Evaluation of a guideline developed to reduce HIV-related stigma and discrimination in healthcare settings and establishing consensus

Published: July 27, 2018Background: Developing guidelines and policies is critical to address HIV-related stigma and discrimination (SAD) in healthcare settings. To this end, a multidisciplinary panel developed a guideline to reduce SAD. This project evaluated the appropriateness of implementing the guideline in the Ethiopian context. Methods: A consensus of the expert panel was established through a modified Delphi technique which was followed by a panel meeting. Initial tentative recommendations were distributed to experts through e-mails to be evaluated using the modified guideline implementability appraisal (GLIA) v.2.0 checklist. Results: In the first round of the Delphi survey, all (13) panel members evaluated the guideline. The overall score for the general domain of the modified GLIA checklist was 96.56%. The scores for individual recommendations ranged from 68.33% to 92.76%. Maximum and minimum scores were attained for measurability (97.71%) and flexibility (59.77%) domains respectively. Percentages mean score lower than 75% was obtained for flexibility and validity domains. Participants suggested that additional tools and training should be added to the guideline. In the second round of the survey, all the recommendations received endorsement with scores above 75%. Maximum and minimum scores were attained for measurability (100%) and flexibility (86.88%) domains respectively. During the panel meeting, issues of responsibility for implementing the guideline were discussed. Conclusion: The project evaluated implementability of a guideline developed to reduce HIV-related SAD in healthcare settings. The Delphi survey was followed by a half-day meeting that helped in further clarification of points.Garumma Tolu Feyissa, Craig Lockwood, Mirkuzie Woldie, Zachary Mun

Reducing HIV-related stigma and discrimination in healthcare settings through the development of an evidence-informed guideline

The stigma and discrimination related to human immunodeficiency virus (HIV) have been obstacles against the achievement of the global health priority targets by negatively impacting adherence to, and uptake of services. As an effort to improve the practice and service in HIV and related areas, this project sought to develop an evidence-informed guideline to reduce HIV-related stigma and discrimination. Aims: The overall aim of this project was to develop an evidence-informed guideline to reduce HIV-related stigma and discrimination among healthcare workers in the Ethiopian context. Method First, I conducted a systematic literature search for guidelines and systematic reviews, followed by systematic review of primary studies. After appraising the evidence found through the literature search, a content analysis of the included units of evidences was carried out to generate a list of working recommendations. Summaries of Findings tables were produced using software package developed by the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) working group. The feasibility and appropriateness of the recommendations were then assessed using the Guideline Implementability Appraisal (GLIA v.2) checklist. Consensus was established through two rounds of a Delphi panel survey and two consensus meetings. The recommendations were also evaluated by external reviewers. In the final phase of this project, barriers and facilitators to the implementation of the guideline were assessed through key informant interviews with health professionals and health managers. Results Through the systematic literature search for guidelines, best practices, tools and systematic reviews I included 12 records (six guideline-related tools, and six systematic reviews). Since adequate conclusive evidence could not be drawn from these resources,a systematic review of quantitative evidence was undertaken. Initially, 31 recommendations and good practice points were extracted and drafted from the content analysis of the documents included. The recommendations were evaluated using a Delphi panel and external experts. Based on these evaluations, 12 recommendations and three good practice points were retained in the final draft. To contextualize the recommendations, barriers and facilitators were further explored using key informant interviews. The key informants suggested that the guideline should be introduced through training, workshops, hard copies, multidisciplinary team (MDT) meeting of experts working on care and treatment of clients living with HIV and HIV mentorship program and through one-to-five networks in healthcare facilities. It was also suggested that the indicators should be integrated into local hospital key performance indicators (KPI). The importance of identifying and establishing the implementation structure, implementation team and a focal person responsible for overseeing the implementation of the guideline was stressed. Key informants specifically reported that the guideline would help to achieve not only HIV-related goals, but also other health facility initiatives such as ‘compassionate,respectful, and caring’ (CRC) services and clean and safe health facility (CASH)initiatives. Conclusion The project sought to develop trustworthy and rigorous guideline that is applicable and can be integrated into current initiatives and practices in the Ethiopian context. The current guideline can be implemented into new and existing health facility initiatives (such as CRC and CASH) and included in platforms like mentorship, multidisciplinary team (MDT) meetings and one-to-five networks. To ensure uptake of this guideline, health managers need to identify the implementation structure, implementation team and a focal person to implement the guideline.Thesis (Ph.D.) -- University of Adelaide, The Joanna Briggs Institute, 201

