Michelle Engelbrecht

Patient- and delivery-level factors related to acceptance of HIV counseling and testing services among tuberculosis patients in South Africa: a qualitative study with community health workers and program managers

BackgroundSouth Africa has a high tuberculosis (TB)-human immunodeficiency virus (HIV) coinfection rate of 73%, yet only 46% of TB patients are tested for HIV. To date, relatively little work has focused on understanding why TB patients may not accept effective services or participate in programs that are readily available in healthcare delivery systems. The objective of the study was to explore barriers to and facilitators of participation in HIV counseling and testing (HCT) among TB patients in the Free State Province, from the perspective of community health workers and program managers who offer services to patients on a daily basis. These two provider groups are positioned to alter the delivery of HCT services in order to improve patient participation and, ultimately, health outcomes.MethodsGroup discussions and semistructured interviews were conducted with 40 lay counselors, 57 directly observed therapy (DOT) supporters, and 13 TB and HIV/acquired immune deficiency syndrome (AIDS) program managers in the Free State Province between September 2007 and March 2008. Sessions were audio-recorded, transcribed, and thematically analyzed.ResultsThe themes emerging from the focus group discussions and interviews included four main suggested barrier factors: (1) fears of HIV/AIDS, TB-HIV coinfection, death, and stigma; (2) perceived lack of confidentiality of HIV test results; (3) staff shortages and high workload; and (4) poor infrastructure to encourage, monitor, and deliver HCT. The four main facilitating factors emerging from the group and individual interviews were (1) encouragement and motivation by health workers, (2) alleviation of health worker shortages, (3) improved HCT training of professional and lay health workers, and (4) community outreach activities.ConclusionsOur findings provide insight into the relatively low acceptance rate of HCT services among TB patients from the perspective of two healthcare workforce groups that play an integral role in the delivery of effective health services and programs. Community health workers and program managers emphasized several patient- and delivery-level factors influencing acceptance of HCT services.

Barriers to HIV counseling and testing uptake by health workers in three public hospitals in Free State Province, South Africa.

Recent WHO/ILO/UNAIDS guidelines recommend priority access to HIV services for health care workers (HCWs), in order to retain and support HCWs, especially those at risk of occupationally acquired tuberculosis (TB). The purpose of this study was to identify barriers to uptake of HIV counselling and testing (HCT) services for HCWs receiving HCT within occupational health units (OHUs). Questions were included within a larger occupational health survey of a 20% quota sample of HCWs from three public hospitals in Free State Province, South Africa. Of the 978 respondents, nearly 65% believed that their co-workers would not want to know their HIV status. Barriers to accessing HCT at the OHU included ambiguity over whether antiretroviral treatment was available at the OHU (only 51.1% knew), or whether TB treatment was available (55.5% knew). Nearly 40% of respondents perceived that stigma as a barrier. When controlling for age and race, the odds of perceiving HIV stigma in the workplace among patient-care health care workers (PCHWs) were 2.4 times that for non-PCHWs [95% confidence interval (CI): 1.80–3.15]. Of the 692 survey respondents who indicated a reason for not using HIV services at the OHU, 38.9% felt that confidentiality was the reason cited. Among PCHWs, the adjusted odds of expressing concern that confidentiality may not be maintained in the OHU were 2.4 times (95% CI: 1.8–3.2) that of non-PCHWs and were higher among Black [odds ratio (OR): 2.7, CI: 1.7–4.2] and Coloured HCWs (OR: 3.0, 95% CI: 1.6–5.6) as compared to White HCWs, suggesting that stigma and confidentiality concerns are still barriers to uptake of HCT. Campaigns to improve awareness of HCT and TB services offered in the OHUs, address stigma and ensure that the workforce is aware of the confidentiality provisions that are in place are warranted.

Scaling up access to antiretroviral drugs in a middle-income country: public sector drug delivery in the Free State, South Africa.

Abstract This article describes the distribution and management of drugs and supplies in scaling up access to public sector antiretroviral treatment (ART) in a middle-income country. More specifically, a case study of the Free State Province of South Africa is presented focusing on: the mobilisation and training of pharmaceutical staff for ART, processes related to the ordering, distribution and storage of medicines, continuity of ART supplies and the impact of ART delivery on other drugs and supplies. Data were obtained from longitudinal research conducted between April 2004 and July 2006 comprising three surveys of the first 20 health facilities providing ART in the province, key informant interviews and observations made of provincial ART Task Team meetings. The supply of ART in the Province was managed through the existing drug supply system but with special mechanisms to ensure integrity of ART supplies and security of stock within the existing supply system. Initial hiccups in the procurement of antiretroviral (ARV) drugs for South Africa (a national function) caused delays in putting patients on ART, although these supply problems were short-lived. At provincial level, not all pharmacist posts created for the programme were filled, and pharmacists working in the rest of the health system were subsequently trained to take on ART programme functions. Electronic systems were not established at all service sites, which in part contributed to delays in the delivery of drugs and supplies to more peripheral units. Adequate space to safely store ARV drugs remained problematic. The introduction of the ART programme did not create disruptions in the supply of non-ART essential drugs, which in fact improved over the period of observation. It is concluded that despite some process, human resource and infrastructural challenges, the drug management system in the Free State succeeded in incorporating public sector ART within its existing drug distribution network and functions, at least in the initial phase of scale up.

