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Florindo M, Gregório J, Rodrigues LM. Lower-Limb Perfusion and Cardiovascular Physiology Are Significantly Improved in Non-Healthy Aged Adults by Regular Home-Based Physical Activities-An Exploratory Study. Life (Basel) 2024; 14:241. [PMID: 38398750 PMCID: PMC10890040 DOI: 10.3390/life14020241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
Common daily activities including walking might be used to improve cardiovascular health in the presence of disease. Thus, we designed a specific home-based physical activity program to assess cardiovascular indicators in an older, non-active, non-healthy population. Ten participants, with a mean age of 62.4 ± 5.6 years old, were chosen and evaluated twice-upon inclusion (D0), and on day 30 (D30)-following program application. Perfusion was measured in both feet by laser Doppler flowmetry (LDF) and by polarised spectroscopy (PSp). Measurements were taken at baseline (Phase 1) immediately after performing the selected activities (Phase 2) and during recovery (Phase 3). Comparison outcomes between D0 and D30 revealed relevant differences in Phase 1 recordings, namely a significant increase in LDF perfusion (p = 0.005) and a significant decrease in systolic blood pressure (p = 0.008) and mean arterial pressure (MAP) (p = 0.037). A correlation between the increase in perfusion and the weekly activity time was found (p = 0.043). No differences were found in Phase 2, but, in Phase 3, LDF values were still significantly higher in D30 compared with D0. These simple activities, regularly executed with minimal supervision, significantly improved the lower-limb perfusion while reducing participants' systolic pressure and MAP, taken as an important improvement in their cardiovascular status.
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Affiliation(s)
- Margarida Florindo
- CBIOS—Research Center for Biosciences & Health Technologies, Universidade Lusófona, 1749 024 Lisboa, Portugal; (M.F.)
- Department of Physiotherapy, ESSCVP—Portuguese Red Cross Health School, 1300 125 Lisboa, Portugal
- Escuela de Doctorado, Programa de Ciencias de la Salud, Universidade de Alcalá, 28034 Madrid, Spain
| | - João Gregório
- CBIOS—Research Center for Biosciences & Health Technologies, Universidade Lusófona, 1749 024 Lisboa, Portugal; (M.F.)
| | - Luís Monteiro Rodrigues
- CBIOS—Research Center for Biosciences & Health Technologies, Universidade Lusófona, 1749 024 Lisboa, Portugal; (M.F.)
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Habboush A, Ekzayez A, Gilmore B. A framework for community health worker optimisation in conflict settings: prerequisites and possibilities from Northwest Syria. BMJ Glob Health 2023; 8:e011837. [PMID: 37407227 PMCID: PMC10335591 DOI: 10.1136/bmjgh-2023-011837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 06/05/2023] [Indexed: 07/07/2023] Open
Abstract
BACKGROUND The world will face a human resource gap of 10 million health workers in 2030. Community health workers (CHWs) can contribute to mitigating this workforce gap while improving equitable access to care and health outcomes. However, questions on how to best implement and optimise CHW programmes, especially across varied contexts, remain. As each context has its determinants for a successful CHW programme, this research identifies and assesses pertinent factors needed for optimal CHW programmes in conflict settings, specifically Northwest Syria. METHODS A mixed-methods study in Northwest Syria consisting of a literature and document review, semistructured interviews with CHWs' team leaders and programme managers, key informant interviews with policymakers and a survey with CHWs was conducted across three research phases from 2018 to 2022. The three phases aimed to identify, refine and finalise a framework for CHW optimisation in humanitarian conflict contexts, respectively. Qualitative data were analysed thematically, and quantitative data were statistically analysed to identify critical trends. RESULTS 16 interviews and 288 surveys were conducted, supplemented by key reports and literature. The framework underwent two iterative rounds of refinement, reflecting varying stakeholders' perceptions of CHW optimisation. The resulting framework presents important implementation factors with subthemes across identified topics of institutionalisation, integration and representation for CHW optimisation in Northwest Syria and other humanitarian conflict contexts. The presented factors are similar in various ways to other fragile low/middle-income country settings. However, in protracted conflict settings like Syria, careful consideration should be given to strategic dimensions such as integration and representation. CONCLUSION For CHW programmes to impact health outcomes in humanitarian conflict settings, they require a set of implementation and design factors relevant to the context. The dynamics of humanitarian funding restrictions, health system capacity and governance structures confront achieving these requirements. Nevertheless, pioneering projects which use available resources are possible. Evidence is needed to understand the impact of CHWs' interventions and further support implementation across humanitarian contexts.
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Affiliation(s)
- Ahmad Habboush
- Research for Health System Strengthening in Syria, UOSSM, Gaziantep, Turkey
- Health Systems, Syria Public Health Network, London, UK
| | - Abdulkarim Ekzayez
- Health Systems, Syria Public Health Network, London, UK
- War Studies, King's College London, London, UK
| | - Brynne Gilmore
- UCD Centre for Interdisciplinary Research, Education and Innovation in Health Systems (UCD IRIS), School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland
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Hoke T, Bateganya M, Toyo O, Francis C, Shrestha B, Philakone P, Pandey SR, Persaud N, Cassell MM, Wilcher R, Mahler H. How Home Delivery of Antiretroviral Drugs Ensured Uninterrupted HIV Treatment During COVID-19: Experiences From Indonesia, Laos, Nepal, and Nigeria. GLOBAL HEALTH, SCIENCE AND PRACTICE 2021; 9:978-989. [PMID: 34933991 PMCID: PMC8691873 DOI: 10.9745/ghsp-d-21-00168] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 08/10/2021] [Indexed: 01/29/2023]
Abstract
INTRODUCTION Faced with the coronavirus disease (COVID-19) pandemic, governments worldwide instituted lockdowns to curtail virus spread. Health facility closures and travel restrictions disrupted access to antiretroviral (ARV) therapy for people living with HIV. This report describes how HIV programs in Indonesia, Laos, Nepal, and Nigeria supported treatment continuation by introducing home delivery of ARVs. METHODS Staff supporting the programs provided accounts of when and how decisions were taken to support ARV home delivery. They captured programmatic information about home delivery implementation using an intervention documentation tool. The 4 country experiences revealed lessons learned about factors favoring successful expansion of ARV home delivery. RESULTS Three of the countries relied on existing networks of community health workers for ARV delivery; the fourth country, Indonesia, relied on a private sector courier service. Across the 4 countries, between 19% and 51% of eligible clients were served by home delivery. The experiences showed that ARV home delivery is feasible and acceptable to health service providers, clients, and other stakeholders. Essential to success was rapid mobilization of stakeholders who led the design of the home delivery mechanisms and provided leadership support of the service innovations. Timely service adaptation was made possible by pre-existing differentiated models of care supportive of community-based ARV provision by outreach workers. Home delivery models prioritized protection of client confidentiality and prevention measures for COVID-19. Sustainability of the innovation depends on reinforcement of the commodity management infrastructure and investment in financing mechanisms. CONCLUSION Home delivery of ARVs is a feasible client-centered approach to be included among the options for decentralized drug distribution. It serves as a measure for expanding access to care both when access to health services is disrupted and under routine circumstances.
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Affiliation(s)
| | | | - Otoyo Toyo
- Achieving Health Nigeria Initiative, Akwa Ibom, Nigeria
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Zakumumpa H, Tumwine C, Milliam K, Spicer N. Dispensing antiretrovirals during Covid-19 lockdown: re-discovering community-based ART delivery models in Uganda. BMC Health Serv Res 2021; 21:692. [PMID: 34256756 PMCID: PMC8276217 DOI: 10.1186/s12913-021-06607-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 06/04/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The notion of health-system resilience has received little empirical attention in the current literature on the Covid-19 response. We set out to explore health-system resilience at the sub-national level in Uganda with regard to strategies for dispensing antiretrovirals during Covid-19 lockdown. METHODS We conducted a qualitative case-study of eight districts purposively selected from Eastern and Western Uganda. Between June and September 2020, we conducted qualitative interviews with district health team leaders (n = 9), ART clinic managers (n = 36), representatives of PEPFAR implementing organizations (n = 6).In addition, six focus group discussions were held with recipients of HIV care (48 participants). Qualitative data were analyzed using thematic approach. RESULTS Five broad strategies for distributing antiretrovirals during 'lockdown' emerged in our analysis: accelerating home-based delivery of antiretrovirals,; extending multi-month dispensing from three to six months for stable patients; leveraging the Community Drug Distribution Points (CDDPs) model for ART refill pick-ups at outreach sites in the community; increasing reliance on health information systems, including geospatial technologies, to support ART refill distribution in unmapped rural settings. District health teams reported leveraging Covid-19 outbreak response funding to deliver ART refills to homesteads in rural communities. CONCLUSION While Covid-19 'lockdown' restrictions undoubtedly impeded access to facility-based HIV services, they revived interest by providers and demand by patients for community-based ART delivery models in case-study districts in Uganda.
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Affiliation(s)
- Henry Zakumumpa
- Makerere University, School of Public Health, Kampala, Uganda.
| | | | - Kiconco Milliam
- Department of Sociology, Kyambogo University, Kampala, Uganda
| | - Neil Spicer
- London School of Hygiene and Tropical Medicine, London, UK
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Angwenyi V, Bunders‐Aelen J, Criel B, Lazarus JV, Aantjes C. 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. HEALTH & SOCIAL CARE IN THE COMMUNITY 2021; 29:353-368. [PMID: 32671938 PMCID: PMC7983972 DOI: 10.1111/hsc.13094] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 05/02/2020] [Accepted: 06/12/2020] [Indexed: 05/08/2023]
Abstract
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.
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Affiliation(s)
- Vibian Angwenyi
- Athena Institute for Research on Innovation and Communication in Health and Life SciencesFaculty of SciencesVrije Universiteit AmsterdamAmsterdamthe Netherlands
- Unit of Equity and HealthDepartment of Public HealthInstitute of Tropical MedicineAntwerpBelgium
- Barcelona Institute for Global Health (ISGlobal)Hospital ClínicUniversity of BarcelonaBarcelonaSpain
| | - Joske Bunders‐Aelen
- Athena Institute for Research on Innovation and Communication in Health and Life SciencesFaculty of SciencesVrije Universiteit AmsterdamAmsterdamthe Netherlands
| | - Bart Criel
- Unit of Equity and HealthDepartment of Public HealthInstitute of Tropical MedicineAntwerpBelgium
| | - Jeffrey V. Lazarus
- Barcelona Institute for Global Health (ISGlobal)Hospital ClínicUniversity of BarcelonaBarcelonaSpain
| | - Carolien Aantjes
- Health Economics and HIV/AIDS Research Division (HEARD)University of KwaZulu‐NatalDurbanSouth Africa
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Etoori D, Wringe A, Renju J, Kabudula CW, Gomez-Olive FX, Reniers G. Challenges with tracing patients on antiretroviral therapy who are late for clinic appointments in rural South Africa and recommendations for future practice. Glob Health Action 2021; 13:1755115. [PMID: 32340584 PMCID: PMC7241554 DOI: 10.1080/16549716.2020.1755115] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background: It is common practice for HIV programmes to routinely trace patients who are late for a scheduled clinic visit to ensure continued care engagement. In South Africa, patients who are late for a scheduled visit are identified from clinic registers, and called by telephone up to three times by designated clinic staff, with home visits conducted for those who are unreachable by phone. It is important to understand outcomes among late patients in order to have accurate mortality data, identify defaulters to attempt to re-engage them into care, and have accurate estimates of patients still in care for planning purposes. Objective: We conducted a study to assess whether tracing of HIV patients in clinics in rural north-eastern South Africa was implemented in line with national policies. Methods: Thirty-three person-day of observations took place during multiple visits to eight facilities between October 2017 and January 2018 during which clinic tracing processes were captured. The facility level implementation processes were compared to the intended tracing process and gaps and challenges were identified. Results: Challenges to implementing effective tracing procedures fell into three broad categories: i) facility-level barriers, ii) issues relating to data, documentation and record-keeping, and iii) challenges relating to the roles and responsibilities of the different actors in the tracing cascade. We recommend improving linkages between clinics, improving record-keeping systems, and regular training of community health workers involved in tracing activities. Improved links between clinics would reduce the chance of patients being lost between clinics. Record-keeping systems could be improved through motivating health workers to take ownership of their data and training them on the importance of complete data. Finally, training of community health workers may improve sustained motivation, and improve their ability to respond appropriately to their clients’ needs. Conclusions: Substantial investment in data infrastructure and healthcare staff training is needed to improve routine tracing.
