Dataset Information

Task shifting in Mozambique: cross-sectional evaluation of non-physician clinicians' performance in HIV/AIDS care.

ABSTRACT:

Background

Many resource-constrained countries now train non-physician clinicians in HIV/AIDS care, a strategy known as 'task-shifting.' There is as yet no evidence-based international standard for training these cadres. In 2007, the Mozambican Ministry of Health (MOH) conducted a nationwide evaluation of the quality of care delivered by non-physician clinicians (técnicos de medicina, or TMs), after a two-week in-service training course emphasizing antiretroviral therapy (ART).

Methods

Forty-four randomly selected TMs were directly observed by expert clinicians as they cared for HIV-infected patients in their usual worksites. Observed clinical performance was compared to national norms as taught in the course.

Results

In 127 directly observed patient encounters, TMs assigned the correct WHO clinical stage in 37.6%, and correctly managed co-trimoxazole prophylaxis in 71.6% and ART in 75.5% (adjusted estimates). Correct management of all 5 main aspects of patient care (staging, co-trimoxazole, ART, opportunistic infections, and adverse drug reactions) was observed in 10.6% of encounters.The observed clinical errors were heterogeneous. Common errors included assignment of clinical stage before completing the relevant patient evaluation, and initiation or continuation of co-trimoxazole or ART without indications or when contraindicated.

Conclusions

In Mozambique, the in-service ART training was suspended. MOH subsequently revised the TMs' scope of work in HIV/AIDS care, defined new clinical guidelines, and initiated a nationwide re-training and clinical mentoring program for these health professionals. Further research is required to define clinically effective methods of health-worker training to support HIV/AIDS care in Mozambique and similarly resource-constrained environments.

SUBMITTER: Brentlinger PE

PROVIDER: S-EPMC2994547 | biostudies-literature | 2010 Oct

REPOSITORIES: biostudies-literature

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Publications

Task shifting in Mozambique: cross-sectional evaluation of non-physician clinicians' performance in HIV/AIDS care.

Brentlinger Paula E PE Assan Américo A Mudender Florindo F Ghee Annette E AE Vallejo Torres José J Martínez Martínez Pilar P Bacon Oliver O Bastos Rui R Manuel Rolanda R Ramirez Li Lucy L McKinney Catherine C Nelson Lisa J LJ

Human resources for health 20101012

<h4>Background</h4>Many resource-constrained countries now train non-physician clinicians in HIV/AIDS care, a strategy known as 'task-shifting.' There is as yet no evidence-based international standard for training these cadres. In 2007, the Mozambican Ministry of Health (MOH) conducted a nationwide evaluation of the quality of care delivered by non-physician clinicians (técnicos de medicina, or TMs), after a two-week in-service training course emphasizing antiretroviral therapy (ART).<h4>Method ...[more]

PMID: 20939909

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Project description:BackgroundThe burden of non-communicable chronic diseases, such as hypertension and diabetes, increases in sub-Saharan Africa. However, the majority of the rural population does still not have access to adequate care. The objective of this study is to examine the effectiveness of integrating care for hypertension and type 2 diabetes by task shifting to non-physician clinician (NPC) facilities in eight rural health districts in Cameroon.MethodsOf the 75 NPC facilities in the area, 69 (87%) received basic equipment and training in hypertension and diabetes care. Effectiveness was assessed after two years on status of equipment, knowledge among trained NPCs, number of newly detected patients, retention of patients under care, treatment cost to patients and changes in blood pressure (BP) and fasting plasma glucose (FPG) among treated patients.ResultsTwo years into the programme, of 54 facilities (78%) available for re-assessment, all possessed a functional sphygmomanometer and stethoscope (65% at baseline); 96% stocked antihypertensive drugs (27% at baseline); 70% possessed a functional glucose meter and 72% stocked oral anti-diabetics (15% and 12% at baseline). NPCs' performance on multiple-choice questions of the knowledge-test was significantly improved. During a period of two years, trained NPCs initiated treatment for 796 patients with hypertension and/or diabetes. The retention of treated patients at one year was 18.1%. Hypertensive and diabetic patients paid a median monthly amount of 1.4 and 0.7 Euro respectively for their medication. Among hypertensive patients with ≥ 2 documented visits (n = 493), systolic BP decreased by 22.8 mmHg (95% CI: -20.6 to -24.9; p < 0.0001) and diastolic BP by 12.4 mmHg (-10.9 to -13.9; p < 0.0001). Among diabetic patients (n = 79) FPG decreased by 3.4 mmol/l (-2.3 to -4.5; p < 0.001).ConclusionsThe integration of hypertension and diabetes into primary health care of NPC facilities in rural Cameroon was feasible in terms of equipment and training, accessible in terms of treatment cost and showed promising BP- and FPG-trends. However, low case-detection rates per NPC and a very high attrition among patients enrolled into care, limited the effectiveness of the programme.

