Improving community health worker performance through supportive supervision: a randomised controlled implementation trial in Pakistan

Abstract

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.

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

“…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.…”

Substantial and sustained reduction in under-5 mortality, diarrhea, and pneumonia in Oshikhandass, Pakistan: evidence from two longitudinal cohort studies 15 years apart

“…Despite the long timespan of this analysis (1989-2014), about a third of the study staff were involved in both the initial study and more recent follow-up and were able to collect comparable information during both periods. However, the supervision and support given to the study staff was more comprehensive in Study 1, which likely had a positive impact on health worker performance as suggested by other studies [35,41]. Similarly, in Study 1 community members could more easily meet with a member of the study team if their child became sick in between visits, but in Study 2 were more likely seek care elsewhere.…”

“…Repeated interactions with health workers and health and hygiene education may have contributed to this success. In Study 1, regular home visits from study staff and their visible presence in the community spanned 7 years, and there was intensive supervision of study staff, maintaining a high level of vigilance in the community and ensuring that the integrity of interventions was preserved [35]. Furthermore, 73% of children in Study 2 were living in a household that had participated in Study 1 and this may have helped preserve knowledge and experience in the community-base and ensured that interventions had a lasting impact.…”

Substantial and sustained reduction in under-5 mortality, diarrhea, and pneumonia in Oshikhandass, Pakistan: evidence from two longitudinal cohort studies 15 years apart

“…A notable strength of this is study is that despite the long timespan of this analysis (1989-2014), about a third of the study staff were involved in both the initial study and more recent follow-up and were able to collect comparable information during both periods. However, the supervision and support given to the study staff was more comprehensive in Study 1, which likely had a positive impact on health worker performance as suggested by other studies [40,46]. Similarly, in Study 1 community members could more easily meet with a member of the study team if their child became sick in between visits, but in Study 2…”