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Does supportive supervision enhance community health worker motivation? A mixed-methods study in four African countries.

ABSTRACT: Supportive supervision is an important element of community health worker (CHW) programmes and is believed to improve CHW motivation and performance. A group supervision intervention, which included training and mentorship of supervisors, was implemented in Ethiopia, Kenya, Malawi and Mozambique. In three of the countries, this was combined with individual and/or peer supervision. A mixed-methods implementation study was conducted to assess the effect of the supervision intervention on CHWs' perceptions of supervision and CHW motivation-related outcomes. In total, 153 in-depth interviews were conducted with CHWs, their supervisors and managers. In addition, questionnaires assessing perceived supervision and motivation-related outcomes (organizational and community commitment, job satisfaction and conscientiousness) were administered to a total of 278 CHWs pre- and post-intervention, and again after 1 year. Interview transcripts were thematically analysed using a coding framework. Changes in perceived supervision and motivation-related outcomes were assessed using Friedman's ANOVA and post hoc Wilcoxon signed-rank tests. Interview participants reported that the supervision intervention improved CHW motivation. In contrast, the quantitative survey found no significant changes for measures of perceived supervision and inconsistent changes in motivation-related outcomes. With regard to the process of supervision, the problem-solving focus, the sense of joint responsibilities and team work, cross-learning and skill sharing, as well as the facilitating and coaching role of the supervisor, were valued. The empowerment and participation of supervisees in decision making also emerged in the analysis, albeit to a lesser extent. Although qualitative and quantitative findings differed, which could be related to the slightly different focus of methods used and a 'ceiling effect' limiting the detection of observable differences from the survey, the study suggests that there is potential for integrating supportive group supervision models in CHW programmes. A combination of group with individual or peer supervision, preferably accompanied with methods that assess CHW performance and corresponding feedback systems, could yield improved motivation and performance.

SUBMITTER: Kok MC

PROVIDER: S-EPMC6263021 | biostudies-literature | 2018 Nov

REPOSITORIES: biostudies-literature

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Does supportive supervision enhance community health worker motivation? A mixed-methods study in four African countries.

Kok Maryse C MC Vallières Frédérique F Tulloch Olivia O Kumar Meghan B MB Kea Aschenaki Z AZ Karuga Robinson R Ndima Sozinho D SD Chikaphupha Kingsley K Theobald Sally S Taegtmeyer Miriam M

Health policy and planning 20181101 9

Supportive supervision is an important element of community health worker (CHW) programmes and is believed to improve CHW motivation and performance. A group supervision intervention, which included training and mentorship of supervisors, was implemented in Ethiopia, Kenya, Malawi and Mozambique. In three of the countries, this was combined with individual and/or peer supervision. A mixed-methods implementation study was conducted to assess the effect of the supervision intervention on CHWs' per ...[more]

PMID: 30247571

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Project description:BackgroundThe strength of a health system-and ultimately the health of a population-depends to a large degree on health worker performance. However, insufficient support to build, manage and optimize human resources for health (HRH) in low- and middle-income countries (LMICs) results in inadequate health workforce performance, perpetuating health inequities and low-quality health services.MethodsThe USAID-funded Human Resources for Health in 2030 Program (HRH2030) conducted a systematic review of studies documenting supervision enhancements and approaches that improved health worker performance to highlight components associated with these interventions' effectiveness. Structured by a conceptual framework to classify the inputs, processes, and results, the review assessed 57 supervision studies since 2010 in approximately 29 LMICs.ResultsOf the successful supervision approaches described in the 57 studies reviewed, 44 were externally funded pilots, which is a limitation. Thirty focused on community health worker (CHW) programs. Health worker supervision was informed by health system data for 38 approaches (67%) and 22 approaches used continuous quality improvement (QI) (39%). Many successful approaches integrated digital supervision technologies (e.g., SmartPhones, mHealth applications) to support existing data systems and complement other health system activities. Few studies were adapted, scaled, or sustained, limiting reports of cost-effectiveness or impact.ConclusionBuilding on results from the review, to increase health worker supervision effectiveness we recommend to: integrate evidence-based, QI tools and processes; integrate digital supervision data into supervision processes; increase use of health system information and performance data when planning supervision visits to prioritize lowest-performing areas; scale and replicate successful models across service delivery areas and geographies; expand and institutionalize supervision to reach, prepare, protect, and support frontline health workers, especially during health emergencies; transition and sustain supervision efforts with domestic human and financial resources, including communities, for holistic workforce support. In conclusion, effective health worker supervision is informed by health system data, uses continuous quality improvement (QI), and employs digital technologies integrated into other health system activities and existing data systems to enable a whole system approach. Effective supervision enhancements and innovations should be better integrated, scaled, and sustained within existing systems to improve access to quality health care.

