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Abstract

Introduction:

The community health agent plays an essential role as a link between the community and health institutions; the effectiveness of their work is crucial in promoting health, prevention, and detection of diseases. Motivation and empowerment could affect the performance of the community agent in carrying out his work.

Objective:

To determine if work motivation and empowerment are factors associated with the self-efficacy of the community health agent.

Methodology:

Observational and cross-sectional study. The study included community health agents in the Non-Governmental Organization ADRA in Imbabura and Pichincha, Ecuador. The sample selected by the census method corresponds to 300 agents. The instruments were the Motivation at Work Scale (R-MAWS), the Psychological Empowerment Scale, and the Professional Self-efficacy Questionnaire (AU10). Descriptive statistical analyses were performed using dispersion and summary measures—a comparative analysis with chi-square. The inferential analysis was done through logistic regression where the B coefficient and the odds ratio (OR) with 95% confidence intervals (CI) were evaluated, P < .05. The theoretical and adjusted model of the structural model allowed us to corroborate the association of the variables.

Results:

Motivation had a positive effect on self-efficacy (OR = 10.091, CI [5.509-18.485], P < .05), empowerment had a minimal effect (OR = 0.664, CI [0.363-1.214], P > .05), which is not significant to predict the perception of self-efficacy.

Conclusion:

This study suggests that to improve the self-efficacy of the work of community health agents, it is necessary to intervene through strategies that keep them motivated in the exercise of their mediation work between the community and health institutions. Likewise, empowering them would contribute to self-efficacy and thus help in the fulfillment of the functions of health agents.

Keywords

motivation empowerment self-efficacy compliance perception community health health agents

Introduction

Community health is relevant because it requires collaborative practices to provide timely care in the face of disease processes.¹ Its importance is highlighted by the need to promote quality of life and reduce comorbidities in the population, where community health agents, through their facilitating role in the community and health institutions, provide tools to the people to reduce diseases.^2,3

Community health agents are members of the community, elected and/or recognized and carry out voluntary actions to promote health aimed at proactively improving health. They are considered key allies in strengthening access to health in their community, since they coordinate with health personnel or other organizations that provide health services.⁴ The impact of community health agents is related to identifying of risk situations, orientation of families and community, and referral of identified cases and risk situations to other members of the health teams. They play an important role in the expansion and consolidation of primary health care; in the same way, they assist in the planning and implementation of health actions at the local level.⁵

Community health programs have many challenges, in some cases, there are few workers and insufficient materials to deal with the health situation of the population.⁶ In addition, greater emphasis is needed to improve and promote community care, which, in turn, leads to an overall strengthening of primary care.^6
-8 Additionally, proactive measures and greater human resources would support the change toward community and comprehensive care, further strengthening primary care.^6
-9

Changes are needed in the strategies and/or strengthening the existing ones to deal with community health problems. It is necessary to move from non-participatory, isolated, and minority community actions to concrete health promotion actions, with interdisciplinary teams and a comprehensive approach.¹⁰ For this reason, it is essential to revitalize primary care focused on the family and the community since primary care actions follow intrapersonal and community models.^11,12

The economic crisis and the weakening of the state make the need arise to promote processes that develop and promote health promotion actions at a local level.^13,14 In this area, the community health agent is a social representative who strongly links with the community.⁴ The development of community agents is important for responding to social problems since they have greater knowledge of the reality in which they operate, and they have the most significant access to the community.^15
-17 In Latin American developing countries, including Ecuador, poverty and social inequality cause a significant increase in vulnerability to disease and the cases of sick people must be identified early.^18,19 For this reason, the community must be participatory, and community agents must be prepared to act and work with health personnel.²⁰

Important variables are developed to achieve health objectives in managing health personnel, including self-efficacy, motivation, and empowerment. An important variable in the health promotion model is self-efficacy, the set of work beliefs to organize and execute actions required to produce specific achievements.²¹ It is developed through experiences of success and mastery, as well as vicarious experience through observing the achievements and failures of others.²² It is a self-perception of one’s abilities; it does not refer to the abilities one possesses to be effective, but to the belief that one can achieve thanks to them.^23,24 People with higher self-efficacy are more optimistic and have less stress; they manage to achieve their goals using the resources in the best way.^25,26

Motivation is the force that makes actions possible and is the degree of interest one has in a subject.²⁷ It is the result of the interrelation of the individual and the stimulus carried out by the organization to create elements that drive and encourage the employee to achieve an objective.²⁸ It is an element that all individuals need to achieve goals in any aspect of life.²⁹

In the workplace, factors or tools are needed to motivate the workforce to do a satisfactory job, focused on people’s growth and psychological needs.³⁰ A motivated worker has better work performance and interaction with his work environment, achieving significant results.^31,32 On the contrary, lacking motivation makes it difficult to perform work efficiently and in quality. Favorable work motivation is consolidated when the leader provides a significant impact through values and examples at work.³³ For this reason, an important issue in personnel management is the motivation of collaborators. The need to have motivated personnel is evident since it affects the achievement of institutional objectives, in this case, in community care, with the participation of community health agents.

