The role of supportive supervision in enhancing and sustaining health education in home management and prevention of malaria among mothers of under-five children

This paper introduces the concept of supportive supervision in community-based nursing intervention as a supervisory tool among health consumers. It provides overview of supportive supervision as management tool to facilitate delivery of quality service by the health care providers. It also describes the adaptability of this concept to supervision of community members following heath education and training with a view to enhancing and sustaining health promotion and prevention of diseases. The author describes utilisation of this tool in promoting and sustaining mothers’ skills in home management and prevention of malaria at a community level and recommends its usage by community health workers as a substitute to home visit for different populations within a community where there is dwindling human and material resources to carry out home visits so as to promote effective outcome.


INTRODUCTION
Health education is a vital component of preventive medical care; its vitality is very significant in primary health care to the extent that it occupies the first position among all the components of the care and at the same time forms an integral part of all other components.The function of health education is underscored in prevention, control and treatment of diseases and dangerous conditions (Tanzania Ministry of Health and Social welfare (TMOHSW), 2010).However, health education or training alone may not be enough to enhance sustenance of community health consumers' knowledge and practice of prevention and in the management of diseases, nurses need to support them through supervision to ensure quality outcome (TMOHSW, 2010).This supervision was always done by community/public health nurses during home visit.However, this tradition is gradually phasing out in Nigeria and it is hampering successful implementation of health care services in the country (Amoran et al., 2012).TMOHSW (2010) indicated that supervision and audit with feedback, combined with written guidelines are generally effective in provision of quality health care services and that multifaceted interventions might be more effective than single intervention.Hughes (2010) quoting Bromberg (1982) defined supervision as "a relationship between two people one of whom has the purpose of using it to improve his work with someone in his or her life and the other who has the purpose of helping him or her to do this".Human and material resources had for several years hindered home visit.Amoran et al. (2012) found out in a study conducted on HIV/AIDS home based care practices among primary health care workers that only 16.6% of the respondents that practised home based care believed that the practice is feasible.Out of those who practised home based care, only 5.7% did home visits weekly, 4.6% monthly and 6.3% quarterly.Similarly, Alenoghena et al. (2014) stated that the implementation of primary health care (PHC) is mainly through services provided by primary health centres and home visits and that the processes of this implementation are facing many constraints in the country.One of the government constraint factors the authors identified was inadequate funding (Alenoghene et al., 2014).In view of this, there is need for a paradigm shift that will provide a forum for supportive supervision within the health centres where the health care providers and health care consumers can meet regularly and jointly identify and solve problems and challenges related to treatment and prevention of diseases.With this only patients with very serious problem will be followed up in their homes with the few available resources.This may contribute beneficially to sustenance of health education and training that might have been provided for the patients/clients.Djibuti et al. (2009) defined supportive supervision as "range of measures to ensure that personnel carry out their activities effectively through direct personal contact on a regular basis to guide, support and assist designated staff to become more competent in their work."This type of supervision can also be adapted for guiding, supporting and assisting the health care consumers to develop selfefficiency in their self-care in the spirit of promoting good health and preventing diseases.

PERSPECTIVE OF SUPPORTIVE SUPERVISION
Supervision is an essential aspect of human resource management for delivery of service that will meet the consumers' needs.Khadivi and Yazdani (2012) stated that supervision has always played an important role in effective and successful performance of educational plans.Hughes (2010) stated that supervision is required to translate plans and programmes into action and necessary to ensure that the subordinates are working according to plans and policies of the organisation.Training people to acquire a skill may not be difficult but the problem is always in the trainees' ability to utilise the skills appropriately and continuously particularly where such trainees are not being directed and supported.Marquez and Kean (2002) stated that supervision may include periodic events, such as site visits or performance reviews.Traditionally, supervision involved inspection and control of staff, but this approach has not been resulting in expected improvement or assisting staff to solve problems.Marquez and Kean (2002) noted that supervisors often blame individuals rather than look for root causes in deficient processes.For this reason, experts in health services administration advocated supportive supervision with a view to ensuring successful implementation of health programmes and better patient outcomes (Asante and Roberts, 2011).Rohde (2006) described supportive supervision as an approach that uses a practical system of objective measures to foster improvements in procedures, personal interactions, and management of primary health care facilities.Marquez and Kean (2002) stated that supportive supervision emphasizes joint problem-solving, mentoring and twoway communication between supervisors and supervisees.This description form the bases for considering utilisation of modified supportive supervision approach in the community health care intervention (home management and prevention of malaria) for enhancing and sustaining health promotion behaviour among health care consumers.Marquez and Kean (2002) identified four basic tasks in the process of supervision, and stated that the supervisor facilitates this process by communicating about, assessing and facilitating the work of the supervisees.These tasks include.

