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Van Hout MC, Akugizibwe M, Shayo EH, Namulundu M, Kasujja FX, Namakoola I, Birungi J, Okebe J, Murdoch J, Mfinanga SG, Jaffar S. Decentralising chronic disease management in sub-Saharan Africa: a protocol for the qualitative process evaluation of community-based integrated management of HIV, diabetes and hypertension in Tanzania and Uganda. BMJ Open 2024; 14:e078044. [PMID: 38508649 PMCID: PMC10961519 DOI: 10.1136/bmjopen-2023-078044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 02/26/2024] [Indexed: 03/22/2024] Open
Abstract
INTRODUCTION Sub-Saharan Africa continues to experience a syndemic of HIV and non-communicable diseases (NCDs). Vertical (stand-alone) HIV programming has provided high-quality care in the region, with almost 80% of people living with HIV in regular care and 90% virally suppressed. While integrated health education and concurrent management of HIV, hypertension and diabetes are being scaled up in clinics, innovative, more efficient and cost-effective interventions that include decentralisation into the community are required to respond to the increased burden of comorbid HIV/NCD disease. METHODS AND ANALYSIS This protocol describes procedures for a process evaluation running concurrently with a pragmatic cluster-randomised trial (INTE-COMM) in Tanzania and Uganda that will compare community-based integrated care (HIV, diabetes and hypertension) with standard facility-based integrated care. The INTE-COMM intervention will manage multiple conditions (HIV, hypertension and diabetes) in the community via health monitoring and adherence/lifestyle advice (medicine, diet and exercise) provided by community nurses and trained lay workers, as well as the devolvement of NCD drug dispensing to the community level. Based on Bronfenbrenner's ecological systems theory, the process evaluation will use qualitative methods to investigate sociostructural factors shaping care delivery and outcomes in up to 10 standard care facilities and/or intervention community sites with linked healthcare facilities. Multistakeholder interviews (patients, community health workers and volunteers, healthcare providers, policymakers, clinical researchers and international and non-governmental organisations), focus group discussions (community leaders and members) and non-participant observations (community meetings and drug dispensing) will explore implementation from diverse perspectives at three timepoints in the trial implementation. Iterative sampling and analysis, moving between data collection points and data analysis to test emerging theories, will continue until saturation is reached. This process of analytic reflexivity and triangulation across methods and sources will provide findings to explain the main trial findings and offer clear directions for future efforts to sustain and scale up community-integrated care for HIV, diabetes and hypertension. ETHICS AND DISSEMINATION The protocol has been approved by the University College of London (UK), the London School of Hygiene and Tropical Medicine Ethics Committee (UK), the Uganda National Council for Science and Technology and the Uganda Virus Research Institute Research and Ethics Committee (Uganda) and the Medical Research Coordinating Committee of the National Institute for Medical Research (Tanzania). The University College of London is the trial sponsor. Dissemination of findings will be done through journal publications and stakeholder meetings (with study participants, healthcare providers, policymakers and other stakeholders), local and international conferences, policy briefs, peer-reviewed journal articles and publications. TRIAL REGISTRATION NUMBER ISRCTN15319595.
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Affiliation(s)
| | | | - Elizabeth Henry Shayo
- Health Systems, Policy and Translational Reseach Section, National Institute for Medical Research, Dar es Salaam, Tanzania, United Republic
| | - Moreen Namulundu
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Wakiso, Uganda
| | | | - Ivan Namakoola
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Wakiso, Uganda
| | | | - Joseph Okebe
- Institute for Global Health, University College London, London, UK
| | - Jamie Murdoch
- School of Life Course and Population Sciences, King's College London, London, London, UK
| | - Sayoki Godfrey Mfinanga
- Muhimbili Medical Research Centre, National Institute for Medical Research Tanzania, Dar es Salaam, Tanzania, United Republic of
| | - Shabbar Jaffar
- Institute for Global Health, University College London, London, UK
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Subbe CP, Steinmo SH, Haskell H, Barach P. Martha's rule: applying a behaviour change framework to understand the potential of complementary roles of clinicians and patients in improving safety of patients deteriorating in hospital. Br J Hosp Med (Lond) 2024; 85:1-6. [PMID: 38416522 DOI: 10.12968/hmed.2023.0422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
AIMS/BACKGROUND Martha's rule stipulates the right of patients and their families to escalate care as a way to improve safety while in hospital. This article analyses the possible impact of the proposed policy through the lens of a behaviour change framework and explores new opportunities presented by the implementation of Martha's rule.. METHODS A descriptive analysis was undertaken of interactions between patients, family, friends and clinicians during clinical deterioration in hospital. The capability-opportunity-motivation behaviour change framework was applied to understand reasons for failure to respond to deterioration. RESULTS Care of deteriorating patients requires recording of vital signs, recognition of abnormalities, reporting through escalation and response by a competent clinician. Regarding the care of patients who deteriorate in hospital, healthcare professionals have capability and motivation to provide safe, high-quality care, but often lack the physical and social opportunity to report or respond through lack of time and peer pressure. Patients and family members have motivation and might have time to support safety systems. Martha's rule or similar arrangements allow healthcare organisations to create opportunities for patients and families to report and escalate care to experts in critical care when they recognise deterioration. CONCLUSIONS The capability-opportunity-motivation behaviour change framework provides insights into the causes of failure to rescue in deteriorating patients and an argument for opportunities through escalation by patients and families through Martha's rule. This might reduce the number of system failures and enable safer care.
