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Beres LK, Mwamba C, Bolton-Moore C, Kennedy CE, Simbeza S, Topp SM, Sikombe K, Mukamba N, Mody A, Schwartz SR, Geng E, Holmes CB, Sikazwe I, Denison JA. Trajectories of re-engagement: factors and mechanisms enabling patient return to HIV care in Zambia. J Int AIDS Soc 2023; 26:e26067. [PMID: 36840391 PMCID: PMC9958345 DOI: 10.1002/jia2.26067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 01/31/2023] [Indexed: 02/26/2023] Open
Abstract
INTRODUCTION While disengagement from HIV care threatens the health of persons living with HIV (PLWH) and incidence-reduction targets, re-engagement is a critical step towards positive outcomes. Studies that establish a deeper understanding of successful return to clinical care among previously disengaged PLWH and the factors supporting re-engagement are essential to facilitate long-term care continuity. METHODS We conducted narrative, patient-centred, in-depth interviews between January and June 2019 with 20 PLWH in Lusaka, Zambia, who had disengaged and then re-engaged in HIV care, identified through electronic medical records (EMRs). We applied narrative analysis techniques, and deductive and inductive thematic analysis to identify engagement patterns and enablers of return. RESULTS We inductively identified five trajectories of care engagement, suggesting patterns in patient characteristics, experienced barriers and return facilitators that may aid intervention targeting including: (1) intermittent engagement;(2) mostly engaged; (3) delayed linkage after testing; (4) needs time to initiate antiretroviral therapy (ART); and (5) re-engagement with ART initiation. Patient-identified periods of disengagement from care did not always align with care gaps indicated in the EMR. Key, interactive re-engagement facilitators experienced by participants, with varied importance across trajectories, included a desire for physical wellness and social support manifested through verbal encouragement, facility outreach or personal facility connections and family instrumental support. The mechanisms through which facilitators led to return were: (1) the promising of living out one's life priorities; (2) feeling valued; (3) fostering interpersonal accountability; (4) re-entry navigation support; (5) facilitated care and treatment access; and (6) management of significant barriers, such as depression. CONCLUSIONS While preliminary, the identified trajectories may guide interventions to support re-engagement, such as offering flexible ART access to patients with intermittent engagement patterns instead of stable patients only. Further, for re-engagement interventions to achieve impact, they must activate mechanisms underlying re-engagement behaviours. For example, facility outreach that reminds a patient to return to care but does not affirm a patient's value or navigate re-entry is unlikely to be effective. The demonstrated importance of positive health facility connections reinforces a growing call for patient-centred care. Additionally, interventions should consider the important role communities play in fostering treatment motivation and overcoming practical barriers.
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Affiliation(s)
- Laura K Beres
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Chanda Mwamba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Carolyn Bolton-Moore
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Department of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Caitlin E Kennedy
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sandra Simbeza
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Stephanie M Topp
- College of Public Health Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia
| | - Kombatende Sikombe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Department of Public Health Environments and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Njekwa Mukamba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Aaloke Mody
- University of Washington St. Louis, St. Louis, Missouri, USA
| | - Sheree R Schwartz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Elvin Geng
- University of Washington St. Louis, St. Louis, Missouri, USA
| | - Charles B Holmes
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Georgetown University, Washington, DC, USA
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Julie A Denison
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Nurash P, Kasevayuth K, Intarakamhang U. Learning programmes and teaching techniques to enhance oral health literacy or patient-centred communication for healthcare providers: A systematic review. Eur J Dent Educ 2020; 24:134-144. [PMID: 31675468 DOI: 10.1111/eje.12477] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 10/07/2019] [Accepted: 10/30/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To investigate the learning programmes and teaching techniques used in interventions to enhance oral health literacy (OHL) or patient-centred communication (PCC) for healthcare providers. MATERIALS AND METHODS A systematic review of OHL and PCC were obtained from four electronic databases (PubMed, ScienceDirect, ProQuest and Scopus) was undertaken. These searches covered the period from January 2008 to December 2017. The quality assessment tool was the Joanna Briggs Institute Critical Appraisal tool for systematic reviews of effectiveness. RESULTS The final review included nine studies amongst a total of 1475 studies. They showed three learning programmes (workshops, training and community-based rotation) and 17 related teaching techniques to promote OHL and PCC. The most commonly used learning programmes to enhance OHL and PCC for healthcare providers were workshops, and the teaching techniques included feedback and reflection. The intervention periods of the programmes took 20 minutes to half a day. The three studies did not have a follow-up, whilst the rest showed a follow-up range of 2 months to 3 years. Interestingly, there was one study, which applied double follow-ups to show the effectiveness of the programme. CONCLUSION Either workshops or training programmes with a combination of teaching techniques were effective in terms of enhancing their OHL or PCC. The more frequent follow-up might increase the long-term effectiveness of the learning programme.
