The challenges of developing an instrument to assess health provider motivation at primary care level in rural Burkina Faso, Ghana and Tanzania

Figures & data

Fig. 1.  QUALMAT conceptual framework of MNH provider motivation and performance. Developed with reference to 3182029–3133.

Table 1. Overview of Cronbach's α coefficients for constructs from pre-test data

Section	Constructs	No. of items	Cronbach's α
I. Demographics (personal information)	Not applicable	9
II. Context Statements exploring provider views about contextual constructs	Work organization	4	0.629
	Competence strengthening	6	0.603
	Role of performance	9	0.728
	Provider feels valued/exploited	4	0.515
III. Attitudes Statements exploring individual provider attitudes	Self-efficacy (locus of control)	5	0.374
	Commitment/intention to leave	3	0.586
	Motivation	3	0.445
	Pride/shame	3	0.726
	Attitudes to patients	3	0.176
	Task meaningfulness	3	0.506
	Energy level/burnout	3	0.526
	Job satisfaction	4	0.735
IV. Behavior Statements exploring general work behavior	Timeliness and attendance	4	0.558
	Behavior to patients	3	0.529
	Conscientiousness	4	0.695
	Cooperativeness	3	0.767

Table 2. Constructs and items that did not perform well psychometrically

Construct	Item	Source	How they did not perform
Self-efficacy (locus of control)	I do not always feel in control of things that affect my work at this workplace	Adapted from 31	Did not load to any factor to the minimum of 0.3 (some negative factor loadings)
	I am confident about my ability to take a normal delivery.	Adapted from 30	Did not load to any factor. The item also caused discussion during pre-test as not all staff were formally mandated to take deliveries and were therefore uncertain about whether they could respond.
Work meaningfulness	I chose my profession to serve our people	Developed with reference to the qualitative research, which showed social values to be a source of motivation in all three countries.	The majority of respondents (strongly) agreed with this statement at pretest.
	I am happy to contribute to providing these important MNH services to the community	Developed with reference to the qualitative research, which showed that being able to help the community was a source of job satisfaction in all three countries	Most respondents (strongly) agreed with this statement at pretest
Provider feels valued/exploited	With this job I have to worry about how to support myself and my family financially	Adapted from 3031	Most respondents (strongly) agreed with this statement at pretest
	My job offers adequate pay compared with similar jobs (e.g. teachers)	3031	Most respondents (strongly) disagreed with this statement at pretest
Attitudes to patients	I feel like I don't care for patients like I used to	31	Did not load to any factor to the minimum of 0.3 (Cronbach's α of this construct was only 0.176)
	Generally I feel great sympathy for the patients	Developed with reference to the qualitative research, which provided examples of MNH providers limited sympathy with patients in all three countries	Did not load to any factor to the minimum of 0.3 (Cronbach's α of this construct was only 0.176)
	It makes me feel appreciated when patients are grateful	Developed with reference to the qualitative research, which show that being able to help patients was a source of job satisfaction in all three countries	Cronbach's α of this construct was only 0.176, however this items loaded to the individual aspects at 0.432 so it was retained.
Pride/shame	There are times when I feel ashamed of how we take deliveries here	Developed by authors, drawing upon the proposal of pride/shame as a construct 30	Most respondents (strongly) disagreed with this statement at pre-test
Motivation	I only do this job so that I get paid at the end of the month	1931	Most respondents (strongly) disagreed with this statement at pre-test
Burnout	The work related to MNH care is the most stressful part of my job	Adapted from 31	Most respondents (strongly) agreed with this statement at pretest
	I feel totally drained at the end of every day	Adapted from 1931	Did not load to any factor to the minimum of 0.3
	After a day off I have new energy to work hard again.	Developed by authors with reference to qualitative findings that indicated that health workers at some facilities do not have sufficient rest and recovery time.	Did not load to any factor to the minimum of 0.3
Satisfaction	My expectations of this job have largely not been met	Developed with reference to qualitative findings, which indicated that when providers described their expectations of their work as having been clear at the outset, their described levels of motivation were higher.	Did not load to any factor to the minimum of 0.3
Timeliness	I am often absent from work	Adapted from 30 as used by 19	Most respondents (strongly) disagreed with this statement at pretest.
	Even if I am called to take a delivery at night, I go to work the next day	Developed with reference to qualitative research that absenteeism is a problem at facilities in all three countries, and that being disturbed for a delivery a night was cited as a reason for needing time off.	Most respondents (strongly) agreed with this statement at pretest
Behavior to patients	I always welcome and praise women who come to deliver at the facility	Developed with reference to qualitative research that indicated that not all staff appreciated the difficulties women faced to come and deliver at a health	Most respondents (strongly) agreed with this statement at pretest
	I may be rude to the patients if they don't do what I ask	Developed with reference to qualitative research that gave examples that ‘not all staff’ are polite to the patients, particularly if they consider they do not accept what a provider suggests.	Most respondents (strongly) disagreed with this statement at pretest
	I usually allow companions to stay with women in labor.	Developed with reference to WHO MNH recommendations.	Most respondents (strongly) disagreed with this statement at pretest
Conscientiousness	I am reliable and dependable at work	30	Most respondents (strongly) agreed with this statement
	At work I do things that need doing without being told	1930	Most respondents (strongly) agreed with this statement
Cooperativeness	I sometimes find it hard to get on with the staff that have a different training to me	Developed based on qualitative research that indicated divisions existed between more highly and lesser trained staff.	Did not load to any factor to the minimum of 0.3

