Peer Reviewed Journal Articles on Conducting Needs Assessments

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Needs Assessment for Performance Improvement of Personnel in Accuse of Epidemiological Surveillance in Kingdom of morocco

• Gerardo Priotto,
• Ahmed Rguig,
• Moncef Ziani,
• Anouk Berger,
• Pierre Nabeth

x

• Published: July 7, 2014
• https://doi.org/x.1371/periodical.pone.0101594

Figures

Abstract

Background

In line with the International Wellness Regulations (IHR 2005), the Kingdom of morocco health surveillance arrangement has been reinforced via infrastructure strengthening and decentralization in its regions. To plan for personnel chapters reinforcement actions, a national workforce needs assessment was conducted by the National Epidemiological Surveillance Service and the World Wellness System.

Methods

The assessment used an ad-hoc method comprising two stages: (1) A survey via a standardized electronic questionnaire, administered to all staff in regional and provincial surveillance teams. Data collected included demographics, basic qualification, complementary training, perceived grooming needs, and preferred training modalities. Individuals were asked to grade, on a nine-point scale, their perception of importance of a given list of tasks and of their capacity to perform them. The gap between perceptions was quantified and described. (2) Field visits to national, regional and provincial sites for direct observation and opinion gathering on broader problems such as motivators, barriers, and preparation needs from the local perspective.

Results

Questionnaire respondents were 122/158 agents at 78 surveillance units countrywide. Mean age was 43.6 years and chore longevity 5.seven years. Only 53% (65/122) had epidemiology grooming, posted in 62% (48/78) of the structures. Cocky-assessed chapters varied by basic qualification and by construction level (regional vs. provincial). The gap between the importance granted to a task and the perceived chapters to perform information technology was sizable, showing an uneven distribution across competency domains, regions, surveillance level and staff's basic qualification. From the opinions gathered, a trouble of staff demotivation and high turnover emerged clearly.

Conclusions

Our method was successful in revealing specific details of the preparation needs countrywide. A national strategy is needed to ensure rational planning of grooming, personnel motivation and long-term sustainability. In terms of preparation, an innovative program should target the specific needs per grouping and per region.

Commendation: Priotto G, Rguig A, Ziani Grand, Berger A, Nabeth P (2014) Needs Assessment for Performance Improvement of Personnel in Charge of Epidemiological Surveillance in Morocco. PLoS 1 9(7): e101594. https://doi.org/10.1371/journal.pone.0101594

Editor: Martyn Kirk, The Australian National University, Australia

Received: Oct 31, 2013; Accepted: June 9, 2014; Published: July 7, 2014

Copyright: © 2014 Priotto et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: The authors have no support or funding to report.

Competing interests: The authors have declared that no competing interests be.

Introduction

The Kingdom of Morocco is organized in regions, which are subdivided into provinces (rural) and prefectures (urban). At the regional and subregional levels, the Ministry of Health is represented past the Regional Advisers of Health and the Provincial/Prefectural Delegation of Health, respectively.

Since 1992, in order to comply with the decentralization and strengthening process launched by the Ministry of Health, the Directorate of Epidemiology and Disease Command (DELM) has established Provincial and Prefectural Epidemiology Cells (CPE), responsible for epidemiological surveillance in these administrative divisions where population ranges from 68,000 to one,264,000 people. In 2002, Regional Observatories of Epidemiology (ORE) were established in all regions, with the objective of managing the epidemiological surveillance at regional level, taking into account regional specificities. OREs supervise the CPE'due south located in their respective region, and centralize the information they generate.

In 2008 the OREs became Regional Observatories of Health (ORS) and their mandate was extended to manage all of the health information for the region. At the time of this study, there were 98 structures in full (ORS plus CPE), each theoretically staffed with at least two people (a physician and a facilitator).

The decentralization was accompanied by infrastructure and equipment enhancement, telecommunications connectivity, and a serial of epidemiology short preparation courses organized betwixt 1996 and 2004.

All these actions aimed to strengthen the public health capacities required by the International Health Regulations (IHR), which WHO Member States accept committed to implementing [1].

