Key factors influencing motivation among health extension workers and health care professionals in four regions of Ethiopia: A cross-sectional study.

BACKGROUND: Although Ethiopia has improved access to health care in recent years, quality of care remains low. Health worker motivation is an important determinant of performance and affects quality of care. Low health care workers motivation can be associated with poor health care quality and client experience, non-attendance, and poor clinical outcome. Objective this study sought to determine the extent and variation of health professionals' motivation alongside factors associated with motivation.
METHODS: We conducted a facility based cross-sectional study among health extension workers (HEWs) and health care professionals in four regions: Amhara, Oromia, South nations, and nationalities people's region (SNNPR) and Tigray from April 15 to May 10, 2018. We sampled 401 health system workers: skilled providers including nurses and midwives (n = 110), HEWs (n = 210); and non-patient facing health system staff representing case team leaders, facility and district heads, directors, and officers (n = 81). Participants completed a 30-item Likert scale ranking tool which asked questions across 17 domains. We used exploratory factor analysis to explore latent motivation constructs.
RESULTS: Of the 397 responses with complete data, 61% (95% CI 56%-66%) self-reported motivation as "very good" or "excellent". Significant variation in motivation was seen across regions with SNNPR scoring significantly lower on a five-point Likert scale by 0.35 points (P = 0.003). The exploratory factor analysis identified a three-factors: personal and altruistic goals; pride and personal satisfaction; and recognition and support. The personal and altruistic goals factor varied across regions with Oromia and SNNPR being significantly lower by 0.13 (P = 0.018) and 0.12 (P = 0.039) Likert points respectively. The pride and personal satisfaction factor were higher among those aged > = 30 years by 0.14 Likert scale points (P = 0.045) relative to those aged between 19-24years.
CONCLUSIONS: Overall, motivation was high among participants but varied across region, cadre, and age. Workload, leave, and job satisfaction were associated with motivation.

Introduction

Health worker motivation is an important determinant of health worker performance and, ultimately, health care quality [1, 2]. Although a range of factors affect health care quality, motivation is an important determinant of health worker effort, retention, and quality of provision, in addition to health care organization, resource availability, and other provider- and patient-related factors [2]. Motivation in the work context can be defined as an individual’s degree of willingness to exert and maintain an effort towards organizational goals [3, 4]. Previous research has identified a number of factors that can affect health worker motivation, which can be broadly categorized in to three areas: social factors such as community expectations and social values; organizational factors such as resources and managerial support; and individual or process factors such as preferences or intrinsic attitudes [5, 6].

Several comparable studies have been conducted in sub-Saharan Africa. A study in Tanzania indicated that 45% of the individuals working in a primary health care unit were unsatisfied with their job. The reasons cited for dissatisfaction were low salaries, factors related to the working environment, and inadequate facilities for performing expected tasks [7]. A systematic review to assess motivation and retention of health care workers in developing countries indicated the importance of financial incentive on health workers motivation [8]. The studies indicated that health workers take pride and are motivated when they feel they could progress. Recognition by the employer and community was one of the most motivating factors for health workers alongside education and training opportunities. Low salaries were demotivating factors for health care provider [5, 8–14]. Low health care workers motivation is a major contributor to the poor health service quality and client experience, long waiting time, nonattendance, and unofficial fee charges and poor clinical outcome [15].

Three previous studies have assessed health worker motivation in Ethiopia quantitatively, though all were small in scale and focused on specific health worker cadres [3, 9, 16]. A study conducted in central Ethiopia revealed that the overall motivation of health professionals working in different hospitals of West Shewa Zone was reasonably high. Motivation was affected by financial incentives. The mean motivation score among health professionals who received monthly financial benefit was significantly higher than those who did not. Health professionals who had master’s degrees and doctors had highest motivation. Professionals who worked for less than five years had less motivation [3]. A study done in public hospitals of West Amhara in Northwest Ethiopia revealed that the mean overall motivation scores were similarly high. Highly trained professionals, young age groups, and professionals who received performance evaluations and professional development promotions were more motivated [16].

However, health care professionals’ motivation working in public health centres in Gedeo Zone of South Nations and nationalities people’s region (SNNPR) was very low. Lack of recognition and appreciation from their immediate supervisor or manager decreased their motivation. Work experience was a positive predictor of job motivation as work experience increased, job motivation increased [9]. A qualitative study indicated that Ethiopian primary health care workers commonly face work-related stress and experience features of burnout, which may contribute to the high turnover of staff and dissatisfaction of both patients and providers [17].

Though research has been done to identify factors associated with motivation in public hospitals and health centres in different regions of Ethiopia, there has been limited research conducted to explore the extent of motivation among Health extension workers (HEWs) working in the community and midlevel health care professionals across the four large regions of Ethiopia, or how motivation differs across cadres and regions. Thus, this study is sought to determine the extent and variation of health professionals’ motivation alongside factors associated with motivation. We collected data from the four regions of Ethiopia, home to 81% of the country’s population: Amhara; Oromia; SNNPR; and Tigray and accommodates most health facilities and health workers. These regions are highly diverse population and have different geographic characteristics improving representativeness [18].

Materials and methods

Study design

We conducted a facility based cross-sectional study among health extension workers (HEWs) and health care professionals in four regions: Amhara, Oromia, South nations, and nationalities people’s region (SNNPR) and Tigray from April 15 to May 10, 2018.

Tool development

We adapted a motivation tool developed and validated among community health workers (CHWs) in Uganda [19], making minor changes to wording to suit the Ethiopian context. The tool consisted of 17 questions. We added 8 additional questions from a health worker motivation evaluation conducted in Tanzania to explore extrinsic motivating factors in more depth [20]. Finally, we included 5 further questions relating to activities related to the quality improvement programme being implemented in our sample. The final tool is shown in Table 1.

Table 1

Motivation questions included in survey, source, and domain from April 15–May 10, 2018.

Domain	Wording	Source
Altruism	My work is important because I help people	[19]
Altruism	As long as I can do what I enjoy, I am not that concerned about exactly what income or awards I earn	QI-specific indicator
Community	I am respected in my community for the work I do	[19]
Income	I am strongly motivated by the income I can earn at work	[20]
Income	To be motivating, hard work must be rewarded with more status and money.	[20]
Income	My salary accurately reflects my skills and workload	[20]
Intention to leave	I intend to stop working in this role in the next 12 months	[19]
Job satisfaction	I am proud of the work I do	[20]
Job satisfaction	In general, I am satisfied with my role	[19]
Knowledge gain	I gain knowledge from being in this role	[19]
Knowledge gain	Training sessions that I attend are worthwhile and add benefit to my career path	QI-specific indicator
Motivation	At the moment I do not feel like working as hard as I can	[20]
Motivation	I feel like performing the duties required of me	[19]
Needs satisfaction	I am strongly motivated by the recognition I get from other people	[20]
Needs satisfaction	It is important that I do a good job so that the health system works well	[19]
Needs satisfaction	My job makes me feel good about myself.	[20]
Needs satisfaction	I feel it is not so important doing a good job if nobody else knows about it	QI-specific indicator
Organisational citizenship	I am willing to do more than is asked of me in my role	[19]
Organisational citizenship	Sometimes I do not understand why I am asked to do certain things, but I do them anyway	[19]
Organisational justice	The system of choosing who attends training sessions is fair	QI-specific indicator
Organisational justice	I do not have enough opportunities to attend training sessions to develop my career	QI-specific indicator
Outcome expectancy	I am keenly aware of the career goals I have set for myself	[20]
Outcome expectancy	If I do well at work, I will achieve my goals	[19]
Programme	I am proud to be working in my role	[19]
Programme commitment	I feel committed to my role	[19]
Resource availability	The health system provides everything I need to do my job properly	[19]
Self-efficacy	I can solve most problems I have at work if I work hard	[19]
Supervision	Suggestions made by people like me on how to improve their work are usually ignored by supervisors	[19]
Supervision	My supervisors and managers are supportive of me	[19]
Workload	I can complete all of the work I am expected to do	[19]

All items had Likert scale response options where 1 = strongly agree, 2 = agree, 3 = neutral, 4 = disagree, 5 = strongly disagree.

