Organizational contextual factors that predict success of a quality improvement collaborative approach to enhance integrated HIV-tuberculosis services: a sub-study of the Scaling up TB/HIV Integration trial

Santhanalakshmi Gengiah, Catherine Connolly, Nonhlanhla Yende-Zuma, Pierre M Barker, Andrew J Nunn, Nesri Padayatchi, Myra Taylor, Marian Loveday, Kogieleum Naidoo, Santhanalakshmi Gengiah, Catherine Connolly, Nonhlanhla Yende-Zuma, Pierre M Barker, Andrew J Nunn, Nesri Padayatchi, Myra Taylor, Marian Loveday, Kogieleum Naidoo

Abstract

Background: A quality improvement (QI) collaborative approach to enhancing integrated HIV-Tuberculosis (TB) services may be effective in scaling up and improving the quality of service delivery. Little is known of the role of organizational contextual factors (OCFs) in influencing the success of QI collaboratives. This study aims to determine which OCFs were associated with improvement in a QI collaborative intervention to enhance integrated HIV-TB services delivery.

Methods: This is a nested sub-study embedded in a cluster-randomized controlled trial. Sixteen nurse supervisors (clusters) overseeing 40 clinics were randomized (1:1) to receive QI training and mentorship, or standard of care support (SOC). In the QI arm, eight nurse supervisors and 20 clinics formed a "collaborative" which aimed to improve HIV-TB process indicators, namely HIV testing, TB screening, isoniazid preventive therapy (IPT) initiations, viral load testing, and antiretroviral therapy for TB patients. OCFs measured at baseline were physical infrastructure, key staff, flexibility of clinic hours, monitoring data for improvement (MDI), and leadership support. Surveys were administered to clinic staff at baseline and month 12 to assess perceptions of supportiveness of contexts for change, and clinic organization for delivering integrated HIV-TB services. Linear mixed modelling was used to test for associations between OCFs and HIV-TB process indicators.

Results: A total of 209 clinic staff participated in the study; 97 (46.4%) and 112 (53.6%) from QI and SOC arms, respectively. There were no differences between the QI and SOC arms scores achieved for physical infrastructure (78.9% vs 64.7%; p = 0.058), key staff (95.8 vs 92; p = 0.270), clinic hours (66.9 vs 65.5; p = 0.900), MDI (63.3 vs 65; p = 0.875, leadership support (46.0 vs 57.4; p = 0.265), and perceptions of supportiveness of contexts for change (76.2 vs 79.7; p = 0.128 and clinic organization for delivering integrated HIV-TB services (74.1 vs 80.1; p = 0.916). IPT initiation was the only indicator that was significantly improved in the parent study. MDI was a significantly associated with increasing IPT initiation rates [beta coefficient (β) = 0.004; p = 0.004].

Discussion: MDI is a practice that should be fostered in public health facilities to increase the likelihood of success of future QI collaboratives to improve HIV-TB service delivery.

Trial registration: Clinicaltrials.gov , NCT02654613 . Registered 01 June 2015.

Keywords: Cluster-randomized trial; HIV-TB integration; Organizational contextual factors; Quality improvement collaboratives; South Africa.

Conflict of interest statement

The authors declare they have no conflicts of interest.

© 2021. The Author(s).

Figures

Fig. 1
Fig. 1
Timing of QI activities and data collection in the SUTHI trial. COACH, Context Assessment in Community Health; PDSA, Plan-Do-Study-Act; LS, learning session; QI, quality improvement; SOC, standard of care; TB, tuberculosis. *The standard of care arm received standard support and supervision for HIV-TB integration
Fig. 2
Fig. 2
Clinic staff categories that responded to surveys at baseline and months 6, 12, and 18. QI, quality improvement; SOC, standard of care; PHC, primary health care

