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Community and Family Health Theses and Dissertations
Theses/dissertations from 2023 2023.
The Influence of Psychosocial Factors on Opioid Decision-Making for Cancer-Related Pain Among Breast Cancer Survivors: A Mixed Method Study , Melody Nichole Chavez
Improving Interview Skills through Virtual Reality with Behavior Skills Training for Students with Disabilities , Garrit DuBois
Theses/Dissertations from 2022 2022
Exploring Parenthood and the Influence of Lived Experiences on Parenting Behaviors Among Child Welfare-Involved Adults , Veronica Howell
Theses/Dissertations from 2021 2021
Multi-object Localization in Robotic Hand , Tsing Tsow
Theses/Dissertations from 2019 2019
Cancer-Related Risk Behaviors and Screening Intention among Recreational Sport Athletes , Aldenise P. Ewing
Understanding the Family Planning Care Experiences of Young Black Women Using an Intersectionality Mixed Methods Approach , Rachel G. Logan
Understanding the Implementation of Integrated Care for People Living with HIV , Vickie A. Lynn
Effects of an Academic Enrichment Program on Elementary-Aged Students' Performance , Lauren E. Nieder
Risk and Resilience Pertaining to Mental Health of Youth Attending a College in Kathmandu Who Were Exposed to the 2015 Earthquakes During Their Adolescence: A Mixed Method Study , Vinita Sharma
Understanding the adoption process of an HPV vaccine school-entry requirement in Puerto Rico , Coralia Vázquez-Otero
Theses/Dissertations from 2018 2018
The Nutrition Transition Among the Andean Kichwas of Ecuador , Vanessa Alicia Chee
Teaching Debit Card Skills Using General Case Programming , Kristin More
An Examination of Factors that Affect the Utilization of Mental Health Services by Adolescents , Nichole A. Murray
An examination of the relationship between health literacy and dietary practices among college students: A test of the Integrated Model of Health Literacy , Alison B. Oberne
Through the Lens of Objectification Theory: Social Media Use and Women's Behavioral Health , Gina-Maria Roca
Theses/Dissertations from 2017 2017
Exploring Nutritional Needs, Roles, and Expectations of Latina Breast Cancer Survivors , Pamela Carolina Birriel
Mixed Method Study of Condom Use among Emerging Adults with New Sex Partners Met Online or Offline , Shana M. Green
Neighborhood Deprivation, Food Insecurity and Gestational Weight Gain , Sabrina Luke
An Exploration of Social Determinants of Health Constructs as Potential Mediators between Disability and Condom Usage , Karina Pineda
Reducing Caregiver Burden: Fostering Healthy Aging and Social Support , Maria A. Rodriguez
Theses/Dissertations from 2016 2016
Using Auditory Feedback to Improve Striking for Mixed Martial Artists , Frank Krukauskas Krukauskas
Contextual Factors and the Syndemic of Alcohol Use and Risky Sexual Behaviors Among Men Who Have Sex with Men , Humberto López Castillo
Exploration of the Pregnancy-Related Health Information Seeking Behavior of Women who Gave Birth in the Past Year , Laura Kathleen Merrell
Investigating Pakistan’s Contraception Rate Plateau: A Multilevel Analysis to Understand the Association between Community Contextual Factors and Modern Contraception Use , Mahmooda Khaliq Pasha
An Assessment of Elementary School Children’s Diet and Physical Activity Levels , Karen Tamara Serrano Arce
Smoking Among Youth Living with HIV: The Intersection of Behavioral Health and Chronic Disease , Todd Wells
Theses/Dissertations from 2015 2015
Food Insecurity and Hunger Experiences and their Impact on Food Pantry Clients in the Tampa Bay , Nora Brickhouse Arriola
Exploring the Underlying Mechanisms of Comorbid ADHD and Eating Disorders , Jennifer Rebecca Bleck
Theoretically Guided Examination of Caregiver Strain and its Relationship with School-Based Mental Health Services Utilization and Parent Engagement in Services , Amy Lynn Green
Pathogenic Policy: Health-Related Consequences of Immigrant Policing in Atlanta, GA , Nolan Sean Kline
Associations between Social Determinants of Health and Adolescent Pregnancy: An Analysis of Data from the National Longitudinal Study of Adolescent to Adult Health , Sarah Britney Maness
Reproductive Health Seeking Behaviors Among Female University Students: An Action Oriented Exploratory Study , Robin Emily Mowson
Women’s Use Of and Decision‐Making Regarding Geo‐Social Networking Applications to Arrange Sexual Experiences , Shireen Mary Noble
HEALTH INFOR[M-ED] : Black College Females Discuss a Virtual Reality (VR) Platform for Sexual Health Education and Training , Henry Arnett Ross
The Influence of Relationship Status on HPV Vaccine Decision-Making among Young Adult Women , Erika L. Thompson
HPV Vaccine Decision-Making among Male Sexual Minorities: An Integrative Theoretical Framework for Vaccine Promotion , Christopher W. Wheldon
Implementation of Medicaid Managed Long-term Services and Supports for Adults with Intellectual and/or Developmental Disabilities: A State’s Experience , Heather Jeanne Williamson
Theses/Dissertations from 2014 2014
Use of System Dynamics Modeling to Explicate the Theory-of-Change of a Social Marketing Innovation , Brian J. Biroscak
Risk Factors for Recurrent Major Depressive Disorder in a Nationally Representative Sample , Graig Charles DeFeo
Residency Education in Preparing Adolescent and Young Adults for Transition to Adult Care: A Mixed Methods Pilot Study , Janet S. Hess
Paternal Support for Breastfeeding: A Mixed Methods Study to Identify Positive and Negative Forms of Paternal Social Support for Breastfeeding As Perceived by First-time Parent Couples , Amy Lester
Monitoring and Use of Social Media In Emergncy Management In Florida , Leila Martini
An Exploration of the Health Experiences of Youth Who Were Trafficked for Sex , Christine Ann Meister
Individual and Partner Characteristics Associated with Genital Herpes Disclosure and the Relationship between Disclosure Outcomes, Rejection, and Future Intentions to Disclose , Jaime L. Myers
Understanding Factors Determining Early Termination from a Government Assistance Program for Maternal and Child Health: The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) , Anthony Dominic Panzera
An Examination of Coalition Functioning and Use of Evidence-Based Practices: A Case Study of Four Community Substance Abuse Coalitions , Nichole M. Snyder
Religiosity, Spirituality, and Depressive Symptoms in Older Adults in an Active Living Community , Monica D'adrianne Solomon
Long-Term Mindfulness Meditation: Anxiety, Depression, Stress And Pain, Is There A Connection For Public Health? , Sara Spowart
Substance Abuse Prevention in American Indian and Alaska Native Communities: Exploration of Guiding Theoretical Underpinnings and Theoretical Fit in Practice , Margaret L. Walsh
Theses/Dissertations from 2013 2013
Universal Tumor Screening for Lynch Syndrome: Identification of system-level implementation factors influencing patient reach , Deborah Le Cragun
The Water Culture Beliefs of Embera Communities and Maternal and Child Health in the Republic of Panama , Ilenia Anneth Forero
An Exploration of the Meaning and Consequences of Unintended Pregnancy among Latina Cultural Subgroups: Social, Cultural, Structural, Historical and Political Influences , Natalie Dolores Hernandez
The Relationship between High School Coaches' Beliefs about Sports Injury and Prevention Practice Readiness , Siwon Jang
Parent Distress in Life with a Child with Type 1 Diabetes , Lauren Nicole Johnson
Parent Pathways: Recognition and Responses to Developmental Delays in Young Children , Jennifer Marshall
The Role of Connectedness and Religious Factors on Bullying Participation among Preadolescents in Puerto Rico , Melissa C. Mercado-Crespo
Utilizing Habit Reversal and Contingency Contracting to Impact Eating Habits With Obese Individuals , Christopher Thomas Scull
Theses/Dissertations from 2012 2012
A Study of Potential Risk Factors of Depression among Latina Breast Cancer Survivors , Claudia Ximena Aguado Loi
Assessing the Psychometric Properties Of A Self-Efficacy Measure Within A Patient Navigation Research Program , Mariana Arevalo
A Cross-National Analysis of the Human Papillomavirus, Sexually Transmitted Infections, and Sexual Behavior among Men , Euna Marie August
A Systematic Review of Interventions to Increase Mental Health Service Use , Jennifer Greene
Beliefs of and Attitudes Toward Sexual Violence by a Diverse Group of Self-Identified Male Collegiate Athletes , Belinda-Rose James
Theses/Dissertations from 2011 2011
Drug Courts Work, but How? Preliminary Development of a Measure to Assess Drug Court Structure and Processes , Blake Barrett
The Role of Male Partners in Childbirth Decision Making: A Qualitative Exploration with First-Time Parenting Couples , Sharon Dejoy
Navigating the Child Welfare System: An Exploratory Study of Families' Experiences , Lianne Fuino Estefan
An Evaluation of the Early Steps Referral Process in Hillsborough County to Detect Delays in Access to Early Intervention Services , Jessica Fry Johnson
Understanding the Psychosocial Aspects of Waterpipe Smoking Among College Students , Mary Pautler Martinasek
Theses/Dissertations from 2010 2010
Low Documented Risk Cesarean Sections and Late-Preterm Births: The Florida Experience , Heather Breeze Clayton
An Exploratory Study of the Intrapersonal, Socio-cultural, and Behavioral Factors that Influence HIV Risk Behaviors Among Ethnic Subgroups of Black Heterosexual Men: The Intersection of the Beliefs and Perceptions of Black Women , Shalewa Noel-Thomas
Before the Storm: Evacuation Intention and Audience Segmentation , Homer J. Rice
The Relationship Between Knowledge and Beliefs About Human Papillomavirus, Acceptance of the Human Papillomavirus Vaccine, and Intentions to Practice Safer Sex Behaviors Among Female College Students , Theresa Scorcia-Wilson
Exploring Colorectal Cancer Diagnosis Disclosure to First-Degree Relatives: An African American Family Case Series , Kamilah B. Thomas
Theses/Dissertations from 2009 2009
Determinants of Nutrition Appointment Non-Attendance among Male Veterans , Claire Fontenot Bell
Exploring the Effects of BMI Health Report Card Letters Among 6 th Grade Students and Parents: An Application of the Social Cognitive Theory , Jenna M. Kaczmarski
Examining the Title X Family Planning Program’s (Public Law 91-572) Legislative History through a Feminist Lens: A Thematic Analysis and Oral Histories with Key Stakeholders in Florida , Cheryl A. Vamos
Theses/Dissertations from 2008 2008
The Getting Ready to Learn Program: An Impact Report , Rosa M. Avila
The Cumulative Effects of Victimization, Community Violence, and Household Dysfunction on Depression and Suicide Ideation in a Cohort of Adolescent Females , Katherine Best
Dental Hygienists' Beliefs, Norms, Attitudes, and Intentions Toward Treating HIV/AIDS Patients , Barbara Clark-Alexander
Organizational Culture in Children's Mental Health Systems of Care , Jessica Mazza
A Modified Obesity Proneness Model in the Prediction of Weight Status Among High School Students , Joyce E. Nickelson
The Role of Pharmacists and Emergency Contraception: An Assessment of Pharmacy School Curricula in the U.S. and the Knowledge, Attitudes, and Dispensing Practices of Florida Pharmacists. , Alice R. Richman
Measuring Culture Change as an Evaluation Indicator: Applying Cultural Consensus Analysis to Cultural Models of Lymphatic Filariasis in Haiti , Kelly M. Simpson
Association among Neonatal Mortality, Weekend or Nighttime Admissions And Staffing in a Neonatal Intensive Care Unit , Leisa J. Stanley
The Social Construction of a Special Needs Program for Hurricanes , Robert E. Tabler Jr., M.A., C.H.E.S.
