How to do (or not to do)… Measuring health worker motivation in surveys in low- and middle-income countries

Abstract A health system’s ability to deliver quality health care depends on the availability of motivated health workers, which are insufficient in many low income settings. Increasing policy and researcher attention is directed towards understanding what drives health worker motivation and how different policy interventions affect motivation, as motivation is key to performance and quality of care outcomes. As a result, there is growing interest among researchers in measuring motivation within health worker surveys. However, there is currently limited guidance on how to conceptualize and approach measurement and how to validate or analyse motivation data collected from health worker surveys, resulting in inconsistent and sometimes poor quality measures. This paper begins by discussing how motivation can be conceptualized, then sets out the steps in developing questions to measure motivation within health worker surveys and in ensuring data quality through validity and reliability tests. The paper also discusses analysis of the resulting motivation measure/s. This paper aims to promote high quality research that will generate policy relevant and useful evidence.

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Approaches to motivate physicians and nurses in low- and middle-income countries: a systematic literature review

Human Resources for Health ◽

10.1186/s12960-020-00522-7 ◽

2021 ◽

Vol 19 (1) ◽

Author(s):

Jaya Gupta ◽

Mariya C. Patwa ◽

Angel Khuu ◽

Andreea A. Creanga

Keyword(s):

Systematic Review ◽

Randomized Trial ◽

Health Worker ◽

Work Motivation ◽

Health Workers ◽

Trial Group ◽

Middle Income ◽

Group Design ◽

Middle Income Countries ◽

Worker Motivation

AbstractPoor health worker motivation, and the resultant shortages and geographic imbalances of providers, impedes the provision of quality care in low- and middle-income countries (LMICs). This systematic review summarizes the evidence on interventions used to motivate health workers in LMICs. A standardized keyword search strategy was employed across five databases from September 2007 -September 2017. Studies had to meet the following criteria: original study; doctors and/or nurses as target population for intervention(s); work motivation as study outcome; study design with clearly defined comparison group; categorized as either a supervision, compensation, systems support, or lifelong learning intervention; and conducted in a LMIC setting. Two independent reviewers screened 3845 titles and abstracts and, subsequently, reviewed 269 full articles. Seven studies were retained from China (n = 1), Ghana (n = 2), Iran (n = 1), Mozambique (n = 1), and Zambia (n = 2). Study data and risk of bias were extracted using a standardized form. Though work motivation was the primary study outcome, four studies did not provide an outcome definition and five studies did not describe use of a theoretical framework in the ascertainment. Four studies used a randomized trial—group design, one used a non-randomized trial—group design, one used a cross-sectional design, and one used a pretest–posttest design. All three studies that found a significant positive effect on motivational outcomes had a supervision component. Of the three studies that found no effects on motivation, two were primarily compensation interventions and the third was a systems support intervention. One study found a significant negative effect of a compensation intervention on health worker motivation. In conducting this systematic review, we found there is limited evidence on successful interventions to motivate health workers in LMICs. True effects on select categories of health workers may have been obscured given that studies included health workers with a wide range of social and professional characteristics. Robust studies that use validated and culturally appropriate tools to assess worker motivation are greatly needed in the Sustainable Development Goals era.

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Factors influencing the motivation of maternal health workers in conflict setting of Mogadishu, Somalia.

10.1101/2022.01.10.22268888 ◽

2022 ◽

Author(s):

Naima Said Sheikh ◽

Abdi Gele

Keyword(s):

