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Global Health: Science and Practice

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Original Articles
Open Access

Improving performance of Zambia Defence Force antiretroviral therapy providers: evaluation of a standards-based approach

Young Mi Kim, Joseph Banda, Webby Kanjipite, Supriya Sarkar, Eva Bazant, Cyndi Hiner, Maya Tholandi, Stephanie Reinhardt, Panganani Dalisani Njobvu, Adrienne Kols and Bruno Benavides
Global Health: Science and Practice August 2013, 1(2):213-227; https://doi.org/10.9745/GHSP-D-13-00053
Young Mi Kim
aJhpiego/USA, an affiliate of Johns Hopkins University, Baltimore, MD, USA
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  • For correspondence: ymkim@jhpiego.net
Joseph Banda
bJhpiego/Zambia, an affiliate of Johns Hopkins University, Lusaka, Zambia
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Webby Kanjipite
bJhpiego/Zambia, an affiliate of Johns Hopkins University, Lusaka, Zambia
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Supriya Sarkar
aJhpiego/USA, an affiliate of Johns Hopkins University, Baltimore, MD, USA
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Eva Bazant
aJhpiego/USA, an affiliate of Johns Hopkins University, Baltimore, MD, USA
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Cyndi Hiner
aJhpiego/USA, an affiliate of Johns Hopkins University, Baltimore, MD, USA
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Maya Tholandi
aJhpiego/USA, an affiliate of Johns Hopkins University, Baltimore, MD, USA
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Stephanie Reinhardt
aJhpiego/USA, an affiliate of Johns Hopkins University, Baltimore, MD, USA
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Panganani Dalisani Njobvu
cZambia Defence Force (ZDF), Defence Force Medical Services (DFMS), Lusaka, Zambia
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Adrienne Kols
aJhpiego/USA, an affiliate of Johns Hopkins University, Baltimore, MD, USA
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Bruno Benavides
aJhpiego/USA, an affiliate of Johns Hopkins University, Baltimore, MD, USA
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Figures & Tables

Figures

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  • Figure 1.
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    Figure 1.

    The 4 Steps of the Standards-Based Management and Recognition (SBM-R) Approach

  • Figure 2.
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    Figure 2.

    Provider Performance: Percentage of Verification Criteria Achieved

    n  =  175 at baseline; 179 at endline.

    *P<.001

Tables

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    • View popup
    Table 1. Facility Readiness Standards, Standards-Based Management and Recognition
    ART Readiness StandardsNo. of Verification CriteriaGeneral Readiness StandardsNo. of Verification Criteria
    ART drug requisition: system for reordering drugs is properly managed5Staffing: sufficient staff are available for daily operations3
    ART drug storage: drugs are properly stored, tracked, and issued9Infrastructure: staff and client comfort and safety are assured6
    Pharmacist counseling: information on ART drugs is offered to clients9Supplies: sufficient stocks of critical supplies are available3
    Individual monitoring plan: plan is developed with client to monitor adherence and toxicities8Management systems: referral, scheduling, communication, and evaluation systems are working7
    Checking adherence: follow-up visits reinforce adherence to treatment, answer questions, and dispense drugs11Waste disposal: waste is handled and disposed of properly5
    Access to lab tests: clients' access to required laboratory tests is ensured2Client records: client files are kept confidential and are readily available5
    Blood drawing: infection prevention and other guidelines are followed9Health information system: timely collection, analysis, and reporting5
    Transport of blood samples: proper collection and transport to laboratory3Performance improvement: ongoing implementation of performance improvement activities5
    Maximum possible ART facility readiness score56Maximum possible general facility readiness score39
    • Abbreviation: ART, antiretroviral therapy.

