A systematic review of the literature on self-management interventions and discussion of their potential relevance for people living with HIV in sub-Saharan Africa

The importance of self-management for better treatment outcomes for HIV patients in a low-income setting: perspectives of HIV experts and service providers

BACKGROUND

Self-management is the most important strategy to improve quality of life in patients with a chronic disease. Despite the increasing number of people living with HIV (PLWH) in low-income countries, very little research on self-management is conducted in this setting. The aim of this research is to understand the perspectives of service providers and experts on the importance of self-management for PLWH.

METHODS

A systematizing expert interview type of qualitative methodology was used to gain the perspectives of experts and service providers. The study participants had experience in researching, managing, or providing HIV service in east and southern African (ESA) countries. All the interviews were audio recorded, transcribed, and translated to English. The quality of the transcripts was ensured by randomly checking the texts against the audio record. A thematic analysis approach supported by Atlas TI version 9 software.

RESULT

PLWH face a variety of multi-dimensional problems thematized under contextual and process dimensions. The problems identified under the contextual dimension include disease-specific, facility-related, and social environment-related. Problems with individual origin, such as ignorance, outweighing beliefs over scientific issues, low self-esteem, and a lack of social support, were mostly highlighted under the process dimensions. Those problems have a deleterious impact on self-management, treatment outcomes, and the quality of life of PLWH. Low self-management is also a result of professional-centered service delivery in healthcare facilities and health service providers' incapacity to comprehend a patient's need beyond the medical concerns. Participants in the study asserted that patients have a significant stake in enhancing treatment results and quality of life through enhancing self-management.

CONCLUSION AND RECOMMENDATION

HIV patients face multifaceted problems beyond their medical issues. The success of medical treatment for HIV is strongly contingent upon patients' self-management practices and the supportive roles of their family, society, and health service providers. The development and integration of self-management practices into clinical care will benefit patients, their families, and the health system.

A qualitative analysis of self-management needs of adolescents and young adults living with perinatally acquired HIV in rural, southwestern Uganda

The number of adolescents living with HIV remains high in sub-Saharan Africa with poorer HIV treatment outcomes among adolescents and young adults compared to individuals in other age groups. For adolescents and young adults living with perinatally acquired HIV (AYLPHIV), the transition from pediatric to adult HIV care is a particularly high-risk period. We conducted a qualitative study to understand self-management needs of AYLPHIV in rural, southwestern Uganda as they prepare to transition to adult HIV care in order to inform relevant interventions that can enable AYLPHIV acquire the necessary skills to manage their illness as they age into adulthood. We conducted 60 in-depth interviews with AYLPHIV (n = 30), caregivers (n = 20) and health care providers (n = 10) from the HIV clinic at Mbarara Regional Referral Hospital. We used an interview guide that focused on perceptions about transition to adult HIV care, challenges with transitioning, navigating HIV care, and self-management needs for AYLPHIV (from the perspectives of AYLPHIV, their caregivers, and health care providers). We used thematic analysis to identify themes related to AYLPHIV's self-management skills. We identified several self-management needs that we grouped under two major themes; social support and empowerment for AYLPHIV to assume responsibility for their own health and to navigate adult HIV care independently. The sub-themes under social support were information support, instrumental support, and emotional support as the sub themes while sub-themes under empowerment included self-advocacy skills, interpersonal skills, self-care skills, and disclosure skills. Taken together, these findings indicate that AYLPHIV need to be supported and empowered to maximize their chances of successfully transitioning to adult HIV care. Support comes from peers and caregivers. AYLPHIV require knowledge about their HIV status and empowerment with different skills including: self-advocacy skills, interpersonal skills, self-care skills, and HIV status disclosure skills, in order to assume responsibilities related to independent HIV care.

Experiences of people living with HIV in low- and middle-income countries and their perspectives in self-management: a meta-synthesis

INTRODUCTION

Availability of anti-retroviral treatment has changed HIV in to a manageable chronic disease, making effective self-management essential. However, only a few studies in low- and middle-income countries (LMICs) reported experiences of people living with HIV (PLWH) on self-management.

