of distribution

WORLD HEALTH

ORGANIZATION

ORGANISATION MONDIALE DE LA SANTE ONCHOCERCIASIS CONTROL PROGRAMME IN WEST AFRICA

PROGRAMME DE LUTTE CONTRE L'ONCHOCERCOSE EN AFRIQUE DE L'OUEST

EXPERT AD\/ISORY COMMITTEE Ad hoc Session

11

-

¹⁵

e EAC.AD.5

Original

: English Dccernber 2001 J

The motivation _{of health} workers involved in the distribution of

ivermectin

(A study from the Republic of Benin)

!

.l

World ^Health Organisation

Onchocerciasis Control Programme in West Africa

The motivation of health workers involved in the

distribution of ivermectin

a study from the Republic of Benin

The planning for the study was jointly undertaken by:

t

AWEDOBA,

K.A.

DEDY,

F.Seri

PROZESKY,

D.R.

PROZESKY,

D.R

SINTONDJI,

F

The system for data analysis was developed by:

lnstitute

of

African Studies

University of Ghana, LEGON, Ghana

I

nstitut d'Ethno-sociologie

Universite de Cocody, ABIDJAN,

COte

d'lvoire Faculty of Health Sciences

University of Pretoria, PRETORIA, South Africa

Faculty of Health Sciences

University of Pretoria, PRETORIA, South Africa

Ministere de le Sant6 Publique et de la Condition F6minine CONTONOU,

Benin

{

Report author:

PROZESKY, D.R. Faculty of Health Sciences

University of Pretoria, PRETORIA, South Africa

December 2001

Acknowledgements

The researchers would like to thank the following persons for their help:

.

At OCP Headquarters Ouagadougou:

*

_Dr Boakye Boatin

*

Dr Komla Siam6vi

*

_{Dr William} Soumbey Alley

.

_{ln Benin:}

*

_{Dr Julius} Gaba, national onchocerciasis co-ordinator

*

_Messrs Abibou and Sikirou, drivers for OCP

*

Health service staff, CDs and villagers in the health districts of K6tou, Dassa-Zoum6, Nikki and Djougou.

,

lt

INDEX

Page no Abbreviations, acronyms, conventions

Executive summary

iv

1

Chapter 1 ^Background

.1

.2 .3

Background to the study Literature survey

Conceptual basis for the research

2 2 2 8

Chapter

2 Methodology

2.1 2.2 2.3 2.4 2.5

Study aim, research question, study design Population and sampling

lnformation sources and instruments Enhancing trustworthiness

Data analysis

I

I I

10 11 11

Chapter 3 Findings: nurses

3.1

Nurses' level of motivation for CDTI

3.2

Factors influencing nurses' motivation for CDTI

12

1 1

2 3

Chapter

4 Findings: community distributors

4.1

CDs' level of motivation for CDTI

4.2

Factors influencing CDs' motivation for CDTI

4.3

Applying the knowledge gained: a case study

22 22 23 34

Chapter 5 Discussion and recommendations

5.1

Dealing with low motivation for CDTI in nurses

5.2

^{Dealing with} low motivation for CDTI in CDs

5.3

Practical considerations

5.4

The way forward

35 35 40 45 46

Appendices

Appendix A Appendix B

Appendix C Appendix D

Appendix E

Plan for field work in Benin Data collection instruments Applying the instruments

Case analysis form: health centre nurses Case analysis form: distributors

48 48 50 60 62 65

lll

CD CDTI CHW 'E'

Abbreviations and acronyms

EPI FCFA MCH OCP PHC TBA WHO

community distributor of ivermectin

community directed treatment with ivermectin community health worker

the effort, energy, excitement, expenditure etc. that someone decides to expend on a certain course of action

expanded programme of immunisation CFA franc

maternal and child health

Onchocerciasis Control Programme in West Africa Primary Health Care

traditional birth attendant World Health Orgtanisation

Conventions

Each case

^(nurses

and CDs) was given a master number. ln the qualitative findings

and discussions data drawn from

a

particular case

are

identified

by that

number

given in

square brackets, as follows: _[13]

lv

EXECUTIVE SUMMARY

The

study

was the

result

of

deliberations at

the

Expert Advisory Committee

of

OCP,

in

1999.

When OCP comes to an end at the end of 2002, the only strategy left to combat onchocerciasis in

the

11 member countries will be community directed treatment with ivermectin (CDTI). ln this activity there are two key players: community distributors of ivermectin (CDs), and the nurses at health centre/ sub-district level who supervise and train the CDs. Evidence from the field points to the fact that there are problems in maintaining the motivation of these two groups of workers.

A study was therefore

required

to

investigate

the level of

motivation

for CDTI, and

factors influencing it.

A

literature study

was

undertaken,

and

Handy's model

of

motivation (1976) identified.

ln

this model motivation

is

seen

to

be specific,

for

particular activities.

This

model

was

used

as

the conceptual basis for the study.

An exploratory; descriptive, cross-sectional study was carried out. Field work took place over a

period of two weeks in three countries: Benin, Ghana and

COte

d'lvoire. A case

study methodology was developed, where semi-structured interviews and discussions provided data from multiple sources. This made it possible to identify the level of motivation of CDs and sub- district nurses with respect to CDTI, as well as the factors influencing such motivation. ln all 14

nurses and 58 CDs from

Benin

were

studied

in depth. For various

reasons

the data

from Ghana

and Cote d'lvoire have not

been analysed

in

depth

to date. The

applicability

of

the present findings to all OCP countries is therefore limited.

It was found that

a

significant proportion

of

nurses and CDs had levels

of

motivation

for

CDTI

that were

medium

or low -

58%

and 53%

respectively.

lt was also found that

CDTI

was

a

relatively low priority in their working lives. Six groups of factors were found

to

influence their level

of

motivation, either positively (as facilitators

of

motivation)

or

negatively (as obstacles to it). These were found to be operating in the following order of importance:

,

_For

_the

nurses: community; health service; personality of the worker; biographical details of the worker; the nature of the job; _financial.

. _{For the CDs: the nature of the} job;

personality

of the worker; financial;

community;

biographical details of the worker; health service.

These factors were analysed in detail, quantitatively and qualitatively, thus clarifying the nature of motivation for CDTI in these two categories of worker in Benin.

