卫生保健提供者对马拉维艾滋病毒感染者默认开具结核预防治疗处方的接受度：一项定性研究。
Health care providers acceptance of default prescribing of TB preventive treatment for people living with HIV in Malawi: a qualitative study.
机构信息
TB Elimination and Health System Innovations - KNCV Tuberculosis Foundation, The Hague, The Netherlands.
Center for Tuberculosis Research, John Hopkins University, Baltimore, MD, USA.
出版信息
BMC Health Serv Res. 2024 Jan 4;24(1):15. doi: 10.1186/s12913-023-10493-9.
BACKGROUND
Tuberculosis (TB) preventive treatment (TPT) substantially reduces the risk of developing active TB for people living with HIV (PLHIV). We utilized a novel implementation strategy based on choice architecture (CAT) which makes TPT prescribing the default option. Through CAT, health care workers (HCWs) need to "opt-out" when choosing not to prescribe TPT to PLHIV. We assessed the prospective, concurrent, and retrospective acceptability of TPT prescribing among HCWs in Malawi who worked in clinics participating in a cluster randomized trial of the CAT intervention.
METHODS
28 in-depth semi-structured interviews were conducted with HCWs from control (standard prescribing approach) and intervention (CAT approach) clinics. The CAT approach was facilitated in intervention clinics using a default prescribing module built into the point-of-care HIV Electronic Medical Record (EMR) system. An interview guide for the qualitative CAT assessment was developed based on the theoretical framework of acceptability and on the normalization process theory. Thematic analysis was used to code the data, using NVivo 12 software.
RESULTS
We identified eight themes belonging to the three chronological constructs of acceptability. HCWs expressed no tension for changing the standard approach to TPT prescribing (prospective acceptability); however, those exposed to CAT described several advantages, including that it served as a reminder to prescribe TPT and routinized TPT prescribing (concurrent acceptability). Some felt that CAT may reduce HCW´s autonomy and might lead to inappropriate TPT prescribing (retrospective acceptability).
CONCLUSIONS
The default prescribing module for TPT has now been incorporated into the point-of-care EMR system nationally in Malawi. This seems to fit the acceptability of the HCWs. Moving forward, it is important to train HCWs on how the EMR can be leveraged to determine who is eligible for TPT and who is not, while acknowledging the autonomy of HCWs.
背景
结核病（TB）预防治疗（TPT）可显著降低 HIV 感染者（PLHIV）发生活动性 TB 的风险。我们采用了一种基于选择架构（CAT）的新型实施策略，使 TPT 处方成为默认选项。通过 CAT，当选择不向 PLHIV 开具 TPT 处方时，卫生保健工作者（HCWs）需要“选择退出”。我们评估了在马拉维参与 CAT 干预的一项集群随机试验的诊所工作的 HCWs 对 TPT 处方的前瞻性、同期和回顾性可接受性。
方法
对来自对照（标准处方方法）和干预（CAT 方法）诊所的 HCWs 进行了 28 次深入的半结构式访谈。在干预诊所，使用内置在即时护理 HIV 电子病历（EMR）系统中的默认处方模块来促进 CAT 方法。根据可接受性的理论框架和正常化过程理论，为定性 CAT 评估制定了访谈指南。使用 NVivo 12 软件对数据进行主题分析。
结果
我们确定了属于可接受性三个时间顺序结构的八个主题。HCWs 对改变 TPT 处方的标准方法表示没有任何抵触（前瞻性可接受性）；然而，那些接触过 CAT 的人描述了几个优点，包括它可以作为开具 TPT 的提醒，并使 TPT 处方常规化（同期可接受性）。一些人认为 CAT 可能会降低 HCW 的自主权，并可能导致不适当的 TPT 处方（回顾性可接受性）。
结论
默认 TPT 处方模块现已纳入马拉维全国即时护理 EMR 系统。这似乎符合 HCWs 的可接受性。展望未来，重要的是要培训 HCWs 如何利用 EMR 来确定谁有资格接受 TPT 治疗，谁没有资格，同时承认 HCWs 的自主权。
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