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

 说明(申请人提供)：尽管有低成本、有效的预防艾滋病毒母婴传播的干预措施可用，并为增加可获得性进行了大量投资，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(SSA)受高度影响的地区，感染艾滋病毒的孕妇经历了一系列复杂的预防母婴传播服务。由于这一复杂的护理级联，儿童艾滋病毒感染在很大程度上仍然没有得到控制，包括在莫桑比克和肯尼亚。为了简化级联反应并改善母婴传播，世界卫生组织(WHO)在2013年发布了更新的指南，将“选项B”包括在内，即艾滋病毒感染妇女在怀孕期间开始终身抗逆转录病毒治疗(ART)，而不考虑CD4计数。备选方案B于2014年在莫桑比克和肯尼亚获得通过，但初步结果显示，抗逆转录病毒药物的遵守和保留情况并不理想。备选方案B的实施面临多种保健系统挑战；包括需要支持护士在服务管理和对符合备选方案B条件的母婴配对的临床护理中发挥更大作用。需要为护士量身定做的决策支持工具来帮助他们的 确定整个艾滋病毒护理级联系统的低效和解决方案。作为在三个SSA国家评估和迭代改进预防母婴传播的系统分析和改进方法的集群随机试验的一部分，我们开发和评估了一个基于Excel(R)的预防母婴传播级联分析工具(PCAT)，该工具为护士提供了一个系统级的视图，以快速和独立地跟踪通过预防母婴传播级联的患者流动。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疫苗提供和艾滋病毒暴露婴儿筛查的覆盖率增加了4-5倍。但PCAT的可用性受到计算机可用性和识字率低的限制，而且使用是由学习护士而不是设施人员领导的。备选方案B的具体步骤(例如，保留护理和遵守)也不是PCAT的一部分。卫生工作者容易管理的提供者决策支持工具更容易被接受、使用，并且更有潜力改善对复杂卫生服务的管理。在诊所员工的参与下，更有可能实施为特定环境量身定做的工具。在这项研究中，我们计划调整和改进基于手机的PCAT应用程序的测试版，并在莫桑比克和肯尼亚测试其可用性和可行性。这项研究将收集初步数据，以便为备选方案B(MPCAT)的移动PCAT应用(MPCAT)提供更大规模的对照试验，并建立在两个国家进行这一试验的能力。目标包括：1)确定备选方案B特定的级联措施，并将其纳入mPCAT；2)评估具有备选方案B系统分析和改进经验的护士对mPCAT的可用性；3)将mPCAT作为更广泛的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.