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Affiliation(s)
- David Etoori
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Alison Wringe
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Jenny Renju
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK.,Department of Epidemiology and Biostatistics, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Chodziwadziwa Whiteson Kabudula
- MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Francesc Xavier Gomez-Olive
- MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Georges Reniers
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK.,MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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Philbin MM, Parish C, Bergen S, Kerrigan D, Kinnard EN, Reed SE, Cohen MH, Sosanya O, Sheth AN, Adimora AA, Cocohoba J, Goparaju L, Golub ET, Fischl M, Alcaide ML, Metsch LR. A Qualitative Exploration of Women's Interest in Long-Acting Injectable Antiretroviral Therapy Across Six Cities in the Women's Interagency HIV Study: Intersections with Current and Past Injectable Medication and Substance Use. AIDS Patient Care STDS 2021; 35:23-30. [PMID: 33400587 PMCID: PMC7826427 DOI: 10.1089/apc.2020.0164] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Medications for antiretroviral therapy (ART) and preexposure prophylaxis (PrEP) are currently daily pill regimens, which pose barriers to long-term adherence. Long-acting injectable (LAI) modalities have been developed for ART and PrEP, but minimal LAI-focused research has occurred among women. Thus, little is known about how women's history of injection for medical or nonmedical purposes may influence their interest in LAI. We conducted 89 in-depth interviews at 6 sites (New York, NY; Chicago, IL; San Francisco, CA; Atlanta, GA; Chapel Hill, NC; Washington, DC) of the Women's Interagency HIV study. Interviews occurred with women living with HIV (n = 59) and HIV-negative women (n = 30) from November 2017 to October 2018. Interviews were recorded, transcribed, and analyzed using thematic content analysis. Women's prior experiences with injections occurred primarily through substance use, physical comorbidities, birth control, or flu vaccines. Four primary categories of women emerged; those who (1) received episodic injections and had few LAI-related concerns; (2) required frequent injections and would refuse additional injections; (3) had a history of injection drug use, of whom some feared LAI might trigger a recurrence, while others had few LAI-related concerns; and (4) were currently injecting drugs and had few LAI-related concerns. Most women with a history of injectable medication would prefer LAI, but those with other frequent injections and history of injection drug use might not. Future research needs to address injection-related concerns, and develop patient-centered approaches to help providers best identify which women could benefit from LAI use.
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Affiliation(s)
- Morgan M. Philbin
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, New York, USA
- Address correspondence to: Morgan M. Philbin, PhD, MHS, Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, 722 West 168th Street, New York, NY 10032, USA
| | - Carrigan Parish
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Sadie Bergen
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Deanna Kerrigan
- Department of Prevention and Community Health, Milken Institute School of Public Health at George Washington University, District of Columbia, USA
| | - Elizabeth N. Kinnard
- Division of Epidemiology, UC Berkeley School of Public Health, Berkeley, California, USA
| | - Sarah E. Reed
- Teachers College, Columbia University, New York, New York, USA
| | - Mardge H. Cohen
- Department of Medicine, John H. Stroger Jr. Hospital of Cook County, Chicago, Illinois, USA
| | - Oluwakemi Sosanya
- Department of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Anandi N. Sheth
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Adaora A. Adimora
- Division of Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jennifer Cocohoba
- Department of Clinical Pharmacy, University of California at San Francisco School of Pharmacy, San Francisco, California, USA
| | - Lakshmi Goparaju
- Department of Medicine, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Elizabeth T. Golub
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Margaret Fischl
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Maria L. Alcaide
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Lisa R. Metsch
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, New York, USA
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Viljoen L, Bond VA, Reynolds LJ, Mubekapi‐Musadaidzwa C, Baloyi D, Ndubani R, Stangl A, Seeley J, Pliakas T, Bock P, Fidler S, Hayes R, Ayles H, Hargreaves JR, Hoddinott G. Universal HIV testing and treatment and HIV stigma reduction: a comparative thematic analysis of qualitative data from the HPTN 071 (PopART) trial in South Africa and Zambia. SOCIOLOGY OF HEALTH & ILLNESS 2021; 43:167-185. [PMID: 33085116 PMCID: PMC7894283 DOI: 10.1111/1467-9566.13208] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 09/16/2020] [Accepted: 09/24/2020] [Indexed: 06/11/2023]
Abstract
Despite continued development of effective HIV treatment, expanded access to care and advances in prevention modalities, HIV-related stigma persists. We examine how, in the context of a universal HIV-testing and treatment trial in South Africa and Zambia, increased availability of HIV services influenced conceptualisations of HIV. Using qualitative data, we explore people's stigma-related experiences of living in 'intervention' and 'control' study communities. We conducted exploratory data analysis from a qualitative cohort of 150 households in 13 study communities, collected between 2016 and 2018. We found that increased availability of HIV-testing services influenced conceptualisations of HIV as normative (non-exceptional) and the visibility of people living with HIV (PLHIV) in household and community spaces impacted opportunities for stigma. There was a shift in community narratives towards individual responsibility to take up (assumingly) widely available service - for PLHIV to take care of their own health and to prevent onward transmission. Based on empirical data, we show that, despite a growing acceptance of HIV-related testing services, anticipated stigma persists through the mechanism of shifting responsibilisation. To mitigate the responsibilisation of PLHIV, heath implementers need to adapt anti-stigma messaging and especially focus on anticipated stigma.
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Affiliation(s)
- Lario Viljoen
- Department of Paediatrics and Child HealthFaculty of Medicine and Health SciencesDesmond Tutu TB CentreStellenbosch UniversityStellenboschSouth Africa
- Department of Sociology and Social AnthropologyStellenbosch UniversityStellenboschSouth Africa
| | - Virginia A. Bond
- ZambartSchool of Public HealthRidgeway CampusUniversity of ZambiaLusakaZambia
- Global Health and Development DepartmentFaculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Lindsey J. Reynolds
- Department of Sociology and Social AnthropologyStellenbosch UniversityStellenboschSouth Africa
| | - Constance Mubekapi‐Musadaidzwa
- Department of Paediatrics and Child HealthFaculty of Medicine and Health SciencesDesmond Tutu TB CentreStellenbosch UniversityStellenboschSouth Africa
| | - Dzunisani Baloyi
- Department of Paediatrics and Child HealthFaculty of Medicine and Health SciencesDesmond Tutu TB CentreStellenbosch UniversityStellenboschSouth Africa
| | - Rhoda Ndubani
- ZambartSchool of Public HealthRidgeway CampusUniversity of ZambiaLusakaZambia
| | - Anne Stangl
- International Center for Research on WomenWashingtonDCUSA
| | - Janet Seeley
- Global Health and Development DepartmentFaculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Triantafyllos Pliakas
- Department of Public Health, Environments and SocietyFaculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Peter Bock
- Department of Paediatrics and Child HealthFaculty of Medicine and Health SciencesDesmond Tutu TB CentreStellenbosch UniversityStellenboschSouth Africa
| | - Sarah Fidler
- Imperial College NIHR BRCImperial College LondonLondonUK
| | - Richard Hayes
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Public HealthLondon School of Hygiene and Tropical MedicineLondonUK
| | - Helen Ayles
- ZambartSchool of Public HealthRidgeway CampusUniversity of ZambiaLusakaZambia
- Department of Public Health, Environments and SocietyFaculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
| | - James R. Hargreaves
- Department of Public Health, Environments and SocietyFaculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Graeme Hoddinott
- Department of Paediatrics and Child HealthFaculty of Medicine and Health SciencesDesmond Tutu TB CentreStellenbosch UniversityStellenboschSouth Africa
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Kupa PM, Geyer LS. A qualitative evaluation of a stress management programme for HIV and AIDS home-based care workers in Tshwane, South Africa. SAHARA J 2020; 17:1-15. [PMID: 32921228 PMCID: PMC7534294 DOI: 10.1080/17290376.2020.1810747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
The HIV and AIDS pandemic resulted in increased demands on the South African healthcare system and contributed to elevated stress levels among healthcare workers, including home-based care workers. The goal of the study was to evaluate a stress management programme for HIV and AIDS home-based care workers in Tshwane, South Africa. Social constructionism was adopted as the theoretical framework of the study. The study implemented intervention research and adopted a qualitative research approach, specifically the instrumental case study. Non-probability sampling, specifically volunteer sampling was utilised to recruit a group of twelve HIV and AIDS home-based care workers (n = 12). The data were collected through semi-structured interviews and administered before and after exposure to the stress management programme. The research findings, based on thematic analysis, revealed that the programme was effective in mitigating the impact of stress experienced by the HIV and AIDS home-based care workers in Tshwane. Recommendations are proffered for the refinement of the newly developed stress management programme for implementation among HIV and AIDS home-based care workers in similar field settings.
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Affiliation(s)
- P M Kupa
- Department of Social Work & Criminology, University of Pretoria, Pretoria, South Africa
| | - L S Geyer
- Department of Social Work & Criminology, University of Pretoria, Pretoria, South Africa
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Goudge J, de Kadt J, Babalola O, Muteba M, Tseng YH, Malatji H, Rwafa T, Nxumalo N, Levin J, Thorogood M, Daviaud E, Watkins J, Griffiths F. Household coverage, quality and costs of care provided by community health worker teams and the determining factors: findings from a mixed methods study in South Africa. BMJ Open 2020; 10:e035578. [PMID: 32819939 PMCID: PMC7440700 DOI: 10.1136/bmjopen-2019-035578] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVE Community health workers (CHWs) are undertaking more complex tasks as part of the move towards universal health coverage in South Africa. CHW programmes can improve access to care for vulnerable communities, but many such programmes struggle with insufficient supervision. In this paper, we assess coverage (proportion of households visited by a CHW in the past year and month), quality of care and costs of the service provided by CHW teams with differing configurations of supervisors, some based in formal clinics and some in community health posts. PARTICIPANTS CHW, their supervisors, clinic staff, CHW clients. METHODS We used mixed methods (a random household survey, focus group discussions, interviews and observations of the CHW at work) to examine the performance of six CHW teams in vulnerable communities in Sedibeng, South Africa. RESULTS A CHW had visited 17% of households in the last year, and we estimated they were conducting one to two visits per day. At household registration visits, the CHW asked half of the questions required. Respondents remembered 20%-25% of the health messages that CHW delivered from a visit in the last month, and half of the respondents took the action recommended by the CHW. Training, supervision and motivation of the CHW, and collaboration with other clinic staff, were better with a senior nurse supervisor. We estimated that if CHW carried out four visits a day, coverage would increase to 30%-90% of households, suggesting that some teams need more CHW, as well as better supervision. CONCLUSION Household coverage was low, and the service was limited. Support from the local facility was key to providing a quality service, and a senior supervisor facilitated this collaboration. Greater investment in numbers of CHW, supervisors, training and equipment is required for the potential benefits of the programme to be delivered.
