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Embedding Research on Implementation of Primary Health Care Systems Strengthening: A Commentary on Collaborative Experiences in Ethiopia, Ghana, and Mozambique. GLOBAL HEALTH, SCIENCE AND PRACTICE 2022; 10:e2200061. [PMID: 36109054 PMCID: PMC9476480 DOI: 10.9745/ghsp-d-22-00061] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 05/11/2022] [Indexed: 02/07/2023]
Abstract
Achieving universal health care coverage requires the adoption of primary health care policies and delivery strategies that are evidence based. Although this has been confronted by manifold challenges, particularly in the health systems of sub-Saharan Africa, there are promising approaches for accomplishing this objective. Salient among these is embedding implementation research (i.e., the study of methods to promote the systematic uptake of evidence-based interventions (EBIs) into routine practice) into policy making and implementation processes. Since 2007, the African Health Initiative of the Doris Duke Charitable Foundation supported partnerships that strengthened primary health systems and policy implementation in 7 countries in sub-Saharan Africa using the embedded implementation research as a core strategy. This programmatic review and analysis aims to identify the core features and processes that characterized how the partnerships operationalized the embedded implementation research approach and understand the factors that helped and constrained partnerships' effective use of this approach. For this, we drew upon findings from a desk review that consisted of 30 examples of embedded implementation research conducted by 3 African Health Initiative partnerships between 2016 and 2021 in Ethiopia, Ghana, and Mozambique. In addition, we conducted and analyzed 13 in-depth interviews with embedded implementation research stakeholders of the 3 projects. Core features and processes of embedded implementation research were: (1) the leadership role of policy decision makers and implementation leaders; (2) positioning research with program implementation at multiple levels of health systems; (3) multidisciplinary and multisectoral partnerships; (4) focus on research capacity building; and (5) real-time feedback loops and knowledge translation. Factors influencing the effectiveness of the embedded implementation research experiences involved: (1) the implementation climate and leadership; (2) opportunities and capacities to circulate and absorb new information; and (3) stakeholders' baseline knowledge and embedded scientists' identification within their organizations.
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Aarons GA, Reeder K, Sam-Agudu NA, Vorkoper S, Sturke R. Implementation determinants and mechanisms for the prevention and treatment of adolescent HIV in sub-Saharan Africa: concept mapping of the NIH Fogarty International Center Adolescent HIV Implementation Science Alliance (AHISA) initiative. Implement Sci Commun 2021; 2:53. [PMID: 34022956 PMCID: PMC8141156 DOI: 10.1186/s43058-021-00156-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 05/04/2021] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION Adolescent HIV prevention and treatment is a high priority for youth healthcare in sub-Saharan Africa. METHODS This study employed concept mapping to identify factors that impact the implementation of HIV prevention and intervention programs for adolescents in sub-Saharan Africa. Key stakeholders including researchers, policymakers, and non-governmental organization (NGO) personnel constituting membership of the NIH-sponsored Adolescent HIV Prevention and Treatment Implementation Science Alliance responded to the question: "In your experience, what factors have facilitated or hindered implementation of evidence-based HIV prevention or treatment for adolescents in sub-Saharan Africa?" Participants generated statements in response to the focus question, sorted them into thematically relevant groups, and rated each statement on its importance and changeability. RESULTS Through data analyses and participant feedback, 15 distinct themes were derived. "Workforce/Workflow" and "HIV Stigma and Adolescent Development" were rated highest for importance, and "Threshold Conditions for Treatment" and "Structure of Implementation Efforts" were rated most changeable. CONCLUSIONS Understanding implementation science determinants and mechanisms can facilitate the uptake of successful implementation and sustainment strategies for the prevention and treatment of HIV in a given context. We placed determinants and mechanisms within the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to provide greater contextual integration with broader theories in implementation science. Implementers across multiple disciplines can use these findings to improve the scale-up of evidence-based practices for adolescent HIV prevention and treatment in sub-Saharan Africa. Implementation approaches that consider the determinants and mechanisms identified in this study and integrated in implementation frameworks will likely have utility for other health conditions and contexts.
