Key points
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Child-friendly spaces were enacted in PHCs in KwaZulu-Natal to create a healing environment for children living with HIV as part of a child-centred care initiative called KidzAlive.
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We interviewed users and providers of these child-friendly spaces to explore their experiences in these spaces.
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Users reported that child-friendly spaces increased their involvement and participation; increased PCGs’ participation in the care of their children and positively transformed the PHC facility into a therapeutic environment.
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Several barriers impeding the success of child-friendly spaces were reported including space constraints; clashing health facility priorities; inadequate management support; inadequate training on how to maximise the child-friendly spaces and their inappropriateness for older children.
Background
Methods
Program overview
Components of the KidzAlive intervention
KidzAlive HCW training and mentorship
KidzAlive talk tool storybook (talk tool)
Child-friendly spaces
Study design
Training of research assistants and pretesting data collection instruments
Data generation process
Interviews with children and their PCGs
Interviews with KidzAlive trained HCWs
Data analysis
Trustworthiness of the findings
Ethical considerations
Results
Demographic characteristics of children and PCGs and KidzAlive trained HCWs
Variable | Frequency | % | Variable |
---|---|---|---|
Sex | Male | 1 | 5% |
Female | 19 | 95% | |
Age (years) | 18-25 | 3 | 15% |
26-30 | 4 | 20% | |
31-40 | 8 | 40% | |
40 and upwards | 5 | 25% | |
Professional designation | Professional nurse | 8 | 40% |
HIV/AIDS Counsellor | 12 | 60% | |
Number of years working with children | 1-3 | 9 | 45% |
4-6 | 2 | 10% | |
7-9 | 7 | 35% | |
10 years and above | 2 | 10% |
Variable | Frequency | % | Variable |
---|---|---|---|
Sex | Male | 3 | 10% |
Female | 27 | 90% | |
Age of primary caregiver | 18–25 | 8 | 27% |
26–30 | 10 | 33% | |
31–40 | 9 | 30% | |
40 and upwards | 3 | 10% | |
Marital status | Married/cohabiting | 19 | 63% |
Single | 7 | 23% | |
Divorce/separated /widowed | 4 | 13% | |
Relationship to the child | Biological mother | 19 | 63% |
Biological father | 1 | 3% | |
Grand parent | 2 | 7% | |
Uncle/Aunt | 4 | 13% | |
Sibling | 4 | 13% | |
Other | 1 | 3% | |
Level of education of primary caregiver | No formal education | 2 | 7% |
Up to primary school | 3 | 10% | |
Up to high school and beyond | 25 | 83% | |
HIV status of primary caregiver | HIV positive | 15 | 50% |
HIV negative | 9 | 30% | |
Unknown | 6 | 20% | |
Child’s age | 5–6 years | 4 | 13% |
7–8 Years | 11 | 37% | |
9 to 10 years | 6 | 20% | |
11–12 years | 9 | 30% | |
Child’s sex | Male | 13 | 43% |
Female | 17 | 57% | |
Child’s age of diagnosis | 0–2 years | 12 | 40% |
3–4 years | 9 | 30% | |
5–6 years | 3 | 10% | |
7–8 Years | 3 | 10% | |
9 to 10 years | 2 | 7% | |
11–12 years | 1 | 3% | |
Disclosure status of child | Not disclosed | 16 | 53% |
Partially disclosed | 5 | 17% | |
Full disclosure | 9 | 30% | |
Child age of disclosure | 2–5 years | 1 | 7% |
6–8 years | 10 | 71% | |
9–12 years | 3 | 21% |
Themes and sub-themes
Child participation and involvement in their own healthcare journey
AQ1: “When children come to the health facility, they fear the nurses or fear being pricked by the nurse either during HIV testing or during blood draw for viral load analysis. However, with the child-friendly spaces, the same children have completely forgotten about all that pain and anxiety such that when they come into the counselling room, they would be itching to sit in the child-friendly space either to draw, colour-in or listen to the story of Sibusiso” 33-year-old nurse, uMkhanyakude District.
