Balancing workload, motivation and job satisfaction in Rwanda: assessing the effect of adding family planning service provision to community health worker duties

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.

Community health workers' quality of comprehensive care: a cross-sectional observational study across three districts in South Africa

Background

Community healthcare worker (CHW) training programs are becoming increasingly comprehensive (an expanded range of diseases). However, the CHWs that the program relies on have limited training. Since CHWs' activities occur largely during household visits, which often go unsupervised and unassessed, long-term, ongoing assessment is needed to identify gaps in CHW competency, and improve any such gaps. We observed CHWs during household visits and gave scores according to the proportion of health messages/activities provided for the health conditions encountered in households. We aimed to determine (1) messages/activities scores derived from the proportion of health messages given in the households by CHWs who provide comprehensive care in South Africa, and (2) the associated factors.

Methods

In three districts (from two provinces), we trained five fieldworkers to score the messages provided by, and activities of, 34 CHWs that we randomly selected during 376 household visits in 2018 and 2020 using a cross-sectional study designs. Multilevel models were fitted to identify factors associated with the messages/activities scores, adjusted for the clustering of observations within CHWs. The models were adjusted for fieldworkers and study facilities (n = 5, respectively) as fixed effects. CHW-related (age, education level, and phase of CHW training attended/passed) and household-related factors (household size [number of persons per household], number of conditions per household, and number of persons with a condition [hypertension, diabetes, HIV, tuberculosis TB, and cough]) were investigated.

Results

In the final model, messages/activities scores increased with each extra 5-min increase in visit duration. Messages/activities scores were lower for households with either children/babies, hypertension, diabetes, a large household size, numerous household conditions, and members with either TB or cough. Increasing household size and number of conditions, also lower the score. The messages/activities scores were not associated with any CHW characteristics, including education and training.

Conclusion

This study identifies important factors related to the messages provided by and the activities of CHWs across CHW teams. Increasing efforts are needed to ensure that CHWs who provide comprehensive care are supported given the wider range of conditions for which they provide messages/activities, especially in households with hypertension, diabetes, TB/cough, and children or babies.

Urban-rural differences in health service-related factors associated with male involvement in family planning services in Abia State, Southeastern Nigeria

Objective

To identify and compare the health service-related factors associated with male involvement in family planning services among the rural and urban areas in Abia State, Nigeria.

Design

A community-based cross-sectional study.

Setting

Twelve communities (six urban and six rural) in Abia State, Nigeria.

Participants

Five hundred and eighty-eight (588) men aged 15-59 years and resident in the study area 6 months before the study were recruited.

Main outcome measure

Male involvement in family planning services.

Results

The mean ages of the respondents were 41.8±8.0 years and 43.1±8.0 years in the urban and rural areas, respectively. Active male involvement in family planning services was significantly higher in urban areas (62.6%, 95%CI: 56.8%-68.1%) compared to the rural areas (47.6%, 95%CI: 41.5%-53.2%. p<0.001). The predictors of male involvement included gender preference of healthcare workers (aOR=1.75, 95%CI:1.01-3.03) and attitude of the healthcare workers (aOR=2.07, 95%CI:1.17-3.67) among the urban participants, compared to occupational status of the respondents (aOR=2.50, 95% CI: 1.16-5.56) and the availability of male-friendly clinics (aOR=2.27, 95%CI:1.25-4.15) among the rural participants.

Conclusion

Health service-related factors associated with male involvement varied between the urban and rural settings. Stakeholders should target addressing health service-related factors by types of settlement while designing family planning programs targeting men.

Funding

No funding was obtained for this study.

Assessing the Utility of a Quality-of-Care Assessment Tool Used in Assessing Comprehensive Care Services Provided by Community Health Workers in South Africa

Background

Few studies exist on the tools for assessing quality-of-care of community health worker (CHW) who provide comprehensive care, and for available tools, evidence on the utility is scanty. We aimed to assess the utility components of a previously-reported quality-of-care assessment tool developed for summative assessment in South Africa.

