Background
The important role of lower-cadre health workers in achieving Universal Health Coverage (UHC) is widely recognised, with community health workers (CHWs) frequently cited as a cost-effective, critical resource for the efficient delivery of primary care in low- and middle-income contexts (LMICs) [
1,
2]. Unfortunately, scaling up and sustaining CHWs programme, as envisioned at Alma-Ata, has been challenging, with wide variations in the availability, coordination, support and management of community health worker programmes [
3]. Accordingly, the most recent
Global strategy on human resources for health: Workforce 2030 [
4] published by the World Health Organization (WHO) reiterates the need to harness the potential of community-based health workers. Specifically, the strategy calls for a global effort to integrate CHWs into national health-care systems as a means to improve their working conditions, capacity, and motivation [
4].
More recently, the WHO have called for rigorous scientific research in the area of community health workers to pay more attention to cross-cutting factors, such as management and supervision, that enable community-based health worker performance [
5]. Decades of research on CHW initiatives to date have suggested several cross-cutting factors that contribute to the success of CHW programmes [
6]. Among these, supportive supervision consistently emerges as a key factor in determining CHW performance, motivation, and retention [
7].
In contrast to more ‘traditional’ methods of supervision, which are frequently characterised by performance audits, inspections, use of checklists, and controlling and authoritarian attitudes [
7‐
10], supportive supervision favours shared performance goals, mentoring, and two-way communication [
11]. Whereas traditional approaches are frequently criticised for their failure to enhance health worker motivation [
12‐
14], supportive approaches to supervision have been shown to increase the impact of CHW programmes as well as the productivity, motivation and job satisfaction of CHWs [
7,
15‐
17]. Moreover, CHWs themselves express clear preferences for supportive approaches that are responsive to the realities of the challenges they face in programme implementation [
14,
18].
In addition to supportive approaches to supervision, CHW programmes often advocate for regular supervision of CHWs. Research suggests however that regular interaction with one’s supervisor is insufficient. When compared to colleagues who had recently been supervised
and felt supported by their supervisor, health workers who had recently been supervised, but did
not feel supported, were found to be less productive [
15]. This suggests that not only are health worker’s perceptions of the supervisory relationship significant, but that perceptions of the supportive nature of this relationship is likely a more important predictor of work-related outcomes than frequency alone. This view is consistent with well-established theories within the work psychology literature, which state that subjective, cognitive appraisals of supervision are critical factors in the prediction of a range of work performance-related factors (e.g., motivation, commitment, job satisfaction) [
19].
While existing tools measure the supervision of CHWs (i.e. the “CHW Assessment and Improvement Matrix” [
20]) by assessing the frequency of supervision and training of supervisors, these measures crucially ignore CHW perceptions of the supervisory process and their impact on work-performance-related factors. Moreover, such tools are lengthy, time-intensive, and require substantial programmatic input and resources; all of which are at a premium within human resource for health programming in LMICs. The need exists to develop a feasible, valid, and reliable measure of perceived supervision that both recognises the experience of supervision from the perspective of the individual health worker and that allows the CHW voice to be heard.
The current study aimed to develop and psychometrically validate a new, simple measure of perceived supervision (the Perceived Supervision Scale (PSS)) that could be used across multiple global health contexts. To maximise the utility of the PSS in LMICs we sought to construct an easily-translatable measure, comprised of a limited number of items that can be quickly and easily administered and scored; an approach that should increase the likelihood of cross-cultural validity and subsequent use.
The development and validation of the PSS included two research phases. Phase 1, conducted in Sierra Leone, was exploratory and sought to determine the most appropriate indicators of perceived supervision from an initial pool of test items. In other words, we sought to determine which items, when included in a questionnaire, measured perceived supervision among CHWs. Phase 2, conducted across six LMICs and over a period of 8 months, sought to provide a comprehensive assessment of the psychometric properties of the PSS. Specifically, this phase assessed the predictive validity, factorial validity, cross-cultural and temporal stability of the factor structure, and the internal reliability of the PSS over time and across multiple cultural contexts. In other words, we sought to determine whether the questionnaire, as developed in the Sierra Leonean context also measured perceived supervision among CHWs across six other contexts, and whether measures of perceived supervision using the PSS at baseline, predicted a number of related human resource for health outcomes 8-months later. Additionally, we assessed whether the total score on the PSS could be used by implementers in the management and monitoring of CHW programmes.
