Strengthening provider-initiated testing and counselling in Zimbabwe by deploying supplemental providers: a time series analysis.

BACKGROUND: Expansion of provider-initiated testing and counselling (PITC) is one strategy to increase accessibility of HIV testing services. Insufficient human resources was identified as a primary barrier to increasing PITC coverage in Zimbabwe. We evaluated if deployment of supplemental PITC providers at public facilities in Zimbabwe was associated with increased numbers of individuals tested and diagnosed with HIV. METHODS: From July 2016 to May 2017, International Training and Education Center for Health (I-TECH) deployed 138 PITC providers to supplement existing ministry healthcare workers offering PITC at 249 facilities. These supplemental providers were assigned to facilities on a weekly basis. Each week, I-TECH providers reported the number of HIV tests and positive diagnoses they performed. Using routine reporting systems, we obtained from each facility the number of clients tested and diagnosed with HIV per month. Including data both before and during the intervention period, and utilizing the weekly variability in placement locations of the supplemental PITC providers, we employed generalized estimating equations to assess if the placement of supplemental PITC providers at a facility was associated with a change in facility outputs. RESULTS: Supplemental PITC providers performed an average of 62 (SD = 52) HIV tests per week and diagnosed 4.4 (SD = 4.9) individuals with HIV per week. However, using facility reports from the same period, we found that each person-week of PITC provider deployment at a facility was associated with an additional 16.7 (95% CI, 12.2-21.1) individuals tested and an additional 0.9 (95% CI, 0.5-1.2) individuals diagnosed with HIV. We also found that staff placement at clinics was associated with a larger increase in HIV testing than staff placement at polyclinics or hospitals (24.0 vs. 9.8; p < 0.001). CONCLUSIONS: This program resulted in increased numbers of individuals tested and diagnosed with HIV. The discrepancy between the average weekly HIV tests conducted by supplemental PITC providers (62) and the increase in facility-level HIV tests associated with one week of PITC provider deployment (16.7) suggests that supplemental PITC providers displaced existing staff who may have been reassigned to fulfil other duties at the facility.

A framework for outcome-level evaluation of in-service training of health care workers.

BACKGROUND: In-service training is a key strategic approach to addressing the severe shortage of health care workers in many countries. However, there is a lack of evidence linking these health care worker trainings to improved health outcomes. In response, the United States President's Emergency Plan for AIDS Relief's Human Resources for Health Technical Working Group initiated a project to develop an outcome-focused training evaluation framework. This paper presents the methods and results of that project. METHODS: A general inductive methodology was used for the conceptualization and development of the framework. Fifteen key informant interviews were conducted to explore contextual factors, perceived needs, barriers and facilitators affecting the evaluation of training outcomes. In addition, a thematic analysis of 70 published articles reporting health care worker training outcomes identified key themes and categories. These were integrated, synthesized and compared to several existing training evaluation models. This formed an overall typology which was used to draft a new framework. Finally, the framework was refined and validated through an iterative process of feedback, pilot testing and revision. RESULTS: The inductive process resulted in identification of themes and categories, as well as relationships among several levels and types of outcomes. The resulting framework includes nine distinct types of outcomes that can be evaluated, which are organized within three nested levels: individual, organizational and health system/population. The outcome types are: (1) individual knowledge, attitudes and skills; (2) individual performance; (3) individual patient health; (4) organizational systems; (5) organizational performance; (6) organizational-level patient health; (7) health systems; (8) population-level performance; and (9) population-level health. The framework also addresses contextual factors which may influence the outcomes of training, as well as the ability of evaluators to determine training outcomes. In addition, a group of user-friendly resources, the Training Evaluation Framework and Tools (TEFT) were created to help evaluators and stakeholders understand and apply the framework. CONCLUSIONS: Feedback from pilot users suggests that using the framework and accompanying tools may support outcome evaluation planning. Further assessment will assist in strengthening guidelines and tools for operationalization.

The rollout of Community ART Refill Groups in Zimbabwe: a qualitative evaluation.

