Participant characteristics
In total, 235 CHWs participated in the study. A large majority were female (89.2%). The median age of the participants was 39 (inter-quartile range [IQR]: 33-45) years. The distribution of informal CHWs (49.4%) was similar to that of formal CHWs (50.6%). The majority (74.5%) of CHWs worked in small town areas. Regarding formal education, just more than three-quarters (75.7%) of the participants had attained a matric/grade 12 certificate. Most (61.3%) CHWs indicated that they were supervised by OTLs relative to PHC facility-based professional nurses/managers (28.1%) or non-governmental organisation (NGO)-based supervisors (9.8%). The median length of service was three (IQR: 1-6) years, the mean TB SHCI competence score was 7.1 (sd: 1.9) out of 9 and the mean the TB SHCI knowledge score was 11.4 (sd: 1.2) out of 28 (Table 1).
Table 1: Participants’ demographic characteristics (N = 235)
Variable
|
n (%)
|
Sex
Male
Female
|
24 (10.2)
211 (89.8)
|
Age in years: (median; IQR)
|
39 (33-45)
|
CHW category
Informal
Formal
|
116 (49.4)
119 (50.6)
|
Location
Urban
Small towns
|
60 (25.5)
175 (74.5)
|
Formal education
Secondary school
Matric/Grade 12
Tertiary
|
42 (17.9)
178 (75.7) 15 (6.4)
|
Supervisor
Outreach team leader
PHC facility-based nurse/manager
NGO-based supervisor
|
144 (61.3)
68 (28.9)
23 (9.8)
|
Length of service in years (median; IQR)
|
3 (1-6)
|
Attended TB SHCI training in the past 12 months
Yes
No
|
164 (69.8)
71 (30.2)
|
TB SHCI competency score (mean; sd)
|
7.1 (1.9)
|
TB SHCI knowledge score (mean; sd)
|
11.4 (1.2)
|
IQR = inter-quartile range; sd = standard deviation.
Exploratory factor analysis of the motivation scale
The Kaiser-Meyer-Olkin measure verified sampling adequacy for the analysis (KMO = 0.838) and the Bartlett’s test of sphericity (X2[120] = 1469.639; p < 0.001) indicated that correlations between items were large enough for the EFA. Three factors had eigenvalues over Kaiser’s criterion of 1 and in combination explained 56.04% of the variance. The scree plot showed inflexions that also justified retaining three factors. Given the convergence of the scree plot and Kaiser’s criterion on three factors, these three factors were retained in the final analysis. Table 2 shows the factor loadings after rotation. The clustering of the items on the factors suggested three distinct factors underlying CHW motivation. Factor 1 represented ‘intrinsic job satisfaction’; factor 2, ‘burnout’; and factor 3 ‘team commitment’. With an Eigen value of 5.30, factor 1 – ‘intrinsic job satisfaction’, comprised of six items and explained 33.1% of the variance in CHW motivation. Factor 2, – ‘burnout’, comprised of five items, had an Eigen value of 2.39 and explained 14.95% of the variance in CHW motivation. Factor 3 – ‘team commitment’ comprised of five items, had an Eigen value of 1.27, and explained 7.95% of the variance in CHW motivation. A total of 14 items were eliminated from the analysis because they did not contribute to a simple factor structure and failed to meet the minimum criteria of having a primary factor loading of 0.4 or above, and no cross-loading of 0.3 or above. Subsequent analysis was based on the derived 16-item scale.
Reliability analysis of the derived motivation scale
In terms of reliability, internal consistency (Cronbach’s Alpha [α]) was calculated for the derived motivation scale as well as the associated individual sub-scales. The 16-item scale showed satisfactory internal consistency with a Cronbach’s α of 0.81. Each of the individual sub-scales also had acceptable internal consistency as reflected by the respective Cronbach’s α values; intrinsic job satisfaction: 0.83; burnout: 0.73; and team commitment: 0.83.
