Effectiveness of educational outreach in infectious diseases management: a cluster randomized trial in Uganda

Feasibility of a multifaceted intervention to improve treatment initiation among patients diagnosed with TB using Xpert MTB/RIF testing in Uganda

BACKGROUND

One in five patients diagnosed with TB in Uganda are not initiated on TB treatment within two weeks of diagnosis. We evaluated a multifaceted intervention for improving TB treatment initiation among patients diagnosed with TB using Xpert® MTB/RIF testing in Uganda.

METHODS

This was a pre-post interventional study at one tertiary referral hospital. The intervention was informed by the COM-B model and included; i) medical education sessions to improve healthcare worker knowledge about the magnitude and consequences of pretreatment loss to follow-up; ii) modified laboratory request forms to improve recording of patient contact information; and iii) re-designed workflow processes to improve timeliness of sputum testing and results dissemination. TB diagnostic process and outcome data were collected and compared from the period before (June to August 2019) and after (October to December 2019) intervention initiation.

RESULTS

In September 2019, four CME sessions were held at the hospital and were attended by 58 healthcare workers. During the study period, 1242 patients were evaluated by Xpert® MTB/RIF testing at the hospital (679 pre and 557 post intervention). Median turnaround time for sputum test results improved from 12 hours (IQR 4-46) in the pre-intervention period to 4 hours (IQR 3-6) in the post-intervention period. The proportion of patients started on treatment within two weeks of diagnosis improved from 59% (40/68) to 89% (49/55) (difference 30%, 95% CI 14%-43%, p<0.01) while the proportion of patients receiving a same-day diagnosis increased from 7.4% (5/68) to 25% (14/55) (difference 17.6%, 95% CI 3.9%-32.7%, p<0.01).

CONCLUSION

The multifaceted intervention was feasible and resulted in a higher proportion of patients initiating TB treatment within two weeks of diagnosis.

Challenges influencing nurse-initiated management of antiretroviral therapy training and implementation in Ngaka Modiri Molema district, North West province

Background

The increasing number of people testing human immunodeficiency virus positive and who demand antiretroviral therapy (ART) prompted the Department of Health to adopt World Health Organization's task shifting where professional nurses (PNs) initiate ART rather than doctors. This resulted in decentralisation of services to primary healthcare (PHC), generating a need to capacitate PNs on nurse-initiated-management of ART (NIMART). The impact of NIMART was assessed and even though there was an increased number of patients on ART, the quality of care is of serious concern.

Aim

The aim of this study was to explore and describe the challenges influencing NIMART training and implementation amongst PNs and programme managers.

Setting

The study was conducted from the PHC facilities, in the rural districts of the North West province.

Methods

An exploratory programme evaluation and contextual research design was used in the study. Purposive sampling was used. Focus group discussion (n = 28) and individual interviews were used to collect data. Data was analysed using ATLAS.ti software.

Results

The results revealed two themes: inadequacy in NIMART training and the healthcare system challenges that influence NIMART training and implementation. Theme 1 included among others the lack of standardised curriculum and model or conceptual framework to strengthen NIMART training. And theme 2 included patient and district healthcare structural system.

Conclusion

There a need to improve NIMART training and implementation through the standardisation of NIMART curriculum, introduction of pre-service NIMART training in institutions of higher learning, addressing staff shortages and negative attitude of PNs providing ART.

Conceptual framework for strengthening nurse-initiated management of antiretroviral therapy training and implementation in North West province

BACKGROUND

The implementation of nurse-initiated management of antiretroviral therapy (NIMART) management training is a challenge in the primary health care (PHC). It is evident from the literature reviewed and the data obtained from the North West province that gaps still exist. There is no conceptual framework providing guidance to NIMART training and implementation.

AIM

Therefore, the aim of this study was to develop a conceptual framework to strengthen NIMART training and implementation in the North West province to improve patients and human immunodeficiency virus (HIV) programme outcomes.

SETTING

The study was conducted in the North West Province, South Africa.

METHODS

A pragmatic, explanatory, sequential, mixed-methods research design was followed. A descriptive and explorative programme evaluation design was used. Data were collected from two sources: antiretroviral therapy (ART) statistics from District Health Information System (DHIS) & Tier.net of 10 PHC facilities to evaluate and determine the impact of NIMART on the HIV programme and five focus group discussions conducted amongst 28 NIMART nurses and three HIV programme managers to describe challenges influencing NIMART training and implementation.

RESULTS

The study revealed that there was low ART initiation compared to the number of clients who tested HIV-positive. There was poor monitoring of patients on ART, which was evident in the low viral load collection and suppression, high loss to follow-up and deaths related to HIV. Challenges exist and this was confirmed by the qualitative findings, including human resource ratios, training and mentoring and the entire absence of a conceptual framework or model that guides training and implementation.

CONCLUSION

The study findings were conceptualised to describe and develop a framework needed to facilitate and influence NIMART training and implementation to improve the HIV programme and patient outcomes. Dickoff, James and Wiedenbach's practice-oriented theory and Donabedian's structure process outcomes model provided a starting point in the ultimate development of the framework. Although the study was limited to the North West province's PHC clinics and community health centres and did not include hospitals, it is of high significance as there is no such conceptual framework in the province or in even South Africa.

