1
|
Dougherty L, Mathur S, Gul X, Spielman K, Tripathi V, Wakefield C, Silva M. Methods and Measures to Assess Health Care Provider Behavior and Behavioral Determinants in Reproductive, Maternal, Newborn, and Child Health: A Rapid Review. GLOBAL HEALTH, SCIENCE AND PRACTICE 2023; 11:e2200407. [PMID: 38035722 PMCID: PMC10698233 DOI: 10.9745/ghsp-d-22-00407] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 06/23/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Health care provider behavior is the outcome of a complex set of factors that are both internal and external to the provider. Social and behavior change (SBC) programs are increasingly engaging providers and introducing strategies to improve their service delivery. However, there is limited understanding of methods and measures applied to assess provider behavioral outcomes and strengthen provider behavior change programming. METHODS Using PubMed, we conducted a rapid review of published research on behaviors of health workers providing reproductive, maternal, newborn, and child health services in low- and middle-income countries (2010-2021). Information on study identifiers (e.g., type of provider), select domains from Green and Kreuter's PRECEDE-PROCEED framework (e.g., predisposing factors such as attitudes), study characteristics (e.g., study type and design), and evidence of theory-driven research were extracted from a final sample of articles (N=89) and summarized. RESULTS More than 80% of articles were descriptive/formative and examined knowledge, attitudes, and practice, mostly related to family planning. Among the few evaluation studies, training-focused interventions to increase provider knowledge or improve competency in providing a health service were dominant. Research driven by behavioral theory was observed in only 3 studies. Most articles (75%) focused on the quality of client-provider interaction, though topics and modes of measurement varied widely. Very few studies incorporated a validated scale to measure underlying constructs, such as attitudes and beliefs, and how these may be associated with provider behaviors. CONCLUSION A need exists for (1) theory-driven approaches to designing and measuring provider behavior change interventions and (2) measurement that addresses important internal and structural factors related to a provider's behavior (beyond knowledge-enhancing training approaches). Additional investment in implementation research is also needed to better understand which SBC approaches are shifting provider behavior and improving client-provider interactions. Finally, theory-driven approaches could help develop empirically measurable and comparable outcomes.
Collapse
Affiliation(s)
| | | | - Xaher Gul
- Pathfinder International, Karachi, Pakistan
| | | | | | | | | |
Collapse
|
2
|
Neill R, Zia N, Ashraf L, Khan Z, Pryor W, Bachani AM. Integration measurement and its applications in low- and middle-income country health systems: a scoping review. BMC Public Health 2023; 23:1876. [PMID: 37770887 PMCID: PMC10537146 DOI: 10.1186/s12889-023-16724-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 09/08/2023] [Indexed: 09/30/2023] Open
Abstract
BACKGROUND Despite growing interest in and commitment to integration, or integrated care, the concept is ill-defined and the resulting evidence base fragmented, particularly in low- and middle-income countries (LMICs). Underlying this challenge is a lack of coherent approaches to measure the extent of integration and how this influences desired outcomes. The aim of this scoping review is to identify measurement approaches for integration in LMICs and map them for future use. METHODS Arksey and O'Malley's framework for scoping reviews was followed. We conducted a systematic search of peer-reviewed literature measuring integration in LMICs across three databases and screened identified papers by predetermined inclusion and exclusion criteria. A modified version of the Rainbow Model for Integrated Care guided charting and analysis of the data. RESULTS We included 99 studies. Studies were concentrated in the Africa region and most frequently focused on the integration of HIV care with other services. A range of definitions and methods were identified, with no single approach for the measurement of integration dominating the literature. Measurement of clinical integration was the most common, with indicators focused on measuring receipt of two or more services provided at a single point of time. Organizational and professional integration indicators were focused on inter- and intra-organizational communication, collaboration, coordination, and continuity of care, while functional integration measured common information systems or patient records. Gaps were identified in measuring systems and normative integration. Few tools were validated or publicly available for future use. CONCLUSION We identified a wide range of recent approaches used to measure integration in LMICs. Our findings underscore continued challenges with lack of conceptual cohesion and fragmentation which limits how integration is understood in practice.