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Affiliation(s)
| | - Siri H Steinmo
- inform_us Health Informatics Critical Care, University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Paul Barach
- Children's Hospital of Michigan, Wayne State University School of Medicine, Detroit, MI, USA
- Jefferson College of Population Health, Philadelphia, PA, USA
- Interdisciplinary Research Institute for Health Law and Science, Sigmund Freud University, Vienna, Austria
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Iwelunmor J, Maureen Obionu I, Shedul G, Anyiekere E, Henry D, Aifah A, Obiezu-Umeh C, Nwaozuru U, Onakomaiya D, Rakhra A, Mishra S, Hade EM, Kanneh N, Lew D, Bansal GP, Ogedegbe G, Ojji D. Assets for integrating task-sharing strategies for hypertension within HIV clinics: Stakeholder's perspectives using the PEN-3 cultural model. PLoS One 2024; 19:e0294595. [PMID: 38165888 PMCID: PMC10760724 DOI: 10.1371/journal.pone.0294595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 11/04/2023] [Indexed: 01/04/2024] Open
Abstract
BACKGROUND Access to antiretroviral therapy has increased life expectancy and survival among people living with HIV (PLWH) in African countries like Nigeria. Unfortunately, non-communicable diseases such as cardiovascular diseases are on the rise as important drivers of morbidity and mortality rates among this group. The aim of this study was to explore the perspectives of key stakeholders in Nigeria on the integration of evidence-based task-sharing strategies for hypertension care (TASSH) within existing HIV clinics in Nigeria. METHODS Stakeholders representing PLWH, patient advocates, health care professionals (i.e. community health nurses, physicians and chief medical officers), as well as policymakers, completed in-depth qualitative interviews. Stakeholders were asked to discuss facilitators and barriers likely to influence the integration of TASSH within HIV clinics in Akwa Ibom, Nigeria. The interviews were transcribed, keywords and phrases were coded using the PEN-3 cultural model as a guide. Framework thematic analysis guided by the PEN-3 cultural model was used to identify emergent themes. RESULTS Twenty-four stakeholders participated in the interviews. Analysis of the transcribed data using the PEN-3 cultural model as a guide yielded three emergent themes as assets for the integration of TASSH in existing HIV clinics. The themes identified are: 1) extending continuity of care among PLWH; 2) empowering health care professionals and 3) enhancing existing workflow, staff motivation, and stakeholder advocacy to strengthen the capacity of HIV clinics to integrate TASSH. CONCLUSION These findings advance the field by providing key stakeholders with knowledge of assets within HIV clinics that can be harnessed to enhance the integration of TASSH for PLWH in Nigeria. Future studies should evaluate the effect of these assets on the implementation of TASSH within HIV clinics as well as their effect on patient-level outcomes over time.
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Affiliation(s)
- Juliet Iwelunmor
- Department of Behavioral Science and Health Education, College for Public Health and Social Justice Saint Louis University, St. Louis, MO, United States of America
| | - Ifeoma Maureen Obionu
- Department of Behavioral Science and Health Education, College for Public Health and Social Justice Saint Louis University, St. Louis, MO, United States of America
| | - Gabriel Shedul
- Department of Family Medicine, University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
- Cardiovascular Research Unit, University of Abuja Teaching Hospital, University of Abuja, Gwagwalada, Abuja, Nigeria
| | - Ekanem Anyiekere
- Department of Community Medicine, Faculty of Clinical Sciences, University of Uyo, Uyo, Nigeria
| | - Daniel Henry
- Cardiovascular Research Unit, University of Abuja Teaching Hospital, University of Abuja, Gwagwalada, Abuja, Nigeria
| | - Angela Aifah
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, United States of America
| | - Chisom Obiezu-Umeh
- Department of Behavioral Science and Health Education, College for Public Health and Social Justice Saint Louis University, St. Louis, MO, United States of America
| | - Ucheoma Nwaozuru
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States of America
| | - Deborah Onakomaiya
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, United States of America
| | - Ashlin Rakhra
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, United States of America
| | - Shivani Mishra
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, United States of America
| | - Erinn M. Hade
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, United States of America
| | - Nafesa Kanneh
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, United States of America
| | - Daphne Lew
- Washington University in St. Louis School of Medicine, St. Louis, MO, United States of America
| | - Geetha P. Bansal
- Fogarty International Center, NIH, Bethesda, MD, United States of America
| | - Gbenga Ogedegbe
- Department of Community Medicine, Faculty of Clinical Sciences, University of Uyo, Uyo, Nigeria
- Institute for Excellence in Health Equity, New York University Grossman School of Medicine, New York, New York, United States of America
| | - Dike Ojji
- Department of Family Medicine, University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
- Department of Internal Medicine, Faculty of Clinical Sciences, College of Health Sciences, University of Abuja, Gwagwalada, Abuja, Nigeria
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Van Hout MC, Zalwango F, Akugizibwe M, Chaka MN, Birungi J, Okebe J, Jaffar S, Bachmann M, Murdoch J. Implementing integrated care clinics for HIV-infection, diabetes and hypertension in Uganda (INTE-AFRICA): process evaluation of a cluster randomised controlled trial. BMC Health Serv Res 2023; 23:570. [PMID: 37268916 DOI: 10.1186/s12913-023-09534-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 05/10/2023] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND Sub-Saharan Africa is experiencing a dual burden of chronic human immunodeficiency virus and non-communicable diseases. A pragmatic parallel arm cluster randomised trial (INTE-AFRICA) scaled up 'one-stop' integrated care clinics for HIV-infection, diabetes and hypertension at selected facilities in Uganda. These clinics operated integrated health education and concurrent management of HIV, hypertension and diabetes. A process evaluation (PE) aimed to explore the experiences, attitudes and practices of a wide variety of stakeholders during implementation and to develop an understanding of the impact of broader structural and contextual factors on the process of service integration. METHODS The PE was conducted in one integrated care clinic, and consisted of 48 in-depth interviews with stakeholders (patients, healthcare providers, policy-makers, international organisation, and clinical researchers); three focus group discussions with community leaders and members (n = 15); and 8 h of clinic-based observation. An inductive analytical approach collected and analysed the data using the Empirical Phenomenological Psychological five-step method. Bronfenbrenner's ecological framework was subsequently used to conceptualise integrated care across multiple contextual levels (macro, meso, micro). RESULTS Four main themes emerged; Implementing the integrated care model within healthcare facilities enhances detection of NCDs and comprehensive co-morbid care; Challenges of NCD drug supply chains; HIV stigma reduction over time, and Health education talks as a mechanism for change. Positive aspects of integrated care centred on the avoidance of duplication of care processes; increased capacity for screening, diagnosis and treatment of previously undiagnosed comorbid conditions; and broadening of skills of health workers to manage multiple conditions. Patients were motivated to continue receiving integrated care, despite frequent NCD drug stock-outs; and development of peer initiatives to purchase NCD drugs. Initial concerns about potential disruption of HIV care were overcome, leading to staff motivation to continue delivering integrated care. CONCLUSIONS Implementing integrated care has the potential to sustainably reduce duplication of services, improve retention in care and treatment adherence for co/multi-morbid patients, encourage knowledge-sharing between patients and providers, and reduce HIV stigma. TRIAL REGISTRATION NUMBER ISRCTN43896688.
