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Nigerian J Paediatrics 2017 vol 44 issue 1

Nigerian J Paediatrics 2017 vol 44 issue 1

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Impact of a child friendly clinic on retention of HIV-infected children in care an intervention study
Niger J Paediatr 2017; 44 (4): 175 – 179
ORIGINAL
Ugwu OR
CC – BY Impact of a child -friendly clinic
on retention of HIV-infected
children in care: an intervention
study
DOI:http://dx.doi.org/10.4314/njp.v44i4.1
Accepted: 22nd August 2017
Abstract : Background: Certain
≥3months after the last scheduled
researchers have reported that a
clinic appointment in a child not
Ugwu OR (
)
child-friendly clinic may improve
known to be dead or transferred
Department of Paediatrics,
patient/caregiver satisfaction at
out of the facility) and retention
University of Port Harcourt
clinic attendance. This could
rate (remaining alive and receiving
Teaching Hospital Port Harcourt
serve as an innovation for reduc-
highly active antiretroviral ther-
ing loss-to-follow up and increas-
apy) were also determined before
ing retention in care.
and after setting up the child-
Aim: To assess the impact of mak-
friendly clinic.
ing the clinic more child-friendly
Results: There were 146 respon-
on clinic experience, retention in
dents before the study and 206
care and loss-to-follow up of HIV
respondents after the intervention.
-infected children.
The retention rate increased from
Method: The study was carried
62.5% to 82% (p=0.02), while the
out in three phases. Phase one was
loss-to-follow up rate dropped
a satisfaction survey to find out
from 27.7% to 7.0% (p=0.00).
the patient/caregivers’ satisfaction
Conclusion: Making the clinic area
of the clinic environment and ser-
child-friendly can impact greatly
vices provided using a self-
on HIV care by improving patient
administered questionnaire. Phase
satisfaction and retention of HIV-
two was the creation of the child-
infected children in care and re-
friendly environment and phase
ducing loss-to-follow up.
three was a post-provision of
child-friendly clinic satisfaction
Key words: HIV, child-friendly
survey. The loss-to-follow up rate
environment, retention in care,
(failure
to
return
to
clinic
loss to follow-up.
Introduction
to be initiated on ART, retention in care is also vital as it
ensures provision of prophylactic medications for oppor-
HIV is a lifelong illness. This means that children in
tunistic infections, and prompt initiation of ART once
care and treatment have to access health facilities fre-
indications arise. Patients actively engaged and retained
quently. This therefore implies that they may miss some
in care are more likely to receive and adhere to pre-
school days, explorative and play activities which are
scribed antiretroviral medication, achieve viral suppres-
sion, and ultimately improve survival. Non-adherence
4
5
necessary for their intellectual and cognitive develop-
ment.
1
to medical appointment was found to be an important
Once an HIV-infected child is diagnosed and linked to
risk factor for treatment failure.
6-8
Retention in care is
care, retention in care becomes necessary in order to
thus an important element of clinical success for both
optimize treatment outcome. In resource-limited set-
the patient and the overall effectiveness of the ART pro-
tings, patient retention poses a serious challenge to
gram.
effective treatment of HIV-infected persons. Fox and
Apart from distance, costs of transportation,
3,9,10
Rosen estimated 36-month retention at 65% in Africa.
2
and
social stigma,
10
For patients on antiretroviral therapy (ART), retention in
an unfriendly clinic environment with
care is critical in order to prevent medication interrup-
negative clinic experience can also be a barrier to reten-
tion in care. Often children are frightened by activities
10
tions, maintain immunologic benefits, prevent HIV re-
sistance, monitor drug toxicity and clinical HIV disease
in clinics, which make clinic visits very unpleasurable.
progression as well as to identify and treat any new op-
This therefore necessitates creating innovations in the
portunistic infections that may occur.
