Abstract
BackgroundIn low-income countries, only about a third of Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) patients eligible for anti-retroviral treatment currently receive it. Providing decentralized treatment close to where patients live is crucial to a faster scale up, however, a key obstacle is limited health system capacity due to a shortage of trained health-care workers and challenges of integrating HIV/AIDS care with other primary care services (e.g. tuberculosis, malaria, respiratory conditions). This study will test an adapted primary care health care worker training and guideline intervention, Practical Approach to Lung Health and HIV/AIDS Malawi (PALM PLUS), on staff retention and satisfaction, and quality of patient care.Methods/DesignA cluster-randomized trial design is being used to compare usual care with a standardized clinical guideline and training intervention, PALM PLUS. The intervention targets middle-cadre health care workers (nurses, clinical officers, medical assistants) in 30 rural primary care health centres in a single district in Malawi. PALM PLUS is an integrated, symptom-based and user-friendly guideline consistent with Malawian national treatment protocols. Training is standardized and based on an educational outreach approach. Trainers will be front-line peer healthcare workers trained to provide outreach training and support to their fellow front-line healthcare workers during focused (1-2 hours), intermittent, interactive sessions on-site in health centers. Primary outcomes are health care worker retention and satisfaction. Secondary outcomes are clinical outcomes measured at the health centre level for HIV/AIDS, tuberculosis, prevention-of-mother-to-child-transmission of HIV and other primary care conditions. Effect sizes and 95% confidence intervals for outcomes will be presented. Assessment of outcomes will occur at 1 year post- implementation.DiscussionThe PALM PLUS trial aims to address a key problem: strengthening middle-cadre health care workers to support the broader scale up of HIV/AIDS services and their integration into primary care. The trial will test whether the PALM PLUS intervention improves staff satisfaction and retention, as well as the quality of patient care, when compared to usual practice.Trial RegistrationCurrent controlled Trials: ISRCTN47805230
Highlights
In 2008, UNAIDS estimated that 33 million people were living with HIV/AIDS [1]
The trial will test whether the PALM PLUS intervention improves staff satisfaction and retention, as well as the quality of patient care, when compared to usual practice
Health centers will be stratified according to funding source; and health centre size as defined by the number of health centre clinical staff postings defined as doctor, nurse, clinical officer or medical assistant working in the clinic at baseline
Summary
The burgeoning load of ART patients at rural health centres in Malawi has placed an increasing burden on health care staff in those centers, in an area where there is a 50% vacancy rate among clinical posts [4] This reflects the situation across sub-Saharan Africa, which suffers from the lowest HCW-to-population ratio in the world [4]. This study will respond to these facts by developing and evaluating a targeted intervention to optimize the clinical effectiveness of, and improve the satisfaction and retention of, healthcare workers in rural health centers This will be accomplished through the collaborative development, implementation and evaluation of an integrated clinical guideline and training intervention that will facilitate the integration of adult HIV/AIDS and TB care with primary care. These are all factors which may affect HCW satisfaction, recruitment and retention in countries such as Malawi [4,14,15,16], a key factor slowing the scale-up of access to high quality HIV/AIDS care in many countries
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