The importance of HIV specialist services for African women living with HIV in Nottingham: results of a qualitative study

This article reports the results of a qualitative study of the experiences of African women living with HIV in Nottingham, UK. Globally, sub-Saharan Africa is the region most severely affected by the HIV pandemic [1]. This pattern is also reflected in the UK where African migrants make up 27% of those diagnosed with HIV despite the fact that they constitute less than 1% of the population [2-4]. Healthcare staff play a central role in meeting the prevention and care needs of people living with HIV/AIDS [5]. In contexts of increasing migration, health workers are called upon to recognise the diverse cultural, social, economic and political histories of their patients, and to understand how these interface with their current living situation, including their HIV-related health and treatment needs [6]. Relatively little research has been conducted to investigate the health experiences of migrant populations living with HIV in the UK, or on their patterns of access to, and utilisation of, HIV treatment and care [7]. Findings from the available, but limited, studies indicate that African migrants tend to present later than other population groups for HIV testing and treatment [8]. This is attributed to a number of obstacles to seeking or accessing care, including individual/community characteristics (such as AIDS-associated stigma, lack of perceived risk and denial), and factors associated with service and welfare provision in the host country--such as perceived discrimination, language and cultural differences, financial constraints and uncertain legal/immigration status [8-10]

Implementing routine provider-initiated HIV testing in public health care facilities in Kenya: a qualitative descriptive study of nurses\u27 experiences

Routine \u27provider-initiated testing and counselling\u27 (PITC) for HIV has been implemented amidst concern over how consent, confidentiality and counselling (the 3C’s) can be maintained in underresourced health care settings. In Kenya, PITC has been rolled out since 2005, HIV prevalence is 7.1% and over 86% of adults have not been tested. Kenyan nurses are the main cadre implementing PITC but little is known about their experiences of incorporating HIV testing into everyday practice and the challenges faced in maintaining the 3’Cs within their work environments. This study aimed to explore these issues and adopted a qualitative multi-method design using a convenience sampling approach. Two focus group discussions (total n=12) and 13 in-depth individual interviews were undertaken with nurses from 11 different public health care facilities in Nairobi and its surrounding areas (including in- and out-patient settings). Data were analysed thematically. Nurses identified a range of personal, client and health system challenges in the everyday application of PITC. These included: (i) the contradictions of normalising a highly stigmatised disease and the difficulty of providing client centred care within a routinised and target oriented work culture; (ii) the challenge of dealing with ethically complex client situations in which the principles of the 3C’s could be difficult to uphold; and, (iii) lack of time, resources, space and recognition within workplace environments (especially in-patient settings) that, likewise, led to problems with maintaining the 3C’s. In-patient nurses in particular identified problems associated with testing in a multi-disciplinary context, suggesting that other health professionals appeared to routinely flout the PITC guidelines. In conclusion, this study shows that the process of translating policy into practice is invariably complex and that more research is needed to explore PITC practices, particularly in in-patient settings. Nurses require supervision and support to negotiate the challenges and to fulfil their roles effectively

Experiences of African immigrant women living with HIV in the U.K.: implications for health professionals

In the U.K. immigrant women from Africa constitute an increasingly large proportion of newly diagnosed cases of HIV. A significant minority of these are refugees and asylum seekers. Very little is known about their experiences of living with HIV/AIDS, their psychosocial needs or their views of health care provision. This paper reports the results of a qualitative study that explored these issues by interviewing eight African women living with HIV in the British city of Nottingham. Women’s ability to live positively with HIV was found to be strongly shaped by their migration history, their legal status, their experience of AIDS-related stigma and their Christian faith. Significantly, health services were represented as a safe social space, and were highly valued as a source of advice and support. The findings indicate that non-judgemental, personalised health care plays a key role in encouraging migrant African women to access psychosocial support and appropriate HIV services

Nurses’ and clients’ perspectives after engagement in the co-designing of solutions to improve provider-client relationships in maternal and child healthcare: a human-centered design study in rural Tanzania