Fig. 2.  Excerpt from final formatted version.

Table 3. Final version of the instrument with sources

Section I Demographics
1	Age
2	Sex
3	Family situation (whether married or single/separated/widowed. Whether live separated from spouse or all/some children for work reasons)
4	Number of dependents financially responsible for
5	Whether work in home district or not
6	Profession
7	Years of schooling overall
8	Years in current position/at current level
9	Years in current facility
Section II Management Aspects
Construct	No. of item	Statement	Source
Work organization	1	This facility provides everything I need to perform well at work	Adapted from 30
	2	There are enough health providers to do the work in this facility	31
	3	Too often the referral system does not work efficiently	Developed by authors with reference to the CDSS, which will prompt the user to refer patients in certain situations.
	4	Maintenance of broken equipment at this facility is prompt and reliable	Developed by authors with reference to the maintenance needs of the CDSS.
Competence strengthening	5	My job duties and responsibilities are clear and specific	Adapted from 30
	6	Relevant guidelines (e.g. National Safe Motherhood Service Protocol in Ghana) are easy to access at this facility	Developed by authors. The guideline inserted was the relevant one from each country. This was the only item that was changed to fit the different countries.
	7	I often feel left alone when I have to make difficult decisions about a patient's care	Developed by authors with reference to the CDSS.
	8	I regularly have access to relevant trainings to keep my skills up to date	Developed by authors.
Role of performance	9	My performance is appraised regularly	Developed by authors with reference to incentives package.
	10	Promotions do not depend on how well or badly one works on the job	Adapted from 30
Self-efficacy	11	It is difficult for me to speak openly to my superiors about how things are really going at work	Adapted from 30
	12	Suggestions made by health workers on how to improve the facility are generally ignored	3031
Provider feels valued/exploited	13	The facility management shows very little concern for me	30
	14	Our rights as health workers are generally not respected	Developed by authors
Section III Performance Aspects
Competence strengthening	1	I do not get feedback from my superiors so it is hard to improve my performance	Adapted from 3047
	2	The feedback I get from my co-workers helps me to improve my work	Adapted from 30
Role of performance	3	Good performance is recognized by our superiors	Adapted from 30
	4	This facility has a fair system for rewarding staff	Developed by authors with reference to incentive package
	5	Some of the team members work well, yet others do not and so this facility doesn't perform well overall	Developed by authors with reference to incentive package
	6	We do not know how our facility is performing compared to others in the district	Developed by authors
	7	Our facility has clear goals that we are working towards	Developed by authors based upon the definition of motivation provided by 29
	8	I am keen use any new tools to improve my performance	Developed by authors with reference to the CDSs.
	9	This facility has a good reputation in the community	Adapted from 30
Meaningfulness	10	I understand how my work contributes to the facility's overall goals	47
Attitudes to patients	11	It makes me feel appreciated when patients are grateful	Developed by authors with reference to qualitative findings.
Pride/shame	12	I am proud to be working for this health facility	31
	13	I am proud to tell others that I work in maternal and neonatal health care	Adapted from 31
Section IV Individual Aspects
Self-efficacy	1	I usually cope well with changes at work	Adapted from 31.
Commitment	2	I intend to leave this facility as soon as I can find another position	Adapted from 31
	3	I would recommend to my children that they choose a profession in maternal health care	Adapted from 31
	4	I am willing to put in a great deal of effort to make this facility successful	Adapted from 30
General & intrinsic motivation	5	These days I feel motivated to work as hard as I can.	Adapted from 31, as used by 19
	6	My profession helps me to achieve my goals in life	Developed by authors to explore alignment between work/personal goals and in reference to cultural factors.
Job satisfaction	7	Overall, I am very satisfied with my work in maternal and neonatal care	Adapted from 31
	8	I am very satisfied to have a position where one works closely with the community	Developed by authors with reference to the primary care level focus
	9	This job gives me a feeling of achievement and accomplishment	30
Timeliness and attendance	10	I am punctual about coming to work	30
	11	I work hard to make sure that no patient has to wait a long time before being seen	Developed by authors with reference to qualitative research.
Conscientiousness	12	I am careful not to make errors at work	30
	13	When I am not sure how to treat a patient's condition I look for information or ask for advice	Developed by authors with reference to the CDSS.
Cooperativeness	14	I try to get on well with the other health staff because it makes the work run more smoothly	Adapted from 30
	15	I get along well with my superiors at work	30