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Affiliation(s)
| | - Flavia Zalwango
- MRC/UVRI & LSHTM Research Unit, MRC/UVRI & LSHTM, Entebbe, Uganda
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Iwelunmor J, Ogedegbe G, Dulli L, Aifah A, Nwaozuru U, Obiezu-Umeh C, Onakomaiya D, Rakhra A, Mishra S, Colvin CL, Adeoti E, Badejo O, Murray K, Uguru H, Shedul G, Hade EM, Henry D, Igbong A, Lew D, Bansal GP, Ojji D. Organizational readiness to implement task-strengthening strategy for hypertension management among people living with HIV in Nigeria. Implement Sci Commun 2023; 4:47. [PMID: 37143131 PMCID: PMC10157928 DOI: 10.1186/s43058-023-00425-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 04/04/2023] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND Hypertension (HTN) is highly prevalent among people living with HIV (PLHIV), but there is limited access to standardized HTN management strategies in public primary healthcare facilities in Nigeria. The shortage of trained healthcare providers in Nigeria is an important contributor to the increased unmet need for HTN management among PLHIV. Evidence-based TAsk-Strengthening Strategies for HTN control (TASSH) have shown promise to address this gap in other resource-constrained settings. However, little is known regarding primary health care facilities' capacity to implement this strategy. The objective of this study was to determine primary healthcare facilities' readiness to implement TASSH among PLHIV in Nigeria. METHODS This study was conducted with purposively selected healthcare providers at fifty-nine primary healthcare facilities in Akwa-Ibom State, Nigeria. Healthcare facility readiness data were measured using the Organizational Readiness to Change Assessment (ORCA) tool. ORCA is based on the Promoting Action on Research Implementation in Health Services (PARIHS) framework that identifies evidence, context, and facilitation as the key factors for effective knowledge translation. Quantitative data were analyzed using descriptive statistics (including mean ORCA subscales). We focused on the ORCA context domain, and responses were scored on a 5-point Likert scale, with 1 corresponding to disagree strongly. FINDINGS Fifty-nine healthcare providers (mean age 45; standard deviation [SD]: 7.4, 88% female, 68% with technical training, 56% nurses, 56% with 1-5 years providing HIV care) participated in the study. Most healthcare providers provide care to 11-30 patients living with HIV per month in their health facility, with about 42% of providers reporting that they see between 1 and 10 patients with HTN each month. Overall, staff culture (mean 4.9 [0.4]), leadership support (mean 4.9 [0.4]), and measurement/evidence-assessment (mean 4.6 [0.5]) were the topped-scored ORCA subscales, while scores on facility resources (mean 3.6 [0.8]) were the lowest. CONCLUSION Findings show organizational support for innovation and the health providers at the participating health facilities. However, a concerted effort is needed to promote training capabilities and resources to deliver services within these primary healthcare facilities. These results are invaluable in developing future strategies to improve the integration, adoption, and sustainability of TASSH in primary healthcare facilities in Nigeria. TRIAL REGISTRATION NCT05031819.
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Affiliation(s)
- Juliet Iwelunmor
- Department of Behavioral Science and Health Education, College for Public Health and Social Justice, Saint Louis University, St. Louis, USA.
| | - Gbenga Ogedegbe
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
- Institute for Excellence in Health Equity, New York University Grossman School of Medicine, New York, NY, USA
| | - Lisa Dulli
- Family Health International 360, Durham, USA
| | - Angela Aifah
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Ucheoma Nwaozuru
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Chisom Obiezu-Umeh
- Department of Behavioral Science and Health Education, College for Public Health and Social Justice, Saint Louis University, St. Louis, USA
| | - Deborah Onakomaiya
- Vilcek Institute of Graduate Biomedical Sciences, New York University Grossman School of Medicine, New York, NY, USA
| | - Ashlin Rakhra
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Shivani Mishra
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Calvin L Colvin
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Ebenezer Adeoti
- Department of Behavioral Science and Health Education, College for Public Health and Social Justice, Saint Louis University, St. Louis, USA
| | | | - Kate Murray
- Family Health International 360, Durham, USA
| | - Henry Uguru
- Cardiovascular Research Unit, University of Abuja and University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
| | - Gabriel Shedul
- Cardiovascular Research Unit, University of Abuja and University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
- Department of Family Medicine, University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
| | - Erinn M Hade
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Daniel Henry
- Cardiovascular Research Unit, University of Abuja and University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
| | - Ayei Igbong
- Family Health International 360, Durham, USA
| | - Daphne Lew
- Washington University School of Medicine, Washington University in St. Louis, St. Louis, USA
| | | | - Dike Ojji
- Cardiovascular Research Unit, University of Abuja and University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
- Department of Internal Medicine, Faculty of Clinical Sciences, College of Health Sciences, University of Abuja, Gwagwalada, Abuja, Nigeria
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Wu L, Liu M, Huang C, Yin J, Zhou H, Hu H. The development of a self-management evaluation scale for elderly adults with hypertension based on the capability, opportunity, and motivation-behaviour (COM-B) model. BMC Geriatr 2023; 23:245. [PMID: 37087433 PMCID: PMC10122353 DOI: 10.1186/s12877-023-03879-1] [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: 05/31/2022] [Accepted: 03/08/2023] [Indexed: 04/24/2023] Open
Abstract
BACKGROUND Using accurate assessment tools to assess patients in clinical practice is important to mining influencing factors and implementing interventions. However, most evaluation tools for the self-management of elderly patients with hypertension lack a theoretical basis and wide applicability, which makes the intervention effect insignificant. METHODS Based on the Capability, Opportunity, and Motivation-Behaviour (COM-B) model, combined with literature review and qualitative research, a questionnaire item pool was initially formulated; then the initial items were screened and adjusted through expert consultation and pre-testing to form an initial scale. A field survey of 450 elderly hypertensive patients was then performed using the initial scale to test the reliability and validity of the scale. Cronbach's alpha, test-retest reliability and composite reliability were used to test the reliability of the scale, and the validity of the scale was evaluated from two aspects: content validity and construct validity. The evaluation results of the content validity of the scale by experts were used as the content validity index; the results of exploratory factor analysis and confirmatory factor analysis were used as the structural validity index to further verify the model structure of the scale and develop a formal scale. RESULTS The final self-management scale included 4 dimensions and 33 items. The Scale-Content Validity Index was 0.920. Exploratory factor analysis extracted four factors that explained 71.3% of the total variance. Cronbach's alpha of the formal scale was 0.867, test-retest reliability was 0.894, and composite reliability of the 4 dimensions were within 0.943 ~ 0.973. Confirmatory factor analysis showed the scale had good construct validity. CONCLUSIONS The Self-management Capability, Support and Motivation-Behaviour scale for elderly hypertensive patients has good reliability and validity, providing a tool for medical staff to evaluate the self-management level of elderly hypertensive patients.
