Abstract
Background: South Africa has seen strides in reducing HIV and tuberculosis (TB); however, adherence counselling for people living with HIV (PLHIV) coinfected with TB remains a challenge, particularly in specific sub-districts like Cape Town. Understanding the attributes of existing training programmes is crucial.
Objectives: This study explored attributes of training programme development for nurses and other health professionals to enhance adherence counselling for PLHIV coinfected with TB in Cape Town.
Method: An integrative literature review was conducted in five steps following PRISMA guidelines. Electronic searches encompassed multiple databases: COCHRANE, PsycINFO, PUBMED, ENMBASE, Science Direct, SCOPUS, SocINDEX, Academic Search Complete, Eric, SABINET, Health Resources and World Health Organization Global Health Library Regional Indexes. Inclusion criteria encompassed English language, peer-reviewed full-text studies on training programme development, qualitative and quantitative, published between January 2012 and May 2021. Exclusion criteria included non-English articles, conference proceedings and irrelevant studies. Thematic data analysis synthesised findings.
Results: Three main themes emerged: participant identification, key programme content and programme implementation process, crucial for effective training programme development.
Conclusion: Identifying participants, defining programme content and outlining implementation processes are pivotal in enhancing nurses’ adherence counselling skills. This approach could stabilise patient treatment adherence, potentially reducing treatment default, loss to follow-up and mortality rates.
Contribution: These findings lay the groundwork for developing effective training programmes aimed at improving adherence counselling among nurses.
Keywords: attributes; training programme development; HIV; TB; coinfection; adherence counselling; nurse.
Introduction
Tuberculosis (TB) is a chronic infectious disease that has represented a major health problem over the centuries, and it has accounted for more human misery, suffering and loss of earning and failure of economic and social development than any other disease (Obeagu & Onuoha 2023).
According to the World Health Organization (WHO 2018) Global Tuberculosis Report, HIV and TB coinfection is a lethal combination, each speeding the other’s progress. People living with HIV (PLHIV) and TB account for one in three HIV-related deaths across the world (Joint United Nations Protocol on HIV and AIDS 2017).
Sub-Saharan Africa is the hardest-hit region, with approximately 70% of all PLHIV coinfected with TB worldwide (Joint United Nations Programme on HIV/AIDS [UNAIDS] 2016). The Stop TB Partnership and the Global Fund to Fight AIDS, TB and Malaria launched Find, Treat All, a joint initiative to scale up the End TB response towards universal access to TB prevention and care (WHO et al. 2020). This initiative stresses the need for a multisectoral approach to addressing the specific needs of PLHIV and TB coinfection (WHO 2018).
Reports published on the HIV and TB coinfection in South Africa highlight that about 35% of deaths among the coinfected persons were because of TB disease (Massyn et al. 2016). Ending the TB epidemic by 2030 is among the health targets of the Sustainable Development Goals (SDG) (Massyn et al. 2018). Adherence to treatment remains the main challenge (Nezenega, Perimal-Lewis & Maeder 2020). This assertion is confirmed in the South African Adherence Guidelines for HIV, TB and noncommunicable diseases (NCDs) (National Department of Health [NDoH] 2016).
The South Africa Strategy Plan (NSP) on HIV, TB and sexually transmitted infections (STIs) (The National Strategic Plan: South African Council SANAC 2018) reports that about 270 000 people became newly diagnosed with HIV, and the 2015 estimate of new TB cases were 450 000. In addition to this, the WHO (2019) reported that there were approximately 64 000 deaths caused by TB disease in South Africa in the year 2019 (WHO 2019). While the prevalence of HIV and TB is high, the Western Cape Province in 2016 recorded 74.6% cases of HIV and TB coinfection (Massyn et al. 2019), with the Cape Town District recording 81.1% of HIV and TB coinfected patients on antiretroviral therapy (ART) (Massyn et al. 2018). According to the 2019 WHO Global Tuberculosis Report: South Africa, in 2018, 104 625 HIV and TB cases were recorded. Also, less than half (49%) of the estimated 815 000 PLHIV who also have TB disease were reported to receive both HIV treatment and TB treatment (UNAIDS 2020).