Statements in bold were included in the peer instrument.

Table 4. Effect of time in current position on mean responses to the three main aspects in Burkina Faso

	R-quadrat	f (1, 81)	p	Non-standardized coefficient
Management aspects	0.065	5.59	0.020*	−0.023
Performance aspects	0.018	1.45	0.233	−0.010
Individual aspects	0.001	0.09	0.770	0.003

F-values have been rounded up to two decimal places, * = p≤0.05.

Table 5. Effect of time in current position on mean responses to the three main aspects in Ghana

	R-quadrat	f (1, 39)	p	Non-standardized coefficient
Management aspects	0.160	7.423	0.010*	−0.039
Performance aspects	0.022	0.864	0.358	−0.008
Individual aspects	0.007	0.272	0.605	−0.006

F-values have been rounded up to two decimal places, * = p≤0.05.

Table 6. Effect of time at current facility on mean responses to the three main aspects in Ghana

	R-quadrat	f (1, 36)	p	Non-standardized coefficient
Management aspects	0.059	2.24	0.143	−0.045
Performance aspects	0.078	3.03	0.091	−0.031
Individual aspects	0.437	8.50	0.006*	−0.069

F-values have been rounded up to two decimal places, * = p≤0.05.

Table 7. Effect of the number of dependents upon mean responses to the three main aspects in Tanzania

	Number of dependents						f-test
	0–4 (N=23)		5–9 (N=33)		10+(N=5)
	Mean	SD	Mean	SD	Mean	SD	f (2, 58)	p	Partial η^2
Management aspects	2.41	0.28	2.41	0.20	2.24	0.36	1.05	0.356	0.035
Performance aspects	1.96	0.27	1.99	0.26	1.72	0.18	2.23	0.117	0.071
Individual aspects	1.76	0.29	1.68	0.26	1.40	0.20	3.66	0.032*	0.122

Mean, standard deviation, and F-values have been rounded up to two decimal places, * = p≤0.05.

Table 8. Effect of time at current facility on mean responses to the three main aspects in Tanzania

	R-quadrat	f (1, 50)	p	Non-standardized coefficient
Management aspects	0.131	7.51	0.008*	−0.014
Performance aspects	0.015	0.74	0.395	−0.005
Individual aspects	0.046	0.11	0.744	−0.002

F-values have been rounded up to two decimal places, * = p≤0.05.

Table 9. The significant effect that age had upon different aspects across the three countries

Country	Aspect	R-quadrat	f (1, 48)	p	Non-standardized coefficient
Burkina Faso	Performance aspects	0.051	4.37	0.040*	−0.012
Ghana	Individual aspects	0.112	6.05	0.018*	−0.010
Tanzania	Performance aspects	0.110	7.44	0.008*	−0.009

F-values have been rounded up to two decimal places, * = p≤0.05.

Table 10. Differences between self and peer responses to the items about provider behavior from all three countries

		Self-assessment		Peer assessment		f-test
Country	Nr	Mean	SD	Mean	SD	f	p	Partial η2
Burkina Faso	83	1.43	0.34	1.69	0.49	(1, 82) 19.26	0.000*	0.190
Ghana	50	1.86	0.36	1.62	0.45	(1, 49) 11.65	0.001*	0.192
Tanzania	58	1.51	0.33	1.72	0.41	(1, 57) 16.62	0.001*	0.226

Mean, standard deviation and F-values have been rounded up to two decimal places, * = p≤0.05.

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