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Affiliation(s)
- Jane Goudge
- Centre for Health Policy, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Julia de Kadt
- Centre for Health Policy, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Olukemi Babalola
- Centre for Health Policy, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Michel Muteba
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Yu-Hwei Tseng
- Centre for Health Policy, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Hlologelo Malatji
- Centre for Health Policy, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Teurai Rwafa
- Centre for Health Policy, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nonhlanhla Nxumalo
- Centre for Health Policy, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jonathan Levin
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Emmanuelle Daviaud
- Health Systems, South African Medical Research Council, Tygerberg, South Africa
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Larki M, Latifnejad Roudsari R. Home-Based Care, the Missing Link in Caring of Patients Living with HIV/AIDS and Their Family Members: A Narrative Review. INTERNATIONAL JOURNAL OF COMMUNITY BASED NURSING AND MIDWIFERY 2020; 8:190-208. [PMID: 32656272 PMCID: PMC7334750 DOI: 10.30476/ijcbnm.2020.82771.1085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Inconsistencies between the number of patients, qualified caregivers and lack of adequate services and resources in the healthcare systems for people living with HIV/AIDS have led to the idea of providing healthcare services for this vulnerable population at home. This study aimed to review the evidence related to the Home-Based Care (HBC) programs in the context of HIV. Literature search was carried out without publication date limit through English databases of Cochrane Library, PubMed, EBSCO, Scopus, Google Scholar, Science Direct, as well as Persian databases including Magiran and SID by the end of July 2019. Out of 1312 studies retrieved from the search of databases, six guidelines and 50 articles met the eligible criteria. The results showed that the overall purpose of HBC is to create hope through providing appropriate care to help the patients and their families to maintain their independence and have the best possible quality of life. The potential benefits of HBC could be discussed in three main categories: 1) patients, including patients’ satisfaction, quality of life, adherence to antiretroviral therapy, preventing mother-to-child transmission, as well as biochemical, social and psychological outcomes, 2) families, consisted of promotinon of family members’ participation, enhancement of family members’ awareness and provision of voluntary counseling and testing, and 3) healthcare systems, containing health care costs, workload at healthcare centers and time spent on services. Given the lessons learnt from the existing HBC programs, developing an alternative approach for providing healthcare at home in the context of HIV seems necessary and could be an agenda for action in health policy making in Iran.
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Affiliation(s)
- Mona Larki
- Student Research Committee, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Robab Latifnejad Roudsari
- Nursing and Midwifery Care Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.,Department of Midwifery, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran
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Angwenyi V, Aantjes C, Kondowe K, Mutchiyeni JZ, Kajumi M, Criel B, Lazarus JV, Quinlan T, Bunders-Aelen J. Moving to a strong(er) community health system: analysing the role of community health volunteers in the new national community health strategy in Malawi. BMJ Glob Health 2018; 3:e000996. [PMID: 30498595 PMCID: PMC6254745 DOI: 10.1136/bmjgh-2018-000996] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 09/17/2018] [Accepted: 09/22/2018] [Indexed: 11/30/2022] Open
Abstract
Since the Alma Ata Declaration in 1978, community health volunteers (CHVs) have been at the forefront, providing health services, especially to underserved communities, in low-income countries. However, consolidation of CHVs position within formal health systems has proved to be complex and continues to challenge countries, as they devise strategies to strengthen primary healthcare. Malawi's community health strategy, launched in 2017, is a novel attempt to harmonise the multiple health service structures at the community level and strengthen service delivery through a team-based approach. The core community health team (CHT) consists of health surveillance assistants (HSAs), clinicians, environmental health officers and CHVs. This paper reviews Malawi's strategy, with particular focus on the interface between HSAs, volunteers in community-based programmes and the community health team. Our analysis identified key challenges that may impede the strategy's implementation: (1) inadequate training, imbalance of skill sets within CHTs and unclear job descriptions for CHVs; (2) proposed community-level interventions require expansion of pre-existing roles for most CHT members; and (3) district authorities may face challenges meeting financial obligations and filling community-level positions. For effective implementation, attention and further deliberation is needed on the appropriate forms of CHV support, CHT composition with possibilities of co-opting trained CHVs from existing volunteer programmes into CHTs, review of CHT competencies and workload, strengthening coordination and communication across all community actors, and financing mechanisms. Policy support through the development of an addendum to the strategy, outlining opportunities for task-shifting between CHT members, CHVs' expected duties and interactions with paid CHT personnel is recommended.
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Affiliation(s)
- Vibian Angwenyi
- Athena Institute for Research on Innovation and Communication in Health and Life Sciences, Faculty of Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Unit of Equity and Health, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Carolien Aantjes
- Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu-Natal, Westville Campus, Durban, South Africa
| | - Ketwin Kondowe
- Phalombe District Health Office, Ministry of Health, Phalombe, Malawi
| | | | - Murphy Kajumi
- Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu-Natal, Westville Campus, Durban, South Africa
| | - Bart Criel
- Unit of Equity and Health, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Jeffrey V Lazarus
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Tim Quinlan
- Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu-Natal, Westville Campus, Durban, South Africa
| | - Joske Bunders-Aelen
- Athena Institute for Research on Innovation and Communication in Health and Life Sciences, Faculty of Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Paid staff or volunteers - does it make a difference? The impact of staffing on child outcomes for children attending community-based programmes in South Africa and Malawi. Glob Health Action 2018; 10:1381462. [PMID: 29214899 PMCID: PMC5727430 DOI: 10.1080/16549716.2017.1381462] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Globally, and in low and middle income countries (LMIC) specifically, there is a critical shortage of workers. The use of volunteers to support such care delivery systems has been examined, there is scant literature on the impact of volunteers on child outcome in high human immunodeficiency virus (HIV)-affected communities. Objectives: To examine the differential impact of paid versus volunteer workforce in Community Based Organisations (CBOs) providing care to children and families affected by the HIV epidemic in South Africa and Malawi on child outcomes over time. Methods: This study compared child outcomes for 989 consecutive children attending CBOs (0.7% refusal) at baseline and 854 at follow-up (86.3% response rate). Results: Children attending CBOs with paid staff had higher self-esteem, fewer emotional/behavioural problems and less perceived stigma. Likewise, children attending CBOs with paid staff had fewer educational risks, and 20 heightened cognitive performance, and the digit-span memory test. After controlling for outcome at baseline, gender, age, HIV status, and disability, attending a CBO with paid staff remained a significant independent predictor of higher self-esteem scores, less perceived stigma, as well as fewer educational risks and better performance on the drawing test. We found no associations between CBO attendance – paid or volunteer – and children’s depressive and trauma symptoms. Conclusions: Our findings show that in order to most optimally impact on child outcome 30 community-based workers (CBWs) should ideally be paid with trained staff. Specialised input for more severe child difficulties is needed.
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Ngugi AK, Nyaga LW, Lakhani A, Agoi F, Hanselman M, Lugogo G, Mehta KM. Prevalence, incidence and predictors of volunteer community health worker attrition in Kwale County, Kenya. BMJ Glob Health 2018; 3:e000750. [PMID: 30105093 PMCID: PMC6074629 DOI: 10.1136/bmjgh-2018-000750] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 06/12/2018] [Accepted: 06/16/2018] [Indexed: 11/05/2022] Open
Abstract
Introduction In underserved populations, the contribution of community health workers (CHWs) is vital to the healthcare systems. Attrition of these workers causes critical breakdowns in the delivery of essential services to these populations. Literature on reasons for attrition is limited, although some have been identified in studies on sustainability of CHW programmes. These factors are, however, likely to be influenced by context. We measured CHW attrition and its predictors in a rural area in Kenya. Methods We conducted a nested case–control study and focus group discussions among CHWs involved in a maternal and child health project. A training register of 1005 CHWs was used to sample and follow CHWs for attrition. Incidence of CHW attrition was calculated using a Poisson model. Separately, we used logistic regression to determine predictors of CHW attrition. Results Of the 1005 CHWs, 498 (49.6%) had left the project by the time of the study. The incidence of attrition was 46.8/1000 person-years (95% CI 38.7 to 56.5). In the case–control study, lack of interest in peer organisation membership (OR 5.3; 95% CI 1.3 to 20.6) was associated with attrition. Absence of refresher training (OR 4.0; 95% CI 2.2 to 7.1) and receiving no feedback from supervisors (OR 2.0; 95% CI 1.0 to 3.9) were also associated with attrition. Discordance in expectations and perceived heavy workload were also identified as key reasons for attrition in the qualitative study. Conclusion This study estimates high prevalence and incidence of CHW attrition in Kwale County, Kenya. Ongoing training, feedback and peer support are also important in enhancing retention of CHWs. Additionally, expectations regarding the roles and benefits of involvement in CHW work should be communicated clearly, and workload should be kept reasonable or negotiated with the CHWs.
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Affiliation(s)
- Anthony K Ngugi
- Centre for Population Health Sciences, Faculty of Health Sciences, Aga Khan University (EA), Nairobi, Kenya
| | - Lucy W Nyaga
- Centre for Population Health Sciences, Faculty of Health Sciences, Aga Khan University (EA), Nairobi, Kenya
| | - Amyn Lakhani
- Centre for Population Health Sciences, Faculty of Health Sciences, Aga Khan University (EA), Nairobi, Kenya
| | - Felix Agoi
- Centre for Population Health Sciences, Faculty of Health Sciences, Aga Khan University (EA), Nairobi, Kenya
| | - Margrette Hanselman
- Centre for Population Health Sciences, Faculty of Health Sciences, Aga Khan University (EA), Nairobi, Kenya
| | - George Lugogo
- Lungalunga Sub-county Public Health Office, Lungalunga Sub-county, Kwale County, Kenya
| | - Kala M Mehta
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
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Morton D, Mayekiso T, Cunningham P. Structural barriers to South African volunteer home-based caregivers providing quality care: the need for a policy for caregivers not affiliated to primary healthcare clinics. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2018; 17:47-53. [PMID: 29504501 DOI: 10.2989/16085906.2017.1397719] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Community home-based care (CHBC) is a critical component of non-formal care in communities in Africa that have a high prevalence of HIV and tuberculosis (TB). Community carers consisting primarily of volunteers are critical role players in African healthcare systems and particularly in South Africa's strategy to fight HIV and AIDS. This paper explores the structural barriers volunteer caregivers need to overcome to provide quality CHBC. The researchers used two focus group discussions with key informants (each with four participants), and semi-structured interviews with six key informants to collect data relating to the meaning of quality CHBC. The data were coded using Tesch's data analysis technique. A major theme that emerged from the results was "Addressing structural challenges to improve the quality of CHBC". Subthemes underpinning this theme were: 1) lack of standardised training of volunteer caregivers; 2) the need for a scope of practice, parameters and legal boundaries; 3) lack of monitoring and evaluation (M&E) of CHBC; and 4) the importance of mentoring and supervision in CHBC. CHBC policy should address the need for standardised training programmes for caregivers, so that they are equipped with multiple skills. Furthermore CHBC policy must emphasise mentoring as well as M&E to encourage quality care. Finally, the policy should provide a clear scope of practice for caregivers to regulate their competencies and boundaries.
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Affiliation(s)
- David Morton
- a Department of Nursing Science , Nelson Mandela University , Port Elizabeth , South Africa
| | - Thoko Mayekiso
- b Vice Chancellor's Office , University of Mpumalanga , Mbombela , South Africa
| | - Peter Cunningham
- c Department of Sociology and Anthropology , Nelson Mandela University , Port Elizabeth , South Africa
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Wood EM, Zani B, Esterhuizen TM, Young T. Nurse led home-based care for people with HIV/AIDS. BMC Health Serv Res 2018; 18:219. [PMID: 29587719 PMCID: PMC5870334 DOI: 10.1186/s12913-018-3002-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 03/14/2018] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Home-based care is used in many countries to increase quality of life and limit hospital stay, particularly where public health services are overburdened. Home-based care objectives for HIV/AIDS can include medical care, delivery of antiretroviral treatment and psychosocial support. This review assesses the effects of home-based nursing on morbidity in people infected with HIV/AIDS. METHODS The trials studied are in HIV positive adults and children, regardless of sex or setting and all randomised controlled. Home-based care provided by qualified nurses was compared with hospital or health-facility based treatment. The following electronic databases were searched from January 1980 to March 2015: AIDSearch, CINAHL, Cochrane Register of Controlled Trials, EMBASE, MEDLINE and PsycINFO/LIT, with an updated search in November 2016. Two authors independently screened titles and abstracts from the electronic search based on the study design, interventions and types of participant. For all selected abstracts, full text articles were obtained. The final study selection was determined with use of an eligibility form. Data extraction was performed independently from assessment of risk of bias. The results were analysed by narrative synthesis, in order to be able to obtain relevant effect measures plus 95% confidence intervals. RESULTS Seven studies met the inclusion criteria. The trial size varied from 37 to 238 participants. Only one trial was conducted in children. Five studies were conducted in the USA and two in China. Four studies looked at home-based adherence support and the rest at providing home-based psychosocial support. Reported adherence to antiretroviral drugs improved with nurse-led home-based care but did not affect viral load. Psychiatric nurse support in those with existing mental health conditions improved mental health and depressive symptoms. Home-based psychological support impacted on HIV stigma, worry and physical functioning and in certain cases depressive symptoms. CONCLUSIONS Nurse-led home-based interventions could help adherence to antiretroviral therapy and improve mental health. Further larger scale studies are needed, looking in more detail at improving medical care for HIV, especially related to screening and management of opportunistic infections and co-morbidities.
