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Top 40 Most Popular Case Studies of 2021

Two cases about Hertz claimed top spots in 2021's Top 40 Most Popular Case Studies

Two cases on the uses of debt and equity at Hertz claimed top spots in the CRDT’s (Case Research and Development Team) 2021 top 40 review of cases.

Hertz (A) took the top spot. The case details the financial structure of the rental car company through the end of 2019. Hertz (B), which ranked third in CRDT’s list, describes the company’s struggles during the early part of the COVID pandemic and its eventual need to enter Chapter 11 bankruptcy. 

The success of the Hertz cases was unprecedented for the top 40 list. Usually, cases take a number of years to gain popularity, but the Hertz cases claimed top spots in their first year of release. Hertz (A) also became the first ‘cooked’ case to top the annual review, as all of the other winners had been web-based ‘raw’ cases.

Besides introducing students to the complicated financing required to maintain an enormous fleet of cars, the Hertz cases also expanded the diversity of case protagonists. Kathyrn Marinello was the CEO of Hertz during this period and the CFO, Jamere Jackson is black.

Sandwiched between the two Hertz cases, Coffee 2016, a perennial best seller, finished second. “Glory, Glory, Man United!” a case about an English football team’s IPO made a surprise move to number four.  Cases on search fund boards, the future of malls,  Norway’s Sovereign Wealth fund, Prodigy Finance, the Mayo Clinic, and Cadbury rounded out the top ten.

Other year-end data for 2021 showed:

• Online “raw” case usage remained steady as compared to 2020 with over 35K users from 170 countries and all 50 U.S. states interacting with 196 cases.
• Fifty four percent of raw case users came from outside the U.S..
• The Yale School of Management (SOM) case study directory pages received over 160K page views from 177 countries with approximately a third originating in India followed by the U.S. and the Philippines.
• Twenty-six of the cases in the list are raw cases.
• A third of the cases feature a woman protagonist.
• Orders for Yale SOM case studies increased by almost 50% compared to 2020.
• The top 40 cases were supervised by 19 different Yale SOM faculty members, several supervising multiple cases.

CRDT compiled the Top 40 list by combining data from its case store, Google Analytics, and other measures of interest and adoption.

All of this year’s Top 40 cases are available for purchase from the Yale Management Media store .

And the Top 40 cases studies of 2021 are:

1.   Hertz Global Holdings (A): Uses of Debt and Equity

2.   Coffee 2016

3.   Hertz Global Holdings (B): Uses of Debt and Equity 2020

4.   Glory, Glory Man United!

5.   Search Fund Company Boards: How CEOs Can Build Boards to Help Them Thrive

6.   The Future of Malls: Was Decline Inevitable?

7.   Strategy for Norway's Pension Fund Global

8.   Prodigy Finance

9.   Design at Mayo

10. Cadbury

11. City Hospital Emergency Room

13. Volkswagen

14. Marina Bay Sands

15. Shake Shack IPO

16. Mastercard

17. Netflix

18. Ant Financial

19. AXA: Creating the New CR Metrics

20. IBM Corporate Service Corps

21. Business Leadership in South Africa's 1994 Reforms

22. Alternative Meat Industry

23. Children's Premier

24. Khalil Tawil and Umi (A)

25. Palm Oil 2016

26. Teach For All: Designing a Global Network

27. What's Next? Search Fund Entrepreneurs Reflect on Life After Exit

28. Searching for a Search Fund Structure: A Student Takes a Tour of Various Options

30. Project Sammaan

31. Commonfund ESG

32. Polaroid

33. Connecticut Green Bank 2018: After the Raid

34. FieldFresh Foods

35. The Alibaba Group

36. 360 State Street: Real Options

37. Herman Miller

38. AgBiome

39. Nathan Cummings Foundation

40. Toyota 2010

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Module 6: Designing a Motivating Work Environment

6.7 optional case study: motivation at xerox.

Figure 6.11 Anne Mulcahy, Former Xerox Chairman of the Board (left), and Ursula Burns, Xerox CEO (right) Source: Photo courtesy of Xerox Corporation.

As of 2010, Xerox Corporation (NYSE: XRX) is a $22 billion, multinational company founded in 1906 and operating in 160 countries. Xerox is headquartered in Norwalk, Connecticut, and employs 130,000 people. How does a company of such size and magnitude effectively manage and motivate employees from diverse backgrounds and experiences? Such companies depend on the productivity and performance of their employees. The journey over the last 100 years has withstood many successes and failures. In 2000, Xerox was facing bankruptcy after years of mismanagement, piles of debt, and mounting questions about its accounting practices.

Anne Mulcahy turned Xerox around. Mulcahy joined Xerox as an employee in 1976 and moved up the corporate ladder, holding several management positions until she became CEO in 2001. In 2005, Mulcahy was named by Fortune magazine as the second most powerful woman in business. Based on a lifetime of experience with Xerox, she knew that the company had powerful employees who were not motivated when she took over. Mulcahy believed that among other key businesses changes, motivating employees at Xerox was a key way to pull the company back from the brink of failure. One of her guiding principles was a belief that in order to achieve customer satisfaction, employees must be interested and motivated in their work. Mulcahy not only successfully saw the company through this difficult time but also was able to create a stronger and more focused company.

In 2009, Mulcahy became the chairman of Xerox’s board of directors and passed the torch to Ursula Burns, who became the new CEO of Xerox. Burns became not only the first African American woman CEO to head a Standard & Poor’s (S&P) company but also the first woman to succeed another woman as the head of an S&P 100 company. Burns is also a lifetime Xerox employee who has been with the company for over 30 years. She began as a graduate intern and was hired full time after graduation. Because of her tenure with Xerox, she has close relationships with many of the employees, which provides a level of comfort and teamwork. She describes Xerox as a nice family. She maintains that Mulcahy created a strong and successful business but encouraged individuals to speak their mind, to not worry about hurting one another’s feelings, and to be more critical.

Burns explains that she learned early on in her career, from her mentors at Xerox, the importance of managing individuals in different ways and not intentionally intimidating people but rather relating to them and their individual perspectives. As CEO, she wants to encourage people to get things done, take risks, and not be afraid of those risks. She motivates her teams by letting them know what her intentions and priorities are. The correlation between a manager’s leadership style and the productivity and motivation of employees is apparent at Xerox, where employees feel a sense of importance and a part of the process necessary to maintain a successful and profitable business. In 2010, Anne Mulcahy retired from her position on the board of directors to pursue new projects.

Discussion Questions

• How do you think Xerox was able to motivate its employees through the crisis it faced in 2000?
• How does a CEO with such a large number of employees communicate priorities to a worldwide workforce?
• How might Ursula Burns motivate employees to take calculated risks?
• Both Anne Mulcahy and Ursula Burns were lifetime employees of Xerox. How does an organization attract and keep individuals for such a long period of time?
• An Introduction to Organizational Behavior. Authored by : Anonymous. Provided by : Anonymous. Located at : http://2012books.lardbucket.org/books/an-introduction-to-organizational-behavior-v1.1/ . License : CC BY-NC-SA: Attribution-NonCommercial-ShareAlike

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Bias Busters: Motivations under the microscope

Despite their best intentions, executives fall prey to cognitive and organizational biases that get in the way of good decision making. In this series, we highlight some of them and offer a few effective ways to address them.

Our topic this time?

Motivations under the microscope

The dilemma.

The CFO at a chemical company is launching a new resource allocation process. Under it, the finance and strategy teams would no longer review requests business unit by business unit. Instead, they would consider proposals in the aggregate, rank them, and funnel resources to the most promising opportunities. It’s a nimbler way to manage resources, the CFO tells senior management—“and, really, the only way we can continue to keep up with the market.” Leaders in the life sciences and advanced-materials businesses are on board with the plan. They can easily point to strong sales growth and recent product innovations to support their resource requests. But other leaders are balking. The head of petrochemicals tells the CFO, “We’re not growing as fast or as much as everyone else, but the revenue from our polymers keeps the lights on around here. Under this new plan, our proposals are never going to get a fair shot.” They and some of the other business unit leaders have already started appealing to the finance and strategy teams for process exceptions, which would essentially defeat the purpose of the new approach.

How can the CFO make the new resource allocation plan work for everyone?

Bias Busters Collection

The research.

The CFO needs to recognize the dynamic at play here, which is a form of the collective action problem—a bias that has vexed business, social science, and political leaders since the dawn of organizations. 1 Todd Sandler, “Collective action: Fifty years later,” Public Choice , September 2015, Volume 164, Number 3/4. It reflects situations in which individuals or teams would be better off in the long term by cooperating with others but fail to do so because of conflicting interests, prompting tensions to rise. The dynamic has also been described as the principal–agent problem, where an agent (an individual or group) acts on behalf of a principal (another individual or group), and if their motivations aren’t in sync, outcomes for both may be suboptimal. 2 Michael C. Jensen and William H. Meckling, “Theory of the firm: Managerial behavior, agency costs and ownership structure,” Journal of Financial Economics , October 1976, Volume 3, Number 4. In the case of the chemical company, business unit leaders are being asked to cooperate with a new process that would have them “compete” with colleagues for access to limited corporate resources. The motivation here is for the different teams to act in their own best interests, which may lead to decreased growth and value to shareholders over time.

How to put your money where your strategy is

One way to counter the collective action problem is for the CFO and executive-leadership team to draw what we call a motivation map. The map could be a literal outline, captured in a spreadsheet or slideshow, or a one-time discussion. Either way, it’s a tool that the CFO and executive-leadership team can use to better understand how business unit leaders would be affected by the new allocation process. Through the mapping exercise, they would first take inventory of each leader’s primary motivations and priorities, looking at factors such as financial incentives, personal goals, and professional status. They could then consider how the status quo supports those motivations and priorities and plan for how to appeal to business unit leaders in a way that would help shift their thinking in a different direction.

In the case of the chemical company, such an exercise could be particularly useful for bringing the head of petrochemicals into the fold. For instance, the CFO and team could ask, “Is this leader’s compensation tied to the size of the business unit’s P&L? Are they currently in a position of influence within the organization—and looking for more?” Based on the answers, the CFO and team could tailor their messaging on the process change accordingly. For instance, if loss of status is a concern, they might offer the petrochemicals head an advisory role on the new resource allocation board. If compensation is the issue, the CFO and team can help redefine financial incentives to reflect the change in the company’s approach to resource management. A formalized mapping exercise can give the CFO and team more information than surface-level statements might.

It can be hard to convince individuals and teams to let go of long-established processes, rituals, and rewards. A motivation map can help senior management determine how best to bring together leaders with different priorities and perspectives, align their incentives, and ultimately move everyone toward a better, more productive place.