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Affiliation(s)
- Gregory A. Aarons
- Department of Psychiatry, University of California San Diego, 9500 Gilman Drive (0812), La Jolla, CA 92093-0812 USA
- UC San Diego Dissemination and Implementation Science Center (UC San Diego ACTRI DISC), Altman Clinical and Translational Research Institute, La Jolla, CA 92093 USA
- Child and Adolescent Services Research Center, 3665 Kearny Villa Rd., Suite 200N, San Diego, CA 92123 USA
| | - Kendal Reeder
- Department of Psychiatry, University of California San Diego, 9500 Gilman Drive (0812), La Jolla, CA 92093-0812 USA
- UC San Diego Dissemination and Implementation Science Center (UC San Diego ACTRI DISC), Altman Clinical and Translational Research Institute, La Jolla, CA 92093 USA
- Child and Adolescent Services Research Center, 3665 Kearny Villa Rd., Suite 200N, San Diego, CA 92123 USA
| | - Nadia A. Sam-Agudu
- Institute of Human Virology and Department of Pediatrics, University of Maryland School of Medicine, 725 West Lombard Street, Baltimore, MD 21201 USA
- International Research Center of Excellence, Institute of Human Virology Nigeria, Plot 252 Herbert Macaulay Way, Abuja, Nigeria
| | - Susan Vorkoper
- NIH Fogarty International Center, Center for Global Health Studies, Bethesda, MD USA
| | - Rachel Sturke
- NIH Fogarty International Center, Center for Global Health Studies, Bethesda, MD USA
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Galle A, Semaan A, Huysmans E, Audet C, Asefa A, Delvaux T, Afolabi BB, El Ayadi AM, Benova L. A double-edged sword-telemedicine for maternal care during COVID-19: findings from a global mixed-methods study of healthcare providers. BMJ Glob Health 2021; 6:e004575. [PMID: 33632772 PMCID: PMC7908054 DOI: 10.1136/bmjgh-2020-004575] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 02/03/2021] [Accepted: 02/10/2021] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION The COVID-19 pandemic has led to a rapid implementation of telemedicine for the provision of maternal and newborn healthcare. The objective of this study was to document the experiences with providing telemedicine for maternal and newborn healthcare during the pandemic among healthcare professionals globally. METHODS The second round of a global online survey of maternal and newborn health professionals was conducted, disseminated in 11 languages. Data were collected between 5 July and 10 September 2020. The questionnaire included questions regarding background, preparedness and response to COVID-19, and experiences with providing telemedicine. Descriptive statistics and qualitative thematic analysis were used to analyse responses, disaggregated by country income level. RESULTS Responses from 1060 maternal and newborn health professionals were analysed. Telemedicine was used by 58% of health professionals and two-fifths of them reported not receiving guidelines on the provision of telemedicine. Key telemedicine practices included online birth preparedness classes, antenatal and postnatal care by video/phone, a COVID-19 helpline and online psychosocial counselling. Challenges reported lack of infrastructure and technological literacy, limited monitoring, financial and language barriers, lack of non-verbal feedback and bonding, and distrust from patients. Telemedicine was considered as an important alternative to in-person consultations. However, health providers emphasised the lower quality of care and risk of increasing the already existing inequalities in access to healthcare. CONCLUSIONS Telemedicine has been applied globally to address disruptions of care provision during the COVID-19 pandemic. However, some crucial aspects of maternal and newborn healthcare seem difficult to deliver by telemedicine. More research regarding the effectiveness, efficacy and quality of telemedicine for maternal healthcare in different contexts is needed before considering long-term adaptations in provision of care away from face-to-face interactions. Clear guidelines for care provision and approaches to minimising socioeconomic and technological inequalities in access to care are urgently needed.
