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Motivational factors affecting the retention of community health workers in a region of Kenya

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  • Save Public Health Research 2013, 3(5): 109-115 DOI: 10.5923/j.phr.20130305.01 Motivational Factors that Influence Retention of Community Health Workers in a Kenyan District Collins Owek1,*, Benard Abong’o2 , Henry Oyugi1, Joseph Oteku3 , Dan Kaseje1, Charles Muruka4, John Njuguna5 1Tropical Institute of Community Health (TICH), Great Lakes University of Kisumu, Box 2224 Kisumu, Kenya 2Department of Biomedical Sciences, M aseno University, Kenya 3Department of M athematics, University of Nairobi, Kenya 4Department of Research and Consultancy, Environmental Health and Allied Services, P.O. Box 19185 – 40123 Kisumu, Kenya 5M inistry of Public Health and Sanitation, Ijara District, P.O. Box 8-70105, M asalani, Kenya Abstract Retention of Co mmun ity Health Workers is important for continuity of health services at the Co mmunity level. The study assessed the motivational approaches that determine the retention of co mmunity health workers in Busia, Kenya. Both quantitative and qualitative approaches were used to collect data from the CHWs and other stakeholders . A total of 300 questionnaires were ad min istered to the CHWs in while six key informants and seven focus group discussions were held. The study revealed that among the CHWs interviewed, about 30% had served for at least 3 years. Only 2% of the CHWs who had been retained considered recognition as being able to motivate them to be retained, while 40% perceived recognition by the community as a determinant that would retain them. Cu rrently 88 % of them acknowledge reimbursements as motivation factor for them to continue serving as CHW. The current motivational determinants are recognition by the community members, skill develop ment, provision incentives and supervision. The perceptions of the CHWs on retention include; community support and health care system support. Pro mpt provision of the working materials fo r the CHWs like bags, CHWs kit, and report ing materials; harmonize the workload for the CHWs in order to improve on quality of care. Keywords Co mmunity Health Workers, Motivation, Retention, Kenya 1. Introduction The World Health Organization[1] defines Co mmun ity Health Workers (CHWs) as workers who live in the community they serve, are selected by that community, accountable to the community they work within, receive a short, defined training and are not necessarily attached to any formal institution. They act as agents of community development[2]. They deliver a variety of co mmunity-based health care services, and are important in areas where the utilizat ion of facility-based services is low. In some instances, CHWs have been trained for specific interventions like malaria control[3-6] and acute respiratory tract infections management with great impact. In 1978, in Alma Atta declaration, CHWs were viewed as a cornerstone to primary health care and agents to stimulate co mmu n it y p art icip at io n in h ealt h p rev ent io n and pro motion, especially in the remote areas[7]. There has b een a g ro w in g co n cern b y b o t h t h e p ro g ramme implementers and the health care system on the approaches * Corresponding author: (Collins Owek) Published online at Copyright © 2013 Scientific & Academic Publishing. All Rights Reserved towards motivation and retention of CHWs. WHO, in 2006 recognized the shortage of health care professionals and it is in this context that the concept of “task shifting” and using CHWs has gained mo mentum. According to the Kenya National Health Sector Strategic Plan II, wh ich rev italizes the need to involve co mmunities in participation of their own health care, there is no doubt that CHWs play an important role for this linkage between the community and the health care system. CHWs act as a lin k between the co mmunity or household members within their catchment areas and the other health care providers mostly at the health facilities[8]. Their roles are to participate in basic pro motive, preventive and even rehabilitative health care. The CHWs, therefore act as so me of the focal persons at the commun ity level. The other structures in the community include co mmunity health committees, health facility committees and the village health committees[8]. In Busia district there have been CHWs since the early nineteen eighties through the primary health care (PHC) initiat ives follo wing the Alma Atta declaration. Currently, the highest numbers of CHWs in the d istrict are concentrated in the largest two divisions, Funyula and Butula, which also have the highest population in Busia d is trict[8 ]. 