Evaluating the Uptake,Acceptability,and Effectiveness of Uliza! Clinicians' HIV Hotline: A Telephone Consultation Service in Kenya

Introduction

In 2003 Kenya initiated a massive scale-up of HIV care and treatment services, including decentralization of antiretroviral therapy (ART). ¹ With concerted efforts to reduce the HIV burden in Kenya, the national HIV prevalence in Kenya dropped from 10% in 1997 to 7.4% in 2007. ² Nyanza province continues to have the highest HIV prevalence in the country, at 15%. ² Kenyan's life expectancy at birth declined from 60 years in the early 1980s to 45 years by 2002, before increasing to 55.3 years in 2007. ³ The fall in life expectancy has been attributed to the emergence of diseases such as HIV, malaria, and tuberculosis, among others.

Although the expansion of HIV care and treatment are making significant strides in sub-Saharan Africa, many of the most heavily burdened areas are also the most under-resourced. ^4,5 Many clinical sites that serve patients who are HIV positive face challenges of insufficient staffing levels and staff training and limited access to consultation resources including books, Internet, and specialists on site. The doctor-patient ratio in Kenya is reported to be 14 per 100,000 patients. ⁶ Although the World Health Organization recommends a nurse-patient ratio of 200 per 100,000, Kenya's ratio stands at 50 per 100,000. ⁷ Few qualified specialists are willing to work in the under-resourced public health sector, particularly in rural areas. ⁴ To rapidly decentralize HIV services, training of healthcare workers has focused on standardized guidelines and protocols taught during short seminar-based courses. ⁸ Healthcare workers often have difficulty applying that knowledge when faced with complicated patients at their facilities, with little or no access to clinical decision-making support. ⁹ Patients often refuse referral to secondary- or tertiary-level facilities, even when quite ill, because of the distance, time away from livelihood, family responsibilities, poor transportation networks, the costs of traveling to the referral site, and paying hospital fees. ¹⁰

Fortunately, the roll-out of HIV care and treatment in sub-Saharan Africa has coincided with the rapid expansion of cell phone coverage in the region. ¹¹ In addition to improving communication between providers and patients, access to mobile phones has been used to facilitate provider-to-provider connections. ¹² Several countries have developed consultation systems that allow healthcare providers to ask questions of experienced clinicians via direct phone calls and e-mail communication. ^{13 –15} Consultation systems provide a support network that builds the confidence of newly trained providers and practitioners in HIV care. In the United States, for example, the National HIV/AIDS Clinicians' Consultation Center (NCCC) supports clinicians nationwide through a”warm-line.” ¹⁶ In Uganda, the AIDS Treatment Information Centre hosts a call-in service that responds to providers' treatment questions. ¹⁷ Similarly, the Prince Leopold Institute of Tropical Medicine in Belgium has developed an Internet-based program using Telemedicine, to enable their experienced providers to respond via e-mail to inquiries made by clinicians in resource-limited settings. ¹⁸ Although these programs provide important services to their constituencies, published formal evaluation of these programs is lacking.

In April 2006, Family AIDS Care and Education Services (FACES), a collaboration between the University of California, San Francisco (UCSF), and the Kenya Medical Research Institute (KEMRI), initiated a telephone consultation service for HIV care providers in parts of Nyanza province in Kenya. The purpose of this study was to evaluate the uptake, acceptability, and effectiveness of this new service.

Materials and Methods

Results

After its first year of service, Uliza! responded to 296 calls from 79 different care providers (Table 1). Over two-thirds of the calls (69%) came from district hospitals and health centers. Clinical officers made the majority of calls from all facility levels (64%), except from dispensaries, which do not have clinical officers; nurses made 100% of the calls from dispensaries (Table 2). Over half of the callers (58.4%) made at least two calls, with a median number of calls per user of 2 (interquartile range (IQR) 1–4). Based on participation rates in the user/nonuser surveys, we estimate that of the staff on site at the time of site visits, 30.0% of staff at month 3 and 54.5% of staff at month 6 had used the service.

Most providers who called had questions regarding ART and tuberculosis (36% and 18%, respectively). Thirty-six percent of cases discussed were pediatric. Most questions were about specific patients; a few questions were about care and treatment logistics and general HIV-care questions (Table 1).

Among the callers who responded to the user surveys, almost all indicated that the service helped them improve the quality of care given to patients, met their consultation needs, and provided advice that helped them the next time they faced a similar situation in their clinical practice; results for these outcomes were relatively constant across the three evaluation periods (Table 3). In addition, nearly all of the respondents felt that the service was useful, convenient, responded in a timely manner, and gave reliable clinical information (Table 3). Most providers depended on Kenyan national guidelines and colleagues at their facilities as alternative sources of information and consultation. Less than 30% used text books or e-mail for clinical information or consultation. To improve clinical practice, most providers felt they needed additional clinical mentorship and training (Table 3).