Non-adherence to TB treatment and ART among HIV and TB coinfected patients is a significant barrier to successful treatment outcomes (Mazinyo et al. 2016). The burden of tablets, length of treatment, the burden of secrecy of HIV and TB condition, patient–provider relationship, patient–household interaction, alcohol intake and stigma remain inevitable in HIV and TB coinfected patients (Mandimika & Friedland 2020; Mbunyuza 2020). To combat the challenge of nonadherence, the South African Department of Health (2015) advocated for the need for adherence counselling to be conducted by an appropriately trained, mentored and supervised counsellor or healthcare worker in HIV and TB coinfected patients. While continuous adherence counselling is identified as essential to enhance medication adherence in HIV and TB coinfected patients (Southern African HIV Clinicians Society n.d.), the number of quality healthcare personnel to offer proper counselling remains a barrier (Mahtab & Coetzee 2017). Already, the clock is ticking for South Africa to reach the ambitious 2025 targets for TB and HIV laid out in the new Global AIDS Strategy for 2021–2026 (End Inequalities. End AIDS. Global AIDS Strategy 2021–2026).
Nurses have identified that TB and HIV adherence counselling remains critically inadequate with the integrated treatment of PLHIV coinfected with TB. Human immunodeficieny virus and TB adherence counselling services that nurses provide to enhance patient compliance remain insufficient. Nurses are the frontline care providers in the South African healthcare system and are pivotal in managing integrated interventions for HIV and TB coinfection (Makhado, Davhana-Maselesele & Farley 2018). According to Phetlhu et al. (2018), all categories of nurses play a role in caring for HIV and TB coinfected patients. Despite that, focussed training is directed towards registered nurses (RNs), specifically for initiation of HIV and TB treatment, and all others who encounter patients on follow-up are not adequately trained to continue with adherence counselling.
In South Africa, individuals (not qualified to undergo nurse training) are trained as community health workers (CHWs) and mentored as counsellors to conduct treatment adherence counselling (South Africa National HIV Counselling and Testing Policy Guidelines 2010). At community healthcare centres (CHC), trained counsellors offer pre- and post-test HIV counselling during screening. However, adherence counselling at the point of initiation of treatment and retention in care where nurses are the leading role players needs to be sufficiently done. Nurses are expected to continue to manage these HIV and TB coinfected patients. However, they need to be adequately trained to do adherence counselling.
This is despite the existence of the adherence guidelines on HIV, TB and NCDs with outlined strategies and procedures for implementation in South Africa. This results in poor treatment adherence, increased rate of treatment interruption and increased transmission of both infections. Therefore, a training programme is imperative to close this gap; hence, this review seeks to summarise how existing training programmes were developed. In doing so, this review highlights the different attributes when developing a training programme. Training programmes, particularly for nurses, have been reported to be effective in scaling up care and providing the individual, the patients and organisations with worthwhile benefits (Elvish et al. 2018; Simelane et al. 2018). Hence, this review aims to explore and describe attributes of a training programme development for nurses to improve adherence counselling of PLHIV coinfected with TB in South Africa. The review question was: What are the existing adherence training programmes for nurses caring for PLHIV coinfected with TB?
Research methods and design
This study used an integrative literature review design to explore and describe attributes of a training programme development for nurses to improve adherence counselling of PLHIV coinfected with TB in a selected health subdistrict, Cape Town. This review is a method to ‘summarise the literature on a specific context or content area, whereby the research is summarised, analysed, and overall conclusions are drawn’ (Whittemore 2005). Similarly, the current integrative review was considered appropriate because it plays a more significant role in evidence-based practice and policy. It can expand nursing science on the troubled issue of adherence counselling of PLHIV coinfected with TB in the CHC settings. Also, as an approach, it considers a combination of diverse methodologies. An integrative review method was considered, as this will fully provide an in-depth understanding of the attributes of concurrent training programmes that will enable the researchers to develop a training programme to improve adherence counselling of PLHIV coinfected with TB for nurses offered at the CHC level. To achieve the aim of this review, a five-step integrative review framework by Whittemore and Knafl (2005) was employed, as presented in Figure 1.
Identification of the research problem
Considering the aforementioned background, it is clear that there exists sufficient literature on the phenomenon in question. The adherence guidelines for HIV, TB and NCDs (2016) report that the NDoH in South Africa compiled a comprehensive adherence guidelines’ document for HIV, TB and NCDs with strategies and procedures to improve linkage, adherence and retention in care. These guidelines place adherence counselling as a core to remove the barriers to adherence. However, its implementation needs to be more adequate. The guidelines clearly highlight that these are mere guidelines, and each province needs to develop ways to facilitate adherence, in this case, among PLHIV coinfected with TB. According to adherence guidelines for HIV, TB and NCDs (2016), critical structures provide related barriers, including poor patient-provider communication, lack of adequate health education, level of engagement and empathy towards patients as well as inadequate training of staff on counselling, particularly adherence counselling. These barriers are reported from a national perspective, which includes the Western Cape as one of the provinces in South Africa.