Background There has been a persistent increase in clients’ dissatisfaction with providers’ competencies in maternal and child healthcare (MCH). Existing interventions have failed to address the complexity of provider-client relationships. Therefore, targeted, contextualized innovative solutions that place providers and clients at the forefront as agents of change in optimizing intervention design and implementation are needed. The study team adopted a co-design strategy as part of Human- Centered Design (HCD) approach, where MCH nurses, clients, and stakeholders partnered to design an intervention package to improve provider-client relationships in rural Tanzania. Objective This paper explored nurses’, clients’, and MCH stakeholders’ perspectives following participation in a co-design stage of the HCD study to generate interventions to strengthen nurse-client relationships in Shinyanga Region. Methods A qualitative descriptive design was used. Thirty semi-structured key informant interviews were conducted in the Swahili language with purposefully selected nurses, clients, and MCH stakeholders. The inclusion criterion was participation in consultative workshops to co-design an intervention package to strengthen nurse-client relationships. Data were transcribed and translated simultaneously, managed using NVivo, and analyzed thematically. Results Three main themes were developed from the analysis, encompassing key learnings from engagement in the co-design process, the potential benefits of co-designing interventions, and co-designing as a tool for behavior change and personal commitment. The key learnings from participation in the co-design process included the acknowledgment that both nurses and clients contributed to tensions within their relationships. Additionally, it was recognized that the benefits of a good nurse-client relationship extend beyond nurses and clients to the health sector. Furthermore, it was learned that improving nurse-client relationships requires interventions targeting nurses, clients, and the health sector. Co-designing was considered beneficial as it offers a promising strategy for designin

Effect of Agency Banking on Performance of Microfinance Banks in Kenya

Purpose: The purpose of this study was to establish the effect of agency banking on performance of microfinance banks in Kenya Methodology: The study adopted positivism philosophy approach and descriptive research design was used. The study also used census survey. The target population was the thirteen Microfinance Banks regulated by the Central Bank of Kenya. The questionnaires were self-administered and primary data was collected from the thirteen regulated microfinance banks. The data was analyzed using the Statistical Package for Social Science. Descriptive and inferential statistics were used for preliminary analysis. Factor analysis was conducted to reduce the number of factors and Kaiser Mayer Olkin and Barlett\u27s test of Sphericity were tested and total variance explained, scree plot and rotated component matrix were drawn. Findings: The descriptive statistics findings disclosed that agency banking has a positive effect on performance of MFBs. This was shown by 71.7% of the respondents were in agreement that agency banking influence the performance of MFBs. The findings showed that the relationship between agency and performance was p value was 0.018 and F test of 5.908 showing that the model was statistically significant for the data set. The coefficient table showed that the equation was Y = 2.680 + 0.355AGB. The findings denoted that agency banking has a moderate relationship with performance of MFBs. The MFBs are using agency banking to grow their businesses thus generating profits and capital gain. Unique Contribution to Theory, Practice and Policy: The study recommends that MFBs should open more agents especially in the rural areas to facilitate population access near services. In addition, the management team and the policy makers should ensure that policies are elaborated to protect the customers from fraud and also exploitation by the business owners due to higher transaction cost and the business operating the agents should be trained on fraud policies because it is affecting many customers. The government and the MFBs should ensure all those operating the agents are well trained on record keeping, managing of funds, and customer care