Discussion
The Perceived Supervision Scale is the first validated tool developed for collecting CHW perceptions of their supervision. The tool is brief, robust and can be applied across multiple, culturally-distinct global health contexts with a wide range of CHW typologies. Despite its recognised importance of supervision in CHW programming, supervision is often one of the weakest and most difficult elements of CHW programming to implement consistently [
9,
32]. The factor structure of the PSS allows researchers and implementers to calculate a sum score of perceived supervision within CHW programming. Specifically, the total PSS score allows for a greater understanding the nature of a positive supervisory relationship. Furthermore, it grants the ability to managers to detect problematic supervisory interactions, prompt the introduction of stronger training programmes, and where necessary, the reorganisation of supervisory arrangements, contributing to the sustainability of CHW programmes. The ability for CHW programme managers to monitor the interpersonal supervisory relationships of CHWs could help prevent deleterious work performance outcomes associated with high staff turnover and loss of worker motivation [
7,
33]. The development of the PSS therefore represents a valuable contribution to global efforts to address human resource for health shortages and towards achieving UHC. Furthermore, the development of the PSS contributes towards addressing more recent calls for rigorous approaches towards scale development for human resource for health programming [
34].
Phase 1 served to derive the most appropriate indicators of perceived supervision. From an initial pool of 12 item statements, developed from the extant literature on CHW supervision, six items were retained. Consistent with previous literature, the items retained as part of the final PSS, reflect the importance of
both supportive and regular aspects of supervision. Interestingly, those items associated with more traditional forms of supervision (i.e. controlling or negative interactions), were least reflective of the nature of perceived supervision among this sample of CHWs. This suggests that CHWs in Sierra Leone perceived the supervision process as a generally positive, supportive, and regular experience. The items retained as part of the supportive supervision factor offer additional insight into what content or skills should be emphasised or included as part of supervision training programmes. More specifically, the items retained in the PSS are consistent with evidence that a supportive supervisor should: meet regularly with CHWs, offer opportunities for knowledge sharing and refresher training [
33], recognise and appreciate the work and efforts of a CHW, take into account the views and ideas of CHWs, and communicate effectively with the CHW [
11].
As it was possible that the observed findings from Phase 1 reflected the idiosyncratic responses of the Sierra Leonean CHWs, it was imperative to assess the replicability of these findings in alternate contexts. Phase 2 confirmed the PSS’s unidimensional structure across multiple samples of CHWs from different contexts, cadres, cultures, and demographics. Additionally, the factorial validity of the PSS was evidenced across time, with the scale exhibiting stable psychometric properties (reliability and validity) over a period of 8 months. Furthermore, the PSS positively predicted a range of work-performance related indicators 8 months later including job satisfaction, work conscientiousness, community commitment, and organizational commitment, while controlling for sex and education. These results indicate that CHWs who perceive greater levels of supervision (i.e. supportive) report greater job satisfaction, work conscientiousness and higher levels of both community and organizational commitment over time. Administering the PSS during early stages of programme implementation, or when used regularly as a monitoring tool, may therefore help managers to adapt supervision approaches before they negatively impact on other organizational factors in the long-term. Although such findings are important, future research should extend upon these findings and assess the effectiveness of the PSS to also predict objective outcomes of CHW performance and community health outcomes.
The current study has several limitations that should be recognised. The selection of the six PSS items was drawn from a sample of CHWs in Sierra Leone, and although the latent structure of these items was confirmed cross-culturally, it is possible that had the scale refinement process been conducted in a different setting, a different set of indicators may have been retained. It is important to note that the PSS is not presented as a comprehensive measure of perceived supervision, but rather a brief measure of the construct that possesses high utility across global health contexts. Second, the country-specific CFA models generated during Phase 2 of the study were carried out using relatively small sample sizes. Although not ideal for latent variable modelling, the small number of indicators in the PSS render this a minor limitation [
35]. Third, it is worth noting that a residual covariance was added between two items in one (Indonesia, time 2) of 17 assessments of model fit. Finally, while the PSS has been validated among CHWs across a range of LMIC contexts, it is necessary to determine the reliability and validity of PSS among more highly skilled cadres of health workers globally.
Acknowledgements
The authors would like to thank the CHWs in seven countries who gave their time to answers questions about their perceptions of supervision. Phase I of this research was made possible thanks to the support of Irish Aid and the people of Ireland through World Vision Ireland’s Access to Infant and Maternal (AIM-Health) programme as well as the Department for International Development and the United Kingdom through their Programmes Partnership Agreement. A special thanks to Allieu Bangura and Joseph Musa of World Vision Sierra Lone for their assistance with organising the collection of the data.
Phase 2 of this research was nested within REACHOUT, a multi-country research consortium aiming to maximize the equity, effectiveness and efficiency of close-to-community services in rural areas and urban slums. Robinson Karuga, Kingsley Chikaphupha, Daniel Gemechu, RaliciaLimato, Irin Akhter and SozinhoNdima from the country REACHOUT teams organised the collection, cleaning and analysis of country data. The REACHOUT Consortium is funded by the European Union FP7 grant (number 306090). This document reflects only the authors’ views and the European Union is not liable for any use that may be made of the information contained therein.