Eileen Kelly Rinaudo is McKinsey’s global director of advancing women executives and is based in McKinsey’s New York office, Tim Koller is a partner in the Denver office, and Derek Schatz is a consultant in the Chicago office.

This article was edited by Roberta Fusaro, an editorial director based in the Waltham, Massachusetts, office.

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Work Motivation: The Roles of Individual Needs and Social Conditions

Thuy thi diem vo.

1 Department of Business Administration, National Taiwan University of Science and Technology, No. 43, Section 4, Keelung Road, Da’an District, Taipei City 106335, Taiwan; wt.ude.tsutn.liam@31880701d (T.T.D.V.); wt.ude.tsutn.liam@nehcwc (C.-W.C.)

Kristine Velasquez Tuliao

2 Graduate Institute of Human Resource Management, National Central University, No. 300, Zhongda Road, Zhongli District, Taoyuan City 320317, Taiwan

Chung-Wen Chen

Associated data.

The data that support this study are publicly available.

Work motivation plays a vital role in the development of organizations, as it increases employee productivity and effectiveness. To expand insights into individuals’ work motivation, the authors investigated the influence of individuals’ competence, autonomy, and social relatedness on their work motivation. Additionally, the country-level moderating factors of those individual-level associations were examined. Hierarchical linear modeling (HLM) was used to analyze data from 32,614 individuals from 25 countries, obtained from the World Values Survey (WVS). Findings showed that autonomy and social relatedness positively impacted work motivation, while competence negatively influenced work motivation. Moreover, the individual-level associations were moderated by the country-level religious affiliation, political participation, humane orientation, and in-group collectivism. Contributions, practical implications, and directions for further research were then discussed.

1. Introduction

Work motivation is considered an essential catalyst for the success of organizations, as it promotes employees’ effective performance. To achieve an organization’s objectives, the employer depends on the performance of their employees [ 1 ]. However, insufficiently motivated employees perform poorly despite being skillful [ 1 , 2 ]. Employers, therefore, need their employees to work with complete motivation rather than just showing up at their workplaces [ 3 ]. Work motivation remains a vital factor in organizational psychology, as it helps explain the causes of individual conduct in organizations [ 4 ]. Consequently, studies on the factors that encourage work motivation can contribute to the theoretical underpinnings on the roots of individual and practical social conditions that optimize individuals’ performance and wellness [ 5 ].

Several decades of research have endeavored to explain the dynamics that initiate work-related behavior. The primary factor examining this aspect is motivation, as it explains why individuals do what they do [ 6 ]. The basic psychological needs have represented a vital rationalization of individual differences in work motivation. Psychological needs are considered natural psychological nutrients and humans’ inner resources. They have a close relationship with individual conduct and have a strong explicit meaning for work performance [ 7 , 8 ]. Different needs are essential drivers of individual functioning due to the satisfaction derived from dealing with them [ 9 ]. In addition to individual-level antecedents, the social context has also been regarded to have implications for work motivation. Social exchange and interaction among individuals accentuate the importance of work motivation as something to be studied with consideration of contextual factors [ 10 ].

Significant contributions have been made to the socio-psychological perspective of work motivation ( Table 1 ). However, current literature shows three deficiencies. First, over 150 papers utilize the key approaches of psychological needs to justify motivational processes in the workplace [ 11 ], which justifies the vital role of psychological needs in interpreting individual work motivation. The association between psychological needs and work motivation has often been implicitly assumed; however, the influence of psychological needs on work motivation has been inadequately tested [ 8 ]. The verification of the extent and the direction of influence will provide a better understanding of, and offer distinct implications for, the facilitation of work motivation. In examining the influence of psychological needs on work motivation, this paper mainly focuses on the intrinsic aspect of motivation. The study of Alzahrani et al. (2018) [ 12 ] argued that although intrinsic motivation is more efficient than extrinsic motivation, researchers have mostly neglected it.

Several investigated predictors of work motivation in general and intrinsic motivation in particular.

Second, there is no study examining the country-level moderating effects of social conditions and national cultures on individual relationships between psychological needs and work motivation. Pinder (2014) [ 20 ] argued that contextual practices could influence variables at the individual level. Culture is a crucial factor influencing motivation [ 15 , 16 , 17 , 18 ]. Researchers (e.g., [ 19 ]) have further suggested that both the proximal social situations (e.g., workgroup) and the distal social situations (e.g., cultural values) in which humans operate influence their need for satisfaction and their motivation type. Intrinsic motivation interacts with prosocial motivation in judging work performance [ 21 ]. By including the social conditions in the framework, prosocial motivation is considered. Prosocial motivation refers to the desire to help and promote the welfare of others [ 22 , 23 ]. The study of Shao et al. (2019) [ 24 ] proposed that prosocial motivation promotes employee engagement in particular organizational tasks. Researchers often consider prosocial motivation as a pattern of intrinsic motivation [ 23 ]. This implies that when intrinsic motivation is investigated, prosocial motivation should be examined together to obtain a comprehensive understanding.

Third, there are few studies using a considerable number of cross-national samples to investigate factors influencing work motivation. A cross-cultural analysis makes the findings more objective by minimizing individual bias towards any particular culture. Therefore, the examination of the study is crucial to expanding insights on the influence of social situations on the individual associations between psychological needs and work motivation.

2. Literature Review and Hypothesis Development

2.1. work motivation: a conceptual background.

Work motivation is considered “a set of energetic forces that originate both within as well as beyond an individual’s being, to initiate work-related behavior, and to determine its form direction intensity and duration” [ 20 ]. Nicolescu and Verboncu (2008) [ 25 ] argued that work motivation contributes directly and indirectly to employees’ performance. Additionally, research (e.g., [ 26 ]) has postulated that work motivation could be seen as a source of positive energy that leads to employees’ self-recognition and self-fulfillment. Therefore, work motivation is an antecedent of the self-actualization of individuals and the achievement of organizations.

Literature has identified several models of work motivation. One of the primary models is Maslow’s (1954) [ 27 ] need hierarchy theory, which proposes that humans fulfill a set of needs, including physiological, safety and security, belongingness, esteem, and self-actualization. Additionally, Herzberg’s (1966) [ 28 ] motivation-hygiene theory proposed that work motivation is mainly influenced by the job’s intrinsic challenge and provision of opportunities for recognition and reinforcement. More contemporary models also emerged. For instance, the study of Nicolescu and Verboncu (2008) [ 25 ] has categorized the types of motivation into four pairs, including positive-negative, intrinsic-extrinsic, cognitive-affective, and economic-moral spiritual. Additionally, Ryan and Deci [ 29 ] focused on intrinsic motivation and extrinsic motivation.

With the existence of numerous factors that relate to work motivation, this paper mainly focuses on intrinsic motivation. Previous research found that emotional intelligence and interpersonal relationship quality predict individuals’ intrinsic motivation [ 14 ]. Additionally, the study of Lin (2020) [ 13 ] argued that personal factors, including age, gender, educational level, living setting, health status, and family support, impact people’s intrinsic motivation. To understand more about intrinsic motivation, the authors examined individuals’ psychological needs. Fulfillment of the basic needs is related to wellness and effective performance [ 7 ]. Since intrinsic motivation results in high-quality creativity, recognizing the factors influencing intrinsic motivation is important [ 5 ].

Although a significant number of important contributions have been made regarding intrinsic motivation, self-determination theory is of particular significance for this study. Self-determination theory (SDT) postulates that all humans possess a variety of basic psychological needs. One of the primary crucial needs is the need for competence [ 30 , 31 ], which makes individuals feel confident and effective in their actions. Additionally, the need for autonomy [ 32 ] is one of the important psychological needs, which makes people satisfied with optimal wellness and good performance obtained as a result of their own decisions. Moreover, SDT proposed the crucial importance of interpersonal relationships and how social forces can influence thoughts, emotions, and behaviors [ 33 ]. This means that the psychological need for social relatedness [ 34 ] also plays a significant role in human’s psychological traits. Individuals need to be cared for by others and care for others to perceive belongingness. The need for relatedness can motivate people to behave more socially [ 35 ].

Prior research (e.g., [ 36 ]) has explored self-determination theory and related theories as approaches to work motivation and organizational behavior. The study of Van den Broeck et al. (2010) [ 37 ] emphasized grasping autonomy, competence, and relatedness at workplaces. This paper contributes to the exhaustive understanding of intrinsic work motivation influenced by further examining the impact of these three factors on work motivation as well as the moderating effects of social contexts.

2.2. Main Effect

2.2.1. individuals’ competence and work motivation.

Competence is “the collective learning in the organization, especially how to coordinate diverse production skills and integrate multiple streams of technologies” [ 38 ]. The study of Hernández-March et al. (2009) [ 39 ] argued that a stronger competence was commonly found in university graduates rather than those without higher education. Competence has been considered a significant factor of work motivation that enhances productivity and profits. Harter’s (1983) [ 40 ] model of motivation proposed that competence enhances motivation because competence promotes flexibility for individuals [ 41 ]. Likewise, Patall et al. (2014) [ 42 ] indirectly argued that competence positively affects work motivation. Individuals become more engaged in activities that demonstrate their competence [ 6 ]. When people perceive that they are competent enough to attain goals, they generally feel confident and concentrate their efforts on achieving their objectives as soon as possible for their self-fulfillment.

Individuals’ competence positively relates to their work motivation.

2.2.2. Individuals’ Autonomy and Work Motivation

Autonomy is viewed as “self-determination, self-rule, liberty of rights, freedom of will and being one’s own person” [ 43 ]. Reeve (2006) [ 44 ] argued that autonomy is a primary theoretical approach in the study of human motivation and emotion. Autonomy denotes that certain conduct is performed with a sense of willingness [ 30 ]. Several researchers (e.g., [ 45 ]) investigated the positive relationship between individuals’ autonomy and work motivation. When humans are involved in actions because of their interest, they fully perform those activities volitionally [ 36 ]. Dickinson (1995) [ 46 ] also proposed that autonomous individuals are more highly motivated, and autonomy breeds more effective outcomes. Moreover, when individuals have a right to make their own decisions, they tend to be more considerate and responsible for those decisions, as they need to take accountability for their actions. Bandura (1991) [ 47 ] has argued that humans’ ability to reflect, react, and direct their actions motivates them for future purposes. Therefore, autonomy motivates individuals to work harder and overcome difficulties to achieve their objectives.

Individuals’ autonomy positively relates to their work motivation.