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Affiliation(s)
- Pariyawit Nurash
- Behavioral Science Research Institute, Srinakharinwirot University, Bangkok, Thailand
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Waweru E, Sarkar NDP, Ssengooba F, Gruénais ME, Broerse J, Criel B. Stakeholder perceptions on patient-centered care at primary health care level in rural eastern Uganda: A qualitative inquiry. PLoS One 2019; 14:e0221649. [PMID: 31461495 PMCID: PMC6713356 DOI: 10.1371/journal.pone.0221649] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 08/12/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Patient-centered care (PCC) offers opportunities for African health systems to improve quality of care. Nonetheless, PCC continually faces implementation challenges. In 2015, Uganda introduced PCC as a concept in their national quality improvement guidelines. In order to investigate whether and how this is implemented in practice, this study aims to identify relevant stakeholders' views on the current quality of primary health care services and their understanding of PCC. This is an important step in understanding how the concept of PCC can be implemented in a resource constrained, sub-Saharan context like Uganda. METHODS This qualitative study was conducted in Uganda at national, district and facility level, with a focus on three public and three private health centres. Data collection consisted of in-depth interviews (n = 49); focus group discussions (n = 7); and feedback meetings (n = 14) across the four main categories of stakeholders identified: patients/communities, health workers, policy makers and academia. Interviews and discussions explored stakeholder perceptions on the interpersonal aspects of quality primary health care and meanings attached to the concept of PCC. A content analysis of Ugandan policy documents mentioning PCC was also conducted. Thematic content analysis was conducted using NVivo 11 to organize and analyze the data. FINDINGS AND CONCLUSION While Ugandan stakeholder groups have varying perceptions of PCC, they agree on the following: the need to involve patients in making decisions about their health, the key role of healthcare workers in that endeavor, and the importance of context in designing and implementing solutions. For that purpose, three avenues are recommended: Firstly, fora that include a wide range of stakeholders may offer a powerful opportunity to gain an inclusive vision on PCC in Uganda. Secondly, efforts need to be made to ensure that improved communication and information sharing-important components of PCC-translate to actual shared decision making. Lastly, the Ugandan health system needs to strengthen its engagement of the transformation from a community health worker system to a more comprehensive community health system. Cross-cutting the entire analysis, is the need to address, in a culturally-sensitive way, the many structural barriers in designing and implementing PCC policies. This is essential in ensuring the sustainable and effective implementation of PCC approaches in low- and middle-income contexts.