110 Collins Owek et al.: M otivational Factors that Influence Retention of Community Health Workers in a Kenyan District Retention of co mmun ity health workers has been a major challenge all over the world. Ethiop ia and Kenya[9] in Africa are examp les that have faced the challenges of retention of community health wo rkers since they look at the work as an opportunity to climb a ladder to other challenging and rewarding tasks. However, countries like Brazil[10] and Pakistan[11] have institutionalized and mainstreamed CHWs and community health co mmittees such that they are part o f mun icipal services and therefore participation is not an alternative but an integral part of the states’ responsibility in health care services delivery. This study investigated motivational factors among community health workers contributing to their retention in Busia district in western Kenya. 2. Methods and Materials i) Study area The study area was Busia district. Two divisions were selected for the study, namely Funyula and Butula d ivisions. Busia district is one of the 20 districts in Western province, Kenya, with an estimated population of 452,468[8]. On ly 16.4% of the population lives in urban area co mpared to the national average of 32.3%[12]. It has six ad ministrative divisions namely; Busia Township, Nambale, Budalangi, Matayos, Butula and Funyula and borders the Republic of Uganda to the west, Bungo ma and Butere d istricts to the east, Teso district to the north and Siaya d istrict to the south. The two divisions (Butula and Funyula) have the largest area of 526km2, 13 locations, 49 sub-locations and 312 villages with a total population of 215,384. Most of the population engages in small-scale agriculture and fishing. According to the Kenya Integrated Household Budget Survey 2005-2006, 69.8% of the population in Busia lives below poverty line (less than US$ 1.00 per day). The literacy level among males is about 76% wh ile that of females is 55.3%[13]. The school dropout rate among the boys is 10% wh ile that of girls is 12%[13]. Only 13.5% of those aged between 15 and 64 years are in wage emp loyment[13]. The major causes of under-five, maternal and infant mortality are malaria (29%), HIV/AIDS (14%), anaemia (14%), diarrhoeal diseases (10%) and pneumonia (7%)[8]. There are a total of 16 health fac ilities in the study area and the distance to a health facility is averagely 4 km. Co mmunity health workers can play a v ital role in facilitating reduction of poor health indicators through improvement of commun ity participation[8] and hence the need to motivate and retain the CHWs by all partners including the co mmun ity members. The co mmun ity health workers in Butula and Funyula divisions are supported by various imp lementing agencies including Medicines san frontiers (M SF) Spain, Academic Model Provid ing Access to Healthcare (AMPATH), Min istry of Health and AMREF. They are mot ivated differently by each of these agencies and their attrit ion rates also vary. AM REF, AMPATH and MSF Spain have supported training of community health workers in the two d ivisions. Therefore, this study has investigated, which approach of motivation and supervision would enhance retention in co mmunity p ro g rams . A total of 910 CHWs were trained by Ministry of Health in the programme areas in Funyula and Butula divisions in 2005. The drop-out rate among these CHWs one year after their training was 17.3 %[8]. ii) Study design This was a cross-sectional study whereby structured questionnaires were ad ministered to 300 CHWs. A total of 6 key informant interviews were also done. They included one member of the District Health Management Team, 2 community leaders (Ch ief of a location and Health facility committee member), 1 health worker supervising CHWs in their respective locations and 2 project officers fro m MSF Spain and AMREF. Seven focus group discussions were conducted, three for health workers, opinion leaders and community leaders. The other four consisted of community health workers, with 2 FGDs for each sex. A total of 32 CHWs were interv iewed in groups of eight fo r each FGD. The FGDs were also stratified according to age, consisting of those below 35 years and those above 35 years for both s exes . Informed consent via writing was obtained from the respondents and the study was approved by the Research Ethics Co mmittee at Great Lakes University of Kisumu. Consent for entry into the area of study was obtained from the DMOH (District Medical Officer of Health), Busia district and the local government ad ministration. SPSS version 16 was used to analyse the data. This was for descriptive and cross tabulation. Thematic analysis was done for qualitative data. iii) Samp ling design The study used both stratified and simp le random sampling design. Stratified samp ling was used to get the number of units fro m each division to constitute the overall sample size using the proportional allocation pegged on the population size of CHWs in each of the two d ivisions through the application of a uniform sampling fraction. The same was done at the locational level. Simp le random sampling was then carried out at the sub-locational level to select the individual co mmunity health worker to be interviewed. Purposive sampling was done to identify the study area where CHWs were trained within the two divisions. Since there were 480 CHWs in Funyula and 383 CHWs in Butula divisions; stratified sampling was used to determine the number to