HEALTH CARE IMPROVEMENT PROJECT
Supporting Patient Self-Management to Improve Chronic HIV Care and Treatment in Tanzania Background
I
n order to strengthen HIV/AIDS services in Tanzania so that they are better adapted to the complex needs of people with chronic conditions, the USAID Health Care Improvement Project (HCI) and the Ministry of Health and Social Welfare (MOHSW) of Tanzania are applying the World Health Organization (WHO)-endorsed Chronic Care Model (CCM) at 14 health facilities in two districts in the region of Morogoro. Providers and health officials for these facilities identified patient self-management as the area of chronic care most in need of improvement and made this their primary focus. Self-management support, a key principle of the CCM, recognizes that
most decisions regarding patients’ health are made on a daily basis by patients themselves, outside of formal health care delivery settings. To achieve sustained improvements in patient outcomes and quality of life, patients need support which not only increases their knowledge about their health, but also helps to build their skills and confidence to self-manage their conditions.
Interventions HCI and district officials worked with providers on improving support for patient self-management. Different elements of chronic care were addressed as needed to strengthen patient self-management support (see Figure 1).
Figure 1. Patient self-management support interventions classified according to the Chronic Care Model (CCM) CCM Element Self Management Support
Changes to Support Patient Self-Management • Patient education, problem solving, goal setting, and action planning. • Peer mentor support.
Delivery System Design
• 55 Peer mentors trained and integrated to support self management and facility operations.
Decision Support
• Job aids and tools for providers and peer mentors to support self management.
Community Resources
Clinical Information System Organization of Health Services
• Peer mentors linked to CBOs. • Community leadres engaged. • Peer mentor self management registers introduced. • HMIS and database use strengthened. • Services re-oriented around self management support. • Integration with home-based care.
JULY 2012 This brief report was prepared by the USAID Health Care Improvement (HCI) Project, which is supported by the American people through the United States Agency for International Development (USAID), with funding support from the US President’s Emergency Plan for AIDS Relief (PEPFAR). HCI is managed by University Research Co., LLC (URC) under the terms of Contract Number GHN-I-03-07-00003-00. URC’s partners on HCI include EnCompass LLC, FHI 360, Health Research Inc./HEALTHQUAL International, Initiatives Inc., Institute for Healthcare Improvement, and Johns Hopkins University Center for Communication Programs. For more information on the work of HCI, please visit www.hciproject.org or email
[email protected].
Playing cards developed by HCI for use by peer mentors as job aids for patient education. The playing cards have messages that provoke the player to ask questions which then lead to discussion of issues faced by HIV-positive people. Photo by Delphina Ntangeki, URC.
Job aids were developed in the form of educational playing cards and pocket guides. The playing cards have messages that prompt discussions about HIV and health-related topics. The pocket guides contain questions commonly asked at the community level along with correct answers to the questions. The guides serve as a reference for peer mentors during their education sessions and as tools to guide discussions. To assist health care workers and provide expertise that comes with first-hand experience in successful HIV self-management, volunteer expert patients, referred to as “peer mentors” in Tanzania, were recruited to work with facility staff. Peer mentors assist other patients with HIV to address their individual barriers to good HIV self-management. Peer mentor roles related to selfmanagement support include: n
Helping patients to set goals and develop action plans to achieve these goals and address barriers to good self-care
n
Health education
n
ART service orientation and assistance with negotiating the health system
n
Informal counseling on various topics (adherence, disclosure, partner testing, isolation, and stigma)
n
Self-disclosure and sharing of personal experiences in living with HIV to help patients overcome their own hurdles in coping with the condition
2 Supporting Patient Self-Management in Tanzania
Expert patients role-playing in preparation for their roles as peer mentors in Morogoro Region. Photo by Suzanne Gaudreault, URC.
In addition, peer mentors have assumed routine clinic tasks to alleviate the workloads of clinic staff and streamline facility operations. Examples of such tasks include recording of patient demographics, height and weight measurement, registration, filing, and triage.
Results The role of peer mentors has increased over time. Difficulties in motivating this all-volunteer workforce, who must also earn a living, arose during the intervention but are being resolved, and practices for creating an enabling environment for peer mentors are emerging. Since the introduction of peer mentors, several patient self-management indicators have shown improvement, such as: appointment-keeping (Figure 2) and patient confidence to self-manage (Figure 3). Peer mentors continue to receive enthusiastic acceptance and praise from health workers and patients as well as ongoing support from local health officials.
Figure 2. Percentage of patients on ART keeping appointments at 10 facilities 100
72
74
71
73
73
70
82
80
77
80
91
86
88
90
78
73
70
Volunteerism contract signed
60
Start of intervention
50 40 30 20 10 0
Jan 2011
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan 2012
Figure 3. Percentage of HIV patients reporting confidence to self-manage at six facilities 100
94
90 80
67
70
71
65 59
60
Volunteerism contract signed 50
42 40
34
34
24
30
27 20 10
0
Start of intervention
Lacking incentives, some peer mentors decrease time at clinic
0
Apr 2011
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb 2012
Supporting Patient Self-Management in Tanzania 3
Key Recommendations Health systems can better adapt care for chronic conditions care by examining and addressing human resource inputs and care processes in the context of supporting patient self-management. Lessons learned from patient selfmanagement support interventions include: n
Service delivery for chronic conditions in a human resource-limited setting: As the prevalence of chronic illness increases in the face of a severe health worker shortage, peer mentors can help to address human resource constraints and alleviate the workloads of health care personnel. Peer mentors are an intrinsically engaged source of labor for improving clinic efficiency and streamlining services.
n
Patient self-management: It is critical to strengthen patient knowledge, skills, and selfconfidence to successfully overcome the problems associated with HIV and to provide good self-care from the time of diagnosis.
n
Patient/Patient collaboration: Peer mentors offer a source of expertise on chronic condition selfmanagement that is of a depth which can only be achieved by a person who successfully self-manages the condition. They are an effective means of enhancing support for people with HIV.
n
Patient/Provider collaboration: Provider assistance with self-management goals and communication between the providers and patients is enhanced by peer mentor support and feedback from peer mentors.
District official in Morogoro reads job aid (“Pocketbook of Frequently Asked Questions about HIV”) developed by HCI. Photo by Suzanne Gaudreault, URC.
USAID Health Care Improvement Project University Research Co., LLC • 7200 Wisconsin Avenue • Bethesda, MD 20814-4811 • USA TEL 301-654-8338 • FAX 301-941-8427 • www.hciproject.org