References

    1. World Health Organization . Global tuberculosis report 2020. Geneva: World Health Organization; 2020.
    1. World Health Organization . WHO policy on collaborative TB/HIV activities. Guidelines for national programmes and other stakeholders. Geneva: WHO; 2012.
    1. Sinai I, Cleghorn F, Kinkel HF. Improving management of tuberculosis in people living with HIV in South Africa through integration of HIV and tuberculosis services: a proof of concept study. BMC Health Serv Res. 2018;18(1):711. doi: 10.1186/s12913-018-3524-9.
    1. South African National Department of Health. National consolidated guidelines: for the prevention of mother-to-child transmission of HIV (PMTCT) and the management of HIV in children, adolescents and adults. 2020. .
    1. Chihota VN, Ginindza S, McCarthy K, Grant AD, Churchyard G, Fielding K. Missed opportunities for TB investigation in primary care clinics in South Africa: experience from the XTEND trial. PloS One. 2015;10(9):e0138149. doi: 10.1371/journal.pone.0138149.
    1. Kweza PF, Van Schalkwyk C, Abraham N, Uys M, Claassens MM, Medina-Marino A. Estimating the magnitude of pulmonary tuberculosis patients missed by primary health care clinics in South Africa. Int J Tuberc Lung Dis. 2018;22(3):264–272. doi: 10.5588/ijtld.17.0491.
    1. Massyn N, Peer N, English R, Padarath A, Barron P, Day C, editors. District health barometer 2015/2016. Durban Health Systems Trust. 2016.
    1. Sunpath H, Hatlen TJ, Naidu KK, Msimango P, Adams RN, Moosa MS, et al. Targeting the third ʻ90ʼ: introducing the viral load champion. Public Health Action. 2018;8(4):225–231. doi: 10.5588/pha.18.0063.
    1. Naidoo K, Gengiah S, Yende-Zuma N, Padayatchi N, Barker P, Nunn A, Subrayen P, Abdool Karim SS. Addressing challenges in scaling up TB and HIV treatment integration in rural primary healthcare clinics in South Africa (SUTHI): a cluster randomized controlled trial protocol. Implement Sci. 2017;12(1):129. doi: 10.1186/s13012-017-0661-1.
    1. Wells S, Tamir O, Gray J, Naidoo D, Bekhit M, Goldmann D. Are quality improvement collaboratives effective? A systematic review. BMJ Qual Saf. 2018;27(3):226–240. doi: 10.1136/bmjqs-2017-006926.
    1. Schouten LM, Hulscher ME, van Everdingen JJ, Huijsman R, Grol RP. Evidence for the impact of quality improvement collaboratives: systematic review. BMJ. 2008;336(7659):1491–1494. doi: 10.1136/.
    1. de la Perrelle L, Radisic G, Cations M, Kaambwa B, Barbery G, Laver K. Costs and economic evaluations of quality improvement collaboratives in healthcare: a systematic review. BMC Health Serv Res. 2020;20(1):155. doi: 10.1186/s12913-020-4981-5.
    1. Franco LM, Marquez L. Effectiveness of collaborative improvement: evidence from 27 applications in 12 less-developed and middle-income countries. BMJ Qual Saf. 2011;20(8):658–665. doi: 10.1136/bmjqs.2010.044388.
    1. Garcia-Elorrio E, Rowe SY, Teijeiro ME, Ciapponi A, Rowe AK. The effectiveness of the quality improvement collaborative strategy in low- and middle-income countries: a systematic review and meta-analysis. PLoS One. 2019;14(10):e0221919. doi: 10.1371/journal.pone.0221919.
    1. Zamboni K, Baker U, Tyagi M, Schellenberg J, Hill Z, Hanson C. How and under what circumstances do quality improvement collaboratives lead to better outcomes? A systematic review. Implement Sci. 2020;15(1):27. doi: 10.1186/s13012-020-0978-z.
    1. Hargreaves S, Rustage K, Nellums LB, Bardfield JE, Agins B, Barker P, Massoud MR, Ford NP, Doherty M, Dougherty G, Singh S. Do quality improvement initiatives improve outcomes for patients in antiretroviral programs in low- and middle-income countries? A systematic review. J Acquir Immune Defic Syndr. 2019;81(5):487–496. doi: 10.1097/QAI.0000000000002085.
    1. Coles E, Anderson J, Maxwell M, Harris FM, Gray NM, Milner G, MacGillivray S. The influence of contextual factors on healthcare quality improvement initiatives: a realist review. Syst Rev. 2020;9(1):94. doi: 10.1186/s13643-020-01344-3.
    1. Kitson A, Harvey G, McCormack B. Enabling the implementation of evidence based practice: a conceptual framework. Qual Health Care. 1998;7(3):149–158. doi: 10.1136/qshc.7.3.149.
    1. Rycroft-Malone J. The PARIHS framework--a framework for guiding the implementation of evidence-based practice. J Nurs Care Qual. 2004;19(4):297–304. doi: 10.1097/00001786-200410000-00002.
    1. Ovretveit JC, Shekelle PG, Dy SM, McDonald KM, Hempel S, Pronovost P, et al. How does context affect interventions to improve patient safety? An assessment of evidence from studies of five patient safety practices and proposals for research. BMJ Qual Saf. 2011;20(7):604–610. doi: 10.1136/bmjqs.2010.047035.
    1. Brennan SE, Bosch M, Buchan H, Green SE. Measuring team factors thought to influence the success of quality improvement in primary care: a systematic review of instruments. Implement Sci. 2013;8(1):20. doi: 10.1186/1748-5908-8-20.
