scholarly journals ‘Oh, she is just a nurse’ Re-imagining the role of the nursing workforce in Uganda after a decade of ART scale-up (2004-2014)

2020 ◽  
Author(s):  
Henry Zakumumpa
Keyword(s):  
Mixed Methods ◽  
Disease Management ◽  
Scale Up ◽  
Task Shifting ◽  
Health Facilities ◽  
Hiv Care ◽  
Scope Of Practice ◽  
Nursing Workforce ◽  
Hiv Disease

Abstract Background The expanding roles and increasing importance of the nursing workforce in health services delivery in resource-limited settings is not adequately documented and sufficiently recognized in the current literature. Drawing upon the theme of 2020 as the international year of the nurse and midwife, we set out to describe how the role of nurses had expanded tremendously in health facilities in Uganda during the era of anti-retroviral therapy (ART) scale-up between 2004 and 2014.Methods A mixed-methods study was conducted in two phases. Phase One entailed a cross-sectional health facility survey (n=195) to assess the extent to which human resource management strategies (such as task shifting) were common. Phase Two entailed qualitative case-studies of 16 (of the 195) health facilities for an in-depth understanding of the strategies adopted (e.g. nurse-centred HIV care). We adopted a qualitatively-led mixed methods approach whereby core thematic analyses were supported by descriptive statistics.Results We found that nurses were the most represented cadre of health workers involved in the overall leadership of HIV clinics across Uganda. Most of nurse-led HIV clinics were based in rural settings although this trend was fairly even across all settings (rural/urban/peri-urban). A number of health facilities in our sample (n=36) deliberately adopted nurse-led HIV care models. Nurses were empowered to be multi-skilled with a wide range of competencies across the HIV care continuum right from HIV testing to mainstream clinical HIV disease management. In several facilities, nursing cadre were the backbone of ART service delivery. A select number of facilities devised differentiated models of task shifting from physicians to doctors to nurses in which the latter handled patients who were stable on ART.Conclusion Overall, our study reveals a wide expansion in the scope-of-practice of nurses during the initial ART scale-up phase in Uganda. Nurses were thrust in roles of HIV disease management that were traditionally the preserve of medical doctors. Our study underscores the importance of reforming regulatory frameworks governing nursing workforce scope of practice in Uganda such as the need for evolving a policy on task shifting which is currently lacking in Uganda.

scholarly journals Reimagining the role of the nursing workforce in Uganda after more than a decade of ART scale-up

2020 ◽  
Author(s):  
Henry Zakumumpa
Keyword(s):  
Disease Management ◽  
Scale Up ◽  
Task Shifting ◽  
Health Facilities ◽  
Hiv Care ◽  
Scope Of Practice ◽  
Nursing Workforce ◽  
Hiv Disease ◽  
Wide Range

Abstract Background The expanding roles and increasing importance of the nursing workforce in health services delivery in resource-limited settings is not adequately documented and sufficiently recognized in the current literature. Drawing upon the theme of 2020 as the international year of the Nurse and Midwife, we set out to describe how the role of nurses expanded tremendously in health facilities in Uganda during the era of anti-retroviral therapy (ART) scale-up that commenced in June 2004.Methods We employed a mixed-methods sequential explanatory research design. Phase One entailed a cross-sectional health facility survey (n=195) to assess the extent to which human resource management strategies (such as task shifting) were common. Phase Two entailed a qualitative multiple case-study of 16 (of the 195) health facilities for an in-depth understanding of the strategies adopted (e.g. nurse-centred HIV care). Descriptive analyses were performed in STATA (v 13) while qualitative data were analyzed by thematic approach.Results We found that nurses were the most represented cadre of health workers involved in the overall leadership of HIV clinics across Uganda. Most nurse-led HIV clinics were based in rural settings however this trend was fairly even across setting (rural/urban/peri-urban). While 181(93%) health facilities allowed non-physician cadre to prescribe ART, a number of health facilities (n=36) or 18% deliberately adopted nurse-led HIV care models. Nurses were empowered to be multi-skilled with a wide range of competencies across the HIV care continuum right from HIV testing to mainstream clinical HIV disease management. In several facilities, nursing cadre were the backbone of ART service delivery. A select number of facilities devised differentiated models of task shifting from physicians to nurses in which the latter handled patients who were stable on ART. Conclusion Overall, our study reveals a wide expansion in the scope-of-practice of nurses during ART scale-up in Uganda. Nurses were thrust in roles of HIV disease management that were traditionally the preserve of physicians. Our study underscores the importance of reforming regulatory frameworks governing nursing workforce scope-of-practice such as the need for developing a policy on task shifting which is currently lacking in Uganda.

