Background
Methods
Setting and context
Study design
Data coding and analysis
Results
Participant characteristics
Participant characteristics (n = 20) | Proportion or Average |
---|---|
Job Type | |
Healthcare provider | 65 % |
Managerial or administrative | 35 % |
Gender – Female | 35 % |
Age (average, in years) | 34 |
Time in Current Job (average, in years) | 4.7 |
Highest Level of Education | |
Form 4 Completion or less | 15 % |
Certificate or Diploma | 45 % |
Bachelor’s Degree | 25 % |
Master’s Degree or higher | 15 % |
Barriers
Barriers at the client level
Factors influencing delayed initial presentation or antenatal clinic non-attendance
“Especially the young girls, they tend to really hide… and most of them are actually forced to come to the clinic… They are reluctant to come because [for] one thing they are not aware they are supposed to start antenatal clinic; they are young mothers so they don’t even know. They are pregnant but their main worry is not how the baby will be [but] it is just what people will say, … and then maybe they fear that probably they will be expelled from school because that is what happens most of the time… probably they come as late as 8 months (#4, female, nurse).”
“Pregnancy is a private thing. There are people who when they are pregnant, they are stigmatized… They even don’t share with the husband for quite some time, even after the pregnancy is four, five months… There are people who would wait for the pregnancy to be visible before they come. That is when now they believe that they are really pregnant (#3, male, community health worker).”
Factors influencing discontinued ANC visits
“[I have seen] some new faces even of women… who are not married or are sex commercial workers, they go where there is money, they float around (#7, female, trained lay healthcare worker).”“[Some women] come for mining purposes, stay there for almost two months or three, you know, the mining also has its season. There are seasons that it’s booming; [but a rainy] season like now, it’s now low. Some clients now migrate towards the lake for fishing and even some go home for farming … depending on how [they are] generating the income (#12, male, health educator).”
“The clients… will wait until they become tired… due to lack of the staffs they may stay there for long before they are seen. So they will be waiting, their children get crying, so these mothers will start complaining… That may bring a challenge to those mothers because if you come to the clinic at eight, then you will leave the clinic even at twelve (#14, female, health educator).”
“[When] they come, they find that there are already twenty people in the queue and you have to wait to be attended to so those are some of the things that make them really feel that they should not come to the clinic.” (#11, male, community health worker)
Preference for traditional birth attendants
“Personalized care, comfort, the home environment, rumors about the hospital… The traditional birth attendant gives extra things like… tea and porridge once they deliver. The traditional birth attendants can be paid in kind. They can be given chicken… instead of money. She’s someone you know from the village and you trust her and you want to have your baby with someone you trust, someone you know. (#18, male, nurse, FACES program technical advisor).”
Male partners/Demands at home
“I know the male partner; they will be happy once they get to know [the pregnant woman’s HIV] status. …They take it as once the partner is negative they already know their status that they are negative (#2, male, laboratory technician).”
Barriers at the provider level
Lack of time/High workload coupled with understaffing
“At times it is so hectic. You are one person and you have to test clients, probably they are several [waiting to be] tested at the initial test and others who come for retest. So probably you will just postpone the one for the retest because you have too much work load (#4, female, nurse).”“You need to have time with somebody and provide an environment where somebody can freely speak of the true issues that are challenging to him or her… [but] there is a queue out there with angry clients who are feeling that you are taking a lot of time (#5, female, HIV testing counselor).”
Burnout/ Attitude
“There is burnout. The staff who is offering the service is already tired probably she has done HIV counseling and testing for 30 people. They’ve talked, they are very tired. You can imagine if one tests HIV negative it’s different from when one tests positive because when one tests HIV positive there is that psychosocial support that comes with the counseling and therefore the counseling is prolonged (#3, male, community health worker).”
Language barrier/Posting
Unaware of retesting importance
Barriers at the facility level
Inconsistent volume of patients
“Something set in the mind in the community that for antenatal care you have to go in the morning… there is a myth in [the local language] Dholuo that when you go after eating ugali [the staple food] at noon… the nurse wouldn’t hear the baby but would hear the ugali in the stomach (#1, female, trained lay healthcare worker).”
Space limitations
“Lack of space is a major, major, major issue. You’ll find a whole MCH [maternal and child client group] with a very congested room. This is the place where you do palpation [of the uterus for fundal height and] you want to do testing. It compromises confidentiality a lot. So space is an issue. Or even counseling session will be done in public or you do it in a group which is not very sufficient (#11, male, community health worker).”
Barriers at the health system level
Consistency of HIV testing kit supply
“There were times when you can go around three weeks without the test kits. So it was a major challenge because the mothers will come back but with no test kits you cannot test them. You will again rebook them [for a new appointment]. There was a time when it went throughout the month without testing (#13, male, trained lay healthcare worker).”
Registers and MCH booklet design
“From the register it’s difficult to answer the question ‘Who should be retested?’ because of the way the register is limited and its design… Maybe in the future if electronic registers can be designed in such a way that we can be able to determine eligibility for retesting then people would be sensitized and they know [it is time to retest]. And we can even give feedback and tell them this month we had 50 people eligible for retesting and we only tested 5; what could have gone wrong? But right now the way things are we can’t do that easily. It will take you a lot of time (#18, male, nurse, FACES program technical advisor).”
Enablers
Enablers at the client level
“They used to know that once you are HIV-positive automatically the child will come out HIV-positive… they were seeing it as something that is obvious [and] expected. But of late once they have started to hear and have seen others who have gone through PMTCT [who] have come out with babies who are HIV-negative. Now the mothers [who are] HIV-positive want to know how she is going to get an HIV-negative child (#9, male, facility manager).”