Rural Primary Healthcare Clinics Research Articles

Evaluating systematic targeted universal testing for tuberculosis in primary care clinics of South Africa: A cluster-randomized trial (The TUTT Trial).

The World Health Organization (WHO) recommends systematic symptom screening for tuberculosis (TB). However, TB prevalence surveys suggest that this strategy does not identify millions of TB patients, globally. Undiagnosed or delayed diagnosis of TB contribute to TB transmission and exacerbate morbidity and mortality. We conducted a cluster-randomized trial of large urban and rural primary healthcare clinics in 3 provinces of South Africa to evaluate whether a novel intervention of targeted universal testing for TB (TUTT) in high-risk groups diagnosed more patients with TB per month compared to current standard of care (SoC) symptom-directed TB testing. Sixty-two clinics were randomized; with initiation of the intervention clinics over 6 months from March 2019. The study was prematurely stopped in March 2020 due to clinics restricting access to patients, and then a week later due to the Coronavirus Disease 2019 (COVID-19) national lockdown; by then, we had accrued a similar number of TB diagnoses to that of the power estimates and permanently stopped the trial. In intervention clinics, attendees living with HIV, those self-reporting a recent close contact with TB, or a prior episode of TB were all offered a sputum test for TB, irrespective of whether they reported symptoms of TB. We analyzed data abstracted from the national public sector laboratory database using Poisson regression models and compared the mean number of TB patients diagnosed per clinic per month between the study arms. Intervention clinics diagnosed 6,777 patients with TB, 20.7 patients with TB per clinic month (95% CI 16.7, 24.8) versus 6,750, 18.8 patients with TB per clinic month (95% CI 15.3, 22.2) in control clinics during study months. A direct comparison, adjusting for province and clinic TB case volume strata, did not show a significant difference in the number of TB cases between the 2 arms, incidence rate ratio (IRR) 1.14 (95% CI 0.94, 1.38, p = 0.46). However, prespecified difference-in-differences analyses showed that while the rate of TB diagnoses in control clinics decreased over time, intervention clinics had a 17% relative increase in TB patients diagnosed per month compared to the prior year, interaction IRR 1.17 (95% CI 1.14, 1.19, p < 0.001). Trial limitations were the premature stop due to COVID-19 lockdowns and the absence of between-arm comparisons of initiation and outcomes of TB treatment in those diagnosed with TB. Our trial suggests that the implementation of TUTT in these 3 groups at extreme risk of TB identified more TB patients than SoC and could assist in reducing undiagnosed TB patients in settings of high TB prevalence. South African National Clinical Trials Registry DOH-27-092021-4901.

The effect of a mobile-learning curriculum on improving compliance to quality management guidelines for HIV rapid testing services in rural primary healthcare clinics, KwaZulu-Natal, South Africa: a quasi-experimental study

BackgroundDespite significant achievements made towards HIV testing, linkage to antiretroviral therapy treatment and viral load suppression, the Sub-Saharan region of Africa continues to be reported to have the highest prevalence of HIV/AIDS, with over 26 million people living with the disease. In light of the added burden on already overwhelmed health systems due to the Covid-19 pandemic, maintaining the reliability and accuracy of point-of-care diagnostics (POC) results is crucial to ensure the sustainability of quality service delivery. The integration of technology-based interventions into nurse education curricula is growing, to help prepare students for the current practice environment which requires access to large amounts of information. The aim of this study was to determine the effect of a Mobile Learning (mLearning) Curriculum on improving the quality of HIV rapid testing services in rural clinics of KwaZulu-Natal (KZN), South Africa.MethodsTo achieve the aim of this study, pre-test and post-test audits were conducted in a quasi-experimental design. Eleven clinics of KZN, with the highest availability and usage of POC diagnostics were selected from a cross-sectional study survey to constitute the sample of this study. The World Health Organization On-site Monitoring Checklist-Assessment of Quality System was adapted and used as an audit tool to evaluate four key quality components. The effect of the mLearning curriculum on HIV testing quality improvement was determined through statistically comparing pre-audit and post-audit results. The independent samples t-test and the Levene’s test were employed to evaluate the equality of measured variables for the two groups. The relationships between variables were estimated using the Pearson pair wise correlation coefficient (p) and correlations were reported as significant at p < 0.05.ResultsA total of 11 clinics was audited at the pretest and 7 clinics were audited post-piloting of the mLearning curriculum. The estimated level of compliance of the participating clinics to quality HIV rapid testing guidelines ranged between poor and moderate quality. The mLearning curriculum was shown to have no statistically significant effect on the quality of POC diagnostic services provided in rural clinics of KZN.ConclusionThe mLearning curriculum was shown to have no statistically significant effect on the quality of HIV rapid testing services provided in participating clinics; however, multiple barriers to the full adoption of the piloted curriculum were identified. The provision of reliable technology devices and improved internet connection were recommended to enhance the adoption of technology-based interventions necessary to improve access to relevant learning material and updated information.

