The best magazine
Abstract and Introduction
Abstract
Health care systems have been described as ideal settings for behaviour change counselling interventions. There is little research evaluating the feasibility of implementing such interventions in routine practice in primary care facilities. We implemented an intervention called Options for Health within routine adherence counselling practice in 20 antiretroviral facilities in Cape Town, South Africa. Lay counsellors were trained to use Options to help clients to optimise ARV adherence and reduce sexual risk behaviour. Counsellors delivered the intervention to 9% of eligible patients over 12 months. Interviews with counsellors revealed barriers to implementation including a lack of counselling space, time pressure and patient resistance to counselling. Counsellors felt that Options was not appropriate for use with all patients and adherence problems, and used parts of the intervention as it suited their needs. Findings revealed weaknesses in the current adherence counselling system that have implications for the feasibility of behaviour change counselling within this context.
Introduction
Healthcare providers are routinely required to give advice, support and counselling for behaviour change. There has been much research around the development and evaluation of clinician-delivered counselling interventions for various health risk behaviours including smoking and high-risk alcohol use. In particular, strategies based on the principles of Motivational Interviewing (MI) (referred to as "behaviour change counselling" or "BCC") have become increasingly popular. There is evidence that such interventions delivered by healthcare professionals in research settings out-perform traditional advice-giving in the management of health behaviour problems and disease. This includes adherence to chronic medication such as antiretrovirals (ARVs) (e.g., ).
BCC interventions have been shown to be effective when encounters are as brief as 15 min, however the likelihood of achieving the intended effect is increased by more than one encounter. Health care systems have been described as ideal settings for behaviour change counselling. This is because of the repeated contact between health care providers and recipients associated with chronic care, which offers the opportunity to monitor progress, adjust behaviour change plans, sustain motivation and maintain positive change.
Options for Health is a BCC intervention aimed at reducing sexual risk behaviour among people attending HIV clinical care. Within the context of a randomised control trial (RCT), Cornman et al. assessed the feasibility of implementing Options for Health within routine clinical care at a hospital-based ARV clinic in KwaZulu-Natal, South Africa. Using three lay ARV adherence counsellors to deliver the intervention, the researchers showed a significant decrease in the number of unprotected sexual events occurring among patients having received the intervention as compared to a standard-of-care control. A review of the patient record forms completed as a part of the Options counselling protocol indicated that the intervention was delivered in 99% of routine patient visits. In total, 103 patients received the intervention, with an average of 2.5 sessions being delivered per patient over a 6 months period. More recently Peltzer et al. implemented Options for Health within the routine HIV counselling and testing service provided by 26 lay counsellors at 13 primary health care clinics in Mpumalanga, South Africa. Results of their pre-post implementation evaluation indicated a significant decrease in sexual risk behaviour, including the use of alcohol and/or drugs in a sexual context. Their assessment of feasibility, also based on a review of patient record forms, indicated that Options was delivered in 98% of counsellor-patient encounters. In total, 488 patients received the intervention, with an average of 2.3 sessions per patient being delivered over a 2 month period.
These data suggest the feasibility of implementing a BCC intervention in South African HIV clinic settings. Research focused on outcomes imposes an infrastructure that is not necessarily present in everyday practice however, and considerable support is usually provided to achieve fidelity of implementation. For example counsellors in Kwa-Zulu Natal were observed "in vivo" for adherence to the Options protocol, and supervision was provided on a weekly basis by a member of the clinic staff. In the study by Peltzer et al. counsellors were compensated R10 (US$1.2) for each Options session conducted and record form completed, and the number of patients receiving Options was capped at 4 per day. Counsellors also received monthly support visits from both trainers and research staff.
We implemented Options for Health: Western Cape (Options WC) within routine ARV adherence counselling practice over 12 months in 20 ARV clinics in Cape Town. Implementation was in response to findings that as many as 44.7% of people initiating ARV treatment in public health clinics in Cape Town had had unprotected sex at last sex. The adherence counselling programme offered the opportunity to combine HIV treatment with prevention. In contrast to the studies described above, implementation was long-term and not incentivised. Options was intended to replace the model according to which adherence counselling is currently practiced, and support for counsellors was provided in a manner consistent with support provided as a part of the regular counselling programme. We conducted process evaluation activities in preparation for an effectiveness trial in which patient outcomes were to be assessed. The aim of the process evaluation was to monitor the extent to which Options was delivered to eligible patients (referred to as intervention coverage), in order to inform the trial findings. In addition, we aimed to determine factors affecting the implementation of the intervention. This paper reports on findings regarding coverage and barriers to the implementation of the intervention.
Source: ...