2.2.3. Individuals’ Social Relatedness and Work Motivation

The psychological need for social relatedness occurs when an individual has a sense of being secure, related to, or understood by others in the social environment [ 48 ]. The relatedness need is fulfilled when humans experience the feeling of close relationships with others [ 49 ]. Researchers (e.g., [ 34 ]) have postulated that the need for relatedness reflects humans’ natural tendency to feel associated with others, such as being a member of any social groups, or to love and care as well as be loved and cared for. Prior studies have shown that social relatedness strongly impacts motivation [ 50 , 51 , 52 ]. Social relatedness offers people many opportunities to communicate with others, making them more motivated at the workplace, aligning them with the group’s shared objectives. Marks (1974) [ 53 ] suggested that social relatedness encourages individuals to focus on community welfare as a reference for their behavior, resulting in enhanced work motivation. Moreover, when individuals feel that they relate to and are cared for by others, their motivation can be maximized since their relatedness need is fulfilled [ 54 ]. Therefore, establishing close relationships with others plays a vital role in promoting human motivation [ 55 ]. When people perceive that they are cared for and loved by others, they tend to create positive outcomes for common benefits to deserve the kindness received, thereby motivating them to work harder.

Individuals’ social relatedness positively relates to their work motivation.

Aside from exploring the influence of psychological needs on work motivation, this paper also considers country-level factors. Previous research (e.g., [ 56 ]) has examined the influence of social institutions and national cultures on work motivation. However, the moderating effects of country-level factors have to be investigated, given the contextual impacts on individual needs, attitudes, and behavior. Although social conditions provide the most common interpretation for nation-level variance in individual work behaviors [ 57 ], few cross-national studies examine social conditions and individual work behaviors [ 56 ]. Hence, this paper investigates the moderating effects, including religious affiliation, political participation, humane orientation, and in-group collectivism, on the psychological needs-work motivation association.

A notable theory to explain the importance of contextual factors in work motivation that is customarily linked with SDT is the concept of prosocial motivation. Prosocial motivation suggests that individuals have the desire to expend efforts in safeguarding and promoting others’ well-being [ 58 , 59 ]. It is proposed that prosocial motivation strengthens endurance, performance, and productivity, as well as generates creativity that encourages individuals to develop valuable and novel ideas [ 21 , 60 ]. Prosocial motivation is found to interact with intrinsic motivation in influencing positive work outcomes [ 21 , 61 ]. However, there are few studies examining the effects of prosocial motivation on work motivation [ 62 ].

Utilizing the concept of prosocial motivation and examining it on a country-level, this paper suggests that prosocial factors promote basic psychological needs satisfaction that reinforces motivational processes at work. Therefore, prosocial behaviors and values may enhance the positive impact of individuals’ basic psychological needs, including competence, autonomy, and social relatedness, on work motivation.

2.3. Moderating Effects

2.3.1. religious affiliation.

Religions manifest values that are usually employed as grounds to investigate what is right and wrong [ 63 ]. Religious affiliation is considered prosocial because it satisfies the need for belongingness and upholds collective well-being through gatherings to worship, seek assistance, and offer comfort within religious communities. Hence, religious affiliation promotes the satisfaction of individuals’ psychological needs, which directs motivation at work and life in general. Research (e.g., [ 64 ]) has argued that religious affiliation is an essential motivational component given its impact on psychological processes. The study of Simon and Primavera (1972) [ 65 ] investigated the relationship between religious affiliation and work motivation. To humans characterized by competence, autonomy, and social relatedness, attachment to religious principles increases their motivation to accomplish organizational goals. Religious membership will increase the influence of psychological needs on work motivation. The tendency of individuals affiliated with any religion to be demotivated is lower compared to those who are not. Individuals with religious affiliations also tend to work harder as the virtue of hard work is aligned with religious principles. Accordingly, religious affiliation may enhance the positive association between individuals’ psychological needs and work motivation.

2.3.2. Political Participation

Political participation, indicated by people’s voting habits, plays a crucial role in ensuring citizens’ well-being and security [ 66 ]. Political participation encourages shared beliefs and collective goals among individuals [ 67 ]. The communication and interaction among people help them grasp the government’s developmental strategies, motivating them to work harder. Political participation is a collective pursuit that makes societal members feel more confident, socially related, and motivated at work to achieve communal targets. Increased political participation reinforces effective public policy to enhance its members’ welfare, congruent with the perspectives of prosocial motivation. The prosocial values and behaviors derived from political participation satisfy human needs and interact positively with intrinsic motivation. Therefore, political participation may strengthen the positive influence of individuals’ competence, autonomy, and social relatedness on work motivation. Conversely, poor political participation is perceived as a separation from the society that may lead to demotivation. In a society with poor political participation, an individualistic mentality is encouraged, thereby decreasing the desire to pursue cooperative endeavors.

2.3.3. Humane Orientation

GLOBE characterizes humane orientation as “the degree to which an organization or society encourages and rewards individuals for being fair, altruistic, generous, caring, and kind to others” [ 68 ]. Research (e.g., [ 69 , 70 ]) has argued that a high humane orientation encourages members to develop a strong sense of belonging, commit to fair treatment, and manifest benevolence. The desire to help others or enhance others’ well-being indicates prosocial values and behaviors [ 71 , 72 ]. Since humane orientation is correlated with philanthropy and promotes good relations, this cultural value may enhance work motivation. Fairness, which is derived from a humane-oriented society, is one of the most vital influences on work motivation [ 1 ]. Moreover, altruism, promoted by humane-oriented societies, encourages individuals to sacrifice individual interests for shared benefits. Altruism then encourages attachment to others’ welfare and increases resources needed for prosocial behaviors such as work [ 73 , 74 ]. Members of humane-oriented countries view work in a positive light—it is an opportunity for them to perform altruistic behaviors and engage in collective actions. Therefore, people are more likely to work harder for common interests in humane-oriented societies. In such conditions, individuals with competence, autonomy, and social relatedness will be more motivated to work. By contrast, a less humane-oriented society gives prominence to material wealth and personal enjoyment [ 75 ]. Although this may be perceived as a positive influence on the association between psychological needs and work motivation, such an individualistic mindset works against the prosocial factors that further motivate individuals.

2.3.4. In-Group Collectivism

House et al. (2004) [ 68 ] defined in-group collectivism as “the degree to which individuals express pride, loyalty, and cohesiveness in their organizations or families”. Collectivistic cultures indicate the need for individuals to rely on group membership for identification [ 76 ]. High collectivism enhances equity, solidarity, loyalty, and encouragement [ 77 , 78 ]. Humans living in a collectivist culture are interdependent and recognize their responsibilities towards each other [ 79 ]. In-group collectivism transfers the concepts of social engagement, interdependence with others, and care for the group over the self (e.g., [ 79 , 80 , 81 ], thereby motivating individuals to work harder for the common interests. Oyserman et al. (2002) [ 82 ] have further argued that individualistic values encourage an independent personality, whereas collectivistic values form an interdependent one. Therefore, in-group collectivism is a prosocial value that emphasizes the importance of reciprocal relationships and encourages people to work harder to benefit the group. By contrast, low collectivism promotes individual interests and personal well-being while neglecting the value of having strong relations with others [ 70 ]. Considering that in-group collectivism promotes individuals’ prosocial behaviors of individuals, people who are competent, autonomous, and socially related to collective societies are less likely to be demotivated at the workplace. Consequently, in-group collectivism may intensify the positive influence of individuals’ competence, autonomy, and social relatedness on their work motivation.

(a–d): The positive relationship between individuals’ competence and their work motivation is enhanced as religious affiliation (a), political participation (b), humane orientation (c), and in-group collectivism (d) increase.

(a–d): The positive relationship between individuals’ autonomy and their work motivation is enhanced as religious affiliation (a), political participation (b), humane orientation (c), and in-group collectivism (d) increase.

(a–d): The positive relationship between individuals’ social relatedness and their work motivation is enhanced as religious affiliation (a), political participation (b), humane orientation (c), and in-group collectivism (d) increase.

3.1. Sample

The data came from the seventh wave (2017–2021) of the World Values Survey (WVS) [ 83 ], which examines humans’ beliefs and values. This survey is performed every five years to explore changes in people’s values and perceptions. Face-to-face interviews, or phone interviews for remote areas, were conducted by local organizations. Almost 90 percent of the world’s population is represented in the WVS. At least 1000 individuals were selected as respondents to exhibit each nation’s population. Further information regarding the WVS can be reached at the WVS website ( http://www.worldvaluessurvey.org , accessed on 14 October 2021).

The samples of this study were based on the availability of national-level data for the moderators and individual-level data for the measures of independent and dependent variables. Respondents without answers on the individual measures and corresponding country-level data were excluded from the analysis. The final data included 32,614 respondents in 25 countries aged 18 and above. The 25 countries included Argentina, Australia, Brazil, China, Colombia, Ecuador, Egypt, Germany, Greece, Guatemala, Hong Kong, Indonesia, Iran, Japan, Kazakhstan, Malaysia, Mexico, New Zealand, Philippines, Russia, South Korea, Taiwan, Thailand, Turkey, and the USA.

3.2. Dependent Variable

Consistent with previous researchers (e.g., [ 84 ]), the authors used four items to gauge individual work motivation, namely “Indicate how important work is in your life”, “People who do not work turn lazy”, “Work is a duty towards society”, and “Work should always come first, even if it means less spare”. The first item was measured on a scale from 1 to 4, in which lower scores indicate a higher level of work importance. The other three items were gauged on a scale from 1 to 5 (1 indicating strongly agree and 5 indicating strongly disagree). The scores for each item were reverse coded, and the mean scores were computed so that higher scores indicate greater work motivation.

3.3. Independent Variables

The independent variables of this study include individuals’ competence, autonomy, and social relatedness. First, people’s competence was measured by the item “What is the highest educational level that you attained” on a scale from 0 to 8, in which higher scores indicate a higher level of educational attainment. The authors used the item to gauge individual competence, as a capacity for learning is highlighted in the examination of competence [ 39 ]. Second, a scale from 1 to 10 was utilized to measure the item “How much freedom of choice and control”, which represented individual autonomy (1 indicating no choice at all and 10 indicating a great deal of choice). The authors used the item to gauge people’s autonomy as this item indicates the degree to which individual can make their own decisions. Finally, the individual’s social relatedness was gauged by twelve items, representing twelve types of organizations where individuals are active/inactive members or do not belong. The twelve items were measured on a scale from 0 to 2 (0 indicating do not belong, 1 indicating inactive member, and 2 indicating active member). The mean score of the twelve items represents the individual’s social relatedness. The membership in organizations represents social relatedness, as this indicates the reciprocal relationship between the individual and the organization through their mutual rights, responsibilities, and obligations towards each other [ 85 ].

