Development and validation of a multi-dimensional scale to assess community health worker motivation

Self-determination, motivation and burnout among residents in Lebanon

In the highly stressful environment of graduate medical residency, residents often grapple with anxiety, depression, and burnout. Those with intrinsic motivation, self-determination (SD), effective coping skills, and mindfulness may exhibit resilience against burnout and its negative effects on well-being. Using the SD theory framework, our study aims to explore the intricate relationship between motivation, stressors, and individual traits, aiming to predict burnout and mental distress among residents in training. We collected data from multispecialty residents through standardized questionnaires assessing SD, motivation, burnout, and mental distress. Structural equation models (SEM) were employed, on subsamples of high and low SD; model fits were checked. Various forms of motivation were tested as mediators between stressors, personality, and the three dimensions of burnout. In the overall sample of 112 participants, extrinsic motivation fully mediates the relation between stressors and low sense of personal accomplishment (indirect Beta = 0.02; p = 0.04). In the introject model, motivation fully mediates the relation between maladaptive coping and depersonalization (indirect Beta = 0.10; p = 0.03). In the intrinsic motivation model, motivation fully mediates the relation between adaptive (indirect Beta = 0.13; p < 0.001), maladaptive coping (indirect Beta = - 0.15; p = 0.01) and depersonalization (indirect Beta = - 0.31; p > 0.001). Among the low SD subgroup, a full mediation effect was found for extrinsic motivation between stressors and depersonalization (indirect Beta = 0.07; p = 0.027) and for intrinsic motivation between adaptive coping and depersonalization (indirect Beta = 0.150; p = 0.014). In the high SD subgroup, mindfulness has a moderation effect on burnout dimensions, positively on the relation between maladaptive coping and depersonalization and negatively on maladaptive coping and emotional exhaustion in the intrinsic and introject models. In both the low and high SD subgroups, regardless of motivation type, emotional exhaustion correlates with anxiety and depression, while depersonalization negatively correlated with mental distress. The presence of SD moderated the effect of stressors on burnout. Mindfulness plays a crucial role in buffering the effect of maladaptive coping on the various dimensions of burnout, linked in its turn to depression and anxiety symptomatology. Mindfulness also exerts a direct inverse effect on personal exhaustion in the low SD subgroup. Further studies are suggested to confirm these findings.

What makes peers credible? A qualitative analysis to operationalize peer credibility in HIV-prevention and treatment programs for Latino MSM

The potential of peers to be effective in delivering HIV interventions is linked at least in part to the degree to which they are perceived as credible sources of HIV-related information. This study aimed to operationalize qualities that would make a LMSM peer implementer credible. We conducted a qualitative analysis of semi-structured interviews with 20 LMSM and focus groups with 11 HIV service implementers. The parent study collected formative data to inform the design of a strategy to enhance the reach of HIV prevention and treatment services to LMSM. The present study examined participant views on qualities necessary for peer implementers to establish credibility among LMSM. We identified five themes regarding peer credibility, including (1) Peers must be trained in HIV prevention and care, (2) Peers should be verified and have a special designation indicating their knowledge and trustworthiness, (3) Peers should convey accurate information and not spread misinformation, (4) Peers should be relatable and interpersonally skilled, and (5) Peers should be engaged with the general LGBTQ + community to generate trust and credibility. Findings can inform the development of acceptable peer strategies for LMSM, peer recruitment, training, and peer supervision.

Quality, Usability, and Trust Challenges to Effective Data Use in the Deployment and Use of the Bangladesh Nutrition Information System Dashboard: Qualitative Study

BACKGROUND

Evidence-based decision-making is essential to improve public health benefits and resources, especially in low- and middle-income countries (LMICs), but the mechanisms of its implementation remain less straightforward. The availability of high-quality, reliable, and sufficient data in LMICs can be challenging due to issues such as a lack of human resource capacity and weak digital infrastructure, among others. Health information systems (HISs) have been critical for aggregating and integrating health-related data from different sources to support evidence-based decision-making. Nutrition information systems (NISs), which are nutrition-focused HISs, collect and report on nutrition-related indicators to improve issues related to malnutrition and food security-and can assist in improving populations' nutritional statuses and the integration of nutrition programming into routine health services. Data visualization tools (DVTs) such as dashboards have been recommended to support evidence-based decision-making, leveraging data from HISs or NISs. The use of such DVTs to support decision-making has largely been unexplored within LMIC contexts. In Bangladesh, the Mukto dashboard was developed to display and visualize nutrition-related performance indicators at the national and subnational levels. However, despite this effort, the current use of nutrition data to guide priorities and decisions remains relatively nascent and underused.

