Attraction and retention of qualified health workers to rural areas in Nigeria: a case study of four LGAs in Ogun State, Nigeria

INTRTODUCTION: A shortage of health workers is a major problem for Nigeria, especially in rural areas where more than 70% of the population live. At the primary care level, trained community health officers provide services normally reserved for doctors or medical specialists. The community health officers must therefore be supported and motivated to provide effective quality healthcare services. This study aimed to determine factors that will attract and retain rural and urban health workers to rural Nigerian communities, and to examine differences between the two groups. METHODS: A cross-sectional survey measured health workers' work experience, satisfaction with, and reasons for undertaking their current work; as well as reasons for leaving a work location. Data were also gathered on factors that attract health workers to rural settings and also retain them. RESULTS; Rural health workers were generally more likely to work in rural settings (62.5%) than their urban counterparts (16.5%). Major rural motivators for both groups included: assurances of better working conditions; effective and efficient support systems; opportunities for career development; financial incentives; better living conditions and family support systems. The main de-motivator was poor job satisfaction resulting from inadequate infrastructure. Rural health workers were particularly dissatisfied with career advancement opportunities. More urban than rural health workers expressed a wish to leave their current job due to poor job satisfaction resulting from poor working and living conditions and the lack of career advancement opportunities. CONCLUSIONS: Motivational factors for attraction to and retention in rural employment were similar for both groups although there were subtle differences. Addressing rural health manpower shortages will require the development of a comprehensive, evidence-based rural health manpower improvement strategy that incorporates a coordinated intersectoral approach, involving partnership with a range of stakeholders in rural health development.     

农村基层卫生服务人员工作行为决定机制：基于工作动机理论的分析

目的:利用认知理论对工作动机的解释,提出一个工作行为决定机制理论框架;并利用两县农村基层卫生服务人员的实证数据,验证此框架中激励人员为卫生系统期望的绩效目标而付出努力的前提条件是否实现。结果:农村基层卫生人员"被激励"的两个条件并未得到满足:农村基层卫生服务工作并不能赋予农村基层卫生人员价值观中偏好的生活和技术支持性物质条件;在农村基层卫生人员认知中机构的技术设备是很少或无法满足工作需要的,并且他们在公共卫生和基本医疗服务方面的工作能力有限。结论:为了引导农村基层卫生人员提高对公共卫生工作的积极性和基本医疗服务质量,需要有针对性地设计和改革人员激励制度。     

RURAL URGENT CARE MODELS: WHAT ARE THEY MADE OF?

ABSTRACT: The study aimed to identify the elements that constitute rural urgent care systems. Participation in the study was sought from health professionals, welfare and emergency services sectors, and community members. Primary data were collected from informants through interviews and focus groups in five rural communities of different sizes. Twelve common elements to rural urgent care systems were identified and divided into two categories: (i) infrastructure; and (ii) personnel. Infrastructure included organisational support, community support, transport, communication and coordination processes, facilities and equipment, and community knowledge and information. Personnel included nurses, doctors, community leaders, health and welfare professionals, emergency service workers and ambulance officers. The study's major outcome was the recognition that rural urgent care systems consist of a balance of interrelated elements. These elements are context driven, with geographical, social and economic environments having a substantial impact on the ability of rural communities to develop and sustain their urgent care systems.     

Identifying factors for job motivation of rural health workers in North Viet Nam

BACKGROUND: In Viet Nam, most of the public health staff (84%) currently works in rural areas, where 80% of the people live. To provide good quality health care services, it is important to develop strategies influencing staff motivation for better performance. METHOD: An exploratory qualitative research was carried out among health workers in two provinces in North Viet Nam so as to identify entry points for developing strategies that improve staff performance in rural areas. The study aimed to determine the major motivating factors and it is the first in Viet Nam that looks at health workers' job perception and motivation. Apart from health workers, managers at national and at provincial level were interviewed as well as some community representatives. RESULTS: The study showed that motivation is influenced by both financial and non-financial incentives. The main motivating factors for health workers were appreciation by managers, colleagues and the community, a stable job and income and training. The main discouraging factors were related to low salaries and difficult working conditions. CONCLUSION: Activities associated with appreciation such as performance management are currently not optimally implemented, as health workers perceive supervision as control, selection for training as unclear and unequal, and performance appraisal as not useful. The kind of non-financial incentives identified should be taken into consideration when developing HRM strategies. Areas for further studies are identified.     