Collapse
Affiliation(s)
- Rachel Neill
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins International Injury Research Unit, Health Systems Program, 615 N. Wolfe Street Suite E8527, Baltimore, MD, 21205, USA.
| | - Nukhba Zia
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins International Injury Research Unit, Health Systems Program, 615 N. Wolfe Street Suite E8527, Baltimore, MD, 21205, USA
| | - Lamisa Ashraf
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins International Injury Research Unit, Health Systems Program, 615 N. Wolfe Street Suite E8527, Baltimore, MD, 21205, USA
| | - Zainab Khan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins International Injury Research Unit, Health Systems Program, 615 N. Wolfe Street Suite E8527, Baltimore, MD, 21205, USA
| | - Wesley Pryor
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, 3010, Australia
| | - Abdulgafoor M Bachani
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins International Injury Research Unit, Health Systems Program, 615 N. Wolfe Street Suite E8527, Baltimore, MD, 21205, USA
| |
Collapse
|
3
|
Hamon JK, Hoyt J, Krishnaratne S, Barbra AA, Morukileng J, Spilotros N, Mbembe M, Marcus S, Webster J. Perceptions of quality and the integrated delivery of family planning with childhood immunisation services in Kenya and Uganda. PLoS One 2022; 17:e0269690. [PMID: 35666759 PMCID: PMC9170085 DOI: 10.1371/journal.pone.0269690] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 05/25/2022] [Indexed: 11/19/2022] Open
Abstract
The integration of family planning (FP) with childhood immunisations is considered a promising approach to addressing postpartum women’s unmet need for FP in resource limited settings. This study set out to examine client and health provider perceptions of the quality of FP services that were integrated with childhood immunisations in Kenya and Uganda. Semi-structured interviews with clients (n = 30) and health providers (n = 27) were conducted in 16 rural health facilities. Interviews centred on the respondents’ experiences receiving/delivering FP services, their interactions with providers/clients, and their views on the quality of FP services. Client and provider perceptions of quality were compared through a thematic analysis of interview transcripts, and findings were synthesised using Jain and Hardee’s revised FP Quality of Care Framework. Using audit data, health facility characteristics and resources were also summarised through descriptive statistics to contextualise the qualitative findings. The dignity and respect experienced by clients was central to the respondents’ perceptions of quality. These two dimensions were not conceptualised as distinct facets of quality, but were instead perceived to be a product of the 1) access to needed services, 2) choice of contraceptives, 3) interpersonal communication, 4) information, and 5) confidentiality afforded to clients. Additionally, clients and providers alike believed that the integration of FP services with childhood immunisations had a positive effect on clients’ access to needed services and on the confidentiality they experienced in a context where modern contraceptive use was stigmatised and where a lack of support from some husbands impeded access to FP services. Understanding clients’ and providers’ conceptualisation of quality is critical to the design of high quality and client-centred integrated FP services.