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Affiliation(s)
- Everlyn Waweru
- Department of Public Health–Health Systems and Equity unit, Institute of Tropical Medicine, Antwerp, Belgium
- Department of Public Health–Quality of Care, Athena Institute, Faculty of Science, Vrije University, Amsterdam, Netherlands
- Faculty of Social Anthropology and Ethnology, University of Bordeaux, Bordeaux, France
| | - Nandini D. P. Sarkar
- Department of Public Health–Health Systems and Equity unit, Institute of Tropical Medicine, Antwerp, Belgium
- Department of Public Health–Quality of Care, Athena Institute, Faculty of Science, Vrije University, Amsterdam, Netherlands
- ISGlobal, Hospital Clinic—University of Barcelona, Barcelona, Spain
| | - Freddie Ssengooba
- Department of Health Policy Planning & Management, Makerere University College of Health Sciences, Kampala, Uganda
| | - Marc- Eric Gruénais
- Faculty of Social Anthropology and Ethnology, University of Bordeaux, Bordeaux, France
| | - Jacqueline Broerse
- Department of Public Health–Quality of Care, Athena Institute, Faculty of Science, Vrije University, Amsterdam, Netherlands
| | - Bart Criel
- Department of Public Health–Health Systems and Equity unit, Institute of Tropical Medicine, Antwerp, Belgium
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Mpimbaza A, Nayiga S, Ndeezi G, Rosenthal PJ, Karamagi C, Katahoire A. Understanding the context of delays in seeking appropriate care for children with symptoms of severe malaria in Uganda. PLoS One 2019; 14:e0217262. [PMID: 31166968 PMCID: PMC6550380 DOI: 10.1371/journal.pone.0217262] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 05/08/2019] [Indexed: 12/02/2022] Open
Abstract
Introduction A large proportion of children with uncomplicated malaria receive appropriate treatment late, contributing to progression of illness to severe disease. We explored contexts of caregiver delays in seeking appropriate care for children with severe malaria. Methods This qualitative study was conducted at the Children’s Ward of Jinja Hospital, where children with severe malaria were hospitalized. A total of 22in-depth interviews were conducted with caregivers of children hospitalized with severe malaria. Issues explored were formulated based on the Partners for Applied Social Sciences (PASS) model, focusing on facilitators and barriersto caregivers’promptseeking and accessing ofappropriate care. The data were coded deductively using ATLAS.ti (version 7.5). Codes were then grouped into families based on emerging themes. Results Caregivers’ rating of initial symptoms as mild illness lead to delays in response. Use of home initiated interventions with presumably ineffective herbs or medicines was common, leading to further delay. When care was sought outside the home, drug shops were preferred over public health facilities for reasons of convenience. Drug shops often provided sub-optimal care, and thus contributed to delays in access to appropriate care. Public facilities were often a last resort when illness was perceived to be progressing to severe disease. Further delays occurred at health facilities due to inadequate referral systems. Conclusion Communities living in endemic areas need to be sensitized about the significance of fever, even if mild, as an indicator of malaria. Additionally, amidst ongoing efforts at bringing antimalarial treatment services closer to communities, the value of drug shops as providers ofrationalantimalarialtreatment needs to be reviewed.
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Affiliation(s)
- Arthur Mpimbaza
- Child Health & Development Centre, Makerere University, College of Health Sciences, Kampala, Uganda
- * E-mail:
| | - Susan Nayiga
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Grace Ndeezi
- Department of Pediatrics & Child Health, Makerere University, College of Health Sciences, Kampala, Uganda
| | - Philip J. Rosenthal
- Department of Medicine, University of California, San Francisco, CA, United States of America
| | - Charles Karamagi
- Department of Pediatrics & Child Health, Makerere University, College of Health Sciences, Kampala, Uganda
- Clinical Epidemiology Unit, Department of Medicine, Makerere University, College of Health Sciences, Kampala, Uganda