    • View popup
    Table 2. Performance Standards for Provision of ART Services, Standards-Based Management and Recognition
    StandardNo. of Verification CriteriaContent
    Initial assessment of patient's condition6Greetings, registration, ask about patient well-being, review medical history
    Assessment of opportunistic infections3Rule out pneumocystis pneumonia, cryptococcal meningitis, and tuberculosis
    Assessment of adverse reactions6Inquire about sleeping problems, nausea, yellow eyes, shortness of breath, etc., and offer reassurance
    Assessment of potential drug interactions3Ask about new medications, document concurrent medications, check for drug interactions
    General health assessment3Inquire about contraception, pregnancy, alcohol and recreational drug use, depression; perform targeted physical exam; request and review laboratory tests
    Verification of how patient is taking ART and cotrimoxazole9Check medication schedule, supplies, missed doses; reinforce adherence; address patient concerns
    Addressing identified issues, as needed8Manage infections, adverse reactions, laboratory abnormalities; make referrals for social services
    Concluding the consultation5Address patient questions, plan return visit, complete registers and applicable forms
    Nutrition counseling5Discuss diet, food preparation, boiling drinking water, hand washing
    Maximum possible ART follow-up score48
    • Abbreviation: ART, antiretroviral therapy.

    • View popup
    Table 3. Percentage Distribution of ART Client Characteristics in Zambia Defence Force Facilities, by Round of Data Collection and Study Group
    BaselineEndline
    CharacteristicsComparison Group
    (n = 94)
    Intervention Group
    (n = 81)
    P valueComparison Group
    (n = 98)
    Intervention Group
    (n = 81)
    P value
    Sex
    Male60.950.6.18a32.753.1.006a
    Female39.149.467.446.9
    Age, in years
    Mean (SD)37.3 (8.3)33.0 (9.4).001b34.3 (11.9)35.8 (10.8).39b
    Educational attainment
    Some primary12.16.3.14a19.017.3.01a
    Primary or52.845.057.939.5
    some secondary
    Secondary35.248.823.243.2
    or higher education
    Pregnant(among women only)
    Yes10.810.8.99a7.98.3.94a
    No89.289.292.191.7
    First or later ART follow-up visit
    First8.81.2.03a7.010.0.78a
    Second3.38.610.510.0
    Third or more87.990.182.680.0
    Duration of ART
    ≤1 year42.738.5.85a36.633.8.63a
    2 years40.743.628.023.8
    3+ years16.518.035.542.5
    • Abbreviations: ART, antiretroviral therapy; SD, standard deviation.

    • P values ≤ .05 were considered statistically significant.

    • ↵a P value from χ2 test

    • ↵b P value from t-test

    • View popup
    Table 4. Facility Readiness to Offer Good-Quality Services: Percentage of Verification Criteria Achieved, by Data Collection Round and Study Group, Among Zambia Defence Force Health Facilities
    Readiness Standardsa (No. of Criteria)Comparison Group (n = 4)Intervention Group (n = 4)
    BaselineEndlineChange (% points)BaselineEndlineChange (% points)
    ART facility readiness
    ART drug requisition (5)100.0100.00100.0100.00
    ART drug storage (9)92.685.2−7.485.291.7+6.5
    Pharmacist counseling (8)85.163.2−19.992.675.0−17.6
    Individual monitoring plans (8)81.365.2−16.175.078.1+3.1
    Checking adherence (12)63.273.2+10.051.576.7+25.2
    Access to lab tests (2)75.066.7−8.3100.0100.00
    Blood drawing (9)96.477.8−18.6100.094.4−5.6
    Transport of blood samples (3)50.050.0062.587.5+25.0
    Total ART readiness score (56)83.778.2−5.588.586.2−2.3
    General facility readiness
    Staffing (3)91.7100.0+8.3100.091.7−8.3
    Infrastructure (6)75.079.2+4.286.795.8+9.1
    Supplies (3)83.388.9+5.6100.0100.00
    Management systems (7)100.096.4−3.695.8100.0+4.2
    Waste disposal (5)80.073.8−6.295.090.0+5.0
    Client records (5)95.0100.0+5.095.085.0−10.0
    Health information system (5)95.080.0−15.095.0100.0+5.0
    Performance improvement (5)80.085.0+5.090.0100.0+10.0
    Total general readiness score (39)85.893.9+8.192.595.1+3.4
    • Abbreviation: ART, antiretroviral therapy.

    • The number of criteria observed at each of the 4 facilities was summed for each readiness standard. This sum was calculated as a percentage of the total number of criteria for each standard, multiplied by 4 to include all 4 facilities.

    • ↵a Missing values removed from numerator and denominator. N/A values recoded as missing.

