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Tipping the balance towards long-term retention in the HIV care cascade: A mixed methods study in southern Mozambique.

ABSTRACT: BACKGROUND:The implementation of quality HIV control programs is crucial for the achievement of the UNAIDS 90-90-90 targets and to motivate people living with HIV (PLWHIV) to link and remain in HIV-care. The aim of this mixed method cross-sectional study was to estimate the linkage and long-term retention in care of PLWHIV and to identify factors potentially interfering along the HIV-care continuum in southern Mozambique. METHODS:A home-based semi-structured interview was conducted in 2015 to explore barriers and facilitators to the HIV-care cascade among individuals that had been newly HIV-diagnosed in community testing campaigns in 2010 or 2012. Linkage and long-term retention were estimated retrospectively through client self-reports and clinical records. Cohen's Kappa coefficient was calculated to measure the agreement between participant self-reported and documented cascade outcomes. RESULTS:Among the 112 interviewed participants, 24 (21.4%) did not disclose their HIV-positive serostatus to the interviewer. While 84 (75.0%) self-reported having enrolled in care, only 69 (61.6%) reported still being in-care 3-5 years after diagnosis of which 17.4% reported having disengaged and re-engaged. An important factor affecting optimal continuum in HIV-care was the impact of the fear-based authoritarian relationship between the health system and the patient that could act as both driver and barrier. CONCLUSION:Special attention should be given to quantify and understand repeated cycles of patient disengagement and re-engagement in HIV-care. Strategies to improve the relationship between the health system and patients are still needed in order to optimally engage PLWHIV for long-term periods.

SUBMITTER: Fuente-Soro L

PROVIDER: S-EPMC6764678 | biostudies-literature | 2019

REPOSITORIES: biostudies-literature

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Tipping the balance towards long-term retention in the HIV care cascade: A mixed methods study in southern Mozambique.

Fuente-Soro Laura L Iniesta Carlos C López-Varela Elisa E Cuna Mauro M Guilaze Rui R Maixenchs Maria M Bernardo Edson Luis EL Augusto Orvalho O Gonzalez Raquel R Couto Aleny A Munguambe Khatia K Naniche Denise D

PloS one 20190927 9

<h4>Background</h4>The implementation of quality HIV control programs is crucial for the achievement of the UNAIDS 90-90-90 targets and to motivate people living with HIV (PLWHIV) to link and remain in HIV-care. The aim of this mixed method cross-sectional study was to estimate the linkage and long-term retention in care of PLWHIV and to identify factors potentially interfering along the HIV-care continuum in southern Mozambique.<h4>Methods</h4>A home-based semi-structured interview was conducte ...[more]

PMID: 31560689

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Project description:IntroductionAlthough the sustainability of the health workforce has been identified as essential to achieving health and wider development objectives, challenges with securing and retaining the healthcare workforce persist. In the UK, there are notable shortages across a wide range of National Health Service (NHS) staff groups, with a high staff turnover indicating retention issues in the healthcare workforce. In addition, gaps exist in understanding the root cause of individual organisation's workforce deficiencies and how their practice environment factors interact to impact workforce recruitment and retention.Methods and analysisAn exploratory mixed-methods approach will be conducted to investigate the impact of organisational practice environment factors on healthcare workforce recruitment and retention in two Integrated Care Systems (ICS) in the East of England. We will conduct an online survey of newly qualified and established nurses and allied health professionals using a questionnaire adapted from two validated instruments. Our calculation suggests a sample size of 373 participants, we will aim to surpass this in our recruitment to strengthen the statistical analyses. Multilevel linear regression models will be fitted to evaluate the association between organisational practice environmental factors and staff recruitment and retention. The qualitative interviews will explore the experiences and perspectives of staff and senior leaders to explain the survey results and any significant associations therein. Also, the interviews will explore how to strengthen the partnership between higher education institutions, Health Education England, health and care service providers, NHS nursing and allied health professional staff to enhance recruiting and retaining staff. An exploratory inductive coding and analysis will follow Braun and Clarke's recommendations to generate key themes from transcribed interview data.Ethics and disseminationEthical approval has been obtained through the University of Suffolk Research Ethics Committee (approval number: RETH(S)22/051). Findings from our work will be disseminated through publications in peer-reviewed journals; presentations at stakeholders' events, professional and academic conferences; and short reports for stakeholders, including participating ICSs.