Collapse
Affiliation(s)
- Jessie K. Hamon
- Department of Disease Control, London School of Hygiene &Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Jenna Hoyt
- Department of Disease Control, London School of Hygiene &Tropical Medicine, London, United Kingdom
| | - Shari Krishnaratne
- Department of Disease Control, London School of Hygiene &Tropical Medicine, London, United Kingdom
| | | | - Job Morukileng
- International Rescue Committee Uganda, Kampala, Uganda
- Uganda Public Health Fellowship Program, Ministry of Health, Kampala, Uganda
| | - Nathaly Spilotros
- International Rescue Committee US, New York, NY, United States of America
| | | | - Seth Marcus
- World Vision US, Monrovia, California, United States of America
| | - Jayne Webster
- Department of Disease Control, London School of Hygiene &Tropical Medicine, London, United Kingdom
| |
Collapse
|
4
|
Discussing Reproductive Plans with Healthcare Providers by Sexually Active Women Living with HIV in Western Ethiopia. AIDS Behav 2020; 24:2842-2855. [PMID: 32212068 DOI: 10.1007/s10461-020-02833-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Discussing reproductive plans with healthcare providers by women living with HIV (WLHIV) can assist in promoting safe reproductive health practices, but little research has been undertaken in this area. A cross-sectional survey was conducted in western Ethiopia in 2018 among 475 sexually active WLHIV. One hundred and twenty seven (26.8%) participants reported becoming pregnant in the last 5 years after being aware of their HIV-positive status; 33.6% reported their intention to have children in the future, and 26.9% were ambivalent about having children. WLHIV who reported general and personalized discussions of reproductive plans with healthcare providers were 30.7% and 16.8%, respectively. Unmarried sexually active women and WLHIV accessing health centers for antiretroviral therapy (ART) were less likely to report both general and personalized discussions than married women and women who accessed ART through hospitals, respectively. WLHIV are both having and intending to have children, highlighting discussions with healthcare providers can deliver support that reduces the risk of vertical and horizontal HIV transmission.
Collapse
|
5
|
Mukamuyango J, Ingabire R, Parker R, Nyombayire J, Abaasa A, Asiki G, Easter SR, Wall KM, Nyirazinyoye L, Tichacek A, Kaslow N, Price MA, Allen S, Karita E. Uptake of long acting reversible contraception following integrated couples HIV and fertility goal-based family planning counselling in Catholic and non-Catholic, urban and rural government health centers in Kigali, Rwanda. Reprod Health 2020; 17:126. [PMID: 32807177 PMCID: PMC7433361 DOI: 10.1186/s12978-020-00981-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 08/11/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND When integrated with couples' voluntary HIV counselling and testing (CVCT), family planning including long acting reversible contraceptives (LARC) addresses prongs one and two of prevention of mother-to-child transmission (PMTCT). METHODS In this observational study, we enrolled equal numbers of HIV concordant and discordant couples in four rural and four urban clinics, with two Catholic and two non-Catholic clinics in each area. Eligible couples were fertile, not already using a LARC method, and wished to limit or delay fertility for at least 2 years. We provided CVCT and fertility goal-based family planning counselling with the offer of LARC and conducted multivariate analysis of clinic, couple, and individual predictors of LARC uptake. RESULTS Of 1290 couples enrolled, 960 (74%) selected LARC: Jadelle 5-year implant (37%), Implanon 3-year implant (26%), or copper intrauterine device (IUD) (11%). Uptake was higher in non-Catholic clinics (85% vs. 63% in Catholic clinics, p < 0.0001), in urban clinics (82% vs. 67% in rural clinics, p < 0.0001), and in HIV concordant couples (79% vs. 70% of discordant couples, p = .0005). Religion of the couple was unrelated to clinic religious affiliation, and uptake was highest among Catholics (80%) and lowest among Protestants (70%) who were predominantly Pentecostal. In multivariable analysis, urban location and non-Catholic clinic affiliation, Catholic religion of woman or couple, younger age of men, lower educational level of both partners, non-use of condoms or injectable contraception at enrollment, prior discussion of LARC by the couple, and women not having concerns about negative side effects of implant were associated with LARC uptake. CONCLUSIONS Fertility goal-based LARC recommendations combined with couples' HIV counselling and testing resulted in a high uptake of LARC methods, even among discordant couples using condoms for HIV prevention, in Catholic clinics, and in rural populations. This model successfully integrates prevention of HIV and unplanned pregnancy.