Methods

In two provinces, we used ratings by 21 CHWs and three team leaders in two primary health care facilities per province regarding whether the tool covered everything that happens during their household visits and whether they were happy to be assessed using the tool (acceptability and face validity), to derive agreement index (≥85%, otherwise the tool had to be revised). A panel of six experts quantitatively validated 11 items of the tool (content validity). Content validity index (CVI), of individual items (I-CVI) or entire scale (S-CVI), should be >80% (excellent). For the inter-rater reliability (IRR), we determined agreement between paired observers' assigned quality-of-care messages and communication scores during 18 CHW household visits (nine households per site). Bland and Altman plots and multilevel model analysis, for clustered data, were used to assess IRR.

Results

In all four CHW and team leader sites, agreement index was ≥85%, except for whether they were happy to be assessed using the tool, where it was <85% in one facility. The I-CVI of the 11 items in the tool ranged between 0.83 and 1.00. For the S-CVI, all six experts agreed on relevancy (universal agreement) in eight of 11 items (0.72) whereas the average of I-CVIs, was 0.95. The Bland-Altman plot limit of agreements between paired observes were −0.18 to 0.44 and −0.30 to 0.44 (messages score); and −0.22 to 0.45 and −0.28 to 0.40 (communication score). Multilevel modeling revealed an estimated reliability of 0.77 (messages score) and 0.14 (communication score).

Conclusion

The quality-of-care assessment tool has a high face and content validity. IRR was substantial for quality-of-care messages but not for communication score. This suggests that the tool may only be useful in the formative assessment of CHWs. Such assessment can provide the basis for reflection and discussion on CHW performance and lead to change.

Analysis of factors affecting medical personnel seeking employment at primary health care institutions: developing human resources for primary health care

BACKGROUND

The serious shortage of human resources for primary health care (PHC) is a common issue in health reforms worldwide. China has proposed that it is an effective way to encourage and guide qualified medical personnel to work in primary health care institutions (PHCIs). However, few studies have been conducted on the willingness and influencing factors of medical personnel to seek employment at PHCIs.

METHODS

Based on implicit theory and lexical approach, pre-investigation was conducted to collect the items that influence the medical personnel to seek employment at PHCIs from the perspective of guided objects. Through a three-phase investigation of 1160 doctors in 29 public hospitals in 9 cities, the items were categorized, and a structural equation model was established and verified to explore the interrelationship of influencing factors.

RESULTS

A total of 6 factors were rotated, including Sense of Gain (SG), Internal Organization Development (IOD), Remuneration and Development (RD), Condition of the City Where the PHCI Is Located (CCPL), Job Responsibilities (JR) and Family Support (FS). The results of the model showed that IOD, RD, JR and FS had a significantly positive effect on the SG. In addition, the FS, RD and JR significantly mediated the relationship between the internal and external environment of PHCIs and SG. The values of the fit index indicated an acceptable-fitting model.

CONCLUSION

Family, remuneration, individual development, and job responsibility are closely related to the willingness of medical personnel to seek employment at PHCIs, and the internal and external environment of PHCIs is also an important factor. Therefore, the development of PHC providers can be promoted by paying attention to the family members of medical personnel, establishing a reasonable remuneration system, providing suitable development opportunities, arranging work rationally and improving the internal construction of PHCIs.

A New Perspective for Improving the Human Resource Development of Primary Medical and Health Care Institutions: A Structural Equation Model Study

In some countries, including China, primary health care is rarely utilized because of medical personnel shortages at primary medical and health care institutions (PMHCIs). Several studies suggest that the most effective solution is to guide qualified doctors and medical graduates to work in PMHCIs, but the studies and measures have been formulated only from the perspective of the government and PMHCIs; few have considered the subjective willingness of medical personnel. Therefore, it is necessary to explore the measures to develop human resources of PMHCIs from the guiding object. This research was divided into two parts based on implicit theory and a lexical approach. The first part collected the factors affecting their choosing PMHCIs for employment, and the second part used exploratory factor analysis (EFA), confirmatory factor analysis (CFA), and structural equation modeling (SEM) to explore the dimensions and paths of the influencing factors. At last, seven factors were obtained from the EFA, and the SEM hypothesis fit the data well. Internal Organization Development, Patient Factor, Remuneration and Development, and Family Support had a significantly positive effect on the Sense of Gain of medical personnel seeking employment at PMHCIs, whereas both Job Responsibilities and Condition of the City Where the PMHCI Is Located had no significant effect. In addition, the indirect effects of Internal Organization Development and Condition of the City Where the PMHCI Is Located on the Sense of Gain were significant. The Patient Factor, Family Support, and Remuneration and Development significantly mediated the relationship between the internal and external environment of the institution and the Sense of Gain, whereas the mediating effect of Job Responsibilities was not significant. The improvement of family support, remuneration and development, and patient factors increase the willingness of medical personnel to seek employment at PMHCIs. In addition, the internal and external environments of a PMHCI play a vital role in guiding medical personnel to PMHCIs for employment. This research provides theoretical support for improving the development of human resources, guiding medical personnel to work in PMHCIs, and promoting the use of primary care services.