    1. Brennan SE, Bosch M, Buchan H, Green SE. Measuring organizational and individual factors thought to influence the success of quality improvement in primary care: a systematic review of instruments. Implement Sci. 2012;7(1):121. doi: 10.1186/1748-5908-7-121.
    1. Bergstrom A, Skeen S, Duc DM, Blandon EZ, Estabrooks C, Gustavsson P, et al. Health system context and implementation of evidence-based practices-development and validation of the Context Assessment for Community Health (COACH) tool for low- and middle-income settings. Implement Sci. 2015;10(1):120. doi: 10.1186/s13012-015-0305-2.
    1. Li SA, Jeffs L, Barwick M, Stevens B. Organizational contextual features that influence the implementation of evidence-based practices across healthcare settings: a systematic integrative review. Syst Rev. 2018;7(1):72. doi: 10.1186/s13643-018-0734-5.
    1. Institute for Healthcare Improvement . The breakthrough series: IHI’s collaborative model for achieving breakthrough improvement. Cambridge: Institute for Healthcare Improvement; 2003.
    1. Langley GJ, Moen RD, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A practical approach to enhancing organizational performance. Second ed. United States of America. 2009.
    1. Charalambous S, Grant AD, Churchyard GJ, Mukora R, Schneider H, Fielding KL. Clinic-level factors influencing patient outcomes on antiretroviral therapy in primary health clinics in South Africa. AIDS. 2016;30(7):1099–1109. doi: 10.1097/QAD.0000000000001014.
    1. Uyei J, Coetzee D, Macinko J, Weinberg SL, Guttmacher S. Measuring the degree of integrated tuberculosis and HIV service delivery in Cape Town, South Africa. Health Policy Plan. 2014;29(1):42–55. doi: 10.1093/heapol/czs131.
    1. Gengiah S, Barker PM, Yende-Zuma N, Mbatha M, Naidoo S, Taylor M, et al. A cluster-randomized controlled trial to improve the quality of integrated HIV-Tuberculosis services in primary health care clinics in South Africa. JIAS. 2021. (in press).
    1. Rendell N, Lokuge K, Rosewell A, Field E. Factors that influence data use to improve health service delivery in low- and middle-income countries. Glob Health Sci Pract. 2020;8(3):566–581. doi: 10.9745/GHSP-D-19-00388.
    1. Hulscher ME, Schouten LM, Grol RP, Buchan H. Determinants of success of quality improvement collaboratives: what does the literature show? BMJ Qual Saf. 2013;22(1):19–31. doi: 10.1136/bmjqs-2011-000651.
    1. Youngleson MS, Nkurunziza P, Jennings K, Arendse J, Mate KS, Barker P. Improving a mother to child HIV transmission programme through health system redesign: quality improvement, protocol adjustment and resource addition. PLoS One. 2010;5(11):e13891. doi: 10.1371/journal.pone.0013891.
    1. Bardfield J, Agins B, Akiyama M, Basenero A, Luphala P, Kaindjee-Tjituka F, Natanael S, Hamunime N. A quality improvement approach to capacity building in low- and middle-income countries. AIDS. 2015;29(Suppl 2):S179–S186. doi: 10.1097/QAD.0000000000000719.
    1. Ogunsola OO, Ajayi O, Ojo O, Adeyeye O, Akinro Y, Oke O, Adurogbola AA, Olajide O. Improving coverage and completion rate of isoniazid preventive therapy among eligible HIV patients using quality improvement approaches: a case study of State Hospital, Ijebu Ode, Ogun State, Nigeria. Pan Afr Med J. 2019;34:193. doi: 10.11604/pamj.2019.34.193.19360.
    1. Osibo B, Oronsaye F, Alo OD, Phillips A, Becquet R, Shaffer N, Ogirima F, Imarhiagbe C, Ameh B, Ezebuka O, Sodzi-Tettey S, Obi A, Afolabi OT, Inedu A, Anyaike C, Oyeledun B. Using small tests of change to improve PMTCT services in Northern Nigeria: experiences from implementation of a continuous quality improvement and breakthrough series program. J Acquir Immune Defic Syndr. 2017;75(Suppl 2):S165–SS72. doi: 10.1097/QAI.0000000000001369.
    1. Krishnan A, Nongkynrih B, Yadav K, Singh S, Gupta V. Evaluation of computerized health management information system for primary health care in rural India. BMC Health Serv Res. 2010;10(1):310. doi: 10.1186/1472-6963-10-310.
    1. Nutley T, Gnassou L, Traore M, Bosso AE, Mullen S. Moving data off the shelf and into action: an intervention to improve data-informed decision making in Cote d'Ivoire. Glob Health Action. 2014;7(1):25035. doi: 10.3402/gha.v7.25035.
    1. Duc DM, Bergstrom A, Eriksson L, Selling K, Thi Thu Ha B, Wallin L. Response process and test-retest reliability of the Context Assessment for Community Health tool in Vietnam. Glob Health Action. 2016;9(1):31572. doi: 10.3402/gha.v9.31572.
    1. Mocumbi S, McKee K, Munguambe K, Chiau R, Hogberg U, Hanson C, et al. Ready to deliver maternal and newborn care? Health providers' perceptions of their work context in rural Mozambique. Glob Health Action. 2018;11(1):1532631. doi: 10.1080/16549716.2018.1532631.

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