be interv iewed using this formula: Funyula: N1 = (480/863 x 270) = 150 Butula: N2 = (383/863) x 270 = 120 Public Health Research 2013, 3(5): 109-115 111 Di vision Funyula But ula Table 1. Stratification in Funyula and Butula Location Bwiri Ageng’a Nambuku Bujumba Marachi central Elugulu Marachi East Numbe r of CHWs 146 180 154 75 102 100 106 863 Numbe r of CHWs to be sample d 46 56 48 23 32 32 33 270 Numbe r of CHWs inte rviewe d 51 61 53 25 36 36 37 300 All the co mmunity health wo rkers were selected randomly and then interviewed. An init ial 270 with additional 30 distributed all over the study area, totalling to 300 CHWs. The sample frame was determined by a list of all the nu mber of co mmunity health workers who had been trained by the M inistry of Health to part icipate in community health programmes. Simple random sampling was used to identify the number of CHWs to be interviewed in each location. The CHWs who were included in the study were those trained by Ministry of Health and were still act ive and continuing with their work as volunteers. A total of 18 enumerators participated in data collection. The enumerators were members of the co mmunity with high school education and with previous experience in conducting surveys. They were trained for two days on how to administer the questionnaires followed by pre-testing in Matayos division, Busia district. Figure 1. 3. Results The mean age of the CHWs was 36 years, the youngest being 18 years and the oldest 59 years. One area chief commented that “the CHWs were recruited as long as they had attained an age of 18 years and above”. Females co mprised 57% and males 43% o f the CHWs, and 30% of the CHWs had served for at least 3 years. An estimated 96% of the CHWs had attained a primary level of education with over half of the CHWs having attained a secondary level of education and 2.4% tertiary level of education. The main source of livelihood was agriculture as cited by 75% of the CHWs followed by 20% in self emp loyment. One CHW leader stated “most of us are not employed and therefore we need regular support”. Majority o f the CHWs were selected by the area ch ief and local leaders (46%) and co mmunity members (38%). Only 4% were selected by health workers. Upon being recruited, 23% of CHWs expected to be paid money, 19% material incentives, 30% trainings and regular updates, 25% to assist the community and 3% to acquire recognition. One key info rmant stated that “Usually the CHWs have a lot of expectations at the beginning, most of them expected to gain on trainings, but if they are not met then some o f them drop out from their work as CHWs”. The CHWs who had served more than 3 years were t wice likely to cite being motivated to assist their community (50%) co mpared to those who had served less than 3 years (25%). An estimated 62 % of the CHWs felt that their working relat ionship with the health facility staff was good, and among the services which they offered that were most appreciated by the community were health education (68%), lin kage to health facility (20%) and home based care (12%). About 27% of the CHWs felt they were recognized by the 112 Collins Owek et al.: M otivational Factors that Influence Retention of Community Health Workers in a Kenyan District community they serve. Recognition entailed validation fro m the community members. One CHW stated “We are usually given opportunity to teach at the baraza (public gathering) and I feel happy about it, especially when some of the villagers refer to me as “daktari” (doctor). The co mmunity also recognizes them especially when they go to chlorinate water sources in the community during cholera outbreaks. In the focus group discussion, CHWs who had worked for at least 3 years acknowledged that some of the factors that have motivated them to continue working include support fro m their spouses, opportunity to give health education in the chief’s public gathering, involvement in outreach services by the health workers and positive attitude by the community members. They also said the t rain ing that they had received fro m the Ministry of Health gave them the confidence in what they were doing. Service and informat ion demand on health issues fro m co mmunity me mbe rs was also cited as a mot ivational factor. Table 2. Distribution of households covered by CHWs Number of households 1-20 21-40 41-60 61-80 81-100 % of CHWs serving 15.4 42.3 15.4 19.2 7.7 An estimated 87% of CHWs catered for more than 20 households (Table 2). When asked how they perceived their workload, 31% of CHWs felt they were seeing too many clients while 62% felt they were seeing the right number of clients. One health worker said that one of the challenges the CHWs are facing is that they are covering a large area and hence there is need to train more CHWs to min imize workload per CHW. The CHWs also found the community quite demanding as aptly stated by one health worker: “They think the CHWs are given a lot of handouts to tak e to them but are not reaching them.” The majo r incentives received by CHWs were reimbursements of transport related costs and lunch allo wance