Barriers common to linkage and retention
Predisposing characteristics
Predisposing characteristics consisted of factors related to knowledge, attitudes and beliefs that hindered linkage and retention. While the majority of barriers were reported for linkage to and retention in HIV care, several barriers were commonly reported across disease categories and were common across linkage and retention.
Poor motivation was reported as a barrier to linkage and retention and was reported across all disease categories. Issues related to hopelessness and feeling tired were particularly challenging for retention. As one caregiver noted: “Some people just get tired of taking their drugs and if there is no improvement in health, some may give up” (Caregiver, Turbo). Another participant further elaborated: “…let us take an example of these sexual workers, they are still having unprotected sex and all that so they get new strains of the virus…through that they take drugs but there is no change then they say, ‘I have been taking these drugs for more than a year now but there is no change, so what is the need for me to continue using the drugs” So they stop using them” (HCP, Chulaimbo). Related to this is forgetfulness which was reported as a barrier to linkage and retention for HIV and HTN but not TB: “We tend to forget that when we feel better after a while, we are cured…its human nature” (Community Leader, Chulaimbo). “The other thing is laziness, when someone has gone to bed and has not taken drugs for example, one will feel too lazy to get up and take the drugs (all laugh) or they forget to take them” (HTN FGD participant, Turbo”).
A lack of knowledge and/or understanding around the need to engage in care also is a barrier to linkage and retention. “…Someone may buy pain killers and feel much better and think they are OK. So if you tell such a person to go to the hospital, they’ll always procrastinate.” (HTN FGD participant, Turbo). An HIV positive patient noted that: “Even when they come for treatment, they expect a quick recovery. But they don’t understand that this is a lifetime treatment. Because of this, they go back and don’t stop coming” (PLWH FGD participant, Turbo). Again, this relates closely to lack of knowledge about the need to take medications: “Somebody might be given a return date to go and monitor progress, when the condition improves he/she says, “Why should I go back to the doctor?” (Religious Leader, Teso). Fear of taking drugs can also act as a major barrier to both linkage and retention. In terms of linkage to HIV, for example, one PLWH noted: “there are some who fear coming for ‘andila’ (the name given to ARVs in the village) because they heard that once you start taking them, you can’t stop for the rest of your life…” (PLWH FGD participant, Chulaimbo).
Many have preferences in alternative medicine. This was reported as a barrier to linkage for HIV and TB and all disease categories for retention. This may stem from fear of the medications themselves. “Take medicines for a very long time but no sign of improvement, a person gives up or tries alternative medicine like herbal medicine” (CHW FGD participant, Teso). Preferences for alternative forms of care may also be influenced by outside forces but can also be reflective of poor treatment literacy (e.g., understanding the need to adhere to appropriate medicines). For example, “…advertisement may put across very appealing message that there is a doctor who has medicine that if you take for two weeks you be back to normal than these other conventional medicine” (CHW FGD participant, Teso). The use of alternative forms of care may result in poor outcomes particularly when individuals fail to engage with appropriate care: “There are people who are positive but have been brainwashed by herbal medicines. They are told herbs cure HIV so they dispose of their ARVs and use them. Some die due to this” (Caregiver FGD participant, Turbo).
The use of alcohol/drugs was reported as a barrier. While misuse was reported for HIV linkage, it was a common barrier in terms of retention: “They are told not to drink and take their medicine. They drink and forget or at times take their medicines while drunk” (Community Leader, Chulaimbo). Another participant noted: “One might stop taking their medication and resort to alcohol. …He does not have the time to come to the hospital or take his medication” (TB FGD participant, Chuliambo).
Cultural beliefs and social norms that can negatively impact linkage and retention were also described: “cultural issues such as a mother in-law and a son-in law being in the same queue” (HCP, Teso). Related to this are religious beliefs: “These pastors tell people that you will be healed through prayers. A patient is told that you have been prayed for, so do not go back for those” (HCP, Teso). Beliefs that their illnesses are a result of witchcraft were also described as a key barrier: “…some symptoms are associated with witchcraft for example, a curse and they know that the symptoms can only be cured with certain systems …say church, if you are bewitched you probably need to see a sorcerer or something like that. While they are trying other interventions, it takes time for them to give up and come to the hospital…they dilly dally at home as they try those other avenues and self medicate, go to the church, go to the herbalist” (HCP, Chulaimbo).
Enabling resources
Stigma was reported as a barrier for all categories with the exception of retention in HTN care. Fear of being recognized and discriminated against may deter an individual from initially linking to care as one HIV positive participant noted: “I am not going, I will be seen” (PLWH FGD participant, Chulaimbo). The same is true for retention, “…They fear to be seen by their neighbors and will also disappear (all laugh).” (HCP FGD participant, Turbo). While common for both linkage and retention to HIV care, stigma was also encountered in other chronic disease categories: “You know if you are diabetic…you are discriminated and this causes you not to come to the hospital” (Caregiver FGD participant, Chulaimbo).
