BackgroundA strong health system requires a competent and caring workforce. A more satisfied and motivated health workforce should be more willing to serve in difficult areas, have lower turnover, and theoretically provide better care to patients. This paper examines the motivation, satisfaction, and correlation with clinical knowledge, of community health nurses (CHNs), a cadre of provider focused on maternal, newborn and child health in rural Ghana.MethodsThis study employed three methods of evaluation. Two quantitative measurements were used: (1) a survey of health worker satisfaction and motivation and (2) a clinical knowledge assessment focusing on maternal, newborn and child health. Both were administered to all rostered CHNs working in the five sampled districts in the Greater Accra and Volta regions in Eastern Ghana (N = 205). Qualitative interviews (N = 29) and focus group discussions (N = 4) were held with selected CHNs in the same districts. These data were analysed using NVivo (Version 10) and Stata (Version 13.0) based on domains of extrinsic and intrinsic motivation including general satisfaction, work environment and access to resources, respect and recognition received and opportunities for advancement.ResultsCHNs desired more training, especially those who were posted at the community level (a Community-based Health Planning and Services post or “CHPS”) versus at a health facility. CHNs working at CHPS believed their work to be more difficult than those posted at health facilities, due to challenges associated with foot travel to visit patients at home, and they were more likely to report having insufficient resources to do their jobs (48% vs 36%). However, CHNs posted at health facilities were more likely to report insufficient opportunities for career advancement than the CHPS nurses (49% vs 33%). CHNs generally reported good relationships with colleagues and being respected by patients but desired more respect from supervisors. The median score on the knowledge assessment was 78%. On average, subgroups of CHNs with different reported levels of satisfaction did not perform differently on the knowledge assessment.ConclusionsCHNs in Ghana were satisfied overall but desired more training, more guidance and supervision, fair pay and opportunities to advance in their career. Improving health worker satisfaction and morale may be important for health worker retention and certain aspects of care but may not have a significant influence on clinical knowledge or performance.

BackgroundScaling up voluntary medical male circumcision (VMMC) to 80% of men aged 15–49 within five years could avert 3.4 million new HIV infections in Eastern and Southern Africa by 2025. Since 2009, Tanzania and Zimbabwe have rapidly expanded VMMC services through different delivery (fixed, outreach or mobile) and intensity (routine services, campaign) models. This review describes the modality and intensity of VMMC services and its influence on the number and age of clients.Methods and FindingsProgram reviews were conducted using data from implementing partners in Tanzania (MCHIP) and Zimbabwe (PSI). Key informant interviews (N = 13 Tanzania; N = 8 Zimbabwe) were conducted; transcripts were analyzed using Nvivo. Routine VMMC service data for May 2009–December 2012 were analyzed and presented in frequency tables. A descriptive analysis and association was performed using the z-ratio for the significance of the difference. Key informants in both Tanzania and Zimbabwe believe VMMC scale-up can be achieved by using a mix of service delivery modality and intensity approaches. In Tanzania, the majority of clients served during campaigns (59%) were aged 10–14 years while the majority during routine service delivery (64%) were above 15 (p<0.0001). In Zimbabwe, significantly more VMMCs were done during campaigns (64%) than during routine service delivery (36%) (p<0.00001); the difference in the age of clients accessing services in campaign versus non-campaign settings was significant for age groups 10–24 (p<0.05), but not for older groups.ConclusionsIn Tanzania and Zimbabwe, service delivery modalities and intensities affect client profiles in conjunction with other contextual factors such as implementing campaigns during school holidays in Zimbabwe and cultural preference for circumcision at a young age in Tanzania. Formative research needs to be an integral part of VMMC programs to guide the design of service delivery modalities in the face of, or lack of, strong social norms.

Background Attention is the capacity to flexibly orient behaviors and thoughts towards a goal by selecting and integrating relevant contextual information. The dorsal cingulate (dCC) and prefrontal (PFC) cortices play critical roles in attention. Evidence indicates that catechol-O-methyltransferase (COMT) modulates dopaminergic tone in the PFC and dCC. Objective In this study, we explored the effect of tolcapone, a CNS penetrant COMT inhibitor that increases cortical dopamine levels, on brain activity during a Variable Attentional Control (VAC) task. Study Design We performed a double-blinded, placebo-controlled, counter-balanced trial with tolcapone (Tasmar, tablets, 100 mg three times a day for 1 day and then 200 mg three times a day for 6 days; ClinicalTrials.gov identifier: NCT00044083). Setting The study was conducted in the Clinical Center of the National Institute of Mental Health from 2005 to 2009. Patients Twenty healthy volunteers (11 males; mean age = 32.7 years) with good imaging and performance data on both arms of the study were investigated. Intervention Participants underwent 3T blood-oxygen-level-dependent (BOLD) functional magnetic resonance imaging (fMRI) while performing the event-related VAC task, which varies attention over three levels of load: LOW, INT (intermediate), and HIGH. Main Outcome Measure Changes in behavioral data and individual contrast images were analyzed using ANOVA with drug and task load as co-factors. Results There was a significant main effect of increasing task load, with resulting decreased accuracy and increased reaction time. While there was no significant effect of tolcapone on these behavioral measures, the neuroimaging data showed a significant effect on load-related changes in dCC, with significantly lower dCC activation on tolcapone compared with placebo. Further, neural activity in dCC correlated positively with COMT enzyme activity (i.e., lower COMT activity and presumably more dopamine was associated with lower activation in dCC, i.e., more efficient information processing). Conclusion Our results show that pharmacological reduction of COMT activity modulates the engagement of attentional mechanisms, selectively enhancing the efficiency of dCC processing in healthy volunteers, reflected as decreased activity for the same level of performance.

Adequate supervision is critical to maintain the performance of health workers who provide essential maternal and child health services in low-resource areas. Supportive supervision emphasizing problem-solving, skill development and mentorship has been shown to improve the motivation and effectiveness of health workers, especially at the community level, but it is not always routinely provided. Previous studies have assessed the uptake of supportive supervision among volunteer health workers and paid health centre staff, but less is known about the supervision experiences of paid community-based staff, such as community health nurses (CHNs) in Ghana. This mixed-methods study explores the frequency and content of CHN supervision in five districts in the Greater Accra and Volta regions of Ghana. We analysed quantitative data from 197 satisfaction surveys and qualitative data from 29 in-depth interviews (IDIs) and four focus group discussions (FGDs) with CHNs. While the majority of CHNs received supervision at least monthly, they reported that supervision was primarily focused on meeting clinical targets (48%) rather than on handling specific cases or patients (23%). Over a third (34%) of CHNs did not agree that supervisors help them with job-related challenges and nearly half (43%) were unsatisfied with their jobs. When asked about their mentorship needs, CHNs reported wanting feedback on how to improve their job performance (40%) and encouragement (30%). There were only slight variations in the frequency and content of supervision based on type of supervisor. During IDIs and FGDs, CHNs offered ideas for how to improve supervision, including more frequent field visits so that supervisors could see the on-the-ground realities of their work, greater respect and positive reinforcement. Overall, CHN motivation and job satisfaction may be strengthened by aligning supervision more closely with the principles of supportive supervision.