Despite the reports on structural barriers, there are no training programmes that sufficiently train all cadre of nurses on adherence counselling, albeit the need for them to implement or use proposed strategies in the adherence guidelines for HIV, TB and NCDs. Hence, there is a need to carry out an integrative literature review to assess the existing attributes in previous training programmes. The variables in this review and the population comprised of articles retrieved from the initial search using the search strategy described as follows.
Literature search
The literature search was done using keywords, and synonyms were used across all included databases with the assistance of an experienced librarian and as per database search criteria (for instance, Mesh in PubMed, descriptor in PsycArticle). The Boolean operators ‘AND’ and ‘OR’ were used to combine all concepts. The search terms for both levels were PLHIV and TB AND training programme; education AND HIV/TB, training programme AND HIV, training, AND TB; training programme AND HIV/TB, training AND medication intake, training for adherence counselling, training for treatment adherence, training programme AND implementation, training programme AND evaluation, educational OR training programme, guidelines AND medication intake, training programme and implementation. Using these terms combined, the following databases were searched: COCHRANE, PsycINFO, PUBMED, ENMBASE, Science Direct, SCOPUS, SocINDEX, Academic Search Complete, Eric, SABINET, Health Resources, the WHO Global Health Library Regional Indexes (AIM [AFRO], LILACS [AMRO/PAHO], IMEMR [EMRO], IMSEAR [SEARO], and WPRIM [WPRO]), Google Scholar, and Sage. The results were imported into Mendeley reference software for further processing. Finally, the reference lists of critical articles identified were hand-searched to identify further relevant articles (Madhani et al. 2014).
Inclusion and exclusion criteria
After stating the purpose of this review and formulating a straightforward review question, the researchers outlined the inclusion and exclusion criteria for this review. This was done to ensure that articles retrieved from the literature were following the set inclusion and exclusion criteria for this integrative review. The selected studies were published in English. Some of the articles were peer-reviewed and full-texted. Some were from international articles like WHO. Also, there was no restriction regarding the setting or the country where the studies were conducted. Grey literature in the form of reports was also included. All studies focussed on training programme development. These studies were published between 01 January 2012 and 31 May 2021. This period was purposively selected, as this duration provided an extensive period to assess primary articles on training programme development. The researchers anticipated that this period would provide relevant reports and recent evidence related to the topic if they existed. The exclusion criteria included articles in the press, conference proceedings, articles that were not relevant to the aim of the review, and non-English articles. Two reviewers performed article selection by reading the titles and abstracts of all the resulting studies and sequentially excluding records according to the inclusion criteria.
Descriptors for the search
Overall, 769 articles were screened across all databases and imported into Mendeley reference manager software. The synthesis of the integrative review consists of the overall quality of the selected studies for the review and the discussion of the answers to the review based on the analysis. After the initial search, all duplicates and irrelevant articles in the Mendeley database were removed, and the search data were exported to an Excel spreadsheet. The selected studies were primarily interventional studies. Then, all irrelevant articles and reports (693) were deleted.
The remaining 76 articles were exported into a rich text table format for abstract screening. The abstracts of the 76 remaining articles were assessed, and a further 61 articles were removed. The remaining 15 articles were evaluated for quality assessment using the Joanna Briggs Institute (JBI) critical appraisal tool. About the review question, six qualitative articles from the selected studies addressed training programme or course development (Henoch et al. 2015; Hinneburg et al. 2020; Malan et al. 2016; Plowright et al. 2018; Van der Giessen et al., 2020), four quantitative articles (Driessche et al. 2009; Elvish et al. 2018; Represas-Represas et al. 2013; Van Der Giessen et al. 2020), three nonresearch documents (Simelane et al. 2018; WHO 2005, 2015) and two mixed-method articles (Couper et al. 2018; Uwimana et al. 2012). Themes were generated from the selected articles for the review. If the title and abstract met the inclusion criteria, the full text of the articles was read to determine if they met the inclusion criteria. A total of 15 articles were included as the final sample in this review. The result of the search process is depicted in Figure 2.