Based on these findings, the following instruments were developed for use in the field:

.

A checklist to assess the level of motivation of nurses and CDs.

.

An instrument to diagnose the reasons for this level of motivation.

.

A schematic plan for remedial action, in case of unsatisfactory levels of motivation.

It is

suggested

that these

instruments be tested

in the field,

particularly

to

establish whether

they can be used to

improve

the

level

of

motivation

for CDTI among

sub-district nurse and CDs.

It is

further suggested

that

similar research

be

carried

out in other

OCP

or

APOC countries.

The applicability of the findings to other disease control programmes at community level is also briefly discussed.

Cha r 1 ^BACKGROUND

1.1 Background to the study

OCP ends

in

December

2002.

Responsibility

for all

residual activities

will by then

have been transferred

to the

11 member countries. These residual activities

will

include epidemiological surveillance, entomological surveillance

and

community

directed treatment with

ivermectin (CDTI). Several levels

of

health worker

will

be implicated

in

performing these tasks. There is

evidence (anecdotal mostly, but also in terms of poorer coverage than was

expected) of problems with

the

motivation of these workers. Accordingly

all

^parties

-

OCP and

the

national

teams - would benefit by a ^greater

understanding

of what drives people to

participate in onchocerciasis control activities.

Only activities

surrounding

CDTI were to be

studied,

and not other

onchocerciasis control

activities like

epidemiological surveillance.

lt is

noted

that the problems

surrounding CDTI implementation

are

likely

to be

generic. For example low salaries,

and the need to

earn an extra income, are also a problem in sectors other than health care.

There is an urgent need to come to grips with these

^problems,

since the sustain ability

of onchocerciasis control is at stake.

1.2 Literature survey

ln this survey an effort is made to gain a

deeper understanding

of the lives of

individuals

working in organisations. This brief overview is taken directly from Handy's

book

"Understanding organisations", and focuses on motivation theory; role theory; and

the sociology of people within organisations.

1.2.1 About the motivation to act or work

Early work on motivation focused on ways in which people could be influenced to do something that the authority/ employer wanted - to employ more of their talent and effort for the benefit or the organisation (or the shareholders) (Vroom and Deci, ^'1970):

Satisfaction theories (Porter and Lawler, 1968)

Satisfaction depends

on

conditions

of

work,

on

morale (which

is the

expectation

that

the

future will fulfil expectations). While satisfaction promotes job stability, there is

little

evidence that it ^improves productivity. lncreased productivity however may lead

to increased satisfaction.

lncentive theories

The incentive most studied

is

money (but it is by no means the only

one).

lncentive theory works if an individual perceives the effort to be worth the reward; if the additional output can be measured and attributed to the individual; and if the individual wants that kind of reward.

lntrinsic theories (based on Maslow, 1954)

* Humans experience needs at different levels

(physiological

-,

self-actualisation).

lf needs are

unsatisfied

they

motivate people

to action. ln the present

situation these needs may be at any level (e.9. actual hunger, to the need for self-actualisation).

2 I

Theory X and Theory Y (McGregor 1960):

- X:

Most workers

are lazy

and lack ambition

- so they

need

to be

organised

by

a ruling class of managers.

- Y:

Organisations

tend to make workers

passive,

but they naturally have

some potential for initiative, responsibility etc. - managers have to unlock this.

These theories depend on underlying assumptions about man (Schein's classification, 1965):

.

Rational-economic man: underlies Theory X - 2 types of people.

'

Socia/ man'.

we

gain

our

sense

of

identity primarily from

our

relationships

with

others

-

so an understanding of these is of great importance in the work situation.

.

Se/f-actualising man: underlies Theory Y.

'

^{Complex man'.}

^man's

^needs

^and

motives vary

with time and

situation,

and he can

often select them at will.

' Psychologicalman

(Levinson1972): every person develops

an'ego ideal'-

strives towards

this, as far as

circumstances

allow. Work is an important part of the 'ego ideal' -

if opportunities are provided to approach the ideal, motivation follows.

Further research shows more clearly how the individual makes decisions on how

to appropriate/ allocate his/ her time, energy, talents.

ln

Handy's model (1976)

'motivation'should

_{be regarded as the}

way

in which individuals deal with individual decisions, to do or not to do something. This decision can be modelled like this:

*(

the individual's

needs

the'motivation

calculus'

- the

individual decides how

much'E'the

to invest

the

results

the individual

wants

feedback

all of this takes place within a

'psychological contract'

as well as

'circumstances of life

and

work'

.

'E' refers to effort, energy, excitement, expenditure etc.

'

^This model assumes that people have some control over their destiny/ freedom of choice 'Needs'i_n the model

These can be classified in different ways:

*

_Maslow's hierarchy: physiological, safety, belonging, esteem, self-actualisation.

*

Roethlisberger and Dickson (1951): physiological, safety, fair treatment, independence, achievement.

*

Herzberg (1966): in work situations there are factors which

-

dissatisfy (hygiene factors) - related to working conditions: ^'why work here?'

-

satisfy (motivators) - related to achievement, recognition etc.: ^'why work harder?'

*

McClelland (1961): people

think

according

to their

needs

for

power;

for

affiliation; for achievement.

3

r

*

_Ardrey (1967): need for identity, security, stimulation.

Each person has her/ his own set of

needs; these

change over time. There is a lot

of evidence that people need to work, even if the rewards are very low.

The oriqin of these needs - the factors that influence them

x

Heredity and early environment.

*

Education: changes models, and therefore needs.

* Self-concept: an individuals' assessment of his/ her capacities,

place aspirations (see also below).

*

Experience: clearly affects how needs develop.

in

society,

The'Motivation calculus' in the model

This is the

mechanism

by which we decide how much 'E' to spend. There are

three elements to the calculation:

*

_The strength of the need

*

_The expectancy that the

'E'will

lead to the desired result

*

_The usefulness of the result - that it really will address/ reduce the need.

Note here that.

* _The

calculation

can

be unconscious

or

deliberate;

it

can

take

account

of

immediate or long-term results.

*

_lf the individualjudges any of the three (strength of need, expectancy, usefulness) to be zero, motivation collapses.

