scholarly journals Exploring drivers and barriers to the utilization of community client-led ART delivery model in South-Western Uganda: patients’ and health workers’ experiences

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Timothy Mwanje Kintu ◽  
Anna Maria Ssewanyana ◽  
Tonny Kyagambiddwa ◽  
Pretty Mariam Nampijja ◽  
Patience Kevin Apio ◽  
...  
Keyword(s):  
Service Delivery ◽  
Health System ◽  
Health Workers ◽  
Full Range ◽  
Health Centre ◽  
Hiv Care ◽  
Differentiated Service ◽  
Western Uganda ◽  
Depth Interviews ◽  
Art Delivery

Abstract Background In an effort to accommodate the growing number of HIV clients, improve retention in care and reduce health care burden, the differentiated service delivery (DSD) models were introduced in 2014. One such model, Community Client-Led ART Delivery (CCLAD) was rolled out in Uganda in 2017. The extent of utilization of this model has not been fully studied. The aim of the study was to explore the patients’ and health workers’ experiences on the utilization of CCLAD model at Bwizibwera Health Centre IV, south western Uganda. Methods This was a descriptive study employing qualitative methods. The study had 68 purposively selected participants who participated in 10 focus group discussions with HIV clients enrolled in CCLAD; 10 in-depth interviews with HIV clients not enrolled in CCLAD and 6 in-depth interviews with the health workers. Key informant interviews were held with the 2 focal persons for DSD. The discussions and interviews were audio recorded, transcribed verbatim and then translated. Both deductive and inductive approaches were employed to analyse the data using in NVivo software. Results Patients’ and health workers’ experiences in this study were categorized as drivers and barriers to the utilization of the CCLAD model. The main drivers for utilization of this model at different levels were: individual (reduced costs, living positively with HIV, improved patient self-management), community (peer support and contextual factors) and health system (reduced patient congestion at the health centre, caring health workers as well as CCLAD sensitization by health workers). However, significant barriers to the utilization of this community-based model were: individual (personal values and preferences, lack of commitment of CCLAD group members), community (stigma, gender bias) and health system (frequent drug stockouts, certain implementation challenges, fluctuating implementing partner priorities, shortage of trained health workers and insufficient health education by health workers). Conclusion Based on our findings the CCLAD model is meeting the objectives set out by Differentiated Service Delivery for HIV care and treatment. Notwithstanding the benefits, challenges remain which call on the Ministry of Health and other implementing partners to address these hindrances to facilitate the scalability, sustainability and the realisation of the full-range of benefits that the model presents.

scholarly journals Patient and Health worker experiences on Utilization of Community Client Led ART Delivery Model in South-Western Uganda: A Qualitative Study

2021 ◽  
Author(s):  
Timothy Mwanje Kintu ◽  
Anna Maria Ssewanyana ◽  
Tonny Kyagambiddwa ◽  
Pretty Mariam Nampijja ◽  
Patience Kevin Apio ◽  
...  
Keyword(s):  
Service Delivery ◽  
Health System ◽  
Health Worker ◽  
Health Workers ◽  
Full Range ◽  
Health Centre ◽  
Retention In Care ◽  
Hiv Care ◽  
Differentiated Service ◽  
Art Delivery