Job Satisfaction ◽

Maternal Health ◽

Health Worker ◽

Health Workers ◽

Sub Saharan Africa ◽

Targeted Interventions ◽

Health Worker Motivation ◽

Tertiary Hospitals ◽

Worker Motivation ◽

Intrinsic Job Satisfaction

Abstract Background: Motivated health workers play an important role in delivering high-quality maternal health services, especially in low-income countries where maternal mortality rates are high, and shortages of human resource for health is prevalent. The aim of this study is to investigate the motivation of maternal health workers in three tertiary hospitals in Mogadishu Somalia. Method: To investigate health worker motivation in Somalia, we used a semi-structured questionnaire that was validated and widely used in Sub-Saharan Africa. Data were collected from 220 health workers across three tertiary hospitals in Mogadishu between February and April 2020. Health worker motivation was measured using seven constructs: general motivation, burnout, job satisfaction, intrinsic job satisfaction, organizational commitment, conscientiousness, timeliness and attendance. A multivariate regression analysis was performed to determine the predictors of health worker motivation. Results: The study found that male health workers have a higher work motivation, with a mean score of 92.75 (SD 21.31) versus 90.43 (SD 21.61) in women. A significant correlation was found between health workers motivation and being an assistant, nurse, physician, pediatric-assistant, midwife, supervisor and pharmacist. Unexpectedly, the gynecologists and midwives were the least motivated groups among the different professions, with mean scores of 83.63, (SD: 27.41) and 86.95 (SD: 21.08), respectively. Of the aforementioned seven motivation constructs, the highest mean motivation scores (from 1-5) were observed in conscientiousness and intrinsic job satisfaction. Conclusion: The results highlight the importance of targeted interventions that increase the motivation of female health workers, particularly gynecologists and midwives in Somalia. This can be done by providing non-financial incentives, in addition to encouraging their participation in the decision-making process. Further research is needed to investigate the effect of a lack of motivation among gynecologists and midwives on maternal health in Somalia.

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The relationship between leadership style and health worker motivation, job satisfaction and teamwork in Uganda

Journal of Healthcare Leadership ◽

10.2147/jhl.s147885 ◽

2018 ◽

Vol Volume 10 ◽

pp. 21-32 ◽

Cited By ~ 8

Author(s):

Conrad Musinguzi ◽

Leticia Namale ◽

Elizeus Rutebemberwa ◽

Aruna Dahal ◽

Patricia Nahirya-Ntege ◽

...

Keyword(s):

Job Satisfaction ◽

Health Worker ◽

Leadership Style ◽

Health Worker Motivation ◽

Worker Motivation ◽

The Relationship

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Scoping review assessing the evidence used to support the adoption of mobile health (mHealth) technologies for the education and training of community health workers (CHWs) in low-income and middle-income countries

BMJ Open ◽

10.1136/bmjopen-2017-019827 ◽

2018 ◽

Vol 8 (7) ◽

pp. e019827 ◽

Cited By ~ 12

Author(s):

Niall Winters ◽

Laurenz Langer ◽

Anne Geniets

Keyword(s):

Systematic Reviews ◽

Scoping Review ◽

Low Income ◽

Health Workers ◽

Education And Training ◽

Evidence Base ◽

Mobile Technologies ◽

Middle Income ◽

And Training ◽

Formal Theories

ObjectivesUndertake a systematic scoping review to determine how a research evidence base, in the form of existing systematic reviews in the field of mobile health (mHealth), constitutes education and training for community health workers (CHWs) who use mobile technologies in everyday work. The review was informed by the following research questions: does educational theory inform the design of the education and training component of mHealth interventions? How is education and training with mobile technology by CHWs in low-income and middle-income countries categorised by existing systematic reviews? What is the basis for this categorisation?SettingThe review explored the literature from 2000 to 2017 to investigate how mHealth interventions have been positioned within the available evidence base in relation to their use of formal theories of learning.ResultsThe scoping review found 24 primary studies that were categorised by 16 systematic reviews as supporting CHWs’ education and training using mobile technologies. However, when formal theories of learning from educational research were used to recategorise these 24 primary studies, only four could be coded as such. This identifies a problem with how CHWs’ education and training using mobile technologies is understood and categorised within the existing evidence base. This is because there is no agreed on, theoretically informed understanding of what counts as learning.ConclusionThe claims made by mHealth researchers and practitioners regarding the learning benefits of mobile technology are not based on research results that are underpinned by formal theories of learning. mHealth suffers from a reductionist view of learning that underestimates the complexities of the relationship between pedagogy and technology. This has resulted in miscategorisations of what constitutes CHWs’ education and training within the existing evidence base. This can be overcome by informed collaboration between the health and education communities.

