Abstract

Background: Sustainability of any Community health worker programme is determined by several internal and external factors and is highly context and region specific. We aimed to identify factors that influence the sustainability of a community health volunteer programme across the globe.

Methods: We conducted a scoping review using the Arksey and O’Malley framework. From four major databases, we extracted qualitative and quantitative peer-reviewed studies published in the English language, from January 2000 to March 2022, that reported on factors influencing sustainability of a community volunteer programme. We adopted a narrative synthesis form to report our findings.

Results: Our search strategy yielded 1086 citations, of which 35 articles were finally included for the review after screening for eligibility. The studies included in our review reported an attrition rate ranging from 9 to 53%. The crucial factors that played a decisive role in sustainability included sociodemographic and sociocultural factors, trust, incentives, identity and recognition, sense of belonging, family support and other programme-related factors.

Conclusion: Our study found that several complex personal and social factors affect the community health volunteers’ performance, thereby impacting the scaling up of a community volunteer programme. Efforts to address these factors would aid policy makers to successfully sustain a volunteership programme in resource-poor settings.

Keywords: community health volunteer, volunteerism, sustainability, scoping review, scale up

Introduction

Community participation is one of the important components of primary healthcare, as per the Alma Ata declaration, 1978 [1]. In recent years, many countries have expanded their health systems by training community health volunteers (CHVs) on a large scale [2, 3]. The World Health Organization has defined community health volunteers as healthcare providers who serve the community in which they live, and receive lower levels of formal training and necessary education than a professional healthcare worker such as nurses and doctors [4]. Studies done in several countries add to the existing evidence that CHVs can contribute significantly to the betterment of varied health outcomes [5, 6, 7, 8]. This process of involving the community in implementing health programmes neutralises health inequalities by positively impacting social capital and social cohesion [9]. Despite their effective contribution, much of the literature is relevant only in developing countries, especially in those lacking adequate healthcare access [10].

Furthermore, CHV performance is context-specific and is linked to several internal and external factors. Despite the crucial role played by the CHVs, retention and sustainability of an effective CHV model have always remained a challenge for several public health interventions. Previous literature has documented that supervision, efficient and effective training, community appreciation for the efforts made, and family support have influenced sustainability to a greater extent [9, 10]. Globally, several CHV-led programmes have reported attrition rates ranging from 3.2% to 77%. [11, 12] Such high attrition rates have raised questions about the relationship between the volunteers and the community and increased the chances of a lost opportunity to effectively use the workforce.

Shah et al identified two forms of volunteerism — formal and informal. Formal volunteerism is done with the help of a group or an organisation and is often structured and embedded inside a community-based organisation or a non-governmental organisation (NGO), while the latter is delivered by an individual to render service to the community [13]. The term “health volunteerism” is the foundation for every CHV model that is often exploited. CHV often decide to volunteer with the intention to support health systems and enhance health literacy of the community and self, and often require constant support from the health system [14]. Furthermore, the concept of volunteerism is itself a complex phenomenon that involves self-motivation, but is determined by several social and psychological determinants. Thus, it is necessary to understand the importance of the internal characteristics of both types, and external social and political influences before implementing them in the community. To bridge this gap, we decided to undertake this review to identify factors that influence the success and sustainability of a Community Health Volunteer programme.

Methods

We conducted a scoping review using the Arksey and O’Malley framework [15].

What factors influence the success and sustainability of a Community Health Volunteer programme?

An extensive search in PROSPERO and Cochrane was done to ensure that no similar review protocol has been reported. This scoping review was done by including all the available evidence exploring the sociodemographic, ethical, economic, and other social factors that influenced the sustainability of an effective CHV model.

A comprehensive and systematic search in databases and search engines such as MEDLINE, Cochrane Library, ScienceDirect, and Google Scholar for literature from January 2000 to May 2022 was done [Supplementary file 1]. In addition, reference lists of primary studies were checked to include more articles relevant to our review. Our literature search was restricted to the period from January 2000 to May 2022, as a prior review by Prasad and Muraleedharan in 2007 had discussed the profile of CHVs, the health outcomes of CHV-run programmes, and organisational issues that influenced the performance of CHVs [16]. Their review highlighted crucial factors such as the selection process of CHVs, their educational status, lack of adequate training, lack of remuneration and supportive supervision, which influence CHV performance [16].