| | - Anne Katahoire
- Child Health & Development Centre, Makerere University, College of Health Sciences, Kampala, Uganda
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Renmans D, Holvoet N, Criel B. Combining Theory-Driven Evaluation and Causal Loop Diagramming for Opening the 'Black Box' of an Intervention in the Health Sector: A Case of Performance-Based Financing in Western Uganda. Int J Environ Res Public Health 2017; 14. [PMID: 28869518 DOI: 10.3390/ijerph14091007] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 08/25/2017] [Accepted: 09/01/2017] [Indexed: 02/08/2023]
Abstract
Increased attention on "complexity" in health systems evaluation has resulted in many different methodological responses. Theory-driven evaluations and systems thinking are two such responses that aim for better understanding of the mechanisms underlying given outcomes. Here, we studied the implementation of a performance-based financing intervention by the Belgian Technical Cooperation in Western Uganda to illustrate a methodological strategy of combining these two approaches. We utilized a systems dynamics tool called causal loop diagramming (CLD) to generate hypotheses feeding into a theory-driven evaluation. Semi-structured interviews were conducted with 30 health workers from two districts (Kasese and Kyenjojo) and with 16 key informants. After CLD, we identified three relevant hypotheses: "success to the successful", "growth and underinvestment", and "supervision conundrum". The first hypothesis leads to increasing improvements in performance, as better performance leads to more incentives, which in turn leads to better performance. The latter two hypotheses point to potential bottlenecks. Thus, the proposed methodological strategy was a useful tool for identifying hypotheses that can inform a theory-driven evaluation. The hypotheses are represented in a comprehensible way while highlighting the underlying assumptions, and are more easily falsifiable than hypotheses identified without using CLD.
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Abstract
OBJECTIVES To determine the extent of provider communication, predictors of good communication and the association between provider communication and patient outcomes, such as patient satisfaction, in seven sub-Saharan African countries. DESIGN Cross-sectional, multicountry study. SETTING Data from recent Service Provision Assessment (SPA) surveys from seven countries in sub-Saharan Africa. SPA surveys include assessment of facility inputs and processes as well as interviews with caretakers of sick children. These data included 3898 facilities and 4627 providers. PARTICIPANTS 16 352 caregivers visiting the facility for their sick children. PRIMARY AND SECONDARY OUTCOME MEASURES We developed an index of four recommended provider communication items for a sick child assessment based on WHO guidelines. We assessed potential predictors of provider communication and considered whether better provider communication was associated with intent to return to the facility for care. RESULTS The average score of the composite indicator of provider communication was low, at 35% (SD 26.9). Fifty-four per cent of caregivers reported that they were told the child's diagnosis, and only 10% reported that they were counselled on feeding for the child. Caregivers' educational attainment and provider preservice education and training in integrated management of childhood illness were associated with better communication. Private facilities and facilities with better infrastructure received higher communication scores. Caretakers reporting better communication were significantly more likely to state intent to return to the facility (relative risk: 1.19, 95% CI 1.16 to 1.22). CONCLUSIONS There are major deficiencies in communication during sick child visits. These are associated with lower provider education as well as less well-equipped facilities. Poor communication, in turn, is linked to lower satisfaction and intention to return to facility among caregivers of sick children. Countries should test strategies for enhancing quality of communication in their efforts to improve health outcomes and patient experience.
