Teambuilding intervention in multi-speciality primary healthcare providers in Pakistan: Results of a sequential mixed methods approach

Teambuilding intervention in multi-speciality primary healthcare providers in Pakistan: Results of a sequential mixed methods approach | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Teambuilding intervention in multi-speciality primary healthcare providers in Pakistan: Results of a sequential mixed methods approach Sara Rizvi Jafree, Humna Ahsan, Rubeena Zakar, Anam Muzamill, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4478141/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background: Pakistan’s primary health services have a sound infrastructure but remain ineffective in serving the needs of the nation. A significant area of concern is the lack of support to improve teambuilding of the multi-speciality primary healthcare providers (HCP). This study had two phases: First, to deliver a teambuilding intervention using a pre-post-test design, and second, to collect qualitative data about barriers to teambuilding. Methods: A total of 42 multi-speciality HCPs from 12 basic health units and 5 rural health centres of Punjab, Pakistan, were part of the teambuilding intervention. We conducted a sequential mixed methods approach, with a quantitative pre-post-test analysis and interviews with 34 HCPs at follow-up qualitative phase. Results: Mean analysis at post-test revealed improved teambuilding skills for coordinating patient care plans ( z =2.881, p=0.004), and skills for conflict management ( z =3.468, p=0.001). HCPs above the age of 30 years and with ≥6 years of service show improvement post intervention in teambuilding skills for collaborating about resources and referrals and conflict management, suggesting that younger and less experienced HCPs need more regular training support. The qualitative data highlighted 11 barriers which prevented optimal teambuilding, falling under broad areas of: (i) system issues, (ii) behavioural and service problems, and (iii) management limitations. We conclude with eight holistic recommendations to secure optimal teamwork, and argue that apart from continued training, there is need to: increase budget allocation; develop integrated care plans; strengthen the referral system; add providers to the team for non-maternal health services; fund joint research of providers; introduce third-party supervision and accountability; and introduce a human resource department. Conclusions: Our study is one of the few studies that attempt to address teamwork issues in primary healthcare teams of the country, showing the benefits and limitations of an interprofessional teambuilding intervention. We conclude that a holistic approach is needed to improve teamwork in the primary-level multi-speciality providers. Trial registration: NCT05389501 primary health primary healthcare providers teambuilding conflict management intervention Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background The success of primary health services is dependent on the coordination, negotiation, shared decision-making, and trust between multi-speciality professionals [ 1 ]. Optimal teamwork at the primary healthcare level is associated with improved patient outcomes and greater job satisfaction of the multi-speciality providers [ 2 ], and reduced costs of healthcare in the long-run due to the strengthening of preventive health services [ 3 ]. One way forward to tackle the work burden and service inefficiencies of the primary HCPs is to support them through interprofessional teambuilding workshops, which can improve primary health services [ 4 ]. However, there are very few studies about the effectiveness of teambuilding interventions in the primary sector are available, mainly because unlike the hospital setting there is less control over conditions in the community settings [ 5 ]. There is also concern that isolated teambuilding literacy interventions may not comprehensively address the issues faced by multi-speciality providers in coordinating and delivering services in the community. Previous research has highlighted that despite a shared philosophy and good work ethics, optimal teamwork of multi-speciality providers is dependent on areas beyond the provider’s skills and attitudes. Furthermore, it includes factors such as healthcare policy and primary health sector infrastructure [ 6 ]. Teamwork in primary health providers is also influenced by organizational and management support, leadership effectiveness, and in recent times the availability and efficiency of technological support. Satisfaction of providers with the range of services and skills of co-workers also influences teamwork, such as the adequacy of the referral system and availability of health providers for different health needs of clients [ 7 ]. Pakistan will be unable to meet its Sustainable Development Goals or internal targets for health service delivery unless there is improvement in primary health services [ 8 ]. The country’s primary health centres consist of basic health units (BHUs) and rural health centres (RHCs). There are currently 5,518 BHUs and 683 RHCs in the country, consisting of a multi-speciality team of healthcare providers (HCPs) [ 9 ]. Due to devolution, each province of Pakistan manages its primary healthcare setup separately. Over half of the population of Pakistan, estimated at 127 million, are found in the Punjab province, which has 2,461 BHUs and 293 RHCs, managed by the Primary and Secondary Healthcare Department (P&SHD), Government of Punjab [ 10 ]. Despite this noteworthy primary health level infrastructure, budget allocations remain extremely low at less than 1% and service of providers either does not reach the large population or remains below standard due to lack of teamwork and coordination for patient care, distant locations, staff unavailability, and governance problems [ 11 ]. Recent indicators suggest there is a downward trend in prenatal care seeking, institutional deliveries, family planning, consultations for new-borns and infants under 5 years, and for routine immunization [ 12 ]. Furthermore, there are major issues of lack of training and support of BHU and RHC HCPs in terms of communication and conflict management [ 13 ]. Excessive role burden, understaffing and low salaries are also major challenges to the motivation, job commitment, and service quality of the BHU and RHC teams [ 14 ]. Aim and research questions In Pakistan there has been no effort so far to improve teamwork in primary HCPs, through regular training or to understand the concerns regarding team effectiveness as experienced by currently working HCPs. Scholars agree that interprofessional teambuilding workshops are a cost-effective short-term solution for resource poor countries like Pakistan [ 15 ], and that qualitative research about teamwork experiences can provide more information about challenges and barriers in delivering health services and the complex relationship between multi-speciality providers [ 16 ]. In lieu of this, this study aimed to adopt a sequential mixed methods approach and to at first step deliver an intervention to improve teambuilding skills in primary HCPs of Pakistan. At second step we aimed to collect qualitative data to understand barriers to teambuilding that may exist beyond educational interventions and skill building for teamwork. Based on the results of this study, we intend to advise the health authorities of the country for improvement in teambuilding for the primary HCPs, as this is known to have direct and positive benefits for patient services and patient outcomes at primary level [ 17 , 18 ]. Improved teambuilding will also save health costs and prevent excess burden on the tertiary health sector over time [ 19 ]. Methods This study adopted a sequential mixed methods approach. At first step, an interprofessional teambuilding intervention was delivered and a pre-post-test questionnaire was used to measure its impact. At second step, qualitative interviews were conducted with participants to understand existing barriers to teambuilding and what factors can make the intervention more effective. Ethics approval for this study was obtained from the Forman Christian College University, Institutional Review Board (IRB-257/04-2021) and this study has been registered with clinicaltrials.gov (identification number: NCT05389501). All participants of the study gave informed consent. Anonymity, confidentiality, and safety of participants were ensured. Stage 1: Interprofessional teambuilding intervention The teambuilding intervention consisted of a one-day training which was interactive and included presentations, brief learning videos, case studies, concept mapping, teambuilding games, and problem-based learning, led by different experts and trainers from the academic community, with specialised degrees in public health, community health, sociology, mass communications, and education. The intervention involved the following three learning areas (Supplementary material A): (i) ‘patient care plans’, (ii) ‘workflow collaboration’, and (iii) ‘conflict management’. The pre-post-test survey was developed, with modifications, using the following standardised surveys: (1) Performance of interprofessional primary health care teams survey [ 20 ]; (2) University of Louisville Communications Survey [ 21 ]; and (3) Conflict Management Questionnaire [ 22 ] (Supplementary material B). The selection criterion for the teambuilding intervention was currently employed HCPs at BHUs and RHC. We contacted and gained approval to collect data from twelve BHUs from areas of Lahore, (including the following BHUs- Halloki, Sarriach, Lakhokki, Jhodo Dheer, Attoki Awan; and the following 24/7 BHUs- Maraka, Ali Razabad, Jallo Pind, Dogrian Kalan, Shahzada, Hair, and Niaz Baig) and five RHCs from areas of Lahore, (including: Choung, Awan Dhai Wala, Barki, Raiwind, and Manga) (Fig. 1 ). We invited all the HCPs at BHUs and RHCs to participate in the intervention but were dependent on their willingness to participate. The intervention took place on December 4, 2023 at the University of Health Sciences. A joint certificate from the University of Health Sciences, University of the Punjab, and Forman Christian College University was awarded to the participants after the intervention. Participants were later also sent the pictures of the award ceremony. However, they were not provided transport stipend. The final sample for the intervention included the following type of health providers: (i) nine lady health workers (LHWs), six lady health visitors (LHVs) and two lady health supervisors (LHSs); (ii) eight Women Medical Officers (WMOs), two Principal Medical Officers (PMOs), one Obstetrician and three dentists; (iii) two School and Health Nutrition Supervisors; (iv) seven nurses; and (v) two allied healthcare staff including a pharmacist and a dispenser. The pre-post-test data was analysed using SPSS 25.0. Descriptive statistics were used to present data about pre-post test results for the intervention. The Wilcoxon Signed Rank Test was used to compare means for pre versus post results for the intervention based on the three study learning areas ‘patient care coordination’, ‘workflow coordination’, and ‘conflict management’. The Mann Whitney Test was used to investigate the relationship between the three study learning areas and sociodemographic characteristics of participants. P-values below 0.05 were considered significant. Stage 2: Qualitative interviews Based on the findings of our post-test results, we developed a semi-structured questionnaire to ask participants about reasons for lack of improvement in the following teambuilding areas: (i) ‘coordination in weekly meetings’ (broader learning area: ‘patient care coordination’); (ii) ‘skills for client record-keeping’ (broader learning area: ‘patient care coordination’); (iii) ‘planning improved workflow’ (broader learning area: ‘workflow coordination’). We also asked them if they wanted to share (iv) any other barriers they may perceive or have experienced which prevent teamwork, co-worker collaboration, and conflict management. We targeted to sample all the 42 participants in the intervention through both in-depth interviews (IDIs) and focus group discussions (FGDs). However, we were dependent on the willingness and availability of HCPs for participation. In total we were able to interview 34 of the intervention participants and hold: (i) 20 IDIs (four with WMOs, four with Nurses, three with LHVs, six with LHWs, two with dentists, and two with dispensers) and (ii) four FGDs with four participants each (two FGDs each with BHU and RHC teams, which included WMOs, Nurses, LHVs, and LHWs). Reasons for some of the intervention participants not being sampled during qualitative phase, included not being available, work pressure, and inability to coordinate time. The qualitative interviews took place between December 22, 2023 to January 13, 2024 in University of Health Sciences. The qualitative data was transcribed into Microsoft Word and independent analysis was done by the first two authors (SRJ and HA). The generated themes were then discussed with the other authors and also shared with some participants (two WMOs, two LHWs, and two LHVs). We received confirmation from all. Results Intervention results Figures 2 – 4 present the comparison in skill development for interprofessional teambuilding from pre to post stage for the three learning domains of: (i) ‘patient care coordination’ (Fig. 2 ); (ii) ‘workflow coordination’ (Fig. 3 ); and (iii) ‘conflict management’ (Fig. 4 ). For the majority of the three learning areas, we find post-test improvement in learning. However, under the broader learning area of ‘patient care coordination’, one specific learning skill of ‘coordination in weekly meetings’ shows decline at post stage (-2.4%) and there was no change at post stage for ‘skills for client record-keeping’ (0%). Under the broader learning area of ‘workflow coordination’, we found no change in one specific