Still, in terms of the man resource operating the system, public health officers have expressed concerns about their capacity to perform adequately and their willingness to stay for a reasonable time in the task. Indeed, it has been observed that in many resource-limited countries, decentralization has reduced the prospects for developing and maintaining skills [2].

In lodge to address this concern, a nation-wide assessment of epidemiology preparation needs of the staff in the ORS and CPE was conducted in a collaborative attempt of the Ministry of Health and the World Health Organization. The objective was to inform the evolution of a strategy to strengthen the workforce, by (1) describing the situation of these public wellness officers, their perception of technical capacities and gaps, as well every bit their grooming needs; and (ii) gathering opinions and suggestions from key managers and beneficiaries of the surveillance system.

Methods

We developed an ad-hoc method inspired by methodologies previously used elsewhere [3] [4] [5] [half dozen]. The assessment was carried out in 2 successive stages: (ane) a standardized questionnaire administered to all staff in regional, prefectural and provincial surveillance teams, and (2) a serial of interviews and field visits for straight ascertainment and stance gathering.

Survey by remote questionnaire

A standardized electronic questionnaire was developed past WHO and sent by e-mail to the staff of all ORS and CPE in the land. The distribution of questionnaires and reception of responses were centralized by the National Epidemiological Surveillance Service (SSE) within the DELM, located in the uppercase Rabat.

The responses were compiled in an electronic database that was subject to quality control and cleaning. Answers to open questions, such every bit descriptions of courses taken, were verified and standardized. Respondents were contacted individually for clarifications where necessary. The questions covered the following areas: general characteristics of personnel; preparation received (anytime in the by) in epidemiology, in public health, in statistics and other subjects; institutions that had provided each training; state of grooming; importance fastened to a listing of 33 tasks/activities linked to epidemiological surveillance; level of competence by job; preparation needs felt; and training modalities preferred.

The list of 33 tasks (Table 1) was developed on the footing of the curriculum and the evaluation results of diverse field epidemiology training courses in which WHO has participated. The level of competence was self-assessed by the survey participants, using the list of tasks. Kickoff, the participants were asked to rank (on a scale of 1 to 9) each job, according to its importance in the exercise of their surveillance duties. 2nd, the same 33 tasks were presented again and participants were asked to assess their ain level of competence to perform each of them, also on a scale of ane to nine. This scale was visually presented in three progressive stages: "weak" (values one–iii), "medium" (values four–six), and "strong" (values 7–nine).

Because both parameters were measured with the same calibration and by the same person, the calculation of the difference between the two figures provided a straight measurement of the gap between the importance attached to a given function and the perceived level of competence for that aforementioned function. The magnitude of this gap helped place where a lack of competence was felt as a priority.

The analysis consisted of quantitative clarification of data, stratifying by area of expertise, basic qualification (degree or diploma giving a professional status pertinent to the job), type of structure (ORS or CPE), and by administrative divisions (region and province/prefecture). Mapping (not shown in this manuscript) was used to present the geographical distribution of sure characteristics.

Responses to the 33 tasks related to surveillance were synthesized for analysis by grouping them into 10 domains, every bit shown in Table 1 and Figures ane, 2 and three.

Figure 3. Competence gap (self-rated), by basic qualification.

Gap between the importance given to surveillance tasks (grouped in 10 broad areas) and the self- estimated competence (rated by each participant using a calibration of i to nine), past bones qualification categories.

https://doi.org/10.1371/journal.pone.0101594.g003

Data analysis was performed with EpiInfo three.v.4 and Stata ten software.

Interviews and field visits

Interviews and field visits were organized with the objectives of (1) gathering information and opinions of cardinal players on broader bug such as motivators and barriers, and on training needs from the local perspective; and (2) directly observing and discussing the methods and tools used for the surveillance activities.