The impact of COVID-19 on primary health care and antibiotic prescribing in rural China: qualitative study

BackgroundIn China, the primary health care (PHC) system has been designated responsible for control and prevention of COVID-19, but not treatment. Suspected COVID-19 cases presenting to PHC facilities must be transferred to specialist fever clinics. This study aims to understand the impact of COVID-19 on PHC delivery and on antibiotic prescribing at a community level in rural areas of central China.MethodsQualitative semi-structured interviews were conducted with 18 PHC practitioners and seven patients recruited from two township health centres and nine village clinics in two rural residential areas of Anhui province. Interviews were transcribed verbatim and analysed thematically.ResultsPHC practitioners reported a major shift in their work away from seeing and treating patients (due to government-mandated referral to specialist Covid clinics) to focus on the key public health roles of tracing, screening and educating in rural areas. The additional work, risk, and financial pressure that PHC practitioners faced, placed considerable strain on them, particularly those working in village clinics. Face to face PHC provision was reduced and there was no substitution with consultations by phone or app, which practitioners attributed to the fact that most of their patients were elderly and not willing or able to switch. Practitioners saw COVID-19 as outside of their area of expertise and very different to the non-COVID-19 respiratory tract infections that they frequently treated pre-pandemic. They reported that antibiotic prescribing was reduced overall because far fewer patients were attending rural PHC facilities, but otherwise their antibiotic prescribing practices remained unchanged.ConclusionsThe COVID-19 pandemic had considerable impact on PHC in rural China. Practitioners took on substantial additional workload as part of epidemic control and fewer patients were seen in PHC. The reduction in patients seen and treated in PHC led to a reduction in antibiotic prescribing, although clinical practice remains unchanged. Since COVID-19 epidemic control work has been designated as a long-term task in China, rural PHC clinics now face the challenge of how to balance their principal clinical and increased public health roles and, in the case of the village clinics, remain financially viable.

Telepsychiatry Consultation for Primary Care Treatment of Children and Adolescents Receiving Child Protective Services in Chile: Mixed Methods Feasibility Study

BackgroundChildren and adolescents living under the supervision of child protective services have complex mental health care needs. The scarcity and uneven distribution of specialized mental health teams in Chile may limit the provision and quality of care for this vulnerable population. Telepsychiatry can address such health inequities.ObjectiveThe objective of this study was to evaluate the feasibility of a telepsychiatry consultation program for primary health care (PHC) treatment of children and adolescents living under the supervision of child protective services.MethodsWe developed a telepsychiatry consultation program for two rural PHC clinics located in central Chile (Valparaíso Region) and evaluated its implementation using a mixed methods study design. The program consisted of videoconferencing mental health consultation sessions scheduled twice per month (each 90 minutes long), over a 6-month period, delivered by child and adolescent psychiatrists based in Santiago, Chile. We described the number of mental health consultation sessions, participant characteristics, perceived usefulness and acceptability, and experiences with the telepsychiatry consultation program.ResultsDuring the 6-month study period, 15 videoconferencing mental health consultation sessions were held. The telepsychiatry consultation program assisted PHC clinicians in assigning the most adequate diagnoses and making treatment decisions on pharmacotherapy and/or psychotherapy of 11 minors with complex care needs. The intervention was perceived to be useful by PHC clinicians for improving the resolution capacity in the treatments of this patient population. Limitations such as connectivity issues were resolved in most sessions.ConclusionsThe telepsychiatry consultation program was feasible and potentially useful to support PHC clinicians in the management of institutionalized children and adolescents with complex psychosocial care needs living in a poorly resourced setting. A larger scale trial should assess clinical outcomes in the patient population. Regulations and resources for this service model are needed to facilitate sustainability and large-scale implementation.

Challenges for Nurses in Providing Patient-Centered Care in Rural Primary Health Care Clinics in Nigeria

Globally, patient-centered care has become the focus of the healthcare system. It is imperative to note that during a global pandemic crisis, patient-centered care principles seek to empower partnering approaches in Primary Health Care (PHC), and have recently gained prominence in nursing practice and applied nursing research. However, nurses are faced with challenges in achieving the desired results in the PHC system. Thus, the study aimed to explore the factors that influence PCC utilization in the PHC facilities in Nigeria. A qualitative exploratory-descriptive design was used for this study. Data collection was conducted with the nurses from PHC facilities through individual interviews. Data saturation was achieved with 35 participants from 30 PHC facilities in Osun State, Nigeria, using a purposive sampling technique. All interviews were audio-recorded, later transcribed verbatim, and analyzed using the thematic analysis approach. NVivo 12 software was used for data management. The results from this study were categorized into two factors: Organizational factors and individual factors. Six themes that emerged from the study include inadequate management support, insufficient opportunities for further training, work overload and time constraints, health personnel readiness to use PCC, dearth enthusiasm for change, and poor nurses’ Accountability. The study shows that nurses encountered diverse challenges in providing patient-centered care. To improve the quality of healthcare delivery in the PHC facilities, there is a need to reinforce adequate management support, education, continued training, and the internal motivation of nurses to achieve transformative health outcomes in the community.