skill of ‘planning improved workflow’. Table 1 presents the Wilcoxon signed rank test results for pre and post learning for interprofessional teambuilding for the three study domains- patient care plans, collaboration with co-workers, and conflict management. We find that the skills for coordinating patient care plans with co-workers show statistically significant improvement at post-test ( z = 2.881, p = 0.004), and that skills for conflict management with co-workers also shows statistically significant improvement at post-test ( z = 3.468, p = 0.001). The results for skills for collaborating about resources and referrals show no significant results. Table 1 Wilcoxon Signed Rank Test results for interprofessional teambuilding learning areas Pre M ± SD Post M ± SD z p-value Skills for coordinating patient care plans with co-workers 7.59 ± 1.230 8.85 ± 2.484 2.881 0.004 Skills for collaborating about resources and referrals 9.14 ± 1.025 9.33 ± 1.408 0.744 0.457 Skills for conflict management 6.73 ± 1.848 7.57 ± 2.176 3.468 0.001 Table 2 presents the Mann Whitney test results with mean ranks for improved teambuilding at post intervention stage based on sociodemographic characteristics of HCPs. We find that HCPs above the age of 30 years show statistically significant improvement at post intervention in skills for collaborating about resources and referrals (U = 48, p = 0.031) and in skills for conflict management (U = 46, p = 0.050). Similarly, we find that HCPs with years of service of 6 years or above show statistically significant improvement at post intervention in skills for collaborating about resources and referrals (U = 143, p = 0.049) and in skills for conflict management (U = 232, p = 0.030). There was no statistical significance found for contract type, health centre type or gender. Table 2 Results for improved teambuilding at post intervention based on age and service years of HCPs Coordinating patient care plans with co-workers Collaborating about resources and referrals Conflict management Mean rank p-value Mean rank p-value Mean rank p-value Age 20–29 years 30 years and above 6.44 8.92 0.166 6.00 9.50 0.031 5.75 9.83 0.050 Gender Male Female 18.43 22.11 0.347 21.13 23.36 0.522 21.46 21.71 0.948 Years of service 1–5 years 6 years and above 12.27 12.77 0.819 11.00 14.27 0.049 10.92 14.36 0.030 Contract type Permanent Contract 23.43 19.16 0.145 19.80 23.55 0.150 19.91 23.42 0.232 Health centre type BHU RHC 21.77 21.06 0.814 20.52 23.09 0.335 20.96 22.38 0.639 * p-values for the Mann Whitney test Qualitative results (i) System issues Insufficient resources prevent collaboration and collegiality HCPs stated that resource shortages prevented effective teamwork and even built resentment with senior management. Complaints about resource shortages dominated team meetings and prevented time from being spent on patient care management or workflow collaboration, with an WMO explaining: “Most of the conversation between co-workers is about resource issues, such as lack of ultrasound machine at BHU, need for updated operation theatres at RHCs, and lab testing facilities at both RHCs and BHUs. Without these resources we cannot serve to the best of our ability and this reduces job satisfaction and motivation”. An LHW shared how she and other HCPs had to step forward to support clients through their own resources and that senior management and the Medical Officers did not help in putting pressure on higher authorities for supplies: “Request for supplies for even basic medicines fall on deaf years. It is the job of our seniors at the centres to follow-up for resources so we can work as a better team. In the end we try to help the poor clients through charity by buying them vaccines and medicines from our salary. We even buy our own registers, to record patient data. But we have limited salary and can only do so much.” HCPs also complained about the work environment and described it as inadequate and uncomfortable, which prevented collegial relations with co-workers and optimal teamwork. During an FGD, a WMO and LHW shared: “There is very few and broken furniture at the centre and no meeting room for health workers. Let alone space for us, we do not even have a separate room for vaccination. Apart from this there is no clean drinking water and food is not provided to us during work. We are expected to work morning to evening without lunch. It’s a gloomy environment, with poor lighting and electricity load-shedding and this also affects how well we can work with each other. We are in need of maintenance of the roof, floors, and sewerage system. The ground level of the centre must be above the road level and reconstruction is badly needed.” Staffing shortages All HCPs complained about the serious staffing shortages at both BHUs and RHCs and stressed that the shortage of staff and extra workload on existing members of the team contributed to low morale and also prevented time for optimal collaboration for work and patient progress. A dispenser shared: “The staff is overburdened. Staff seats are empty and providers have not been hired, such as the medical technicians. Only one person is handling everything including online patient record keeping.” A nurse contributed that the primary healthcare team needed more field workers: “Much more outreach staff is needed, mainly- LHWs, vaccinators, and sanitary inspectors. Basically, the surveillance team which goes to the field for case investigation in coordination with the CEO Health office has to be improved and efficient. They are not able to cater to all the patients at the moment and they are overburdened. This creates resentment within the healthcare teams as well. ” HCPs also shared that there was positive integration of technology at BHUs and RHCs, but without the needed technological support staff. An LHV described how having to record electronic data was creating major issues in teamwork, patient record-keeping, and co-worker collaboration: “ Data entry on EMR (electronic medical record database) is difficult and we are feeling overburdened. If we have support from a data operator, we can give more time to patients and have more constructive meetings with co-workers to manage our work better. ” Another LHV complained about the extra workload due to technological demand for data recording, and the loss of time and personal resources due to poor internet support: “ Data entry on EMR on tabs has further increased our workload. Internet is needed to make entries on EMR but internet services are not good or not working all together on most days. We have to use our own data packages sometimes and we are not compensated for this.” Resentment over differences in pay and employment benefits HCPs complained about differences in compensation and employment benefits, which also created resentment and negatively affected teambuilding and mutual respect. There was a hierarchy in pay, work hours, workload and benefits, with LHWs, LHVs and nurses claiming that they had greater workload and in comparison were paid less. One LHW shared: “Our salary needs to be increased and our contract structure should match that of the doctors. We never get any bonuses, for example on Eidh or new years. The doctors get paid more than us, and they get residential areas to stay in. This is not fair. After all, we are providing the same support, if not more, to the patients. There is no provision for health insurance for the LHWs. Even though we are the backbone of the primary and secondary healthcare setup for Pakistan. Even if we die on the job, our families will get nothing (employee death compensation)”. One of the WMOs shared that comparison with the private sector also reduced work morale and efforts for teamwork: “Our salaries do not match the private sector and we get very few leaves and holidays.” Lack of care plans and targeted providers for other health issues Unanimously all HCPs interviewed agreed that there was need for extended care plans beyond maternal and child health, with targeted providers allocated to treat other ailments. It was agreed that optimal teamwork and collaboration for work was possible once effective and comprehensive health services were planned and executed at primary level. An LHS highlighted the lack of support for aging population and chronic disease prevalence: “Chronic diseases and cough and TB of elders are major issues. We need separate staff to serve them (LHS). Working as an ineffective team, and not doing the needful for our clients affects how we perceive ourselves as a team.” An LHV shared that female and child malnourishment was an issue: “Poverty has increased overtime, women and children are malnourished and they have commonly have low HB. Infectious disease is out of control, not just due to health illiteracy, but poverty.” A nurse corroborated that child medicine and targeted providers for child health were needed: “ We need supplies of field medicine...for smaller children especially who regularly suffer from fever, cough, stomach worms, and diarrhoea”. Overall, the HCPs agreed that their perception as a successful team and willingness and enthusiasm to collaborate with each other was influenced by the range and comprehensiveness of their services. (ii) Behavioural and service problems Referral failure HCPs described issues of referral failure, with non-availability and bad treatment of physicians being major issues. There were complaints especially by LHWs and nurses regarding non-availability and lack of services by physicians. One LHW described: “Referring patients to the BHU and RHC means having to accompany the patient and ensure that the doctor is available and treats the patient. We use our own transport and it can take all day. If the patient goes alone, she will almost always return from the centre without consultation or complete diagnosis.” A nurse further described that the physicians do not listen to patients or provide them services satisfactorily: “It costs the patients time and money to visit the RHC. The doctors here, however, do not listen or provide adequate services to treat the ailment, which makes us (LHWs and nurses) who refer the patients look extremely bad. This also results in patients turning to private services or local quack healers and not trusting our referral system.” Co-worker interaction issues Many of the HCPs complained about co-worker interaction and behavioural issues which prevented coordination and teamwork, such as rude behaviour, use of crude language, and attitude problems which prevent coordination and learning: “Personalities and backgrounds of HCPs are very different. Some LHSs and doctors use abrupt and crude language. We have to be very tolerant and ignore things.” Another LHW stated: “The paramedical staffs’ behaviour is very bad and we are unable to deal or coordinate with them.” A WMO shared issues with new team members: “New co-workers who get assigned or posted always have attitude problems and we have to be very patient for the first year” . One LHV described: “LHSs put on a show most of the time, they don’t have that much knowledge or skill. They just like to show attitude.” Lack of joint research A few HCPs shared that the primary healthcare team did not coordinate for research and that this would improve their work coordination and teamwork: “ Research collaboration is needed to improve work relations and identify problems in a systematic manner” (WMO). A nurse shared the benefits to both teamwork and professional development in research collaboration: “If we do research together, it will make us sincere to each other at the workplace. Also, research efforts can help us to update our degrees and get MPhil degrees.” (iii) Management limitations Unsupportive management HCPs highlighted concerns with unsupportive managers and supervisors and agreed that management failures prevented effective teamwork and collaboration with co-workers. One nurse stating: “I wish I could change the management staff, namely the doctor on duty and the District Health Authority personnel.” An LHW shared her resentment with senior managers who did not help subordinates in genuine grievances: “There are pay delays with no response from management. After all, the management knows how hard we work and how desperately we need our salary at the start of the month.” Another LHW contributed that: “Food and transport allowances (FTA) are very low. What upsets us is that seniors [doctors] know this, but they don’t help or coordinate to support us (LHW).” Yet another LHW shared the lack of trust between principals and subordinates which created hostility and advised about the need for a Human Resources Department: “The area in charge- this includes the CEO health office, District Health Authority, LHS in particular to the IRMNCH department, are non-cooperative. Payments are always delayed. We need an HR to oversee this.” Hierarchies preventing communication with seniors There were issues related to hierarchies and barriers in communication with management and direct supervisors, which prevented optimal teamwork and patient care management. One LHW shared: “We cannot solve many of the problems, as there is a hierarchy. This hierarchy prevents us from approaching the senior management and we cannot share our challenges related to the client.” A LHV shared how unreasonable her supervisor was and how this prevented them from having a positive working relationship or collaborating further for progress: “The LHS demands that we reach by 9am at all costs. She threatens us that she will get us fired if we are late, even if there is smog (visibility issues) or transport difficulties and we cannot reach the centre on time. She (LHS) does not know how to talk to us or treat us like human beings. Even if there is a family emergency we cannot share it with her.” Lack of training HCPs shared that they needed more support for ongoing training and skill development, without which teambuilding and coordinating care for patients was not possible. A WMO shared that: “ Proper training of paramedics and