On the other hand, empowerment is given to people in the faculty for adequate decision-making. It is about empowering workers to develop good teamwork with their skills, providing confidence and resources, and giving authority to make the most of collective talent, where staff and their abilities are recognized to achieve positive results on the job.³⁴ Empowerment is linked to power; it is defined as a sum of powers whose logic is that not only those who acquire it benefit, and it has two important moments: one individual and the other collective.³⁵ It guides the development of individual capacities, such as forming an active set of transformative practices with others.³⁶ It is a need that must be seen as a priority in the different spheres of society.³⁷

The need for empowerment in community health management is consolidated as a priority component in the effectiveness of health care activities. Especially for community health agents, capitalizing on their collective knowledge and practices in health will impact the achievement of institutional objectives since they have knowledge of the community and can propose ideas for solving health problems in the community where they operate.

The participation of self-efficacious community health agents strengthens the achievement of health promotion goals. Since they face the complexity of the health process and articulate the different knowledge and activities within the community.³⁸ To this end, in this study, we postulate that motivation and empowerment are associated factors that can explain the self-efficacy of community health agents (Figure 1).

Figure 1.

Conceptual model on the study variables.

In this context, this research aims to determine if motivation and empowerment are factors associated with the self-efficacy of community health agents. Since there are few studies related to the subject, the present work is developed so that the results become the basis for strategies that favor efficient access to health services with the active participation of community agents.

Methods

Type of Study and Population

This is an observational and cross-sectional study. Community health agents who work in the Non-Governmental Organization ADRA, in Imbabura and Pichincha, Ecuador, between August and October 2022, participated in the study. The sample selected by the census method corresponds to 303 agents. The inclusion criteria were: over 18 years of age, who live in the intervention area, their enrollment in the NGO program is regular, that they have at least 6 months of seniority, and that they wish to participate voluntarily in the research work. People who did not have a direct relationship with the NGO at the time of data collection were excluded; they no longer worked for more than 3 months.

Data Collection Instruments

The instruments used for data collection were the Motivation at Work Scale (R-MAWS), originally built and adapted to the Spanish language by Gagné. Reliability analysis was carried out in Argentina, with Cronbach’s alpha coefficient, according to dimensions: external regulation (α = .81), introjected regulation (α = .68), identified regulation (α = .76), intrinsic motivation (α = .80), and demotivation (α = .67).³⁰ It consists of 19 items on a Likert-type scale ranging from 1 (Strongly disagree) to 7 (Strongly agree). The Psychological Empowerment Scale, GM (1995), was also used. Reliability analysis was carried out in Lima, Peru, with Cronbach’s Alpha for the total instrument α = 0.855 and each one of the dimensions: 0.875, 0.858, 0.782, and 0.786.³⁹ The scale consists of four subscales (competence, meaning, autonomy, and impact) with four items on a response scale ranging from 1 = strongly disagree to 7 = strongly agree.⁴⁰ Similarly, the Professional Self-efficacy Questionnaire (AU10) was used to evaluate workers’ beliefs about their abilities to successfully carry out activities related to their profession. The content analysis with Ayken’s V indicated that the items are representative of the evaluated construct. The reliability analysis obtained high indicators in H (.843) and Omega McDonald corrected, .809 based on latent variables.²² It has a single factor, consisting of 10 items presented on a Likert-type scale: Never = 0; almost never = 1; sometimes = 2; regularly = 3; many times = 4; almost always = 5; always = 6.

Data Collection

The instruments were administered using a Google Forms. Before data collection, coordination was carried out with the group leaders of the study areas, and a virtual meeting was held with the health agents, where the nature and objectives of the study were explained to them and they were invited to participate in the study. In this meeting, doubts and questions were resolved, and the instruments were shared through WhatsApp groups.

