The impact of leadership hubs on the uptake of evidence-informed nursing practices and workplace policies for HIV care: a quasi-experimental study in Jamaica, Kenya, Uganda and South Africa

Abstract

BackgroundThe enormous impact of HIV on communities and health services in Sub-Saharan Africa and the Caribbean has especially affected nurses, who comprise the largest proportion of the health workforce in low- and middle-income countries (LMICs). Strengthening action-based leadership for and by nurses is a means to improve the uptake of evidence-informed practices for HIV care.MethodsA prospective quasi-experimental study in Jamaica, Kenya, Uganda and South Africa examined the impact of establishing multi-stakeholder leadership hubs on evidence-informed HIV care practices. Hub members were engaged through a participatory action research (PAR) approach. Three intervention districts were purposefully selected in each country, and three control districts were chosen in Jamaica, Kenya and Uganda. WHO level 3, 4 and 5 health care institutions and their employed nurses were randomly sampled. Self-administered, validated instruments measured clinical practices (reports of self and peers), quality assurance, work place policies and stigma at baseline and follow-up. Standardised average scores ranging from 0 to 1 were computed for clinical practices, quality assurance and work place policies. Stigma scores were summarised as 0 (no reports) versus 1 (one or more reports). Pre-post differences in outcomes between intervention and control groups were compared using the Mantel Haenszel chi-square for dichotomised stigma scores, and independent t tests for other measures. For South Africa, which had no control group, pre-post differences were compared using a Pearson chi-square and independent t test. Multivariate analysis was completed for Jamaica and Kenya. Hub members in all countries self-assessed changes in their capacity at follow-up; these were examined using a paired t test.ResultsResponse rates among health care institutions were 90.2 and 80.4 % at baseline and follow-up, respectively. Results were mixed. There were small but statistically significant pre-post, intervention versus control district improvements in workplace policies and quality assurance in Jamaica, but these were primarily due to a decline in scores in the control group. There were modest improvements in clinical practices, workplace policies and quality assurance in South Africa (pre-post) (clinical practices of self—pre 0.67 (95 % CI, 0.62, 0.72) versus post 0.78 (95 % CI, 0.73–0.82), p = 0.002; workplace policies—pre 0.82 (95 % CI, 0.70, 0.85) versus post 0.87 (95 % CI, 0.84, 0.90), p = 0.001; quality assurance—pre 0.72 (95 % CI, 0.67, 0.77) versus post 0.84 (95 % CI, 0.80, 0.88)). There were statistically significant improvements in scores for nurses stigmatising patients (Jamaica reports of not stigmatising—pre-post intervention 33.9 versus 62.4 %, pre-post control 54.7 versus 64.4 %, p = 0.002—and Kenya pre-post intervention 35 versus 51.6 %, pre-post control 34.2 versus 47.8 %, p = 0.006) and for nurses being stigmatised (Kenya reports of no stigmatisation—pre-post intervention 23 versus 37.3 %, pre-post control 15.4 versus 27 %, p = 0.004). ...

Combating HIV stigma in low‐ and middle‐income healthcare settings: a scoping review

“…Review of the titles and abstracts identified 80 studies for full-text examination, after which 19 studies were found to meet criteria regarding the outcome of interest (enacted healthcare stigma), the study population (healthcare workers) and study design (intervention; Figure 1). Most of the studies were published as full articles in peer reviewed journals [44][45][46][47][48][49][50][51][52][53][54][55][56][57], with the remainder published as conference abstracts [58][59][60] or public reports [61][62][63] (Table 1). According to the World Bank geoscheme [89], a third of studies were located in sub-Saharan Africa [45,48,57,59,61,63,83] followed by South Asia [44,54,55,58,60,62].…”

“…Only one study was conducted in the Middle East and Northern Africa [53] (Figure 2). Additionally, two studies had sites in multiple countries, most of which were collectively located in sub-Saharan Africa [47], but one of which also had a single site in Latin American and the Caribbean [56]. The most common study design was a single group pre/post-test comparison [44,45,47,51,52,54,57,59,60,62,63] followed by pre/post-test comparisons with a control group [46,49,55,56,58,61,63] (including one that used a comparative effectiveness trial design [49]) and RCTs [48,50,75].…”

“…Regarding impact, all but one study [47] reported that their intervention was effective in reducing HIV stigma in healthcare settings. However, in 10 of the studies [44,45,48,[55][56][57][58][59]63,76], the overall conclusion was drawn from selectively focusing on the subset of stigma scale items where a significant effect was observed. In these cases, changes in the other scale items either lacked statistical significance or in one case the control condition experienced greater stigma reduction than the intervention [56].…”

“…Of these, three described steps taken to validate the measure, whether by conducting psychometric analyses of the scales [46,57] or by pilot-testing questions with local community members [48]. The remainder of studies relied on existing stigma measurement tools which were either used "as is" [44,45,47,52,55,56,60,75] or with modifications informed by consultation with local experts [53,62,63] or by pre-testing the instrument in target communities [49,54].…”

The path to longer and healthier lives for all Africans by 2030: the Lancet Commission on the future of health in sub-Saharan Africa

“…Action research on the initiative suggests absorptive capacity can be strengthened and consequently improve evidencebased HIV care but only if the initiatives are formally mainstreamed into the health authorities which can sustain them. 102 A qualitative study involving interviews with health-care leaders in Ethiopia, Ghana, Liberia, and Rwanda identified five key themes central to effective leadership: "having an aspirational, valuebased vision for improving the future health of the country; being self-aware and having the ability to identify and use complementary skills of others; investing in and managing relationships; using data in decision making; and sustaining a commitment to learning". 103 The study identified a gap in the use of data to monitor and improve performance.…”