LHWs for patient management is desperately needed.” An LHW stated that this was the first time in her two-decade career that she was offered on-the-job-training: “In my 21 years of employment this is the first time someone has offered us training for teambuilding. We needed this before we started working.” Another WMO shared the complexity of the primary care team, which consisted of multiple providers with diverse roles and that continued training and coordination was key to their success: “The main thing at our centre is the coordination of different providers. Thus, we need continued training for coordination and skill development so we can all do our jobs well. This way the BHU will work like a well-oiled machine to serve patients.” Absence of supervision and accountability HCPs highlighted the need for supervision of providers and monitoring of care plans for patients. They stressed that accountability and trust with co-workers was the first step to teambuilding and coordination; and also trust and respect. One LHW shared: “Some of our co-workers need to be monitored for punctuality, dedication, and regularity.” A nurse described in detail the consequences of absent providers: “At the BHUs and RHCs, the LHV provides vaccination services, manages the deliveries and assists the doctor. Mostly, the LHV carries out the delivery and the doctors are not present, especially in the evening and night-time (for 24/7 BHUs). This is why we have little respect for the doctors and obviously this affects our teamwork.” An LHW described how they were accountable themselves but needed coordination from supervisors to update patient files and meetings to discuss patient cases: “No one calls us weekly to make and update the patient file. We are only required to make a register and update the BHU monthly about pregnant women in the community. If our superiors call us weekly to update family files and discuss patient cases it would be much better.” A nurse contributed that job descriptions needed updating: “New job description and responsibilities are needed, especially for the outreach staff, IT staff and LHVs.” Discussion We aimed to deliver an intervention for teambuilding in this study and to follow-up with participants at stage two for qualitative interviews to further understand needs and barriers related to optimal teambuilding. Our intervention results revealed that HCPs showed improvement in skills to coordinate patient care plans with co-workers and for conflict management with co-workers. Other research corroborates that short workshops for skill building in coordinating patient care plans and improving interpersonal relations in HCPs lead to improved teamwork and performance in HCPs [ 15 ]. However, skills for collaborating about resources and referrals show no significant results. This may be because resources and referrals need to be organized and mandated by higher authorities at the workplace [ 23 , 24 ]. We also found associations between socio-demographic characteristics of HCPs and improved learning post the intervention, with HCPs above the age of 30 years and with 6 or more years of experience showing improved skills for collaborating about resources and referrals and in skills for conflict management, compared to younger and less experienced HCPs. Interestingly, there was no significant difference in learning based on contract type, health centre type, or gender. Other research confirms that HCPs and healthcare specialists with longer years of study in the medical field and greater years of work have more understanding and knowledge about teamwork and conflict management [ 25 ]. Providers above the age of 35 years may respond better to training on the job and skill development as they are more committed to continued learning and expect greater returns; whereas younger providers may feel they are still young and have more time for learning and training [ 26 ]. Overall, our intervention results confirm that the primary healthcare team of Pakistan can be supported with low-cost literacy interventions delivered regularly by the academic community for non-medical training needs, and that this support should be regularly provided to them to improve their commitment to job and their patients [ 6 ]. Additionally, the Primary and Secondary Healthcare Department runs a network of training centres for HCPs at provincial and district level, Provincial Health Development Centre and District Health Development Centres, which are not delivering teambuilding interventions at the moment. This centre needs to be leveraged for teambuilding and conflict management capacity building. With regards the second phase of the study and follow-up qualitative interviews, we found three broad barriers to optimal teamwork: system issues, behavioural and service problems, and management limitations. Under the theme of healthcare system issues, HCPs argued that insufficient resources, staffing shortages, and lack of care plans and targeted providers for non-maternal health issues prevented optimal teamwork and collaboration. Local scholarship confirms that primary HCPs in Pakistan suffer from critical problems of resource shortages, staffing shortages, and inefficient care plans [ 27 , 28 ]. International literature also describes how resource and staffing shortages can contribute to frustration and excessive work burden in HCPs, resulting in compromised teamwork [ 29 ]. Pakistan’s primary health services are skewed towards maternal health services, and our findings reveal that HCPs are experiencing challenges in both serving and referring patients for other ailments such as chronic diseases, aging health issues, and child health. Local research confirms that health outcomes of women of reproductive years takes priority in the planning and delivery of primary health services, which complicates healthcare team respect and trust in serving the needs of other population groups, such as unmarried people and infants, aging population, special needs people, and refugees and displaced people [ 30 ]. Our findings also suggest that HCPs who earn less than their co-workers and have inferior contract structures show less commitment to teamwork and collaboration due to resentment and dissatisfaction with employers. Research from another developing country experiencing inflation like Pakistan, confirms that providers who earn less than their colleagues have less commitment to job and teamwork [ 31 ]. Under the theme of behavioural and service problems we found that HCPs complained about referral failure, co-worker interaction issues, and lack of collaboration for joint research. Referrals to physicians were described as unsuccessful due to physicians’ inattention, unavailability, or inability to listen to patient and co-workers, which weakened co-worker trust and confidence, preventing teamwork and also future referrals. Referral is the central and integral feature of primary healthcare services, but for it to remain efficient there is need for multi-speciality teamwork and information management [ 32 ]. Physicians, Lady Health Supervisors, and paramedical staff were labelled as being rude and having a dismissive attitude, which again prevented teamwork and coordination. Other research confirms that despite having specialised skills and dedicated work experience, HCPs can have communication and language issues which prevents effective teamwork [ 33 ]. Under the theme of management limitations, we found that HCPs connect ineffective teamwork with unsupportive management, hierarchies preventing communication with seniors, and lack of training in co-workers. Managers and direct supervisors, especially of nurses and LHWs, were described as non-responsive, unhelpful, and unreasonable in their demands. Several research, summarised through a systematic review, confirms that unacceptable behaviour and bullying of seniors, negatively affects the coordination, teamwork, and performance of HCPs [ 34 ]. Other local research confirms that there is very low budget allocation for the primary sector in Pakistan, with much of the limited 1% healthcare budget getting streamed to the tertiary care and salaries of providers [ 35 , 36 ], with almost no budget reserved for training and supervision of management and supervisor-supervisee relations [ 37 , 38 ]. HCPs shared that paramedics and LHWs especially needed training for patient care plans and job descriptions of the multi-speciality teams. Other research suggests that skill upgradation, job description upgradation, and continued training for better communication of HCPs is needed not just for patient safety and to improve uptake of services, but to foster mutual trust and respect amongst co-workers in the health sector [ 39 , 40 ]. Strengths and limitations One of the strengths of this study is that it adopts a sequential mixed methods design to understand the impact of a teambuilding intervention and to further probe through qualitative interviews about barriers to teamwork beyond literacy interventions. We were successful in sampling different multi-speciality providers and delivering a joint interprofessional intervention, which is beneficial for communication, problem-solving, and optimising results in practice. During the qualitative phase, apart from IDIs, we also had FGDs with multi-speciality providers present and this allowed providers to share their challenges and experiences, with some mentioning they had not been able to do this before. Another strength of this study is that the intervention and qualitative interviews have been conducted by academicians from different backgrounds in public health and the social sciences. We believe future interventions, surveys for co-worker satisfaction, and research in primary health service quality can be managed by the academic community in Pakistan, which will relieve some of the burden on healthcare administration and initiate efforts that are not being made at the moment in the country. However, we acknowledge the possible limitation of not being able to sample other provinces and cities in Pakistan, and the Hawthorne effect, with participants reporting post test results or providing qualitative data due to attention generated by the research. Another limitation is that we were not able to sample all centres or HCPs working in the primary sector, and were dependent on permission to sample certain centres and the willingness of HCPs to participate. Conclusions Our study is one of the few studies that attempt to address teamwork issues in primary healthcare teams of the country, showing the benefits and limitations of an interprofessional teambuilding intervention through qualitative data. We conclude that a holistic approach is needed to improve teamwork in the primary-level multi-speciality providers, which we summarise in the eight parts mentioned below (Fig. 5 ). Each of these recommendations are based on the regional findings of this study based on empirical evidence, and require coordinated efforts by the P&SHD, federal and provincial ministries, and the private and academic sector. (1) Increase in budget allocation for the primary healthcare sector streamed to improving resources (specifically ultrasound machines at BHUs and RHCs, operation theatres at RHCs, lab testing facilities at both BHUs and RHCs, availability of basic medicines and vaccines, infrastructure maintenance, safe water/ food availability during work hours, and internet services for electronic medical records [EMR]), staffing (specially medical technicians, LHVs, LHWs, attendants, cleaning staff, security guards, vaccinators, sanitary inspectors in the field, EMR technicians/data operators), health services for non-maternal health needs and transport for poor patients, and continued training of providers. (2) Skill upgradation and continued training of HCPs specifically for co-worker coordination, interpersonal behaviour, conflict management, and patient service quality, with use of pedagogical tools including traditional presentation-based instruction, team-building exercises, case-based learning, and problem-based learning. There is also need for more focused training for younger HCPs (less than 30 years), HCPs with less work experience (less than 6 years), paramedical staff, and LHWs. (3) Development of integrated patient care plans with focus multi-speciality provider coordination for care pathways, care maps, and patient follow-up and recovery pathways. This would be dependent on efficient patient record-keeping through the EMR system, and regular co-worker meetings and consistent collaboration for developing a structured means of implementing local protocols of healthcare. (4) Strengthening of the referral system with focus on co-treatment, workflow coordination, improved services, weekly co-worker meetings with presentation/ discussion of patient case files, intra-facility referrals, patient record-keeping, and updating of healthcare provider job descriptions. (5) Adding targeted providers for non-maternal health issues : The primary health services need to be expanded, specifically for chronic disease management, diseases related to aging population, support for infants or child health, and poverty-related disease management such as infectious disease management and malnourishment. (6) Funding and mandating joint research of multi-speciality primary healthcare teams- made possible by linking contract renewal and promotions with joint research. (7) Third-party supervision and accountability : in lieu of central leadership limitations we recommend that primary healthcare teams and management should be managed by a third-party, with focus on: attendance and availability of providers during work hours (specifically physicians), service delivery, quality of patient care, co-worker interaction, subordinate support and fair treatment of managers (specifically direct supervisors of LHWs and LHVs, District Health Authority, District Health Officers, senior and junior doctors), and longitudinal data collection about the impact of teamwork on patient