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Affiliation(s)
- Elizabeth M. Wood
- Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Babalwa Zani
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
| | - Tonya M. Esterhuizen
- Centre for Evidence-based Health Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Taryn Young
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
- Centre for Evidence-based Health Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Cataldo F, Seeley J, Nkhata MJ, Mupambireyi Z, Tumwesige E, Gibb DM. She knows that she will not come back: tracing patients and new thresholds of collective surveillance in PMTCT Option B. BMC Health Serv Res 2018; 18:76. [PMID: 29391055 PMCID: PMC5796350 DOI: 10.1186/s12913-017-2826-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 12/29/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Malawi, Uganda, and Zimbabwe have recently adopted a universal 'test-and-treat' approach to the prevention of mother-to-child transmission of HIV (Option B+). Amongst a largely asymptomatic population of women tested for HIV and immediately started on antiretroviral treatment (ART), a relatively high number are not retained in care; they are labelled 'defaulters' or 'lost-to-follow-up' patients. METHODS We draw on data collected as part of a study looking at ART decentralization (Lablite) to reflect on the spaces created through the instrumentalization of community health workers (CHWs) for the purpose of bringing women who default from Option B+ back into care. Data were collected through semi-structured interviews with CHWs who are designated to trace Option B+ patients in Uganda, Malawi and Zimbabwe. FINDINGS Lost to follow up women give a range of reasons for not coming back to health facilities and often implicitly choose not to be traced by providing a false address at enrolment. New strategies have sought to utilize CHWs' liminal positionality - situated between the experience of living with HIV, having established local social ties, and being a caretaker - in order to track 'defaulters'. CHWs are often deployed without adequate guidance or training to protect confidentiality and respect patients' choice. CONCLUSIONS CHWs provide essential linkages between health services and patients; they embody the role of 'extension workers', a bridge between a novel health policy and 'non-compliant patients'. Option B+ offers a powerful narrative of the construction of a unilateral 'moral economy', which requires the full compliance of patients newly initiated on treatment.
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Affiliation(s)
- Fabian Cataldo
- Dignitas International, Medical and Research Department, P.O.Box 1071, Zomba, Malawi
| | - Janet Seeley
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H9SH UK
- Medical Research Council /Uganda Virus Research Institute, Research Unit on AIDS, P.O.Box 49, Entebbe, Uganda
| | - Misheck J. Nkhata
- Dignitas International, Medical and Research Department, P.O.Box 1071, Zomba, Malawi
| | - Zivai Mupambireyi
- University of Zimbabwe, P.O.Box MP167, Mount Pleasant, Harare, Zimbabwe
| | - Edward Tumwesige
- Medical Research Council /Uganda Virus Research Institute, Research Unit on AIDS, P.O.Box 49, Entebbe, Uganda
| | - Diana M. Gibb
- Medical Research Council Clinical Trials Unit at University College London, 90 High Holborn WC1V 6LJ, London, UK
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Hatzipapas I, Visser MJ, Janse van Rensburg E. Laughter therapy as an intervention to promote psychological well-being of volunteer community care workers working with HIV-affected families. SAHARA J 2017; 14:202-212. [PMID: 29169302 PMCID: PMC5706473 DOI: 10.1080/17290376.2017.1402696] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The study explores the experiences of volunteer community care workers working with HIV-affected families, participating in laughter therapy. Laughter therapy is being used as an intervention to positively influence individuals experiencing various forms of emotional distress. Community care workers play a vital role in the support of the HIV/AIDS-infected and -affected members in communities. The nature of this type of work and their limited training contributes to high levels of secondary trauma and emotional exhaustion. The purpose of the study was firstly, to explore the effects of working with orphans and vulnerable children (OVC) on the community care workers and secondly, to establish the impact that laughter therapy has to positively combat stresses of working within the care workers' environment. All the community care workers from a community-based organisation that provides care for HIV/AIDS-infected and -affected OVC and their families in the greater region of Soweto, South Africa, took part in daily laughter therapy sessions for one month. To assess the experiences of participants of laughter therapy, seven community care workers agreed to participate in a mixed method assessment. Interviews were conducted before and after the intervention using the Interpretative Phenomenological Analysis as framework. As supportive data, a stress and anxiety and depression scale were added in the interview. Participants reported more positive emotions, positive coping, improved interpersonal relationships and improvement in their care work after exposure to laughter therapy. Quantitative results on stress, anxiety and depression for each participant confirmed observed changes. Laughter therapy as a self-care technique has potential as a low-cost intervention strategy to reduce stress and counteract negative emotions among people working in highly emotional environments.
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Affiliation(s)
- Irene Hatzipapas
- MA Counselling Psychology, Department of Psychology, University of Pretoria, Pretoria, South Africa
| | - Maretha J. Visser
- PhD, Professor in the Department of Psychology, University of Pretoria, Pretoria, South Africa
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Vogt F, Kalenga L, Lukela J, Salumu F, Diallo I, Nico E, Lampart E, Van den Bergh R, Shah S, Ogundahunsi O, Zachariah R, Van Griensven J. Brief Report: Decentralizing ART Supply for Stable HIV Patients to Community-Based Distribution Centers: Program Outcomes From an Urban Context in Kinshasa, DRC. J Acquir Immune Defic Syndr 2017; 74:326-331. [PMID: 27787343 PMCID: PMC5305289 DOI: 10.1097/qai.0000000000001215] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Facility-based antiretroviral therapy (ART) provision for stable patients with HIV congests health services in resource-limited countries. We assessed outcomes and risk factors for attrition after decentralization to community-based ART refill centers among 2603 patients with HIV in Kinshasa, Democratic Republic of Congo, using a multilevel Poisson regression model. Death, loss to follow-up, and transfer out were 0.3%, 9.0%, and 0.7%, respectively, at 24 months. Overall attrition was 5.66/100 person-years. Patients with >3 years on ART, >500 cluster of differentiation type-4 count, body mass index >18.5, and receiving nevirapine but not stavudine showed reduced attrition. ART refill centers are a promising task-shifting model in low-prevalence urban settings with high levels of stigma and poor ART coverage.
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Affiliation(s)
- Florian Vogt
- *Institute of Tropical Medicine Antwerp, Antwerp, Belgium; †Doctors Without Borders/Médecins Sans Frontières, Kinshasa, Democratic Republic of the Congo; ‡Réseau National des Organisations d'Assise Communautaires, Kinshasa, Democratic Republic of the Congo; §Ministry of Health, Kinshasa, Democratic Republic of the Congo; ‖Doctors Without Borders/Médecins Sans Frontières, Brussels, Belgium; and ¶World Health Organization, Geneva, Switzerland
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Robillard A, Padi A, Lewis K, Julious C, Troutman J. Advice for prevention from HIV-positive African-American women: 'My story is not just a story'. CULTURE, HEALTH & SEXUALITY 2017; 19:630-642. [PMID: 27796161 DOI: 10.1080/13691058.2016.1243732] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Large disparities in HIV incidence, prevalence and mortality exist for African-American women, especially in the southern region of the USA. Based on the culture-centric health promotion model, HIV-positive African American women can use their stories to support primary prevention. The purpose of this study was to document advice from HIV-positive African-American women (n = 25) to young African-American women, as described in their own cultural narratives collected through qualitative interviews. Content analysis of women's advice identified five common themes revolving broadly around: (1) advice for prevention, (2) support systems for prevention, (3) education, (4) empowerment/self-care and (5) potential barriers to prevention. Advice reflected recommendations based on personal experience and highlighted social determinants linked to HIV, such as stigma, access to education and healthcare, social support, and gender and power dynamics. Women also offered advice for coping with an HIV-positive diagnosis. Communication with parents, family and friends regarding education and social support emerged as an important interpersonal factor for participants, as were interactions with sexual/romantic partners. Stigma, at the community level, was consistently discussed as a hindrance to prevention. Narratives of HIV-positive women as community health agents of change can enhance the effectiveness of HIV prevention interventions for young US African-American women.
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Affiliation(s)
- Alyssa Robillard
- a Health Promotion, Education, and Behavior , University of South Carolina, Arnold School of Public Health , Columbia , USA
| | - Akhila Padi
- a Health Promotion, Education, and Behavior , University of South Carolina, Arnold School of Public Health , Columbia , USA
| | - Kaleea Lewis
- a Health Promotion, Education, and Behavior , University of South Carolina, Arnold School of Public Health , Columbia , USA
| | - Carmen Julious
- b Palmetto AIDS Life Support Services Inc , Columbia , USA
| | - Jamie Troutman
- a Health Promotion, Education, and Behavior , University of South Carolina, Arnold School of Public Health , Columbia , USA
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An assessment of the HIV/TB knowledge and skills of home-based carers working in the North West province in South Africa: a cross-sectional study. BMC Health Serv Res 2017; 17:285. [PMID: 28420356 PMCID: PMC5395798 DOI: 10.1186/s12913-017-2238-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 04/07/2017] [Indexed: 11/10/2022] Open
Abstract
Background Home-based carers (HBCs) play a critical role in ensuring the success of the primary health care re-engineering strategy in South Africa. Their role includes ensuring improved access to and delivery of primary health care at the household level, and better co-ordination and improved linkages between community and health facilities for HIV/TB services. The objective of this study was to assess the knowledge, skills, challenges and training needs of HBCs involved in HIV/TB care in one sub-district in the North-West province of South Africa. Methods We conducted a descriptive, cross-sectional study in which 157 HBCs were interviewed to assess their knowledge and skills regarding HIV and TB. Data were collected using a pre-tested semi-structured questionnaire. Quantitative and qualitative data were analysed using SPSS statistical software and thematic analysis respectively. Results One hundred and forty-four (92%) of the interviewees were female and 13 (8%) were male. The median age of the participants was 35 years (interquartile range (IQR): 22–27). The median score for knowledge of both HIV and TB questions was 66% (IQR: 57–75). In general, HIV knowledge scores were higher than TB knowledge scores (73% versus 66%). A significant association was found between knowledge scores and formal training (p < 0.05), and knowledge scores and highest educational levels (p < 0.05). Irrespective of knowledge, HBCs reported providing a variety of services to support HIV/TB services in the communities in which they worked. HBCs also reported facing various challenges in their jobs related to stigma and the social contexts in which they work. Conclusion The study showed that the overall knowledge of HBCs was limited, given the skills required and the services they provide. Given the increasing role of HBCs in various health initiatives, targeted interventions are required to support and improve their competencies and service provision.
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Poku NK, Bonnel R. Funding of community-based interventions for HIV prevention. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2017; 15:163-71. [PMID: 27399046 DOI: 10.2989/16085906.2016.1194300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Since the start of the HIV epidemic, community responses have been at the forefront of the response. Following the extraordinary expansion of global resources, the funding of community responses rose to reach at least US$690 million per year in the period 2005-2009. Since then, many civil society organisations (CSOs) have reported a drop in funding. Yet, the need for strong community responses is even more urgent, as shown by their role in reaching the Joint United Nations Programme on HIV/AIDS (UNAIDS) Fast-Track targets. In the case of antiretroviral treatment, interventions need to be adopted by most people at risk of HIV in order to have a substantial effect on the prevention of HIV at the population level. This paper reviews the published literature on community responses, funding and effectiveness. Additional funding is certainly needed to increase the coverage of community-based interventions (CBIs), but current evidence on their effectiveness is extremely mixed, which does not provide clear guidance to policy makers. This is especially an issue for adolescent girls and young women in Eastern and Southern Africa, who face extremely high infection risk, but the biomedical prevention tools that have been proven effective for the general population still remain pilot projects for this group. Research is especially needed to isolate the factors affecting the likelihood that interventions targeting this group are consistently successful. Such work could be focused on the community organisations that are currently involved in delivering gender-sensitive interventions.
