Training CHWs to Support Re-Engagement in TB/HIV Care in the Context of Depression and Substance Use

培训社区卫生工作者支持在抑郁和药物滥用的情况下重新参与结核病/艾滋病毒护理

• 批准号: 10212231
• 负责人: Jessica F Magidson
• 金额: $ 22.97万
• 依托单位: UNIV OF MARYLAND, COLLEGE PARK
• 依托单位国家: 美国
• 财政年份: 2020
• 资助国家: 美国
• 起止时间: 2020-07-07 至 2023-05-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10212231
• 关键词: AIDS/HIV problem; Address; Affect; Africa South of the Sahara; Alcohol abuse; Behavior; Behavioral; Belief; Caring; Cause of Death; Cessation of life; Clinic; Community Health Aides; Data; Drug usage; Effectiveness; Exhibits; Feedback; HIV; HIV/TB; Health Personnel; Home; Home visitation; Incidence; Individual; Infrastructure; Interview; Link; Maintenance; Mental Depression; Mental Health; Methods; Modeling; Morbidity - disease rate; Motivation; National Institute of Mental Health; Outcome; Patient Care; Patients; Play; Population; Problem Solving; Provider; Qualitative Evaluations; Role; Sampling Studies; Site; South Africa; Structure; Training; Training Programs; Tuberculosis; Visit; Vulnerable Populations; Work; acceptability and feasibility; alcohol and other drug; antiretroviral therapy; barrier to care; base; care outcomes; co-infection; comorbidity; design; effectiveness implementation study; effectiveness implementation trial; follow-up; help-seeking behavior; implementation science; implementation strategy; improved; mortality; motivational enhancement therapy; novel; programs; skills; social stigma; substance use; treatment as usual; treatment optimization; tuberculosis treatment

Project Summary. South Africa (SA) is home to the largest number of people living HIV/AIDS (PLWH; 7.7 million) and one of the highest incidence rates of tuberculosis (TB) globally. Poor engagement in care contributes to HIV and TB morbidity and mortality in SA. Community health workers (CHWs) are frontline workers who play a central role in re-engaging patients who are lost to follow-up (LTFU) in TB/HIV care in SA. Despite existing CHW programs focused on re-engaging patients who are LTFU, people with depression, hazardous alcohol use, or other substance use (SU) are particularly susceptible to poor engagement in TB/HIV care and have a greater likelihood of being LTFU. Further, our pilot data shows that CHWs have high levels of stigma towards patients with depression, hazardous alcohol use, and other SU, which can further undermine engagement in TB/HIV care in this vulnerable population. Reducing CHW stigma towards depression and SU and providing CHWs skills to re-engage this population in care may be a unique opportunity to strengthen the TB/HIV care cascades and improve TB/HIV outcomes. Guided by the Link and Phelan stigma framework and the Situated Information Motivation Behavioral Skills Model of Care Initiation and Maintenance (sIMB-CIM), this proposal builds upon our prior work by developing and adapting a novel CHW training program to reduce CHW stigma towards depression and SU, and evaluating theoretically-driven implementation science outcomes and patient re-engagement in TB/HIV care. We are leveraging a robust, existing infrastructure of CHWs doing home visits with patients with TB/HIV co-infection who are LTFU, thus promoting the sustainability of the proposed model. We propose to (1) identify multi-level barriers and facilitators to implementing a CHW-oriented training to reduce stigma towards patients with depression and substance use to promote re-engagement in TB/HIV care by conducting semi-structured interviews with CHWs, providers, and patients with TB/HIV and depression and/or SU (n=30) and observational assessments of CHWs making home visits (n=10) to individuals with TB/HIV who were LTFU. Using this feedback, we will (2) adapt the proposed CHW training and implementation strategy and obtain feedback on the feasibility and acceptability from five CHWs and their patients (four patients each; n=20). We will then (3) evaluate the implementation and preliminary effectiveness of the adapted CHW training program to reduce CHW stigma towards depression and SU and promote re-engagement in TB/HIV care using a Type 2, hybrid effectiveness-implementation study guided by Proctor’s implementation model. We propose a stepped wedge design with six clinics (10 CHWs in each), to evaluate: 1) Feasibility, acceptability and fidelity of the CHW training (primary; implementation); 2) CHW stigma towards depression and SU among TB/HIV co- infected patients (primary; effectiveness); 3) Patient re-engagement in TB/HIV care over six months (secondary). This proposal is responsive to the FOA and NIMH priorities as an implementation science study to optimize the reach and impact of CHW programs to reduce barriers to TB/HIV care for patients with depression and SU.

项目摘要。南非 (SA) 是艾滋病毒/艾滋病感染者（PLWH；7.7）数量最多的国家。 百万），也是全球结核病 (TB) 发病率最高的国家之一。 导致南澳州艾滋病毒和结核病发病率和死亡率的第一线是社区卫生工作者 (CHW)。 在南澳结核病/艾滋病毒护理中失访患者 (LTFU) 的重新参与方面发挥着核心作用的工作人员。 尽管现有的 CHW 计划侧重于重新吸引 LTFU 患者、抑郁症患者、 危险饮酒或其他物质使用 (SU) 特别容易受到结核病/艾滋病毒参与度的影响 此外，我们的试点数据显示，社区卫生工作者的感染率较高。 使患者对抑郁症、危险饮酒和其他 SU 产生耻辱，这可能会进一步损害 减少社区卫生工作者对抑郁症和 SU 的耻辱感。 向社区卫生工作者提供技能，使这些人群重新获得护理可能是加强社区卫生服务的一个独特机会 在 Link 和 Phelan 耻辱框架以及 护理启动和维护的情景信息动机行为技能模型 (sIMB-CIM)，这 该提案建立在我们之前的工作基础上，通过开发和调整新颖的社区卫生工作者培训计划来减少社区卫生工作者 耻辱抑郁和 SU，并评估理论驱动的科学实施成果和 我们正在利用社区卫生工作者在家中提供的强大的现有基础设施，帮助患者重新参与结核病/艾滋病毒护理。 探访 LTFU 结核病/艾滋病毒双重感染患者，从而促进拟议方案的可持续性 我们建议 (1) 确定多层次的障碍和促进因素，以实施面向社区卫生工作者的培训 减少对抑郁症和药物滥用患者的耻辱，以促进重新参与结核病/艾滋病毒护理 与社区卫生工作者、提供者以及结核病/艾滋病毒和抑郁症患者进行半结构化访谈和/或 SU (n=30) 和社区卫生工作者对 TB/HIV 患者进行家访的观察性评估 (n=10) 根据这些反馈，我们将 (2) 调整拟议的 CHW 培训和实施策略。 并从五名社区卫生工作者及其患者（每名四名患者； n=20）然后我们将（3）评估改编后的CHW培训的实施情况和初步效果。 减少社区卫生工作者对抑郁症和 SU 的耻辱并促进重新参与结核病/艾滋病毒护理的计划 以 Proctor 实施模型为指导的第 2 类混合有效性实施研究。 具有六个诊所（每个诊所 10 个社区卫生工作者）的阶梯式楔形设计，用于评估： 1) 可行性、可接受性和保真度 社区卫生工作者培训（主要；实施）；2) 社区卫生工作者对结核病/艾滋病毒感染者中的抑郁症和 SU 的耻辱 感染患者（主要；有效性）；3) 患者在六个月内重新参与结核病/艾滋病毒护理（次要）。 该提案响应了 FOA 和 NIMH 的优先事项，作为一项实施科学研究，以优化 CHW 计划的覆盖面和影响力旨在减少抑郁症和 SU 患者的结核病/艾滋病毒护理障碍。