2017年-世界发展银行全球_Evaluation_of_the_National_Adherence_Guidelines_for_Chronic_Diseases_in_South_Africa___Patient_Perspectives_on_Differentiated_Care_Models_2017_85页_4mb

Summary of Evaluation of the National Adherence Guidelines for Chronic Diseases in South Africa: Patient Perspectives on Differentiated Care Models

Core Content

This report evaluates the National Adherence Guidelines (AGL) for chronic diseases in South Africa, with a focus on HIV treatment adherence. It is based on a cluster-randomized mixed methods study involving 24 health facilities across four provinces (12 intervention and 12 control sites). The AGL promotes a differentiated care model that simplifies and adapts services to reduce the burden on the health system while improving patient outcomes.

The study examined five key interventions within the AGL:

• Fast Track Initiation Counselling (FTIC)
• Decentralized Medication Delivery (DMD)
• Adherence Clubs (AC)
• Early Tracing of Missed Appointments (TRIC)
• Enhanced Adherence Counselling (EAC)

Patient perspectives were collected through 631 surveys and 24 focus group discussions (FGDs) with 156 participants. The data were used to answer four key evaluation questions regarding patient satisfaction, barriers and facilitators of adherence, strengths and weaknesses of interventions, and additional strategies for adherence improvement.

Main Findings

1. Patient Satisfaction with Care

• Patients in intervention sites generally reported higher satisfaction with care compared to control sites.
• Adherence clubs (AC) and decentralized medication delivery (DMD) were particularly well-received.
• Patients in ACs and DMD experienced greater convenience, time savings, and improved quality of care.

2. Barriers and Facilitators of ART Initiation and Adherence

• Barriers included:
  • Food insecurity
  • Medication side effects
  • Long waiting times
  • Travel time to clinics
  • Poor staff attitudes and support
  • Fear of accidental disclosure
• Facilitators included:
  • Use of reminders (e.g., cell phones)
  • Disclosure of HIV status to supportive individuals
  • Social support from community health workers and groups

3. Strengths and Weaknesses of Interventions

• Adherence Clubs (AC):
  • Strengths: Increased patient support, improved adherence, and better communication.
  • Weaknesses: Limited awareness among some patients, and challenges in maintaining consistent participation.
• Decentralized Medication Delivery (DMD):
  • Strengths: Convenience, time savings, and reduced clinic congestion.
  • Weaknesses: Issues with scripting and staffing at DMD pick-up points.
• Fast Track Initiation Counselling (FTIC):
  • Strengths: Additional support after initiation, which improved adherence.
  • Weaknesses: Poor staff attitude and service during initiation could undermine effectiveness.
• Early Tracing (TRIC):
  • Strengths: Beneficial for retention in care.
  • Weaknesses: Some patients were unaware of being traced, especially after early missed appointments.
• Enhanced Adherence Counselling (EAC):
  • Strengths: Provided personalized support and motivation.
  • Weaknesses: Risk of chastising patients for non-adherence, which can demotivate them.

4. Additional Strategies for Adherence Improvement

• Patients suggested:
  • Increased support from community health workers.
  • Blood draws at ACs or DMD pick-up points.
  • Additional training for counsellors to ensure effective communication and support.
  • Improved data collection systems to ensure accurate tracking of patient outcomes and tracing activities.

Key Messages and Recommendations

• Clinic readiness is essential before implementing the AGL, including addressing staff attitudes, resource allocation, and organizational support.
• Post-initiation counselling is critical for patient adherence and should be tailored to individual needs.
• Adherence clubs and DMD should be implemented together to maximize benefits and ensure patient choice.
• Standardized registers for patient tracing are needed to improve retention and monitoring.
• Staff training and orientation are vital for successful implementation and improved patient perception of care quality.

Conclusion

The National Adherence Guidelines have the potential to improve ART initiation and adherence through differentiated care models. However, their success depends on effective implementation, staff engagement, and patient-centered approaches. The study highlights the importance of triangulating qualitative and quantitative data to better understand the impact and acceptability of each intervention, and to inform future scaling and refinement of the AGL in South Africa.