Globally, there are approximately 36.7 million
people living with HIV, with an estimated 3.8 million individuals newly
infected with HIV and about 5,000 new infections per day in the year 2017-2018.
Integration of HIV treatment with primary care services improves effectiveness,
efficiency and equity in service delivery. In Embu teaching and referral
hospital, integration of HIV services with other primary health services were
initiated in 2014 and up to date, the integration has not been fully adopted by
the clients therefore, the study sought to establish the perception of seropositive clients on integrated HIV and
primary health care services in Embu Teaching and Referral hospital. A cross
sectional survey design was used to collect data from a sample of 312
seropositive clients who were selected using simple random method. A structured
and semi-structured questionnaire was used to collect quantitative data while
key informant interviews (KII) and Focus Group Discussions (FGDs) helped to
collect qualitative data. The tools were reliable at Cronbach’s alpha of 0.7.
SPSS version 25 was used to analyze the data. A binary logistic regression
model was used to predict the effect of determinants of utilization of
integrated HIV services and primary health care services.
Results:
Majority of the respondents (59.6%) were aged over 35 years with majority being
female (58.9%) and the married were 57.6% of the total sample. On perception on
integrated services 76.5% had a positive perception.
Conclusion:
Majority of the clients had a positive perception towards the integrated
service. They perceived the staff attitude as positive and acknowledged that
integration allowed them opportunities to share their life experiences.
However, they felt there was need to increase services provided under the
integrated arrangement such as cancer screening, TB clinics and other services
such as blood pressure monitoring.
Recommendation: The
Government of Kenya through the Ministry of Health should engage the county
government and support from NGO`s to come up with structures and resources
needed to expand the facility in terms of
facility space and incorporation of other primary health care services
like cancer screening, diabetes screening, dental and ophthalmology services.
Keywords: Perception,
Integrated services, Embu teaching and referral hospital, HIV patients, Primary
health care services
INTRODUCTION
Globally, there are approximately 36.7
million people living with HIV in the year 2017-2018, with an estimated 3.8
million individuals newly infected with HIV and about 5,000 new infections per
day [1]. Among these people 2.1 million are children and teenagers below 15
years of age, most of them from sub Saharan Africa. The vast majority of people
living with HIV are in low- and middle-income countries. In 2017, there were
19.6 million people living with HIV (53%) in eastern and southern Africa, 6.1
million (16%) in western and central Africa, 5.2 million (14%) in Asia and the
Pacific, and 2.2 million (6%) in Western and Central Europe and North America.
Despite implementing some of the preventive measures many people living with
HIV or at risk for HIV still do not have access to proper care and treatment
[1].
In Sub-Saharan Africa, integration of HIV and
family planning services has been shown to have several benefits [3]. These
includes services rendered are affordable to clients, reduction of stigma and
discrimination. Other studies conducted in South Africa on perception of integration
of HIV and sexual reproductive health care, suggested a preference for
integrated care among female clients, particularly because of stigma reduction
and higher access to contraceptives [4]. Some of the perception of clinicians
and clients on integration of primary health care and HIV services showed that
about 80% of the respondents were satisfied with integration because the
organization of services and confidentiality prevented stigma and
discrimination. Majority of participants in the fully and partially integrated
facilities reported that clinicians treated them with respect, privacy and
confidentiality. Other participants referred staffs as rude and unfriendly,
increased waiting time before one is attended to, interruption of consultation
which was seen as infringement of privacy. Similar study showed that clients
felt that there were delays related to lack of punctuality to report on duty
after lunch and tea break, poor staff communication regarding delays in
patients consultations like when they break for lunch the staffs do not
communicate to the clients [5].
Majority of the respondents in a study
conducted in Ethiopia reported positive feelings towards the disease and
therefore can disclose their status to their families comfortably and 50% of
the respondents mentioned that TB carry the same stigma as HIV, this kind of
stigma is reduced when integration of services is embraced [6]. Integration of
HIV services and TB treatment demonstrated relative success of integrated and
co-located TB/HIV services in Swaziland and revealed timely ART uptake for
HIV-positive TB patients in resource-limited, but integrated settings [7].
