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 [7,8,9,10], 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 [12,13,14], 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, 15,16,17]. 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.