scholarly journals Effects of transition on HIV and non-HIV services and health systems in Kenya: a mixed methods evaluation of donor transition

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Daniela C. Rodríguez ◽  
Diwakar Mohan ◽  
Caroline Mackenzie ◽  
Jess Wilhelm ◽  
Ezinne Eze-Ajoku ◽  
...  
Keyword(s):  
Mixed Methods ◽  
Service Delivery ◽  
Health Systems ◽  
Local Level ◽  
Health Facilities ◽  
Government Support ◽  
Hiv Care ◽  
Local Context ◽  
Mixed Methods Evaluation ◽  
The Us

Abstract Background In 2015 the US President’s Emergency Plan for AIDS Relief (PEPFAR) initiated its Geographic Prioritization (GP) process whereby it prioritized high burden areas within countries, with the goal of more rapidly achieving the UNAIDS 90–90-90 targets. In Kenya, PEPFAR designated over 400 health facilities in Northeastern Kenya to be transitioned to government support (known as central support (CS)). Methods We conducted a mixed methods evaluation exploring the effect of GP on health systems, and HIV and non-HIV service delivery in CS facilities. Quantitative data from a facility survey and health service delivery data were gathered and combined with data from two rounds of interviews and focus group discussions (FGDs) conducted at national and sub-national level to document the design and implementation of GP. The survey included 230 health facilities across 10 counties, and 59 interviews and 22 FGDs were conducted with government officials, health facility providers, patients, and civil society. Results We found that PEPFAR moved quickly from announcing the GP to implementation. Despite extensive conversations between the US government and the Government of Kenya, there was little consultation with sub-national actors even though the country had recently undergone a major devolution process. Survey and qualitative data identified a number of effects from GP, including discontinuation of certain services, declines in quality and access to HIV care, loss of training and financial incentives for health workers, and disruption of laboratory testing. Despite these reports, service coverage had not been greatly affected; however, clinician strikes in the post-transition period were potential confounders. Conclusions This study found similar effects to earlier research on transition and provides additional insights about internal country transitions, particularly in decentralized contexts. Aside from a need for longer planning periods and better communication and coordination, we raise concerns about transitions driven by epidemiological criteria without adaptation to the local context and their implication for priority-setting and HIV investments at the local level.

scholarly journals Barriers and facilitators associated with HIV testing uptake in South African health facilities offering HIV Counselling and Testing

2016 ◽  
Vol 21 ◽  
pp. 86-95 ◽  
Author(s):  
Neo Mohlabane ◽  
Bomkazi Tutshana ◽  
Karl Peltzer ◽  
Aziza Mwisongo
Keyword(s):  
Hiv Testing ◽  
South African ◽  
Health Workers ◽  
Scale Up ◽  
Health Facilities ◽  
Barriers And Facilitators ◽  
Hiv Care ◽  
Treatment Needs ◽  
Hiv Test ◽  
Hiv Counselling And Testing

Background: The scale-up of HIV Counselling and Testing (HCT) in South Africa to 4500 public health facilities and the service's provision in mobile and non-medical sites was aimed at increasing HCT uptake. However, some people still have never had an HIV test.Objective: An HCT survey was carried out to ascertain barriers and facilitators for HIV testing in South Africa.Methods: A cross-sectional survey of 67 HCT-offering health facilities in 8 South African provinces was undertaken. Individuals (n = 489) who had not tested for HIV on the day of the site visit were interviewed on awareness of HCT services, HIV testing history and barriers to HIV testing. Frequencies were run to describe the sample characteristics, barriers and facilitators to HIV testing. Bivariate and multivariate logistic regression was usedt o identify the association between never tested for HIV with socio-demographics, awareness of HCT services and type of HCT facilities.Results: In all 18.1% participants never had an HIV test. Major barriers to HCT uptake comprise being scared of finding out one's HIV test result or what people may say, shyness or embarrassment, avoidance of divulging personal information to health workers and fear of death. In multivariate analysis the age group 55 years and older, and not being recommended to have an HIV test were associated with never had an HIV test. Potential facilitators for HIV testing include community or household HIV testing, providing incentives for those who test for HIV, mandatory HIV testing and disclosure of HIV status by those who test HIV positive.Conclusion: The benefits of HCT which include the reduction of HIV transmission, the availability of HIV care and treatment needs to be emphasized to enhance HCT uptake.

