Staff perspectives on the feasibility of the person-centered care assessment tool (PCC-at) in HIV treatment settings in Ghana: a mixed-methods study

Abstract

Person-centered care (PCC) aims to improve client’s experiences in HIV care while advancing outcomes. This study team developed the PCC assessment tool (PCC-AT) to assess PCC service performance in HIV treatment settings in Ghana. Study objectives aimed to describe the range of PCC-AT scores within and across study facilities and examine the feasibility of PCC-AT implementation in diverse HIV treatment settings. The PCC-AT was piloted at five health facilities providing HIV services among 37 staff. Immediately following each pilot, focus group discussions (FGDs) were conducted to gather feasibility data. Thematic qualitative analysis was conducted on translated FGD transcripts. Across facilities, providers scored highest in the staffing domain, followed by service provision, and direct client support. Time required to implement the PCC-AT averaged 62 minutes. Providers described the tool as well-structured, user-friendly, relevant, reflective of the core PCC delivery elements, and useful in elucidating actions to improve PCC service delivery across domains. The PCC-AT holds potential to strengthen activities that support clients’ broader clinical, mental and psychosocial wellbeing by offering friendly services that attend to each client’s holistic needs while contributing progress towards epidemic control.

Keywords:

• AIDS
• antiretroviral treatment
• HIV
• Ghana
• mixed-methods
• person-centered care
• people living with HIV

Introduction

Person-centered care (PCC) is increasingly recognized as a critical approach to improve client experiences in HIV care while advancing service accessibility and treatment outcomes [1–3]. The International AIDS Society defines PCC as “…a multidisciplinary, integrated and long-term focused approach to care for people living with and affected by HIV that is responsive to their evolving needs, priorities and preferences [4].” PCC responds to individual client’s needs and preferences via provider–client communication which provides the basis for understanding each client’s personal situation and priorities [5].

Models of PCC implementation in HIV treatment settings in the literature focus on increasing access to HIV services while ensuring that they welcome diverse populations. These include key population (KP) and adolescent friendly services, weekend and evening clinics for specific populations, short messaging service (SMS) appointment reminders, individual and group adherence support, family-based health education, follow-up on missed visits, differentiated treatment distribution models including multi-month dispensing, peer-based approaches, service outreaches, among others. These models have demonstrated increased treatment initiation, adherence, retention, and viral suppression and contributed to reduced gender disparity gaps [2,3,6–10].

While there is a growing evidence base for PCC as a critical suite of practices that hold potential to improve health outcomes, comprehensive PCC models are scarce and inconsistently implemented [11]. This is, in part, attributed to lack of inputs from clients who should be involved in the co-design of PCC services, the lack of provider training and skills in PCC, under-resourced facilities, and silo-ed systems that do not support integrated, comprehensive services that effectively and efficiently fulfill the needs of diverse populations [11,12].

Research in Ghana reveals a demonstrated national commitment to implement PCC, evidenced by integration of PCC within quality assurance activities, logistical support to implement PCC, and education for nurses and other staff on client care [1]. However, critical gaps remain including concerns that clients are unable to report service-related issues and challenges due to language and unequal power dynamics with health providers, lack of a common conceptual understanding of PCC, and lack of clearly defined PCC goals and objectives [1].

Standardizing PCC assessment is a critical step to identify and close gaps in service accessibility, treatment, and retention, and develop targeted service strengthening activities to enable consistent PCC service implementation. Drawing from a previously published systematic literature review by this study team [13] and multiple globally implemented HIV service assessment structures [14,15], this study team developed the PCC assessment tool (PCC-AT) to assess PCC service performance in diverse HIV treatment settings in the Western region of Ghana (Supplement 1). The PCC-AT is informed by the PCC framework established via the systematic literature review (Figure 1) [13].

Figure 1. Framework for PCC.

The PCC-AT is an Excel-based tool that measures health facility staff perspectives on PCC service delivery within HIV treatment settings. PCC-AT implementation, led by a trained facilitator, requires in-depth discussions amongst health facility staff to assign a score using a benchmarking approach [16] for each of the 56 performance expectations linked to the three domains and twelve subdomains of PCC. Once scoring is complete, the PCC-AT process concludes with action planning which guides health facility staff to identify areas of weakness and their causes, and to develop strengthening activities to address gaps.

Through piloting the PCC-AT and holding focus group discussions (FGD) with participating health facility staff, this study provides insights into the implementability of the PCC-AT in HIV treatment settings in Ghana. The study objectives are to:

1. Describe the range of PCC-AT scores within and across study facilities.

2. Describe the feasibility of PCC-AT implementation in diverse HIV treatment settings and understand required changes to the tool to enhance its feasibility.