METHODS

This meta-synthesis of qualitative studies investigated perspectives of PLWH in LMICs on self-management. Various databases, including PubMed, EMBASE, EBSCO, and CINHAL, were searched through June 2022. Relevant additional articles were also included using cross-referencing of the identified papers. We used a thematic synthesis guided by the "Model of the Individual and Family Self-Management Theory" (IFSMT).

RESULT

PLWH in LIMICs experience a variety of challenges that restrict their options for effective self-management and compromises their quality of life. The main ones include: misconceptions about the disease, poor self-efficacy and self-management skills, negative social perceptions, and a non-patient-centered model of care that reduces the role of patients. The experiences that influenced the ability to practice self-management are summarized in context (the condition itself, physical and environmental factors, individual and family factors) and process factors (knowledge and beliefs, relationship with the health care worker, self-regulation skills and abilities, and social facilitation). Context and process greatly impacted quality of life through the self-management practices of the patients.

CONCLUSION AND RECOMMENDATION

PLWH encounter multiple challenges, are not empowered enough to manage their own chronic condition, and their needs beyond medical care are not addressed by service providers. Self-management practice of these patients is poor, and service providers do not follow service delivery approaches that empower patients to be at the center of their own care and to achieve an effective and sustainable outcome from treatment. These findings call for a comprehensive well thought self-management interventions.

Male and female Asians living with HIV: a text-mining analysis comparing their concerns

Introduction

Asians are "a forgotten population" whose HIV prevention and treatment needs have long been ignored. Studies on people living with HIV/AIDS (PLWHA) have primarily reported on physical and psychological conditions among men and gender minorities.

Methods

We used data-mining to select words and word patterns from pooled in-depth interviews conducted with 33 women and 12 men (n = 45) who were HIV positive and residing in San Francisco, United States, Shanghai, Beijing, or Taipei, China. We analyzed gender-based data (male vs. female) within the participant responses.

Results

Disclosure of HIV serostatus was discussed by both genders of PLWHA. Participants were concerned whether they should disclose their diagnosis and how to disclose it to their family members. Specifically, for women, family relationships and financial burdens were discussed most often. In terms of men, HIV disclosure was the key concern followed by disclosure of their sexual preference and concerns over what people were saying about them in the community.

Conclusion

This project compared and contrasted concerns of Asian HIV-positive men and women. As healthcare providers promoting self-management by HIV-positive individuals of both genders, it is important to consider that there may be significant differences between them. Future interventions should consider how gender role influences self-management strategies in PLWHA and how support can be targeted to achieve a better quality of life for PLWHA.

How the Term 'Self-Management' is Used in HIV Research in Low- and Middle-Income Countries: A Scoping Review

This scoping review assessed how the term 'self-management' (SM) is used in peer-reviewed literature describing HIV populations in low- and middle-income countries (LMIC). This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. OVID Medline, Embase, CAB Abstracts, and EBSCO CINAHL, Scopus, and Cochrane Library were searched up to September 2021 for articles with SM in titles, key words, or abstracts. Two team members independently screened the titles and abstracts, followed by the full-text. A data extraction tool assisted with collecting findings. A total of 103 articles were included. Since 2015, there has been a 74% increase in articles that use SM in relation to HIV in LMIC. Fifty-three articles used the term in the context of chronic disease management and described it as a complex process involving active participation from patients alongside providers. Many of the remaining 50 articles used SM as a strategy for handling one's care by oneself, with or without the help of community or family members. This demonstrates the varied conceptualizations and uses of the term in LMIC, with implications for the management of HIV in these settings. Future research should examine the applicability of SM frameworks developed in high-income settings for LMIC.

Self-management interventions for adolescents living with HIV: a systematic review

BACKGROUND

Self-management interventions aim to enable people living with chronic conditions to increase control over their condition in order to achieve optimal health and may be pertinent for young people with chronic illnesses such as HIV. Our aim was to evaluate the effectiveness of self-management interventions for improving health-related outcomes of adolescents living with HIV (ALHIV) and identify the components that are most effective, particularly in low-resource settings with a high HIV burden.

METHODS

We considered randomised controlled trials (RCTs), cluster RCTs, non-randomised controlled trials (non-RCTs) and controlled before-after (CBA) studies. We did a comprehensive search up to 1 August 2019. Two authors independently screened titles, abstracts and full texts, extracted data and assessed the risk of bias. We synthesised results in a meta-analysis where studies were sufficiently homogenous. In case of substantial heterogeneity, we synthesised results narratively. We assessed the certainty of evidence using GRADE and presented our findings as summaries in tabulated form.

