Dataset Information

Mixed-methods evaluation of a telehealth collaborative care program for persons with HIV infection in a rural setting.

ABSTRACT:

Background

Delivery of comprehensive care for persons with human immunodeficiency virus (HIV) infection in rural and low prevalence settings presents many challenges. We developed and evaluated a telehealth collaborative care (TCC) program for persons with HIV in a rural area.

Objective

To determine the feasibility of TCC, and identify factors influencing implementation in rural settings.

Design

Mixed methods evaluation of a quality improvement program with pre-measures and post-measures.

Patients

Veterans with HIV infection in Iowa and Illinois.

Intervention

TCC integrated HIV specialty care delivered by clinical video telehealth, with primary care delivered by generalist providers, in seven Community Based Outpatient Clinics (CBOCs) serving rural areas. Principles guiding TCC design were: 1) clear delineation of specialty and primary care clinic roles in co-managed care; 2) creation of processes to improve care coordination between specialty and primary care teams; and 3) use of a patient registry for population management across sites.

Measures

Veterans Affairs (VA) healthcare system performance measures for care for HIV infection and common comorbidities, patient travel time to obtain care, and patient satisfaction. Qualitative evaluation involved semi-structured telephone interviews with patients.

Key results

Thirty of 32 eligible patients chose TCC over traveling to the HIV clinic for all care. Among 24 patients in TCC during the June 2011-May 2012 evaluation period, median age was 54 (range, 40-79), most (96 %) were men, and median CD4 count was 707 cells/cm(3) (range, 233-1307). VA performance measures were met for > 90 % of TCC patients. Median yearly travel time decreased from 320 min per patient prior to TCC to 170 min during TCC (p?DiscussionTelehealth Collaborative Care is a feasible approach to providing accessible and comprehensive care for persons with HIV in rural settings.

SUBMITTER: Ohl M

PROVIDER: S-EPMC3744312 | biostudies-literature | 2013 Sep

REPOSITORIES: biostudies-literature

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Publications

Mixed-methods evaluation of a telehealth collaborative care program for persons with HIV infection in a rural setting.

Ohl Michael M Dillon Dena D Moeckli Jane J Ono Sarah S Waterbury Nancee N Sissel Jo J Yin Jun J Neil Brian B Wakefield Bonnie B Kaboli Peter P

Journal of general internal medicine 20130309 9

<h4>Background</h4>Delivery of comprehensive care for persons with human immunodeficiency virus (HIV) infection in rural and low prevalence settings presents many challenges. We developed and evaluated a telehealth collaborative care (TCC) program for persons with HIV in a rural area.<h4>Objective</h4>To determine the feasibility of TCC, and identify factors influencing implementation in rural settings.<h4>Design</h4>Mixed methods evaluation of a quality improvement program with pre-measures and ...[more]

PMID: 23475640

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Project description:IntroductionDespite carrying a disproportionately high burden of depression, patients in low-income countries lack access to effective care. The collaborative care model (CoCM) has robust evidence for clinical effectiveness in improving mental health outcomes. However, evidence from real-world implementation of CoCM is necessary to inform its expansion in low-resource settings.MethodsWe conducted a 2-year mixed-methods study to assess the implementation and clinical impact of CoCM using the WHO Mental Health Gap Action Programme protocols in a primary care clinic in rural Nepal. We used the Capability Opportunity Motivation-Behaviour (COM-B) implementation research framework to adapt and study the intervention. To assess implementation factors, we qualitatively studied the impact on providers' behaviour to screen, diagnose and treat mental illness. To assess clinical impact, we followed a cohort of 201 patients with moderate to severe depression and determined the proportion of patients who had a substantial clinical response (defined as ≥50% decrease from baseline scores of Patient Health Questionnaire (PHQ) to measure depression) by the end of the study period.ResultsProviders experienced improved capability (enhanced self-efficacy and knowledge), greater opportunity (via access to counsellors, psychiatrist, medications and diagnostic tests) and increased motivation (developing positive attitudes towards people with mental illness and seeing patients improve) to provide mental healthcare. We observed substantial clinical response in 99 (49%; 95% CI: 42% to 56%) of the 201 cohort patients, with a median seven point (Q1:-9, Q3:-2) decrease in PHQ-9 scores (p<0.0001).ConclusionUsing the COM-B framework, we successfully adapted and implemented CoCM in rural Nepal, and found that it enhanced providers' positive perceptions of and engagement in delivering mental healthcare. We observed clinical improvement of depression comparable to controlled trials in high-resource settings. We recommend using implementation research to adapt and evaluate CoCM in other resource-constrained settings to help expand access to high-quality mental healthcare.

