BACKGROUND:
Understanding
the motivations and perspectives of providers in following guidance and evidence-based
policies can contribute to the evidence on
how to better implement and deliver care, particularly in resource-constrained
settings. This study explored how providers' attitudes and behaviors influenced the implementation of an
intervention, provider-initiated HIV testing
and counseling, in primary health care settings in Botswana.
METHODS:
Using a
grounded-theory approach, we purposively selected and interviewed 45 providers
in 15 facilities in 3 districts and inductively analyzed data for themes and
patterns.
RESULTS:
We found
that nurses across facilities and districts were largely resistant to offering
and delivering provider-initiated testing and counseling for HIV (PITC) for three reasons:
- they felt they
were overworked and had no time,
- they felt it was not their job, and
- they were afraid to counsel patients, particularly fearing a positive HIV test.
These factors were largely related to
health system constraints that affected the capacity of providers to do their
job. An important underlying themes emerged: nurses and lay counselors were
unsatisfied with pay and career prospects, which made them unmotivated to work
in general. Variations were seen by urban and rural areas: nurses in urban
areas felt generally overworked and PITC was seen as contributing to the
workload. While nurses in rural areas did not feel overworked, they felt that
PITC was not their job and they were unmotivated because of general unhappiness
with their rural posts.
CONCLUSIONS:
The
attitudes and behaviors of
providers and barriers they faced played a critical role in whether and how
PITC was being implemented in Botswana. Provider factors should be considered
in the improvement of existing PITC programs and design of new ones. Addressing
constraints faced by providers can do more to improve supply of human resources
than merely recruiting more providers.
Below: Theme “I am unsatisfied with
my job.” This figure displays the frequency of sub-codes within the theme “I am
unsatisfied with my job” emerging from interviews with providers in the study.
The pie chart labeled All Districts presents
the frequency of sub-codes in this theme in all the districts combined, while
the three smaller pie charts show frequencies disaggregated by providers’
responses in urban, rural, and urban village districts included in the study
Below: Theme 2 “I do not want to
counsel patients.” This figure displays the frequency of sub-codes within the
theme “I do not want to counsel patients” emerging from interviews with
providers in the study. The pie chart labeled All Districts presents
the frequency of sub-codes within this theme in all the districts combined,
while the three smaller pie charts show frequencies disaggregated by providers’
responses in urban, rural, and urban village districts included in the study
- 1Harvard T. H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, 02115, USA. sma826@mail.harvard.edu.
- 2Harvard T. H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, 02115, USA. tbaernig@hsph.harvard.edu.
- 3Africa Centre for Population Health, University of KwaZulu-Natal, KwaZulu-Natal, South Africa. tbaernig@hsph.harvard.edu.
- 4Harvard T. H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, 02115, USA. ndaniels@hsph.harvard.edu.
- 5Harvard T. H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, 02115, USA. marlink@hsph.harvard.edu.
- 6Harvard T. H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, 02115, USA. mroberts@hsph.harvard.edu.
- Implement Sci. 2016 Feb 11;11(1):18. doi: 10.1186/s13012-015-0361-7.
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