* Most decisions are not made this way but by ^precedent - ^but at some stage

the decisions are made which set the precedents, and then

the

calculus probably operates at that stage.

'Resu/ts'in the model

These must be specified, since without knowledge of

the

intended results

it

is not possible

to complete the

calculus.

There

must

also be

feedback

about whether they have

been achieved, or the calculus stops operating.

The 'Psvcholoqical

contract'in

lhe mOdel

This is a set of

mutual expectations between

the

employer

and the worker - what

each expects from the other, and will give in return. lt is a kind of contract. Note in this regard:

*

Most individuals belong to different organisations, and fulfil some of

their

needs in one and some in another.

*

_{lf the} contract is perceived too differently by the two parties conflict results.

*

lf they view the contract in the same way the 'motivation' becomes clear to both.

There are different types of contract (Handy, 1976):

x

Coercive - the 'E' appears through fear of punishment, and will not last.

*

Calculafive

- the

most common form, usually used

in

industry (and

the

health service).

Since the contract is voluntary, 'E' has to be paid for by the organisation in some way.

*

Cooperafive - the worker gets more say in goals and how to achieve them, which elicits

'E'.

_{lt has to} be voluntary though.

Often more than one type of contract operates in an organisation at the same time.

The implicafions of all of this are:

. 'Motivation' happens when the

psychological

contract as viewed by the employer

and employee is the same.

.

_{There is no} one 'right' theory of motivation - each case is unique, for an individual in a given set of circumstances.

.

Changes pushed through

in

organisations involve changes

in the

psychological contract ^- and may therefore affect motivation.

4

I

'

^{lf a} calculation does not provide the desired results, the individual experiences drssonance, which brings with it stress. The individual copes by increasing 'E'; or lowering expectations;

or deciding s/he doesn't need the result after all.

Irrloney has a specific place as a motivating agent:

' ^lt

operates within the calculus

('E'

is expected

to

bring more money, which

it is

hopes will meet a specific need).

,

Money is all-embracing - it can meet a great many needs (but not all).

'

^{Money is the basis for} comparison. There is much evidence that equity (for which money is the evidence) is the need/ motivator here, rather than money itself.

'

^Money

^{is a}

reinforcement: but

only if it is tied to

specific additional

work, over a

specific (short) time.

' ln the long run

money

is

probably

the

simplest (and cheapest)

way of

rewarding people - rather than status, security or job satisfaction.

Motivation

theory

helps

one to

understand

how

most individuals,

given who they are,

make decisions about their lives. So the nature of the person making the decision is crucial - but also very hard to understand. What makes him/ her to be what s/he is?

'

The notion of self-concept (Mead ^'1 934, Horney 1951 ) is useful here - our needs are rooted in our self-concept. The way in which a self-concept is formed is not well understood:

* _lt

comes largely from our selection

of

models early

in life

(at adolescence).

ln

today's society the choice of models is much wider than before.

x

_The process of forming a self-concept is often traumatic (during adolescence).

*

_As

_we

grow older

we fix on a

self-concept

-

which

we then

protect, e.g.

by

having as friends those who accept it as valid.

*

DifferenU traumatic experiences can change our self-concept, always an uncomfortable process.

*

Commitments (to a specific role of job) shape and stabilise self-concepts (Becker 1960).

' Another useful notion here is psychological success (Argyris 1964). People seek

to enhance their self-concepU increase their self-esteem by setting goals which enhance their self-concept, and achieving those goals usrng their own methods:

*

Experiences

of

success

lead to

feelings

of

competence, willingness

to take risks

in areas in which the person feels are important.

*

Experiences of failure tend

to

make

an

individual 'draw inward'

to

protect him/ herself, and breed low achievement.

*

The theory is that 'psychological success' becomes

the

main need for

an

individual

-

it

is the way the other

needs operate,

since if they are met

'psychological success' is achieved.

A

person will only spend 'E' _on an activity if it enhances her/ his self-concept,

if

it

will

bring her/ him 'psychological success'. Also,

if

s/he has not chosen the way to achieve the goal, less 'psychological success' results, and so less

'E'will

be allocated.

5

1.2.2 About roles

Role theory is a specific way of looking at the interaction

the forces in a person: personality, skills the forces in her/ his surroundings

Any person in any given situation occupies a role in relation to the other people in it The following well-known concepts in role theory form the background to any discussion:

.

_{Role sef:}

_The

other people

in a

given situation, around

the 'focal

person', with whom that person has a more than trivial relationship.

.

_Role definition:

A

combination

of the

'role expectations'

that the

members

of the

role set have

of the 'focal role'.

Role definition

is

often made clear

by 'role signs':

uniform, place, furniture etc.

.

Role ambiguity: When there is uncertainty in the minds of the members of the role set, or

of

the 'focal _person', about her/ his role in a given situation:

*

_For some 'focal persons' this is welcome - they like the space, the freedom. Others are stressed

by it:

uncertainty about responsibility, about

others'

expectations, about how one is to be evaluated, about advancement.

*

_{lf the role set} is not clear about the role of the focal person, insecurity, irritation etc. may result.

. _Role incompatibility: When the ^'role expectations' of the set are well known,

but incompatible with

the'focal

role':

*

_{The focal} person's boss and subordinates may have different expectations.

x _{The focal}

_person

_him/

herself may have different expectations from

other

members of the set.

.

_{Role conflict:}

_The

_{result of}

_the

_need

_{for a}

_person

_to

_carry

_out

_{more than}

_one

_{role (each of}

which is completely clear to all concerned) at the same time.

lt

is the differing nature of the roles that causes the conflict.

.

_Role overload: A form of role conflict. Most people can handle some role conflict, but when it becomes too much role overload results (an inability to cope with the conflicting demands of the different roles). Note that this is not the same as 'work overload'.

.

Role underload:

The role

definition

is out of

line

with a

person's self-concept

-

s/he feels capable of handling a bigger role, or more roles.

An

important concept

in

role theory

is

role sfress

-

which may result from role ambiguity, role incompatibility, role conflict, role overload, role underload:

Sometimes

this stress is ^good,

enhances performance

- 'role pressure'.

Sometimes

it

is harmful -'

role

strain''.

*

This has been shown

to

lead to the symptoms of tension (irritation, excessive attention to detail, excessive sickness etc.); to low morale; to difficulties in communication.

