Behind the scenes of the PRIME intervention: designing a complex intervention to improve malaria care at public health centres in Uganda

Figures & data

Fig. 1 Health workers’ and community members’ aspirations for good quality healthcare.

Fig. 2 Barriers to providing good quality care at health centres.

Table 1 Activities considered but excluded as out of scope for the PRIME intervention

Potential intervention activity	Reasons for consideration drawn from formative research	Reasons not included in the PRIME intervention
Reinstate/supplement the primary healthcare fund	• Insufficient funds to meet daily health centre costs, including transporting drugs, paying for cleaning services, and purchasing supplies  • Health workers request payment for services	• Bureaucratically and administratively challenging to implement  • Opportunity for misappropriation  • Unsustainable after the study period
Fill staffing gaps at health centres in accordance with Ministry of Health guidelines	• Many patients and too few staff  • Low motivation of staff due to overburdened workloads  • Health centres not fully functional due to insufficient availability of staff  • Staff not at recommended levels	• Bureaucratically and politically challenging to implement  • Limited availability of health workers nationwide  • Requires substantial funding  • Unsustainable after the study period
Pay/supplement staff salaries	• Health workers not paid on time or in full  • Low motivation of staff due to lack of pay  • Time spent in alternative employment activities  • Health workers request payment for services	• Bureaucratically and administratively challenging to implement  • Not likely to be successful due to national payroll system challenges  • Requires substantial funding  • Unsustainable after the study period
Implement ICCM through VHTs	• Community medicine distributors/VHTs important source of care, treatment, and referral in the community  • Need to determine a sustainable VHT ICCM programme: community sensitization, training, VHT kits, drug supply, supervision	• ICCM and VHT policy under revision and implementation timelines uncertain  • Potential challenges with the operationalization of the new policy  • Required drug formulations for pneumonia not yet available
Improve the drug supply chain for AL	• Frequent stock-outs of AL and other essential drugs, leading community members to seek care elsewhere  • Stock-outs due to challenges with quantification, ordering, storage, district level stock of AL, and numerous logical barriers	• Other programmes already addressing the drug supply chain  • Imminent implementation of new ‘push’ system, potential for misalignment  • Unlikely to yield results due to challenges at higher levels of the system
Work with district and partners to ensure supply of mRDTs and thermometers	• World Health Organization guidelines for malaria case management, but limited supply of mRDTs to health centres  • Thermometers not supplied or available in health centres	• No options for partnering with other stakeholders/partners providing mRDTs and thermometers identified; therefore, they would have to be directly supplied by the PRIME intervention
Implement community sensitization	• Attract patients to health centres by communicating new/improved services using local councillors, social gatherings, word of mouth, mass media, community dialogues	• It was suggested to focus on word of mouth/VHTs to communicate information; however, the VHT programme was not implemented during the study period
Include supervision and coaching as part of HCM modules	• Supervision is described by health workers as ‘fault finding, unsupportive and infrequent’, leading to demotivation	• Weak evidence demonstrating effectiveness of supervision  • Challenging logistics of implementing supervision activities
Implement 3-month SOA to complement PCS	• Lack of patient-centred thinking due to low motivation and lack of awareness of how emotions can affect actions and relationships with others	• 3-month activities not aligned with other intervention training packages; therefore revised to weekly activities to fit within four PCS modules

ICCM=integrated community case management; VHT=village health team; AL=artemether–lumefantrine; mRDT=malaria rapid diagnostic test; HCM=health centre management; PCS=patient-centred services; SOA=self-observation activities.

