Health Policy 77 (2006) 290–303

Reasons for participation in and needs for continuing

professional education among health workers in Ghana
Hirotsugu Aiga a,b,c,∗
aEmergency Needs Assessment Unit, United Nations World Food Programme (WFP), Via Cesare Giulio Viola 68/70,
Parco de’ Medici, 00148 Rome, Italy
b Department of Health Policy and Planning, School of International Health, Faculty of Medicine,

The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan

c Department of Global Health, School of Public Health and Health Services, Medical Center, The George Washington University,
2175 K Street, NW, Suite 810, Washington, DC 20037, USA

Abstract

The reasons for participation in continuing professional education (CPE) programs among health workers importantly deter-
mine the level of post-CPE application in daily servicing practice and finally the quality of health services. To categorize and
distinguish type of reasons in an evidence-based manner, background factors associated with reasons were identified through
conducting a census targeting the health workers in three regions of Ghana (N = 6696). The total number of subjects where health
workers found CPE needs produced significantly positive odds ratios (OR > 1) with three reasons (‘to maintain and improve
professional knowledge and skills’, ‘to interact and exchange views with colleagues’, and ‘to obtain a higher job status’) of four
employed for this study. That implies that health workers with those reasons have more quantities of CPE needs. Conversely,
the total number of subjects where health workers found CPE needs produced significantly negative odds ratio with ‘to gain
relief from routine’ indicating it is an extrinsic reason. Therefore, whether ‘to gain relief from routine’ is chosen as a reason for
participation could be criterion of differentiating between the types of reason.
© 2005 Elsevier Ireland Ltd. All rights reserved.

Keywords: Continuing professional education; Health workers; Human resources development; Ghana

1. Introduction and background
Continuing professional education (CPE) for health
workers is widely recognized as an effective means
∗ Tel.: +39 06 6513 2177; fax: +39 06 6513 3080 (Italy);
Tel.: +81 3 5841 3688; fax: +81 3 5841 3637 (Japan);
Tel.: +1 202 416 0406; fax: +1 202 496 0400 (USA).
E-mail addresses: hiroaiga@f6.dion.ne.jp,
hirotsugu.aiga@wfp.org, ihphxa@gwumc.edu.
for the improvement of health status among local
populations, through equipping them with updated
technical knowledge and skills [1] and improving
morale and attitudes towards work [2]. There has been,
however, an increased skepticism concerning the effec-
tiveness of CPE [3]. Traditionally, health administra-
tors do not believe that CPE dramatically improves
the health workers’ performance [4] because there is
no assurance that the desired changes in professional