Exploring task-shifting practices in antiretroviral treatment facilities in the Free State Province, South Africa

There is good progress with the implementation of South Africas antiretroviral treatment program. The country, however, faces human resource shortages that could be addressed through appropriate task shifting. During 2009, we studied task shifting from nurses to community health workers (CHWs) for HIV treatment and care at 12 primary health-care clinics in Free State Province, South Africa. We found inefficiency in nurse deployment, and nurses spent considerable time on training, counseling, and administrative tasks that could be shifted to CHWs. Such a shift will require the South African Ministry of Health to recognize CHWs formally in the health system.

Accuracy of Tuberculosis Routine Data and Nurses' Views of the TB-HIV Information System in the Free State, South Africa

Christo Heunis, PhD, is an Associate Professor, Centre for Health Systems ResearchD and Research Associate, Centre for Health Systems Research & Development, University of the Free State, Bloemfontein. Gladys Kigozi, MSc, is a Junior Researcher and Doctoral Student, Centre for Health Systems Research & Development, University of the Free State, Bloemfontein. Michelle Engelbrecht, PhD, is a Senior Researcher, Centre for Health Systems Research&Development, University of the Free State, Bloemfontein. Yolisa Tsibolane, BA Cur, is a Senior Manager, TB Management Programme, Free State Department of Health, Bloemfontein. Sonja van der Merwe, B Soc Sc, is an Assistant Director, TB Programme Surveillance, Free State Department of Health, Bloemfontein. Seipati Motlhanke, BA Cur, is an Assistant Director, TB-HIV/AIDS Programme Integration, Free State Department of Health, Bloemfontein. Reliable data are a prerequisite for evidence-based decision making in health care policy (AbouZahr & Boerma, 2005). Accurate measurement is crucial in evaluating epidemic trends, as well as in planning and monitoring disease-specific service provision. On the basis of a systematic review of descriptive and comparative studies and previous reviews of health information technologies, Chaudhry et al. (2006) demonstrated the efficacy of information gathered using health information technologies, such as electronic health records, to improve both quality and efficiency of health care. Sound data are especially vital for the success of large-scale public sector health programs in developing countries where limited human and financial resources require their optimal use (Fraser et al., 2005). Lippeveld (in AbouZahr & Boerma, 2005) defined a health information system (HIS) as an “integrated effort to collect, process, report and use health information and knowledge to influence policy-making, programme action and research” (p. 579). HISs are especially important when responses need to be urgent, as in the case of epidemic diseases such as

Tuberculosis and blood-borne infectious diseases: workplace conditions and practices of healthcare workers at three public hospitals in the Free State

Healthcare workers (HCWs) have increased risks due to continued exposure to patients with infectious diseases, particularly tuberculosis and hepatitis B. This study assessed workplace conditions and practices regarding air- and blood-borne infections in public hospitals in the Free State. Workplace audits were conducted in intensive care, medical wards and casualty departments at three Free State public hospitals. A questionnaire survey was also administered to a targeted 20% stratified quota sample at these facilities. Of the 513 HCWs surveyed, 21.2% reported needle-stick injuries and other body fluid exposure and 19.1% were not adequately protected against hepatitis B. Additionally, 68.3% were never screened for tuberculosis, 54.8% did not wear N95® respirators when needed, only 28.5% washed their gloves and 19.8% did not always wash their hands between caring for different patients. Physicians were at highest risk of needle-stick injuries, were less compliant with hand hygiene, and associated with lowe...

Considerations for preparing a randomized population health intervention trial: lessons from a South African–Canadian partnership to improve the health of health workers