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Affiliation(s)
- Lirong Wu
- School of Nursing, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, China
- The Affiliated Changsha Central Hospital, Hengyang Medical School, University of South China, Hunan, 410013, Changsha, China
| | - Minhui Liu
- Nursing School of Central South University, Changsha, 410013, China
| | - Chongmei Huang
- Nursing School of Central South University, Changsha, 410013, China
| | - Jinzhi Yin
- School of Nursing, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, China
- The Affiliated Changsha Central Hospital, Hengyang Medical School, University of South China, Hunan, 410013, Changsha, China
| | - Hui Zhou
- School of Nursing, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, China
- The Affiliated Changsha Central Hospital, Hengyang Medical School, University of South China, Hunan, 410013, Changsha, China
| | - Hongjuan Hu
- The First Affiliated Hospital, Department of Public Service/Nursing department, Hengyang Medical School, University of South China, Hunan, 421001, Hengyang, China.
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Rakhra A, Mishra S, Aifah A, Colvin C, Gyamfi J, Ogedegbe G, Iwelunmor J. Sustaining capacity building and evidence-based NCD intervention implementation: Perspectives from the GRIT consortium. FRONTIERS IN HEALTH SERVICES 2022; 2:891522. [PMID: 36925894 PMCID: PMC10012828 DOI: 10.3389/frhs.2022.891522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 06/30/2022] [Indexed: 11/13/2022]
Abstract
Background Implementation science has been primarily focused on adoption of evidence-based interventions, and less so on sustainability, creating a gap in the field. The Global Research on Implementation and Translation Science (GRIT) Consortium is funded by the National Heart Lung and Blood Institute (NHBLI) to support the planning, implementation, and sustainability of Late-Stage Phase 4 Translational Research (T4TR) and capacity building for NCD prevention and control in eight low-and middle-income countries (LMICs). This paper highlights perspectives, including barriers, facilitators, opportunities, and motivators for sustaining capacity building and evidence-based hypertension interventions within LMICs. Methods Guided by the Capacity, Opportunity, Motivation, Behavior (COM-B) Model, this study surveyed GRIT consortium members on the barriers, facilitators, key motivators, and opportunities for sustaining capacity building and evidence-based hypertension interventions in LMICs. Thematic analysis was used to identify themes and patterns across responses. Results Twenty-five consortium members across all eight sites and from various research levels responded to the survey. Overarching themes identifying facilitators, key motivators and opportunities for sustainability included: (1) access to structured and continuous training and mentorship; (2) project integration with existing systems (i.e., political systems and health systems); (3) adaption to the local context of studies (i.e., accounting for policies, resources, and utilizing stakeholder engagement); and (4) development of interventions with decision makers and implementers. Barriers to sustainability included local policies and lack of infrastructure, unreliable access to hypertension medications, and lack of sufficient staff, time, and funding. Conclusion Sustainability is an important implementation outcome to address in public health interventions, particularly as it pertains to the success of these initiatives. This study provides perspectives on the sustainability of NCD interventions with a focus on mitigating their NCD burden in LMICs. Addressing multilevel factors that influence the sustainability of capacity building and interventions will have notable implications for other global NCD efforts going forward. Current and future studies, as well as consortium networks, should account for sustainability barriers outlined as it will strengthen program implementation, and long-term outcomes.
