each HEW. Thus, allocating supervision time equally among the 1to5NLs might have been be a challenge for the HEWs and perhaps put much of the time on those with no or low education.
Recognition and/or appreciation of accomplishments has previously been cited as one of the most important motivating factors for CHWs [
36,
39]. In our study, it was significantly affected by education, marital status, length of service, and previous volunteer service engagement. 1to5NLs who had no formal education, who were living in union, who served for less years, and had no previous volunteer engagement were more likely to report dissatisfaction with the amount of recognition and appreciation that they received from their supervisors than their counterparts. The dissatisfaction of the 1to5NLs with no formal education on recognition and appreciation of accomplishments may stem from the desire to get more attention and consequently more support as they are non-literate and use only illustrations to educate their group members and record information. Despite the burden on married CHWs in rural areas due to child rearing and domestic chores, family attitude towards their role as CHW and whether they experienced family disapproval may encourage or discourage the CHWs to continue as volunteers. Studies have shown that familial disapproval was found to be a barrier for volunteer tasks and a reason for resigning particularly for women whose husbands saw the long hours laid on such activities inappropriate [
50‐
52]. Thus, volunteering for the job, executing their responsibility as a HDA network leader coupled with other competing tasks at home, and the challenge of possible families’ or husbands’ disapproval might have contributed to the higher expectation of married 1to5NLs who are living with their partners to be recognized and appreciated by their supervisors than their counterparts.
Consistent with our study, while more experienced volunteers who served for many years in previous or current position were settled or integrated well within their community, the newly recruited CHWs usually faced challenges and require more recognition and support from their supervisors [
33,
53,
54]. Mutale et al. in their study had observed that the longer the health workers stayed in post the more motivated they were [
54]. Similarly, a study in a Kenyan district found that CHWs who had served for more than 3 years were twice more likely to mention that they are being motivated to serve their community than those who had served for less than 3 years [
55].
Limitations of the study
We employed only a quantitative method based on questions tested in other contexts. Due to time and other resource constraints, the study did not include a qualitative approach that would have helped to explore how and what conditions would motivate the 1to5NLs. In addition, the study was based on questions asked directly to the 1to5NLs and did not assess their performance. Although the questions were worded both positively and negatively to reduce response bias, the answers might have been influenced by the respondents’ perception to each of the question and what they think the investigators wishes to hear/social desirability bias. Looking further to the data, we have also observed that the percentage of “Score 1” to each of the motivational items is very small, suggesting the existence of central-tendency bias in their response (a condition where respondents are hesitant to rate attributes at the extremes of the scale and prone to rate most attributes at the center of the scale; one of the weaknesses of Likert scale). As a result, the mean score to each of the motivational factors fall between 3 and 4 on the scale. Another weakness of the Likert scale is that the space between each scale cannot possibly be equidistant. Thus, the result of this study should be interpreted keeping in mind that degree of literacy level of the respondents to comprehend the questions, difficulty to distinguish the scales or response categories, insufficient attention to questions due to time pressure, lack of fluency of interviewers in asking the questions, and other cultural reasons might have affected the responses of the study participants. Furthermore, the result may not represent all 1to5NLs in the country as the factors contributing to their motivation level may vary from region to region depending on the knowledge and skills of their supervisors and the support they get from kebele councils.