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ORIGINAL ARTICLE
Year : 2023 | Volume
: 67
| Issue : 1 | Page : 54-60
A Time and Motion Study of Community Health Workers in Rural Area of Ballabgarh, Haryana
Suprakash Mandal1, Ramadass Sathiyamoorthy2, Harshal Ramesh Salve3, Ravi Kumar4, Rakesh Kumar3
1 Resident, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
2 Assistant Professor, Department of Community and Family Medicine, All India Institute of Medical Sciences, Madurai, Tamil Nadu, India
3 Additional Professor, Comprehensive Rural Health Services Project, Ballabgarh, Haryana, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
4 Assistant Professor, Department of Community Medicine, North Delhi Municipal Corporation Medical College, Hindurao Hospital, Delhi, India
Correspondence Address:
Harshal Ramesh Salve
Additional Professor Comprehensive Rural Health Services Project, Ballabgarh Center for Community Medicine All India Institute of Medical Sciences, New Delhi
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijph.ijph_907_22
Abstract
Introduction: Health workforce is the important pillar of health system in India. Efficient utilization of scarce community-level human resources in health care is critical to ensure optimum care in a community. Objective: To describe the time utilization pattern of health workers (HWs) during field activity at the primary healthcare level and to study the facilitators and barriers in efficient time utilization. Methods: A mixed-method study with a time and motion approach was carried out in the rural areas of Ballabgarh block of Haryana. Time and motion approach was continuous, direct, synchronous and both active and passive method of time logging was adapted. Electronic Geo-Positioning System based mobile, timestamp application and the digital stopwatch were used to capture time utilization. The quality of the data collected in the daily work plan during the household (HH) visits was assessed using semi-structured interview schedule. In-depth interview with the HWs was carried out to understand the facilitating factors and barriers in their efficient functioning. Results: Proportion of HH s covered in data collection for time and motion patterns was 36% out of the total number of HH s in the SCs. The completeness of work plan was 74.8%. The average number of HHs covered per day by an HW was 38. Mean (standard deviation [SD]) time duration spent in each HH in completing the work plan was 2.9 (0.8) minutes. Mean (SD) total distance travelled by HW per day was 1845.1 (974.2) metres. Mean (SD) time duration spent idle in the field was 22.7 (13.0) minutes. Proportion of effective time utilised in the field was 54.3%. Several enabling factors and barriers were identified at personal, community, and health system level. Conclusion: Only half of the allotted time was effectively utilized by the HWs for house visit in the community. Planning the beat schedule as per the feasibility and ensuring quality of HH visits using information technology is critical for providing primary healthcare at village level.
Keywords: Community, rural, time-motion, worker
CRHSP - Ballabgarh Study Group Nitika Sharma, Chitrangada Mistry, Arjun MC, Aparna Prashanth, Roy Arokiam Daniel, Muthathal S, Alok Kumar, Sunanda Gupta, Surbhi Gupta, Aftab Ahmad, Anwita Khaitan, Dr. Kapil Yadav, Dr. Shashi Kant Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
Introduction 
Adequate utilization of scarce human resources in health care is critical to ensure last mile health care delivery in community.[1],[2] Health workers (HWs) have been playing a significant role at the forefront of health care delivery, more importantly in rural areas in India. HWs act as an interface of the health system with the community at the grassroots level, providing all the primary health care services as envisaged by the Government of India. HWs at the subcenter (SC) are involved in providing health promotion and preventive services as per the national health programmes and outreach activities in their catchment areas.[3] Global report by World Health Organisation in the “A universal truth: No health without a workforce (2013)” remarked about the shortage of HW leading to compromised quality of services.[4]
India has a three-tier health system: primary, secondary, and tertiary level. Although there was a shortage of healthcare across all three-level, the problem is more in the remote areas.[5],[6] As per Rural Health Statistics 20182019, there was a deficiency of 29.9% of female health assistants and 43.6% of male HWs at Primary Health Centers (PHCs). At the subcenter (SC) level, there is also reported shortfall of female and male HWs 8.8% and 18.6%, respectively.[7] As per a study in Haryana district in 2017, there was 66.6% and 50% deficiency of male and female HW respectively.[8] Along with the deficiency of workforce, the existing workers failed to utilise the time efficiently.[9],[10],[11] The healthworkers at a sun-centre plays a vital role in implementation of different preventive, promotive and curative components.[12],[13] Regular addition of newer initiatives under national health programmes is adding to the work burden of the HWs.[5],[13] The problem of shortfall of human resources at peripheral centres will get more aggravated if there is low work efficiency.