Abstract BackgroundIn an effort to accommodate the growing number of stable HIV clients, improve retention in care and reduce health care burden the differentiated service delivery (DSD) models were introduced in 2014. One such model, Community Client Led ART Delivery (CCLAD) was rolled out in Uganda in 2017. The extent of utilization of this model has not been fully studied. The aim of the study was to explore the patient and health worker experiences on the utilization of CCLAD model at Bwizibwera Health Centre IV, south western Uganda.MethodsThis was a descriptive study employing qualitative methods. The study had 68 purposively selected participants who participated in 10 Focus Group Discussions with HIV clients enrolled in CCLAD; 10 in-depth interviews with HIV clients not enrolled in CCLAD and 6 health workers. Key informant interviews were held with the 2 focal persons for DSD. The discussions and interviews were audio recorded, transcribed verbatim and then translated. Both deductive and inductive approaches were employed to analyse the data using in NVivo software. ResultsPatient and health worker experiences in this study were categorized as drivers and barriers to the utilization of the CCLAD model. The main drivers for utilization of this model at different levels were: individual (reduced costs, living positively with HIV, improved patient self-management), community (peer support and contextual factors) and health system (reduced patient congestion at the health centre, caring health workers as well as CCLAD sensitization by health workers). However, significant barriers to the utilization of this community-based model were: individual (personal values and preferences, lack of commitment of CCLAD group members), community (stigma, gender bias) and health system (frequent drug stockouts, certain implementation challenges, fluctuating implementing partner priorities, shortage of trained health workers and insufficient health education by health workers).ConclusionBased on our findings the CCLAD model is meeting the objectives set out by Differentiated Service Delivery for HIV care and treatment. Notwithstanding the benefits, challenges remain which call on the Ministry of Health and other implementing partners to address these hindrances to facilitate the scalability, sustainability and the realisation of the full-range of benefits that the model presents.

scholarly journals “You Cannot Catch Fish Near the Shore nor Can You Sell Fish Where There Are No Customers”: Rethinking Approaches for Reaching Men With HIV Testing Services in Blantyre Malawi

2021 ◽  
Vol 15 (2) ◽  
pp. 155798832110113
Author(s):  
Alinane Linda Nyondo-Mipando ◽  
Mphatso Kumwenda ◽  
Leticia Chimwemwe Suwedi- Kapesa ◽  
Sangwani Salimu ◽  
Thokozani Kazuma ◽  
...  
Keyword(s):  
Health System ◽  
Hiv Testing ◽  
Hiv Care ◽  
Differentiated Service ◽  
Group Discussions ◽  
Outreach Services ◽  
Care Workers ◽  
Hiv Testing Services ◽  
Depth Interviews ◽  
Testing And Counseling

HIV testing is the entry point to the cascade of services within HIV care. Although Malawi has made positive strides in HIV testing, men are lagging at 65.5% while women are at 81.6%. This study explored the preferences of men on the avenues for HIV testing in Blantyre, Malawi. This was a descriptive qualitative study in the phenomenological tradition in seven public health facilities in Blantyre, Malawi, among men and health-care workers (HCWs). We conducted 20 in-depth interviews and held 14 focus group discussions among 113 men of varying HIV statuses. All our participants were purposively selected, and data were digitally recorded coded and managed through NVivo. Thematic analysis was guided by the differentiated service delivery model. Men reported a preference for formal and informal workplaces such as markets and other casual employment sites; social places like football pitches, bars, churches, and “bawo” spaces; and outreach services in the form of weekend door-to-door, mobile clinics, men-to-men group. The health facility was the least preferred avenue. The key to testing men for HIV is finding them where they are. Areas that can be leveraged in reaching men are outside the routine health system. Scaling up HIV testing among men will require targeting avenues and operations outside of the routine health system and leverage them to reach more men with services. This suggests that HIV testing and counseling (HTC) uptake among men may be increased if the services were provided at informal places.

scholarly journals A mixed-methods evaluation of the uptake of novel differentiated ART delivery models in a national sample of health facilities in Uganda

2021 ◽  
Author(s):  
Henry Zakumumpa ◽  
Kimani Makobu ◽  
Ntawiha Wilbrod ◽  
Everd Maniple
Keyword(s):  
Mixed Methods ◽  
Health System ◽  
Fast Track ◽  
Health Workers ◽  
Drug Distribution ◽  
Health Facilities ◽  
Hiv Care ◽  
Adult Males ◽  
Community Based ◽  
Art Delivery