Collapse
Affiliation(s)
| | - Rosine Ingabire
- Projet San Francisco, Rwanda Zambia HIV Research Group, Kigali, Rwanda
| | - Rachel Parker
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA, USA
| | - Julien Nyombayire
- Projet San Francisco, Rwanda Zambia HIV Research Group, Kigali, Rwanda
| | - Andrew Abaasa
- London School of Hygiene & Tropical Medicine (LSHTM), Keppel Street, London, WC1E 7HT, UK
- Medical Research Council, Uganda Vaccine Research Institute & LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Gershim Asiki
- Medical Research Council, Uganda Vaccine Research Institute & LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Sarah Rae Easter
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kristin M Wall
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Amanda Tichacek
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA, USA
| | - Nadine Kaslow
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Emory University, Atlanta, GA, USA
| | - Matt A Price
- International AIDS Vaccine Initiative, New York, NY, USA
- Department of Epidemiology and Biostatistics, University of California at San Francisco, San Francisco, CA, USA
| | - Susan Allen
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA, USA.
| | - Etienne Karita
- Projet San Francisco, Rwanda Zambia HIV Research Group, Kigali, Rwanda
| |
Collapse
|
6
|
Narasimhan M, Yeh PT, Haberlen S, Warren CE, Kennedy CE. Integration of HIV testing services into family planning services: a systematic review. Reprod Health 2019; 16:61. [PMID: 31138307 PMCID: PMC6538541 DOI: 10.1186/s12978-019-0714-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Despite significant interest in integrating sexual and reproductive health (SRH) services into HIV services, less attention has been paid to linkages in the other direction. Where women and girls are at risk of HIV, offering HIV testing services (HTS) during their visits to family planning (FP) services offers important opportunities to address both HIV and unwanted pregnancy needs simultaneously. METHODS We conducted a systematic review of studies comparing FP services with integrated HTS to those without integrated HTS or with a lower level of integration (e.g., referral versus on-site services), on the following outcomes: uptake/counseling/offer of HTS, new cases of HIV identified, linkage to HIV care and treatment, dual method use, client satisfaction and service quality, and provider knowledge and attitudes about integrating HTS. We searched three online databases and included studies published in a peer-reviewed journal prior to the search date of June 20, 2017. RESULTS Of 530 citations identified, six studies ultimately met the inclusion criteria. Three studies were conducted in Kenya, and one each in Uganda, Swaziland, and the USA. Most were in FP clinics. Three were from the Integra Initiative. Overall rigor was moderate, with one cluster-randomized trial. HTS uptake was generally higher with integrated sites versus comparison or pre-integration sites, including in adjusted analyses, though outcomes varied slightly across studies. One study found that women at integrated sites were more likely to have high satisfaction with services, but experienced longer waiting times. One study found a small increase in HIV seropositivity among female patients testing after full integration, compared to a dedicated HIV tester. No studies comparatively measured linkage to HIV care and treatment, dual method use, or provider knowledge/attitudes. CONCLUSIONS Global progress and success for reaching SRH and HIV targets depends on progress in sub-Saharan Africa, where women bear a high burden of both unintended pregnancy and sexually transmitted infections, including HIV. While the evidence base is limited, it suggests that integration of HTS into FP services is feasible and has potential for positive joint outcomes. The success and scale-up of this approach will depend on population needs and health system factors.
