Long-term retention and associated factors among volunteer community health workers in southwestern Uganda: a 17-to-21-year retrospective cohort study

Community health workers (CHWs) are central to primary healthcare delivery in low-resource settings, yet evidence on what sustains their engagement beyond a decade is limited, particularly in sub-Saharan Africa. This study examined long-term retention and its associated factors among volunteer CHWs in southwestern Uganda, 17 to 21 years after their initial selection and training. We conducted a quantitative retrospective cohort study using a census approach in April 2024 across three districts in south western Uganda where a cohort of CHWs were selected and trained between 2004 and 2008. Data were collected in April 2024 using a pretested, structured, interviewer-administered questionnaire. Data were analysed using STATA version 14.1. Descriptive statistics characterized the study population, stratified by retention status. Bivariate and Multivariable Poisson regression models were used to identify factors independently associated with long term retention of CHWs.

From the 404 CHWs selected and trained in the period 2004-2008, 265 (65.6%) were still resident in the study districts. Of 265 CHWs, 161 (60.8%) were categorized as retained. Factors independently associated with retention were: peer support (adjusted incidence rate ratio [IRR] = 2.21, 95% confidence interval [CI]: 1.48–3.32, p < 0.001), always having access to reporting tools (adjusted IRR = 1.46, 95% CI: 1.10–1.95, p = 0.01), and intermittent access to reporting tools (adjusted IRR = 1.39, 95% CI: 1.08–1.79, p = 0.01). The most common reasons for exit were family duties, poor personal health, and community rejection. Over 60% of trained CHWs remained active after nearly two decades, indicating that volunteer CHW programmes can achieve sustained long-term engagement. Peer support and reliable access to reporting tools were the strongest modifiable predictors of retention. Strengthening these low-cost programmatic supports may be a cost-effective strategy for improving CHW retention in similar low-resource settings, and programme managers should prioritise structured peer-support networks and a consistent supply of reporting tools.