3.4. Moderators

The four country-level moderators in this study were religious affiliation, political participation, humane orientation, and in-group collectivism. Similar to prior research (e.g., [ 86 ]), the authors used the percentage of the country’s population with religious affiliation obtained from Pew Research Center 2015 [ 87 ]. Secondly, the index of voter turnout collected from the International Institute for Democracy and Electoral Assistance [ 88 ] was utilized to gauge political participation. Voting habits are an indicator of an individual’s presence in their country’s life, and a nation with a high index of voter turnout illustrates its substantial degree of political participation [ 89 ]. Finally, two cultural values, including humane orientation and in-group collectivism, were obtained from the GLOBE study [ 68 ]. The authors used scores on cultural practices as the moderators for this study because they indicate the actual behaviors as “the way things are done in this culture” [ 68 ].

3.5. Control Variables

Several individual-level and country-level elements related to the dependent variable were considered control variables. The effects of gender, marital status, age, and income level were accounted for, as these four variables are basic personal factors that may impact individual’s motivation [ 90 ]. Gender (1 indicating male and 0 indicating female) and marital status (1 indicating married and 0 indicating other status) were dummy coded. Moreover, age was measured in years, while income level was gauged using a scale from 1 representing the lowest group to 10 representing the highest group. Along with the above individual-level controls, education and family strength were treated as country-level control variables. Education and family are primary institutions that shape individuals’ motivation [ 91 , 92 ]. Similar to prior researchers (e.g., [ 93 ]), education was computed as two-thirds of the adult literacy rate attained from the UNESCO Institute for Statistics 2020 [ 94 ] and one-third of the mean years of schooling obtained from the Human Development Report 2020 [ 95 ]. This score is commonly approved as representing access to education in a country [ 42 ]. Regarding family strength, the score was quantified by the ratio of divorces to marriages per 1000 members of the population consistent with previous researchers (e.g., [ 93 ]). The data was obtained from the United Nations Demographic Yearbook [ 96 ].

3.6. Measurement and Analysis

To perform the descriptive statistics, cross-level correlations, scale reliability, confirmatory factor analysis, convergent validity, and discriminant validity, the authors utilized SPSS software.

The framework of this study considers independent variables, dependent variables, and moderators at different levels. Thus, the authors used a hierarchical linear model (HLM) [ 97 ] to test the hypotheses. HLM was defined as a “complex form of ordinary least squares (OLS) regression that is used to analyze variance in the outcome variables when the predictor variables are at varying hierarchical levels” [ 98 ]. This technique evaluates the impacts of higher-level outcomes on lower-level ones while preserving an appropriate degree of analysis [ 99 ]. HLM has been employed in several cross-level studies (e.g., [ 100 , 101 ]).

Table 2 presents a matrix of correlations and sample statistics from the individual-level to country-level variables. Table 3 and Table 4 report convergent and discriminant validity test results, respectively. Finally, Table 5 illustrates results for hypotheses testing using HLM. Three models are presented in the table: those of individual-level main effects and control variables (Model 1), those of country-level main effects (Model 2), and country-level moderating effects (Model 3).

Descriptive statistics, cross-level correlations and scale reliability a,b,c .

a   n = 32,614 level 1; n = 25, level 2. b * p < 0.05, ** p < 0.01. c The reliability found in the parentheses is expressed as Cronbach’s alpha for scales with ≥four items.

Convergent validity.

Discriminant validity—Fornell and Larcker’s criterion.

* p < 0.05.

HLM results: (The DV is work motivation) a,b .

a , n = 32,614 level 1; n = 25, level 2. b , †, p < 0.10, * p < 0.05, ** p < 0.01, *** p < 0.001.

For the confirmatory factor analysis, previous research (e.g., [ 102 , 103 , 104 ]) suggested that analysis of each variable requires at least three items. Factor analysis using statistical software will provide imprecise results if there are fewer than three items per variable [ 105 ]. Therefore, the authors only performed Confirmatory Factor Analysis (CFA) for social relatedness and work motivation.

To assess the measurement, convergent and discriminant validity were tested. Composite Reliability (CR) and Average Variance Extracted (AVE) were performed to illustrate convergent validity. The study of Hair et al. (2019) [ 106 ] suggested that CR is required to be above a threshold of 0.7. On the other hand, the AVE value should be higher than a threshold of 0.5 [ 107 ]. As shown in Table 3 , CR is acceptable while AVE is slightly lower than a threshold of 0.5. Despite the limitation of AVE, the acceptable result of the discriminant validity is achieved. The discriminant validity was tested using Fornell and Larcker (1981)’s criterion [ 107 ]. This proposes that the square root of the AVE of any latent variable should be higher than its correlation with any other construct. The result of the discriminant validity test indicates that all the two latent constructs have a square root of AVE higher than its correlation with the other construct, as presented in Table 4 .

The authors argued that individuals’ competence (H1), autonomy (H2), and social relatedness (H3) positively relate to their work motivation. However, the findings only supported H2 (β2 = 0.036, p < 0.001) and H3 (β3 = 0.042, p < 0.001). In contrast, the findings presented that H1 was also significant, but in the opposite direction compared with our original prediction. The result suggests that individuals’ competence negatively relates to their work motivation.

In Hypotheses 4a–d, we proposed that higher levels of religious affiliation (4a), political participation (4b), humane orientation (4c), and in-group collectivism (4d) strengthen the relationship described in H1. However, the results only demonstrated support for the two hypotheses, H4c (γ13 = 0.032, p < 0.001) and H4d (γ14 = 0.042, p < 0.001). In contrast, the findings presented that H4a was also significant, but opposite our initial prediction. This different result proposes that a higher level of religious affiliation weakens the association between individuals’ competence and work motivation.

In Hypotheses 5a–d, the authors argued that the higher levels of religious affiliation (5a), political participation (5b), humane orientation (5c), and in-group collectivism (5d) enhance the positive relationship between individuals’ autonomy and their work motivation. However, the results only supported the two hypotheses H5b (γ22 = 0.012, p < 0.05) and H5c (γ23 = 0.012, p < 0.1), while H5a and H5d were not significant.

In Hypotheses 6a–d, the authors argued that the higher levels of religious affiliation (6a), political participation (6b), humane orientation (6c), and in-group collectivism (6d) enhance the positive relationship between individuals’ social relatedness and their work motivation. However, the results only supported H6c (γ33 = 0.019, p < 0.01). In contrast, the findings indicated that H6d was also significant, but in the opposite direction compared to our initial hypothesis. The different result suggests that higher in-group collectivism weakens the positive association between individuals’ social relatedness and work motivation. Figure 1 , Figure 2 , Figure 3 , Figure 4 and Figure 5 represent the significant moderators of the associations examined.

The association between competence and work motivation at different levels of humane orientation.

The association between competence and work motivation at different levels of in-group collectivism.

The association between autonomy and work motivation at different levels of political participation.

The association between autonomy and work motivation at different levels of humane orientation.

The association between social relatedness and work motivation at different levels of humane orientation.

Regarding the statistical results of the control variables, gender, marital status, and age consistently indicated significant positive relationships with work motivation across three models. On the other hand, family strength indicated a significant negative association to work motivation only in Model 1.

5. Discussion

The study’s objective was to examine the influence of individuals’ competence, autonomy, and social relatedness on their work motivation, as well as the impact of country-level moderators, including religious affiliation, political participation, humane orientation, and in-group collectivism on their relationships. Seven primary findings are crucial in this research. First, people’s autonomy and social relatedness positively relate to their work motivation. This result is in line with the findings of prior researchers (e.g., [ 45 , 52 ]), postulating that humans’ autonomy and social relatedness breeds work motivation. The study of Theurer et al. (2018) [ 108 ] argued that, among motivational elements, autonomy had been found to greatly predict positive work motivation. When people feel they have enough control over their activities, they are more confident and motivated to work. Along with autonomy, humans’ social relatedness promotes communal benefits, thereby motivating people to work harder for their organization. Second, the association between individual competence and work motivation is moderated by cultural values, including humane orientation and in-group collectivism. The findings are consistent with the viewpoints of prior researchers (e.g., [ 69 , 70 , 77 , 78 ]), namely that a society with higher levels of humane orientation and in-group collectivism strengthens altruism, solidarity, loyalty, and the encouragement of individuals, which results in work motivation. Consequently, there will be an increase in the differences in individuals’ competence and work motivation if they live in a society with greater humane orientation and in-group collectivism. Third, political participation and humane orientation moderate the relationship between individual autonomy and work motivation. These results are in line with the investigations of prior researchers (e.g., [18,45), which found that social circumstances and cultural practices promote people’s motivation. Accordingly, the differences in individuals’ autonomy based on their work motivation will be enhanced if they belong to nations with higher political participation and humane orientation. Fourth, the association between social relatedness and work motivation is moderated by humane orientation. Accordingly, in a humane-oriented society, the differences in individuals’ social relatedness based on their work motivation will be strengthened.

The remaining findings were contrary to the original propositions. Pinder (2014) [ 20 ] argued that it is possible to find that contextual practices can influence variables at the individual level in the opposite prediction in motivation research. Fifth, individuals’ competence negatively influences their work motivation. This finding proposes that more competent individuals are less motivated at work. One possible interpretation of this opposite result is that, when the majority of the organization members recognize individuals’ competence, these individuals may perceive that it is not necessary to devote most of their time and energy to work anymore. These individuals may believe that no matter how unwillingly they perform, they are still competent enough because of their prior achievements. Additionally, competent individuals recognize that they have already sacrificed their enjoyment of life for their previous successes; therefore, they tend to offset this by investing their valuable time in other aspects. This is consistent with other researchers’ investigations (e.g., [ 109 ]), which found that low-skilled individuals are more often compelled to engage in regular work activities and are more easily motivated than others. By contrast, highly competent individuals tend to be motivated by challenging tasks and improving themselves through further education. Sixth, the relationship between competence and work motivation is negatively moderated by religious affiliation. This finding suggests that religious affiliation weakens the association between individuals’ competence and work motivation. One possible explanation for this finding is that strong religious beliefs are the foundation for virtuous living [ 110 ]. Individuals with religious affiliation usually employ religious principles to guide their behavior, regardless of their competence. In other words, both competent and incompetent individuals tend to be more motivated at the workplace if they are affiliated with any religion, thereby diminishing the influence of competence in work motivation. Seventh, the relationship between social relatedness and work motivation is negatively moderated by in-group collectivism. This result proposes that a higher degree of in-group collectivism weakens the association between individuals’ social relatedness and work motivation. One possible explanation for this is that, under an in-group collective society, people put more weight on mutual relationships and encourage acts that may build up the solidarity of groups. Since in-group collectivism is viewed as a social attachment in which people emphasize the group over the self (e.g., [ 79 , 80 , 81 ]), individuals are fairly conscious of their responsibility to the group regardless of their social relatedness. Both socially related and unrelated individuals belonging to in-group collective cultures tend to work harder for common goals. Accordingly, the influence of individuals’ social relatedness on their work motivation is reduced.