Collapse
Affiliation(s)
- Manjulaa Narasimhan
- Department of Reproductive Health and Research and UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme, World Health Organization, Geneva, Switzerland
| | - Ping Teresa Yeh
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Sabina Haberlen
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | | | - Caitlin E. Kennedy
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| |
Collapse
|
7
|
Li L, Liang LJ, Lin C, Feng N, Cao W, Wu Z. An intervention to improve provider-patient interaction at methadone maintenance treatment in China. J Subst Abuse Treat 2019; 99:149-155. [PMID: 30797387 DOI: 10.1016/j.jsat.2019.01.022] [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: 10/15/2018] [Revised: 01/30/2019] [Accepted: 01/30/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND This study evaluated an intervention aiming to improve methadone maintenance therapy (MMT) service providers' interaction with their patients in China. METHODS Sixty-eight MMT clinics were randomized to either an intervention or a control condition. Providers in the intervention group attended three group training sessions to enhance their communication skills. Trained providers were encouraged to practice the taught communication skills through provider-initiated individual sessions with their patients. A total of 418 service providers completed assessments from baseline to 24-month. Linear mixed-effects regression models were used to compare self-reported short-term and sustained improvement in provider-patient interaction between the intervention and the control conditions. RESULTS The intervention group service providers perceived significantly greater short-term and sustained improvement in provider-patient interaction compared to the control group service providers (estimated difference (±SE): 1.20 (0.24) and 1.35 (0.33), respectively; p-values < 0.0001). Providers' baseline job satisfaction was significantly associated with a greater perceived improvement in provider-patient interaction for both periods (reg. coef. (±SE): 0.02 (0.01) and 0.04 (0.01) for short-term and sustained periods, respectively; p-values < 0.01). CONCLUSION Study findings suggest that the intervention could be beneficial for improving perceived provider-patient interaction in MMT programs. Service providers' job satisfaction should be addressed in training programs for the improvement of provider-patient interaction.
Collapse
Affiliation(s)
- Li Li
- Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, USA.
| | - Li-Jung Liang
- Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, USA
| | - Chunqing Lin
- Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, USA
| | - Nan Feng
- Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, USA
| | - Wei Cao
- Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, USA
| | - Zunyou Wu
- National Center for AIDS/STD Control and Prevention, Chinese Centers for Disease Control and Prevention, Beijing, China
| |
Collapse
|
8
|
Hopkins J, Collins L. How linked are national HIV and SRHR strategies? A review of SRHR and HIV strategies in 60 countries. Health Policy Plan 2018; 32:iv57-iv66. [PMID: 29194540 PMCID: PMC5886072 DOI: 10.1093/heapol/czw119] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2016] [Indexed: 11/13/2022] Open
Abstract
The connection between HIV and sexual and reproductive health and rights (SRHR) is widely recognised along with the benefits of linking them at the legal/policy, health systems, and service delivery levels. However, despite increased rhetoric about the need for this three-tiered approach, integrated service delivery has not been fully addressed at the legal/policy level through national strategies. Thus a review of HIV and SRHR strategies was conducted for 60 countries, determining the extent to which they reflected the intersections between HIV and SRHR. Each HIV strategy was scored on whether five key SRHR components were incorporated and had an associated measurable target. SRHR strategies were similarly assessed for incorporation of five HIV components and associated targets. HIV strategies had a higher level of inclusion of SRHR components with a global average of 6.6/10 compared to 3.7/10 for SRHR strategies. The highest scoring component was the elimination of mother-to-child transmission of HIV (EMTCT) and the lowest was SRHR of people living with HIV. Countries with higher scores in one strategy tended to have higher scores in the other but there was no difference over time. Whilst there has been increased global commitment since 2004 to link SRHR and HIV, insufficient headway has been made in linking related national strategies. Although EMTCT is included with targets in the majority of HIV and SRHR strategies, the broader SRHR needs of women living with HIV are not. Also, condoms are not being considered an effective triple protection tool. HIV and SRHR strategies provide direction and targets which ultimately may influence funding and vice versa. Therefore, it is essential that these strategies are right-based and incorporate the key connections between SRHR and HIV with measurable targets to realise the full benefits of a joint response.