Comparison of index-linked HIV testing for children and adolescents in health facility and community settings in Zimbabwe: findings from the interventional B-GAP study

SummaryBackgroundIndex-linked HIV testing, whereby children of individuals with HIV are targeted for testing, increases HIV yield but relies on uptake. Community-based testing might address barriers to testing access. In the Bridging the Gap in HIV testing and care for children in Zimbabwe (B-GAP) study, we investigated the uptake and yield of index-linked testing in children and the uptake of community-based vs facility-based HIV testing in Zimbabwe.MethodsB-GAP was an interventional study done in the city of Bulawayo and the province of Matabeleland South between Jan 29 and Dec 12, 2018. All HIV-positive attendees (index patients) at six urban and three rural primary health-care clinics were offered facility-based or community-based HIV testing for children (age 2–18 years) living in their households who had never been tested or had tested as HIV-negative more than 6 months ago. Community-based options involved testing in the home by either a trained lay worker with a blood-based rapid diagnostic test (used in facility-based testing), or by the child's caregiver with an oral HIV test. Among consenting individuals, the primary outcome was testing uptake in terms of the proportion of eligible children tested. Secondary outcomes were uptake of the different HIV testing methods, HIV yield (proportion of eligible children who tested positive), and HIV prevalence (proportion of HIV-positive children among those tested). Logistic regression adjusting for within-index clustering was used to investigate index patient and child characteristics associated with testing uptake, and the uptake of community-based versus facility-based testing.FindingsOverall, 2870 index patients were linked with 6062 eligible children (3115 [51·4%] girls [sex unknown in seven], median age 8 years [IQR 5–13]). Testing was accepted by index patients for 5326 (87·9%) children, and 3638 were tested with a known test outcome, giving an overall testing uptake among 6062 eligible children of 60·0%. 39 children tested positive for HIV, giving an HIV prevalence among the 3638 children of 1·1% and an HIV yield among 6062 eligible children of 0·6%. Uptake was positively associated with female sex in the index patient (adjusted odds ratio [aOR] 1·56 [95% CI 1·38–1·77], p<0·0001) and child (aOR 1·10 [1·03–1·19], p=0·0080), and negatively associated with any financial cost of travel to a clinic (aOR 0·86 [0·83–0·88], p<0·0001), increased child age (6–9 years: aOR 0·99 (0·89–1·09); 10–15 years: aOR 0·91 [0·83–1·00]; and 16–18 years: aOR 0·75 [0·66–0·85]; p=0·0001 vs 2–5 years), and unknown HIV status of the mother (aOR 0·81 [0·68–0·98], p=0·027 vs HIV-positive status). Additionally, children had increased odds of being tested if community-based testing was chosen over facility-based testing at screening (1320 [73·9%] children tested of 1787 vs 2318 [65·5%] of 3539; aOR 1·49 [1·22–1·81], p=0·0001).InterpretationThe HIV yield of index-linked testing was low compared with blanket testing approaches in similar settings. Index-linked HIV testing can improve testing uptake among children, although strategies that improve testing uptake in older children are needed. Community based testing by lay workers is a feasible strategy that can be used to improve uptake of HTS among children and adolescents.FundingUK Medical Research Council, UK Department for International Development, Wellcome Trust.

Registered Nurses’ Lived Experiences of HIV Counselling and Testing in Rural Primary Healthcare Clinics in Eastern Cape, South Africa

The increase in the global rates of human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) has had far reaching effects on healthcare services around the world. The aim of the study was to explore and describe the lived experiences of registered nurses (RNs) involved in daily implementation of HIV counselling and testing (HCT) in rural primary healthcare (PHC) clinics in Eastern Cape, South Africa. The researcher used a qualitative, descriptive and contextual design. Purposive sampling was used to select the participants. A total of 19 semi-structured interviews were conducted with the RNs until data saturation was achieved. The findings revealed that the RNs experienced HCT to be overwhelming. They also showed signs of stress, frustration, despair and sadness because most of the tested clients had positive results and the number of clients testing positive was increasing. Thus, it is recommended that all professionals working with HCT should be made aware of the emotional outcomes of working in HCT services. Furthermore, it is recommended that a programme to support RNs to cope better with HCT should be developed through further research.

Challenges facing professional nurses implementing the Integrated Management of Childhood Illness programme in rural primary health care clinics, Limpopo Province, South Africa.