Theses/Dissertations from 2007 2007
Attitudinal factors related to driving behaviors of young adults in Belize: An application of the precaution adoption process model , Ismael A. Hoare
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Home > Graduate Theses, Dissertations, and Capstone Projects > ALL-PROGRAMS > HLTH_COMMUNITY_HEALTH_THESES
Community Health Education Theses
Theses/dissertations from 2023 2023.
Identifying Barriers to Dental Care Among Hispanics in Southwest Minnesota , Lissette Garza
Theses/Dissertations from 2022 2022
The Assessment of Emergency Preparedness Among University Students , Arliah Cox
Stress Coping Responses of Undergraduate University Students Prior to & Since the Onset of the COVID-19 Pandemic , Kaylee Diefenderfer
Perceptions of Well-Being Among College Majors , Baylee Jahraus
Theses/Dissertations from 2021 2021
Assessment of Perceived Levels of Stress and Coping Mechanism Use Among Elementary School Teachers , Lauren Larson
Theses/Dissertations from 2020 2020
An Assessment of Knowledge, Behavior, and Consumption Patterns Surrounding Sugar- Sweetened Beverages Among Young Adults , Anne Harguth
Perceptions, Attitudes, Self-Efficacy, and Behaviors of Mouthguard Use Among Collegiate Athletes , Heather Prosser
Human Papillomavirus (HPV) Infection and Vaccine Knowledge and Attitudes among University Students , McKenzie Schmitz
Theses/Dissertations from 2019 2019
Assessment of Perceived Levels of Stress and Coping Mechanisms Among University Students , Nancy Adomako-Saahene
A Needs Assessment: The Barriers Preventing Students at a Large Midwestern University from Accessing the Dental Clinic on Campus for Preventative Care , Pamela Briese
Incentive-Use in Worksite Wellness Programs in MN Government Agencies , Sandra Bromley
Assessing Knowledge, Attitude and Practices of Hand Hygiene Among University Students , Linda Afia Mbroh
Blood Pressure Screening Practices Among Dental Hygienists , Mariah Sullinger
Theses/Dissertations from 2018 2018
Assessment of Stress Related Issues and Coping Mechanisms among College Students , Emeka Okoro
Assessing the Relationship Between Parenting Styles and Dietary Behaviors Among Young Adults , Breanna Tofteland
Theses/Dissertations from 2017 2017
Workplace Management Knowledge and Support for Employee Breastfeeding Practices , Elizabeth Heimer
Student’s Oral Health Knowledge, Oral Health Practices, and Their Susceptibility to Oral Health Diseases at a Midwestern University , Mouhamed Koubaytari
Avian and Pandemic Influenza Knowledge and Risk Perception in Southern Minnesota , Holly Munch
Preconception Health Knowledge among Undergraduate Women , Ashley Mae Paulsen
Complementary and Alternative Medicine: Current Mind-Body Practices and Perceptions of Undergraduate Students , Julia Ann Marie Putz
Screen Time and Sleep Condition among Selected College Students , Angela Lynn Sargent
Understanding Zoonotic Enteric Disease in Minnesota: A Spatio Temporal Analysis and Causal Theory Approach , Suchismita Swain
The Relationship Between Religiosity and Depression Among Sampled Kenyans In The Twin Cities Metro Area , Dorcas Waite
Theses/Dissertations from 2016 2016
North Minneapolis Residents' Knowledge and Awareness of Indoor Air Quality in Older Residences , Blisse Marie Cajacob
Impact of Stigma on Attitudes towards Seeking Professional Psychological Help for Depression , Anna Marie Dierks
Fruit and Vegetable Availability, Nutrition Education and Access Amongst Food Pantries in California, Maine, Mississippi and South Dakota , Sarah L. Fowler
An Analysis of Western Medicine Mistrust Among Selected African Immigrant Women in Minnesota , Wanjiru Julie Gicheru
Minnesota Collaborative Agreement: Potential for Dental Hygienists to Increase Direct Access for Underserved Populations , Rachel Jane Kashani-Legler
Human Papillomavirus and Human Herpesvirus-8: Knowledge, Perception of Risk and Barriers to Screening and Treatment among Selected Students at Africa University, Zimbabwe , Rujeko Olga Machinga
Young Adults’ Attitudes and Perceptions on Health Insurance and their Health Insurance Literacy Levels , Law Yang
Theses/Dissertations from 2015 2015
Relationship between Nurses' Job Satisfaction and Quality of Healthcare They Deliver , Samuel Aron
Employees' Interests and Preferences Regarding Worksite Exercise Programs , Amber Butcher
Religiosity, Spirituality, and Quality of Life Among Selected University Students , Abby Austin Kreitlow
Health Literacy Proficiency, Sources of Health Information, and Perceived Barriers to Health Literacy Among Selected Members of the Hmong Community in Minnesota , Amanda Vang
Elderly Patient Adherence to Ocular Pharmaceuticals; Impact of Educational and Physical Barriers , Lucky Wagner
Theses/Dissertations from 2014 2014
Physical Environment and Women's Physical Activity Behaviors , Beth Ann Brisky
Plan B Emergency Contraception: Sampled University Students' Knowledge, Attitudes, and Behaviors , Natalie Hazel
Risk Perceptions of Cardiovascular Disease in College Students , Antonia Kolas
Knowledge of HPV, Perception of Risk, and Intent to obtain HPV Vaccination among sampled Male University Students at Minnesota State University, Mankato , Lia Lambert
Sex Education Background of Students at MSU, Mankato Prior to Enrollment at the University , Natalie McConkey
Sampled University Students' Perceived Risk of Diabetes & Self-reported Diabetes Risk Factors , Ajibike R. Shodunke
University Students' Perceptions Of The Severity Of Binge Drinking , Lauren Eleanore Stone
Breastfeeding knowledge, practice, attitudes, and influencing factors: Findings from a selected sample of breastfeeding mothers in Bemidji, Minnesota , Hadeel Adnan Tanash
Recognition of and Attitudes Toward, Intimate Partner Violence Among Sampled University Students , Samantha Maureen Wobschall
Theses/Dissertations from 2013 2013
Health Promotion in the Workplace: Exploring Perspectives of Barriers and Incentives to Employee Participation , Amanda Conlon
The Relationship Between Emotional Intelligence And Alcohol Use Among Students at Minnesota State University - Mankato , Ganisher Davlyatov
The Impact of Telephonic Health Coaching on Physical Activity, Healthy Eating, and Cholesterol Levels , Jill Marie Hansen
Selected College Students' Perceptions, Knowledge and Awareness of Sexual Abuse of Children , Farhiya A. Muse
Access to EMS Services and Training, Knowledge, and Perceptions Related to First Aid and Cardiopulmonary Resuscitation (CPR) Skills Among College Students , Feifei Sun
Theses/Dissertations from 2012 2012
Mothers' Health and Health Behaviors that Influence Childhod Obesity Maternal BMI and Infant Feeding Methods , Mohamed Abdullah Alammari
Assessment of Selected University Students' Knowledge of Blood Donation and the Relationship with Intent to Donate Blood , Jeffrey Allerson
Study of International Students' Definations of, and Perceptions About, Domestic Violence Against Women , Sarbinaz Zamirovna Bekmuratova
Health Care Providers' Intention to Provide Culturally Competent Health Care to Somali Based Upon the Indirect Measures of the Integrated Behavioral Model , Amanda Kaye Ciesinski
The Relationship Between Religiosity & Selected Health Behaviors of African Americans of the Pentecostal Faith , Caprice Jones-Agunbiade
Perceptions of Risk Associated with Unintended Pregnancy and Sexually Transmitted Infections among University Women attending Minnesota State University, Mankato , Jessica Maria Seide
The Relationship Between Disordered Eating Behaviors and Exercise Addiction Among Selected University Students at Minnesota State University, Mankato , Haley Wasko
Theses/Dissertations from 2011 2011
Assessing Students' Risk Factors for Type II Diabetes at a Midwest Public University , Nicole DeCourcy Ferrian
An Investigation on HIV Related Stigma to Improve HIV Prevention Efforts in North Dakota , Krissie Lynn Mayer-Guerard
Use of Social Marketing Promotional Strategies to Create Awareness of Worksite Health Promotion Programs: A Survey of Program Coordinators , Anna Catherine Stahl
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- Published: 11 February 2022
Qualitative assessment of community health workers’ perspective on their motivation in community-based primary health care in rural Malawi
- Myness Kasanda Ndambo 1 ,
- Fabien Munyaneza 1 ,
- Moses Banda Aron 1 ,
- Basimenye Nhlema 1 na1 &
- Emilia Connolly 1 , 2 , 3 na1
BMC Health Services Research volume 22 , Article number: 179 ( 2022 ) Cite this article
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Community Health Workers (CHWs) have a positive impact on the provision of community-based primary health care through screening, treatment, referral, psychosocial support, and accompaniment. With a broad scope of work, CHW programs must balance the breadth and depth of tasks to maintain CHW motivation for high-quality care delivery. Few studies have described the CHW perspective on intrinsic and extrinsic motivation to enhance their programmatic activities.
