Patient and health worker perspectives on quality of HIV care and treatment services in Haiti.

BACKGROUND: Poor quality of care is a barrier to engagement in HIV care and treatment in low- and middle-income country settings. This study involved focus group discussions (FGD) with patients and health workers in two large urban hospitals to describe quality of patient education and psychosocial support services within Haiti's national HIV antiretroviral therapy (ART) program. The purpose of this qualitative study was to illuminate key gaps and salient "ingredients" for improving quality of care. METHODS: The study included 8 FGDs with a total of 26 male patients and 32 female patients and 15 smaller FGDs with 57 health workers. The analysis used a directed content analysis method, with the goal of extending existing conceptual frameworks on quality of care through rich description. RESULTS: Dimension of safety, patient-centeredness, accessibility, and equity were most salient. Patients noted risks to privacy with both clinic and community-based services as well as concerns with ART side effects, while health workers described risks to their own safety in providing community-based services. While patients cited examples of positive interactions with health workers that centered their needs and perspectives, they also noted concerns that inhibited trust and satisfaction with services. Health workers described difficult working conditions that challenged their ability to provide patient-centered services. Patients sought favored relationships with health workers to help them navigate the health care system, but this undermined the sense of fairness. Both patients and health workers described frustration with lack of resources to assist patients in dire poverty, and health workers described great pressure to help patients from their "own pockets." CONCLUSIONS: These concerns reflected the embeddedness of patient - provider interactions within a health system marked by scarcity, power dynamics between patients and health workers, and social stigma related to HIV. Reinforcing a respectful and welcoming atmosphere, timely service, privacy protection, and building patient perception of fairness in access to support could help to build patient satisfaction and care engagement in Haiti. Improving working conditions for health workers is also critical to achieving quality.

The Situated Information, Motivation, and Behavioral Skills Model of HIV Antiretroviral Therapy Adherence Among Persons Living With HIV in Haiti: A Qualitative Study Incorporating Culture and Context.

ABSTRACT: To inform a clinic-based adherence-promotion intervention, this qualitative study applied the Situated Information, Motivation, and Behavioral Skills Model of Care Initiation and Maintenance to elucidate cultural and contextual factors affecting antiretroviral therapy adherence in Haiti. From the 23 focus group discussions with patients ( n = 58) and health care workers ( n = 57), culturally specific themes emerged relating to Information (e.g., conflicts with allopathic medicine and heuristics about how treatment failure occurs), Motivation (e.g., protecting family members, health and physical appearance, material advantages, and relationships with health workers), and Behavioral Skills (e.g., managing food intake and side effects, navigating health services utilization, accessing medication, and advocating for care needs). Recommendations include: provide therapeutic education on HIV drug resistance; promote the concept of "undetectable = untransmittable"; develop treatment buddy relationships; invest in training and enforcement of patient privacy, transparency, and fairness in access to services and resources; and provide patient-centered behavioral skills counseling.

Establishing content for a digital educational support group for new adolescent mothers in the Dominican Republic: a user-centered design approach.

BACKGROUND: As digital interventions to improve health become widespread globally, it is critical to include target end-users in their design. This can help ensure interventions are maximally beneficial among intended populations. OBJECTIVES: To generate the content of a digital educational support group, administered through WhatsApp, for new adolescent mothers and establish participants' cellular access and WhatsApp use. PARTICIPANTS: Adolescent mothers with new babies. METHODS: We completed a two-phase user-centered design process. In phase I design sessions, participants discussed their postpartum experiences and completed an activity to elucidate their health and wellbeing information needs. In phase II sessions, participants individually identified which health information topics were important to them, then all topics were prioritized as a group. Phase II participants also completed a brief survey on cell phone access and WhatsApp use. RESULTS: Phase I included 24 participants, 21 of whom completed phase II. Priority health and wellbeing information topics in the postpartum period were identified as: child growth and development, understanding your baby, common childhood illnesses, breastfeeding, childhood nutrition, family planning, and self-care. Of phase II participants, 45% had cellular phone access and none had a data plan. Cellular service was inconsistently obtained with data packages or Wi-Fi. 30% of participants had no experience using WhatsApp. CONCLUSIONS: Participants identified numerous health information needs, which will serve as the content for our planned digital support group and provides valuable insight for health care providers globally. Less than half of participants had consistent cellular phone access, and none had reliable access to cellular service.

Digital Educational Support Groups Administered through WhatsApp Messenger Improve Health-Related Knowledge and Health Behaviors of New Adolescent Mothers in the Dominican Republic: A Multi-Method Study.

BACKGROUND: (1)In limited-resource settings such as the Dominican Republic, many factors contribute to poor health outcomes experienced by adolescent mothers, including insufficient support and/or health knowledge. In response, we designed a digital educational support group, administered through WhatsApp Messenger, for new adolescent mothers. The purpose of this study was to assess if participation in this digital support group could improve health outcomes and health behaviors. METHODS: (2)Participants completed questionnaires with a health literacy screener, demographic items, knowledge questions, the Index of Autonomous Functioning, and five Patient Reported Outcomes Measurement Information System scales before and after the moderator-led intervention. Differences between pre- and post-intervention scores were calculated and perceptions of the intervention were explored through in-depth interviews analyzed with content analysis. Participants' well-baby visit attendance and contraceptive use were compared to that of controls and a national sample. RESULTS: (3)Participants' (N = 58) knowledge scores increased (p < 0.05). Participants were 6.58 times more likely to attend well-baby visits than controls (95% CI: 2.23-19.4) and their contraceptive use was higher than that of the national sample (p < 0.05). Participants indicated the intervention was enjoyable and beneficial. CONCLUSION: (4)This adolescent-centered digital intervention is a promising method to improve health outcomes and health behaviors of young mothers in limited-resource settings.

Patient-Provider Communication and Information, Motivation, and Behavioral Skills in HIV-Positive Adults Initiating Antiretroviral Therapy in Haiti.

While Haiti has scaled up use of antiretroviral therapy (ART), current studies suggest sub-optimal adherence threatens long-term viral suppression in this understudied setting. Patient-provider communication (PPC) and information, motivation, and behavioral skills (IMB) have been implicated in ART adherence globally. However, no studies have examined their relevance in Haiti. The present mixed-methods study utilized cross-sectional survey data from 128 ART-initiating patients at 2 large HIV treatment sites in Haiti, as well as observational data from 12 clinic visits, to document associations between adherence-related PPC and IMB. Multivariate regression analyses suggested that PPC is associated with IMB constructs. At the bivariate level, more effective PPC was associated with higher levels of adherence-related information and motivation, but not behavioral skills. Observational findings indicate infrequent and non-collaborative adherence support. Taken together, findings lay the groundwork for additional research in the area of PPC, IMB, and ART adherence in Haiti.