when they attend meetings outside their villages. This was cited by 85% of CHWs and another 38.5% cited material incentives. These include t -shirts and insecticide-treated nets. Some CHWs were being supported by NGOs like MSF with drug kits, bicycles and a monthly bicycle maintenance allowance of one thousand shillings (12 dollars). In one FGD, some CHWs are given short term work as stated by one nurse “During the national, provincial or district health campaigns, we also consider the active CHWs to participate and hence they get some allowances.” One chief said that the community members are so poor that they are not able to give the CHWs any incentives. The CHWs in the focus groups discussions acknowledged that they receive the above mentioned incentives and that peer support has also contributed in motivating them. When asked how they wished to be supported, 76% of CHWs stated they be provided with working materials, 65% with reimbursements, 40% with recognition, 32% with trainings and 8% with supervision and means of co mmunications. When being recruited 23% of CHWs interviewed expected to be paid; 30% expected trainings; 19% material incentives and 25% expected community support. Of the CHWs who had served for more than 3 years, 96% had attended refresher trainings compared to 70% among those who had served less than 3 years. In the FGDs with CHWs, trainings were cited as one of the ways that have motivated them since it imp roves their knowledge and skills on health issues. One CHW said that “trainings have enabled us to have confidence while serving the community members since we have insight of what we are doing but where we are not sure, we consult the health workers”. According to one NGO project officer, the trainings have been scheduled in modules, which are spread over two years. The commun ity leaders stated that trainings are a motivation to CHWs but added “frequent updates are needed rather than being updated once a year the way NGO X is doing”. CHWs are supervised by volunteer leaders, who have been trained for a week and each leader supervises 10 CHWs. In turn, one health worker supervises 12 such supervisors. The trends of supervision among CHWs by their supervisors was 23.3% of CHWs are supervised weekly, 38% monthly, 4.8% quarterly and 32% rarely by their supervisors compared to 43% of CHWs who are rarely supervised by health workers and 36.2% have never had a meeting with the health workers manning the health facility serving their catch ment area (table 3). In the FGDs with health workers, they said they are not able to visit the CHWs in the villages regularly as they are overwhelmed by work at the health facility with one health worker stating “Occasionally, I visit the CHWs especially when there is an outbreak of a disease like cholera or to follow up measles cases.” When asked to rate their working relationship with the health workers, 15.3% o f CHWs rated it as poor, 34.5% as fair and 44.9% as good. Table 3. Frequency of supervision of CHWs by health workers Frequency Weekly Monthly Quart erly Biannually No supervision % of CHWs supervised 7.7 33.9 4.7 8.0 45.6 4. Discussion The dropout rate among CHWs after one year was 17.3%. Since the study was done after 3 years, the drop out is estimated to have been slightly over 50%. This could explain why only 30% of CHWs sampled had served for 3 years and above. Thus it may be assumed that the retention Public Health Research 2013, 3(5): 109-115 113 rate of CHWs was 30% after 3 years. In Bangladesh, the dropout rate for CHWs was between 31-44% and the reasons for attrition were due to household chores, other socio-economic activities wh ich appeared more profitable and high targets set by the supervisors (Winch et al., 2000). In Bhutan,[14] the attrition rate of the Village Health Workers was between 50– 55% in most districts after a period of five years’ implementation of community health programs. The main reasons cited were interference with personal work (70%), family pressure (12%), too hard job (9%) and nothing to be gained (6%). Bhattacharyya et al[15] reported an attrition rate of 68% between one to three years of imp lementation of a health pro ject. An attrition rate of 85% was reported in Ethiopia for a child survival programme[15], after the first year of imp lementation and the reasons that were given were due to; lack of training on supervision for health workers, no transport for supervision and lack of awareness of the community members on the roles of the CHWs. The Kenya National Health Sector Strategic Plan II (2005-2010) states that a CHW should visit t wenty households each having an average of 5 members, thereby adding up to a total of 100 people at least on a monthly basis. The majority of CHWs (85%) were covering mo re than this. This means they may have covered a wide area and not be able to frequently visit all the households regularly (at least once a month). The linkage between the CHWs and the health facilities was weak, given that 36% of CHWs have never met the health workers. This could stem fro m the fact that the health wo rkers were marginalized right fro