Hiring Effective Health Promoters

We study the impact of different approaches to hiring health promoters (HPs) in Mozambican neighborhoods. Neighborhoods are randomly assigned to different treatments (hiring approaches), and then health promoters are hired using the randomly-assigned hiring approach. Some neighborhoods are randomly assigned to be control areas, and serve as counterfactuals.

The employer in our study is the Pro-Progresso program. Pro-Progresso is an HIV/AIDS community public health program that hires Health Promoters (HPs) to promote HIV testing and refills of antiretroviral therapy (ART) medication among residents of a defined neighborhood.

Applicants for each HP position are selected by a hiring panel composed of three local stakeholders. Upon hiring, an HP works for two months in a defined neighborhood that does not overlap with other HPs' neighborhoods. They are compensated on the basis of HIV tests and ART refills they facilitate among residents of their neighborhood. Their compensation also includes a fixed-salary base and a bonus based on measures of stigmatizing attitudes and information related to HIV in the neighborhood population.

The hiring process begins with the posting of a job advertisement in a stratum (group of neighborhoods). HP applicants fill out a written application and then are screened for meeting minimum criteria (based on education level, local language ability, and knowledge about HIV). Those meeting the minimum criteria are allowed to continue in the hiring process.

HP applicants continuing in the hiring process first sit for an interview with the hiring panel, and then work an on-the-job trial period for one week.

The hiring panel assesses and ranks candidates after the interview, and then again after the trial period. This generates two separate rankings of candidates: the T2 (post-interview) ranking and the T3 (post-trial-period) ranking, respectively.

After the interviews and trial period are completed in a stratum, neighborhoods are then randomly assigned to control, T1, T2, or T3. (In other words, applicants and hiring panels do not know which neighborhoods will be in which experimental conditions until after the selection process is completed in a stratum.)

In treatment neighborhoods (T1, T2, and T3), HPs are chosen based on the randomly assigned selection method. (See Experimental Design, below, for full details.) In T2 neighborhoods, the highest-ranked candidate from the T2 (post-interview) ranking is offered the job. In T3 neighborhoods, the highest-ranked candidate from the T3 (post-trial-period) ranking is offered the job.

2023-07-10

2025-02-28

The sum of the following:
- Number of HIV tests carried out on residents of a neighborhood.
- Number of ART prescription refills collected by residents of a neighborhood.

Outcomes are calculated from administrative data provided by the local public health clinic where HIV tests and ART refills are carried out.

Taking the sum of HIV tests and ART refills maps precisely to the HP compensation formula. HPs receive piece-rate compensation for each HIV test and ART prescription refill by residents of the neighborhood in which they work. The rate of piece-rate compensation is the same for an HIV test and for an ART refill.

1. Treatment 1 (T1): First hiring approach. A health promoter hired using the first hiring approach works in this neighborhood alone for two months. Minimal qualifications are based on education level, knowledge of local language, and knowledge about HIV.

2. Treatment 2 (T2): Second hiring approach. A health promoter hired using the second hiring approach works in this neighborhood alone for two months. The hiring panel also has access to data used to determine minimal qualifications.

3. Treatment 3 (T3): Third hiring approach. A health promoter hired using the third hiring approach works in this neighborhood alone for two months.

4. Control neighborhood. No health promoter works in this neighborhood. (Depending on the spatial structure of neighborhoods, in some strata there may be more than one control neighborhood.)

1. Treatment 1 (T1): "Minimal information'" work neighborhood. A health promoter randomly selected from the pool of applicants meeting minimal qualifications works in this neighborhood alone for two months. Minimal qualifications are based on education level, knowledge of local language, and knowledge about HIV.

2. Treatment 2 (T2): "Interview'" work neighborhood. An HP selected by the hiring panel based on interviews works in this neighborhood alone for two months. The hiring panel also has access to data used to determine minimal qualifications.

3. Treatment 3 (T3): "Full information'" work neighborhood. An HP selected by the hiring panel based on all information (minimal qualifications data, interviews, and trial period results) works in this neighborhood alone for two months.

4. Control neighborhood. No health promoter works in this neighborhood. (Depending on the spatial structure of neighborhoods, in some strata there may be more than one control neighborhood.)

Randomization done in office by computer

Neighborhood

Yes

At least 64 strata (groups of neighborhoods)

At least 256 neighborhoods

Assuming 64 strata and four (4) study neighborhoods in each, the neighborhood sample size in each treatment arm will be:
64 neighborhoods T3.
64 neighborhoods T2.
64 neighborhoods T1.
64 neighborhoods control. (As the study progresses, we may define more than one control neighborhood in some areas. The total number of control neighborhoods may therefore be above this number.)