RESULTS

We included 14 studies, comprising 12 RCTs and two non-RCTs. Most studies were conducted in the United States, one in Thailand and four in Africa. Interventions were diverse, addressing a variety of self-management domains and including a combination of individual, group, face-to-face, cell phone or information communication technology mediated approaches. Delivery agents varied from trained counsellors to healthcare workers and peers. Self-management interventions compared to usual care for ALHIV made little to no difference to most health-related outcomes, but the evidence is very uncertain. Self-management interventions may increase adherence and decrease HIV viral load, but the evidence is very uncertain. We could not identify any particular components of interventions that were more effective for improving certain outcomes.

CONCLUSION

Existing evidence on the effectiveness of self-management interventions for improving health-related outcomes of ALHIV is very uncertain. Self-management interventions for ALHIV should take into account the individual, social and health system contexts. Intervention components need to be aligned to the desired outcomes.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019126313.

An evaluation of self-management outcomes among chronic care patients in community home-based care programmes in rural Malawi: A 12-month follow-up study

This paper investigates the impact of community home-based care (CHBC) on self-management outcomes for chronically ill patients in rural Malawi. A pre- and post-evaluation survey was administered among 140 chronically ill patients with HIV and non-communicable diseases, newly enrolled in four CHBC programmes. We translated, adapted and administered scales from the Stanford Chronic Disease Self-Management Programme to evaluate patient's self-management outcomes (health status and self-efficacy), at four time points over a 12-month period, between April 2016 and May 2017. The patient's drop-out rate was approximately 8%. Data analysis included descriptive statistics, tests of associations, correlations and pairwise comparison of outcome variables between time points, and multivariate regression analysis to explore factors associated with changes in self-efficacy following CHBC interventions. The results indicate a reduction in patient-reported pain, fatigue and illness intrusiveness, while improvements in general health status and quality of life were not statistically significant. At baseline, the self-efficacy mean was 5.91, which dropped to 5.1 after 12 months. Factors associated with this change included marital status, education, employment and were condition-related; whereby self-efficacy for non-HIV and multimorbid patients was much lower. The odds for self-efficacy improvement were lower for patients with diagnosed conditions of longer duration. CHBC programme support, regularity of contact and proximal location to other services influenced self-efficacy. Programmes maintaining regular home visits had higher patient satisfaction levels. Our findings suggest that there were differential changes in self-management outcomes following CHBC interventions. While self-management support through CHBC programmes was evident, CHBC providers require continuous training, supervision and sustainable funding to strengthen their contribution. Furthermore, sociodemographic and condition-related factors should inform the design of future interventions to optimise outcomes. This study provides a systematic evaluation of self-management outcomes for a heterogeneous chronically ill patient population and highlights the potential and relevant contribution of CHBC programmes in improving chronic care within sub-Saharan Africa.

Patient perspectives on interpersonal aspects of healthcare and patient-centeredness at primary health facilities: A mixed methods study in rural Eastern Uganda

INTRODUCTION

Patient-centered care (PCC) is an approach to involve patients in health care delivery, to contribute to quality of care, and to strengthen health systems responsiveness. This article aims to highlight patient perspectives by showcasing their perceptions of their experience of PCC at primary health facilities in two districts in Uganda.

METHODS

A mixed methods cross-sectional study was conducted in three public and two private primary health care facilities in rural eastern Uganda. In total, 300 patient exit survey questionnaires, 31 semi-structured Interviews (SSIs), 5 Focus Group Discussions (FGDs) and 5 feedback meetings were conducted. Data analysis was guided by a conceptual framework focusing on (1) understanding patients' health needs, preferences and expectations, (2) describing patients perceptions of their care experience according to five distinct PCC dimensions, and (3) reporting patient reported outcomes and their recommendations on how to improve quality of care.

