运用聚类分析和德尔菲调查法确定坦桑尼亚、乌干达和赞比亚的艾滋病护理与治疗服务提供模式。
Identifying models of HIV care and treatment service delivery in Tanzania, Uganda, and Zambia using cluster analysis and Delphi survey.
作者信息
Tsui Sharon, Denison Julie A, Kennedy Caitlin E, Chang Larry W, Koole Olivier, Torpey Kwasi, Van Praag Eric, Farley Jason, Ford Nathan, Stuart Leine, Wabwire-Mangen Fred
机构信息
Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, USA.
Department of Medicine - Infectious Diseases, Johns Hopkins University School of Medicine, 733 N. Broadway, Baltimore, MD, USA.
出版信息
BMC Health Serv Res. 2017 Dec 6;17(1):811. doi: 10.1186/s12913-017-2772-4.
BACKGROUND
Organization of HIV care and treatment services, including clinic staffing and services, may shape clinical and financial outcomes, yet there has been little attempt to describe different models of HIV care in sub-Saharan Africa (SSA). Information about the relative benefits and drawbacks of different models could inform the scale-up of antiretroviral therapy (ART) and associated services in resource-limited settings (RLS), especially in light of expanded client populations with country adoption of WHO's test and treat recommendation.
METHODS
We characterized task-shifting/task-sharing practices in 19 diverse ART clinics in Tanzania, Uganda, and Zambia and used cluster analysis to identify unique models of service provision. We ran descriptive statistics to explore how the clusters varied by environmental factors and programmatic characteristics. Finally, we employed the Delphi Method to make systematic use of expert opinions to ensure that the cluster variables were meaningful in the context of actual task-shifting of ART services in SSA.
RESULTS
The cluster analysis identified three task-shifting/task-sharing models. The main differences across models were the availability of medical doctors, the scope of clinical responsibility assigned to nurses, and the use of lay health care workers. Patterns of healthcare staffing in HIV service delivery were associated with different environmental factors (e.g., health facility levels, urban vs. rural settings) and programme characteristics (e.g., community ART distribution or integrated tuberculosis treatment on-site).
CONCLUSIONS
Understanding the relative advantages and disadvantages of different models of care can help national programmes adapt to increased client load, select optimal adherence strategies within decentralized models of care, and identify differentiated models of care for clients to meet the growing needs of long-term ART patients who require more complicated treatment management.
背景
包括诊所人员配备和服务在内的艾滋病护理与治疗服务的组织形式，可能会影响临床和财务结果，但在撒哈拉以南非洲（SSA），几乎没有人尝试描述不同的艾滋病护理模式。了解不同模式的相对优缺点，可为资源有限环境（RLS）中抗逆转录病毒疗法（ART）及相关服务的扩大规模提供参考，特别是鉴于随着各国采用世界卫生组织的检测与治疗建议，服务对象群体不断扩大。
方法
我们对坦桑尼亚、乌干达和赞比亚19家不同的抗逆转录病毒治疗诊所的任务转移/任务分担做法进行了特征描述，并使用聚类分析来确定独特的服务提供模式。我们进行了描述性统计，以探讨各聚类在环境因素和项目特征方面的差异。最后，我们采用德尔菲法系统地利用专家意见，以确保聚类变量在撒哈拉以南非洲抗逆转录病毒治疗服务实际任务转移的背景下具有意义。
结果
聚类分析确定了三种任务转移/任务分担模式。各模式的主要差异在于医生的可获得性、分配给护士的临床责任范围以及非专业医护人员的使用情况。艾滋病服务提供中的医护人员配置模式与不同的环境因素（如医疗机构级别、城市与农村环境）和项目特征（如社区抗逆转录病毒治疗分发或现场综合结核病治疗）相关。
结论
了解不同护理模式的相对优缺点，有助于国家项目适应增加的服务对象负担，在分散式护理模式中选择最佳的依从性策略，并为服务对象确定差异化的护理模式，以满足长期接受抗逆转录病毒治疗且需要更复杂治疗管理的患者日益增长的需求。
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