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Publication Details
AFRICAN RESEARCH NEXUS
SHINING A SPOTLIGHT ON AFRICAN RESEARCH
Implementing nurse-initiated and managed antiretroviral treatment (NIMART) in South Africa: a qualitative process evaluation of the STRETCH trial
Implementation Science, Volume 7, No. 1, Article 66, Year 2012
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Description
Background: Task-shifting is promoted widely as a mechanism for expanding antiretroviral treatment (ART) access. However, the evidence for nurse-initiated and managed ART (NIMART) in Africa is limited, and little is known about the key barriers and enablers to implementing NIMART programmes on a large scale. The STRETCH (Streamlining Tasks and Roles to Expand Treatment and Care for HIV) programme was a complex educational and organisational intervention implemented in the Free State Province of South Africa to enable nurses providing primary HIV/AIDS care to expand their roles and include aspects of care and treatment usually provided by physicians. STRETCH used a phased implementation approach and ART treatment guidelines tailored specifically to nurses. The effects of STRETCH on pre-ART mortality, ART provision, and the quality of HIV/ART care were evaluated through a randomised controlled trial. This study was conducted alongside the trial to develop a contextualised understanding of factors affecting the implementation of the programme.Methods: This study was a qualitative process evaluation using in-depth interviews and focus group discussions with patients, health workers, health managers, and other key informants as well as observation in clinics. Research questions focused on perceptions of STRETCH, changes in health provider roles, attitudes and patient relationships, and impact of the implementation context on trial outcomes. Data were analysed collaboratively by the research team using thematic analysis.Results: NIMART appears to be highly acceptable among nurses, patients, and physicians. Managers and nurses expressed confidence in their ability to deliver ART successfully. This confidence developed slowly and unevenly, through a phased and well-supported approach that guided nurses through training, re-prescription, and initiation. The research also shows that NIMART changes the working and referral relationships between health staff, demands significant training and support, and faces workload and capacity constraints, and logistical and infrastructural challenges.Conclusions: Large-scale NIMART appears to be feasible and acceptable in the primary level public sector health services in South Africa. Successful implementation requires a comprehensive approach with: an incremental and well supported approach to implementation; clinical guidelines tailored to nurses; and significant health services reorganisation to accommodate the knock-on effects of shifts in practice.Trial registration: ISRCTN46836853. © 2012 Georgeu et al.; licensee BioMed Central Ltd.
Authors & Co-Authors
Georgeu, Daniella
South Africa, Cape Town
University of Cape Town Lung Institute
Colvin, Christopher J.
South Africa, Cape Town
Faculty of Health Sciences
Lewin, Simon A.
Norway, Oslo
Nasjonalt Kunnskapssenter for Helsetjenesten
South Africa, Tygerberg
South African Medical Research Council
Fairall, Lara R.
South Africa, Cape Town
University of Cape Town Lung Institute
South Africa, Cape Town
Faculty of Health Sciences
Bachmann, Max Oscar
United Kingdom, Norwich
University of East Anglia, Norwich Medical School
Uebel, Kerry E.
South Africa, Cape Town
University of Cape Town Lung Institute
South Africa, Bloemfontein
University of the Free State, School of Medicine
Zwarenstein, Merrick F.
South Africa, Cape Town
University of Cape Town Lung Institute
South Africa, Cape Town
Faculty of Health Sciences
Canada, Toronto
University of Toronto
Draper, Beverly
South Africa, Cape Town
University of Cape Town Lung Institute
Bateman, E. D.
South Africa, Cape Town
University of Cape Town Lung Institute
South Africa, Cape Town
Faculty of Health Sciences
Statistics
Citations: 119
Authors: 9
Affiliations: 7
Identifiers
Doi:
10.1186/1748-5908-7-66
e-ISSN:
17485908
Research Areas
Health System And Policy
Infectious Diseases
Study Design
Randomised Control Trial
Study Approach
Qualitative
Study Locations
South Africa