Economic Effects of the Outmigration of Obstetric Services in a Rural County

Obstetrical health care resources have been declining in rural areas since 1980, resulting in reduced prenatal care that can result in higher medical costs. Loss of health care services is known to have negative economic consequences for rural communities. This article illustrates how hospitals and other providers of medical services can be used as vehicles for local economic development. Provision of medical services is an important component of the economic base of all communities and especially of small rural communities with hospitals. When a community loses medical services to another community, it loses both direct and indirect economic benefits. The research presented here analyzes the economic effects of outmigration of obstetric services from a rural "perimeter" community in Wyoming. The combined direct and indirect economic losses are shown to be significant. Annual revenue losses to the local hospital were estimated as high as 12 percent. It is important to make explicit the economic losses that result from reductions in health care. Such research, combined with knowledge of negative health and social factors can provide community leaders with additional motivation to find solutions to declining health care in rural areas.     

Involving communities in health service planning in primary care

Recent health service policy in the United Kingdom has emphasized the need to involve local people in health service planning. This paper will describe how local communities were involved in the development of Primary Care Resource Centres. These centres are designed to provide a base for the delivery of a range of health, social welfare and information services within a community setting. Four centres in the process of being developed in one region were selected for in-depth study. The main method of data collection consisted of semi-structured interviews with key “stakeholders”, namely purchasers and providers of primary health care, social care providers, hospital outreach staff and local community and voluntary group workers (Weiss 1983). This paper examines how the health service organizations developing the centres involved local communities in planning them and the obstacles and difficulties encountered. The paper suggests lessons that can be learned for future community involvement in the planning of local health services.     

Staff shortages in the mental health workforce: the case of the disappearing approved social worker

Approved social worker (ASW) numbers in England and Wales were compared on the basis of two national surveys conducted in 1992 and 2002. These data were supplemented by reports published by the Employers' Organisation in the intervening years. Although raw numbers suggested a modest absolute increase over this time, rates of ASW's per 100,000 population declined by over 50%. Possible explanations for this dramatic fall are explored. The authors conclude that specific and targeted action needs to be taken by the government and public sector employers to determine the numbers of mental health social workers needed in modernised community mental health services.     

"If you want to sit on your butts you'll get nothing!" Community activism in response to threats of rural hospital closure in southern New Zealand

Problems of ensuring rural health services in New Zealand have intensified as successive governments have attempted to limit expenditure and health agencies have seen rural services as relatively 'expendable'. From the literature two sets of indicators are identified: the factors influencing successful retention of rural services and the outcomes for the community. Interview and documentation data indicate the extent to which these characteristics and outcomes were present in nine rural community health trusts in southern New Zealand during the 1990s. Variability in outcome and success of community response to threats to rural services relates to the factors identified from the literature, particularly community leadership and capability, but also the prominent role played by local professionals. Given the common political and economic context, these local factors proved important in determining which communities successfully retained hospital services.     

The effectiveness of culturally appropriate interventions to manage or prevent chronic disease in culturally and linguistically diverse communities: a systematic literature review

Culturally and linguistically diverse (CALD) communities in Australia experience both significant health disparities and a lack of access to services. Consequently, there have been calls for culturally appropriate services for people with chronic disease in CALD populations. This paper presents a systematic review of the literature on the effectiveness of culturally appropriate interventions to manage or prevent chronic disease in CALD communities. Evidence was sought from randomized controlled trials and controlled studies that examined strategies for promoting cultural competence in health service delivery to CALD communities. The outcomes examined included changes in consumer health behaviours, utilisation/satisfaction with the service, and the cultural competence of health-care providers. Of the 202 studies that were identified only 24 met the inclusion criteria. The five categories of intervention that were identified included: (1) the use of community-based bi-lingual health workers; (2) providing cultural competency training for health workers; (3) using interpreter service for CALD people; (4) using multimedia and culturally sensitive videos to promote health for CALD people and (5) establishing community point-of-care services for CALD people with chronic disease. The review supported the use of trained bi-lingual health workers, who are culturally competent, as a major consideration in the development of an appropriate health service model for CALD communities.     