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Affiliation(s)
- Nana K Poku
- a Health Economics and HIV and AIDS Research Division (HEARD) , University of KwaZulu-Natal , Durban , South Africa
| | - René Bonnel
- a Health Economics and HIV and AIDS Research Division (HEARD) , University of KwaZulu-Natal , Durban , South Africa
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Choko AT, MacPherson P, Webb EL, Willey BA, Feasy H, Sambakunsi R, Mdolo A, Makombe SD, Desmond N, Hayes R, Maheswaran H, Corbett EL. Uptake, Accuracy, Safety, and Linkage into Care over Two Years of Promoting Annual Self-Testing for HIV in Blantyre, Malawi: A Community-Based Prospective Study. PLoS Med 2015; 12:e1001873. [PMID: 26348035 PMCID: PMC4562710 DOI: 10.1371/journal.pmed.1001873] [Citation(s) in RCA: 265] [Impact Index Per Article: 29.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 07/31/2015] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Home-based HIV testing and counselling (HTC) achieves high uptake, but is difficult and expensive to implement and sustain. We investigated a novel alternative based on HIV self-testing (HIVST). The aim was to evaluate the uptake of testing, accuracy, linkage into care, and health outcomes when highly convenient and flexible but supported access to HIVST kits was provided to a well-defined and closely monitored population. METHODS AND FINDINGS Following enumeration of 14 neighbourhoods in urban Blantyre, Malawi, trained resident volunteer-counsellors offered oral HIVST kits (OraQuick ADVANCE Rapid HIV-1/2 Antibody Test) to adult (≥16 y old) residents (n = 16,660) and reported community events, with all deaths investigated by verbal autopsy. Written and demonstrated instructions, pre- and post-test counselling, and facilitated HIV care assessment were provided, with a request to return kits and a self-completed questionnaire. Accuracy, residency, and a study-imposed requirement to limit HIVST to one test per year were monitored by home visits in a systematic quality assurance (QA) sample. Overall, 14,004 (crude uptake 83.8%, revised to 76.5% to account for population turnover) residents self-tested during months 1-12, with adolescents (16-19 y) most likely to test. 10,614/14,004 (75.8%) participants shared results with volunteer-counsellors. Of 1,257 (11.8%) HIV-positive participants, 26.0% were already on antiretroviral therapy, and 524 (linkage 56.3%) newly accessed care with a median CD4 count of 250 cells/μl (interquartile range 159-426). HIVST uptake in months 13-24 was more rapid (70.9% uptake by 6 mo), with fewer (7.3%, 95% CI 6.8%-7.8%) positive participants. Being "forced to test", usually by a main partner, was reported by 2.9% (95% CI 2.6%-3.2%) of 10,017 questionnaire respondents in months 1-12, but satisfaction with HIVST (94.4%) remained high. No HIVST-related partner violence or suicides were reported. HIVST and repeat HTC results agreed in 1,639/1,649 systematically selected (1 in 20) QA participants (99.4%), giving a sensitivity of 93.6% (95% CI 88.2%-97.0%) and a specificity of 99.9% (95% CI 99.6%-100%). Key limitations included use of aggregate data to report uptake of HIVST and being unable to adjust for population turnover. CONCLUSIONS Community-based HIVST achieved high coverage in two successive years and was safe, accurate, and acceptable. Proactive HIVST strategies, supported and monitored by communities, could substantially complement existing approaches to providing early HIV diagnosis and periodic repeat testing to adolescents and adults in high-HIV settings.
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Affiliation(s)
- Augustine T. Choko
- Malawi–Liverpool–Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- * E-mail:
| | - Peter MacPherson
- Department of Public Health and Policy, University of Liverpool, Liverpool, United Kingdom
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Emily L. Webb
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Barbara A. Willey
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Helena Feasy
- Malawi–Liverpool–Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Rodrick Sambakunsi
- Malawi–Liverpool–Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Aaron Mdolo
- Malawi–Liverpool–Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | - Nicola Desmond
- Malawi–Liverpool–Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Department of Public Health and Policy, University of Liverpool, Liverpool, United Kingdom
| | - Richard Hayes
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Hendramoorthy Maheswaran
- Malawi–Liverpool–Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Division of Health Sciences, Warwick Medical School, Coventry, United Kingdom
| | - Elizabeth L. Corbett
- Malawi–Liverpool–Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- London School of Hygiene & Tropical Medicine, London, United Kingdom
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Root R, Van Wyngaard A, Whiteside A. Reckoning HIV/AIDS care: A longitudinal study of community home-based caregivers and clients in Swaziland. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2015; 14:265-74. [PMID: 26291481 DOI: 10.2989/16085906.2015.1059864] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The article is a descriptive case study of a community home-based care (CHBC) organisation in Swaziland that depicts the convergence of CHBC expansion with substantially improved health outcomes. Comprised of 993 care supporters who tend to 3 839 clients in 37 communities across southern Swaziland, Shiselweni Home-based Care (SHBC) is illustrative of many resource-limited communities throughout Africa that have mobilised, at varying degrees of formality, to address the individual and household suffering associated with HIV/AIDS. To better understand the potential significance of global and national health policy/programming reliance on community health workers (task shifting), we analysed longitudinal data on both care supporter and client cohorts from 2008 to 2013. Most CHBC studies report data from only one cohort. Foremost, our analysis demonstrated a dramatic decline (71.4%) among SHBC clients in overall mortality from 32.2% to 9.2% between 2008 and 2013. Although the study was not designed to establish statistical significance or causality between SHBC expansion and health impact, our findings detail a compelling convergence among CHBC, improved HIV health practices, and declines in client mortality. Our analysis indicated (1) the potential contributions of community health workers to individual and community wellbeing, (2) the challenges of task-shifting agendas, above all comprehensive support of community health workers/care supporters, and (3) the importance of data collection to monitor and strengthen the critical health services assigned to CHBC. Detailed study of CHBC operations and practices is helpful also for advancing government and donor HIV/AIDS strategies, especially with respect to health services decentralisation, in Swaziland and similarly profiled settings.
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Affiliation(s)
- Robin Root
- a Department of Sociology & Anthropology , Baruch College, City University of New York , New York , USA
| | - Arnau Van Wyngaard
- b Department of Science of Religion and Missiology , University of Pretoria , South Africa.,c Shiselweni Home-Based Care , Swaziland
| | - Alan Whiteside
- d CIGI Chair in Global Health Policy , Balsillie School of International Affairs and Wilfrid Laurier University , Waterloo , Canada
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Morton D, Mayekiso T, Cunningham P. Support for volunteer caregivers and its influence on the quality of community home-based care in the Eastern Cape, South Africa. JOURNAL OF PSYCHOLOGY IN AFRICA 2015. [DOI: 10.1080/14330237.2015.1021509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- David Morton
- Department of Nursing Science, Nelson Mandela Metropolitan University, Port Elizabeth, South Africa
| | - Thoko Mayekiso
- Vice Chancellor's Office, University of Mpumalanga, Mbombela, South Africa
| | - Peter Cunningham
- Department of Sociology and Anthropology, Nelson Mandela Metropolitan University, Port Elizabeth, South Africa
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Moyer E, Igonya EK. When families fail: shifting expectations of care among people living with HIV in Nairobi, Kenya. Anthropol Med 2015; 21:136-48. [PMID: 25175290 PMCID: PMC4200576 DOI: 10.1080/13648470.2014.924298] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The availability of free antiretroviral treatment in public health facilities since 2004 has contributed to the increasing biomedicalization of AIDS care in Kenya. This has been accompanied by a reduction of funding for community-based care and support organizations since the 2008 global economic crisis and a consequent donor divestment from HIV projects in Africa. This paper explores the ways that HIV interventions, including support groups, home-based care and antiretroviral treatments have shaped expectations regarding relations of care in the low-income area of Kibera in Nairobi, Kenya, over the last decade. Findings are based on 20 months of ethnographic research conducted in Nairobi between January 2011 and August 2013. By focusing on three eras of HIV treatment – pre-treatment, treatment scale-up, and post-crisis – the authors illustrate how family and community-based care have changed with shifts in funding. Many support groups that previously provided HIV care in Kibera, where the state is largely absent and family networks are thin, have been forced to cut services. Large-scale HIV treatment programmes may allow the urban poor in Nairobi to survive, but they are unlikely to thrive. Many care needs continue to go unmet in the age of treatment, and many economically marginal people who had found work in care-oriented community-based organizations now find themselves jobless or engaged in work not related to HIV.
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Affiliation(s)
- Eileen Moyer
- a Department of Anthropology , University of Amsterdam , the Netherlands
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Cataldo F, Kielmann K, Kielmann T, Mburu G, Musheke M. 'Deep down in their heart, they wish they could be given some incentives': a qualitative study on the changing roles and relations of care among home-based caregivers in Zambia. BMC Health Serv Res 2015; 15:36. [PMID: 25627203 PMCID: PMC4324023 DOI: 10.1186/s12913-015-0685-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 01/07/2015] [Indexed: 11/10/2022] Open
Abstract
Background Across Sub-Saharan Africa, the roll-out of antiretroviral treatment (ART) has contributed to shifting HIV care towards the management of a chronic health condition. While the balance of professional and lay tasks in HIV caregiving has been significantly altered due to changing skills requirements and task-shifting initiatives, little attention has been given to the effects of these changes on health workers’ motivation and existing care relations. Methods This paper draws on a cross-sectional, qualitative study that explored changes in home-based care (HBC) in the light of widespread ART rollout in the Lusaka and Kabwe districts of Zambia. Methods included observation of HBC daily activities, key informant interviews with programme staff from three local HBC organisations (n = 17) and ART clinic staff (n = 8), as well as in-depth interviews with home-based caregivers (n = 48) and HBC clients (n = 31). Results Since the roll-out of ART, home-based caregivers spend less time on hands-on physical care and support in the household, and are increasingly involved in specialised tasks supporting their clients’ access and adherence to ART. Despite their pride in gaining technical care skills, caregivers lament their lack of formal recognition through training, remuneration or mobility within the health system. Care relations within homes have also been altered as caregivers’ newly acquired functions of monitoring their clients while on ART are met with some ambivalence. Caregivers are under pressure to meet clients and their families’ demands, although they are no longer able to provide material support formerly associated with donor funding for HBC. Conclusions As their responsibilities and working environments are rapidly evolving, caregivers’ motivations are changing. It is essential to identify and address the growing tensions between an idealized rhetoric of altruistic volunteerism in home-based care, and the realities of lay worker deployment in HIV care interventions that not only shift tasks, but transform social and professional relations in ways that may profoundly influence caregivers’ motivation and quality of care.
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Affiliation(s)
- Fabian Cataldo
- Dignitas International, Research Department, Zomba, Malawi.
| | - Karina Kielmann
- Institute for International Health and Development, Queen Margaret University, Edinburgh, Scotland.
| | | | - Gitau Mburu
- International HIV/AIDS Alliance, Brighton, UK. .,Division of Health Research, Lancaster University, Lancaster, UK.
| | - Maurice Musheke
- Zambia AIDS Related Tuberculosis Project, University of Zambia, Lusaka, Zambia.