3
For patients yet
provision of care for children in order to improve clinic
176
experience.
compared. The loss to follow up (LTFU) and retention
A child-friendly environment (which is a protected
rates were determined before and after setting up the
space where a child feels both physically and emotion-
child-friendly clinic. This was calculated from the regis-
ally secure and at ease) helps to reduce the fear, anxi-
11
ter of all children and adolescents who have been en-
ety and distress often associated with clinic visits. The
rolled to receive care and treatment before and after the
children will be able to spend waiting time doing enjoy-
intervention. Only HIV-infected children who have been
able things thus making clinic visits pleasurable. In hav-
initiated on ART were included. HIV exposed infants
ing positive experiences with the clinics, parents are
whose status is not known were excluded from the
encouraged to bring their children regularly for sched-
study. A patient was considered LTFU if he/she has
uled out-patient clinic visits thereby enhancing retention
failed to return to clinic ≥3 months after the last sched-
in care.
uled clinic appointment and is not known to be dead or
transferred out of the facility. Retention was defined as
Only very few researches have reported the impact of a
remaining alive and receiving highly active ART (i.e not
child friendly clinic on the retention in care of HIV-
registered as deceased, transferred out or LTFU) at the
infected children. The aim of this study was to assess the
paediatric infectious disease clinic using clinic visit
impact of making the clinic more child-friendly on clinic
dates.
The retention rate was calculated as:
12
experience, retention in care and loss to follow up of
HIV-infected children.
Number of patients alive and on ART X 100
No. of patients alive and on ART +
No. of patients who have died +
No. of patients that are LTFU
Material and Methods
Data were analysed using the Statistical Package of So-
The study was done in the Consultant Paediatric Clinic
cial Sciences (SPSS) version 15. Chi-square test (and
of the University of Port Harcourt Teaching Hospital
Fisher’s exact test where applicable) were used as tests
and was carried out in three phases. In order to objec-
of statistical significance and a p-value of <0.05 was
tively assess the impact the study will have on the users,
considered as significant.
a satisfaction survey was done during phase one (over a
period of 3 months before the intervention) using a pre-
tested self-administered questionnaire (for those literate
enough to read and write) and interviewer-administered
Results
(for those who cannot read or write) to find out the care-
givers’ satisfaction of the clinic environment and ser-
A hundred and forty six caregivers/adolescents
vices provided. Tracking of patients was also done by
responded before the study while there were 206 respon-
either the expert clients (volunteer mothers of HIV-
dents after the creation of the child friendly clinic. Ma-
infected children) through home visitation or the doctors
jority of the children had been receiving care and treat-
through phone communication.
ment in the facility for over three years.
On the child friendliness of the facility (Table1), 88
Phase two was the creation of the child-friendly environ-
(60.3%) responded that the accessibility of the waiting
ment. The clinic area was painted with artistic drawings
area was fair or poor, 93 (63.7%) described the level of
in child-friendly colours with the common cartoon char-
comfort as being fair or poor while only 62(42.5%) re-
acters. More seats were provided for both parents and
sponded that the clinic facility was child friendly before
children. Educational materials including story books,
the renovations and adjustments to improve the clinic
writing materials, crayons, encyclopedia, activity mate-
environment. On the other hand, 206 (100%) of the
rials and toys were provided for the different age groups
respondents rated the accessibility of the waiting area
(Fig. 1A and B). The children were allowed to play
for the children as being excellent or good, 206 (100%)
freely under direct vision of the parents and nurses. The
felt that the overall level of comfort of the waiting area
expert clients also gave health talks to the children and
for the child and the child friendliness of the facility was
engaged them in healthy debates on health related issues
also excellent or good after the intervention.