AQ2: “I enjoyed playing in the child-friendly spaces. I liked the story of Sibusiso and Bheki. Before, when I used to come to the health facility, the nurse only asked me if I was feeling ok. After that, she would speak to my mom”, 6-year-old girl, eThekwini District.
AQ3: “When the nurse wants to prick me, she says that I must be brave like Sibusiso. When she finishes, I can go and play with my toys in the play area. I enjoy playing in this area because I previously used to just sit on the bench”, 6-year-old boy, Zululand District.
AQ4: “I now enjoy going to the health facility because we learn a lot about germs and how to put them to sleep using goodnight medicine. I like my nurse because she makes me laugh and we play games, and sometimes she tells me a story. I also ask her questions when I don’t understand and she always asks me how I am feeling”, 5-year-old boy, eThekwini District.
AQ6: “Now children can talk to the healthcare worker when they are in the child-friendly spaces because they have time to talk to our children. The children are always asking us questions about why they are at the health centre. Thus, the healthcare worker answers and gives the child adequate information to make them understand more about HIV and why they should take medicine to make soldier cells strong”, 40-year-old father to a 10-year-old boy, uMgungundlovu District.
AQ7: “I think he enjoys visiting the clinic compared to the previous visits where he would be on my lap for the duration of the visit”, 36-year-old primary caregiver to a 7-year-old boy, eThekwini District.
HCW confidence in the provision of child-friendly HIV services
BQ1: “The child-friendly spaces and activities conducted in the space are user-friendly and they suit the ages of our children. You know that all children enjoy playing with toys, drawing and colouring with crayons so this was a very clever way to make our children lose their fear for nurses. Even the children now know about the stigma because of the ‘hand of safety’ drawing which is used to identify the people that support the child at home, thereby providing an opportunity for the the KidzAlive trained HCW to address stigma. My grandchild really loves their nurses because of these spaces”, 60-year-old, grandmother to a 7-year-old boy, eThekwini District.
BQ3: “Visuals make it easy to share a difficult subject with the child. Crayon/colouring-in makes the child feel more at ease to talk and interact with the caregiver. The hand of safety tool also assures the primary caregiver that the child will not share information with anyone outside the hand of safety”, 25-year-old nurse, eThekwini District.
BQ4: “When children draw their artwork, we stick it on the wall for them to see it and if it’s not finished, we keep it and give it back to the child. This increases their willingness to come back and finish their drawings and it is an icebreaker for us because we are sometimes intimidated by our fear of talking to children and not knowing how to start the conversation with them. It is also easy to provide a recap using their artwork”, 32-year-old HIV counsellor, Zululand District.
BQ5: “When I am in the child-friendly space, I feel like I am at my school, but it’s more fun because I get to do artwork and the nurse tells me funny stories, which make me laugh. I really enjoy playing in this space, and I don’t mind coming to the clinic. Before, I would just sit on the bench, so it was boring to come to the clinic with my mother”, 6-year-old boy, eThekwini District.
PCGs’ participation in the care of their children
CQ1: “Before, I feared to bring my grandchild to the clinic. But when I went to the clinic and spoke to the nurse and they saw the place where they would provide the services to my grandson, my worry was lessened. I have disclosed to my child that they have HIV in the child-friendly space, with the support of the nurse who answered all the questions using a language that the child understood. I must confess that disclosure has made my child understand the reason why they are taking meds and it has also freed me as a parent and I now have hope that my child will grow and be a success in life”, 55-year- old grandmother to an 8-year-old boy, uMkhanyakude District.
CQ2: “The experience was painful yet educational because it taught me that it is important to tell my child about their illness, so they can accept it in their early stages of life. The health provider taught me how to talk to my child and how to play games with her, which has improved our relationship. I am no longer afraid because previously, the child would ask me questions which were very hard to answer. I like our sessions at the clinic because now the children are more recognised, and the service is directly focused on them”, 34-year-old mother to a 9-year-old girl, Zululand District.