BackgroundUnder-five mortality and morbidity could be reduced through increased implementation of the Integrated Management of Childhood Illness (IMCI) strategy. The aim of the study was to determine challenges facing IMCI-trained professional nurses on implementing this strategy when managing children less than 5 years of age.MethodsA quantitative descriptive survey method was used. The target populations were IMCI-trained professional nurses with the sample of 208 respondents. Data were collected through self-report questionnaires and analysed using statistical analysis system software.ResultsThe implementation of the IMCI strategy by IMCI-trained professional nurses in Vhembe primary health care (PHC) clinics continues to face challenges, making it difficult for professional nurses to follow guidelines. These challenges range from staff barriers, management barriers, poor management process and poor infrastructure. All these challenges lead to poor-quality under-five patient care.ConclusionRegardless of the IMCI strategy being implemented since its inception in 1999, the under-five mortality remains not reduced. This is related to the identified challenges facing the IMCI-trained professional nurses implementing the strategy.

Stakeholders' Perspectives for the Development of a Point-of-Care Diagnostics Curriculum in Rural Primary Clinics in South Africa-Nominal Group Technique.

Poor knowledge and adherence to point-of-care (POC) HIV testing standards have been reported in rural KwaZulu-Natal (KZN), a high HIV prevalent setting. Improving compliance to HIV testing standards is critical, particularly during the gradual phasing out of lay counsellor providers and the shifting of HIV testing and counselling duties to professional nurses. The main objective of this study was to identify priority areas for development of POC diagnostics curriculum to improve competence and adherence to POC diagnostics quality standards for primary healthcare (PHC) nurses in rural South Africa. Method: PHC clinic stakeholders were invited to participate in a co-creation workshop. Participants were purposely sampled from each of the 11 KwaZulu-Natal Districts. Through the Nominal Group Technique (NGT), participants identified training related challenges concerning delivery of quality point of care diagnostics and ranked them from highest to lowest priority. An importance ranking score (scale 1–5) was calculated for each of the identified challenges. Results: Study participants included three PHC professional nurses, one TB professional nurse, one HIV lay councilor, one TB assistant and three POC diagnostics researchers, aged 23–50. Participants identified ten POC diagnostics related challenges. Amongst the highest ranked challenges were the following:absence of POC testing Curriculum for nurses, absence of training of staff on HIV testing and counselling as lay counsellor providers are gradually being phased out,. absence of Continuous Professional Development opportunities and lack of Staff involvement in POC Management programs. Conclusion: Key stakeholders perceived training of PHC nurses as the highest priority for the delivery of quality POC diagnostic testing at PHC level. We recommend continual collaboration among all POC diagnostics stakeholders in the development of an accessible curriculum to improve providers’ competence and ensure sustainable quality delivery of POC diagnostic services in rural PHC clinics.

Accessibility of pregnancy-related point-of-care diagnostic tests for maternal healthcare in rural primary healthcare facilities in Northern Ghana: A cross-sectional survey

BackgroundImproving access to maternal healthcare in resource-limited settings plays a critical role in improving maternal health outcomes and reducing maternal deaths. However, barriers and challenges may exist in rural clinics and could affect successful implementation. This study assessed the current accessibility of pregnancy-related point-of-care (POC) diagnostic tests for maternal healthcare in rural primary healthcare (PHC) clinics in northern Ghana. MethodWe randomly selected 100 PHC clinics providing maternal healthcare from a total list of 356 PHC clinicss obtained from the Regional Health Directorate. Selected clinics were surveyed from February to March 2018, using an adopted survey tool. We obtained data for clinic-level staffing, availability, usage, and desired POC diagnostic tests. Stata 14 was used for data analysis. FindingsMajority (64%) of the respondents were midwives. The mean ± standard deviation (SD) years of work experience and working hours per week were estimated at 5.6 years ± 0.4 and 122 hours ± 5.2 respectively. Average antenatal clinic attendance (clinic census) per month was 65 ± 67 pregnant women (Range: 3–360). The mean ± SD POC tests available and use was 4.9 tests ± 2.2. POC tests for malaria, HIV, urine pregnancy, and blood pressure monitoring devices were available in most clinics. POC tests requested by the clinics to assist them care for pregnant women included: Glucose-6-phosphate dehydrogenase (95%); hepatitis C (94%); sickling (91%); tuberculosis, blood glucose and blood type (89%) each; urinary tract infection (87%); urine protein (81%); hepatitis B (78%); haemoglobin (76%); and syphilis (76%). InterpretationThere is poor accessibility to pregnancy-related POC diagnostic tests for maternal healthcare due to low availability (≤5 tests per PHC clinic) of POC tests in rural PHC clinics in northern Ghana.