and group plays/activities. A video entertainment was
also provided and was used as an opportunity to train the
Before the intervention, majority 93(63.7%) complained
young minds on positive behaviours. In addition, the
that the sitting arrangement in the clinic was inadequate
child’s school schedule was taken into account when
while 86(58.9%) felt that the level of cleanliness was not
booking for clinic appointments (most appointments
good. After the scaling up of facilities at the clinic,
were put during midterm break and holidays [3-4
there was a significant improvement in the responses as
monthly on average] and exam periods avoided as much
206 (100%) responded that seats were now adequate and
as possible).
all 206 (100%) agreed that the level of cleanliness had
improved. Both before and after the scaling-up of clinic
Phase three was another clinic satisfaction survey (done
facilities, majority 132(90.4%) and 206(100%) respec-
over three months) after the provision of the child-
tively agreed that opportunities for learning and relaxa-
friendly environment. Responses before and after the
tion should be provided for the children in the clinic.
provision of the child-friendly environment were
On the willingness to continue treatment at the facility ,
177
before the renovation to improve the clinic environment,
Table 2: Retention and loss to follow-up rates before and
66 (45.2%) were not willing to come back based on their
after making the clinic more child-friendly
past experiences. On the other hand after the renova-
Parameters
Before
After
p-value
tion, all 206 (100%) were very willing and happy to
No.
No.
continue their child’s treatment in the facility based on
Cumulative No. of enrolled children 301
378
Total No. lost to follow up
72
23
the remarkable improvement they had seen and would
Cumulative No. of deaths
41
45
recommend the facility to other members of the public.
Loss to follow up rate
27.7%
7.0%
0.00
The improvements in the responses after provision of
Overall Retention rate
62.5%
82.0%
0.02
the child-friendly service environment were all signifi-
cant (p=0.00).
Before the study, a total of 301 children/adolescents had
Discussion
been enrolled to receive care and treatment at the facility
out of which 72 met the LTFU criteria giving a LTFU
Retention in HIV care has been defined by WHO as
rate of 27.7% (Table 2). After improvement in the clinic
continuous engagement from diagnosis, initiation on
ART and retention in lifelong ART care. This implies
13
facility, 378 had been enrolled in the register. Eight
(11%) patients who were LTFU had been successfully
that the individual remains connected to medical care
tracked and returned to care, 37 (51%) returned on their
once enrolled, and is able to adhere to critical aspects of
own while 4 (6%) reappeared because they were ill.
care including attendance of regular follow-up appoint-
ments as prescribed by a health care provider.
9
None of them was receiving any care or treatment else-
where. Twenty-three were still lost to follow up. The
Although care and treatment programs in resource-
LTFU rate significantly dropped to 7.0% (p=0.00),
limited settings have reached millions of HIV-infected
while the overall retention rate significantly increased
patients, retention in care is a critical but challenging
from 62.5% to 82% (p=0.02).
aspect of efforts to optimize patient outcomes. Poor re-
tention can range from missing a single scheduled clinic
Table 1: General assessment of the patient/caregivers’ satis-
visit to outright loss-to-follow up (failure of a patient not
faction and child friendliness of the clinic environment
known to have died to present to clinic for a certain pe-
riod of time). A review of 33-patients cohort studies
9
Parameters
Before
After
p-value
Assessed
No. (%)
No. (%)
taking ART in 13 African countries suggested that only
Total
146
206
60% of patients remain enrolled in programs after 2
years, LTFU accounting for 56% of all attrition.
14
Accessibility of the waiting area:
In a
Excellent
13(8.9)
155 (75.2)
retrospective cohort study of HIV-infected children and
Good
45(30.8)
51 (24.8)
adults attending an ART clinic in Ethiopia, the preva-
Fair/Poor
88(60.3)
0 (0.0)
0.00
lence of LTFU from ART was 26.7%. This was com-
15
Level of comfort:
parable to the LTFU rate in the present study.