At central level, the interviewees included relevant officials of the Ministry building of Wellness's directorates which are involved in public health surveillance and the wellness information system, as well every bit epidemiology training providers. In each region visited nosotros interviewed the Regional Health Director as well equally the technical personnel conducting surveillance tasks at the ORS and at to the lowest degree at 1 CPE. For the field visits nosotros selected five regions with different performance levels (appraised by the DELM on the basis of recent experience), in society to obtain representative results, especially regarding the inter-region variability. The visits and interviews were prepared on the footing of the results of the questionnaire, the review of documents and tools used for public health surveillance in Morocco, and the results of other consultations carried out in the past 10 years on related bug. Interviews were conducted in person and documented verbatim. A semi-structured interview guide included questions pertaining to interviewees' expectations regarding the output of the surveillance arrangement, their working experience with the surveillance units that had revealed capacity gaps, their beliefs about the nature of existing barriers, and their beliefs about training modalities that would be most effective. Probing questions were used where necessary to seek comprehensive information.

Qualitative data from the interviews and field observations were analyzed manually with a qualitative thematic approach, without coding or quantitative transformation, looking for deeper meaning in the individual expressions and observations. Salient ideas stemming from different sources were triangulated to identify areas of convergence. The convergent ideas were initially documented by type of source in the study report. In this manuscript they are further consolidated, and presented in 3 distinct theme categories (Training Needs, Grooming Modalities, and Other Issues Concerning Man Resources).

Results

Results of the survey by remote questionnaire

In November 2010 the electronic questionnaire was sent by e-mail to all 158 staff located at performance health surveillance structures. At the time there were 8 CPE without staff. The manual of the questionnaires and the responses was confirmed every bit successful, rapid, and cost-free. Between that date and Jan 2011, 122 responses to the questionnaire were obtained from 78 structures. All these questionnaires were answered completely: no questions were left unanswered. The distribution of respondents by region was uneven, with 51% concentrated in 5 regions (Rabat-Salé-Zemmour-Zaër, Oriental, Souss-Massa-Draa, Tanger-Tétouan and Fez-Boulemane). The hateful age was 43.half dozen years and the mean seniority in the current position was 5.7 years (Table ii). Overall, the ORS staff had less seniority in their job than the CPE staff (mean iv.2 vs. six.3 years), although their age was not different. Basic qualifications inside the ORS teams were more various, sometimes composing multidisciplinary teams with rich skill mixes.

Only 53% (65/122) of the staff had epidemiology training and they were posted in 62% (48/78) of the surveillance structures. The epidemiology training received by staff was unevenly distributed beyond the regions: of a total of 92 courses in which the respondents had participated, most of the participation was full-bodied in the regions of Fez-Boulemane, Souss-Massa-Draa and Tanger-Tétouan (median of 12 epidemiology courses followed past the team, range 11 to 14), while on the other extreme, in 5 other regions a median of i course had been followed by the whole team (range 0 to ii).

Of the surveillance tasks presented in the questionnaire, all 33 tasks were perceived as very important by all staff, both at the ORS and the CPE teams (the median score ranged from 7 to 9). The most frequently highlighted were the tasks in the areas of ethics and computing (full general median score ix for both). Outbreak investigation was seen as relatively less important (full general median 7.7). Knowledge of the International Health Regulations (IHR) was seen as less of import for staff at the CPE'due south (CPE median 7).

The bulk of staff considered they did not have an adequate level of competence in most areas. The areas of IHR, outbreak investigation and analytical methods applied to inquiry, stood out equally particularly weak.

The comparison across basic qualification groups (Effigy 2) revealed substantial differences by area of expertise and by bones qualification, which exposed key details of the training needs. For example, physicians graded themselves higher than others in most areas, except in the supervision and evaluation areas. The competence levels of medical assistants were oftentimes discordant with that of doctors and nurses: college in scientific advice and computing, while lower in data analysis, investigation and surveillance system operation.

The self-assessed level of competence likewise showed disparities across regions (data not shown).

The gap between the importance granted to a chore and the individual chapters to perform information technology was of considerable magnitude for the majority of respondents. The overall difference betwixt the two parameters, which were measured on a 9-points scale, showed a median of one.vii points. A marked disparity was seen between the bones qualification groups: physicians exhibited smaller gaps (magnitude of 0–2 points) than the group of medical assistants and "others" (i–5 points), while the group of nurses was in an intermediate situation (1–3 points). The magnitude of the gap varied per blazon of chore as well (Figure 3).