We utilized an exploratory qualitative study design with CHWs employed in the household model in Neno District, Malawi, to explore their perspectives on intrinsic and extrinsic motivators and dissatisfiers in their work. Data was collected in 8 focus group discussions with 90 CHWs in October 2018 and March–April 2019 in seven purposively selected catchment areas. All interviews were audiotaped, transcribed verbatim, coded, and analyzed using Dedoose.
Themes of complex intrinsic and extrinsic factors were generated from the perspectives of the CHWs in the focus group discussions. Study results indicate that enabling factors are primarily intrinsic factors such as positive patient outcomes, community respect, and recognition by the formal health care system but can lead to the challenge of increased scope and workload. Extrinsic factors can provide challenges, including an increased scope and workload from original expectations, lack of resources to utilize in their work, and rugged geography. However, a positive work environment through supportive relationships between CHWs and supervisors enables the CHWs.
This study demonstrated enabling factors and challenges for CHW performance from their perspective within the dual-factor theory. We can mitigate challenges through focused efforts to limit geographical distance, manage workload, and strengthen CHW support to reinforce their recognition and trust. Such programmatic emphasis can focus on enhancing motivational factors found in this study to improve the CHWs’ experience in their role. The engagement of CHWs, the communities, and the formal health care system is critical to improving the care provided to the patients and communities, along with building supportive systems to recognize the work done by CHWs for the primary health care systems.
Peer Review reports
Community Health Workers (CHWs) are recognized as an integral part of the primary health care (PHC) system essential for achieving Universal Health Coverage (UHC) [ 1 , 2 ]. The World Health Organization (WHO) recognizes CHWs as lay health care workers who are members of the community where they are selected and are answerable to the same community they are working for while supported by the health system [ 3 , 4 , 5 ]. CHWs are a vital, diverse group that links people from their homes and communities to critical health and social services within their communities [ 6 ]. Their responsibilities may include screening, providing education, promoting access to and linkage to PHC services, engaging in highly specific disease-related activities such as medication observation and adherence, and even direct patient care [ 4 , 7 , 8 ]. Through these roles, CHWs have shown potential for improving population health by preventing and managing various chronic diseases in geographically and economically diverse settings in low and middle-income countries [ 4 , 8 , 9 , 10 , 11 , 12 ].
With the broad scope of work, CHW programs must balance the breadth and depth of tasks to maintain high-quality care delivery and CHW motivation [ 13 , 14 ]. Previous studies suggest that CHWs are motivated by trust and respect from patients and the community, managers’ support and encouragement, and health knowledge acquisition that can be shared in their communities. They are dissatisfied by poor incentives and working conditions, limited health supplies and equipment, disrespect and limited support from the formal health care workers, and lack of transportation [ 15 , 16 , 17 , 18 ]. These motivation factors are broadly reported, but the contextualization is less commonly described, especially in a rural household-based CHW programs to inform program implementation and improvement.
This study uses the Herzberg’s dual-factor theory [ 19 ] of motivation to describe factors from the CHW perspective that stimulate or decrease motivation among CHWs in rural Malawi to inform programmatic optimization. The motivation-hygiene theory postulates that distinct factors cause job satisfaction and motivate workers with different factors causing dissatisfaction [ 19 ]. Factors that motivate workers are intrinsic to the work itself and include achievement, responsibility, trust, leadership, opportunities for advancement, recognition, and the work itself. Extrinsic factors -independent from the actual work - cause dissatisfaction in work and are linked to incentives, working conditions, resources, quality of leadership, and job security. Intrinsic factors will increase motivation and productivity, but extrinsic factors can reduce motivation if absent. Prior studies have successfully described intrinsic and extrinsic factors for CHWs but have primarily focused on challenges [ 15 , 20 , 21 , 22 ].
Understanding intrinsic and extrinsic factors in community health worker programs can help structure programs for improving performance, health worker motivation, and retention to inform improvements in implementation [ 23 , 24 ]. To explore CHW’s perspectives on their job satisfaction, motivation, and challenges affecting their performance, we conducted a qualitative study utilizing focus group discussions with CHWs in rural Malawi. The knowledge on factors from the CHW perspective that impact performance and thus program effectiveness will inform CHW leadership on programmatic and motivation adjustments to maximize care.
Neno district is a remote, rural, and impoverished district situated in Southwest Malawi with an estimated 144,442 people in 2020 [ 25 ]. The district hospital is not accessible by tarmac roads due to mountainous terrain and poor infrastructure. The majority of the population of Neno are subsistence farmers who live on less than 1.90 USD per day, and 95.5% do not have access to electricity [ 26 ].
Community health worker household model in Neno District
At the inception of the CHW program in 2007, CHWs were positioned to support and accompany TB and HIV patients on clinical visits, treatment adherence, and psychosocial support that led to improved patient adherence and clinical outcomes [ 27 , 28 ]. In 2016, the CHW program transitioned to the polyvalent household model. In this model, each household in the district is assigned a CHW regardless of disease for universal coverage. The household model focuses on eight major disease areas: 1) TB; 2) HIV; 3) STIs; 4) non-communicable diseases (NCDs); 5) family planning; 6) maternal and neonatal health; 7) child health, and 8) malnutrition screening in children under 5 years old [ 29 ].
Structurally, the household model is a three-tiered program with CHW, senior CHW (SCHW), and site supervisor (SS) roles designed in alignment with the national community health worker structure. Community health workers are called Health Surveillance Assistants (HSAs). HSAs are part of the Ministry of Health (MoH) Environmental Health Department. They are one of the most prominent cadres of the Ministry of Health workforce across Malawi, with over 9400 HSAs in service [ 30 ]. They support Village Clinics for preventive care for under-five children and pregnant women and manage care for pediatric malnutrition and tuberculosis cases [ 30 , 31 ]. At the community level in Neno, one HSA serves approximately 540 households with case-finding, prevention, and essential case management. In terms of individuals, this translates to approximately a ratio of 1 HSA to 2300 people, which leads to poor coverage where households may go for long periods without interacting with their assigned HSAs [ 30 , 32 ]. Thus, the household model was designed to complement the HSA program with a large cadre of > 1000 CHWs to act as foot soldiers to the HSAs. The HSAs frequently interact with SS to identify clients to follow up and other tasks for the CHW and SCHW and coordinate on village clinics and activities.
