Level of adherence to treatment guidelines for nimart among TB and HIV patients: a conceptual mode

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.