Background
Methods
Data collection
Facility | Turnovera | Volumeb | Testing at baselinec | SSIs | FGDs | |||
---|---|---|---|---|---|---|---|---|
HIV | Syphilis | Malaria | Hbd | |||||
1 | Low | High | Yes | No | Yes | Yes | 1 F nurse, 1 M nurse | group 1: n = 5; group 2: n = 12 |
2 | Low | Medium | Yes | No | Yes | No | 1 F nurse, 1 M nurse | group 1: n = 9; group 2: n = 9 |
3 | Low | Medium | Yes | No | No | No | 1 F nurse, 1 M nurse, 1 M clinical officer | group 1: n = 10 |
4 | Medium | Low | Yes | No | No | No | 2 M nurses | group 1: n = 10 |
5 | Medium | Low | Yes | No | Yes | No | 1 F nurse, 1 M nurse, 1 M HTC | group 1: n = 9; group 2: n = 10 |
6 | Low | Medium | Yes | No | No | No | 1 F nurse, 1 M nurse | group 1: n = 12; group 2: n = 13 |
7 | High | High | Yes | No | No | Yes | 1 F nurse, 1 M nurse, 1 F HTC, 1 F lab tech | group 1: n = 11; group 2: n = 8 |
Analysis
Results
Service delivery at dispensaries | Community context of cultures and concerns | Wider health system: policy, programme and management | |
---|---|---|---|
Appropriateness | Healthcare workers’ professional motivations Services pregnant women want at ANC | Time and costs of reaching facilities | National guideline requirements |
Acceptability | Healthcare workers: Complexity of POCTs Proficiency of testing Observabilitya of test results Trialabilityb of POCTs Workload Attitude towards gaining knowledge and new skills Pregnant women: Trust and confidence in results | Community stigma, gender violence and partner involvement | County level decision makers would need to value and prioritize integrated antenatal testing and allocate funds to ensure its continuity |
Feasibility | Motivation of healthcare workers Drugs and commodities for services Training and quality assurance of healthcare worker performance Pregnant women’s degree of comfort in asking for services | Community culture and attitudes that influence timing of first ANC visit | Procurement and funding systems for commodities and drugs Sufficiency of human resources to meet demand Working conditions Quality and synergy of training |
Appropriateness of integrated POCT
Local service delivery and wider health system
“At least we are able to manage ANC mothers wholly instead of us referring, you know we used to refer, even for Hb we used to refer to Siaya but at least now we can do all those.”-female nurse (facility 1)
“…but now when we were testing the mothers, there was this test Rhesus and urinalysis, how I wish they could add one for urinalysis so that you deal with the mother as a whole.”-female nurse (facility 5)
“Malaria, we were not also doing it but I think integration is better because … and these days you will get to find that, I usually get so many positives for malaria and Hb, I’ve even got Hb of 4.9. Now I was imagining if we did not have this Hb machine, like if you just test the mother for HIV as usual and tell her to go. Maybe she does not even have money to go to the District hospital to go for other tests, what will happen to that mother? I think that is what brings these maternal deaths because we do not take the precaution during the antenatal period.” -female nurse (facility 6)
Community context
“it was very challenging, you find the mother at the first visit, you tell them: go to diagnosis, go to district, go and test this and this. They don’t go. They don’t always go and the next day when they come it is just blank” –clinical officer (facility 3)
“Sometimes there are some services which we do not offer which will force us to refer them to next level, of which because of the poverty in this area, some do not even go” -male nurse (facility 1)
Acceptability of integrated POCT
Local service delivery
“I think the pipette for syphilis was challenging at first before I did some more training on it, using pipette for syphilis, that was the place the challenges were coming in, but we manage to fill the loop hole, I know how to use the pipette.” -male HIV testing counsellor (facility 5)
“When we were starting we also complained, we never wanted to be given more and there was no additional staff. We talked about that and finally we are able to cope. Yeah, we can just do them as we continue doing the other things.” -male nurse (facility 4)
“Yes, when it started I saw it was a lot of work, but now it has made it easy because I can perform all the tests on the table” -female nurse (facility 5)
“let me give an example to where I was, the difference to now, because there everything was done through the lab, but now here, they come here to VCT [voluntary testing and counselling] room, we do everything at once, so time management is adhered. And using one single prick, the client can get results at once. That is what the clients actually were complaining, if I’m testing for HIV and then they go again to be pricked for malaria, I think we were having a challenge, but since the IPOC came, we just do everything within one prick.”-male HIV testing counsellor (facility 5)