These study findings are complemented by findings documented from a set of key informant interviews (KIIs) conducted concurrently among clients receiving antiretroviral treatment (ART) services at study health facilities which gathered their perspectives on facility performance as compared to health facility staff-determined PCC-AT scores.

Materials and methods

This study employed an exploratory mixed method, cross-sectional study design. Quantitative analysis consisted of analyzing within and between facility PCC-AT scores. Qualitative data collection took place after PCC-AT pilots and consisted of focus group discussions (FGDs) with health facility staff. The study was guided by a vulnerable and marginalized populations approach and a health equity lens [17,18].

Study setting

The USAID Strengthening the Continuum of Care project in Ghana was selected for this study due to: 1) availability of clinical sites supported by the project that are providing direct HIV treatment services; 2) expressed interest of project staff to scale-up PCC in an effort to strengthen services; and 3) availability of project staff already knowledgeable about the PCC-AT given their participation during the PCC framework and PCC-AT development stages. Out of the 121 project-supported health facilities, five health facilities were purposively sampled to represent geographical and size diversity in the levels of health facilities providing HIV treatment service in Ghana. Facilities include one Regional Hospital, two Government Hospitals, one Health Center and a Quasi-Government (military) health facility which also serves civilians. This mix of facilities covers urban, parastatal, and community settings. The five participating facilities are located across three districts (Sekondi-Takoradi Metropolitan Assembly, Effia Kwesimintsim Municipal Assembly and Shama District) in Western Region (one of the three PEPFAR supported regions of Ghana), spanning from the Ivory Coast (Comoé District) in the west to the Central region in the east. The region covers an area of 13,842 sq. kilometers with a population of 2,060,585 [19].

Study population

Health facility staff

The study team called study health facility administrators in advance to notify them of the date of data collection. Health facility staff were recruited to participate on the day of data collection, aiming to have a minimum of seven health facility staff members participate in each PCC-AT pilot. The sample-unit for each facility is the facility’s ART team members and participant selection was purposive based upon their knowledge and availability to participate. Facility ART team members primarily include nurses, in addition to lab technicians, counselors, pharmacists/dispensing technicians, data managers/officers, and community group liaisons whose core work at the facility includes directly providing HIV services to clients. Inclusion criteria prioritized ART team members with at least one year or more of experience providing HIV services to clients in the facility. Exclusion criteria included any staff not employed at the health facility, or any staff that were not involved in direct client care or with knowledge of the systems that support client care. Where possible the same participants who participated in the PCC-AT pilot also participated in the FGDs immediately following the pilot.

PCC-at procedures

Data collectors, who were multilingual with high proficiency in English, Twi and Fante languages (dominant spoken languages in the study settings), underwent a two-day training led by the PCC-AT developers, consisting of a general introduction on the purpose and nature of the study, instruction on obtaining informed consent, interviewing and facilitation techniques, data storage, and practice implementing the PCC-AT. A lead facilitator was designated responsible for introducing the study, collecting informed consent, and facilitating the PCC-AT process with the health facility team through a guided discussion.

Prior to commencing each PCC-AT, the study team distributed a study summary sheet and obtained written consent (Supplement 2) from each health facility participant which was signed in the presence of a self-selected witness. The PCC-AT was implemented in available meeting spaces and service delivery rooms within each study health facility. Following consent, the lead facilitator guided PCC-AT implementation in a neutral manner so that health facility staff assessed their own strengths and weaknesses through discussing each performance expectation, using a specified benchmarking approach (e.g., yes/no or all/mostly/partly/none) coded for each performance expectation. The assessment process was intended to promote information sharing, a healthy internal dialogue, and consensus building by including a range of staff who could discuss institutional abilities, systems, procedures, and policies in various domains that influence PCC to arrive at a consensus for the 56 performance expectations across each of the twelve subdomains. Once scoring was completed, the facilitators led action planning processes by guiding participants to identify areas of weakness, discussing the reasons for the low scores, and identifying activities to strengthen PCC within that subdomain.

Design and measure construct

Feasibility

Implementation of the PCC-AT in each of the five study facilities was immediately followed by an FGD which was recorded and later transcribed by the data collectors. The study team used a FGD guide (Supplement 3) to collect qualitative data on users’ experiences of the process (e.g., length of time, ease of use, comprehensibility), reactions to results and content (e.g., relevance, comprehensiveness, ability of the tool to assess PCC), and perceptions of the tool’s usability in the context of the health facility workplace. Information was also gathered on any required changes to enhance its implementation. To ensure study rigor, a third study team member observed the FGDs to ensure that the data was collected according to the study protocol.