Equity for health delivery: Opportunity costs and benefits among Community Health Workers in Rwanda

Community Health Workers (CHWs) play a vital role delivering health services to vulnerable populations in low resource settings. In Rwanda, CHWs provide village-level care focused on maternal/child health, control of infectious diseases, and health education, but do not receive salaries for these services. CHWs make up the largest single group involved in health delivery in the country; however, limited information is available regarding the socio-economic circumstances and satisfaction levels of this workforce. Such information can support governments aiming to control infectious diseases and alleviate poverty through enhanced healthcare delivery. The objectives of this study were to (1) evaluate CHW opportunity costs, (2) identify drivers for CHW motivation, job satisfaction and care provision, and (3) report CHW ideas for improving retention and service delivery. In this mixed-methods study, our team conducted in-depth interviews with 145 CHWs from three districts (Kirehe, Kayonza, Burera) to collect information on household economics and experiences in delivering healthcare. Across the three districts, CHWs contributed approximately four hours of volunteer work per day (range: 0-12 hrs/day), which translated to 127 684 RWF per year (range: 2 359-2 247 807 RWF/yr) in lost personal income. CHW out-of-pocket expenditures (e.g. patient transportation) were estimated at 36 228 RWF per year (range: 3 600-364 800 RWF/yr). Participants identified many benefits to being CHWs, including free healthcare training, improved social status, and the satisfaction of helping others. They also identified challenges, such as aging equipment, discrepancies in financial reimbursements, poverty, and lack of formal workspaces or working hours. Lastly, CHWs provided perspectives on reasonable and feasible improvements to village-level health programming that could improve conditions and equity for those providing and using the CHW system.

Household coverage, quality and costs of care provided by community health worker teams and the determining factors: findings from a mixed methods study in South Africa

OBJECTIVE

Community health workers (CHWs) are undertaking more complex tasks as part of the move towards universal health coverage in South Africa. CHW programmes can improve access to care for vulnerable communities, but many such programmes struggle with insufficient supervision. In this paper, we assess coverage (proportion of households visited by a CHW in the past year and month), quality of care and costs of the service provided by CHW teams with differing configurations of supervisors, some based in formal clinics and some in community health posts.

PARTICIPANTS

CHW, their supervisors, clinic staff, CHW clients.

METHODS

We used mixed methods (a random household survey, focus group discussions, interviews and observations of the CHW at work) to examine the performance of six CHW teams in vulnerable communities in Sedibeng, South Africa.

RESULTS

A CHW had visited 17% of households in the last year, and we estimated they were conducting one to two visits per day. At household registration visits, the CHW asked half of the questions required. Respondents remembered 20%-25% of the health messages that CHW delivered from a visit in the last month, and half of the respondents took the action recommended by the CHW. Training, supervision and motivation of the CHW, and collaboration with other clinic staff, were better with a senior nurse supervisor. We estimated that if CHW carried out four visits a day, coverage would increase to 30%-90% of households, suggesting that some teams need more CHW, as well as better supervision.

CONCLUSION

Household coverage was low, and the service was limited. Support from the local facility was key to providing a quality service, and a senior supervisor facilitated this collaboration. Greater investment in numbers of CHW, supervisors, training and equipment is required for the potential benefits of the programme to be delivered.