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FIGURE 2: PRISMA flow diagram depicting the selection process and final number of selected articles in this study. |
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Articles for review were further critically appraised using the JBI appraisal tool ([PDF] 2017 Guidance for the Conduct of JBI Scoping Reviews n.d.).
It is a list of 10 questions with three possible answers (Yes, No and Unclear). Although the tool did not have a score, the researchers, in line with other researchers (Ma et al. 2020; Semegni et al. 2021) decided to give a score of 1 to all questions with a ‘Yes’ for an answer and 0 to all questions with a ‘No’ for an answer, and 0.5 for all questions with an ‘Unclear’ answer. The studies with scores between 0 and 2 were considered as poor quality. The scores between 3 and 4 were regarded as fair quality, and scores between 6 and 10 were good quality. In the end, 15 articles were assessed for quality and were good; hence, they were included in the review as indicated in Table 1.
| TABLE 1: Summary of articles included in the review. |
Also, there was no restriction regarding the setting or the country where the studies were conducted. Grey literature in the form of reports was also included. Both qualitative and quantitative articles on training programme development were included. The exclusion criteria included articles in the press, conference proceedings, articles that were not relevant to the aim of the review, and non-English articles. Two reviewers performed article selection by reading the titles and abstracts of all the resulting studies and sequentially excluding records according to the inclusion criteria (Jackson et al. 2015).
Data evaluation
To assess the methodological quality, the articles selected were assessed by two independent reviewers for validity prior to their inclusion in the review. Descriptive data extraction and presentation were done to extract attributes of training programme development that would assist the researcher in developing a training programme for nurses to enhance adherence counselling in the Khayelitsha health subdistrict, which was the aim of the study. All 15 studies with good methodological quality were retained, and data extraction was conducted using the JBI extraction tool. All the studies in the different articles applied a quantitative, mixed-method or qualitative approach. In terms of quality assessment, the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) was used for critical appraisal (Peters et al. 2015). This tool contains a separate appraisal checklist for each type of study design. Using this instrument, two reviewers assessed the articles independently before inclusion in the final review. Any disagreements which arose among the reviewers were resolved through discussion sessions. The JBI-MAStARI tool was used to extract the data. The data extracted included details about the author(s), country, design, aim(s), sample size, settings and the result of the review. Conclusions were also extracted. These checklists critically evaluated the study’s clarity of aims, objectives, methods and appropriateness of data analysis. It also provides a comprehensive checklist of 10 evaluation criteria (Lei et al. 2014).
Evaluation tools have been developed to assist in the critical appraisal of research studies, and they provide a template of key questions to assist in the critical appraisal of quantitative research studies (Long et al. n.d.). The methodological data extracted included the author(s), country, design, aim(s), sample size, setting, result and conclusion (Table 1).
Review articles were critically appraised using the JBI appraisal tool (Guidance for the Conduct of JBI Scoping Reviews 2017). It is a list of 10 questions with three possible answers (Yes, No and Unclear). Although the tool did not have a score, the researchers, in line with other researchers (Ma et al. 2020; Semegni et al. 2021) gave a score of 1 to all questions with a ‘Yes’ for an answer and 0 to all questions with a ‘No’ for an answer, and 0.5 for all questions with an ‘Unclear’ answer. The studies with scores between 0 and 2 were considered as poor quality. The scores between 3 and 4 were considered fair quality, and scores between 6 and 10 were good quality.
Data analysis
The purpose of the analysis stage in the integrative review was to synthesise the evidence through coding, categorising and summarising the primary sources into an unbiased integrated conclusion about the research problem (Whittemore & Knalf 2005). As a result of the heterogeneity of the studies included in this review, a meta-analysis or meta-synthesis could not be used (Higgins et al. 2003). In this review, thematic data analysis was employed for analysing and synthesising the findings of the studies included. Thematic analysis is a broadly used, flexible method for identifying, analysing and reporting patterns within data. Moreover, this method of analysis was found to be suitable for this review because it organises the main themes or concepts across diverse literature sources (A Step-by-Step Guide to Conducting an Integrative Review 2020).
Therefore, the extracted findings of the 15 articles were synthesised using a thematic analysis approach based on significant recommendations for developing a training programme. Thematic analysis is a method for identifying, analysing and reporting patterns (themes and subthemes) within data. It minimally organises and describes your data set in (rich) detail (Braun & Clarke 2006).
