From the HIVQUAL International Update

KATUTURA HEALTH CENTER, NAMIBIA 
Prevention Education

Katutura Health Center, located in a suburb of the Windhoek district, is staffed by two doctors, five nurses, one pharmacist, two pharmacy technicians, one pharmacy assistant, two data clerks, four counselors, one revenue clerk, one maintenance person, and three expert patients.

Health Center staff chose prevention education as their QI focus, because of low performance demonstrated in this area.

Investigation of data revealed that patients starting treatment were not receiving required prevention education at the time of initiation because of poor scheduling.  For example, one day 40 patients arrived, and on another day only five showed up.

During this analysis, staff also identified a link between poor patient adherence and prevention education deficits. Additional obstacles included perceived patient disinterest in counseling, and delays between adherence counseling and ARV initiation.

Katutura staff decided on a two phase improvement strategy. Phase I, January – June 2009, included: ensuring consistent documentation, such as recording in patient charts at time of counseling; positive living counseling for all patients regardless of eligibility (including disclosure, nutrition, substance use, condoms and family planning); patient referrals for adherence counseling based on eligibility; designated days for particular services; and introduction of a patient scheduling tool to assist counselors in general management of patient load.

To bolster adherence for all new patients beginning on HAART, a DVD was developed and produced on-site at Katutura Health Center (with technical support from students at the University of Namibia [UNAM]). The movie, “Your ARV Treatment,” is screened every Friday for all patients beginning on ART treatment, during which time patients are assembled to watch the video and later engaged in a Q&A session. Created in the three chief languages of the region (English, Oshiwambo and Afrikaans), the video begins with a step-by-step introduction to Katutura’s clinical services and the consultation process. The video emphasizes ART adherence, and reinforces preventive behaviors (covering disclosure, substance use, condoms and family planning). 

As a result of this multi-level improvement approach, prevention education performance increased seven-fold from 6% at round 3, to 42% at round 4 data collection.



Beginning in June 2009, and running until December 2009, Katutura initiated Phase II of their strategy. During this time, staff introduced prevention education and adherence counseling sessions for patients with more than one year of ARV therapy; continued TB screening; focused on initiation and adherence with isoniazid prophylaxis (IPT); instituted counseling and screening before refills were completed to reinforce patient knowledge about drug regimens; and worked to acquire additional audio visual tools to continue multimedia educational interventions to improve patient knowledge.

Even within an ambitious and well-managed QI program, challenges lay ahead. Katutura’s quality improvement activities are labor intensive (requiring multiple trained staff and regimented documentation); involve patient coordination with a focus on adherence; and confront language barriers between patients and staff.

Undaunted, Katutura staff has also initiated a QI project in response to food security and alcohol screening measures, two indicators unique to Namibia. To address these issues, staff devised a new screening tool, established routine screening to be initiated by counselors, and arranged to complete a screening tool for all patient visits.