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Kok MC, Dieleman M, Taegtmeyer M, Broerse JEW, Kane SS, Ormel H, Tijm MM, de Koning KAM. Which intervention design factors influence performance of community health workers in low- and middle-income countries? A systematic review. Health Policy Plan 2014; 30:1207-27. [PMID: 25500559 PMCID: PMC4597042 DOI: 10.1093/heapol/czu126] [Citation(s) in RCA: 306] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2014] [Indexed: 12/21/2022] Open
Abstract
Community health workers (CHWs) are increasingly recognized as an integral component of the health workforce needed to achieve public health goals in low- and middle-income countries (LMICs). Many factors influence CHW performance. A systematic review was conducted to identify intervention design related factors influencing performance of CHWs. We systematically searched six databases for quantitative and qualitative studies that included CHWs working in promotional, preventive or curative primary health services in LMICs. One hundred and forty studies met the inclusion criteria, were quality assessed and double read to extract data relevant to the design of CHW programmes. A preliminary framework containing factors influencing CHW performance and characteristics of CHW performance (such as motivation and competencies) guided the literature search and review. A mix of financial and non-financial incentives, predictable for the CHWs, was found to be an effective strategy to enhance performance, especially of those CHWs with multiple tasks. Performance-based financial incentives sometimes resulted in neglect of unpaid tasks. Intervention designs which involved frequent supervision and continuous training led to better CHW performance in certain settings. Supervision and training were often mentioned as facilitating factors, but few studies tested which approach worked best or how these were best implemented. Embedment of CHWs in community and health systems was found to diminish workload and increase CHW credibility. Clearly defined CHW roles and introduction of clear processes for communication among different levels of the health system could strengthen CHW performance. When designing community-based health programmes, factors that increased CHW performance in comparable settings should be taken into account. Additional intervention research to develop a better evidence base for the most effective training and supervision mechanisms and qualitative research to inform policymakers in development of CHW interventions are needed.
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Affiliation(s)
- Maryse C Kok
- KIT Health, Royal Tropical Institute, Amsterdam, The Netherlands,
| | | | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK and
| | | | - Sumit S Kane
- KIT Health, Royal Tropical Institute, Amsterdam, The Netherlands
| | - Hermen Ormel
- KIT Health, Royal Tropical Institute, Amsterdam, The Netherlands
| | - Mandy M Tijm
- KIT Health, Royal Tropical Institute, Amsterdam, The Netherlands
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Gibbs A, Campbell C, Maimane S. Can local communities 'sustain' HIV/AIDS programmes? A South African example. Health Promot Int 2014; 30:114-25. [PMID: 25351362 DOI: 10.1093/heapro/dau096] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Globally, there is a renewed interest in building the local sustainability of HIV/AIDS programmes to ensure that once funders withdraw, local communities can sustain programmes. While the 'local sustainability assumption' is widespread, little research has assessed this. In this article, we assess the sustainability of the Entabeni Project, a community-based intervention that sought to build women's local leadership and capacity to respond to HIV/AIDS through a group of volunteer carers, 3 years after external support was withdrawn. Overall, the sustainability of the Entabeni Project was limited. The wider social and political context undermined volunteer carers' sense that they could affect change, with little external support for them from government and NGOs, who struggled to engage with local community organizations. At the community level, some church leaders and community members recognized the important role of health volunteers, many continued to devalue the work of the carers, especially once there was no external organization to support and validate their work. Within the health volunteer group, despite extensive efforts to change dynamics, it remained dominated by a local male leader who denied others active participation while lacking the skills to meaningfully lead the project. Our case study suggests that the local-sustainability assumption is wishful thinking. Small-scale local projects are unlikely to be able to challenge the broader social and political dynamics hindering their sustainability without meaningful external support.
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Affiliation(s)
- Andrew Gibbs
- University of KwaZulu-Natal, Durban, South Africa
| | - Catherine Campbell
- Institute of Social Psychology, London School of Economics and Political Science, London, UK
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Practicalities and challenges in re-orienting the health system in Zambia for treating chronic conditions. BMC Health Serv Res 2014; 14:295. [PMID: 25005125 PMCID: PMC4094789 DOI: 10.1186/1472-6963-14-295] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 07/02/2014] [Indexed: 11/26/2022] Open
Abstract
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.
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Moyer E, Hardon A. A Disease Unlike Any Other? Why HIV Remains Exceptional in the Age of Treatment. Med Anthropol 2014; 33:263-9. [DOI: 10.1080/01459740.2014.890618] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Zulu JM, Kinsman J, Michelo C, Hurtig AK. Hope and despair: community health assistants' experiences of working in a rural district in Zambia. HUMAN RESOURCES FOR HEALTH 2014; 12:30. [PMID: 24886146 PMCID: PMC4065545 DOI: 10.1186/1478-4491-12-30] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Accepted: 04/29/2014] [Indexed: 05/16/2023]
Abstract
BACKGROUND In order to address the challenges facing the community-based health workforce in Zambia, the Ministry of Health implemented the national community health assistant strategy in 2010. The strategy aims to address the challenges by creating a new group of workers called community health assistants (CHAs) and integrating them into the health system. The first group started working in August 2012. The objective of this paper is to document their motivation to become a CHA, their experiences of working in a rural district, and how these experiences affected their motivation to work. METHODS A phenomenological approach was used to examine CHAs' experiences. Data collected through in-depth interviews with 12 CHAs in Kapiri Mposhi district and observations were analysed using a thematic analysis approach. RESULTS Personal characteristics such as previous experience and knowledge, passion to serve the community and a desire to improve skills motivated people to become CHAs. Health systems characteristics such as an inclusive work culture in some health posts motivated CHAs to work. Conversely, a non-inclusive work culture created a social structure which constrained CHAs' ability to learn, to be innovative and to effectively conduct their duties. Further, limited supervision, misconceptions about CHA roles, poor prioritisation of CHA tasks by some supervisors, as well as non- and irregular payment of incentives also adversely affected CHAs' ability to work effectively. In addition, negative feedback from some colleagues at the health posts affected CHA's self-confidence and professional outlook. In the community, respect and support provided to CHAs by community members instilled a sense of recognition, appreciation and belonging in CHAs which inspired them to work. On the other hand, limited drug supplies and support from other community-based health workers due to their exclusion from the government payroll inhibited CHAs' ability to deliver services. CONCLUSIONS Programmes aimed at integrating community-based health workers into health systems should adequately consider multiple incentives, effective management, supervision and support from the district. These should be tailored towards enhancing the individual, health system and community characteristics that positively impact work motivation at the local level if such programmes are to effectively contribute towards improved primary healthcare.
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Affiliation(s)
- Joseph Mumba Zulu
- Department of Public Health, School of Medicine, University of Zambia, P.O. Box 50110, Lusaka, Zambia
- Umeå International School of Public Health (UISPH), Umeå University, Umeå SE 90185, Sweden
| | - John Kinsman
- Umeå International School of Public Health (UISPH), Umeå University, Umeå SE 90185, Sweden
| | - Charles Michelo
- Department of Public Health, School of Medicine, University of Zambia, P.O. Box 50110, Lusaka, Zambia
| | - Anna-Karin Hurtig
- Umeå International School of Public Health (UISPH), Umeå University, Umeå SE 90185, Sweden
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Chishinga N, Godfrey-Faussett P, Fielding K, Ayles H. Effect of home-based interventions on virologic outcomes in adults receiving antiretroviral therapy in Africa: a meta-analysis. BMC Public Health 2014; 14:239. [PMID: 24606968 PMCID: PMC3974116 DOI: 10.1186/1471-2458-14-239] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Accepted: 02/27/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The success of adherence to combination antiretroviral therapy (ART) in sub-Saharan Africa is hampered by factors that are unique to this setting. Home based interventions have been identified as possible strategies for decentralizing ART care and improving access and adherence to ART. There is need for evidence at individual- or community-level of the benefits of home-based interventions in improving HIV suppression in African patients receiving ART. METHODS We conducted a systematic review and meta-analysis of the literature to assess the effect of home-based interventions on virologic outcomes in adults receiving ART in Africa. RESULTS A total of 260 publications were identified by the search strategy, 249 were excluded on initial screening and 11 on full review, leaving 5 publications for analysis. The overall OR of virologic suppression at 12 months after starting ART of home-based interventions to standard of care was 1.13 (95% CI: 0.51-2.52). CONCLUSIONS There was insufficient data to know whether there is a difference in HIV suppression at 12 months in the home-based arm compared with the standard of care arm in adults receiving ART in Africa. Given the few trials conducted from Africa, there is need for further research that measures the effects of home-based models on HIV suppression in African populations.
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Affiliation(s)
- Nathaniel Chishinga
- Zambia AIDS-related TB Project, School of Medicine, P.O Box 50697, Ridgeway campus, Lusaka, Zambia
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Peter Godfrey-Faussett
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Katherine Fielding
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Helen Ayles
- Zambia AIDS-related TB Project, School of Medicine, P.O Box 50697, Ridgeway campus, Lusaka, Zambia
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
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Models of delivering palliative and end-of-life care in sub-Saharan Africa: a narrative review of the evidence. Curr Opin Support Palliat Care 2014; 7:223-8. [PMID: 23572158 DOI: 10.1097/spc.0b013e328360f835] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW This narrative review examines evidence for models of palliative and end-of-life (eol) care delivery in sub-Saharan Africa (SSA) since 2010. It highlights recent developments, on-going challenges and innovative approaches used to address obstacles to increased access to care. RECENT FINDINGS Electronic databases were searched for the literature published in English during the period 2010-2012 around broad thematic areas of palliative and eol care delivery models in SSA. Literature showed increased palliative and eol care service development, underpinned by advocacy work undertaken by regional and national palliative care associations. Despite this increase, care provision remains inadequately integrated in national public health agendas and systems. Consequently, it continues to be heavily reliant upon nongovernmental, community-based and home-based care (HBC) models. Efforts are, however, underway to integrate palliative care into national health systems, which should increase access to care. National policies and government financing will be important to sustain this integration. SUMMARY Although community and HBC programs remain primary models of palliative and eol care delivery in SSA, there is an urgent need to develop a public health approach that integrates care into national health systems to increase accessibility.
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Perry HB, Zulliger R, Rogers MM. Community health workers in low-, middle-, and high-income countries: an overview of their history, recent evolution, and current effectiveness. Annu Rev Public Health 2014; 35:399-421. [PMID: 24387091 DOI: 10.1146/annurev-publhealth-032013-182354] [Citation(s) in RCA: 475] [Impact Index Per Article: 47.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Over the past half-century, community health workers (CHWs) have been a growing force for extending health care and improving the health of populations. Following their introduction in the 1970s, many large-scale CHW programs declined during the 1980s, but CHW programs throughout the world more recently have seen marked growth. Research and evaluations conducted predominantly during the past two decades offer compelling evidence that CHWs are critical for helping health systems achieve their potential, regardless of a country's level of development. In low-income countries, CHWs can make major improvements in health priority areas, including reducing childhood undernutrition, improving maternal and child health, expanding access to family-planning services, and contributing to the control of HIV, malaria, and tuberculosis infections. In many middle-income countries, most notably Brazil, CHWs are key members of the health team and essential for the provision of primary health care and health promotion. In the United States, evidence indicates that CHWs can contribute to reducing the disease burden by participating in the management of hypertension, in the reduction of cardiovascular risk factors, in diabetes control, in the management of HIV infection, and in cancer screening, particularly with hard-to-reach subpopulations. This review highlights the history of CHW programs around the world and their growing importance in achieving health for all.
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Moshabela M, Gitomer S, Qhibi B, Schneider H. Development of non-profit organisations providing health and social services in rural South Africa: a three-year longitudinal study. PLoS One 2013; 8:e83861. [PMID: 24358314 PMCID: PMC3865296 DOI: 10.1371/journal.pone.0083861] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 11/10/2013] [Indexed: 01/31/2023] Open
Abstract
Introduction In an effort to increase understanding of formation of the community and home-based care economy in South Africa, we investigated the origin and development of non-profit organisations (NPOs) providing home- and community-based care for health and social services in a remote rural area of South Africa. Methods Over a three-year period (2010-12), we identified and tracked all NPOs providing health care and social services in Bushbuckridge sub-district through the use of local government records, snowballing techniques, and attendance at NPO networking meetings—recording both existing and new NPOs. NPO founders and managers were interviewed in face-to-face in-depth interviews, and their organisational records were reviewed. Results Forty-seven NPOs were formed prior to the study period, and 14 during the study period – six in 2010, six in 2011 and two in 2012, while four ceased operation, representing a 22% growth in the number of NPOs during the study period. Histories of NPOs showed a steady rise in the NPO formation over a 20-year period, from one (1991-1995) to 12 (1996-2000), 16 (2001-2005) and 24 (2006-2010) new organisations formed in each period. Furthermore, the histories of formation revealed three predominant milestones – loose association, formal formation and finally registration. Just over one quarter (28%) of NPOs emerged from a long-standing community based programme of ‘care groups’ of women. Founders of NPOs were mostly women (62%), with either a religious motivation or a nursing background, but occasionally had an entrepreneurial profile. Conclusion We observed rapid growth of the NPO sector providing community based health and social services. Women dominated the rural NPO sector, which is being seen as creating occupation and employment opportunities. The implications of this growth in the NPO sector providing community based health and social services needs to be further explored and suggests the need for greater coordination and possibly regulation.