The Neno district population has 14 catchment areas, each served by a health facility - 12 primary health facilities and 2 hospitals - Neno District Hospital and Lisungwi Community Hospital. The household model recruits CHWs by catchment area with mapping to determine the overall number of households and the required CHWs to serve the community adequately. Then through engagement meetings with community leaders and structures, potential CHW candidates are nominated based on a designated selection criterion. Selected CHWs are assessed for literacy, and successful candidates are further taken through a five-day foundational training with subsequent quarterly one-day refresher training. Working materials are provided in the form of job cards, registers, and logbooks. Supervisory structures of senior CHWs and SSs receive further training and meet regularly with CHWs for ongoing supportive supervision and mentorship.
Community health worker role description
The primary roles of the CHW are to monitor the health of their assigned households, conduct health education activities, screen and link community members to essential health services at the health facility, collect data for reporting, and support patients and community members in their assigned households. The CHW’s roles are summarized into five main categories, namely; 1) monitor/screen; 2) educate; 3) collect data and report; 4) accompany/refer; and 5) support. Each CHW is assigned 20–40 households within their community, depending on village size and geography. They are expected to visit each household at least once a month with frequent visits to households with members who have active disease or need of follow-up or support. CHWs receive a monthly stipend of approximately USD 22. CHWs are supervised by senior CHWs and SSs within the 14 catchment areas in the district who work closely with the facility-based MoH community health care workers – the health surveillance assistants (HSAs). They meet regularly in a month at the community and facility level to review and validate data, receive program updates and plan their work.
Senior community health worker role description
SCHWs work as CHWs attending to ~ 15 assigned households as above and have an advising and supervisory role. They support village-level monitoring and supervision of 10–15 CHWs with verifying data and troubleshooting household challenges—the SCHWs complete spot checks with mentorship and coaching with the assigned CHWs each quarter. Additionally, the SCHW serves as a community TB sputum collection agent, where sputum is collected from presumptive TB clients and submitted to the health facility. They receive a monthly stipend of approximately USD 33 and are supervised by the SS with quarterly visits at the household level and participate in the monthly data reviews.
Site supervisor role description
SSs serve as the primary link between the CHW program management and MoH’s facility-based community health team. SSs supervise and mentor SCHWs and CHWs through spot checks, data monitoring support, and supervisory meetings. They are responsible for data aggregation, record keeping, and monthly reporting. They jointly work with the HSAs to ensure CHW collaboration with specific emphasis on TB and malnutrition programs.
Study design
We utilized an exploratory qualitative design of focus group discussions (FGDs) with CHWs and SCHWs to examine CHW perspectives on facilitating factors and challenges on their ability to perform their duties. FGDs were conducted in October 2018 and March–April 2019. Of the 14 catchment areas in the Neno district, seven catchment areas (Midzemba, Zalewa, Chifunga, Ligowe, Neno District Hospital, Nsambe, and Dambe) were purposively selected to take part in this study per topography. We purposively selected ninety (90) participants from these catchment areas with consideration of four criteria; 1) the type of CHW (CHW versus SCHW), 2) CHW age to include both young and old participants, 3) gender to include a balance of males and females, and 4) duration of work as CHWs (“new” to include those working < 5 years; “old” to include those working > 5 years) (Table 1 ). We chose this approach to recruit a diverse group of CHWs and SCHWs with different experiences to find diverse perspectives on their enabling factors and challenges that affect their performance.
Data collection
In October 2018, four FGDs of CHWs and SCHWs were conducted. Each FGD comprised 9–12 participants, with one FGD in the catchment of Zalewa, Chifunga, Ligowe, and Dambe. In March – April 2019, an additional four FGDs were conducted with SCHWs only with 9–12 participants per group with one FGD in the catchments of Midzemba, Chifunga, Neno District Hospital, and Nsambe.
The study team developed two question guides for this study (Appendix 1 and 2 ). One question guide was developed for the combined FGDs (CHWs and SCHWs), and the second question guide targeted SCHWs with a focus on their supervisory roles with overlapping question prompts. For the combined FGDs (CHWs and SCHWs), we asked participants on knowledge and perspective of CHW services, CHW’s influence on health care seeking and community trust, inter-program relationships, perceived differences between CHWs and other health cadres such as HSAs, and ideas for program improvement.
The guides were developed in English, translated into the local language of Chichewa, and pretested with CHWs and SCHWs in the Neno District Hospital catchment area before use. We did not recruit CHWs and SCHWs who participated in pretesting for the main study. The content and translations were adjusted from feedback before formal data collection. The organization recruited the research fellow (MKN) and three research assistants for the evaluation study, with the research fellow facilitating data collection. These positions were not part of the implementation team and did not have prior knowledge of the household model in Neno, Malawi. The facilitator explained the study to participants and obtained signed written informed consent. The study was conducted by the Declaration of Helsinki guidelines and regulations [ 33 ]. Each FGD was recorded and took approximately 2 hours.
Data analysis
Transcripts were transcribed verbatim in Chichewa and then translated to English and later uploaded in Dedoose version 8.3.17 for data management. Transcription was done by the research fellow (MKN) and double-checked by (BN), who listened to all audio recordings and verified the translation from Chichewa to English before loading them in Dedoose. The data were analyzed using qualitative content analysis [ 34 ]. The research fellow familiarized with the data set through immersion by the repeated and active reading of transcripts [ 35 ]. To ensure the reliability of coding and consistency, the research fellow, BN and EC independently read the first three transcripts line by line to deductively assign codes to similar concepts that repeatedly emerged from the data in line with study objectives [ 36 ]. The first codebook was generated from the first three transcripts through a consensus process by looking at commonalities and differences [ 36 ]. The research fellow then coded the rest of the transcripts, with feedback from the senior authors, deleted repeated codes, and added new ones until a final codebook was created. The final codebook was agreed upon by the joint consensus of all authors [ 36 , 37 ]. We identified relationships between these codes, repeatedly identified codes were merged, and themes and sub-themes were generated from these codes. We chose quotes for each theme and sub-theme summarizing the main points [ 35 , 36 ].
CHWs’ motivation and performance were influenced by diverse elements that arise from the complex context in which they work as a conduit between the community and the formal health care system. As the narratives of the CHWs were examined, findings were deductively identified around common themes of intrinsic and extrinsic enabling factors and challenges CHWs face in performing their roles. Intrinsic factors included patient outcomes, community respect and recognition by formal health care workers, which enabled the CHW performance, but led to a challenging extrinsic factor of increased workload. Extrinsic factors included position scope and workload, work relationships, workplace environment, and geographical accessibility. Most of the extrinsic factors had motivational aspects and challenges for CHWs except for geographical accessibility, which was a consistent barrier in this environment (Fig. 1 ).
Mapping Enabling Factors and Challenges from the Community Health Worker Perspective in Rural Malawi
Intrinsic factors
Patient outcomes and community respect.
Through the focus group discussions, it was clear that CHWs recognize they are valued and appreciated in their communities by providing support and care trusted by individuals. The CHWs reported they are considered ‘doctors’ and respected leaders in rural communities where most families do not have immediate access to facility-based healthcare. Through this confidence in the CHW work, individuals were able to seek care at facilities with positive results and even sometimes life-saving treatment, which built gratitude for the CHW with social connectedness between the community and the CHWs. The CHWs were motivated by this relationship to enhance their performance, and it fostered professional status and trust in the CHWs.
“One man was very sick and the relatives were thinking that he has been bewitched. When I suggested to take him to the hospital, they told me not to trouble myself because the man will soon die. I took the man to the hospital on my bike. He was tested HIV positive and I have been helping him to adhere to medication. Within two months, the man picked up. The relatives came to thank me that without me their relative would have died. Even himself he is very thankful to me. They see me as their king and I walk majestically because of that.” CHW in Chifunga
“Household model is good. In my area, I am able to differentiate how life was in the past and now. Before, we could find a lot of sick people in the homes due to long distances to the hospitals as well as poor health seeking behavior. People opted for traditional medicine. Now, having taught them through home visits, they rush to the hospital when sick and are careful on preventive measures.” SCHW in Neno district hospital
With dependable, high-quality work and positive results from seeking care, CHWs reported that the community had great confidence in their abilities. Through the trust in the CHW abilities and training they receive, households and individuals would request CHWs to provide psychosocial support and advice with problems even beyond the supported health care topics such as marital affairs. One CHW shared;
“ … we even help in marriage issues when there are some disagreements. We help resolve their disputes. When it is beyond us when the tension is too much, we refer them to social welfare … .” CHW in Zalewa
CHWs reported embracing a unique supportive role in their communities beyond their expected duties. CHWs often stated spending more time than required per their job descriptions and often could even monetarily assist clients with hiring transport or helping with hospital-associated costs. These personal tasks contributed positively to clients’ well-being and instilled a relationship of gratitude with the CHW, which motivated the CHWs in their performance. However, this practice could lead to CHWs working beyond their routine tasks which may be a challenge in scope and resultant workload for the CHWs.