0168-8510/$ – see front matter © 2005 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.healthpol.2005.07.023
 H. Aiga / Health Policy 77 (2006) 290–303
competency or performance will occur [5]. Despite
this critical argument, CPE issues have been insuffi-
ciently addressed and analyzed in academic research
[6], especially within a developing country context.
Nevertheless, a tremendous amount of funds have been
invested in educating health workers in developing
countries by governmental development agencies and
non-governmental organizations (NGOs) for decades
without clearly analyzing the total CPE situation in
those countries. One of the reasons for little research
concerning healthcare human resources such as CPE
is the lack of recognition and understanding of human
resources as an authentic area of research, despite its
equal importance, for example, to biomedical research
[2]. It is necessary to conduct research to more precisely
describe and analyze CPE in order for the effective uti-
lization of financial resources since human resources
account for 60–80% of recurrent cost in health service
delivery [7–9].
Health workers’ reasons for participation in CPE
are critical in determining the extent to which new
knowledge and skills are applied to daily practice [10].
In particular, the analyses on reasons for participation
and self-perceived needs among health workers play a
key role in maximizing effectiveness of CPE because
they reflect health workers’ psychology and motiva-
tion towards CPE. The reasons for participation were
addressed and analyzed in several earlier studies in
developed countries. The major reasons for participa-
tion in CPE in those studies include: (i) ‘to maintain
and improve professional knowledge, and skills’; (ii)
‘to interact and exchange views with colleagues’; (iii)
‘to obtain a higher job status’; (iv) ‘to gain relief from
routine’; (v) ‘to comply with employer’s and author-
ity’s requirements’ [10–12]. In addition, multiplicity
and complexity were confirmed in health workers’
way of selecting these reasons [13]. ‘Compliance with
employer’s and authority’s requirements’ as a reason
has been discussed exclusively in the studies in devel-
oped countries where mandatory CPE participation is
required for renewal of professional licenses [11,14].
However, the reasons for participation in CPE among
health workers in developing countries, where gener-
ally there is no mandatory CPE requirement for renew-
ing licenses, have been rarely addressed.
Past studies on the linkage between the reasons
for participation and post-CPE application revealed
that extrinsic reasons are negatively correlated with
291
Fig. 1. CPE process framework.
the level of application in daily practice [10,12,15]. In
contrast, intrinsic reasons brought about more proac-
tive application [16]. A certain relationship exists
between the type of reasons and needs that health
workers identify because CPE programs are often
successful when the reasons are more intrinsic and
the needs are also met [17,18]. A study in the United
States indicated that the reasons for participation
vary significantly according to the type of profession,
career stage, professional experience, and personal
characteristics [10]. Another study indicated that
nurses’ self-perceived CPE needs might be one of
the determinants of participation [19]. However, the
relationship between health workers’ individual CPE
needs and the reasons for participation has been rarely
analyzed in an evidence-based manner (Fig. 1).
Health status of the populations in Ghana has sig-
nificantly improved since 1982 and is generally better
in terms of major health indicators than other West
African countries [20]. Infant mortality rate and under-
five mortality rate dropped respectively from 77 and
148 per 1000 liverbirths in 1988 to 57 and 107 in
1998 [21]. It is being ravaged by both newly emerging
infectious diseases such as HIV/AIDS and reemerging
infectious diseases such as malaria, tuberculosis and
cholera. The incidence of non-communicable diseases
also continues to rise sharply, particularly in urban
areas [22]. There is also a remarkable discrepancy in
health status between northern and southern parts of
292 H. Aiga / Health Policy 77 (2006) 290–303
the country, e.g. the Northern region’s under-five mor-
tality rate is 2.7 times higher than that of Greater Accra
region in the south [23].
In Ghana, a shortage of and unequal distribution
of healthcare human resources are currently one of the
most critical issues that prevent improved access to and
quality of health services [24,25]. To address this issue,
the Ghanaian Ministry of Health (MOH) has placed
increased emphasis on CPE by adopting the In-Service
Training Policy (ISTP) in 1997 that calls for the system-
atic delivery of CPE programs [26]. The ISTP describes
in detail the conceptual framework for the CPE sys-
tem and its implementation schedule. However, it does
not adequately address the motivational orientation in
CPE.
2. Research questions
The CPE situation in developing countries differs
in many ways from that in developed countries. For
example, the costs of CPE, including per diem and
accommodation, are fully or partially covered most fre-
quently by the governments in developing countries,
while those costs are usually paid by the health work-
ers in developed countries. Both financial and tech-
nical supports are often provided by the development
agencies to a variety of CPE programs in developing
countries [27,28]. Training of health workers in service
in developing countries is one of the most emphasized
strategies in the framework for development assistance.
However, the reasons for participation in CPE pro-
grams in developing countries are nearly ignored or
insufficiently considered by development agencies.
Reasons for participation in CPE have been dis-
cussed primarily in terms of the level of post-CPE
application. Cividin and Ottoson attempted to catego-
rize the reasons for participation into two types, i.e.
intrinsic and extrinsic [10]. However, their study did not
present clear definitions of these two types of reasons.
This is probably because some reasons had both intrin-
sic and extrinsic aspects and clear demarcation of them
was difficult. Therefore, it is necessary to distinguish
and categorize reasons for participation in a theoretical
manner. In view of this, the following research ques-
tions were established for this study.
What factors are associated with reasons for par-
ticipation in CPE in developing country? How can we
categorize reasons for participation in relation to indi-
vidual CPE needs in an evidenced-based approach?
