'I believe that the staff have reduced their closeness to patients': an exploratory study on the impact of HIV/AIDS on staff in four rural hospitals in Uganda

Improvisation and harm avoidance: An ethnographic study of adherence to postnatal care protocols in two hospitals in Southern Ghana

Providers' adherence to case management protocols can affect quality of care. However, how and why protocols are adhered to by frontline health workers in low- and middle-income countries is not always clear. This study explored midwives' adherence to national postnatal care protocols in two public hospitals in Southern Ghana using an ethnographic study design. Ninety participant observations and 88 conversations were conducted over a 20-months period, and two group interviews held with the midwives in the two hospitals. Data was analysed using a grounded theory approach. Findings: Midwives collectively decided when to adhere, modify or totally ignore postnatal care protocols. Adherence often occurred if required resources (equipment, tools, supplies) were available. Modification occurred when midwives felt that strict adherence could have negative implications for patients and they could be seen as acting 'unprofessionally'. Ignoring or modifying protocols also occurred when midwives were uncertain of the patient's health condition; basic supplies, logistics and infrastructure needed for adherence were unavailable or inappropriate; or midwives felt they might expose themselves or their clients to physical, psychological, emotional, financial or social harm. Regardless of the reasons that midwives felt justified to ignore or modify postnatal care protocols, it appeared in many instances to lead to the provision of care of suboptimal quality. Conclusion and recommendations: Providing clinical decision-making protocols is not enough to improve mother and new born care quality and outcomes. Faced with constraining conditions of work, providers are likely to modify guidelines as part of coping behaviour. Addressing constraining conditions of work must accompany guidelines. This includes adequate risks protection for health workers and clients; and resolution of deficits in essential equipment, infrastructure, supplies and staffing.

Job satisfaction and turnover intentions among health care staff providing services for prevention of mother-to-child transmission of HIV in Dar es Salaam, Tanzania

BACKGROUND

Option B+ for the prevention of mother-to-child transmission (PMTCT) of HIV (i.e., lifelong antiretroviral treatment for all pregnant and breastfeeding mothers living with HIV) was initiated in Tanzania in 2013. While there is evidence that this policy has benefits for the health of the mother and the child, Option B+ may also increase the workload for health care providers in resource-constrained settings, possibly leading to job dissatisfaction and unwanted workforce turnover.

METHODS

From March to April 2014, a questionnaire asking about job satisfaction and turnover intentions was administered to all nurses at 36 public-sector health facilities offering antenatal and PMTCT services in Dar es Salaam, Tanzania. Multivariable logistic regression models were used to identify factors associated with job dissatisfaction and intention to quit one's job.

RESULTS

Slightly over half (54%, 114/213) of the providers were dissatisfied with their current job, and 35% (74/213) intended to leave their job. Most of the providers were dissatisfied with low salaries and high workload, but satisfied with workplace harmony and being able to follow their moral values. The odds of reporting to be globally dissatisfied with one's job were high if the provider was dissatisfied with salary (adjusted odds ratio (aOR) 5.6, 95% CI 1.2-26.8), availability of protective gear (aOR 4.0, 95% CI 1.5-10.6), job description (aOR 4.3, 95% CI 1.2-14.7), and working hours (aOR 3.2, 95% CI 1.3-7.6). Perceiving clients to prefer PMTCT Option B+ reduced job dissatisfaction (aOR 0.2, 95% CI 0.1-0.8). The following factors were associated with providers' intention to leave their current job: job stability dissatisfaction (aOR 3.7, 95% CI 1.3-10.5), not being recognized by one's superior (aOR 3.6, 95% CI 1.7-7.6), and poor feedback on the overall unit performance (aOR 2.7, 95% CI 1.3-5.8).

CONCLUSION

Job dissatisfaction and turnover intentions are comparatively high among nurses in Dar es Salaam's public-sector maternal care facilities. Providing reasonable salaries and working hours, clearer job descriptions, appropriate safety measures, job stability, and improved supervision and feedback will be key to retaining satisfied PMTCT providers and thus to sustain successful implementation of Option B+ in Tanzania.