Project description:AimTo describe variation in task shifting from GPs to practice assistants/nurses in 34 countries and to explain differences by analysing associations with characteristics of the GPs and their practices and features of the health care systems.BackgroundRedistribution of tasks and responsibilities in primary care are driven by changes in demand, such as the growing number of patients with chronic conditions, and workforce developments, including staff shortage. The need to manage an expanding range of services has led to adaptations in the skill-mix of primary care teams. These developments are hampered by barriers between professional domains.MethodsData were collected between 2011 and 2013 through a cross-sectional survey among approximately 7,200 general practitioners (GPs) in 34 countries. Task shifting is measured through a composite score of GPs' self-reported shifting of tasks. Independent variables at GP and practice level are as follows: innovativeness; part-time working; availability of staff; location and population of the practice. Country-level independent variables are as follows: demand for and supply of care, nurse prescribing, and professionalisation of practice assistants/nurses. Multilevel analysis is used to account for clustering of GPs in countries.FindingsCountries vary in the degree of task shifting. Regarding GP and practice characteristics, use of electronic health records and availability of support staff in the practice are positively associated with task shifting and GPs' working hours negatively, in line with our hypotheses. Age of the GPs is, contrary to our hypothesis, positively related to task shifting. These variables explain 11% of the variance at GP level. Two country variables are related to task shifting: a lower percentage of practices without support staff in a country and nurse prescribing rights coincide with more task shifting. The percentage of practices without support staff has the strongest relationship, explaining 73% of the country variation.

Project description:AimTo describe variation in task shifting from general practitioners (GPs) to practice assistants/nurses in 34 countries, and to explain differences by analysing associations with characteristics of the GPs, their practices and features of the health care systems.BackgroundRedistribution of tasks and responsibilities in primary care are driven by changes in demand for care, such as the growing number of patients with chronic conditions, and workforce developments, including staff shortage. The need to manage an expanding range of services has led to adaptations in the skill mix of primary care teams. However, these developments are hampered by barriers between professional domains, which can be rigid as a result of strict regulation, traditional attitudes and lack of trust.MethodsData were collected between 2011 and 2013 through a cross-sectional survey among approximately 7200 GPs in 34 countries. The dependent variable 'task shifting' is measured through a composite score of GPs' self-reported shifting of tasks. Independent variables at GP and practice level are: innovativeness; part-time working; availability of staff; location and population of the practice. Country-level independent variables are: institutional development of primary care; demand for and supply of care; nurse prescribing as an indicator for professional boundaries; professionalisation of practice assistants/nurses (indicated by professional training, professional associations and journals). Multilevel analysis is used to account for the clustering of GPs in countries.FindingsCountries vary in the degree of task shifting by GPs. Regarding GP and practice characteristics, use of electronic health record applications (as an indicator for innovativeness) and age of the GPs are significantly related to task shifting. These variables explain only little variance at the level of GPs. Two country variables are positively related to task shifting: nurse prescribing and professionalisation of primary care nursing. Professionalisation has the strongest relationship, explaining 21% of the country variation.

Project description:BACKGROUND:Human Immunodeficiency Virus (HIV), Hepatitis, and Tuberculosis (TB) are three primary communicable infections have the likely potential to cause severe morbidity in prison settings. The prison has the most favorable environment for the transmission of infections. We conducted this survey to determine the prevalence and feasibility of rapid diagnostic tests in an active screening of these infectious diseases in prison. METHODS:This cross-sectional survey conducted in central Jail Gaddani, one of the largest prisons in the Balochistan province of Pakistan. All prisoners, jail staffs, and staff's family members participated. Informed consent obtained from each participant before the screening. Van equipped with digital X-ray linked with Computer-Aided Detection for TB (CAD4TB) software used for testing. Sputum samples tested on Xpert for MTB/RIF assay and blood specimens collected for HIV and hepatitis serology. Diagnosed TB patients enrolled for treatment at Basic Management Unit (BMU), reactive on hepatitis Rapid Diagnostic Tools (RDTs) were referred for further testing and management, while HIV reactive referred to Anti Retro Viral (ARV) center for Anti Retro Viral Treatment (ART). RESULTS:A total of 567 participants offered screening, 63% (356) prisoners, 23% (129) staff's family members, and 14% (82) jail staffs. Among tested 10.3% (58/562) were hepatitis seropositive (Hepatitis-C 41 [7.29%] Hepatitis-B, 16 [2.84%] Hepatitis B&C both, 01 [0.17%]). In reactive participants, 49 were prisoners, 08 were jail staffs, and 01 was the staff's family member. HIV seropositive was 4% (24/566), and all were prisoners. Almost 99% (565/567) screened by digital X-ray, 172 (30%) were with abnormal CAD4TB suggestion (score?>?50), out of them sputum of 26% (148) tested on Xpert, and 2% (03) found Mycobacterium tuberculosis Positive (MTB+). A total of five TB patients were detected; out of two were diagnosed clinically. Co-morbidities observed in 15 patients, (01?TB/HIV co-infected, 12 HIV/HCV, 01 HIV/HBV, and 01 HBV/HCV). CONCLUSION:The high frequency of infectious diseases in prison is alarming. For limiting the transmission of infections among prison and community, immediate steps are needed to be taken for improvement of prisons condition by application of recommended screening protocols at the time of the first entry of prisoners in prisons.