Taking Ghana as a case, this study attempts to
address the above research questions through the anal-
ysis of the survey data.
3. Methods
3.1. Survey design
A survey was conducted to identify the factors asso-
ciated with the varying reasons among health workers
for participation in CPE programs in Ghana. Due to
the lack of available information concerning past CPE
programs, it was not possible to estimate a statistically
representative sample size. For this reason, the survey
was designed in the form of census, targeting all the
MOH health workers in three of the 10 regions in Ghana
(Volta, Western, and Brong Ahafo regions). These three
regions were selected because they are average in terms
of both the MOH staffing status [29] and major health
indicators such as infant mortality rate [21]. Therefore,
it was assumed that the situation of human resource
development, including CPE, in the three regions was
at average level in the country. In this study, the MOH’s
definition of a government health worker (i.e. all types
of occupational groups working as either permanent
or contracted full-time employees of the MOH) was
employed.
The survey was conducted during the period from
June to July 1997, using a self-administered question-
naire. The survey teams made visits to health facilities
which were operated by the MOH, and to mission-
ary health facilities where the MOH staffs were being
seconded. The questionnaire forms were completed
by individuals after being given verbal instruction in
their local languages. The forms were field-checked
and locally collected during the survey team’s visit.
Those who were on short leave or otherwise tem-
porarily absent were requested to complete the form
and send it back to the survey team. Those who were
on long leave (such as maternity leave and overseas
fellowship leave) were excluded from the sampling
frame.
In the questionnaire, health workers were asked the
reasons for participation in CPE, their self-perceived
CPE needs in the form of the number of CPE subjects
 H. Aiga / Health Policy 77 (2006) 290–303
as well as their years of professional experience and
demographic data.
Of 7691 health workers, including those on long
leave and 497 MOH-operated health facilities in the
three regions [30,31], 6696 health workers (87.1%) and
444 health facilities (89.3%) took part in the study.
3.2. Reasons for participation in CPE
In this study, four types of reasons for participation
of five prominent ones reported in earlier studies in
developed countries were employed: (i) R1 : ‘to main-
tain and improve professional knowledge and skills’;
(ii) R2 : ‘to interact and exchange views with col-
leagues’; (iii) R3 : ‘to obtain a higher job status’; (iv)
R4 : ‘to gain relief from routine’. In the pretest (N = 43),
no respondents chose ‘to comply with employer’s and
authority’s requirements’ as a reason for participation.
And this is one of the typical reasons identified in devel-
oped countries. Therefore, it was excluded while it is
the representative extrinsic reason that is common in
developed countries due to mandatory CPE require-
ment.
The reasons employed were arranged in the order
of the extent to which proactive post-CPE applica-
tion was expected: from R1 (the most highly expected)
to R4 (the least expected). It was ideally desirable to
request respondents to rate the level of importance
for each reason on a seven-point scale ranging from
‘Not important (=1 point)’ to ‘Extremely important (=7
points)’ based on the participation reasons scale (PRS),
a tool for assessing the reasons for participation in CPE
[13]. However, the results of the pretest did not assure
the reliable level of reproducibility in their responses.
Therefore, the questions were asked in a dichotomous
manner (i.e. ‘Yes’ or ‘No’) for each of four reasons.
3.3. Background variables on reasons for
participation in CPE
To identify key factors associated with the reasons
for participation, background variables were sought.
The results of the pretest indicated that the proportion
of the response ‘Yes’ to each employed reason was
estimated to be higher among: health technical staff;
those who perceived CPE needs in a greater number
of subjects; the health workers who were in higher
ranking positions. Moreover, past studies reported that
293
the reasons for participation were significantly based
on the type of profession and career stage as well
as professional experience, and personal characteris-
tics such as age, gender, and marital status [10,32].
Given the above information, seven background vari-
ables were employed: (i) self-perceived CPE needs
in the form of the total number of CPE subjects; (ii)
type of occupational group; (iii) rank of post in MOH
personnel system; (iv) professional working experi-
ence in the form of the number of years spent as an
MOH employee; (v) age; (vi) gender; and (vii) marital
status.
The tentative MOH’s official classification of CPE
programs, that was available, categorized all the CPE
programs into 34 subjects according to the themes and
topics addressed (footnote for Table 2). The results
of the pretest did not assure a reliable level of repro-
ducibility for rating the level of importance of sub-
jects on a seven-point scale. On the other hand, to ask
whether CPE is necessary for respective subjects in
dichotomous manner (‘Yes’ or ‘No’) produced higher
reproducibility. Then, the total number of CPE sub-
jects in which an individual health worker perceived
CPE needs was employed, as the magnitude of self-
perceived CPE needs. There are 72 occupational groups
in the Ghanaian MOH personnel system [33]. To enable
data to be analyzed in a statistically valid manner, all
the 72 occupational groups were re-categorized into
four groups: (i) health technical staff; (ii) administrative
staff; (iii) non-health technical staff; and (iv) support
staff. This was a necessary step because the numbers
of those who were categorized into respective profes-
sional sub-groups under health technical staff were not
great enough to analyze and compare independently
(Table 1).
3.4. Data analysis
Both bivariate and multivariate analyses were under-
taken to identify the significantly associated back-
ground variables (independent variables) with the
respective reasons for participation (dependent vari-
ables). Since the dependent variables are dichotomous
and the independent variables are composed of both
categorical and ratio ones, two types of bivariate anal-
yses were employed. First, the association between
four of seven independent variables that are categorical
(type of occupational group, rank of post in MOH per-
294 H. Aiga / Health Policy 77 (2006) 290–303