Frederick Taylor emphasized that the low efficiency is mostly due to waste of human effort. Time and motion study, an integrated concept by Taylor and Frank, is a scientific method of observing the time and motion involved at every step of a task which is helpful to reduce process time as well as in increasing the time utilisation.[14],[15] Since long the time and motion study method has been used to gain knowledge of work, and reason of inefficiency in healthcare setting. Kapoor et al. studied time utilisation pattern of HWs in the same area in 1996.[16] In-depth study of the HWs at village level activity is essential to improve the service delivery.[17] As there is an apparent increase of population in the catchment areas of the subcentres and change in focus areas to non-communicable diseases, there was a need to understand the time utilization and motion of the HWs. We aimed to describe the time utilization pattern of HWs during field activity at the primary healthcare level and to study the facilitators and barriers in efficient time utilization.
Materials and Methods Study setting: The study area is a rural health and demographic surveillance site situated at rural area of Ballabgarh block of Faridabad district of Haryana, India.[18] The study area under this site had two PHC with 12 subcentres (SC) which serve 1,03,510 population (April 2019 to March 2020) residing at 28 villages. The health workforce consisted of Health Educators (HE), Health Assistants (HA) and HWs Male (MHW) and HW Female (FHW).
Study design
A cross-sectional study with mixed-methods approach was carried out from June to August 2019. Time and motion approach was used to study the time utilisation and movement of HWs. Time and motion approach was continuous, direct, and synchronous using both active and passive methods of time logging.[14],[19] Active time logging was the method to manually record the time taken in each house for interview. It was done by the investigator with a handheld digital stop watch. The passive time logging was to record the time logged automatically by the GIS software while tagging the geolocation of the houses. Geolocation was tagged for each house immediately after entering the premises of the houses. The duration of time gap between two geolocations tagging was the sum of time of interview of first house and the time taken to move to the next house.
Beat schedule was the roster for daily activity plan for HWs in the SCs prepared for a month duration. It was organised into four to five weeks a month by a maximum of six days a week. It consisted of 24-27 working days with 40-50 sessions per SC per month. Each day in the beat schedule was split into morning (0900 h to 1300 h) and afternoon (1400 h to 1600 h) sessions. In the morning sessions, HWs were involved in HH visits except on Wednesday when immunisation sessions were conducted. During the afternoon sessions, antenatal care clinics, extended health clinics and non-communicable clinics were conducted. Monthly work plan was developed for each SC from the Health Management Information System (HMIS).[20] It consisted of basic demographic information of each HH along with scope for capturing the vital events viz. births, deaths, marriages, immunisation records, reproductive and family planning records, and chronic diseases records. Records in the filled work plan got entered into HMIS on monthly basis to update the information.
The work plan includes the details of the beneficiaries for whom the services are to be provided by the HWs during house hold visit.