Sampling and data collection

We sampled 401 health system workers: skilled providers including nurses and midwives (n = 110), HEWs (n = 210); and non-patient facing health system staff representing case team leaders, facility and district heads, directors, and officers (n = 81). The survey was part of a baseline evaluation of a quality improvement (QI) program delivered by the Institute for Healthcare Improvement (IHI) in partnership with the Ministry of Health Ethiopia (MOH). Although the sampling frame of this study is based on the IHI program, data are from pre-intervention baseline data collection, and we do not expect motivation to have been influenced by the intervention at this point. The IHI program was implemented in 19 districts: 7 in Oromia, 5 in Amhara, 5 in SNNPR, and 2 in Tigray. Using a random number generator, we randomly selected one intervention district from each region (Jimma Town, Wogera, Chena, and Degua Tembien respectively). We added one additional randomly selected district in Amhara because Wogera would not have yielded 50 eligible respondents—our target for each region. We further purposively sampled two additional districts from Oromia and SNNPR (Bunno Bedelle and Chencha respectively) where qualitative evaluative work took place, to triangulate findings in a larger evaluation of IHI’s QI program. Data collection was conducted by seven research assistants who received one week training at the start of the data collection process and then were matched to their home regions where they have experience working in and speak local language to assist with community entry and mitigate language issues. The data quality was assured by using validated tools, trained data collectors, and conducting interviews in the local languages. The survey was piloted out of 19 district health office staff in December 2017. No changes were made to the survey between piloting and the final survey as it was understood well by participants, assessed through debriefing interviews after survey completion.

In each district, we mapped the hospital, all health centres and health posts, and approached the district health office for permission letters that was later obtained. In each hospital and health centre, we obtained a list of all eligible health care professionals and HEWs. We then randomly selected participants for interviews. In each district, we interviewed around 50 participants across a range of health worker and management cadres, including the heads or clinical directors of the district, each hospital, and each health centre. We interviewed around four maternal and child health care providers from the hospitals and two from each health centre, and around five HEWs from each health centre. A target sample size of 50 respondents per region was chosen, based on the primary research question of assessing changes in motivation as measured by Likert scale questions, in line with a rule of thumb in exploratory factor analysis that 50 participants per cluster is a reasonable sample size to detect differences across clusters [21].

In each hospital or health centre, we obtained a list of all eligible MNH providers and randomly selected participants for interviews. Their names were written in alphabetical order next to a column of randomly generated numbers and interviewers sequentially chose participants from the smallest random number upwards until the requisite number of participants was reached. If participants were not available, we sought to arrange interviews via phone and returned to the facility up to three times before classifying them as unreachable and selecting the next worker from the list. Data were entered on tablet computers using Open Data Kit software (www.opendatakit.org) and exported to STATA V.13.

Data analysis

We categorized the responses according to sociodemographic factors using counts and percentages as appropriate.

To explore the underlying correlations and associations and identify factors within the survey items, we first re-coded the survey items from the 5-point Likert scale from poor to fair, good, very good and excellent to a continuous variable from 1 (poor) to 5 (excellent). Next, we used the re-coded items in an exploratory factor analysis. For the exploratory factor analysis, we first removed items from our list of 30 questions which had poor psychometric performance, removing items which had more than 10% missing data, items which were given the same score of over 80% of participants, and items which did not load on any factors up to a level of 0.4 in initial factor analysis. We used a threshold of 0.4 to assume a strong relationship with a factor, and the optimal number of factors was established through a scree test and multiple runs [22, 23]. We used maximum likelihood ProMax oblique rotation to reduce the number of variables with high loadings and to allow factors to be correlated. Construct validity was indicated by loading at least three items per factor and absence of substantive cross-loading.

We explored the association of overall motivation and with the motivation factors identified with overall job satisfaction and demographic and structural factors including gender, location, cadre, age, perceived gross salary, work experience, using univariate and multivariate ordinary least squares regression models, and show ordered logit model results in the S1 & S2 Appendices. Variables having p value ≤ 0.2 in the bivariate analysis were fitted into a multivariable regression model to control the effects of confounding. Normality assumptions were checked by Schapiro—Francia W tests, and variance inflation factor estimates were generated for regressors [24]. Average job satisfaction was assessed by re-coding the 5-point Likert scale ranging from least satisfied with their job (1) to most satisfied (5) as a continuous variable.

Ethical considerations

Written informed consent was obtained from all participants. The study was undertaken with ethical approval from the Observational Research Ethics Committee of the London School of Hygiene and Tropical Medicine (Ref: 14429) and a program evaluation waiver from the Ethics Committee of the Ethiopian Public Health Association (Ref: EPHA/OG/2380).

Results

Sociodemographic characteristics

Of 401 people surveyed, 397 responded complete giving a response rate of 99%. Most of the respondents were between 25–30 years of age (232, 58.44%) and female (288, 72.73%). Two hundred five (51%) of respondents had greater than 4 years of work experience, and (208, 52.39%) of the respondents were HEWs shown in Table 2.

Table 2

Background characteristics of participants from four regions, (n = 397), April 15–May 10, 2018.

Variables	Number (%)
Region
Amhara	81 (20.40)
Oromia	105 (26.45)
SNNPR	137 (34.51)
Tigray	74 (18.64)
Age (Years)
19–24	90 (22.67)
25–30	232 (58.44)
>30	75 (18.89)
Job title
Health extension workers	208 (52.39)
Care provider (Nurse, Midwife, health officer…) *	109 (27.46)
Case team Leaders	63 (15.71)
Other (facility and district heads, directors, and officers)	17 (4.28)
Gender
Male	109 (27.46)
Female	288 (72.54)
Work experience
<6month	56 (14.11)
6month-1year	40 (10.08)
1-2years	42 (10.58)
2-4years	54 (13.60)
>4years	205 (51.64)

Fig 1 plots the responses to each motivational task, where 1 represents “strongly agree” and 5 represents “strongly disagree”, and blue dots represent items where a lower score is a priori better (e.g., “I am respected in my community for the work I do”) and red dots where a lower score is worse (e.g., “I intend to stop working in this role in the next 12 months”).

Fig 1

Plot of responses to motivational survey items among participants from four regions of Ethiopia, April 15–May 10, 2018.

Motivation construction—Exploratory factor analysis

We ran a factor analysis and ultimately found that the three-factor model fit the data best. We removed 11 items which did not load to 0.4 on any factor. We calculated the final factor score by multiplying the items by the factor score and summing. Table 3 shows the factor loadings. In addition to the factor loading above 0.4, we used eigen values >1 as a criterion to reduce the number of factors into three. We labelled the three factors as personal and altruistic goals; pride and personal satisfaction; and recognition and support. The minimum and maximum score for personal and altruistic goals was 1 and 4.85; for pride and personal satisfaction it was 1 and 4.17; and for recognition and support, it was 1 and 4.5.

Table 3

Exploratory factor analysis results showing the factor loadings by individual items April 15–May 10, 2018.

Variable	Factor 1: Personal and altruistic goals	Factor 2: Pride and personal satisfaction	Factor 3: Recognition and support	Uniqueness
My work is important because I help people	0.65			0.44
I am respected in my community for the work I do	0.58			0.51
I am keenly aware of the career goals I have set for myself	0.57			0.50
I feel committed to my role	0.56			0.44
If I do well at work, I will achieve my goals	0.54			0.57
I am willing to do more than is asked of me in my role	0.47			0.68
I can solve most problems I have at work if I work hard	0.37			0.70
I can complete all the work I am expected to do		0.41		0.68
I feel like performing the duties required of me		0.53		0.55
I am proud of the work I do		0.57		0.50
I am proud to be working in my role		0.65		0.43
In general, I am satisfied with my role		0.57		0.64
My job makes me feel good about myself.		0.54		0.57
It is important that I do a good job so that the health system works well			0.48	0.51
Training sessions that I attend are worthwhile and add benefit to my career path			0.49	0.59
To be motivating, hard work must be rewarded with more status and money.			0.58	0.57
I am strongly motivated by the recognition I get from other people			0.44	0.62
I gain knowledge from being in this role			0.62	0.38
My supervisors and managers are supportive of me			0.36	0.73

Factor 1 interpreted to represent personal and altruistic goals. Factor 2 interpreted to represent pride and personal satisfaction. Factor 3 interpreted to represent recognition and support.

Motivation level

Of the total respondents, 61% were motivated, responding “very good” or “excellent” (95% CI 57%–66%). The most motivating factor mentioned by 70% of the participants was the opportunity to improve health. The most demotivating factor mentioned by 29% participants was workload (95% CI 34%–39%).