*

People use different mechanisms to

dealwith

role stress:

-

Unilateral strategies

-

redefining

the

role, without consultation.

This may

result in retaliation and an escalation of the problem.

-

Cooperative strategies - which require good relationships with colleagues (but note that role stress tend to undermine such relationships).

6

Three situations in particular have been shown to lead to role stress:

*

Respon sibility for the work

of

others: the higher the rank, the greater the stress.

* lnnovative functions: power centres are conservative (even if they say they

want innovation).

* lntegrative/ boundary functions: the coordinator - becomes the focal ^point for

the frustrations of others.

Personality traits strongly influence people's ability to handle role stress:

*

Sociabilify: persons with deep-rooted work relationships handle stress better.

*

Emotional sensitivity: too much of it leads to more tension being experienced; too little of it produces bad relationships - and more stress.

*

Flexibility/ rigidity: the role set applies more pressure to people perceived to be flexible.

!

I

1.2.3 About people within organisations

A

useful concept related

to

roles comes from organisational culture

theory

(Harrison 1972). Four basic organisational cultures are described:

The pouzer culture

It depends

on a

central power source,

with

influence spreading

out

from that

figure; is

highly political; puts faith in the individual; judges by results; is tolerant of means; thrives on insecurity and challenge.

.

_{The culture}

It

develops pillars

-

departments

with

special functions

and

strengths; progression

in

each of

these is

possible;

it is

bureaucratic

- the

role

is

more important

than the

individual; rules are seen as crucial; it does well in a stable environment.

The fask culture

It is project or task oriented; groups of people get together to do

jobs

_{because they are skilled,} not because of their place in

a

hierarchy; very adaptable; difficult

to

control; power lies where the stronger strands of the net intersect.

The p culture

This is

rare.

The

individual is

the

starting point.

lf

there

is a

structure

it

exists only

to

support each individual in what s/he wants to do - a co-operative.

The importance of these models is that particular individuals appear to be better suited

to particular organisational cultures, and the roles that go with these.

The

questionof

learning within an

organisationis

also relevant. Workers at

all

levels are going to have

to

learn

to

carry out new tasks.

lt

must be remembered that every vertical programme does this kind of training on a regular basis. ln connection with training:

For learning to occur the individual must want to learn, must feel the need for it in her/ his work.

ldeally s/he should

volunteer

to attend!

Othenrvise

s/he will comply (by attending) but

not necessarily learn.

Learning must

be

^'owned'

- it

must be seen

to be

close

to the

learner's

work, in

time and in content. lf learning is not immediately used it fades quickly.

!

7

I

Compensafion

within

organisations

is a central

issue,

since it is closely related to

motivation However:

Pay

in

most organisations is seen as compensation, not

as

incentive. Pay is what you get for

doing

something,

rather than

inspiring

you

towards

greater achievements. lt only has

that motivating effect when:

*

_{The reward follows} closely on the improved/ additional performance, _{so the} worker can see that the two are closely linked.

x _The

differential (between

the

one

who

does

the

extra

work and the one who

doesn't) is considerable.

Even if additional pay is offered, very soon the problem of equity comes in. Large differentials

in pay for the same

cadre

are not

tolerated

in

organisations

- why should X get more

pay because s/he happens to have this extra task, whereas I have other extra tasks for which I get nothing?

Promotion (the other main method

of

compensation)

- this is of

relevance

in the

case

of

the nurses, but not the CDs.

lf rewards such as promotion and more pay are not offered, the only remaining reward for effort

is

increased

job

satisfaction

-

but studies show that

this

effect,

even if it

exists, does not last beyond

a

short

time. lt

must be followed by

a

tangible reward. Praise

in itself is

also

not

an adequate reward.

1.3 Conceptual basis for the research

It was decided

to

use Handy's model, as depicted in the diagram

in

Section 1.2, as

the

basis for coming to groups with the concept of 'motivation'for the present research.

The findings of the present research led to a

refinement

of the model: adding the

concept

"circumstances of life and work" as a group of factors influencing motivation.

8

Chapter 2 METHODOLOGY

2.1 Study aim, research question, study design 2.1.1 Study aim

To

gain an

in-depth understanding

of the

motivation

of

health care workers

at

different levels, to participate effectively

in

onchocerciasis control activities

that

have been assigned

to

them

or

for which they have volunteered. This understanding is necessary because local motivation will clearly play

an

important part in the successful continuation of control activities, when OCP has come to an end and is no longer a driving force and source of resources.

2.1.2 Research question

The main research question is

W^hat are the levels ofmotivation for CDT work n both communitvdstributorS ⁽CDs₎ and the heaIth centre eve nUrseSWho tan a nd SE the m?

The following sub-questions follow:

.

What determines and influences this motivation?

' ^{Are the}

^levels

^of

motivation sufficient for the work that needs

to

be done,

to

be carried out in the long term?

2.1.3 Study design

Exploratory; descriptive, cross-sectional.

Case studies: health centre nurses and community distributors

2.2 Population and sampling 2.2.1 Population

The following persons concerned

with

implementing onchocerciasis control measures (especially CDTI), in the 11 OCP countries:

r

persons responsible for onchocerciasis control at district level

'

^persons undertaking CDTI activities at sub-districU health centre level

.

village level distributors.

It was subsequently decided to focus on the last two groups.

2.2.2 Sampling

The size of the sample was constrained by availability of finance for the study:

'

3 researchers, with an assistant each;2 vehicles for each team of 2.

'

^{1 month's}

^work

(in total), including planning (4 days) and analysis (1 week). This weeks for field work.

9

left about 2

The

countries

had to be sampled, giving a spectrum of:

.

Francophone-Anglophone health systems

.

_{Stronger/ weaker economies}

.

_{Countries where} CDTI is going well/ not going so well

.

_Original programme areas/ extension areas

Ghana Cote d'lvoire 86nin

Within each country

districts

had

to

be sampled: those where CDTI is taking place - including ones:

.

Where the coverage is good, and where it is poor

. Where CDTI is just

_starting,

_{and where} it has

been

going on

for some time

. Where the

epidemiological situation

is

unsatisfactory

(since

CDTI will have to continue there for some time)

.