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Affiliation(s)
- Ashlin Rakhra
- New York University Grossman School of Medicine, New York, NY, United States
| | - Shivani Mishra
- New York University Grossman School of Medicine, New York, NY, United States
| | - Angela Aifah
- New York University Grossman School of Medicine, New York, NY, United States
| | - Calvin Colvin
- New York University Grossman School of Medicine, New York, NY, United States
| | - Joyce Gyamfi
- New York University School of Global Public Health, New York, NY, United States
| | - Gbenga Ogedegbe
- New York University Grossman School of Medicine, New York, NY, United States
| | - Juliet Iwelunmor
- Department of Behavioral Sciences and Health Education, College for Public Health & Social Justice, Saint Louis University, St. Louis, MO, United States
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Bukenya D, Van Hout MC, Shayo EH, Kitabye I, Junior BM, Kasidi JR, Birungi J, Jaffar S, Seeley J. Integrated healthcare services for HIV, diabetes mellitus and hypertension in selected health facilities in Kampala and Wakiso districts, Uganda: A qualitative methods study. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000084. [PMID: 36962287 PMCID: PMC10021152 DOI: 10.1371/journal.pgph.0000084] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 11/15/2021] [Indexed: 11/18/2022]
Abstract
Health policies in Africa are shifting towards integrated care services for chronic conditions, but in parts of Africa robust evidence on effectiveness is limited. We assessed the integration of vertical health services for HIV, diabetes and hypertension provided in a feasibility study within five health facilities in Uganda. From November 2018 to January 2020, we conducted a series of three in-depth interviews with 31, 29 and 24 service users attending the integrated clinics within Kampala and Wakiso districts. Ten healthcare workers were interviewed twice during the same period. Interviews were conducted in Luganda, translated into English, and analysed thematically using the concepts of availability, affordability and acceptability. All participants reported shortages of diabetes and hypertension drugs and diagnostic equipment prior to the establishment of the integrated clinics. These shortages were mostly addressed in the integrated clinics through a drugs buffer. Integration did not affect the already good provision of anti-retroviral therapy. The cost of transport reduced because of fewer clinic visits after integration. Healthcare workers reported that the main cause of non-adherence among users with diabetes and hypertension was poverty. Participants with diabetes and hypertension reported they could not afford private clinical investigations or purchase drugs prior to the establishment of the integrated clinics. The strengthening of drug supply for non-communicable conditions in the integrated clinics was welcomed. Most participants observed that the integrated clinic reduced feelings of stigma for those living with HIV. Sharing the clinic afforded privacy about an individual's condition, and users were comfortable with the waiting room sitting arrangement. We found that integrating non-communicable disease and HIV care had benefits for all users. Integrated care could be an effective model of care if service users have access to a reliable supply of basic medicines for both HIV and non-communicable disease conditions.
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Affiliation(s)
| | - Marie-Claire Van Hout
- Public Health Institute, Liverpool John Moores University, Liverpool, United Kingdom
| | | | - Isaac Kitabye
- MRC/UVRI & LSHTM Uganda Research Unit, Entebbe, Uganda
| | | | | | | | - Shabbar Jaffar
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Janet Seeley
- MRC/UVRI & LSHTM Uganda Research Unit, Entebbe, Uganda
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Manavalan P, Wanda L, Galson SW, Thielman NM, Mmbaga BT, Watt MH. Hypertension Care for People With HIV in Tanzania: Provider Perspectives and Opportunities for Improvement. J Int Assoc Provid AIDS Care 2021; 20:23259582211052399. [PMID: 34751055 PMCID: PMC8743911 DOI: 10.1177/23259582211052399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
One in three people with HIV (PWH) has hypertension. However, most hypertensive PWH in sub-Saharan Africa are unaware of their hypertension diagnosis and are not on treatment. To better understand barriers to hypertension care faced by PWH, we interviewed 15 medical providers who care for patients with HIV and hypertension in northern Tanzania. The data revealed barriers at the patient, provider, and system level and included: stress, depression, and HIV-related stigma; lack of hypertension knowledge; insufficient hypertension training; inefficient prescribing practices; challenges with counselling; capacity limitations in hypertension care; high costs of care; and lack of routine hypertension screening and follow-up. Opportunities for improvement focused on prioritizing resources and funding towards hypertension care. System-related challenges were the underlying cause of barriers at individual levels. Strategies that focus on strengthening capacity and utilize existing HIV platforms to promote hypertension care delivery are urgently needed to improve cardiovascular outcomes among PWH.
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Affiliation(s)
- Preeti Manavalan
- 3463University of Florida, Gainesville, FL, USA.,3065Division of Infectious Diseases at Duke Medical Centre, Durham, NC, USA.,199688Duke Global Health Institute, Durham, NC, USA
| | - Lisa Wanda
- 108095Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Sophie W Galson
- 3065Division of Infectious Diseases at Duke Medical Centre, Durham, NC, USA.,199688Duke Global Health Institute, Durham, NC, USA
| | - Nathan M Thielman
- 3065Division of Infectious Diseases at Duke Medical Centre, Durham, NC, USA.,199688Duke Global Health Institute, Durham, NC, USA
| | - Blandina T Mmbaga
- 199688Duke Global Health Institute, Durham, NC, USA.,108095Kilimanjaro Clinical Research Institute, Moshi, Tanzania.,108094Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Melissa H Watt
- 199688Duke Global Health Institute, Durham, NC, USA.,University of Utah, Salt Lake City, UT, USA
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Muddu M, Ssinabulya I, Kigozi SP, Ssennyonjo R, Ayebare F, Katwesigye R, Mbuliro M, Kimera I, Longenecker CT, Kamya MR, Schwartz JI, Katahoire AR, Semitala FC. Hypertension care cascade at a large urban HIV clinic in Uganda: a mixed methods study using the Capability, Opportunity, Motivation for Behavior change (COM-B) model. Implement Sci Commun 2021; 2:121. [PMID: 34670624 PMCID: PMC8690902 DOI: 10.1186/s43058-021-00223-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 09/30/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Persons living with HIV (PLHIV) receiving antiretroviral therapy (ART) have a high prevalence of hypertension (HTN) and increased risk of mortality from cardiovascular diseases. HTN and HIV care integration is recommended in Uganda, though its implementation has lagged. In this study, we sought to analyze the HTN and HIV care cascades and explore barriers and facilitators of HTN/HIV integration within a large HIV clinic in urban Uganda. METHODS We conducted an explanatory sequential mixed methods study at Mulago ISS clinic in Kampala, Uganda. We determined proportions of patients in HTN and HIV care cascade steps of screened, diagnosed, initiated on treatment, retained, and controlled. Guided by the Capability, Opportunity, Motivation and Behavior (COM-B) model, we then conducted semi-structured interviews and focus group discussions with healthcare providers (n = 13) and hypertensive PLHIV (n = 32). We coded the qualitative data deductively and analyzed the data thematically categorizing them as themes that influenced HTN care positively or negatively. These denoted barriers and facilitators, respectively. RESULTS Of 15,953 adult PLHIV, 99.1% were initiated on ART, 89.5% were retained in care, and 98.0% achieved control (viral suppression) at 1 year. All 15,953 (100%) participants were screened for HTN, of whom 24.3% had HTN. HTN treatment initiation, 1-year retention, and control were low at 1.0%, 15.4%, and 5.0%, respectively. Barriers and facilitators of HTN/HIV integration appeared in all three COM-B domains. Barriers included low patient knowledge of HTN complications, less priority by patients for HTN treatment compared to ART, sub-optimal provider knowledge of HTN treatment, lack of HTN treatment protocols, inadequate supply of anti-hypertensive medicines, and lack of HTN care performance targets. Facilitators included patients' and providers' interest in HTN/HIV integration, patients' interest in PLHIV peer support, providers' knowledge and skills for HTN screening, optimal ART adherence counseling, and availability of automated BP machines. CONCLUSION The prevalence of HTN among PLHIV is high, but the HTN care cascade is sub-optimal in this successful HIV clinic. To close these gaps, models of integrated HTN/HIV care are urgently needed. These findings provide a basis for designing contextually appropriate interventions for HTN/HIV integration in Uganda and other low- and middle-income countries.