Both qualitative and quantitative peer-reviewed studies published in the English language were included in the review. Supporting evidence from other mixed methods studies was also screened for its eligibility and was included. In addition, studies using qualitative techniques for data collection such as focus group discussion (FGD), in-depth interviews (IDI), and Key Informant Interviews (KII), were included. Studies from books, conference abstracts and other unpublished literature were excluded.

We set out to understand the various factors that influenced the sustainability of the CHV model.

After the study selection, the principal investigator scrutinised the extracted data and retrieved the study characteristics in a predetermined data extraction format. Data entry was also double-checked for accuracy. The necessary information was extracted from the included studies.

Risk of bias assessment of individual included articles was not undertaken, as it was not consistent with the requirements of a scoping review [17].

We adopted a narrative synthesis form of data analysis, and represented all data qualitatively (content analysis) and quantitatively (frequency analysis) for the conduct of this scoping review. The information obtained was analysed independently by both authors and subsequently compared and collated with other study findings using an integrated knowledge translation approach [18, 19].

Results

The search strategy yielded around 1086 citations, of which 103 were duplicates. Of the remaining 983 articles, 718 were excluded after initial screening for the title, keywords and abstract. Of the remaining 265 articles, 98 were not retrieved as their free-full text version was not available. The remaining 167 articles were subjected to secondary screening, of which 132 were excluded (91 as they answered a different research question, 9 as they were not in the English language, and 32 as they reported outcomes other than the sustainability of the CHV model). Finally, 35 articles were included for the final scoping review [20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54]. Figure 1 explains the study selection process and study flow. Table 1 [available online only] presents the general characteristics of the included studies.

Sustainability is defined in literature as “the degree to which an innovation continues to br used after the initial efforts to secure them are completed” [20]. A few studies have also tried to quantitatively estimate sustainability as the persistence of any programme or intervention more than a year after research or implementation is complete [10, 41]. Through our review, we observed that 11/35 (31%) studies reported attrition rates, among which the rate of attrition varied between 9-53% across various study settings.

All studies included in the review either used qualitative, quantitative or mixed methods approaches to evaluate the factors that influence sustainability. The major drivers that influenced the sustainability of their work included:

Personal characteristics such as age, gender, occupation, marital status, and education act as crucial internal factors that play a pivotal role in the sustainability of motivation from within [38]. Studies have shown that attrition is more apparent among women when compared to men, due to family constraints and inability to perform community work beyond certain working hours, or due to a heavy workload [28, 38, 39,50, 51]. A majority of the studies have stated that age is an important factor that contributed to sustainability; ie, more volunteers above 40 years tend to remain in the programme as compared to young adults who tend to drop out owing to other commitments [10, 33, 38]. Quantitative results have shown that married individuals tend to stay in the volunteer programme despite their commitments. Retention rates were higher among the educated and those employed in the unorganised sector when compared to the salaried organised sector [39]. This reflects the constraints faced by volunteers holding a job while also spending time in community work. Studies also observed higher retention rates among men and women who are married [32,41].

A majority of the studies reported lack of financial incentives as an important determinant of sustainability of a CHV model. This proves that the term “volunteer” does not wholly translate into free work. The CHVs who render services to the communities outside their working hours expect a basic remuneration to keep them motivated. [22, 24, 29, 31, 36, 42, 45, 47, 48, 49, 50]

Studies have stated that the selection of CHVs outside the community or outside the already existing community-based organisations (CBO) makes the model more volatile and vulnerable. Volunteers, when selected from the local community, tend to have a better understanding of the community [20, 21, 25]. Choosing or preferring volunteers from already existing CBOs will give a sense of accountability, ownership, and the opportunity to establish networks [23,24, 26,42, 46].

Studies have shown that in certain settings, the line drawn between volunteering and conditional expectations from the health staff fails to exist. Sometimes, the volunteers are overstretched and expected to work beyond their free time affecting the quality of their work and satisfaction. In a few instances, studies have reported that CHVs had to forgo their family time or daily chores for rendering community services. Such practices might impede satisfaction that a CHV is expected to gain from volunteering [21, 33, 40, 47].

Choosing CHVs from among individuals already established in the community for volunteering services increases the level of trust that the community has in the volunteers. This trust would enable the CHV network to establish a strong bond between the community and the health team, which might in turn enhance the accountability and sustainability of the programme [25, 27, 28, 29, 42, 44, 45].