TOPIC: "The level of nurses' knowledge on occupational post exposure to hepatitis B infection in the Tamale metropolis, Ghana"

Background

Health care workers especially nurses in developing countries are at serious risk for infection from blood-borne pathogens particularly hepatitis B virus (HBV) — because of the high prevalence of such pathogens in many poorer regions of the world. Employers are required to establish exposure-control plans that include post exposure follow-up for their employees and to comply with incident reporting requirements.

This study assessed the level of knowledge and awareness of nurses in the Tamale Metropolis of Ghana on occupational post exposure measures to hepatitis B, and their risk of being infected. Hepatitis B vaccination status of nurses was also assessed.

Methods

A cross-sectional study was conducted involving 108 nurses of varied categories who were selected by simple random sampling from west and central hospitals in the Tamale Metropolis of Ghana. Data was collected using a semi-structured questionnaire. SPSS version 16 was used for the analysis of data.

Results

Ninety-four percent (94.4%) of the nurses considered themselves susceptible to occupational infection of HBV. About 23.4% were able to mention all the key elements of the post exposure management with 12.1% having adequate knowledge on post exposure prophylactic treatment against HBV. However, only 48 (44.4%) nurses have received hepatitis B vaccination. Thirty-six (75%) of those immunized had received three doses as required while the remaining had less than 3 doses. Some (38.9%) recap used needles before disposal and 30.2% do not decontaminate blood and body fluids before disposal.

Conclusion

Nurses are aware of their risk of occupational exposure to hepatitis B but lack the requisite knowledge on post exposure management as well as measures that reduce the exposure. Nurses should familiarize with the principles of post exposure management as part of job orientation and on-going job training. Also, there is a need for a national policy on occupational safety and health which should include HB vaccination of health care workers as a requirement for appointment into the health service.

Clinic-level factors influencing patient outcomes on antiretroviral therapy in primary health clinics in South Africa

OBJECTIVES

To explore which clinic-level factors influence treatment outcomes in a multisite antiretroviral therapy (ART) programme in South Africa.

DESIGN

Retrospective cohort study using 36 clinics.

METHODS

We used random effects modelling to investigate clinic-level factors influencing ART outcomes, adjusting for patient-level factors and accounting for clustering at clinic level. Outcomes were unsuppressed viral load (>400 copies/ml) at 24 months after ART start and time to loss to follow-up.

RESULTS

At clinic level, the mean proportion of patients with unsuppressed viral load at 24 months was 16% (range 8-33%). Loss to follow-up was also highly variable across clinics ranging from 3.5 to 23.4/100 person-years. Unsuppressed viral load was associated with a lower doctor-patient ratio [for every 500 patients, compared with >2.6 doctors: <0.7 doctors: adjusted odds ratio (OR) 1.52, 95% confidence interval (CI) 1.04-2.21; 0.7-2.6 doctors, OR 1.33, CI 0.91-1.93, P trend 0.04] after adjustment for patient factors. Combinations of psychosocial support interventions were weakly associated with reduced loss to follow-up [>6 interventions vs. <4 interventions: hazard ratio 0.39 (CI 0.15 - 1.04), P = 0.11]. Flexibility of services, integration of services, staff motivation, staff leadership and location of clinic were not consistently associated with improved outcomes.

CONCLUSION

The dominant clinic-level influences on patient outcomes were doctor : patient ratio, and combination interventions to reduce loss to follow-up. Further research is needed to define optimum staffing levels that are required to roll out ART and the combination intervention that is most effective to reduce loss to follow-up.

Improving Midwifery Care in Ugandan Public Hospitals: The Midwives' Perspective

BACKGROUND

A serious shortage of nurses and midwives in public hospitals has been reported in Uganda. In addition, over 80% of the nurses and midwives working in public hospitals have been found to have job stress and only 17% to be satisfied on the job. Stress and lack of job satisfaction affect quality of nursing and midwifery care and puts patients' lives at risk. This is coupled with rampant public outcry about the deteriorating nursing and midwifery care in Ugandan public hospitals.

OBJECTIVE

To explore factors that result in poor quality of midwifery care and strategies to improve this care from the perspective of the midwives.

