Transcript Title 26pt Bold

Increasing the Effectiveness of ARV Programs:
Using Strategic Information on Individuals and
Communities
Carla Makhlouf Obermeyer
July 1, 2003
Outline:
Involving individuals and communities
What sort of strategic information?
How we get it
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Neglecting the individual and community
dimensions of ARV programs is hazardous
Many public health interventions :
•are designed in a generic way that is not informed by local conditions
•neglect key strategic information
•make incorrect assumptions about individuals’ responses, condemn or
dictate behaviors to individuals they mean to serve
Danger that ARV programs will also face difficulties as a result of
unanticipated community responses -- opposition , rumors, or indifference
Assuming demand for testing and counseling, or expecting obedience from
patients on treatment is unlikely to achieve high adherence
Suboptimal adherence results in ineffective care, waste of resources, and
drug resistance
Understanding local contexts, “community preparedness” and
response are crucial to the success of any program
Involving individuals.
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Characteristics of strategic information to involve
individuals and communities
1. Expands our scope beyond narrowly defined factors, to
include what happens outside of health facilities
2. Helps formulate realistic goals, translate key elements
and adapt tools to local contexts
3. Strategic information about local concepts is essential
to plan effective programs
4. Is attentive to the role of “culture” but does not
overstate it
Such information is an integral part of M & E
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1. Strategic information expands our scope to
include what happens outside of health facilities
Treatment is not simply about the moment of taking
the drug; the decision needs to be made over and
over again
Testing is not just getting information
The formal system is but one source of information on
treatment, others sources offer competing
information
Consider individuals’ motivations, reasons for key
behaviors and figure out how to foster change
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2. Strategic information helps formulate realistic goals
and adapt tools
High adherence: what drives it, what undermines it?
Expectations from treatment reflect understandings of illness
Obstacles to high adherence--forgetting, side-effects,
“treatment fatigue”-- are the same but different
reminders, instructions and support mechanisms have
to be context-specific
Testing and counseling programs: how they fit in the local
health system
Considering local understandings of illness and
therapy, local patterns of health care use will
strengthen program effectiveness
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3. Strategic information about local concepts is
essential to plan effective programs
Misconceptions
Misunderstandings
Missed
opportunities
Doubts about HIV: the Mbecki affair
The meaning of tests: taking blood
Seropositivity and disclosure
Counseling: does it help?
Ambivalence about medications: trust
and control
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How can we get such strategic information – 1
An integrated
approach
Mixed
methods
Who can do it
Combines tools from survey, in-depth
ethnography, and rapid assessment
Anything that will help reveal views from
the other side: observations, interviews,
focus groups, cultural domain analyses,
pile sorts…
Adding open-ended questions to surveys
Staff who can be trained to observe, listen,
and make good notes
Staff that can analyze information and make
actionable recommendations
Collaborative projects contribute to
capacity building
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How can we get such strategic information – 2
When
At baseline
At key points
Routinely through the project
Cost
Scale and depth can be adapted to
available resources; anything is better
than completely neglecting this dimension
Products
Recommendations for improving
effectiveness, based on good cultural
information
Better communication
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Conclusion
As for other elements of efforts to scale
up, we have to learn by doing . . .
. . . but this has to be done
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