Studies have identified family support as one of the vital determinants of sustainability of a CHV programme. Support from spouse, children and other family members are essential drivers that influence not just the effectiveness of services rendered, but also long-term sustainability and even the phenomenon of “volunteering” as a whole [31, 34, 35].

A few CHVs have also expressed their hope that future opportunities like preference in government posts or local village jobs open up through this CHV participation [23, 30, 32, 42].

CHVs have also stated that it becomes difficult for them to forgo daily routines, childcare, attending important social and family functions for community-related work, thereby forcing them to either allot little time for community work or withdraw from the organisation [36, 37,45]. A few studies have also added transportation as a major concern, especially in resource-poor settings, where they are forced to use their own motorbikes for outreach activities. The reimbursement that they receive is either insufficient or delayed [42, 48, 50, 51].

The following programme-related factors play a decisive role in influencing the long-term sustainability of any CHV programme.

a. Selection and coordination: It is necessary to consider if the volunteer has truly volunteered out of their own interest, and if he/she is the right person for a specific health intervention. These criteria need to be looked into for sustaining the activity. Clearer description of roles and responsibilities during the selection of CHV’s and coordination of their day-to-day activities would also facilitate volunteering.

b. Training and retraining: This serves as a basic necessity for any CHV programme. Sensitisation of volunteers to the intervention and pre-interventional training is necessary, not only for sustainability but also for effective implementation and success of the programme [38, 43, 46, 49, 50, 52].

c. Supportive supervision: This is often acknowledged as a crucial lever that ensures the sustainability of any community health intervention and especially that of a community health volunteer model. This enables the volunteers to stay motivated. Recent studies have endorsed supportive supervision as an effective tool to enhance the knowledge, performance, productivity and sustainability of CHVs [44,49, 50, 52, 53] .

d. Accountability: Reporting of services rendered to the community leaders or village health leaders or to the health team makes the CHV accountable to the community. This could always be supplemented with frequent record reviews, monitoring and observations, grievance redressal, and obtaining constructive feedback [41,46,49].

Though they often remain unnoticed, a few studies have documented that the occurrence of vital events in the families of CHVs plays a significant role in sustaining the participation of CHVs in the programme. Any occurrence of key events such as migration, marriage, death or childbirth might influence the volunteer to rethink the decision to continue his/her volunteering for community work [23, 39].

Being granted an identity and recognition are basic requirements for a volunteer programme. In some studies supporting the same, CHVs had expressed their insecurities about continuing in the programme in case they are not granted proper recognition and identity. Volunteers have raised concerns about facing difficulty in carrying out community work without provision of identity cards and labelled T-shirts [27, 32, 43, 45, 46, 51].

A few studies have shown greater sustainability of CHV programmes where the volunteers were provided with basic security needs such as travel allowance, safe travel, a place to stay to ensure physical safety, provision of basic amenities such as torches, headlights and umbrellas, etc [41,45,51].

Discussion

We undertook this scoping review to gather the available evidence and understand and describe the factors that influence the sustainability of a community health volunteer programme. There is plenty of literature on the effectiveness of CHV programmes; however, research focusing on the long-term sustainability of these programmes, or studies exploring the factors that determined the sustainability or non-sustainability of a particular programme are sparse [37,54]. Sustainability is an inherent component of any community health programme and is a crucial outcome that influences the scaling up of the programme to higher levels. Scaling up of a programme — through additional financial and human resource allocation — is futile when it is not sustainable. Thus, awareness of the key factors influencing sustainability becomes integral to scaling up any community health programme. This could pave the way for policymakers and other stakeholders to identify factors that could substantially influence budgeting, resource allocation and scalability of any pilot or small-scale programme [55]. Our findings are in line with several studies from India that explored the factors motivating the accredited social health activists (ASHAs) [55].

Our scoping review has systematically collated data from various study sources and designs, thereby generating concrete evidence regarding sustainability of CHV programmes. Studies included in our review were neither done in ideal settings nor reported all the necessary information; however, any report on factors influencing the sustainability of a community health volunteer model was chosen to build a construct of determinants [37, 38].