Table 1 sonnel system, gender, and marital status) and reasons

Characteristics of respondents for participation was examined using χ2 test.
Number of %a Second, the associations between the other two inde-
respondents
pendent variables that are ratio (professional working
Gender
Male 2498 37.3 experience in the form of number of years spent as a
Female 4198 62.7 MOH employee and age) and reasons for participa-
Professional working experience as a MOH employee (year) tion were examined using a non-parametric method
(mean = 17.1, S.D. = 8.0) (Mann–Whitney’s U-test). Furthermore, Spearman’s
<10 1440 21.8 correlation coefficients rs were calculated between
10–19 2847 43.1
20–29 1936 29.3 every combination of two background variables to
30≤ 389 5.9 detect mutually correlating background variables and
Age (year) (mean = 42.1, S.D. = 7.7) possible collinearity among the independent vari-
<20 2 0.0003 ables. Spearman’s correlation analyses were employed
20–29 379 5.7 because both ordinal categorical and ratio variables
30–39 2516 38.1
40–49 2649 40.1 were dealt with.
50≤ 1056 16.0 Since the dependent variables were dichotomous,
Type of occupational group the statistical technique employed for multivariate
Health technical staff 3341 50.1 analyses was logistic regression. Dummy variables
Medical doctor 143 2.1 were created for categorical independent variables.
Medical assistant 132 2.0
Nurse 1175 17.6 The largest categories were selected as reference cate-
Midwife 580 8.7 gories [34]. The background variables without signifi-
Public health nurse 666 10.0 cant association in bivariate analyses (p < 0.05) were
Pharmacist 33 0.5
Laboratory technician 66 1.0
dropped from the independent variables for logis-
Radiographer 27 0.4 tic regression. Furthermore, when both rs > 0.5 and
Nutritionist 47 0.7 p < 0.01 were detected in Spearman’s correlation anal-
Physiotherapist 11 0.2
Mortuary officer 17 0.3
ysis between two independent variables employed for
Health educator 12 0.2 logistic regression, an interaction term of them to the
Malaria control officer 31 0.5 models was added [35,36]. Data obtained through the
Leprosy control officer 96 1.4 survey were analyzed using SPSS for Windows (ver-
Environmental health officer 64 1.0
Biostatistician 86 1.3 sion 11.0).
Other health technical staff 155 2.3
Administrative staffb 1335 20.0
Non-health technical staffc 146 2.2
Support staffd 1850 27.7
4. Results
Rank of post in MOH personnel system
Director 33 0.5 The characteristics of individual respondents in the
Senior officer 815 12.2 survey are presented in Table 1. Female health work-
Junior officer 5827 87.3 ers accounted for 62.7%. Professional working experi-
Type of duty station ence in the form of number of years spent as a MOH
Hospital 3064 45.8 employee was nearly in normal distribution, and 43.1%
Health center 1898 28.3
Clinic 654 9.8 of respondents had 10–19 years professional working
Maternity home 23 0.3 experience. Half of respondents were health technical
Health administration office 837 12.5 staff and 20% were administrative staff. Only 12.7%
Training/research institute 220 3.3
were either directors or senior officers.
Total 6696 100.0
a Totals may not sum to n = 6696 owing to missing observations. 4.1. Overview of the reasons for participation
b Administrative staff include: administrator, accountant, and secretary.
c Non-health technical staff include: engineer, laundry superitendent, supply
and store officer, and hospital maintenance technician. Fig. 2 shows the reasons for participation in CPE
d Support staff include: orderly, driver, landerer, and security guard.
among the health workers. Of all the respondents
 H. Aiga / Health Policy 77 (2006) 290–303
Fig. 2. Reasons for pariticipation in CPE programs.
(N = 6696), 6490 (96.9%) perceived that CPE is nec-
essary. Of those (n = 6490), 5873 respondents (90.5%)
perceived CPE is necessary to maintain and improve
professional knowledge and skills. Similarly, 3294
(50.8%) and 2799 (43.1%) responded that CPE is nec-
essary, respectively, ‘to interact and exchange views
with colleagues’ and ‘to obtain a higher job status’.
Only 469 (7.2%) responded that CPE is necessary ‘to
gain relief from routine’.
Since four dichotomous questions were asked on
the respective reasons for participation, there were the-
oretically and actually 16 (=24 ) groups in total. Among
them, there were two dominant groups that accounted
for relatively greater proportions. These groups are
composed of those who responded ‘Yes–Yes–Yes–No’
(group (D): n = 1664, 24.85%) and ‘Yes–No–No–No’
(group (H): n = 1575, 23.52%): to the questions in
the order of the extent to which proactive post-CPE
application is expected (R1 > R2 > R3 > R4 ) (Fig. 3).
These two groups are followed by another two of
‘Yes–Yes–Yes–No’ (group (B): n = 1235, 18.44%) and
‘Yes–No–Yes–No’ (group (F): n = 1098, 16.40%). All
the other groups accounted for relatively smaller pro-
portion ranging from 0.04% to 3.64% of the total num-
ber of the respondents.
295
4.2. Bivariate and multivariate analyses
The associated variables with the reasons for par-
ticipation were explored through statistical process-
ing. Table 2 shows the results of bivariate analy-
sis. Significant χ2 (p < 0.05) was not produced for
the type of occupational group with R4 , for gen-
der with R3 and R4 , and for marital status with R1
and R3 . Professional experience and age did not pro-
duce, in Mann–Whitney’s U-test, significant differ-
ences (p < 0.05) for R3 and R4 . These variables without
statistical significances were dropped from indepen-
dent variables for the respective multivariate analyses.
Subsequently, only to R2 (to interact and exchange
views with colleagues), were all the seven background
variables applied as the independent variables for mul-
tivariate analyses.
Among the independent variables employed
for multivariate analyses, a significantly higher
Spearman’s correlation coefficient (rs = 0.628 > 0.5,
p < 0.001) was detected between professional experi-
ence and age. This indicates the possible collinearity
between the two variables. It is reasonable that these
two variables could be correlated because the number
of years spent as a MOH employee, to a certain extent,
 296
H. Aiga / Health Policy 77 (2006) 290–303
Fig. 3. Reason for participation in CPE programs and self-perceived needs in the form of the total number of CPE subjects.
Table 2
Bivariate analysis on reasons for participation in CPE programs with background variables
Type of analysis R1 : to maintain and improve professional R2 : to interact and exchange views with R3 : to get higher status in job R4 : to get relief from routine
knowledge and skills colleagues
Yes (n = 5873) No (n = 617) p-Value Yes (n = 3294) No (n = 3196) p-Value Yes (n = 2799) No (n = 3691) p-Value Yes (n = 469) No (n = 6021) p-Value
Self-perceived needs in the Mann–Whitney’s 4.58 ± 4.51 2.03 ± 2.71 <0.001** 5.45 ± 4.91 3.20 ± 3.53 <0.001** 4.89 ± 4.60 3.92 ± 4.26 <0.001** 3.64 ± 4.72 4.39 ± 4.41 <0.001**
form of the total number of U-test
CPE subjectsa
Type of occupational group χ2 test
Support staff 1427 (24.4%) 262 (43.2%) <0.001** 664 (20.2%) 1025 (32.3%) <0.001** 767 (27.5%) 922 (25.1%) <0.001** 115 (25.2%) 1574 (26.2%) 0.505
Non-health technical staff 125 (2.1%) 20 (3.3%) 31 (0.9%) 114 (3.6%) 60 (2.1%) 85 (2.3%) 6 (1.3%) 139 (2.3%)