Factors related to overall motivation

Table 4 shows the results of the regression model with overall motivation as the outcome variable and several explanatory factors fitted.

Table 4

Factors associated with overall motivation among participants form four regions April 15–May 10, 2018.

Factor	Coef.	95% CI	P-value
Region
Amhara	Reference
Oromia	0.19	(-0.04, 0.42)	0.110
SNNPR	-0.35	(-0.59, -0.12)	0.003
Tigray	-0.05	(-0.32, 0.21)	0.685
Job title
HEW	Reference
Health care providers	0.13	(0.32, -0.05)	0.161
Case team Leaders	-0.19	(0.03, -0.41)	0.096
Other (facility and district heads, directors, and officers)	-0.23	(0.17, -0.64)	0.269
Workload
Light: more than enough time to complete duties	Reference
Medium: enough time to complete duties	-0.48	(-0.90, -0.06)	0.024
Heavy: barely enough time to complete duties	-0.29	(0.11, 0.70)	0.163
Perceived gross salary fair
Very fair	Reference
Quite fair	0.00	(-0.79, 0.80)	0.995
Neither fair nor unfair	0.29	(-0.54, 1.12)	0.488
Quite unfair	0.10	(-0.69, 0.90)	0.798
Very unfair	-0.04	(-0.87, 0.78)	0.914
Average job satisfaction	0.23	(0.13, 0.34)	0.001

The overall motivation score mean was 2.18 out of 5 (95% CI 2.10, 2.27; P = 0.001). Average job satisfaction was strongly associated with higher motivation (P = 0.001). We found variation in motivation across regions, where participants from SNNPR reported lower motivation than the Amhara region by 0.35 (95% CI 0.12, 0.59; P = 0.003). Participants who have a medium workload (meaning that they have enough time to complete duties) were also less motivated than participants who have a light workload by 0.48 points (95% CI -0.90, -0.06; P = 0.024), though high workload was not significantly different. There was no significant variation in overall motivation with job title and perceived fairness of gross salary.

Factor 1: Personal and altruistic goals

The first factor identified items which related to personal success and goal setting and altruism. We refer to this factor as “personal and altruistic goals”. The mean response for personal and altruistic goals was 1.61 Likert points (95% CI 1.56, 1.66; P = 0.001). From the results of the regression analysis summarized in Table 5, average job satisfaction was strongly associated with higher personal and altruistic goals score (P = 0.001). Variation in personal and altruistic goals was seen among regions, where participants from Oromia and SNNPR had lower personal and altruistic goal scores than Amhara region by 0.13 Likert points (95% CI -0.25, -0.02; P = 0.018) and 0.12 Likert points (95% CI -0.23, -0.01; P = 0.039) respectively. Average leave (days out of work) was another significant factor associated with personal and altruistic goals, where an increase of 1 was associated with a decrease in personal and altruistic goals of 0.08 Likert points (95% CI -0.12, -0.04; P = 0.001). Age, gender, and perceived fairness of salary had no significant association with personal and altruistic goals.

Table 5

Association between motivation factors and demographic and structural factors among participants from four regions April 15–May 10, 2018.

	Factor 1: personal and altruistic goals			Factor 2: pride and personal satisfaction			Factor 3: recognition and support
Factor	Coef.	95% CI	P-value	Coef.	95% CI	P-value	Coef.	95% CI	P-value
Gender
Male	Reference			Reference			Reference
Female	0.01	(-0.08, 0.09)	0.896	-0.02	(-0.12, 0.08)	0.720	-0.01	(-0.17, 0.14)	0.863
Region
Amhara	Reference			Reference			Reference
Oromia	0.13	(-0.02, -0.25)	0.018	0.00	(-0.11, 0.11)	0.969	-0.15	(-0.29, -0.01)	0.034
SNNPR	0.12	(-0.01, -0.23)	0.039	- 0.10	(-0.21, 0.01)	0.064	-0.17	(-0.32, -0.03)	0.017
Tigray	0.04	(-0.17, 0.08)	0.523	0.08	(-0.04, 0.2)	0.175	0.08	(-0.07, 0.24)	0.290
Age
19–24	Reference			Reference			Reference
25–30	0.04	(-0.14,0.5)	0.403	0.07	(-0.02, 0.19)	0.180	-0.02	(-0.16, 0.10)	0.710
>30	0.01	(-0.01, 0.13)	0.915	0.14	(0.01, 0.28)	0.045	0.04	(-0.13, 0.21)	0.633
Perceived gross salary fair
Very fair	Reference						Reference
Quite fair	-0.27	(0.10, -0.65)	0.155				-0.15	(-0.61, 0.30)	0.514
Neither fair nor unfair	-0.27	(0.12, -0.66)	0.181				0.01	(-0.47, 0.48)	0.976
Quite unfair	-0.21	(0.17, -0.59)	0.277				0.01	(-0.45, 0.46)	0.973
Very unfair	-0.26	(0.13, -0.65)	0.199				0.09	(-0.39, 056)	0.712
Work experience
<6month				Reference
6month-1year				-0.02	(-0.18, 0.14)	0.824	-0.35	(-0.83, 0.12)	0.147
1-2years				-0.00	(-0.16, 0.15)	0.971	-0.29	(-0.76, 0.18)	0.227
2-4years				0.11	(-0.37, 0.26)	0.145	-0.34	(-0.80, 0.12)	0.151
>4years				-0.06	(-0.18, 0.07)	0.366	-0.39	(-0.85, 0.07)	0.099
Job title
HEW							Reference
Healthcare provides							0.12	(0.00, 0.25)	0.053
Case team Leaders							0.02	(-0.17, 0.20)	0.862
Other (facility and district heads, directors, and officers)							-0.01	(-0.28, 0.25)	0.929
Average job satisfaction	0.34	(0.29, 0.39)	0.001	0.06	(0.09, 0.02)	0.004	0.09	(0.14, 0.04)	0.001
Average leave	-0.08	(-0.04, -0.12)	0.001	0.56	(0.50, 0.61)	0.001	0.35	(0.29, 0.41)	0.001

Factor 2: Pride and personal satisfaction

The second factor consisted of variables relating to the pride and personal satisfaction respondents experienced in their jobs, and the satisfaction their jobs gave them. The mean score of pride and personal satisfaction was 1.78 Likert points (95% CI 1.72, 1.84; P = 0.001). A regression analysis in Table 5 indicated that pride and personal satisfaction score vary among age groups. There were significantly high scores among those older than 30 years old by 0.14 Likert points (95% CI 0.01, 0.28; P = 0.045) as compared to those between the ages of 19–24 years old. Likewise, as average leave (time out of work) increased by 1, pride and personal satisfaction score decreased by 0.06 Likert points (95% CI -0.09, -0.02; P = 0.004). Another factor affecting pride and personal satisfaction was average job satisfaction. Average job satisfaction is strongly associated with high pride and personal satisfaction (P = 0.001). Gender, Region, and work experience did not have significant association with pride and personal satisfaction.

Factor 3: Recognition and support

Factor 3 synthesised survey items focusing on the recognition and support those participants received from colleagues and seniors. The mean score of recognition and support was 1.77 (95% CI 1.72, 1.83; P = 0.001). From the regression analysis indicated in Table 5, factors associated with recognition and support were job title, region, leave (time out of work) and job satisfaction. Recognition and support scores were high among health care providers as compared to HEWs by 0.12 Likert points (95% CI 0.001, 0.25; P = 0.053). Compared to Amhara region, recognition and support scores were significantly low among SNNPR by 0.15 Likert points (95% CI -0.32, -0.03; P = 0.017) and Oromia region by 0.17 Likert points (95% CI -0.29, -0.01; P = 0.034). Another factor affecting recognition and support was job satisfaction. Average job satisfaction is strongly associated with higher recognition and support score (P = 0.001). However, as average leave days increased by one, recognition and support scores significantly decreased by 0.09 Likert points (95% CI -0.14, -0.04; P = 0.001). Age, work experience, gender, and perception of fairness of salary has no significant association with recognition and support.

Discussion

Our study results indicated that more than 60% of HEW and health workers were motivated to do their job. Key factors identified to influence motivation were region, age, job title, work experience, job satisfaction, and leave days. The motivation domains identified in a three-factor analysis was effort in personal and altruistic goals; pride and personal satisfaction; and recognition (financial and managerial) support.