Of late, it is considered that the rights of CHVs need to be assessed and addressed beforehand to ensure full participation of CHVs in any community health programme. These rights include the right to volunteer and withdraw, the right to social recognition, incentivisation, inclusivity, etc [14, 36 , 40]. The importance of personal characteristics (selection criteria), family and community support are well established by several previous studies and reviews [56]. These factors are necessary to keep up the momentum, despite the hardships CHVs face during community work. The sense of job satisfaction and family support is not only crucial for the sustainability of community work but also decisive for volunteering [57].

The wide ranging differences in attrition rates among the included studies could be due to variations in the study settings, nature of work expected, and availability of remuneration, motivation and community support. It was also interesting to observe that sustainability or retention is better when the community-based initiative comes from a well-established organisation or NGOs that have previously been involved in community work. NGOs could serve as resources for mobilising remote communities, empowering and training volunteers, establishing local social relations, providing microfinance or economic support to the volunteers, building capacity and enhancing self-reliance, thereby promoting the sustainability of the model [58]. More CHVs tend to drop out when the attempt is new, or is not long-term, or when there is a lack of leadership and team effort [41, 44, 47].

As stated above, there are a number of variables that affect the CHVs’ capacity to provide effective services. Motivation, is an important determinant in CHV recruitment, retention, and performance, and may even be a determining factor in the delivery of effective services [20]. Provision of incentives or CHV remuneration has always remained a long-standing challenge for many community-based programme implementers and NGOs [58]. Incentives, which can include anything from uniforms, volunteer allowances, and pay [59, 60], might affect motivation, in turn. The relationship between incentives, motivation, retention, and CHVs’ performance has been illustrated by Daniels et al [60]. The kind, extent, and combination of incentives that would increase the motivation of CHVs have been extensively debated. Financial incentives range from allowances for volunteers, and fixed salary for individuals who are formally employed to performance-based rewards. Different studies have shown that the financial support differed for paid employees and volunteers (3 USD to 100 USD) [60]. The second group of volunteers, who were not paid salaries, received tangible rewards such as clothing, health insurance, or work-related equipment like boots and bags. Community recognition, preferential treatment in receiving drugs or during OPD visits in health centres, and support in acquisition of new skills, are examples of non-material incentives. Other possible incentives include bicycles and other modes of transportation, consistent supplies, training opportunities, and supportive supervision. These incentives, which represent the fundamental resources to be made accessible by the health system for CHVs to perform well, are often referred to as “job enablers” [61]. These tangible rewards and job facilitators not only helped them in their work but also boosted the reputation of community health programmes among CHVs and the populations they worked with.

Ours is one among the very few available reviews that focus on personal and social factors influencing the sustainability of a CHV model. We have adopted a narrative synthesis to report our results, after searching for relevant literature in all four major databases. However, in our review, we did not study the effect of various interventions that the CHVs contributed to the sustainability of the model.

A noteworthy point is that the sustainability of a programme is heavily dependent on the need for and the nature of the intervention provided. In case a community health programme is self-reliant through external or internal funding, then remuneration or programme costs will not be an issue, which might take care of the most important reason for attrition, namely the low remuneration. In cases where funding is an issue, the programme needs to have adequate community support, constant motivation and training to make it sustainable. Also, when the need of the intervention is met, it is necessary to re-deploy CHVs to other already existing programmes or train them for a newer objective, rather than dissolving the volunteer group. Further, future research must focus on programme-related factors that would influence the sustainability of the CHV model, an aspect that is often missed. Future research could be strengthened by the use of newer techniques such as Health Technology Assessment and health policy and systems research that would enable policy makers to have a bird’s eye view of the CHV model and its sustainability.

It was also noted that there was significant variability in the definition of attrition used in the limited literature available on CHV sustainability. Different studies used varied definitions to call their model sustainable, which could influence the retention percentage reported in these studies [9, 41]. Thus, our review emphasises the need to have a programmatic definition for defining “retention”, thereby making comparisons possible.

Conclusion

Our study results showed that the sustainability of any CHV programme is a complex process and is determined by several individual-level (trust, sociodemographic factors, incentives, family support), community-level (sociocultural barriers, identity and recognition) and programme-level factors (selection process, training and supervision).

Acknowledgments: We would like to acknowledge the Rural Women’s Social Education Centre team and the Thakur Foundation for the fellowship programme. We would also like to extend our gratitude to all the resource faculty of the writeshop sessions, and the other fellows for their constructive feedback.

Conflict of Interest: Nil