Abstract
BackgroundPrevious operational research studies have demonstrated the feasibility of large-scale public sector ART programs in resource-limited settings. However, organizational and structural determinants of quality of care have not been studied.MethodsWe estimate multivariate regression models using data from 13 urban HIV treatment facilities in Zambia to assess the impact of structural determinants on health workers’ adherence to national guidelines for conducting laboratory tests such as CD4, hemoglobin and liver function and WHO staging during initial and follow-up visits as part of Zambian HIV care and treatment program.ResultsCD4 tests were more routinely ordered during initial history and physical (IHP) than follow-up (FUP) visits (93.0 % vs. 85.5 %; p < 0.01). More physical space, higher staff turnover and greater facility experience with ART was associated with greater odds of conducting tests. Higher staff experience decreased the odds of conducting CD4 tests in FUP (OR 0.93; p < 0.05) and WHO staging in IHP visit (OR 0.90; p < 0.05) but increased the odds of conducting hemoglobin test in IHP visit (OR 1.05; p < 0.05). Higher staff burnout increased the odds of conducting CD4 test during FUP (OR 1.14; p < 0.05) but decreased the odds of conducting hemoglobin test in IHP visit (0.77; p < 0.05) and CD4 test in IHP visit (OR 0.78; p < 0.05).ConclusionPhysical space plays an important role in ensuring high quality care in resource-limited setting. In the context of protocolized care, new staff members are likely to be more diligent in following the protocol verbatim rather than relying on memory and experience thereby improving adherence. Future studies should use prospective data to confirm the findings reported here.
Highlights
Previous operational research studies have demonstrated the feasibility of large-scale public sector ART programs in resource-limited settings
Study population Setting Of the more than 150 HIV care and treatment facilities run by Ministry of Health (MOH) in Lusaka Urban District, we focused on 13 because of the similarity in geographic location, conditions of service-delivery for these clinics and, availability of data on staff burnout in these facilities from a healthcare worker survey [9] conducted between March and June 2007
Initial History and Physical (IHP) visit: At the initial visit, we examined whether patients were correctly assessed according to WHO and national guidelines
Summary
Previous operational research studies have demonstrated the feasibility of large-scale public sector ART programs in resource-limited settings. Operational research studies have recently demonstrated the feasibility of large scale ART programs within public sector, based on satisfactory clinical outcomes such as survival and treatment success [1,2,3]. Recent studies have measured structural factors of service delivery such as worker satisfaction and motivation [6,7,8,9] and have uncovered a number of predictors of dissatisfaction These include public vs private sector employment, workload, availability of resources, salaries [10], and low levels of staffing, management support and control over their practice [11]. Few studies have examined whether structural and organizational factors are determinants of quality of care in these resource-limited settings
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