Setting of expectations
"For supervision to be effective, the supervisor and the supervisee must set clear expectations or standards against which performance and results can be measured".

Monitoring and assessment of performance
"The existing standards or guidelines will continually assist in monitoring and assessment to know the extent to which they are met at all levels of the system; whether for individual health care providers, or within and among facilities, and at the district (regional) and national (central) levels".

Identifying problems and opportunities
"If there are gaps between expectations and outcome, the supervisor will facilitate a team process to examine potential causes and possible solutions.By facilitating open communication and teamwork, the supervisor can help to identify opportunities to improve the overall quality of care".

Taking action
"The supervisor helps to mobilize necessary human, financial, material, political, and institutional resources to implement intervention.He or she motivates and supports the providers to address performance gaps or opportunities for improvement" (Marquez and Kean, 2002: p. 6).
The process of supportive supervision is continuous or cyclical; as new activities are commencing, expectations are set and the process continues.
Supportive supervision is quality results oriented and aims at improving individual's performance.Kyabayinze et al. (2010) found out in their study on the use of rapid diagnostic tests (RDTs) to improve malaria diagnosis and fever case management at primary health care (PHC) facilities in Uganda that there was decreased trend of presumptive treatment in anti-malaria drug (AMD) prescriptions following supportive supervision they rendered to the study subjects.They recommended that there should be technical support supervision after comprehensive training on parasite-based malaria case management in order to ensure sustained use of RDTs and the trend of AMD prescription.
In another study on role of supportive supervision on immunization programme outcome conducted by Djibuti et al. (2009), the findings revealed that the effect of intervention on immunization managers independently contributed to the improvement of self-perceived knowledge to carry out supportive supervision.There was also a significant impact on reduction of number of self-perceived barriers to supportive supervision.Further to this, there was improved service outcomes inform of decreased vaccine wastage and increased immunization coverage (Djibuti et al., 2009).Sebastian (2008) as cited in Stanhope and Lancaster (2008) remarked that supervision might occur on-site when the nurse manager is present and while the activity is being performed or off-site when the nurse is providing care in a community setting.These studies confirmed the vital role that supportive supervision plays in improving clients' outcome generally in primary health care services.Although, there have not been many supportive supervision interventions that directly focused on members of the community, the author experimented an off-site supportive supervision among mothers of under-five children in Ido-Osun Egbedore LGA, Osun State Nigeria for six months.