RESULTS

Patient expectations were shaped by their access to the facility, costs incurred and perceived quality of care. Patients using public facilities reported doing so because of their proximity (78.3% in public PHCs versus 23.3% in private PHCs) and because of the free services availed. On the other hand, patients attending private facilities did so because of their perception of better quality of care (84.2% in private PHCs versus 21.7% in public PHCs). Patients expectations of quality care were expressed as the availability of medication, shorter waiting times, flexible facility opening hours and courteous health workers. Analysis of the 300 responses from patients interviewed on their perception of the care they received, pointed to higher normalized scores for two out of the five PCC dimensions considered: namely, exploration of the patient's health and illness experience, and the quality of the relationship between patient and health worker (range 62.1-78.4 out of 100). The qualitative analysis indicated that patients felt that communication with health workers was enhanced where there was trust and in case of positive past experiences. Patients however felt uncomfortable discussing psychological or family matters with health workers and found it difficult to make decisions when they did not fully understand the care provided. In terms of outcomes, our findings suggest that patient enablement was more sensitive than patient satisfaction in measuring the effect of interpersonal patient experience on patient reported outcomes.

DISCUSSION AND CONCLUSION

Our findings show that Ugandan patients have some understanding of PCC related concepts and express a demand for it. The results offer a starting point for small scale PCC interventions. However, we need to be cognizant of the challenges PCC implementation faces in resource constrained settings. Patients' expectations in terms of quality health care are still largely driven by biomedical and technical aspects. In addition, patients are largely unaware of their right to participate in the evaluation of health care. To mitigate these challenges, targeted health education focusing on patients' responsibilities and patient's rights are essential. Last but not least, all stakeholders must be involved in developing and validating methods to measure PCC.

Interventions to improve self-management of adults living with HIV on Antiretroviral Therapy: A systematic review

Introduction

Since its initial recognition, HIV has been responsible for around 35 million deaths globally. The introduction of Antiretroviral Therapy has helped to reduce mortality from HIV. However, the resulting increased longevity has influenced the experience of people living with HIV, which now manifests as a chronic condition requiring effective self-management. This review aimed to identify and evaluate the effectiveness of interventions to improve self-management of adults living with HIV on Antiretroviral therapy.

Methods

The review included published experimental studies addressing interventions to improve self-management of adults living with HIV on Antiretroviral Therapy. Studies were included if they addressed two or more outcomes of self-management, as defined by the Theory of Individual and Family Self-Management. The search covered four databases and was limited to papers published in the English language from 2001 to March 30, 2019. The reference lists of included studies were further searched for additional studies. Two independent reviewers using the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI SUMARI) assessed the methodological quality of the reviewed papers. Data extraction was undertaken using the JBI SUMARI standardized data extraction tool. As the included papers were not homogeneous, it was not possible to conduct a meta-analysis. A narrative synthesis was undertaken to synthesize the findings of the included studies.

Results

The search identified 337 articles from which 10 experimental and 2 quasi-experimental studies were included. The total participant sample in the included studies was 1661 adults living with HIV. The overall evidence quality of the findings was considered moderate. Many of the studies included in this review comprised multi-component interventions to improve self-management. Skills training, in conjunction with other forms of interventions, particularly phone counseling, was commonly employed and generally effective in improving self-management outcomes. Counseling with a symptom management manual was another employed and effective intervention, followed by technology-assisted self-management interventions. The most common outcomes measured were maintaining medication adherence and quality of life, followed by symptom management, self-efficacy, coping, and social support.

Conclusions

Interventions to improve self-management varied across studies. However, promising outcomes achieved in the majority of studies through interventions comprising a combination of skills training, phone counseling, counseling with symptom management manuals, and technology-assisted interventions.

Adolescent human immunodeficiency virus self-management: Associations with treatment adherence, viral suppression, sexual risk behaviours and health-related quality of life

Background

With the advent of access to antiretroviral treatment (ART), human immunodeficiency virus (HIV) has become a chronic disease and self-management is an important component of its care. Research to date has not explored associations between adolescent HIV self-management and treatment adherence, viral suppression, sexual risk behaviour and health-related quality of life (HRQoL).

Objectives

To explore the associations between adolescent HIV self-management and treatment adherence, viral suppression, sexual risk behaviour and HRQoL.

Methods

A quantitative cross-sectional study of 385 adolescents living with HIV (ALHIV) aged 13–18 years, who were recruited from 11 healthcare facilities between March and August 2017 in the Cape Metropole of the Western Cape, South Africa, provided the data that were examined in this self-completed questionnaire. Validated scales were used to measure key variables. The most recent viral load (VL) was obtained from the participants’ clinic folder, taking into account that VL is done annually.