Community participation in organising rural general practice: Is it sustainable?

OBJECTIVE: We analysed community participation in organising rural general medical practice in order to suggest ways to extend and sustain it. DESIGN: A multisite, embedded case-study design collecting data through semistructured interviews, non-participation observation and a document analysis. SETTING: One remote and two rural communities in Australia. PARTICIPANTS: Community members, GPs, health professionals, government officers and rural medical workforce consultants. RESULTS: High levels of community participation in recruiting and retaining GPs, organising the business model, and contributing to practice infrastructure were evident. Community participation in designing health care was uncommon. Participation was primarily to ensure viable general practice services necessary to strengthen the social and economic fabric of the community. There were factors about the decision-making and partnership processes in each of the communities that threatened the viability of community participation. CONCLUSIONS: We recommend that a concept of community development and explicit facilitation of the processes involved is necessary to strengthen participation, create effective partnerships and ensure inclusive decision-making.     

村卫生室人员执业现状及待遇保障分析——基于6省18县的调查

目的:分析村卫生室人员执业现状及待遇保障情况。方法:根据经济社会发展水平抽取6省18县(市/区),利用自制调查表调查18县下辖的全部村卫生室。结果:每千农村人口村卫生室人员均数0.7~1.9人;每村卫生室人员均数为1.36~3.24人;部分省村卫生室60岁人员占比超过20%;50%以上村卫生室人员学历为中专且仅有乡村医生执业证书;西部2省村卫生室人员医疗责任险覆盖比例低于11%;除江苏外,其他5省村卫生室人员主要参加新农村养老保险;江苏每村卫生室人员公共卫生和基药补助最高,福建省最低;纳入乡镇卫生院编制管理的村卫生室人员占比低于20%;除江苏外,70%以上村卫生室人员提供24小时服务;村卫生室流出人员超过新进人员。结论及建议:提高村医素质并明确身份;保障村医待遇;鼓励开展研究提出吸引卫生人员到农村执业的更切实可行的建议。     

Community health workers in Canada and the US: working from the margins to address health equity

In this commentary, we address community health workers’ (CHWs) marginalized social location within the health care systems of Canada and the US. This marginalization is due, in part, to their being a workforce shaped by socio-structural factors, such as gender discrimination, racism, and poor socio-economic conditions. This marginalization challenges their ability to address health equity. We propose system-level and workforce-level policy changes that build toward an empowerment path for CHWs to realize their full potential to address health equity. Regarding the work they do and the populations they serve, system-level changes would allow CHWs to strengthen their intimate connection with, and commitment to, advancing health and well-being in their marginalized communities. Workforce-level changes would target their peripheral status by addressing multiple structural factors and altering organizational arrangements to remove their marginalization as a workforce. Together these system-level and workforce-level changes would greatly enhance the health and social services systems.     

Social work practice in a rural community collaborative to improve perinatal care

U.S. rural women encounter many logistical and psychosocial barriers to prenatal care, including high poverty rates, high rates of inadequate health insurance, health care provider shortages, transportation problems and health care systems that may be inadequate or unresponsive to the needs of poor women. The purpose of this article is to describe the role of the social worker in rural communities in the development, implementation and evaluation of a community effort that sought to improve prenatal care through a collaborative of health and human services organizations. The nature of social work participation and the implications for social work are discussed.     

The relative influence of the community and the health system on work performance: a case study of community health workers in Colombia

A central component of the primary health care approach in developing countries has been the development and utilization of community-based health workers (CHWs) within the national health system. While the use of these front line workers has the potential to positively influence health behavior and health status in rural communities, there continues to be challenges to effective implementation of CHW programs. Reports of high turnover rates, absenteeism, poor quality of work, and low morale among CHWs have often been associated with weak organizational and managerial capacity of government health systems. However, no systematic research has examined the contribution of work-related factors to CHW job performance. The research reported in this paper examines the relative influence of reward and feedback factors associated with the community compared to those associated with the health system on the performance of CHWs. The data are drawn from a broader study of health promoters (CHWs) conducted in two departments (provinces) in Colombia in 1986. The research was based on a theoretical model of worker performance that focuses on job related sources of rewards and feedback. A survey research design was employed to obtain information from a random sample of rural health promoters (N = 179) and their auxiliary nurse supervisors about CHW performance and contributing factors. The findings indicate that feedback and rewards from the community have a greater influence on work performance (defined as degree of perceived goal attainment on job tasks) than do those stemming from the health system.(ABSTRACT TRUNCATED AT 250 WORDS)     