Our finding of high overall motivation is consistent with several other studies. For example, a study conducted in West Amhara, Northwest Ethiopia showed that 59% of care providers working in hospitals were motivated [16]. In West Shewa Zone of Oromia region, the overall mean motivation score of health professionals from three hospitals was 64% [3]. In this study, motivation varied significantly from region to region, which previous smaller studies have not been able to explore. This variation is consistent with a study from Kenya that also found motivational factors varied from region to region [11]. SNNPR had the lowest motivation, consistent with a study done among health professionals in SNNPR’s Gedeo zone where only 17% of respondents were highly motivated. This could need further exploratory studies [9].

Personal and altruistic goals of health providers were significantly lower among participants from Oromia and SNNPR compared to those from the Amhara region. Average job satisfaction is strongly associated with high efforts in personal and altruistic goal.

Motivation related to pride and personal satisfaction was significantly high among participants older than 30 years of age as compared to those 24 years and younger. This study was consistent with studies from Central Ethiopia and South Ethiopia where age was a major predictor of motivation; as age increased, motivation to do their job increased [9, 12]. Similar studies in Burkina Faso, Ghana and Tanzania showed that age has a significant effect on motivation [25]. Pride and personal satisfaction factor were significantly high among participants whose job satisfaction was high as of different studies in Ethiopia explains [26].

Recognition and support were significantly low among participants from SNNPR and Oromia region and was associated with low motivation. This could be due to instability within the system or the lack of capacity to supervise the health care workers located in a large geographical area. Among participants with increased average leave, recognition support was significantly low. This may explain why participants who were taking leave more were less motivated. Recognition and support were significantly higher among health care providers than among HEWs. Having more recognition (financial and managerial) support was a positive predictor for job satisfaction and motivation [8, 27, 28].

A strength of this study was that data was collected from four (Amhara, Oromia, SNNPR, Tigray) major regions of Ethiopia where most of the country’s population live and the regional variation of motivation was studied at the same time, and the health care workers and health extension workers motivation were compared, in addition this study addressed computing multiple associated factors with the overall motivation and three motivation factors identified during factor analysis. Nevertheless, limitations remain. Motivation was self-reported and may therefore be subject to acceptability biases in the face-to-face interviews conducted. Knowledge that interviews were conducted by interviewers from a public university and evaluating an IHI programme may have biased responses. The skilled care provider sample was too small to conduct a subgroup analysis among specific groups of interest such as doctors or midwives. Region-level analyses may have been underpowered to variation in motivation, particularly in the presence of heterogeneity in motivation within regions, for example by cadre, or other unobserved variables. The sampling strategy was not optimized to account for or detect potentially important heterogeneity between regions, urban and rural areas, or QI programme areas, which may further reduce power to detect across-region variation. Qualitative work could have been conducted alongside quantitative data collection to understand why variation exists in motivation between regions and personal characteristics. Finally, we were unable to assess the link between health worker motivation and the quality of care provided which remains under-researched.

Conclusion

Motivation was high among the respondents from the four regions. Key factors associated with motivation were region, age, job title, workload, job satisfaction, long leave days and work experience. Further studies are needed to explore the reason for variation in motivation across regions and job title.

Questionnaire used for data collection in ODK file was prepared in both local (Amharic) and English language.

(XLSX)

Click here for additional data file.

Table A1.

Results from ordered logit model showing factors associated with overall motivation among participants form four regions April 15- May10, 2018.

(PDF)

Click here for additional data file.

Table A2.

Results from ordered logit model showing association between motivation factors and demographic and structural factors among participants from four regions April 15- May10,2018.

(PDF)

Click here for additional data file.

30 Jun 2021

PONE-D-21-09235

Key factors influencing motivation among health extension workers and health care professionals in four regions of Ethiopia: a cross-sectional study.

PLOS ONE

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I also have some comments that I hope can improve the current version of the paper:

1) raw 127: you mention the "woredas", I am suspecting it is something like regions? Please either give the interpretation for international readers that are not familiar with local terms or substitute with the international term.

2) raws 175-176: you mention that you utilise regression models. Please elaborate more. Do you estimate OLS models (I am suspecting yes, based on my comment below) and why you choose the OLS regression since your dependent is qualitative?

3) Raws 179-181: you state that the job satisfaction scores are recoded to transform the variable to a continuous one (if I understand correctly). How do you do that and what is the rationale to justify this transformation?

4) Raws 240-242: you state that "... where an increase of 1 in job 241 satisfaction was associated with an increase in motivation of 0.23 points". I would discourage you from using such strong assumptions. For one, the models estimated do not necessarity imply causation and secondly, both variables are qualitative so such an interpration has no logical meaning. I would advise estimating logit/ordered logit models and assess the probability to respond a higher/lower score base on certain characteristics of respondents, since it would make more sense to do that. Please remove such quantitative interpretations from the results and the discussion.

5) Please interpret your findings with caution: state the problems of establishing causality and remove statements that suggest otherwise (for example rows 316-317).

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Reviewer #1: Partly

Reviewer #2: Yes

**********

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Reviewer #1: Yes

Reviewer #2: Yes

**********

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Reviewer #1: Yes

Reviewer #2: No

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Reviewer #2: Yes

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Reviewer #1: It is a commendable study to have collected data from four different regions of Ethiopia and different cadres of health workers, including HEWs. The addition of the following information would improve the quality of this manuscript.

1. references

In the Introduction/Methods sections, it is better to cite the reference (e.g. line 60 of page 3, line 66 of page 4 [to add additional reference as you state "three studies" in the beginning], line 100 of page 5, and Source column of Table 1 of page 6 [rather than describing which study, cite the reference number])

2. name of the location: "Degua Temben" line 129 on page 8, might be Degua "Tembien"

3. Sampling

One of the biggest concerns of this manuscript was the sampling. Please kindly respond to the following points:

a. Does the sample size for this study have enough statistical power to discern the regional difference of motivation among four regions, especially having Tigray only 50 participants.

b. Please state how the target of 50 respondents was set.

c. Did the authors consider cluster random sampling taking population size, rural/urban differences, intervention/non-intervention areas of IHI into consideration? If not, why not?

Reviewer #2: This is the manuscript titled "Key factors influencing motivation among health extension workers and health care professionals in four regions of Ethiopia: a cross-sectional study." by Mehiret A. et al.

Firstly, I would like to thank the authors for this work. This is an important study that attempts to address Key factors influencing motivation among health extension workers and health care professionals in four regions of Ethiopia. The study sheds light on the challenges of ensuring quality care through motivated health extension workers and health care professionals. All countries worldwide have signed up to the United Nations Sustainable Development Goals (UNSDGs) and have committed to achieving universal health coverage, including financial risk protection, access to quality essential healthcare services, and access to safe, adequate, quality, affordable essential medicines and vaccines for all. However, health care coverage in Ethiopia is still a big concern, which requires addressing all components. Therefore, I am glad to be a reviewer of this work.

As a general comment, the authors should improve the language, introduction, and discussion section.

Specific comments

Abstract

- Background: The authors need to justify more the reason that initiates them to study this topic. Make sure to show the gap clearly, and include the objective also.

- Method: the authors should explain the critical components of an abstract such as study period, study setting,

Introduction:

- The introduction was written pretty well but still needs to show the consequences of inadequate health professionals and health extension worker motivation on the population health in general, such as death, a dropout from service, prolonged hospitalization, poor attitude to health facilities visit and soon.

Methods

- Line page 10: check for typo-error such as … established through a “Scree” test and multiple…

- Page 10, on lines 179 to 181, the authors mentioned that “the average job satisfaction was assessed by re-coding the 5-point Likert scale ranging from most satisfied with their job (1) to least satisfied (5) as a continuous variable.” Why did they need to consider scale one as most satisfied and scale five least? The revers will be more logical. Can you please explain this? Most studies and scholars use 5 as the most satisfied, while 1 is the least satisfied.

Result sections

1. Table titles are not self-explanatory. Table/figure titles must be self-explanatory, which means every audience should be understood what the figure/table contains.

2. The number of the total participants is not consistently explained in the document. For example, the authors told us that only 397 participants were provided their responses. However, they explained 401 respondents in the table. Similarly, the authors should re-check that the sum of all participants is similar to the total respondents. E.g., in Table 2: region, the sum of 107, 106, 137, 50 is 400, which is not equal to the total participants explained by the title. Same table, data for age: the sum of 90, 232, 75 is …. Check other also.