When participants were asked (in an open-ended question) to proper noun areas of knowledge where they felt the chief need for preparation, a majority (82.8%) pointed to Epidemiology (where the nearly cited spontaneous categorizations were "field", "general" and "surveillance" epidemiology), followed by Biostatistics (58.2%) and Informatics (49.2%).

Regarding the preferred learning modalities, of the post-obit 4 choices presented, the large majority (91.4%) opted for the face-to-face courses, followed past self-learning meaty disks (59.4%), online courses with remote tutoring (52.9%) and self-learning online courses (51.6%).

Nosotros explored the possible associations betwixt the chapters gap and the distance of a duty station from the capital, Rabat, but the distance gene lonely did not show a articulate trend.

Results of the interviews and field visits

These activities were conducted in January 2011. The interviews carried out with high-level officers and team members included the following governmental institutions: Advisers of Epidemiology and Disease Command (DELM), Directorate of Hospitals and Outpatient Intendance (DHSA), National Constitute of Hygiene (INH), National Institute of Health Administration (INAS), Sectionalisation of Computer science and Methods (DIM), Directorate of Planning and Fiscal Resources (DPRF), Communication Division (DIV.COM), and Poisonous substance and Pharmacovigilance Center (CAPM).

We carried out field visits in the following 5 regions: Gharb-Chrarda-Beni-Hassen, 1000 Casablanca, Chaouia-Ouardigha, Tanger-Tétouan, and Rabat-Salé-Zemmour-Zaër. In total, 5 regional directors (or interim directors) were interviewed, 5 ORS and 7 CPE were visited. Interviewees from different institutions and at different levels provided their ain perspective stemming from their particular position and feel. Nosotros institute no contradictory views. Rather complementary perceptions with a high degree of convergence were established.

The most common observations are reported time to come, grouped in three thematic categories.

Training Needs.

The skills level is very uneven amidst staff. Due to the high turnover, many of those who are currently in part accept non received training specific to their duties. Training programs attended past the ORS and CPE staff are frequently inadequate for their bodily functions. Preparation courses taken abroad are generally based on contexts, examples and needs different from those of Kingdom of morocco.

There is need for grooming that is amend adapted to the type of surveillance structure (ORS or CPE), as responsibilities are different (east.g. data management at CPE'southward is express to epidemiological information while the ORS's bargain with all health information). ORS teams need specific training on certain national wellness information tools, such every bit the National Health Information System (SNIS) and the Wellness Care Facilities Databank (BOSS). Training would have greater impact if it was more focused on specific regional health issues.

Preparation supply has non been constant over time, and current training programs are insufficient, in terms of output and specificity, to accost the needs of the surveillance workforce at all levels.

The areas of knowledge prioritized by interviewees included: informatics, data direction and analysis (in detail for surveillance functions), basic epidemiology and surveillance methods, early warning systems, scientific communication, risk communication, feedback communication, supervision methods and remediation of abyss and timeliness problems. The ORS teams put frontwards some boosted priority needs, pertinent to their responsibilities: planning and direction, monitoring and evaluation of surveillance systems, information analysis for non-communicable diseases, research methods, and geographic information systems.

Grooming Modalities.

Interviewees offered a number of suggestions regarding the design of training programs: to avert grouping together individuals with different qualification profiles (physicians, medical assistants, nurses, etc); to plan the immediate application of the skills acquired in the trainee'due south job, nether tutoring; to adapt training contents to the specific needs; to avoid dense theory and exercises without applied application; to decentralize training in regions; to link training to the organization/participation in scientific conferences; to streamline the system of preparation in a style that minimizes the fourth dimension taken on the staff's activities.

Other bug concerning homo resources.

Surveillance staff lack motivation, which leads to high turnover and understaffing. Several factors were mentioned: their routine is mostly limited to data collection without analysis and publication, a poor career progression, poor visibility of their role and the fruits of their work, and professional isolation.

Staff tend to stay a short time in office, and many that depart (mostly via transfers to positions in different wellness sectors) are not replaced because potential candidates exercise not feel attracted to these jobs.

Well-nigh of the training courses completed by staff were not officially recognized and did non have an impact on career progression.

