Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.
Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
J Int AIDS Soc. 2023 Jul;26 Suppl 1(Suppl 1):e26114. doi: 10.1002/jia2.26114.
Implementation of patient-centred care (PCC) practices in HIV treatment depends on healthcare workers' (HCWs) perceptions of the acceptability, appropriateness and feasibility of such practices (e.g. use of intentional, metric-driven activities to improve patient experiences).
We applied rapid, rigorous formative research methods to refine a PCC intervention for future trial. In 2018, we conducted focus group discussions (FGDs) with 46 HCWs purposefully selected from two pilot sites. We elicited HCW perceptions of HIV service delivery, HCW motivation and perceived value of patient experience measures intended to improve PCC. FGDs utilized participatory methods to understand HCW responses to patient-reported care engagement challenges and Scholl's PCC Framework principles (e.g. seeing a patient as a unique person), enablers (e.g. care coordination) and activities (e.g. patient involvement). Our rapid analysis used analytic memos, thematic analysis, research team debriefs and HCW feedback to inform time-sensitive trial implementation.
While HCWs nearly universally identified with and supported principles of PCC in both facilities, they raised practical barriers given the practice environment. HCWs described motivation to help patients, attached value to seeing positive health outcomes and the importance of teamwork. However, HCWs reported challenges with enablers needed to deliver PCC. HCWs cited a work culture characterized by differential power dynamics between cadres and departments restricting HCW autonomy and resource access. Barriers included inflexibility in accommodating individual patient needs due to high patient volumes, limited human resources, laboratory capacity, infrastructure and skills translating patient perspectives into practice. HCW motivation was negatively influenced by encounters with "difficult patients," and feeling "unappreciated" by management, resulting in cognitive dissonance between HCW beliefs and behaviours. However, the enactment of PCC values also occurred. Results suggested that PCC interventions should reduce practice barriers, highlighting the value of mentors who could help HCWs dynamically engage with health system constraints, to facilitate PCC.
While HCWs perceived PCC principles as acceptable, they did not think it universally appropriate or feasible given the practice environment. Participatory and rapid methods provided timely insight that PCC interventions must provide clear and effective systems enabling PCC activities by measuring and mitigating relational and organizational constraints amenable to change such as inter-cadre coordination.
在 HIV 治疗中实施以患者为中心的护理（PCC）实践取决于医疗保健工作者（HCWs）对这些实践的可接受性、适当性和可行性的看法（例如，使用有目的的、以度量为驱动的活动来改善患者体验）。
我们应用快速、严格的形成性研究方法来改进未来试验的 PCC 干预措施。2018 年，我们在两个试点地点有目的地进行了 46 名 HCW 的焦点小组讨论（FGD）。我们引出了 HCW 对 HIV 服务提供的看法、HCW 的动机以及旨在改善 PCC 的患者体验措施的感知价值。FGD 采用参与式方法了解 HCW 对患者报告的护理参与挑战以及 Scholl 的 PCC 框架原则（例如，将患者视为独特的个体）、促进因素（例如，护理协调）和活动（例如，患者参与）的反应。我们的快速分析使用分析备忘录、主题分析、研究团队汇报和 HCW 反馈来为敏感的试验实施提供信息。
虽然 HCWs 在两个机构中几乎普遍认同并支持 PCC 的原则，但他们在实践环境中提出了实际障碍。HCWs 描述了帮助患者的动机，认为看到积极的健康结果和团队合作很重要。然而，HCWs 报告了提供 PCC 所需的促进因素方面的挑战。HCWs 提到了一种工作文化，其特点是不同的权力动态在干部和部门之间限制了 HCW 的自主权和资源获取。障碍包括由于患者数量多、人力资源有限、实验室能力、基础设施和将患者观点转化为实践的技能有限，难以灵活地满足个别患者的需求。HCW 的动机受到与“困难患者”的接触以及管理层的“不被赏识”的负面影响，从而导致 HCW 的信念和行为之间产生认知失调。然而，PCC 价值观的实施也发生了。结果表明，PCC 干预措施应减少实践障碍，强调导师的价值，导师可以帮助 HCW 动态应对卫生系统的限制，促进 PCC。
虽然 HCWs 认为 PCC 原则是可以接受的，但他们认为鉴于实践环境，它们并非普遍适用或可行。参与式和快速方法提供了及时的见解，即 PCC 干预措施必须提供明确有效的系统，通过衡量和减轻可改变的关系和组织限制（例如，干部之间的协调），为 PCC 活动提供便利。