INTRODUCTION: Community ART Refill Groups (CARGs) are an antiretroviral therapy (ART) delivery model where clients voluntarily form into groups, and a group member visits the clinic to collect ART for all group members. In late 2016, Zimbabwe began a nationwide rollout of the CARG model. We conducted a qualitative evaluation to assess the perceived effects of this new national service delivery model. METHODS: In March-June 2018, we visited ten clinics implementing the CARG model across five provinces of Zimbabwe and conducted a focus group discussion with healthcare workers and in-depth interviews with three ART clients per clinic. Clinics had implemented the CARG model for approximately one year. All discussions were audio recorded, transcribed, and translated into English, and thematic coding was performed by two independent analysts. RESULTS: In focus groups, healthcare workers described that CARGs made ART distribution faster and facilitated client tracking in the community. They explained that their reduced workload allowed them to provide better care to those clients who did visit the clinic, and they felt that the CARG model should be sustained in the future. CARG members reported that by decreasing the frequency of clinic visits, CARGs saved them time and money, reducing previous barriers to collecting ART and improving adherence. CARG members also valued the emotional and informational support that they received from other members of their CARG, further improving adherence. Multiple healthcare workers did express concern that CARG members with diseases that begin with minor symptoms, such as tuberculosis, may not seek treatment at the clinic until the disease has progressed. CONCLUSIONS: We found that healthcare workers and clients overwhelmingly perceive CARGs as beneficial. This evaluation demonstrates that the CARG model can be successfully implemented on a national scale. These early results suggest that CARGs may be able to simultaneously improve clinical outcomes and reduce the workload of healthcare workers distributing ART.

Reflective teaching practices: an approach to teaching communication skills in a small-group setting.

Small-group teaching is particularly suited for complex skills such as communication. Existing work has identified the basic elements of small-group teaching, but few descriptions of higher-order teaching practices exist in the medical literature. Thus the authors developed an empirically driven and theoretically grounded model for small-group communication-skills teaching. Between 2002 and 2005, teaching observations were collected over 100 hours of direct contact time between four expert facilitators and 120 medical oncology fellows participating in Oncotalk, a semiannual, four-day retreat focused on end-of-life communication skills. The authors conducted small-group teaching observations, semistructured interviews with faculty participants, video or audio recording with transcript review, and evaluation of results by faculty participants. Teaching skills observed during the retreats included a linked set of reflective, process-oriented teaching practices: identifying a learning edge, proposing and testing hypotheses, and calibrating learner self-assessments. Based on observations and debriefings with facilitators, the authors developed a conceptual model of teaching that illustrates an iterative loop of teaching practices aimed at enhancing learners' engagement and self-efficacy. Through longitudinal, empirical observations, this project identified a set of specific teaching skills for small-group settings with applicability to other clinical teaching settings. This study extends current theory and teaching practice prescriptions by describing specific teaching practices required for effective teaching. These reflective teaching practices, while developed for communication skills training, may be useful for teaching other challenging topics such as ethics and professionalism.

Training tomorrow's global health leaders: applying a transtheoretical model to identify behavior change stages within an intervention for health leadership development.

Training health professionals in leadership and management skills is a key component of health systems strengthening in low-resource settings. The importance of evaluating the effectiveness of these programs has received increased attention over the past several years, although such evaluations continue to pose significant challenges. This article presents evaluation data from the pilot year of the Afya Bora Fellowship, an African-based training program to increase the leadership capacity of health professionals. Firstly, we describe the goals of the Afya Bora Fellowship. Then, we present an adaptation of the transtheoretical model for behavior change called the Health Leadership Development Model, as an analytical lens to identify and describe evidence of individual leadership behavior change among training participants during and shortly after the pilot year of the program. The Health Leadership Development Model includes the following: pre-contemplation (status quo), contemplation (testing and internalizing leadership), preparation - (moving toward leadership), action (leadership in action), and maintenance (effecting organizational change). We used data from surveys, in-depth interviews, journal entries and course evaluations as data points to populate the Health Leadership Development Model. In the short term, fellows demonstrated increased leadership development during and shortly after the intervention and reflected the contemplation, preparation and action stages of the Health Leadership Development Model. However, expanded interventions and/or additional time may be needed to support behavior change toward the maintenance stages. We conclude that the Health Leadership Development Model is useful for informing health leadership training design and evaluation to contribute to sustainable health organizational change.