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Affiliation(s)
- Martin Muddu
- Makerere University Joint AIDS Program (MJAP), Kampala, Uganda
- Uganda Initiative for Integrated Management of Non-Communicable Diseases (UINCD), Kampala, Uganda
| | - Isaac Ssinabulya
- Uganda Initiative for Integrated Management of Non-Communicable Diseases (UINCD), Kampala, Uganda
- Department of Internal Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
- Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
| | - Simon P. Kigozi
- Infectious Disease Research Collaboration (IDRC), Kampala, Uganda
| | | | - Florence Ayebare
- Child Health and Development Centre, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Mary Mbuliro
- Makerere University Joint AIDS Program (MJAP), Kampala, Uganda
| | - Isaac Kimera
- Makerere University Joint AIDS Program (MJAP), Kampala, Uganda
| | | | - Moses R. Kamya
- Makerere University Joint AIDS Program (MJAP), Kampala, Uganda
- Uganda Initiative for Integrated Management of Non-Communicable Diseases (UINCD), Kampala, Uganda
- Department of Internal Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
- Infectious Disease Research Collaboration (IDRC), Kampala, Uganda
| | - Jeremy I. Schwartz
- Uganda Initiative for Integrated Management of Non-Communicable Diseases (UINCD), Kampala, Uganda
- Section of General Internal Medicine, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06511 USA
| | - Anne R. Katahoire
- Child Health and Development Centre, Makerere University College of Health Sciences, Kampala, Uganda
| | - Fred C. Semitala
- Makerere University Joint AIDS Program (MJAP), Kampala, Uganda
- Department of Internal Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
- Infectious Disease Research Collaboration (IDRC), Kampala, Uganda
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Batte C, Mukisa J, Rykiel N, Mukunya D, Checkley W, Knauf F, Kalyesubula R, Siddharthan T. Acceptability of patient-centered hypertension education delivered by community health workers among people living with HIV/AIDS in rural Uganda. BMC Public Health 2021; 21:1343. [PMID: 34233648 PMCID: PMC8264981 DOI: 10.1186/s12889-021-11411-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 06/29/2021] [Indexed: 12/03/2022] Open
Abstract
Background The prevalence of hypertension is increasing among people living with HIV/AIDS (PLWHA) in low- and middle-income countries (LMICs). However, knowledge of the complications and management of hypertension among PLWHA in Uganda remains low. We explored the acceptability of implementing hypertension (HTN) specific health education by community health workers (CHWs) among PLWHA in rural Uganda. Methods We conducted a qualitative study consisting of 22 in-depth interviews (14 PLWHA/HTN and 8 CHWs), 3 focus group discussions (FGDs), 2 with PLWHA/HTN and 1 with CHWs from Nakaseke district, Uganda. Participants were interviewed after a single session interaction with the CHW. Data were transcribed from luganda (local language) into English and analyzed using thematic analysis. We used Sekhon’s model of acceptability of health Interventions to explore participants’ perceptions. Results Participants believed CHWs utilized easy-to-understand, colloquial, non-technical language during education delivery, had a pre-existing rapport with the CHWs that aided faster communication, and had more time to explain illness than medical doctors had. Participants found the educational material (PocketDoktor™) to be simple and easy to understand, and perceived that the education would lead to improved health outcomes. Participants stated their health was a priority and sought further disease-specific information. We also found that CHWs were highly motivated to carry out the patient-centered education. While delivering the education, CHWs experienced difficulties in keeping up with the technical details regarding hypertension in the PocketDoktor™, financial stress and patient questions beyond their self-perceived skill level and experience. PLWHA/HTN had challenges accessing the health facility where the intervention was delivered and preferred a household setting. Conclusions Hypertension patient-centered education delivered by CHWs using the PocketDoktor™ was acceptable to PLWHA and hypertension in Nakaseke area in rural, Uganda. There is need for further studies to determine the cost implications of delivering this intervention among PLWHA across LMIC settings. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-11411-6.
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Affiliation(s)
- Charles Batte
- School of Medicine, Lung Institute, Makerere University College of Health Sciences, Upper Hill Mulago Hill, Kampala, Uganda.