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Affiliation(s)
- Anna Galle
- ICRH, Department of Public Health and Primary Care, Ghent University, Gent, Belgium
| | - Aline Semaan
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Elise Huysmans
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Constance Audet
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Anteneh Asefa
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Therese Delvaux
- Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
| | | | - Alison Marie El Ayadi
- Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, California, USA
| | - Lenka Benova
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
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Kredo T, Cooper S, Abrams AL, Muller J, Schmidt BM, Volmink J, Atkins S. 'Building on shaky ground'-challenges to and solutions for primary care guideline implementation in four provinces in South Africa: a qualitative study. BMJ Open 2020; 10:e031468. [PMID: 32474422 PMCID: PMC7264636 DOI: 10.1136/bmjopen-2019-031468] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Revised: 03/24/2020] [Accepted: 04/03/2020] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES Clinical guidelines support evidence-informed quality patient care. Our study explored perspectives of South African subnational health managers regarding barriers to and enablers for implementation for all available primary care guidelines. DESIGN We used qualitative research methods, including semistructured, individual interviews and an interpretative perspective. Thematic content analysis was used to develop data categories and themes. SETTING We conducted research in four of nine South African provinces with diverse geographic, economic and health system arrangements (Eastern Cape, Western Cape, KwaZulu-Natal, Limpopo). South Africa is a middle-income country with high levels of inequality. The settings represented public sector rural and peri-urban health facilities. PARTICIPANTS Twenty-two participants with provincial and district health management roles, that comprised implementation and/or training on primary care guidelines, were included. RESULTS Participants recommended urgent consideration of health system challenges, particularly financial constraints, impacting on access to the guidelines themselves and to medical equipment and supplies necessary to adhere to guidelines. They suggested that overcoming service delivery gaps requires strengthening of leadership, clarification of roles and enhanced accountability. Participants suggested that inadequate numbers of skilled clinical staff hampered guideline use and, ultimately, patient care. Quality assurance of training programmes for clinicians-particularly nurses-interdisciplinary training, and strengthening post-training mentorship were recommended. Furthermore, fit-for-purpose guideline implementation necessitates considering the unique settings of facilities, including local culture and geography. This requires guideline development to include guideline end users. CONCLUSIONS Guidelines are one of the policy tools to achieve evidence-informed, cost-effective and universal healthcare. But, if not effectively implemented, they have no impact. Subnational health managers in poorly resourced settings suggested that shortcomings in the health system, along with poor consultation with end users, affect implementation. Short-term improvements are possible through increasing access to and training on guidelines. However, health system strengthening and recognition of socio-cultural-geographic diversity are prerequisites for context-appropriate evidence-informed practice.
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Affiliation(s)
- Tamara Kredo
- Cochrane South Africa, South African Medical Research Council, Tygerberg, South Africa
- Department of Medicine, Division of Clinical Pharmacology, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
| | - Sara Cooper
- Cochrane South Africa, South African Medical Research Council, Tygerberg, South Africa
- School of Public Health and Family Medicine, University of Cape Town Faculty of Health Sciences, Observatory, Western Cape, South Africa
| | - Amber Louise Abrams
- Cochrane South Africa, South African Medical Research Council, Tygerberg, South Africa
| | - Jocelyn Muller
- Cochrane South Africa, South African Medical Research Council, Tygerberg, South Africa
| | - Bey-Marrié Schmidt
- Cochrane South Africa, South African Medical Research Council, Tygerberg, South Africa
| | - Jimmy Volmink
- Cochrane South Africa, South African Medical Research Council, Tygerberg, South Africa
- Deans office and Centre for Evidence Based Health Care, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
| | - Salla Atkins
- New Social Research and Faculty of Social Sciences, Tampere University, Tampere, Pirkanmaa, Finland
- Department of Public Health Sciences, Karolinska Institute, Stockholm, Stockholm County, Sweden
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Suryavanshi N, Kadam A, Kanade S, Gupte N, Gupta A, Bollinger R, Mave V, Shankar A. Acceptability and feasibility of a behavioral and mobile health intervention (COMBIND) shown to increase uptake of prevention of mother to child transmission (PMTCT) care in India. BMC Public Health 2020; 20:752. [PMID: 32448299 PMCID: PMC7245843 DOI: 10.1186/s12889-020-08706-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 04/15/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A cluster-randomized trial recently demonstrated that an integrated behavioral and mobile technology intervention improved uptake of key components of a Prevention of Mother to Child Transmission (PMTCT) Option B+ program, among HIV- infected pregnant/breastfeeding women in India. To guide scale-up and optimize programmatic implementation, we conducted a mixed-methods evaluation of the feasibility and acceptability of this intervention. METHODS The COMmunity Home Based INDia (COMBIND) study, was conducted in four districts of Maharashtra, India and randomized 119 integrated counseling and testing centers (ICTC) and their outreach workers (ORWs) to the COMBIND intervention, an integrated mHealth application that allowed digital data capture, PMTCT educational videos, SMS alerts for missed visits and reminder for visits, combined with personal empowerment and motivational interviewing training for ORWs. This qualitative evaluation was done through 15 in-depth interviews (IDIs) with ORWs and 15 IDIs with HIV-infected pregnant/breastfeeding women from the intervention arm. Utilizing a concurrent nested mixed-method evaluation approach, we assess the feasibility and acceptability of the study intervention. RESULTS All 30 participants reported that the PMTCT videos were essential in providing easy to understand information on critical aspects of HIV and necessary care related to PMTCT practices. A majority of the ORWs reported that the personal empowerment training with motivational interviewing skills training increased their confidence, motivation and gave them the tools for effectively supporting their clients. The mHealth application improved their working style as it facilitated targeted PMTCT information support, systemized data capture, streamlined their health education delivery practice and provided a sense of work satisfaction. The SMS appointment alerts improved retention in HIV care for mother and baby to the smaller proportion that had access to their phones. Despite reported improvements in knowledge and communication, few ORWs reported that structural challenges such as limited drug stocks, lack of HIV kits or unavailability of trained staff at ICTC, may hamper the uptake of PMTCT services, thus resulting in limited significant impacts of COMBIND on PMTCT outcomes. CONCLUSION This study found that COMBIND intervention is scalable, feasible, beneficial and very well accepted by ORWs and patients, however structural challenges in goods and services remain.