A lack of finances was reported across all categories except as a barrier for retention for HTN care. Specific challenges were given related to the need for food “There are some people for TB (pause) you know…when you are using those drugs you need to eat well. A person may not be having food…taking the drugs without the food weakens a person and that is why some people leave them” (CHW FGD participant, Turbo). Broader issues with costs were also described “The patient is supposed to come to the clinic on a monthly basis and it becomes expensive for many” (HCP, Turbo). A religious leader pointed to the larger issue: “…when somebody is poor it becomes a silent killer…” (Religious Leader, Teso).
Busy schedules and domestic chores may act as a barrier, particularly in the context of widespread poverty. In particular, “Other competing factors at home may affect appointments” (CHW FGD participant, Teso). This can affect both linkage and retention particularly when confounded by financial challenges: “She looks for food for the children. What can use for travel (to the clinic) instead she uses for food” (CHW FGD participant, Turbo). Employment may also interfere with an individual’s ability to be retained: “At times you might miss your appointment date due to working elsewhere. Most of us are casual laborers so you might go to a place where you are not close to a clinic” (Caregiver FGD participant, Turbo).
Distance/access to the health facility was reported as a barrier for all diseases and as a barrier to both linkage and retention: “…Distance and terrain of some places. If a person has no means (pauses) reaching here is a problem.” (HCP, Chulaimbo). Distance to the clinic was particularly a challenge for individuals with financial constraints: “You see, in the remote areas, transport to get to the health facility could be an issue. It could be Kenya shillings 100–300 on a motorbike. Most people will not afford this” (HTN FGD participant, Turbo). A long distance and poor access can negatively affect the health of patient. The negative impacts of distance and poor access were also described: “For TB (Pauses) people who come from far and they are suffering from TB, the distance covered is long and the patient will be tired” (CHW FGD participant, Teso). Another explained that the “…mama who has to walk for 6 or 7 km is too unfair” (Religious Leader, Teso).
The distance to the clinic may be particularly a problem particularly when participants also have to deal with slow service and long queues: “…One can wait for the doctor from 6 am to 6 pm and does not see the doctor after all that long wait” (HTN FGD participant, Turbo). As one Caregiver noted, “If they come and realize that the services are slow, they might get upset and go away, never to return” (Caregiver FGD participant, Turbo). Furthermore, the cost of treatment was reported as a barrier for linkage and retention for HIV. The cost of the drugs themselves was a barrier: “Drugs are expensive” (HCP, Chulaimbo). Another participant noted that “Some just lack money. There is no need to come to the clinic because they have no money to buy drugs” (CHW FGD participant, Turbo).
Patient-provider relationships were a commonly reported factor affecting linkage and retention for both communicable and non-communicable chronic diseases. The nature of the relationship was described as being particularly important “It also depends on health providers. The way they talk to us. You may get one who is so good and talks to you so well but at time you may get another one that is arrogant, harass you. You give up” (HTN FGD participant, Teso). Many participants spoke to issues with maintaining confidentiality: “…Health providers may know this client very well and we are human beings. This provider may go home and expose the status (i.e., HIV)” (HCP, Teso). When patients miss a visit or are late for a visit, they fear to be scolded by their health providers: “…There are those who start but stop along the way. In most cases the health care providers contribute. Maybe the way they talk to you is bad. There was a time I defaulted. I missed an appointment date for the child so when I came the doctor was too harsh on me…I went and stayed for some years…. So the manner in which the doctor talks to the patient makes a lot” (Caregiver FGD participant, Turbo). If a patient misses a visit or is late for an appointment, the clinic staff may scold them: “When you come late, you are told to go back and add another year before you come. The health care providers chase you away” (Caregiver FGD participant, Turbo). Another individual noted that: “health providers are very strict on adherence and if you missed to take medicines as required they are harsh on you and some people fear that. If they have done such mistakes they prefer staying at home” (PLWH FGD participant, Teso).
Stigma associated with the facility itself was reported as a barrier to linkage and retention with “AMPATH being particularly associated with HIV” (PLWH FGD participant, Teso). This may cause individuals to not link: “Some just stay at home without seeking medical attention. Some have even passed on because they fear coming to AMPATH” (PLWH FGD participant, Teso). Participants described their experiences and coping strategies: “…in our clinic the CDM patients, hypertensive and diabetic, they queue with the HIV patients…when the patients are queuing, they want to tell their neighbour, the next person, you know, I am not HIV+, I have a CDM card (lots of laughs). And the next time, they won’t come to the clinic because they are queuing with the HIV positives (HTN FGD participant, Turbo). Stigma associated with AMPATH was not unique to patients as one healthcare provider eluded: “Another problem is the AMPATH thing. The community knows that anyone who is found on the premises is HIV+. …even the staff” (HCP, Turbo).