m the recru it ment of CHWs, with only 4% o f health workers involved. The chiefs and the health facility committee members may have selected their friends and close associates, given their influence. These CHWs might have had motives which were incongruent with the programme’s goal e.g. to earn an inco me. The study showed that 23% of CHWs during recruit ment expected monetary gains. If their motives are not realized, they are likely to drop out. In India between 54% and 93% of the CHWs were selected by the public health midwives[16] and the experience in India of health wo rker involvement in the recruit ment had better results on performance and retention[17]. Recognition of CHWs by the commun ity was low given that 73% of CHWs felt they were not recognized since the community members and the local leaders did not provide them with incentives. A major shortcoming is that the programmes did not put in place co mmunity health co mmittees. These play a key role in mot ivating CHWs, and they comprise of members of the community who have been selected to co-ordinate community health activ ities on behalf of their members[8]. They provide an appropriate and supportive social environment for the work of CHWs and health workers by taking responsibility for governance at the community level and mobilizing co mmun ities for involvement in health promotion activit ies. These entail preparing a co mmunity Annual Operational Plan (AOP) on health-related issues; networking with other sectors e.g. agriculture; resource mobilization for imp lementing the co mmunity wo rk plan and ensuring accountability and transparency; facilitate negotiations and conflict resolution among stakeholders at the community level; monitoring and evaluation of the community work plan including the work o f the CHWs through monthly review meetings; and holding quarterly consultative meet ings with health facility management committee[8]. In Ghana[7], the Village Health Co mmittees (VHCs) supported the community health programme by and even providing transport for health workers supervising the CHWs. In Gongola State in Nigeria[7] the support of the VHCs played an important role in job satisfaction of the Village Health Workers (an equivalent of CHWs). The CHWs in Busia district were supervised by volunteer supervisors who had undergone one week train ing. One volunteer supervisor was in charge of 10 CHWs. One health worker was in charge of 12 supervisors and by extension 120 CHWs. This could exp lain why four out of ten CHWs reported to having never met a health worker. Inadequate staffing of health workers may have increased the workload at the health facilities, leaving little time for supportive supervision of CHWs. There was also the lack of supervision checklist and competing tasks. This is similar to Malawi’s situation[17] where regular supervision was one of the main challenges. The CHWs were not being g iven any financial incentives. When asked what would motivate them to continue working as CHWs, 75% of the CHWs mentioned the working materials (bags, IEC materials, notebooks, pens) and 65% financial incentives. This is an increase fro m their pre-recru it ment expectations where only 43% of CHWs expected financial and material incentives. Financial incentives have been linked to CHW retention. In Bangladesh, CHWs who joined with the expectation of income were almost twice as likely to remain as CHWs since it they felt it improved their social status, and the poorest CHWs were significantly mo re likely to stay in the programme than the richest, since they felt that by working hard, incentives are likely to be improved[18]. In one program volunteers who were paid less tended to leave the programme even earlier (1-2yrs) while those paid more left between 1.5– 3.2 years[15]. Majority of CHWs engage in farming as a means of livelihood. Th is could be due to the fact that majority o f the population lives in the rural area and given the high levels of poverty, majority of the residents are likely to engage in subsistence farming. The Govern ment of Kenya has no funds to pay the CHWs a monthly incentive. So me CHWs can be involved in short term work like immunization campaigns where they are paid some allo wance. A mo re sustainable option would be to start inco me generating activities for the CHWs. Since farming is their main source of livelihood, it may be feasible to start agro-based income generating projects for the CHWs. These may include bee 114 Collins Owek et al.: M otivational Factors that Influence Retention of Community Health Workers in a Kenyan District keeping, fish farming; poultry keeping or rearing dairy goats. The CHWs would be encouraged to form groups which will be registered with the social services department as community based organisations (CBOs) since this contributed to motivate CHWs in Bangladesh[14]. These will also be eligible to apply for the various devolved government funds e.g. YEF (Youth Enterprise Fund), Women Enterprise Fund and HIV/AIDS-related funds. These may motivate CHWs and in the long run improve on their retention. Nearly all the CHWs received