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Affiliation(s)
- Nishi Suryavanshi
- Lakshya Society for Public Health Education and Research, 307, Block II, Llyod Chambers, Mangalwar Peth, Pune, Maharashtra, 411001, India.
| | - Abhay Kadam
- Lakshya Society for Public Health Education and Research, 307, Block II, Llyod Chambers, Mangalwar Peth, Pune, Maharashtra, 411001, India
| | - Savita Kanade
- Lakshya Society for Public Health Education and Research, 307, Block II, Llyod Chambers, Mangalwar Peth, Pune, Maharashtra, 411001, India
| | - Nikhil Gupte
- Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Amita Gupta
- Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Robert Bollinger
- Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Vidya Mave
- Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Anita Shankar
- Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA
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Program implementation gaps and ethical issues in the prevention of HIV infection among infants, children, and adolescents in sub-Saharan Africa. Pediatr Res 2020; 87:406-413. [PMID: 31663519 DOI: 10.1038/s41390-019-0645-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 08/31/2019] [Accepted: 10/23/2019] [Indexed: 12/30/2022]
Abstract
Strategies for HIV prevention among infants, children, and adolescents have evolved significantly over the past 20 years. These include the global scale-up of simplified multidrug HIV regimens for pregnant women, leading to impressive reductions in new child HIV infections. However, significant gaps remain, especially in high HIV-burden sub-Saharan African countries. For example, many pregnant women living with HIV (WLHIV) are unable to access and sustain HIV testing and treatment partly due to low agency and harmful gender norms. Among pregnant WLHIV, adolescent girls face an additional layer of societal and health-system barriers in accessing care for themselves and their exposed infants. Legal and structural barriers limit access to HIV prevention-related sexual and reproductive health services among high-risk adolescents, including girls and young men who have sex with men. Key ethical issues underlying HIV prevention gaps for infants, children, and adolescents prevail. This narrative review explores these issues and highlights counter-measures for programming and policy, including gender empowerment, improving access to and appropriateness of critical health services, rights-based policy and legislation, closing research gaps, and considering the values and preferences of young people for HIV prevention and treatment services.
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Ramlagan S, Rodriguez VJ, Peltzer K, Ruiter RAC, Jones DL, Sifunda S. Self-Reported Long-Term Antiretroviral Adherence: A Longitudinal Study Among HIV Infected Pregnant Women in Mpumalanga, South Africa. AIDS Behav 2019; 23:2576-2587. [PMID: 31228026 PMCID: PMC6766468 DOI: 10.1007/s10461-019-02563-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
We evaluate the impact of a multi-session cognitive behavioral prevention of mother to child transmission (PMTCT) intervention on antiretroviral therapy (ART) adherence. A total of 683 women were enrolled into a randomized control trial conducted at twelve community health centres (CHCs) in Mpumalanga Province. Participants were randomized to Standard Care or Enhanced PMTCT Intervention (EI). EI received three group and three individual intervention sessions. EI impact was ascertained on ART adherence (baseline vs 12 months post-partum). Women in the intervention groups were less likely to remain stable with regards to ART adherence over time compared to the control groups. In predicting if women become adherent over time, the intervention condition had no impact. However, the intervention condition was significantly positively associated with change to non-adherence. The enhanced cognitive-behavioral PMTCT intervention did not show any improvement in relation to maternal ART adherence relative to standard PMTCT care.Trial registration Clinicaltrials.gov: number NCT02085356.