Abstract INTRODUCTIONSince 2017, Uganda has been implementing differentiated antiretroviral therapy services (DARTS) to improve the quality of HIV care and health-system efficiencies. The Ministry of Health endorsed five models. The community-based models include Community Client-Led Drug Delivery (CCLAD) and Community Drug Distribution Points (CDDPs), with facility-based models being either Fast Track Drug Refill (FTDR), Facility Based Group (FBG) or Facility-Based Individual Management (FBIM). It is unclear what the uptake of DARTS is since roll-out in 2017. We set out to assess the extent of uptake of DARTS models and to describe barriers to uptake of either facility-based or community-based models.METHODSBetween August and December 2019, we conducted a mixed-methods study entailing a cross-sectional health facility survey (n=116) and in-depth interviews (n=18) with ART clinic managers in ten case-study facilities as well as six focus group discussions (56 participants) with patients enrolled in DARTS models. Facilities were selected based on the 10 geographic sub-regions of Uganda. Statistical analyses were performed in STATA (v13) while qualitative data were analyzed by thematic approach. The qualitative arm of our study was dominant.RESULTSMost facilities 63 (57%) commenced implementation of DARTS in 2018. The most implemented facility-based model was Fast Track Drug Refill (FTDR) implemented in 100 (86%) of health facilities. Community Client-Led ART Delivery (CCLAD) was the most popular community model implemented in more than a half of facilities (63/116 or 54%). Community Drug Distribution Points (CDDP) model had the lowest uptake and was implemented in only 33 (24.88%) facilities. Overall, there has been a higher uptake of facility-based models. Barriers to enrollment in community-based models include; HIV-related stigma and a fear of breach of confidentiality of HIV status, low enrollment of adult males in community models. Health-system constraints include insufficient training of health workers in DARTS and inadequate funding to facilities for implementing community-based models.CONCLUSIONTo the best of our knowledge this is the first study reporting national DARTS coverage in Uganda. There is need to devise stigma-reduction interventions to enhance uptake of community models and increased donor and government funding for community models to maximize DARTS potential for achieving health-system efficiencies.

scholarly journals Reducing time to differentiated service delivery for newly diagnosed people living with HIV in Kigali, Rwanda: study protocol for a pilot, unblinded, randomised controlled study

BMJ Open ◽  
2021 ◽  
Vol 11 (4) ◽  
pp. e047443
Author(s):  
Jonathan Ross ◽  
Gad Murenzi ◽  
Sarah Hill ◽  
Eric Remera ◽  
Charles Ingabire ◽  
...  
Keyword(s):  
Service Delivery ◽  
Health Centre ◽  
Albert Einstein College ◽  
Secondary Outcome ◽  
Controlled Study ◽  
People Living With Hiv ◽  
Newly Diagnosed ◽  
Differentiated Service ◽  
Viral Loads ◽  
Living With Hiv

IntroductionCurrent HIV guidelines recommend differentiated service delivery (DSD) models that allow for fewer health centre visits for clinically stable people living with HIV (PLHIV). Newly diagnosed PLHIV may require more intensive care early in their treatment course, yet frequent appointments can be burdensome to patients and health systems. Determining the optimal parameters for defining clinical stability and transitioning to less frequent appointments could decrease patient burden and health system costs. The objectives of this pilot study are to explore the feasibility and acceptability of (1) reducing the time to DSD from 12 to 6 months after antiretroviral therapy (ART) initiation,and (2) reducing the number of suppressed viral loads required to enter DSD from two to one.Methods and analysesThe present study is a pilot, unblinded trial taking place in three health facilities in Kigali, Rwanda. Current Rwandan guidelines require PLHIV to be on ART for ≥12 months with two consecutive suppressed viral loads in order to transition to less frequent appointments. We will randomise 90 participants to one of three arms: entry into DSD at 6 months after one suppressed viral load (n=30), entry into DSD at 6 months after two suppressed viral loads (n=30) or current standard of care (n=30). We will measure feasibility and acceptability of this intervention; clinical outcomes include viral suppression at 12 months (primary outcome) and appointment attendance (secondary outcome).Ethics and disseminationThis clinical trial was approved by the institutional review board of Albert Einstein College of Medicine and by the Rwanda National Ethics Committee. Findings will be disseminated through conferences and peer-reviewed publications, as well as meetings with stakeholders.Trial registration numberNCT04567693.

scholarly journals Access to Complex Abortion Care Service and Planning Improved through a Toll-Free Telephone Resource Line