“One of my households did not have a toilet and the man is weak so I personally dug the pit on his behalf.” CHW in Dambe
“I once helped a person who did not have relatives to support him at the hospital. He had TB, and I was his guardian … I also hired a motorbike to take the client to the hospital as he couldn’t have done it on his own.” SCHW in Ligowe
Recognition by facility health care workers
Participants reported an excellent working relationship with formal health care providers with positive recognition of their work in the community. In the FGDs, CHWs reported that both cadres trust each other’s care of the clients. The CHWs stated that their work has improved the community’s health and decreased the number of clients requiring to visit the health facility. The CHWs further noted that the lower numbers at the facility, in turn, helps the health facility staff to lessen their workload and makes the CHWs feel proud of the care they are giving individuals. The recognition both by health facility staff and the clients with seeing the beneficial outcomes increased CHW confidence and motivation in their performance.
“When I take a client to the hospital, doctors provide good care hence people in the community trust me more when they see positive outcomes after seeing the doctor... there is a good relationship with people who work at the hospital and people trust us when we ask them to go to the hospital that they will be healed.” SCHW in Neno district hospital
“Yes, we feel like we are trustworthy. Even healthcare providers at the hospital are able to note that with our coming in, their work pressure is manageable. If you go to the OPD [outpatient department], you will find that there are fewer people as compared to the queues that were there previously. All this is happening because we help people in the villages through home visits.” SCHW in Midzemba
The CHWs reported acting as foot soldiers for the primary health care system at the facility level. With the CHW’s ability to support community primary health care, the over-worked HSAs utilized the CHWs to follow up on household-level tasks in their communities.
“You know as CHWs we do the job that was previously done by HSAs. They would previously walk around the communities following up pregnant women and distributing chlorine. That is now done by us and they just get reports … so yes, they are happy with what we are doing in the communities”. CHW in Zalewa
“We work a lot. We have taken the place of HSAs as previously they could go around the community to monitor pregnant women but now, they no longer do that … we are the ones doing it. We do even more than what they were doing … we just give them reports.” CHW in Dambe
Extrinsic factors
Position scope and workload.
Each CHW cadre (CHW, SCHW, and SS) has a specific job description and expectations with tasks aligned to support the eight disease focus areas in the household model. As demonstrated by CHWs in the FGDs, they have built trust and social connectedness in the communities they serve and with health facility staff by executing these tasks capably and efficiently. Even though this has motivated CHWs, it led to additional requests and demands on their time from clients and the health facility staff. CHWs perceived that their roles expanding past their original job descriptions challenged their knowledge and performance and made them feel under-appreciated. The increased scope was demonstrated through examples of where CHWs were asked to do tasks or counsel on disease areas they had not been trained on, or clients requested specific medications or tests that they do not routinely administer.
“...We also add some stuff that we were not trained on such as malaria and sanitation. Sometimes even cancer we tackle. When they ask us difficult questions, we refer them to the doctors. So we already have too much work.” CHW in Dambe
“Clients ask us for simple supplies like paracetamol and some contraceptives. Sometimes people walk long distances to the hospital just to receive pain killers. The community expects us to have such in stock for easy accessibility.” CHW in Chifunga
Similarly, at a health facility level, CHW participants described that their ability to reach clients at the household level and provide high-quality screening, referral, and care placed their services in high demand. Therefore, when designing new programs, the organization or health facility included new tasks requiring CHW involvement with expansion of care delivery.
“ … Also there are some projects that just come in and require our involvement since we are best suited in the communities … .” SCHW in Midzemba
Again, this recognition and value in CHW work enabled their performance. However, even though this shows the highly valued work the CHWs perform, with too many additional tasks and increased scope, it increased CHW workload and scope which challenged their performance.
“ … And then they keep adding jobs … because we have a lot of tasks. After 3 weeks we are supposed to submit reports to our supervisor so we really work under pressure … ” CHW in Zalewa
In the household model, the number of households in original job descriptions was set to 20–40 for CHWs and 10–15 for SCHWs. However, with adjustments in household assignments due to village growth, replacement of CHWs, and sometimes personal relationships with clients, many of the CHWs reported taking on additional households above the target number. CHWs indicated that this could be caused by their own motivation to take on additional households. However, it could also be due to attrition, geographical adjustments, or other CHW’s lack of work in other circumstances. No matter the reason, with more households, the CHWs had an increased workload, which affected their performance.
“The number is too big. 40 is just a limit as for me I have 54 houses. I cannot work efficiently as a volunteer. I am just a volunteer as such I fail to visit all the houses in one month as a result some are not visited.” CHW in Ligowe
“I was given 15 households but now I have 25 as some households were not comfortable with their CHWs and some CHWs had more households and I just had to relieve them. As such, I have more pressure and my output is affected.” SCHW in Midzemba
Workplace relationships
There is a supervision structure in the household model as described in the methods with CHWs reporting to SCHWs and SCHWs reporting to SSs. CHWs reported that this structure with mentorship and supportive supervision facilitated relationships between CHWs and the overall function of the program. Having two higher-level cadres to support CHWs, allowed for knowledge and skills transfer, improved delivery of tasks and shared supervisor and peer support in working through challenges. This support enabled the CHWs to perform their tasks to the high standards of care.
“When I have a problem, I make it known to the senior so that I can be assisted before the issue goes to the site supervisor... The Site Supervisor also helps us with skills on how to approach the household which may be difficult or unapproachable. They also visit our households. They teach and then tell me where I have done well as well as where I have not done well and then corrects me.” CHW in Zalewa
“We interact well with our CHWs. We hold meetings where we discuss challenges that they meet so that together we can find a solution. The frequent meetings help us to build a good relationship and work together. We also mentor them in areas where we feel that they are not doing well. We interact with the Site supervisor during the meeting when we submit reports and we discuss issues that we have failed to handle in the community.” SCHW in Dambe
Despite many positive outputs through the supervisory and peer support structure, there were some difficulties reported in interpersonal relationships between CHWs that challenged performance. This was discussed in the FGDs most often through the example of a CHW who is older or has worked longer than their supervising SCHW. In some situations, these differences led to the older or more experienced CHW not being open to constructive criticism or instructions from the supervising SCHW, leading to a strained interpersonal relationship on both sides. However, it was discussed that site supervisors had aided in building positive working relationships between CHWs and SCHWs, which had improved this challenge.
“Some CHWs who have worked longer than us the SCHWs do not take instructions as they think they know the work better than we do. Of course, the SS has been tackling this issue such that the current situation is better off than at first.” SCHW in Midzemba
Work environment
The household model provides CHWs with teaching aids such as charts, job cards, and booklets used for education in households. With these inputs, CHWs felt enabled to complete tasks and are easily identified in the community as health care workers as they carry the materials from house to house.
“At some point we were given bags so when we move around carrying our registers in those bags, we could hear people pointing at us that those are health workers. It feels good to be recognized as somebody in the community. Some even call us doctors when they see us with our teaching aids. So, by giving us such supplies, we feel very good.” CHW in Zalewa
Despite the educational materials enabling the CHW work, CHWs reported the need for additional and enhanced teaching aids to continue their high-quality services. The CHWs expressed that with updated educational materials or teaching aids to leave with clients, would have an increased beneficial impact on the community.
“Here in Ligowe we do not have enough teaching aids. We would therefore appreciate if we can be considered e.g. family planning, some have, others do not have … enlarge font for teaching aids as some elderly clients fail to see properly … we should have more teaching aids so that you leave them a copy to go through and then ask questions during the next visit. Some people even ask us to be writing notes for them so that they can have notes to go through when we are away.” CHW in Chifunga
Additionally, the CHWs work in very rural and remote terrain with several months of daily rainfall that challenges their ability to deliver services. CHWs expressed that regularly replenished protective gear would allow them to more frequently visit all assigned households and motivate them through the show of support with these inputs.
“As we approach the rainy season, the management should consider buying us necessary materials e.g. boots, raincoats and necessary bags. We feel complete with such supplies … it has taken long since we were given the same and they are worn out.” CHW in Dambe
Even though attrition overall is low in the household model, with a workforce of > 1200 members, it occurs that CHWs need to be replaced. CHWs reported a challenge when new CHWs are recruited within the household model and are not immediately trained by the CHW leadership. Then existing SCHWs are required to visit households without a current CHW, and then when the replacement is hired, sometimes even train him or her. Participants noted that when this occurs, the added work on the current CHW results in demotivation. Furthermore, there were concerns by the CHWs that the replacements trained only by the lower-level cadres might not be best prepared for scheduled tasks and performance to the standards set in the household model.
“Yes, though not a lot but we have CHWs who resigned and opted for greener pastures … on top of our heavy workload, we have to provide on job training for the new joiners. Mind you, such CHWs cannot perform the same way as those that went through normal training since we can also forget some things. It is important that management should look into this seriously.” SCHW in Midzemba
In the household model, CHWs and SCHWs are hired as volunteers who receive a stipend for their work with the expectation that it supplements other income or work. However, during FGDs, the CHWs noted that the routine tasks in the expected time were too much for a volunteer and challenged their performance. CHWs expressed that their stipend should increase or be fully employed by the organization, which would further recognize them as trusted primary health care professionals; and, in turn, motivate them.
