PDF(Pubmed)
Abstract：
BACKGROUND: Tuberculosis (TB) preventive treatment (TPT) substantially reduces the risk of developing active TB for people living with HIV (PLHIV). We utilized a novel implementation strategy based on choice architecture (CAT) which makes TPT prescribing the default option. Through CAT, health care workers (HCWs) need to \"opt-out\" when choosing not to prescribe TPT to PLHIV. We assessed the prospective, concurrent, and retrospective acceptability of TPT prescribing among HCWs in Malawi who worked in clinics participating in a cluster randomized trial of the CAT intervention.
METHODS: 28 in-depth semi-structured interviews were conducted with HCWs from control (standard prescribing approach) and intervention (CAT approach) clinics. The CAT approach was facilitated in intervention clinics using a default prescribing module built into the point-of-care HIV Electronic Medical Record (EMR) system. An interview guide for the qualitative CAT assessment was developed based on the theoretical framework of acceptability and on the normalization process theory. Thematic analysis was used to code the data, using NVivo 12 software.
RESULTS: We identified eight themes belonging to the three chronological constructs of acceptability. HCWs expressed no tension for changing the standard approach to TPT prescribing (prospective acceptability); however, those exposed to CAT described several advantages, including that it served as a reminder to prescribe TPT and routinized TPT prescribing (concurrent acceptability). Some felt that CAT may reduce HCW´s autonomy and might lead to inappropriate TPT prescribing (retrospective acceptability).
CONCLUSIONS: The default prescribing module for TPT has now been incorporated into the point-of-care EMR system nationally in Malawi. This seems to fit the acceptability of the HCWs. Moving forward, it is important to train HCWs on how the EMR can be leveraged to determine who is eligible for TPT and who is not, while acknowledging the autonomy of HCWs.
METHODS: 28 in-depth semi-structured interviews were conducted with HCWs from control (standard prescribing approach) and intervention (CAT approach) clinics. The CAT approach was facilitated in intervention clinics using a default prescribing module built into the point-of-care HIV Electronic Medical Record (EMR) system. An interview guide for the qualitative CAT assessment was developed based on the theoretical framework of acceptability and on the normalization process theory. Thematic analysis was used to code the data, using NVivo 12 software.
RESULTS: We identified eight themes belonging to the three chronological constructs of acceptability. HCWs expressed no tension for changing the standard approach to TPT prescribing (prospective acceptability); however, those exposed to CAT described several advantages, including that it served as a reminder to prescribe TPT and routinized TPT prescribing (concurrent acceptability). Some felt that CAT may reduce HCW´s autonomy and might lead to inappropriate TPT prescribing (retrospective acceptability).
CONCLUSIONS: The default prescribing module for TPT has now been incorporated into the point-of-care EMR system nationally in Malawi. This seems to fit the acceptability of the HCWs. Moving forward, it is important to train HCWs on how the EMR can be leveraged to determine who is eligible for TPT and who is not, while acknowledging the autonomy of HCWs.
摘要：
背景：结核病（TB）预防性治疗（TPT）大大降低了HIV感染者（PLHIV）患活动性TB的风险。我们使用了一种基于选择体系结构（CAT）的新颖实现策略，该策略使TPT规定了默认选项。通过CAT,当选择不给PLHIV开TPT时，卫生保健工作者(HCWs)需要“选择退出”。我们评估了前景，并发,以及在参与CAT干预整群随机试验的诊所工作的马拉维HCWs中TPT处方的回顾性可接受性。
方法：对来自对照（标准处方方法）和干预（CAT方法）诊所的HCWs进行了28次深入的半结构化访谈。CAT方法在干预诊所中使用内置到护理点HIV电子病历（EMR）系统中的默认处方模块来促进。基于可接受性的理论框架和规范化过程理论，开发了定性CAT评估的访谈指南。使用主题分析对数据进行编码，使用NVivo12软件。
结果：我们确定了八个主题，属于可接受性的三个时间顺序结构。HCWs对改变TPT处方的标准方法(预期可接受性)没有表示紧张；然而，那些暴露于CAT的人描述了几个优点，包括提醒您规定TPT和常规TPT规定（同时可接受性）。有些人认为CAT可能会降低HCW的自主性，并可能导致不适当的TPT处方（回顾性可接受性）。
结论：TPT的默认处方模块现已纳入马拉维全国的定点护理EMR系统。这似乎符合HCW的可接受性。往前走,重要的是培训HCWs如何利用EMR来确定谁有资格获得TPT，谁没有资格，同时承认HCWs的自主性。
方法：对来自对照（标准处方方法）和干预（CAT方法）诊所的HCWs进行了28次深入的半结构化访谈。CAT方法在干预诊所中使用内置到护理点HIV电子病历（EMR）系统中的默认处方模块来促进。基于可接受性的理论框架和规范化过程理论，开发了定性CAT评估的访谈指南。使用主题分析对数据进行编码，使用NVivo12软件。
结果：我们确定了八个主题，属于可接受性的三个时间顺序结构。HCWs对改变TPT处方的标准方法(预期可接受性)没有表示紧张；然而，那些暴露于CAT的人描述了几个优点，包括提醒您规定TPT和常规TPT规定（同时可接受性）。有些人认为CAT可能会降低HCW的自主性，并可能导致不适当的TPT处方（回顾性可接受性）。
结论：TPT的默认处方模块现已纳入马拉维全国的定点护理EMR系统。这似乎符合HCW的可接受性。往前走,重要的是培训HCWs如何利用EMR来确定谁有资格获得TPT，谁没有资格，同时承认HCWs的自主性。