Effect of Mobile Banking on Performance of Microfinance Banks in Kenya

Purpose: The purpose of this study was to establish the effect of mobile banking on performance of microfinance banks in Kenya Methodology: The study adopted positivism philosophy approach and descriptive research design was used. The study also used census survey. The target population was the thirteen Microfinance Banks regulated by the Central Bank of Kenya. The questionnaires were self-administered and primary data was collected from the thirteen regulated microfinance banks. The data was analyzed using the Statistical Package for Social Science. Descriptive and inferential statistics were used for preliminary analysis. Factor analysis was conducted to reduce the number of factors and Kaiser Mayer Olkin and Barlett\u27s test of Sphericity were tested and total variance explained, scree plot and rotated component matrix were drawn. Findings: The findings showed that majority of the respondents were in agreement that it is easy to deposit and withdraw cash, transfer funds, apply loan and check the balance using mobile banking. The hypothesis (H02) findings showed that mobile banking had a significant effect on performance of MFBs. The summary model showed that the R was 0.280 and R square of 0.078. This implied that mobile banking predicted 7.8% of the performance of MFBs. The ANOVA results showed that F value was 4.940 and a p value of 0.030 which indicates that it was statistically significant. After the T test mobile banking beta coefficient was the regression model was generated Y = 2.841+ 0.271MBA. Unique Contribution to Theory, Practice and Policy: The study recommends that MFBs should partner with telecommunication services providers to develop products and services which are customer oriented and easy to use. They should develop strategies on market penetration by creating awareness on the product and services available in the market

\u27People are creating policy up there, they are not coming down\u27: nurses\u27 views on the expansion of routine provider-initiated HIV testing and counselling in Nairobi, Kenya.

In this report, we present selected findings from an exploratory piece of qualitative research on HIV testing that was undertaken in 2007-2008 with nurses in Nairobi, Kenya. At the same time, we share our own story of how this research came about and how NHIVNA research funding was able to lay the foundations for a larger study that will hopefully give voice to patients and HIV nurses in Nairobi and will develop HIV nursing research capacity in the country

Understanding the lived experiences Caregiving for Children Living with Disabilities in Mukuru Slums, Kenya; Implications for Health and Wellness in Caregiving

Caregivers are entrusted with provision of the needs of those who are incapacitated by disabilities in the society. However, they face many challenges in the process of caregiving. This study investigated the health and wellbeing challenges experienced by caregivers of children living with disabilities and to explore the coping mechanisms employed by caregivers of children living with disability. It adopted descriptive cross-sectional study design and a qualitative phenomenological method of data collection. In-depth interviews were conducted to collect data from sixteen (16) primary caregivers of children with disabilities. Data were audio recorded, transcribed and analyzed using Max Qualitative Data Analysis Software Version 12. Authority to collect the data was sought from county government Embakasi Constituency. The study established health consequences of caregiving included physical activity limitations, physical exhausted during caregiving, side effects of some of the medications and risks of developing high blood pressure, ulcers and depression. The study concludes that caregivers of Children Living with Disability face unique social, economic and health and wellbeing experiences. The study therefore recommends programs aimed at addressing such challenges as a necessary public health initiative

Co-construction of consent and counselling during Provider Initiated Counselling and Testing (PITC) in Nairobi Kenya

