Table 1 Provider perception questions from survey

Perceived social status question stem: During the survey, research assistants were instructed to show respondents a drawing of a ladder with 10 rungs and read this stem to them:

“This ladder represents where people stand in Kenya. At the top of the ladder are the people who are the best off, those who have the most money, most education, and best jobs. At the bottom are the people who are the worst off, those who have the least money, least education, worst jobs, or no job.”

After reading the question stem, they then read the following questions:

“Thinking of when you were growing up (before you had your own family and before you became a health care provider), where will you place your family’s social status on this ladder?” and “Thinking of now, where will you place your social status? Select the rung that best represents where you think you stand now on the ladder?”

The selected ranks were used to measure Perceived social status of family growing up and Perceived social status now respectively.

Perceived accomplishments: This was measured by asking the question: “Thinking of what you wish you will have accomplished at this stage in your life, would you say you have accomplished less than you hoped, exactly what you hoped, or more than you hoped?”

Perceived availability of work supplies: This was measured by asking the question: “On a scale of 0 to 10, where 0 means that you don’t have any of the things you need to effectively do your work, such as medicines and supplies, and 10 means you have everything you need to work with, where will you place your situation in this facility?”

Effort-reward imbalance and overcommitment: These were both measured with the Effort Reward Imbalance Questionnaire: a validated 16 item measure based on the work stress model to assess the balance between efforts spent (3 items), rewards received (7 items), and commitments (6 items) (Siegrist, Li, & Montano, 2014). Each item has responses on a 4-point scale from strongly disagree to strongly agree (see additional file 1 for questions).

Effort Reward Imbalance was calculated as the effort score (the sum of the 3 effort items) divided by reward score (the sum of the 7 reward items) multiplied by a correction factor (k = 7/3) used to adjust for the unequal number of items of the effort and reward scores. Higher scores indicate more effort reward imbalance.

Overcommitment was calculated as the sum of responses to 6 commitment items. Scores range from 6 to 24, with higher scores indicating higher commitment to one’s work.