    • View popup
    Table 5. ART Performance: Results of Bivariate and Multivariate Analyses of Percentage of ART Verification Criteria Achieved, by Data Collection Round and Study Condition, Among Zambia Defence Force Health Facilities
    Bivariate Analysis
    ART Performance Standard and Study Condition% AchievedChange From Baseline to Endline Within GroupMultivariate Analysisa
    Baseline
    (n = 175)
    Endline
    (n = 179)
    % PointsP valueAdjusted P value for Change Within GroupP value for Interaction
    Initial assessment of patient's condition
    Comparison90.192.3+2.2.08.67.001
    Intervention79.699.1+19.5.001.001
    Check for signs of opportunistic infections
    Comparison86.267.8−18.4.001.28.13
    Intervention65.282.9+17.7.001.33
    Assessment of adverse reactions
    Comparison61.250.0−11.2.005.001.10
    Intervention44.078.9+34.9.001.22
    Assessment of potential drug interactions
    Comparison44.279.8+35.6.001.001.26
    Intervention33.180.7+47.6.001.001
    General health assessment
    Comparison68.383.5+15.2.001.25.29
    Intervention62.393.0+30.7.001.001
    Verify how patient is taking ART
    Comparison57.084.6+27.6.001.05.93
    Intervention59.891.0+31.2.001.02
    Addressing identified issues
    Comparison32.960.1+27.2.001.20.93
    Intervention45.085.4+40.4.001.001
    Concluding the consultation
    Comparison100.098.7−1.3.06.17.83
    Intervention100.098.1−1.9.03.25
    Nutrition counseling
    Comparison4.62.0−2.6.09.41.001
    Intervention1.642.3+40.7.001.001
    Overall ART score
    Comparison62.269.6+7.4.001.13.09
    Intervention57.584.2+26.7.001.008
    • Abbreviation: ART, antiretroviral therapy.

    • P values ≤ .05 were considered statistically significant.

    • ↵a Results from generalized linear regression with Poisson distribution adjusted for Zambia Defence Force branch and clustering within a facility.

Additional Files

  • Figures
  • Tables
  • GHSP-D-13-00053 Supplementary Material

    The Zambia Defence Force has applied the Standards-Based Management and Recognition (SBM-R) approach at some of their military health facilities to improve antiretroviral therapy (ART) services. A study evaluating the effectiveness of the SBM-R approach examined 2 components of quality of care: (1) facilities' readiness to offer ART services, and (2) providers' performance during ART follow-up consultations. Readers are free to use or adapt the data collection tools below used in the study to evaluate these 2 quality components in their own programs and studies.

    Files in this Data Supplement:

    • Supplementary Material - Kim, et al. doi: 10.9745/GHSP-D-13-00053 Observation Checklist: Antiretroviral Treatment (ART) Follow up
    • Supplementary Material - Kim, et al. doi: 10.9745/GHSP-D-13-00053 Performance Standards for Providing Antiretroviral Treatment (ART) in Zambia: Preparedness/Support Systems
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Global Health: Science and Practice: 1 (2)
Global Health: Science and Practice
Vol. 1, No. 2
August 01, 2013
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Improving performance of Zambia Defence Force antiretroviral therapy providers: evaluation of a standards-based approach
Young Mi Kim, Joseph Banda, Webby Kanjipite, Supriya Sarkar, Eva Bazant, Cyndi Hiner, Maya Tholandi, Stephanie Reinhardt, Panganani Dalisani Njobvu, Adrienne Kols, Bruno Benavides
Global Health: Science and Practice Aug 2013, 1 (2) 213-227; DOI: 10.9745/GHSP-D-13-00053

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Improving performance of Zambia Defence Force antiretroviral therapy providers: evaluation of a standards-based approach
Young Mi Kim, Joseph Banda, Webby Kanjipite, Supriya Sarkar, Eva Bazant, Cyndi Hiner, Maya Tholandi, Stephanie Reinhardt, Panganani Dalisani Njobvu, Adrienne Kols, Bruno Benavides
Global Health: Science and Practice Aug 2013, 1 (2) 213-227; DOI: 10.9745/GHSP-D-13-00053
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