HIV This Week

Zachariah R, Ford N, Philips M, S Lynch, Massaquoi M, Janssens V, Harries AD. Task shifting in HIV/AIDS: opportunities, challenges and proposed actions for sub-Saharan Africa. Trans R Soc Trop Med Hyg. 2008 Nov 5. [Epub ahead of print]

Sub-Saharan Africa is facing a crisis in human health resources due to a critical shortage of health workers. The shortage is compounded by a high burden of infectious diseases; emigration of trained professionals; difficult working conditions, and low motivation. In particular, the burden of HIV has led to the concept of task shifting being increasingly promoted as a way of rapidly expanding human resource capacity. This refers to the delegation of medical and health service responsibilities from higher to lower cadres of health staff, in some cases non-professionals. This paper, drawing on Médecins Sans Frontières’ experience of scaling-up antiretroviral treatment in three sub-Saharan African countries (Malawi, South Africa and Lesotho) and supplemented by a review of the literature, highlights the main opportunities and challenges posed by task shifting and proposes specific actions to tackle the challenges. The opportunities include: increasing access to life-saving treatment; improving the workforce skills mix and health-system efficiency; enhancing the role of the community; cost advantages and reducing attrition; and international ‘brain drain’. The challenges include: maintaining quality and safety; addressing professional and institutional resistance; sustaining motivation and performance; and preventing deaths of health workers from HIV. Task shifting should not undermine the primary objective of improving patient benefits and public health outcomes.

Editors’ note: Given that an estimated 2.4 million doctors and nurses are needed to meet the Millennium Development Goals, it is no surprise that increasing attention has turned to task shifting, a concept dating back decades. This excellent review provides examples to highlight the opportunities and challenges of task shifting in HIV care in sub-Saharan Africa. It lays out the main operational research priorities (quality, safety, acceptability, cost, management, and impact) to obtain data for decision-making to improve task shifting outcomes iteratively.

The tenets of fuzzy trace theory are summarized with respect to their relevance to health and medical decision making. Illustrations are given for HIV prevention, cardiovascular disease, surgical risk, genetic risk, and cancer prevention and control. A core idea of fuzzy trace theory is that people rely on the gist of information, its bottom-line meaning, as opposed to verbatim details in judgment and decision making. This idea explains why precise information (e.g., about risk) is not necessarily effective in encouraging prevention behaviours or in supporting medical decision making. People can get the facts right, and still not derive the proper meaning, which is key to informed decision making. Getting the gist is not sufficient, however. Retrieval (e.g., of health-related values) and processing interference brought on by thinking about nested or overlapping classes (e.g., in ratio concepts, such as probability) are also important. Theory-based interventions that work (and why they work) are presented, ranging from specific techniques aimed at enhancing representation, retrieval, and processing to a comprehensive intervention that integrates these components.

Editors’ note: An interesting read, this paper presents fuzzy trace theory assumptions of how health information is mentally represented, retrieved, and processed in decision–making and subsequent behaviour. Verbatim facts (including graphs, numbers, pictures, literal information, etc.) are less likely to influence judgment and decision-making than are gist representations (subjective, qualitative interpretations of information based on emotion, education, culture, previous experience, worldview, and level of development). Risk reduction interventions based on fuzzy trace theory build capacity for automatic responses to contextual cues that signal risk (rather than deliberative thinking), retrieval of core values and principles relevant in risky contexts, and their application to make healthy decisions. Do you get the gist?