BackgroundCommunity health worker motivation is an important consideration for improving performance and addressing maternal, newborn, and child health in low and middle-income countries. Therefore, identifying health system interventions that address motivating factors in resource-strained settings is essential. This study is part of a larger implementation research project called Nigraan, which is intervening on supportive supervision in the Lady Health Worker Programme to improve community case management of pneumonia and diarrhea in rural Pakistan. This study explored the motivation of Lady Health Supervisors, a cadre of community health workers, with particular attention to their views on supportive supervision.MethodsTwenty-nine lady health supervisors enrolled in Nigraan completed open-ended structured surveys with questions exploring factors that affect their motivation. Thematic analysis was conducted using a conceptual framework categorizing motivating factors at individual, community, and health system levels.ResultsSupportive supervision, recognition, training, logistics, and salaries are community and health system motivating factors for lady health supervisors. Lady health supervisors are motivated by both their role in providing supportive supervision to lady health workers and by the supervisory support received from their coordinators and managers. Family support, autonomy, and altruism are individual level motivating factors.ConclusionsHealth system factors, including supportive supervision, are crucial to improving lady health supervisor motivation. As health worker motivation influences their performance, evaluating the impact of health system interventions on community health worker motivation is important to improving the effectiveness of community health worker programs.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1641-x) contains supplementary material, which is available to authorized users.
BackgroundWhere access to facilities for childhood diarrhea and pneumonia is inadequate, community case management (CCM) is an effective way of improving access to care. In Pakistan, utilization of CCM for these diseases through the Lady Health Worker Program remains low. Challenges of access to facilities persist leading to delayed care and poor outcomes. Estimating caregiver knowledge, understanding their perceptions and practices, and recognizing how these are related to care seeking decisions about childhood diarrhea and pneumonia is crucial to bring about coherence between supply and demand-side practices.MethodsData was collected from family caregivers to explore their knowledge, perceptions and practices regarding childhood diarrhea and pneumonia. Data from a household survey with 7025 caregivers, seven focus group discussion (FGDs), seven in-depth interviews (IDIs), and 20 detailed narrative interviews are used to explore caregiver knowledge, perceptions and practices.ResultsHousehold survey shows that most family caregivers recognize main signs and symptoms of diarrhea such as loose stools (76%). Fewer recognize signs and symptoms of pneumonia such as breathing problems (21%). Few caregivers (18%) have confidence in lady health workers’ (LHWs) ability to treat childhood diarrhea and pneumonia. Care seeking from LHWs remains negligible (< 1%). Caregivers overwhelmingly prefer to seek care from doctors (97%). Seventy-five percent caregivers sought care from private providers and 45% from public providers.FGDs, IDIs, and narrative interviews show that care mostly begins with home remedies and sometimes self-prescribed medicines. Treatment delays occur because of caregiver inability to recognize disease, use of home remedies, financial constraints, and low utilization of community based LHW services. Caregivers do not seek care from LHWs because of lack of trust and LHWs’ inability to provide medicines. If finances allow, private doctors, who caregivers perceive as more responsive, are preferred over public sector doctors. Financial resources, availability of time, support for household chores by family and community determine whether, when, and from whom caregivers seek care.ConclusionsMany children do not receive recommended diarrhea and pneumonia treatment on time. Taking into consideration caregiver concerns, adequate supply of medicines to LHWs, improved facility level care could improve care seeking practices and child health outcomes.Trial registrationThe trial is registered with ‘Australian New Zealand Clinical Trials Registry’. Registration Number: ACTRN12613001261707. Registered 18 November 2013.
Aim: To assess the effect of enhanced supportive supervision of lady health workers (LHWs) by lady health supervisors on integrated community case management of childhood pneumonia and diarrhoea.Methods: A total of thirty-four supervisors were randomly assigned to intervention and comparison arms. The intervention included enhanced training of supervisors on supervisory skills and written feedback to LHWs by supervisors. The performance of both cadres was assessed three times. Household surveys judged caregiver practices.Results: Intervention arm LHWs performed better than those in the comparison arm in assessing dehydration (92% [n = 25] vs 64% [n = 25]) and in classifying diarrhoea correctly (68% [n = 25] vs 40% [n = 25]). The two arms differed little in correct disease classification for pneumonia (44% [n = 25] vs 40% [n = 25]). Supervisory performance of intervention arm supervisors was better than that in the comparison arm in correcting the workers' clinical examination skills (64% [n = 25] vs 40% [n = 25]) and more frequent feedback. In the household survey, only 18% (n = 2182) intervention and 23% (n = 2197) comparison arm caregivers considered LHWs capable of providing diarrhoea and pneumonia care. Commodities for integrated community case management were not regularly available to workers.Conclusion: Supportive supervision can improve community case management performance. Support through refresher training, logistics and commodities is essential.We explored whether enhancing supervision skills of supervisors improves the ability of community health workers to diagnose and manage childhood diarrhoea and pneumonia. We compared the effect of enhanced supervision of supervisors with routine supervisory practices on health worker performance. Supervisors in the intervention arm provided better quality supervision more frequently, and health workers in the intervention arm performed better in assessing dehydration and in correct classification of disease, particularly diarrhoea.
Background: Pakistan's Lady Health Worker Programme aims to provide care to children sick with pneumonia and diarrhoea, which continues to cause 27 % under-five mortality in Pakistan. The quality of supervision received by Lady Health Workers (LHWs) in the programme influence their knowledge and skills, in turn impacting their ability to provide care.
Background: Despite 60% coverage by Lady Health Worker (LHW) Program, 30% of child deaths in Pakistan are still due to diarrhea and pneumonia. Caregivers are an important stakeholder yet there is little information on their case management practices and utilization of LHW Program. This study explored caregivers' knowledge and practices about childhood diarrhea and pneumonia and utility of LHW services before and after a supportive supervision intervention. Methods: Cross sectional surveys were conducted with caregivers' (mothers) pre and post intervention in project NIGRAAN. The intervention aimed to improve LHSs clinical and supervisory skills of lady health supervisors in order to improve LHW performance and ultimately impact caregiver practices. 4250 households were surveyed. Questionnaire was adapted from PDHS 2012-13. Differences between intervention and control groups were assessed using chi square test. P-value of <0.05 was considered significant. Results: Comparing baseline to end line, there were significant overall improvements in caregivers' knowledge of loose motion (62 to 84%) and dehydration (12 to 18%) as signs and symptoms of childhood diarrhea. There was also a significant overall increase in caregivers' knowledge of presenting features of pneumonia-i.e. fever (58 to 86%), cough (51 to 61%) and breathing problems (25 to 57%). The proportion of caregivers seeking advice for diarrhea from public sector significantly improved in intervention arm from 20% to 29%. Private sector however remained overall preferred choice for care seeking. There was significant overall improvement in awareness about LHWs functioning (93 to 99%) and household visits (91 to 98%). Actual care seeking from LHWs however stayed low (≤ 0.3%) Conclusion: In order to improve utility and expand coverage of LHW Program interventions aimed at providing supportive supervision have the potential to improve caregiver practices and utilization of available services and decrease childhood deaths due to preventable illnesses.
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