Thailand

Spotlight: Phonphisai Hospital

Using multiple data sources to drive stigma reduction and HIV QI activities at Phonphisai Hospital, Thailand

Background

Phonphisai Hospital is a district health facility located in Thailand’s
Nong Khai Province, approximately 540 km northeast of Bangkok (Figure 1). The HIV clinic at Phonphisai provides care to over 600 people living with HIV (PLWH).

In 2018, the Hospital elected to participate in the Bureau of TB, HIV, STI's (BATS) national initiative to reduce HIV-related stigma and discrimination (S&D). As one of 50 participating hospitals across 13 provinces, Phonphisai Hospital received coaching and support to
conduct a baseline assessment of S&D among healthcare workers
(HCW) and PLWH, and develop a facility-wide plan to address the
findings using participatory S&D training and quality improvement (QI)
tools and methods.

Using Multiple Data Sources for S+D QI Activities

To generate a comprehensive assessment of HIV-related S&D and its effects on HIV clinical outcomes, Phonphisai Hospital staff used insights from three data sources: (1) clinical outcomes data from the national HIV database; (2) survey results from HCWs; and (3) survey results and feedback from PLWH. By uniting these three data sources, Hospital staff developed a data-driven plan to reduce S&D and improve the quality of HIV care. 

Clinical Outcomes
Review of clinical outcomes data by Phonphisai HIV clinic staff revealed gaps in three national indicators: (1) CD4 count at entry into care; (2) care engagement; and (3) mortality within one year of initiation. In 2017, for example, 61% of newly diagnosed cases presented with a CD4 count less than 200, 22% of PLWH were lost to follow up during the past 12 months, and 5% of new patients had died within the first year of treatment. Through root cause analysis as part of ongoing QI activities, clinic staff identified S&D as key drivers of suboptimal performance in these indicators, prompting a desire to measure its prevalence.

Results of PLWH Surveys and Feedback
In 2018, Phonphisai conducted an assessment of S&D among PLWH using a web-based survey platform (REDCap) or self-administered paper survey. Results of a representative survey revealed that many PLWH had experienced S&D in the healthcare setting, and that anticipations of S&D had often impacted their desire to seek treatment (Figure 2). Moreover, interviews with PLWH identified several institutional practices they felt to be particularly stigmatizing and discriminatory, including indiscrete or inappropriate discussion of patients’ health information in public areas, separate waiting areas, equipment, and documentation procedures for PLWH, placement of PLWH at the end of queues for surgical and dental procedures, and use of masks during non- clinical encounters.

Results of HCW Surveys
Results of pre-intervention HCW surveys showed that many staff were fearful of HIV infection through provision of care to PLWH, and often used double gloves to protect themselves from exposure (Figure 3). In addition, respondents reported that they had sometimes observed their colleagues unwilling to provide care to PLWH, or providing care to PLWH that was perceived to be of poorer quality.

Generating a Data-Driven Response to Reduce S&D

Interventions to reduce S&D
Following collection and analysis of data from clinical performance, HCW surveys, and PLWH surveys and feedback, each department implemented its own package of interventions to address root causes of S&D: knowledge of HIV transmission, facility policies, and HCW communication (Table 1). To measure the impact of interventions, Phonphisai staff will repeat assessments of all three data sources in early 2019.

Lessons Learned

In its use of multiple data sources to inform its stigma-reduction interventions, Phonphisai Hospital aims to develop a data-driven response to the creation of a clinical environment that is free of stigma and discrimination. Through its approach, the hospital team has adopted several ”best practices” that are crucial to the successful implementation of S+D QI activities.

  • Using multiple data sources to develop and monitor interventions. Stigma and discrimination are routinely identified as common root causes of poor HIV care outcomes, especially for members of key and vulnerable populations who face other barriers to treatment success. By using performance data alongside findings from HCW surveys and patient feedback, facilities can identify subpopulations (e.g., virally unsuppressed PLWH) who may be acutely impacted by S+D in the healthcare setting, and ensure that interventions are tailored to optimize the care experiences of these patients.
  • Enabling department-specific responses. Manifestations of stigma and discrimination may vary by clinical context due to differences in design, management, and clinical focus. Moreover, interventions shown to work in one setting may not—in the absence of careful adaptation—work with the same efficacy as in another. Encouraging staff feedback and engagement, and empowering individual departments is therefore a key strategy for tailoring interventions to unique contexts, insofar as they remain aligned with facility-level policies and strategies.
  • Supplementing findings of PLWH surveys with other data on patient experience. Findings from surveys are useful in confirming that a problem exists, but may not always provide precise insight on how to fix it. Interviews, patient fora, and other methods can therefore be helpful to confirm the findings of a formal survey, and identify specific departments, circumstances, and encounters that generate S+D experienced by PLWH in the healthcare setting.

Acknowledgements

In its production of this Spotlight, UCSF-HEALTHQUAL acknowledges the staff of Phonphisai Hospital and the Bureau of AIDS, TB, and STIs for their contributions and careful review, to the Global Fund for support of site-level training activities, and Chiang Mai University for its ongoing technical assistance. The Southeast Asia Stigma Reduction QI Learning Network is supported by the U.S. President’s Emergency Plan for AIDS Relief as part of the Health Resources and Services Administration’s (HRSA) Quality Improvement Capacity for Impact Project (QICIP). The contents are the responsibility of UCSF-HEALTHQUAL and do not necessarily reflect the views of the U.S. Government.