OBJECTIVE

The goal of this study is to better understand how Bangladesh's NIS, including the Mukto dashboard, has been used and areas for improvement to facilitate its use for evidence-based decision-making toward ameliorating nutrition-related service delivery and the health status of communities in Bangladesh.

METHODS

Primary data collection was conducted through qualitative semistructured interviews with key policy-level stakeholders (n=24). Key informants were identified through purposive sampling and were asked questions about the experiences and challenges with the NIS and related nutrition dashboards.

RESULTS

Main themes such as trust, data usability, personal power, and data use for decision-making emerged from the data. Trust in both data collection and quality was lacking among many stakeholders. Poor data usability stemmed from unstandardized indicators, irregular data collection, and differences between rural and urban data. Insufficient personal power and staff training coupled with infrastructural challenges can negatively affect data at the input stage. While stakeholders understood and expressed the importance of evidence-based decision-making, ultimately, they noted that the data were not being used to their maximum potential.

CONCLUSIONS

Leveraging DVTs can improve the use of data for evidence-based decision-making, but decision makers must trust that the data are believable, credible, timely, and responsive. The results support the significance of a tailored data ecosystem, which has not reached its full potential in Bangladesh. Recommendations to reach this potential include ensuring a clear intended user base and accountable stakeholders are present. Systems should also have the capacity to ensure data credibility and support ongoing personal power requirements.

Success in vaccination programming through community health workers: a qualitative analysis of interviews and focus group discussions from Nepal, Senegal and Zambia

OBJECTIVES

Community health workers are essential to front-line health outreach throughout low-income and middle-income countries, including programming for early childhood immunisation. Understanding how community health workers are engaged for successful early childhood vaccination among countries who showed success in immunisation coverage would support evidence-based policy guidance across contexts.

DESIGN

We employed a multiple case study design using qualitative research methods.

SETTING

We conducted research in Nepal, Senegal and Zambia.

PARTICIPANTS

We conducted 207 interviews and 71 focus group discussions with 678 participants at the national, regional, district, health facility and community levels of the health systems of Nepal, Senegal and Zambia, from October 2019 to April 2021. We used thematic analysis to investigate contributing factors of community health worker programming that supported early childhood immunisation within each country and across contexts.

RESULTS

Implementation of vaccination programming relied principally on the (1) organisation, (2) motivation and (3) trust of community health workers. Organisation was accomplished by expanding cadres of community health workers to carry out their roles and responsibilities related to vaccination. Motivation was supported by intrinsic and extrinsic incentives. Trust was expressed by communities due to community health worker respect and value placed on their work.

CONCLUSION

Improvements in immunisation coverage was facilitated by community health worker organisation, motivation and trust. With the continued projection of health worker shortages, especially in low-income countries, community health workers bridged the equity gap in access to vaccination services by enabling wider reach to underserved populations. Although improvements in vaccination programming were seen in all three countries-including government commitment to addressing human resource deficits, training and remuneration; workload, inconsistency in compensation, training duration and scope, and supervision remain major challenges to immunisation programming. Health decision-makers should consider organisation, motivation and trust of community health workers to improve the implementation of immunisation programming.

A systematic review of the types, workload, and supervision mechanism of community health workers: lessons learned for Indonesia

BACKGROUND

Community health workers (CHWs) have demonstrated capability to improve various health indicators, however, many programmes require support in meeting their objectives due to subpar performance and a high rate of CHW attrition. This systematic review investigated the types of CHWs, their workloads, and supervision practices that contribute to their performance in different countries.

METHODS

The search was carried out in November 2022 in Medline, Embase, and Neliti for studies published in Indonesian or English between 1986 and 2022 that reported public health services delivered by CHWs who live and serve the community where they live but are not considered health professionals. The findings were synthesised using a thematic analysis to assess key factors influencing the performance of CHWs.

RESULTS

Sixty eligible articles were included in this review. CHWs were responsible for more than two diseases (n = 35) and up to fifteen, with more than eighteen activities. Their roles covered the human life cycle, from preparation for pregnancy, care for newborns, health for children, adolescents, and productive age to elderly individuals. They were also involved in improving environmental health, community empowerment, and other social issues hindering access to health services. They carried out promotive, preventive, and curative interventions. The CHW-population ratio varied from eight to tens of thousands of people. Some CHWs did not have a clear supervision system. Challenges that were often faced by CHWs included inappropriate incentives, inadequate facilities, insufficient mentoring, and supervision, many roles, and a broad catchment area. Many studies revealed that CHWs felt overburdened and stressed. They needed help to balance their significant work and domestic tasks.