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Project description:BACKGROUND:In remote rural Tanzania, the rate of linkage into HIV care was estimated at 28% in 2014. This study explored facilitators and barriers to linkage to HIV care at individual/patient, health care provider, health system, and contextual levels to inform eventual design of interventions to improve linkage to HIV care. METHODS:We conducted a descriptive qualitative study nested in a cohort study of 1012 newly diagnosed HIV-positive individuals in Mbeya region between August 2014 and July 2015. We conducted 8 focus group discussions and 10 in-depth interviews with recently diagnosed HIV-positive individuals and 20 individual interviews with healthcare providers. Transcripts were analyzed inductively using thematic content analysis. The emergent themes were then deductively fitted into the four level ecological model. RESULTS:We identified multiple factors influencing linkage to care. HIV status disclosure, support from family/relatives and having symptoms of disease were reported to facilitate linkage at the individual level. Fear of stigma, lack of disclosure, denial and being asymptomatic, belief in witchcraft and spiritual beliefs were barriers identified at individual's level. At providers' level; support and good patient-staff relationship facilitated linkage, while negative attitudes and abusive language were reported barriers to successful linkage. Clear referral procedures and well-organized clinic procedures were system-level facilitators, whereas poorly organized clinic procedures and visit schedules, overcrowding, long waiting times and lack of resources were reported barriers. Distance and transport costs to HIV care centers were important contextual factors influencing linkage to care. CONCLUSION:Linkage to HIV care is an important step towards proper management of HIV. We found that access and linkage to care are influenced positively and negatively at all levels, however, the individual-level and health system-level factors were most prominent in this setting. Interventions must address issues around stigma, denial and inadequate awareness of the value of early linkage to care, and improve the capacity of HIV treatment/care clinics to implement quality care, particularly in light of adopting the 'Test and Treat' model of HIV treatment and care recommended by the World Health Organization.

Project description:INTRODUCTION:Addressing malnutrition is one of the key components of HIV care among people living with HIV. Since 2010, a nutritional program has been implemented to address malnutrition amongst HIV patients in Ethiopia, with patients enrolled in the program for 3 months (for mild acute malnutrition) and 6 months (for severe acute malnutrition). However, utilisation and effectiveness of the nutritional programs remain unexplored. This study aimed to examine individual level determinants and contextual factors influencing the effectiveness of the nutritional program in the Tigray region of Ethiopia. METHODS AND SETTING:The study employed a mixed-methods approach involving quantitative and qualitative research methods. In the quantitative phase of the study, records from 1757 adult patients, including socio-demographic characteristics, clinical and nutritional program outcomes were retrieved from three selected hospitals in the Tigray region, Ethiopia. Logistic regression analysis was used to identify the individual demographic and socioeconomic, clinical and immunological, and anthropometric and nutritional determinants of nutritional outcomes. The qualitative study included 33 individual interviews with adult patients, health providers, and program managers. Interview data were analysed using a framework analysis approach. RESULTS:Amongst study participants, 55.3% (95% CI = 53.2?57.4) recovered from malnutrition, 19% (95% CI, 17.3?20.7) did not complete the program, and 21% (95% CI = 19.7?23.4) completed the program but failed to recover from malnutrition. In the multivariable logistic regression analysis, those who were: living in urban areas (AOR = 1.44, 95% CI = 1.05?1.97), employed (AOR = 1.39, 95% CI = 1.01?1.93), attending Shul (AOR = 4.6, 95% CI = 3.15?6.71) and Lemlem Karl (AOR = 2.5, 95% CI = 1.69?3.71) hospitals, in clinical stages II (AOR = 2.49, 95% CI = 1.59?3.91) and III (AOR = 1.46(1.02?2.07), on ART for less than six months (AOR = 1.61, 95% CI = 1.09?2.39), anaemic (AOR = 1.77, 95% = 1.29?2.41), and diagnosed with severe acute malnutrition at enrolment (AOR = 6.43, 95% CI = 4.69?8.3); were less likely to complete the program. Results for those who completed the program indicated that urban residence, (AOR = 1.46, 95% CI = 1.4?2.91), attending Shul (AOR = 2.92, 95% CI = 2.04?4.19) and Lemlem Karl (AOR = 1.49, 95% CI 1.05?2.11) hospitals, having bedridden functional status (AOR = 0.36, 95% CI = 0.15?0.83), advanced WHO clinical stage (WHO clinical stage IV) (AOR = 0.52, 95% CI = 0.28?0.98) and severe malnutrition at enrolment (AOR = 4.25, 95% CI = 3.02?5.98)) predicted non-response to the nutritional program. Qualitative interviews revealed that the taste and perceived side effects of the nutritional supplement provided as part of the nutritional program, sharing/selling practices, religious and sociocultural issues, distance and poor access to the health services were barriers to program utilisation. Nutritional counselling and health service-related factors such as a previous enrolment in the program and positive experience in the health service were enablers of program utilisation. CONCLUSION:There was a clear nexus between contextual factors such as distance, quality of health service and sociocultural factors, and individual patient characteristics with the effectiveness of the nutritional program. Taking individual and contextual factors into consideration in program design, planning and implementation is essential if the nutritional program in HIV care services is to achieve its goal in addressing malnutrition amongst people living with HIV.

Dataset Information

Mixed-methods evaluation of a telehealth collaborative care program for persons with HIV infection in a rural setting.

Background

Objective

Design

Patients

Intervention

Measures

Key results

Publications

Mixed-methods evaluation of a telehealth collaborative care program for persons with HIV infection in a rural setting.

Similar Datasets

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