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Affiliation(s)
- Elysia Larson
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Hannah H Leslie
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Margaret E Kruk
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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Erb S, Letang E, Glass TR, Natamatungiro A, Mnzava D, Mapesi H, Haschke M, Duthaler U, Berger B, Muri L, Bader J, Marzolini C, Elzi L, Klimkait T, Langewitz W, Battegay M. Health care provider communication training in rural Tanzania empowers HIV-infected patients on antiretroviral therapy to discuss adherence problems. HIV Med 2017; 18:623-634. [PMID: 28296019 PMCID: PMC5599974 DOI: 10.1111/hiv.12499] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2016] [Indexed: 12/30/2022]
Abstract
Objectives Self‐reported adherence assessment in HIV‐infected patients on antiretroviral therapy (ART) is challenging and may overestimate adherence. The aim of this study was to improve the ability of health care providers to elicit patients’ reports of nonadherence using a “patient‐centred” approach in a rural sub‐Saharan African setting. Methods A prospective interventional cohort study of HIV‐infected patients on ART for ≥ 6 months attending an HIV clinic in rural Tanzania was carried out. The intervention consisted of a 2‐day workshop for health care providers on patient‐centred communication and the provision of an adherence assessment checklist for use in the consultations. Patients’ self‐reports of nonadherence (≥ 1 missed ART dose/4 weeks), subtherapeutic plasma ART concentrations (< 2.5th percentile of published population‐based pharmacokinetic models), and virological and immunological failure according to the World Health Organization definition were assessed before and after (1–3 and 6–9 months after) the intervention. Results Before the intervention, only 3.3% of 299 patients included in the study reported nonadherence. Subtherapeutic plasma ART drug concentrations and virological and immunological failure were recorded in 6.5%, 7.7% and 14.5% of the patients, respectively. Two months after the intervention, health care providers detected significantly more patients reporting nonadherence compared with baseline (10.7 vs. 3.3%, respectively; P < 0.001), decreasing to 5.7% after 6–9 months. A time trend towards higher drug concentrations was observed for efavirenz but not for other drugs. The virological failure rate remained unchanged whereas the immunological failure rate decreased from 14.4 to 8.7% at the last visit (P = 0.002). Conclusions Patient‐centred communication can successfully be implemented with a simple intervention in rural Africa. It increases the likelihood of HIV‐infected patients reporting problems with adherence to ART; however, sustainability remains a challenge.
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Affiliation(s)
- S Erb
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - E Letang
- Ifakara Health Institute, Ifakara Branch, Ifakara, Tanzania.,Swiss Tropical and Public Health Institute of Basel, Basel, Switzerland.,ISGlobal, Barcelona Centre for International Health Research (CRESIB), University Hospital Clínic de Barcelona, Barcelona, Spain
| | - T R Glass
- Swiss Tropical and Public Health Institute of Basel, Basel, Switzerland
| | | | - D Mnzava
- Ifakara Health Institute, Ifakara Branch, Ifakara, Tanzania
| | - H Mapesi
- Ifakara Health Institute, Ifakara Branch, Ifakara, Tanzania
| | - M Haschke
- Division of Clinical Pharmacology and Toxicology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - U Duthaler
- Division of Clinical Pharmacology and Toxicology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - B Berger
- Division of Clinical Pharmacology and Toxicology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - L Muri
- Swiss Tropical and Public Health Institute of Basel, Basel, Switzerland
| | - J Bader
- Molecular Virology, Department of Biomedicine, University of Basel, Basel, Switzerland
| | - C Marzolini
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - L Elzi
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, University of Basel, Basel, Switzerland.,Ospedale Regionale di Bellinzona e Valli, Bellinzona, Switzerland
| | - T Klimkait
- Molecular Virology, Department of Biomedicine, University of Basel, Basel, Switzerland
| | - W Langewitz
- Institute of Psychosomatic Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - M Battegay
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, University of Basel, Basel, Switzerland
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Chandler CIR, Burchett H, Boyle L, Achonduh O, Mbonye A, DiLiberto D, Reyburn H, Onwujekwe O, Haaland A, Roca-Feltrer A, Baiden F, Mbacham WF, Ndyomugyenyi R, Nankya F, Mangham-Jefferies L, Clarke S, Mbakilwa H, Reynolds J, Lal S, Leslie T, Maiteki-Sebuguzi C, Webster J, Magnussen P, Ansah E, Hansen KS, Hutchinson E, Cundill B, Yeung S, Schellenberg D, Staedke SG, Wiseman V, Lalloo DG, Whitty CJM. Examining Intervention Design: Lessons from the Development of Eight Related Malaria Health Care Intervention Studies. Health Syst Reform 2016; 2:373-388. [PMID: 31514719 PMCID: PMC6176770 DOI: 10.1080/23288604.2016.1179086] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract—Rigorous evidence of “what works” to improve health care is in demand, but methods for the development of interventions have not been scrutinized in the same ways as methods for evaluation. This article presents and examines intervention development processes of eight malaria health care interventions in East and West Africa. A case study approach was used to draw out experiences and insights from multidisciplinary teams who undertook to design and evaluate these studies. Four steps appeared necessary for intervention design: (1) definition of scope, with reference to evaluation possibilities; (2) research to inform design, including evidence and theory reviews and empirical formative research; (3) intervention design, including consideration and selection of approaches and development of activities and materials; and (4) refining and finalizing the intervention, incorporating piloting and pretesting. Alongside these steps, projects produced theories, explicitly or implicitly, about (1) intended pathways of change and (2) how their intervention would be implemented.The work required to design interventions that meet and contribute to current standards of evidence should not be underestimated. Furthermore, the process should be recognized not only as technical but as the result of micro and macro social, political, and economic contexts, which should be acknowledged and documented in order to infer generalizability. Reporting of interventions should go beyond descriptions of final intervention components or techniques to encompass the development process. The role that evaluation possibilities play in intervention design should be brought to the fore in debates over health care improvement.