Collapse
|
9
|
Birdthistle IJ, Fenty J, Collumbien M, Warren C, Kimani J, Ndwiga C, Mayhew S. Integration of HIV and reproductive health services in public sector facilities: analysis of client flow data over time in Kenya. BMJ Glob Health 2018; 3:e000867. [PMID: 30245866 PMCID: PMC6144905 DOI: 10.1136/bmjgh-2018-000867] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 05/24/2018] [Accepted: 05/28/2018] [Indexed: 11/07/2022] Open
Abstract
Introduction Integration of HIV/AIDS with reproductive health (RH) services can increase the uptake and efficiency of services, but gaps in knowledge remain about the practice of integration, particularly how provision can be expanded and performance enhanced. We assessed the extent and nature of service integration in public sector facilities in four districts in Kenya. Methods Between 2009 and 2012, client flow assessments were conducted at six time points in 24 government facilities, purposively selected as intervention or comparison sites. A total of 25 539 visits were tracked: 15 270 in districts where 6 of 12 facilities received an intervention to strengthen HIV service integration with family planning (FP); and 10 266 visits in districts where half the facilities received an HIV-postnatal care intervention in 2009–2010. We tracked the proportion of all visits in which: (1) an HIV service (testing, counselling or treatment) was received together with an RH service (FP counselling or provision, antenatal care, or postnatal care); (2) the client received HIV counselling. Results Levels of integrated HIV-RH services and HIV counselling were generally low across facilities and time points. An initial boost in integration was observed in most intervention sites, driven by integration of HIV services with FP counselling and provision, and declined after the first follow-up. Integration at most sites was driven by temporary rises in HIV counselling. The most consistent combination of HIV services was with antenatal care; the least common was with postnatal care. Conclusions These client flow data demonstrated a short-term boost in integration, after an initial intervention with FP services providing an opportunity to expand integration. Integration was not sustained over time highlighting the need for ongoing support. There are multiple opportunities for integrating service delivery, particularly within antenatal, FP and HIV counselling services, but a need for sustained systems and health worker support over time. Trial registration number NCT01694862
Collapse
Affiliation(s)
- Isolde J Birdthistle
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Justin Fenty
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Martine Collumbien
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | | | - Susannah Mayhew
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | | |
Collapse
|
10
|
Siapka M, Obure CD, Mayhew SH, Sweeney S, Fenty J, Initiative I, Vassall A. Impact of integration of sexual and reproductive health services on consultation duration times: results from the Integra Initiative. Health Policy Plan 2017; 32:iv82-iv90. [PMID: 29194545 PMCID: PMC5886289 DOI: 10.1093/heapol/czx141] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2017] [Indexed: 11/24/2022] Open
Abstract
The lack of human resources is a key challenge in scaling up of HIV services in Africa's health care system. Integrating HIV services could potentially increase their effectiveness and optimize the use of limited resources and clinical staff time. We examined the impact of integration of provider initiated HIV counselling and testing (PITC) and family planning (FP counselling and FP provision) services on duration of consultation to assess the impact of PITC and FP integration on staff workload. This study was conducted in 24 health facilities in Kenya under the Integra Initiative, a non-randomized, pre/post intervention trial to evaluate the impact of integrated HIV and sexual and reproductive health services on health and service outcomes. We compared the time spent providing PITC-only services, FP-only services and integrated PITC/FP services. We used log-linear regression to assess the impact of plausible determinants on the duration of clients' consultation times. Median consultation duration times were highest for PITC-only services (30 min), followed by integrated services (10 min) and FP-only services (8 min). Times for PITC-only and FP-only services were 69.7% higher (95% Confidence Intervals (CIs) 35.8-112.0) and 43.9% lower (95% CIs -55.4 to - 29.6) than times spent on these services when delivered as an integrated service, respectively. The reduction in consultation times with integration suggests a potential reduction in workload. The higher consultation time for PITC-only could be because more pre- and post-counselling is provided at these stand-alone services. In integrated PITC/FP services, the duration of the visit fell below that required by HIV testing guidelines, and service mix between counselling and testing substantially changed. Integration of HIV with FP services may compromise the quality of services delivered and care must be taken to clearly specify and monitor appropriate consultation duration times and procedures during the process of integrating HIV and FP services.