METHOD

It was a qualitative exploratory design. Participants were midwives and their supervisors working in four Regional Referral hospitals in Uganda. Data was collected by FGDs and KIIs. Content analysis was used to analyze the transcribed data from the voice recordings.

RESULTS

Four major themes emerged from the study. They were organizational (poor work environment and lack of materials/equipment), professional (midwives' attitudes, lack of supervision), public/consumer issues (interference) and policy issues (remuneration, promotion and retirement).

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Midwives love their work but they need support to provide quality care. Continuous neglect of midwives' serious concerns will lead to more shortages as more dissatisfied midwives leave service.

Patient satisfaction at accredited antiretroviral treatment sites in the Gert Sibande District

BACKGROUND

Patient satisfaction has been used as a significant indicator of quality services provided by healthcare personnel. With the largest antiretroviral therapy (ART) programme in the world, the healthcare industry is struggling increasingly with challenges of meeting patients' requirements and expectations for quality ART service provision. This study was conducted in order to identify the importance of factors contributing to satisfaction or dissatisfaction.

AIM

This study sought to explore and describe the general satisfaction or dissatisfaction of patients with accredited ART hospital sites at public health facilities in the Gert Sibande District, Mpumalanga and to identify factors contributing to either satisfaction or dissatisfaction.

SETTING

Six hospitals that initiated ART in the district, participated in the study.

METHOD

The study was conducted using a sample of 300 patients. Proportional random sampling was used in selecting the number of patients from each facility. A structured interview with each participating patient was conducted using a standardised structured questionnaire. The first available required number of patients that complied with requirements from each of the six hospitals was selected for the interview. Descriptive statistics were used to analyse data and data with qualitative aspects were captured and categorised manually.

RESULTS

The major factors contributing to satisfaction included the availability of medicines and knowledge regarding how to take medication. Factors contributing to dissatisfaction on the part of the patients included confidentiality issues, long waiting periods, shortage of staff and dirty toilets.

CONCLUSION

This study indicated general satisfaction with the ART-related services at the accredited ART hospital sites in the Gert Sibande District. Regular monitoring and evaluation are recommended.

Changes in clients' care ratings after HIV prevention training of hospital workers in Malawi

OBJECTIVE

To examine the changes in clients' health-care ratings before and after hospital workers received an HIV prevention intervention in Malawi, which increased the workers' personal and work-related HIV prevention knowledge, attitudes and preventive behaviors.

DESIGN

Pre- and post-intervention client surveys.

SETTING

A large urban referral hospital in Malawi.

PARTICIPANTS

Clients at purposefully selected inpatient and outpatient units on designated days (baseline, n = 310 clients; final, n = 683).

INTERVENTION

Ten-session peer-group intervention for health workers focused on HIV transmission, personal and work-related prevention, treating clients and families respectfully and incorporating HIV-related teaching.

MAIN OUTCOME MEASURES

Brief face-to-face clients' interview obtaining ratings of confidentiality of HIV, whether HIV-related teaching occurred and ratings of service quality.

RESULTS

Compared with baseline, at the final survey, clients reported higher confidence about confidentiality of clients' HIV status (83 vs. 75%, P < 0.01) and more clients reported that a health worker talked to them about HIV and AIDS (37 versus 28%, P < 0.01). More clients rated overall health services as 'very good' (five-item mean rating, 68 versus 59%, P < 0.01) and this was true for both inpatients and outpatients examined separately. However, there was no improvement in ratings of the courtesy of laboratory or pharmacy workers or of the adequacy of treatment instructions in the pharmacy.

CONCLUSIONS

HIV prevention training for health workers can have positive effects on clients' ratings of services, including HIV-related confidentiality and teaching, and should be scaled-up throughout Malawi and in other similar countries. Hospitals need to improve laboratory and pharmacy services.