outcomes and HCP satisfaction. (8) Introducing a human resource department to manage issues related to delayed pay, competitive compensation package (compared to private sector), fair allocation of food and transport allowance, reducing gaps in wages and contractual benefits across health specialties, bullying at the workplace, and other employment concerns (leave allowance, death allowance to families, health insurance, and housing). Measuring effective teamwork and job performance of multi-speciality teams and linking results with performance review process for annual contracts, salary increments, and promotions. Abbreviations BHU Basic health unit EMR Electronic medical record FGD Focus group discussion HCP Healthcare provider IDI In-depth interview LHS Lady health supervisor LHV Lady health visitor LHW Lady health worker P&SHD Primary and Secondary Healthcare Department PMO Principal Medical Officer RHC Rural health centre WMO Women Medical Officer Declarations Ethics approval and consent to participate Ethics approval for this study has been received from the Institutional Review Board of the Forman Christian College University (IRB-257/04-2021). Anonymity, confidentiality and safety of participants was guaranteed and informed consent was taken. There was no risk to participants as the study does not involve any clinical interventions. Consent for publication Not applicable. Availability of data and materials The datasets analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding The National Research Program for Universities (NRPU), Higher Education Commission of Pakistan, has funded this project under its priority areas for national relevance of: Innovative Governance and Reforms. The funding number is: 20-14670/NRPU/R&D/HEC/2021 2021. The funding body is not involved in study design, data management, or data interpretation. Authors’ contributions SRJ and HA conceptualized the project, gained funding, and oversaw the study, intervention and data collection. SRJ, HA, AM, RZ, SKB, and BAAK prepared the study tools and intervention material, collected the data and delivered the intervention. The data was analyzed by SRJ and HA. AUM and FF critically revised the manuscript for important intellectual content. All authors read and approved the final manuscript. Acknowledgements We are grateful to Dr. Aisha Tahir and Dr. Saira Khalid at University of Health Sciences for supporting us in contacting BHUs and RHCs. We would also like thank our team of data collectors and data transcribers including Muhammad Farhan, Muhammad Shah Zaib Gul, Shagoofa Younis, Syed Mujahid Abbas Rizvi, Reeha Batool, Maheen Abid, Rida Zahra, and Hassnain Khan. We also appreciate the support of Basic Health Unit (BHU) In-charges including Dr Kanza Aslam (BHU-Thokar Niaz Baig, Munir Garden), Dr Rana Fayyaz (BHU-Leel), Dr Fareeha Javed-BHU Shahpur Kanjran and Dr Rabia-BHU Jallo Village for allowing access to the BHUs for data collection. We are thankful to Dr Khadija Shakrulla, Associate Professor of Geography at Forman Christian College (A Chartered University) for providing her volunteer services regarding the map of Lahore. References Sangaleti C, Schveitzer MC, Peduzzi M, Zoboli ELCP, Soares CB. 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Transforming practice organizations to foster lifelong learning and commitment to medical professionalism. Acad Med. 2000;75(7):708–17. Hussain R, Rashidian A, Hafeez A, Mirzaee N. Factors influencing healthcare seeking behaviour at primary healthcare level, in Pakistan. Journal of Ayub Medical College Abbottabad. 2019;31(2):201–6. Hashami MF. Healthcare systems & its challenges in Pakistan. International Journal of Social Sciences. 2000;9(1):19–23. Yanchus NJ, Ohler L, Crowe E, Teclaw R, Osatuke K. ‘You just can’t do it all’: A secondary analysis of nurses' perceptions of teamwork, staffing and workload. Journal of Research in Nursing. 2017;22(4):313–25. Jafree SR, Mahmood QK, Sohail MM, Asim M, Barlow J. Narrative synthesis systematic review of Pakistani women’s health outcomes from primary care interventions. BMJ Open. 2022;12(8):e061644. Kalamawei I, Abeki S, Dienye PO. Determination of factors that influence job satisfaction among health workers in Southern Nigeria. Journal of Hospital Administration. 2016;5(2):6–14. Greenwood-Lee J, Jewett L, Woodhouse L, Marshall DA. A categorisation of problems and solutions to improve patient referrals from primary to specialty care. BMC Health Serv Res. 2014;18:986. Leonard MW, Frankel AS. Role of effective teamwork and communication in delivering safe, high‐quality care. Mount Sinai Journal of Medicine: A Journal of Translational and Personalized Medicine. 2011;78(6):820–6. Guo L, Ryan B, Leditschke IA, Haines KJ, Cook K, Eriksson L, Olusanya O, Selak T, Shekar K, Ramanan M. Impact of unacceptable behaviour between healthcare workers on clinical performance and patient outcomes: a systematic review. BMJ Qual Saf. 2022;31(9):679–87. Brollo F, Hanedar E, Walker MS. Pakistan: Spending needs for reaching sustainable development goals (SDGs). International Monetary Fund; 2021. Jafree SR, Barlow J. Systematic review and narrative synthesis of the key barriers and facilitators to the delivery and uptake of primary healthcare services to women in Pakistan. BMJ Open. 2023;13(10):e076883. Zaidi SA, Bigdeli M, Langlois EV, Riaz A, Orr DW, Idrees N, Bump JB. Health systems changes after decentralisation: progress, challenges and dynamics in Pakistan. BMJ Glob Health. 2019;4(1):e001013. Jafree SR. Social Policy for Women in Pakistan. Cham: Springer; 2023. Amin F, Sabzwari S. Workforce issues of general practice in a developing country: Pakistan. Australian Journal of General Practice. 2018;47(9):651–3. Ariff S, Soofi SB, Sadiq K, Feroze AB, Khan S, Jafarey SN, Bhutta ZA. Evaluation of health workforce competence in maternal and neonatal issues in public health sector of Pakistan: an assessment of their training needs. BMC Health Serv Res. 2010;10:319. Additional Declarations No competing interests reported. Supplementary Files SupplementarymaterialA.pdf SupplementarymaterialB.pdf Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 05 Dec, 2025 Reviews received at journal 05 Dec, 2025 Reviewers agreed at journal 21 Nov, 2025 Reviewers agreed at journal 24 Sep, 2025 Reviewers agreed at journal 30 Aug, 2025 Reviews received at journal 12 Aug, 2025 Reviewers agreed at journal 24 Jul, 2025 Reviewers invited by journal 21 Jul, 2025 Submission checks completed at journal 27 May, 2024 Editor assigned by journal 27 May, 2024 First submitted to journal 25 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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22:23:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4478141/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4478141/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":58154851,"identity":"5194afbc-4a4f-47d8-a4c1-369ac6a2161e","added_by":"auto","created_at":"2024-06-11 20:41:44","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":223193,"visible":true,"origin":"","legend":"\u003cp\u003eMap of Lahore, showing exact locations of sampled BHUs and RHCs\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4478141/v1/16fa98f994732f47977913e9.jpg"},{"id":58154856,"identity":"70071214-3f7f-4ac9-a21f-4c73991600ce","added_by":"auto","created_at":"2024-06-11 20:41:44","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":153358,"visible":true,"origin":"","legend":"\u003cp\u003ePre-post-test results for patient care coordination\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4478141/v1/155ae2802c5147223b0ed4a6.jpg"},{"id":58154852,"identity":"283aeaa7-4cf8-4c25-8abc-fed44161a7ea","added_by":"auto","created_at":"2024-06-11 20:41:44","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":159023,"visible":true,"origin":"","legend":"\u003cp\u003ePre-post-test results for workflow coordination\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4478141/v1/2a82689a8774a4c4e2edd28c.jpg"},{"id":58154854,"identity":"4bee7079-cb6b-4c68-b9e0-7b7088a58982","added_by":"auto","created_at":"2024-06-11 20:41:44","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":146545,"visible":true,"origin":"","legend":"\u003cp\u003ePre-post-test results for conflict management\u003c/p\u003e","description":"","filename":"Figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4478141/v1/c001b027e7bf3e36c17cd750.jpg"},{"id":58154855,"identity":"dc8cc30f-66ea-42ee-beed-45e4f6921f6d","added_by":"auto","created_at":"2024-06-11 20:41:44","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":169804,"visible":true,"origin":"","legend":"\u003cp\u003eEight area holistic approach recommended based on the study findings to secure optimal teamwork in the primary-level multi-specialty providers\u003c/p\u003e","description":"","filename":"Figure5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4478141/v1/5f12ac186b3241397ff13119.jpg"},{"id":58155386,"identity":"f52ed87d-edee-4ca5-8e0a-c27e3a80a073","added_by":"auto","created_at":"2024-06-11 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Optimal teamwork at the primary healthcare level is associated with improved patient outcomes and greater job satisfaction of the multi-speciality providers [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], and reduced costs of healthcare in the long-run due to the strengthening of preventive health services [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. One way forward to tackle the work burden and service inefficiencies of the primary HCPs is to support them through interprofessional teambuilding workshops, which can improve primary health services [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, there are very few studies about the effectiveness of teambuilding interventions in the primary sector are available, mainly because unlike the hospital setting there is less control over conditions in the community settings [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere is also concern that isolated teambuilding literacy interventions may not comprehensively address the issues faced by multi-speciality providers in coordinating and delivering services in the community. Previous research has highlighted that despite a shared philosophy and good work ethics, optimal teamwork of multi-speciality providers is dependent on areas beyond the provider\u0026rsquo;s skills and attitudes. Furthermore, it includes factors such as healthcare policy and primary health sector infrastructure [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Teamwork in primary health providers is also influenced by organizational and management support, leadership effectiveness, and in recent times the availability and efficiency of technological support. Satisfaction of providers with the range of services and skills of co-workers also influences teamwork, such as the adequacy of the referral system and availability of health providers for different health needs of clients [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePakistan will be unable to meet its Sustainable Development Goals or internal targets for health service delivery unless there is improvement in primary health services [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The country\u0026rsquo;s primary health centres consist of basic health units (BHUs) and rural health centres (RHCs). There are currently 5,518 BHUs and 683 RHCs in the country, consisting of a multi-speciality team of healthcare providers (HCPs) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Due to devolution, each province of Pakistan manages its primary healthcare setup separately. Over half of the population of Pakistan, estimated at 127\u0026nbsp;million, are found in the Punjab province, which has 2,461 BHUs and 293 RHCs, managed by the Primary and Secondary Healthcare Department (P\u0026amp;SHD), Government of Punjab [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite this noteworthy primary health level infrastructure, budget allocations remain extremely low at less than 1% and service of providers either does not reach the large population or remains below standard due to lack of teamwork and coordination for patient care, distant locations, staff unavailability, and governance problems [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Recent indicators suggest there is a downward trend in prenatal care seeking, institutional deliveries, family planning, consultations for new-borns and infants under 5 years, and for routine immunization [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Furthermore, there are major issues of lack of training and support of BHU and RHC HCPs in terms of communication and conflict management [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Excessive role burden, understaffing and low salaries are also major challenges to the motivation, job commitment, and service quality of the BHU and RHC teams [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eAim and research questions\u003c/h2\u003e \u003cp\u003eIn Pakistan there has been no effort so far to improve teamwork in primary HCPs, through regular training or to understand the concerns regarding team effectiveness as experienced by currently working HCPs. Scholars agree that interprofessional teambuilding workshops are a cost-effective short-term solution for resource poor countries like Pakistan [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], and that qualitative research about teamwork experiences can provide more information about challenges and barriers in delivering health services and the complex relationship between multi-speciality providers [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn lieu of this, this study aimed to adopt a sequential mixed methods approach and to at first step deliver an intervention to improve teambuilding skills in primary HCPs of Pakistan. At second step we aimed to collect qualitative data to understand barriers to teambuilding that may exist beyond educational interventions and skill building for teamwork. Based on the results of this study, we intend to advise the health authorities of the country for improvement in teambuilding for the primary HCPs, as this is known to have direct and positive benefits for patient services and patient outcomes at primary level [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Improved teambuilding will also save health costs and prevent excess burden on the tertiary health sector over time [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study adopted a sequential mixed methods approach. At first step, an interprofessional teambuilding intervention was delivered and a pre-post-test questionnaire was used to measure its impact. At second step, qualitative interviews were conducted with participants to understand existing barriers to teambuilding and what factors can make the intervention more effective. Ethics approval for this study was obtained from the Forman Christian College University, Institutional Review Board (IRB-257/04-2021) and this study has been registered with clinicaltrials.gov (identification number: NCT05389501). All participants of the study gave informed consent. Anonymity, confidentiality, and safety of participants were ensured.