An educational intervention to update health workers about HIV and infant feeding

Clinical guidelines are used to translate research findings into evidence-based clinical practice but are frequently not comprehensively adopted by health workers (HWs). HIV and infant feeding guidelines were revised by the World Health Organization to align feeding advice for HIV-exposed and unexposed infants, and these were adopted in South Africa in 2017. We describe an innovative, team-based, mentoring programme developed to update HWs on these guidelines. The intervention was underpinned by strong theoretical frameworks and aimed to improve HWs' attitudes, knowledge, confidence, and skills about breastfeeding in the context of HIV. On-site workshops and clinical mentoring used interactive participatory methods and a simple low-tech approach, guided by participants' self-reported knowledge gaps. Workshops were conducted at 24 participating clinics over three sessions, each lasting 1-2 hr. Evaluation data were collected using a self-administered questionnaire. Of 303 participating HWs, 249/303 (82.2%) attended all workshops. Achieving high workshop attendance was challenging and "catch-up" sessions were required to achieve good coverage. Common knowledge gaps identified included antiretroviral therapy adherence monitoring during breastfeeding and management of viral load results (173 participants), management of breast conditions (79), and advice about expressing and storing breastmilk (64). Most participants reported all their knowledge gaps were addressed and anticipated that their practice would change. We describe a feasible, sustainable approach to updating HWs on HIV and infant feeding guidelines and improving skills in breastfeeding counselling in resource-constrained settings. This approach could be adapted to other topics and, with further evaluation, implemented at scale using existing resources.

How Effective are Mentoring Programs for Improving Health Worker Competence and Institutional Performance in Africa? A Systematic Review of Quantitative Evidence

Introduction

Mentoring programs are frequently recommended as innovative and low-cost solutions, and these have been implemented in many healthcare institutions to tackle multiple human resource-related challenges. This review sought to locate, appraise and describe the literature reporting on mentorship programs that were designed to improve healthcare worker competence and institutional performance in Africa.

Methods

This review searched and synthesized reports from studies that assessed the effectiveness of mentorship programs among healthcare workers in Africa. We searched for studies reported in the English language in EMBASE, CINAHL, COCHRANE and MEDLINE. Additional search was conducted in Google Scholar.

Results

We included 30 papers reporting on 24 studies. Diverse approaches of mentorship were reported: a) placing a mentor in health facility for a period of time (embedded mentor), b) visits by a mobile mentor, c) a mentoring approach involving a team of mobile multidisciplinary mentors, d) facility twinning, and e) within-facility mentorship by a focal person or a manager.

Implication for practice

Mentoring interventions were effective in improving the clinical management of infectious diseases, maternal, neonatal and childhood illnesses. Mentoring interventions were also found to improve managerial performance (accounting, human resources, monitoring and evaluation, and transportation management) of health institutions. Additionally, mentoring had improved laboratory accreditation scores. Mentoring interventions may be used to increase adherence of health professionals to guidelines, standards, and protocols. While different types of interventions (embedded mentoring, visits by mobile mentors, facility twinning and within-facility mentorship by a focal person) were reported to be effective, there is no evidence to recommend one model of mentoring over other types of mentoring.

Implications for research

Further research—experimental methods measuring the impact of different mentoring formats and longitudinal studies establishing their long-term effectiveness—is required to compare the effectiveness and cost-effectiveness of different models of mentoring. Further studies are needed to explore why and how different mentoring programs succeed and the meaningfulness of mentoring programs for the different stakeholders are also required.

Synergistic Impact of Training Followed by On-Site Support on HIV Clinical Practice: A Mixed-Design Study in Uganda With Pre/Post and Cluster-Randomized Trial Components

BACKGROUND

Task shifting can expand antiretroviral therapy access, but little is known about effective approaches to improve clinical practice among midlevel practitioners (MLPs) such as clinical officers, nurses, and midwives. The Integrated Infectious Diseases Capacity Building Evaluation compared training alone with training combined with on-site support (OSS).

METHODS

Two MLPs each from 36 health facilities attended the 5-week Integrated Management of Infectious Disease training. After training, 18 facilities randomly assigned to arm A received OSS for 9 months, whereas 18 arm B facilities did not. Clinical faculty assessed MLP HIV clinical practice on 6 tasks: history taking, physical examination, laboratory investigations, diagnosis, treatment, and patient education. We analyzed the effect of training alone and training combined with OSS as the pre/post change within each arm. We analyzed the incremental effect of OSS with a difference-in-difference analysis that compared changes between arms.

RESULTS

Training alone and training combined with OSS significantly improved clinical practice in patient history taking (13% and 24% increase, respectively), physical examination (54% and 71%), laboratory investigations (32% and 20%), and diagnosis (31% and 51%). Combined training and OSS also improved patient education significantly (72% increase). Effect sizes for training combined with OSS were larger than for training alone except for laboratory investigations, and the effects were robust in sensitivity analyses. The incremental effect of OSS on diagnosis was significant [adjusted relative risk = 1.23; 95% confidence interval = 1.00 to 1.50].

CONCLUSIONS

Combined training and OSS improved MLP HIV clinical practice over training alone and can contribute to continued expansion of access to antiretroviral therapy.