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      Provider perspectives on PrEP for adolescent girls and young women in Tanzania: The role of provider biases and quality of care

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          Abstract

          Background

          Oral pre-exposure prophylaxis (PrEP) has the potential to reduce HIV acquisition among adolescent girls and young women (AGYW) in sub-Saharan Africa. However, health care providers’ (HCPs) perspectives and interactions with potential clients can substantially influence effective provision of quality health services. We examine if HCPs’ knowledge, attitude, and skills, as well as their perceptions of facility readiness to provide PrEP are associated with their willingness to provide PrEP to AGYW at high risk of HIV in Tanzania.

          Methods

          A self-administered questionnaire was given to 316 HCPs from 74 clinics in two districts and 24 HCPs participated in follow-up in-depth interviews (IDIs). We conducted bivariate and multivariable Poisson regression to assess factors associated with willingness to provide PrEP to AGYW. Thematic content analysis was used to analyze the IDIs, which expanded upon the quantitative results.

          Results

          Few HCPs (3.5%) had prior PrEP knowledge, but once informed, 61.1% were willing to prescribe PrEP to AGYW. Higher negative attitudes toward adolescent sexuality and greater concerns about behavioral disinhibition due to PrEP use were associated with lower willingness to prescribe PrEP. Qualitatively, HCPs acknowledged that biases, rooted in cultural norms, often result in stigmatizing and discriminatory care toward AGYW, a potential barrier for PrEP provision. However, better training to provide HIV services was associated with greater willingness to prescribe PrEP.

          Conversely, HCPs feared the potential negative impact of PrEP on the provision of existing HIV services (e.g., overburdened staff), and suggested the integration of PrEP into non-HIV services and the use of paramedical professionals to facilitate PrEP provision.

          Conclusions

          Preparing for PrEP introduction requires more than solely training HCPs on the clinical aspects of providing PrEP. It requires a two-pronged strategy: addressing HCPs’ biases regarding sexual health services to AGYW; and preparing the health system infrastructure for the introduction of PrEP.

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          Most cited references25

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          Patient perceptions of the quality of health services.

          As calls are made for a more patient-centered health care system, it becomes critical to define and measure patient perceptions of health care quality and to understand more fully what drives those perceptions. This chapter identifies conceptual and methodological issues that make this task difficult, including the confusion between patient perceptions and patient satisfaction and the difficulty of determining whether systematic variations in patient perceptions should be attributed to differences in expectations or actual experiences. We propose a conceptual model to help unravel these knotty issues; review qualitative studies that report directly from patients on how they define quality; provide an overview of how health plans, hospitals, physicians, and health care in general are currently viewed by patients; assess whether and how patient health status and demographic characteristics relate to perceptions of health care quality; and identify where further, or more appropriately designed, research is needed. Our aim is to find out what patients want, need and experience in health care, not what professionals (however well-motivated) believe they need or get.
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            Assessing health system performance in developing countries: a review of the literature.

            With the setting of ambitious international health goals and an influx of additional development assistance for health, there is growing interest in assessing the performance of health systems in developing countries. This paper proposes a framework for the assessment of health system performance and reviews the literature on indicators currently in use to measure performance using online medical and public health databases. This was complemented by a review of relevant books and reports in the grey literature. The indicators were organized into three categories: effectiveness, equity, and efficiency. Measures of health system effectiveness were improvement in health status, access to and quality of care and, increasingly, patient satisfaction. Measures of equity included access and quality of care for disadvantaged groups together with fair financing, risk protection and accountability. Measures of efficiency were appropriate levels of funding, the cost-effectiveness of interventions, and effective administration. This framework and review of indicators may be helpful to health policy makers interested in assessing the effects of different policies, expenditures, and organizational structures on health outputs and outcomes in developing countries.
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              Fundamental elements of the quality of care: a simple framework.

              J Bruce (2015)
              This article argues for attention to a neglected dimension of family planning services--their quality. A framework for assessing quality from the client's perspective is offered, consisting of six parts (choice of methods, information given to clients, technical competence, interpersonal relations, follow-up and continuity mechanisms, and the appropriate constellation of services). The literature is reviewed regarding evidence that improvements in these various dimensions of care result in gains at the individual level; an even scarcer body of literature is reviewed for evidence of gains at the level of program efficiency and impact. A concluding section discusses how to make practical use of the framework and distinguishes three vantage points from which to view quality: the structure of the program, the service-giving process itself, and the outcome of care, particularly with respect to individual knowledge, behavior, and satisfaction with services.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Formal analysisRole: MethodologyRole: SupervisionRole: Writing – original draftRole: Writing – review & editing
                Role: Formal analysisRole: MethodologyRole: Writing – review & editing
                Role: ConceptualizationRole: MethodologyRole: Writing – original draftRole: Writing – review & editing
                Role: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Writing – review & editing
                Role: Data curationRole: Formal analysisRole: Writing – review & editing
                Role: MethodologyRole: Writing – review & editing
                Role: InvestigationRole: Project administrationRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: MethodologyRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                27 April 2018
                2018
                : 13
                : 4
                : e0196280
                Affiliations
                [1 ] Population Council, Washington, DC, United States of America
                [2 ] CSK Research Solutions, Dar es Salaam, Tanzania
                [3 ] National AIDS Control Programme, Dar es Salaam, Tanzania
                UNAIDS, UNITED STATES
                Author notes

                Competing Interests: The affiliation with CSK Research Solutions does not alter our adherence to PLOS ONE policies on sharing data and materials. The authors declare no competing interests. Additionally, the content of this manuscript has not been published, or submitted for publication elsewhere.

                Author information
                http://orcid.org/0000-0003-1645-6734
                Article
                PONE-D-17-43440
                10.1371/journal.pone.0196280
                5922529
                29702659
                1a98a13a-04ab-433e-99ed-649e6789e520
                © 2018 Pilgrim et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 12 December 2017
                : 8 April 2018
                Page count
                Figures: 0, Tables: 5, Pages: 21
                Funding
                Funded by: funder-id http://data.crossref.org/fundingdata/funder/10.13039/100000865, Bill & Melinda Gates Foundation;
                Award ID: OPP1150068
                Funded by: funder-id http://dx.doi.org/10.13039/100000865, Bill and Melinda Gates Foundation;
                Award ID: OPP1136778
                Funded by Bill & Melinda Gates Foundation-OPP1150068- https://www.gatesfoundation.org/ Bill & Melinda Gates Foundation-OPP1136778- https://www.gatesfoundation.org/ The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. CSK Research Solutions (CSK) is a private firm that supports design and implementation of research studies and program monitoring and evaluation activities in Tanzania. CSK did not fund the study but served as the Tanzanian research partner in the study. CSK received a sub-contract from the Population Council to collect data, participate in data analysis and participate in the preparation of the manuscript.
                Categories
                Research Article
                People and Places
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                People and Places
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                Biology and Life Sciences
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                Microbial Pathogens
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