H. Aiga / Health Policy 77 (2006) 290–303

Administrative staff 1133 (19.3%) 172 (28.3%) 523 (15.9%) 782 (24.6%) 650 (23.3%) 655 (17.8%) 96 (21.0%) 1209 (20.1%)
Health technical staff 3175 (54.2%) 153 (25.2%) 2071 (63.0%) 1257 (39.6%) 1316 (47.1%) 2012 (54.8%) 240 (52.5%) 3088 (51.4%)

Rank of post in MOH χ2 test

personnel system
Junior officer 5065 (86.3%) 562 (93.5%) <0.001** 2731 (83.0%) 2896 (91.1%) <0.001** 2495 (89.3%) 3132 (85.2%) <0.001** 393 (86.4%) 5234 (87.0%) 0.001**
Director 773 (13.2%) 37 (6.2%) 531 (16.1%) 279 (8.8%) 288 (10.3%) 522 (14.2%) 54 (11.9%) 756 (12.6%)
Senior officer 31 (0.5%) 2 (0.3%) 29 (0.9%) 4 (0.1%) 11 (0.4%) 22 (0.6%) 8 (1.8%) 25 (0.4%)

Professional working Mann–Whitney’s 17.00 ± 8.13 18.18 ± 7.19 0.003** 16.80 ± 8.29 17.43 ± 7.71 0.001** 17.29 ± 7.82 16.97 ± 8.23 0.334 17.04 ± 8.60 17.12 ± 8.02 0.665
experience as a MOH U-test
employee (year)
Age (year) Mann–Whitney’s 41.88 ± 7.61 42.76 ± 7.67 0.027* 41.71 ± 7.71 42.22 ± 7.51 0.013* 41.86 ± 7.46 42.03 ± 7.74 0.225 42.19 ± 8.33 41.94 ± 7.57 0.571
U-test
Gender χ2 test
Male 1998 (35.2%) 297 (48.3%) <0.001** 983 (30.7%) 1293 (42.4%) <0.001** 986 (36.4%) 1290 (36.4%) 0.959 168 (37.8%) 2108 (36.3%) 0.511
Female 3681 (64.8%) 297 (51.7%) 2219 (69.3%) 1759 (57.6%) 1726 (63.6%) 2252 (63.6%) 276 (62.2%) 3702 (63.7%)

Marital status χ2 test

Single, divorced, widowed 929 (16.0%) 80 (13.5%) 0.213 558 (17.1%) 451 (14.4%) <0.001** 432 (15.6%) 577 (15.6%) 0.913 85 (19.0%) 924 (15.5%) <0.001**
Separated 107 (1.8%) 14 (2.4%) 75 (2.3%) 46 (1.5%) 54 (2.0%) 67 (1.8%) 21 (4.7%) 100 (1.7%)
Married 4771 (82.2%) 497 (84.1%) 2628 (80.6%) 2640 (84.2%) 2282 (82.4%) 2986 (82.3%) 341 (76.3%) 4927 (82.8%)

The numbers do not add up to the total in the above rows in most variables due to missing values and rounding.
* p < 0.05.
** p < 0.01.
a The tentative classification categorized the CPE programs into 34 themes: (1) basic clinical skills; (2) chronic diseases; (3) emergency care; (4) infection control; (5) specialized clinical skills; (6) acute respiratory infection; (7) community
health; (8) diarrhea; (9) EPI and NID; (10) Guinea worm; (11) health education and promotion; (12) infectious diseases; (13) leprosy; (14) malaria; (15) nutrition; (16) general public health; (17) STIs and AIDS; (18) tuberculosis; (19) TBA
training; (20) reproductive health; (21) safe motherhood; (22) bioetics; (23) computer skills; (24) drug supply management; (25) financial management; (26) information management; (27) health management; (28) hospital management;
(29) staff training; (30) office management; (31) personnel management; (32) store management; (33) survey methods; and (34) others.