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Affiliation(s)
- Mosa Moshabela
- School of Public Health, University of Witwatersrand, Johannesburg, South Africa
- Rural AIDS and Development Action Research, University of Witwatersrand, Acornhoek, South Africa
- * E-mail:
| | - Shira Gitomer
- Geneva Global, Wayne, Philadelphia, Pennsylvania, United States of America
| | - Bongiwe Qhibi
- Rural AIDS and Development Action Research, University of Witwatersrand, Acornhoek, South Africa
| | - Helen Schneider
- School of Public Health, University of the Western Cape, Cape Town, South Africa
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Developing the national community health assistant strategy in Zambia: a policy analysis. Health Res Policy Syst 2013; 11:24. [PMID: 23870454 PMCID: PMC3724745 DOI: 10.1186/1478-4505-11-24] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Accepted: 07/11/2013] [Indexed: 12/03/2022] Open
Abstract
Background In 2010, the Ministry of Health in Zambia developed the National Community Health Assistant strategy, aiming to integrate community health workers (CHWs) into national health plans by creating a new group of workers, called community health assistants (CHAs). The aim of the paper is to analyse the CHA policy development process and the factors that influenced its evolution and content. A policy analysis approach was used to analyse the policy reform process. Methodology Data were gathered through review of documents, participant observation and key informant interviews with CHA strategic team members in Lusaka district, and senior officials at the district level in Kapiri Mposhi district where some CHAs have been deployed. Results The strategy was developed in order to address the human resources for health shortage and the challenges facing the community-based health workforce in Zambia. However, some actors within the strategic team were more influential than others in informing the policy agenda, determining the process, and shaping the content. These actors negotiated with professional/statutory bodies and health unions on the need to develop the new cadre which resulted in compromises that enabled the policy process to move forward. International agencies also indirectly influenced the course as well as the content of the strategy. Some actors classified the process as both insufficiently consultative and rushed. Due to limited consultation, it was suggested that the policy content did not adequately address key policy content issues such as management of staff attrition, general professional development, and progression matters. Analysis of the process also showed that the strategy might create a new group of workers whose mandate is unclear to the existing group of health workers. Conclusions This paper highlights the complex nature of policy-making processes for integrating CHWs into the health system. It reiterates the need for recognising the fact that actors’ power or position in the political hierarchy may, more than their knowledge and understanding of the issue, play a disproportionate role in shaping the process as well as content of health policy reform.
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van Heerden A, Norris S, Tollman S, Richter L, Rotheram-Borus MJ. Collecting maternal health information from HIV-positive pregnant women using mobile phone-assisted face-to-face interviews in Southern Africa. J Med Internet Res 2013; 15:e116. [PMID: 23748182 PMCID: PMC3713928 DOI: 10.2196/jmir.2207] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2012] [Revised: 12/21/2012] [Accepted: 01/13/2013] [Indexed: 11/13/2022] Open
Abstract
Background Most of the world’s women living with human immunodeficiency virus (HIV) reside in sub-Saharan Africa. Although efforts to reduce mother-to-child transmission are underway, obtaining complete and accurate data from rural clinical sites to track progress presents a major challenge. Objective To describe the acceptability and feasibility of mobile phones as a tool for clinic-based face-to-face data collection with pregnant women living with HIV in South Africa. Methods As part of a larger clinic-based trial, 16 interviewers were trained to conduct mobile phone–assisted personal interviews (MPAPI). These interviewers (participant group 1) completed the same short questionnaire based on items from the Technology Acceptance Model at 3 different time points. Questions were asked before training, after training, and 3 months after deployment to clinic facilities. In addition, before the start of the primary intervention trial in which this substudy was undertaken, 12 mothers living with HIV (MLH) took part in a focus group discussion exploring the acceptability of MPAPI (participant group 2). Finally, a sample of MLH (n=512) enrolled in the primary trial were asked to assess their experience of being interviewed by MPAPI (participant group 3). Results Acceptability of the method was found to be high among the 16 interviewers in group 1. Perceived usefulness was reported to be slightly higher than perceived ease of use across the 3 time points. After 3 months of field use, interviewer perceptions of both perceived ease of use and perceived usefulness were found to be higher than before training. The feasibility of conducting MPAPI interviews in this setting was found to be high. Network coverage was available in all clinics and hardware, software, cost, and secure transmission to the data center presented no significant challenges over the 21-month period. For the 12 MHL participants in group 2, anxiety about the multimedia capabilities of the phone was evident. Their concern centered on the possibility that their privacy may be invaded by interviewers using the mobile phone camera to photograph them. For participants in group 3, having the interviewer sit beside vs across from the interviewee during the MPAPI interview was received positively by 94.7% of MHL. Privacy (6.3%) and confidentiality (5.3%) concerns were low for group 3 MHL. Conclusions Mobile phones were found both to be acceptable and feasible in the collection of maternal and child health data from women living with HIV in South Africa. Trial Registration Clinicaltrials.gov NCT00972699; http://clinicaltrials.gov/ct2/show/NCT00972699 (Archived by WebCite at http://clinicaltrials.gov/ct2/show/NCT00972699)
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Pallas SW, Minhas D, Pérez-Escamilla R, Taylor L, Curry L, Bradley EH. Community health workers in low- and middle-income countries: what do we know about scaling up and sustainability? Am J Public Health 2013; 103:e74-82. [PMID: 23678926 DOI: 10.2105/ajph.2012.301102] [Citation(s) in RCA: 186] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We sought to provide a systematic review of the determinants of success in scaling up and sustaining community health worker (CHW) programs in low- and middle-income countries (LMICs). METHODS We searched 11 electronic databases for academic literature published through December 2010 (n = 603 articles). Two independent reviewers applied exclusion criteria to identify articles that provided empirical evidence about the scale-up or sustainability of CHW programs in LMICs, then extracted data from each article by using a standardized form. We analyzed the resulting data for determinants and themes through iterated categorization. RESULTS The final sample of articles (n = 19) present data on CHW programs in 16 countries. We identified 23 enabling factors and 15 barriers to scale-up and sustainability, which were grouped into 3 thematic categories: program design and management, community fit, and integration with the broader environment. CONCLUSIONS Scaling up and sustaining CHW programs in LMICs requires effective program design and management, including adequate training, supervision, motivation, and funding; acceptability of the program to the communities served; and securing support for the program from political leaders and other health care providers.
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Rachlis B, Sodhi S, Burciul B, Orbinski J, Cheng AHY, Cole D. A taxonomy for community-based care programs focused on HIV/AIDS prevention, treatment, and care in resource-poor settings. Glob Health Action 2013; 6:1-21. [PMID: 23594416 PMCID: PMC3629264 DOI: 10.3402/gha.v6i0.20548] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Revised: 03/18/2013] [Accepted: 03/18/2013] [Indexed: 11/25/2022] Open
Abstract
Community-based care (CBC) can increase access to key services for people affected by HIV/AIDS through the mobilization of community interests and resources and their integration with formal health structures. Yet, the lack of a systematic framework for analysis of CBC focused on HIV/AIDS impedes our ability to understand and study CBC programs. We sought to develop taxonomy of CBC programs focused on HIV/AIDS in resource-limited settings in an effort to understand their key characteristics, uncover any gaps in programming, and highlight the potential roles they play. Our review aimed to systematically identify key CBC programs focused on HIV/AIDS in resource-limited settings. We used both bibliographic database searches (Medline, CINAHL, and EMBASE) for peer-reviewed literature and internet-based searches for gray literature. Our search terms were ‘HIV’ or ‘AIDS’ and ‘community-based care’ or ‘CBC’. Two co-authors developed a descriptive taxonomy through an iterative, inductive process using the retrieved program information. We identified 21 CBC programs useful for developing taxonomy. Extensive variation was observed within each of the nine categories identified: region, vision, characteristics of target populations, program scope, program operations, funding models, human resources, sustainability, and monitoring and evaluation strategies. While additional research may still be needed to identify the conditions that lead to overall program success, our findings can help to inform our understanding of the various aspects of CBC programs and inform potential logic models for CBC programming in the context of HIV/AIDS in resource-limited settings. Importantly, the findings of the present study can be used to develop sustainable HIV/AIDS-service delivery programs in regions with health resource shortages.
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Affiliation(s)
- Beth Rachlis
- Global Health Division Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
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Abstract
This article summarizes the conclusions and recommendations from the articles in this supplement. It presents a call for greater clarity of thinking related to projections of future need for HIV treatment and care. The demands placed on HIV treatment and care services will increase for the foreseeable future while the resources available for this are likely to remain constant or to decline. This highlights the need for realistic budgeting by national governments. The key strategies that should be employed to sustain HIV treatment and care programmes in high HIV-prevalence low and middle-income countries over the coming decade include further decentralization, task shifting, and integration of HIV services with other chronic disease treatment services. At the same time, greater attention will need to be given to the provision of mental healthcare for those living with HIV; to the specific treatment needs of children, adolescents, pregnant women and older people; and to the standard collection of validated indicators of treatment outcomes within national programmes. For the considerable gains that have been achieved to be sustained, funders--both internal and external to the country concerned--need to prioritize investment in operations research to maximise the efficiency of their other investments in HIV treatment and care services.
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Campbell L. Men’s experiences delivering palliative home health care in rural South Africa:an exploratory study. Int J Palliat Nurs 2012; 18:612-8. [DOI: 10.12968/ijpn.2012.18.12.612] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Laura Campbell
- School of Education, University of KwaZulu-Natal, Durban, South Africa
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Leon N, Schneider H, Daviaud E. Applying a framework for assessing the health system challenges to scaling up mHealth in South Africa. BMC Med Inform Decis Mak 2012; 12:123. [PMID: 23126370 PMCID: PMC3534437 DOI: 10.1186/1472-6947-12-123] [Citation(s) in RCA: 134] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2012] [Accepted: 10/17/2012] [Indexed: 11/15/2022] Open
Abstract
Background Mobile phone technology has demonstrated the potential to improve health service delivery, but there is little guidance to inform decisions about acquiring and implementing mHealth technology at scale in health systems. Using the case of community-based health services (CBS) in South Africa, we apply a framework to appraise the opportunities and challenges to effective implementation of mHealth at scale in health systems. Methods A qualitative study reviewed the benefits and challenges of mHealth in community-based services in South Africa, through a combination of key informant interviews, site visits to local projects and document reviews. Using a framework adapted from three approaches to reviewing sustainable information and communication technology (ICT), the lessons from local experience and elsewhere formed the basis of a wider consideration of scale up challenges in South Africa. Results Four key system dimensions were identified and assessed: government stewardship and the organisational, technological and financial systems. In South Africa, the opportunities for successful implementation of mHealth include the high prevalence of mobile phones, a supportive policy environment for eHealth, successful use of mHealth for CBS in a number of projects and a well-developed ICT industry. However there are weaknesses in other key health systems areas such as organisational culture and capacity for using health information for management, and the poor availability and use of ICT in primary health care. The technological challenges include the complexity of ensuring interoperability and integration of information systems and securing privacy of information. Finally, there are the challenges of sustainable financing required for large scale use of mobile phone technology in resource limited settings. Conclusion Against a background of a health system with a weak ICT environment and limited implementation capacity, it remains uncertain that the potential benefits of mHealth for CBS would be retained with immediate large-scale implementation. Applying a health systems framework facilitated a systematic appraisal of potential challenges to scaling up mHealth for CBS in South Africa and may be useful for policy and practice decision-making in other low- and middle-income settings.
