Longitudinal Analysis of Community Health Extension Worker Retention in Hard-to-Reach Niger Delta Settlements,

The retention of community health extension workers (CHEWs) in remote areas is a significant challenge for primary healthcare systems in sub-Saharan Africa. Nigeria’s Niger Delta region, with its difficult terrain and limited infrastructure, exemplifies this workforce dilemma. This longitudinal study aimed to analyse the three-year retention rates of CHEWs deployed to hard-to-reach settlements in the Niger Delta. Its objectives were to determine the proportion of CHEWs retained after three years and to identify key factors influencing their decision to remain in or leave their posts. A longitudinal cohort study was conducted. A cohort of newly deployed CHEWs across multiple hard-to-reach settlements was identified and followed up at regular intervals over a three-year period. Data were collected through structured interviews, field supervisor reports, and official employment records. Quantitative data on retention were analysed descriptively, while qualitative data on influencing factors were analysed thematically. Only 38% of the initial cohort of CHEWs were retained in their original hard-to-reach settlements after three years. Thematic analysis identified poor living conditions, lack of career progression opportunities, and feelings of professional isolation as the predominant themes associated with attrition. Retention of CHEWs in hard-to-reach Niger Delta settlements is low, threatening the sustainability of primary healthcare delivery in these communities. Systemic issues related to deployment conditions and career structures are primary drivers of workforce loss. To improve retention, health authorities should implement targeted incentive packages, ensure adequate provision of basic amenities at posting sites, and create clear pathways for professional advancement. Regular supportive supervision and community integration initiatives are also recommended. Health workforce retention, community health workers, primary healthcare, rural health services, Niger Delta, Nigeria This study provides longitudinal evidence on CHEW retention rates and the specific factors influencing attrition in a hard-to-reach Nigerian context, informing targeted policy and management interventions.