CONCLUSIONS

Effective planning that considered the scope of work of CHWs in proportion to their responsibilities and the provision of necessary facilities were crucial factors in improving the performance of CHWs. Supportive supervision and peer-supervision methods are promising, however, any CHW supervision required a detailed protocol. This systematic review emphasised the opportunity for CHW management system improvement in Indonesia.

Assessing Nurse Competency in the Veterans Health Administration Registered Nurse Transition-to-Practice Residency Program: Item Pool Content Validation

BACKGROUND

New graduate registered nurse (RN) competencies are complex and difficult to measure. Psychometrically sound tools are needed to evaluate competencies for nurses participating in nurse residencies.

PURPOSE

Project aims were to develop an item pool for a tool to measure new graduate RN competencies for the Veterans Health Administration RN Transition-to-Practice Residency Program; validate item pool content; and use consensus methods to improve item pool content validity.

METHODS

A sequential, mixed-methods design was used. Item pool creation, content validation, and revisions included a collaborative process with the evaluation team, operational stakeholders, and subject matter experts (SMEs).

RESULTS

Inclusion of SMEs in item development enhanced item pool content validity to measure nurse competency. Stakeholder feedback ensured programmatic logistical and evaluation concerns were met.

CONCLUSIONS

Engaging SMEs in conceptualization, item development, and aligning existing standards enhanced item pool content validity to measure nurse competencies for new graduate RNs.

Examining Roles, Support, and Experiences of Community Health Workers During the COVID-19 Pandemic in Bangladesh: A Mixed Methods Study

INTRODUCTION

Understanding community health workers' (CHWs) experiences of sustaining routine health care promotion and provision activities as well as their challenges in adopting new responsibilities within a dynamic context is critical. This study explored the roles and perspectives of CHWs within the government-led coronavirus disease (COVID-19) community health response in Bangladesh.

METHODS

We conducted a mixed methods study to explore the government's response to COVID-19 and its association with community health programming through a telephone-based survey of 370 government-employed CHWs. We also conducted 28 in-depth interviews with policy makers, program managers, CHW supervisors, and CHWs. We conducted exploratory and regression analysis of survey data and qualitative analysis of interview data.

RESULTS

The majority of CHWs reported receiving training related to COVID-19, including community-based prevention strategies from government and nongovernment stakeholders. Access to infection prevention supplies differed significantly by CHW cadre, and perspectives on the provision of adequate supplies varied qualitatively. CHWs reported slight decreases in routine work across all health areas early in the pandemic, and a majority reported added COVID-19-related responsibilities as the pandemic continued, including advising on signs/symptoms in their communities and referring suspected cases of COVID-19 for advanced facility care. Regression analyses showed that government support and integration of CHWs into their response-particularly being trained on COVID-19-predicted CHW capacity to advise communities on symptoms and provide routine services.

DISCUSSION

Government-employed CHWs in Bangladesh continued to provide health education and routine services in their communities despite pandemic- and response-related challenges. Varied support and differential CHW cadre-specific effects on COVID-19 awareness building in the community, referral, and routine service provision merit attention in Bangladesh's pluralistic community health system. While COVID-19 infection and government-mandated lockdowns restricted CHW mobility, the workers' capacity to continue service provision and education can be leveraged in vaccination and surveillance efforts moving forward.

Development of a community health workers perceptual and behavioral competency scale for preventing non-communicable diseases (COCS-N) in Japan

BACKGROUND

Community health workers in Japan are commissioned to work on a voluntary basis on behalf of their communities, to promote healthy behaviors. They are a valuable resource because they can often provide health information and services for local residents with whom professionals find it difficult to engage. However, no instruments exist for evaluating perceptual and behavioral competencies for prevention of non-communicable diseases among voluntary unpaid community health workers in developed countries. This study aimed to develop a community health workers perceptual and behavioral competency scale for preventing non-communicable diseases (COCS-N), and to assess its reliability and validity.

METHODS

We conducted a cross-sectional study using a self-reported questionnaire. A total of 6480 community health workers across 94 local governments in Japan were eligible to participate. We evaluated the construct validity of the COCS-N using confirmatory factor analysis, and assessed internal consistency using Cronbach's alpha. We used the European Health Literacy Survey Questionnaire and the Community Commitment Scale to assess the criterion-related validity of the COCS-N.