\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStage 1: Interprofessional teambuilding intervention\u003c/h2\u003e \u003cp\u003eThe teambuilding intervention consisted of a one-day training which was interactive and included presentations, brief learning videos, case studies, concept mapping, teambuilding games, and problem-based learning, led by different experts and trainers from the academic community, with specialised degrees in public health, community health, sociology, mass communications, and education. The intervention involved the following three learning areas (Supplementary material A): (i) \u0026lsquo;patient care plans\u0026rsquo;, (ii) \u0026lsquo;workflow collaboration\u0026rsquo;, and (iii) \u0026lsquo;conflict management\u0026rsquo;. The pre-post-test survey was developed, with modifications, using the following standardised surveys: (1) Performance of interprofessional primary health care teams survey [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]; (2) University of Louisville Communications Survey [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]; and (3) Conflict Management Questionnaire [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] (Supplementary material B).\u003c/p\u003e \u003cp\u003eThe selection criterion for the teambuilding intervention was currently employed HCPs at BHUs and RHC. We contacted and gained approval to collect data from twelve BHUs from areas of Lahore, (including the following BHUs- Halloki, Sarriach, Lakhokki, Jhodo Dheer, Attoki Awan; and the following 24/7 BHUs- Maraka, Ali Razabad, Jallo Pind, Dogrian Kalan, Shahzada, Hair, and Niaz Baig) and five RHCs from areas of Lahore, (including: Choung, Awan Dhai Wala, Barki, Raiwind, and Manga) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). We invited all the HCPs at BHUs and RHCs to participate in the intervention but were dependent on their willingness to participate.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe intervention took place on December 4, 2023 at the University of Health Sciences. A joint certificate from the University of Health Sciences, University of the Punjab, and Forman Christian College University was awarded to the participants after the intervention. Participants were later also sent the pictures of the award ceremony. However, they were not provided transport stipend. The final sample for the intervention included the following type of health providers: (i) nine lady health workers (LHWs), six lady health visitors (LHVs) and two lady health supervisors (LHSs); (ii) eight Women Medical Officers (WMOs), two Principal Medical Officers (PMOs), one Obstetrician and three dentists; (iii) two School and Health Nutrition Supervisors; (iv) seven nurses; and (v) two allied healthcare staff including a pharmacist and a dispenser.\u003c/p\u003e \u003cp\u003eThe pre-post-test data was analysed using SPSS 25.0. Descriptive statistics were used to present data about pre-post test results for the intervention. The Wilcoxon Signed Rank Test was used to compare means for pre versus post results for the intervention based on the three study learning areas \u0026lsquo;patient care coordination\u0026rsquo;, \u0026lsquo;workflow coordination\u0026rsquo;, and \u0026lsquo;conflict management\u0026rsquo;. The Mann Whitney Test was used to investigate the relationship between the three study learning areas and sociodemographic characteristics of participants. P-values below 0.05 were considered significant.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStage 2: Qualitative interviews\u003c/h2\u003e \u003cp\u003eBased on the findings of our post-test results, we developed a semi-structured questionnaire to ask participants about reasons for lack of improvement in the following teambuilding areas: (i) \u0026lsquo;coordination in weekly meetings\u0026rsquo; (broader learning area: \u0026lsquo;patient care coordination\u0026rsquo;); (ii) \u0026lsquo;skills for client record-keeping\u0026rsquo; (broader learning area: \u0026lsquo;patient care coordination\u0026rsquo;); (iii) \u0026lsquo;planning improved workflow\u0026rsquo; (broader learning area: \u0026lsquo;workflow coordination\u0026rsquo;). We also asked them if they wanted to share (iv) any other barriers they may perceive or have experienced which prevent teamwork, co-worker collaboration, and conflict management.\u003c/p\u003e \u003cp\u003eWe targeted to sample all the 42 participants in the intervention through both in-depth interviews (IDIs) and focus group discussions (FGDs). However, we were dependent on the willingness and availability of HCPs for participation. In total we were able to interview 34 of the intervention participants and hold: (i) 20 IDIs (four with WMOs, four with Nurses, three with LHVs, six with LHWs, two with dentists, and two with dispensers) and (ii) four FGDs with four participants each (two FGDs each with BHU and RHC teams, which included WMOs, Nurses, LHVs, and LHWs). Reasons for some of the intervention participants not being sampled during qualitative phase, included not being available, work pressure, and inability to coordinate time. The qualitative interviews took place between December 22, 2023 to January 13, 2024 in University of Health Sciences. The qualitative data was transcribed into Microsoft Word and independent analysis was done by the first two authors (SRJ and HA). The generated themes were then discussed with the other authors and also shared with some participants (two WMOs, two LHWs, and two LHVs). We received confirmation from all.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eIntervention results\u003c/h2\u003e \u003cp\u003eFigures \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e present the comparison in skill development for interprofessional teambuilding from pre to post stage for the three learning domains of: (i) \u0026lsquo;patient care coordination\u0026rsquo; (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e); (ii) \u0026lsquo;workflow coordination\u0026rsquo; (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e); and (iii) \u0026lsquo;conflict management\u0026rsquo; (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). For the majority of the three learning areas, we find post-test improvement in learning. However, under the broader learning area of \u0026lsquo;patient care coordination\u0026rsquo;, one specific learning skill of \u0026lsquo;coordination in weekly meetings\u0026rsquo; shows decline at post stage (-2.4%) and there was no change at post stage for \u0026lsquo;skills for client record-keeping\u0026rsquo; (0%). Under the broader learning area of \u0026lsquo;workflow coordination\u0026rsquo;, we found no change in one specific skill of \u0026lsquo;planning improved workflow\u0026rsquo;.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the Wilcoxon signed rank test results for pre and post learning for interprofessional teambuilding for the three study domains- patient care plans, collaboration with co-workers, and conflict management. We find that the skills for coordinating patient care plans with co-workers show statistically significant improvement at post-test (\u003cem\u003ez\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.881, p\u0026thinsp;=\u0026thinsp;0.004), and that skills for conflict management with co-workers also shows statistically significant improvement at post-test (\u003cem\u003ez\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.468, p\u0026thinsp;=\u0026thinsp;0.001). The results for skills for collaborating about resources and referrals show no significant results.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eWilcoxon Signed Rank Test results for interprofessional teambuilding learning areas\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre\u003c/p\u003e \u003cp\u003eM\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost\u003c/p\u003e \u003cp\u003eM\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ez\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSkills for coordinating patient care plans with co-workers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.59\u0026thinsp;\u0026plusmn;\u0026thinsp;1.230\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.85\u0026thinsp;\u0026plusmn;\u0026thinsp;2.484\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.881\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.004\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSkills for collaborating about resources and referrals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.14\u0026thinsp;\u0026plusmn;\u0026thinsp;1.025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.33\u0026thinsp;\u0026plusmn;\u0026thinsp;1.408\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.744\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.457\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSkills for conflict management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.73\u0026thinsp;\u0026plusmn;\u0026thinsp;1.848\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.57\u0026thinsp;\u0026plusmn;\u0026thinsp;2.176\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.468\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents the Mann Whitney test results with mean ranks for improved teambuilding at post intervention stage based on sociodemographic characteristics of HCPs. We find that HCPs above the age of 30 years show statistically significant improvement at post intervention in skills for collaborating about resources and referrals (U\u0026thinsp;=\u0026thinsp;48, p\u0026thinsp;=\u0026thinsp;0.031) and in skills for conflict management (U\u0026thinsp;=\u0026thinsp;46, p\u0026thinsp;=\u0026thinsp;0.050). Similarly, we find that HCPs with years of service of 6 years or above show statistically significant improvement at post intervention in skills for collaborating about resources and referrals (U\u0026thinsp;=\u0026thinsp;143, p\u0026thinsp;=\u0026thinsp;0.049) and in skills for conflict management (U\u0026thinsp;=\u0026thinsp;232, p\u0026thinsp;=\u0026thinsp;0.030). There was no statistical significance found for contract type, health centre type or gender.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eResults for improved teambuilding at post intervention based on age and service years of HCPs\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eCoordinating patient care plans with co-workers\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eCollaborating about resources and referrals\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eConflict management\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean rank\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean rank\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean rank\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003cp\u003e20\u0026ndash;29 years\u003c/p\u003e \u003cp\u003e30 years and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.44\u003c/p\u003e \u003cp\u003e8.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.166\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.00\u003c/p\u003e \u003cp\u003e9.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.031\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.75\u003c/p\u003e \u003cp\u003e9.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.050\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003cp\u003eMale\u003c/p\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.43\u003c/p\u003e \u003cp\u003e22.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.347\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.13\u003c/p\u003e \u003cp\u003e23.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.522\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e21.46\u003c/p\u003e \u003cp\u003e21.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.948\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears of service\u003c/p\u003e \u003cp\u003e1\u0026ndash;5 years\u003c/p\u003e \u003cp\u003e6 years and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.27\u003c/p\u003e \u003cp\u003e12.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.819\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.00\u003c/p\u003e \u003cp\u003e14.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.049\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10.92\u003c/p\u003e \u003cp\u003e14.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.030\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContract type\u003c/p\u003e \u003cp\u003ePermanent\u003c/p\u003e \u003cp\u003eContract\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.43\u003c/p\u003e \u003cp\u003e19.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.145\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19.80\u003c/p\u003e \u003cp\u003e23.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e19.91\u003c/p\u003e \u003cp\u003e23.