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Affiliation(s)
- Natalie Leon
- Health Systems Research Unit, Medical Research Council of South Africa, P.O. Box 19070, Tygerberg, Cape Town, 7505, South Africa.
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Lees S, Kielmann K, Cataldo F, Gitau-Mburu D. Understanding the linkages between informal and formal care for people living with HIV in sub-Saharan Africa. Glob Public Health 2012; 7:1109-19. [PMID: 23116123 DOI: 10.1080/17441692.2012.733403] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
In response to the human resource challenges facing African health systems, there is increasing involvement of informal care providers in HIV care. Through social and institutional interactions that occur in the delivery of HIV care, linkages between formal and informal systems of care often emerge. Based on a review of studies documenting the relationships between formal and informal HIV care in sub-Saharan Africa, we suggest that linkages can be conceptualised as either 'actor-oriented' or 'systems-oriented'. Studies adopting an actor-oriented focus examine hierarchical working relationships and communication practices among health systems actors, while studies focusing on systems-oriented linkages document the presence, absence or impact of formal inter-institutional partnership agreements. For linkages to be effective, the institutional frameworks within which linkages are formalised, as well as the ground-level interactions of those engaged in care, ought to be considered. However, to date, both actor- and system-oriented linkages appear to be poorly utilised by policy makers to improve HIV care. We suggest that linkages between formal and informal systems of care be considered across health systems, including governance, human resources, health information and service delivery in order to improve access to HIV services, enable knowledge transfer and strengthen health systems.
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Affiliation(s)
- Shelley Lees
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.
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Antiretroviral treatment for HIV in rural Uganda: two-year treatment outcomes of a prospective health centre/community-based and hospital-based cohort. PLoS One 2012; 7:e40902. [PMID: 22815862 PMCID: PMC3398945 DOI: 10.1371/journal.pone.0040902] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Accepted: 06/14/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In sub-Saharan Africa, a shortage of trained health professionals and limited geographical access to health facilities present major barriers to the expansion of antiretroviral therapy (ART). We tested the utility of a health centre (HC)/community-based approach in the provision of ART to persons living with HIV in a rural area in western Uganda. METHODS The HIV treatment outcomes of the HC/community-based ART program were evaluated and compared with those of an ART program at a best-practice regional hospital. The HC/community-based cohort comprised 185 treatment-naïve patients enrolled in 2006. The hospital cohort comprised of 200 patients enrolled in the same time period. The HC/community-based program involved weekly home visits to patients by community volunteers who were trained to deliver antiretroviral drugs to monitor and support adherence to treatment, and to identify and report adverse reactions and other clinical symptoms. Treatment supporters in the homes also had the responsibility to remind patients to take their drugs regularly. ART treatment outcomes were measured by HIV-1 RNA viral load (VL) after two years of treatment. Adherence was determined through weekly pill counts. RESULTS Successful ART treatment outcomes in the HC/community-based cohort were equivalent to those in the hospital-based cohort after two years of treatment in on-treatment analysis (VL≤400 copies/mL, 93.0% vs. 87.3%, p = 0.12), and in intention-to-treat analysis (VL≤400 copies/mL, 64.9% and 62.0%, p = 0.560). In multivariate analysis patients in the HC/community-based cohort were more likely to have virologic suppression compared to hospital-based patients (adjusted OR = 2.47, 95% CI 1.01-6.04). CONCLUSION Acceptable rates of virologic suppression were achieved using existing rural clinic and community resources in a HC/community-based ART program run by clinical officers and supported by lay volunteers and treatment supporters. The results were equivalent to those of a hospital-based ART program run primarily by doctors.
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Busza J, Walker D, Hairston A, Gable A, Pitter C, Lee S, Katirayi L, Simiyu R, Mpofu D. Community-based approaches for prevention of mother to child transmission in resource-poor settings: a social ecological review. J Int AIDS Soc 2012; 15 Suppl 2:17373. [PMID: 22789640 PMCID: PMC3499910 DOI: 10.7448/ias.15.4.17373] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2011] [Accepted: 05/16/2012] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Numerous barriers to optimal uptake of prevention of mother to child transmission (PMTCT) services occur at community level (i.e., outside the healthcare setting). To achieve elimination of paediatric HIV, therefore, interventions must also work within communities to address these barriers and increase service use and need to be informed by evidence. This paper reviews community-based approaches that have been used in resource-limited settings to increase rates of PMTCT enrolment, retention in care and successful treatment outcomes. It aims to identify which interventions work, why they may do so and what knowledge gaps remain. METHODS First, we identified barriers to PMTCT that originate outside the health system. These were used to construct a social ecological framework categorizing barriers to PMTCT into the following levels of influence: individual, peer and family, community and sociocultural. We then used this conceptual framework to guide a review of the literature on community-based approaches, defined as interventions delivered outside of formal health settings, with the goal of increasing uptake, retention, adherence and positive psychosocial outcomes in PMTCT programmes in resource-poor countries. RESULTS Our review found evidence of effectiveness of strategies targeting individuals and peer/family levels (e.g., providing household HIV testing and training peer counsellors to support exclusive breastfeeding) and at community level (e.g., participatory women's groups and home-based care to support adherence and retention). Evidence is more limited for complex interventions combining multiple strategies across different ecological levels. There is often little information describing implementation; and approaches such as "community mobilization" remain poorly defined. CONCLUSIONS Evidence from existing community approaches can be adapted for use in planning PMTCT. However, for successful replication of evidence-based interventions to occur, comprehensive process evaluations are needed to elucidate the pathways through which specific interventions achieve desired PMTCT outcomes. A social ecological framework can help analyze the complex interplay of facilitators and barriers to PMTCT service uptake in each context, thus helping to inform selection of locally relevant community-based interventions.
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Affiliation(s)
- Joanna Busza
- Department of Population Studies, London School of Hygiene & Tropical Medicine, London, UK.
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Uwimana J, Zarowsky C, Hausler H, Jackson D. Training community care workers to provide comprehensive TB/HIV/PMTCT integrated care in KwaZulu-Natal: lessons learnt. Trop Med Int Health 2012; 17:488-96. [PMID: 22296235 DOI: 10.1111/j.1365-3156.2011.02951.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To describe a participatory approach to implement and evaluate ways to integrate and train community care workers (CCWs) to enhance collaborative TB/HIV/PMTCT activities, and home-based HIV counseling and testing (HCT) at community level. METHODS The intervention study was conducted in Sisonke, a rural district of KwaZulu Natal, South Africa. A baseline household (HH) survey was conducted in 11 villages. Six villages were randomly selected into intervention and control clusters. Training was provided first to CCWs from the intervention cluster (IC) followed by the control cluster (CC). Routine monthly data from CCWs were collected from March-December 2010. The data was subjected to bivariate tests. RESULTS The baseline HH survey revealed that of 3012 HH members visited by CCWs in 2008, 21% were screened for TB symptoms, 7% were visited for TB adherence support and 2% for ART adherence, and 1.5% were counselled on infant feeding options. A total of 89 CCWs were trained. Data show that during the study period in IC, 684 adults were offered HCT by CCWs, 92% accepted HCT and tested and 7% tested HIV-positive and were referred to the clinic for further care. Of 3556 adults served in IC, 44% were screened for TB symptoms and 32% for symptoms of sexually transmitted infections (STIs) and 37% of children were traced as TB contact. Out of 6226 adults served in CC, 10% were screened for TB symptoms and 7% for STI symptoms. The differences in uptake of services between IC and CC were statistically significant (p<0.05). CONCLUSION The findings of this study suggest higher uptake of TB and STI symptoms screening, TB contact tracing and home based HCT in the intervention clusters. This study suggests that up-skilling CCWs could be one avenue to enhance TB/HIV case finding, TB contact tracing and linkages to care.
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Affiliation(s)
- J Uwimana
- School of Public Health, University of the Western Cape, Cape Town, South Africa.
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Campbell LM. Experiences of nurses practising home-based palliative care in a rural South African setting. Int J Palliat Nurs 2011; 17:593-8. [DOI: 10.12968/ijpn.2011.17.12.593] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Shin S, Muñoz M, Zeladita J, Slavin S, Caldas A, Sanchez E, Callacna M, Rojas C, Arevalo J, Sebastian JL, Bayona J. How does directly observed therapy work? The mechanisms and impact of a comprehensive directly observed therapy intervention of highly active antiretroviral therapy in Peru. HEALTH & SOCIAL CARE IN THE COMMUNITY 2011; 19:261-271. [PMID: 21143333 PMCID: PMC8324021 DOI: 10.1111/j.1365-2524.2010.00968.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
From December 2005 through August 2008, we provided community-based accompaniment with supervised antiretroviral therapy (CASA) to impoverished individuals starting highly active antiretroviral therapy. Adherence support was provided for 18 months by a community-based team comprised of several nurses and two types of community health workers: field supervisors and directly observed therapy (DOT) volunteers. To complement our quantitative data collection in 2008 using purposive sampling, we conducted two gender-mixed focus group discussions with 13 CASA patient participants and 13 DOT volunteers from Lima, Peru to identify the mediating mechanisms by which CASA improved well-being, and to understand the benefits of the intervention, as perceived by these individuals. Using standard qualitative methods for the review and analysis of transcripts and interview notes, we identified central themes and developed a coding scheme for categorising participants' statements. Two individuals blinded to each other's coding, coded interview transcripts for theme and content from which a third reviewer compared their coding to arbitrate discrepancies. Additional domains were added if necessary and all domains were integrated into a theoretical scheme. Among the forms of support delivered by the CASA team, DOT volunteers reported emotional support, instrumental support, directly observed therapy, building trust, education, advocacy, exercise of moral authority and preparation for transition off CASA support. CASA participants described outcomes of improved adherence, ability to resume social roles, increased self-efficacy, hopefulness, changes in non-HIV-related behaviour, reduced internalised and externalised stigma, as well as ability to disclose. Both sets of focus group participants highlighted remaining challenges after completion of CASA support: stigma in the community, difficulties achieving economic recovery and persistent barriers to health services. Based on our prior quantitative and qualitative outcomes reported here, we argue that DOT of highly active antiretroviral therapy could be designed to optimise psychosocial recovery during the period of DOT.
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Affiliation(s)
- Sonya Shin
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA 02115, USA.
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Kielmann K, Cataldo F. Tracking the rise of the "expert patient" in evolving paradigms of HIV care. AIDS Care 2010; 22 Suppl 1:21-8. [PMID: 20680857 DOI: 10.1080/09540121003721000] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
In the context of rolling out antiretroviral treatment programmes in resource-constrained settings, "expert patients" are hailed as an important step towards greater involvement of people living with HIV (PLHIV) in HIV care, and in addressing the human resources crisis. The rise of the "expert patient" in HIV care partly echoes the move towards greater patient agency and self-management that informs health services delivery in industrialised countries. However, the "expert patient" also represents a particular moment in the trajectory of PLHIVs' quest for greater access to treatment and health care. In this paper, we examine the unique evolution and 'instrumentalisation' of PLHIV in public health in relation to shifts in the epidemiology, interventions and socio-political response related to HIV since the 1980s. Synthesised broadly as "risk-based", "empowerment", "structural" and "activist" approaches, four key paradigms are identified that attribute different levels of citizenship for PLHIV, that is the motivation, agency and responsibility to act not only on their own interests, but also on behalf of collective interests in HIV prevention and care. We problematise the concept of the patient-citizen by drawing attention to the context-specificity of such notions as patient identity, capacity and rights as well as the structural realities of access to treatment, and broader engagement with the health system. We conclude by offering some thoughts on the applicability of 'expert patient' approaches across a broad range of settings.
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Affiliation(s)
- Karina Kielmann
- London School of Hygiene and Tropical Medicine, Health Policy Unit, London, UK.
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