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Patient and nurse perspectives of a nurse-led community-based model of HIV care delivery in Malawi: a qualitative study.

ABSTRACT: BACKGROUND:Differentiated models of care (DMOC) are used to make antiretroviral therapy (ART) accessible to people living with HIV (PLHIV). In Malawi, Lighthouse Trust has piloted various DMOCs aimed at providing quality care while reducing personal and logistical barriers when accessing clinic-based healthcare. One of the approaches was community-based provision of ART by nurses to stable patients. METHODS:To explore how the nurse-led community ART programme (NCAP) is perceived, we interviewed eighteen purposively selected patients receiving ART through NCAP and the four nurses providing the community-based health care. Information obtained from them was complemented with observations by the study team. Interviews were recorded and transcribed. Data was analysed using manual coding and thematic analysis. RESULTS:Through the NCAP, patients were able to save money on transportation and the time it took them to travel to a health facility. Caseloads and waiting times were also reduced, which made patients more comfortable and gave nurses the time to conduct thorough consultations. Closer relationships were built between patients and care providers, creating a space for more open conversations (although this required care providers to set clear boundaries and stick to schedule). Patients' nutritional needs and concerns related to stigma remain a concern, while operational issues affect the quality of the services provided in the community. Considerations for community-led healthcare programmes include the provision of transportation for care providers; the physical structure of community sites (in regard to private spaces); the timely consolidation of data collected in the field to a central database; and the need for care providers to cover multiple facility-based staff roles. CONCLUSIONS:The patients interviewed in this study preferred the NCAP approach to the facility-based model of care because it saved them money on transport, reduced waiting-times, and allowed for a more thorough consultation, while continuing to provide quality HIV care. However, when considering a community-level DMOC approach, certain factors - including staff transportation and workload - must be taken into consideration and purposefully planned.

SUBMITTER: Sande O

PROVIDER: S-EPMC7227037 | biostudies-literature | 2020 May

REPOSITORIES: biostudies-literature

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Patient and nurse perspectives of a nurse-led community-based model of HIV care delivery in Malawi: a qualitative study.

Sande Odala O Burtscher Doris D Kathumba Daneck D Tweya Hannock H Phiri Sam S Gugsa Salem S

BMC public health 20200514 1

<h4>Background</h4>Differentiated models of care (DMOC) are used to make antiretroviral therapy (ART) accessible to people living with HIV (PLHIV). In Malawi, Lighthouse Trust has piloted various DMOCs aimed at providing quality care while reducing personal and logistical barriers when accessing clinic-based healthcare. One of the approaches was community-based provision of ART by nurses to stable patients.<h4>Methods</h4>To explore how the nurse-led community ART programme (NCAP) is perceived, ...[more]

