Retention and attrition of community health volunteers in rural Malawi; a mixed-methods study.

backgroundCommunity health volunteers (CHVs) are an important resource for supporting health service delivery, surveillance, and social programmes. However, retention and attrition of CHVs remain a big challenge. This study explored factors affecting the retention and attrition of CHVs working as village reporters (VRs) responsible for community-based death notification in the Malaria Vaccine Implementation Program (MVIP) in Malawi.

methodsThis mixed-methods exploratory study, which intersected with the case studies, was conducted from November 2022 to March 2023 in nine rural districts in southern and central Malawi. Purposive sampling was used to select 64 study participants for qualitative interviews. Using case studies, we conducted six in-depth interviews (IDIs) with CHVs who had dropped out, were reachable, and agreed to be interviewed-many were dispersed, hesitant to attend meetings, or unreachable for focus group discussions (FGDs). We held five FGDs (n = 50) with CHVs who remained in the MVIP for shared norms and experiences and eight key informant interviews (KIIs) with health workers, opinion leaders, and program staff to provide insights into health workers motivation, supervisory and program perspectives. Thematic analysis and the social capital framework (roles, relationships, and empowerment) were used to analyse and interpret the qualitative data. The qualitative study was complemented by a cross-sectional survey involving 696 randomly selected participants from a pool of 2,861 CVHs to demonstrate the trends of retention over time. Descriptive statistics were computed from quantitative survey data, with retention as a primary outcome (defined as whether a CHVs was willing to stay in the program).

resultsAt the start of the program in 2019, a total of 2,861 CHVs were recruited by March 2023; only 295 (10.3%) had dropped out. Among 696 CHVs surveyed, the most commonly reported factors associated with retention were incentives (643; 92%), participation in exchange visits (377; 54%), and managing a small geographical area (275; 40%). Qualitative data from FGDs and KIIs corroborated these findings and identified compassion for serving others, financial and non‑financial incentives, and flexibility to work across multiple programmes as key motivators for continued participation. Factors associated with attrition included experiences of ridicule or disrespect, lack of opportunities for personal development, and limited career progression. IDIs with CHVs who left the programme provided in‑depth accounts of these individual‑level drivers, which helped explain patterns observed in the survey.

conclusionEngagement of CHVs in community-based programs can be promoted by offering opportunities to serve others, incentives, and flexibility to work on multiple programmes. However, it is also important to address ridicule-making fun or rude comments and limited personal and career development, which act as barriers to the continued engagement of lay health workers.