“The work is too much such that we do not find time to do our own things that can help us generate income to earn a living, we would therefore appreciate if our stipend is increased so that we do not complain if we spend more time on it.” CHW in Zalewa
“As you know we are volunteers. Much as we appreciate the money we receive, in real sense it is too little, so we need to be doing other things to earn a living. If they can hire us as employees, I think it could be good for us as we will be able to dedicate our time to the fullest. In this way, things will go on smoothly . ” CHW in Ligowe
Geographic accessibility
Neno district has very challenging and mountainous terrain, especially in the rainy season with flooded rivers, mudslides, and impassable roads. Furthermore, some villages and areas have households with long distances in between them. Thus CHWs reported mobility challenges even with reasonable household allocations, which challenges their performance. There were recommendations for transport support to improve outputs.
“Some of us walk long distance to reach households that are within our villages so they should provide us with bicycles. In my case, sometimes I work throughout the day just to cover three households because my households are very far apart...” CHW in Zalewa
Due to a broader geographical area in supervision and sputum collection, SCHWs are provided transport support with bicycles. However, SCHWs reported that with rough conditions and a lack of repair, the bicycles break down and are unusable. Similarly, to no transport support, the lack of reliable transport decreases the SCHW performance. There were appeals made to improve transport conditions for enhanced performance for all CHWs.
“I travel long and hilly distances to the facility hence the bicycles that we have do not help at all … at least if we had push bikes … sometimes they break down on our way to the hospital to submit sputum and we just return back home despite covering a long distance. This demotivates us.” SCHW in Dambe
By utilizing the dual-factor theory, examination of intrinsic and extrinsic factors can enhance understanding of enabling and challenging factors in CHW performance to improve primary healthcare delivery. The results of this exploratory study of CHW show that enabling factors are mostly intrinsic with positive patient outcomes, community respect, and recognition by the formal health care system. Extrinsic factors can also enable CHWs to work in supportive relationships between CHWs and supervisors and provided educational materials to enhance performance. The challenges mainly lay within extrinsic factors: increased scope and workload, lack of up-to-date resources and transport support, and rugged geography. One interesting connection between intrinsic and extrinsic factors was that the CHWs were motivated by intrinsic factors of positive patient outcomes and the corresponding trust and confidence in their care by the community and health facility staff through their capable work. However, this led in some circumstances to extrinsic challenges of additional workload and increased scope of work that led to CHW performance and demotivation challenges.
Most of the intrinsic factors in the household model were enabling from the perspective of the CHWs. Through the CHWs providing high-quality screening, referral, and patient follow-up, the patients have improved health knowledge, care-seeking behaviors, and outcomes. Furthermore, the CHWs felt well respected and trusted in their communities, with relationships built on trust and empathy from this beneficial impact. This echoes findings in other studies where CHW’s motivation stems from interpersonal relationships of trust and social standing in the community [ 38 , 39 , 40 , 41 , 42 ]. These factors encourage CHWs to improve performance and extend themselves to help their communities, leading to deeper relationships with individuals and going above and beyond their job description. Examples in this study include paying out of pocket for patients’ healthcare costs, providing housework, or moderating interpersonal relationships. Even though these actions were altruistic and born from the firm social connections between the CHWs and their patients and communities, it challenges the CHWs in expanding the scope and work required beyond their formal expectations. Similarly, Oliver et al. [ 14 ] demonstrated that the integrative role of CHWs enables effective care and places CHWs straddling the tasks of formal health care providers and more of a “social work” function within the community that can lead to tension and dissatisfaction.
Participants reported an excellent working relationship with the formal health care providers with the intrinsic factor of recognition of their work which motivated the CHWs. A Cochrane review [ 38 ] on barriers and facilitators of CHW implementation showed that support from health systems gives CHWs creditability. Furthermore, health professionals often appreciate the CHW’s contributions in reducing workload along with their communication skills, referrals, and commitment to patients [ 38 ].
However, one challenging extrinsic factor is that with increased CHW scope and workload imposed by themselves and health facility staff, CHWs can feel demotivated with barriers to optimized service delivery. For example, the CHWs often meet additional requests for information and screening on tasks outside the eight disease focus areas, expanded scope of responsibilities, and take on additional households. Task shifting is typical in CHW programs in low-resourced settings but is an important extrinsic factor that can lead to demotivation and decrease program effectiveness [ 1 , 38 , 43 , 44 , 45 ]. In Malawi specifically, a prior study conducted on the community health workers at the facility level (e.g., HSAs) demonstrated that heavy workload and competing tasks lead to health care workers not performing all their assigned tasks [ 46 ]. Therefore, it is not surprising in this context that health facility staff may utilize the CHWs to perform some of their tasks due to their own overburdening. In this sense, the use of CHWs as “foot soldiers” for the HSAs is successful task shifting as seen in other settings and endorsed by the World Health Organization (WHO) to tackle health worker shortages [ 47 , 48 , 49 ]. However, performance and motivation can waiver with task shifting, as suggested by the CHWs in this study and others [ 47 , 50 ]. As clearly defined by the WHO, checks, and balances on workload and provider capabilities are required to protect the health care workers and patients in care from maintaining high-quality care and performance [ 47 ]. Therefore, to successfully utilize the HSAs and CHWs to provide care in the rural Neno district, we must ensure both cadres have clarity of responsibilities with enough staff, time, and training to perform tasks adequately. They must be supported with solid leadership and governance without overburdening with resultant demotivation and potentially poor performance with poor client care.
Challenging extrinsic factors included workplace environment, training and resources, and difficult geographical accessibility with lack of transportation. Other CHW studies in India and South Africa highlight similar barriers [ 16 , 22 ]. Training and capacity building are vital components of CHW programs as it distinguishes CHWs from being just another concerned member of the community. However, we found that training sometimes was left to the CHW supportive supervision structure, which added to their workload and dissatisfaction. Furthermore, there was concern that training by peers could be substandard to formalized training by CHW leadership. Out of date or inadequate job aids, equipment, and resources also constrain CHW effectiveness and motivation. Without all relevant resources and tools, CHWs feel that they are not giving the health education desired by the community and may become less relevant. Even though monetary incentives are debated within CHW programs, we found that CHWs appreciated their stipend in exchange for their professional services. Furthermore, due to the tasks at hand, time requirements, and needs within the community, through the FGDs the CHWs requested increased stipends or full employment benefits from the organization to match the amount of work expected and to motivate them. Similarly, other community health worker studies in Malawi and beyond have identified low salaries as dissatisfiers to their work [ 32 , 38 , 44 , 50 ].
In community-based care, challenging geographical environments and inadequate transportation are common problems, especially in mountainous and poorly developed areas [ 1 , 9 , 51 , 52 ]. Although the program was designed for CHWs to provide services within their community and within walking distance, the reality from the discussions with CHWs is that they can cover much larger areas. Without reliable transportation and added households outside their communities, the lack of accessibility added to CHW workload and travel decreased performance and household visits. Likewise, other studies have shown that frequently required visits, broad geographical coverage, and lack of transportation were dissatisfiers of the CHW work environment [ 22 , 50 , 52 ]. Considerations for programmatic improvement include redistribution of households to decrease walking distances and limit household numbers and investigation of reliable transportation solutions.
Our findings show that bidirectional solid and supportive relationships between CHWs themselves and supervisors encourage collaborative work and increase morale. Barriers to interpersonal relationships between CHWs can be due to older CHWs or more experience reporting to those younger or without experience. This interpersonal relationship factor is extrinsic through the relationships and work environment but has the intrinsic aspect of peer recognition. Similar to our findings, prior studies on CHW performance show that supportive supervision and mentorship are critical to program success, along with the opportunity to share experiences with fellow CHWs [ 11 , 15 ]. Programmatic improvement considerations include clear, high-quality performance standards for supervisors not based on age or length of service with clear communication to all CHWs with work on productive and bidirectional relationships between CHWs and supervisors.
CHWs are critical “bridges” between the community and the facility-based primary health care system that provide competent care within the community [ 4 ]. This study demonstrated important enabling intrinsic and extrinsic factors for CHWs such as education and teaching aids, robust supportive supervision, positive patient outcomes, and trusting relationships between CHWs and communities and health facility staff. However, there is also a need to improve both levels to facilitate CHW motivation and performance with key recommendations from this study. Firstly, we must ensure CHWs and health facility staff, including HSAs, have clarity of responsibilities with adequate staff, time, inputs, and training to perform tasks adequately. Secondly, strong leadership and governance are required to ensure positive client care and outcomes that motivate health care staff with optimized performance.
Furthermore, attention to interpersonal relationships between peers and supervisors must be prioritized with adequate training, teaching resources, transport, and monetary incentives to motivate high-quality work. Lastly, many CHWs are deployed in rural and remote areas taking care of clients without immediate access to facilities. We must ensure that CHW leadership structures and CHWs jointly set scheduled tasks, scope, and geographical spread for a motivated and productive CHW workforce to provide high-quality care delivery to rural populations. Further investigations into CHW performance may include health facility staff perspective and expectations of CHW work, valuable support systems for CHWs, optimized educational tools from the perspective of health facility staff, CHWs, and clients, how to facilitate CHW peer, community, and facility recognition, and trust.