Table 2 PRIME training and workshop modules

Training in FCM
Aim: To train health workers in use of mRDTs and build clinical skills for managing malaria and other febrile illnesses
Barriers addressed	Module	Topic
• Poor knowledge of malaria case management • Inadequate/unavailable infrastructure or diagnostic laboratory facilities	Training module	• How to evaluate patients with fever and select patients for mRDT testing  • Performing and reading an mRDT  • Management of a patient with fever and a positive or negative mRDT  • Recognition and referral of patients with severe illness  • mRDT storage and monitoring
	Supervision visits	• Observation and feedback on:   • Use of mRDTs   • Skills in fever case management   • Stock management of AL and mRDTs   • Recording mRDT results in patient registers
Workshop in HCM
Aim: To develop in-charge health workers’ accountable practices in management of finances, supplies, and health information
Barriers addressed	Module	Topic
• Poor management of resources by those in charge	HCM 00: Introduction to HCM	• The role of accountability as a health worker
• Low motivation of staff due to poor health centre administration • Under-utilization or lack of appropriate tools to appropriately mange health centres • Low use of records to monitor and manage resources and report to local and district stakeholders	HCM 01: Primary healthcare fund management HCM 02: Drug supply management HCM 03: Health information management	• Budgeting and accounting using the Primary Health Care Fund management tool  • Budgeting and accounting – putting it all together  • Principles of the drug distribution system  • Forms required in drug distribution cycle  • The ACT Drug Distribution Assessment Tool  • Why quality information matters  • The information cycle – from patient to patient
Workshop in PCS
Aim: To improve health workers’ interpersonal communication with patients and other health centre staff and to build consultation skills
Barriers addressed	Module	Topic
• Lack of patient-centred thinking • Communication problems including language barrier	PCS 00: Introduction to PCS and SOA	• Thinking about my role as a health worker  • Introduction to PCS  • Introduction to SOA
• Discrimination/preferential treatment of patients • Inappropriate use of volunteers • Poor relationships between staff and communities • Poor patient flow and management	PCS 01: Communication skills part 1 PCS 02: Communication skills part 2 PCS 03: Building a positive work environment PCS 04: Improving the patient visit	• Building rapport  • Active listening  • Asking good questions  • Giving good information  • HCM changes  • Dealing with stress at work  • Communication review  • Patient welcome and orientation

mRDT=malaria rapid diagnostic test; HCM=health centre management; PCS=patient-centred services; SOA=self-observation activities.

Table 3 Example of revisions made to the PCS and HCM modules as a result of piloting

Description of revision made	Reason for revision	Example of revision made
Reduced the total number of objectives across the modules so that only one or two new concepts were introduced per module	The total number of learning objectives and amount of content was ambitious for the 3-hour module format. Learning was best taken up when there were only one or two concepts per module.	• Concepts for improving communication with patients were introduced over two modules with two concepts per module:   • PCS 01: Communication Skills Part 1 introduced building rapport and active listening   • PCS 02: Communication Skills Part 2 introduced asking good questions and giving good information
Simplified language and revised learning objectives to only introduce only one new word per module	Overall, the language needed to be reduced to meet the education level of the learners New words required time and expertise to introduce and be taken up by learners.	• Reduced number of new words (such as building rapport, triage, open/closed questions, or automatic emotional responses) to one or two per module
Revised learning objectives to include more group work activities	Learners responded well to group work activities, were more engaged with each other, and retained more learning points, compared to didactic teaching activities. For example, learners struggled to understand and perform calculations required for drug supply management when these were taught didactically.	• Revised learning objective for drug supply management to ‘Accurately complete the forms required in the drug distribution system’. Calculations for the forms were completed as group work, and more information was provided in the learners’ manual for later reference when completing forms at the health centre.
Rephrased objectives with abstract concepts into simpler ideas communicated with activities or games	Abstract concepts took a long time to introduce and give adequate examples; learners understood concepts better when they had an example or activity to describe the concept.	• Learning objective on appreciating barriers to attending the health centre, both logistical (transportation, time, etc.) and emotional (anxiety, confusion), was introduced using a maze activity to demonstrate how these barriers prevent access to health services.

HCM=health centre management; PCS=patient-centred services.

Fig. 3 PRIME intervention programme theory and logic model.

Fig. 4 PRIME implementation theory. (Adapted and reproduced with permission from Ref. 39.)