Results

Adolescents who reported higher HIV self-management were more likely to be adherent to treatment (t = 4.435 [336], p < 0.01), virally suppressed (t = 2.376 [305], p = 0.02) and to practise consistent condom use (t = 1.947 [95], p = 0.54). Structural equation modelling (SEM) indicated a significant relationship between self-management and HRQoL (r = 0.43, p < 0.01), whilst non-adherent treatment taking behaviour, correlated with elevated VL log values. No significant correlation was found between self-management and sexual risk behaviour.

Conclusion

Targeting adolescents’ skills related to HIV self-management in the clinical setting may improve adolescents’ treatment taking behaviour, viral suppression rates and their HRQoL.

Exploring and Prioritization of Mobile-Based Self-Management Strategies for HIV Care

OBJECTIVE

Appropriate mobile-based self-management strategies can be as new approaches to decelerate the HIV infection progression and improve the quality of life. This study aims at (i) identifying in the literature mobile-based self-management strategies for HIV care and (ii) prioritizing those from the point of view of infectious diseases specialists. This study provides some clues to design useful mobile-based self-management tools for HIV patients, from the point of view of practitioners.

METHODS

This mixed methods study was done in two main phases. In the first phase, a review was conducted in: PubMed, Web of Science, Science Direct, Scopus, and Ovid. In this manner, related studies published between 2010 and 2017 and in the English language were reviewed. In the second phase, identified mobile-based self-management strategies were scored and prioritized by 23 participants. Frequency distribution and mean reports were calculated using SPSS statistical software.

RESULTS

By detailed reviewing of 24 related articles, the HIV mobile-based self-management strategies were identified in 47 categories and subcategories. According to the findings, "enhance the quality of life" was the main self-management strategy addressed by reviewed studies. However, "antiretroviral therapy and medication adherence" was reported at a higher rate to be a more helpful strategy than "enhance the quality of life".

CONCLUSION

In this study, helpful HIV mobile-based self-management strategies were identified that can be used to guide self-management interventions which have the potential to improve the healthcare services for people living with HIV.

Measuring Adolescent HIV Self-management: An Instrument Development Study

Adolescent HIV self-management is a complex phenomenon that has been poorly researched. A mixed-method explorative sequential research design was used to develop an instrument to measure adolescent HIV self-management in the context of the Western Cape, South Africa. The development and validation was undertaken in four phases: (i) individual interviews and focus groups with adolescents aged 13 to 18, their caregivers and healthcare workers (n = 56); (ii) item identification; (iii) item refinement through cognitive interviewing (n = 11), expert review (n = 11) and pilot testing (n = 33); and (iv) psychometric evaluation (n = 385). The final scale consists of five components with 35 items encompassing the construct of adolescent HIV self-management. The developed scale had acceptable reliability (0.84) and stability (0.76). Factor analysis indicated a good model-fit that support the structural validity (RMSEA = 0.052, p = 0.24; RMR = 0.065; CFI = 0.9). Higher self-management was associated with better HIV-related and general health outcomes, which supports the criterion- and convergent validity of the instrument.

[Therapeutic patient education practices in Ivory Cost: investigation among health professionals]

INTRODUCTION

Patient education is an important component in the management and monitoring of chronic diseases. It plays an important role in the decline of the disease severity, mortality and socioeconomic burden and the complications of these chronic diseases. In Côte d’Ivoire, there are few studies to evaluate the reality of this activity.

OBJECTIVE

To explore the practice of patient education in Ivory Coast.

METHOD

This qualitative study has been carried out by means of semi-structured interviews with 24 healthcare professionals including 14 health managers for individual interviews and 10 care providers for focus group discussion.

RESULTS

There are various representations of therapeutic patient education among health professionals. There was no real distinction between patient education and the broader concept of health education. Absence of national patient education policy, the lack of training in TPE and lack of experience of educational practice lead health professionals to realize an unstructured educational activity.

CONCLUSION

These results show the need for Côte d’Ivoire to have a national policy of patient education to educate patients in accordance with international recommendations.