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Affiliation(s)
- Clare I R Chandler
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK
| | - Helen Burchett
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK
| | - Louise Boyle
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK
| | - Olivia Achonduh
- Laboratory for Public Health Research Biotechnologies, The Biotechnology Center, University of Yaoundé I , Yaoundé , Cameroon
| | - Anthony Mbonye
- School of Public Health-Makerere University & Commissioner Health Services, Ministry of Health , Kampala , Uganda
| | - Deborah DiLiberto
- Clinical Research Department , London School of Hygiene & Tropical Medicine , London , UK
| | - Hugh Reyburn
- Disease Control Department , London School of Hygiene & Tropical Medicine , London , UK
| | - Obinna Onwujekwe
- Department of Pharmacology and Therapeutics , University of Nigeria Enugu-Campus , Enugu , Nigeria
| | - Ane Haaland
- Institute of Health and Society , Department of Community Medicine , Blindern , Oslo , Norway
| | | | - Frank Baiden
- Malaria Group, Kintampo Health Research Centre , Kintampo , Ghana
| | - Wilfred F Mbacham
- Laboratory for Public Health Research Biotechnologies, The Biotechnology Center, University of Yaoundé I , Yaoundé , Cameroon
| | | | - Florence Nankya
- Infectious Diseases Research Collaboration , Kampala , Uganda
| | - Lindsay Mangham-Jefferies
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK
| | - Sian Clarke
- Disease Control Department , London School of Hygiene & Tropical Medicine , London , UK
| | - Hilda Mbakilwa
- Joint Malaria Programme, Kilimanjaro Christian Medical Centre , Moshi , Tanzania
| | - Joanna Reynolds
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK
| | - Sham Lal
- Disease Control Department , London School of Hygiene & Tropical Medicine , London , UK
| | - Toby Leslie
- Disease Control Department , London School of Hygiene & Tropical Medicine , London , UK
| | | | - Jayne Webster
- Disease Control Department , London School of Hygiene & Tropical Medicine , London , UK
| | - Pascal Magnussen
- Centre for Medical Parasitology, Faculty of Health and Medical Sciences, University of Copenhagen , Copenhagen , Denmark
| | - Evelyn Ansah
- Dangme West District Health Directorate, Ghana Health Service , Dodowa , Ghana
| | - Kristian S Hansen
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK
| | - Eleanor Hutchinson
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK
| | - Bonnie Cundill
- Disease Control Department , London School of Hygiene & Tropical Medicine , London , UK
| | - Shunmay Yeung
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK
| | - David Schellenberg
- Disease Control Department , London School of Hygiene & Tropical Medicine , London , UK
| | - Sarah G Staedke
- Disease Control Department , London School of Hygiene & Tropical Medicine , London , UK
| | - Virginia Wiseman
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK.,School of Public Health and Community Medicine , Kensington , New South Wales , Australia
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Altaras R, Nuwa A, Agaba B, Streat E, Tibenderana JK, Martin S, Strachan CE. How Do Patients and Health Workers Interact around Malaria Rapid Diagnostic Testing, and How Are the Tests Experienced by Patients in Practice? A Qualitative Study in Western Uganda. PLoS One 2016; 11:e0159525. [PMID: 27494507 DOI: 10.1371/journal.pone.0159525] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 07/04/2016] [Indexed: 11/25/2022] Open
Abstract
Background Successful scale-up in the use of malaria rapid diagnostic tests (RDTs) requires that patients accept testing and treatment based on RDT results and that healthcare providers treat according to test results. Patient-provider communication is a key component of quality care, and leads to improved patient satisfaction, higher adherence to treatment and better health outcomes. Voiced or perceived patient expectations are also known to influence treatment decision-making among healthcare providers. While there has been a growth in literature on provider practices around rapid testing for malaria, there has been little