Priority Topics for Health Education to Support HIV Self-Management in Limited-Resource Settings

Evaluation of an HIV-related Education Intervention Scale-up: A Hybrid Type 3 Effectiveness-implementation Study in the Dominican Republic

We developed an infographic intervention to augment HIV-related education in the Dominican Republic (DR), which demonstrated preliminary success in pilot studies. We then partnered with the United States Agency for International Development's (USAID) HIV Services and Systems Strengthening program in the DR to scale up the intervention. We used a two-tier Training-of-Trainer (TOT) method to teach intervention administration. N = 12 program leaders completed the tier-1 training and subsequently taught N ~ 102 clinical staff to use infographics with people with HIV (PWH) (tier-2 trainings). Study Aim 1 was to assess implementation outcomes; Aim 2 was to explore infographic influences on program-level health outcomes. We conducted a hybrid type 3 effectiveness-implementation study with three data components: (1) Surveys bookending tier-1 and tier-2 trainings; (2) Focus groups with tier-1 and tier-2 trainees; and (3) program-level data. We designed surveys according to Kirkpatrick's Training Evaluation Model and analyzed responses with descriptive statistics and/or Fisher's exact tests. We led four focus groups with a theory-driven guide and analyzed transcripts with conventional qualitative content analysis. We analyzed program-level data by comparing outcomes before and after infographic use with advanced statistical modeling. All 12 program leaders completed tier-1, and 36 staff completed tier-2 surveys; focus groups comprised eight tier-1 and 27 tier-2 trainees; program-level data pertained to 4,318 PWH. Surveys and focus groups indicated the TOT method is feasible, acceptable, and sustainable. Program-level findings showed PWH were more likely to attend scheduled visits and be virally suppressed following infographic implementation. Results indicate our intervention can likely enhance HIV education at large scale.

Interventions for Type 2 Diabetes reduction among older people living with HIV in Harare

BACKGROUND

Interventions for Type 2 Diabetes reduction among older people aged more than 50 years living with HIV (PLWH) are pertinent as they face excess risks amid a growing population of ageing PLWH.

AIM

To describe interventions for Type 2 Diabetes reduction among older people living with HIV in Harare Urban DistrictSetting: The study was conducted in a low socio-economic setting from five primary health care clinics in Harare urban District.

METHODS

A qualitative multi-method approach was applied using an exploratory descriptive design and an integrative review literature. The exploratory descriptive study collected data from two purposively selected samples; (1) older PLWH and (2) nurses. Whittemore and Knafl's framework was used for the integrative literature review with articles from 2013 to 2023 selected. Data source triangulation was applied using Braun and Clark's content analysis framework. Ethical approval was obtained (14056739_CREC_CHS_2022).

RESULTS

23 older PLWH with mean age, 62 years, 9 nurses with an average of 6 years' experience and 12 articles comprised the three data sources.  Key themes that emerged were that, screening should include; assessment from a younger age; assessment of HIV and ART-specific risks; diagnostic testing of Type 2 diabetes tests at ART initiation and routinely. Health education should provide information on adequate physical activity parameters and increased consumption of fruits and vegetables. Metformin may be considered as a pharmacological intervention where lifestyle interventions fail.

CONCLUSION

The proposed interventions suggest measures to reduce Type 2 Diabetes and mitigate excess risks faced by older PLWH.Contribution: Improved screening, health education and pharmacological interventions for older PLWH in primary health care settings enable Type 2 Diabetes reduction.

A pilot test of an infographic-based health communication intervention to enhance patient education among Latino persons with HIV

OBJECTIVE

To pilot test an infographic-based health communication intervention that our team rigorously designed and explore whether its implementation leads to better health outcomes among Latino persons with HIV (PWH).

MATERIALS AND METHODS

Latino PWH (N = 30) living in New York City received the intervention during health education sessions at 3 study visits that occurred approximately 3 months apart. At each visit, participants completed baseline or follow-up assessments and laboratory data were extracted from patient charts. We assessed 6 outcomes (HIV-related knowledge, self-efficacy to manage HIV, adherence to antiretroviral therapy, CD4 count, viral load, and current and overall health status) selected according to a conceptual model that describes pathways through which communication influences health outcomes. We assessed changes in outcomes over time using quantile and generalized linear regression models controlling for the coronavirus disease 2019 (COVID-19) research pause and new patient status (new/established) at the time of enrollment.

RESULTS

Most participants were male (60%) and Spanish-speaking (60%); 40% of participants identified as Mixed Race/Mestizo, 13.3% as Black, 13.3% as White, and 33.3% as "other" race. Outcome measures generally improved after the second intervention exposure. Following the third intervention exposure (after the COVID-19 research pause), only the improvements in HIV-related knowledge and current health status were statistically significant.