Data Analysis

Descriptive statistical analyses were performed using dispersion and summary measures. In order to identify the relationships between the variables, the data were dichotomized to perform the bivariate analysis. For this purpose, a cut-off point was assigned to half of the scores obtained from the instruments, to achieve the indicators’ high or low levels. An analysis of associations with chi-square and Fisher’s exact test was also performed, assuming a P-value less than .05 as significant. The logistic regression analysis was performed for the inferential analysis. The selection of variables was carried out considering that we have as hypotheses two explanatory variables (motivation and empowerment) and a response variable (self-efficacy). Both were included in the model and other variables with significant P-values were selected for the model. In the explanatory model of logistic regression, the B coefficient and the ExpB (OR) were evaluated with 95% confidence intervals (CI), considering the value P < .05 as significant. Finally, the analysis was carried out with structural equations to support that the motivation and empowerment variables explain the self-efficacy variable. A global evaluation was carried out to evaluate the model, in which the comparative inferential fit indices were applied. Goodness-of-fit measures were the Comparative Fit Index (CFI), Tucker Lewis Index (TLI), and Root Mean Square Error of Approximation (RMSEA). All the analysis was carried out using IBM SPSS Statistics V25.

Ethical Aspects

The Postgraduate School of the Universidad Peruana Unión Ethics Committee authorized the study. The results of this study may be published regarding approval Number 2022-CEEPG-0000184. Ethical considerations such as data confidentiality, respect for people, and voluntary participation in the study were taken into account. Likewise, the participants were notified that in the initial part of the instrument, they would find the invitation to answer the questions if they agreed to participate in the study and gave their informed consent.

Results

General Characteristics of the Population

Table 1 presents the sociodemographic information of the 303 study participants. 85.5% are women, the mean (M) age is 42 years with a standard deviation (SD) of 14 years. Regarding the participants’ education level, 61.4% have a secondary level, followed by 20.8% with a university education. In relation to marital status, 62.4% are married or in a free union. The majority of the participants are from Guayaquil (41.6%). 67% work as community health agents between 1 and 3 years, and 94.7% work as community agents in the community where they live. 50.2% show high motivation, 98.3% of community agents have low empowerment, and 84.2% have high perceived self-efficacy.

Table 1.

General Data on Community Health Agents.

(n = 303)	N	%
Sex
Male	44	14.5
Female	259	85.5
Age (M ± SD) 42 ± 14
Education level
Elementary	54	17.8
Secondary	186	61.4
University	63	20.8
Marital status
Married/civil union	189	62.4
Single/widowed/divorced	114	37.6
The area where the project is located
Cayambe	88	29.0
Guayaquil	126	41.6
Huaquillas	26	8.6
Quito	63	20.8
Time in years that you support as a community agent
Less than 1 year	73	24.1
From 1 to 3 years	203	67.0
From 4 to 6 years	16	5.3
From 7 years to more	11	3.6
You live in the community where you are a community agent.
Yes	287	94.7
No	16	5.3
Motivation
Low	151	49.8
High	152	50.2
Empowerment
Low	298	98.3
High	5	1.7
Self-efficacy
Low	48	15.8
High	255	84.2

Abbreviation: M ± SD: mean ± standard deviation.

Bivariate Analysis

In the bivariate analysis, it was obtained that the level of education (P = .001), the area where the project is located (P = .004), time in years that supports as a community agent (P = .010), and motivation (P = .001) show a significant association with self-efficacy. The empowerment has no significant statistical relationship with the self-efficacy variable (0.179). The values are added in column form (Table 2).

Table 2.

Analysis of Associations Between General Data, Motivation, and Empowerment With Self-Efficacy of the Community Health Agent.

Variables	Self-efficacy				P-value
	Low		High
	n = 48	%	n = 255	%
Sex
Female	39	81.3	220	86.3	.241
Male	9	18.7	35	13.7	.241
Marital status
Married/co-habitant	30	62.5	159	62.4	.560
Single/widowed/divorced	18	37.5	96	37.6	.560
Education level
Elementary	6	12.5	48	18.8	.001*
Secondary	21	43.8	165	64.7
University	21	43.8	42	16.5
The area where the project is located
Cayambe	10	20.8	78	30.6	.004*
Guayaquil	31	64.6	95	37.3
Huaquillas	3	6.3	23	9
Quito	4	8.3	59	23.1
Time in years that you support as a community agent
Less than 1 year	16	33.3	57	22.4	.010*
From 1 to 3 years	23	47.9	180	70.6
From 4 to 6 years	5	10.4	11	4.3
From 7 years to more	4	8.4	7	2.7
You live in the community where you are agent
Yes	43	89.6	244	95.7	.090
No	5	10.4	11	4.3	.090
Motivation
Low	39	81.3	112	43.9	.001*
High	9	18.8	143	56.1	.001*
Empowerment
Low	46	95.8	252	98.8	.179
High	2	4.2	3	1.2	.179

P < .05, statistically significant.