scholarly journals Protocol for a mixed-methods exploratory investigation into the role of health information technology for the provision of cancer care in Indonesia

F1000Research ◽  
2020 ◽  
Vol 9 ◽  
pp. 904
Author(s):  
Aufia Espressivo ◽  
Herindita Puspitaningtyas ◽  
Susanna H. Hutajulu ◽  
Anis Fuad ◽  
Matthew J. Allsop
Keyword(s):  
Information Technology ◽  
Information Systems ◽  
Mixed Methods ◽  
Health Information Technology ◽  
Health Information ◽  
Cancer Care ◽  
Health Facilities ◽  
Theory Of Change ◽  
Referral System

Background: Cancer and its management can incur high costs, high risks and high demand. In Indonesia, there remains gap in the availability of national cancer data despite the establishment of a National Committee for Cancer Control. Multiple pilot projects have been developed by the Ministry of Health to improve the delivery of care, including interventions utilising digital health approaches and integrated referral information systems. However, it is not yet clear to what extent these approaches influence patient management or the experience of cancer patients themselves. This research aims to explore the current role of health information technology (HIT) in the provision of services and treatments for patients with cancer from primary to tertiary healthcare centres in Yogyakarta, Indonesia. Methods: The study will adopt an observational mixed-methods single case study design of health facilities involved in the delivery of cancer services in a sub-national health system. We will collect data through face-to-face interviews with a range of health professionals involved in the delivery of cancer care. Patients will be interviewed to share their views and experiences of the existing cancer referral system and communication with health facilities. Alongside interviews, we will undertake an analysis of routine data from participating health facilities to assess gaps in existing information systems. Data analysis will include framework analysis for qualitative data alongside descriptive analyses of quantitative data. Findings will be used to inform conceptual maps to be presented as part of Theory of Change workshops focused on understanding how the existing cancer referral system works, why and for whom, with a focus on future refinement and intervention development.  Conclusion: Our findings will inform critical thinking around the design, implementation, adaptation, and evaluation of existing systems. Through early engagement and participation of key stakeholders and project partners, we intend that findings will have immediate utility.

scholarly journals Applying Human-centered Design to Maximize Acceptability, Feasibility, and Usability of Mobile Technology Supervision in Kenya: A Mixed Methods Pilot Study Protocol

2020 ◽  
Author(s):  
Noah Triplett ◽  
Sean Munson ◽  
Anne Mbwayo ◽  
Teresia Mutavi ◽  
Bryan Weiner ◽  
...  
Keyword(s):  
Mixed Methods ◽  
Mobile Technology ◽  
Qualitative Interviews ◽  
Pilot Trial ◽  
Scale Up ◽  
Task Shifting ◽  
Self Report ◽  
Future Research ◽  
Human Centered Design ◽  
Lay Counselors

Abstract Background: Although research continues to support task-shifting as an effective model of delivering evidence-based practices (EBPs), little scholarship has focused how to scale up and sustain task-shifting in low- and middle-income countries, including how to sustainably supervise lay counselors. Ongoing supervision is critical to ensure EBPs are delivered with fidelity; however, the resources and expertise required to provide ongoing supervision may limit the potential to scale up and sustain task shifting. Opportunities may exist to leverage mobile technology to replace or supplement in-person supervision in low-resource contexts, but contextual variables, such as network connectivity and lay counselor preferences surrounding mobile technology, must be examined and considered when designing and implementing mobile technology supervision.Methods: This study builds from an existing randomized trial in Kenya, wherein teachers and community health volunteers have been trained to provide trauma-focused cognitive behavioral therapy as lay counselors. The study will use an iterative and mixed methods approach, with qualitative interviews and a Human-Centered Design (HCD) workshop informing a non-randomized pilot trial. Semi-structured interviews will be conducted with lay counselors and supervisors to understand how mobile technology is currently being used for supervision and determine the barriers and facilitators to mobile technology supervision. Data from these interviews will inform an HCD workshop, where lay counselors and supervisors “re-design” supervision to most effectively leverage mobile technology. Workshop participants will also participate in focus groups to gather perceptions on the use of HCD techniques. The final outcome of the workshop will be a set of refined workflows, which will be tested in a mixed method, nonrandomized pilot with newly trained lay counselors and existing supervisors. The pilot trial will evaluate the acceptability, feasibility, and usability of mobile technology supervision through self-report questionnaires as well as perceptions of effectiveness through qualitative interviews with a subset of lay counselors and all supervisors.Discussion: This study will provide a launching point for future research on supervision and methods to engage stakeholders to design and tailor interventions and implementation supports to fit low-resourced contexts.