PMID: 32410597

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Project description:BackgroundUndiagnosed HIV infection remains substantial in key population subgroups including adolescents, older adults, and men, driving ongoing transmission in sub-Saharan Africa. We evaluated the impact, safety, and costs of community-led delivery of HIV self-testing (HIVST), aiming to increase HIV testing in underserved subgroups and stimulate demand for antiretroviral therapy (ART).Methods and findingsThis cluster-randomised trial, conducted between October 2018 and July 2019, used restricted randomisation (1:1) to allocate 30 group village head clusters in Mangochi district, Malawi to the community-led HIVST intervention in addition to the standard of care (SOC) or the SOC alone. The intervention involved mobilising community health groups to lead the design and implementation of 7-day HIVST campaigns, with cluster residents (≥15 years) eligible for HIVST. The primary outcome compared lifetime HIV testing among adolescents (15 to 19 years) between arms. Secondary outcomes compared: recent HIV testing (in the last 3 months) among older adults (≥40 years) and men; cumulative 6-month incidence of ART initiation per 100,000 population; knowledge of the preventive benefits of HIV treatment; and HIV testing stigma. Outcomes were measured through a post-intervention survey and at neighboring health facilities. Analysis used intention-to-treat for cluster-level outcomes. Community health groups delivered 24,316 oral fluid-based HIVST kits. The survey included 90.2% (3,960/4,388) of listed participants in the 15 community-led HIVST clusters and 89.2% (3,920/4,394) of listed participants in the 15 SOC clusters. Overall, the proportion of men was 39.0% (3,072/7,880). Most participants obtained primary-level education or below, were married, and reported a sexual partner. Lifetime HIV testing among adolescents was higher in the community-led HIVST arm (84.6%, 770/910) than the SOC arm (67.1%, 582/867; adjusted risk difference [RD] 15.2%, 95% CI 7.5% to 22.9%; p < 0.001), especially among 15 to 17 year olds and boys. Recent testing among older adults was also higher in the community-led HIVST arm (74.5%, 869/1,166) than the SOC arm (31.5%, 350/1,111; adjusted RD 42.1%, 95% CI 34.9% to 49.4%; p < 0.001). Similarly, the proportions of recently tested men were 74.6% (1,177/1,577) and 33.9% (507/1,495) in the community-led HIVST and SOC arms, respectively (adjusted RD 40.2%, 95% CI 32.9% to 47.4%; p < 0.001). Knowledge of HIV treatment benefits and HIV testing stigma showed no differences between arms. Cumulative incidence of ART initiation was respectively 305.3 and 226.1 per 100,000 population in the community-led HIVST and SOC arms (RD 72.3, 95% CI -36.2 to 180.8; p = 0.18). In post hoc analysis, ART initiations in the 3-month post-intervention period were higher in the community-led HIVST arm than the SOC arm (RD 97.7, 95% CI 33.4 to 162.1; p = 0.004). HIVST uptake was 74.7% (2,956/3,960), with few adverse events (0.6%, 18/2,955) and at US$5.70 per HIVST kit distributed. The main limitations include the use of self-reported HIV testing outcomes and lack of baseline measurement for the primary outcome.ConclusionsIn this study, we found that community-led HIVST was effective, safe, and affordable, with population impact and coverage rapidly realised at low cost. This approach could enable community HIV testing in high HIV prevalence settings and demonstrates potential for economies of scale and scope.Trial registrationClinicaltrials.gov NCT03541382.

Project description:Background. A culture of stringent drug policy, one-size-fits-all treatment approaches, and drug-related stigma has clouded clinical HIV practice in the United States. The result is a series of missed opportunities in the HIV care environment. An approach which may address the broken relationship between patient and provider is harm reduction-which removes judgment and operates at the patient's stage of readiness. Harm reduction is not a routine part of care; rather, it exists outside clinic walls, exacerbating the divide between compassionate, stigma-free services and the medical system. Methods. Qualitative, phenomenological, semi-structured, individual interviews with patients and providers were conducted in three publicly-funded clinics in Chicago, located in areas of high HIV prevalence and drug use and serving African-American patients (N = 38). A deductive thematic analysis guided the process, including: the creation of an index code list, transcription and verification of interviews, manual coding, notation of emerging themes and refinement of code definitions, two more rounds of coding within AtlasTi, calculation of Cohen's Kappa for interrater reliability, queries of major codes and analysis of additional common themes. Results. Thematic analysis of findings indicated that the majority of patients felt receptive to harm reduction interventions (safer injection counseling, safer stimulant use counseling, overdose prevention information, supply provision) from their provider, and expressed anticipated gratitude for harm reduction information and/or supplies within the HIV care visit, although some were reluctant to talk openly about their drug use. Provider results were mixed, with more receptivity reported by advanced practice nurses, and more barriers cited by physicians. Notable barriers included: role-perceptions, limited time, inadequate training, and the patients themselves. Discussion. Patients are willing to receive harm reduction interventions from their HIV care providers, while provider receptiveness is mixed. The findings reveal critical implications for diffusion of harm reduction into HIV care, including the need to address cited barriers for both patients and providers to ensure feasibility of implementation. Strategies to address these barriers are discussed, and recommendations for further research are also shared.

Project description:BackgroundSwitzerland, with its decentralized health system, has seen the emergence of a variety of care models to meet the complex needs of asylum seekers. A network of public and private providers was designed in the canton Vaud, in which a nurse-led team acts as a first contact point to the health system and provides health checks, preventive care, and health education to this population. In addition, the service plays a case management role for more complex and vulnerable patients. While the network has been examined from a clinical angle, we provide the first descriptive evidence on the care and cost trajectories of asylum seekers in the canton.MethodsWe used routinely collected administrative, patient-level data in a Swiss region responsible for 10% of the asylum seekers in the country. We extracted data on all asylum seekers aged 18 or older who entered the network between 2012 and 2015. The data covered all healthcare costs during the period until they left the network, either because they were granted residence, they left the country, or until 31 December 2018. We estimated random effects regression models for costs and consultations within and outside the network for each month of stay in the network. We investigated language barriers in access to care by stratifying the analysis between patients who spoke one of the official Swiss languages or English and patients who did not speak any of these languages.Principal findingsWe found that both overall health care costs and contacts with the nurse-led team were relatively high during the first year of stay. Asylum seekers then progressively integrated into the regular health system. Individuals who did not speak the language generally had more contacts with the network and fewer contacts outside.ConclusionsIn this exploratory study, we observe a transition from nurse-led specific care with frequent contacts to care in the regular health system. This leads us to generate the hypothesis that a nurse-led, patient-centered care network for asylum seekers can play an important role in providing primary care during the first year after their arrival and can subsequently help them navigate autonomously within the conventional healthcare system.