A research carried out on patient’s
perception on HIV treatment integration with other services reported that most
clients were satisfied with integration of services [8]. However, the clients
reported that the staffs’ attitude, number of staffs in health facilities and
health care provider, patient communication were significantly affecting
patients’ satisfaction levels. In Cameroon integration has led to increased
utilization of HIV services, therefore when integration is implemented well and
staffs’ attitude and communication improved; patient level of satisfaction was
predicted to improve significantly [8].
In Kenya, a study done on experiences of
health care providers with integrated HIV and reproductive health services
revealed that more clients were satisfied and were willing to uptake HIV
testing than in stand-alone clinics. It also revealed that with increased
number of clients, infrastructural deficiencies hindered effective delivery of
the services as well as limiting quality time for counseling of the patients
due to shortage of staffs in relation to high numbers of in flowing clients
[4]. Some providers reported that integration enhanced job satisfaction by
providing a better quality service, which led to their receiving more regular
positive feedback from clients. Collocation of HIV services and primary health
care addresses the issue of scarce resource allocation, integration maximizes
use of health facility structures and ensures that funds targeted for
construction of HIV facilities will also benefit primary health care; therefore
both patients can access health care regardless of their HIV status [9].
A recent review identified various
discriminatory behaviors and negative attitude towards HIV patients. Some of
the behaviors were denial of care and testing or status disclosure without
consent, verbal abuse, additional fee and overuse of gloves especially health
care providers on HIV patients. It has been speculated that stand alone HIV
services may be stigmatizing, as clients are labeled as they walk through the
door resulting in an involuntary disclosure of status. Other structural
influences include avoidance or isolation of HIV clients and labeling of
buildings and rooms [9]. Integration is also likely to reorganize health care
delivery which may disrupt service provision and cause dissatisfaction among
patients. Further integration of specialized services into primary care
services may not always result in better patient and service level outcome for
example integration of HIV services with sexual and reproductive health
services may be hindered by increased patient burden, inadequate staffing and
resistance from existing health care workers. Integrating services for STI into
routine health services may result in lower utilization and reduced patient
satisfaction [10].
In Embu County, HIV prevalence is at 3.3%
according to Kenya HIV Estimates 2015.The County contributed 0.7% of the people
living with HIV in Kenya, with women having a higher prevalence (4.5%) than
that of men (2.0%). In a report released by Kenya Demographic Health Survey in
2014, it is evident that 36% of men and 16% of women in Embu County never sought
HIV testing services; therefore the county needs more innovative strategies to
improve on HIV testing and counseling, reduce HIV related stigma and promote
client satisfaction towards HIV services, to bridge the unmet gaps [11].
METHODOLOGY
A cross-sectional descriptive survey design
was used to generate both quantitative and qualitative data. This design was
appropriate since the study was carried out at a specific point in time without
any manipulation of the variables. The study population in this study was
sero-positive HIV clients. A target population of 1650 clients was applied as
per the comprehensive care clinic register; approximately 55 clients per day
receive HIV services, a sample of 312 respondents was used in the study. They
were appropriate for this study because they are informed about integration and
they are the main beneficiaries of these services. Reliability of the tool was
tested and the Cronbach’s alpha was calculated and was found to be at (p=0.817)
which showed a high degree of reliability of the variables.
Quantitative data was analyzed using SPSS
version 25 and thematic analysis was done for qualitative data using N-Vivo
version 11. A simple logistic regression model was fitted, to determine the set
of significant variables for each of the dependent variables. Variable
selection for the multivariable analysis was done dropping for all those
covariates with a p-value >0.05 from the main analysis. The second stage of
variable selection entailed forward selection coupled with the likelihood ratio
tests. 5% level of significance was applied on all analyses.
RESULTS
Demographic
characteristics
The demographic characteristics were divided
into: non-illness related characteristics and illness related characteristics.
Non-illness related characteristics included age, gender, marital status,
religion and level of education. On the other hand, illness related
characteristics included whether or not client was on ART, duration of ART,
utilization of other services beside HIV care under one roof, whether one ever
received medical care in the clinic, employment status, distance from home to
the facility and services being currently sought at the clinic.