Collapse
Affiliation(s)
- Mariana Siapka
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Carol Dayo Obure
- Human Capital Youth and Skills Development Department, African Development Bank, Abidjan, Côte d'Ivoire
| | - Susannah H Mayhew
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Sedona Sweeney
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Justin Fenty
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Integra Initiative
- Full list of Integra Initiative team members is provided in the Acknowledgements
| | - Anna Vassall
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| |
Collapse
|
11
|
Mayhew SH, Sweeney S, Warren CE, Collumbien M, Ndwiga C, Mutemwa R, Lut I, Colombini M, Vassall A. Numbers, systems, people: how interactions influence integration. Insights from case studies of HIV and reproductive health services delivery in Kenya. Health Policy Plan 2017; 32:iv67-iv81. [PMID: 29194544 PMCID: PMC5886080 DOI: 10.1093/heapol/czx097] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2017] [Indexed: 11/12/2022] Open
Abstract
Drawing on rich data from the Integra evaluation of integrated HIV and reproductive-health services, we explored the interaction of systems hardware and software factors to explain why some facilities were able to implement and sustain integrated service delivery while others were not. This article draws on detailed mixed-methods data for four case-study facilities offering reproductive-health and HIV services between 2009 and 2013 in Kenya: (i) time-series client flow, tracking service uptake for 8841 clients; (ii) structured questionnaires with 24 providers; (iii) in-depth interviews with 17 providers; (iv) workload and facility data using a periodic activity review and cost-instruments; and (v) contextual data on external activities related to integration in study sites. Overall, our findings suggested that although structural factors like stock-outs, distribution of staffing and workload, rotation of staff can affect how integrated care is provided, all these factors can be influenced by staff themselves: both frontline and management. Facilities where staff displayed agency of decision making, worked as a team to share workload and had management that supported this, showed better integration delivery and staff were able to overcome some structural deficiencies to enable integrated care. Poor-performing facilities had good structural integration, but staff were unable to utilize this because they were poorly organized, unsupported or teams were dysfunctional. Conscientious objection and moralistic attitudes were also barriers.Integra has demonstrated that structural integration is not sufficient for integrated service delivery. Rather, our case studies show that in some cases excellent leadership and peer-teamwork enabled facilities to perform well despite resource shortages. The ability to provide support for staff to work flexibly to deliver integrated services and build resilient health systems to meet changing needs is particularly relevant as health systems face challenges of changing burdens of disease, climate change, epidemic outbreaks and more.
Collapse
Affiliation(s)
- Susannah H Mayhew
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Sedona Sweeney
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Martine Collumbien
- Department of Social and Environmental Health Research, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Richard Mutemwa
- Centre for Infectious Disease Control – Zambia (CIDRZ), Zambia
| | | | - Integra Initiative
- Full list of Integra Initiative team members is provided in the Acknowledgements
| | - Manuela Colombini
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Anna Vassall
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| |
Collapse
|
12
|
Mayhew SH, Hopkins J, Warren CE. Building integrated health systems: lessons from HIV, sexual and reproductive health integration. Health Policy Plan 2017; 32:iv1-iv5. [PMID: 29194546 PMCID: PMC5886152 DOI: 10.1093/heapol/czx142] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2017] [Indexed: 11/23/2022] Open
Affiliation(s)
- Susannah H Mayhew
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Jonathan Hopkins
- Independent Consultant, formerly, International Planned Parenthood Federation, London, UK and
| | | |
Collapse
|
13
|
Warren CE, Mayhew SH, Hopkins J. The Current Status of Research on the Integration of Sexual and Reproductive Health and HIV Services. Stud Fam Plann 2017; 48:91-105. [PMID: 28493283 PMCID: PMC5518217 DOI: 10.1111/sifp.12024] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Integration of services for sexual and reproductive health (SRH) and HIV has been widely promoted globally in the belief that both clients and health providers benefit through improvements in quality, efficient use of resources, and lower costs, helping to maximize limited health resources and provide comprehensive client-centered care. This article builds on the growing body of research on integrated sexual SRH and HIV services. It brings together critical reviews on issues within the wider SRH and rights agenda and synthesizes recent research on integrated services, drawing on the Integra Initiative and other major research. Unintended pregnancy and HIV are intrinsically interrelated SRH issues, however broadening the constellation of services, scaling up, and mainstreaming integration continue to be challenging. Overcoming stigma, reducing gender-based violence, and meeting key populations' SRH needs are critical. Health systems research using SRH as the entry point for integrated services and interaction with communities and clients is needed to realize universal health coverage.