Adolescent HIV Self-management: Lived Experiences of Adolescents, Caregivers, and Health Care Workers in a South African Context

Adolescence is a complex developmental phase, made more complex by chronic disease. When dealing with treatment and the health impact of chronic diseases, adolescents need to learn to self-manage an array of challenges. Unfortunately, there is a gap in the literature related to chronic disease self-management in adolescents living with HIV. We describe the phenomenon from the perspectives of adolescents, caregivers, and health care workers (HCWs) in South Africa. Individual interviews were conducted with 6 adolescents, 6 caregivers, and 6 HCWs, followed by 5 adolescent focus groups. Interpretive phenomenology guided exploration of social and cultural experiences and found that adolescent self-management required an understanding of HIV and hope for the future. Adolescents also needed skills to prioritize and negotiate care while managing stigma. These processes were facilitated by love and support, primarily from immediate family, and by the adolescent engaging with family, HCWs, and peers.

A close look at lay-led self-management programs for chronic diseases and health care utilisation: A systematic review and meta-analysis

Introduction: Chronically ill people are confronted with significant challenges when dealing with health care services. Lay-led self-management programs aim to improve self-management skills and might enable patients to make appropriate decisions as to when to use health care services. Contrary to the general attitude that self-management programs reduce health care utilisation, we suspect that better self-management skills lead to increased or possibly more appropriate health care utilisation. Our review and meta-analysis sheds light on the relationship between lay-led self-management programs and health care utilisation. Methods: In March 2017, we searched 7 databases (CDSR, DARE, HTA, Medline, CINAHL, PsycInfo, and SSCI) to perform a systematic review and meta-analysis to identify studies that reported empirical data on lay-led self-management programs and health care utilisation. We extracted the characteristics of all primary studies and the data of four indicators of utilisation (physician visits, emergency department visits, hospital admissions, and length of stay in hospital), and analysed the role of health care utilisation in these studies. We present the results in frequency tables and as a conventional meta-analysis with the standardized mean difference (SMD), 95% confidence intervals (CI), and pooled overall effect sizes using RevMan 5.3.5. The manuscript follows the PRISMA checklist. Results: Overall, we include 49 primary studies; 10 studies provided sufficient data for the meta-analysis. Health care utilisation played a different role in the studies; 15 studies reported a clear explicit hypothesis on the influence of a lay-led self-management program on health care utilisation, and 17 studies assumed an implicit assumption. 8 studies discussed the possibility that a lay-led self-management program could lead to more appropriate health care utilisation. The meta-analysis showed mixed results, and many effect sizes were not statistically significant. The participants of a lay-led self-management program had fewer emergency department visits (SMD: -0.08; 95% CI: -0.15 to -0.01; p=0.02) than the control group. Conclusion: Although the statistically significant effects of the meta-analysis are low, our overall findings show that only a small number of the included studies tackled the task of comprehensively investigating self-management skills in the context of health care utilisation. This fails to do justice to the potential of self-management programs. It is essential to consider the appropriateness of health care utilisation. We propose the term self-management-sensitive utilisation for this purpose.

[Designing and evaluating therapeutic education tools for people living with HIV]

In the context of therapeutic education for people living with HIV in Africa, educational tools must be adapted to their living environment.

OBJECTIVES

To describe the process of designing education tools for patients living with HIV and evaluate their use by African caregivers-educators.

METHODS

An eight-step participatory and formative process was carried out to design educational tools. Twenty-one caregivers-educators from nine French-speaking African countries in three focus groups were interviewed on the way in which they used these tools.

RESULTS

Fourteen people were trained in the process of designing the tools and training caregivers-educators in their use. Two toolkits were developed (adults and children/adolescents). The image folder was the tool most commonly used. Educators in all countries used tools to address self-care and psychosocial coping skills. The criteria for choosing the tools were linked to their attractiveness, ease of use, their adaptation to the patient's needs and characteristics, and the degree of mastery by the caregiver-educator. The tools helped to structure the education sessions. Brakes to their use were organizational and lack of experience or mastery.

CONCLUSION

The participatory and formative approach enabled educators working with patients living with HIV in French-speaking Africa to appropriate the tools. Training was a crucial step in enabling caregiver-educators to master and disseminate the tools, and design new tools.

