Level of adherence to treatment guidelines for nimart among TB and HIV patients: a conceptual mode
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Makhado, Lufuno
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Abstract
Tuberculosis (TB) is the leading cause of death among people living with human
immunodeficiency virus (HIV). At least one in four deaths among people living with
HIV & AIDS (PLWH) can be attributed to TB, and many of these deaths occur in
resource-limited settings. Although policies, strategies and treatment guidelines are
in place, the epidemic of HIV associated TB continues to grow, particularly in South
Africa. HIV is a key driver of the global rise in TB cases through accelerated
progression of TB and great risk of reactivation. Adherence to treatment guidelines
have been shown to improve patient outcomes. Adherence to treatment guidelines
in nurse-led interventions had been found to be moderate to better. The
improvement of care for TB & HIV co-infected patients depends on the proper
adherence to treatment guidelines.
Guidelines had been changing to meet the needs of patients and the health care
system. Furthermore, South Africa's health system is pre-dominated by nurses and
TB & HIV integrated interventions rely on nurses initiating and managing
antiretroviral (ARV) and TB treatment. However, there is little or no evidence of
adherence and compliance to TB & HIV co-infection treatment guidelines among
nurses providing care, treatment and support to HIV-infected TB patients outside of
research protocols. The purpose of this study was to evaluate nurses initiating and
managing ART (NIMART) adherence to treatment guidelines and to explore factors
influencing adherence to treatment guidelines in order to conceptualise the finding
into a conceptual model of treatment guidelines adherence.
An explanatory sequential mixed method design was used in this study and
comprised two phases. Phase 1 used a descriptive cross-sectional study to describe
the level of adherence to treatment guidelines among Primary Health
Care/Community Health Centres (PHC/CHC) with nurses initiating and managing
ART/TB treatment. Six hundred and eighty eight (688) patient medical records were
randomly sampled from 16 randomly selected PHC/CHC facilities in Ugu district in
Kwazulu-Natal Province (KZN) and Ngaka Modiri Molema district in North-West
Province (NWP). A structured data abstraction tool was used as an instrument to
collect data. The Statistical Packages for Socia! Sciences (SPSS; version 20) computer
software was used for data analysis. Adherence to treatment by nurses was crosstabulated
against demographic characteristics to detect possible patterns and
variations. The means and standard variations of all continuous variables were
calculated. Result presentations include frequency tables generated by SPSS. The
differences in means of scales and variables across demographic characteristics were
compared through a t-test. Multiple linear regression analysis was done to establish
the predictors of measures of adherence to treatment guidelines using the backward
methods. Correlation was done to establish relationships between measures of
adherence to treatment guidelines and patient treatment outcomes.
Phase 2 used an exploratory-descriptive study to explore and describe the
anticipated facilitators and challenges for adherence to treatment guidelines among
nurses initiating and managing ART and TB treatment through focus group
interviews. An interview guide was used to ensure focus during the interview.
Demographic variables were analysed from the focus group demographic data sheet.
The aim was to identify the themes suggested by participants. Transcripts were
reviewed to identify themes, sub-themes and categories. Axial coding was then
performed. By this process, the emerging themes from data were further delineated
along their respective properties and dimensions, and sub-categories generated. The
researchers used a two-axis grid, with the focus groups comprising one axis and the
key content areas comprising the second axis, and reviewed these categories and
sub-categories. Statements were compared within and across sessions for
consistency.
The results revealed a significant difference between the two provinces with regard
to the level of adherence to treatment guidelines with NWP having about 91%
moderate and 9% high adherence to evaluations done at diagnosis or before
initiation of treatment as compared to about 74% moderate and 14% high in KZN.
About 73% of patient records in KZN had highly adhered to the treatment guidelines
with regard to evaluations done on Initiation of ART with NWP having only about
35% of high adherence to treatment guidelines, hence there was a marked statistical
difference between the two provinces (p<0.001). There was a marked moderate to
high level of adherence to treatment guidelines to evaluations done at ART initiation.
A low level of adherence was revealed by this study as the majority of patients files
were not monitored for CD4 cell counts and viral load in both KZN (71.2%) and NWP
(88.5%), respectively. However there was a significant difference between the two
provinces at p<O.OOl.
There was no significant relationship between patient treatment outcome and
adherence to treatment guidelines with regard to TB diagnosis (r=0.035; p=0.867)
and TB regimen (r=0.145; p=0.498). A moderate significant negative association
between patient treatment outcome and TB monitoring was found (r=0.449;
p=0.24).
Two themes emerged from the focus group interviews as barriers and facilitators of
adherence to treatment guidelines. Barriers were inclusive of factors related to
negative attitude towards the treatment guidelines, knowledge/awareness and
behaviour and facilitators comprised of the following sub-themes, namely, attitude,
knowledge/awareness and behavioural change.
For adherence to treatment guidelines to improve, a number of factors should be
considered and implemented thus -the guidelines recommendations, organisational
and patient factors as well as support, supervision and mentorship towards the
NIMART nurses. NIMART nurses should be supported and supervised in their
initiation and management of ART roles in order for them to be competent and
confident about quality TB & HIV service provision. Continuous professional
development (CPO) in the TB & HIV area should also be promoted as NIMART need
constant supervision by physicians and pharmacists and continuous updating and
orientation to new drugs, practice and knowledge.
Description
PhD (Nursing), North-West University, Mafikeng Campus, 2014