6. Limitations and Future Research

Despite its significant contributions, this study has its limitations. The use of secondary data represents the fact that the data collection process was beyond the authors’ control. However, the collection of cross-national data is time-consuming and costly. The authors used the available data but strove for the efficient use of multilevel data. The secondary data also limited the measurement of individual-level factors based on the available data. Moreover, it is quite complex to gauge an individual’s work motivation appropriately, since personal work motivation may not be one-dimensional. Nevertheless, the authors made efforts to employ the measurements utilized by prior research. Moreover, it is complicated to measure social factors such as political participation. There are challenges in investigating social contexts due to the absence of direct measurements [ 111 ]. This compels the authors to identify substitute measurements for this study. Finally, this study covered 25 samples from 25 countries with different characteristics. Despite the attempt of this study to include the most relevant social conditions in the framework, the influence of other national differences and cultural sensitivities were not considered.

This paper directs further research considering that several frameworks and approaches should be employed to better examine motivation [ 112 ]. First, as some of the results were opposite to the original propositions based on the theoretical foundations employed, combining different concepts and approaches is necessary to enhance perspectives of psychological needs and social issues. For instance, the relationship between competence and work motivation can be further investigated by employing other theories to understand their association better. Similarly, the moderating effects of social contexts such as religious affiliation and in-group collectivism should be further examined to obtain a more in-depth comprehension of the roles of contextual circumstances and cultural values in individual-level relationships. Additionally, self-determination theory and the concept of prosocial motivation may be used to explore motivation towards specific behavior in organizations, such as organizational citizenship and proactive behaviors. Organizational context, such as rewards, training, and culture, can be considered as part of the framework to enhance the conception of work motivation.

7. Conclusions

This study has utilized a multilevel framework to examine the influence of psychological needs and social context on work motivation. Through this research, a deeper understanding of the roles of competence, autonomy, and social relatedness, as well as social situations and cultural values on work motivation, is achieved. The contrary findings call for integrating other concepts and approaches towards a more comprehensive knowledge of work motivation.

Along with the theoretical contribution, the study’s findings offer practical implications. The satisfaction of psychological needs promotes self-motivation, which creates positive outcomes. Hence, organizations can provide programs and activities to promote employees’ autonomy and social relatedness as this will enhance their work motivation. Employee empowerment can be advocated by encouraging them to make their own decisions at the workplace, providing constructive criticisms rather than instilling the fear of failure. Additionally, managers should encourage solidarity, support, and mutual care among employees. Putting more weight on employees’ fulfillment of needs will further increase employees’ motivation, thereby diminishing costs related to stress or turnover [ 50 ]. To establish a novel mechanism towards promoting work motivation in the entire nation, the government should pay attention to the political structure and conditions that encourage citizens’ participation. Additionally, a culture of humane orientation should be promoted in the workplace and society so that solidarity, kind assistance, and altruism among communities as well as among individuals can be strengthened. For instance, teamwork should be encouraged for employees to help each other overcome difficulties at the workplace or share responsibilities with their colleagues. This will motivate people to work harder for collective goals, contributing to the development of organizations.

Author Contributions

Conceptualization, T.T.D.V. and K.V.T.; data collection, T.T.D.V.; methodology, T.T.D.V. and K.V.T.; formal analysis, T.T.D.V. and K.V.T.; resources, K.V.T. and C.-W.C.; writing-original draft, T.T.D.V. and K.V.T.; writing-review, editing & proofreading, T.T.D.V., K.V.T. and C.-W.C.; visualization, K.V.T.; supervision, K.V.T. and C.-W.C.; project administration, K.V.T. All authors have read and agreed to the published version of the manuscript.

This paper does not receive funding from any individuals or organizations.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Data availability statement, conflicts of interest.

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Watershed Management and Words of Motivation

An expert on watershed management and planning, incoming chair Ken Genskow shares his thoughts on the water resources management program.

If you asked Ken Genskow for advice on watershed planning and management, he would tell you to always anticipate change. “Things are always changing … it’s the one constant in this field,” he says. Genskow has encountered his own fair share of “change” throughout his career path — he graduated from the University of Illinois Urbana-Champaign (UIUC) with a bachelor’s degree in general engineering, but soon realized he wanted to switch gears to doing environmental work. He then joined the Peace Corps and was assigned to Nepal for three years, working as an urban planner and engineer. 

Genskow was unfamiliar with the field of urban planning, but grew to love the work he did with the Peace Corps. Upon returning to the United States, he returned to UIUC for a master’s degree in urban planning, where he discovered a particular interest in natural resources planning. He furthered this interest at the University of Wisconsin–Madison, pursuing a PhD in urban and regional planning. After graduating, he worked in watershed planning with the UW–Madison Division of Extension , which led to a faculty position in UW–Madison’s Department of Landscape and Urban Planning. Now, he’s a professor in the landscape and urban planning department, an affiliate of the Nelson Institute, and was recently named the chair of the Nelson Institute’s water resources management (WRM) program.

Are you currently working on any projects or research? I recently received funding to lead a project with Paul Block [Nelson’s Reid A. Bryson Distinguished Professor of Climate, People and Environment], and [Wisconsin State Climatologist] Steve Vavrus. The project is helping communities in rural Wisconsin prepare for extreme weather impacts. With this project, we’re able to focus on the specific needs of farmers, agricultural advisors, hazard and emergency planners, and school districts, and how they’re going to address climate adaptation issues. 

Is there a specific project or study that’s stood out to you as a favorite? A lot of my work is focused on the human dimensions of watershed planning and management; how we make decisions, what influences those decisions, and how our responses — both through governmental action and individual land management — relate to the environment. Almost 20 years ago, I was part of a project that was a partnership between the U.S. Environmental Protection Agency and several land-grant universities across the region, including UW–Madison. We created a program called Social Indicators for Nonpoint Source Pollution, and that’s been really gratifying. Recently I’ve been working with some of my colleagues on a retrospective of that. It’s very much still useful and relevant — there are groups in Wisconsin and in most other states who are using our approach for some of their watershed planning work.

What are some of your responsibilities as the chair of the water resources management program? The role focuses on connecting with students about the WRM program and studies, as well as connecting them with other faculty across campus. We’re also working on forming stronger connections with alumni including an initiative identifying ways for alumni to connect with current WRM students. 

What do students take away from the WRM program? I want students to leave the program with the confidence that they have the ability to approach any water resource management challenge. They will know where to begin and how to engage others in addressing problems. It’s a very interdisciplinary program, so you can’t expect any individual to know everything, but we emphasize collaboration and working in teams in order to assemble resources to address any environmental problem. 

What would you say to people considering a master’s degree in the WRM program? Wisconsin is a great place to study water. This is a rich environment for people interested in learning about and protecting water and a great way to get involved is through this degree program. It’s wonderful for addressing real-life water resources challenges and environmental problems. I encourage anyone to talk with me, other program faculty, and alumni to get a sense of the breadth of issues that people learn about and work towards solving in the WRM program. 

Case study of condominium management in Brazil: survey of 30 years of maintenance and renovation costs of a 1982 multifamily residential building

• Research Article
• Published: 15 May 2024
• Volume 9 , article number  88 , ( 2024 )

Cite this article

• Adryelle Dias Novaes Machado   ORCID: orcid.org/0009-0006-7623-7671 1 ,
• Anna Luiza Dias Siqueira   ORCID: orcid.org/0009-0001-4092-828X 1 ,
• Júlia Assumpção de Castro   ORCID: orcid.org/0000-0002-2175-0199 1 ,
• Aldo Ribeiro de Carvalho   ORCID: orcid.org/0000-0003-2767-4374 1 ,
• Romário Parreira Pita   ORCID: orcid.org/0009-0008-8196-6443 1 &
• Julia Castro Mendes   ORCID: orcid.org/0000-0002-6323-5355 1 , 2  

This study carries out a case study of maintenance costs in a multi-family residential building built in 1982 in a mid-size city in Brazil. The condominium's monthly cost reports (maintenance fees) were analyzed for 30 years, between 1991 and 2021. This long period of analysis unprecedented in the literature. Expenses were classified by system and type of maintenance (preventive, corrective or modernization renovation). We identified that maintenance on elevator systems and gardens  summed up the highest costs throughout the period, while envelope conservation, sewage systems and water tanks presented the lowest costs. Disregarding the extreme years and correcting for inflation, the average expenditure on maintenance in the last 5 years (2017–2021) was 175% higher than the first 5 years analyzed (1991–1995), with the condominium fee being 43.6% higher. If the (predictable) maintenance expenses over the years were considered from the beginning of the building's operation, current families could be paying around 15% less in condominium fees. In conclusion, for an efficient maintenance management system, construction professional must focus on maintenance from the project design stage, provide a financial reserve for future upkeeping and renovation from the beginning of occupation, and prepare a robust user manual.

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Acknowledgements

We would like to express our gratitude to the institutions that offered financial support for this work: CAPES (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - phD scholarship awarded to Aldo Ribeiro de Carvalho and Júlia Assumpção de Castro - finance code 001); CNPq (Conselho Nacional de Desenvolvimento Científico e Tecnológico - grant 305818/2023-6 - PQ Researcher - for Julia Mendes) and PROPPI/UFOP (Pró-Reitoria de Pesquisa e Inovação da UFOP).

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Adryelle Dias Novaes Machado, Anna Luiza Dias Siqueira, Júlia Assumpção de Castro, Aldo Ribeiro de Carvalho, Romário Parreira Pita & Julia Castro Mendes

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All authors contributed to the study conception and design. Conceptualization: Júlia Assumpção de Castro, Romário Parreira Pita ; Methodology: Julia Castro Mendes; Formal analysis and investigation: Adryelle Dias Novaes Machado, Anna Luiza Dias Siqueira, Júlia Assumpção de Castro, Aldo Ribeiro de Carvalho; Writing: Júlia Assumpção de Castro, Aldo Ribeiro de Carvalho; Writing - review and editing: Aldo Ribeiro de Carvalho; Resources: Julia Castro Mendes; Supervision: Julia Castro Mendes. All authors read and approved the final manuscript.

