Usability and Feasibility of a Phone-based Decision Support Tool for Option B+

 描述（由申请人提供）：尽管有低成本、有效的干预措施来预防母婴艾滋病毒传播（pMTCT），并有大量投资来增加其可用性，但将科学进步转化为实践的情况并不理想。在撒哈拉以南非洲受影响严重的地区，感染艾滋病毒的孕妇需要接受一系列复杂的预防母婴传播服务。由于这种复杂的护理级联，儿童艾滋病毒感染在很大程度上仍然不受控制，包括在莫桑比克和肯尼亚。为了简化级联并改进预防母婴传播，世界卫生组织（世卫组织）于2013年发布了更新的指导方针，纳入了“选项B+"，即感染艾滋病毒的妇女在怀孕期间开始终身抗逆转录病毒治疗（ART），而无论CD 4计数如何。2014年，莫桑比克和肯尼亚采用了备选方案B+，但初步结果显示，抗逆转录病毒药物的坚持和保留情况并不理想。方案B+的实施面临着多种卫生系统挑战;包括需要支持护士在方案B+合格母婴对的服务管理和临床护理中发挥更大的作用。需要为护士量身定制的决策支持工具，以帮助他们 确定艾滋病毒护理级联系统的效率低下和解决方案。作为在三个sSA国家评估和迭代改进pMTCT的系统分析和改进方法的群集随机试验的一部分，我们开发并评估了基于Excel（r）的pMTCT级联分析工具（PCAT），该工具为护士提供了系统级视图，以快速独立地跟踪pMTCT级联中的患者流量。当与持续的质量改进相结合时，干预措施与孕产妇抗逆转录病毒药物供应和艾滋病毒暴露婴儿筛查覆盖率增加4-5倍有关。但是PCAT的可用性受到计算机可用性和识字率低的抑制，并且由研究护士而不是设施人员领导使用。备选方案B+-具体步骤（如继续护理和坚持）也不是《预防酷刑和其他残忍、不人道或有辱人格的待遇或处罚公约》的一部分。易于卫生工作者管理的提供者决策支持工具更容易被接受、可用，并且更有潜力改善复杂卫生服务的管理。更有可能实施针对特定环境定制的工具，并让诊所工作人员参与其中。在这项研究中，我们计划调整和完善基于手机的PCAT应用程序的beta测试版本，并在莫桑比克和肯尼亚测试其可用性和可行性。本研究将收集初步数据，为方案B+（mPCAT）的移动的PCAT应用的大型对照试验提供信息，并建立在两个国家开展本试验的能力。目标包括：1）确定选项B+特定级联措施并纳入mPCAT; 2）在有选项B+系统分析和改进经验的护士中评估mPCAT的可用性; 3）将mPCAT作为更广泛系统分析和改进方法的一部分进行可行性测试。

 DESCRIPTION (provided by applicant): Despite the availability of low-cost, efficacious interventions to prevent mother-to-child HIV transmission (pMTCT), and significant investments to increase their availability, the translation of scientific advances into practice has been sub-optimal. In highly affected regions in sub-Saharan Africa (sSA), HIV-infected pregnant women navigate a complex, sequential cascade of pMTCT services. Due to this complex care cascade, pediatric HIV infection remains largely uncontrolled, including in Mozambique and Kenya. To simplify the cascade and improve pMTCT, the World Health Organization (WHO) released updated guidelines in 2013 to include "Option B+", in which HIV-infected women initiate life-long anti-retroviral therapy (ART) during pregnancy regardless of CD4 count. Option B+ was adopted in Mozambique and Kenya in 2014, but initial results show sub-optimal ARV adherence and retention. Multiple health system challenges to Option B+ implementation exist; including the need to support the expanded role of nurses in service management and clinical care of Option B+ eligible mother-infant pairs. Decision-support tools tailored to nurses are needed to help their identification of systems inefficiencies and solutions across the HIV care cascade. As part of a cluster randomized trial of a systems analysis and improvement approach to assess and iteratively improve pMTCT in three sSA countries, we developed and evaluated an Excel(r)-based pMTCT cascade analysis tool (PCAT) that provides a systems-level view for nurses to rapidly and independently track patient flow through the pMTCT cascade. When combined with continuous quality improvement, the intervention was associated with a 4-5 fold greater rate of increase in coverage of maternal ARV provision and HIV-exposed infant screening. But the PCAT's usability was inhibited by low computer availability and literacy, and use was led by study nurses rather than facility personnel. Option B+-specific steps (e.g. retention in care and adherence), were also not part of the PCAT. Provider decision- support tools that are easily managed by health workers are more acceptable, usable and have more potential to improve management of complex health services. Tools tailored to specific environments with engagement from clinic staff are more likely to be implemented. In this study, we plan to adapt and refine a beta-tested version of a phone-based PCAT application, and test its usability and feasibility in Mozambique and Kenya. This study will collect preliminary data to inform a larger, controlled trial of the mobile PCAT application for Option B+ (mPCAT) and build capacity to conduct this trial in both countries. Aims include: 1) Identify Option B+-specific cascade measures and incorporate into the mPCAT; 2) Assess the usability of the mPCAT among nurses experienced with systems analysis and improvement for Option B+; 3) Feasibility test the mPCAT as part of a broader systems analysis and improvement approach.