Data analysis

Quantitative analysis

The study team used descriptive analysis for facility scores for each domain and subdomain. Quantitative analysis also included information collected on how many and which ART provider team members (by cadre) participated in the PCC-AT pilot, their years of experience at the health facility, and gender.

Qualitative analysis

Thematic analysis consisted of coding of FGD findings. FGD transcription data were analyzed, and key themes were applied using NVivo software. Thematic coding of the transcript text allowed for deconstruction of the text and uncovered emergent themes, concepts, issues, and ideas. Initial FGD transcripts were coded separately by two members of the study team according to the framework and compared to ensure intercoder reliability.

Data security

Participant confidentiality was protected throughout study procedures including: 1) omitting names of participants on any data collection materials, 2) storing data in a secure place, 3) developing codes that did not include any potential identifiers (e.g., staff positions), and 4) maintaining strict adherence to the principles of voluntary participation, confidentiality, anonymity and protection of human subjects as guaranteed by the consent form.

Ethical approval and protocol registration

This study received ethical approval from JSI’s IRB (IRB #22-53E) and Ghana Health Service Ethics Review Committee (Protocol ID NO: GHS-ERC 008/10/22). The protocol was registered with the Open Science Framework (OSF) prior to data collection (https://doi.org/10.17605/OSF.IO/763M4).

Results

Across the five study facilities, a total of 37 health facility staff participated in the study with seventy percent of study participants female (Table 1). The mean years of experience was 4.7 (±3.9) years with most participants (73%) having between 1-5 years of experience. Sixty percent of the study participants were Nurses, followed by Laboratory Scientist/Technicians and Data Officers (14%) and Pharmacist/Pharmacist Technicians (11%).

Table 1. Study participant characteristics.

Characteristic	Frequency (%)
Gender
Female	26 (70.3)
Male	11 (29.7)
Years of experience
Mean (SD)	4.7 (±3.9)
<1 year	2 (5.4)
1–5 years	25 (67.6)
6–10 years	7 (18.9)
11–15 years	3 (8.1)
Cadre of Health Staff
Physician/Physician Assistant	1 (2.7)
Nurse (ART Nurse, Nurse Midwife/Community Health Nurse)	22 (59.5)
Laboratory Scientist/Laboratory Technician	5 (13.5)
Pharmacist/Pharmacist Technician	4 (10.8)
Data Officer/Health Information Officer/Health Promotion Officer	5 (13.5)
Total	37 (100.0)

Within study facilities, the minimum number of participants was four with the maximum being ten participants. The mean years of experience within each study facility ranged between 3.6 to 5.5 years. Nurses were the most common cadre to participate across study facilities (Figure 2), with every facility having representation of at least two nurses, as well as one staff member from the pharmacy and one holding a data-related role. See Supplement 4 for a detailed list of study participants within each study facility.

Figure 2. Description of health facility staff participants.

PCC-at scores

On a scale of 1-4, study facilities demonstrated a consistent trend in performance across domains with staffing scoring the highest (range 2.3–3.8) followed by service provision (range 1.8–3.3) and direct client support (range 1.5–2.5) (Figure 3). Within the staffing domain, the subdomain of availability scored highest (3.4) while the subdomain of competency scored lowest (2.6). Within the service provision domain, the subdomain of service efficiency and integration scored highest (3.0) while digital health worker support tools scored lowest (2.0). Within the direct client support domain, the subdomain of psychosocial support scored highest (3.0) while the subdomain of logistical support scored lowest (1.0). See Supplement 5 for detailed scores by domain and subdomain.

Figure 3. Summary PCC-at scores.

Figure 4 depicts the frequency of PCC-AT scores by subdomain. Subdomains that scored high on average showed more range in scores by facility. Subdomains that scored low on average showed little to no range in scores by facility. Client feedback mechanisms demonstrated the greatest variability in scores while logistical support demonstrated the least variability. Facilities were more aligned on low scores than high scores, suggesting similar PCC challenges and areas for improvement.

Figure 4. Frequency of PCC-at scores by sub-domain.

Feasibility

Length of time

The required time to implement the PCC-AT ranged between 53–75 min with an average of 62 min. FGDs revealed that approximately one hour in duration was within an acceptable range for four out of five facilities, while participants from one facility stated that a duration of 30 min is preferable.

Ease of use, relevance, ability to assess PCC

Participants described the tool as well-structured, user-friendly, relevant, and reflected the core PCC delivery elements. Moreover, staff described the tool as useful in elucidating actions within their control, as well as actions requiring administrative advocacy, to improve PCC service delivery across domains.