Data collection
We purposively selected two SCs from each PHC. One being the nearest, and the other farthest from the PHC. Each SC has two HWs HWs were involved in completing the daily work plan according to the beat schedule. We aimed to cover fifty per cent of the beat schedule in each SC in whichwhatever number of houses was visited by healthworkers was included. The HWs were shadowed by the investigator starting from the SC to observe and record each step of the motions involved during the entire period of household (HH) visits. In-depth Interviews (IDI) were conducted to understand the factors for adherence to beat the schedule, satisfaction of the HWs and beneficiaries, challenges faced by the HW in personal, professional, administrative and social levels in their work environment
The study had two components as described below,
Quantitative component
Active data collection in the field was carried out by shadowing the HWs in their routine activities at the SC. Each investigator was involved in data collection from two SCs. The time duration taken in the activities was carried out by using a pretested mobile application based freely available digital stopwatch was used which had data storing and sharing opportunities over digital platform. For the recording of location and time-stamp, we used a pretested freely available mobile application working on Geographic Information System, which accessed the satellite signal from USA-based Global Positioning System (GPS). The following information was collected with the above-mentioned tools [Box 1].
We had collected data from the field visits of the HWs such as the number of houses locked or non-responded, size of village residential area in square kilometres, number of remote or isolated habitation of each village and their distance from SC. The quality of the HH visits by the HWs has was assessed by a semi-structured interview schedule to supplement the time component at field. These two aspects i.e., quantification of the time and the quality of visit was included to capture the comprehensive assessment and the output of the visit by the HW. It consisted of seven items with each item score ranging from one to six. “One” is extremely poor quality and “six” being excellent. The seven items used to assess quality of HH visits are given in [Box 2].[21],[22]
Qualitative component
We conducted IDI among a randomly selected five HWs working in the study are after the quantitative data collection was over. IDI guides were used to gather information on the factors for adherence of beat schedule, satisfaction of the HW and beneficiaries, challenges faced by the HW in personal, professional, administrative and social levels in their work environment. The interviews were conducted until achieving saturation of information. All interviews were digitally audio-recorded and transcribed verbatim manually.
Statistical analysis
Data were exported to Microsoft Excel (Version 2016) from digital stopwatch and GPS enabled time-stamp mobile application. Frequency and proportion were used to report the categorical variables. Mean and Standard Deviation (SD) were reported for continuous variables. The effective time utilised in the field was calculated as proportion of mean total time duration spent in the field minus mean time duration spent idle to total time available in the morning session. The total time available was 240 minutes. The idle time was calculated by the following formula: Idle time = Total time spent in field – (total duration of house visit interview + total duration taken for transit between houses) The formula of effective time utilisation was = ×100%.Weighted mean minutes and SD were used to derive the time duration spent in each HH for completing the work plan and time duration spent in transit from one HH to another HH. Quality of HH visit results was represented in Box plot. These analyses were carried out using Stata 12.0 (Stata Corp LP, College Station, Texas, USA). IDI data transcripts were analysed using thematic analysis. Microsoft Word (Version 2016) was used to store and code the transcripts. By careful analysis and comparison between the IDIs, descriptive themes were derived inductively from the transcripts.
The Institute Ethics Committee of the All India Institute of Medical Sciences, New Delhi, approved the study. Written informed consent was obtained from all participants after providing information about the purpose of the study and an information sheet in local language (Hindi).
Results Baseline characteristics of the SCs understudy
SC Dayalpur was present in the PHC Dayalpur campus which caters to villages Dayalpur, Phaphunda and Khera. It had a total population of 7,356 residing in 1,315 HHs. SC Nawada was 10 km away from the PHC which caters to villages Nawada, Bhukharpur and Mujedi. It had a total population of 8,878 residing in 1,487 HHs. SC Chhainsa was situated in the PHC Chhainsa campus which caters to village Chhainsa. It had a total population of 11089 residing in 1887 HHs. SC Fatehpur Billoch-II was 10 km away from the PHC which caters to village Fatehpur Billoch-II. It had a total population of 8,712 residing in 1,425 HHs.
Beat schedule and work plan
The beat schedule detailed out HH visit plan by the HWs. The average number of HHs to be visited by an HW per day was 94. Description of beat schedule and work plan of SCs part of the study is given in [Table 1]. There were 24 to 27 working days with 15 to 17 sessions per subcentre per month during study period. The beat schedule was organised into four to five weeks in a month by a maximum of six days in a week. SC beat schedule format in the study area) Total number of morning sessions involved in HH visits by an HW ranged from 15 to 17 sessions. Four to six days were used in routine immunization by both the HWs. For the antenatal care clinics and extended health clinics three to seven-afternoon sessions were used. Proportion of HHs covered in data collection for time and motion patterns was 36% out of the total number of HHs in the SCs. Completeness of work plan was 74.8%. Average number of HHs covered per day by an HW was 38.