To represent different ethnic groups, if feasible.

1 district per team

per

week=4districtsper

country

Within each district

sub-districts/ health centres

had to be sampled:

.

Those with easy access, and those that are hard to get to/ far from the district or town

. _{Those that have a} small workload in terms of ^patient care

and

flllqgqs

to visit, and those that have a large load.

4 sub-districts/

health

centres per district

(as many as can be done ⁱⁿ a week)

Within each

sub-districU

health centre

catchment

area villages with

CDs had to be sampled:

.

A random sample (if villages are all more or less similar)

.

Taking into account access/ distance; compactness; population.

3 ^villages per

sub- districU health centre (as many as can be done ⁱⁿ one day)

Practically speaking this meant a daily routine in the field of visiting:

!

one health centre/ sub-district (separate interviews with 1-2 staff members)

.

followed by 2-3 villages (interviews with CDs)

At 4-5 working days per week (the rest taken up with travel) this gave a sample size of:

.

_Per

country:

4 district oncho. officers, 16 peripheral health workers, 48 CDs

. Total:

16

district oncho. officers,

48

periphera! health workers,

150 CDs The number of CDs was eventually quite a bit higher, since many villages had two or more CDs

2.3 lnformation sources and instruments 2.3.1 Sources of information

The following sources were used

People involved in CDTI gave information about themselves and about others:

* _the district officers in charge of

programmes

(including onchocerciasis); the

nurses/

technical officers

a

sub-districU health centre level, responsible

for

implementing CDTI in their areas; the village level CDs; the villagers who select the CDs

* _{also the national}

onchocerciasis coordinator,

the regional officer with

responsibility for onchocerciasis, and the district medical officer.

Documents and statistics related to the CDTI work in the districts concerned

l0

2.3.2 Data collection instruments

The principal instrument was

a

set

of

schedules for semi-structured interviews (see Appendix B).

Data obtained were be recorded by hand, using patterned note taking where needed. lf more than

one

respondent

of a level was ^present a focus group discussion was held, using the

same instruments.

2.3.3 Pretesting the instruments

The

instruments

were

^pretested

in the L6o

region

of

Burkina Faso,

which is

conveniently near Ouagadougou, and where there is a small CDTI programme operating. A few changes resulted.

2.4 Enhancing trustworthiness

Steps

were taken to

enhance

the

trustworthiness

of data collected,

according

to the

accepted criteria in qualitative _research:

Criterion

Step/

activity

Credibility Triangulation: multiple sources, methods, investigations

Analysis and discussion of differences

between researchers and their findrngs

Transferability ^I _Clear reports

of

how

the

research process develops, how hypotheses were arrived at

Confirmability Keeping a research journal

Triangulation: multiple sources, methods, investiqations

a

Qependability ^I Triangulation: multiple sources, methods, investiqations

2.5 Data analysis

For each of the two levels of worker under consideration there were multiple sources of information

(the

interviews

with

themselves,

and

with

the

colleagues

above and

below

them; also in

some cases documentary evidence). ln each case:

. _{The level of}

motivation

for CDTI (= the

amount

of 'E' they were willing to spend on

work related

to

CDTI) was determined, and categories of 'motivation' established (see Sections 3.1 and ^4.1 _).

' The data from

different sources were triangulated,

to build up case

studies

for

nurses and CDs.

' ^{The factors}

influencing motivation

were

extracted

from the stories of each case,

counted, scored (on a scale of 1-3) and richly described.

Qualitative data were entered and analysed using Word software. Biographical data

and commonly recurring phenomena were analysed quantitatively using Excel software.

ln

the

actual event only data from Benin were analysed (although they were collected in all three countries):

.

_{14 health centre nurses}

.

58 community distributors.

ll

I

Gha r 3 FINDINGS: NURSES

3.1 Nurses' level of motivation for CDTI

As the data were being collected, a framework was developed to conceptualise nurses' motivation for

cDTl,

and then to assign a value to it. The following was the result:

ln this model, 'achievement' was seen to consist of five elements:

'

Coverage level: proportion of villages in the programme

.

Training of CDs: how well it was done

.

lvermectin supply: whether shortages happen

.

Supervision of CDs: how frequently, how well done

'

Opinion of the community, the CDs, the district supervisor about the nurse's work

Factors influencing motivation were similarly identified and classified

as the

field work proceeded (see Section

3.2

below).

The

model

was

tested

and

refined iteratively during

the

course

of

the research. For the 14 health centre nurses in the sample the following was found:

Motivation level of nurses

medium

motivation

levels

high -oo

E 7 6 5 4 3 2

1

0

low

__)

Fewer than half of the nurses were found to be highly motivated for CDTI - _a finding with important implications for the sustainability of the CDTI programme.

The five elements of achievement score high

a

vated Hiohlv

factors and relativel few obsfac/es There are man fa

I

Averaoe n

Facilita factors and obsfac/es of moderate Average levels of achievement

I

vated Poorlv

Ail fiveeements ofachievementdre low⁽one ortwo may beaverage The facilita factors are few and the obsfac/es m

r- _I

r ^I-

I I

I I

t2

n

3.2 Factors influencing nurses' motivation for ^CDTI

Using the methodology described in Chapter 2 above, the factors promoting or

^hindering

motivation for CDTI were explored. The following should be noted:

. _The

factors promoting

and

hindering motivation are termed 'facilitators' and 'obstacles' in the ensuing discussion.

.

Six groups

of

factors presented themselves from the data,

for

both facilitators and obstacles.

These groups are related to:

*

_The

_community

within which the nurse worked

*

_The

personality

of the nurse

*

_The nature of the

job

(of a nurse, in implementing CDTI)

*

_The

health service

within which the nurse worked

*

_{The nurse's}

biographical

particulars (past life and experience)

*

_The

_financial

situation of the nurse.

There is

inevitably

some degree of overlap

between

these categories. ln

summary, their relative strength was found to be the following:

Factors affecting motivation in nurses

6

4

3

2

o

to G'

o o

o-

'6

o)

=

5

Efacilitators

I

^obstacles

0

conmrnity health service personality biographical the job f inancial

category of factor

ln this diagram the term 'weight per case' is an indication of the strength with which that group of factors influences motivation for CDTI. The following scoring system was used:

\)- z- l=

the factor was one of the group that had the most powerful impact on motivation the factor had a lesser but definite impact on motivation

the factor is but seems to have had little im ct on motivation

r3

1

a These factors operate at different points in the motivation model of Section 1.2.1 above

* Psychological contract

Needs of/ results for the nurse Circumstances of life/ work.