• What I can add on is that with such things it helps us to abreast ourselves with the current and the standardized methods.

• It was very useful because these questions have been able to give us some guidance…. And go ahead in…

Perceptions of utility and comprehensiveness

FGD participants from all five facilities stated that the PCC-AT is a useful tool to facilitate improvements in PCC. Participants from one facility noted the holistic nature of the tool which requires providers to consider mental health, gender-based violence and other challenges that clients may experience. Another facility stated that the utility of the PCC-AT lies within its content including the subdomain performance expectations which provide guidance for actions at the core of PCC. Another stated that the PCC-AT raises provider awareness of aspects of PCC that should be standardized within a health facility and can contribute to the development of standardized client feedback mechanisms.

• So, from the beginning it was talking about clients, approaches we use, how we get information from them, how they are also able to get to us. It was well angled. To the point of gender-based violence, mental issues, and all that.

• …and in terms of documentation, there are certain things we do as a facility, we don’t have a standard register though it’s being done. So when such things (in the PCC-AT) come up, we remind ourselves that we need to get something standard where we can put in feedback and things like that so it’s helpful.

Frequency of use

Participants from all five facilities reported that they envision using the PCC-AT at regular intervals with three facilities suggesting quarterly PCC-AT assessments and two facilities reporting that it would be useful every six months.

PCC-at content findings and potential changes

Contextualization

Participants advised against significant adjustments to the performance expectations and the response options in the tool. Instead, it was suggested that prior to PCC-AT implementation, the probing techniques within the tool should be tailored to meet each facility context. There were minor suggestions for brevity or rephrasing for clarity and accuracy. Participants were unfamiliar with the terms ‘community-led monitoring’ and ‘bi-directional referral system’ within the tool which require further explanation.

Confidentiality

The performance expectation that refers to adherence reminder calls and sharing test results over the phone or online may not be appreciated by clients who have privacy and confidentiality concerns.

• At times, the clients, you know, the phones, they don’t even want you…, especially the people who don’t want the other… their partners to know… Sometimes when they realize that a call is coming from here, they say it’s a wrong number.

Health education

The prompt for distributing IEC materials should prioritize low-literacy materials including pictures, videos, radio, etc. that do not require participants to read.

• We told you that our clients basically here don’t like reading…We will need more animation or pictorial things to communicate more to them.

ART dispensation

The performance expectation that refers to providing pill boxes or customized packaging to help clients keep track of medications and/or to optimize their privacy was confusing. Participants noted that clients often have their own methods for disguising their medication; suggestions that could be understood as altering ART packaging should be removed out of concerns that alterations could interfere with the integrity of the drug.

• Some of them, even on their own, remove it. They remove the label…when they get home, they do it themselves but as for repackaging here ….

• …actually we don’t really encourage that because we don’t want the medication to… moisture… we want the desiccant to be in, the paper one…

Logistical and basic needs support

A lack of resources presents barriers to providing logistical support to clients. Participants often do not ask clients questions associated with logistical support (providing transport fees, food support, childcare, etc.) because they are aware that the clients have needs that cannot be supported by the facility. In some instances, FGD participants noted that they have personally given clients’ money out of their own pockets, but their donations were not financially supported by the health facility.

• …just a personal something in case the person comes and I'm taking it from my own pocket, we do that. or maybe not with an NGO but when someone comes and wants to support the needy people…, just this Sunday one was done for one pregnant woman. She was called to come, they made her an item of confinement for delivery, and a little token of money was given.

• What I want to add on is, at times when they come and they’re sick, the administrator sometimes waives some costs. That is being done.

• …if we don’t generate any revenue from this department, why would they (the MOH) invest here? If you go and you can tell them to provide us something small which we can use to support them, that will be good.

External barrier

Participants noted that some aspects of the PCC-AT performance expectations were outside of the health facility’s scope of work. This included:

• Home-based ART delivery which is led by local NGOs and not by the facility itself.

• Digital healthcare records that are accessible to staff are limited due to lack of permissions. Clients also are unable to electronically access their medical records including to receive their viral load (VL) results.

• Staff training often takes place off-site. The Ghana Health Service (GHS) or the implementing partner selects training attendees which limits the number of staff who receive training on specific aspects of PCC. Participants indicated that there are limited resources to host on-site PCC training for staff.

  • The reason is that sometimes the letters (for training) come and you’re not in the position to dictate who goes unless they specify that this specific staff should go…so ideally it has to pass through the administration, for them to come to a conclusion and say okay the team has decided that staff A or staff B should go.