Background: The global policy focus of today’s HIV efforts and strategies is to reverse the spread of HIV/AIDS and provide care, treatment and support. A key component of this strategy is to increase individual HIV status awareness through expansion of HIV testing and counselling (HTC). However, the numbers tested still remain and evidence suggests that there are significant missed opportunities for HIV testing in clinical settings. One key strategy to expand HTC in clinical settings has been to implement a policy of ‘provider initiated counselling and testing’ (PITC) in which all patients accessing health facilities for treatment are routinely offered a HIV test. The introduction of PITC has brought with it a ‘dilution’ of the previously lengthy and stringent testing process by doing away with signed informed consent and extensive pre and post-test counselling. The previous process was recognised as a barrier to public health gains of HIV testing expansion, particularly as it differentiated an HIV test from other routine medical tests resulting in a sense of HIV exceptionalism. In its place, the PITC policy recommends an opt-out approach and replaces the extensive pre-test counselling with an information giving session placing more emphasis on post-test counselling in cases where the result is positive. This change has given rise to debates about the potential for PITC to infringe patients’ rights to informed consent and counselling especially in developing countries. Emerging evidence from the exploration of the PITC process within antenatal settings in the Sub Saharan Africa has revealed some of the complexities of implementing PITC guidelines in different cultural and healthcare contexts.These studies suggest that information giving and consent are difficult to apply in contexts characterized by healthcare worker dominance, lack of sufficient resources and time constraints. This study aims to specifically investigate how patients [and counsellors] co-construct informed consent and perform counselling during the PITC consultation. Thus it examined ‘real time’ patient-counselor interaction within hospital outpatient and inpatient settings in Kenya; to explore the patient’s experience of a routine HIV test and to evaluate how sociocultural norms influence the PITC process in this context. Methods: In order to explore the context of the routine testing consultation and the way the interaction played out, a qualitative research approach was adopted, utilizing multiple data collection methods (interviews, observations and audio recording of consultations). The study was carried out in two government run health facilities in Kenya’s capital, Nairobi. The intention was to follow patients through the PITC process, i.e. before testing, during the HIV test and (whenever possible) after the HIV test. To get a broader picture of the events during the routine HIV testing consultation, additional interviews were conducted with 5 nurse-counsellors whose consultations had been observed. Ethical approval was obtained from the Kenya National Research Council, Kenya Medical Research Institute and the Aga Khan University Ethics Committee. The data were analysed using Charmaz’s constructivist grounded theory approach which allowed for a systematic yet flexible approach to analysis. This method facilitated immersion and engagement with the data, and provided a means of managing the different data sets in the study and undertaking a process of constant comparison within and between data sets. Findings: Results from the study suggest that HIV remains a highly stigmatised illness in Kenyan society and is associated with death and perceived lack of morality. This is still the case in spite of years of health promotion and high profile media campaigns raising awareness about HIV and the availability and effectiveness of treatment. The context of stigma shaped the consultation so that both patients and counsellors worked together to help patients to maintain a ‘moral face’. Patients tended to withhold information on risky sexual behaviour whilst the counsellors avoided inquiring into this domain. The PITC consultation was characterised by a counsellor dominated approach to communication and health promotion. Counsellor inputs were generic, highly scripted and didactic rather than patient-centred. As a result, the counsellors’ style of communication allowed little space for personalised risk assessment or for patients to ask questions or to express concerns. Further on, the findings suggest that informed consent requiring explicit refusal of the test offer was difficult to achieve in an environment where the HIV test was not framed as a choice and patients came to the health facility expecting to be told what to do. Nevertheless, in spite of the obvious lack of explicit informed consent and the counsellor dominated interaction, post-test interviews revealed that patients were satisfied with the nature of the interaction. Implications: The study concludes that there is a considerable distance between the policy recommendations and their implementation on the ground due to the complexity of real world practice. This distance does not necessarily constitute a disregard for the guideline recommendations but, rather, is an attempt to adapt to the prevailing environment. Lay constructions about HIV (HIV stigma) and the existing norms of patient-provider interaction that are characterised by a passive patient and a dominant health care provider shape the way the consultation unfolds. PITC training programs and manuals need to include skills and strategies that can support counsellors to navigate the consultation and provide quality care within this prevailing context

Communication and interaction in the context of routine provider initiated HIV testing and counselling for HIV: the case of Kenya