SUPPORTIVE SUPERVISION AS A TOOL FOR COMMUNITY HEALTH NURSING INTERVENTION
The author and two other public health nurses (research assistants / supervisor) conducted a quasi-experimental study on home management and prevention of malaria utilising one control group and two intervention groups; health education and supportive supervision group (HESSG) and health education only group (HEG).Mothers of under-five children in one of the intervention groups (HESSG) had off-site supportive supervision in the form of personal interactions during monthly meetings for six months after the health education programme.This is in consonance with the statement of Marquez and Kean (2002) that supervision may include periodic events, such as site visits or performance reviews.During this period, the researchers collaborated with the mothers to identify and solve problems that stopped them from adequately preventing and treating malaria among the under-five children where such children had malaria episodes.The second intervention group (HEG) had only health education programmes which were similar to what the HESSG had.The health education programme was guided by a manual developed by the researchers from orientation package on malaria prevention and control produced by National Malaria Control Programme and other relevant textbooks and journals.
The inclusion of supportive supervision as an intervention in the study was the researcher's attempt to promote sustainability of health promotion behaviour which the mothers had acquired from the health education programme.The intervention was one of the reinforcing factors considered in her study's conceptual model.Supportive supervision has been recognised as significant administrative tool among health care providers (Asante and Roberts, 2011), the researcher modified it to be useful for reinforcing health consumers' changed behaviour.This was an attempt to evaluate an alternative to traditional home visit follow up which has become non-existent in most primary health care settings due to dwindling human resources and logistic facilities particularly vehicles for transportation (Alenoghene et al., 2014).
The modality for the supportive supervision should be based on the four tasks identified by Marquez and Kean (2002), that is, setting of expectations, monitoring and assessment of performance, identifying problems and opportunities and taking action.A checklist must be developed to moderate the supportive supervision.A pre-supervision meeting is necessary to be held with the supervisees to explain the purpose of the supportive supervision and for setting up the expectations during the supervision period.Similarly, prior to the supportive supervision meetings, brief meetings should be held with supervisors (when they are more than one) to review the checklist for the supervision and ensure uniformity of supervision process.This checklist is to be used to document the supervisees' experiences during utilisation of the intervention e.g. home management and prevention of malaria.Dates, time and venue for the supportive supervision meetings should be jointly determined by the supervisees and their supervisors at the end of the health education programme.Regular reminder is mandatory via various media like radio announcements, use of cell phones, announcements in the mosques and churches, e.t.c.Monitoring and assessment of performance of the participants was done retroactively during the monthly meetings because it was not possible to know when the children would have fever.The checklist guided the proceedings of the meetings, problems and opportunities were jointly identified by the supervisors (the researcher and the assistants) and the mothers and appropriate solutions were proffered to the problems during the meetings.Financial constraint, anxiety over outcome of the illness, children crying excessively and inability to go to farm/shops/work were the commonest problems identified and solved.At the end of the meetings, supervisors summarised the contents of the modules of the health education programme to serve as reminder to the mothers with emphasis on the expectations.
The monthly interactive meetings assisted the mothers to open up and discuss their problems within themselves and with the supervisors.Many of them reported that they realised that their problems were not peculiar to them thus enjoying peer support.The meetings served as group therapy forum and as reminder of health education programme with a view to promoting sustainability of the health promotion behaviour.
The limitation of this strategy was mothers' poor attendance at the monthly meetings despite the mobilisation strategies.There was no time throughout the six months when the attendance was up to 50% except at the sixth month when the State Government in collaboration with the Federal Ministry of Health distributed long lasting insecticide nets (LLINs) to all women in the communities.This enhanced the women's attendance as the distribution took place in the venue of the supportive supervision meetings.

CHALLENGES OF SUPPORTIVE SUPERVISION TO COMMUNITY HEALTH NURSING
Utilization of supportive supervision intervention for health care consumers is a unique innovation.It is commonly used to enhance performance of service providers and its effect had been previously studied among formal institutions but not in the communities.Some of the attributes of the strategy is the ability to jointly identify and solve health problems through mentoring and two-way communication between supervisors and supervisees rather than health care providers (supervisors) blaming the individuals for inaction.With this, the community health nurses will be able to assume responsible and effective position in successful implementation of all strategies for achievement of health promotion and maintenance in the communities.This model will be found useful with the present dwindling human resources and logistic support for home visit that is almost going into obsolescence.The health care providers will be using supportive supervision meetings to receive feedback from the health care consumers, reinforce their good practices and correct bad practices as well as myths and misconceptions.
Integration of supportive supervision clinic meetings for health care consumers require the attention of the policy makers for appropriate intervention in terms of policy, training and retraining of the primary health care providers in rendering this mentorship care.In addition, the community health nurses can identify interested community members to be trained as role model mothers with a view to complimenting provision of quality health care within their communities.

CONCLUSION
It is hope that the concept of home visiting in community health care practice could be modified to depict supportive supervision for caregivers in the communities to foster improvements in procedures, personal interactions, and provision of quality health care services.The dwindling human and material resources for home visits should not be allowed to completely hinder following clients up rather, the community health nurses could organise supportive supervision meetings where clients can express their challenges and problems they are encountering in management of any disease.It is also important that malaria control interventions, focusing on promotion of prompt access to appropriate and effective treatment should as well recognise and address other perceived and real barriers to malaria healthseeking behaviour.Such barriers are the cost of anti-malarial drugs in the community and the private sector, accessibility to health facilities, insufficient number of health care providers, and empowerment of mothers as decision-makers at the household level.Further study should also be carried out on utilisation of supportive supervision among health care consumers.