The Namibia Treatment Literacy Approach: Empowering Patients with Knowledge on Antiretroviral Therapy Through Audiovisual Materials Authors Francis Kalemeera 1, Jennie Lates 1, Johannes Gaeseb 1, Evans Sagwa 2, David Mabirizi 2, Assegid Mengistu 1, Elena Moreno 1, Emmy-Else Hango 3, Francina Tjituka 2, Meghan Majorowski 4 and Rebecca Oser 4 Affiliations 1.Ministry of Health and Social Services, Namibia 2.Management Sciences for Health, Namibia 3.Catholic Health Services, Namibia 4.Broad Reach HealthCare Presenter: Francis Kalemeera Ministry of Health and Social Services, Namibia

Background (1)  The Ministry of Health and Social Services (MoHSS) Namibia initiated a free antiretroviral therapy (ART) program in 2003  The need to provide health care workers with information on ART was identified  The Therapeutics Information and Pharmacovigilance Centre (TIPC) was established (2007) to improve safe medicine use and provide unbiased information on medicines including ARVs  A rapid assessment (2008) to identify TIPC future activities showed that Health facilities utilised a checklist to ensure all relevant topics were covered when counselling ART patients  The lack of standardised messages being given during ART counselling led MoHSS to design the Treatment Literacy Approach (TLA) programme.  The TLA emphasises the use of different methods to educate patients on their medication

Background (2)  MoHSS and partners developed a treatment literacy toolkit : DVDs (Intended to be watched with guidance from a counsellor). The DVDs dealt with four priority themes including: 1.Preparing to start ARV therapy; 2.Starting ARV therapy; 3.Alcohol and adherence; and 4.Long-term adherence to ARV therapy. Flipchart (Story telling flipchart, led by counselor) Posters (reinforcing messages on the video and in flipchart, with phrases to help interpret the picture message)  Materials were piloted before roll out to ensure that they were conveying the intended messages.  The TLA materials were implemented in 6 ART clinics in October 2009, and evaluated.

Evaluation of TLA Materials  The objectives of evaluation were to assess the TLA materials for their: Effectiveness in empowering patients with ART knowledge, and Efficiency in terms of time spent on educating HIV infected patients who are on ART Methods  Design: Post-Test Only Control Group Design  Selection of sites: Purposive selection  Target population: Patients who started ART between Oct 2009–May 2010

Methods cont.  Patient selection: Systematic random sampling  Data quality assurance: data collectors were trained  Data Collection: May to June Patients were assessed using an interview with 36 knowledge questions; facility data was collected; time spent counselling patients on ART was recorded  Data analysis: Chi-square test was used to compare average knowledge scores between intervention and control sites. Time spent on counselling individual patients on HAART was collected, summed, and averages for facilities were calculated

Results (1) 1.Number of patients: Intervention sites 181; Control Sites 93 2.Number of facilities: Intervention sites 6; Control sites 4 3.Demographics: comparable 4.Usage of tools: The control sites used flipcharts and posters different from the TLA materials. Below is a summary of how materials were used:  Control sites reported usage of materials as follows: video-0%; flipchart-50%; and posters-50%  Patients at control sites reported exposure to treatment literacy materials as follows: video-4%; flipchart-6%; and poster-37%  All Intervention sites reported to have used the TLA materials  Patients at intervention sites reported exposure to treatment literacy materials as follows: video-60%; flipchart-78%; and poster-51%

Results (2) 5.Exposure: Variable exposure to the TLA materials How patients were exposed to the flipchartHow patients were exposed to the DVD

Results (3) 6.Knowledge scores: Patients at intervention sites had higher scores (Table 1) 7.Adherence: Intervention sites’ patients reported better adherence (Table 1) 8.Time spent on counselling: Intervention and control sites spent an average of 2.3 and 9.7 minutes/patient on ART counselling 9.Counsellors’ views: TLA materials had more content than materials used before and they stimulated patient involvement Score Control sites Intervention sites % of questions in which this group had higher scores 25%75% Total patient knowledge score out of 36 knowledge questions 79%85% CI 95%; p-value = Adherence % of pts reporting missing doses of ARVs 20.7%11.7% Table 1: Table of Knowledge Scores and Adherence Findings

Conclusions  The TLA is effective in empowering patients with ART knowledge  TLA appears to be associated with improved time efficiency, allowing counsellors to concentrate on patients with adherence problems  Other public health programmes in Resource Limited Settings could benefit from guided group education as that utilised in TLA implementation Key Lessons Learnt  The TLA creates an environment for patients to actively participate in discussions on ART, which boosts their understanding and staff motivation  In addition to training in technical use of the TLA materials, the roll-out of TLA requires capacity building of users in TLA implementation plans to support 100% patient exposure

Implications  The TLA provides structure for patient education, leading to standardised, consistent messages being passed onto all patients regardless of the health worker involved  Roll-out of TLA videos to general public through community cinemas, and public television is expected to positively support adherence Future Studies  The effect of patient knowledge of antiretroviral therapy on treatment outcomes  The effect of collaborative approaches on cost reduction of TL programmes