Background
Linkage to care: a crucial step in HIV control and disease outcome
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Enhancing the capabilities of government (public policy and management oversight);
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Improving the performance of implementing and provider organizations;
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Strengthening the capabilities and performance of individual providers and front-line workers;
Study setting
Characteristics of health care provision in relation to HIV care in Mbeya region
Design
Methods
Districts | Type of Site | No of FGDs | No of IDI-Clients | No of IDIs- HCP |
---|---|---|---|---|
Facility based sites | ||||
Kyela | Kyela Hospital | 0 | 1 | 2 |
Ipinda Health Centre | 1 | 1 | 1 | |
Mbozi | Vwawa Hospital | 0 | 0 | 1 |
Tunduma health Centre | 1 | 1 | 2 | |
Mbeya Rural | Ifisi Hospital | 1 | 1 | 1 |
Inyala health centre | 0 | 0 | 2 | |
Chunya | Chunya hospital | 1 | 1 | 2 |
Makongolosi Dispensary | 0 | 0 | 1 | |
Mobile/outreach sites | ||||
Kyela | ST JOHN HUS-Kyela | 1 | 1 | 2 |
MMRC mobile- Kyela | 0 | 1 | 1 | |
Mbozi | SHDEPHA - Mpemba | 0 | 0 | 1 |
MMRC Mobile-Mbozi | 1 | 0 | 0 | |
Mbeya Rural | KIHUMBE- Mbalizi | 1 | 1 | 1 |
MMRC mobile- Mbeya Rural | 0 | 0 | 1 | |
Chunya | KIHUMBE- Chunya | 0 | 1 | 2 |
MMRC- Mobile- Chunya | 1 | 0 | 1 | |
TOTAL | 8 | 10 | 20 |
Rigor and trustworthiness
Ethical considerations
Results
Study sites and characteristics of respondents
Factors identified as influencing linkage to care
Level | Categories | Themes/Factors |
---|---|---|
Individual | Facilitators | Individuals being sick at the time of diagnosis |
Individuals disclosing their status to someone | ||
Social and moral support from family members/relatives and from other PLHIV | ||
Barriers | Fear of stigma | |
Denial and being asymptomatic | ||
Poor health literacy | ||
Lack or fear of disclosure | ||
Belief in witchcraft and traditional treatment | ||
Spiritual beliefs | ||
Health Care Provider | Facilitators | Support or encouragement from health care providers |
Good patient-healthcare provider relationship | ||
Barriers | Negative attitude from healthcare provider | |
Health System | Facilitators | Availability of referral procedures i.e. referral letter/Referral form |
Good service organization | ||
Barriers | Poor clinic procedures and visit schedules | |
Clinic over-crowding | ||
Long waiting times at the clinic | ||
Few care and treatment centers and inadequate resources | ||
Shortage of staff | ||
Inadequate CD4 testing machines (malfunctioning) | ||
Contextual | Facilitators | Short distance Less costs to clinic |
Barriers | Long distance high transport cost |
Results overview
Individual level
Facilitators to linkage to care
Individuals being sick at the time of diagnosis
“Initially, I didn’t think it was necessary to go [to the hospital] but one day I had a fever. I felt my hands and legs not working at all. I thought I am going to die. I asked my sister to take me to the hospital for medication” [IDI-Client3].
“They stay at home until they are seriously sick is when they go to the hospital for registration” [FGD7].
Individuals disclosing their status to someone
“Most of my relatives know my status after since I told them. They support me. Sometimes they escort me to the clinic” [IDI-Client3].
Social and moral support from family members/relatives and from other PLHIV
“I started suffering so I decided to ask my elder brother to escort me to do the test [HIV] and I was found HIV positive” [FGD3].
“My sister encouraged me, she said it not the end of the world, I will be okay when I start medication, and there are so many people who are in this [HIV] situation” [IDI-Client8].
“At our place Lusungo, we have formed the HIV support group which we meet every 15 of the month to discuss issues and encourage each other… we contribute little money for emergency …like if someone does not have transport fare we give” [FGD2].
Individual level barriers to linkage to care
Fear of stigma
“They do not like going to the hospital; some fear that other people will see them at the clinic and know that they are infected” [FGD1].“Most of them is because they fear that people will see them at CTC and start pointing fingers” [IDI-HCP2].
Denial and being asymptomatic
“I was pregnant and I went to the clinic for antenatal care. They [clinicians] tested my blood and told that I am infected with HIV. I did not believe it because I was not sick and had no other health problem apart from being pregnant” [IDI-Client9].
“Some clients do not believe they are infected because they are healthy” [IDI-HCP7].
Poor health literacy (lack of understanding of the importance of being in care)
“Maybe education is still low, they do not understand that is importance to start ART care while you are still strong than when you are very weak” [IDI-HCP9]“Also some people are just ignorant especially those who do not have any symptoms, they do not see the importance of being in care if they are not sick.” [IDI-HCP5].
Lack or fear of disclosure
“Many women are facing problems when disclosing HIV status to the men and some lead to divorce” [FGD3].“They do not tell their partners, so it becomes difficult for them to come to the clinic and they come secretively” [IDI-HCP13].
Belief in witchcraft and traditional treatment
“When I started getting sick, my in-law took me to a traditional healer, he said I am bewitched. He [traditional healer] started treating me with different herbs, some for drinking and others for bathing. I wasn’t getting any better so I told him; I want to go to the hospital” [FGD 2].