3. Page 16, line 234/5… most demotivating factor mentioned by 29% … add the confidence interval.

4. What are your criteria for selecting a reference group in the regression analysis?

Discussion section

1. What is the reason or reference to say motivation among HEW is high?

2. What is the possible reason health extension workers get motivated in the Amhara region compared to the SNNP? This might be good to scale up to other regions.

Recommendation

- Based on your finding, what do you suggest/recommend for the concerned body?

**********

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Reviewer #1: No

Reviewer #2: Yes: Cheru Tesema Leshargie

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Submitted filename: Concern.docx

Click here for additional data file.

11 Oct 2021

September 3, 2021

Manuscript PONE-D-21-09235

Response to reviewers

Dear Editor in Chief

Thank you so much for the opportunity you have given us to re-submit a revised manuscript entitled “Key factors influencing motivation among health extension workers and health care professionals in four regions of Ethiopia: a cross sectional study.” for consideration for publication in PLOS ONE.

We appreciate the time and effort you and the reviewers dedicated to providing feedback to our manuscript and are grateful for the insightful comments on and valuable improvements made to our paper.

We have incorporated most of the suggestions made by the reviewers. Those changes are highlighted with yellow color within the revised manuscript with track changes. Please see below a blue colored point-by-point response to the reviewers’ comments and concerns. Please note that all page numbers and line numbers refer to the revised manuscript.

Thank you so much once again!

Reviewers’ comments to the Authors

Comment from academic editor

1. Row 127: you mention the "woredas", I am suspecting it is something like regions? Please either give the interpretation for international readers that are not familiar with local terms or substitute with the international term.

Authors response: thank you. The author substituted “Woreda” with known equivalent term “District” as indicated in line 129,130,132,145,146,148,150.

Comment from academic editor

2. Row 175-176: you mention that you utilise regression models. Please elaborate more. Do you estimate OLS models (I am suspecting yes, based on my comment below) and why you choose the OLS regression since your dependent is qualitative?

Authors response: thank you. Yes, the Authors used OLS models to explore determinants of motivation level. We have now changed methods text to read (additions in bold): “We explored the association of overall motivation and with the motivation factors identified with overall job satisfaction and several demographic and structural factors including gender, location, cadre, age, perceived gross salary, work experience, using univariate and multivariate ordinary least squares regression models, and show ordered logistic regression model results in the appendix 1&2 mentioned in line 186 and supporting file S2&3 as in line 524&516.

Ordinary least squares models are able to give unbiased coefficients for ordered categorical outcomes, though we accept the point that interpretation is difficult, and this is non-standard in some fields. As above, therefore, we have fitted ordered logistic regression models to the data and present results in the appendix. The results of these models are consistent with OLS results with respect to sign, significance, and magnitude of independent variable coefficients.

Comment academic editor

3. Rows 179-181: you state that the job satisfaction scores are recoded to transform the variable to a continuous one (if I understand correctly). How do you do that and what is the rationale to justify this transformation?

Author response: We did not transform the variables; we simply took categorical Likert Scale responses ranging from most satisfied in their job (5) to least satisfied (1) and used this as dependent variable (as described in line 190-191).

Comment from academic editor

4. Rows 240-242: you state that "... where an increase of 1 in job 241 satisfaction was associated with an increase in motivation of 0.23 points". I would discourage you from using such strong assumptions. For one, the models estimated do not necessarily imply causation and secondly, both variables are qualitative, so such an interpretation has no logical meaning. I would advise estimating logit/ordered logit models and assess the probability to respond a higher/lower score base on certain characteristics of respondents, since it would make more sense to do that. Please remove such quantitative interpretations from the results and the discussion.

Author response: Thank you for pointing this out, and we agree interpretation is difficult here. We have changed these results to describe sign and significance rather than magnitude as suggested on the following lines:

line 251-253 reads as “Average job satisfaction was strongly associated with higher motivation (P=0.001).”

line 273-285 reads as “From the results of the regression analysis summarized in Table 5, average job satisfaction was strongly associated with higher personal and altruistic goals score (P=0.001).”

line 294-296 reads as “Average job satisfaction is strongly associated with high pride and personal satisfaction (P=0.001)”

line 309-311 reads as “Average job satisfaction is strongly associated with higher recognition and support score (P=0.001).”

Comment from academic editor

5. Please interpret your findings with caution: state the problems of establishing causality and remove statements that suggest otherwise (for example rows 316-317).

Author response: Thank you for pointing this out, and as above we have changed this language throughout. Sentences corrected based on the reviewer comments as in line 331-333: reads as “Average job satisfaction is strongly associated with high efforts in personal and altruistic goal.”

Comment from reviewer #1

It is a commendable study to have collected data from four different regions of Ethiopia and different cadres of health workers, including HEWs. The addition of the following information would improve the quality of this manuscript.

Author response: Thank you for reviewing the manuscript, and for your comments which have improved the paper.

Comment from Reviewer #1

1. References

In the Introduction/Methods sections, it is better to cite the reference (e.g. line 60 of page 3, line 66 of page 4 [to add additional reference as you state "three studies" in the beginning], line 100 of page 5, and Source column of Table 1 of page 6 [rather than describing which study, cite the reference number])

Authors response: thank you for pointing this out. Reference included in the introduction and Method section, and on table 1 source column as on line 67, 76,109, 115&16 table 1 of page 7 line.

Comment from Reviewer #1

2. Name of the location: "Degua Temben" line 129 on page 8, might be Degua "Tembien"

Author response: thank you it is a typing error corrected as Degua “Tembien” as on line 131

Comment from Reviewer #1

3. Sampling One of the biggest concerns of this manuscript was the sampling. Please kindly respond to the following points:

a. Does the sample size for this study have enough statistical power to discern the regional difference of motivation among four regions, especially having Tigray only 50 participants?

Author response: Thank you for pointing this out, this is a good point. We found this as a typing error where the participants from Tigray were74 as shown in page 13 of table 2, in addition we have added the following text in the limitations section of the discussion in line 356-359:

“Region-level analyses may have been underpowered to variation in motivation, particularly in the presence of heterogeneity in motivation within regions, for example by cadre, or other unobserved variables.”

b. Please state how the target of 50 respondents was set.

Author response: Thank you for allowing us to clarify this. We have added the following to the methods section as shown in line153-156:

“A target sample size of 50 respondents per region was chosen, based on the primary research question of assessing changes in motivation as measured by Likert scale questions, in line with a rule of thumb in exploratory factor analysis that 50 participants per cluster is a reasonable sample size to detect differences across clusters (20).”

c. Did the authors consider cluster random sampling taking population size, rural/urban differences, intervention/non-intervention areas of IHI into consideration? If not, why not?

Author response: Thank you for pointing this out. Cluster random sampling was not possible due to operational constraints, but the reviewer is correct to suggest that this would have allowed us to consider variation by potentially important observable characteristics in the sampling design. We have added the following to the limitations section to acknowledge this as shown in line 359-361:

“The sampling strategy was not optimized to account for or detect potentially important heterogeneity between regions, urban and rural areas, or QI program areas, which may further reduce power to detect across-region variation.”

Comment from reviewer#2

This is the manuscript titled "Key factors influencing motivation among health extension workers and health care professionals in four regions of Ethiopia: a cross-sectional study." by Mehiret A. et al.

Firstly, I would like to thank the authors for this work. This is an important study that attempts to address Key factors influencing motivation among health extension workers and health care professionals in four regions of Ethiopia. The study sheds light on the challenges of ensuring quality care through motivated health extension workers and health care professionals. All countries worldwide have signed up to the United Nations Sustainable Development Goals (UNSDGs) and have committed to achieving universal health coverage, including financial risk protection, access to quality essential healthcare services, and access to safe, adequate, quality, affordable essential medicines and vaccines for all. However, health care coverage in Ethiopia is still a big concern, which requires addressing all components. Therefore, I am glad to be a reviewer of this work.

As a general comment, the authors should improve the language, introduction, and discussion section.

Author response: Thank you. we are very much grateful to the reviewers for their close reading of the paper and constructive comments which we believe to improve our paper.

Comment from reviewer #2

1. Background: The authors need to justify more the reason that initiates them to study this topic. Make sure to show the gap clearly and include the objective also.

Author Response: thank you for pointing this out. The reviewer is correct, and we have included the gap and objective.