Project description:Shortages of human resources for health (HRH) have severely hampered the rollout of antiretroviral therapy (ART) in sub-Saharan Africa. Current rollout models are hospital- and physician-intensive. Task shifting, or delegating tasks performed by physicians to staff with lower-level qualifications, is considered a means of expanding rollout in resource-poor or HRH-limited settings.We conducted a systematic literature review. Medline, the Cochrane library, the Social Science Citation Index, and the South African National Health Research Database were searched with the following terms: task shift*, balance of care, non-physician clinicians, substitute health care worker, community care givers, primary healthcare teams, cadres, and nurs* HIV. We mined bibliographies and corresponded with authors for further results. Grey literature was searched online, and conference proceedings searched for abstracts.We found 2960 articles, of which 84 were included in the core review. 51 reported outcomes, including research from 10 countries in sub-Saharan Africa. The most common intervention studied was the delegation of tasks (especially initiating and monitoring HAART) from doctors to nurses and other non-physician clinicians. Five studies showed increased access to HAART through expanded clinical capacity; two concluded task shifting is cost effective; 9 showed staff equal or better quality of care; studies on non-physician clinician agreement with physician decisions was mixed, with the majority showing good agreement.Task shifting is an effective strategy for addressing shortages of HRH in HIV treatment and care. Task shifting offers high-quality, cost-effective care to more patients than a physician-centered model. The main challenges to implementation include adequate and sustainable training, support and pay for staff in new roles, the integration of new members into healthcare teams, and the compliance of regulatory bodies. Task shifting should be considered for careful implementation where HRH shortages threaten rollout programmes.

Project description:BackgroundPhysician-nurse task shifting in primary care appeals greatly to health policymakers. It promises to address workforce shortages and demands of high-quality, affordable care in the healthcare systems of many countries. This systematic review was conducted to assess the evidence about physician-nurse task shifting in primary care in relation to the course of disease and nurses' roles.MethodsWe searched MEDLINE, Embase, The Cochrane Library and CINAHL, up to August 2012, and the reference list of included studies and relevant reviews. All searches were updated in February 2014. We selected and critically appraised published randomized controlled trials (RCTs).ResultsTwelve RCTs comprising 22,617 randomized patients conducted mainly in Europe met the inclusion criteria. Nurse-led care was delivered mainly by nurse practitioners following structured protocols and validated instruments in most studies. Twenty-five unique disease-specific measures of the course of disease were reported in the 12 RCTs. While most (84 %) study estimates showed no significant differences between nurse-led care and physician-led care, nurses achieved better outcomes in the secondary prevention of heart disease and a greater positive effect in managing dyspepsia and at lowering cardiovascular risk in diabetic patients. The studies were generally small, of varying follow-up episodes and were at risk of biases. Descriptive details about roles, qualifications or interventions were also incomplete or not reported.ConclusionTrained nurses may have the ability to achieve outcome results that are at least similar to physicians' for managing the course of disease, when following structured protocols and validated instruments. The evidence, however, is limited by a small number of studies reporting a broad range of disease-specific outcomes; low reporting standards of interventions, roles and clinicians' characteristics, skills and qualifications; and the quality of studies. More rigorous studies using validated tools could clarify these findings.

Dataset Information

Task shifting in Mozambique: cross-sectional evaluation of non-physician clinicians' performance in HIV/AIDS care.

Background

Methods

Results

Conclusions

Publications

Task shifting in Mozambique: cross-sectional evaluation of non-physician clinicians' performance in HIV/AIDS care.

Similar Datasets

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