Geographical Accessibility of Antenatal Diagnostic Services in Rural Ghana' Primary Health Care Clinics: The Role of District Hospitals/Medical Laboratories Locations in the Upper East Region

Background: Efforts to reduce maternal mortality to less than 70 per 100000 live births is a priority of the Government of Ghana and globally. Access to district hospitals/medical laboratories from rural primary healthcare (PHC) clinics for antenatal diagnostic services is critical for improving pregnancy outcomes and reducing maternal mortality. We assessed the geographical accessibility of district hospitals/medical laboratories for antenatal diagnostic services in Upper East Region, Ghana. Methods: We assembled detailed spatial data on weighted 100 rural clinics and their district hospitals/medical laboratories; and landscape features influencing journeys in the region. These were used in a geospatial model to estimate actual distance and travel time from a PHC facility to the nearest district hospital/medical laboratory for diagnostic services. Distribution of facilities was done using spatial autocorrelation (Global Moran's I) run in ArcMap 10.4.1. Logistics regression analysis was done utilizing STATA 14 to determine the strength of association between geographical accessibility and pregnancy outcome predictors. Findings: Of the 100 rural clinics included in the analysis, only 15% were located less than 10km (travel time: 5-30 minutes) to their nearest referral health facilities. The likelihood of a pregnant woman accessing a referral facility for diagnostic services in the region was after every 25 km (range: 0.2-62). Spatial distribution of the referral facilities was shown to be dispersed (MI= -0.69, z-score= -2.05, p=0.04). Likewise, the spatial distribution of the PHC clinics appeared to be at random (MI=0.01, z-score = 0.33, p=0.74). Logistic regression showed maternal mortality (OR=1.25, [95%CI=1.1-1.4] p<0.05); stillbirth (OR=1.1, [95%CI= 1.0-1.2], p=0.01); and miscarriage/abortion (OR=1.13, [95%CI=1.1-1.2]; p<0.05) were significantly associated with poor geographical accessibility. nterpretation: Geographical location of a district hospital/medical laboratory affected geographical accessibility of antenatal diagnostic services for rural populations in Upper East Region, Ghana. Targeted improvement of essential point-of-care diagnostics in rural primary health care clinics is recommended for both maternal healthcare and the general population. Funding: University of KwaZulu-Natal, College of Health Sciences Research Scholarship. Declaration of Interest: None declared. Ethical Approval: This study was approved by the Navrongo Health Research Centre Institutional Review Board/Ghana Health Service (approval number: NHRCIRB291) and the University of KwaZulu-Natal Biomedical Research Ethics Committee (approval number: BE565/17). Permission was obtained from the Upper East Regional Health Directorate prior to conducting the study. All study participants signed an informed consent prior to participating in this study.

Operational assessment of point-of-care diagnostics in rural primary healthcare clinics of KwaZulu-Natal, South Africa: a cross-sectional survey

BackgroundThe World Health Organization (WHO) called for new clinical diagnostic for settings with limited access to laboratory services. Access to diagnostic testing may not be uniform in rural settings, which may result in poor access to essential healthcare services. The aim of this study is to determine the availability, current usage, and need for point-of-care (POC) diagnostic tests among rural primary healthcare (PHC) clinics in South Africa’s KwaZulu-Natal (KZN) province.MethodsWe used the KZN’s Department of Health (DoH) clinic classification to identify the 232 rural PHC clinics in KZN, South Africa. We then randomly sampled 100 of 232 rural PHC clinics. Selected health clinics were surveyed between April to August 2015 to obtain clinic-level data for health-worker volume and to determine the accessibility, availability, usage and need for POC tests. Professional healthcare workers responsible for POC testing at each clinic were interviewed to assess the awareness of POC testing. Data were survey weighted and analysed using Stata 13.ResultsAmong 100 rural clinics, the average number of patients seen per week was 2865 ± 2231 (range 374–11,731). The average number of POC tests available and in use was 6.3 (CI: 6.2–6.5) out of a potential of 51 tests. The following POC tests were universally available in all rural clinics: urine total protein, urine leukocytes, urine nitrate, urine pregnancy, HIV antibody and blood glucose test. The average number of desired POC diagnostic tests reported by the clinical staff was estimated at 15 (CI: 13–17) per clinic. The most requested POC tests reported were serum creatinine (37%), CD4 count (37%), cholesterol (32%), tuberculosis (31%), and HIV viral load (23%).ConclusionSeveral POC tests are widely available and in use at rural PHC clinics in South Africa’s KZN province. However, healthcare workers have requested additional POC tests to improve detection and management of priority disease conditions.Trial registrationClinical Trials.gov Identifier: NCT02692274

Evaluation of antenatal rapid human immunodeficiency virus testing in rural South Africa.

