Implementing nurse-initiated and managed antiretroviral treatment (NIMART) in South Africa: a qualitative process evaluation of the STRETCH trial

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dc.contributor.authorGeorgeu, Daniellaen_ZA
dc.contributor.authorColvin, Christopheren_ZA
dc.contributor.authorLewin, Simonen_ZA
dc.contributor.authorFairall, Laraen_ZA
dc.contributor.authorBachmann, Maxen_ZA
dc.contributor.authorUebel, Kerryen_ZA
dc.contributor.authorZwarenstein, Merricken_ZA
dc.contributor.authorDraper, Beverlyen_ZA
dc.contributor.authorBateman, Ericen_ZA
dc.date.accessioned2015-11-04T11:55:01Z
dc.date.available2015-11-04T11:55:01Z
dc.date.issued2012en_ZA
dc.description.abstractBACKGROUND: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:ISRCTN46836853en_ZA
dc.identifier.apacitationGeorgeu, D., Colvin, C., Lewin, S., Fairall, L., Bachmann, M., Uebel, K., ... Bateman, E. (2012). Implementing nurse-initiated and managed antiretroviral treatment (NIMART) in South Africa: a qualitative process evaluation of the STRETCH trial. <i>Implementation Science</i>, http://hdl.handle.net/11427/14677en_ZA
dc.identifier.chicagocitationGeorgeu, Daniella, Christopher Colvin, Simon Lewin, Lara Fairall, Max Bachmann, Kerry Uebel, Merrick Zwarenstein, Beverly Draper, and Eric Bateman "Implementing nurse-initiated and managed antiretroviral treatment (NIMART) in South Africa: a qualitative process evaluation of the STRETCH trial." <i>Implementation Science</i> (2012) http://hdl.handle.net/11427/14677en_ZA
dc.identifier.citationGeorgeu, D., Colvin, C. J., Lewin, S., Fairall, L., Bachmann, M. O., Uebel, K., ... & Bateman, E. D. (2012). Implementing nurse-initiated and managed antiretroviral treatment (NIMART) in South Africa: a qualitative process evaluation of the STRETCH trial. Implement Sci, 7(66).en_ZA
dc.identifier.ris TY - Journal Article AU - Georgeu, Daniella AU - Colvin, Christopher AU - Lewin, Simon AU - Fairall, Lara AU - Bachmann, Max AU - Uebel, Kerry AU - Zwarenstein, Merrick AU - Draper, Beverly AU - Bateman, Eric AB - 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 DA - 2012 DB - OpenUCT DO - 10.1186/1748-5908-7-66 DP - University of Cape Town J1 - Implementation Science LK - https://open.uct.ac.za PB - University of Cape Town PY - 2012 T1 - Implementing nurse-initiated and managed antiretroviral treatment (NIMART) in South Africa: a qualitative process evaluation of the STRETCH trial TI - Implementing nurse-initiated and managed antiretroviral treatment (NIMART) in South Africa: a qualitative process evaluation of the STRETCH trial UR - http://hdl.handle.net/11427/14677 ER - en_ZA
dc.identifier.urihttp://hdl.handle.net/11427/14677
dc.identifier.urihttp://dx.doi.org/10.1186/1748-5908-7-66
dc.identifier.vancouvercitationGeorgeu D, Colvin C, Lewin S, Fairall L, Bachmann M, Uebel K, et al. Implementing nurse-initiated and managed antiretroviral treatment (NIMART) in South Africa: a qualitative process evaluation of the STRETCH trial. Implementation Science. 2012; http://hdl.handle.net/11427/14677.en_ZA
dc.language.isoengen_ZA
dc.publisherBioMed Central Ltden_ZA
dc.publisher.departmentInstitute of Infectious Disease and Molecular Medicineen_ZA
dc.publisher.facultyFaculty of Health Sciencesen_ZA
dc.publisher.institutionUniversity of Cape Town
dc.rightsThis is an Open Access article distributed under the terms of the Creative Commons Attribution Licenseen_ZA
dc.rights.holder2012 Georgeu et al.; licensee BioMed Central Ltden_ZA
dc.rights.urihttp://creativecommons.org/licenses/by/2.0en_ZA
dc.sourceImplementation Scienceen_ZA
dc.source.urihttp://www.implementationscience.com/en_ZA
dc.subject.otherAntiretroviral treatmenten_ZA
dc.subject.otherNIMARTen_ZA
dc.subject.otherSouth Africaen_ZA
dc.subject.otherPrimary healthcareen_ZA
dc.subject.otherNurse trainingen_ZA
dc.subject.otherProcess evaluationen_ZA
dc.subject.otherPALSA PLUSen_ZA
dc.titleImplementing nurse-initiated and managed antiretroviral treatment (NIMART) in South Africa: a qualitative process evaluation of the STRETCH trialen_ZA
dc.typeJournal Articleen_ZA
uct.type.filetypeText
uct.type.filetypeImage
uct.type.publicationResearchen_ZA
uct.type.resourceArticleen_ZA
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