RESULTS

In total, we received 3140 valid responses. The confirmatory factor analysis identified eight items from two domains, with perceptions covered by "Sharing the pleasure of living a healthy life" and behavioral aspects by "Creating healthy resources" (goodness-of-fit index = 0.991, adjusted goodness-of-fit index = 0.983, comparative fit index = 0.993, root mean square error of approximation = 0.036). Cronbach's alpha was 0.88. COCS-N scores were correlated with European Health Literacy Survey Questionnaire scores and Community Commitment Scale scores (r = 0.577, P < 0.001 and r = 0.447, P < 0.001).

CONCLUSIONS

The COCS-N is a brief, easy-to-administer instrument that is reliable and valid for community health workers. This study will therefore enable the assessment and identification of community health workers whose perceptual and behavioral competency could be improved through training and activities. Longitudinal research is needed to verify the predictive value of the COCS-N, and to apply it to a broader range of participants in a wider range of settings.

Introduction of digital reporting platform to integrate community-level data into health information systems is feasible and acceptable among various community health stakeholders: A mixed-methods pilot study in Mopti, Mali

BACKGROUND

Integration of community-level health data within Mali's web-based District Health Information System (DHIS2) is underexplored. This study conducted in Mopti, Mali examined challenges and enablers affecting integration and investigated how digital technology optimizes data quality, availability, and use.

METHODS

This pre-post mixed-methods study compared community health workers' (CHWs') experiences reporting routine community-level data using the DHIS2 digital application on tablets and paper forms. 141 CHWs participated in quantitative surveys and focus group discussions at baseline and endline. In-depth interviews were conducted with 18 and eight CHW supervisors and 12 and 11 other stakeholders at baseline and endline, respectively. We calculated changes in CHW performance, and job satisfaction among intervention and comparison groups using the difference-in-difference (DID) estimator controlling for baseline characteristics. Routine longitudinal DHIS2 data described timeliness and completeness of CHW reporting. Thematic analysis of qualitative data explained implementation challenges and enablers, and considerations for data use.

RESULTS

The median number of health talks and household visits among intervention group CHWs increased from baseline to endline compared to the comparison group (DID estimator; P < 0.05 for both), as did aspects of job satisfaction (satisfaction with opportunities to contribute ideas to improve services and coordination with supervisors and stakeholders, P < 0.1). CHWs reported high levels of comfort and confidence navigating the tablet for data collection and on-time reporting. While CHWs experienced challenges -tablet quality, limited network connection and increased workload, they preferred the digital to paper system. Stakeholder, supervisor and CHW roles in data review and decision-making appear unchanged from baseline to endline, though some supervisors found the tablets improved data timeliness and completeness. Routine longitudinal DHIS2 data confirm high rates of data timeliness and completeness before and after the intervention, with little or no change over time.

CONCLUSIONS

CHW tablet use for data collection and reporting is feasible and desirable, however, program and policy changes are needed for this to be a fully-functional system. Future efforts need to consider how to ensure site-level network connectivity; quality, compatibility and functionality of digital technology; and routine supportive systems for CHWs and community health actors on data use.

The Client Empowerment in Community Health Systems Scale: Development and validation in three countries

BACKGROUND

Effectively measuring client empowerment is critical for monitoring and supporting empowerment through interventions, including via community health workers (CHWs) on the front line. Yet a comprehensive measure capturing the multidimensional aspects of client empowerment is not currently available. We aimed to develop and validate the Client Empowerment in Community Health Systems (CE-CHS) Scale in three countries.

METHODS

We used data from cross-sectional surveys from 2019-2020 with clients of CHWs in Bangladesh (n = 1384), Haiti (n = 616), and Kenya (n = 306). Nineteen candidate CE-CHS Scale items were adapted from existing health empowerment and sociopolitical control scales. Items spanned three hypothesized sub-domains: personal agency around health (eg, "I feel in control of my health"), agency in sharing health information with others (eg, "I feel confident sharing health information with my family/friends"), and empowerment in community health systems (eg, "Most facility/managers would listen to any concerns I raise"). Face and content validity of items were assessed via two focus group discussions in Haiti. For each country, we conducted split-sample exploratory/confirmatory factor analyses (EFA/CFA) and assessed internal consistency reliability. We assessed convergent validity by comparing final full-scale and sub-dimension scores to theoretically related variables.

