To protect participant and location identity, pseudonyms were used in presenting quotes and the following codes were used (table 1).
Table 1: Coding for participant characteristics
Assistant facility head
Community health worker
Our analysis emphasised three key themes: (1) narratives on how the health system works (including sub themes on the selection and role of CHWs and the role of supervisors and role allocation) (2) barriers s to task sharing (including barriers associated with community conflict, the farming season and system hindrances); and (3) enablers including intrinsic motivation and community development.
Theme 1: The community health system in context: how the health system works
Selection and the Role of CHWs
Study participants (CHVs and facility heads) described how CHWs are selected by communities, with the involvement of relevant community stakeholders such as men, women, youth, and religious leaders. This selection is normally completed in collaboration with the existing health system and specifically the community head. However, a facility head mentioned how selection processes, especially within border states, have been influenced by ethnoreligious crises.” You know we will have to put our own in these locations…” (Ar Pee Ay, F, 22 years’ experience). The CHWs selected are generally dependent on the type of community and nature of the tasks. However, those of a certain ethnic and religious group are selected, whilst certain groups are left out of the selection process, due to fragile circumstances associated with the inclusion of non-indigenes who do not belong to the predominant religious group in that community.
The range of tasks performed by allCHWs were mainly promotive and preventive and none had purely curative or rehabilitative roles. Health promotion tasks included awareness creation including school-based deworming, mosquito net distributions, immunizations (especially polio). “I tell the district head about the distributions and he calls the community members to inform them…” (Bee Jay Kay, CHW, M, 25 years’ experience). Some also focused on personal and environmental sanitation. Preventive tasks included distributing medicines, nets distributions, immunizations and very rarely (in one participant), school eye screening. There was more priority placed on communicable diseases control.
Most participants described that gender intersects with other characteristics to shape selection processes or perceptions of the role of CHWs. However, one participant stated that lower literacy levels among females and their domestic demands limit their selection as volunteers.
“Yes, sometimes they pick equally, but sometimes we the males are more compared to the females. Sometimes you get to see that the woman is pregnant or has a newborn and sometimes lacking a cook for her children, so that alone leaves her restricted” (Dee Eye, M, 25 years old, 8 years’ experience).
Another participant gave reasons for more male selections“…because when we were distributing mectizan…it is the males who read in the past and most women are not literate…” (Dan Eye, M, 50 years old, 18 years experience).
The role of supervisors and task allocation
Supervisors are trained on tasks which they cascade to CHWs so they can do their roles which as outlined above are mainly focused on prevention and promotion of communicable diseases such as malaria, schistosomiasis, soil transmitted helminths and polio. Supportive supervision strctures were limited, and attitudes were mixed with some seeing supervision as either absent or punitive, for example“When we commence the work, we are with our supervisors…. If we make a mistake, they point it out, … “(Bee Kay, M, 25 years’ experience).
“I have never had any supervisor come to see my work since I started volunteering” (Ay Pee, F, 17 years experience).
The task allocation process begins with training of the supervisors by the local government staff, and the supervisors then train the CHWs. The state implementers are responsible for this above the LGA level. Tasks are then collectively allocated to the CHWs by the supervisors, who rarely provide supportive supervision. Reports are then initially written by the CHWs and sometimes reviewed by supervisors and submitted, which is a rare, shared task amongst CHWs.
“I also encourage the teachers to send timely reports because if they do so, their work is complete. I also inquire that the report has been sent” (Ayar, CHW, M, 12 years experience).
The task allocation process is clearly structured in terms of selection of volunteers, preparing them and their supervisors for the tasks, which further links the community with the health system and views on its effectivness were mixed .
Theme 2: Barriers and enablers to task sharing
Barriers to performance
This theme looked at circumstances, physical and intangible barriers that limit effective task performance and allocations. Sub themes emerged around community and household conflict, the farming season and system hindrances.
Community and Household Conflict
Facility heads and CHWs were both faced with barriers in allocating and undertaking tasks in areas affected by conflict. A facility head described the decline in community participation in health activities due to conflict stating that “but when we started this thing in 2007 to 2010 the community have been supporting but now the community are not supporting at all from the crises we experience, especially due to ethnic and religious differences.” (Ar Pee Ay, F, 22 years experience).