Project description:BackgroundMany low and middle- income countries (LMICs) are repositioning community health worker (CHW) programmes to provide a more comprehensive range of promotive and preventive services and referrals to the formal health service. However, insufficient supervision, fragmented programmes, and the low literacy levels of CHWs often result in the under-performance of the programmes. We evaluate the impact of a roving nurse mentor working with CHW teams proving supportive supervision in a semi-rural area of South Africa.MethodsWe conducted a longitudinal process evaluation, using in-depth interviews, focus groups and observations prior to the intervention, during the intervention, and 6 months post-intervention to assess how the effects of the intervention were generated and sustained. Our participants were CHWs, their supervisors, clients and facility staff members and community representatives.ResultsThe nurse mentor operated in an environment of resource shortages, conflicts between CHWs and facility staff, and an active CHW labour union. Over 15 months, the mentor was able to (1) support and train CHWs and their supervisors to gain and practice new skills, (2) address their fears of failing and (3) establish operational systems to address inefficiencies in the CHWs' activities, resulting in improved service provision. Towards the end of the intervention the direct employment of the CHWs by the Department of Health and an increase in their stipend added to their motivation and integration into the local primary care clinic team. However, given the communities' focus on accessing government housing, rather than better healthcare, and volatile nature of the communities, the nurse mentor was not able to establish a collaboration with local structures.ConclusionsA roving nurse mentor overseeing several CHW teams within a district healthcare system is a feasible option, particularly in a context where there is a shortage of qualified supervisors to support CHWs activities. A roving nurse mentor can contribute to the knowledge and skills development of the CHWs and enhance the capacity of junior supervisors. However, the long-term sustainability of the effects of intervention is dependent on CHWs' formal employment by the Department of Health.

Project description:BackgroundCommunity health workers (CHWs) play significant roles in improving health practices in under- resourced communities. This study evaluated an early childhood development (ECD) project in Tanzania assessing the effect of mobile video use, supervision and mentorship to improve quality of CHW counseling skills.MethodsCHWs participating in the Malezi Project in Tabora Region were enrolled in a mixed methods pre-post evaluation. CHWs previously trained in UNICEF's Care for Child Development package were further trained in counselling caregivers on nurturing care and father engagement using videos. Health providers were trained to provide ECD-focused supervision/mentorship of CHWs in facilities and during home visits. At baseline and endline, CHWs completed interviews and trained study staff observed and scored CHW counseling sessions using a structured checklist which were reduced into six dimensions through principal component analysis: introduce, educate, ask, plan/problem solve, interact/encourage, and responsive care. Twenty-five in-depth interviews were completed with caregivers and four focus group discussions with CHWs were conducted.ResultsAlmost all (n = 107; 95%) 119 enrolled CHWs completed the expected eight observations (n = 471 baseline; n = 453 endline). At endline, more CHWs reported having one-on-one meetings with their supervisors (51% increasing to 75%; p < .0002) and that supervisors accompanied them to households for mentoring (60% increasing to 89%; p < .0001). We observed a shift in CHW counselling skills in clinic and home sessions. Scores in the categories of introduce, plan/problem solve, and interact/encourage significantly improved between baseline and endline; scores for ask and educate remained unchanged or decreased at both timepoints. Two-thirds of caregivers interviewed reported that father's involvement with their child increased due to CHW visits. Male participation increased in home observation sessions from 5.6% at baseline to 17.6% at endline (p < .0001).ConclusionUse of videos, supervision, and mentorship were associated with CHW performance improvements in providing nurturing care counselling and in father engagement, especially in home settings.