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Determinants and consequences of health worker motivation in hospitals in Jordan and Georgia

Social Science & Medicine ◽

10.1016/s0277-9536(03)00203-x ◽

2004 ◽

Vol 58 (2) ◽

pp. 343-355 ◽

Cited By ~ 107

Author(s):

Lynne Miller Franco ◽

Sara Bennett ◽

Ruth Kanfer ◽

Patrick Stubblebine

Keyword(s):

Health Worker ◽

Health Worker Motivation ◽

Worker Motivation

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How primary healthcare workers obtain information during consultations to aid safe prescribing in low-income and lower middle-income countries: a systematic review

BMJ Global Health ◽

10.1136/bmjgh-2019-002094 ◽

2020 ◽

Vol 5 (4) ◽

pp. e002094 ◽

Cited By ~ 1

Author(s):

Chris Smith ◽

Michelle Helena van Velthoven ◽

Nguyen Duc Truong ◽

Nguyen Hai Nam ◽

Vũ Phan Anh ◽

...

Keyword(s):

Low Income ◽

Primary Healthcare ◽

Healthcare Workers ◽

Health Workers ◽

Internet Access ◽

Sources Of Information ◽

Quality Of Reporting ◽

Middle Income ◽

Middle Income Countries ◽

Registration Number

BackgroundWe systematically reviewed the evidence on how primary healthcare workers obtain information during consultations to support decision-making for prescribing in low and lower middle-income countries.MethodsWe searched electronic databases, consulted the Healthcare Information For All network, hand searched reference lists, ran citation searches of included studies and emailed authors of identified papers. Two reviewers extracted data and appraised quality with relevant tools.ResultsOf 60 497 records found, 23 studies met our inclusion criteria. Fourteen studies were observational and nine were interventional. Frequently mentioned sources of information were books, leaflets, guidelines, aids and the internet. These sources were sometimes out of date and health workers reported being confused which to use. Internet access varied and even when it was available, use was limited by technical issues. Of the five electronic tools that were assessed, four had positive outcomes. Tools assisted prescribers with medicine selection and dosage calculations, which increased prescribing accuracy. The quality of reporting varied but was overall low.DiscussionStudies indicated a lack of up-to-date and relevant medicine information in low and lower middle-income settings. Internet-based sources appeared to be useful when it is possible to download content for offline use and to update when there is internet access. Electronic tools showed promise, but their accuracy needs to be validated and they should focus on giving actionable advice to guide prescribers.PROSPERO registration numberCRD42018091088.

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Barriers and facilitators of implementation of a community cardiovascular disease prevention programme in Mukono and Buikwe districts in Uganda using the Consolidated Framework for Implementation Research

Implementation Science ◽

10.1186/s13012-020-01065-0 ◽

2020 ◽

Vol 15 (1) ◽

Author(s):

Rawlance Ndejjo ◽

Rhoda K. Wanyenze ◽

Fred Nuwaha ◽

Hilde Bastiaens ◽

Geofrey Musinguzi

Keyword(s):