Barriers to CHWs participation in conflicted affected areas included personal choices and attitudes, ethnoreligious background and trust. The quote below summarizes the common perceptions regarding trust that may be exacerbated by ethno- religious viewpoint and linked to national legislation and the right to voluntary decisions.“Sometimes during polio, if we get to Muslim communities and say “Asalam alakum”(the Muslim greeting), as we are Christians, they tell us to stay outside and sometimes they say they will not give their children…” (Ess ,M, Christian, 8 years’ experience).
All participants proferred solutions to overcoming challenges without being prompted. For example, when medicines are administered in communities by the CHWs and refusals from the community occur, the CHWs discuss the reasons why these medicines are necessary to promote healthy individuals and communities. If communities still refuse to take the medicines, despite explanations of benefits of doing so by the CHWs (which appeared to be a common experience), the focal person and the district head are informed.
At the household level, Ayar linked barriers in his participation to his gendered role within his family. He highlighted their disatisfaction with him abandoning family needs for the community, which was seen as not providing much gain. Another participant also shared similar views regarding this.“…Challenges may come from your wife or children saying you have refused to do what will help the home, but something that is not beneficial.”(M, farmer, 12 years of experience). This was a recurring challenge from family members, and amplified in contexts of poverty.
Timing of Task Allocation
A male assistant facility head and most CHWs, mentioned the rainy season as being a hindrance to them and coinciding with peak periods of medicines and net distributions, leading to community inaccessibiliytincreased attrition rates and negatively affecting farmwork. This was linked to the broader economic challenges they face.
“… Sometimes I don’t go to the farm… and when distributing drugs I can’t go to the farm except I give money to people that will go to farm for me,…” (Yoo Ay, 10 years’ experience).
This contributed to CHW attrition as emphasised by Ay Adi; “Some have stopped because of this.”( CHW, M, 7 years experience). The majority of CHWs suggested the need for a change in timing of campaign based activities to support them to fulfil their role in this task shifting activity.
Financial and Logistical Limitations
The financial remunerations increased over the years and CHWs were paid in cash ($6.30 naira equivalent) in 2018. However, this has currently changed to bank payments which has resulted in delayed or no payments to the CHWs, as most of them do not have bank accounts. Those who have them, travel to urban areas where the banks are, which can bring additional security challenges. They spend transportation costs and are left with little, as bank charges are deducted. A facility head mentioned this and how the current dwindling support has lead to attrition.
“…,CDDs what they are giving them the community is not supporting them thinking that the NGOs are supporting them, but the NGOs is only the transport allowance that they are giving them…”(Ar Pee Ay, F, 22 years experience).
A CHW mentioned scarcity of commodities as a major system challenge. This also affected his own household as he forfeited his net for a community member, showing some of the sacrifices CHWs make. …” I was given 100 nets... I initially kept one for myself, but an elderly man said he did not get one, so I gave him my own...” (Dan Eye, M,18 years’ experience).
Logistic challenges related to transportation and financing were also mentioned by most participants. Some of them incurred out of pocket spending, as a result. Additionally, a robust system for logistics does not exist. When we distributed nets, we used my brother’s motorcycle and went house to house using our own money. We did not receive any money for that...” (Ayar, M, 12 years experience).
The need for more structured and stable incentivisation was a clear theme and a common view amongst both supervisors and CHWs.
Clear strong themes here included the intrinsic motivation among CHWs to volunteer and attributing most of their rewards to blessings from God, despite the often unsafe contexts that they work in. A participant expressed this as, “…I am happy to do this because of the recognition I get in the community. Some think I am a health worker, and this makes me happy..., I am well respected” (Ay Em, CHW, M, 19 years experience). Support from supervisors motivated them the most, despite the challenges they faced by living and working in conflict contexts.
A participant emphatically mentioned that “I am happy that you came because if we are doing this work and are being called and asked questions like this, it is good... This has not been done here since I started” (Ar Ay Emm, AFH, F, 2 years experience). This emphasises how CHWs (unlike in many contexts) have not participated in research, and have limited opportunities to share their expereinces and the challenges they face in these fragile contexts.
Partner support through financial support and the provision of medicines, bed nets among other commodities that CHWs distribute to their communities, was a powerful sentiment enabling most volunteers. A CHW had this to say…” the medicines are donated to us from the foreign nations. They told us the value in foreign currency and if we are to convert it to our own, it will be a lot of money…” ( Ess, CHW, M, 8 years experience).