Need factors
The perceived severity of disease and symptoms experienced may also influence whether an individual engages in care. For example, an individual may not understand or recognize disease symptoms: “… generally within the Teso community they have not identified the symptoms of TB or even know that TB is a killer… Most people who have TB take it as a normal cough; others see it as a chest problem… They deny TB as a name.” (Religious Leader, Teso). “It’s only when people are critically ill to the point that they cannot walk on their own that they can decide to come to the health facility [Laughter]” (HTN FGD participant, Turbo). This also speaks to an individuals’ perceived health status: “Maybe one came when he was very weak and after using medication he improves and thinks he is cured” (TB FGD participant, Chulaimbo). Feeling better was a particular challenge for retention: “when one improves he thinks he is healed and stops coming to the clinic. He feels he is of good health” (Traditional Healer, Chulaimbo).
This has implications for treatment effectiveness and poor health outcomes: “....We have seen some patients that when they take medicines their health improves and they believe that they are now completely healed. They leave medicines and for some time their health deteriorates and they come back to the clinic whereby sometimes they even die” (CHW FGD participant Teso).
Similar reports have been given for TB: “There are some drugs like ones for TB. When you start using them you feel dizzy and you might even collapse. Some patients fear when they experience the side effects, then they stop using drugs” (Caregiver FGD participant, Turbo). Related to retention is the issue of having to take drugs long-term: “There are some who fear coming for ARVS drugs because they heard that once you start taking them, you can’t stop for the rest of your life. They wonder and say, ‘Will I take these drugs till I die? This is stress and I can’t’ [Laughter]. So there are people who fear taking drugs” (PLWH FGD participant, Chulaimbo).
Lack of partner support/discordance was reported as a barrier to linkage to TB care and was reported across disease categories as a barrier to retention: “A lack of support from partners matters. My husband said to me, ‘You die with your pressure so that I re-marry. What are you still doing? Just die’ [Laughs]. It is not until I looked for my own money that I came to the hospital” (CHW FGD participant, Teso). Fear of being blamed, in the case of HIV, also was brought up: “It is an issue among youth and couples…especially when one partner is tested, when she goes back home, she doesn’t know whether the partner is positive or negative so she decides to keep quiet because if she says anything, it will be concluded that maybe she is the one who brought it.” (HCP, Teso). One caregiver noted that without proper support from one’s partner, retention in care is a challenge: “You may not be able to meet all your needs or the husband might not be supportive. You then decide to stop treatment and sit back” (Caregiver FGD participant, Teso).
Inadequate social support, more generally was a commonly reported barrier. In some cases, this can affect whether an individual is able to get to the clinic: e.g. “some have been identified but they are too weak but can’t get somebody to accompany them to the hospital” (HCP, Chulaimbo). Inadequate support may also lead an individual to not get better particularly if there is no one to help take care of them or remind them to take their drugs: “there are some children who are HIV positive and quite a good number of them are orphans so it is a caregiver who takes care of them….and to some extent the condition of the child is worse and if the caregiver doesn’t have a heart to take care of that child, he/she becomes fatigued and stops bringing the child for care” (HCP, Chulaimbo). Furthermore, challenges within households can also present challenges: “In some families there is a lot of violence that sometimes discourages a woman to continue with drugs” (Religious Leader, Chulaimbo).
Facilitators
In general, there were fewer facilitators compared to barriers and most facilitators were reported for linkage to HIV care.
Predisposing characteristics
While poor motivation was a barrier to linkage and retention, having a strong personal initiative was reported as a facilitator to linkage and retention for all disease categories. In terms of linkage, taking responsibility for one’s health can drive individuals to seek out care as one participant noted: “I think it is personal responsibility. People are concerned about their health and they have realized that chronic diseases like hypertension and diabetes are not diseases of the rich - Anybody can get it. So they are coming to the clinic because they are concerned.” (HCP, Turbo). One patient further noted that “people like us who want our health to be prolonged, come here…” (PLWH FGD participant, Teso). Personal initiative was also described as a facilitator to takings medications as prescribed: “In my opinion, it is very important for me to take drugs because if I don’t, I might die. It is better to take good care of my health by completing the dose as instructed by the doctor” (TB FGD participant, Chulaimbo).
A belief in treatment, and in AMPATH, was also an important facilitator. In terms of linkage, an individual may come for care “because they are assured that his health being taken care of. Then AMPATH has been on the ground for long and people are aware of the services offered.” An improvement in health also works to facilitate retention. As one traditional healer noted: “Once people start using the medication, they improve. The fact that TB is treatable motivates people to come for treatment” (Traditional Healer, Chulaimbo).