Determinants of Motivation among Healthcare Workers in the East African Community between 2009-2019: A Systematic Review

Healthcare workers are an essential element in the functionality of the health system. However, the health workforce impact on health systems tends to be overlooked. Countries within the Sub-Saharan region such as the six in the East African Community (EAC) have weak and sub-optimally functioning health systems. As countries globally aim to attain Universal Health Coverage and the Sustainable Development Goal 3, it is crucial that the significant role of the health workforce in this achievement is recognized. In this systematic review, we aimed to synthesise the determinants of motivation as reported by healthcare workers in the EAC between 2009 and 2019. A systematic search was performed using four databases, namely Cochrane library, EBSCOhost, ProQuest and PubMed. The eligible articles were selected and reviewed based on the authors' selection criteria. A total of 30 studies were eligible for review. All six countries that are part of the EAC were represented in this systematic review. Determinants as reported by healthcare workers in six countries were synthesised. Individual-level-, organizational/structural- and societal-level determinants were reported, thus revealing the roles of the healthcare worker, health facilities and the government in terms of health systems and the community or society at large in promoting healthcare workers' motivation. Monetary and non-monetary determinants of healthcare workers' motivation reported are crucial for informing healthcare worker motivation policy and health workforce strengthening in East Africa.

Motivational interviewing to promote long-acting reversible contraception among Rwandan couples wishing to prevent or delay pregnancy

BACKGROUND

Few family-planning programs in Africa base demand creation and service delivery on theoretical models. Motivational interviewing is a counseling modality that facilitates reflection on the benefits and disadvantages of a health outcome to encourage behavior change.

OBJECTIVES

We evaluate a couples-focused joint family-planning and HIV counseling intervention using motivational interviewing to enhance uptake of long-acting reversible contraception (Paragard copper intrauterine device or Jadelle hormonal implant) among Rwandan couples.

STUDY DESIGN

In this experimental study, couples receiving care at 8 government health clinics in Kigali, the capital city, were referred from a parent study of couples who did not want more children or wanted to wait at least 2 years for their next pregnancy. Long-acting reversible contraception methods were offered on site following joint HIV testing and family-planning counseling. At the first follow-up visit 1 month after enrollment in the parent study, couples who had not yet chosen a long-acting reversible contraception method were interviewed separately using motivational interviewing and then brought together and again offered long-acting reversible contraception.

RESULTS

Following motivational interviewing, 78 of 229 couples (34%) requested a long-acting reversible contraception method (68 implant and 10 intrauterine device). Long-acting reversible contraception uptake after motivational interviewing was associated with the woman being Catholic (vs Protestant/Muslim/other, adjusted odds ratio, 2.87, 95% confidence interval, 1.19-6.96, P = .019) or having an income (vs no income, adjusted odds ratio, 2.54, 95% confidence interval, 1.12-5.73, P = .025); the couple having previously discussed long-acting reversible contraception (adjusted odds ratio, 8.38, 95% confidence interval, 2.54-27.59, P = .0005); either partner believing that unplanned pregnancy was likely with their current method (adjusted odds ratio, 6.67, 95% confidence interval, 2.77-16.11, P < .0001); or that they might forget to take or make an appointment for their current method (adjusted odds ratio, 4.04, 95% confidence interval, 1.32-12.34, P = .014). Neither partner mentioning that condoms also prevent HIV/sexually transmitted infection was associated with long-acting reversible contraception uptake (adjusted odds ratio, 2.86, 95% confidence interval, 1.17-7.03, P = .022), as was the woman citing long-term duration of action of the implant as an advantage (adjusted odds ratio, 5.41, 95% confidence interval, 1.86-15.76, P = .002). The woman not listing any side effects or disadvantages of implants was associated with long-acting reversible contraception uptake (adjusted odds ratio, 5.42, 95% confidence interval, 2.33-12.59, P < .0001). Clinic location (rural vs urban), couple HIV status, and concerns about negative economic effects of an unplanned pregnancy were significant in bivariate but not multivariate analysis.

CONCLUSION

Encouraging couples to reflect on the benefits and disadvantages of long-acting reversible contraception methods, the likelihood of unplanned pregnancy with their current contraception, and the impact of an unplanned pregnancy is an effective motivational interviewing technique in family-planning counseling. One third of couples who did not want a pregnancy for at least 2 years but had not chosen a long-acting reversible contraception method when provided with standard family-planning counseling did so after motivational interviewing. Involving the male partner in family-planning discussions facilitates joint decision making about fertility goals and contraceptive choice. Combining family planning and joint HIV testing for couples allows targeted focus on dual-method use with discordant couples, who are advised to use condoms for HIV/sexually transmitted infection prevention along with a more effective contraceptive for added protection against unplanned pregnancy.