scholarly journals Informing the scale-up of Kenya’s nursing workforce: a mixed methods study of factors affecting pre-service training capacity and production

2014 ◽  
Vol 12 (1) ◽  
Author(s):  
Ashley A Appiagyei ◽  
Rose N Kiriinya ◽  
Jessica M Gross ◽  
David N Wambua ◽  
Elizabeth O Oywer ◽  
...  
Keyword(s):  
Mixed Methods ◽  
Scale Up ◽  
Mixed Methods Study ◽  
Nursing Workforce ◽  
Factors Affecting ◽  
Training Capacity ◽  
Service Training

scholarly journals Improving child tuberculosis contact identification and screening in Lesotho: Results from a mixed-methods cluster-randomized implementation science study

PLoS ONE ◽  
2021 ◽  
Vol 16 (5) ◽  
pp. e0248516
Author(s):  
Yael Hirsch-Moverman ◽  
Andrea A. Howard ◽  
Joanne E. Mantell ◽  
Limakatso Lebelo ◽  
Koen Frederix ◽  
...  
Keyword(s):  
Mixed Methods ◽  
Scale Up ◽  
Healthcare Providers ◽  
Standard Of Care ◽  
Health Facilities ◽  
Community Based ◽  
Childhood Tb ◽  
Quantitative Results ◽  
Cluster Randomized ◽  
Depth Interviews

Background Child tuberculosis (TB) contact management is recommended for preventing TB in children but its implementation is suboptimal in high TB/HIV-burden settings. The PREVENT Study was a mixed-methods, clustered-randomized implementation study that evaluated the effectiveness and acceptability of a community-based intervention (CBI) to improve child TB contact management in Lesotho, a high TB burden country. Methods Ten health facilities were randomized to CBI or standard of care (SOC). CBI holistically addressed the complex provider-, patient-, and caregiver-related barriers to prevention of childhood TB. Routine TB program data were abstracted from TB registers and cards for all adult TB patients aged >18 years registered during the study period, and their child contacts. Primary outcome was yield (number) of child contacts identified and screened per adult TB patient. Generalized linear mixed models tested for differences between study arms. CBI acceptability was assessed via semi-structured in-depth interviews with a purposively selected sample of 20 healthcare providers and 28 caregivers. Qualitative data were used to explain and confirm quantitative results. We used thematic analysis to analyze the data. Results From 01/2017-06/2018, 973 adult TB patients were recorded, 490 at CBI and 483 at SOC health facilities; 64% male, 68% HIV-positive. At CBI and SOC health facilities, 216 and 164 child contacts were identified, respectively (p = 0.16). Screening proportions (94% vs. 62%, p = 0.13) were similar; contact yield per TB case (0.40 vs. 0.20, p = 0.08) was higher at CBI than SOC health facilities, respectively. CBI was acceptable to caregivers and healthcare providers. Conclusion Identification and screening for TB child contacts were similar across study arms but yield was marginally higher at CBI compared with SOC health facilities. CBI scale-up may enhance the ability to reach and engage child TB contacts, contributing to efforts to improve TB prevention among children.

scholarly journals Applying human-centered design to maximize acceptability, feasibility, and usability of mobile technology supervision in Kenya: a mixed methods pilot study protocol

2021 ◽  
Vol 2 (1) ◽  
Author(s):  
Noah S. Triplett ◽  
Sean Munson ◽  
Anne Mbwayo ◽  
Teresia Mutavi ◽  
Bryan J. Weiner ◽  
...  
Keyword(s):  
Mixed Methods ◽  
Mobile Technology ◽  
Qualitative Interviews ◽  
Pilot Trial ◽  
Scale Up ◽  
Task Shifting ◽  
Self Report ◽  
Human Centered Design ◽  
Lay Counselors ◽  
Link Type

