National Evaluation of HIV Service Resource Allocation in Tanzania.

Using time-driven activity-based costing (TDABC), we examined resource allocation and costs for HIV services throughout Tanzania at patient and facility levels. This national, cross-sectional analysis of 22 health facilities quantified costs and resources associated with 886 patients receiving care for five HIV services: antiretroviral therapy, prevention of mother-to-child transmission, HIV testing and counseling, voluntary medical male circumcision, and pre-exposure prophylaxis. We also documented total provider-patient interaction time, the cost of services with and without inclusion of consumables, and conducted fixed-effects multivariable regression analyses to examine patient- and facility-level correlates of costs and provider-patient time. Findings showed that resources and costs for HIV care varied significantly throughout Tanzania, including as a function of patient- and facility-level characteristics. While some variation may be preferable (e.g., needier patients received more resources), other areas suggested a lack of equity (e.g., wealthier patients received more provider time) and presented opportunities to optimize care delivery protocols.

A consultation with feedback approach to supporting fidelity to a peer-delivered intervention for posttraumatic stress disorder.

Background: Despite promising findings regarding the safety, fidelity, and effectiveness of peer-delivered behavioral health programs, there are training-related challenges to the integration of peers on health care teams. Specifically, there is a need to understand the elements of training and consultation that may be unique to peer-delivered interventions. Methods: As part of a pilot effectiveness-implementation study of an abbreviated version of Skills Training in Affective and Interpersonal Regulation (STAIR) for posttraumatic stress disorder (PTSD), we conducted a mixed-methods process evaluation utilizing multiple data sources (questionnaires and field notes) to characterize our approach to consultation and explore relations between fidelity, treatment outcome, and client satisfaction. Results: Peer interventionists exhibited high fidelity, defined by adherence (M = 93.7%, SD = 12.3%) and competence (M = 3.7 "competent," SD = 0.5). Adherence, ß = .69, t(1) = 3.69, p < .01, and competence, ß = .585, t(1) = 2.88, p < .05, were each associated with trial participant's satisfaction, but not associated with clinical outcomes. Our synthesis of fidelity-monitoring data and consultation field notes suggests that peer interventionists possess strengths in interpersonal effectiveness, such as rapport building, empathy, and appropriate self-disclosure. Peer interventionists evidenced minor challenges with key features of directive approaches, such as pacing, time efficiency, and providing strong theoretical rationale for homework and tracking. Conclusion: Due to promise of peers in expanding the behavioral health workforce and engaging individuals otherwise missed by the medical model, the current study aimed to characterize unique aspects of training and consultation. We found peer interventionists demonstrated high fidelity, supported through dynamic training and consultation with feedback. Research is needed to examine the impact of consultation approach on implementation and treatment outcomes. Plain Language Summary: Peers-paraprofessionals who use their lived experiences to engage and support the populations they serve-have been increasingly integrated into health care settings in the United States. Training peers to deliver interventions may provide cost savings by way of improving efficient utilization of professional services. Despite promising findings in regard to safety, intervention fidelity, and effectiveness of peer delivery, there are important challenges that need to be addressed if peers are to be more broadly integrated into the health care system as interventionists. These include challenges associated with highly variable training, inadequate supervision, and poor delineation of peer's roles within the broader spectrum of care. Thus, there is a need to understand the unique components of training and consultation for peers. We report key findings from an evaluation of a pilot study of an abbreviated version of Skills Training in Affective and Interpersonal Regulation (STAIR) for posttraumatic stress disorder (PTSD), adapted for peer delivery. We characterize our approach to consultation with feedback and explore relations between fidelity, treatment outcome, and client satisfaction. Our study extends the small yet growing literature on training and consultation approaches to support fidelity (adherence and competence) among peer interventionists. Organizations hoping to integrate peers on health care teams could utilize our fidelity-monitoring approach to set benchmarks to ensure peer-delivered interventions are safe and effective.

Peer delivery of a brief cognitive-behavioral treatment for posttraumatic stress disorder: A hybrid effectiveness-implementation pilot study.

OBJECTIVE: Posttraumatic stress disorder (PTSD) treatment delivery by peer specialist providers could increase access to and engagement with PTSD treatment in low resource settings. The current pilot study tested the feasibility, acceptability, and initial effectiveness of a peer-delivered, brief cognitive-behavioral therapy for PTSD. METHOD: Four certified peer specialists delivered the intervention to 18 participants with probable PTSD. We assessed PTSD symptoms weekly and administered surveys and interviews at baseline and posttreatment. RESULTS: Our mixed-methods approach suggests that the intervention was feasible and acceptable, demonstrating high client satisfaction. We also found significant improvements in PTSD, depressive, anxiety, and general stress symptoms. CONCLUSIONS: Peer-delivered interventions may be a good fit for addressing posttraumatic stress symptoms for people accessing care in low resource settings. Future research should evaluate peer-delivered PTSD treatment as a strategy for both reducing symptoms and improving access and engagement in professional care.