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.

The supervisory relationships of community health workers in primary health care: social network analysis of ward-based outreach teams in Ngaka Modiri Molema District, South Africa

“…Supervision is often thought of as a dyadic relationship between the supervisor and the supervisee, leaving out other actors within the system. Yet the evidence from this study shows that approached holistically, supportive supervision involves a wide range of actors and relationships within a system 9. There is considerable evidence, from both the NW and elsewhere, that CHWs/WBOTs are often treated as outsiders by actors in the PHC system and perceive themselves as exploited and unacknowledged by the broader system 16 22–25.…”

“…A holistic approach to supportive supervision would thus include managerial, development and support elements (figure 1). The management element involves the compliance to organisational standards, monitoring of work processes and allocation of resources; development refers to technical support to improve skills and knowledge through formal and informal training; and the support element addresses morale and motivation, which includes strengthening relationships and attending to supervisee needs, both instrumental and emotional 4 9…”

“…Such a holistic conception requires viewing supervision not just as a dyadic relationship between a supervisee and their immediate line supervisor,10–14 but rather as a system operating at several levels with a range of functions involving different actors and relationships and forms of interaction, for example, one-on-one, group and peer supervision, and so on, simultaneously 7 9. In this sense, supervision can be thought of as a set of relationships embedded in the wider context of social and professional relationships and hierarchies within the health system.…”

Using research networks to generate trustworthy qualitative public health research findings from multiple contexts

“…Throughout the analysis process, we looked for commonalities to see where similar contexts yielded similar results and where they differed, viewing both types of findings as valuable. Not all inter-country findings were generalized across all settings; some publications were limited to a sub-set [33][34][35][36][37]. A detailed example of empirical and conceptual transferability is captured in Table 4.…”

Peer supervision experiences of drug sellers in a rural district in East-Central Uganda: a qualitative study

“…Peer supervision is a type of supervision where people of similar hierarchical status or who perceive themselves as equal encourage and enhance learning and development [10]. Peer supervision has been shown to enhance community health worker motivation,performance and quality of care when combined with supportive supervision [11,12]. However, much of this evidence has been generated from public health settings with less data coming from private and infomal health providers who play a signi cant role in health provision in low and middle income countries [13].…”