analysis of inter-personal communication around the testing process. We investigated how healthcare providers and patients interact and engage throughout the diagnostic and treatment process, and how the testing service is experienced by patients in practice. Methods This research was conducted alongside a larger study which explored determinants of provider treatment decision-making following negative RDT results in a rural district (Kibaale) in mid-western Uganda, ten months after RDT introduction. Fifty-five patients presenting with fever were observed during routine outpatient visits at 12 low-level public health facilities. Observation captured communication practices relating to test purpose, results, diagnosis and treatment. All observed patients or caregivers were immediately followed up with in-depth interview. Analysis followed the ‘framework’ approach. A summative approach was also used to analyse observation data. Results Providers failed to consistently communicate the reasons for carrying out the test, and particularly to RDT-negative patients, a diagnostic outcome or the meaning of test results, also leading to confusion over what the test can detect. Patients appeared to value testing, but were frustrated by the lack of communication on outcomes. RDT-negative patients were dissatisfied by the absence of information on an alternative diagnosis and expressed uncertainty around adequacy of proposed treatment. Conclusions Poor provider communication practices around the testing process, as well as limited inter-personal exchange between providers and patients, impacted on patients’ perceptions of their proposed treatment. Patients have a right to health information and may be more likely to accept and adhere to treatment when they understand their diagnosis and treatment rationale in relation to their perceived health needs and visit expectations.
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Staedke SG, Maiteki-Sebuguzi C, DiLiberto DD, Webb EL, Mugenyi L, Mbabazi E, Gonahasa S, Kigozi SP, Willey BA, Dorsey G, Kamya MR, Chandler CIR. The Impact of an Intervention to Improve Malaria Care in Public Health Centers on Health Indicators of Children in Tororo, Uganda (PRIME): A Cluster-Randomized Trial. Am J Trop Med Hyg 2016; 95:358-367. [PMID: 27273646 PMCID: PMC4973182 DOI: 10.4269/ajtmh.16-0103] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 05/04/2016] [Indexed: 12/02/2022] Open
Abstract
Optimizing quality of care for malaria and other febrile illnesses is a complex challenge of major public health importance. To evaluate the impact of an intervention aiming to improve malaria case management on the health of community children, a cluster-randomized trial was conducted from 2010–2013 in Tororo, Uganda, where malaria transmission is high. Twenty public health centers were included; 10 were randomized in a 1:1 ratio to intervention or control. Households within 2 km of health centers provided the sampling frame for the evaluation. The PRIME intervention included training in fever case management using malaria rapid diagnostic tests (mRDTs), patient-centered services, and health center management; plus provision of mRDTs and artemether–lumefantrine. Cross-sectional community surveys were conducted at baseline and endline (N = 8,766), and a cohort of children was followed for approximately 18 months (N = 992). The primary outcome was prevalence of anemia (hemoglobin < 11.0 g/dL) in children under 5 years of age in the final community survey. The intervention was delivered successfully; however, no differences in prevalence of anemia or parasitemia were observed between the study arms in the final community survey or the cohort. In the final survey, prevalence of anemia in children under 5 years of age was 62.5% in the intervention versus 63.1% in control (adjusted risk ratio = 1.01; 95% confidence interval = 0.91–1.13; P = 0.82). The PRIME intervention, focusing on training and commodities, did not produce the expected health benefits in community children in Tororo. This challenges common assumptions that improving quality of care and access to malaria diagnostics will yield health gains.