Limitations
This study was conducted in a small rural and remote district in Malawi, limiting generalizability. However, Neno District has similar geographical and socioeconomic aspects to many rural areas in Sub-Saharan Africa, with several themes shared amongst the literature on motivation and job performance in CHWs. The study was conducted in the stated household model program focusing on screening, linkage, and patient follow-up without CHWs providing direct diagnostics or medication, which differs in scope from other CHW programs even within Malawi and other countries. However, many of the challenges and enablers found in this study are universal for health care workers, as demonstrated in other studies referenced, and can be utilized when implementing or improving community health worker programs and projects.
This study demonstrated enabling factors and challenges for CHW performance from their perspective within the dual-factor theory. We propose an enhancement of capable and motivated CHWs to facilitate trusting relationships that lead to positive patient outcomes while improving the clarity of responsibilities with adequate staff, transport, and training to perform tasks adequately. We recommend CHW programs provide robust training and education, supportive supervision, and leadership with jointly set scheduled tasks, scope, and geographical spread for a motivated and productive CHW workforce. Empowering CHWs by raising awareness and working together to mitigate challenges and enhance motivational factors can engage them as active partners in programmatic improvement to deliver high-quality primary care in the community.
Availability of data and materials
The dataset generated and analyzed during the current study is not publicly available. Even without identifiers such as names, the dataset could potentially hold identifiable participant information in aggregate form due to sex and catchment area along with potential disease status. Neno District is a small district, and with potential identifiers, we believe it would be ethically inappropriate to publicly share the data that could reveal our participants’ identities if read by someone within the district. The dataset or part of it could be available from the corresponding author on reasonable request with permission from the Neno District Research Committee ( [email protected] ).
Abbreviations
Community Health Workers
Partners In Health
Abwenzi Pa Za Umoyo
Tuberculosis
Non Communicable Diseases
Sexually Transmitted Infections
Focus Group Discussions
Senior Community Health Workers
Site Supervisors
Human Immunodeficiency Virus
Antiretroviral Therapy
Health Surveillance Assistant
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Acknowledgments
We are grateful to the CHWs, SCHWs, Healthcare workers, patients, and community members who participated in the study. We acknowledge the Samuel Family Foundation for the financial support and the APZU community health, clinical, monitoring and evaluation, and operations departments for the collaborations. We acknowledge the District Health Management Team and health care workers of the Neno District for the work they do for patients and the support given to the CHWs. We appreciate the support rendered by the following research assistants: Marcus Gondwe, Elizabeth Kayange, and Mumderanji Balakasi.
This study was supported by the Samuel Family Foundation, Canada (PIHC project MA.LI.CHW.17). The funding body had no role in the study’s design, data collection, analysis, interpretation of data, or write-up of the manuscript.
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Basimenye Nhlema and Emilia Connolly are co-senior authors.
Authors and Affiliations
Partners In Health/Abwenzi Pa Za Umoyo, PO Box 56, Neno, Blantyre, Malawi
Myness Kasanda Ndambo, Fabien Munyaneza, Moses Banda Aron, Basimenye Nhlema & Emilia Connolly
Division of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, 45267, USA
Emilia Connolly
Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45529, USA
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MKN, BN, and EC conceptualized and designed the study. MKN collected data, analyzed data, and drafted the manuscript with assistance from BN and EC. BN and EC also reviewed the transcripts and the codebook. EC, BN, FM, and MBA reviewed the manuscript, provided input, and suggested additions and changes. All authors read and approved the final manuscript.
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Correspondence to Myness Kasanda Ndambo .
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This study was approved by the National Health Science Research Committee (NHSRC) in Malawi with protocol number 1059 titled “ Lessons Learned from Monitoring and Evaluation of Community Health Initiatives in Neno District, Malawi .” Written informed consent was obtained from all participants before data collection. The study was conducted by the Declaration of Helsinki guidelines and regulations.
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Ndambo, M.K., Munyaneza, F., Aron, M.B. et al. Qualitative assessment of community health workers’ perspective on their motivation in community-based primary health care in rural Malawi. BMC Health Serv Res 22 , 179 (2022). https://doi.org/10.1186/s12913-022-07558-6
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29 Dissertation Topics In Community Health
As its name suggests, community health is associated with the heath of the overall community and how nursing profession can aid in maintaining a good overall community health. Dissertation topics in community health cover different associated topics of interest. Students studying in different academic levels utilize different research strategies to understand the explore the basic areas of community health. All the primary health issues that are faced by communities are studied under the umbrella of community health. Incorporation of community health areas with other disciplines is also a research paradigm that has gained a lot of attention recently.
Dissertation Topics In Community Health
We have prepared an extensive list of community health dissertation topics so that our readers can go through them and choose any topic as per their interest:
- Quality assurance in community health nursing: a review of literature.
- Community health nursing: challenges and opportunities in the developing countries of the world.
- Effects of Watson’s philosophy on community health nursing practices: a review of literature.
- Community health nursing practices in the geographically isolated areas of the world: focus on the health of women and children.
- Effects of the self-efficacy of community health nurses on the nursing practices: a correlational analysis.
- Ethnically diverse populations and community health nursing: challenges and interventions involved.
- Formulating a focus group research design to collect aggregate-level data for understanding the domain of community health nursing.
- Studying the correlation of job satisfaction and workplace stress in the context of community health nursing.
- Ethical decision-making in community health nursing: challenges and interventions involved.
- Role played by community health nurses in the care of insulin-dependent diabetic patients: a quantitative study.
- How community health nurses can promote awareness related to colorectal cancer at the community levels? A systematic study.
- Community health nursing and osteoporosis: a review of literature.
- Importance of participatory action research in the domain of community health nursing: a qualitative study.
- Community health centers and community health nurses: clients’’ perceptions about quality of nursing practice.
- Community health nursing practices for the smoking initiation prevention among teenagers in the community.
- Teaching community health nursing students: role played by visual simulations.
- Community health nursing by region: a systematic analysis.
- Rural versus urban community health nursing practices: a comparative analysis in UK.
- High risk infants and community health nursing interventions: a descriptive analysis.
- COVID-19 pandemic and community health nursing in developed countries of the world.
- Antibiotic over-prescribing and community health nursing interventions.
- Importance of prevention-focused community health nursing practices.
- A comparative analysis of different models related to community health nursing practices.
- Community health nursing practices for homeless people: a UK-based research study.
- Community health nursing practices and child abuse potential inventory: implementations in child abuse prevention programs.
- Importance of nurses in primary health care provision programs: a systematic analysis.
- Legal aspects associated with community health nursing practices.
- Psychology and community health nursing.
- Stress and burnout in community health nurses.
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Dissertations / Theses on the topic 'Community health nursing – Swaziland'
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Brookbank, Kathleen. "HIV : impact on community health nursing personnel." Virtual Press, 1992. http://liblink.bsu.edu/uhtbin/catkey/834518.
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Mngadi, Patricia Thuli. "Adolescent pregnancy and parenthood in Swaziland : quality of care, community support and health care service needs /." Stockholm, 2007. http://diss.kib.ki.se/2007/978-91-7140-725-2/.
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Chang, Pei-Jen. "Factors influencing occupational health nursing practice." Thesis, King's College London (University of London), 1994. https://kclpure.kcl.ac.uk/portal/en/theses/factors-influencing-occupational-health-nursing-practice(117dd5b4-81ff-45dd-8966-3ea83809c449).html.
Carter, Nancy Jo Crumpler Thomas P. Spycher Ellen A. "Perceptions of challenges and knowledge and skill for community based nursing practice." Normal, Ill. : Illinois State University, 2007. http://proquest.umi.com/pqdweb?index=0&did=1414124161&SrchMode=1&sid=3&Fmt=2&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1205251510&clientId=43838.
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Weierbach, Florence M. "IGNITES Voices from Our Community." Digital Commons @ East Tennessee State University, 2018. https://dc.etsu.edu/etsu-works/7371.
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Weierbach, Florence M. "Integrating Community Concepts, DNP Essentials & Practice." Digital Commons @ East Tennessee State University, 2012. https://dc.etsu.edu/etsu-works/7402.
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Bjorn, Agnes Marie. "Community health assessment and nursing care needs of the elderly." Thesis, University of Manchester, 1989. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.237239.
Murray, Christopher J. L. "The determinants of health improvement in developing countries : case-studies of St. Lucia, Guyana, Paraguay, Kiribati, Swaziland and Bolivia." Thesis, University of Oxford, 1988. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.304625.
Alcazar, Maria. "Childhood/teen obesity in the Hispanic community." Thesis, California State University, Long Beach, 2015. http://pqdtopen.proquest.com/#viewpdf?dispub=1587255.
Obesity in the United States should be of great concern to all Americans. The rates of obesity among children and adolescents have been on the rise, demonstrating the need for action now. Obesity at a young age can lead to obesity into adulthood, thereby also increasing the risk of health issues such as the development of high blood pressure and diabetes. Many factors go into play when dealing with obesity, yet the factors that will be considered in this study are the effects of decrease activity and the impact of BMI of a child or teen. Another factor that will be consideed in this study is the consumption of sugar sweetened beverages and how this also affects a child or teens BMI.
Teasdale, John Kevin. "Reassurance in nursing." Thesis, Sheffield Hallam University, 1992. http://shura.shu.ac.uk/3162/.