Project description:BackgroundMinimally invasive tissue sampling (MITS), also named minimally invasive autopsy is a post-mortem method shown to be an acceptable proxy of the complete diagnostic autopsy. MITS improves the knowledge of causes of death (CoD) in resource-limited settings. Its implementation requires understanding the components of acceptability, including facilitators and barriers in real-case scenarios.MethodsWe undertook a mixed-methods analysis comparing anticipated (hypothetical scenario) and experienced (real-case scenario) acceptability of MITS among relatives of deceased children in Mozambique. Anticipated acceptability information was obtained from 15 interviews with relatives of deceased children. The interview focus was on whether and why they would allow the procedure on their dead child in a hypothetical scenario. Experienced acceptability data were obtained from outcomes of consent requested to relatives of 114 deceased children during MITS implementation, recorded through observations, clinical records abstraction and follow-up informal conversations with health care professionals and semi-structured interviews with relatives.ResultsNinety-three percent of relatives indicated that they would hypothetically accept MITS on their deceased child. A key reason was knowing the CoD to take preventive actions; whereas the need to conform with the norm of immediate child burial, the secrecy of perinatal deaths, the decision-making complexity, the misalignment between MITS' purpose and traditional values, lack of a credible reason to investigate CoD, and the impotency to resuscitate the deceased were identified as potential points of hesitancy for acceptance. The only refusing respondent linked MITS to a perception that sharing results would constitute a breach of confidentiality and the lack of value attached to CoD determination. Experienced acceptability revealed four different components: actual acceptance, health professionals' hesitancy, relatives' hesitancy and actual refusal, which resulted in 82% of approached relatives to agree with MITS and 79% of cases to undergo MITS. Barriers to acceptability included, among others, health professionals' and facilities' unpreparedness to perform MITS, the threat of not burying the child immediately, financial burden of delays, decision-making complexities and misalignment of MITS' objectives with family values.ConclusionsMITS showed high anticipated and experienced acceptability driven by the opportunity to prevent further deaths. Anticipated acceptability identified secrecy, confidentiality and complex decision-making processes as barriers, while experienced acceptability revealed family- and health facility-level logistics and practical aspects as barriers. Health-system and logistical impediments must also be considered before MITS implementation. Additionally, the multiple components of acceptability must be taken into account to make it more consistent and transferrable.

Project description:BackgroundIn 2009 health insurers AOK and Bosch BKK introduced the "FacharztProgramm Kardiologie" - a program for coordinated ambulatory cardiology care in the German state of Baden-Württemberg. It aims for efficient, medical guideline-oriented cardiology care to reduce avoidable hospitalizations as well as costs of care. A high number of cardiologists participate and the program has served as blueprint for programs in other medical fields. With many prerequisites and conditions involved, its implementation cannot be expected to be self-directed. Still, only little data on the actual implementation exists. We aimed to determine to what extent medical specialists and cooperating general practitioners implemented the program, which components they adapted, and which contextual factors they deemed relevant.MethodsWe collected data from primary care practices of medical specialists and general practitioners within Baden-Württemberg. Qualitative data was obtained through structured telephone interviews with participating and non-participating medical specialists as well as general practitioners cooperating with the program and general practitioners not cooperating. Interviews were analyzed through content-structuring qualitative content analyses via MAXQDA. Quantitative data was obtained using anonymous written questionnaires completed by participating and non-participating medical specialists as well as general practitioners cooperating with the program. Analyses were performed using SPSS Statistics, mainly with regard to differences within and between groups of physicians.ResultsMost components of the program regarding medical care were well implemented. However, access to medical care was not completely as intended due to high numbers of patients participating in the program and prioritization by physicians. Procedures for communication and cooperation between medical specialists and general practitioners were only partially adhered to and standardized communication was not implemented. A range of regional and practice-related contextual factors influenced implementation and outcomes.ConclusionsImplementation of this program was mixed. Contextual factors posed individual challenges to participating physicians which can't be captured by an encompassing program. Both control mechanisms and tailoring of the program to medical care seem needed.Trial registrationThough not a clinical study, we deemed registration appropriate to ensure transparency. The study has been registered as a non-interventional observation study at the German Clinical Trials Register under ID: DRKS00013070.

