BACKGROUND Recipients of health services value not only convenience but also respectful, kind, and helpful providers. To date, research to improve person-centred HIV treatment has focused on making services easier to access (eg, differentiated service delivery) rather than the interpersonal experience of care. We developed and evaluated a person-centred care (PCC) intervention targeting practices of health-care workers. METHODS Using a stepped-wedge, cluster-randomised design, we randomly allocated 24 HIV clinics stratified by size in Zambia into four groups and introduced a PCC intervention that targeted caring aspects of the behaviour of health-care workers in one group every 6 months. The intervention entailed training and coaching for health-care workers on PCC practices (to capacitate), client experience assessment with feedback to facilities (to create opportunities), and small performance-based incentives (to motivate). In a probability sample of clients who were pre-trained on a client experience exit survey and masked to facility intervention status, we evaluated effects on client experience by use of mean score change and also proportion with poor encounters (ie, score of ≤8 on a 12-point survey instrument). We examined effects on missed visits (ie, >30 days late for next scheduled encounter) in all groups and retention in care at 15 months in group 1 and group 4 by use of electronic health records. We assessed effects on treatment success at 15 months (ie, HIV RNA concentration <400 copies per mL or adjudicated care status) in a prospectively enrolled subset of clients from group 1 and group 4. We estimated treatment effects with mixed-effects logistic regression, adjusting for sex, age, and baseline care status. This trial is registered at the Pan-African Clinical Trials Registry (202101847907585), and is completed. FINDINGS Between Aug 12, 2019, and Nov 30, 2021, 177 543 unique clients living with HIV made at least one visit to one of the 24 study clinics. The PCC intervention reduced the proportion of poor visits based on exit surveys from 147 (23·3%) of 632 during control periods to 33 (13·3%) of 249 during the first 6 months of intervention, and then to eight (3·5%) of 230 at 6 months or later (adjusted risk difference [aRD] for control vs ≥6 months intervention -16·9 percentage points, 95% CI -24·8 to -8·9). Among all adult scheduled appointments, the PCC intervention reduced the proportion of missed visits from 90 593 (25·3%) of 358 741 during control periods to 40 380 (22·6%) of 178 523 in the first 6 months, and then 52 288 (21·5%) of 243 350 at 6 months or later (aRD for control vs the intervention -4·2 percentage points, 95% CI -4·8 to -3·7). 15-month retention improved from 33 668 (80·2%) of 41 998 in control to 35 959 (83·6%) of 43 005 during intervention (aRD 5·9 percentage points, 95% CI 0·6 to 11·2), with larger effects in clients newly starting treatment (aRD 12·7 percentage points, 1·4 to 23·9). We found no effect on treatment success (based on viral load) in a nested subcohort (379 [83·7%] of 453 in the control phase vs 402 [83·8%] of 480 in the intervention phase; aRD 0·9 percentage points, -5·4 to 7·2). INTERPRETATION Improving the caring aspects of health-care worker behaviour is feasible in public health settings, enhances client experience, reduces missed appointments, and increases retention. FUNDING The Bill & Melinda Gates Foundation.

中文翻译：

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赞比亚多成分、以人为本的护理干预对客户体验和 HIV 治疗结果的影响：一项阶梯式楔形、整群随机试验。


背景 卫生服务的接受者不仅重视便利，还重视尊重、善良和乐于助人的提供者。迄今为止，改善以人为本的 HIV 治疗的研究侧重于使服务更容易获得（例如，差异化服务提供），而不是护理的人际体验。我们开发并评价了针对医护人员实践的以人为本的护理 （PCC） 干预措施。方法 使用阶梯楔形、整群随机设计，我们将赞比亚的 24 家 HIV 诊所按规模分为四组，并引入了一项 PCC 干预，针对一组医护人员行为的护理方面，每 6 个月进行一次。干预包括对医护人员进行 PCC 实践的培训和指导（以提高能力）、客户体验评估并反馈给设施（创造机会）和基于绩效的小额激励措施（激励）。在接受客户体验退出调查预培训并对设施干预状态不知情的客户概率样本中，我们通过使用平均分数变化以及与不良遭遇的比例（即，在 12 分调查工具上得分为 ≤8）来评估对客户体验的影响。我们通过使用电子健康记录检查了对所有组的错过就诊 （即下一次预定就诊延迟 >30 天） 和第 1 组和第 4 组 15 个月时护理保留率的影响。我们评估了第 1 组和第 4 组前瞻性入组的客户子集在 15 个月时对治疗成功的影响 （即 HIV RNA 浓度 <400 拷贝/mL 或裁定的护理状态）。我们用混合效应 logistic 回归估计治疗效果，调整性别、年龄和基线护理状态。 该试验已在泛非临床试验注册处 （202101847907585） 注册，并已完成。调查结果在 2019 年 8 月 12 日至 2021 年 11 月 30 日期间，177 543 名 HIV 感染者至少访问了 24 个研究诊所之一。PCC 干预将基于退出调查的不良就诊比例从控制期间 632 例中的 147 例 （23·3%） 降低到干预前 6 个月 249 例中的 33 例 （13·3%），然后在 6 个月或更晚时降低到 230 例中的 8 例 （3·5%），对照组与 ≥ 6 个月干预相比的调整后风险差 [aRD] -16·9 个百分点， 95% CI -24·8 至 -8·9）。在所有成人预定预约中，PCC 干预将错过就诊的比例从控制期间的 358 741 例中的 90 593 例 （25·3%） 降低到前 6 个月内 178 523 例的 40 380 例 （22·6%），然后在 6 个月或更晚时降低 243 350 例中的 52 288 例 （21·5%），对照的 aRD -4·2 个百分点， 95% CI -4·8 至 -3·7）。干预期间，15 个月保留率从对照组 41 998 例中的 33 668 例 （80·2%） 提高到 43 005 例中的 35 959 例 （83·6%） （aRD 5·9 个百分点，95% CI 0·6 至 11·2），对新开始治疗的客户影响更大 （aRD 12·7 个百分点，1·4 至 23·9）。我们发现对嵌套亚队列（对照组为 453 例中的 379 例 [83·7%] ，干预期为 480 例中的 402 例 [83·8%];aRD 0·9 个百分点，-5·4 至 7·2）的治疗成功率（基于病毒载量）没有影响。解释 在公共卫生环境中，改善医护人员行为的关怀方面是可行的，可以增强客户体验，减少错过预约，并提高保留率。资金 比尔和梅琳达·盖茨基金会。