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Bassett IV, Yan J, Govere S, Khumalo A, Shazi Z, Nzuza M, Aung T, Rahman K, Zionts D, Dube N, Tshabalala S, Bogart LM, Parker RA. Does type of antiretroviral therapy pick-up point influence 12-month virologic suppression in South Africa? AIDS Care 2024; 36:1518-1527. [PMID: 38861653 PMCID: PMC11343678 DOI: 10.1080/09540121.2024.2361817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 05/24/2024] [Indexed: 06/13/2024]
Abstract
We assessed the impact of community- versus clinic-based medication pick-up on rates of virologic suppression in an observational cohort of adults on ART enrolled in a decentralized antiretroviral therapy program (CCMDD) in South Africa. Participants either attended clinics where they were given the choice to pick up ART in community venues or traditional clinics, or clinics where this pathway was assigned. Among 1856 participants, 977 (53%) opted for community ART pick-up at enrollment, and 1201 (86%) were virologically suppressed at one year. Because of missing data on virologic suppression, primary results are based on a model incorporating multiple imputation. In addition to age and gender, distance from clinic and year of HIV diagnosis were included in the multivariable model. There was no difference in opting for clinic- vs. community-based pick-up with regard to achieving 12-month virologic suppression (aRR 1.02, 95% CI 0.98-1.05) in clinics offering choice. There was no impact of assigning all participants to an external pick-up point (aRR 1.00, 95% CI 0.95-1.06), but virologic suppression was reduced in the clinic that assigned participants to clinic pick-up (aRR 0.87, 95% CI 0.81-0.92). These results suggest that provision of community-based ART has not reduced continued virologic suppression in the population enrolled in the CCMDD program.
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Affiliation(s)
- Ingrid V. Bassett
- Massachusetts General Hospital, Division of Infectious Diseases, Boston, Massachusetts, USA
- Massachusetts General Hospital, Medical Practice Evaluation Center, Boston, Massachusetts, USA
- Center for AIDS Research (CFAR), Harvard University, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Africa Health Research Institute, Durban, South Africa
| | - Joyce Yan
- Massachusetts General Hospital, Biostatistics Center, Boston, Massachusetts, USA
| | | | | | - Zinhle Shazi
- AIDS Healthcare Foundation, Durban, South Africa
| | | | - Taing Aung
- Massachusetts General Hospital, Medical Practice Evaluation Center, Boston, Massachusetts, USA
| | - Kashfia Rahman
- Massachusetts General Hospital, Medical Practice Evaluation Center, Boston, Massachusetts, USA
| | - Dani Zionts
- Massachusetts General Hospital, Medical Practice Evaluation Center, Boston, Massachusetts, USA
| | - Nduduzo Dube
- AIDS Healthcare Foundation, Durban, South Africa
| | - Sandile Tshabalala
- South Africa Department of Health, Province of KwaZulu-Natal, South Africa
| | | | - Robert A. Parker
- Center for AIDS Research (CFAR), Harvard University, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Massachusetts General Hospital, Biostatistics Center, Boston, Massachusetts, USA
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Leslie HH, Lippman SA, van Heerden A, Manaka MN, Joseph P, Weiner BJ, Steward WT. Adapting and testing measures of organizational context in primary care clinics in KwaZulu-Natal, South Africa. BMC Health Serv Res 2024; 24:744. [PMID: 38886792 PMCID: PMC11184827 DOI: 10.1186/s12913-024-11184-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 06/07/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND Implementation science frameworks situate intervention implementation and sustainment within the context of the implementing organization and system. Aspects of organizational context such as leadership have been defined and measured largely within US health care settings characterized by decentralization and individual autonomy. The relevance of these constructs in other settings may be limited by differences like collectivist orientation, resource constraints, and hierarchical power structures. We aimed to adapt measures of organizational context in South African primary care clinics. METHODS We convened a panel of South African experts in social science and HIV care delivery and presented implementation domains informed by existing frameworks and prior work in South Africa. Based on panel input, we selected contextual domains and adapted candidate items. We conducted cognitive interviews with 25 providers in KwaZulu-Natal Province to refine measures. We then conducted a cross-sectional survey of 16 clinics with 5-20 providers per clinic (N = 186). We assessed reliability using Cronbach's alpha and calculated interrater agreement (awg) and intraclass correlation coefficient (ICC) at the clinic level. Within clinics with moderate agreement, we calculated correlation of clinic-level measures with each other and with hypothesized predictors - staff continuity and infrastructure - and a clinical outcome, patient retention on antiretroviral therapy. RESULTS Panelists emphasized contextual factors; we therefore focused on elements of clinic leadership, stress, cohesion, and collective problem solving (critical consciousness). Cognitive interviews confirmed salience of the domains and improved item clarity. After excluding items related to leaders' coordination abilities due to missingness and low agreement, all other scales demonstrated individual-level reliability and at least moderate interrater agreement in most facilities. ICC was low for most leadership measures and moderate for others. Measures tended to correlate within facility, and higher stress was significantly correlated with lower staff continuity. Organizational context was generally more positively rated in facilities that showed consistent agreement. CONCLUSIONS As theorized, organizational context is important in understanding program implementation within the South African health system. Most adapted measures show good reliability at individual and clinic levels. Additional revision of existing frameworks to suit this context and further testing in high and low performing clinics is warranted.