Background: The global policy focus of today’s HIV efforts and strategies is to reverse the spread of HIV/AIDS and provide care, treatment and support. A key component of this strategy is to increase individual HIV status awareness through expansion of HIV testing and counselling (HTC). However, the numbers tested still remain low and evidence suggests that there are significant missed opportunities for HIV testing in clinical settings. One key strategy to expand HTC in clinical settings has been to implement a policy of ‘provider initiated counselling and testing’ (PITC) in which all patients accessing health facilities for treatment are routinely offered a HIV test. The introduction of PITC has brought with it a ‘dilution’ of the previously lengthy and stringent testing process by doing away with signed informed consent and extensive pre and post test counselling. The previous process was recognised as a barrier to public health gains of HIV testing expansion, particularly as it differentiated an HIV test from other routine medical tests resulting in a sense of HIV exceptionalism. In its place, the PITC policy recommends an opt-out approach and replaces the extensive pre test counselling with an information giving session placing more emphasis on post test counselling in cases where the result is positive. This change has given rise to debates about the potential for PITC to infringe patients’ rights to informed consent and counselling especially in developing countries. Emerging evidence from the exploration of the PITC process within antenatal settings in the Sub Saharan Africa has revealed some of the complexities of implementing PITC guidelines in different cultural and healthcare contexts. These studies suggest that information giving and consent are difficult to apply in contexts characterized by healthcare worker dominance, lack of sufficient resources and time constraints. This study aimed to specifically investigate how patients and counsellors co-construct informed consent and perform counselling during the PITC consultation. It examined ‘real time’ patient-counsellor interaction within hospital outpatient and inpatient settings in Kenya, explored the patient’s experience of a routine HIV test and evaluated how stigma and patient – provider interaction norms influence the PITC process in this context. Methods: In order to explore the context of the routine testing consultation and the way the interaction played out, a qualitative research approach was adopted, utilizing multiple data collection methods (interviews, observations and audio recording of consultations). The study was carried out in two government run health facilities in Kenya’s capital, Nairobi. The intention was to follow patients through the PITC process, i.e. before testing, during the HIV test and (whenever possible) after the HIV test. To get a broader picture of the events during the routine HIV testing consultation, additional interviews were conducted with five nurse-counsellors whose consultations had been observed. Ethical approval was obtained from the Kenya National Research Council, Kenya Medical Research Institute and the Aga Khan University Ethics Committee. The data were analysed using Charmaz’s constructivist grounded theory approach which allowed for a systematic yet flexible approach to analysis. This method facilitated immersion and engagement with the data, and provided a means of managing the different data sets in the study and undertaking a process of constant comparison within and between data sets. Findings: Results from the study suggest that HIV remains a highly stigmatised illness in Kenyan society and is associated with death and immorality. This is still the case in spite of years of health promotion and high profile media campaigns raising awareness about HIV and the availability and effectiveness of treatment. The context of stigma shaped the consultation so that both patients and counsellors worked together to help patients to maintain a ‘moral face’. Patients tended to withhold information on risky sexual behaviour whilst the counsellors avoided inquiring into this domain. The PITC consultation was characterised by a counsellor dominated approach to communication and health promotion. Counsellor inputs were generic, highly scripted and didactic rather than patient-centred. As a result, the counsellors’ style of communication allowed little space for personalised risk assessment or for patients to ask questions or to express concerns. The findings suggest that informed consent enabling explicit refusal of the test offer was difficult to achieve in an environment where the HIV test was not framed as a choice and patients came to the health facility expecting to be told what to do. Nevertheless, in spite of the obvious lack of explicit informed consent and the counsellor dominated interaction, post test interviews revealed that patients were satisfied with the nature of the interaction. The study concludes that there is a considerable distance between the policy recommendations and their implementation on the ground due to the complexity of real world practice. Lay constructions about HIV (HIV stigma) and the existing norms of patient-provider interaction that are characterised by a passive patient and a dominant health care provider shape the way the consultation unfolds. PITC training programs and manuals need to include skills and strategies that can support counsellors manage an uncomfortable interaction and emphasis the need to ensure an individualized post test counselling is carried out. The thesis makes several contributions to knowledge. The study pays attention to the operationalization of PITC recommendations thus illuminating how the PITC policy is translated into practice within a developing country like Kenya. It informs the existing debates on how informed consent and counselling should be implemented. The study findings suggest that in spite of the global debates on what constitutes ideal informed consent and counselling, in practice, sociocultural norms shape how these issues are translated and implemented. However, the study indicates that diversion from the PITC policy recommendations does not necessarily constitute a disregard for the recommendations but, rather, is an attempt to adapt to the prevailing environment. The study methodology enabled unique insights to be gained on how counselling and consent are constructed and managed in the PITC setting through the use of observations / audio recording to examine ‘real time’ interactions. The research study has been able to illuminate barriers that are posed by sociocultural and organisational structures in the real world implementation of the PITC policy. Therefore, my study suggests that the national PITC policy needs to consider the practical problems faced on the ground in developing contextually appropriate recommendations for the conduct of PITC and implementation of key guidelines