Table 1 show that 8.9% (27) of the respondents were aged 18-22 years, 8.6% (26) were aged between 23-26 years, 1.7% (5) of the respondents were aged 27-31 years, 21.2% (64) were aged between 32-35 years while those who were over 35 years constituted 59.6% (180).Majority, i.e., 98.7% (298) had received the combined HIV care and other services under one roof, while 1.3% (4) had not. Concerning duration of medical care in the clinic, 0.7% (2) had received care for less than 1 year, 27.8% (84) had received care for 1-2 years, and 26.8% (81) had received care for 3-5 years while 44.7% (135) had received care for more than 5 years.
Figure 1 shows that most respondents, i.e.,
35.1% (106) were seeking ART services and health education, while the services
least sought after were immunization and curative services with 2% (6) and 1.3%
(4), respectively.
HIV PATIENTS’ UTILIZATION OF INTEGRATED HIV
AND PRIMARY HEALTH CARE SERVICES
Utilization was
assessed using a set of 5 practice questions from which results the status was
either “utilization” or “non-utilization”. Utilization with regard to action
taken when one experienced HIV related illnesses( practice question 1) meant,
visiting the health facility immediately, utilization regarding appointments
(practice question 2) meant not missing any appointment, utilization regarding
drugs (practice question 3) meant not missing the prescribed drugs, utilization
regarding conventional medicine (practice question 4) meant taking only
prescribed medicine given at the clinic and utilization regarding consultations
(practice question 5) meant consulting the health worker whenever in doubt.
Table 3 shows that 99.3%
(300) of the respondents visited the health facility immediately whenever they
experienced an illness related to HIV infection, while 0.7% (2) tried other
measures at home. Majority, i.e., 66.9% (202) had ever missed appointment given
in the course of care while 33.1% (100) had never missed any appointment. Most
respondents, i.e., 77.8% (235) had never missed to take any drugs or treatment
options given in the facility of care while 22.2% (67) had missed some
treatment.
Figure 2 shows that majority of the respondents, i.e., 86.8% (262) utilized integrated HIV and primary health care services while 12.9% (39) did not.
PERCEPTIONS OF HIV PATIENTS ON INTEGRATED PRIMARY HEALTH CARE SERVICES
Perceptions were
assessed through a set of 10 likert form statements where responses were
“agree”, “disagree”, “strongly agree”, and “strongly disagree”. Three
statements that had been negatively phrased were reverse coded before analysis.
Those who either agreed or strongly agreed were considered as having a positive
perception, while those who either disagreed or strongly disagreed were
considered as having a negative perception. Positive perception implied that
the patients were satisfied, while negative perception implied that the
patients were not satisfied.
Table 4 Shows that most respondents either “agreed” or “strongly agreed” which was indicative of an overall positive perception.The researcher went ahead and computed a variable known as “perception score” in order to assess the perception statuses for individual respondents. The responses were coded as follows: Strongly agree=4, agree=3, disagree=2 and strongly disagree=1. The maximum one would score was 40 (4 × 10) and the lowest possible score was 10 (1 × 10). A score of at least 30 meant a positive perception and below that was meant a negative perception.
Figure 3 shows that 76.5%
of the respondents had a positive perception of the services offered at the clinic
while 23.5% had a negative perception. Positive perception was indicative of
satisfaction while negative perception was indicative of dissatisfaction.
Perceptions were cross-tabulated against utilization of integrated HIV and
primary health care services.
Table 5 shows that there
was no significant relationship between client perceptions and utilization of
integrated HIV and primary health care services (χ2 (1, N=302)
=2.486, p=0.092), therefore the null hypothesis that there is no statistically
significant relationship between perception and utilization of HIV integrated
primary health care services was accepted.
QUALITATIVE
DATA ANALYSIS ON PERCEPTIONS
Qualitative data
from focused group discussions and key informant questionnaire was analysed
thematically and theme summaries were given under each theme. The emerging
themes from focused group discussions were: staff attitude, sharing information
with others, and availability of resources.
Staff attitude
The staff attitude
was generally positive as perceived by the clients. Staffs were patient, nice,
humble, understanding, polite and they gave undivided attention to the clients.