Table 1: Time utilization and motion pattern of health workers in the field for completion of work plan according to the beat schedule*Time utilisation and motion pattern
The official time of reporting to the SC was 0900 Hrs. HWs reached SCs on official reporting on 75% of the days during data collection month. In 90% of the days, HWs reached the first HH in the field before 1000 Hrs. Mean (SD) time duration spent by an HW in reaching the first HH in field from the SC was 7.8 (1.9) min [Table 1]. Mean (SD) time duration spent in each HH in completing the work plan was 2.9 (0.8) minutes per visit. Mean (SD) time duration spent in transit from one HH to another HH by an HW in the field was 0.6 (0.3) minutes. Mean (SD) distance between the HHs was 38.9 metres. Mean (SD) total distance travelled by an HW per day was 1845.1 (974.2) metres. Mean (SD) time duration spent idle in the field was 22.7 (13.0) minutes. Proportion of effective time utilised in the field was 54.3%.
Quality of household visits
The distribution of quality score of house visits of each day by the HW was plotted in Box plot for the seven parameters [Figure 1]. The IQR of the individual domains were overlapping for all seven domains. The median score in establishing rapport varied from 3 to 4. Discussing issues out of the work plan had least score among all the domains. Rest of the domains Score for rest of the domains were in the range of 3 to 4.
Figure 1: Distribution of scores by subdomains of quality of household visitsFacilitating factors and barriers in the efficient functioning of HWs
HWs, general, were satisfied with the duration of field visits and believed that to cater to health needs of the population HH visit was essential. The qualitative results are summarized in [Figure 2].
Figure 2: Framework of facilitating factors and barriers in efficient functioning as reported by health workersPersonal factors
According to the HWs, people were usually polite, humble and receptive to the advice and intervention. HWs believed that co-worker's support, self-motivation and awareness, and communication skills were very important in the effective delivery of care.
They also believed that lack of family support, increased workload, transportation and health status of the HWs were hindering the service provision.
Community-level factors
HWs were of the opinion that there was good community support and local body support (Panchayat, schools and other organization co-ordination).
They were also of the opinion that lack of beneficiaries co-operation, lack of belief in modern medicine, local community beliefs and practices hinder community participation (such as dumping placenta for male child, hukkah, Smoke chullahs etc.) and extreme climatic conditions hindered service provision.
Health system factors
HWs also felt that digitalized and frequently updated work plan, supervision, regular training of staff, vital events discussion to find the problem and plan according to the gaps identified and unconditional support from the primary health care were some of the factors which were very crucial in delivering effective service provision.
They believed that vacant positions and deficiency of male HW in all the SCs affected their overall performance. They also felt that frequent stock out of drugs and consumables, random unscheduled meetings, frequent newer initiatives for implementation adversely affected their performance.
Discussion Proportion of effective time utilised in the field by the HWs was 54.3%. We observed the meantime (SD) spent in the field was 152.5 (21.7) minutes. The un-utilized time was mostly spent in the early morning to reach the sub-centre, the pre-lunch period where visit was stopped/completed before the scheduled time of forenoon session. The quality and quantity of the house visit were low. However, it should be viewed in the context that the expected number of house visits was much more than what could be possible in a day. The mean time utilized in each house visit was around three minutes. The finding was similar to the study done by Kapoor et al. in 1996 in the same setting where each HW spent a mean time of 3.3 minutes for each house visit.[16]
Singh et al. conducted a mixed-method type, time and motion study in 2018 in Andhra Pradesh. They found that auxiliary nurse midwife (ANM) spent a median of 7.04 hrs/day, male multipurpose HW (M-MPW) spent a median of 5.44 hrs/day, AWW spent median 6.50 hrs/day out of eight hours.[9] Though the study assessed total time utilisation of the day for each of the HW it could not provide effective time utilisation. Moreover their job responsibilities did not have any standard work plan for house to house visit. In spite of it, the study reported the number of hours spent out of total expected. In our study, 54.3% of the time was effectively used by the HW in performing their duties according to a standard work plan for the house to house visit. This is again influenced by the type of road condition, weather, spread of the houses etc., A cross-sectional study by Narayanasamy et al. in 2018 done in Puducherry among 19 ANM and 10 male HWs showed that male HWs utilized 45% of their time for vector control programs and 11% for other programs.[11] HWs' time utilization included travelling (8-10%), patient education (5-10%) and personal activities (6-12%).