Family responsibilities and fear of losing a child were common facilitators to linkage for all disease categories and for retention to HIV and TB care. “Another reason is that we have children at home that depend on us. You do not wait to get wasted until you are not able to provide for your family” (HTN FGD participant, Teso). It was also important to protect children from getting sick: “so when you come here you are told if you take your child to clinic you can save your child from getting HIV…Like me I fear to lose a child like I did, he was my first born (Caregiver FGD participant, Teso).
Enabling resources
These were the most common type of facilitators for linkage and retention to care. Good provider-patient relationships were the most commonly reported facilitator to care: “There was a time when patients were picked from their homes to the hospital. When one fails to come to the clinic, he is followed up. The healthcare providers love the patients and this motivates them to come for care” (Traditional Healer, Chulaimbo). Being treated with respect was important for patients: “Staff are warm. They help with counseling from testing through to treatment” (PLHW FGD participant, Teso). Related to this is how patients are spoken to: “the nurse who gives us medication talks to us nicely. I don’t know whether I am the only one she talks to well but she treats me so well. She asks me several questions concerning my health before she gives me the drugs” (TB FGD participant, Chulaimbo).
Accessibility of the health facility was also reported as a facilitator. Bringing services to the community was noted: “AMPATH brought very good services to Chulaimbo” (Religious Leader, Chulaimbo). Proximity to one’s home is also an important facilitator: “Personally, I am very happy coming here because it’s a clinic next to our homes, expenses have been reduced. I commend AMPATH for that. It has made it possible for us to attend the clinic on a regular basis” (HTN FGD participant, Turbo). Another noted: “I enrolled here because it was near” (TB FGD participant, Teso).
The provision of integrated services was cited as a facilitator to care for HIV and TB linkage and retention. Including food services was particularly important: “We also have these patients who will feel like for sure they have been helped for the six months they participated in the food program and they feel appreciated and they will come back to the clinic, because they say that they were helped at the time of need” (HCP, Turbo). This was particularly important context of widespread poverty: “Free food especially at this time of famine. There is no food at home and you are so weak that you cannot provide for yourself. You don’t care even if people see you at AMPATH it is about the disease. It is not your choice. These people are very good. If you call, them the driver just brings you food or they make follow ups to see how you are doing” (CHW FGD participant, Teso). The integration of TB-HIV care was also seen as positive: “OK, for TB patients, since the integration of the TB/HIV clinic… the number of TB patients coming to the clinic is steadily rising and also the retention of these clients is perfect and the adherence to medication is good. So I think I can relate this to the kind of services we are offering, that it is centered to one person who is always available to attend to the client” (HCP, Turbo).
Related to this are the services available: “Some clients told me that they go to other health facilities where weight is only checked and given ARVs. AMPATH takes all the vitals, tests blood pressure, pulse, weight and temperature (pauses)…everything. It gives very good drugs” (PLWH FGD participant, Chulaimbo). The provision of free/subsidized services was also described as a facilitator: “It’s a place where they can get drugs at the revolving pharmacy; the prices are lower compared to the prices they pay with in chemists in town” (HCP, Turbo).
Peer support/testimonies and family and social support were reported facilitators for the majority of categories with the latter being an important facilitator for linkage and retention in all disease categories. The role of peer testimonies and improvements in health could work to influence individuals to link with care: “I had a friend that was wasted and people never thought that he would recover but I met him afterwards. He was so healthy and was able to do his work. He gave me counselling and that is how I got to come to the hospital” (HTN FGD participant, Teso). It could also work to encourage one’s own acceptance of their illness and it many ways they “themselves become the facilitators” (Traditional healer, Chulaimbo). Another participant noted that “It helps… Because it encourages, you talk about some issues (pause). You encourage each other” (CHW FGD participant, Turbo). Peer testimonies can help individuals to disclose their own status: “....I joined a support group where I got to know how to disclose after counselling. If you want to live long with HIV (pauses) you talk about. Don’t keep it for yourself”, I was told” (PLWH FGD participant, Chulaimbo).
Family and social support can help individuals to come to terms with their illness and link to care: “If there is no improvement, his own people will advise him to go to the hospital” (Traditional Healer, Chulaimbo). Social support also works to encourage positive behaviors that are important for maintaining one’s health: “Yes, you must be given time to think and make a personal decision. I was tested and given one week to go and think over it. My mother really encouraged me” (PLWH FGD participant, Chulaimbo). As some participants noted, it can depend on the family: “If the family understands then you will not suffer a lot of trauma” (PLWH FGD participant, Teso). Importantly, children and families could also remind patients to take their medications: “When I’m held up with some domestic chores my children remind me that have you taken drugs? “I have heard or I’m going to take them now I do reply”’ There is support” (HTN FGD participant, Teso).
Need factors
Severity of illness and fear of restarting treatment were two need factors considered as facilitators to linkage and retention to TB care, respectively.