The revised text on background section of Abstract on line 24-27 of Page2 reads as “Low health care workers motivation can be associated with poor health care quality and displeasure to clients, long patient waiting time, non-attendance, and poor clinical outcome. Thus, this study sought to determine the extent and variation of health professionals’ motivation alongside factors associated with motivation.”

Comment from reviewer #2

2. Method: the authors should explain the critical components of an abstract such as study period, study setting,

Author response: Thank you for pointing this out. Study time and setting incorporated on the method section of the Abstract line 28-30 of page2

“We conducted a facility based cross-sectional study among health extension workers (HEWs) and health care professionals in four regions: Amhara, Oromia, South nations, and nationalities people’s region (SNNPR) and Tigray from April 15 to May 10, 2018.”

Comment from reviewer #2

The introduction was written pretty well but still needs to show the consequences of inadequate health professionals and health extension worker motivation on the population health in general, such as death, a dropout from service, prolonged hospitalization, poor attitude to health facilities visits and soon.

Authors response. Thank you for the insight included the consequences of low motivation to service on page4/5 line 72-75 reads as “Low health care workers motivation is the major contributor to the poor health service quality and can be associated with displeasure to clients, long waiting time, nonattendance, and unofficial fee charges and poor clinical outcome.”

Comment from reviewer #2

Method section

1. Line page 10: check for typo-error such as … established through a “Scree” test and multiple…

Authors response: Thank you for pointing this out. Word corrected as “scree test” on line179 of page11

2. Page 10, on lines 179 to 181, the authors mentioned that “the average job satisfaction was assessed by re-coding the 5-point Likert scale ranging from most satisfied with their job (1) to least satisfied (5) as a continuous variable.” Why did they need to consider scale one as most satisfied and scale five least? The revers will be more logical. Can you please explain this? Most studies and scholars use 5 as the most satisfied, while 1 is the least satisfied.

Author Response: Thank you for pointing this out. The Author recognized as an error and corrected on page 12 of line 190-192 Reads as “Average job satisfaction was assessed by re-coding the 5-point Likert scale ranging from least satisfied with their job (1) to most satisfied (5) as a continuous variable.”

Comment from reviewer #2

Result section

1. Table titles are not self-explanatory. Table/figure titles must be self-explanatory, which means every audience should be understood what the figure/table contains.

Author response: thank you for pointing this out. Table & figure titles Corrected.

The corrected table and titles read as follows

Table 1. Motivation questions included in survey, source, and domain from April 15-May10,2018 (Line 116 on page6)

Table 2. Background characteristics of participants from four regions, (n=397), April 15-May10,2018 (Page13 line205)

Figure 1. Plot of responses to motivational survey items among participants from four regions of Ethiopia, April 15-May10,2018 (Page 14 of line213)

Table 3. Exploratory factor analysis results showing the factor loadings by individual items April 15- May 10, 2018 (line237 page16)

Table 4. Factors associated with overall motivation among participants form four regions April 15- May10, 2018 (line265 of page 18)

Table 5. Association between motivation factors and demographic and structural factors among participants from four regions April 15- May10,2018. (Line 284 of page 20)

2. The number of the total participants is not consistently explained in the document. For example, the authors told us that only 397 participants were provided their responses. However, they explained 401 respondents in the table. Similarly, the authors should re-check that the sum of all participants is similar to the total respondents. E.g., in Table 2: region, the sum of 107, 106, 137, 50 is 400, which is not equal to the total participants explained by the title. Same table, data for age: the sum of 90, 232, 75 is …. Check other also.

Author response: thank you! The author corrected with the total respondents completed the survey n= 397 in the manuscript result section and tables as shown on line 205, table2 of page13.

3. Page 16, line 234/5… most demotivating factor mentioned by 29% … add the confidence interval.

Authors response: thank you! Confidence interval on page 17 line247, read as “The most demotivating factor mentioned by 29% participants was workload (95% CI 34% - 39%).”

4. What are your criteria for selecting a reference group in the regression analysis?

Author’s response:

The Authors have no reason to justify but the criteria for selecting the reference group were the random Alphabet order (Amhara).

Comment from reviewer #2

Discussion

1. What is the reason or reference to say motivation among HEW is high?

Author response: thank you. The Author is trying to explain that the respondents 61% of them were motivated to do their job. The Authors did not mention the specific group of professionals (HEW).

2. What is the possible reason health extension workers get motivated in the Amhara region compared to the SNNP? This might be good to scale up to other regions.

Author response Thank you. From regression analysis the recognition and support motive among respondent were significantly lower in SNNPR & OROMIA as compared to Amhara region. This may explain that recognition and support in this region high. As studies show that recognition is a major predictor for motivation.

3. Based on your finding, what do you suggest/recommend for the concerned body?

Authors response: thank you recommendation included, and these can be found in the manuscript page25 line 370-371

“Further studies are needed to explore the reason for variation in motivation across regions and cadre type.”

Supporting information:

#1Questionnnaire: All variables included in the analysis are explained fully in the text and figures, and we have sought to ensure that replication would be possible from these. Questionnaire used for data collection was done with ODK as in line 164-165. We will provide the ODK file which was developed in Amharic and English language up on reasonable request.

#2 Data: We will provide the data analyzed and interpreted DOI of the current manuscript up on reasonable request.

#3 Pretest: The survey was piloted out of 19 woreda health office staff in December 2017. No changes were made to the survey between piloting and the final survey as it was understood well by participants, assessed through debriefing interviews after survey completion as shown in line141-144.

Submitted filename: Response to reviewers.docx

Click here for additional data file.

7 Feb 2022

16 Feb 2022

Feb 16, 2022

Manuscript PONE-D-21-09235

Response to reviewers

Dear Editor in Chief

Thank you so much for the opportunity you have given us to re-submit a revised manuscript entitled “Key factors influencing motivation among health extension workers and health care professionals in four regions of Ethiopia: a cross sectional study.” for consideration for publication in PLOS ONE.

We appreciate the time and effort you and the reviewers dedicated to providing feedback to our manuscript and are grateful for the insightful comments on and valuable improvements made to our paper.

We have incorporated most of the suggestions made by the reviewer. Those changes are highlighted with yellow color within the revised manuscript with track changes. Please see below a blue colored point-by-point response to the reviewers’ comments and concerns. Please note that all page numbers and line numbers refer to the revised manuscript.

Thank you so much once again!

Reviewer #1 no comment

Reviewer# 2: Key factors influencing motivation among health extension workers and health care professionals in four regions of Ethiopia: a cross-sectional study.

I am excited to get the opportunity to review the manuscript mentioned above. In general, the manuscript is a well-stated and essential area for the developing country. However, before accepting publication, the authors should consider the following issues.

Abstract:

Include the objective of the study in the abstract section. Make sure to use the same abstract in the system and main manuscript. The abstract in the main manuscript has no objectives, while the abstract in the system contains it.

Authors Response: thank you for pointing out this. We have included the objective on page 2 line 26-27 and it reads as ’Objective this study sought to determine the extent and variation of health professionals’ motivation alongside factors associated with motivation.’

What does non-patient-facing health system staff mean? Who are they?

Authors response: thank you for asking, non-patient facing health system staffs are professionals working in different structures of a health system. It is stated on the abstract on page 2 line 32-33 as ’non-patient facing health system staff representing case team leaders, facility and district heads, directors, and officers (n=81).’

Please give space between a statement and citation throughout the manuscript.

Authors response: Thank you for the comment, corrected accordingly as shown on line 50, 53, 55, 65, 72, 106, 109, 188, 322, 325, 332 and 343.

Line 65 -66

What was the finding of the study? Why did the author explain these studies?

Authors response: Thank you, the study assessed motivation and retention of health care workers and indicated importance of financial incentives on health workers motivation. In our study, there are different factors associated with motivation including financial incentives and revealed that financial and managerial support were significantly associated with health professionals job satisfaction, region, leave days and job title as specified on the result section on page 22 line 300 -310. These also further explained on the discussion section on page 24 on line 341 - 343 as ‘Recognition and support were significantly higher among health care providers than among HEWs. Having more recognition (financial and managerial) support was a positive predictor for job satisfaction and motivation.’

Even though the sample size is smaller, it includes four regions (Amhara, Oromo, SNNPR, and Tigray), which is good and improves the representativeness of the finding. But, what is your justification for including these? Why not Harari, Gambella.

Authors response: we believed that the four regions are home to more than 81% of the population in Ethiopia and accommodates most health facilities and health workers. These regions are highly diverse population and have different geographic characteristics improving representativeness as stated on page 6, line number 100 - 102.