“You can feel bad because when pricked many times and you have less blood you find that your blood level gets low.”-pregnant woman (facility 5)
“but they will not take it very serious because they have seen you have not even tested but when I test them, I always show them and tell them your Hb is this and you are supposed to have this. At least the mother can now understand because she has read it directly from [the machine] and I have explained they should be at what level, in fact they take it very serious.” -male nurse (facility 2)
“I always know because if you go there [health facility], and maybe they are doing an HIV test, if it comes out one line after testing it’s negative and if they are two then you are positive. So I know very well.”- pregnant woman (facility 6)
“You cannot deny the results because after the tests, they are only yours; they are not combined with another person’s results to make you doubt that it is someone else’s. So when the results are back, you have to check to see if it is negative or positive. If it is found to be negative, you just take it to be yours, you will not deny.” -pregnant woman (facility 7)
“we had some problem with it [HIV test] and actually…in interpreting the results, it used to give some faint line at the test site. It was causing a lot of problems with the clients. They are saying the line was faint.” -male nurse (facility 2)
Community context
“Some women are afraid that they will be tested for HIV and they are afraid, so they prefer going to the CHW [community health worker].”- pregnant woman (facility 5)
“They do counselling well for you to accept the result just as she had mentioned earlier that you see the test results yourself and confirm that they are yours and if added with counselling you just feel comfortable.”-pregnant woman (facility 5)
“Sometimes you are given enough counselling, sometimes not. When you are well counselled you feel okay but when you are not told enough you feel worried, so you can also ask to know. So you should just be free to ask them so that you go back feeling okay.”-pregnant woman (facility 7)
“When you are found to be having the illnesses, whoever was with you should sit with you and counsel you so that you can be at peace.”- pregnant woman (facility 3)
“I have told my husband to take me to the clinic as a motorcyclist so when we arrived I told him it is just for a few minutes he should wait for me and after the doctor was done with me I lied to him that the doctor was calling him so that he can be told something and when we reached at the doctors place I told him that I want us to be tested to know our HIV status so there was no way he could leave me here alone (laughing). We were tested both of us now.”- pregnant woman (facility 5)
“If you are found to be positive, it is important to test the spouse also so that they also know their health status. Most of them do not accept. So they rely on your results saying that if you are positive, they are also and if you are not, they also are not.”- pregnant woman (facility 7)
“They check your ANC book, so if you are negative they also know that they are negative.”- pregnant woman (facility 3)
“You can find some men, after knowing your status and the doctor has given you protective measures, some men do not accept to use the condoms. They say they cannot use them and if you also deny, some really get violent and beat you up.”- pregnant woman (facility 7)
“You just keep silent because you stay in his house, in their home, in their land”- pregnant woman (facility 7)
Feasibility of integrated POCT
Local service delivery and wider health system
“if you are stationed in MCH that is ok, but if you are taking care of PSC [patient support care for HIV positives], taking care of outpatient clients…you don’t give quality, let me say this.” -male nurse (facility 2)
“Sometimes you are here alone, you are doing all the work in the facility, so you work until you are tired because first of all you have the patients themselves and sometimes they can be very many they reach even 100 of them and you are alone. You are the one who is doing the malaria testing, you are the one who is prescribing and you are the one issuing the drugs, you also have the antenatal mothers and sometimes you can also have a mother in labour- those are some of the challenges we get so sometimes I’m sure we don’t even give quality work (laughing). So when things are that way you just think of chasing everybody out of the compound if they have nothing to do. You do things at a very fast speed because now you even don’t want time with the patient and you have talked such that you don’t feel like asking the patient her problems because you are tired, that is something I have experienced and then also if you have that burn out the patients will say that the sister is talking badly but I normally tell them it’s because I’m tired, that is the problem.” -female nurse (facility 2)