The data below make

it

possible

to

understand the motivation

of

nurses involved in CDTI at a deeper level. Only some of these factors are however realistically amenable to change.

ln the discussion following each group of factors is dealt with.

* Quantitatively: in the

form

of a

table which illustrates

the

nature

and

relative strength of facilitators and obstacles related to that factor.

* Qualitatively:

in the form of a discussion, illuminating the facilitators and obstacles in more detail, and based on qualitative data obtained from the full range of sources.

3.2.1'Community' factors

Table

3.1 'Community'factors influencing nurses' motivation for

CDTI

Factor

Where it

works Weight

per case

aL

o .=o o(!

ll

A qood relationship with the community Psycholoqical contract 1.3

5.1

Feels appreciated by/ integrated into the

community

'

Needs of/ results for the nurse

.

Psycholoqicalcontract ^1.3

Villagers are keen on the treatment

-

expensive but free Psychological contract ^{1 1}

Knows people in the community who can

help Circumstances of life/ work ^{1 1}

Afraid her/ his reputation will suffer if s/he

doesn't do the distribution well Needs ofl results for nurse 0.3

ao o(!

tt

o

o

CDs nag about

^payment,

or

are ^jealous

of her/ his salary Psychological contract 1.4

5.4

CDs often not

available

-

occupied with

personal affairs

.

Circumstances of life/ work

.

Needs of/ results for the nurse 1.3 People

in

villages

are

illiterate

-

hard to

persuade them

'

Psychologicalcontract

.

Needs of/ results for the nurse ^1.1 CDs need to be policed all the time, to do

the work

.

Psychologicalcontract

.

_Needs

ofi

results for the nurse 1.0 Problems

with

communication

-

doesn't

speak the vernacular Circumstances of life/ work 0.4

Conflict with the community/

leaders won't cooperate freely

.

Psychologicalcontract

.

Circumstances of life/ work ^0.2

The group of factors most commonly and strongly influencing motivation were those related to the community

within which the nurse was

working.

The overall effect of the obstacles was

only slightly more than that of the facilitators.

Nurses'task was made easier by a good relationship with their local communities - thus improving

their

motivation

for CDTI. This

required nurses

to work

through accepted community authority

l4

structures, both traditional and administrative [30]. They were rewarded with cooperation for taking trouble to get

to

know

the

leadership [41] ^and

to

make use of other influential persons [34; 35]. ^tt

was

noted

that a

^situation

of

social peace made

the

work easier

[33].

Even villages which were slow

to

cooperate

at the

beginning soon became involved

[34]. lt

helped

if the

nurse spoke the local language well [43] or was working in the place where s/he had been born and bred [42].

ln

one

or two

situations

the

local authorities were not very helpful [34]. This

was in

one situation related

to the rather

isolationist culture

of a

local

tribe [36], and in

another

to the fact that

the community wanted more than one round of treatment per year _[40]. A few nurses could not speak the local language, and had

to

rely on translators in their dealings

with

patients and communities [12, 35]. This naturally made their CDTI work more difficult.

Communities noticed and appreciated nurses who liked 'mixing in with them, and acting

the

way they

do'

[33], or who were always available ⁱⁿ the health centre

-

and responded with cooperation [36]; on the other hand nurses were aware of the need to succeed with

the

CDTI, for

the

sake of their reputations [37]. ln such situations the nurses felt accepted and

appreciated[12;30;

40] and enjoyed living

in the

community concerned [36].

ln

one case villagers

even

presented

the

nurse with harvest produce as a gesture of thanks [37].

The fact that

the

ivermectin

was

being supplied free

of

charge had

a

very positive effect as well.

The cooperation of village leaders was fostered by it [35], ^and villagers even came

to

ask for it to

be given more

frequently

[37]. The

^nurses

felt good

about offering something

for free, so

that everyone could benefit [29]. Finally many CDs themselves felt proud to be associated with offering this free benefit to their communities [37]. All of this made the task of the nurses that much easier.

Concerning obstacles

to

motivation,

by far the

most powerful

group in the

entire

study was

the attitude and conduct of the CDs - a combined 'weight per case' of 3.7. The CDs wanted to be paid [41]

and

expect

the

nurses

to

be

their

advocate

to

achieve

that [35]. CDs

suspected nurses _of getting extra money for the CDTI work _{[41] or} of holding back fees due to them _[42] - after all CDTI is a 'project' and other projects come with money [43]. Although the nurses appreciated the justice

of the CDs' claims [a3] they got worn down by the

constant

nagging [a3]. They were

equally

frustrated by the need to police CDs

constantly

- e.g. regarding reports that were late,

or ivermectin that

was

not fetched [37; ^38]. The fact that many CDs were only available after hours (since they work _{in their} fields by day) was also a frustration [34].

t5

3.2.2'Health service' factors

Table

3.2 ^'Health service'factors influencing nurses' motivation for cDT!

Factor

_{Where it}

works Weight

per case

aL

o(!

E

'o tLG

The

health service provides

her/

him with the necessa ry transport and fuel

.

Circumstances of life/ work

.

Psycholoqicalcontract ^1.7

4.2

S/he is

regularly supervised/ encouraged

by her/ his superiors, with respect to CDTI

.

Circumstances of life/ work

.

Psycholoqicalcontract ^0.8

The health centre/ district covers

all expenses incurred in CDTI

Circumstances of life/ work

Psycholooical contract 0.6

Her/ his predecessor oriented her/

him

well, handed on necessary documentation Circumstances of life/ work 0.6 CDTI

is

included

in her/ his

official 'basic

package of activities' Circumstances of life/ work 0.5

oo

E

(E

o

o

Lack of

resources (transport,

fuel) -

late/

insufficient

.

Circumstances of life/ work

.

Psychologicalcontract ^1.2

4.4

Poor means of long

distance

communication, so wastes time travellinq Circumstances of life/ work 1 1

Promises

about per diems not

kepU not reimbursed

.