2014 ◽  
Vol 2014 ◽  
pp. 1-4 ◽  
Author(s):  
Wendy V. Norman ◽  
Barbara Hestrin ◽  
Royce Dueck
Keyword(s):  
Health Care ◽  
British Columbia ◽  
Health Services ◽  
Service Delivery ◽  
Service Providers ◽  
Full Range ◽  
Health Centre ◽  
Access Barriers ◽  
Care Providers ◽  
Abortion Care

Background. Providing equitable access to the full range of reproductive health services over wide geographic areas presents significant challenges to any health system. We present a review of a service provision model which has provided improved access to abortion care; support for complex issues experienced by women seeking nonjudgmental family planning health services; and a mechanism to collect information on access barriers. The toll-free pregnancy options service (POS) of British Columbia Women’s Hospital and Health Centre sought to improve access to services and overcome barriers experienced by women seeking abortion.Methods. We describe the development and implementation of a province-wide toll-free telephone counseling and access facilitation service, including establishment of a provincial network of local abortion service providers in the Canadian province of British Columbia from 1998 to 2010.Results. Over 2000 women annually access service via the POS line, networks of care providers are established and linked to central support, and central program planners receive timely information on new service gaps and access barriers.Conclusion. This novel service has been successful in addressing inequities and access barriers identified as priorities before service establishment. The service provided unanticipated benefits to health care planning and monitoring of provincial health care related service delivery and gaps. This model for low cost health service delivery may realize similar benefits when applied to other health care systems where access and referral barriers exist.

scholarly journals Factors influencing the retention of secondary midwives at health centres in rural areas in Cambodia: the role of gender—a qualitative study

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Kimiko Abe ◽  
Bandeth Ros ◽  
Kimly Chea ◽  
Rathavy Tung ◽  
Suzanne Fustukian
Keyword(s):  
Rural Health ◽  
Rural Areas ◽  
Health Workers ◽  
Gender Norms ◽  
Health Centre ◽  
Influential Factors ◽  
Security Issues ◽  
Factors Influencing ◽  
Health Centres ◽  
Depth Interviews

Abstract Background Retention of skilled midwives is crucial to reducing maternal mortality in rural areas; hence, Cambodia has been trying to retain at least one secondary midwife who can provide basic emergency obstetric care at every health centre even in rural areas. The factors influencing the retention of midwives, but not solely secondary midwives, have been identified; however, the security issues that affected female health workers during the conflict and the post-conflict years and gender issues have been unexplored. This study explores these and other potential factors influencing secondary midwife retention and their significance. Methods Sequential two-stage qualitative interviews explored influential factors and their significance. The first stage comprised semi-structured interviews with 19 key informants concerned with secondary midwife retention and in-depth interviews with eight women who had deliveries at rural health centres. Based on these interview results, in-depth interviews with six secondary midwives who were deployed to a rural health centre were conducted in the second stage. These midwives ranked the factors using a participatory rural appraisal tool. These interviews were coded with the framework approach. Results Living with one’s parents or husband, accommodation and security issues were identified as more significant influential factors for secondary midwife retention than current salary and the physical condition of the health centre. Gender norms were entrenched in these highly influential factors. The deployed secondary midwives who were living apart from one’s parents or spouse requested transfer (end of retention) to health centres closer to home, as other midwives had done. They feared gender-based violence, although violence against them and the women around them was not reported. The health workers surrounding the midwives endorsed the gender norms and the midwives’ responses. The ranking of factors showed similarities to the interview results. Conclusions This study suggests that gender norms increased the significance of issues with deployments to rural areas and security issues as negative factors on female health workforce retention in rural areas in Cambodia. This finding implies that further incorporating gendered perspectives into research and developing and implementing gender-responsive policies are necessary to retain the female health workforce, thereby achieving SDGs 3 and 5.

scholarly journals Leaving No Man Behind: How Differentiated Service Delivery Models Increase Men’s Engagement in HIV Care

2020 ◽  
Author(s):  
Ferdinand C. Mukumbang
Keyword(s):  
Service Delivery ◽  
Critical Realism ◽  
Theory Development ◽  
Perceived Usefulness ◽  
Hiv Care ◽  
Potential Contribution ◽  
Differentiated Service ◽  
Hiv Services ◽  
Service Delivery Models ◽  
Delivery Models

