title: Effect of Performance Feedback on Community Health Workers' Motivation and Performance in Madhya Pradesh, India: A Randomized Controlled Trial.
abstract: BACKGROUND
  Small-scale community health worker (CHW) programs provide basic health services and strengthen health systems in resource-poor settings. This paper focuses on improving CHW performance by providing individual feedback to CHWs working with an mHealth program to address malnutrition in children younger than 5 years.
  
  
  OBJECTIVE
  The paper aims to evaluate the immediate and retention effects of providing performance feedback and supportive supervision on CHW motivation and performance for CHWs working with an mHealth platform to reduce malnutrition in five districts of Madhya Pradesh, India. We expected a positive impact on CHW performance for the indicator they received feedback on. Performance on indicators the CHW did not receive feedback on was not expected to change.
  
  
  METHODS
  In a randomized controlled trial, 60 CHWs were randomized into three treatment groups based on overall baseline performance ranks to achieve balanced treatment groups. Data for each treatment indicator were analyzed with the other two treatments acting as the control. In total, 10 CHWs were lost to follow-up. There were three performance indicators: case activity, form submissions, and duration of counseling. Each group received weekly calls to provide performance targets and discuss their performance on the specific indicator they were allocated to as well as any challenges or technical issues faced during the week for a 6-week period. Data were collected for a further 4 weeks to assess intertemporal sustained effects of the intervention.
  
  
  RESULTS
  We found positive and significant impacts on duration of counseling, whereas case activity and number of form submissions did not show significant improvements as a result of the intervention. We found a moderate to large effect (Glass's delta=0.97, P=.004) of providing performance feedback on counseling times in the initial 6 weeks. These effects were sustained in the postintervention period (Glass's delta=1.69, P<.001). The counseling times decreased slightly from the intervention to postintervention period by 2.14 minutes (P=.01). Case activity improved for all CHWs after the intervention. We also performed the analysis by replacing the CHWs lost to follow-up with those in their treatment groups with the closest ranks in baseline performance and found similar results.
  
  
  CONCLUSIONS
  Calls providing performance feedback are effective in improving CHW motivation and performance. Providing feedback had a positive effect on performance in the case of duration of counseling. The results suggest that difficulty in achieving the performance target can affect results of performance feedback. Regardless of the performance information disclosed, calls can improve performance due to elements of supportive supervision included in the calls encouraging CHW motivation.
authors.affiliation: Dimagi Software Innovations, Cambridge, MA, United States.
authors.forename: Sangya
authors.identifier: http://orcid.org/0000-0002-0598-2272
authors.initials: S
authors.lastname: Kaphle
authors.affiliation: Real Medicines Foundation, 11700 National Blvd, Suite 234, Los Angeles, CA, United States.
authors.forename: Michael
authors.identifier: http://orcid.org/0000-0002-8126-5507
authors.initials: M
authors.lastname: Matheke-Fischer
authors.affiliation: Dimagi Software Innovations, Cambridge, MA, United States.
authors.forename: Neal
authors.identifier: http://orcid.org/0000-0003-0027-3247
authors.initials: N
authors.lastname: Lesh
keywords: community health workers; mHealth apps; motivation; performance feedback; supportive supervision