“The timer now, you know consume a lot of time, you have to wait for like 20 minutes and you have a long queue so there is a bit of a challenge there.” -male nurse (facility 7)
“Because there are few doctors here, we do not get enough counselling because there are many patients who are being attended to by one person. When the doctors were two, they would give enough counselling when they are free.” -pregnant woman (facility 4)
“Pregnant women can avoid coming to the clinic because they are afraid of meeting the healthcare workers”- pregnant women (facility 1)
“But you know when we come to the clinic we find different types of nurses sometimes you find her not in the moods and you get afraid of asking but if you find a happy one then you are also happy such that you share with her your problems.” -pregnant woman (facility 6)
“…how can you work without supplies that means you will go to the health facility and sit because clients need to be helped because they need help and they come, you diagnose them and you don’t help them with the drugs.” -male nurse (facility 6)
“You feel so bad when a mother comes and you ask her to buy it [drugs]. When she comes for the next visit, you ask her, did you buy? She will tell you no, I did not buy. I went to the chemist and they told me they sell it at 150 shillings and I did not have the money. Now you feel so bad, that is why I decided to buy the first batch but I can’t continue buying. Because we are not paid and we are paid, in fact poorly. So I cannot also manage to buy it, it is as if I am becoming another NGO.” -female nurse (facility 6)
“Right now we are having shortage of gloves, so it is forcing us to work under, let’s say under pressure, because if there is no gloves sometimes it is hard to work in such conditions” -male HIV testing counsellor (facility 5)
“it has been worse…things have changed…when we were still under the national government, drugs used to come to facilities…and they were punctual…but nowadays, you can even stay for months without drugs and when they bring in drugs, they bring that which you are going to use for about two weeks.” -female nurse (facility 6)
“Actually… personally I believe that health should have been devolved much, much later but it was rushed, and you can see, the management is poor. Just the other day, health workers within the county were threatening to go on strike. And part of the problem is just the management. I think some of these staff was devolved from the national government when the county government had not put in the structures to manage this work force from the national government and probably make some input. And again, also the input of the county government in terms of even staff employment, supplying of drugs … all these like I told you earlier that we have experienced shortage of drugs for quite a long time.” -male clinical officer (facility 3)
“There is no right treatment given to us because you can be prescribed for drugs and you don’t have money to go and buy them so there is no good treatment given.” -pregnant women (facility 2)
“It is good because at least you follow the right procedures. It also helps in getting the correct result because in IPOC I know there is timing of the results and the [not clear] measures. Because before IPOC came, I didn’t know anything to do with timing of the… I knew there was timing but the timer was not there. Yeah, so the results maybe, you give the result before time of which the results can be inaccurate. Yeah, and also the procedures at least they follow up on how to do the procedures so that we can do them correctly.” -female nurse (facility 7)
Community context
“Some women are afraid of walking while pregnant and since the CHW [community health worker] is next to her than the hospital she prefers going to the CHW because she can always go there once in seven months but in hospital they will tell her to go to the hospital every month and that doesn’t make her happy so she goes to the CHW.” -pregnant women (facility 5)
“We should start attending the clinic at four months and it should be every month without fail so that we can be helped. At four months you will have known your status in pregnancy.” -pregnant woman (facility 6)
“Some also don’t go to the hospital because they think they will be asked money” -pregnant woman (facility 5)