Working in challenging environments
The sociocultural environment had a significant impact on the motivation of the HWs, including community expectations and social values as described in Figure
1[
40]. All of the HWs perceived themselves as front-line workers in a dangerous and contested environment, with perseverance despite these challenges being a defining characteristic particularly in Port Moresby, NCD. Port Moresby, the capital city of PNG, is well known for its violent crime that threatens the safety and security of all citizens. For example, one clinic visited in Port Moresby had recently moved to a new location due to problems with armed robberies and other security issues. The need to have security guards at entrance gates was common at most health facilities visited, but particularly in urban settings.
The risk to physical safety taken by staff, including volunteers, who enter volatile areas, such as settlement areas, market places and villages, to assist in the follow-up of clients and in health promotion activities was highlighted by many respondents. While risk is most obviously associated with Port Moresby, risk was also identified in other contexts including the associated risks of travelling for outreach service such as poor roads, weather and other roadside crimes. For example, in the mountainous area of the highlands of EHP, poor road conditions are a frequent hazard along with unpredictability of civil unrest amongst neighbouring tribes. The best illustration of other forms of physical risk is explained by a medical officer in NCD:
They [the volunteers] do all the hard work in the field. They get abused for talking about sex openly in the market and in the villages. They actually have been threatened and some of them have even had their bags stolen. But they put up with all of this. (Male medical officer, NCD)
Social risk, or the risks associated with the stigma of working in sexual and reproductive health, was also a concern for many. Dealing explicitly with matters pertaining to sexual and reproductive health is largely seen as a cultural taboo by the whole of the PNG community:
This is a Melanesian society and they will criticise you … In our culture we don’t go around going into details about human sexual health, but we are working through this. So this topic [sexual health] is often seen as shameful to our clients, other community members and other people in our country. (Female medical officer, NCD)
However, although all the HWs acknowledged the risks, both physical and social, they all were able to describe other positive inspiration for engaging in these health services.
The local community played an integral role in the performance and motivation of most of the HWs, with positive motivation more likely to arise from interactions with the community rather than from the health system itself. Most of the HWs expressed dissatisfaction with the administration of the health system, arguing that this also contributed to the difficult working environment. For example, according to some HWs, key officials rarely acknowledged or showed appreciation for the work that they did. However, as one CHW described about his involvement in a sexual and reproductive health programme, despite this negativity there were other reasons that inspired service.
… I think I am doing a lot of work that the government doesn’t see, and at times I feel I want to leave this job and go away. But, the heart that I have for my own men is why I have been so patient. So I am still doing this work. (Male community health worker, EHP)
For most respondents, the sense of community was local and specific and inspired a deep commitment to the work that was being done. A few respondents were motivated by the perceived contribution the service had to improving the socioeconomic environment of the community. For example, one HW’s own perceived assumption that men required vasectomy due to the economic pressures of having a larger family in PNG was the stated impetus for his involvement in NSV. By providing the NSV service the HW would be alleviating men and families of these pressures, particularly in more rural areas.
The success of the service is because the people are in need of the service. I think they are considering their needs like school fees, food and cooking. So, they tell me that to control their family, it will make their lives easier and they contact the service so they don’t have any more children and ongoing school fees etc. (Male community health worker, Madang Province)
A majority of the HWs were also supportive of a MC programme to be implemented in PNG. This support seemed to be also driven from their community concern, ranging from prevention of HIV to minimization of complications following penile foreskin cutting completed by a non-HW. For example, as one respondent explained:
I will definitely encourage people to come for circumcision because it’s healthy, and like in PNG, most circumcisions are done in the village and it is dangerous. (Female nurse, West New Britain Province)
However, one HW was resistant about the possibility of a national MC programme for fear that this would raise community expectations of complete protection from HIV and could result in retribution in the event of a circumcised man becoming HIV-positive. The complex network of cultural obligations in which HWs engage as a result of the cultural context of the communities in which they work was also identified to contribute to HW engagement in programmes:
If circumcised men are infected, they will point their fingers to us the health people and say, ‘You said I will not get it and I went for circumcision but now I got it and your words are lies’. They will not believe us and this has its consequences too. (Male health extension officer, EHP)
HWs perceived themselves as actors, able to effect local change. The importance that a HW placed on their service heightened their determination to succeed. In some cases, HWs demonstrated particular concern and urgency to deliver services that may be considered elective or non-essential.
They have a problem in the village and I need to help, I need to stay with them and perform vasectomies in the villages. It’s my heartfelt sympathy for my own people. (Male nursing officer, NCD)
This sense of community was also articulated at a national level by a few respondents. Despite the social diversity of the respondents and known existence of significant tribal divisions in PNG, some comments were framed in terms of national pride and a genuine concern for the ‘fellow countrymen’ they served. This depth of emotion was evident in the narrative of one respondent, who wept as she reported:
All the things we do are for Papua New Guinea people. Just to serve the Papua New Guinea people is an honour. This [the work done in the clinic] is very important, for my country and for my people. I can work the extra hours or extra weekends. If I have to serve it I will serve it. I do have a lot of commitment for this project. I am the back bone of this project and I do all the background. You know, I will do it for the name of Papua New Guinea. I want to serve my people. So if it means taking a weekend then I will do it. I have a heart for my people. (Female administration officer urban clinic, NCD)
This sense of commitment to serve the country appears to be best explained as being embedded in the religious convictions of the HWs.