Project description:ObjectiveTo review the impact of clinical supervision of post-registration/qualification healthcare professionals on healthcare organisational outcomes.BackgroundClinical supervision is a professional support mechanism that benefits patients, healthcare professionals and healthcare organisations. Whilst evidence is growing on the impact of clinical supervision on patient and healthcare professional outcomes, the evidence base for the impact of clinical supervision on organisational outcomes remains weak.MethodsThis review used a convergent segregated approach to synthesise and integrate quantitative and qualitative research findings, as per the Joanna Briggs Institute's recommendations for mixed methods systematic reviews. Databases searched included CINAHL, Embase, PubMed, PschINFO, and Scopus. Whilst a narrative synthesis was performed to present the findings of the quantitative and qualitative studies, the evidence from both quantitative and qualitative studies was subsequently integrated for a combined presentation. The review followed the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.ResultsThirty-two studies including 27 quantitative, two qualitative and three mixed methods studies, were included in the review. The results of the quantitative analysis showed that effective clinical supervision was associated with lower burnout and greater staff retention, and effective supervisor was associated with lower burnout and greater job satisfaction. Qualitative findings showed that healthcare professionals believed that adequate clinical supervision could mitigate the risk of burnout, facilitate staff retention, and improve the work environment, while inadequate clinical supervision can lead to stress and burnout. The evidence from quantitative and qualitative studies were complementary of each other.ConclusionClinical supervision can have a variable effect on healthcare organisational outcomes. The direction of this effect appears to be influenced by the effectiveness of both the clinical supervision provided and that of the clinical supervisor. This highlights the need for organisations to invest in high quality supervision practices if maximal gains from clinical supervision are to be attained.

Project description:BackgroundActive screening by mobile teams is considered the most effective method for detecting gambiense-type human African trypanosomiasis (HAT) but constrained funding in many post-conflict countries limits this approach. Non-specialist health care workers (HCWs) in peripheral health facilities could be trained to identify potential cases for testing based on symptoms. We tested a training intervention for HCWs in peripheral facilities in Nimule, South Sudan to increase knowledge of HAT symptomatology and the rate of syndromic referrals to a central screening and treatment centre.Methodology/principal findingsWe trained 108 HCWs from 61/74 of the public, private and military peripheral health facilities in the county during six one-day workshops and assessed behaviour change using quantitative and qualitative methods. In four months prior to training, only 2/562 people passively screened for HAT were referred from a peripheral HCW (0 cases detected) compared to 13/352 (2 cases detected) in the four months after, a 6.5-fold increase in the referral rate observed by the hospital. Modest increases in absolute referrals received, however, concealed higher levels of referral activity in the periphery. HCWs in 71.4% of facilities followed-up had made referrals, incorporating new and pre-existing ideas about HAT case detection into referral practice. HCW knowledge scores of HAT symptoms improved across all demographic sub-groups. Of 71 HAT referrals made, two-thirds were from new referrers. Only 11 patients completed the referral, largely because of difficulties patients in remote areas faced accessing transportation.Conclusions/significanceThe training increased knowledge and this led to more widespread appropriate HAT referrals from a low base. Many referrals were not completed, however. Increasing access to screening and/or diagnostic tests in the periphery will be needed for greater impact on case-detection in this context. These data suggest it may be possible for peripheral HCWs to target the use of rapid diagnostic tests for HAT.

Project description:BackgroundThe health system in South Sudan faces extreme domestic resource constraints, low capacity, and protracted humanitarian crises. Supportive supervision is believed to improve the quality of health care and service delivery by compensating for flaws in health workforce management. This study aimed to explore the current supervision practices in South Sudan and identify areas for quality improvement.MethodsThe study employed qualitative approaches to collect and analyse data from six purposefully selected counties. Data were collected from 194 participants using semi-structured interviews (43 health managers) and focus group discussions (151 health workers). Thematic content analysis was used to yield an in-depth understanding of the supervision practices in the health sector.ResultsThe study found that integrated supportive supervision and monitoring visits were the main approaches used for health services supervision in South Sudan. Supportive supervision focused more on health system administration and less on clinical matters. Although fragmented, supportive supervision was carried out quarterly, while monitoring visits were either conducted monthly or ad hoc. Prioritization for supportive supervision was mainly data driven. Paper-based checklists were the most commonly used supervision tools. Many supervisors had no formal training on supportive supervision and only learned on the job. The health workers received on-site verbal feedback and, most times, on-the-job training sessions through coaching and mentorship. Action plans developed during supervision were inadequately followed up due to insufficient funding. Insecurity, poor road networks, lack of competent health managers, poor coordination, and lack of adequate means of transport were some of the challenges experienced during supervision. The presumed outcomes of supportive supervision were improvements in human resource management, drug management, health data reporting, teamwork, and staff respect for one another.ConclusionSupportive supervision remains a daunting task in the South Sudan health sector due to a combination of external and health system factors. Our study findings suggest that strengthening the processes and providing inputs for supervision should be prioritized if quality improvement is to be attained. This necessitates stronger stewardship from the Ministry of Health, integration of different supervision practices, investment in the capacity of the health workforce, and health infrastructure development.

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Does supportive supervision enhance community health worker motivation? A mixed-methods study in four African countries.

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Does supportive supervision enhance community health worker motivation? A mixed-methods study in four African countries.

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