Patients experiences of self-management and strategies for dealing with chronic conditions in rural Malawi

BACKGROUND

The high burden of chronic communicable diseases such as HIV/AIDS, and an escalating rise of non-communicable diseases (NCDs) in Malawi and other sub-Saharan African countries, calls for a shift in how health care services are designed and delivered. Patient-centred care and patient self-management are critical elements in chronic care, and are advocated as universal strategies. In sub-Saharan Africa, there is need for more evidence around the practice of patient self-management, and how to best support patients with chronic conditions in the African context. Our study explored self-management practices of patients with different chronic conditions, and their strategies to overcome care challenges in a resource-constrained setting in Malawi.

METHODS

This is primarily a qualitative study, involving patients with different chronic conditions from one rural district in Malawi. Data are drawn from semi-structured questions of a survey with 129 patients (from the third of four-part data collection series), 14 in-depth interviews, and four focus-group discussions with patients (n = 31 respondents). A framework approach was used for qualitative analysis, and descriptive statistical analysis was performed on survey data.

RESULTS

Patients demonstrated ability to self-manage their conditions, though this varied between conditions, and was influenced by individual and external factors. Factors included: 1) ability to acquire appropriate disease knowledge; 2) poverty level; 3) the presence of support from family caregivers and community-based support initiatives; 4) the nature of one's social relations; and 5) the ability to deal with stressors and stigma. NCD and HIV comorbid patients were more disadvantaged in their access to care, as they experienced frequent drug stock-outs and incurred additional costs when referred. These barriers contributed to delayed care, poorer treatment adherence, and likelihood of poorer treatment outcomes. Patients proved resourceful and made adjustments in the face of (multiple) care challenges.

CONCLUSION

Our findings complement other research on self-management experiences in chronically ill patients with its analysis on factors and barriers that influence patient self-management capacity in a resource-constrained setting. We recommend expanding current peer-patient and support group initiatives to patients with NCDs, and further investments in the decentralisation of integrated health services to primary care level in Malawi.

The impact of leadership hubs on the uptake of evidence-informed nursing practices and workplace policies for HIV care: a quasi-experimental study in Jamaica, Kenya, Uganda and South Africa

BACKGROUND

The enormous impact of HIV on communities and health services in Sub-Saharan Africa and the Caribbean has especially affected nurses, who comprise the largest proportion of the health workforce in low- and middle-income countries (LMICs). Strengthening action-based leadership for and by nurses is a means to improve the uptake of evidence-informed practices for HIV care.

METHODS

A prospective quasi-experimental study in Jamaica, Kenya, Uganda and South Africa examined the impact of establishing multi-stakeholder leadership hubs on evidence-informed HIV care practices. Hub members were engaged through a participatory action research (PAR) approach. Three intervention districts were purposefully selected in each country, and three control districts were chosen in Jamaica, Kenya and Uganda. WHO level 3, 4 and 5 health care institutions and their employed nurses were randomly sampled. Self-administered, validated instruments measured clinical practices (reports of self and peers), quality assurance, work place policies and stigma at baseline and follow-up. Standardised average scores ranging from 0 to 1 were computed for clinical practices, quality assurance and work place policies. Stigma scores were summarised as 0 (no reports) versus 1 (one or more reports). Pre-post differences in outcomes between intervention and control groups were compared using the Mantel Haenszel chi-square for dichotomised stigma scores, and independent t tests for other measures. For South Africa, which had no control group, pre-post differences were compared using a Pearson chi-square and independent t test. Multivariate analysis was completed for Jamaica and Kenya. Hub members in all countries self-assessed changes in their capacity at follow-up; these were examined using a paired t test.

