Development and validation of the ExPRESS instrument for primary health care providers’ evaluation of external supervision

Background: External supervision of primary health care facilities to monitor and improve services is common in low-income countries. Currently there are no tools to measure the quality of support in external supervision in these countries. Aim: To develop a provider-reported instrument to assess the support delivered through external supervision in Rwanda and other countries. Methods: “External supervision: Provider Evaluation of Supervisor Support” (ExPRESS) was developed in 18 steps, primarily in Rwanda. Content validity was optimised using systematic search for related instruments, interviews, translations, and relevance assessments by international supervision experts as well as local experts in Nigeria, Kenya, Uganda and Rwanda. Construct validity and reliability were examined in two separate field tests, the first using exploratory factor analysis and a test–retest design, the second for confirmatory factor analysis. Results: We included 16 items in section A (‘The most recent experience with an external supervisor’), and 13 items in section B (‘The overall experience with external supervisors’). Item-content validity index was acceptable. In field test I, test–retest had acceptable kappa values and exploratory factor analysis suggested relevant factors in sections A and B used for model hypotheses. In field test II, models were tested by confirmatory factor analysis fitting a 4-factor model for section A, and a 3-factor model for section B. Conclusions: ExPRESS is a promising tool for evaluation of the quality of support of primary health care providers in external supervision of primary health care facilities in resource-constrained settings. ExPRESS may be used as specific feedback to external supervisors to help identify and address gaps in the supervision they provide. Further studies should determine optimal interpretation of scores and the number of respondents needed per supervisor to obtain precise results, as well as test the functionality of section B.