A study was conducted by Tilahun et al. in 2014 in Ethiopia among 44 Health Extension workers.[23] They found that time at work was 15.5 days out of the 21 days. It was also found that the time was spent at work ranged from 4.5 hrs to 6.5 hrs/day. Maximum time was spent in health education or services (12.8%), meetings, training (9.3%) recordkeeping, reporting (13.2%), travel (15.5%), waiting for clients in the health post (24.9%), building relationships in the community (13.3%). Though our study did not categorized the spent time for each of the activities but in terms of total hours spent was similar to this study.
Manual of comprehensive community and home-based health care model developed by WHO in 2004 provided model for HH visits.[24] It has given one model example of weekly schedulefor HW. Here morning OPD was followed by house visit in the afternoon. However, the specific house number and day wise schedule was not found. In contrary to this, our schedule was more comprehensive mentioning the place, worker, house numbers and day of visit apriori. It enables the house visit more structured and regular for the workers also.
It has been also found that among the different domains of quality of house visit, lowest score was obtained for the discussion of the issues which was not in the work schedule. The reason might be the higher number of scheduled houses to be visited in a day. The interpersonal relationship also plays a probable role in creating a favourable situation to discuss.
The interplay of the facilitating factors and barriers were behind the low efficiency in the field. Our findings were similar to another study Samiksha Singh et al. where these factors in presence of increasing workload was found to reduce work efficiency.[9] At personal level the communication skill of the workers and motivation played important role in engaging with the community people. In the other side, the awareness, attitude support of the community were the key factors for the facilitation of the visit time and quality.
Ayushman Bharat emphasizes the need for Health and Wellness Centres (HWC) in place of SCs.[25] HWCs proposed to provide comprehensive primary care services for both communicable and non-communicable diseases. The “human resource for health” requirement for existing SCs was estimated to be around 12.6 lakh by 2022.
The strength of the study was the use of digital geotagging applications for the capture of motion and digital time stamp applications for time utilization analysis. Generalisability of the findings are limited because of the nature of the PHC organisational structure and its purpose. Since the HW were shadowed, it can be assumed that the time utilisation pattern might be an overestimation than the routine pattern.The HW in PHCs of other parts of the country may not be under similar working conditions and resources as our study PHC. Our study neither assess the program wise detailed time utilisation nor the total time spent at a sub-centre.Some of the factors like the distance of the SC from the residence of the HWs, weather conditions during HH visits were not assessed.
Conclusion HWs used half of their daily working hours in the field effectively. One fourth of the time during the field visit was spent for leisure activity. Quality of the interaction during HH visit was satisfactory. The major barriers to quality of services were perceived burden of daily HH visits, inadequate manpower at the sub-centres, drug stock-outs and lack of referral linkages. In presence of scarcity of HWs and increasing level of services, the effective utilisation is critical. This evidence is helpful to get idea of existing time utilisation of HW at field. Optimizing the time in field by prioritising the work is the way forward in the situation of inadequate manpower and resources. Incorporation of interventions such as use of information technology, GIS mapping, teleconference facilities is suggested to ease out the workload of the HWs s but also ensure improvement of quality of services at grass-root level more effectively in a country like India.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
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