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.232\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth centre type\u003c/p\u003e \u003cp\u003eBHU\u003c/p\u003e \u003cp\u003eRHC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.77\u003c/p\u003e \u003cp\u003e21.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.814\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.52\u003c/p\u003e \u003cp\u003e23.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.335\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20.96\u003c/p\u003e \u003cp\u003e22.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.639\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e* p-values for the Mann Whitney test\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eQualitative results\u003c/h2\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003e(i) System issues\u003c/h2\u003e \u003cdiv id=\"Sec10\" class=\"Section4\"\u003e \u003ch2\u003eInsufficient resources prevent collaboration and collegiality\u003c/h2\u003e \u003cp\u003eHCPs stated that resource shortages prevented effective teamwork and even built resentment with senior management. Complaints about resource shortages dominated team meetings and prevented time from being spent on patient care management or workflow collaboration, with an WMO explaining: \u003cem\u003e\u0026ldquo;Most of the conversation between co-workers is about resource issues, such as lack of ultrasound machine at BHU, need for updated operation theatres at RHCs, and lab testing facilities at both RHCs and BHUs. Without these resources we cannot serve to the best of our ability and this reduces job satisfaction and motivation\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003cp\u003eAn LHW shared how she and other HCPs had to step forward to support clients through their own resources and that senior management and the Medical Officers did not help in putting pressure on higher authorities for supplies: \u003cem\u003e\u0026ldquo;Request for supplies for even basic medicines fall on deaf years. It is the job of our seniors at the centres to follow-up for resources so we can work as a better team. In the end we try to help the poor clients through charity by buying them vaccines and medicines from our salary. We even buy our own registers, to record patient data. But we have limited salary and can only do so much.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eHCPs also complained about the work environment and described it as inadequate and uncomfortable, which prevented collegial relations with co-workers and optimal teamwork. During an FGD, a WMO and LHW shared: \u003cem\u003e\u0026ldquo;There is very few and broken furniture at the centre and no meeting room for health workers. Let alone space for us, we do not even have a separate room for vaccination. Apart from this there is no clean drinking water and food is not provided to us during work. We are expected to work morning to evening without lunch. It\u0026rsquo;s a gloomy environment, with poor lighting and electricity load-shedding and this also affects how well we can work with each other. We are in need of maintenance of the roof, floors, and sewerage system. The ground level of the centre must be above the road level and reconstruction is badly needed.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eStaffing shortages\u003c/h2\u003e \u003cp\u003eAll HCPs complained about the serious staffing shortages at both BHUs and RHCs and stressed that the shortage of staff and extra workload on existing members of the team contributed to low morale and also prevented time for optimal collaboration for work and patient progress. A dispenser shared: \u003cem\u003e\u0026ldquo;The staff is overburdened. Staff seats are empty and providers have not been hired, such as the medical technicians. Only one person is handling everything including online patient record keeping.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eA nurse contributed that the primary healthcare team needed more field workers: \u003cem\u003e\u0026ldquo;Much more outreach staff is needed, mainly- LHWs, vaccinators, and sanitary inspectors. Basically, the surveillance team which goes to the field for case investigation in coordination with the CEO Health office has to be improved and efficient. They are not able to cater to all the patients at the moment and they are overburdened. This creates resentment within the healthcare teams as well.\u003c/em\u003e\u0026rdquo;\u003c/p\u003e \u003cp\u003eHCPs also shared that there was positive integration of technology at BHUs and RHCs, but without the needed technological support staff. An LHV described how having to record electronic data was creating major issues in teamwork, patient record-keeping, and co-worker collaboration: \u0026ldquo;\u003cem\u003eData entry on EMR (electronic medical record database) is difficult and we are feeling overburdened. If we have support from a data operator, we can give more time to patients and have more constructive meetings with co-workers to manage our work better.\u003c/em\u003e\u0026rdquo;\u003c/p\u003e \u003cp\u003eAnother LHV complained about the extra workload due to technological demand for data recording, and the loss of time and personal resources due to poor internet support: \u0026ldquo;\u003cem\u003eData entry on EMR on tabs has further increased our workload. Internet is needed to make entries on EMR but internet services are not good or not working all together on most days. We have to use our own data packages sometimes and we are not compensated for this.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eResentment over differences in pay and employment benefits\u003c/h2\u003e \u003cp\u003eHCPs complained about differences in compensation and employment benefits, which also created resentment and negatively affected teambuilding and mutual respect. There was a hierarchy in pay, work hours, workload and benefits, with LHWs, LHVs and nurses claiming that they had greater workload and in comparison were paid less. One LHW shared: \u003cem\u003e\u0026ldquo;Our salary needs to be increased and our contract structure should match that of the doctors. We never get any bonuses, for example on Eidh or new years. The doctors get paid more than us, and they get residential areas to stay in. This is not fair. After all, we are providing the same support, if not more, to the patients. There is no provision for health insurance for the LHWs. Even though we are the backbone of the primary and secondary healthcare setup for Pakistan. Even if we die on the job, our families will get nothing (employee death compensation)\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003cp\u003eOne of the WMOs shared that comparison with the private sector also reduced work morale and efforts for teamwork: \u003cem\u003e\u0026ldquo;Our salaries do not match the private sector and we get very few leaves and holidays.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eLack of care plans and targeted providers for other health issues\u003c/h2\u003e \u003cp\u003eUnanimously all HCPs interviewed agreed that there was need for extended care plans beyond maternal and child health, with targeted providers allocated to treat other ailments. It was agreed that optimal teamwork and collaboration for work was possible once effective and comprehensive health services were planned and executed at primary level. An LHS highlighted the lack of support for aging population and chronic disease prevalence: \u003cem\u003e\u0026ldquo;Chronic diseases and cough and TB of elders are major issues. We need separate staff to serve them (LHS). Working as an ineffective team, and not doing the needful for our clients affects how we perceive ourselves as a team.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eAn LHV shared that female and child malnourishment was an issue: \u003cem\u003e\u0026ldquo;Poverty has increased overtime, women and children are malnourished and they have commonly have low HB. Infectious disease is out of control, not just due to health illiteracy, but poverty.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eA nurse corroborated that child medicine and targeted providers for child health were needed: \u0026ldquo;\u003cem\u003eWe need supplies of field medicine...for smaller children especially who regularly suffer from fever, cough, stomach worms, and diarrhoea\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e Overall, the HCPs agreed that their perception as a successful team and willingness and enthusiasm to collaborate with each other was influenced by the range and comprehensiveness of their services.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e(ii) Behavioural and service problems\u003c/h2\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003eReferral failure\u003c/h2\u003e \u003cp\u003eHCPs described issues of referral failure, with non-availability and bad treatment of physicians being major issues. There were complaints especially by LHWs and nurses regarding non-availability and lack of services by physicians. One LHW described: \u003cem\u003e\u0026ldquo;Referring patients to the BHU and RHC means having to accompany the patient and ensure that the doctor is available and treats the patient. We use our own transport and it can take all day. If the patient goes alone, she will almost always return from the centre without consultation or complete diagnosis.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eA nurse further described that the physicians do not listen to patients or provide them services satisfactorily: \u003cem\u003e\u0026ldquo;It costs the patients time and money to visit the RHC. The doctors here, however, do not listen or provide adequate services to treat the ailment, which makes us (LHWs and nurses) who refer the patients look extremely bad. This also results in patients turning to private services or local quack healers and not trusting our referral system.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eCo-worker interaction issues\u003c/h2\u003e \u003cp\u003eMany of the HCPs complained about co-worker interaction and behavioural issues which prevented coordination and teamwork, such as rude behaviour, use of crude language, and attitude problems which prevent coordination and learning: \u003cem\u003e\u0026ldquo;Personalities and backgrounds of HCPs are very different. Some LHSs and doctors use abrupt and crude language. We have to be very tolerant and ignore things.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eAnother LHW stated: \u003cem\u003e\u0026ldquo;The paramedical staffs\u0026rsquo; behaviour is very bad and we are unable to deal or coordinate with them.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eA WMO shared issues with new team members: \u003cem\u003e\u0026ldquo;New co-workers who get assigned or posted always have attitude problems and we have to be very patient for the first year\u0026rdquo;\u003c/em\u003e.\u003c/p\u003e \u003cp\u003eOne LHV described: \u003cem\u003e\u0026ldquo;LHSs put on a show most of the time, they don\u0026rsquo;t have that much knowledge or skill. They just like to show attitude.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eLack of joint research\u003c/h2\u003e \u003cp\u003eA few HCPs shared that the primary healthcare team did not coordinate for research and that this would improve their work coordination and teamwork: \u0026ldquo;\u003cem\u003eResearch collaboration is needed to improve work relations and identify problems in a systematic manner\u0026rdquo;\u003c/em\u003e (WMO).\u003c/p\u003e \u003cp\u003eA nurse shared the benefits to both teamwork and professional development in research collaboration: \u003cem\u003e\u0026ldquo;If we do research together, it will make us sincere to each other at the workplace. Also, research efforts can help us to update our degrees and get MPhil degrees.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e(iii) Management limitations\u003c/h2\u003e \u003cdiv id=\"Sec19\" class=\"Section3\"\u003e \u003ch2\u003eUnsupportive management\u003c/h2\u003e \u003cp\u003eHCPs highlighted concerns with unsupportive managers and supervisors and agreed that management failures prevented effective teamwork and collaboration with co-workers. One nurse stating: \u003cem\u003e\u0026ldquo;I wish I could change the management staff, namely the doctor on duty and the District Health Authority personnel.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eAn LHW shared her resentment with senior managers who did not help subordinates in genuine grievances: \u003cem\u003e\u0026ldquo;There are pay delays with no response from management. After all, the management knows how hard we work and how desperately we need our salary at the start of the month.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eAnother LHW contributed that: \u003cem\u003e\u0026ldquo;Food and transport allowances (FTA) are very low. What upsets us is that seniors [doctors] know this, but they don\u0026rsquo;t help or coordinate to support us (LHW).\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eYet another LHW shared the lack of trust between principals and subordinates which created hostility and advised about the need for a Human Resources Department: \u003cem\u003e\u0026ldquo;The area in charge- this includes the CEO health office, District Health Authority, LHS in particular to the IRMNCH department, are non-cooperative. Payments are always delayed. We need an HR to oversee this.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eHierarchies preventing communication with seniors\u003c/h2\u003e \u003cp\u003eThere were issues related to hierarchies and barriers in communication with management and direct supervisors, which prevented optimal teamwork and patient care management. One LHW shared: \u003cem\u003e\u0026ldquo;We cannot solve many of the problems, as there is a hierarchy. This hierarchy prevents us from approaching the senior management and we cannot share our challenges related to the client.