The Namibia Treatment Literacy Approach: Empowering Patients with Knowledge on

Antiretroviral Therapy Through Audiovisual Materials

AuthorsFrancis Kalemeera1, Jennie Lates1, Johannes Gaeseb1, Evans Sagwa2, David Mabirizi2, Assegid Mengistu1, Elena Moreno1, Emmy-Else Hango3, Francina Tjituka2, Meghan Majorowski4 and Rebecca Oser4

Affiliations1.Ministry of Health and Social Services, Namibia2.Management Sciences for Health, Namibia3.Catholic Health Services, Namibia4.Broad Reach HealthCare

Presenter: Francis Kalemeera

Ministry of Health and Social Services, Namibia

Background (1) The Ministry of Health and Social Services (MoHSS) Namibia

initiated a free antiretroviral therapy (ART) program in 2003 The need to provide health care workers with information on ART

was identified The Therapeutics Information and Pharmacovigilance Centre

(TIPC) was established (2007) to improve safe medicine use and provide unbiased information on medicines including ARVs

A rapid assessment (2008) to identify TIPC future activities showed that Health facilities utilised a checklist to ensure all relevant topics were covered when counselling ART patients

The lack of standardised messages being given during ART counselling led MoHSS to design the Treatment Literacy Approach (TLA) programme.

The TLA emphasises the use of different methods to educate patients on their medication

Background (2) MoHSS and partners developed a treatment literacy toolkit :

DVDs (Intended to be watched with guidance from a counsellor). The DVDs dealt with four priority themes including:1. Preparing to start ARV therapy; 2. Starting ARV therapy; 3. Alcohol and adherence; and 4. Long-term adherence to ARV therapy.

Flipchart (Story telling flipchart, led by counselor) Posters (reinforcing messages on the video and in flipchart, with

phrases to help interpret the picture message) Materials were piloted before roll out to ensure that they

were conveying the intended messages. The TLA materials were implemented in 6 ART clinics in

October 2009, and evaluated.

Evaluation of TLA Materials The objectives of evaluation were to assess the TLA materials

for their: Effectiveness in empowering patients with ART knowledge,

and Efficiency in terms of time spent on educating HIV infected

patients who are on ART

Methods Design: Post-Test Only Control Group Design Selection of sites: Purposive selection Target population: Patients who started ART between Oct

2009–May 2010

Methods cont.

Patient selection: Systematic random sampling Data quality assurance: data collectors were trained Data Collection: May to June 2010.

Patients were assessed using an interview with 36 knowledge questions; facility data was collected; time spent counselling patients on ART was recorded

Data analysis: Chi-square test was used to compare average knowledge scores between

intervention and control sites. Time spent on counselling individual patients on HAART was collected,

summed, and averages for facilities were calculated

Results (1)

1. Number of patients: Intervention sites 181; Control Sites 932. Number of facilities: Intervention sites 6; Control sites 43. Demographics: comparable 4. Usage of tools: The control sites used flipcharts and posters

different from the TLA materials. Below is a summary of how materials were used:

Control sites reported usage of materials as follows: video-0%; flipchart-50%; and posters-50%

Patients at control sites reported exposure to treatment literacy materials as follows: video-4%; flipchart-6%; and poster-37%

All Intervention sites reported to have used the TLA materials Patients at intervention sites reported exposure to treatment literacy

materials as follows: video-60%; flipchart-78%; and poster-51%

Results (2)

5. Exposure: Variable exposure to the TLA materialsHow patients were exposed to the flipchart How patients were exposed to the DVD

Video with guidance

Video without

guidance

Did not see video

0%

20%

40%

60%

80%

100%

50%

10%

40%

2% 2%

96.0%

Intervention Control

Type of exposure to video

Whole Sections No ex-posure

0%

25%

50%

75%

100%

60%

18% 22%

2% 4%

94%

Intervention Control

Type of exposure to flipchart

Results (3)6. Knowledge scores: Patients at intervention sites had higher

scores (Table 1)7. Adherence: Intervention sites’ patients reported better

adherence (Table 1)8. Time spent on counselling: Intervention and control sites spent

an average of 2.3 and 9.7 minutes/patient on ART counselling9. Counsellors’ views: TLA materials had more content than

materials used before and they stimulated patient involvement

Score Control

sitesIntervention

sites

% of questions in which this group had higher scores 25% 75%

Total patient knowledge score out of 36 knowledge questions

79% 85%CI 95%; p-value = 0.0002

Adherence% of pts reporting missing doses of ARVs 20.7% 11.7%

Table 1: Table of Knowledge Scores and Adherence Findings

Conclusions The TLA is effective in empowering patients with ART knowledge TLA appears to be associated with improved time efficiency,

allowing counsellors to concentrate on patients with adherence problems

Other public health programmes in Resource Limited Settings could benefit from guided group education as that utilised in TLA implementation

Key Lessons Learnt The TLA creates an environment for patients to actively

participate in discussions on ART, which boosts their understanding and staff motivation

In addition to training in technical use of the TLA materials, the roll-out of TLA requires capacity building of users in TLA implementation plans to support 100% patient exposure

Implications

The TLA provides structure for patient education, leading to standardised, consistent messages being passed onto all patients regardless of the health worker involved

Roll-out of TLA videos to general public through community cinemas, and public television is expected to positively support adherence

Future Studies The effect of patient knowledge of antiretroviral therapy on

treatment outcomes The effect of collaborative approaches on cost reduction of TL

programmes