297
 298
Table 3
Logistic regression on the reasons for participation in CPE with background variables
R1 : to maintain and improve professional R2 : to interact and exchange R3 : to get higher status in job R4 : to get relief from routine
knowledge and skills views with colleagues
OR (95% CI) p-Value OR (95% CI) p-Value OR (95% CI) p-Value OR 95% CI p-Value
Self-perceived needs in the form of the 1.200 1.143–1.260 <0.001** 1.093 1.076–1.110 <0.001** 1.082 1.068–1.096 <0.001** 0.960 0.936–0.985 0.002**
total number of CPE subjectsa
Type of occupational group <0.001** <0.001** <0.001** Not applied
Support staff 0.380 0.291–0.497 <0.001** 0.602 0.522–0.695 <0.001** 1.581 1.386–1.802 <0.001**

H. Aiga / Health Policy 77 (2006) 290–303

Non-health technical staff 0.608 0.349–1.060 0.080 0.322 0.212–0.490 <0.001** 1.441 1.021–2.033 <0.001**
Administrative staff 0.411 0.314–0.539 <0.001** 0.546 0.471–0.632 <0.001** 1.879 1.637–2.156 0.038*
Health technical staff = reference 1.000 1.000 1.000

Rank of post in MOH personnel system 0.172 <0.001** <0.001** <0.001**

Senior officer 1.454 0.964–2.193 0.074 1.571 1.309–1.886 <0.001** 0.673 0.572–0.792 <0.001** 0.982 0.722–1.334 0.906
Director 42.767 0.000–9.9 × 106 0.551 9.316 2.224–39.02 0.002** 0.562 0.264–1.200 0.137 5.161 2.276–11.70 <0.001**
Junior officer = reference 1.000 1.000 1.000 1.000

Professional working experience as a 0.937 0.872–1.005 0.070 0.987 0.951–1.024 0.475 Not applied Not applied
MOH employee (year)
Age (year) 0.989 0.961–1.018 0.452 0.998 0.983–1.013 0.760 (Not applied) (Not applied)

Sex Not applied Not applied

Male 0.718 0.586–0.878 0.001** 0.729 0.645–0.825 <0.001**
Female = reference 1.000

Marital status Not applied 0.281 Not applied <0.001**

Single, divorced, widowed 1.052 0.906–1.222 0.508 1.352 1.052–1.738 0.019*
Separated 1.358 0.910–2.026 0.134 3.174 1.951–5.164 <0.001**
Married = reference 1.000 1.000
Professional working experience as a 1.001 0.999–1.002 0.322 1.000 0.999–1.001 0.957 Not applied Not applied
MOH employee × age
N = 6490.
* p < 0.05.
** p < 0.01.
 H. Aiga / Health Policy 77 (2006) 290–303 299