South African guidelines recommend two rapid tests for diagnosing human immunodeficiency virus (HIV) using the serial HIV testing algorithm, but the accuracy and compliance to this algorithm is unknown in rural clinics. We evaluated the accuracy of HIV rapid testing and the time to receiving test results among pregnant women in rural KwaZulu-Natal (KZN). We observed the accuracy of rapid HIV testing algorithms for 208 consenting antenatal patients accessing voluntary HIV testing services in nine rural primary healthcare (PHC) clinics in KZN. A PHC-based HIV counsellor obtained finger-prick whole blood from each participant to perform rapid testing using the Advanced Quality™ One Step anti-HIV (1&2) and/or ABON™ HIV 1/2/O Tri-Line HIV test. A research nurse obtained venous blood for an enzyme-linked immunosorbent assay (ELISA) HIV test, which is the gold standard diagnostic test. We recorded the time of receipt of HIV test results for each test. Among 208 pregnant women with a mean age of 26 years, 72 women from nine rural PHC clinics were identified as HIV-positive by two rapid tests with an HIV-prevalence of 35% (95% Bayesian credibility intervals [BCI]: 28% - 41%). Of the 208 patients, 135 patients from six clinics were tested with the serial HIV testing algorithm. The estimated sensitivity and specificity for the 135 participants were 100% (95% confidence interval [CI]: 93% - 100%) and 99% (CI: 95% - 100%), respectively. The positive predictive value and negative predictive value were estimated at 98% (CI: 94% - 100%) and 95% (CI: 88% - 99%), respectively. All women received their HIV rapid test results within 20 min of testing. Test stock-out resulted in poor test availability at point-of-care, preventing performance of a second HIV test in three out of nine PHC clinics in rural KZN. Despite the poor compliance with national guidelines for HIV rapid testing services, HIV rapid test results provided to pregnant women in rural PHC clinics in KZN were generally accurate and timely. Test stock-out was shown to be one of the barriers to test availability in rural PHC clinics, resulting in poor compliance with guidelines. We recommend a compulsory confirmation HIV rapid test for all HIV-negative test results obtained from pregnant patients in rural and resource-limited settings.

Geographical Accessibility of Referral Health Facilities from Rural Primary Healthcare Clinics for Antenatal Diagnostic Services in the Upper East Region, Ghana

Background: Efforts to reduce maternal mortality to less than 70 per 100000 live births is a priority of the Government of Ghana and globally. Access to referral health facilities from rural primary healthcare (PHC) clinics for antenatal diagnostic services is critical for improving pregnancy outcomes and reducing maternal mortality. We assessed the geographical accessibility of referral health facilities from rural clinics for antenatal diagnostic services in Upper East Region, Ghana. Methods: We assembled detailed spatial data on weighted 100 rural clinics, referral health facilities, and landscape features influencing journeys in the region. These were used in a geospatial model to estimate actual distance and travel time from a PHC facility to the nearest referral facility for diagnostic services. Distribution of facilities was done using spatial autocorrelation (Global Moran's I) run in ArcMap 10.4.1. Logistics regression analysis was done utilizing STATA 14 to determine the strength of association between long distances and pregnancy outcome predictors. Findings: Of the 100 rural clinics included in the analysis, only 15% were located less than 10km (travel time: 5-30 minutes) to their nearest referral health facilities. The likelihood of a pregnant woman accessing a referral facility for diagnostic services in the region was after every 25 km (range: 0.2-62). Spatial distribution of referral facilities was found to be dispersed (p<0.05, z-score= -2.05). Likewise, the spatial distribution of the PHCs appear to be at random (p<0.05, z-score = 0.33). Logistic regression showed maternal mortality (OR=1.25, 95%CI=1.1-1.4); stillbirth (OR=1.1, 95%CI= 1.0-1.2); and miscarriage/abortion (OR=1.13, 95%CI=1.1-1.2) were significantly associated with long distance all p<0.05. Mean test results turnaround time from referred clients to the PHC clinic midwife was estimated at 15.4 (SD= 8.6, 95%CI= 13.7-17.1). No form of electronic option for communicating test results existed between the rural clinics and their referral facilities. Interpretation: There is poor geographical accessibility of referral health facilities from rural PHC clinics for antenatal diagnostic services in Upper East Region, Ghana. Targeted improvement of essential point-of-care diagnostics in rural clinics is recommended for both maternal healthcare and the general population. Funding: University of KwaZulu-Natal, College of Health Sciences Research Scholarship. Declaration of Interest: None declared. Ethical Approval: This study was approved by the Navrongo Health Research Centre Institutional Review Board/Ghana Health Service (approval number: NHRCIRB291) and the University of KwaZulu-Natal Biomedical Research Ethics Committee (approval number: BE565/17). Permission was obtained from the Upper East Regional Health Directorate prior to conducting the study. All study participants signed an informed consent prior to participating in this study.

Accessibility of Point-of-Care Diagnostic Services for Maternal Health in Lower Healthcare Facilities in Northern Ghana: A Cross-Sectional Survey