"Because Even the Person Living With HIV/AIDS Might Need to Make Babies" - Perspectives on the Drivers of Feasibility and Acceptability of an Integrated Community Health Worker Model in Iringa, Tanzania

Background: Countries with health workforce shortages are increasingly turning to multipurpose community health workers (CHWs) to extend integrated services to the community-level. However, there may be tradeoffs with the number of tasks a CHW can effectively perform before quality and/or productivity decline. This qualitative study was conducted within an existing program in Iringa, Tanzania where HIV-focused CHWs working as volunteers received additional training on maternal, newborn, and child health (MNCH) promotion, thereby establishing a dual role CHW model.

Methods: To evaluate the feasibility and acceptability of the combined HIV/MNCH CHW model, qualitative in-depth interviews (IDIs) with 36 CHWs, 21 supervisors, and 10 program managers were conducted following integration of HIV and MNCH responsibilities (n=67). Thematic analysis explored perspectives on task planning, prioritization and integration, workload, and the feasibility and acceptability of the dual role model. Interview data and field observations were also used to describe implementation differences between HIV and MNCH roles as a basis for further contextualizing the qualitative findings.

Results: Perspectives from a diverse set of stakeholders suggested provision of both HIV and MNCH health promotion by CHWs was feasible. Most CHWs attempted to balance HIV/MNCH responsibilities, although some prioritized MNCH tasks. An increased workload from MNCH did not appear to interfere with HIV responsibilities but drew time away from other income-generating activities on which volunteer CHWs rely. Satisfaction with the dual role model hinged on increased community respect, gaining new knowledge/skills, and improving community health, while the remuneration-level caused dissatisfaction, a complaint that could challenge sustainability.

Conclusions: Despite extensive literature on integration, little research at the community level exists. This study demonstrated CHWs can feasibly balance HIV and MNCH roles, but not without some challenges related to the heavier workload. Further research is necessary to determine the quality of health promotion in both HIV and MNCH domains, and whether the dual role model can be maintained over time among these volunteers.

Community health worker promotions increase uptake of long-acting reversible contraception in Rwanda

BACKGROUND

We coordinated community health worker (CHW) promotions with training and support of government clinic nurses to increase uptake of long-acting reversible contraception (LARC), specifically the copper intrauterine device (IUD) and the hormonal implant, in Kigali, Rwanda.

METHODS

From August 2015 to September 2016, CHW provided fertility goal-based family planning counseling focused on LARC methods, engaged couples in family planning counseling, and provided written referrals to clients expressing interest in LARC methods. Simultaneously, we provided didactic and practical training to clinic nurses on LARC insertion and removal. We evaluated: 1) aggregate pre- versus post-implementation LARC uptake as a function of CHW promotions, and 2) demographic factors associated with LARC uptake among women responding to CHW referrals.

RESULTS

7712 referrals were delivered by 184 CHW affiliated with eight government clinics resulting in 6072 family planning clinic visits (79% referral uptake). 95% of clinic visits resulted in LARC uptake (16% copper IUD, 79% hormonal implant). The monthly average for IUD insertions doubled from 29 prior to service implementation to 61 after (p < 0.0001), and the monthly average for implant insertions increased from 109 to 309 (p < 0.0001). In adjusted analyses, LARC uptake was associated (p < 0.05) with the CHW referral being issued to the couple (versus the woman alone, adjusted odds ratio, aOR = 2.6), having more children (aOR = 1.3), desiring more children (aOR = 0.8), and having a religious affiliation (aOR = 2.9 Protestant, aOR = 3.1 Catholic, aOR = 2.5 Muslim each versus none/other). Implant versus non-LARC uptake was associated with having little or no education; meanwhile, having higher education was associated with IUD versus implant uptake.

CONCLUSIONS

Fertility goal-based and couple-focused family planning counseling delivered by CHW, coupled with LARC training and support of nursing staff, substantially increased uptake of LARC methods.

