Exploring factors affecting Anganwadi workers’ performance motivation: a mixed-methods study in a tertiary care center of central India

INTRODUCTION

Health is a fundamental human right and every country should make laws and policies that protect people's right to health.¹ WHO showed how helpful community health volunteers are in reaching health goals like making sure fewer children die, helping mothers stay healthy, and fighting diseases like HIV/AIDS and malaria.² A “community health worker” is a broad term that includes many different types of local healthcare providers, ranging from nurse-midwives to home-based caregivers and salaried-staffs to volunteers.³ Community health workers help people to reach and use healthcare services, and they also encourage communities to adopt healthy habits.⁴

India’s integrated child development services (ICDS) scheme employs 12.72 lakh Anganwadi workers (AWWs) to enhance child well-being and development, reduce health risks, and support maternal education for better child care. The Anganwadi centres (AWCs) offer six services: supplementary nutrition, health and nutrition education, pre-school education, immunization, referral services, and health check-up. The scheme targets children aged 0-6 years, as well as pregnant women and lactating mothers.⁵

Roles and responsibilities of AWWs range from creating awareness and providing information to the community on healthy living, nutrition, basic sanitation and hygienic practices to counselling mothers and pregnant women. It includes setting up supplementary food for beneficiaries using local foods, to educate mothers about nutrition and breastfeeding, and to assist with immunization, ante-natal and post-natal check-ups and referrals.⁶

Motivation refers to how much someone is willing to put in effort and keep it up to achieve the organization's goals.⁷ It also refers to an AWW’s level of interest and readiness to take on and enhance assigned responsibilities related to community health.⁸

The motivation of AWWs is crucial for the success of ICDS services, yet understanding about what affects their performance is limited. There is a lack of comprehensive analysis of factors affecting AWWs. The present study aims to bridge this gap by examining how individual, program, community, and organizational factors impact AWWs’ motives.

The existing literature on AWWs’ performance motivation are scanty. With this background, the present study was conducted in the field practice area of urban health training center of a medical college to evaluate the factors affecting the performance of AWWs.

METHODS

This cross-sectional study was conducted for a period of 3 months from January to March 2024. It employed a mixed-methods approach, that is, a combination of qualitative and quantitative techniques, which incorporated both survey and focus group discussions among the AWWs. The study was conducted in two clusters randomly selected in an urban field practice area of central India. The two areas were chosen as they were comparable in the number of Anganwadis. Thus, 105 AWWs were interviewed for the quantitative aspect and another 40 AWWs sampled purposively for the qualitative aspect.

The quantitative survey tool constituted a validated questionnaire with 16 parameters.⁸ The motivation factors were broadly classified into individual and environmental, environmental was further divided into health system and community level factors. Their level of motivation was reported on a Likert scale of 1 (strongly disagree) to 5 (strongly agree). The composite score of all questions decided the level of motivation under each parameter. An AWW was considered as motivated on a particular parameter if her mean score was above 3.

At the health system level, the exploration was on the organization and management of the healthcare delivery system [e.g., availability of services and commodities, incentives, monitoring and training of AWWs, interaction with supervisors, peers and non-governmental organizations (NGOs)]. The community level parameters consisted of community response, recognition of AWW and participation in activities. At the individual level, abilities, inducements to perform, job satisfaction, family support, etc. were explored.

The focus group discussions (FGDs) explored AWWs’ current experiences and perceptions, on the factors affecting their performance motivation. 4 FGDs, each consisting of 10 participants, were conducted. There were mixed groups of AWWs from different socio-economic and demographic backgrounds. Each FGD took between 45 and 60 minutes and interviews were conducted till the data saturation as per purposive sampling. The discussions were directed by an FGD guide with broad themes and specific probes. The interviews were conducted at a convenient location, with refreshments provided for the participants. The FGDs were audio recorded, and field notes were taken. Linear regression tests were used to explore the association between the level of performance motivation and the sociodemographic factors of AWWs. The qualitative data were transcribed verbatim and translated into English. These translations were grouped into themes and subthemes. The qualitative findings were triangulated with the survey results. Data collection was conducted according to a predesigned protocol.

RESULTS

The survey consisted of 105 AWWs (Table 1), of which the majority of the study subjects 45 (42.85) belonged to socio economic class III according to modified Kuppuswamy scale. Most of them 60 (57.14) had a high school certificate of formal education, and experience of more than 10 years as AWW 77 (73.33%). Majority of the women 102 (97.14%) had undergone a refresher training less than 2 years ago (Table 1).

The overall level of motivation was high among 45 (42.85%) AWWs, moderate among 42 (40%) and low among 18 (17.14%) AWWs.