Project description:IntroductionGirl child, early and forced marriage (CEFM) persists in South Asia, with long-term consequences for girls. CARE's Tipping Point Initiative (TPI) addresses the causes of CEFM by challenging repressive gender norms and inequalities. The TPI engages different participant groups on programmatic topics and supports community dialogue to build girls' agency, shift inequitable power relations, and change community norms sustaining CEFM.Methods/analysisThe Nepal TPI impact evaluation has an integrated, mixed-methods design. The quantitative evaluation is a three-arm, cluster randomised controlled trial (control; Tipping Point Programme (TPP); TPP+ with emphasised social norms change). Fifty-four clusters of ~200 households were selected from two districts (27:27) with probability proportional to size and randomised. A household census ascertained eligible study participants, including unmarried girls and boys 12-16 years (1242:1242) and women and men 25+ years (270:270). Baseline participation was 1134 girls, 1154 boys, 270 women and 270 men. Questionnaires covered agency; social networks/norms; and discrimination/violence. Thirty in-depth interviews, 8 key-informant interviews and 32 focus group discussions were held across eight TPP/TPP+ clusters. Guides covered gender roles/aspirations; marriage decisions; girls' safety/mobility; collective action; perceived shifts in child marriage; and norms about girls. Monitoring involves qualitative interviews, focus groups and session/event observations over two visits. Qualitative analyses follow a modified grounded theory approach. Quantitative analyses apply intention to treat, regression-based difference-in-difference strategies to assess impacts on primary (married, marriage hazard) and secondary outcomes, targeted endline tracing and regression-based methods to address potential selection bias.Ethics/disseminationThe Nepal Social Welfare Council approved CARE Nepal to operate in the study districts. Emory (IRB00109419) and the Nepal Health Research Council (161-2019) approved the study. We follow UNICEF and CARE guidelines for ethical research involving children and gender-based violence. Study materials are here or available on request. We will share findings through clinicaltrials.gov, CARE reports/briefs and publications.Trial registration numberNCT04015856.

Project description:BACKGROUND:Adverse events (AE) resulting from voluntary medical male circumcision (VMMC) are commonly used to measure program quality. Mozambique's VMMC program data reports a combined moderate and severe AE rate of 0.2% through passive surveillance. With active surveillance, similar programs report AE rates ranging from 1.0 to 17.0%. The objective of this activity was to assess potential underreporting of AEs via the passive surveillance system in Mozambique. METHODS:This mixed-methods assessment randomly selected one third (16) of all 46 VMMC clinics through stratified sampling, based on volume. A retrospective record review was conducted including patient clinical files, stock records of Amoxicillin/Clavulanic Acid (the choice antibiotic for VMMC-related infections), and clinic-level AE rates from the national database. Records from the month of April 21 to May 20, 2017 were analyzed to identify both reported and potentially unreported AEs. In addition, external, expert clinicians observed post-operative visits (n = 167). Descriptive statistics were calculated, including difference between reported and identified AEs, an adjusted retrospective AE rate, and an observed prospective AE rate in each clinic. RESULTS:A total of 5352 circumcisions were performed in the 16 clinics: 8 (0.15%) AEs were reported. Retrospective clinical record reviews identified 36 AEs (0.67%); AE severity or type was unknown. Using Amoxicillin/Clavulanic Acid dispensation as a proxy for VMMC-related infections, 39 additional AEs infections were identified, resulting in an adjusted AE rate of 1.4%, an 8.3 fold increase from the reported AE rate. Prospective, post-operative visit observations of 167 clients found 10 AEs (5.9%); infection was common and boys 10-14 years old represented 80% of AE clients. CONCLUSIONS:Evidence suggests underreporting of AEs in the Mozambican VMMC program. Quality improvement efforts should be implemented in all VMMC sites to improve AE identification, documentation and prevention efforts.

Dataset Information

Tipping the balance towards long-term retention in the HIV care cascade: A mixed methods study in southern Mozambique.

Publications

Tipping the balance towards long-term retention in the HIV care cascade: A mixed methods study in southern Mozambique.

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