• National stock outs and shortages of reagents, test kits and condoms interfere with person-centered service delivery.

  • …because previously they were issuing them for free and the Septrin for free but suddenly they’ve stopped with both the Septrin and condoms.

  • So we order medical stock and they bring it and now they’re saying it’s a national problem. But they’ve received some and they want to see how they will be able to distribute them. It just happened recently.

Participants noted that these challenges do not require changing the tool, but rather raise awareness that the tool should be adaptable so that it can be contextualized prior to implementation.

Discussion

This paper describes findings from a feasibility study of the PCC-AT, which to our knowledge is the first tool that takes a systematic approach to assessing comprehensive PCC within HIV treatment services. The study findings will inform finalization of the PCC-AT which has the potential to fill an important role linked to providing person-centered care in HIV treatment settings. The tool also provides a clear road map to help facilities identify and close gaps in service accessibility, treatment, and retention to improve PCC at the facility level.

Study findings elucidated common areas of weakness for PCC service provision. Not surprisingly logistical and basic needs support was the greatest challenge. It is clear from the FGDs that clients experience financial challenges that can interfere with their ability to purchase food and travel to/from health facilities. While providers and local NGOs have sporadically drawn from their own pockets to support patients, there is limited evidence of a systematic strategy regionally or nationally. Studies from the region at large indicate that financial incentives support re-engagement in care suggesting that investments in logistical and basic needs support may be an important opportunity to support treatment continuity, especially for clients who are required to travel lengthy distances to access HIV treatment services [20,21].

The PCC-AT pilots elucidated several areas that participants reported were outside of the locus of control of the facilities, including access to digital health records, extending service availability to additional hours and days of the week, home-based ART delivery, and ensuring staff have access to offsite training. However, some of these components may be accomplished through advocacy and strategic community partnerships. Additional training for facilitators to help PCC-AT participants develop creative PCC strengthening activities, such as advocacy to administrative and government stakeholders via partnering with community-based organizations who offer some of these services, could further increase the feasibility of the PCC-AT. Client agency, including health education, and client digital support tools were also common areas of weakness suggesting that investments in technology and making health education more accessible are potentially important interventions to improve PCC.

Regarding feasibility findings, participants found the PCC-AT to be easy to use, comprehensible, and not time intensive, in addition to finding it relevant, comprehensive, and helpful to enable a standardized method to assess PCC. Participants affirmed the relevance of performance expectations and response options under each subdomain and expressed that they should remain, but the option to contextualize the performance expectations based upon available resources will be helpful to suit diverse health facilities’ available resources and the populations they serve. The study findings that were classified as outside of the health facility staffs’ control call to attention the fundamental importance of improving supportive systems to enable PCC at the health facility level. Sustainable progress to improve PCC requires intentional partnership between health ministries and other government stakeholders, international donors, NGOs, implementing partners including community-based organizations, and clients to enable health facilities to provide consistent PCC [11].

Study limitations

While this study is comprehensive given the scope of the PCC-AT, the perspectives are limited to 37 staff across five health facilities in Western region of Ghana. Purposive sampling techniques increase the risk of selection bias. There may also be response biases due to social desirability of participants within FGD settings. There were also limitations due to physical space. In four out of the five facilities, the pilots were conducted in service delivery rooms which were interrupted at times, limiting privacy and attention. In one facility, there was also a power outage so the tool could not be projected and administered as initially intended. It is also important to note that participants’ experiences with the tool will likely vary in diverse settings. The study team seeks to address this through conducting a larger preliminary effectiveness study of the PCC-AT in Zambia with another project team once the PCC-AT has been adapted based upon these study findings. Results within this manuscript do not cover client perspectives which is fundamental to designing person-centered care interventions, however, the study team collected client perspective data which will also be shared.

Conclusions

The PCC-AT was universally well-received, and participants expressed interest in using it routinely to measure PCC delivery at facility level and to inform action plans to address identified gaps. The PCC-AT will be adapted based on these study findings to clarify specific terminology and integrate facilitator training and probing techniques to contextualize the tool and elicit PCC strengthening actions that address areas both within and outside facilities’ locus of control. Upon finalization, the study team will ensure that the PCC-AT is widely available for use. Health facility administrators may consider its adoption and routine implementation given the demonstrated feasibility of the PCC-AT tool to assess PCC and inform strengthening activities that support clients’ broader clinical, mental, and psychosocial wellbeing.

Consent

We confirm that all participants provided informed consent in order to participate in this research.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The support for this article was funded by JSI Research and Training Institute, Inc.