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Affiliation(s)
- Hannah H Leslie
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, San Francisco, USA.
| | - Sheri A Lippman
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, San Francisco, USA
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Alastair van Heerden
- Division of Human and Social Capabilities, Human Sciences Research Council, Durban, South Africa
- Department of Paediatrics, School of Clinical Medicine, Faculty of Health Sciences, SAMRC/WITS Developmental Pathways for Health Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Mbali Nokulunga Manaka
- Division of Human and Social Capabilities, Human Sciences Research Council, Durban, South Africa
| | - Phillip Joseph
- Division of Human and Social Capabilities, Human Sciences Research Council, Durban, South Africa
| | - Bryan J Weiner
- Departments of Global Health and Health Systems and Population Health, University of Washington, Seattle, USA
| | - Wayne T Steward
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, San Francisco, USA
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Browne EN, Stoner MCD, Kabudula C, Dufour MSK, Neilands TB, Leslie HH, West RL, Peacock D, Gómez-Olivé FX, Kahn K, Pettifor A, Lippman SA. Exploring the Relationship Between Anticipated Stigma and Community Shared Concerns about HIV on Defaulting from HIV Care in Rural South Africa. STIGMA AND HEALTH 2024; 9:173-180. [PMID: 38983717 PMCID: PMC11230650 DOI: 10.1037/sah0000475] [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] [Indexed: 07/11/2024]
Abstract
Although stigma has been associated with people living with HIV defaulting from care, there is a gap in understanding the specific impact of individual stigma and community-level concern about HIV on defaulting. Methods This is a secondary analysis of a unique dataset that links health facility-based medical records to a population-representative community survey conducted in 2018 in rural Mpumalanga province, South Africa. We used the parametric g-formula to estimate associations among individual anticipated stigma, low perceived community and local leader concern about HIV, and defaulting from care in the prior year. In addition, we estimated the population-level effects of intervening to reduce stigma and increase concern on defaulting. Results Among 319 participants on treatment, 42 (13.2%) defaulted from care during the prior year. Anticipated stigma (risk ratio [RR] 1.22, 95% confidence interval [CI]: 0.72, 2.74), low perceived concern about HIV/AIDS from community leadership (RR 1.12, 95% CI 0.76, 3.38), and low shared concerns about HIV/AIDS in the community (RR 1.37; 95% CI 0.79, 3.07) were not significantly associated with default. Hypothetical population intervention effects to remove individual anticipated stigma and low community concerns yielded small reductions in default (~1% reduction). Conclusions In this sample, we found limited impact of reducing anticipated stigma and increasing shared concern about HIV on retention in care. Future studies should consider the limitations of this study by examining the influence of other sources of stigma in more detail and assessing how perceptions of stigma and concern impact the full HIV testing and care cascade.