Positive community responses to an arts–health program designed to tackle diabetes and kidney disease in remote Aboriginal communities in Australia: a qualitative study

Objective : The Western Desert Kidney Health Project (WDKHP) is an innovative clinical screening, arts–health and community development program, staffed by Aboriginal health workers. The WDKHP is aimed at prevention and early detection, improving the chance of better management of kidney disease among people in 10 predominantly Aboriginal communities in rural Western Australia. This paper aimed to understand community responses to the WDKHP in three of these communities. Methods : Interviews were undertaken with 26 Aboriginal people living in three remote communities. Community responses were analysed with attention to the social organisation of participants in each community and a focus on the perspectives of key groups, identified here as ‘Community Leaders’, ‘Homelanders’, ‘Refuge Seekers’ and ‘Dislocated’. Results : Participants from all groups reported that the WDKHP was highly acceptable, and an effective means of drawing attention to the need for prevention, early detection and management of diabetes and kidney disease. The integration of Aboriginal health workers to explain the project contributed to the high rates of participation in clinical screening. Conclusions : Outreach clinical services can be an appropriate method of engaging people in remote communities in addressing diabetes and kidney disease. Implications : The remote community setting can act as an ‘enabler’ of healthy lifestyle for Aboriginal people, particularly when augmented by well‐designed outreach programs.     

Lay perspectives on lay health worker roles, boundaries and participation within three UK community-based health promotion projects

This paper examines lay interpretations of lay health worker roles within three UK community-based health promotion projects. It argues that understanding lay health worker roles requires critical analysis of the complex interrelationships between professionals, lay workers and the communities receiving a programme. Findings are presented that are drawn from a qualitative study of lay engagement in public health programme delivery where a key objective was to examine the perspectives of community members with the experience of receiving services delivered by lay health workers. Interviews and focus groups were conducted with 46 programme recipients from three case study projects; a breastfeeding peer support service, a walking for health scheme and a neighbourhood health project. The results show how participants interpreted the function and responsibilities of lay health workers and how those roles provided personalized support and facilitated engagement in group activities. Further insights into community participation processes are provided revealing the potential for active engagement in both formal and informal roles. The paper concludes that social relationships are core to understanding lay health worker programmes and therefore analysis needs to take account of the capacity for community members to move within a spectrum of participation defined by increasing responsibility for others.     

A theory of how rural health services contribute to community sustainability

Study and opinion suggest that health services play a significant role in supporting the social fabric of fragile rural communities. We draw on empirical evidence about the added-value contributions of health services to communities and unite it with theory of capitals to propose a theoretical model depicting how rural health services contribute to community sustainability. While providing an analytical framework, the paper also points to construction of a measurement tool for enabling planners to measure the contributions of diverse sectors to community sustainability and predict or measure the impact of changes to models of service delivery on the future of rural communities.     

Barriers to managing mental health in Western Australia

Objective: To explore the views of community‐care and mental health workers on barriers to the management of mental health problems in rural Western Australia, and how these could be addressed. Design: Qualitative content analysis of semi‐structured interviews. Setting: Community and mental health services in Esperance. Subjects: One hundred per cent of relevant mental health workers, 86% of community health professionals and representatives from a wide range of community organisations were interviewed (n =38). Main outcome measures: The views of community‐care and mental health workers on barriers to the management of mental health, and how these could be addressed. Results: Barriers included confusion about the role of mental health services, limited after‐hours access and help for those in situational crisis, communication problems between services, differences in working practices and difficulties in dealing with the stigma of mental illness in rural communities. Suggested solutions were an expansion of counselling services and multi‐agency shared care with clinical streams for adults, those aged > 65 and children. Conclusion: This study revealed a number of barriers that are being addressed through a memorandum of understanding between services.