Table 2: Exploratory factor analysis of CHW motivation to perform SHCI
Item
|
Factor 1: Intrinsic job satisfaction
|
Factor 2: Burnout
|
Factor 3:Team commitment
|
I have happy thoughts and feelings about those I am able to help
|
0.896
|
0.006
|
-0.087
|
I am proud of what I can do to help others
|
0.743
|
0.000
|
-0.044
|
I believe I can make a difference in my work
|
0.621
|
-0.040
|
0.173
|
I am a hard worker
|
0.574
|
-0.034
|
0.170
|
I am punctual when coming to work
|
0.492
|
-0.032
|
0.109
|
I do things that need doing without being asked or told
|
0.461
|
0.035
|
0.217
|
I feel overwhelmed because my workload seems endless
|
-0.070
|
0.793*
|
0.160
|
I feel overwhelmed by my work as a CHW
|
-0.052
|
0.673*
|
0.212
|
Sometimes when I get up in the morning I dread having to face another day at work
|
0.047
|
0.665*
|
-0.119
|
I only do this job to get paid
|
-0.130
|
0.448*
|
-0.066
|
I feel emotionally drained at the end of every day
|
0.146
|
0.416*
|
-0.183
|
I am proud to be working for the WBPHCOT
|
0.051
|
-0.088
|
-0.761
|
I feel committed to working with this WBPHCOT
|
0.086
|
0.022
|
-0.739
|
The WBPHCOT inspires me to do my very best in my job working in the community
|
0.059
|
0.022
|
-0.705
|
I am satisfied with the services being provided by me
|
0.133
|
0.067
|
-0.495
|
My work makes me feel satisfied
|
0.235
|
-0.105
|
-0.419
|
% variance explained
|
33.14
|
14.95
|
7.95
|
Cronbach’s α
|
0.83
|
0.73
|
0.83
|
Mean out of 4
|
3.66
|
2.57
|
3.49
|
SD
|
0.39
|
0.64
|
0.53
|
Extraction method: principal axis factoring. Rotation: Oblimin with Kaiser Normalisation. *Scores for negatively worded questions were reverse coded such that 1 = strongly agree, 2 = strongly agree, 3 = strongly disagree and 4 = strongly disagree, a high score suggested higher motivation.
CHW motivation level
The mean motivation scores are depicted in Table 3. The scoring was such that higher mean scores suggested higher motivation. The highest mean score was established for the item “I am a hard worker,” (n = mean: 3.78; sd: 0.45), implying that respondents would describe themselves as highly motivated in this respect. The lowest mean scores were for the item “I feel emotionally drained at the end of every day,” (mean: 2.31; sd: 0.93) and “I feel overwhelmed by my work as a CHW,” (mean: 2.31; sd: 0.95) implying that some respondents felt demotivated in these respects. The raw item scores were then summarised and the total score was divided by the total number of items measuring CHW motivation. The mean motivation score was 52.26 (sd: 5.86) out of 64 implying that overall, the CHWs were inclined to be well motivated to perform TB SHCI. In additional analysis, formal CHWs scored statistically significantly higher (t(233) = 2.157; p = 0.013) than informal CHWs on the team commitment sub-scale (formal CHWs — mean: 17.82; sd: 2.48 vs. informal CHWs — mean: 17.07; sd: 2.82). However, job satisfaction and burnout scores were not significantly different across these groups. Comparison of motivation scores across the geographical areas yielded a statistically significant difference on the burnout scale, where CHWs from the urban area scored higher (t(233) = 2.665; p = 0.008) than those from rural/small towns (urban area — mean: 13.10; sd: 3.13 vs. rural/small towns: — mean: 11.85; sd: 3.09)
Table 3: Level of motivation among CHWs (N = 235)