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eA LHV shared how unreasonable her supervisor was and how this prevented them from having a positive working relationship or collaborating further for progress: \u003cem\u003e\u0026ldquo;The LHS demands that we reach by 9am at all costs. She threatens us that she will get us fired if we are late, even if there is smog (visibility issues) or transport difficulties and we cannot reach the centre on time. She (LHS) does not know how to talk to us or treat us like human beings. Even if there is a family emergency we cannot share it with her.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eLack of training\u003c/h2\u003e \u003cp\u003eHCPs shared that they needed more support for ongoing training and skill development, without which teambuilding and coordinating care for patients was not possible. A WMO shared that: \u0026ldquo;\u003cem\u003eProper training of paramedics and LHWs for patient management is desperately needed.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eAn LHW stated that this was the first time in her two-decade career that she was offered on-the-job-training: \u003cem\u003e\u0026ldquo;In my 21 years of employment this is the first time someone has offered us training for teambuilding. We needed this before we started working.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eAnother WMO shared the complexity of the primary care team, which consisted of multiple providers with diverse roles and that continued training and coordination was key to their success: \u003cem\u003e\u0026ldquo;The main thing at our centre is the coordination of different providers. Thus, we need continued training for coordination and skill development so we can all do our jobs well. This way the BHU will work like a well-oiled machine to serve patients.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eAbsence of supervision and accountability\u003c/h2\u003e \u003cp\u003eHCPs highlighted the need for supervision of providers and monitoring of care plans for patients. They stressed that accountability and trust with co-workers was the first step to teambuilding and coordination; and also trust and respect. One LHW shared: \u003cem\u003e\u0026ldquo;Some of our co-workers need to be monitored for punctuality, dedication, and regularity.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eA nurse described in detail the consequences of absent providers: \u003cem\u003e\u0026ldquo;At the BHUs and RHCs, the LHV provides vaccination services, manages the deliveries and assists the doctor. Mostly, the LHV carries out the delivery and the doctors are not present, especially in the evening and night-time (for 24/7 BHUs). This is why we have little respect for the doctors and obviously this affects our teamwork.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eAn LHW described how they were accountable themselves but needed coordination from supervisors to update patient files and meetings to discuss patient cases: \u003cem\u003e\u0026ldquo;No one calls us weekly to make and update the patient file. We are only required to make a register and update the BHU monthly about pregnant women in the community. If our superiors call us weekly to update family files and discuss patient cases it would be much better.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eA nurse contributed that job descriptions needed updating: \u003cem\u003e\u0026ldquo;New job description and responsibilities are needed, especially for the outreach staff, IT staff and LHVs.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe aimed to deliver an intervention for teambuilding in this study and to follow-up with participants at stage two for qualitative interviews to further understand needs and barriers related to optimal teambuilding. Our intervention results revealed that HCPs showed improvement in skills to coordinate patient care plans with co-workers and for conflict management with co-workers. Other research corroborates that short workshops for skill building in coordinating patient care plans and improving interpersonal relations in HCPs lead to improved teamwork and performance in HCPs [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. However, skills for collaborating about resources and referrals show no significant results. This may be because resources and referrals need to be organized and mandated by higher authorities at the workplace [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe also found associations between socio-demographic characteristics of HCPs and improved learning post the intervention, with HCPs above the age of 30 years and with 6 or more years of experience showing improved skills for collaborating about resources and referrals and in skills for conflict management, compared to younger and less experienced HCPs. Interestingly, there was no significant difference in learning based on contract type, health centre type, or gender. Other research confirms that HCPs and healthcare specialists with longer years of study in the medical field and greater years of work have more understanding and knowledge about teamwork and conflict management [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Providers above the age of 35 years may respond better to training on the job and skill development as they are more committed to continued learning and expect greater returns; whereas younger providers may feel they are still young and have more time for learning and training [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOverall, our intervention results confirm that the primary healthcare team of Pakistan can be supported with low-cost literacy interventions delivered regularly by the academic community for non-medical training needs, and that this support should be regularly provided to them to improve their commitment to job and their patients [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Additionally, the Primary and Secondary Healthcare Department runs a network of training centres for HCPs at provincial and district level, Provincial Health Development Centre and District Health Development Centres, which are not delivering teambuilding interventions at the moment. This centre needs to be leveraged for teambuilding and conflict management capacity building.\u003c/p\u003e \u003cp\u003eWith regards the second phase of the study and follow-up qualitative interviews, we found three broad barriers to optimal teamwork: system issues, behavioural and service problems, and management limitations. Under the theme of healthcare system issues, HCPs argued that insufficient resources, staffing shortages, and lack of care plans and targeted providers for non-maternal health issues prevented optimal teamwork and collaboration. Local scholarship confirms that primary HCPs in Pakistan suffer from critical problems of resource shortages, staffing shortages, and inefficient care plans [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. International literature also describes how resource and staffing shortages can contribute to frustration and excessive work burden in HCPs, resulting in compromised teamwork [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePakistan\u0026rsquo;s primary health services are skewed towards maternal health services, and our findings reveal that HCPs are experiencing challenges in both serving and referring patients for other ailments such as chronic diseases, aging health issues, and child health. Local research confirms that health outcomes of women of reproductive years takes priority in the planning and delivery of primary health services, which complicates healthcare team respect and trust in serving the needs of other population groups, such as unmarried people and infants, aging population, special needs people, and refugees and displaced people [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Our findings also suggest that HCPs who earn less than their co-workers and have inferior contract structures show less commitment to teamwork and collaboration due to resentment and dissatisfaction with employers. Research from another developing country experiencing inflation like Pakistan, confirms that providers who earn less than their colleagues have less commitment to job and teamwork [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUnder the theme of behavioural and service problems we found that HCPs complained about referral failure, co-worker interaction issues, and lack of collaboration for joint research. Referrals to physicians were described as unsuccessful due to physicians\u0026rsquo; inattention, unavailability, or inability to listen to patient and co-workers, which weakened co-worker trust and confidence, preventing teamwork and also future referrals. Referral is the central and integral feature of primary healthcare services, but for it to remain efficient there is need for multi-speciality teamwork and information management [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Physicians, Lady Health Supervisors, and paramedical staff were labelled as being rude and having a dismissive attitude, which again prevented teamwork and coordination. Other research confirms that despite having specialised skills and dedicated work experience, HCPs can have communication and language issues which prevents effective teamwork [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUnder the theme of management limitations, we found that HCPs connect ineffective teamwork with unsupportive management, hierarchies preventing communication with seniors, and lack of training in co-workers. Managers and direct supervisors, especially of nurses and LHWs, were described as non-responsive, unhelpful, and unreasonable in their demands. Several research, summarised through a systematic review, confirms that unacceptable behaviour and bullying of seniors, negatively affects the coordination, teamwork, and performance of HCPs [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Other local research confirms that there is very low budget allocation for the primary sector in Pakistan, with much of the limited 1% healthcare budget getting streamed to the tertiary care and salaries of providers [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], with almost no budget reserved for training and supervision of management and supervisor-supervisee relations [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. HCPs shared that paramedics and LHWs especially needed training for patient care plans and job descriptions of the multi-speciality teams. Other research suggests that skill upgradation, job description upgradation, and continued training for better communication of HCPs is needed not just for patient safety and to improve uptake of services, but to foster mutual trust and respect amongst co-workers in the health sector [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eOne of the strengths of this study is that it adopts a sequential mixed methods design to understand the impact of a teambuilding intervention and to further probe through qualitative interviews about barriers to teamwork beyond literacy interventions. We were successful in sampling different multi-speciality providers and delivering a joint interprofessional intervention, which is beneficial for communication, problem-solving, and optimising results in practice. During the qualitative phase, apart from IDIs, we also had FGDs with multi-speciality providers present and this allowed providers to share their challenges and experiences, with some mentioning they had not been able to do this before.\u003c/p\u003e \u003cp\u003eAnother strength of this study is that the intervention and qualitative interviews have been conducted by academicians from different backgrounds in public health and the social sciences. We believe future interventions, surveys for co-worker satisfaction, and research in primary health service quality can be managed by the academic community in Pakistan, which will relieve some of the burden on healthcare administration and initiate efforts that are not being made at the moment in the country. However, we acknowledge the possible limitation of not being able to sample other provinces and cities in Pakistan, and the Hawthorne effect, with participants reporting post test results or providing qualitative data due to attention generated by the research. Another limitation is that we were not able to sample all centres or HCPs working in the primary sector, and were dependent on permission to sample certain centres and the willingness of HCPs to participate.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOur study is one of the few studies that attempt to address teamwork issues in primary healthcare teams of the country, showing the benefits and limitations of an interprofessional teambuilding intervention through qualitative data. We conclude that a holistic approach is needed to improve teamwork in the primary-level multi-speciality providers, which we summarise in the eight parts mentioned below (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Each of these recommendations are based on the regional findings of this study based on empirical evidence, and require coordinated efforts by the P\u0026amp;SHD, federal and provincial ministries, and the private and academic sector.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e(1) \u003cem\u003eIncrease in budget allocation for the primary healthcare sector\u003c/em\u003e streamed to improving resources (specifically ultrasound machines at BHUs and RHCs, operation theatres at RHCs, lab testing facilities at both BHUs and RHCs, availability of basic medicines and vaccines, infrastructure maintenance, safe water/ food availability during work hours, and internet services for electronic medical records [EMR]), staffing (specially medical technicians, LHVs, LHWs, attendants, cleaning staff, security guards, vaccinators, sanitary inspectors in the field, EMR technicians/data operators), health services for non-maternal health needs and transport for poor patients, and continued training of providers.