Expanding Understanding of Community Health Worker Programs: A Cross-Sectional Survey on the Work, Satisfaction, and Livelihoods of CHWs in Madagascar

With health worker shortages in rural areas, community health workers (CHWs) are instrumental to the sustainability of primary health care and to the ability to meet health needs. Identifying appropriate operational models and incentive structures is an important element of long-term success. This article reports on CHWs’ work demands and affective response to their volunteer work within the broader context of their livelihoods in Madagascar. A cross-sectional survey of 874 CHWs, called Agents de Santé Communautaire (ACs), from 14 districts across 5 regions was conducted in June 2015. Only 44% of ACs had cash savings. Subsistence farming was the main livelihood strategy; ninety-two percent of ACs were food insecure and 89% had experienced a shock in the past year. Overall, 77% of ACs financed commodity resupply through sales of health products and 18% from their personal savings; stock-outs at point of supply and financial and time constraints were the main reported challenges in getting health products. The average satisfaction score with AC work was 3 out of 4. This assessment from Madagascar helps unveil a more comprehensive view of the reality of CHWs’ lives. Managers need to take into account the potential implications of the demands of CHW work on already precarious livelihoods.

An intervention to improve provider-patient interaction at methadone maintenance treatment in China

BACKGROUND

This study evaluated an intervention aiming to improve methadone maintenance therapy (MMT) service providers' interaction with their patients in China.

METHODS

Sixty-eight MMT clinics were randomized to either an intervention or a control condition. Providers in the intervention group attended three group training sessions to enhance their communication skills. Trained providers were encouraged to practice the taught communication skills through provider-initiated individual sessions with their patients. A total of 418 service providers completed assessments from baseline to 24-month. Linear mixed-effects regression models were used to compare self-reported short-term and sustained improvement in provider-patient interaction between the intervention and the control conditions.

RESULTS

The intervention group service providers perceived significantly greater short-term and sustained improvement in provider-patient interaction compared to the control group service providers (estimated difference (±SE): 1.20 (0.24) and 1.35 (0.33), respectively; p-values < 0.0001). Providers' baseline job satisfaction was significantly associated with a greater perceived improvement in provider-patient interaction for both periods (reg. coef. (±SE): 0.02 (0.01) and 0.04 (0.01) for short-term and sustained periods, respectively; p-values < 0.01).

CONCLUSION

Study findings suggest that the intervention could be beneficial for improving perceived provider-patient interaction in MMT programs. Service providers' job satisfaction should be addressed in training programs for the improvement of provider-patient interaction.

Job satisfaction among anesthetists in Ethiopia-a national cross-sectional study

BACKGROUND

Ethiopia has substantially increased production of associate clinician anesthetists. This study aimed to determine the level of and factors that predict job satisfaction among a national sample of anesthetists.

METHODS

A cross-sectional study conducted in 2014 sampled 252 anesthetists. Respondents rated 37 items related to job satisfaction and working and living conditions using a Likert scale, which ranged from 1 (strongly disagree) to 5 (strongly agree). Univariate and multivariable logistic regressions were used to determine factors associated with the main outcome variable, level of job satisfaction. Adjusted odds ratios and 95% confidence intervals were calculated to show the magnitude of associations.

RESULTS

Less than half (n = 107, 42.5%) of anesthetists were satisfied with their job. Work environment (aOR = 1.87, 95% CI = 1.06, 3.31) and more than 10 years of experience working in the public health system (aOR = 4.96, 95% CI = 1.11, 22.13) were predictors of job satisfaction in the multivariable model.

CONCLUSION

Ethiopian anesthetists have low levels of job satisfaction, with work environment and years of experience being factors that predict their satisfaction positively. Motivation and retention of this cadre will require emphasis on creating a safe and conducive work environment, and interventions designed to motivate junior anesthetists.

Assessing the Competency and Acceptability of Community Health Worker Provision of Standard Days Method® in Family Planning Services in Gisagara District, Rwanda

This study assesses the competency and acceptability of community-based provision of Standard Days Method^® (SDM) to first-time users in Rwanda. The national strategy equips community health workers (CHWs) to resupply pills, injectables and condoms to existing clients. With the aim of expanding access, SDM provision to first-time users was added to the method mix in Gisagara district and assessed with a 12 month prospective, mixed methods study. Thirty percent of SDM clients had never used a method of family planning and 58 percent had not been using a method for at least three months. Eighty-seven percent of CHWs correctly screened clients to use SDM and 92 percent accurately explained how to use CycleBeads to prevent pregnancy. After being counseled by the CHWs, 89 percent of clients reported knowledge of all key steps required in using SDM to prevent pregnancy. Nearly all SDM clients (99 percent) believed that CHWs were able to counsel them adequately. These results suggest that CHWs were able to offer SDM as part of their family planning responsibilities, and the study adds to the evidence on the role of CHWs in expanding contraceptive access and choice.

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

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.