In addition to generating evidence for policy makers and program implementers on the effectiveness of PALM PLUS, baseline and interim results and outcomes from this study will inform future versions of the PALM PLUS clinical tool and training curriculum. In the first phase of qualitative inquiry, health care workers were interviewed on their knowledge of PALM PLUS and availability of training opportunities. All participants reported that they had attended traditional trainings in the past 12 months, most of them as trainees and a few as trainers. Respondents from intervention sites described the PALM PLUS on-site training approach as participatory, while those who had participated in the workshop/seminar approach traditionally used by the MoH characterized themselves more as passive listeners during the training sessions. The PALM PLUS approach was thought to generate interest in the training content, as trainees and trainers interacted and shared patient-care experiences. PALM PLUS trainees recommended this approach to training because it accorded the participants an opportunity to plan their training schedule in a manner that avoided disrupting health service delivery at their facilities. The approach was also felt to relieve the participants of travel to distant training sites, which, according to some respondents, saved time and resources.
Participants in intervention sites felt the streamlined PALM PLUS tool empowered them to provide better health services to patients. They felt that the symptom-based approach used in PALM PLUS improved their recognition of the patient’s problems and their ability to offer appropriate treatment. Although respondents commended the tool as being useful in clinical practice, many indicated that its utilization had the chance of slowing down patient consultations, which was felt to be problematic at times when patient queues were long. Many respondents stated that once they became familiar with its content and algorithmic approach, they did not use the PALM PLUS clinical tool routinely at the point of care, as they gained familiarity with the material. They also stated that time pressures dissuaded them from routine use of the PALM PLUS clinical tool. This finding echoes qualitative evidence from South Africa, where experienced primary care providers indicated that the PALSA PLUS guideline was viewed more as a learning tool and reference guide, rather than a point-of-care “checklist”. However, nurses with less primary care experience used the PALSA PLUS guideline more regularly as a job-aid [10
Almost all respondents mentioned allowances normally received during off-site MoH training as an important merit of that approach to training, and lack of the same in the PALM PLUS approach was considered to be a de-motivating factor for training. One trainer indicated that even though most training sessions were conducted during off-duty time, there was less participation from nurses than clinicians. This trainer felt that this might be due to of the lack of allowances provided to attend the PALM PLUS training sessions. When asked how they felt about attending an onsite training that might not give allowances, some HCW from control sites stated that they expected to receive allowances regardless of the site of training, onsite or off-site, as they felt this was a motivating factor for attending the training.
Baseline analysis of staff satisfaction surveys indicated no difference between HCW in intervention and control sites in terms of job satisfaction, professional satisfaction, likelihood of quitting in the next 12 months, plan to leave present job in the specified period, and perceived ease associated with finding a new job. The p-values for all variables were >0.05. Level of satisfaction was also assessed for different amenities among HCW: wages/salary, allowances, working hours, schedule flexibility, childcare availability, professional prestige, colleagues, staffing level, resources available, control over practice, pension, educational opportunities, responsiveness, clinical supervision, performance evaluation, and equipment/technology. There was no difference in terms of satisfaction with these amenities between HCW in intervention and control sites. There were high levels of overall satisfaction at intervention and control sites, however there were lower levels of baseline satisfaction on amenities in both groups.
Interim analysis of HCW absentee rates at health centres showed low absentee rates in all health centres, with attendance rates of greater than 95%. Of all the possible reasons for absences from their health centre post (sick leave, vacation, off-site training, other reason for being absent), being absent due to an off-site training was the most frequent reason cited by HCW (38% of all absent days).
Cumulative data on staffing levels for the first 12-month period of the study show that, on average, there were 8 clinical officers, 1 doctor, 19 medical assistants and 73 nurses per month in the control sites; and ten clinical officers, 16 medical assistants, 65 nurses and no doctor working per month in the intervention sites. Staff mobility monitoring shows that, on average, there were 3 staff and 4 staff departing from the control and intervention sites respectively, per month in the same 12-month period. On average, 2 new staff and 4 new staff joined control sites and intervention respectively, per month. The most common reason for departing a health centre was MoH initiated transfer, as indicated by 47 of 79 (59%) HCW departing from a health centre citing this reason. We hypothesize that staff turnover may have an impact on study outcomes, although we will attempt to adjust for this in future analyses.