Project description:BACKGROUND:Prevention of new HIV infections is a critical public health issue. The highest HIV testing gaps are in men, adolescents 15-19?years old, and adults 40?years and older. Community-based HIV testing services (HTS) can contribute to increased testing coverage and early HIV diagnosis, with HIV self-testing (HIVST) strategies showing promise. Community-based strategies, however, are resource intensive, costly and not widely implemented. A community-led approach to health interventions involves supporting communities to plan and implement solutions to improve their health. This trial aims to determine if community-led delivery of HIVST can improve HIV testing uptake, ART initiation, and broader social outcomes in rural Malawi. METHODS:The trial uses a parallel arm, cluster-randomised design with group village heads (GVH) and their defined catchment areas randomised (1:1) to community-led HIVST or continue with the standard of the care (SOC). As part of the intervention, informal community health cadres are supported to plan and implement a seven-day HIVST campaign linked to HIV treatment and prevention. Approximately 12?months after the initial campaign, intervention GVHs are randomised to lead a repeat HIVST campaign. The primary outcome includes the proportion of adolescents 15-19?years old who have tested for HIV in their lifetime. Secondary outcomes include recent testing in adults 40?years and older and men; ART initiation; knowledge of HIV prevention; and HIV testing stigma. Outcomes will be measured through cross-sectional surveys and clinic registers. Economic evaluation will determine the cost per person tested, cost per person diagnosed, and incremental cost effectiveness ratio. DISCUSSION:To the best of our knowledge, this is the first trial to assess the effectiveness of community-led HTS, which has only recently been enabled by the introduction of HIVST. Community-led delivery of HIVST is a promising new strategy for providing periodic HIV testing to support HIV prevention in rural communities. Further, introduction of HIVST through a community-led framework seems particularly apt, with control over healthcare concurrently devolved to individuals and communities. TRIAL REGISTRATION:Clinicaltrials.gov registry ( NCT03541382 ) registered 30 May 2018.

Project description:BackgroundPerinatal care nurses are well positioned to provide the education and support new fathers need to navigate the transition to fatherhood and to encourage positive father involvement from the earliest hours of a child's life. To effectively serve fathers in perinatal settings, it is important to understand the attitudes, beliefs, and behaviors of healthcare providers that may encourage and engage them, or alternatively alienate and discourage them.MethodsThis qualitative study involved structured interviews with ten NICU and postpartum nurses from hospitals in two large Texas cities. The interview protocol was designed to elicit descriptive information about nurses' attitudes and beliefs, sense of efficacy and intention for working with fathers, as well as their father-directed behaviors. Nurses were recruited for the study using a purposive sampling approach. Interviews were conducted by telephone and lasted approximately 25 to 35 min. Data were analyzed using a qualitative descriptive approach.ResultsOverall, study participants held very positive subjective attitudes toward fathers and father involvement. Nevertheless, many of the nurses signaled normative beliefs based on race/ethnicity, gender, and culture that may moderate their intention to engage with fathers. Participants also indicated that their education as well as the culture of perinatal healthcare are focused almost entirely on the mother-baby dyad. In line with this focus on mothers, participants comments reflected a normative belief that fathers are secondary caregivers to their newborns, there to help when the mother is unavailable.ConclusionsNurse attitudes and practices that place mothers in the role of primary caregiver may be interpreted by fathers as excluding or disregarding them. Further research is needed to validate the results of this small-scale study, and to assess whether and how provider attitudes impact their practices in educating and engaging fathers in newborn care.

Dataset Information

Patient and nurse perspectives of a nurse-led community-based model of HIV care delivery in Malawi: a qualitative study.

Publications

Patient and nurse perspectives of a nurse-led community-based model of HIV care delivery in Malawi: a qualitative study.

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