Table 2.

Socio-ecological factors ^a affecting implementation of the Strengthening Technical Assistance for Routine Immunization Training (START) approach in Uganda, July 2013 – December 2014^b.

Social, political and Uganda National Expanded Programme on Immunization (UNEPI) environment

•Predominant training styles used to train the health workforce - classroom-style group training •Culturally, staff performing the work do not often attend classroom-style group training for technical work, a privilege often reserved for those in leadership positions •Fluctuation in the number of operational districts and health centers and those who provide RI services, due to changing boundaries and funding •Availability of national-level health system strengthening funding for UNEPI •Occasional stock-out of vaccines which halted provision of routine immunization services •Community demand for immunization services was high, so staff were busy •UNEPI requirement that all districts complete annual microplans for routine immunization – affected demand for support to do this •UNEPI tools for planning and monitoring not available, incorrect, or not viewed as user-friendly •Frequent mass immunization campaigns, for which planning and monitoring is conducted have built workforce capacity for planning and monitoring, but reduced time for planning and monitoring, and supportive supervision, about RI activities) •Introduction of new vaccines into the UNEPI program (seen as opportunity to enhance planning and establish program monitoring, both of which START approach could support) •Hard-to-reach districts and health centers, due to geographical isolation, non-Government ownership or insecurity limited scope of START consultants work •Limited/no availability of, inaccurate, and competing sources of target population data which reduced utility of planning and routine monitoring

Community

•Differing relationships with and between: higher levels of health system, political leaders, community, staff, supervisors, non-government organizations in the health sector, other non-health sectors of government. Good relationships were critical for the START consultants work. •Anti-vaccination groups in the community affect demand for vaccination services and individuals workload in trying to overcome this challenge •Acceptance of a foreigner, both at work and in the broader community

Organizational

•Insufficient ownership and commitment to EPI at the district and health center level, resulting in poor allocation of resources to these activities •Competing priorities for funding and human resources, due to limited supply of both •High staff turnover at district and health center level •No means of transport for district staff to conduct supportive supervision, or competition for available transport •Requirement for additional allowance for movement outside of usual place of work •Management structure which did not afford training opportunities to staff not in management positions

Interpersonal

•Competing priorities for health care worker time •Poor relationships/perceptions of supervisors and/or co-workers

Individual

•Attrition of participants from classroom-style training, often in response to demands of their regular work •Perception of the value of the knowledge and skilling being taught •Lack of awareness of the need for, importance of, or barriers to planning and monitoring of UNEPI program activities •Low levels of knowledge and skills in UNEPI planning and monitoring •Many staff needed repeated exposure to, and application of, knowledge and skills •Insufficient salary which reduced staff motivation •External motivation main driver of action, though this was often limited by infrequent or inadequate supervision, infrequent requirement for planning data, and insufficient oversight of accuracy of administrative vaccination data received from health center or district level

^aFramework used for reporting adapted from the Social Ecological Model [49].

^bDeveloped from collation of feedback from the START consultant interviews, field observations and internal discussions with staff managing the START approach in Uganda.