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Simons, Lucy. "Community mental health nurses' perspectives on the treatment of people with common mental health problems." Thesis, University of Southampton, 2006. https://eprints.soton.ac.uk/57942/.
Dobbins, Elizabeth M. "Non-Language Barriers to Effective Care of the Hispanic Population." Digital Commons @ East Tennessee State University, 2015. https://dc.etsu.edu/honors/274.
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Runciman, Phyllis Janet. "Interpreting health promotion with older people in community health nursing : education and practice perspectives." Thesis, Glasgow Caledonian University, 2010. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.547440.
Bennett, Amanda Dawn. "Project GENESIS: Community Assessment of a Rural Southeastern Arizona Border Community." Diss., The University of Arizona, 2009. http://hdl.handle.net/10150/194342.
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Brehm, Jerrilyn S., M. Yasin, and Florence M. Weierbach. "Building Trust with Novice Community Based Preceptors." Digital Commons @ East Tennessee State University, 2018. https://dc.etsu.edu/etsu-works/7397.
Bolton, Mychal. "Perceived Barriers to Obtaining Psychiatric Treatment at Johnson City Community Health Center." Digital Commons @ East Tennessee State University, 2014. https://dc.etsu.edu/honors/223.
Earle, Wendy. "Factors that influence heart failure self-management of community dwelling individuals." Thesis, University of Ottawa (Canada), 2005. http://hdl.handle.net/10393/27195.
Mobley, Deborah. "The Lived Experience of Faith Community Nurses Living the Call to Health Ministry." VCU Scholars Compass, 2010. http://scholarscompass.vcu.edu/etd/101.
Morton, Jea, Florence M. Weierbach, Rebecca Sutter, Kae Livsey, J. Bliss, Jerrilyn S. Brehm, and J. Metcalf. "Transforming Community Health Nursing Education: Lessons Learned from Individual and Cross Grantee Program Evaluations from a Federal Bachelor of Science in Community Practicum Awards." Digital Commons @ East Tennessee State University, 2019. https://dc.etsu.edu/etsu-works/7379.
Schoonover, Heather Diane. "Barriers to research utilization among registered nurses working in a community hospital." Online access for everyone, 2006. http://www.dissertations.wsu.edu/Thesis/Spring2006/H%5FSchoonover%5F033106.pdf.
Meurier, Clency Emmanuel. "Improving the quality of nursing care : a study of nursing errors and their reduction." Thesis, University College London (University of London), 1998. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.287996.
Keith, Rosalind R. "Initiating Nicotine Cessation in a Community Mental Health Center." ScholarWorks, 2016. https://scholarworks.waldenu.edu/dissertations/2128.
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Boulle, Therese Marie. "Developing an Understanding of the factors related to the effective functioning of Community Health Committees in Nelson Mandela Bay Metropolitan Municipality, Eastern Cape Province, South Africa." Thesis, University of the Western Cape, 2007. http://etd.uwc.ac.za/index.php?module=etd&action=viewtitle&id=gen8Srv25Nme4_4635_1253238212.
This research aimed to investigate the factors related to the functioning of Community Health Committees in Nelston MandelaBay Municipality. It intended to elicit information on factors which promote and inhibit their effective functioning. It used the qualitative research methods of focus group discussions, concluded with a sample of Community Health Committee members, and in depth, individual interviews with key informants. The contents of the transcriptions of all focus group discussions and in-depth individual interviews were analysed so as to identify the recurring themes and key suggestions.The findings indicated that Community Health Committees are not functioning as per their original intention and that relevant policies have not been accurately translated into practice.
Fordham, Maria. "Being and becoming a specialist public health nurse : net weaving in homeless health care." Thesis, University of Bedfordshire, 2012. http://hdl.handle.net/10547/304613.
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Adams, Faiza Kajee. "Violence in nursing : perceived prevalence and impact in community health clinics in Cape Town." Master's thesis, University of Cape Town, 2010. http://hdl.handle.net/11427/12733.
Udjombala, Hilka Tuyenikelao. "Malaria in Namibia : a community study." Thesis, Stellenbosch : Stellenbosch University, 2001. http://hdl.handle.net/10019.1/52329.
Sapsford, Lesley Eliaine. "The professional development of primary health care nurses in integrated self managing teams." Thesis, Bucks New University, 1998. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.270297.
Dudley, Nancy Elizabeth. "Factors Influencing the Uptake of Community-based Palliative Care." Thesis, University of California, San Francisco, 2016. http://pqdtopen.proquest.com/#viewpdf?dispub=10133428.
Over the past ten years, community-based palliative care (CBPC) has rapidly expanded as older adults are living in the community longer with advanced illness and high symptom burden. Yet there are no models of standardized care for this population. It has been suggested that primary and secondary palliative care be delivered in the primary care setting to address palliative care needs in the community. However, a description of older adults in primary care with advanced illness and symptom burden who would benefit from primary and secondary palliative care, and a description of the process to deliver care are lacking. The aim of this dissertation was to explore the facilitators and barriers to providing palliative care in primary care, and to describe the prevalence of advanced illness and symptoms of older adults in primary care to identify who would benefit from palliative care in primary care.
Using a grounded theory methodology, twenty semi-structured interviews were conducted with primary care and palliative care providers in academic and community settings. Four major themes emerged from the data that are facilitators and barriers in care coordination: (i) role clarity; (ii) feedback and communication; (iii) time constraint and workforce; (iv) education.
A secondary analysis was conducted using the National Ambulatory and Hospital Medical Care Surveys 2009-2011 to examine primary care visits. There were more visits by older adults to primary care for advanced illness and symptoms than to non-primary care. More visits were due to advanced COPD, CHF, dementia, pain, depression, anxiety, fatigue, and insomnia compared to non-primary care. This research contributes to our knowledge of the delivery of palliative care in the community and the patient population that could benefit from primary and specialty palliative care. I offer a conceptual model of the process of primary care and specialty palliative care in order to coordinate care for older adults with advanced illness and progressive symptomatology.
Sattler, Victoria. "Understanding the meaning of an international community focused teaching-learning experience in Peru." Pullman, Wash. : Washington State University, 2009. http://www.dissertations.wsu.edu/Thesis/Fall2009/v_sattler_111909.pdf.
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Morton, Jea, Mary Kay Goldschmidt, Rebecca Sutter, Kae Livsey, D. Martin, Florence M. Weierbach, J. Bliss, and J. Metcalf. "Preparing Graduates for Roles in Community-based Nursing Practice." Digital Commons @ East Tennessee State University, 2018. https://dc.etsu.edu/etsu-works/7381.
McLaughlin, Michael P. "Community college nursing and allied health education programs, and Iowa's healthcare workforce." [Ames, Iowa : Iowa State University], 2009.
Coombs, Maureen A. "Medicine, nursing and policy development in intensive care : an ethnography to explore the contemporary nursing role." Thesis, Oxford Brookes University, 2000. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.323909.
Davis, Kierrynn Miriam Davis. "Cartographies of rural community nursing and primary health care : mapping the in-between spaces /." [Richmond, N.S.W.] : University of Western Sydney, Hawkesbury, 1998. http://library.uws.edu.au/adt-NUWS/public/adt-NUWS20030509.135659/index.html.
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- Case Reports
Yeast Communities of the Moscow City Soils
- Experimental Articles
- Published: 02 June 2018
- Volume 87 , pages 407–415, ( 2018 )
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- A. N. Tepeeva 1 ,
- A. M. Glushakova 1 &
- A. V. Kachalkin 1
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Yeast abundance and diversity were studied in the soils (topsoil) of Moscow city: urban soils under lawn vegetation and close to the areas of household waste disposal, as well as in zonal soddy-podzolic soils (retisols) in parks (Losiny Ostrov and Izmailovo). The numbers of soil yeasts were similar in all studied urban biocenoses (on average ~3.5 × 10 3 CFU/g). From all studied soils, 54 yeast species were isolated. The highest yeast diversity was found in the soils adjacent to the areas of household waste storage. Soils from different urban sites were found to have different ratios of ascomycetous and basidiomycetous yeasts: basidiomycetes predominated in urban soils under lawn vegetation, while in the areas close to the waste disposal sites their share was considerably lower. The differences between the studied urban soils were also found in the structure of soil yeast complexes. In urban soils with high anthropogenic impact, the isolation frequency of clinically important yeast species ( Candida parapsilosis , C. tropicalis , Diutina catenulata , and Pichia kudriavzevii ) was as high as 35% of all studied samples, while its share in the community was 17%. The factors responsible for development of specific features of yeast communities in various urban soils are discussed in the paper.
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A. N. Tepeeva, A. M. Glushakova & A. V. Kachalkin
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Original Russian Text © A.N. Tepeeva, A.M. Glushakova, A.V. Kachalkin, 2018, published in Mikrobiologiya, 2018, Vol. 87, No. 3.
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Tepeeva, A.N., Glushakova, A.M. & Kachalkin, A.V. Yeast Communities of the Moscow City Soils. Microbiology 87 , 407–415 (2018). https://doi.org/10.1134/S0026261718030128
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Received : 06 September 2017
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Issue Date : May 2018
DOI : https://doi.org/10.1134/S0026261718030128
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