Excellent
8(5.5)
188 (91.3)
Good
45(30.8)
18 (8.7)
Fair/Poor
93(63.7)
0 (0.0)
0.00
The retention rate in this study was 62.5% before the
Level of cleanliness of waiting area:
interventions to retain patients in care. This was similar
Excellent
7 (4.8)
153 (74.3)
to the findings in other reports in studies in sub-Saharan
Africa. A number of studies have sought to understand
2
Very Good
53 (36.3)
53 (25.7)
Fair/Poor
86 (58.9)
0 (0.0)
0.00
the determinants of retention through identifying factors
associated with poor retention.
10
Child friendliness of the facility:
Apart from distance,
Excellent
13 (8.9)
121 (58.7)
stigma
10, 17
transportation cost,
3, 9, 10, 16
and tight work
Good
49 (33.6)
85 (41.3)
schedules, an unfriendly clinic environment can pose a
Fair/Poor
84 (57.5)
0 (0.0)
0.00
great challenge to retaining patients in care in resource-
Need for Opportunities for
limited settings.
10
learning and relaxation:
Retention in care is thus influenced
Agree
132 (90.4)
206 (100)
not only by socioeconomic factors of the patient, but
Indifferent
12 (8.2)
0 (0.0)
also by external factors like the health system (including
Disagree
2 (1.4)
0 (0.0)
0.00
clinic environment, care providers and supporting ser-
Willingness to continue
vices).
9
treatment at the facility:
Willing
80 (54.8)
206 (100)
Goals to improve retention could be divided into those
Not willing
66 (45.2)
0 (0.0)
0.00
that reduce patient costs (e.g. making it easier to access
care financially) and those that increase patient benefits
(e.g. improving quality of services).
13
In a meeting on
retention in HIV Programmes by WHO, one of the areas
identified as potentially important in improving services
and retention of children and adolescents in care was
provision of child- and adolescent- friendly clinic sched-
ules.
13
This was corroborated in this study as the chil-
dren and their caregivers were significantly more satis-
fied (and more willing to continue care) and the reten-
tion rate significantly improved to 82% after making the
178
clinic more child-friendly. Satisfaction with the clinic
Conclusion
experience predicts whether or not patients return for
care. Children who enjoy their visit are usually more
Making the clinic area child-friendly was associated
willing to come back for follow-up. Among people liv-
with improving patient’s satisfaction and retention of
ing with HIV, satisfaction with care has been shown to
HIV-infected children in care and reducing loss to fol-
positively influence retention in HIV care and adherence
low-up. Given the difficulty in identifying and linking
to ART.
18
Patients who were not retained in care may
patients to care, we cannot afford to lose them once en-
have been less satisfied with their clinic experience and
gaged in care. There is need to carry out a regular satis-
for that reason did not return for scheduled appointment
faction survey in order to identify areas in the services
visits. In Uganda, scaling up paediatric HIV care
that have gaps that needs to be filled in order to improve
through many programs that included creating child-
access and sustain retention in care. More attention
friendly service environments was very important in
needs to be given to finding the patients who miss
maximizing paediatric capture and parents’ satisfaction.
scheduled clinic visit (using the most cost-effective
19
methods) before they become LTFU.
Lee et al
20
examined the association between availabil-
ity of youth friendly services and retention in HIV care
and reported that youths living with HIV were more
Conflict of Interest: None
likely to be retained in care at clinics with a youth-
Funding: None
friendly waiting area. In the study by Yehia et al , par-
10
ticipants in both groups (retained and not retained in
care) identified presence of social support, patient-
friendly clinic services and positive relationships with
providers and clinic staff as facilitators to retention in
Acknowledgement
HIV care.
The author is grateful to all the children and their par-
When children have a pleasurable clinic experience,
ents for their participation in helping to improve HIV
parents are likely to appreciate it and are more likely to
care and to Clinton Health Access Initiative (CHAI) for
tell their friends about the child friendliness of the clinic.
providing the funds for the educational materials and
This will encourage other members of the community to
patient tracking.
access care in the facility. This may have accounted for
the large numbers of children who returned on their own
after making the clinic more child-friendly.
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