Circumstances of life/ work

.

Psychologicalcontract ^0.8 Supervision

for nurses' CDTI

activities is

relatively poor

.

Circumstances of life/ work

.

Psycholoqicalcontract ^0.7

CDTI not included in 'basic package of

activities' Circumstances of life/ work 0.6

Aspects

of the

health service strongly affected nurse motivation regarding CDTI, facilitating and obstructing motivation in more or less equal measure.

Among these factors the issue of transport stands

out.

ln situations where transport for CDTI was available and paid for there was generally

a

positive attitude _[35; 37; 38]. The transport (usually a

motorcycle)

could be hired [35], or be

^provided

by the health centre itself [37] or by the

EPI programme [38]. ^Funding - i.e. money for fuel - could also be from a variety of sources. The health centre

often had to top it up from its own

revenue [35] since

the funding from the

district was almost always

too little. Often

funding

was only

available

for one of the

aspects

of CDTI

(e.9.

training) and not

for

others (e.9. supervision) [12]. ln some cases the transport was either absent

[29] or

objectively

too little - even though its was used in an

integrated

way, and ^planned

ⁱⁿ

advance, it simply could not cope with all the programmes that had to be run [12]. Not surprisingly a constant battle to obtain transport had a negative effect on motivation.

The

lack

of other

resources needed

for

CDTI similarly

had a

negative

effect on

motivation, by making tasks more

onerous.

The staffing level at

a

health centre might be too low to cope with all the programmes that need to be run _112). A shortage of ivermectin could equally cause problems:

'l

didn't have enough tablets, so the communities who weren't treated weren't pleased with me. lt

was

demotivating.

And I can't help it, it's the fault of the higher levels' [30; also 36]. A

related theme was

the

lack

of

telecommunications. Since

the

post

was

not dependable and

in

any case took too long [12], nurses ^had to spend

a

lot of time driving

to

meetings

or

delivering messages ^- up to 25% of their working time _[34].

l6

Supervision

of

CDTI activities by district and national level staff was also important as

a

motivator [13;

36]. Such

supervision

worked by

helping

the

nurses

to solve

problems

in the field

_{[30], or} simply by encouraging

the

nurses

in

their work [42]. ln several cases supervisory visits

to

health centres did take place, but CDTI was not on the supervisors'agenda [34; 36]. ^Failure to supervise adequately was sometimes due to a lack of transport at district level [35].

The willingness

of

nurses

to

engage

in

CDTI activities

was in

some cases clearly linked

to

their perception that

the

programme had been officially approved [38; 39] and had become

an

integral part of health centre's activities _[33]. As a result nurses felt obliged to work on it [39]. This

waslhe

case in spite of the fact that CDTI had not yet been officially included in

the

list

of

basic activities for health centres [34].

3.2.3'Personality' factors

Table

3.3 'Personality'factors influencing nurses' motivation for cDTt

Factor

_{Where it}

works Weight

per case

thL

o

.=G

'6 (!

LL

S/he is interested in working with

the

commun and likes it Needs ofl results for the nurse 1.6 4.1

S/he is

public-spirited, wishes

to

protect

the commun Needs ofl results for the nurse 1.4

S/he takes ride in doi her/ his ob well Needs of/ results for the nurse 0.6 Her/

his family members have

suffered

from onchocerciasis Needs of/ results for the nurse 0.6

I

o o(!

-oa

o

S/he has

too

many interests outside her/

his work; s/he is often away from work

Needs

ofl

results for the nurse Circumstances of life/ work 0.7

1.6 S/he

is not interested in this aspect

of

her/ his work Needs of/ results for the nurse 0.6

Her/ his morale is low - feels

the

Ministry treats her/ him shabbi

.

Psychologicalcontract

.

_Needs

_ofl

results for the nurse 0.3

The personality of the nurses had

a

marked effect on their motivation

-

considerably more positive than negative

A strong motivating factor was an interest that the nurse had in working with the community. Such persons enjoyed the community contact [40] or found the concept of 'prevention _{is better}

thin

cure' attractive

[30;

39]. Others however were simply not very interested

in this

aspect

of

their work - preferring MCH, for example [38]. As a result they might not undertake all the component activities of CDTI properly

-

e.g. neglecting

to

send reports _1251. Otners were perceived

as

being generally slow,

this

being ascribed

for

example

to

being near retirement age [a1].

yet

_{others naO}

io .rny

interests or activities _outside their health centre work that this

wai

OounO to have a negative effect on their motivation for CDTI. This showed itself in absences of up to 30 days per

yearLn

family or community affairs _{[30; a1].}

ln a related theme nurses spoke of pride in doing their work well: 'You _have

to

love your job, _that,s what makes

a

man' [39].

They

spoke

of it

being

a

matter

of

^pride

to

achieve high'coverage _[33]

and

of

the obligation they

felt to

make _CDTI work, since

it is a

State programme and the

Orr!

id

given

free [37].

Supervisors spoke

of the

'professional conscience'

oi a

particular nurse

t3gli

^of

t1 itv

ly

nurses being conscientious and meticulous

l42land

^{dedicated to the}

job

_[13]. There were however a few cases where nurses appeared to be suffering from low morale - expressing feelings of being exploited and underpaid [30; 41].

Several nurses showed clear signs of public spiritedness, which motivated them

to

be involved in CDTI - wishing

to

^{protect people from} suffering [39], and more specifically from blindness [12; ^13;

371;

and in so

doing feeling useful

to

society

[41]. ln a few

cases actual

family

members

of

the nurse had suffered from onchocerciasis [34].

3.2.4'Biographical' factors

Table

3.4 'Biographical'factors influencing nurses' motivation for

CDTI

Factor

^Where

it works Weight

per case aL

o .=G

'6 tLo

S/he has general experience

as a

nurse

in charqe of a health centre Circumstances of life/ work 1.4 S/he knows CDTI, has been trained in ^it, 3.4

has worked in it Circumstances of life/ work 1.4

S/he has

previously

taken part in

mass

distribution of ivermectin Circumstances of life/ work 0.5

I

o_o (!