DISCUSSION AND CONCLUSION

Our infographic-based health communication intervention may lead to better health outcomes among Latino PWH, but larger trials are needed to establish efficacy. From this work, we contribute suggestions for effective infographic use for patient-provider communication to enhance patient education in clinical settings.

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

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

Clinician Use of HIV-Related Infographics During Clinic Visits in the Dominican Republic is Associated with Lower Viral Load and Other Improvements in Health Outcomes

We designed an infographic intervention to help clinicians provide health information to persons living with HIV. In this study, we assessed the extent to which our intervention may improve objectively and subjectively measured health outcomes (CD4 count, viral load, and engagement with clinician among others) when integrated into routine visits in the Dominican Republic. In this pretest-posttest study, we followed participants for 9 months at 3-month intervals. Physicians administered the intervention during participants' first 3 visits. Outcome measures, selected using a conceptual model, were assessed at 4 time points. We assessed changes in outcomes over time with general linear regressions and Wilcoxon Signed-Rank tests. Participants (N = 50) were mostly female (56%) and had been living with HIV for a mean of 6.3 years (SD = 6.1). All outcomes, except CD4 count, demonstrated statistically significant improvements by study end. This provides preliminary evidence our intervention may improve outcomes, but further testing is needed.

Feasibility and acceptability of using information visualizations to improve HIV-related communication in a limited-resource setting: a short report

Infographics (visualizations that present information) can assist clinicians to offer health information to patients with low health literacy in an accessible format. In response, we developed an infographic intervention to enhance clinical, HIV-related communication. This study reports on its feasibility and acceptability at a clinical setting in the Dominican Republic. We conducted in-depth interviews with physicians who administered the intervention and patients who received it. We conducted audio-recorded interviews in Spanish using semi-structured interview guides. Recordings were professionally transcribed verbatim then analyzed using descriptive content analysis. Physician transcripts were deductively coded according to constructs of Bowen et al.'s feasibility framework and patient transcripts were inductively coded. Three physicians and 26 patients participated. Feasibility constructs endorsed by physicians indicated that infographics were easy to use, improved teaching, and could easily be incorporated into their workflow. Coding of patient transcripts identified four categories that indicated the intervention was acceptable and useful, offered feedback regarding effective clinical communication, and recommended improvements to infographics. Taken together, these data indicate our intervention was a feasible and acceptable way to provide clinical, HIV-related information and provide important recommendations for future visualization design as well as effective clinical communication with similar patient populations.

Evaluation of a Community-Based Self-Management Program to Increase Access to Rehabilitation for People Living with HIV

We qualitatively evaluated a novel educational program to help people living with HIV understand the role of rehabilitation, facilitate access to rehabilitation, and promote self-management of chronic disease in Canada. The program incorporated components of self-efficacy, client-centered care, peer education, and problem-based learning. Delivery of the community-engaged program was viewed as feasible and acceptable; however, a flexible delivery model was deemed important. Perceived learning was related to rehabilitation, advocacy, and taking responsibility for one's health. A co-leader model and access to online resources were strengths. Future work should assess the ability to apply advocacy knowledge and skills to access rehabilitation services.

Developing Infographics to Facilitate HIV-Related Patient-Provider Communication in a Limited-Resource Setting

BACKGROUND

Productive patient-provider communication is a recognized component of high-quality health care that leads to better health outcomes. Well-designed infographics can facilitate effective communication, especially when culture, language, or literacy differences are present.

OBJECTIVES

This study aimed to rigorously develop infographics to improve human immunodeficiency virus (HIV)-related patient-provider communication in a limited-resource setting. A secondary purpose was to establish through participant feedback that infographics convey intended meaning in this clinical and cultural context.

METHODS

We adapted a participatory design methodology, developed in a high-resource setting, for use in the Dominican Republic. Initially, content to include was established using a data-triangulation method. Then, infographics were iteratively generated and refined during five phases of design sessions with three stakeholder groups: (1) 25 persons living with HIV, (2) 8 health care providers, and (3) 5 domain experts. Suggestions for improvement were incorporated between design sessions and questions to confirm interpretability of infographics were included at the end of each session.

RESULTS

Each participant group focused on different aspects of infographic designs. Providers drew on past experiences with patients and offered clinically and contextually relevant recommendations of symbols and images to include. Domain experts focused on technical design considerations and interpretations of infographics. While it was difficult for patient participants to provide concrete suggestions, they provided feedback on the meaning of infographics and responded clearly to direct questions regarding possible changes. Fifteen final infographics were developed and all participant groups qualitatively confirmed that they displayed the intended content in a culturally appropriate and clinically meaningful way.

CONCLUSION

Incorporating perspectives from various stakeholders led to the evolution of designs over time and generated design recommendations that will be useful to others creating infographics for use in similar populations. Next steps are to assess the feasibility of using infographics to improve clinical communication and patient outcomes.