Background: Improving access to maternal healthcare in resource limited settings plays a critical role in improving maternal health outcomes and reducing maternal deaths. However, barriers and challenges may exist in rural clinics and could affect successful implementation. This study assessed the current accessibility of point-of-care (POC) diagnostic services for maternal healthcare in rural primary healthcare (PHC) clinics in Northern Ghana. Method: We randomly selected 100 PHC clinics providing maternal healthcare from a total list of 356 PHCs obtained from the regional health directorate. Selected clinics were surveyed from 15th February to 31st March, 2018 using an adopted survey tool. We obtained data for clinic-level staffing, availability, usage, and desired POC diagnostic tests. One antenatal clinic in-charge or a Physician Assistant from each facility was interviewed to assess their knowledge on POC diagnostic tests. Stata 14 was used for data analysis. Findings: Majority (64%) of the respondents were midwives. Average years of work experience and working hours per week were estimated at 5.6 (CI: 4.8-6.3) and 122 (CI: 111.9-132.6) respectively. Average antenatal clinic attendance per month was 65±67 (range 3-360). Mean POC tests available and use was 4.9 (CI: 4.5-5.4) out of 15 tests. Respondents' knowledge on POC test was 99.2 (CI: 99.7-100.5). The study found a positive correlation between availability and use though regression analysis showed no significance. POC test for malaria; HIV; urine pregnancy; and blood pressure were available in most clinics. Desired POC tests included: Glucose-6-phosphate dehydrogenase (95%); hepatitis c (94%); sickling (91%); tuberculosis, blood glucose and blood type (89%) each; urinary tract infection (87%), urine protein (81%); hepatitis b (78%); haemoglobin (76%); and syphilis (76%). Interpretation: There is poor accessibility of POC diagnostic services for maternal healthcare as results of low availability of POC tests in rural primary healthcare clinics in Northern Ghana. Funding: College of Health Sciences Scholarship. Declaration of interests: None declared. Ethics approval and consent to participate: This study was approved by the Navrongo Health Research Centre Institutional Review Board/Ghana Health Service (approval number: NHRCIRB291) and the University of KwaZulu-Natal Biomedical Research Ethics Committee (approval number: BE565/17). Permission was obtained from the Upper East Regional Health Directorate prior to conducting the study. All study participants signed an informed consent prior to participating in this study.

Addressing challenges in scaling up TB and HIV treatment integration in rural primary healthcare clinics in South Africa (SUTHI): a cluster randomized controlled trial protocol

BackgroundA large and compelling clinical evidence base has shown that integrated TB and HIV services leads to reduction in human immunodeficiency virus (HIV)- and tuberculosis (TB)-associated mortality and morbidity. Despite official policies and guidelines recommending TB and HIV care integration, its poor implementation has resulted in TB and HIV remaining the commonest causes of death in several countries in sub-Saharan Africa, including South Africa. This study aims to reduce mortality due to TB-HIV co-infection through a quality improvement strategy for scaling up of TB and HIV treatment integration in rural primary healthcare clinics in South Africa.MethodsThe study is designed as an open-label cluster randomized controlled trial. Sixteen clinic supervisors who oversee 40 primary health care (PHC) clinics in two rural districts of KwaZulu-Natal, South Africa will be randomized to either the control group (provision of standard government guidance for TB-HIV integration) or the intervention group (provision of standard government guidance with active enhancement of TB-HIV care integration through a quality improvement approach). The primary outcome is all-cause mortality among TB-HIV patients. Secondary outcomes include time to antiretroviral therapy (ART) initiation among TB-HIV co-infected patients, as well as TB and HIV treatment outcomes at 12 months. In addition, factors that may affect the intervention, such as conditions in the clinic and staff availability, will be closely monitored and documented.DiscussionThis study has the potential to address the gap between the establishment of TB-HIV care integration policies and guidelines and their implementation in the provision of integrated care in PHC clinics. If successful, an evidence-based intervention comprising change ideas, tools, and approaches for quality improvement could inform the future rapid scale up, implementation, and sustainability of improved TB-HIV integration across sub-Sahara Africa and other resource-constrained settings.Trial registrationClinicaltrials.gov, NCT02654613. Registered 01 June 2015.

Evaluating quality management systems for HIV rapid testing services in primary healthcare clinics in rural KwaZulu-Natal, South Africa.