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Affiliation(s)
- Erica N Browne
- Women's Global Health Imperative, RTI International, Berkeley, CA, USA
| | - Marie C D Stoner
- Women's Global Health Imperative, RTI International, Berkeley, CA, USA
| | - Chodziwadziwa Kabudula
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mi-Suk Kang Dufour
- School of Public Health, Division of Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Torsten B Neilands
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Hannah H Leslie
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Rebecca L West
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Department of Global Health, Boston University School of Public Health
| | | | - F Xavier Gómez-Olivé
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Audrey Pettifor
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Sheri A Lippman
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
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van de Water BJ, Brooks MB, Matji R, Ncanywa B, Dikgale F, Abuelezam NN, Mzileni B, Nokwe M, Moko S, Mvusi L, Loveday M, Gimbel S. Systems analysis and improvement approach to optimize tuberculosis (SAIA-TB) screening, treatment, and prevention in South Africa: a stepped-wedge cluster randomized trial. Implement Sci Commun 2024; 5:40. [PMID: 38627799 PMCID: PMC11021007 DOI: 10.1186/s43058-024-00582-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 04/06/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND The use of systems engineering tools, including the development and use of care cascades using routinely collected data, process mapping, and continuous quality improvement, is used for frontline healthcare workers to devise systems level change. South Africa experiences high rates of tuberculosis (TB) infection and disease as well as HIV co-infection. The Department of Health has made significant gains in HIV services over the last two decades, reaching their set "90-90-90" targets for HIV. However, TB services, although robust, have lagged in comparison for both disease and infection. The Systems Analysis and Improvement Approach (SAIA) is a five-step implementation science method, drawn from systems engineering, to identify, define, and implement workflow modifications using cascade analysis, process mapping, and repeated quality improvement cycles within healthcare facilities. METHODS This stepped-wedge cluster randomized trial will evaluate the effectiveness of SAIA on TB (SAIA-TB) cascade optimization for patients with TB and high-risk contacts across 16 clinics in four local municipalities in the Sarah Baartman district, Eastern Cape, South Africa. We hypothesize that SAIA-TB implementation will lead to a 20% increase in each of: TB screening, TB preventive treatment initiation, and TB disease treatment initiation during the 18-month intervention period. Focus group discussions and key informant interviews with clinic staff will also be conducted to determine drivers of implementation variability across clinics. DISCUSSION This study has the potential to improve TB screening, treatment initiation, and completion for both active disease and preventive measures among individuals with and without HIV in a high burden setting. SAIA-TB provides frontline health care workers with a systems-level view of their care delivery system with the aim of sustainable systems-level improvements. TRIAL REGISTRATION Clinicaltrials.gov, NCT06314386. Registered 18 March 2024, https://clinicaltrials.gov/study/NCT06314386 . NCT06314386.
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Affiliation(s)
- Brittney J van de Water
- Connell School of Nursing, Boston College, 140 Commonwealth Avenue, Chestnut Hill, MA, 02467, USA.
| | - Meredith B Brooks
- School of Public Health, Boston University, 715 Albany Street, Boston, MA, 02118, USA
| | - Refiloe Matji
- AQUITY Innovations, 114 Sovereign Drive, Centurion, South Africa
| | - Betty Ncanywa
- AQUITY Innovations, Greenacres Park, Gqeberha, South Africa
| | - Freck Dikgale
- AQUITY Innovations, 114 Sovereign Drive, Centurion, South Africa
| | - Nadia N Abuelezam
- Connell School of Nursing, Boston College, 140 Commonwealth Avenue, Chestnut Hill, MA, 02467, USA
| | - Bulelwa Mzileni
- Department of Health, Sarah Baartman District, 16 Grace Street, Gqeberha, South Africa
| | - Miyakazi Nokwe
- Department of Health, Eastern Cape, Dukumbana Building, Bisho, South Africa
| | - Singilizwe Moko
- Department of Health, Eastern Cape, Dukumbana Building, Bisho, South Africa
- Walter Sisulu University, Mthatha, South Africa
| | - Lindiwe Mvusi
- National Department of Health, 1112 Voortrekker Road, Pretoria, South Africa
| | - Marian Loveday
- HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Francie Van Zijl Drive, Parow Valley, Cape Town, South Africa
| | - Sarah Gimbel
- Department of Child, University of Washington, Family & Population Health Nursing, Gerberding HallSeattle, WA, 98195, USA
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Selohilwe O, Fairall L, Bhana A, Kathree T, Zani B, Folb N, Lund C, Thornicroft G, Petersen I. Challenges and opportunities for implementation and dissemination of a task- sharing counselling intervention for depression at primary health care level in South Africa. Int J Ment Health Syst 2023; 17:7. [PMID: 36998053 PMCID: PMC10064738 DOI: 10.1186/s13033-023-00575-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 03/08/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND The treatment gap for mental health services is a growing public health concern. A lay-counselling service located at primary health care (PHC) level could potentially help to close the large treatment gap for common mental disorders in South Africa. The aim of this study was to understand multilevel factors contributing to implementation and potential dissemination of such a service for depression at PHC level. METHODS Process qualitative data of the lay-counselling service for patients with depressive symptoms was collected alongside a pragmatic randomized controlled trial evaluating a collaborative care model that included a lay-counselling service for patients with