Amsterdam Institute for Global Health and Development (AIGHD), Department of Global Health, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.
Department of Strategic Information, National AIDS Control Programme, Dodoma, Tanzania.
PLoS One. 2022 Mar 15;17(3):e0265307. doi: 10.1371/journal.pone.0265307. eCollection 2022.
Differentiated service delivery (DSD) offers benefits to people living with HIV (improved access, peer support), and the health system (clinic decongestion, efficient service delivery). ART clubs, 15-30 clients who usually meet within the community, are one of the most common DSD options. However, evidence about the quality of care (QoC) delivered in ART clubs is still limited.
We conducted a concurrent triangulation mixed-methods study as part of the Test & Treat project in northwest Tanzania. We surveyed QoC among stable clients and health care workers (HCW) comparing between clinics and clubs. Using a Donabedian framework we structured the analysis into three levels of assessment: structure (staff, equipment, supplies, venue), processes (time-spent, screenings, information, HCW-attitude), and outcomes (viral load, CD4 count, retention, self-worth).
We surveyed 629 clients (40% in club) and conducted eight focus group discussions, while 24 HCW (25% in club) were surveyed and 22 individual interviews were conducted. Quantitative results revealed that in terms of structure, clubs fared better than clinics except for perceived adequacy of service delivery venue (94.4% vs 50.0%, p = 0.013). For processes, time spent receiving care was significantly more in clinics than clubs (119.9 vs 49.9 minutes). Regarding outcomes, retention was higher in the clubs (97.6% vs 100%), while the proportion of clients with recent viral load <50 copies/ml was higher in clinics (100% vs 94.4%). Qualitative results indicated that quality care was perceived similarly among clients in clinics and clubs but for different reasons. Clinics were generally perceived as places with expertise and clubs as efficient places with peer support and empathy. In describing QoC, HCW emphasized structure-related attributes while clients focused on processes. Outcomes-related themes such as improved client health status, self-worth, and confidentiality were similarly perceived across clients and HCW.
We found better structure and process of care in clubs than clinics with comparable outcomes. While QoC was perceived similarly in clinics and clubs, its meaning was understood differently between clients. DSD catered to the individual needs of clients, either technical care in the clinic or proximate and social care in the club. Our findings highlight that both clinic and DSD care are required as many elements of QoC were individually perceived.
差异化服务提供（DSD）为艾滋病毒感染者（改善获得途径、同伴支持）和卫生系统（诊所去拥堵、高效服务提供）带来了益处。ART 俱乐部是最常见的 DSD 选择之一，它是指通常在社区内聚集的 15-30 名患者。然而，ART 俱乐部提供的护理质量（QoC）证据仍然有限。
我们作为坦桑尼亚西北部 Test & Treat 项目的一部分，开展了一项同时使用三角测量法的混合方法研究。我们调查了稳定患者和卫生保健工作者（HCW）的 QoC，对诊所和俱乐部进行了比较。我们使用 Donabedian 框架将分析分为三个评估层面：结构（员工、设备、用品、场地）、过程（时间投入、筛查、信息、HCW 态度）和结果（病毒载量、CD4 计数、保留率、自我价值感）。
我们调查了 629 名患者（40%在俱乐部），并进行了 8 次焦点小组讨论，同时调查了 24 名 HCW（25%在俱乐部）并进行了 22 次个人访谈。定量结果显示，在结构方面，俱乐部的表现优于诊所，除了服务提供场所的感知充足程度（94.4%对 50.0%，p = 0.013）。在过程方面，接受护理的时间在诊所显著长于俱乐部（119.9 对 49.9 分钟）。在结果方面，俱乐部的保留率更高（97.6%对 100%），而诊所的近期病毒载量<50 拷贝/ml 的患者比例更高（100%对 94.4%）。定性结果表明，诊所和俱乐部的患者对优质护理的看法相似，但原因不同。诊所通常被认为是具有专业知识的地方，而俱乐部则被认为是具有同伴支持和同理心的高效地方。在描述 QoC 时，HCW 强调了与结构相关的属性，而患者则侧重于过程。患者和 HCW 都同样认为改善客户健康状况、自我价值感和保密性等结果相关主题。
我们发现俱乐部的护理结构和过程优于诊所，结果相当。虽然诊所和俱乐部的 QoC 感知相似，但患者和 HCW 对其意义的理解却不同。差异化服务提供满足了患者的个人需求，无论是诊所的技术护理，还是俱乐部的临近和社会护理。我们的研究结果表明，诊所和 DSD 护理都需要，因为 QoC 的许多要素都是个人感知的。