Table 5:

Association between motivation factors and 271 demographic and structural factors

Use consistent decimal numbers throughout the document. Example region: (-0.21, 0.006) 0.064

Authors response: Thank you for pointing this out, the decimal numbers corrected accordingly throughout the document. On page number 13 table 2 (region _Amhara %), on page number 17-line number 249, on page number 18 Table 4 perceived gross salary fair (p value), on page number 19 in line number 270, on page number 20-21 table 5 gender factor 2 (coef.), region factor 2 (coef.), factor 2 region (95%CI), age>30 factor1 (95%CI), work experience factor2 (coef.), factor3 job title (95%CI), on page number 22 in line number 299.

Discussion session

Page 22 and line 301-302: add the figure with confidence interval.

Authors response: thank you for pointing out, we have included the interval accordingly it reads as ‘the mean score of recognition and support was 1.77 (95% CI 1.72,1.83; P=0.001)’on page 22 line 299.

Page 22 and line 303: delete one “factor”.

Authors response: thank you deleted accordingly.

Page 22 and lines 303 - 314: How do you think your finding is different from the previous one? Consider this comment for all results?

Authors response: line number 303-314 our study finding “motivation varied from region to region’’ is different in its scope that the study was conducted in four big regions and regional variation of motivation was studied at the same time. In addition, the health care workers motivation and health extension workers motivation were compared, and this study is different in computing multiple characteristics with the overall motivation and three motivation factors.

The three factors also indicated variation with associated factors (region, age, leave days, job satisfaction, perceived gross salary, workload…) as on page number 17-line number 249-257, on page number 19-line number 271-280, and on page number 22-line number 287 – 295.

This has been addressed in the manuscript discussion section on page 24 and line number 345-349 stated as ‘A strength of this study was that data was collected from four (Amhara, Oromia, SNNPR, Tigray) major regions of Ethiopia where most of the country’s population live and the regional variation of motivation was studied at the same time, and the health care workers and health extension workers motivation were compared, in addition this study addressed computing multiple associated factors with the overall motivation and three motivation factors identified during factor analysis.’

What is the limitation of your study?

Authors response: thank you for this question, we have already stated a number of limitations in the manuscript on page24 & 25, line number 348-361:

‘Motivation was self-reported and may therefore be subject to acceptability biases in the face-to-face interviews conducted. Knowledge that interviews were conducted by interviewers from a public university and evaluating an IHI programme may have biased responses. The skilled care provider sample was too small to conduct a subgroup analysis among specific groups of interest such as doctors or midwives. Region-level analyses may have been under powered to variation in motivation, particularly in the presence of heterogeneity in motivation within regions, for example by cadre, or other unobserved variables. The sampling strategy was not optimized to account for or detect potentially important heterogeneity between regions, urban and rural areas, or QI programme areas, which may further reduce power to detect across-region variation. Qualitative work could have been conducted alongside quantitative data collection to understand why variation exists in motivation between regions and personal characteristics. Finally, we were unable to assess the link between health worker motivation and the quality of care provided which remains under-researched.’

Submitted filename: Response to reviewers.docx

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21 Apr 2022

Submitted filename: cheru comment.pdf

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28 May 2022

Dear Editor in Chief

Thank you so much for the opportunity you have given us to re-submit a revised manuscript entitled “Key factors influencing motivation among health extension workers and health care professionals in four regions of Ethiopia: a cross sectional study.” for consideration for publication in PLOS ONE.

We appreciate the time and effort you and the reviewers dedicated to providing feedback to our manuscript and are grateful for the insightful comments and valuable improvements made to our paper.

We have incorporated most of the suggestions made by the reviewer. Those changes are highlighted with yellow color within the revised manuscript with track changes. Please see below a blue colored point-by-point response to the reviewers’ comments and concerns. Please note that all page numbers and line numbers refer to the revised manuscript.

Thank you so much once again!

Reviewer#1: No comment

Reviewer# 2:

The abstract is not structured well. the authors need to restructure it clearly separating the important sections.

Authors response: Thank you. Yes, we separated all the important components of the abstract Background, Objectives, Methods, Results, and conclusion section without violating the PLOS ONE manuscript body submission guideline. The statement explained as

“Background: Although Ethiopia has improved access to health care in recent years, quality of care remains low. Health worker motivation is an important determinant of performance and affects quality of care. Low health care workers motivation can be associated with poor health care quality and client experience, non-attendance, and poor clinical outcome. Objective his study sought to determine the extent and variation of health professionals’ motivation alongside factors associated with motivation.

Methods: We conducted a facility based cross-sectional study among health extension workers (HEWs) and health care professionals in four regions: Amhara, Oromia, South nations, and nationalities people’s region (SNNPR) and Tigray from April 15 to May 10, 2018. We sampled 401 health system workers: skilled providers including nurses and midwives (n=110), HEWs (n=210); and non-patient facing health system staff representing case team leaders, facility and district heads, directors, and officers (n=81). Participants completed a 30-item Likert scale ranking tool which asked questions across 17 domains. We used exploratory factor analysis to explore latent motivation constructs.

Results: Of the 397 responses with complete data, 61% (95% CI 56%-66%) self-reported motivation as “very good” or “excellent”. Significant variation in motivation was seen across regions with SNNPR scoring significantly lower on a five-point Likert scale by 0.35 points (P=0.003). The exploratory factor analysis identified a three-factors: personal and altruistic goals; pride and personal satisfaction; and recognition and support. The personal and altruistic goals factor varied across regions with Oromia and SNNPR being significantly lower by 0.13 (P=0.018) and 0.12 (P=0.039) Likert points respectively. The pride and personal satisfaction factor were higher among those aged >=30 years by 0.14 Likert scale points (P=0.045) relative to those aged between 19-24years.

Conclusions: Overall, motivation was high among participants but varied across region, cadre, and age. Workload, leave, and job satisfaction were associated with motivation.”

Reviewer#2

The method section needs to be restructured. Some important sections were still not included. Try to consider all necessary components.

Authors response: thank you, we included the necessary components “Study design” and moved the sentence under Materials and Methods sub section (study design) as stated in line 104-107 as “We conducted a facility based cross-sectional study among health extension workers (HEWs) and health care professionals in four regions: Amhara, Oromia, South nations, and nationalities people’s region (SNNPR) and Tigray from April 15 to May 10, 2018. “

In addition, on sub section (sampling and data collection) in line 131-133 reads as “We sampled 401 health system workers: skilled providers including nurses and midwives (n=110), HEWs (n=210); and non-patient facing health system staff representing case team leaders, facility and district heads, directors, and officers (n=81).”

Reviewer#2

Line136: Why purposive? How do you analyze data obtained from the two randomly and nonrandom?

Authors response: thank you. Purposive sampling was done for two Woreda which had simultaneous qualitative work ongoing in the broader QI evaluation (Page 144).

There was no evidence (before or after) analysis that key dimensions or results differed between randomly and non-randomly chosen woreda, so these data are pooled together. This analysis strategy was also taken in two previously published papers using this dataset:

Quaife, M., Estafinos, A. S., Keraga, D. W., Lohmann, J., Hill, Z., Kiflie, A., ... & Schellenberg, J. (2021). Changes in health worker knowledge and motivation in the context of a quality improvement programme in Ethiopia. Health policy and planning, 36(10), 1508-1520.

Lamba, S., Arora, N., Keraga, D. W., Kiflie, A., Jembere, B. M., Berhanu, D., ... & Quaife, M. (2021). Stated job preferences of three health worker cadres in Ethiopia: a discrete choice experiment. Health Policy and Planning, 36(9), 1418-1427.

Reviewer#2

Line 155, Why 50? Some regions contain larger number of the population Line 162

Authors response:

As stated on in line 163-166 “A target sample size of 50 respondents per region was chosen, based on the primary research question of assessing changes in motivation as measured by Likert scale questions, in line with a rule of thumb in exploratory factor analysis that 50 participants per cluster is a reasonable sample size to detect differences across clusters (21)”. Weighting the number of respondents by region size would not have led to more generalizable inference.

Reviewer #2 Result section line 202, 203 Add frequency

Authors response:

Thank you included the frequency as on line 210-211. Reads as “Two hundred five (51%) of respondents had greater than 4 years of work experience, and (208, 52.39%) of the respondents were HEWs shown in Table 2.”