Item
|
n (%) agreed
|
Mean (standard deviation) out of 4
|
Job satisfaction
|
|
|
I have happy thoughts and feelings about those I am able to help
|
233 (99.1)
|
3.72 (0.47)
|
I am proud of what I can do to help others
|
234 (99.6)
|
3.76 (0.44)
|
I believe I can make a difference in my work
|
231 (98.3)
|
3.68 (0.50)
|
I am a hard worker
|
232 (98.7)
|
3.78 (0.45)
|
I am punctual when coming to work
|
222 (94.5)
|
3.52 (0.63)
|
I do things that need doing without being asked or told
|
222 (94.5)
|
3.52 (0.62)
|
Burnout
|
|
|
I feel overwhelmed because my workload seems endless*
|
122 (51.9)
|
2.42 (0.94)
|
I feel overwhelmed by my work as a CHW*
|
136 (57.9)
|
2.31 (0.95)
|
Sometimes when I get up in the morning I dread having to face another day at work*
|
117 (49.8)
|
2.51 (0.97)
|
I only do this job to get paid*
|
28 (11.9)
|
3.29 (0.78)
|
I feel emotionally drained at the end of every day*
|
137 (58.3)
|
2.31 (0.93)
|
Team commitment
|
|
|
I am proud to be working for the WBPHCOT
|
215 (91.5)
|
3.44 (0.78)
|
I feel committed to working with this WBPHCOT
|
217 (92.3)
|
3.47 (0.71)
|
The WBPHCOT inspires me to do my very best in my job working in the community
|
220 (93.6)
|
3.52 (0.64)
|
I am satisfied with the services being provided by me
|
222 (94.5)
|
3.50 (0.67)
|
My work makes me feel satisfied
|
220 (93.6)
|
3.52 (0.67)
|
Mean motivation score was 52.26 (sd: 5.86) out of 64; N = 235. *Scores for negatively worded questions were reverse coded such that 1 = strongly agree, 2 = strongly agree, 3 = strongly disagree and 4 = strongly disagree, a high score suggested higher motivation.
Determinants of CHW motivation to perform TB SHCI
A multiple regression was carried out to investigate whether CHW motivation to perform TB SHCI based upon CHWs’ sex, age, education, category, location, length of service, attendance of most recent TB SHCI training, and TB SHCI knowledge and competence. Preliminary analyses were performed to ensure that the assumptions of linearity, independence of errors, homoscedasticity, unusual points and normality of residuals were met. The results of the regression indicated that the model explained 16.3% of the variance and that the model was a significant predictor of CHW motivation to perform SHCI (F9, 210 = 4.540; p<0.001; R2 = 0.163). Table 4 depicts the determinants of CHW motivation. CHW age (β = 0.117, p = 0.030), location (B = 1.759, p = 0.038), length of service (β = -0.505, p <0.001), attendance of TB SHCI training (B = 1.833, p = 0.33), and TB SHCI competence (β = 0.713, p <0.001) contributed statistically significantly to motivation.
Table 4: Multiple regression model for the determinants of CHW motivation
Predictor
|
Unstandardised coefficient
|
p-value
|
B
|
Standard error
|
Constant
|
37.842
|
6.236
|
<0.001
|
Sex
Male
Female
|
-1.630
|
1.212
|
0.180
|
Age
|
0.117
|
0.053
|
0.030
|
Education
Matric/Grade 12
Secondary school
Tertiary
|
-0.978
|
0.888
|
0.272
|
CHW category
Informal
Formal
|
0.059
|
0.849
|
0.945
|
CHW Location
Urban
Rural/small town
|
1.759
|
0.842
|
0.038
|
CHW length of service
|
-0.505
|
0.138
|
<0.001
|
Attended TB SHCI training in the past 12 months
No
Yes
|
1.833
|
0.854
|
0.033
|
TB SHCI knowledge score
|
0.398
|
0.318
|
0.212
|
TB SHCI competency score
|
0.713
|
0.202
|
0.001
|
Overall p = <0.001; R2 = 0.163