Transformation of the PHC setting into a therapeutic environment for children
DQ1: “The child-friendly spaces have provided us with a space of our own, where we are accepted as children and we do children’s activities. The spaces are very colourful, and they remind us of our school environment which is very nice because it makes us forget that we are here for HIV. This reduces our fear and discomfort”, 9-year-old girl, eThekwini District.
DQ3: “Before, the health facility never used to care about changing the place to accommodate the needs of both children and adults. Now the children are well accommodated and there are books for them, toys and a place where they can play. This is important for our children who are HIV positive and must visit the clinic every month. These spaces have really changed the services for children”, 38-year-old father to a 7-year-old boy, Zululand District.
DQ4: “When you walk into the health facility and you see the child-friendly space, you see that the clinic environment has changed, and it is very accommodating for children. This is very pleasing to us as parents to see that the clinic makes an effort for our children”, 55-year-old grandfather to a 6-year-old boy, eThekwini District.
DQ5: “I had only seen children’s play areas at private clinics and private hospitals. Now even those of us in the community have a private hospital experience at our health facilities because of KidzAlive. The community is commenting when they see the child-friendly space, telling us that they like the way we are trying to include their children”, 42-year-old HIV counsellor, eThekwini District.
Barriers to the effective use of child-friendly spaces in healthcare settings
EQ1: “There simply is no space to create child-friendly spaces. We sometimes create temporary spaces. Well, this works for us, at least for now”, 40-year-old HIV Counsellor, Zululand District.
EQ3: “My fear is that the community now knows that children that go to the child-friendly spaces are HIV positive. I don’t want people to know my business so sometimes I think the space can make me disclose unwillingly that I am positive and that I infected my child”, 34-year-old mother to a 9-year-old girl, Zululand District.
EQ4: “My manager doesn’t understand the programme and when I am using the tools, more time is used, and she complains that the health facility gets congested. I must explain that providing services to children takes longer as I must counsel both parties [primary caregiver and the child] and ensure that they understand what I would be talking about. I think its best that the managers also receive training so that they understand the whole process and what it takes”, 32-year-old HIV counsellor, Zululand District.
EQ5“Although we have created the child-friendly spaces, we still need additional training and support on how to fully utilise them to improve our services to children and their caregivers”, 25-year-old HIV counsellor, uMkhanyakude District.
EQ6: “We still need training on how to create adolescent friendly chill-rooms for older children and adolescents because the spaces we have are for children. Dealing with adolescents is not easy so we need training on how to engage and keep them interested”, 32-year-old, HIV counsellor, Zululand District.
EQ7“The Department of Health has asked us to put in place a chill-room for older children and adolescents to increase their willingness to visit the health facility and participation in their care. I am happy to say that the KidzAlive intervention provides that continuity of care for children. After they outgrow the child-friendly spaces, they can visit the adolescent chill rooms. So, the child-friendly spaces were a very good idea for younger children”, 35-year-old nurse, uMgungundlovu District.
EQ8: “Children take toys from the child-friendly space and when you try to take the toy back after the session, the child refuses and there is a lot of crying. In the end, we allow them to take the toys away and we never see them again. I think we need to start getting some balloons as giveaways. Importantly, because we lose so many toys, we need to replace them and for that, we need the support from our facility manager”, 46-year-old nurse, uMkhanyakude District.
EQ9: “I can’t sit in those tiny pre-school chairs because I’m big. I would look ridiculous. Hence, I think we as older children need some space of our own. Some of the games that are played in these spaces are for much younger children. Maybe something for us older children will also improve our experiences of care. But I must say that healthcare workers are very attentive, and they now ask a lot of questions and allow me to ask questions. They provide simple answers which are easy to understand”, 11-year-old girl, uMkhanyakude District.