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Affiliation(s)
- Shandir Ramlagan
- Social Aspects of Public Health, Human Sciences Research Council, Private Bag X41, Pretoria, 0001 South Africa
- Department of Work & Social Psychology, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Violeta J. Rodriguez
- Department of Psychiatry and Behavioral Sciences, Miller School of Medicine, University of Miami, 1400 NW 10th Ave, Miami, FL 33136 USA
- Department of Psychology, University of Georgia, Athens, GA 30605 USA
| | - Karl Peltzer
- Social Aspects of Public Health, Human Sciences Research Council, Private Bag X41, Pretoria, 0001 South Africa
- Department of Research and Innovation, University of Limpopo, Sovenga, 0727 South Africa
| | - Robert A. C. Ruiter
- Department of Work & Social Psychology, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Deborah L. Jones
- Department of Psychiatry and Behavioral Sciences, Miller School of Medicine, University of Miami, 1400 NW 10th Ave, Miami, FL 33136 USA
| | - Sibusiso Sifunda
- Social Aspects of Public Health, Human Sciences Research Council, Private Bag X41, Pretoria, 0001 South Africa
- Department of Work & Social Psychology, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
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Schmitz K, Basera TJ, Egbujie B, Mistri P, Naidoo N, Mapanga W, Goudge J, Mbule M, Burtt F, Scheepers E, Igumbor J. Impact of lay health worker programmes on the health outcomes of mother-child pairs of HIV exposed children in Africa: A scoping review. PLoS One 2019; 14:e0211439. [PMID: 30703152 PMCID: PMC6355001 DOI: 10.1371/journal.pone.0211439] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 01/14/2019] [Indexed: 02/06/2023] Open
Abstract
Background Increased demand for healthcare services in countries experiencing high HIV disease burden and often coupled with a shortage of health workers, has necessitated task shifting from professional health workers to Lay Health Workers (LHWs) in order to improve healthcare delivery. Maternal and Child Health (MCH) services particularly benefit from task-shifting to LHWs or similar cadres. However, evidence on the roles and usefulness of LHWs in MCH service delivery in Sub-Saharan Africa (SSA) is not fully known. Objectives To examine evidence of the roles and impact of lay health worker programmes focusing on Women Living with HIV (WLH) and their HIV-exposed infants (HEIs). Methods A scoping review approach based on Arksey and O’Malley’s guiding principles was used to retrieve, review and analyse existing literature. We searched for articles published between January 2008 and July 2018 in seven (7) databases, including: MEDLINE, Embase, PsycINFO, Joanna Briggs, The Cochrane Library, EBM reviews and Web of Science. The critical constructs used for the literature search were “lay health worker”, “community health worker”, “peer mentor”, “mentor mother,” “Maternal and Child health worker”, “HIV positive mothers”, “HIV exposed infants” and PMTCT. Results Thirty-three (33) full-text articles meeting the eligibility criteria were identified and included in the final analysis. Most (n = 13, 39.4%) of the included studies were conducted in South Africa and used a cluster RCT design (n = 13, 39.4%). The most commonly performed roles of LHWs in HIV specific MCH programmes included: community engagement and sensitisation, psychosocial support, linkage to care, encouraging women to bring their infants back for HIV testing and supporting default tracing. Community awareness on Mother to Child Transmission of HIV (MTCT), proper and consistent use of condoms, clinic attendance and timely HIV testing of HEIs, as well as retention in care for infected persons, have all improved because of LHW programmes. Conclusion LHWs play significant roles in the management of WLH and their HEIs, improving MCH outcomes in the process. LHW interventions are beneficial in increasing access to PMTCT services and reducing MTCT of HIV, though their impact on improving adherence to ART remains scanty. Further research is needed to evaluate ART adherence in LHW interventions targeted at WLH. LHW programmes can be enhanced by increasing supportive supervision and remuneration of LHWs.
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Affiliation(s)
| | - Tariro Jayson Basera
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- * E-mail:
| | - Bonaventure Egbujie
- School of Public Health, University of Western Cape, Cape Town, South Africa
| | - Preethi Mistri
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Nireshni Naidoo
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Witness Mapanga
- Center for Health Policy, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Jane Goudge
- Center for Health Policy, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | | | - Jude Igumbor
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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