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Evaluation of integrated community case management of the common childhood illness program in Gondar city, northwest Ethiopia: a case study evaluation design

• Mekides Geta 1 ,
• Geta Asrade Alemayehu 2 ,
• Wubshet Debebe Negash 2 ,
• Tadele Biresaw Belachew 2 ,
• Chalie Tadie Tsehay 2 &
• Getachew Teshale 2  

BMC Pediatrics volume  24 , Article number:  310 ( 2024 ) Cite this article

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Integrated Community Case Management (ICCM) of common childhood illness is one of the global initiatives to reduce mortality among under-five children by two-thirds. It is also implemented in Ethiopia to improve community access and coverage of health services. However, as per our best knowledge the implementation status of integrated community case management in the study area is not well evaluated. Therefore, this study aimed to evaluate the implementation status of the integrated community case management program in Gondar City, Northwest Ethiopia.

A single case study design with mixed methods was employed to evaluate the process of integrated community case management for common childhood illness in Gondar town from March 17 to April 17, 2022. The availability, compliance, and acceptability dimensions of the program implementation were evaluated using 49 indicators. In this evaluation, 484 mothers or caregivers participated in exit interviews; 230 records were reviewed, 21 key informants were interviewed; and 42 observations were included. To identify the predictor variables associated with acceptability, we used a multivariable logistic regression analysis. Statistically significant variables were identified based on the adjusted odds ratio (AOR) with a 95% confidence interval (CI) and p-value. The qualitative data was recorded, transcribed, and translated into English, and thematic analysis was carried out.

The overall implementation of integrated community case management was 81.5%, of which availability (84.2%), compliance (83.1%), and acceptability (75.3%) contributed. Some drugs and medical equipment, like Cotrimoxazole, vitamin K, a timer, and a resuscitation bag, were stocked out. Health care providers complained that lack of refreshment training and continuous supportive supervision was the common challenges that led to a skill gap for effective program delivery. Educational status (primary AOR = 0.27, 95% CI:0.11–0.52), secondary AOR = 0.16, 95% CI:0.07–0.39), and college and above AOR = 0.08, 95% CI:0.07–0.39), prescribed drug availability (AOR = 2.17, 95% CI:1.14–4.10), travel time to the to the ICCM site (AOR = 3.8, 95% CI:1.99–7.35), and waiting time (AOR = 2.80, 95% CI:1.16–6.79) were factors associated with the acceptability of the program by caregivers.

Conclusion and recommendation

The overall implementation status of the integrated community case management program was judged as good. However, there were gaps observed in the assessment, classification, and treatment of diseases. Educational status, availability of the prescribed drugs, waiting time and travel time to integrated community case management sites were factors associated with the program acceptability. Continuous supportive supervision for health facilities, refreshment training for HEW’s to maximize compliance, construction clean water sources for HPs, and conducting longitudinal studies for the future are the forwarded recommendation.

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Integrated Community Case Management (ICCM) is a critical public health strategy for expanding the coverage of quality child care services [ 1 , 2 ]. It mainly concentrated on curative care and also on the diagnosis, treatment, and referral of children who are ill with infectious diseases [ 3 , 4 ].

Based on the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) recommendations, Ethiopia adopted and implemented a national policy supporting community-based treatment of common childhood illnesses like pneumonia, Diarrhea, uncomplicated malnutrition, malaria and other febrile illness and Amhara region was one the piloted regions in late 2010 [ 5 ]. The Ethiopian primary healthcare units, established at district levels include primary hospitals, health centers (HCs), and health posts (HPs). The HPs are run by Health Extension Workers (HEWs), and they have function of monitoring health programs and disease occurrence, providing health education, essential primary care services, and timely referrals to HCs [ 6 , 7 ]. The Health Extension Program (HEP) uses task shifting and community ownership to provide essential health services at the first level using the health development army and a network of woman volunteers. These groups are organized to promote health and prevent diseases through community participation and empowerment by identifying the salient local bottlenecks which hinder vital maternal, neonatal, and child health service utilization [ 8 , 9 ].

One of the key steps to enhance the clinical case of health extension staff is to encourage better growth and development among under-five children by health extension. Healthy family and neighborhood practices are also encouraged [ 10 , 11 ]. The program also combines immunization, community-based feeding, vitamin A and de-worming with multiple preventive measures [ 12 , 13 ]. Now a days rapidly scaling up of ICCM approach to efficiently manage the most common causes of morbidity and mortality of children under the age of five in an integrated manner at the community level is required [ 14 , 15 ].

Over 5.3 million children are died at a global level in 2018 and most causes (75%) are preventable or treatable diseases such as pneumonia, malaria and diarrhea [ 16 ]. About 99% of the global burden of mortality and morbidity of under-five children which exists in developing countries are due to common childhood diseases such as pneumonia, diarrhea, malaria and malnutrition [ 17 ].

In 2013, the mortality rate of under-five children in Sub-Saharan Africa decreased to 86 deaths per 1000 live birth and estimated to be 25 per 1000live births by 2030. However, it is a huge figure and the trends are not sufficient to reach the target [ 18 ]. About half of global under-five deaths occurred in sub-Saharan Africa. And from the top 26 nations burdened with 80% of the world’s under-five deaths, 19 are in sub-Saharan Africa [ 19 ].

To alleviate the burden, the Ethiopian government tries to deliver basic child care services at the community level by trained health extension workers. The program improves the health of the children not only in Ethiopia but also in some African nations. Despite its proven benefits, the program implementation had several challenges, in particular, non-adherence to the national guidelines among health care workers [ 20 ]. Addressing those challenges could further improve the program performance. Present treatment levels in sub-Saharan Africa are unacceptably poor; only 39% of children receive proper diarrhea treatment, 13% of children with suspected pneumonia receive antibiotics, 13% of children with fever receive a finger/heel stick to screen for malaria [ 21 ].

To improve the program performance, program gaps should be identified through scientific evaluations and stakeholder involvement. This evaluation not only identify gaps but also forward recommendations for the observed gaps. Furthermore, the implementation status of ICCM of common childhood illnesses has not been evaluated in the study area yet. Therefore, this work aimed to evaluate the implementation status of integrated community case management program implementation in Gondar town, northwest Ethiopia. The findings may be used by policy makers, healthcare providers, funders and researchers.

Method and material

Evaluation design and settings.

A single-case study design with concurrent mixed-methods evaluation was conducted in Gondar city, northwest Ethiopia, from March 17 to April 17, 2022. The evaluability assessment was done from December 15–30, 2021. Both qualitative and quantitative data were collected concurrently, analyzed separately, and integrated at the result interpretation phase.

The evaluation area, Gondar City, is located in northwest Ethiopia, 740 km from Addis Ababa, the capital city of the country. It has six sub-cities and thirty-six kebeles (25 urban and 11 rural). In 2019, the estimated total population of the town was 338,646, and 58,519 (17.3%) were under-five children. In the town there are eight public health centers and 14 health posts serving the population. All health posts provide ICCM service for more than 70,852 populations.

Evaluation approach and dimensions

Program stakeholders.

The evaluation followed a formative participatory approach by engaging the potential stakeholders in the program. Prior to the development of the proposal, an extensive discussion was held with the Gondar City Health Department to identify other key stakeholders in the program. Service providers at each health facility (HCs and HPs), caretakers of sick children, the Gondar City Health Office (GCHO), the Amhara Regional Health Bureau (ARHB), the Minister of Health (MoH), and NGOs (IFHP and Save the Children) were considered key stakeholders. During the Evaluability Assessment (EA), the stakeholders were involved in the development of evaluation questions, objectives, indicators, and judgment criteria of the evaluation.

Evaluation dimensions

The availability and acceptability dimensions from the access framework [ 22 ] and compliance dimension from the fidelity framework [ 23 ] were used to evaluate the implementation of ICCM.

Population and samplings

All under-five children and their caregivers attended at the HPs; program implementers (health extension workers, healthcare providers, healthcare managers, PHCU focal persons, MCH coordinators, and other stakeholders); and ICCM records and registries in the health posts of Gondar city administration were included in the evaluation. For quantitative data, the required sample size was proportionally allocated for each health post based on the number of cases served in the recent one month. But the qualitative sample size was determined by data saturation, and the samples were selected purposefully.

The data sources and sample size for the compliance dimension were all administrative records/reports and ICCM registration books (230 documents) in all health posts registered from December 1, 2021, to February 30, 2022 (three months retrospectively) included in the evaluation. The registries were assessed starting from the most recent registration number until the required sample size was obtained for each health post.

The sample size to measure the mothers’/caregivers’ acceptability towards ICCM was calculated by taking prevalence of caregivers’ satisfaction on ICCM program p  = 74% from previously similar study [ 24 ] and considering standard error 4% at 95% CI and 10% non- responses, which gave 508. Except those who were seriously ill, all caregivers attending the ICCM sites during data collection were selected and interviewed consecutively.

The availability of required supplies, materials and human resources for the program were assessed in all 14HPs. The data collectors observed the health posts and collected required data by using a resources inventory checklist.

A total of 70 non-participatory patient-provider interactions were also observed. The observations were conducted per each health post and for health posts which have more than one health extension workers one of them were selected randomly. The observation findings were used to triangulate the findings obtained through other data collection techniques. Since people may act accordingly to the standards when they know they are observed for their activities, we discarded the first two observations from analysis. It is one of the strategies to minimize the Hawthorne effect of the study. Finally a total of 42 (3 in each HPs) observations were included in the analysis.

Twenty one key informants (14 HEWs, 3 PHCU focal person, 3 health center heads and one MCH coordinator) were interviewed. These key informants were selected since they are assumed to be best teachers in the program. Besides originally developed key informant interview questions, the data collectors probed them to get more detail and clear information.

Variables and measurement

The availability of resources, including trained healthcare workers, was examined using 17 indicators, with weighted score of 35%. Compliance was used to assess HEWs’ adherence to the ICCM treatment guidelines by observing patient-provider interactions and conducting document reviews. We used 18 indicators and a weighted value of 40%.