regular training updates courtesy of three NGOs. These were M SF Spain, which is supporting the implementation of ho me-based care for people living with HIV, AMREF, which is supporting the implementation child survival programme and AMPATH, which is involved in out-reach activities on HIV prevention and control. These NGOs had agreed to recruit different CHWs, but a few CHWs ended up working fo r mo re than one NGO. This could be so as to get more incentives. Incentives offered by these NGOs varied and the study did not look at these and their impact on motivation. In Nepal, four NGOs pooled their resources together with Nepalese Ministry of Health and collaborated to strengthen pneumonia treat ment through community health volunteers[19]. Th is also motivated the CHWs and they were ab le to identify with the co mmunity and the Ministry of Health and not necessarily with an NGO. This would be a better strategy towards sustainability of co mmun ity health worker programmes. the process of data collection for this research project. REFERENCES [1] World Health Organization. Community health workers: Working document for the WHO study group. Geneva: World Health Organization, 1987. [2] Abbatt, F. Scaling up health and education workers: Community Health Workers. DFID, UK, 2005. [3] Delacollette C, Van der Stuyft P, Molima K., “Using Community Health Workers for malaria control: experience in Zaire.” Bulletin of the World Health Organization 74(4): 423- 430, 1996. [4] Lwilla F, Schellenberg D, M asanja H, Acosta C, Aponte J et al, “Evaluation of efficacy of community based vs. Institutional based direct observed short course treatment for the control of tuberculosis in Kilombero district, Tanzania”. Tropical M edicine & International Health 8(3):204-210, 2003. [5] Gennaro S, Dugyi E, Doud JM , Kershbaumer R. “Health promotion for childbearing women in Rubanda, Uganda”. Journal of Perinatal and Neonatal Nursing. ; 16:39–50, 2002. [6] M iller, RA Country watch: Kenya Sex Health Exch (3): 5-6, 1998. [7] Walt, G. “Are large scale volunteer community health workers programmes feasible? A case study of Sri Lanka”. Social science and medicine 29(5): 599-608, 1989. 5. Conclusions The study sought to find out what contributed to the retention of the CHWs in Busia d istrict as this could inform similar co mmun ity programmes to emulate this experience. The study concluded that both material incentives like T-shirts, Insecticide Treated Nets, bicycles and financial incentives among others, contribute to retention of CHWs. Other incentives that are essential for retention of CHWs include continuous trainings, working materials and supervision. Recognition by the co mmun ity members and family support plays an important role towards motivation and hence retention of the co mmunity volunteers. When the CHWs were recru ited, incentives and financial gain was not what they expected but as they continued with the work, they realized that they required them as a motivation to continue on supporting the communities effect ively. It is therefore, reco mmended programmes engaging CHWs should consider for continuous material incentives and regular remunerations to enable retention ACKNOWLEDGEMENTS We remain gratefu l to David Wamalwa, the Programme Manager of Busia AM REF and all h is staff for supporting [8] Republic of Kenya. Busia district health report. Unpublished, 2007. [9] CARE Kenya. Community Initiative for Child Survival. CARE, Kenya, 2000. [10] Lehmann U and Sanders D. Community Health Workers, what do we know about them? The state of the evidence on programs, activities, costs and impact on health outcomes of using CHW. Wor ld Health Organization, Switzerland, 2007. [11] Andrew, J, Felton G, Wewers, et al, “Use of CHWs research in Ethnic minority women”, J Nurs Scholarch, 2004. [12] Republic of Kenya. 2011. Open data cet/counties/Busia?&page=3. Accessed 7/11/2011. [13] Andrew, J, Felton G, Wewers, et al (2004) Use of CHWs research in Ethnic minority women, J Nurs Scholarch. [14] UNICEF. M anagement of sick children by CHWs: intervention models and programme examples. UNICEF/WHO, Switzerland, 2006. [15] Bhattacharyya K, Winch P, LeBan K, Tien M . Community Health Worker Incentives and Disincentives: How they Affect M otivation, Retention and Sustainability, United States Agency for International Development, USA, 2001 [16] Walt, G. Community Health Workers in national programs. Just another pair of hands? M ilton Keynes: Open University press, 1992. [17] Kadzindira, J & Chilowa, W. Role of Health Surveillance Public Health Research 2013, 3(5): 109-115 115 Assistant in the delivery of health services and immunization in M alawi. UNICEF, 2001. dex_14066.html Accessed 7/1/2011. [18] Alam K, Tasneem S, Oliveras S. “Retention of female volunteer community health workers in Dhaka slums: a case-control study”. Health Policy and Planning Sep 7(E pub), 2011. [19] Government of Nepal, Department of Health Services. National family health, female community volunteer programme: revised strategy, M inistry of Health, Nepal, 2003.

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