They expressed readiness to attend to patients’ needs, by being good listeners
which showed a caring and concerned attitude for patients. However, some staffs
were a bit strict on late comers who ended up missing out on important services
like health education and counseling. Someone narrated, “Staffs are very harsh
when one comes to the clinic late. This is my body, am an adult and voluntarily
came to the clinic to know my HIV status, l have been utilizing this services
voluntarily, coming late once in a while is not one`s fault and no one should
incriminate me if l fail to attend 8 a.m health talk sessions” (Focused group
discussion respondent 4).
Some staffs also
failed to recognise the patients in pain and appropriate pain management
measures were ignored.
Sharing information with others
Patients shared on
how drugs were affecting them. Old clients shared their experiences, patients
learnt from each other, patients were able to interact and learn, some clients
came from other facilities and shared their experiences, staffs also shared
about their personal health and this motivated the patients a lot. There was a
lot of sharing of experiences related to stigmatization.
Availability and use of resources
Clients felt that
the waiting times needed to be reduced. More lab tests, e.g. cancer screening,
pregnancy tests for youths, and blood sugar monitoring needed to be incorporated
in the clinic to cover all illnesses even the minor ones. Multivitamin drugs
needed to be availed all the time and health talks for patients who could not
make it to come early in the morning, when health talks usually took place.
More space needed to be availed for the waiting bay and more clinics built,
e.g. chest clinic for TB patients.
The themes for key
informant questionnaire were integrated services and utilization of integrated
services.
Integrated services (key informant interview)
Integrated services
meant getting a package of standardized care under one roof. The services were
efficient in terms of saving time and space, thus, enabling clients get
satisfaction of service offered. Challenges included lack of some essential
services such as cervical cancer screening necessitating referral to other
departments. There was limited space and clients waited outside the room for a
certain service provider to attend to them. Support was needed from NGOS and
county government in funding essential services missed out, in construction of
more rooms and providing reagents and all consumables.
Utilization of integrated services
The services were
accessible to clients easily enhancing more utilization by clients demanding
for them e.g. partner testing. Integration of services led to job satisfaction
in serving clients. Using the available resources, the health system had
distributed and allocated funds and personnel to serve people living with HIV.
During focus group
discussion, it was broadly argued that generally staff attitude was generally
positive as perceived by the clients. Staffs were patient, nice, humble,
understanding, polite and they gave undivided attention to the clients.
However, some staffs were a bit strict on late comers who ended up missing out
on important services like health education which took place at exactly 8.00am
in the morning. This finding echoed what [4] found out that the clinicians
could give the patient a listening hear, respect them irrespective of their
status and could spend more time with the patient to their satisfaction.
Similar study reported that clinicians treated the patients with respect,
privacy and confidentiality other participants referred staffs as rude and
unfriendly, as depicted in the finding.
The findings also concurred with early research done in Kisumu, which
reported that educative sessions, and positive staff attitude were of great
significance especially in an integrated care program: this session’s increased
patient’s satisfaction [10].
CONCLUSION
Majority of the
clients had a positive perception towards the integrated service. They
perceived the staff attitude as positive and acknowledged that integration
allowed them opportunities to share their life experiences. However, they felt
there was need to increase services provided under the integrated arrangement
such as cancer screening, TB clinics and other services such as blood pressure
monitoring.
RECOMMENDATION
i.
The Government
of Kenya through the Ministry of Health should engage the county government and
support from NGO’s to come up with structures and resources needed in order to
expand the facility in terms of facility space and incorporation of other
primary health care services like cancer screening, diabetes screening, dental
and ophthalmology services.
ii.
The hospital
administration should come up with strategies and avenues which will enable the
clients to channel their complaints, dissatisfaction and grievances comfortably
without fear. This will enable the health workers to know their weaknesses and
even improve the services provided to the clients.
ACKNOWLEDGEMENT
My Appreciation
goes to my dedicated academic supervisors, Dr. Moses Muraya and to Dr. Micah
Matiang`i for the untiring technical and moral support provided throughout the
study process. Exceptional gratitude goes to my family for their continued
support both spiritual and financial support. Thanks to my colleagues at work
and my classmates for their support throughout my master’s program. My special
appreciation goes to administrative officers in Embu Level Five, Comprehensive
Care Clinic in charge and peer support workers for their unwavering support
during collection of my research data.
Thank you all for
your support.
FUNDING
None
CONFLICT OF INTEREST
None declared, authors
declare no special interest.
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