Implementing nurse-initiated and managed antiretroviral treatment (NIMART) in South Africa: a qualitative process evaluation of the STRETCH trial
Tóm tắt
Task-shifting is promoted widely as a mechanism for expanding antiretroviral treatment (ART) access. However, the evidence for nurse-initiated and managed ART (NIMART) in Africa is limited, and little is known about the key barriers and enablers to implementing NIMART programmes on a large scale. The STRETCH (Streamlining Tasks and Roles to Expand Treatment and Care for HIV) programme was a complex educational and organisational intervention implemented in the Free State Province of South Africa to enable nurses providing primary HIV/AIDS care to expand their roles and include aspects of care and treatment usually provided by physicians. STRETCH used a phased implementation approach and ART treatment guidelines tailored specifically to nurses. The effects of STRETCH on pre-ART mortality, ART provision, and the quality of HIV/ART care were evaluated through a randomised controlled trial. This study was conducted alongside the trial to develop a contextualised understanding of factors affecting the implementation of the programme. This study was a qualitative process evaluation using in-depth interviews and focus group discussions with patients, health workers, health managers, and other key informants as well as observation in clinics. Research questions focused on perceptions of STRETCH, changes in health provider roles, attitudes and patient relationships, and impact of the implementation context on trial outcomes. Data were analysed collaboratively by the research team using thematic analysis. NIMART appears to be highly acceptable among nurses, patients, and physicians. Managers and nurses expressed confidence in their ability to deliver ART successfully. This confidence developed slowly and unevenly, through a phased and well-supported approach that guided nurses through training, re-prescription, and initiation. The research also shows that NIMART changes the working and referral relationships between health staff, demands significant training and support, and faces workload and capacity constraints, and logistical and infrastructural challenges. Large-scale NIMART appears to be feasible and acceptable in the primary level public sector health services in South Africa. Successful implementation requires a comprehensive approach with: an incremental and well supported approach to implementation; clinical guidelines tailored to nurses; and significant health services reorganisation to accommodate the knock-on effects of shifts in practice. ISRCTN46836853
Tài liệu tham khảo
Callaghan M, Ford N, Schneider H: A systematic review of task- shifting for HIV treatment and care in Africa. Hum Resour Health. 2010, 8: 8-10.1186/1478-4491-8-8.
World Health Organization: Treat train retain. Task Shifting: Global Recommendations and Guidelines. 2007, WHO, Geneva,http://www.who.int/healthsystems/task_shifting/en/,
Zachariah R, Ford N, Philips M, Lynch S, Massaquoi M, Janssens V, Harries AD: Task shifting in HIV/AIDS: opportunities, challenges and proposed actions for sub-Saharan Africa. Trans R Soc Trop Med Hyg. 2009, 103: 549-558. 10.1016/j.trstmh.2008.09.019.
Morris MB, Chapula BT, Chi BH, Mwango A, Chi HF, Mwanza J, Manda H, Bolton C, Pankratz DS, Stringer JS, Reid SE: Use of task-shifting to rapidly scale-up HIV treatment services: experiences from Lusaka, Zambia. BMC Health Serv Res. 2009, 9: 5-10.1186/1472-6963-9-5.
World Health Organization: Health worker shortages and the response to HIV/AIDS. 2006, WHO, Geneva,http://www.who.int/hiv/toronto2006/TTR2_eng.pdf,
Bolton-Moore C, Mubiana-Mbewe M, Cantrell RA, Chintu N, Stringer EM, Chi BH, Sinkala M, Kankasa C, Wilson CM, Wilfert CM: Clinical outcomes and CD4 cell response in children receiving antiretroviral therapy at primary health care facilities in Zambia. JAMA. 2007, 298: 1888-1899. 10.1001/jama.298.16.1888.
Colvin CJ, Fairall L, Lewin S, Georgeu D, Zwarenstein M, Bachmann MO, Uebel KE, Bateman ED: Expanding access to ART in South Africa: the role of nurse-initiated treatment. S Afr Med J. 2010, 100: 210-212.