Data were extracted and represented textually. To facilitate the comparison of the training attributes and interpretation, data were reduced according to specific ‘issues, variables and sample characteristics’, and then data were displayed in the form of matrices, graphs or charts to allow for comparison in order to identify patterns, themes or relationships and drawing conclusion and verification (Whittermore & Knaft 2005).
Characteristics of the studies
A total of 15 articles met the inclusion criteria and were all included in this review. This review included qualitative (6) training reports (3) and quantitative (6) studies. All included studies alluded to training programmes. The countries associated with the articles in this review were Kenya (1), South Africa (3), Geneva (2), the Republic of Congo (1), the United Kingdom (1), Germany (1), Spain (1), the Netherlands (2), Nigeria (1), Uganda (1) and Tanzania (1).
Ethical considerations
Ethical clearance to conduct this study was obtained from the University of the Western Cape Biomedical Research Ethics Committee (reference no. BM19/8/9) on 01 July 2021.
Results
Interpreting the extracted data about the review question was the final phase of the integrative review. The review results are presented in a narrative format, supported with tables. The themes and subthemes that emerged from the integrative literature review analysis are shown in Table 2.
| TABLE 2: Summary of the themes and subthemes. |
Three main themes emerged from the analysis of this review as depicted in Table 2: (1) need to identify the participant, (2) key content for the programme and (3) process of implementing the programme. These themes and subthemes emerged as successful programme development’s most influential intervention characteristics.
Theme 1: Need to identify the participant
In this review, the need to identify the participants for developing a training programme was identified. This attribute reflects the reality of what happens at healthcare facilities. This includes effective communication.
Subtheme 1.1: Effective communication
Effective communication was recommended as one of the critical attributes to be included in developing a training programme. This attribute was identified in four articles and documents (Henoch et al. 2015; Van Der Giessen et al. 2020; WHO 2015). The relevance of communication in developing a training programme was described by WHO (2015) as primary in the English language. Adequate time should be allocated for proper communication to be achieved. The WHO (2015) also highlighted that, for proper communication to be achieved, the nurse’s and patient’s tone must be free, open and respectful. Van Der Giessen et al. (2020) indicated that healthcare professionals lack the confidence to effectively communicate with patients with limited literacy; hence, the authors needed to develop and evaluate a training programme for healthcare professionals to increase effective communication. Henoch et al. (2015) reported that the effectiveness of the intervention was the boost in communication of the nurse with patients. Van Der Giessen et al. (2020) further recommended self-efficacy towards communication on counselling, using plain language and teach-back methods, hence confidence in effectively communicating with the patients.
Theme 2: Key content for the programme
This review identified several critical contents for the programme development to improve adherence counselling. They include required skill and knowledge in counselling, and nurses’ confidence to effectively counsel patients considering knowledge, counselling process and counselling content, among others.
Subtheme 2.1: Required skill and knowledge in counselling
Out of the 15 articles and documents appraised, 5 highlighted that nurses should possess the required skills and knowledge in counselling. Driessche et al. (2009) and Elvish et al. (2018) recommended that nurses incorporate their self-clinical knowledge and experience in counselling and see counselling as an identified required skill to achieve adherence to counselling of patients. They further highlight that the training programme should adapt existing training materials on counselling HIV and TB patients, prevention of mother-to-child transmission and management of opportunistic infections. Simelane et al. (2018) further concur that the required skill and knowledge in counselling in a training programme should consider the nurses’ existing clinical knowledge and experience. Hinneburg et al. (2020) recommend that the required skill and knowledge in counselling should make use of comprehension of the conditions at hand that require counselling, and in this review, it would be PLHIV coinfected with TB. Elvish et al. (2018) and Plowright et al. (2018) also report that knowledge about the conditions that require adherence counselling should be included in the training programme for nurses and CHWs.
Subtheme 2.2: Nurse–patient relationship
The nurse–patient relationship was identified in two documents in this review and recommended as a practice for developing a training programme for PLHIV coinfected with TB. This therapeutic relationship should be practised through problem-solving exercises, open discussions, and the exchange of information between the patient and the nurse (WHO 2005). This was further elaborated by WHO (2015), which recommended that English should be the primary language of communication with the patient. In case translation is needed, it should be employed so that the patient can fully comprehend the counselling service offered by the nurse. In addition, adequate counselling time should be considered, and the nurse should display a free tone consisting of an open and respectful attitude during the counselling session. A conducive environment should be created for proper counselling service; hence, an excellent nurse–patient relationship will also be established.
Subtheme 2.3: Nurse confidence |
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