Background Community-based cluster-randomized controlled trials (RCTs) are increasingly being conducted to address pressing global health concerns. Preparations for clinical trials are well-described, as are the steps for multi-component health service trials. However, guidance is lacking for addressing the ethical and logistic challenges in (cluster) RCTs of population health interventions in low- and middle-income countries. Objective We aimed to identify the factors that population health researchers must explicitly consider when planning RCTs within North-South partnerships. Design We reviewed our experiences and identified key ethical and logistic issues encountered during the pre-trial phase of a recently implemented RCT. This trial aimed to improve tuberculosis (TB) and Human Immunodeficiency Virus (HIV) prevention and care for health workers by enhancing workplace assessment capability, addressing concerns about confidentiality and stigma, and providing onsite counseling, testing, and treatment. An iterative framework was used to synthesize this analysis with lessons taken from other studies. Results The checklist of critical factors was grouped into eight categories: 1) Building trust and shared ownership; 2) Conducting feasibility studies throughout the process; 3) Building capacity; 4) Creating an appropriate information system; 5) Conducting pilot studies; 6) Securing stakeholder support, with a view to scale-up; 7) Continuously refining methodological rigor; and 8) Explicitly addressing all ethical issues both at the start and continuously as they arise. Conclusion Researchers should allow for the significant investment of time and resources required for successful implementation of population health RCTs within North-South collaborations, recognize the iterative nature of the process, and be prepared to revise protocols as challenges emerge.Background Community-based cluster-randomized controlled trials (RCTs) are increasingly being conducted to address pressing global health concerns. Preparations for clinical trials are well-described, as are the steps for multi-component health service trials. However, guidance is lacking for addressing the ethical and logistic challenges in (cluster) RCTs of population health interventions in low- and middle-income countries. Objective We aimed to identify the factors that population health researchers must explicitly consider when planning RCTs within North–South partnerships. Design We reviewed our experiences and identified key ethical and logistic issues encountered during the pre-trial phase of a recently implemented RCT. This trial aimed to improve tuberculosis (TB) and Human Immunodeficiency Virus (HIV) prevention and care for health workers by enhancing workplace assessment capability, addressing concerns about confidentiality and stigma, and providing onsite counseling, testing, and treatment. An iterative framework was used to synthesize this analysis with lessons taken from other studies. Results The checklist of critical factors was grouped into eight categories: 1) Building trust and shared ownership; 2) Conducting feasibility studies throughout the process; 3) Building capacity; 4) Creating an appropriate information system; 5) Conducting pilot studies; 6) Securing stakeholder support, with a view to scale-up; 7) Continuously refining methodological rigor; and 8) Explicitly addressing all ethical issues both at the start and continuously as they arise. Conclusion Researchers should allow for the significant investment of time and resources required for successful implementation of population health RCTs within North–South collaborations, recognize the iterative nature of the process, and be prepared to revise protocols as challenges emerge.

Resources and infrastructure for the delivery of antiretroviral therapy at primary health care facilities in the Free State Province, South Africa

There are concerns as to whether South Africas public health system has sufficient resources, human and otherwise, to ensure universal access to antiretroviral treatment (ART). We report on public sector implementation of the Comprehensive Care Management and Treatment (CCMT) programme in the Free State Province, South Africa, in particular whether the primary health care (PHC) infrastructure was able to mobilise the necessary inputs to effectively provide ART, without undermining other services within facilities. A longitudinal study was conducted of the first 16 PHC facilities accredited to provide ART in the province. The facilities were visited on three occasions over 2 years, involving both structured and open-ended interviews with professional and lay staff, and observations of available resources. The resources assessed were staffing, space, essential equipment, drug supplies and laboratory systems. Approximately one-fifth (20%) of professional nurses were allocated to the CCMT programme in the facilities, although the overall number of professional nurses increased by only 14%. This process resulted in some displacement of professional nurses towards the CCMT Programme away from other services in the facilities. However, this could have been partially compensated for by task shifting towards community health workers and the appointment of additional support staff. Staff were largely positive about the programme. Drug supplies, availability of equipment and laboratory systems, although good at the baseline, improved further over the period of observation. The lack of adequate space to accommodate the new programme was a frequently reported problem. Overall, our assessment is that the PHC infrastructure in the Free States public health system is capable of implementing and benefiting from the CCMT programme. Nevertheless, constraints in the availability of professional staff threaten future implementation of both the CCMT and other PHC programmes.

Workplace interventions to reduce HIV and TB stigma among health care workers - Where do we go from here?

Fear of stigma and discrimination among health care workers (HCWs) in South African hospitals is thought to be a major factor in the high rates of HIV and tuberculosis infection experienced in the health care workforce. The aim of the current study is to inform the development of a stigma reduction intervention in the context of a large multicomponent trial. We analysed relevant results of four feasibility studies conducted in the lead up to the trial. Our findings suggest that a stigma reduction campaign must address community and structural level drivers of stigma, in addition to individual level concerns, through a participatory and iterative approach. Importantly, stigma reduction must not only be embedded in the institutional management of HCWs but also be attentive to the localised needs of HCWs themselves.

Tuberculosis infection control practices in primary healthcare facilities in three districts of South Africa

South Africa has one of the highest incidence of tuberculosis in the world, which can partly be attributed to poor infection control in public healthcare (PHC) facilities. The aim of the study was to explore the extent of tuberculosis and infection control training, as well as facility-level managerial, administrative, environmental and personal protection, infection control measures, at PHC facilities. Cross-sectional surveys were conducted at 127 PHC facilities across three districts of South Africa. Data collection was achieved through interviews with tuberculosis nurses, observations of infection control practices and a review of the clinic records. Univariate analysis was performed using SPSS® version 17. Limited implementation of World Health Organization infection control measures was identifed. In terms of facility controls, 43.3% of the clinics did not have an infection control committee and 40.9% did not have a clinic specifc infection control plan. In terms of administrative controls, 94.5% of...