IntroductionRapid HIV tests have improved access to HIV diagnosis and treatment by providing quick and convenient testing in rural clinics and resource-limited settings. In this study, we evaluated the quality management system for voluntary and provider-initiated point-of-care HIV testing in primary healthcare (PHC) clinics in rural KwaZulu-Natal (KZN), South Africa.Material and methodsWe conducted a quality assessment audit in eleven PHC clinics that offer voluntary HIV testing and counselling in rural KZN, South Africa from August 2015 to October 2016. All the participating clinics were purposively selected from the province-wide survey of diagnostic services. We completed an on-site monitoring checklist, adopted from the WHO guidelines for assuring accuracy and reliability of HIV rapid tests, to assess the quality management system for HIV rapid testing at each clinic. To determine clinic’s compliance to WHO quality standards for HIV rapid testing the following quality measure was used, a 3-point scale (high, moderate and poor). A high score was defined as a percentage rating of 90 to 100%, moderate was defined as a percentage rating of 70 to 90%, and poor was defined as a percentage rating of less than 70%. Clinic audit scores were summarized and compared. We employed Pearson pair wise correlation coefficient to determine correlations between clinics audit scores and clinic and clinics characteristics. Linear regression model was computed to estimate statistical significance of the correlates. Correlations were reported as significant at p ≤0.05.ResultsNine out of 11 audited rural PHC clinics are located outside 20Km of the nearest town and hospital. Majority (18.2%) of the audited rural PHC clinics reported that HIV rapid test was performed by HIV lay counsellors. Overall, ten clinics were rated moderate, in terms of their compliance to the stipulated WHO guidelines. Audit results showed that rural PHC clinics’ average rating score for compliance to the WHO guidelines ranged between 64.4% (CI: 44%– 84%) and 89.2% (CI: 74%– 100%).Ten out of eleven of the clinics were rated as moderate (70–89%). All clinic have scored highest for the following audit component: equipment; process control and specimen management; and facility ad safety, with 100%. Clinics obtained the lowest scores for the assessment audit component followed by process improvement and organisation, with 40.9% (CI: 15.7–66.1%), 45.5% (CI: 10.4–80.5%) and 56.8% (CI: 31.8 81.8%), respectively. A statistically significant correlation was observed between the following: category of staff performing the HIV rapid tests in the audited clinics and service and satisfactory audit component; weekly average number of patients using the audited PHC clinics and service and satisfactory audit component; number of HIV lay counsellors in the audited clinics and quality control audit component with p<0.05.DiscussionIn the small audit of primary healthcare clinics located within the rural part of KwaZulu-Natal, results revealed an overall moderate rating of the quality management system for rapid HIV testing. Improvements in the organisation, quality control, process improvement and assessment components could enable a higher quality assurance rating for rural HIV testing in KwaZulu-Natal.

Implementation of Point-of-Care Diagnostics in Rural Primary Healthcare Clinics in South Africa: Perspectives of Key Stakeholders.

Introduction: Key stakeholders’ involvement is crucial to the sustainability of quality point-of-care (POC) diagnostics services in low-and-middle income countries. The aim of this study was to explore key stakeholder perceptions on the implementation of POC diagnostics in rural primary healthcare (PHC) clinics in South Africa. Method: We conducted a qualitative study encompassing in-depth interviews with multiple key stakeholders of POC diagnostic services for rural and resource-limited PHC clinics. Interviews were digitally recorded and transcribed verbatim prior to thematic content analysis. Thematic content analysis was conducted using themes guided by the World Health Organisation (WHO) quality-ASSURED (Affordable, Sensitive, Specific, User friendly, Rapid and to enable treatment at first visit and Robust, Equipment free and Delivered to those who need it) criteria for POC diagnostic services in resource-limited settings. Results: 11 key stakeholders participated in the study. All stakeholders perceived the main advantage of POC diagnostics as enabling access to healthcare for rural patients. Stakeholders perceived the current POC diagnostic services to have an ability to meet patients’ needs, but recommended further improvement of the following areas: research on cost-effectiveness; improved quality management systems; development of affordable POC diagnostic and clinic-based monitoring and evaluation. Conclusions: Key stakeholders of POC diagnostics in rural PHC clinics in South Africa highlighted the need to assess affordability and ensure quality assurance of current services before adopting new POC diagnostics and scaling up current POC diagnostics.

Addressing challenges in scaling up TB and HIV treatment integration in rural primary healthcare clinics in South Africa (SUTHI): a cluster randomized controlled trial protocol

Addressing challenges in scaling up TB and HIV treatment integration in rural primary healthcare clinics in South Africa (SUTHI): a cluster randomized controlled trial protocol

Weight status and associated factors among HIV infected people on antiretroviral therapy in rural Dikgale, Limpopo, South Africa.

BackgroundUnderweight in human immunodeficiency virus (HIV)-infected people on antiretroviral therapy (ART) complicates the management of HIV infection and contributes to mortality, whereas overweight increases the risk of cardiovascular disease (CVD).AimThe study determined weight status and associated factors in people with HIV infection receiving ART.SettingRural primary health care clinics in Dikgale, Limpopo province, South Africa.MethodsA cross-sectional study in which data were collected using the World Health Organization (WHO) stepwise approach to surveillance (STEPS) questionnaire and calculated using WHO analysis programmes guide. Weight and height were measured using standard WHO procedures, and body mass index was calculated as weight (kg)/height (m2). Data on ART duration were extracted from patients’ files. CD4 lymphocyte counts and viral load were determined using standard laboratory techniques.ResultsOf the 214 participants, 8.9%, 54.7% and 36.4% were underweight, normal weight and overweight, respectively. Physical activity (OR: 0.99, p = 0.001) and male gender (OR: 0.29, p = 0.04) were negatively associated with overweight. Men who used tobacco were more likely to be underweight than non-tobacco users (OR: 10.87, p = 0.02). Neither ART duration nor viral load or CD4 count was independently associated with underweight or overweight in multivariate analysis.ConclusionA high proportion of people on ART were overweight and a smaller proportion underweight. There is a need to simultaneously address the two extreme weight problems in this vulnerable population through educating them on benefits of avoiding tobacco, engaging in physical activity and raising awareness of CVD risk.