Supportive supervision and constructive relationships with healthcare workers support CHW performance: Use of a qualitative framework to evaluate CHW programming in Uganda

Teralynn Ludwick,Teddy Kyomuhangi,Sheila Robinson,Eleanor Turyakira,Kimberly Manalili,Jennifer L Brenner

doi:10.1186/s12960-018-0272-1

Abstract

BackgroundWhile evidence supports community health worker (CHW) capacity to improve maternal and newborn health in less-resourced countries, key implementation gaps remain. Tools for assessing CHW performance and evidence on what programmatic components affect performance are lacking. This study developed and tested a qualitative evaluative framework and tool to assess CHW team performance in a district program in rural Uganda.MethodsA new assessment framework was developed to collect and analyze qualitative evidence based on CHW perspectives on seven program components associated with effectiveness (selection; training; community embeddedness; peer support; supportive supervision; relationship with other healthcare workers; retention and incentive structures). Focus groups were conducted with four high/medium-performing CHW teams and four low-performing CHW teams selected through random, stratified sampling. Content analysis involved organizing focus group transcripts according to the seven program effectiveness components, and assigning scores to each component per focus group.ResultsFour components, ‘supportive supervision’, ‘good relationships with other healthcare workers’, ‘peer support’, and ‘retention and incentive structures’ received the lowest overall scores. Variances in scores between ‘high’/‘medium’- and ‘low’-performing CHW teams were largest for ‘supportive supervision’ and ‘good relationships with other healthcare workers.’ Our analysis suggests that in the Bushenyi intervention context, CHW team performance is highly correlated with the quality of supervision and relationships with other healthcare workers. CHWs identified key performance-related issues of absentee supervisors, referral system challenges, and lack of engagement/respect by health workers. Other less-correlated program components warrant further study and may have been impacted by relatively consistent program implementation within our limited study area.ConclusionsApplying process-oriented measurement tools are needed to better understand CHW performance-related factors and build a supportive environment for CHW program effectiveness and sustainability. Findings from a qualitative, multi-component tool developed and applied in this study suggest that factors related to (1) supportive supervision and (2) relationships with other healthcare workers may be strongly associated with variances in performance outcomes within a program. Careful consideration of supervisory structure and health worker orientation during program implementation are among strategies proposed to increase CHW performance.

Highlights

While evidence supports community health worker (CHW) capacity to improve maternal and newborn health in less-resourced countries, key implementation gaps remain
Study design While the literature identifies various factors related to CHW performance, the relative impact of these factors on performance is not clear? What elements of the CHW system have the greatest impact on performance? A conceptual framework for CHW effectiveness and rating tool was developed and applied in this study to test its usage in comparing the performance of CHW teams and generating evidence on factors that contribute to variances in CHW team performance
Our study found that components related to ‘supportive supervision’ and ‘good relationships with other healthcare workers’ were most important in differentiating performance levels of CHW teams

Summary

Introduction

While evidence supports community health worker (CHW) capacity to improve maternal and newborn health in less-resourced countries, key implementation gaps remain. Insufficient space is given to CHW voices as part of evidence-gathering and assessment processes [8] Recognizing this gap, there is a need to better identify which system- and program-level processes, structures, and strategies contribute to the implementation of effective interventions [7, 18,19,20]. To better understand the workings of CHW interventions and address implementation challenges, greater attention needs to be placed on developing and applying innovative and rigorous systemsoriented methods that can provide evidence on how different elements of the system are functioning, how they are interacting, and their impact on program outcomes [13, 19]

Methods

Results

Discussion

Conclusion