Therapist Perception Of The Clarity And Implementability Of Relevant Recommendations From American Academy Of Orthopedic Surgeon’s Distal Radius Fracture Clinical Practice Guidelines

Fractures of the distal radius are common and can cause substantial either transient or permanent impairment and disability. Clinical practice guidelines (CPGs) are systematically developed statements or recommendations based on the best available evidence and aimed at assisting health care practitioners in clinical decision-making. Many professional organizations have developed practice guidelines for common clinical conditions. The overall objective of this thesis is to evaluate the therapist\u27s perception of the clarity and implementability of rehabilitation relevant recommendations from The American Academy of Orthopaedic Surgeons (AAOS) CPG for distal radius fractures (DRF) and to identify the quality of CPG related to DRF. To address my study objective, first, I categorized the AAOS DRF CPG using the International Classification of Functioning Disability and Health (ICF) and International Classification of Diseases ICD-10 using linking procedures and compare the content codes of the CPG with the ICF hand core sets as the reference standard. Then I conducted a cognitive interview study to understand the therapist\u27s perceptions of the clarity and implementability of the recommendations. To further understand the implementability of the AAOS DRF CPG, I conducted a cross-sectional survey on the implementability of the AAOS DRF guidelines using the guideline implementability appraisal tool (GLIA). And we conducted a systematic literature review to identify and appraise CPGs relevant to the management of DRF s using the AGREE II tool. The results of the thesis indicate that the AAOS DRF CPG focuses on surgical interventions and has minimal linkage to the constructs of the CF constructs (activity or participation) and the ICF Hand Core Set. In my qualitative study, I found that eight of ten recommendations sampled from the AAOS DRF CPG were considered vague and unimplementable by therapists in their clinical practice, due to the lack of clarity and information on what to implement, how to implement, and to measure the adherence and outcomes of the recommendation. In the systematic review I found that for the selected CPGs developed by professional organizations in the UK, Canada, USA, Denmark, and Norway, the AGREE score for the scope and purpose domain ranged from 61% to 94% and the stakeholder involvement domain ranged from 13% to 97%. The rigor of the development domain score ranged from 38% to 95%. and for the clarity of the presentation domain score ranged from 63% to 83%. Scores were lowest on the domain of applicability and ranged from 18% to 60% and the score for the editorial independence domain ranged from 54% to 79% This work implicates that CPG that focus on rehabilitation after DRF are needed and improving the implementability of the CPG recommendations by making them more specific and actionable while providing resources would assist with the implementation. Therapists need to be aware and understand variability existing in quality, the rigor of development, and the applicability of these guidelines. The future guideline should consider implementation during development including ready access to the details about the level recommended in intervention reporting guidelines

Really Natural Linear Indexed Type Checking

Recent works have shown the power of linear indexed type systems for enforcing complex program properties. These systems combine linear types with a language of type-level indices, allowing more fine-grained analyses. Such systems have been fruitfully applied in diverse domains, including implicit complexity and differential privacy. A natural way to enhance the expressiveness of this approach is by allowing the indices to depend on runtime information, in the spirit of dependent types. This approach is used in DFuzz, a language for differential privacy. The DFuzz type system relies on an index language supporting real and natural number arithmetic over constants and variables. Moreover, DFuzz uses a subtyping mechanism to make types more flexible. By themselves, linearity, dependency, and subtyping each require delicate handling when performing type checking or type inference; their combination increases this challenge substantially, as the features can interact in non-trivial ways. In this paper, we study the type-checking problem for DFuzz. We show how we can reduce type checking for (a simple extension of) DFuzz to constraint solving over a first-order theory of naturals and real numbers which, although undecidable, can often be handled in practice by standard numeric solvers