should be in linear relation to age. Therefore, an interac-

tion term of the two variables was added to the logistic
regression models when both these two variables were
employed as the independent variables. Thus, the final
models for logistic regressions on each dependent vari-
able (R1 , R2 , R3 , and R4 ) are as follows:
R1 = f(total number of CPE subjects chosen, occu-
pational group, rank, professional experience, age,
gender, yeas of experience × age);
R2 = f(total number of CPE subjects chosen, occu-
pational group, rank, professional experience, age,
gender, marital status, yeas of experience × age);
R3 = f(total number of CPE subjects chosen, occupa-
tional group, rank);
R4 = f(total number of CPE subjects chosen, occupa-
tional group, rank, marital status).
Table 3 shows the results of the logistic regres-
sions. Note that only self-perceived needs produced
significant odds ratios in every dependent variable.
Its odds ratios were positive and the highest with R1 Fig. 4. Relationship between odds ratios and self-perceived needs in
(OR = 1.200 > 1) and decreased through to negative and the form of the total number of CPE subjects.
the lowest with R4 (OR = 0.960 < 1) in parallel to the
order of the extent which proactive post-CPE applica-
tion is expected. Both mean of the total number of CPE more frequently with significance. Conversely, junior
subjects and the odds ratio were less than one only in R4 staffs were likely to select R3 . Marital status produced
(Fig. 4). Fig. 3 shows the mean of total number of CPE significant odds ratios only with R4 (to gain relief
subjects chosen of all the 16 groups. Non-parametric from routine). The odds ratio of those who are single,
test (Mann–Whiteny’s U-test) was undertaken to com- divorced, or widowed with R4 was relatively higher
pare the total number of subjects in CPE needs between (1.352 times) than married. The odds ratio of those
respective two groups. The results of the tests indicate being separated with R4 was much higher (3.174 times)
that R4 (to gain relief from routine) presented both sig- than married.
nificantly positive (between groups (M) and (N)) and While significant odds ratios were not produced,
negative contributions (between groups (O) and (P)) to professional experience and age produced slightly neg-
the total number of CPE subjects chosen. ative association with R1 and R2 (OR < 1). However,
All the other independent variables except for the the odds ratios of the interaction term between these
total number of CPE subjects produced significant odds two were nearly equal to 1, indicating no association
ratios (p < 0.05) only with a part of dependent variables. with R1 and R2 . Thus, the associations of professional
The odds ratios of support staff, non-health technical experience and age with R1 and R2 were limited.
staff, and administrative staff with R1 and R2 were sig-
nificantly lower (OR < 1) than health technical staff.
Conversely, support staff, non-health technical staff, 5. Discussion
and administrative staff produced significantly higher
odds ratios (OR > 1) with R3 (to obtain a higher job 5.1. Associated factors with reasons for
status) than health technical staff. Similar trend was participation in CPE
confirmed in rank of post. Compared with junior staff,
directors and senior staff selected, respectively, R2 Self-perceived needs in the form of the total num-
extremely (9.316 times) and relatively (1.571 times) ber of CPE subjects was the only independent variable
300 H. Aiga / Health Policy 77 (2006) 290–303
significantly associated with all the four reasons for par-
ticipation, by producing a positive odds ratio with R1 ,
R2 , and R3 and negative odds ratio with R4 (Table 3).
Fig. 4 also indicates that the majority of those who
chose R4 did not present even one concrete subject in
which they need CPE. This implies that R4 (‘to gain
relief from routine’) contributes to decrease of self-
perceived CPE needs.
R4 (‘to gain relief from routine’) was the only reason
that contributed to a significantly less total number of
CPE subjects chosen in non-parametric test (between
(O) and (P)) (Fig. 3). This coincides that the above
findings. Hence, this suggests that there be a cutoff
point between R3 and R4 that differentiates desirable
and undesirable reasons.
Of all the reasons for participation, R1 (‘to maintain
and improve professional knowledge and skills’) pro-
duced the greatest positive odds ratio with the total
number of CPE subjects chosen in logistic regres-
sions. Comparing among those who chose only one
reason: groups (H), (L), (N), and (O), the order of
the mean total number of CPE subjects chosen was
R2 (3.34) < R1 (3.29) < R3 (1.97) < R4 (0.35) (Fig. 4).
Moreover, selection of R1 produced the greatest and
significant difference in mean of the number of sub-
jects chosen (p < 0.001, d = 2.55) in non-parametric test
(Fig. 3). Therefore, R1 could be a strong predicator or
criterion that characterizes the level of willingness to
participate.
The type of occupational group was a significantly
associated variable for R1 , R2 , and R3 (Table 3). Com-
pared with health technical staff, all the other types of
staff produced significantly lower odds ratios with R1
and R2 . This indicates that health technical staff chose
the reasons that would likely support greater post-CPE
application than all the other occupational groups. On
the other hand, R3 was more frequently chosen by
administrative, non-health technical and support staff,
than by health technical staff.
The Ghanaian MOH adopted the policy that at
least one CPE opportunity should be ensured every 3
years among all the types of health workers includ-
ing administrative, non-health technical, and support
staff [26,37]. However, the tentative official classifica-
tion of CPE programs seems to have been developed
assuming health technical and administrative staff as
a major CPE target. This may have made it difficult
for non-health technical and support staff to choose
the appropriate subjects according to their CPE needs.
For example, CPE courses on ‘EPI and NID’ often
include the contents of micro-planning and logistic
guidance on the national immunization day (NID) for
supply and store officers (non-health technical staff)
and drivers (support staff). However, the classification
did not allow those staff to adequately anticipate the
contents of those CPE programs. For this reason, it is
likely that they could not find the appropriate subjects
and subsequently chose the reasons with lower expec-
tation of post-CPE application.
The significant association of marital status only
demonstrates that single, divorced, or widowed health
workers were likely to choose the reason with the
lowest expectation of post-CPE application (R4 ) sig-
nificantly more than married health workers. Similarly,
separated health workers tended to select R4 more fre-
quently with significance.
Not significant but a slightly negative odds ratios
was found for professional experience and age with R1
and R2 , implying that younger health workers have a
stronger desire to improve their knowledge and skills
and exchange views on professional tasks with col-
leagues. However, they have learned relatively updated
knowledge and skills during pre-service training, more
recently than older health workers. Tassone and Heck
reported, in their review of several studies in the United
States, that younger health workers consider relief from
routine is more important than older health workers
[12].
The odds ratio of rank of post in our study seemingly
demonstrates converse result to the study of Tassone
and Heck. Senior staff and directors were more likely to
select the reasons that have a higher expectation of post-
CPE application such as R1 and R2 than junior staff.
However, a significant difference was not detected in
mean of age among ranks (junior staff = 41.5 years old,
senior staff = 46.6, and directors = 40.2). Junior staffs
are not necessarily young health workers like 20s and
30s. Therefore, this study does not necessarily dis-
agreed with that of Tassone’s study.
5.2. Measurement of CPE needs
This study attempted to quantify the magnitude of
CPE needs in the form of the total number of CPE
subjects identified. This raises two issues, i.e. methods
to quantify and validity of self-perceived needs.
 H. Aiga / Health Policy 77 (2006) 290–303
First, given that CPE needs are defined as a discrep-
ancy between an existing set of circumstances and a
more desirable set of circumstances [5,38], the magni-
tude of an individual’s CPE needs could be theoretically
quantified by summing up the numbers of respective
CPE subjects chosen. To more precisely quantify the
needs, it is necessary to weight each subject through rat-
ing the importance of respective CPE subjects accord-
ing to point scaling [13]. This is because the level of
importance and the amount of knowledge and skills
they want in one CPE subject would vary depending
on the health worker.
Second, self-perceived CPE needs in this study
might have been exaggerated by health workers to
a certain extent primarily. There are several major
data sources for CPE needs assessment: health work-
ers, supervisors and employers, patients, and treatment
records. Thus, ideally CPE needs should be assessed
from a variety of perspectives [6,39,40]. However, it is
necessary to focus on specific data source(s) since the
resources to be invested to needs assessment such as
human and financial resources are often very limited
[38]. Self-perceived CPE needs, based on a question-
naire, provide us with the most useful and reliable
data in a cost-effective manner [41–43]. Health work-
ers can, to a great extent, objectively assess both their
performance and their deficiencies in knowledge and
skills through encountering problems or uncertainties
in daily practice [3]. Therefore, a larger sample size is
recommended probably to minimize or control for the
risk of overestimation and exaggeration of CPE needs.
In this sense, the data colleted in this study might ensure
a certain reliability and representativeness.
The pretest for the survey implied difficulties in
ensuring reproducibility in responses to questions on
the level of importance in multi-point scale. For this
reason, this study employed dichotomous way of ask-
ing their reasons for participation. In past studies in
which the scales such as the PRS were utilized, it is
unclear whether reproducibility was tested. Therefore,
further precise data is necessary to evaluate the validity
of using such scales.
Many development agencies tend to provide train-
ing programs exclusively for the purpose of smoother
implementation of specific projects on ad-hoc basis
without appropriate coordination. This undesirable sit-
uation is observed not only in health sector but also
in other sectors. The development-agency-driven CPE
301
makes it difficult for the governments to take leadership
on and systematize CPE as a part of health policy. Also,
it most likely discourages health workers to think about
CPE needs in a more proactive and serious manner.
6. Conclusion and recommendations
The results of this study indicate that the reason
‘to maintain and improve professional knowledge and
skills’ is a strong predicator or criterion that character-
izes the level of willingness to participate in CPE pro-
grams. Additionally, it was suggested that whether the
reason for participating in CPE is ‘to gain relief from
routine’ be a cutoff point that differentiates desirable
and undesirable reasons. It sounds reasonable but rather
like nothing new. However, this conclusion should be
recognized as a solid basis since it was the conclusion
reached through a series of statistical analyses using a
large sample size (=6696). It is proposed that policy
and decision makers of the ministry of health of other
countries with similar situation consider the findings
of this study in order to more carefully implement CPE
programs.
This study employed the total number of subjects
where CPE is necessary because it was useful to capture
and compare the crude magnitude of individual needs
while assuring reproducibility. However, more precise
way of quantifying the magnitude of CPE needs may
need to be explored to further deploy the research in
this area.
There is great room for further research concern-
ing the reasons for participation in CPE programs
among health workers. It is unfortunate when sub-
stantial money from taxpayers in both developed and
developing countries is invested, in the form of grants or
loans, to health workers in developing countries with-
out a precise and clear analysis of CPE needs. It is
strongly recommended that CPE situation be carefully
reviewed and scrutinized prior to investing to it. Oth-
erwise, skepticism of CPE will be stuck and remaining
in the vicious cycle.
Acknowledgements
I gratefully acknowledge Ken Saoge, Charles
Acquah, and Stephen Ntow of Human Resources Divi-
302 H. Aiga / Health Policy 77 (2006) 290–303

