Study design: A descriptive cross-sectional study design was used in this study. The cross-sectional study design was chosen based on the fact that it was appropriate for exploring the relationships that exist between the HSAs tasks, role stressors and job satisfaction at a single given point in time [15].
Study site: The study was conducted in districts of Mangochi, Lilongwe and Mzimba South which represented the south, centre and northern regions of Malawi respectively. Lilongwe district had both urban and rural representation. The urban setting was selected for comparison if there were any differences in the role stressors and job satisfaction between the rural HSAs and the urban HSAs.
Inclusion and Exclusion Criteria. All HSAs working in the three selected districts under the government of Malawi payroll and working in either CHAM or Ministry of Health facilities and had work experience of two or more years were eligible to participate in the study. Subsequently, all HSAs working outside the three selected districts and had a work experience less than two years were excluded from the study.
Study Participants and Sampling: The study participants were HSAs. Overall, the population of HSAs in the three districts was 1924.The sample size for the study was 385 HSAs and was calculated based on Lemeshow et al.16 sample size calculation formula for a cross-sectional study. Since studies to explore role conflict, role ambiguity, role overload and job satisfaction of HSAs had not been conducted in Malawi, it was assumed that 50% of the HSAs were affected by the phenomenon. 20% was factored in considering the rate of the non-responses. This increased the sample size to 462. Since 9 HSAs did not meet the inclusion criteria a total number of 453 questionnaires were distributed and the response rate was 93.5%. Multistage sampling was done at several stages. The PPS sampling was run several times to ensure all the three regions in Malawi had representation. All the 29 districts were listed together with their HSAs population for PPS sampling. PPS sampling was chosen because it accorded an opportunity of selecting districts and health facilities with high numbers of HSAs.
Data Collection
A standardized face to face self-administered questionnaire having five sections was used to measure study variables. The first section collected socio-demographic data, while the subsequent sections collected data on HSAs task prioritization (as taken from the HSAs job description), role conflict and role ambiguity, role overload and job satisfaction using adapted instruments as illustrated in the subsequent sub sections of this report. To adapt some items for the questionnaires, permission was sought from the American Psychological Association (APA), the University of Minnesota Vocational Psychology Research through the Rights Link of the Copyright Clearance Centre.
Instruments
Role conflict and Ambiguity Scale
A role conflict and ambiguity (RCA) scale developed by Rizzo et al.19 was used to measure role conflict and role ambiguity. The scale in total had 14 items, 6 items for role ambiguity and 8 items for role conflict. The scale was a 5-point Likert–type response format (from 1= ‘strongly disagree’ and 5= ‘strongly agree’). The RCA scale was chosen because it has been widely used in literature and is the most dominant tool used in role conflict and role ambiguity studies [17,18].
Role Overload Scale
The Role Overload Scale (ROS) developed by Reilly23 was used. The ROS is a 13- item questionnaire (“there are too many demands on my time”) with a 5-point Likert-type response format (from 1= ‘strongly disagree’ and 5= ‘strongly agree’). The tool had a Cronbach’s alpha of 0.88. Other researchers had found the Cronbach's alpha ranging from 0.89 to 0.94 [20–22]. The Minnesota Satisfaction Questionnaire of the shorter version, the MSQ20 was used to collect data on job satisfaction. The tool had been widely used in both developed and developing countries [23]. It is a 20-item questionnaire with a 5-point Likert type response format (from 1= very dissatisfied to 5 very satisfied). The instrument is also reported to have high Cronbach's alpha ranging between 0.70 to 0.80 [24].
The Task Inventory Scale
The task inventory scale developed by Burgel et al25 was adapted in this study to collect information on HSAs job tasks. The instrument has been used in previous studies by Mbambo26 and Uys27 in studies related to job analysis of selected health workers in a district health system in KwaZulu-Natal for the South African PHC package of services. The instrument was modified and tasks not relevant to this study were removed and replaced with HSAs tasks contained in their job description to develop a final instrument. For each task, two options were required: to tick in the most appropriate box whether the task applied to the setting and the frequency the task was carried out (less than once per week, 1-5 times per week, 6-10 times per week and more than ten times per week). In addition, the questionnaire had a demographic section where all information pertaining to demographic variables were collected.
Pretesting
The data collection tools were first pre-tested before distribution to respondents. The pre-test was done among HSAs in Nkhotakota a different district from the sampled districts. The pre-test was conducted with the intention to identify items in the questionnaire which were not clearly drafted and might not be clear in the reader’s view. The identified items were corrected and once the corrections were made, the questionnaire was ready for distribution to the respondents. The pre-test findings were not incorporated into the main study.
Reliability and Validity of the Instruments
Internal consistency was used to assess the reliability of the scales and subscales. This was carried out to find out if there was consistency in the way the respondents responded to the items on the questionnaire. Cronbach’s alpha (α) was used for this purpose. The RCA, the ROS and the MSQ scales had all a Cronbach’s alpha ≥.70. Originally, the authors had high Cronbach’s alpha ranging from .80 to .90 but this was deemed acceptable since the instruments were adapted and translated into the vernacular language (Chichewa) which is commonly spoken in most districts in Malawi. An alpha value of ≥ 0.70 is desirable, although values that are slightly below 0.70 are usually considered acceptable [28].
Statistical Analysis
Statistical analysis was performed with Statistical Package for Social Sciences (SPSS) software version 23. The statistics used in the analysis included mean, correlation coefficient and Principal Component Analysis (PCA). The Mean was used to determine overall scores for curative and preventive roles, the correlations were used to determine the relationships between variables while, the PCA was used to identify factors for role stressors and job satisfaction.
Public Involvement
HSAs were involved in the design and conduct of this research. During the feasibility stage, translation of the data collection tools to a vernacular language, was informed by discussions with HSAs through a focus group session. During data collection, some HSAs were involved as study team members. Once the study has been published, participants will be sent details of the results in a study newsletter suitable for a non-specialist audience.