| | - John Mukisa
- Department of Immunology and Molecular Biology, School of Biomedical Sciences, Makerere University College of Health Sciences, Kampala, Uganda
| | - Natalie Rykiel
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA.,Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, USA
| | - David Mukunya
- Faculty of Health Sciences, Busitema University, Mbale, Uganda
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA.,Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, USA
| | - Felix Knauf
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Robert Kalyesubula
- School of Medicine, Lung Institute, Makerere University College of Health Sciences, Upper Hill Mulago Hill, Kampala, Uganda
| | - Trishul Siddharthan
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA.,Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, USA
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Van Hout MC, Bachmann M, Lazarus JV, Shayo EH, Bukenya D, Picchio CA, Nyirenda M, Mfinanga SG, Birungi J, Okebe J, Jaffar S. Strengthening integration of chronic care in Africa: protocol for the qualitative process evaluation of integrated HIV, diabetes and hypertension care in a cluster randomised controlled trial in Tanzania and Uganda. BMJ Open 2020; 10:e039237. [PMID: 33033029 PMCID: PMC7542920 DOI: 10.1136/bmjopen-2020-039237] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION In sub-Saharan Africa, the burden of non-communicable diseases (NCDs), particularly diabetes mellitus (DM) and hypertension, has increased rapidly in recent years, although HIV infection remains a leading cause of death among young-middle-aged adults. Health service coverage for NCDs remains very low in contrast to HIV, despite the increasing prevalence of comorbidity of NCDs with HIV. There is an urgent need to expand healthcare capacity to provide integrated services to address these chronic conditions. METHODS AND ANALYSIS This protocol describes procedures for a qualitative process evaluation of INTE-AFRICA, a cluster randomised trial comparing integrated health service provision for HIV infection, DM and hypertension, to the current stand-alone vertical care. Interviews, focus group discussions and observations of consultations and other care processes in two clinics (in Tanzania, Uganda) will be used to explore the experiences of stakeholders. These stakeholders will include health service users, policy-makers, healthcare providers, community leaders and members, researchers, non-governmental and international organisations. The exploration will be carried out during the implementation of the project, alongside an understanding of the impact of broader structural and contextual factors. ETHICS AND DISSEMINATION Ethical approval was granted by the Liverpool School of Tropical Medicine (UK), the National Institute of Medical Research (Tanzania) and TASO Research Ethics Committee (Uganda) in 2020. The evaluation will provide the opportunity to document the implementation of integration over several timepoints (6, 12 and 18 months) and refine integrated service provision prior to scale up. This synergistic approach to evaluate, understand and respond will support service integration and inform monitoring, policy and practice development efforts to involve and educate communities in Tanzania and Uganda. It will create a model of care and a platform of good practices and lessons learnt for other countries implementing integrated and decentralised community health services. TRIAL REGISTRATION NUMBER ISRCTN43896688; Pre-results.
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Affiliation(s)
- Marie-Claire Van Hout
- Public Health Institute, Liverpool John Moores University, Liverpool, Merseyside, UK
| | - Max Bachmann
- Norwich Medical School, University of East Anglia Faculty of Medicine and Health Sciences, Norwich, UK
| | - Jeffrey V Lazarus
- Barcelona Institute for Global Health (ISGlobal), Hospital Clinic, University of Barcelona, Barcelona, Catalunya, Spain
| | - Elizabeth Henry Shayo
- Muhimbili Centre, National Institute for Medical Research, Dar es Salaam, Dar es Salaam, Tanzania, United Republic of
| | - Dominic Bukenya
- MRC/UVRI/LSHTM Uganda Research Unit, Medical Research Council Uganda, Entebbe, Uganda
| | - Camila A Picchio
- Barcelona Institute for Global Health (ISGlobal), Hospital Clinic, University of Barcelona, Barcelona, Catalunya, Spain
| | - Moffat Nyirenda
- MRC/UVRI/LSHTM Uganda Research Unit, Medical Research Council Uganda, Entebbe, Uganda
| | - Sayoki Godfrey Mfinanga
- Muhimbili Centre, National Institute for Medical Research, Dar es Salaam, Dar es Salaam, Tanzania, United Republic of
| | - Josephine Birungi
- MRC/UVRI/LSHTM Uganda Research Unit, Medical Research Council Uganda, Entebbe, Uganda
| | - Joseph Okebe
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, Liverpool, UK
| | - Shabbar Jaffar
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, Liverpool, UK
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So-Armah K, Benjamin LA, Bloomfield GS, Feinstein MJ, Hsue P, Njuguna B, Freiberg MS. HIV and cardiovascular disease. Lancet HIV 2020; 7:e279-e293. [PMID: 32243826 DOI: 10.1016/s2352-3018(20)30036-9] [Citation(s) in RCA: 124] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 01/27/2020] [Accepted: 01/28/2020] [Indexed: 12/24/2022]
Abstract
HIV-related cardiovascular disease research is predominantly from Europe and North America. Of the estimated 37·9 million people living with HIV worldwide, 25·6 million live in sub-Saharan Africa. Although mechanisms for HIV-related cardiovascular disease might be the same in all people with HIV, the distribution of cardiovascular disease risk factors varies by geographical location. Sub-Saharan Africa has a younger population, higher prevalence of elevated blood pressure, lower smoking rates, and lower prevalence of elevated cholesterol than western Europe and North America. These variations mean that the profile of cardiovascular disease differs between low-income and high-income countries. Research in, implementation of, and advocacy for risk reduction of cardiovascular disease in the global context of HIV should account for differences in the distribution of traditional cardiovascular disease risk factors (eg, hypertension, smoking), consider non-traditional cardiovascular disease risk factors (eg, access to antiretroviral therapy with more benign cardiovascular disease side effect profiles, indoor air pollution), and encourage the inclusion of relevant risk reduction approaches for cardiovascular disease in HIV-care guidelines. Future research priorities include implementation science to scale up and expand integrated HIV and cardiovascular disease care models, which have shown promise in sub-Saharan Africa; HIV and cardiovascular disease epidemiology and mechanisms in women; and tobacco cessation for people living with HIV.
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Affiliation(s)
- Kaku So-Armah
- Boston University School of Medicine, Boston, MA, USA.