depressive symptoms. Semi-structured key informant interviews (SSI) were conducted with a purposive sample of PHC providers (lay-counsellors, nurse practitioners, operational managers), lay-counsellor supervisors, district and provincial managers, and patients in receipt of services. A total of 86 interviews were conducted. The Consolidated Framework for Implementation Research (CFIR) was used to guide data collection as well as Framework Analysis to determine barriers and facilitators for implementation and dissemination of the lay-counselling service. RESULTS Facilitators identified include supervision and support available for counsellors; person focused counselling approach; organizational integration of the counsellor within facilities. Barriers included lack of organizational support of the counselling service, including lack of counselling dedicated space; high counsellor turnover, resulting in a counsellor not available all the time; lack of an identified cadre to deliver the intervention in the system; and treatment of mental health conditions including counselling not included within mental health indicators. CONCLUSIONS Several system level issues need to be addressed to promote integration and dissemination of lay-counselling services within PHC facilities in South Africa. Key system requirements are facility organizational readiness for improvement of integration of lay-counselling services; formal recognition of counselling services provided by lay counsellors as well as inclusion of lay counselling as a treatment modality within mental health treatment data element definitions and the need for diversification of the roles of psychologists to include training and supervision of lay counsellors was also emphasized.
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Affiliation(s)
- One Selohilwe
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, 4001, South Africa.
| | - Lara Fairall
- Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa
- School of Life Course & Population Sciences, King's College London, London, UK
| | - Arvin Bhana
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, 4001, South Africa
- Health Systems Research Unit, South African Medical Research Centre, Durban, 4091, South Africa
| | - Tasneem Kathree
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, 4001, South Africa
| | - Babalwa Zani
- Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa
| | - Naomi Folb
- Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa
| | - Crick Lund
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Graham Thornicroft
- Centre for Global Mental Health and Centre for Implementation Science, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Inge Petersen
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, 4001, South Africa
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West RL, Lippman SA, Twine R, Maritze M, Kahn K, Leslie HH. Providers' definitions of quality and barriers to providing quality care: a qualitative study in rural Mpumalanga Province, South Africa. JOURNAL OF GLOBAL HEALTH SCIENCE 2021; 3. [PMID: 35419555 PMCID: PMC9004593 DOI: 10.35500/jghs.2021.3.e1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Background: South Africa requires high-quality primary health care (PHC) to retain patients and optimize outcomes. While prior research has identified implementation challenges within the PHC system, there is less understanding of how providers define quality, their perceptions of barriers to providing quality care, and how they overcome these barriers. This study assesses provider views on quality at primary care clinics in a rural sub-district of Mpumalanga Province. Methods: We conducted in-depth interviews with providers in early 2019 on the value of quality metrics for providers and patients, what indicators they would use to assess clinic performance, and barriers and facilitators of delivering care. Interviews were conducted in Shangaan, audio-recorded, and translated into English. A deductive approach was used to develop a provisional coding schema, which was then refined using an inductive approach in response to patterns and themes emerging from the data. Results: Twenty-three providers were interviewed (83% female, 65% professional nurses). Providers did not give a single standard definition of quality care. Clinic structure and resources emerged as a key issue, as providers linked deficiencies in infrastructure and support to deficits in care delivery. Providers identified mitigating strategies including informal coordination across clinics to address medication and equipment shortages. Common across the providers’ discussion was poor communication between the district, PHC supervisors, and implementers at the facility level. Conclusion: Providers connected deficits in quality of care to inadequate infrastructure and insufficient support from district and provincial authorities; mitigating strategies across clinics could only partially address these deficits. The existence of a national quality measurement program was not broadly reflected in providers’ views on quality care. These findings underscore the need for effective district and national approaches to support individual facilities, accompanied by feedback methods designed with input from frontline service providers.
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Affiliation(s)
- Rebecca L West
- Boston University School of Public Health, Boston, MA, USA.,Division of Prevention Science, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Sheri A Lippman
- Division of Prevention Science, Department of Medicine, University of California San Francisco, San Francisco, CA, USA.,MRC-Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Rhian Twine
- MRC-Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Meriam Maritze
- MRC-Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kathleen Kahn
- MRC-Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Hannah H Leslie
- Division of Prevention Science, Department of Medicine, University of California San Francisco, San Francisco, CA, USA.,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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