From the user surveys, we identified two important barriers to use of Uliza!: (1) poor cellular phone network coverage at a few sites, and (2) slow response time of the Uliza! consultants. Some healthcare providers did not use the service, because they had access to alternative sources of information, including colleagues and the Kenyan national guidelines for care and treatment of persons infected with HIV (Table 4). Among respondents to the nonuser surveys, the most frequently cited reasons for not using the service were not knowing about the service, not having a question to ask, and using other resources to answer their questions (Table 4).

Of the 174 consultations made during the first 9 months of the service, we were able to retrieve 101 (58%) of the corresponding medical records during the site visits. Of these, the advice given by the consultation service was implemented and documented in 72 (71%) cases. This percentage increased from 52% (11 of 21 records) in the first quarter of the service to 84% (36 of 43 records) in the second, and 81% (30 of 37 records) in the third quarter. In those cases that the recommendations were not completely followed as documented in the medical records, most discrepancies resulted from waiting for laboratory tests that were not available immediately at the facility. In those situations, the patient was often referred to a higher-level facility.

Discussion

The purpose of this study was to evaluate the uptake, acceptability, and effectiveness of a new HIV cell phone-based consultation service. We found that most healthcare providers in HIV clinics use a HIV telephone consultation service when it is easily accessible. Although only approximately 54.5% of healthcare staff surveyed at 6 months had used the service, this may reflect the natural chain of consultation that takes place within a facility. Junior staff will ask on-site colleagues or senior staff for assistance first. If together they are still uncertain, then it is the senior-most staff who generally call Uliza! In fact, most consultation calls came from clinical officers at sites that had clinical officers and from nurses in facilities which did not have clinical officers as staff.

The majority of calls came from high-volume health facilities, which were the sites that have been offering HIV services for longer (so more patients and more long-term complications) and often run their HIV clinic throughout the week (compared with low-volume sites that often have HIV clinics for 1 or 2 days per week).

This study found that the advice given through the service was usually implemented. The service increased access to current information on HIV prevention, care, and treatment, thereby improving access to quality of care for patients in this resource-limited and remote setting. Although providers had been trained on use of the Kenyan National Guidelines and most had access to the guidelines on site, this did not always lead to their proper use. The consultants, by referring to the Kenyan National Guidelines, strengthened their use by pointing the callers to specific pages to find information regarding the specific call. The guidelines were primarily algorithmic and provided guidance on typical patient care scenarios; however, they could not be continuously updated or include complex or unusual clinical presentations. The consultants had Internet access, additional references, and telephone access to HIV specialists, so they could provide the most up-to-date information tailored to each individual case.

Our study also demonstrated that first-time callers were likely to call Uliza! again. This repeated calling may indicate behavior change among healthcare providers toward adopting a culture of asking questions whenever in doubt. Historically, most clinicians working in resource-limited settings have had infrequent access to consultation as a result of the busy patient load, limited access to on-site medical expertise, and a poor telecommunication infrastructure. ^13,18

Most users of the service found it reliable and convenient to use, in part because of the real-time response by consultants while the patient was still in the examination room. Nevertheless, occasional slow responses were a barrier to use of Uliza ! . During the first year of the service, slow responses were the result of the consultants having simultaneous clinical responsibilities while they responded to calls. With this feedback, we believe that a call center could be established in which the consultants could be relieved of other clinical responsibilities and take turns responding to calls.

A limitation of our study is that, although we demonstrated that advice given was usually implemented, we could not be certain that the advice led directly to improved patient outcomes. The direct measurement of patient outcome and its causality would be difficult to prove. Nevertheless, we believe that the methods used, including audit of patient records, abstraction of data, and correlation with the consultation form, are reasonable proxies for improved medical care affected by the service.

We believe our findings underscore the potential utility of a HIV telephone consultation service provided to healthcare providers in resource-limited settings. Moreover, the service provided a means to mentor clinical staff, especially those without many alternatives for continuing medical and nursing education. The widespread availability of cellular phones makes them an ideal tool for connecting providers to real-time consultation. ^11,19 With the current cost of a cell-phone call in Kenya, only $0.04, this service has become even more cost effective than when it was first initiated in 2006. Finally, as countries throughout sub-Saharan Africa decentralize HIV care and treatment to more remote locations, Uliza! and similar consultation hotlines will play an important role in increasing access to current treatment information and management advice for complicated patients. Further evaluation of scale-up of phone consultation services should include the impact on healthcare worker long-term knowledge, quality of care, and cost effectiveness.