Fairall L, Zwarenstein M, Bateman E, Bachman M, Lombard C, Majara B, Joubert G, English R, Bheekie A, van Rensburg D: Effect of educational outreach to nurses on tuberculosis case detection and primary care of respiratory illness: pragmatic cluster randomised controlled trial. BMJ. 2005, 331: 750-754. 10.1136/bmj.331.7519.750.
Bheekie A, Buskens I, Allen S, English R, Mayers P, Fairall L, Majara B, Bateman E, Zwarenstein M, Bachman M: The practical approach to lung health in South Africa (PALSA) intervention:respiratory guideline implementation for nurse trainers. Int Nurs Rev. 2006, 53: 261-268. 10.1111/j.1466-7657.2006.00520.x.
English R, Bateman E, Zwarenstein M, Fairall L, Bheekie A, Bachman M, Majara B, Ottmani S, Scherpbier R: Development of a South African integrated syndromic respiratory disease guideline for primary care. Prim Care Respir J. 2008, 17 (3): 156-163. 10.3132/pcrj.2008.00044.
Stein J, Lewin S, Fairall L, Mayers P, English R, Bheekie A, Bateman E, Zwarenstein M: Building capacity for antiretroviral delivery in South Africa: a qualitative evaluation of the PALSA PLUS nurse training programme. BMC Heal Serv Res. 2008, 8: 240-10.1186/1472-6963-8-240.
Bachmann MO, Fairall LR, Lombard C, Timmerman V, van der Merwe S, Bateman ED, Zwarenstein M: Effect on tuberculosis outcomes of educational outreach to South African clinics during two randomised trials. Int J Tuber Lung Dis. 2010, 14: 311-317.
Zwarenstein M, Fairall LR, Lombard C, Mayers P, Bheekie A, English RG, Lewin S, Bachmann MO, Bateman E: Outreach education for integration of HIV/AIDS care, antiretroviral treatment, and tuberculosis care in primary care clinics in South Africa: PALSA PLUS pragmatic cluster randomised trial. BMJ. 2011, 342: d2022-10.1136/bmj.d2022.
Fairall LR, Bachmann MO, Louwagie GM, van Vuuren C, Chikobvu P, Steyn D, Staniland GH, Timmerman V, Msimanga M, Seebregts CJ: Effectiveness of antiretroviral treatment in a South African program: a cohort study. Arch Intern Med. 2008, 168: 86-93. 10.1001/archinternmed.2007.10.
Fairall LR, Bachmann MO, Zwarenstein MF, Lombard CJ, Uebel K, van Vuuren C, Steyn D, Boulle A, Bateman ED: Streamlining tasks and roles to expand treatment and care for HIV: randomised controlled trial protocol. Trials. 2008, 9: 21-10.1186/1745-6215-9-21.
Fairall L, Bachmann MO, Lombard C, Timmerman V, Uebel K, Zwarenstein M, Boulle A, Georgeu D, Colvin CJ, Lewin S: Effectiveness of task-shifting antiretroviral treatment from doctors to primary care nurses in South Africa (STRETCH): pragmatic cluster randomised trial. Lancet. in press
Uebel K, Fairall L, Rensburg D, Mollentze W, Bachmann MO, Lewin S, Zwarenstein M, Colvin CJ, Georgeu D, Mayers P: Task shifting and integration of HIV care into primary care in South Africa: the development and content of the streamlining tasks and roles to expand treatment and care for HIV (STRETCH) intervention. Implement Sci. 2011, 6: 86-97. 10.1186/1748-5908-6-86.
Grimshaw JM, Zwarenstein M, Tetroe JM, Godin G, Graham ID, Lemyre L, Eccles MP, Johnston M, Francis JJ, Hux J: Looking inside the black box: a theory-based process evaluation alongside a randomised controlled trial of printed educational materials (the Ontario printed educational message, OPEM) to improve referral and prescribing practices in primary care in Ontario, Canada. Implement Sci. 2007, 2: 38-10.1186/1748-5908-2-38.