RESULTS

All participants in Bangladesh and Kenya were female, as were 85% in Haiti. Mean age in Bangladesh and Kenya was around 25 years; 40 in Haiti. EFA/CFA resulted in a final 16-item CE-CHS Scale representing the three hypothesized sub-scales. Three items were dropped in EFA due to poor performance. CFA fit statistics were good for the full-scale and each sub-scale. The mean CE-CHS score (range 1 to 4) was 2.4 in in Bangladesh, 2.8 in Haiti, and 3.0 in Kenya. Cronbach's alpha and ordinal theta of the full and sub-scales were greater than 0.7. Increased empowerment was associated with increased trust in CHWs, influence of CHWs on empowerment, satisfaction with CHW services, number of CHW interactions, civic engagement, and education, with slight variations in magnitude and significance by country.

CONCLUSIONS

Findings suggest that the 16-item CE-CHS Scale is valid and reliable. This scale can be used to assess levels and determinants of, and changes in, client empowerment in future implementation research and monitoring of community health systems.

Measuring quality of care at the community level using the contraceptive method information index plus and client reported experience metrics in Bangladesh

BACKGROUND

Low rates of contraceptive continuation in Bangladesh are a symptom of poor quality family planning (FP) counseling. Improving family planning counseling by the country's community health care workers (CHWs) could improve contraceptive continuation. This study explores client experiences of care from CHWs, as measured by the method information index plus (MII+) and communication quality metric.

METHODS

Conducted in a peri-urban sub-district with low contraceptive use rates, this mixed methods study explores FP client experiences with community-based counseling and referrals by Family Welfare Assistants (FWAs), a CHW cadre providing FP services. Client- and patient-reported experience with community FP services was measured by the MII+ and communication quality metric. A quantitative post-service exit survey was coupled with observations of the interactions between 62 FWAs and 692 female clients to measure FWA and client FP knowledge, FWA capacities, attitudes, quality of FP communication, FP referrals, and contraceptive uptake.

RESULTS

Summary MII+ scores suggest that only 20% of clients reported adequate provision of information for informed decisions. Observations and self-reporting alike suggest moderate to high quality of communication during FWA and client interactions. Despite FWAs' theoretical knowledge of long-acting reversible and permanent FP methods, few clients were referred to facilities for them; 81% of clients who preferred a pill received it, while only 34% of clients seeking long-acting methods received needed referrals.

CONCLUSIONS

Quality community-based FP counseling could help address rising contraceptive discontinuation rates in Bangladesh. While MII and MII+ scores in this study were low, and FWA evinced numerous misconceptions, FWAs demonstrated strong communication skills that facilitate rapport and trust with their clients and communities. Bangladesh's policy and programs should capitalize upon these relationships and enhance CHWs' knowledge of all method types, and side effects management, with updated job aids, refresher training, and supervision.

Measuring client trust in community health workers: A multi-country validation study

BACKGROUND

Client trust in community health workers (CHWs) is integral for improving quality and equity of community health systems globally. Despite its recognized conceptual and pragmatic importance across health areas, there are no quantitative measures of trust in the context of community health services. In this multi-country study, we aimed to develop and validate a scale that assesses trust in CHWs.

METHODS

To develop the scale, we used a consultative process to conceptualize and adapt items and domains from prior literature to the CHW context. Content validity and comprehension of scale items were validated through 10 focus group discussions with 75 community members in Haiti, and Kenya. We then conducted 1939 surveys with clients who interacted with CHWs recently in Bangladesh (n = 1017), Haiti (n = 616), and Kenya (n = 306). To analyze the 15 candidate scale items we conducted a split sample exploratory/confirmatory factor analysis (EFA/CFA), and then assessed internal consistency reliability of resulting set of items. Finally, we assessed convergent validity via multivariable models examining associations between final scale scores with theoretically related constructs.

RESULTS

Factor analyses resulted in a 10-item Trust in CHWs Scale with two factors (sub-scales): Health care competence (5 items) and Respectful communication (5 items). The qualitative data also underscored these two sub-domains. The full scale had good internal consistency reliability in Bangladesh, Haiti and Kenya (alphas 0.87, 0.86, and 0.92, respectively; all alphas for subscales were also > 0.7, most > 0.8). Greater scores on Trust in CHWs were positively associated with increased client empowerment, familiarity with CHWs, satisfaction with recent client-CHW interaction, and positive influence of CHW on client empowerment. Scale scores were not influenced by the age, sex, parity, education, and wealth quintiles in across countries and may be affected by contextual factors.

CONCLUSIONS

The Trust in CHWs Scale, which includes Health care competence and Respectful communication sub-scales, is the first such scale developed and validated globally. Our findings suggest this 10-item scale is a reliable and valid tool for quantifying clients' trust in CHWs, with potential utility for tracking and improving CHW and health systems performance over time.