Developing a tool to measure satisfaction among health professionals in sub-Saharan Africa.

BACKGROUND: In sub-Saharan Africa, lack of motivation and job dissatisfaction have been cited as causes of poor healthcare quality and outcomes. Measurement of health workers' satisfaction adapted to sub-Saharan African working conditions and cultures is a challenge. The objective of this study was to develop a valid and reliable instrument to measure satisfaction among health professionals in the sub-Saharan African context. METHODS: A survey was conducted in Senegal and Mali in 2011 among 962 care providers (doctors, midwives, nurses and technicians) practicing in 46 hospitals (capital, regional and district). The participation rate was very high: 97% (937/962). After exploratory factor analysis (EFA), construct validity was assessed through confirmatory factor analysis (CFA). The discriminant validity of our subscales was evaluated by comparing the average variance extracted (AVE) for each of the constructs with the squared interconstruct correlation (SIC), and finally for criterion validity, each subscale was tested with two hypotheses. Two dimensions of reliability were assessed: internal consistency with Cronbach's alpha subscales and stability over time using a test-retest process. RESULTS: Eight dimensions of satisfaction encompassing 24 items were identified and validated using a process that combined psychometric analyses and expert opinions: continuing education, salary and benefits, management style, tasks, work environment, workload, moral satisfaction and job stability. All eight dimensions demonstrated significant discriminant validity. The final model showed good performance, with a root mean square error of approximation (RMSEA) of 0.0508 (90% CI: 0.0448 to 0.0569) and a comparative fit index (CFI) of 0.9415. The concurrent criterion validity of the eight dimensions was good. Reliability was assessed based on internal consistency, which was good for all dimensions but one (moral satisfaction < 0.70). Test-retest showed satisfactory temporal stability (intra class coefficient range: 0.60 to 0.91). CONCLUSIONS: Job satisfaction is a complex construct; this study provides a multidimensional instrument whose content, construct and criterion validities were verified to ensure its suitability for the sub-Saharan African context. When using these subscales in further studies, the variability of the reliability of the subscales should be taken in to account for calculating the sample sizes. The instrument will be useful in evaluative studies which will help guide interventions aimed at improving both the quality of care and its effectiveness.

Solidarity or financial sustainability: an analysis of the values of community-based health insurance subscribers and promoters in Senegal.

OBJECTIVES: Although community-based health insurance (CBHI) seemed promising to improve access to health care, its implementation has been slow and laborious. We hypothesize that the existing tension between the competing objectives of solidarity and financial sustainability that are pursued by CBHI may partly account for this. This paper aims to evaluate if there is a gap between CBHI subscribers' values and their promoters', and to determine which characteristics of subscribers and CBHIs are associated with their values. METHODS: A study of all Senegal CBHI organizations was undertaken in 2002. The analysis includes: 1) content of interviews with subscribers and promoters; and 2) multilevel logistical analysis of the links between characteristics of subscribers (n = 394) and organizations (n = 46) and composite indicators representing values (redistribution, solidarity when difficulties, solidarity between healthy and unhealthy). RESULTS: Promoters emphasize financial sustainability; subscribers are split between financial sustainability and solidarity. Men, polygamous families and individuals with a lower socio-professional status are twice as likely to be in favour of redistribution; subscribers who participate in decision-making and those who think their CBHI is facing difficulties are less in favour of solidarity. At CBHI level, although the variance was significant, none of the variables were retained. CONCLUSION: More attention should be given to reducing the gap between promoters' and subscribers' values, and to increasing member participation in the processes involved in implementing CBHI. This could help all actors involved to understand and improve determinants of enrolment in, and performance of CBHI, thus increasing access to health care for vulnerable populations in developing countries.

QUARITE (quality of care, risk management and technology in obstetrics): a cluster-randomized trial of a multifaceted intervention to improve emergency obstetric care in Senegal and Mali.

BACKGROUND: Maternal and perinatal mortality are major problems for which progress in sub-Saharan Africa has been inadequate, even though childbirth services are available, even in the poorest countries. Reducing them is the aim of two of the main Millennium Development Goals. Many initiatives have been undertaken to remedy this situation, such as the Advances in Labour and Risk Management (ALARM) International Program, whose purpose is to improve the quality of obstetric services in low-income countries. However, few interventions have been evaluated, in this context, using rigorous methods for analyzing effectiveness in terms of health outcomes. The objective of this trial is to evaluate the effectiveness of the ALARM International Program (AIP) in reducing maternal mortality in referral hospitals in Senegal and Mali. Secondary goals include evaluation of the relationships between effectiveness and resource availability, service organization, medical practices, and satisfaction among health personnel. METHODS/DESIGN: This is an international, multi-centre, controlled cluster-randomized trial of a complex intervention. The intervention is based on the concept of evidence-based practice and on a combination of two approaches aimed at improving the performance of health personnel: 1) Educational outreach visits; and 2) the implementation of facility-based maternal death reviews. The unit of intervention is the public health facility equipped with a functional operating room. On the basis of consent provided by hospital authorities, 46 centres out of 49 eligible were selected in Mali and Senegal. Using randomization stratified by country and by level of care, 23 centres will be allocated to the intervention group and 23 to the control group. The intervention will last two years. It will be preceded by a pre-intervention one-year period for baseline data collection. A continuous clinical data collection system has been set up in all participating centres. This, along with the inventory of resources and the satisfaction surveys administered to the health personnel, will allow us to measure results before, during, and after the intervention. The overall rate of maternal mortality measured in hospitals during the post-intervention period (Year 4) is the primary outcome. The evaluation will also include cost-effectiveness.