Green J, Thorogood N: Qualitative methods for health research. 2009, Sage, Los Angeles, 2
Silverman D: Interpreting qualitative data : methods for analyzing talk, text, and interaction. 2006, SAGE Publications, London, 3
Marshall C, Rossman GB: Designing qualitative research. 2006, Sage Publications, Thousands Oaks, 4
Patton MQ: Qualitative research and evaluation methods. 2002, Sage Publications, Thousand Oaks, 3
Lewin S, Dick J, Zwarenstein M, Lombard CJ: Staff training and ambulatory tuberculosis treatment outcomes: a cluster randomised controlled trial in South Africa. Bull World Health Organ. 2005, 83: 250-259.
Stein J, Lewin S, Fairall L: Hope is the pillar of the universe: health-care providers’ experiences of delivering anti-retroviral therapy in primary health-care clinics in the Free State province of South Africa. Soc Sci Med. 2007, 64: 954-964. 10.1016/j.socscimed.2006.10.028.
Lehmann U, Van Damme W, Barten F, Sanders D: Task shifting: the answer to the human resources crisis in Africa?. Hum Resour Health. 2009, 7: 49-10.1186/1478-4491-7-49.
Travis P, Bennett S, Haines A, Pang T, Bhutta Z, Hyder AA, Pielemeier NR, Mills A, Evans T: Overcoming health-systems constraints to achieve the Millennium Development Goals. Lancet. 2004, 364: 900-906. 10.1016/S0140-6736(04)16987-0.
Sprague C, Chersich MF, Black V: Health system weaknesses constrain access to PMTCT and maternal HIV services in South Africa: a qualitative enquiry. AIDS Res Ther. 2011, 8: 10-10.1186/1742-6405-8-10.
Schneider H, Coetzee D, Van Rensburg D, Gilson L: Differences in antiretroviral scale-up in three South African provinces: the role of implementation management. BMC Health Serv Res. 2010, 10 Suppl 1: S4-
Stetler CB, Legro MW, Rycroft-Malone J, Bowman C, Curran G, Guihan M, Hagedorn H, Pineros S, Wallace CM: Role of “external facilitation” in implementation of research findings: a qualitative evaluation of facilitation experiences in the Veterans Health Administration. Implement Sci. 2006, 1: 23-10.1186/1748-5908-1-23.
Lewin S, Green J: Ritual and the organisation of care in primary care clinics in Cape Town, South Africa. Soc Sci Med. 2009, 68: 1464-1471. 10.1016/j.socscimed.2009.02.013.
May C, Finch T, Mair F, Ballini L, Dowrick C, Eccles M, Gask L, MacFarlane A, Murray E, Rapley T: Understanding the implementation of complex interventions in health care: the normalization process model. BMC Health Serv Res. 2007, 7: 148-10.1186/1472-6963-7-148.
Sanne I, Orrell C, Fox MP, Conradie F, Ive P, Zeinecker J, Cornell M, Heiberg C, Ingram C, Panchia R: Nurse versus doctor management of HIV-infected patients receiving antiretroviral therapy (CIPRA-SA): a randomised non-inferiority trial. Lancet. 2010, 376: 33-40. 10.1016/S0140-6736(10)60894-X.
Rycroft-Malone J, Fontenla M, Bick D, Seers K: Protocol-based care: impact on roles and service delivery*. J Eval Clin Pract. 2008, 14: 867-873. 10.1111/j.1365-2753.2008.01015.x.
Bosch-Capblanch X, Liaqat S, Garner P: Managerial supervision to improve primary health care in low- and middle-income countries. Cochrane Database Syst Rev. 2011, CD006413-9
Ilott I, Booth A, Rick J, Patterson M: How do nurses, midwives and health visitors contribute to protocol-based care? a synthesis of the UK literature. Int J Nurs Stud. 2010, 47: 770-780. 10.1016/j.ijnurstu.2009.12.023.