Cardiovascular Disease ◽

Low Income ◽

Implementation Research ◽

Health Workers ◽

Scale Up ◽

Barriers And Facilitators ◽

Prevention Programme ◽

Intervention Implementation ◽

Design Quality ◽

Middle Income

Abstract Background In low- and middle-income countries, there is an increasing attention towards community approaches to deal with the growing burden of cardiovascular disease (CVD). However, few studies have explored the implementation processes of such interventions to inform their scale up and sustainability. Using the consolidated framework for implementation research (CFIR), we examined the barriers and facilitators influencing the implementation of a community CVD programme led by community health workers (CHWs) in Mukono and Buikwe districts in Uganda. Methods This qualitative study is a process evaluation of an ongoing type II hybrid stepped wedge cluster trial guided by the CFIR. Data for this analysis were collected through regular meetings and focus group discussions (FGDs) conducted during the first cycle (6 months) of intervention implementation. A total of 20 CHWs participated in the implementation programme in 20 villages during the first cycle. Meeting reports and FGD transcripts were analysed following inductive thematic analysis with the aid of Nvivo 12.6 to generate emerging themes and sub-themes and thereafter deductive analysis was used to map themes and sub-themes onto the CFIR domains and constructs. Results The barriers to intervention implementation were the complexity of the intervention (complexity), compatibility with community culture (culture), the lack of an enabling environment for behaviour change (patient needs and resources) and mistrust of CHWs by community members (relative priority). In addition, the low community awareness of CVD (tension for change), competing demands (other personal attributes) and unfavourable policies (external policy and incentives) impeded intervention implementation. On the other hand, facilitators of intervention implementation were availability of inputs and protective equipment (design quality and packaging), training of CHWs (Available resources), working with community structures including leaders and groups (process—opinion leaders), frequent support supervision and engagements (process—formally appointed internal implementation leaders) and access to quality health services (process—champions). Conclusion Using the CFIR, we identified drivers of implementation success or failure for a community CVD prevention programme in a low-income context. These findings are key to inform the design of impactful, scalable and sustainable CHW programmes for non-communicable diseases prevention and control.

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Quality assurance systems of pharmaceutical distributors in low-income and middle-income countries: weaknesses and ways forward

BMJ Global Health ◽

10.1136/bmjgh-2020-003147 ◽

2020 ◽

Vol 5 (10) ◽

pp. e003147

Author(s):

Ariadna Nebot Giralt ◽

Anthony Bourasseau ◽

Gareth White ◽

Corinne Pouget ◽

Patricia Tabernero ◽

...

Keyword(s):

Quality Assurance ◽

Low Income ◽

Poor Quality ◽

Health Coverage ◽

Quality Systems ◽

Model Quality ◽

Convenience Sample ◽

Middle Income ◽

For Profit ◽

Middle Income Countries

IntroductionAccess to quality-assured medicines is an essential prerequisite for universal health coverage, and pharmaceutical distributors play an important role to assure the quality of medicines along the supply chain.MethodsWe retrospectively assessed the compliance with WHO quality standards, that is, the Model Quality Assurance System for Procurement Agencies (MQAS) or the good distribution practices (GDP), of a convenience sample of 75 public, private-for-profit and non-for-profit distributors, audited by QUAMED in 14 low-income and middle-income countries (LMICs) between 2017 and 2019. We calculated the compliance per quality assurance activity, and we defined the percentage of compliant distributors, that is, the percentage (%) of distributors with MQAS or GDP levels of >2 for each activity.ResultsThe distributors in our sample were mainly private for-profit (66/75). Only one MQAS-audited distributor out of 11 was found compliant with all MQAS-activities, while none out of 64 GDP-assessed distributors were found compliant with all GDP activities. The GDP-assessed distributors were generally less compliant with WHO standards than MQAS-audited distributors. Common weaknesses and strengths were observed. The activities with lowest compliance were quality control, and physical storage conditions, while those with highest compliance were warehouse organisation and stock control.ConclusionsThe quality systems of pharmaceutical distributors in LMICs remain weak. For preventing harm caused by poor-quality medicines, a comprehensive and stringent regulatory oversight should be urgently implemented; the WHO MQAS-standards and GDP-standards should be incorporated in national regulations; and reliable information on the quality systems of distributors (and manufacturers from which they buy) should be publicly available.

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