Table 3 shows the logistic regression model, where it was shown that the area of the health project (OR = 2.570, CI [.135-.520], P < .05) and motivation (OR = 10.091, CI [5.509-18.485], P < .05), explain the self-efficacy of community agents. Health agents in the Cayambe area are 2.5 times more likely to have high self-efficacy than those in the Huaquillas/Quito area. Similarly, health agents with high motivation are 10 times more likely to have high effectiveness than those with low motivation. On the other hand, empowerment has an opposite effect (OR = 0.664, CI [0.363-1.214], P > .05), which is not significant in explaining the perception of Self-efficacy. Additionally, working less than 3 years and agents with basic/secondary studies have 66% and 73.5% lower probability of having self-efficacy.

Table 3.

An Explanatory Model of Logistic Regression.

	Sig.	ExpB	95% CI ExpB
	Sig.	ExpB	[LL, UL]
Working time
From 4 to more years		1	(Reference)
Less than 3 years	.020*	0.340	[.136, .846]
Education level
University		1	(Reference)
Basic/secondary	.001*	0.265	[.135, .521]
Project area
Huaquillas/Quito		1	(Reference)
Cayambe/Guayaquil	.033*	2.570	[.135, .521]
Motivation
Low		1	(Reference)
High	0.001*	10.091	[5.509, 18,485]
Empowerment
Low		1	(Reference)
Appropriate	0.183	0.664	[0.363, 1.24]
Constant	0.001	0.154

Abbreviations: ExpB, odds ratio; LI, lower limit; UL, upper limit.

P < .05, statistically significant.

By the other hand, Table 4 shows the findings in the theoretical and adjusted models obtained by structural equations analysis. According to the fit indices, there was a significant improvement in these values in the adjusted model: Comparative Fit Index (CFI > 0.95), Tucker-Lewis Index (TLI > 0.90), Root Mean Square Error of Approximation (RMSEA < 0.08), which are the most important in a structural model. In the theoretical model, it is observed that the estimated values are not met, while in the adjusted model, by removing the “identified regulation” dimension from the motivation variable, the model better fits the goodness indices. The CFI is 0.964, the TLI is 0.944, and the RMSEA is 0.083, CI [0.77-0.89], which indicates that the model is adequate for the prognosis of the professional self-efficacy variable, explained by motivation (β = 0.52) and empowerment (β = −.21) (Figure 2). This means that motivation has a direct relationship with self-efficacy with an intermediate relationship strength, while empowerment has the opposite relationship. These results are similar to those obtained in the logistic regression analysis.

Table 4.

Goodness-of-Fit Indices of the Theoretical Model and the Fitted Model.

Theoretical model		Fitted model
Goodness of fit index	Value	Goodness of fit index	Value
GFI	0.803	GFI	0.945
AGFI	0.672	AGFI	0.893
CFI	0.821	CFI	0.964
TLI	0.756	TLI	0.944
NFI	0.808	NFI	0.952
IFI	0.822	IFI	0.965
RMSEA	0.183	RMSEA	0.083

Abbreviations: AGFI, adjusted goodness of fit index; CFI, comparative fit index; GFI, goodness of fit index; IFI, incremental fit index; NFI, normed fit index; RMSEA, root mean square error of approximation; TLI, Tucker-Lewis index.

Figure 2.

Explanatory structural model.

Figure 2 presents the results of the structural equation analysis of the motivation and empowerment variables as explanatory variables of self-efficacy, showing that the adjusted model is the most appropriate to explain the self-efficacy variable.

Discussion

The findings of this article reinforced the significance of self-efficacy in shaping a worker’s approach to work, influenced by motivation and empowerment in health agents. This aligns with prior research in both health and the business sector, which has similarly highlighted the interplay between motivation and self-efficacy.

Motivation is nurtured by internal cognitive and affective actions, enhancing workplace capacities through the significant impact of self-efficacy on choices, effort, persistence, and achievement.⁴¹ A study with nurses from Mexico City, found that work motivation and self-efficacy beliefs were directly related, considering that the relationship of the variables could be facilitated the older the nurses are.⁴² Another study determined that work motivation generated self-efficacy, and motivation leads workers to define their way of working.⁴³ In our study, motivation and self-efficacy are significantly related, giving rise to workers defining their way of working, which contributes to achieving health objectives.