Abstract Background Although research continues to support task-shifting as an effective model of delivering evidence-based practices (EBPs), little scholarship has focused how to scale up and sustain task-shifting in low- and middle-income countries, including how to sustainably supervise lay counselors. Ongoing supervision is critical to ensure EBPs are delivered with fidelity; however, the resources and expertise required to provide ongoing supervision may limit the potential to scale up and sustain task shifting. Opportunities may exist to leverage mobile technology to replace or supplement in-person supervision in low-resource contexts, but contextual variables, such as network connectivity and lay counselor preferences surrounding mobile technology, must be examined and considered when designing and implementing mobile technology supervision. Methods This study builds from an existing randomized trial in Kenya, wherein teachers and community health volunteers have been trained to provide trauma-focused cognitive behavioral therapy as lay counselors. The study will use an iterative and mixed methods approach, with qualitative interviews and a Human-Centered Design (HCD) workshop informing a non-randomized pilot trial. Semi-structured interviews will be conducted with lay counselors and supervisors to understand how mobile technology is currently being used for supervision and determine the barriers and facilitators to mobile technology supervision. Data from these interviews will inform an HCD workshop, where lay counselors and supervisors “re-design” supervision to most effectively leverage mobile technology. Workshop participants will also participate in focus groups to gather perceptions on the use of HCD techniques. The final outcome of the workshop will be a set of refined workflows, which will be tested in a mixed method, nonrandomized pilot with newly trained lay counselors and existing supervisors. The pilot trial will evaluate the acceptability, feasibility, and usability of mobile technology supervision through self-report questionnaires as well as perceptions of effectiveness through qualitative interviews with a subset of lay counselors and all supervisors. Discussion This study will provide a launching point for future research on supervision and methods to engage stakeholders to design and tailor interventions and implementation supports to fit low-resourced contexts. Trial registration The parent trial from which this study builds was registered on ClinicalTrials.gov on August 9, 2017 (NCT03243396).

Human Immunodeficiency Virus Hematology

Hematology ◽  
2003 ◽  
Vol 2003 (1) ◽  
pp. 294-313 ◽  
Author(s):  
Paul A. Volberding ◽  
Kelty R. Baker ◽  
Alexandra M. Levine
Keyword(s):  
Human Immunodeficiency Virus ◽  
Hiv Infection ◽  
Hiv Care ◽  
Hiv Disease ◽  
Secondary Infections ◽  
Antiretroviral Drug ◽  
Immunodeficiency Virus ◽  
History Of ◽  
Relationship Of

Abstract The advent of potent antiretroviral therapy has altered the expected natural history of human immunodeficiency virus (HIV) infection and of many previously associated opportunistic complications, including malignancies. At the same time, HIV suppression hasn’t affected all of these complications equally and the longer expected survival of infected patients may allow the development of newer complications. Additionally, the use of potent antiretroviral combination therapy may itself lead to hematological toxicities. Together these changes affect the consultation role of the hematology-oncology specialist in comprehensive HIV care and demand ongoing education. In Section I, Dr. Paul Volberding reviews the biology of antiretroviral drug development and the progression in discovering new agents as the viral life cycle is further elucidated. He briefly summarizes the process of combining agents to achieve the degree of viral suppression required for long-term clinical benefit. In Section II, Dr. Kelty Baker reviews the effects of HIV and its therapy on hematologic dyscrasia and clotting disorders. She summarizes how therapy may decrease certain previously common manifestations of HIV disease while adding new problems likely to result in referral to the hematologist. In addition, she addresses the role of secondary infections, such as parvovirus, in this spectrum of disorders. In Section III, Dr. Alexandra Levine discusses the still challenging aspects of HIV associated non-Hodgkin’s lymphoma and the association between HIV infection and Hodgkin’s disease. She addresses current controversies in the pathogenesis of HIV related lymphomas and summarizes a number of recent trials of combination chemotherapy, with or without monoclonal antibodies, in their management. Additionally, she reviews the complex relationship of HIV disease with multicentric Castleman’s disease and recent attempts to manage this disorder.

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