The sociodemographic factors that were significant for higher motivation were age and educational status.

Level of performance motivation among the CHWs

The level of motivation was the highest on social responsibility and altruism (mean 4.5; 75.2% of AWWs). The self-efficacy on job scored a mean of 4.4 (72.45%); intrinsic job satisfaction had a mean of 4.3 among 83.8% of AWWs followed by nature of responsibilities (4.20; 72.38%). The adequacy of training positioned next with a mean score of 4.10 (87.6%).

The degree of motivation was the least on the adequacy of incentive (1.92; 2.8%), followed by their satisfaction on the level of healthcare infrastructure (2.03; 39%). The AWWs had low motivation on their work load (2.18; 41%) and community opinion on the health care system (2.6; 3.8%).

They had a moderate level of motivation (mean 3-4) on satisfaction of work modality (3.12; 25.7%), 3.56 for supportive supervision (91.4%) and enjoying the autonomy to move, express opinions and execute the responsibilities (3.77; 86.1%). The recognition from the community, family and health system scored moderately (3.89; 71.4%), as did self-motivation (3.94; 73.33%) and peer support (3.98; 88.57%).

Factors affecting the performance motivations

Individual level

Anganwadi work as an additional source of income (62%) and a sense of social responsibility (42%) were factors that enabled the workers motivation.

“I enjoy my job because I assist my community, and they value my efforts. They trust me when they need help with sickness or health advice”. AWW#3

“My family’s social status has improved due to my role as a health worker. Many women around me seek my advice regarding health and it makes me happy”. AWW #5

Community health workers (CHWs) enjoy their job because they can help their community, and both families and the community appreciate their efforts. The important services they provide keep them motivated, and they take pride in serving their community. CHWs also find inspiration in seeing positive changes in the community because of their work.

Community level

CHWs are encouraged by the support they receive from their peers and community. Many CHWs say the community welcomes them warmly and appreciates their efforts. They feel valued and respected for improving health awareness and practices. But some CHWs face challenges when discussing sensitive topics like contraception or HIV.

“When we visit the community, we get a lot of help. People greet us warmly, offer drinks and food, and speak kindly to us. They like me because they know who I am and what I do”. AWW#5

"We’re receiving more support from women’s groups and are more excited about doing things together in the community”. AWW#8

Helping the community as an AWW and empowering society inspired many. They found that women were more open to their health advice and participated more in community activities compared to men.

Health system level

Having supportive colleagues and receiving regular training are what motivates AWWs. There is also a good peer group for support and discussions.

“Training teaches us about new illnesses and helps us respond to the community's questions”. AWW#10

“We even have our own WhatsApp group. We share our progress and concerns on it and remain connected through it”. AWW#20

Demotivating factors

Individual level

AWWs reported that they lack time for routine tasks due to their involvement in various additional activities such as accompanying external agencies on field visits, organizing events, assisting in research, and attending meetings. Travel consumes much of their time, and new programs or guidelines often increase their workload, leading to job burnout and limited opportunities for career and skill development, impacting their motivation.

“In addition to our regular tasks, we’re often called upon to join visiting teams, camps, events, and surveys. This leaves us with very little time to focus on our usual duties”. AWW#3

“Our workload is not matched by our salary, and we don’t see opportunities for promotions or job security”. AWW#40

Family and community level

Long work hours lead to a lack of support from family members. Daily travel for work is seen as unsafe and inconvenient for women. Because of their long hours, they struggle to fulfil their family responsibilities and spend time with their loved ones.

“My family doesn’t fully understand everything I do. They see me working long hours, going out into the community, and they worry. They don't always realize how important my work is, how I help families and children stay healthy. Sometimes, they wish I could spend more time at home with them”. AWW#28

Health system level

AWWs mentioned they lack proper support like tools and supplies for their work, such as weighing scales, blood pressure devices, registers, notebooks, and travel assistance. They noted that, damaged equipment wasn't replaced, and government supplies of medicines and other essentials were running low.

“We frequently struggle to get the supplies we need for our work. Sometimes, the weighing scales or the medicines we need are not available, and it makes our job harder, recently, when we faced a shortage of medicines, but fortunately our supervisor worked hard to get them for us as soon as possible”. AWW# 17

DISCUSSION

The study investigated factors influencing the motivation of Anganwadi workers (AWWs) in a tertiary care center in central India. Understanding the drivers of motivation among AWWs is crucial for enhancing the effectiveness of India’s integrated child development services (ICDS) scheme, which relies heavily on their contributions to child well-being, maternal education, and community health.