| | - Laura A Benjamin
- UCL Queen Square Institute of Neurology, University College London, London, UK; Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Gerald S Bloomfield
- Duke Global Health Institute, Duke University, Durham, North Carolina, NC, USA
| | | | | | | | - Matthew S Freiberg
- Vanderbilt University Medical Center, Nashville VA Medical Center, VA Tennessee Valley Healthcare System, Nashville, TN, USA
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Nurses' perceptions on implementing a task-shifting/sharing strategy for hypertension management in patients with HIV in Nigeria: a group concept mapping study. Implement Sci Commun 2020; 1:58. [PMID: 32885213 PMCID: PMC7427907 DOI: 10.1186/s43058-020-00048-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 06/10/2020] [Indexed: 02/07/2023] Open
Abstract
Background People living with HIV (PWH) in Africa have higher burden of cardiovascular diseases (CVD) compared to the general population, probably due to increased burden of hypertension (HTN). In this study, we explored nurses’ perceptions of factors that may influence the integration of an evidence-based task-shifting/sharing strategy for hypertension control (TASSH) into routine HIV care in Lagos, Nigeria. Methods Using group concept mapping, we examined the perceptions of 22 nurses from HIV clinics in Lagos. Participants responded to a focused prompt on the barriers and facilitators of integrating TASSH into HIV care; next, separate focus groups generated relevant statements on these factors; and statements were then sorted and rated on their importance and feasibility of adoption to create cluster maps of related themes. The statements and cluster maps were categorized according to the Consolidated Framework for Implementation Research (CFIR) domains. Results All study participants were women and with 2 to 16 years’ experience in the provision of HIV care. From the GCM activities, 81 statements were generated and grouped into 12 themes. The most salient statements reflected the need for ongoing training of HIV nurses in HTN management and challenges in adapting TASSH in HIV clinics. A synthesis of the cluster themes using CFIR showed that most clusters reflected intervention characteristics and inner setting domains. The potential challenges to implementing TASSH included limited hypertension knowledge among HIV nurses and the need for on-going supervision on implementing task-shifting/sharing. Conclusions Findings from this study illustrate a variety of opinions regarding the integration of HTN management into HIV care in Nigeria. More importantly, it provides critical, evidence-based support in response to the call to action raised by the 2018 International AIDS Society Conference regarding the need to implement more NCD-HIV integration interventions in low-and middle-income countries through strategies, which enhance human resources. This study provides insight into factors that can facilitate stakeholder engagement in utilizing study results and prioritizing next steps for TASSH integration within HIV care in Nigeria.
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Muddu M, Tusubira AK, Nakirya B, Nalwoga R, Semitala FC, Akiteng AR, Schwartz JI, Ssinabulya I. Exploring barriers and facilitators to integrated hypertension-HIV management in Ugandan HIV clinics using the Consolidated Framework for Implementation Research (CFIR). Implement Sci Commun 2020; 1:45. [PMID: 32885202 PMCID: PMC7427847 DOI: 10.1186/s43058-020-00033-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 04/15/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Persons living with HIV (PLHIV) receiving antiretroviral therapy have increased risk of cardiovascular disease (CVD). Integration of services for hypertension (HTN), the primary CVD risk factor, into HIV clinics is recommended in Uganda. Our prior work demonstrated multiple gaps in implementation of integrated HTN care along the HIV treatment cascade. In this study, we sought to explore barriers to and facilitators of integrating HTN screening and treatment into HIV clinics in Eastern Uganda. METHODS We conducted a qualitative study at three HIV clinics with low, intermediate, and high HTN care cascade performance, which we classified based on our prior work. Guided by the Consolidated Framework for Implementation Research (CFIR), we conducted semi-structured interviews and focus group discussions with health services managers, healthcare providers, and hypertensive PLHIV (n = 83). Interviews were transcribed verbatim. Three qualitative researchers used the deductive (CFIR-driven) method to develop relevant codes and themes. Ratings were performed to determine valence and strengths of each CFIR construct regarding influencing HTN/HIV integration. RESULTS Barriers to HTN/HIV integration arose from six CFIR constructs: organizational incentives and rewards, available resources, access to knowledge and information, knowledge and beliefs about the intervention, self-efficacy, and planning. The barriers include lack of functional BP machines, inadequate supply of anti-hypertensive medicines, additional workload to providers for HTN services, PLHIV's inadequate knowledge about HTN care, sub-optimal knowledge, skills and self-efficacy of healthcare providers to screen and treat HTN, and inadequate planning for integrated HTN/HIV services.Relative advantage of offering HTN and HIV services in a one-stop centre, simplicity (non-complex nature) of HTN/HIV integrated care, adaptability, and compatibility of HTN care with existing HIV services are the facilitators for HTN/HIV integration. The remaining CFIR constructs were non-significant regarding influencing HTN/HIV integration. CONCLUSION Using the CFIR, we have shown that while there are modifiable barriers to HTN/HIV integration, HTN/HIV integration is of interest to patients, healthcare providers, and managers. Improving access to HTN care among PLHIV will require overcoming barriers and capitalizing on facilitators using a health system strengthening approach. These findings are a springboard for designing contextually appropriate interventions for HTN/HIV integration in low- and middle-income countries.
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Affiliation(s)
- Martin Muddu
- grid.11194.3c0000 0004 0620 0548Department of Internal Medicine, Makerere University College of Health Sciences, Kampala, Uganda ,Uganda Initiative for Integrated Management of Non-Communicable Diseases (UINCD), Kampala, Uganda ,grid.11194.3c0000 0004 0620 0548Makerere University Joint AIDS Program (MJAP), P.O. Box 7587, Kampala, Uganda
| | - Andrew K. Tusubira
- Uganda Initiative for Integrated Management of Non-Communicable Diseases (UINCD), Kampala, Uganda
| | - Brenda Nakirya
- Uganda Initiative for Integrated Management of Non-Communicable Diseases (UINCD), Kampala, Uganda
| | - Rita Nalwoga
- Uganda Initiative for Integrated Management of Non-Communicable Diseases (UINCD), Kampala, Uganda
| | - Fred C. Semitala
- grid.11194.3c0000 0004 0620 0548Department of Internal Medicine, Makerere University College of Health Sciences, Kampala, Uganda ,grid.11194.3c0000 0004 0620 0548Makerere University Joint AIDS Program (MJAP), P.O. Box 7587, Kampala, Uganda
| | - Ann R. Akiteng
- Uganda Initiative for Integrated Management of Non-Communicable Diseases (UINCD), Kampala, Uganda
| | - Jeremy I. Schwartz
- Uganda Initiative for Integrated Management of Non-Communicable Diseases (UINCD), Kampala, Uganda ,grid.47100.320000000419368710Section of General Internal Medicine, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06511 USA
| | - Isaac Ssinabulya
- grid.11194.3c0000 0004 0620 0548Department of Internal Medicine, Makerere University College of Health Sciences, Kampala, Uganda ,Uganda Initiative for Integrated Management of Non-Communicable Diseases (UINCD), Kampala, Uganda ,grid.416252.60000 0000 9634 2734Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
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