Moshabela Mosa, Schneider Helen, Cleary Susan M, Pronyk Paul M, Eyles John
a University of the Witwatersrand, School of Public Health , 7 York Road, Parktown , 2193 , Johannesburg.
Afr J AIDS Res. 2011 Dec;10(4):393-401. doi: 10.2989/16085906.2011.646654.
We conducted an evaluation of healthcare accessibility among patients taking antiretroviral treatment (ART) after they were 'down-referred' from hospital-based programmes to primary healthcare (PHC) centres in a rural South African setting. A cross-sectional design was used to study 109 PHC users compared to a randomly selected control group of 220 hospital-based users. Both groups were matched for a minimum duration on ART of six months. Using a comprehensive healthcare-accessibility framework, the participants were asked about availability, affordability and acceptability of their ART care in structured exit interviews that were linked to their ART-clinic record reviews. Unadjusted and adjusted regression models were used. Down-referral was associated with reduced transportation and meal costs (p = 0.001) and travel time to an ART facility (p =0.043). The down-referred users were less likely to complain of long queues (adjusted odds ratio [AOR] 0.06; 95% confidence interval [95% CI]: 0.01-0.29), were more likely to feel respected by health providers (AOR 4.43; 95% CI: 1.07-18.02), perceived lower stigma (AOR 0.25; 95% CI: 0.07-0.91), and showed a higher level of ART adherence (AOR 8.71; 95% CI: 1.16-65.22) than the hospital-based users. However, the down-referred users preferred to consult with doctors rather than nurses (AOR 3.43; 95% CI: 1.22-9.55) and they were more likely to visit private physicians (AOR 7.09; 95% CI: 3.86-13.04) and practice self-care (AOR 4.91; 95% CI: 2.37-10.17), resulting in increased health-related expenditure (p = 0.001). Therefore, the results indicate both gains and losses in ART care for the patients, and suggest that down-referred patients save time and money, feel more respected, perceive lower stigma and show better adherence levels. However, unintended consequences include increased costs of using private physicians and self-care, highlighting the need to further promote the potential gains of down-referral interventions in resource-poor settings.
我们对南非农村地区接受抗逆转录病毒治疗（ART）的患者从医院项目“下转”至初级卫生保健（PHC）中心后的医疗可及性进行了评估。采用横断面设计，研究了109名初级卫生保健使用者，并与随机选取的220名医院使用者对照组进行比较。两组患者接受抗逆转录病毒治疗的最短时长均为6个月。使用一个全面的医疗可及性框架，在与他们的抗逆转录病毒治疗诊所记录审查相关联的结构化退出访谈中，询问参与者其抗逆转录病毒治疗护理的可及性、可负担性和可接受性。使用了未调整和调整后的回归模型。下转与交通和餐饮成本降低（p = 0.001）以及前往抗逆转录病毒治疗机构的出行时间缩短（p = 0.043）相关。下转的使用者抱怨长队的可能性较小（调整后的优势比[AOR]为0.06；95%置信区间[95%CI]：0.01 - 0.29），更有可能感到受到医疗服务提供者的尊重（AOR 4.43；95%CI：1.07 - 18.02），感受到的耻辱感较低（AOR 0.25；95%CI：0.07 - 0.91），并且与医院使用者相比，表现出更高水平的抗逆转录病毒治疗依从性（AOR 8.71；95%CI：1.16 - 65.22）。然而，下转的使用者更倾向于咨询医生而非护士（AOR 3.43；95%CI：1.22 - 9.55），他们更有可能去看私人医生（AOR 7.09；95%CI：3.86 - 13.04）并进行自我护理（AOR 4.91；95%CI：2.37 - 10.17），这导致与健康相关的支出增加（p = 0.001）。因此，结果表明患者在抗逆转录病毒治疗护理方面有得有失，表明下转的患者节省了时间和金钱，感觉更受尊重，感受到的耻辱感更低，并且表现出更好的依从水平。然而，意外后果包括使用私人医生和自我护理的成本增加，这凸显了在资源匮乏环境中进一步推广下转干预潜在益处的必要性。