“He [traditional healer] said it was one of my neighbors in the market who is jealous of me. He [the neighbor] had put something in my store that is causing us to suffer from unknown diseases” [IDI-Client 2].
Spiritual belief
“You know when there is a problem you become worried so you can come here [clinic] or try other places. They say they pray for you and you will be healed” [FGD 4].
“Some patients go to the new churches. The pastors in those churches they pray for them and give them holy water to take and they tell them you will be healed” [IDI-HCP 3].
Health care provider level
Health care provider facilitators to linkage to care
Support or encouragement from health care providers
“Frankly speaking, the health providers here treat us nicely. They explained to me step-by-step on how to use drugs. I thank them. It is two weeks now since I started the drugs. They are providing good services” [FGD3].
“They [the nurses] even gave me the drugs for preventing chest infection and another disease.” [IDI-Client6].
Good patient-health care provider relationship
“The nurses are very polite and helping us a lot” [FGD1].
“Generally the service providers are treating us well; we do not have any complaint” [FGD4].
Health care provider barriers to linkage to care
Poor health care provider attitude and use of abusive language
“When we reach here [clinic], they look at us like we are not normal human beings, they discriminate against us. They tell us to come very early but you see they start attending to us at 01:00 in the afternoon and sometimes you end up not getting the drugs” [FGD2].
“Truly, shouting can contribute so much, it hurts. You think I am sick then doctor barks or shouts at me, so they decide to stop coming” [FGD6].
Health system level
Health system facilitators for linkage to care
Availability of referral procedures
“If the client is positive, I refer him/her to CTC with this form (referral form) we have to make sure they are registered in the book” [IDI-HCP1].
“We refer the client we give him/her a referral letter with CD4 results print out and we also do HIV staging so that the CTC clinician can decide on how to continue” [IDI-HCP7].
“I sometimes take the letter from here (Testing site) and I accompany the person to the clinic at the [District] hospital, I take them through all steps” [FGD 1].
Service design or clinic services organization
“Normally when I find a positive client, I go to the next room where we keep the documents for registration and the CTC cards, so I register him/her in the CTC register and give them a CTC clinic number with the treatment card” [IDI-HCP1].
“He [the care provider] gave me the letter and asked me to go to room number 10, show this [registration card] to the nurse. They gave me a card then I went into another room to give blood for CD4” [FGD 2].
Health system barriers to linkage to care
Disorganized clinic procedures and visit schedules
“We do CD4 testing on Wednesdays and Fridays, the other days is for in-patients’ tests. So if it is Wednesday and the client comes early, they go directly to the CD4 testing section and they are given a date to come for results normally. This could be in about three or four days’ time” [IDI-HCP10].
“He gave me some papers (referral form) to go with and show the nurse at the CTC. I went and the nurse said I should come on Tuesday for registration” [IDI-Client2].
Clinic overcrowding
“So even when you tell a client to go and join the queue for registration, he says ‘there are too many people, I will come tomorrow’ and that is it. They disappear. We don’t know whether they go to other clinics or what happens to them” [IDI-HCP9].
“For the matter of staying a long time it is because we are so many, therefore, we take a lot of time” [FGD1].
Long waiting times at the clinic
“Patients wait for services for a very long time because the same staff has to go in the wards to assist, and then come here again for HIV client. For example, on Wednesday when they come for adherence treatment classes we can only start with them after 12 noon, and they always complain” [IDI-HCP6].
“We wait for services for a very long time and the waiting place is open when it is raining, we suffer a lot” [IDI-Client1].
Inadequate resources and equipment
“There is a severe shortage of staff here; clients wait for CTC services for hours before they are attended to. We are only two nurses and one doctor per shift if one of them is sick or on leave, patients wait up to 4 o'clock in the evening” [IDI-HCP6].
“The problem is, we depend on only this hospital for all people in Chunya, people from Lupa tingatinga and all other villages…and Chunya is big” [FGD4].
“Also, the recurrent problem is with the CD4 machine [breakdown]. Maybe the government can help us by buying a new machine, even two we are so many here who need the service” [IDI-Client1].
“Most of the patients there are delayed due to CD4. This is the only site with a working CD4 machine. We receive patients from Sumbawanga even Nakonde from Zambia because this service is not available in their areas” [IDI-HCP14].
Contextual level
Contextual facilitators of linkage to care
Proximity and low travel cost to the clinic
“I do not live very far from here, I just get a boda-boda [hired motorbike] and I pay only one thousand [less than half a dollar] and I can even walk if I want to” [IDI-Client6].
“For me, distance is not a problem, I walk for about ten minutes and am here, sometimes I send my daughter to bring the card for me and put it in the box while am still at home, when I come here I just wait for my turn to take medication” [FGD7].
Contextual barriers to linkage to care
Long distance and high transport cost to CTCs (transport challenges)
“We refer our clients to either … hospital [about 10-15 Km] to… the health center also about same distance. They say ‘I do not have bus fare for now” [IDI-HCP11].
“Transport is very costly. Sometimes, I borrow money from friends and sometimes I come with my bicycle but I do not have the energy to ride for a long distance” [IDI-Client2].
“Binti-manyanga is far, it is about 100 kilometers from here and the cost of transport is very high about 28000 to 30000 [about $14] per trip” [FGD4].