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Affiliation(s)
- Sarah G Staedke
- Department of Clinical Research, Department of Medical Statistics, Department of Infectious Disease Epidemiology, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom.,Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Deborah D DiLiberto
- Department of Clinical Research, Department of Medical Statistics, Department of Infectious Disease Epidemiology, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Emily L Webb
- Department of Clinical Research, Department of Medical Statistics, Department of Infectious Disease Epidemiology, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Levi Mugenyi
- Infectious Diseases Research Collaboration, Kampala, Uganda.,I-Biostat, Hasselt University, Diepenbeek, Belgium
| | - Edith Mbabazi
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Simon P Kigozi
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Barbara A Willey
- Department of Clinical Research, Department of Medical Statistics, Department of Infectious Disease Epidemiology, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Grant Dorsey
- Department of Medicine, University of California, San Francisco, California
| | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda.,Makerere University College of Health Sciences, Kampala, Uganda
| | - Clare I R Chandler
- Department of Clinical Research, Department of Medical Statistics, Department of Infectious Disease Epidemiology, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
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DiLiberto DD, Staedke SG, Nankya F, Maiteki-Sebuguzi C, Taaka L, Nayiga S, Kamya MR, Haaland A, Chandler CIR. Behind the scenes of the PRIME intervention: designing a complex intervention to improve malaria care at public health centres in Uganda. Glob Health Action 2015; 8:29067. [PMID: 26498744 PMCID: PMC4620687 DOI: 10.3402/gha.v8.29067] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 09/20/2015] [Accepted: 09/22/2015] [Indexed: 12/30/2022] Open
Abstract
Background In Uganda, health system challenges limit access to good quality healthcare and contribute to slow progress on malaria control. We developed a complex intervention (PRIME), which was designed to improve quality of care for malaria at public health centres. Objective Responding to calls for increased transparency, we describe the PRIME intervention's design process, rationale, and final content and reflect on the choices and challenges encountered during the design of this complex intervention. Design To develop the intervention, we followed a multistep approach, including the following: 1) formative research to identify intervention target areas and objectives; 2) prioritization of intervention components; 3) review of relevant evidence; 4) development of intervention components; 5) piloting and refinement of workshop modules; and 6) consolidation of the PRIME intervention theories of change to articulate why and how the intervention was hypothesized to produce desired outcomes. We aimed to develop an intervention that was evidence-based, grounded in theory, and appropriate for the study context; could be evaluated within a randomized controlled trial; and had the potential to be scaled up sustainably. Results The process of developing the PRIME intervention package was lengthy and dynamic. The final intervention package consisted of four components: 1) training in fever case management and use of rapid diagnostic tests for malaria (mRDTs); 2) workshops in health centre management; 3) workshops in patient-centred services; and 4) provision of mRDTs and antimalarials when stocks ran low. Conclusions The slow and iterative process of intervention design contrasted with the continually shifting study context. We highlight the considerations and choices made at each design stage, discussing elements we included and why, as well as those that were ultimately excluded. Reflection on and reporting of ‘behind the scenes’ accounts of intervention design may improve the design, assessment, and generalizability of complex interventions and their evaluations.
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Affiliation(s)
- Deborah D DiLiberto
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK;
| | - Sarah G Staedke
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK.,Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | | | - Lilian Taaka
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Susan Nayiga
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda.,School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Ane Haaland
- Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Clare I R Chandler
- Department of Global Health & Development, London School of Hygiene & Tropical Medicine, London, UK
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