-oo

o

S/he knows nothing about CDTI,

^has

never been trained in it Circumstances of life/ work 0.4 A woman - not respected by the CDs Circumstances of life/ work 0.4 1.1 S/he is new to _{the iob} Circumstances of life/ work 0.3

Biographical factors, i.e. the nurses'life and work history, affected motivation much more positively than negatively.

Having experience as

a

nurse in charge of a health centre made it easier

to

manage programmes such as CDTI [34; 40]; on the other ^hand

a

lack of experience made some nurses more tentative [33; 39].

The

training

that the

majority

of

nurses received

in

CDTI gave

them

confidence _[many examples];

others

however

had

recently been transferred,

had not yet been trained and

didn't really know how

to

go about the

job

_{[29; 33].} One had been trained

but

had clearly not mastered the essentials of CDTI in spite of it _[43]. The experience gained as member of a team undertaking mass distribution

of

ivermectin

in

previous years familiarised some nurses

with

many aspects of CDTI [13; 34].

ln

one case

a

nurse had heard about the onchocerciasis control programme while still at school, and was therefore interested in it [33]. The fact that the nurse was a woman made ^it more difficult in some cases to command the respect of CDs, leading to lower motivation [38].

t8

3.2.5 'Job'factors

Table

3.5 'Job'factors influencing nurses' motivation for

CDTI

Factor

Where it

works Weight

per case

(!o

LL

S/he is only responsible for a few villages Circumstances of life/ work 1.3 1.3

I

o_o (!

o

o

Many villages, distant hamlets,

access

difficult, poor roads Circumstances of life/ work 1.4

S/he is often away on official

business, 2.6

so too little time Circumstances of life/ work 0.9

S/he has a heavy administrative burden Circumstances of life/ work 0.3

The

majority

of

nurses

were

reportedly undertaking

the full

range

of

CDTI activities expected of them. However

the

nature of the

job

in

a

number of cases affected

the

motivation

of the

nurses - negatively rather than positively.

The

most significant negative effect

on

motivation

was

due

to the fact

that there were

too

many villages in the area to visit (such as the encampments of nomads) [34] or that the roads to some of them were

not

suitable for motorcycles [36]. In

a

related theme, if villages were very diffuse CDs were continually complaining and asking for money 141)- a constant irritation to nurses, who could

do

nothing

about it.

Conversely nurses with few villages

to

cover naturally found

the

task easier t38l

Another theme was that the nature of the nurses' job at the health centres in many cases required them to be away from the workplace for significant amounts of time

-

up to 80 or 90 days ^{per year} [36,

43]. The

purpose

of these

absences might

be to

collect

fuel (e.g. for the fridge); to

fetch/

change expired vaccines;

to

bank monies; for special meetings; for

any

large-scale 'actions', e.g.

the

polio vaccination;

to

cope with sudden demands

for

information;

for

emergencies etc. t34].

lf

more than

one

programme

was on at a

given time some CDTI activities might

be

left

out -

e.g.

supervision of distribution [34]. The nurses' administrative burden could also be heavy at times - so 'if another job came on top of the usual load there is less motivation' [33].

The

relative priority of

CDTI in the

job

Nurses

were asked to list the

activities

they

regularly undertake

as part of their work, and

to prioritise

them

in terms of their importance, and the amount

of

time they take. The following was found:

Average number of work-related activities undertaken: 4.0

t9

Table

3.6 Priority ratings for nurses'work-related activities

Work-related

Activity

Priority rating out of 4.0 Curative care

EPI

Management Maternal health IEC

CDTI

Leprosy proqramme 1.0 1.5 2.0 2.1 2.2 2.9 3.1

ln

spite

of a

likely amount

of

politeness bias (since it was known that

the

researchers were 'from the oncho programme')the priority given to CDTI is low.

Nurses were also asked to give

the

reasons for prioritising their activities in the way they did. The following was found:

Table

3.7

^Reasons

for assigning priorities to activities

Activity Reasons for assigning a particular priority Hiqh oriority activities

.

Curative care

.

EPI

.

_Management

.

Maternal health

a a

These are the common activities, which involve lots of patients These are the activities which keep me busy every day.

These activities are the raison d'6tre of the health centre.

Low prio ritv activities CDTI

Leprosy programme

These activities I carry out seldom - they take little time.

These activities deal with conditions which are rare, even if they are serious.

The reasons for assigning a low priority to CDTI are clear. lt took place infrequently, and was seen

as

rather peripheral to

the

core activities which are the raison d'6tre of

the

health centre: curative care, EPl, maternal health and management.

3.2.6'Financial' factors

Tabte

3.8 'Financial'factors influencing nurses' motivation for

CDTI

Factor

Where it

works Weight

per case o(E

l!

S/he has enough other sources

of revenue (e.9. spouse works)

.

_Needs

_ofi

_results for the nurse

.

Circumstances of life/ work 0.8 0.8

o

-go

G

o

o

S/he has

dayto-day

^problems

in

making ends meet

.

Needs of/ results for the nurse

.

Circumstances of life/ work ^0.2

S/he has a heavy family

^load/ 0.4 responsibility

.

_Needs of/ results for the nurse

.

Circumstances of life/ work ^0.1

20

Salaries

were

regularly

paid

but they were low:

an

lnfirmier

de

Sant6 started

at

FCFA

34

000 a month ($ ^+S1, and an lnfirmier Diplome de l'Etat at FCFA 44 000 ($ SS). Thereafter an increment of only FCFA

2 000

($ 2.S01 every two years was usual.

lt

is therefore contrary

to

expectations that financial factors appeared

to

have little effect

on

nurse motivation,

and that the

influence

of

this effect on motivation was more positive than negative.

ln the health districts visited nurses were allowed to earn money in their spare time, as long as this didn't detract from their work [12]. Almost

all

nurses did this, usually

in the

field

of

agriculture, or sometimes commerce; more often

than

not

they

hired labour

to do the work for them,

and only became involved themselves

after

hours

or on

weekends

[34; 39; 41;

42].

Their

spouses also

earned: in

salaried

jobs, by

manual

work, by trading etc. [33; 37; 42]. Most nurses

therefore reported coping financially, generating an overall family income at

a

reasonably satisfactory level.

There were cases however where failure of agricultural enterprises and heavy family commitments made it hard to make ends meet, resulting in a worrying level of personal debt _{[35; 37].}

2t