Background: Men demonstrate disproportionately poor uptake and engagement in HIV services with strong evidence linking men’s disinclination to engage in HIV services to their masculinity, necessitating adaptive programming to accommodate HIV-positive men. Differentiated service delivery models (DSDMs) – streamlined patient-centred antiretroviral treatment (ART) delivery services – have demonstrated the potential to improve men’s engagement in HIV services. However, it is unclear how and why these models contribute to men’s reframing of ART-friendly masculinities – a set of attributes, behaviours and roles associated with boys and men that favour the uptake and use of ART. We sought to unveil how and why DSDMs support the formation of ART-friendly masculinities to enhance men’s participation in HIV-related services. Methods: A theory-driven qualitative approach underpinned by critical realism was conducted with 30 adult men using 3 types of DSDMs: facility-based adherence clubs (FACs), community-based adherence clubs (CACs) and quick pharmacy pick-ups (QPUPs). Focus group discussions (FGDs) (6) and in-depth interviews (IDIs) (20) were used to elicit information from purposively selected participants based on their potential contribution to the theory development – theoretical sampling. Recordings were transcribed verbatim in isiXhosa, then translated to English and analysed thematically. Theoretical constructs (themes) related to programme context and generative mechanisms were distilled and linked by retroduction and abductive thinking to formulate explanatory theories. Results: Three bundles of mechanisms driving the adoption of ART-friendly masculinities by men using DSDMs were identified. (1) DSDMs instil a sense of cohesion (social support and feeling of connectedness), which enhances their reputational masculinity – having the know-how and being knowledgeable. (2) DSDMs provide a sense of assurance by providing reliable, convenient, stigma-free services, which makes men feel strong and resilient (respectability identity). (3) Through perceived usefulness, the extent to which an individual believes the model enhances their disease management, DSDMs enhance men’s ability to be economically productive and take care of their family (responsibility identity). Conclusion: DSDMs enhance the refashioning of ART-friendly versions of masculinity, thus improving men’s engagement in HIV services. Their effectiveness in refashioning men’s masculinities to ART friendly masculinities can be improved by ensuring conducive conditions for group interactions and including gender-transformative education to their existing modalities.

scholarly journals Implementation of differentiated service delivery for paediatric HIV care and treatment: opportunities, challenges and experience from seven sub-Saharan African countries

2020 ◽  
Vol 8 (3) ◽  
pp. e000393
Author(s):  
Rebecca Abelman ◽  
Catharina Alons ◽  
Jeni Stockman ◽  
Ivan Teri ◽  
Anna Grimsrud ◽  
...  
Keyword(s):  
Service Delivery ◽  
Children And Adolescents ◽  
Care Delivery ◽  
Hiv Care ◽  
Differentiated Service ◽  
Viral Load Suppression ◽  
African Countries ◽  
Care And Treatment ◽  
Sub Saharan ◽  
Living With Hiv

Differentiated service delivery (DSD) models for HIV often exclude children and adolescents. Given that children and adolescents have lower rates of HIV diagnosis, treatment and viral load suppression, there is a need to use DSD to meet the needs of children and adolescents living with HIV. This commentary reviews the concept of DSD, examines the application of DSD to the care of children and adolescents living with HIV, and describes national guidance on use of DSD for children and adolescents and implementation of DSD for HIV care and treatment in children and adolescents in Elizabeth Glaser Pediatric AIDS Foundation (EGPAF)–supported programmes in seven sub-Saharan countries between 2017 and 2019. Programme descriptions include eligibility criteria, location and frequency of care delivery, healthcare cadre delivering the care, as well as the number of EGPAF-supported facilities supporting each type of DSD model. A range of DSD models were identified. While facility-based models predominate, several countries support community-based models. Despite significant uptake of various DSD models for children and adolescents, there was variable coverage within countries and variability in age criteria for each model. While the recent uptake of DSD models for children and adolescents suggests feasibility, more can be done to optimise and extend the use of DSD models for children and adolescents living with HIV. Barriers to further DSD uptake are described and solutions proposed. DSD models for children and adolescents are a critical tool that can be optimised to improve the quality of HIV care and outcomes for children and adolescents.

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