Mothers’ /caregivers’/ acceptance of ICCM service was examined using 14 indicators and had a weighted score of 25%. The indicators were developed with a five-point Likert scale (1: strongly disagree, 2: disagree, 3: neutral, 4: agree and 5: strongly agree). The cut off point for this categorization was calculated using the demarcation threshold formula: ( \(\frac{\text{t}\text{o}\text{t}\text{a}\text{l}\, \text{h}\text{i}\text{g}\text{h}\text{e}\text{s}\text{t}\, \text{s}\text{c}\text{o}\text{r}\text{e}-\,\text{t}\text{o}\text{t}\text{a}\text{l}\, \text{l}\text{o}\text{w}\text{e}\text{s}\text{t} \,\text{s}\text{c}\text{o}\text{r}\text{e}}{2}) +total lowest score\) ( 25 – 27 ). Those mothers/caregivers/ who scored above cut point (42) were considered as “satisfied”, otherwise “dissatisfied”. The indicators were adapted from the national ICCM and IMNCI implementation guideline and other related evaluations with the participation of stakeholders. Indicator weight was given by the stakeholders during EA. Indicators score was calculated using the formula \(\left(achieved \,in \%=\frac{indicator \,score \,x \,100}{indicator\, weight} \right)\) [ 26 , 28 ].

The independent variables for the acceptability dimension were socio-demographic and economic variables (age, educational status, marital status, occupation of caregiver, family size, income level, and mode of transport), availability of prescribed drugs, waiting time, travel time to ICCM site, home to home visit, consultation time, appointment, and source of information.

The overall implementation of ICCM was measured by using 49 indicators over the three dimensions: availability (17 indicators), compliance (18 indicators) and acceptability (14 indicators).

Program logic model

Based on the constructed program logic model and trained health care providers, mothers/caregivers received health information and counseling on child feeding; children were assessed, classified, and treated for disease, received follow-up; they were checked for vitamin A; and deworming and immunization status were the expected outputs of the program activities. Improved knowledge of HEWs on ICCM, increased health-seeking behavior, improved quality of health services, increased utilization of services, improved data quality and information use, and improved child health conditions are considered outcomes of the program. Reduction of under-five morbidity and mortality and improving quality of life in the society are the distant outcomes or impacts of the program (Fig.  1 ).

Integrated community case management of childhood illness program logic model in Gondar City in 2022

Data collection tools and procedure

Resource inventory and data extraction checklists were adapted from standard ICCM tool and check lists [ 29 ]. A structured interviewer administered questionnaire was adapted by referring different literatures [ 30 , 31 ] to measure the acceptability of ICCM. The key informant interview (KII) guide was also developed to explore the views of KIs. The interview questionnaire and guide were initially developed in English and translated into the local language (Amharic) and finally back to English to ensure consistency. All the interviews were done in the local language, Amharic.

Five trained clinical nurses and one BSC nurse were recruited from Gondar zuria and Wegera district as data collectors and supervisors, respectively. Two days training on the overall purpose of the evaluation and basic data collection procedures were provided prior to data collection. Then, both quantitative and qualitative data were gathered at the same time. The quantitative data were gathered from program documentation, charts of ICCM program visitors and, exit interview. Interviews with 21 KIIs and non-participatory observations of patient-provider interactions were used to acquire qualitative data. Key informant interviews were conducted to investigate the gaps and best practices in the implementation of the ICCM program.

A pretest was conducted to 26 mothers/caregivers/ at Maksegnit health post and appropriate modifications were made based on the pretest results. The data collectors were supervised and principal evaluator examined the completeness and consistency of the data on a daily basis.

Data management and analysis

For analysis, quantitative data were entered into epi-data version 4.6 and exported to Stata 14 software for analysis. Narration and tabular statistics were used to present descriptive statistics. Based on established judgment criteria, the total program implementation was examined and interpreted as a mix of the availability, compliance, and acceptability dimensions. To investigate the factors associated with ICCM acceptance, a binary logistic regression analysis was performed. During bivariable analysis, variables with p-values less than 0.25 were included in multivariable analysis. Finally, variables having a p-value less than 0.05 and an adjusted odds ratio (AOR) with a 95% confidence interval (CI) were judged statistically significant. Qualitative data were collected recorded, transcribed into Amharic, then translated into English and finally coded and thematically analyzed.

Judgment matrix analysis

The weighted values of availability, compliance, and acceptability dimensions were 35, 40, and 25 based on the stakeholder and investigator agreement on each indicator, respectively. The judgment parameters for each dimension and the overall implementation of the program were categorized as poor (< 60%), fair (60–74.9%), good (75-84.9%), and very good (85–100%).

Availability of resources

A total of 26 HEWs were assigned within the fourteen health posts, and 72.7% of them were trained on ICCM to manage common childhood illnesses in under-five children. However, the training was given before four years, and they didn’t get even refreshment training about ICCM. The KII responses also supported that the shortage of HEWs at the HPs was the problem in implementing the program properly.

I am the only HEW in this health post and I have not been trained on ICCM program. So, this may compromise the quality of service and client satisfaction.(25 years old HEW with two years’ experience)

All observed health posts had ICCM registration books, monthly report and referral formats, functional thermometer, weighting scale and MUAC tape meter. However, timer and resuscitation bag was not available in all HPs. Most of the key informant finding showed that, in all HPs there was no shortage of guideline, registration book and recording tool; however, there was no OTP card in some health posts.

“Guideline, ICCM registration book for 2–59 months of age, and other different recording and reporting formats and booklet charts are available since September/2016. However, OTP card is not available in most HPs.”. (A 30 years male health center director)

Only one-fifth (21%) of HPs had a clean water source for drinking and washing of equipment. Most of Key-informant interview findings showed that the availability of infrastructures like water was not available in most HPs. Poor linkage between HPs, HCs, town health department, and local Kebele administer were the reason for unavailability.

Since there is no water for hand washing, or drinking, we obligated to bring water from our home for daily consumptions. This increases the burden for us in our daily activity. (35 years old HEW)

Most medicines, such as anti-malaria drugs with RDT, Quartem, Albendazole, Amoxicillin, vitamin A capsules, ORS, and gloves, were available in all the health posts. Drugs like zinc, paracetamol, TTC eye ointment, and folic acid were available in some HPs. However, cotrimoxazole and vitamin K capsules were stocked-out in all health posts for the last six months. The key informant also revealed that: “Vitamin K was not available starting from the beginning of this program and Cotrimoxazole was not available for the past one year and they told us they would avail it soon but still not availed. Some essential ICCM drugs like anti malaria drugs, De-worming, Amoxicillin, vitamin A capsules, ORS and medical supplies were also not available in HCs regularly.”(28 years’ Female PHCU focal)

The overall availability of resources for ICCM implementation was 84.2% which was good based on our presetting judgment parameter (Table  1 ).

Health extension worker’s compliance

From the 42 patient-provider interactions, we found that 85.7%, 71.4%, 76.2%, and 95.2% of the children were checked for body temperature, weight, general danger signs, and immunization status respectively. Out of total (42) observation, 33(78.6%) of sick children were classified for their nutritional status. During observation time 29 (69.1%) of caregivers were counseled by HEWs on food, fluid and when to return back and 35 (83.3%) of children were appointed for next follow-up visit. Key informant interviews also affirmed that;

“Most of our health extension workers were trained on ICCM program guidelines but still there are problems on assessment classification and treatment of disease based on guidelines and standards this is mainly due to lack refreshment training on the program and lack of continuous supportive supervision from the respective body.” (27years’ Male health center head)

From 10 clients classified as having severe pneumonia cases, all of them were referred to a health center (with pre-referral treatment), and from those 57 pneumonia cases, 50 (87.7%) were treated at the HP with amoxicillin or cotrimoxazole. All children with severe diarrhea, very severe disease, and severe complicated malnutrition cases were referred to health centers with a pre-referral treatment for severe dehydration, very severe febrile disease, and severe complicated malnutrition, respectively. From those with some dehydration and no dehydration cases, (82.4%) and (86.8%) were treated at the HPs for some dehydration (ORS; plan B) and for no dehydration (ORS; plan A), respectively. Moreover, zinc sulfate was prescribed for 63 (90%) of under-five children with some dehydration or no dehydration. From 26 malaria cases and 32 severe uncomplicated malnutrition and moderate acute malnutrition cases, 20 (76.9%) and 25 (78.1%) were treated at the HPs, respectively. Of the total reviewed documents, 56 (93.3%), 66 (94.3%), 38 (84.4%), and 25 (78.1%) of them were given a follow-up date for pneumonia, diarrhea, malaria, and malnutrition, respectively.

Supportive supervision and performance review meetings were conducted only in 10 (71.4%) HPs, but all (100%) HPs sent timely reports to the next supervisory body.

Most of the key informants’ interview findings showed that supportive supervision was not conducted regularly and for all HPs.

I had mentored and supervised by supportive supervision teams who came to our health post at different times from health center, town health office and zonal health department. I received this integrated supervision from town health office irregularly, but every month from catchment health center and last integrated supportive supervision from HC was on January. The problem is the supervision was conducted for all programs.(32 years’ old and nine years experienced female HEW)

Moreover, the result showed that there was poor compliance of HEWs for the program mainly due to weak supportive supervision system of managerial and technical health workers. It was also supported by key informants as:

We conducted supportive supervision and performance review meeting at different time, but still there was not regular and not addressed all HPs. In addition to this the supervision and review meeting was conducted as integration of ICCM program with other services. The other problem is that most of the time we didn’t used checklist during supportive supervision. (Mid 30 years old male HC director)

Based on our observation and ICCM document review, 83.1% of the HEWs were complied with the ICCM guidelines and judged as fair (Table  2 ).

Acceptability of ICCM program

Sociodemographic and obstetric characteristics of participants.

A total of 484 study participants responded to the interviewer-administered questionnaire with a response rate of 95.3%. The mean age of study participants was 30.7 (SD ± 5.5) years. Of the total caregivers, the majority (38.6%) were categorized under the age group of 26–30 years. Among the total respondents, 89.3% were married, and regarding religion, the majorities (84.5%) were Orthodox Christian followers. Regarding educational status, over half of caregivers (52.1%) were illiterate (unable to read or write). Nearly two-thirds of the caregivers (62.6%) were housewives (Table  3 ).

All the caregivers came to the health post on foot, and most of them 418 (86.4%) arrived within one hour. The majority of 452 (93.4%) caregivers responded that the waiting time to get the service was less than 30 min. Caregivers who got the prescribed drugs at the health post were 409 (84.5%). Most of the respondents, 429 (88.6%) and 438 (90.5%), received counseling services on providing extra fluid and feeding for their sick child and were given a follow-up date.

Most 298 (61.6%) of the caregivers were satisfied with the convenience of the working hours of HPs, and more than three-fourths (80.8%) were satisfied with the counseling services they received. Most of the respondents, 366 (75.6%), were satisfied with the appropriateness of waiting time and 431 (89%) with the appropriateness of consultation time. The majority (448 (92.6%) of caregivers were satisfied with the way of communicating with HEWs, and 269 (55.6%) were satisfied with the knowledge and competence of HEWs. Nearly half of the caregivers (240, or 49.6%) were satisfied with the availability of drugs at health posts.