The findings of this study shed light on several important factors influencing AWWs’ motivation. Firstly, individual-level factors such as an additional source of income and a sense of social responsibility emerged as key motivators. This aligns with existing literature by Gopalan et al, highlighting the importance of intrinsic factors like altruism and extrinsic factors like financial incentives in influencing healthcare workers’ motivation.⁸

At the community level, AWWs reported feeling valued and respected by their peers and community members, which contributed to their motivation. In a study done by Tripathy et al this sense of recognition and support is consistent with studies emphasizing the role of social support in promoting healthcare workers’ motivation and job satisfaction.⁹

Additionally, the study identified factors at the health system level that impact AWWs’ motivation. Supportive colleagues, regular training, and access to necessary tools and supplies were cited as motivating factors. Conversely, challenges such as inadequate infrastructure and limited access to essential supplies were reported as demotivating factors. A study done by George et al and John et al reported the importance of organizational support and resources in fostering healthcare workers’ motivation and job satisfaction.^10,11

The study had some limitations. The way participants were chosen might have been biased because they were chosen for convenience, which means they might not represent all Anganwadi workers. Since the study only looked at factors affecting motivation at one point in time, it didn’t show how these factors might change over time or affect motivation in the long term. Participants in surveys and focus groups might give answers that they think are socially acceptable, rather than their true feelings or experiences. This could affect the accuracy of the information gathered.

CONCLUSION

This study provides valuable insights into the motivation levels of Anganwadi workers (AWWs) in central India. It reveals that while many AWWs are highly motivated by their sense of social responsibility, self-efficacy, and intrinsic job satisfaction, challenges such as inadequate incentives, dissatisfaction with healthcare infrastructure, and heavy workloads remain significant demotivating factors. Sociodemographic factors like age and educational status were found to play a crucial role in influencing motivation levels. The study underscores the importance of supportive supervision, adequate training, and community appreciation in bolstering AWWs’ motivation. Moving forward, addressing these challenges could not only enhance job satisfaction among AWWs but also improve healthcare delivery within their communities. This research contributes to a deeper understanding of how organizational and systemic improvements can sustain and boost motivation among frontline healthcare workers, ultimately benefiting community health outcomes in similar settings globally.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. WHO. Health is a fundamental human right. Available from: https://www.who.int/news-room/commentaries/detail/health-is-a-fundamental-human-right. Accessed on 11 May 2024.
2. 2. Bhutta ZA, Lassi ZS, Pariyo G, Huicho L. Global experience of community health workers for delivery of health-related millennium development goals: a systematic review, country case studies, and recommendations for integration into national health systems. Glob Health Workforce Alliance. 2010;1(249):6.
3. 3. Lehmann U, Sanders D. Policy brief: community health workers: what do we know about them? The state of the evidence on programmes, activities, costs and impact on health outcomes of using community health workers. Evid Inf Policy. 2007; 2.
4. 4. O’Donovan J, Verkerk M, Winters N, Chadha S, Bhutta MF. The role of community health workers in addressing the global burden of ear disease and hearing loss: a systematic scoping review of the literature. BMJ Glob Health. 2019;4(2):e001141.
5. 5. Press Information Bureau. 13.63 lakh Anganwadi Centres (AWCs) of the 14 lakh AWCs sanctioned across the country are operational as on 01.06.2018. Available from: https://pib.gov.in/newsite/PrintRelease.aspx?relid=181218. Accessed on 12 May 2024.
6. 6. Mission Saksham Anganwadi and Poshan 2.0. Scheme guidelines. Available from: https://wcd.nic.in/sites/default/files/Final_Saksham_Anganwadi_and_Mission_2.0_guidelines_July_29_2022.pdf. Accessed on 12 May 2024.
7. 7. Dieleman M, Cuong PV, Anh LV, Martineau T. Identifying factors for job motivation of rural health workers in North Viet Nam. Hum Resource Health. 2003;1(1):10.
8. 8. Gopalan S, Mohanty S, Das A. Assessing community health workers’ performance motivation: a mixed-methods approach on India’s accredited social health activists (ASHA) programme. BMJ Open. 2012;2.
9. 9. Tripathy JP, Goel S, Kumar AM. Measuring and understanding motivation among community health workers in rural health facilities in India-a mixed method study. BMC Health Serv Res. 2016;16:1-0.
10. 10. George MS, Pant S, Devasenapathy N, Ghosh-Jerath S, Zodpey SP. Motivating and demotivating factors for community health workers: a qualitative study in urban slums of Delhi, India. WHO South-East Asia. J Public Health. 2017;6(1):82.
11. 11. John A, Nisbett N, Barnett I, Avula R, Menon P. Factors influencing the performance of community health workers: a qualitative study of Anganwadi Workers from Bihar, India. PloS One. 2020;15(11):e0242460.