Staff feel disconnected from peers carrying out like work nationally and internationally. They lack incentives and opportunities to present their work and to learn from others.

Give-and-take

The methods used in this assessment immune for the collection of quantitative and qualitative data that, combined, provided a fairly comprehensive insight of the training needs and other important elements that affect the strength of the workforce. The use of an electronic questionnaire that could be successfully transmitted to all staff turned out an effective method to obtain country-broad standardized information in a very brusk time and at little cost. Having analyzed these data prior to the field visits was useful in selecting the regions to visit and in structuring the interviews for an optimal exploration of key issues.

Our findings confirmed the concerns of national public wellness officers: that an important weak betoken in the Moroccan surveillance system is the lack of appropriate human being resources, both in number and in skills. Throughout the national network, many surveillance facilities are understaffed, and some are even totally vacant. There appears to be a need for redistribution over the territory, although this betoken requires further analysis by the health authorities. The distribution of staff should be guided by the interplay of several factors, including the relative workload, the local constraints, the mapping of public health risks, the strategic priorities and the administrative and socio-political constraints.

The design of this study did non include the search for factors influencing the chapters gap in a given health surveillance structure, and our exploratory analysis of the distance factor did not reveal this variable equally a stand up-alone proxy. A broad-ranging, multivariate analysis would be needed to unveil the contributing factors in the context of Kingdom of morocco. This blazon of analysis would be all-time done via a quantitative report with planned endpoints and effect measures, using a representative sample with a size sufficient for multivariable methods. Such report tin can be informative for fine-tuning the training curricula and the human resources policy, only should non stand in the manner of immediate action, as at this phase many key issues accept been identified with a big consensus, providing leads on which to work.

Nosotros recommend the formulation of a national strategy to ensure the rational planning of preparation, the loftier motivation of personnel, and the long-term sustainability of performance. Considering the issue of the health workforce is complex, comprising many actors and stakeholders [7], i of the weather condition for success of such a strategy is the involvement of loftier-profile decision-makers, non simply of the health sector, but of all other sectors that play a role, and that would eventually be required to contribute. The application of this strategy is to exist followed and adjusted over time past the same actors that conceived its design.

The skill level of surveillance staff throughout the national network is highly variable. Launching a new training program appears necessary, which should accept a larger coverage than the current programs, and should target the specific needs per professional group and per type of surveillance facility. In coherence with the current national policy for public health, grooming should be decentralized in order to ameliorate tailor the methods and contents to the needs in each region. With this approach, an additional advantage expected is the minimization of the time for which the trainees would be absent from their duties. On the other paw, expected disadvantages may include overall fourth dimension to achieve and/or financial outlay. As suggested by many of the interviewees in this report, the contents and modalities of preparation activities would exist better adapted to the needs if they were developed with the participation of representatives from the target audience.

The observed continual loss of human resource in the sector appears to be associated with low motivation to stay in the job and difficulty filling vacancies that are not bonny to the appropriate candidates. Information technology is clear, therefore, that another type of activity, beyond training, is needed to strengthen the workforce in a sustainable way. This activity, as found in this assessment, could involve measures to improve the formal recognition of training accomplished by staff, the clarity of career paths, the visibility and valorization of staffs' contribution to public health, and the participation in professional peer networks and activities.

Performance does not depend solely on the individual workers' knowledge and competencies, but as well on the work environment, which may pose, in reality, the greatest barriers. It is important that a performance improvement strategy takes into account a comprehensive model encompassing both the individual elements (knowledge/skills, chapters, motives) and the environmental elements (information, resource, incentives) [viii]. Such a systematic approach is key to determining the underlying causes of the performance gaps, and for targeting specific improvements with a loftier affect.

Acknowledgments

The authors wish to thank all the Moroccan staff that participated in this written report and provided the required information via written questionnaires and/or via person-to-person interviews. We acknowledge the contribution of Dr Julie Dubourg for the survey data assay. The Morocco Ministry of Wellness provided the transportation to all points visited by the team.

Writer Contributions

Conceived and designed the experiments: GP PN AB. Performed the experiments: GP AR MZ. Analyzed the information: GP. Wrote the newspaper: GP AR MZ AB PN.

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