Work motivation in all fields is essential when generating self-efficacy since they are directly correlated with the idea that a worker creates self-efficacy when working as a team, which at first sight may be contradictory; however, a person with self-efficacy and previously motivated can perform in different scenarios either individually or in a group.⁴⁴ Within the health sector, it is important to support the work community and the leadership since, in this way, work motivation and the belief in self-efficacy to continue working could be facilitated, considering workloads.⁴²

Occupational self-efficacy and intrinsic motivation significantly influence job performance, and intrinsic motivation is a partial mediator in this relationship.⁴⁵ It has been observed the components of interdependence and self-efficacy have a motivating potential toward employees’ work behavior.⁴⁶ It should be noted that even in personal life, motivation is related to self-efficacy because when the person feels and experiences emotional states, they consider the possibility of achieving the proposed objectives, for which the authors have confirmed that both theoretically and statistically, the variables are related.

Self-efficacy and motivation were studied to investigate their influence on workers’ performance, identifying that both are performance predictors and that motivation and self-efficacy are related but not significantly.⁴⁷ In motivated people, self-efficacy will be adequate, and in this way, they will perform better in the context in which it develops.⁴¹ Through motivation, the worker can meet internal needs such as recognition at work; motivated health personnel develop better in their functions, proposing new ways of working and creating strategies.⁴⁸ Intrinsic motivation and creative self-efficacy are related, and the finding highlights the importance of intrinsic motivation and creative self-efficacy in the relationship.⁴⁹

In a study with Mexican nurses, they found that there is a significant statistical association between self-efficacy and empowerment within health centers.⁵⁰ At the same time, it has been shown that people with high levels of empowerment generate self-efficacy since it allows the development of the worker’s and the institution’s activities.⁵¹

Empowerment is a term that has been developing, and in the work context, it is the degree of self-confidence that generates a worker’s self-efficacy.⁵² In another area, self-efficacy and emotional intelligence are shown as factors that promote dedication to work.⁵³ In the present study, no statistically significant relationship was found, which could be related to the presence of some intervening variable and may be the reason for a subsequent study. However, some studies show that greater perceived structural empowerment and self-efficacy can increase professional success, thus being related in practice.⁵⁴ Similarly, another study revealed that nurses rated high levels of self-efficacy for medical asepsis and, to some extent, this appeared to be related to structural empowerment.⁵⁵

Self-efficacy is directly related to motivation, giving rise to motivation related to empowerment.⁵⁶ A person’s non-compliance with self-efficacy standards could lead to a vicious cycle downward in performance; implementing different strategies could encourage compliance with performance standards, thus helping employees feel successful by increasing their self-efficacy and empowerment.⁵⁷

Relevant Implications of the Study

The findings of this study have relevant implications for the practice of health agents, applying to all situations. Health centers and care institutions must consider that, by having workers with a high level of motivation, they will have workers with a high level of self-efficacy, as well as consider having high levels of empowerment and thus reflect said actions in compliance with objectives, in the quality of care. The present investigation and its results could help improve care in community prevention and surveillance centers and assertive decision-making based on the personnel who work within.

The present research and its results could help improve care in community prevention and surveillance centers and assertive decision-making based on the personnel who work within.

It is important to promote the motivation of the community agent, since, in this way, efficient self-efficacy will be maintained, which allows him to develop his work activities correctly. In addition, this indicates the possibility that an agent motivated by his self-efficacy can meet the goal that has been proposed. Motivating an agent to keep stress levels low and put their skills on the job is essential.

Additionally, the empowerment of the community agent would help him to face better some situations that arise in the community, such as dealing with various difficulties in the performance of his work, work overload, resistance from the authorities, ignorance of his role between the community and the emotional overload that occurs as a product of being intermediaries between the residents and the authorities. Therefore, empowering the community agent and keeping him motivated improves his self-efficacy, allowing him to face the emotional burden that is accentuated when he provides psychosocial support and welcomes the suffering of others. Finally, the results of this study may allow improvements at the managerial level, benefiting health agents in their work providing care to the community.

Limitations

Our study has some limitations that must be considered. First, motivation, empowerment, and self-efficacy were assessed using a self-administered questionnaire. Therefore, the results may be vulnerable to bias due to social desirability effects or memory effects. However, the fact that validated scales have been used is a strength of the study. Second, it is a cross-sectional study; due to the health emergency context, it was not feasible to plan a longitudinal study. Therefore, confirming a causal relationship between the variables under study is impossible, and future longitudinal studies are recommended. Finally, the sample was census from a single NGO, so it does not allow extrapolation of the results. However, it is important to mention that the workers of this organization serve four areas of Ecuador. For the study, the central and northern areas of the country (Cayambe, Guayaquil) were taken, south and center of the country (Huaquillas, Quito), evidencing adequate coverage. Future studies should consider providing evidence that can be generalized to community health workers nationally and in other regions.

Conclusions

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Salomón Huancahuire-Vega

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