Computable analysis and notions of continuity in Coq

We give a number of formal proofs of theorems from the field of computable analysis. Many of our results specify executable algorithms that work on infinite inputs by means of operating on finite approximations and are proven correct in the sense of computable analysis. The development is done in the proof assistant Coq and heavily relies on the Incone library for information theoretic continuity. This library is developed by one of the authors and the paper can be used as an introduction to the library as it describes many of its most important features in detail. While the ability to have full executability in a formal development of mathematical statements about real numbers and the like is not a feature that is unique to the Incone library, its original contribution is to adhere to the conventions of computable analysis to provide a general purpose interface for algorithmic reasoning on continuous structures. The results that provide complete computational content include that the algebraic operations and the efficient limit operator on the reals are computable, that certain countably infinite products are isomorphic to spaces of functions, compatibility of the enumeration representation of subsets of natural numbers with the abstract definition of the space of open subsets of the natural numbers, and that continuous realizability implies sequential continuity. We also formalize proofs of non-computational results that support the correctness of our definitions. These include that the information theoretic notion of continuity used in the library is equivalent to the metric notion of continuity on Baire space, a complete comparison of the different concepts of continuity that arise from metric and represented-space structures and the discontinuity of the unrestricted limit operator on the real numbers and the task of selecting an element of a closed subset of the natural numbers

Evidence-based decision support in HIV/TB care: designing treatment, monitoring, and assessment support for care providers

Introduction: HIV and tuberculosis (TB) coinfection, which is a major challenge for healthcare systems worldwide, requires effective strategies to support care providers in applying best clinical evidence in making treatment decisions about the care of individ- ual patients. Clinical decision support (CDS) systems have the potential to facilitate the implementation of evidence-based guidelines in clinical practice. Aim: The aim of this thesis was to explore how a CDS system could be designed to sup- port the adoption of evidence-based guidelines in the treatment of HIV-related TB. Study design: The HIV outpatient clinic at the Karolinska University Hospital, Huddinge, Stockholm, was the setting for a user-centered design approach structured in three phases: contextual analysis (Studies I and II), design (Study III), and evaluation (Study IV). Study I explores care providers’ challenges and requirements; Study II, which describes socio- demographic and clinical characteristics of patients in this setting, analyzes the factors associated with anti-TB treatment success as well as adverse drug reactions; Study III proposes a CDS framework of drug therapy recommendations that is applied to HIV- related TB treatment guidelines; Study IV formatively evaluates the conceptual design of a CDS prototype that is based on the framework developed in Study III. Methods: In Study I, the contextual analysis is based on observations and interviews. Study II analyses patient treatment outcomes in the research setting between the years 1987 to 2010 (inclusive). Study III presents the design that is based on prototyping and guideline modeling. Study IV uses focus groups of physicians and nurses in the evalua- tion of the design. Results: The contextual analysis revealed challenges related to the complexity of HIV- related TB treatment (Studies I and II). Because the care providers thought they lacked sufficient experience with HIVTB drug therapy, they sought improved support tools and structures (Study I). Combined HIV and TB treatment was related to treatment success, but was also associated with adverse drug reactions (Study II). The design phase ap- plied the eviTMA (evidence-based Treatment, Monitoring, and Assessment) framework to model HIV-related TB treatment guidelines. This resulted in a CDS prototype that models alternative drug therapy options, their expected effects, and recommended mon- itoring routines (Study III). The care providers identified several potential benefits of the eviTMA CDS prototype including support for decision making, collaboration, and qual- ity improvement work (Study IV). Identified concerns that need to be addressed in future include the risk of overdependence on CDS, increased workload, and aspects related to the implementation and maintenance of a CDS system (Study IV). Conclusions: The main contribution of this thesis is the eviTMA CDS framework de- signed to support care providers in the adoption of evidence-based drug therapy rec- ommendations. The framework was evaluated in a CDS prototype for HIV-related TB treatment. Application to other conditions was desired by care providers and should be explored in future