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      “It Is Like That, We Didn't Understand Each Other”: Exploring the Influence of Patient-Provider Interactions on Prevention of Mother-To-Child Transmission of HIV Service Use in Rural Tanzania

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          Abstract

          Interactions between patients and service providers frequently influence uptake of prevention of mother-to-child transmission (PMTCT) HIV services in sub-Saharan Africa, but this process has not been examined in depth. This study explores how patient-provider relations influence PMTCT service use in four government facilities in Kisesa, Tanzania. Qualitative data were collected in 2012 through participatory group activities with community members (3 male, 3 female groups), in-depth interviews with 21 women who delivered recently (16 HIV-positive), 9 health providers, and observations in antenatal clinics. Data were transcribed, translated into English and analysed with NVIVO9 using an adapted theoretical model of patient-centred care. Three themes emerged: decision-making processes, trust, and features of care. There were few examples of shared decision-making, with a power imbalance in favour of providers, although they offered substantial psycho-social support. Unclear communication by providers, and patients not asking questions, resulted in missed services. Omission of pre-HIV test counselling was often noted, influencing women's ability to opt-out of HIV testing. Trust in providers was limited by confidentiality concerns, and some HIV-positive women were anxious about referrals to other facilities after establishing trust in their original provider. Good care was recounted by some women, but many (HIV-positive and negative) described disrespectful staff including discrimination of HIV-positive patients and scolding, particularly during delivery; exacerbated by lack of materials (gloves, sheets) and associated costs, which frustrated staff. Experienced or anticipated negative staff behaviour influenced adherence to subsequent PMTCT components. Findings revealed a pivotal role for patient-provider relations in PMTCT service use. Disrespectful treatment and lack of informed consent for HIV testing require urgent attention by PMTCT programme managers. Strategies should address staff behaviour, emphasizing ethical standards and communication, and empower patients to seek information about available services. Optimising provider-patient relations can improve uptake of maternal health services more broadly, and ART adherence.

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          Most cited references 28

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          Patient-centredness: a conceptual framework and review of the empirical literature.

           P Bower,  Charles Mead (2000)
          A 'patient-centred' approach is increasingly regarded as crucial for the delivery of high quality care by doctors. However, there is considerable ambiguity concerning the exact meaning of the term and the optimum method of measuring the process and outcomes of patient-centred care. This paper reviews the conceptual and empirical literature in order to develop a model of the various aspects of the doctor-patient relationship encompassed by the concept of 'patient-centredness' and to assess the advantages and disadvantages of alternative methods of measurement. Five conceptual dimensions are identified: biopsychosocial perspective; 'patient-as-person'; sharing power and responsibility; therapeutic alliance; and 'doctor-as-person'. Two main approaches to measurement are evaluated: self-report instruments and external observation methods. A number of recommendations concerning the measurement of patient-centredness are made.
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            Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango).

            Shared decision-making is increasingly advocated as an ideal model of treatment decision-making in the medical encounter. To date, the concept has been rather poorly and loosely defined. This paper attempts to provide greater conceptual clarity about shared treatment decision-making, identify some key characteristics of this model, and discuss measurement issues. The particular decision-making context that we focus on is potentially life threatening illnesses, where there are important decisions to be made at key points in the disease process, and several treatment options exist with different possible outcomes and substantial uncertainty. We suggest as key characteristics of shared decision-making (1) that at least two participants-physician and patient be involved; (2) that both parties share information; (3) that both parties take steps to build a consensus about the preferred treatment; and (4) that an agreement is reached on the treatment to implement. Some challenges to measuring shared decision-making are discussed as well as potential benefits of a shared decision-making model for both physicians and patients.
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              Development of a framework for person-centred nursing.

              This paper presents the development and content of a person-centred nursing framework. Person-centred is a widely used concept in nursing and health care generally, and a range of literature articulates key components of person-centred nursing. This evidence base highlights the links between this approach and previous work on therapeutic caring. The framework was developed through an iterative process and involved a series of systematic steps to combine two existing conceptual frameworks derived from empirical studies. The process included the mapping of original conceptual frameworks against the person-centred nursing and caring literature, critical dialogue to develop a combined framework, and focus groups with practitioners and co-researchers in a larger person-centred nursing development and research project to test its face validity. The person-centred nursing framework comprises four constructs -prerequisites, which focus on the attributes of the nurse; the care environment, which focuses on the context in which care is delivered; person-centred processes, which focus on delivering care through a range of activities; and expected outcomes, which are the results of effective person-centred nursing. The relationship between the constructs suggests that, to deliver person-centred outcomes, account must be taken of the prerequisites and the care environment that are necessary for providing effective care through the care processes. The framework described here has been tested in a development and research project in an acute hospital setting. Whilst there is an increasing empirical base for person-centred nursing, as yet little research has been undertaken to determine its outcomes for patients and nurses. The framework developed can be described as a mid-range theory. Further testing of the framework through empirical research is required to establish its utility for nursing practice and research.
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                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, USA )
                1932-6203
                2014
                2 September 2014
                : 9
                : 9
                Affiliations
                [1 ]Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
                [2 ]National Institute for Medical Research, Mwanza, Tanzania
                Duke University Medical Center, United States of America
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Conceived and designed the experiments: AG AW IB GM DM MU. Performed the experiments: AG. Analyzed the data: AG AW. Contributed to the writing of the manuscript: AG AW IB GM DM MU. Assisted in recruitment of health officials and coordinated preparatory discussions with health facilities: DM. Coordinated fieldwork logistics in his role as overall manager of the Kisesa cohort study: MU.

                PONE-D-14-16613
                10.1371/journal.pone.0106325
                4152246
                25180575

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                Counts
                Pages: 12
                Funding
                This study was funded through the East Africa IeDEA Consortium by the United States National Institutes of Health – the Eunice Kennedy Shriver National Institute Of Child Health & Human Development (NICHD) and the National Institute Of Allergy And Infectious Diseases (NIAID), grant award 3U01AI069911-06S2 ( http://www.nih.gov/ http://www.iedea.org/) – and the Global Fund Round 9, grant number TNZ-911-G14-S ( http://www.theglobalfund.org/en/). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Medicine and health sciences
                Public and occupational health
                Preventive medicine
                HIV prevention
                Women's Health
                People and Places
                Geographical Locations
                Africa
                Research and Analysis Methods
                Research Design
                Qualitative Studies
                Custom metadata
                The authors confirm that, for approved reasons, some access restrictions apply to the data underlying the findings. Data are not publicly available due to ethical restrictions, but are available on request by contacting researchdatamanagement@ 123456lshtm.ac.uk .

                Uncategorized

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