RESULTS

Response rates among health care institutions were 90.2 and 80.4 % at baseline and follow-up, respectively. Results were mixed. There were small but statistically significant pre-post, intervention versus control district improvements in workplace policies and quality assurance in Jamaica, but these were primarily due to a decline in scores in the control group. There were modest improvements in clinical practices, workplace policies and quality assurance in South Africa (pre-post) (clinical practices of self-pre 0.67 (95 % CI, 0.62, 0.72) versus post 0.78 (95 % CI, 0.73-0.82), p = 0.002; workplace policies-pre 0.82 (95 % CI, 0.70, 0.85) versus post 0.87 (95 % CI, 0.84, 0.90), p = 0.001; quality assurance-pre 0.72 (95 % CI, 0.67, 0.77) versus post 0.84 (95 % CI, 0.80, 0.88)). There were statistically significant improvements in scores for nurses stigmatising patients (Jamaica reports of not stigmatising-pre-post intervention 33.9 versus 62.4 %, pre-post control 54.7 versus 64.4 %, p = 0.002-and Kenya pre-post intervention 35 versus 51.6 %, pre-post control 34.2 versus 47.8 %, p = 0.006) and for nurses being stigmatised (Kenya reports of no stigmatisation-pre-post intervention 23 versus 37.3 %, pre-post control 15.4 versus 27 %, p = 0.004). Multivariate results for Kenya and Jamaica were non-significant. Twelve hubs were established; 11 were active at follow-up. Hub members (n = 34) reported significant improvements in their capacity to address care gaps.

CONCLUSIONS

Leadership hubs, comprising nurses and other stakeholders committed to change and provided with capacity building can collectively identify issues and act on strategies that may improve practice and policy. Overall, hubs did not provide the necessary force to improve the uptake of evidence-informed HIV care in their districts. If hubs are to succeed, they must be integrated within district health authorities and become part of formal, legal organisations that can regularise and sustain them.

Finding Meaning: HIV Self-Management and Wellbeing among People Taking Antiretroviral Therapy in Uganda

The health of people living with HIV (PLWH) and the sustained success of antiretroviral therapy (ART) programmes depends on PLWH’s motivation and ability to self-manage the condition over the long term, including adherence to drugs on a daily basis. PLWH’s self-management of HIV and their wellbeing are likely to be interrelated. Successful self-management sustains wellbeing, and wellbeing is likely to motivate continued self-management. Detailed research is lacking on PLWH’s self-management processes on ART in resource-limited settings. This paper presents findings from a study of PLWH’s self-management and wellbeing in Wakiso District, Uganda. Thirty-eight PLWH (20 women, 18 men) were purposefully selected at ART facilities run by the government and by The AIDS Support Organisation in and around Entebbe. Two in-depth interviews were completed with each participant over three or four visits. Many were struggling economically, however the recovery of health and hope on ART had enhanced wellbeing and motivated self-management. The majority were managing their condition well across three broad domains of self-management. First, they had mobilised resources, notably through good relationships with health workers. Advice and counselling had helped them to reconceptualise their condition and situation more positively and see hope for the future, motivating their work to self-manage. Many had also developed a new network of support through contacts they had developed at the ART clinic. Second, they had acquired knowledge and skills to manage their health, a useful framework to manage their condition and to live their life. Third, participants were psychologically adjusting to their condition and their new ‘self’: they saw HIV as a normal disease, were coping with stigma and had regained self-esteem, and were finding meaning in life. Our study demonstrates the centrality of social relationships and other non-medical aspects of wellbeing for self-management which ART programmes might explore further and encourage.

Practicalities and challenges in re-orienting the health system in Zambia for treating chronic conditions

Background

The rapid evolution in disease burdens in low- and middle income countries is forcing policy makers to re-orient their health system towards a system which has the capability to simultaneously address infectious and non-communicable diseases. This paper draws on two different but overlapping studies which examined how actors in the Zambian health system are re-directing their policies, strategies and service structures to include the provision of health care for people with chronic conditions.

Methods

Study methods in both studies included semi-structured interviews with government health officials at national level, and governmental and non-governmental health practitioners operating from community-, primary health care to hospital facility level. Focus group discussions were conducted with staff, stakeholders and caregivers of programmes providing care and support at community- and household levels. Study settings included urban and rural sites.

Results

A series of adaptations transformed the HIV programme from an emergency response into the first large chronic care programme in the country. There are clear indications that the Zambian government is intending to expand this reach to patients with non-communicable diseases. Challenges to do this effectively include a lack of proper NCD prevalence data for planning, a concentration of technology and skills to detect and treat NCDs at secondary and tertiary levels in the health system and limited interest by donor agencies to support this transition.

Conclusion

The reorientation of Zambia’s health system is in full swing and uses the foundation of a decentralised health system and presence of local models for HIV chronic care which actively involve community partners, patients and their families. There are early warning signs which could cause this transition to stall, one of which is the financial capability to resource this process.