sion, the Ghanaian Ministry of Health for their coop-
erative advice in the study design. I am also grateful
to Frank Nyonator of Volta Regional Health Adminis-
tration, Mohammed Bin-Ibrahim of Western Regional
Health Administration, and Kofi Asare of Brong Ahafo
Regional Health Administration, for their tremendous
supports in data collection. I would like to also thank
Japan International Cooperation Agency (JICA) and
Gesellschaft fűr Technische Zusammenarbeit (GTZ)
for its generous support to this study. I wish to thank
James E. Banta and Jennifer Vollett-Krech of the
George Washington University for their comments.
This work is dedicated to all the health workers in
Ghana. This work was supported by the Foundation
for Advanced Studies on International Development
(FASID), Japan.
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Hirotsugu Aiga, MPH PhD, is a senior programme adviser at Emer-
gency Needs Assessment Unit, United Nations World Food Pro-
gramme. He is also: (i) an adjunct associate professor at Department
of Global Health, School of Public Health and Health Services, The
George Washington University, USA; (ii) a visiting research fellow
at Department of Health Policy and Planning, School of International
Health, The University of Tokyo, Japan. He has undertaken public
health field works in the Philippines, Indonesia, Thailand, Vietnam,
India, Japan, Russian Federation, Kazakhstan, Kyrgyz, Uzbekistan,
Turkmenistan, Azerbaijan, Liberia, Ghana, Sudan, and Tanzania, and
has extensive experience of research and project supervision with
both bilateral and international development agencies in Asia and
Sub-Saharan Africa. His main areas of expertise are environmental
health, human resource development, epidemiology, and food secu-
rity/nutrition.