\u003c/p\u003e \u003cp\u003e(2) \u003cem\u003eSkill upgradation and continued training of HCPs\u003c/em\u003e specifically for co-worker coordination, interpersonal behaviour, conflict management, and patient service quality, with use of pedagogical tools including traditional presentation-based instruction, team-building exercises, case-based learning, and problem-based learning. There is also need for more focused training for younger HCPs (less than 30 years), HCPs with less work experience (less than 6 years), paramedical staff, and LHWs.\u003c/p\u003e \u003cp\u003e(3) \u003cem\u003eDevelopment of integrated patient care plans\u003c/em\u003e with focus multi-speciality provider coordination for care pathways, care maps, and patient follow-up and recovery pathways. This would be dependent on efficient patient record-keeping through the EMR system, and regular co-worker meetings and consistent collaboration for developing a structured means of implementing local protocols of healthcare.\u003c/p\u003e \u003cp\u003e(4) \u003cem\u003eStrengthening of the referral system\u003c/em\u003e with focus on co-treatment, workflow coordination, improved services, weekly co-worker meetings with presentation/ discussion of patient case files, intra-facility referrals, patient record-keeping, and updating of healthcare provider job descriptions.\u003c/p\u003e \u003cp\u003e(5) \u003cem\u003eAdding targeted providers for non-maternal health issues\u003c/em\u003e: The primary health services need to be expanded, specifically for chronic disease management, diseases related to aging population, support for infants or child health, and poverty-related disease management such as infectious disease management and malnourishment.\u003c/p\u003e \u003cp\u003e(6) Funding and mandating joint research of multi-speciality primary healthcare teams- made possible by linking contract renewal and promotions with joint research.\u003c/p\u003e \u003cp\u003e(7) \u003cem\u003eThird-party supervision and accountability\u003c/em\u003e: in lieu of central leadership limitations we recommend that primary healthcare teams and management should be managed by a third-party, with focus on: attendance and availability of providers during work hours (specifically physicians), service delivery, quality of patient care, co-worker interaction, subordinate support and fair treatment of managers (specifically direct supervisors of LHWs and LHVs, District Health Authority, District Health Officers, senior and junior doctors), and longitudinal data collection about the impact of teamwork on patient outcomes and HCP satisfaction.\u003c/p\u003e \u003cp\u003e(8) \u003cem\u003eIntroducing a human resource department\u003c/em\u003e to manage issues related to delayed pay, competitive compensation package (compared to private sector), fair allocation of food and transport allowance, reducing gaps in wages and contractual benefits across health specialties, bullying at the workplace, and other employment concerns (leave allowance, death allowance to families, health insurance, and housing). Measuring effective teamwork and job performance of multi-speciality teams and linking results with performance review process for annual contracts, salary increments, and promotions.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBHU\u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Basic health unit\u003c/p\u003e\n\u003cp\u003eEMR\u0026nbsp; \u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Electronic medical record\u003c/p\u003e\n\u003cp\u003eFGD\u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Focus group discussion\u003c/p\u003e\n\u003cp\u003eHCP\u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Healthcare provider\u003c/p\u003e\n\u003cp\u003eIDI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;In-depth interview\u003c/p\u003e\n\u003cp\u003eLHS\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Lady health supervisor\u003c/p\u003e\n\u003cp\u003eLHV\u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Lady health visitor\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLHW\u0026nbsp; \u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Lady health worker\u003c/p\u003e\n\u003cp\u003eP\u0026amp;SHD \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Primary and Secondary Healthcare Department\u003c/p\u003e\n\u003cp\u003ePMO\u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Principal Medical Officer\u003c/p\u003e\n\u003cp\u003eRHC\u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Rural health centre\u003c/p\u003e\n\u003cp\u003eWMO \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Women Medical Officer\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthics approval for this study has been received from the Institutional Review Board of the Forman Christian College University (IRB-257/04-2021). Anonymity, confidentiality and safety of participants was guaranteed and informed consent was taken. There was no risk to participants as the study does not involve any clinical interventions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe National Research Program for Universities (NRPU), Higher Education Commission of Pakistan, has funded this project under its priority areas for national relevance of: Innovative Governance and Reforms. The funding number is: 20-14670/NRPU/R\u0026amp;D/HEC/2021 2021.\u003c/p\u003e\n\u003cp\u003eThe funding body is not involved in study design, data management, or data interpretation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors’ contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSRJ and HA conceptualized the project, gained funding, and oversaw the study, intervention and data collection. SRJ, HA, AM, RZ, SKB, and BAAK prepared the study tools and intervention material, collected the data and delivered the intervention. The data was analyzed by SRJ and HA. AUM and FF critically revised the manuscript for important intellectual content. All authors read and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe are grateful to Dr. Aisha Tahir and Dr. Saira Khalid at University of Health Sciences for supporting us in contacting BHUs and RHCs. We would also like thank our team of data collectors and data transcribers including Muhammad Farhan, Muhammad Shah Zaib Gul, Shagoofa Younis, Syed Mujahid Abbas Rizvi, Reeha Batool, Maheen Abid, Rida Zahra, and Hassnain Khan. We also appreciate the support of Basic Health Unit (BHU) In-charges including Dr Kanza Aslam (BHU-Thokar Niaz Baig, Munir Garden), Dr Rana Fayyaz (BHU-Leel), Dr Fareeha Javed-BHU Shahpur Kanjran and Dr Rabia-BHU Jallo Village for allowing access to the BHUs for data collection. We are thankful to Dr Khadija Shakrulla, Associate Professor of Geography at Forman Christian College (A Chartered University) for providing her volunteer services regarding the map of Lahore.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSangaleti C, Schveitzer MC, Peduzzi M, Zoboli ELCP, Soares CB. Experiences and shared meaning of teamwork and interprofessional collaboration among health care professionals in primary health care settings: a systematic review. JBI Database System Rev Implement Rep. 2017;15(11):2723\u0026ndash;88.\u003c/li\u003e\n\u003cli\u003eLemieux-Charles L, McGuire WL. What do we know about health care team effectiveness? A review of the literature. Med Care Res Rev. 2006;63(3):263\u0026ndash;300.\u003c/li\u003e\n\u003cli\u003eSawicki OA, Mueller A, Klaa\u0026szlig;en-Mielke R, Glushan A, Gerlach FM, Beyer M, Wensing M, Karimova K. 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International Monetary Fund; 2021. \u003c/li\u003e\n\u003cli\u003eJafree SR, Barlow J. Systematic review and narrative synthesis of the key barriers and facilitators to the delivery and uptake of primary healthcare services to women in Pakistan. BMJ Open. 2023;13(10):e076883.\u003c/li\u003e\n\u003cli\u003eZaidi SA, Bigdeli M, Langlois EV, Riaz A, Orr DW, Idrees N, Bump JB. Health systems changes after decentralisation: progress, challenges and dynamics in Pakistan. BMJ Glob Health. 2019;4(1):e001013.\u003c/li\u003e\n\u003cli\u003eJafree SR. Social Policy for Women in Pakistan. Cham: Springer; 2023.\u003c/li\u003e\n\u003cli\u003eAmin F, Sabzwari S. Workforce issues of general practice in a developing country: Pakistan. Australian Journal of General Practice. 2018;47(9):651\u0026ndash;3.\u003c/li\u003e\n\u003cli\u003eAriff S, Soofi SB, Sadiq K, Feroze AB, Khan S, Jafarey SN, Bhutta ZA. Evaluation of health workforce competence in maternal and neonatal issues in public health sector of Pakistan: an assessment of their training needs. BMC Health Serv Res. 2010;10:319.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"human-resources-for-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"hrhe","sideBox":"Learn more about [Human Resources for Health](http://human-resources-health.biomedcentral.com)","snPcode":"12960","submissionUrl":"https://submission.nature.com/new-submission/12960/3","title":"Human Resources for Health","twitterHandle":"@HRH_Journal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"primary health, primary healthcare providers, teambuilding, conflict management, intervention","lastPublishedDoi":"10.21203/rs.3.rs-4478141/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4478141/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/em\u003e Pakistan’s primary health services have a sound infrastructure but remain ineffective in serving the needs of the nation. A significant area of concern is the lack of support to improve teambuilding of the multi-speciality primary healthcare providers (HCP). This study had two phases: First, to deliver a teambuilding intervention using a pre-post-test design, and second, to collect qualitative data about barriers to teambuilding.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/em\u003e A total of 42 multi-speciality HCPs from 12 basic health units and 5 rural health centres of Punjab, Pakistan, were part of the teambuilding intervention. We conducted a sequential mixed methods approach, with a quantitative pre-post-test analysis and interviews with 34 HCPs at follow-up qualitative phase.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/em\u003e Mean analysis at post-test revealed improved teambuilding skills for coordinating patient care plans (\u003cem\u003ez\u003c/em\u003e=2.881, p=0.004), and skills for conflict management (\u003cem\u003ez\u003c/em\u003e=3.468, p=0.001). HCPs above the age of 30 years and with ≥6 years of service show improvement post intervention in teambuilding skills for collaborating about resources and referrals and conflict management, suggesting that younger and less experienced HCPs need more regular training support. The qualitative data highlighted 11 barriers which prevented optimal teambuilding, falling under broad areas of: (i) system issues, (ii) behavioural and service problems, and (iii) management limitations. We conclude with eight holistic recommendations to secure optimal teamwork, and argue that apart from continued training, there is need to: increase budget allocation; develop integrated care plans; strengthen the referral system; add providers to the team for non-maternal health services; fund joint research of providers; introduce third-party supervision and accountability; and introduce a human resource department.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003e\u003c/em\u003eOur study is one of the few studies that attempt to address teamwork issues in primary healthcare teams of the country, showing the benefits and limitations of an interprofessional teambuilding intervention. We conclude that a holistic approach is needed to improve teamwork in the primary-level multi-speciality providers.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eTrial registration:\u003c/strong\u003e\u003c/em\u003e NCT05389501\u003c/p\u003e","manuscriptTitle":"Teambuilding intervention in multi-speciality primary healthcare providers in Pakistan: Results of a sequential mixed methods approach","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-11 20:41:39","doi":"10.21203/rs.3.rs-4478141/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-05T22:10:17+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-05T06:18:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"337961935115870711811479460776309081808","date":"2025-11-21T06:44:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"139144826197622586654957578826134876036","date":"2025-09-25T01:04:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"18759093711707053824668398055277036954","date":"2025-08-30T15:58:19+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-12T11:48:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"229198583567069573661969811861070970483","date":"2025-07-24T11:24:54+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-21T19:48:46+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-27T07:12:14+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-27T07:12:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"Human Resources for Health","date":"2024-05-25T22:09:39+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"human-resources-for-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"hrhe","sideBox":"Learn more about [Human Resources for Health](http://human-resources-health.biomedcentral.com)","snPcode":"12960","submissionUrl":"https://submission.nature.com/new-submission/12960/3","title":"Human Resources for Health","twitterHandle":"@HRH_Journal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6a2f8b23-0c75-4990-acfe-f12742a2bb3d","owner":[],"postedDate":"June 11th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-26T11:38:15+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-11 20:41:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4478141","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4478141","identity":"rs-4478141","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}