Reviewer #2

Page13, 18 and 21 in Table 2,4 & 5: (job title Other) who are this try to explain or mention all

Authors response: Thank you. We included all as Other (facility and district head, directors, and officers), and Leaders as case team leader, on page 13, 18, 21 in table 2, 4 and 5.

Reviewer #2

Discussion: How high is it? Where is the figure? What was your reference to conclude finding is high? How much is the variation among region and cadre?

Authors response:

Thank you for pointing out this. We corrected the wording as per the comment.

Our study has revealed the extent of motivation indicating 61% (majority of the participants were motivated to do their job). We stated as “Our study results indicated that more than 60% of HEW and health workers were motivated to do their job. Key factors identified to influence motivation were region, age, job title, work experience, job satisfaction, and leave days.”

We also already cited references from previous studies to compare with our study. Though, the studies were conducted among health professionals working in hospitals.

The study has also indicated the regional variation in general was under powered as already mentioned as a limitation in line 367-373.

Submitted filename: Response to reviewers.docx

Click here for additional data file.

31 May 2022

29 Jun 2022

Dear Editor in Chief

Thank you so much for the opportunity you have given us to re-submit a revised manuscript entitled “Key factors influencing motivation among health extension workers and health care professionals in four regions of Ethiopia: a cross sectional study.” for consideration for publication in PLOS ONE.

We appreciate the time and effort you and the reviewers dedicated to providing feedback to our manuscript and are grateful for the insightful comments and valuable improvements made to our paper.

We have incorporated most of the suggestions made by the reviewer. Those changes are highlighted with yellow color within the revised manuscript with track changes. Please see below a blue colored point-by-point response to the reviewers’ comments and concerns. Please note that all page numbers and line numbers refer to the revised manuscript.

Thank you so much once again!

Reviewer#1: No comment

Reviewer# 2:

The abstract is not structured well. the authors need to restructure it clearly separating the important sections.

Authors response: Thank you. Yes, we separated all the important components of the abstract Background, Objectives, Methods, Results, and conclusion section without violating the PLOS ONE manuscript body submission guideline. The statement explained as

“Background: Although Ethiopia has improved access to health care in recent years, quality of care remains low. Health worker motivation is an important determinant of performance and affects quality of care. Low health care workers motivation can be associated with poor health care quality and client experience, non-attendance, and poor clinical outcome. Objective this study sought to determine the extent and variation of health professionals’ motivation alongside factors associated with motivation.

Methods: We conducted a facility based cross-sectional study among health extension workers (HEWs) and health care professionals in four regions: Amhara, Oromia, South nations, and nationalities people’s region (SNNPR) and Tigray from April 15 to May 10, 2018. We sampled 401 health system workers: skilled providers including nurses and midwives (n=110), HEWs (n=210); and non-patient facing health system staff representing case team leaders, facility and district heads, directors, and officers (n=81). Participants completed a 30-item Likert scale ranking tool which asked questions across 17 domains. We used exploratory factor analysis to explore latent motivation constructs.

Results: Of the 397 responses with complete data, 61% (95% CI 56%-66%) self-reported motivation as “very good” or “excellent”. Significant variation in motivation was seen across regions with SNNPR scoring significantly lower on a five-point Likert scale by 0.35 points (P=0.003). The exploratory factor analysis identified a three-factors: personal and altruistic goals; pride and personal satisfaction; and recognition and support. The personal and altruistic goals factor varied across regions with Oromia and SNNPR being significantly lower by 0.13 (P=0.018) and 0.12 (P=0.039) Likert points respectively. The pride and personal satisfaction factor were higher among those aged >=30 years by 0.14 Likert scale points (P=0.045) relative to those aged between 19-24years.

Conclusions: Overall, motivation was high among participants but varied across region, cadre, and age. Workload, leave, and job satisfaction were associated with motivation.”

Reviewer#2

The method section needs to be restructured. Some important sections were still not included. Try to consider all necessary components.

Authors response: thank you, we included the necessary components “Study design” and moved the sentence under Materials and Methods sub section (study design) as stated in line 104-107 as “We conducted a facility based cross-sectional study among health extension workers (HEWs) and health care professionals in four regions: Amhara, Oromia, South nations, and nationalities people’s region (SNNPR) and Tigray from April 15 to May 10, 2018. “

In addition, on sub section (sampling and data collection) in line 131-133 reads as “We sampled 401 health system workers: skilled providers including nurses and midwives (n=110), HEWs (n=210); and non-patient facing health system staff representing case team leaders, facility and district heads, directors, and officers (n=81).”

Reviewer#2

Line136: Why purposive? How do you analyze data obtained from the two randomly and nonrandom?

Authors response: thank you. Purposive sampling was done for two Woreda which had simultaneous qualitative work ongoing in the broader QI evaluation (Page 144).

There was no evidence (before or after) analysis that key dimensions or results differed between randomly and non-randomly chosen woreda, so these data are pooled together. This analysis strategy was also taken in two previously published papers using this dataset:

Quaife, M., Estafinos, A. S., Keraga, D. W., Lohmann, J., Hill, Z., Kiflie, A., ... & Schellenberg, J. (2021). Changes in health worker knowledge and motivation in the context of a quality improvement programme in Ethiopia. Health policy and planning, 36(10), 1508-1520.

Lamba, S., Arora, N., Keraga, D. W., Kiflie, A., Jembere, B. M., Berhanu, D., ... & Quaife, M. (2021). Stated job preferences of three health worker cadres in Ethiopia: a discrete choice experiment. Health Policy and Planning, 36(9), 1418-1427.

Reviewer#2

Line 155, Why 50? Some regions contain larger number of the population Line 162

Authors response:

As stated on in line 163-166 “A target sample size of 50 respondents per region was chosen, based on the primary research question of assessing changes in motivation as measured by Likert scale questions, in line with a rule of thumb in exploratory factor analysis that 50 participants per cluster is a reasonable sample size to detect differences across clusters (21)”. Weighting the number of respondents by region size would not have led to more generalizable inference.

Reviewer #2 Result section line 202, 203 Add frequency

Authors response:

Thank you included the frequency as on line 210-211. Reads as “Two hundred five (51%) of respondents had greater than 4 years of work experience, and (208, 52.39%) of the respondents were HEWs shown in Table 2.”

Reviewer #2

Page13, 18 and 21 in Table 2,4 & 5: (job title Other) who are this try to explain or mention all

Authors response: Thank you. We included all as Other (facility and district head, directors, and officers), and Leaders as case team leader, on page 13, 18, 21 in table 2, 4 and 5.

Reviewer #2

Discussion: How high is it? Where is the figure? What was your reference to conclude finding is high? How much is the variation among region and cadre?

Authors response:

Thank you for pointing out this. We corrected the wording as per the comment.

Our study has revealed the extent of motivation indicating 61% (majority of the participants were motivated to do their job). We stated as “Our study results indicated that more than 60% of HEW and health workers were motivated to do their job. Key factors identified to influence motivation were region, age, job title, work experience, job satisfaction, and leave days.”

We also already cited references from previous studies to compare with our study. Though, the studies were conducted among health professionals working in hospitals.

The study has also indicated the regional variation in general was under powered as already mentioned as a limitation in line 367-373.

Reviewers comment

The number of the total participants is not consistently explained in the document. For example, the authors told us that only 397 participants were provided their responses. However, they explained 401 respondents in the table. Similarly, the authors should re-check that the sum of all participants is similar to the total respondents. E.g., in Table 2: region, the sum of 107, 106, 137, 50 is 400, which is not equal to the total participants explained by the title. Same table, data for age: the sum of 90, 232, 75 is …. Check other also.

Authors Response

Thank you!

We have checked and corrected the number of participants during the 1st and 2nd review period (earlier versions).

Currently, we also included a sentence to further clarify the surveyed participants and response rate in line 202 as “Of 401 people surveyed, 397 responded complete giving a response rate of 99%.”

Submitted filename: Response to Reviewers.docx

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22 Jul 2022

Key factors influencing motivation among health extension workers and health care professionals in four regions of Ethiopia: a cross-sectional study.

PONE-D-21-09235R4

Dear Dr. Adillo,

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Additional Editor Comments (optional):

Reviewers' comments:

8 Sep 2022

PONE-D-21-09235R4

Key factors influencing motivation among health extension workers and health care professionals in four regions of Ethiopia: a cross-sectional study.

Dear Dr. Quaife:

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