Collapse
|
14
|
Mayhew SH, Ploubidis GB, Sloggett A, Church K, Obure CD, Birdthistle I, Sweeney S, Warren CE, Watts C, Vassall A. Innovation in Evaluating the Impact of Integrated Service-Delivery: The Integra Indexes of HIV and Reproductive Health Integration. PLoS One 2016; 11:e0146694. [PMID: 26800517 PMCID: PMC4723242 DOI: 10.1371/journal.pone.0146694] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2015] [Accepted: 12/20/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The body of knowledge on evaluating complex interventions for integrated healthcare lacks both common definitions of 'integrated service delivery' and standard measures of impact. Using multiple data sources in combination with statistical modelling the aim of this study is to develop a measure of HIV-reproductive health (HIV-RH) service integration that can be used to assess the degree of service integration, and the degree to which integration may have health benefits to clients, or reduce service costs. METHODS AND FINDINGS Data were drawn from the Integra Initiative's client flow (8,263 clients in Swaziland and 25,539 in Kenya) and costing tools implemented between 2008-2012 in 40 clinics providing RH services in Kenya and Swaziland. We used latent variable measurement models to derive dimensions of HIV-RH integration using these data, which quantified the extent and type of integration between HIV and RH services in Kenya and Swaziland. The modelling produced two clear and uncorrelated dimensions of integration at facility level leading to the development of two sub-indexes: a Structural Integration Index (integrated physical and human resource infrastructure) and a Functional Integration Index (integrated delivery of services to clients). The findings highlight the importance of multi-dimensional assessments of integration, suggesting that structural integration is not sufficient to achieve the integrated delivery of care to clients--i.e. "functional integration". CONCLUSIONS These Indexes are an important methodological contribution for evaluating complex multi-service interventions. They help address the need to broaden traditional evaluations of integrated HIV-RH care through the incorporation of a functional integration measure, to avoid misleading conclusions on its 'impact' on health outcomes. This is particularly important for decision-makers seeking to promote integration in resource constrained environments.
Collapse
Affiliation(s)
- Susannah H. Mayhew
- Department of Global Health & Development, London School of Hygiene & Tropical Medicine, 15–17 Tavistock Place, London, WC1H 9SH, United Kingdom
- * E-mail:
| | - George B. Ploubidis
- Centre for Longitudinal Studies, Department of Social Science, UCL Institute of Education, University College London, 55–59 Gordon Square, London, WC1H 0NU, United Kingdom
| | - Andy Sloggett
- Department of Population Health, London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT, United Kingdom
| | - Kathryn Church
- Department of Population Health, London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT, United Kingdom
| | - Carol D. Obure
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, P.O. Box 4002, Basel, Switzerland
| | - Isolde Birdthistle
- Department of Population Health, London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT, United Kingdom
| | - Sedona Sweeney
- Department of Global Health & Development, London School of Hygiene & Tropical Medicine, 15–17 Tavistock Place, London, WC1H 9SH, United Kingdom
| | - Charlotte E. Warren
- Reproductive Health Services and Research, Population Council, Suite 280, 4301 Connecticut Ave NW, Washington, District of Columbia, 20008, United States of America
| | - Charlotte Watts
- Department of Global Health & Development, London School of Hygiene & Tropical Medicine, 15–17 Tavistock Place, London, WC1H 9SH, United Kingdom
| | - Anna Vassall
- Department of Global Health & Development, London School of Hygiene & Tropical Medicine, 15–17 Tavistock Place, London, WC1H 9SH, United Kingdom
| | | |
Collapse
|