The overall acceptability of the ICCM program was 75.3%, which was judged as good. A low proportion of acceptability was measured on the cleanliness of the health posts, the appropriateness of the waiting area, and the competence and knowledge of the HEWs. On the other hand, high proportion of acceptability was measured on appropriateness of waiting time, way of communication with HEWs, and the availability of drugs (Table  4 ).

Factors associated with acceptability of ICCM program

In the final multivariable logistic regression analysis, educational status of caregivers, availability of prescribed drugs, time to arrive, and waiting time were factors significantly associated with the satisfaction of caregivers with the ICCM program.

Accordingly, the odds of caregivers with primary education, secondary education, and college and above were 73% (AOR = 0.27, 95% CI: 0.11–0.52), 84% (AOR = 0.16, 95% CI: 0.07–0.39), and 92% (AOR = 0.08, 95% CI: 0.07–0.40) less likely to accept the program as compared to mothers or caregivers who were not able to read and write, respectively. The odds of caregivers or mothers who received prescribed drugs were 2.17 times more likely to accept the program as compared to their counters (AOR = 2.17, 95% CI: 1.14–4.10). The odds of caregivers or mothers who waited for services for less than 30 min were 2.8 times more likely to accept the program as compared to those who waited for more than 30 min (AOR = 2.80, 95% CI: 1.16–6.79). Moreover, the odds of caregivers/mothers who traveled an hour or less for service were 3.8 times more likely to accept the ICCM program as compared to their counters (AOR = 3.82, 95% CI:1.99–7.35) (Table  5 ).

Overall ICCM program implementation and judgment

The implementation of the ICCM program in Gondar city administration was measured in terms of availability (84.2%), compliance (83.1%), and acceptability (75.3%) dimensions. In the availability dimension, amoxicillin, antimalarial drugs, albendazole, Vit. A, and ORS were available in all health posts, but only six HPs had Ready-to-Use Therapeutic Feedings, three HPs had ORT Corners, and none of the HPs had functional timers. In all health posts, the health extension workers asked the chief to complain, correctly assessed for pneumonia, diarrhea, malaria, and malnutrition, and sent reports based on the national schedule. However, only 70% of caretakers counseled about food, fluids, and when to return, 66% and 76% of the sick children were checked for anemia and other danger signs, respectively. The acceptability level of the program by caretakers and caretakers’/mothers’ educational status, waiting time to get the service and travel time ICCM sites were the factors affecting its acceptability. The overall ICCM program in Gondar city administration was 81.5% and judged as good (Fig.  2 ).

Overall ICCM program implementation and the evaluation dimensions in Gondar city administration, 2022

The implementation status of ICCM was judged by using three dimensions including availability, compliance and acceptability of the program. The judgment cut of points was determined during evaluability assessment (EA) along with the stakeholders. As a result, we found that the overall implementation status of ICCM program was good as per the presetting judgment parameter. Availability of resources for the program implementation, compliance of HEWs to the treatment guideline and acceptability of the program services by users were also judged as good as per the judgment parameter.

This evaluation showed that most medications, equipment and recording and reporting materials available. This finding was comparable with the standard ICCM treatment guide line [ 10 ]. On the other hand trained health care providers, some medications like Zink, Paracetamol and TTC eye ointment, folic acid and syringes were not found in some HPs. However the finding was higher than the study conducted in SNNPR on selected health posts [ 33 ] and a study conducted in Soro district, southern Ethiopia [ 24 ]. The possible reason might be due to low interruption of drugs at town health office or regional health department stores, regular supplies of essential drugs and good supply management and distribution of drug from health centers to health post.

The result of this evaluation showed that only one fourth of health posts had functional ORT Corner which was lower compared to the study conducted in SNNPR [ 34 ]. This might be due poor coverage of functional pipe water in the kebeles and the installation was not set at the beginning of health post construction as reported from one of ICCM program coordinator.

Compliance of HEWs to the treatment guidelines in this evaluation was higher than the study done in southern Ethiopia (65.6%) [ 24 ]. This might be due to availability of essential drugs educational level of HEWs and good utilization of ICCM guideline and chart booklet by HEWs. The observations showed most of the sick children were assessed for danger sign, weight, and temperature respectively. This finding is lower than the study conducted in Rwanda [ 35 ]. This difference might be due to lack of refreshment training and regular supportive supervision for HEWs. This also higher compared to the study done in three regions of Ethiopia indicates that 88%, 92% and 93% of children classified as per standard for Pneumonia, diarrhea and malaria respectively [ 36 ]. The reason for this difference may be due to the presence of medical equipment and supplies including RDT kit for malaria, and good educational level of HEWs.

Moreover most HPs received supportive supervision and performance review meeting was conducted and all of them send reports timely to next level. The finding of this evaluation was lower than the study conducted on implementation evaluation of ICCM program southern Ethiopia [ 24 ] and study done in three regions of Ethiopia (Amhara, Tigray and SNNPR) [ 37 ]. This difference might be due sample size variation.

The overall acceptability of the ICCM program was less than the presetting judgment parameter but slightly higher compared to the study in southern Ethiopia [ 24 ]. This might be due to presence of essential drugs for treating children, reasonable waiting and counseling time provided by HEWs, and smooth communication between HEWs and caregivers. In contrast, this was lower than similar studies conducted in Wakiso district, Uganda [ 38 ]. The reason for this might be due to contextual difference between the two countries, inappropriate waiting area to receive the service and poor cleanness of the HPs in our study area. Low acceptability of caregivers to ICCM service was observed in the appropriateness of waiting area, availability of drugs, cleanness of health post, and competence of HEWs while high level of caregiver’s acceptability was consultation time, counseling service they received, communication with HEWs, treatment given for their sick children and interest to return back for ICCM service.

Caregivers who achieved primary, secondary, and college and above were more likely accept the program services than those who were illiterate. This may more educated mothers know about their child health condition and expect quality service from healthcare providers which is more likely reduce the acceptability of the service. The finding is congruent with a study done on implementation evaluation of ICCM program in southern Ethiopia [ 24 ]. However, inconsistent with a study conducted in wakiso district in Uganda [ 38 ]. The possible reason for this might be due to contextual differences between the two countries. The ICCM program acceptability was high in caregivers who received all prescribed drugs than those did not. Caregivers those waited less than 30 min for service were more accepted ICCM services compared to those more than 30 minutes’ waiting time. This finding is similar compared with the study conducted on implementation evaluation of ICCM program in southern Ethiopia [ 24 ]. In contrary, the result was incongruent with a survey result conducted by Ethiopian public health institute in all regions and two administrative cities of Ethiopia [ 39 ]. This variation might be due to smaller sample size in our study the previous one. Moreover, caregivers who traveled to HPs less than 60 min were more likely accepted the program than who traveled more and the finding was similar with the study finding in Jimma zone [ 40 ].

Strengths and limitations

This evaluation used three evaluation dimensions, mixed method and different data sources that would enhance the reliability and credibility of the findings. However, the study might have limitations like social desirability bias, recall bias and Hawthorne effect.

The implementation of the ICCM program in Gondar city administration was measured in terms of availability (84.2%), compliance (83.1%), and acceptability (75.3%) dimensions. In the availability dimension, amoxicillin, antimalarial drugs, albendazole, Vit. A, and ORS were available in all health posts, but only six HPs had Ready-to-Use Therapeutic Feedings, three HPs had ORT Corners, and none of the HPs had functional timers.

This evaluation assessed the implementation status of the ICCM program, focusing mainly on availability, compliance, and acceptability dimensions. The overall implementation status of the program was judged as good. The availability dimension is compromised due to stock-outs of chloroquine syrup, cotrimoxazole, and vitamin K and the inaccessibility of clean water supply in some health posts. Educational statuses of caregivers, availability of prescribed drugs at the HPs, time to arrive to HPs, and waiting time to receive the service were the factors associated with the acceptability of the ICCM program.

Therefore, continuous supportive supervision for health facilities, and refreshment training for HEW’s to maximize compliance are recommended. Materials and supplies shall be delivered directly to the health centers or health posts to solve the transportation problem. HEWs shall document the assessment findings and the services provided using the registration format to identify their gaps, limitations, and better performances. The health facilities and local administrations should construct clean water sources for health facilities. Furthermore, we recommend for future researchers and program evaluators to conduct longitudinal studies to know the causal relationship of the program interventions and the outcomes.

Data availability

Data will be available upon reasonable request from the corresponding author.

Abbreviations

Ethiopian Demographic and Health Survey

Health Center/Health Facility

Health Extension Program

Health Extension Workers

Health Post

Health Sector Development Plan

Integrated Community Case Management of Common Childhood Illnesses

Information Communication and Education

Integrated Family Health Program

Integrated Management of Neonatal and Childhood Illness

Integrated Supportive Supervision

Maternal and Child Health

Mid Upper Arm Circumference

Non-Government Organization

Oral Rehydration Salts

Outpatient Therapeutic program

Primary health care unit

Rapid Diagnostics Test

Ready to Use Therapeutic Foods

Sever Acute Malnutrition

South Nation Nationalities People Region

United Nations International Child Emergency Fund

World Health Organization

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Acknowledgements

We are very grateful to University of Gondar and Gondar town health office for its welcoming approaches. We would also like to thank all of the study participants of this evaluation for their information and commitment. Our appreciation also goes to the data collectors and supervisors for their unreserved contribution.

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Mekides Geta

Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, P.O. Box 196, Gondar, Ethiopia

Geta Asrade Alemayehu, Wubshet Debebe Negash, Tadele Biresaw Belachew, Chalie Tadie Tsehay & Getachew Teshale

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All authors contributed to the preparation of the manuscript. M.G. conceived and designed the evaluation and performed the analysis then T.B.B., W.D.N., G.A.A., C.T.T. and G.T. revised the analysis. G.T. prepared the manuscript and all the authors revised and approved the final manuscript.

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Geta, M., Alemayehu, G.A., Negash, W.D. et al. Evaluation of integrated community case management of the common childhood illness program in Gondar city, northwest Ethiopia: a case study evaluation design. BMC Pediatr 24 , 310 (2024). https://doi.org/10.1186/s12887-024-04785-0

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Received : 20 February 2024

Accepted : 22 April 2024

Published : 09 May 2024

DOI : https://doi.org/10.1186/s12887-024-04785-0

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