Evaluating the effectiveness of patient education and empowerment to improve patient-provider interactions in antiretroviral therapy clinics in Namibia.

In order to increase patient active engagement during patient-provider interactions, we developed and implemented patient training sessions in four antiretroviral therapy (ART) clinics in Namibia using a "Patient Empowerment" training curriculum. We examined the impact of these trainings on patient-provider interactions after the intervention. We tested the effectiveness of the intervention using a randomized parallel group design, with half of the 589 enrolled patients randomly assigned to receive the training immediately and the remaining randomized to receive the training 6 months later. The effects of the training on patient engagement during medical consultations were measured at each clinic visit for at least 8 months of follow-up. Each consultation was audiotaped and then coded using the Roter Interaction Analysis System (RIAS). RIAS outcomes were compared between study groups at 6 months. Using intention-to-treat analysis, consultations in the intervention group had significantly higher RIAS scores in doctor facilitation and patient activation (adjusted difference in score 1.19, p = .004), doctor information gathering (adjusted difference in score 2.96, p = .000), patient question asking (adjusted difference in score .48, p = .012), and patient positive affect (adjusted difference in score 2.08, p = .002). Other measures were higher in the intervention group but did not reach statistical significance. We have evidence that increased engagement of patients in clinical consultation can be achieved via a targeted training program, although outcome data were not available on all patients. The patient training program was successfully integrated into ART clinics so that the trainings complemented other services being provided.

Pediatric HIV Disclosure Intervention Improves Knowledge and Clinical Outcomes in HIV-Infected Children in Namibia.

OBJECTIVES: Using routinely collected data, we evaluated a nationally implemented intervention to assist health care workers and caregivers with HIV disclosure to children. We assessed the impact of the intervention on child's knowledge and health outcomes. METHODS: Data were abstracted from national databases and patient charts for HIV-infected children aged 7-15 years attending 4 high-volume HIV clinics in Namibia. Disclosure rates, time to disclosure, and HIV knowledge in 314 children participating in the intervention were analyzed. Logistic regression was used to identify correlates of partial vs. full disclosure. Paired t-tests and McNemar tests were used to compare adherence and viral load (VL) before versus after intervention enrollment. RESULTS: Among children who participated in the disclosure intervention, 11% knew their HIV status at enrollment and an additional 38% reached full disclosure after enrollment. The average time to full disclosure was 2.5 years (interquartile range: 1.2-3 years). Children who achieved full disclosure were more likely to be older, have lower VLs, and have been enrolled in the intervention longer. Among children who reported incorrect knowledge regarding why they take their medicine, 83% showed improved knowledge after the intervention, defined as knowledge of HIV status or adopting intervention-specific language. On comparing 0-12 months before vs. 12-24 months after enrollment in the intervention, VL decreased by 0.5 log10 copies per milliliter (N = 42, P = 0.004), whereas mean adherence scores increased by 10% (N = 88, P value < 0.001). CONCLUSIONS: This HIV disclosure intervention demonstrated improved viral suppression, adherence, and HIV knowledge and should be considered for translation to other settings.

"We Are Now Free to Speak": Qualitative Evaluation of an Education and Empowerment Training for HIV Patients in Namibia.

Although numerous studies provide evidence that active patient engagement with health care providers improves critical outcomes such as medication adherence, very few of these have been done in low resource settings. In Namibia, patient education and empowerment trainings were conducted in four antiretroviral (ART) clinics to increase patient engagement during patient-provider interactions. This qualitative study supplements findings from a randomized controlled trial, by analyzing data from 10 in-depth patient interviews and 94 training evaluation forms. A blended approach of deductive and inductive coding was used to understand training impact. Findings indicated the trainings increased patients' self-efficacy through a combination of improved HIV-related knowledge, greater communication skills and enhanced ability to overcome complex psychosocial barriers, such as fear of speaking up to providers. This study suggests patient empowerment training may be a powerful method to engage HIV patients in their own care and treatment.