Peer group intervention for HIV prevention among health workers in Chile

We tested the impacts of a professionally assisted peer-group intervention on Chilean health workers' HIV-related knowledge, attitudes, and behaviors using a quasi-experimental design with a pretest and 3-month posttest. Two Santiago suburbs were randomly assigned to the intervention or delayed intervention control condition. Five community clinics per suburb participated. Interested workers at the intervention (n = 262) and control (n = 293) clinics participated and completed both evaluations. At posttest, intervention clinic workers had higher knowledge and more positive attitudes regarding HIV, condoms, stigmatization, and self-efficacy for prevention. They reported more partner discussion about safer sex, less unprotected sex, and more involvement in HIV prevention activities in the clinic and the community, but they did not report fewer sexual partners or more standard precautions behaviors. Because of these positive impacts, the program will become a regular continuing education unit that can be used to meet health-worker licensing requirements.

Acceptability and feasibility of integration of HIV care services into antenatal clinics in rural Kenya: a qualitative provider interview study

The aim of this study was to explore the perspectives of healthcare providers on the advantages and disadvantages of integrating HIV care services, including highly active antiretroviral therapy (HAART), into antenatal care (ANC) clinics in rural Kenya. We conducted a qualitative study using in-depth interviews and thematic analysis; 36 healthcare providers from six health centres in Nyanza Province, Kenya participated. Effects on service providers included increased workload due to the incorporation of specialised HIV services into ANC clinics. Providers observed that integration results in decreased patient time spent at the health facility, increased efficiency and closer provider-patient relationships; all leading to increased patient satisfaction. Providers also said that women would be more likely to receive HAART and adhere to their treatment as a result of improved confidentiality and decreased stigma. However, a minority of providers noted that integration could result in longer appointment times for HIV-positive women at ANC clinics leading to inadvertent disclosure. Integration could lead to strengthened ANC, postpartum care, prevention of mother-to-child transmission and HIV care for women and their families. However, integration efforts need to take into account potential negative effects on ANC provider workload, disclosure and the quality of care.

Improving universal precautions and client teaching for rural health workers: a peer-group intervention

Health workers can contribute to HIV prevention by minimizing HIV transmission in health facilities and increasing client teaching. We offered a peer-group intervention for Malawian rural health workers to build their universal precautions and teaching skills. A quasi-experimental design using independent sample surveys and observations compared health workers in an intervention and delayed intervention control district at baseline and at 15 and 30 months post-intervention. Controlling for demographic factors, the intervention district had more reported HIV teaching at 15 and 30 months and also had higher universal precautions knowledge and fewer needle stick injuries at 30 months. Observations at 15 and 30 months post-intervention showed higher levels of teaching in the intervention district. Observed glove wearing and hand washing were also higher at 30 months. This intervention should be made available for health workers in Malawi and provides a potential model for other high-HIV prevalence countries.

Peer group intervention reduces personal HIV risk for Malawian health workers

PURPOSE

To test a peer group intervention to address personal HIV prevention needs of rural health workers in Malawi.

DESIGN

Using a quasi-experimental design, we compared district health workers in two districts of Malawi that were randomly assigned to either the intervention or delayed control condition. We used independent sample surveys at baseline, 15 months, and 30 months postintervention. Intervention district workers received a peer group intervention after the baseline; control district workers received the delayed intervention after final data collection.

METHODS

The 10-session intervention for primary prevention of HIV infection was based on the primary healthcare model, behavioral change theory, and contextual tailoring based on formative evaluation. Differences in HIV-related knowledge, attitudes, self-efficacy, and behaviors were analyzed using t tests and multiple regression controlling for baseline differences.

FINDINGS

Health workers in the intervention district had higher general HIV knowledge, more positive attitudes about condoms, higher self-efficacy for safer sex, and more involvement in community HIV prevention at both the 15-month and 30-month postintervention survey. At 30 months, intervention district workers also reported less stigmatizing attitudes toward persons living with AIDS, more HIV tests, and lower risky sexual behaviors.

CONCLUSION

The intervention should be sustained in current sites and scaled up for health workers throughout Malawi as part of a multisectoral response to HIV prevention.

CLINICAL RELEVANCE

Incorporating a peer group intervention focused on personal as well as work-related HIV prevention can reduce health workers' risky behaviors in their personal lives, potentially reducing morbidity and mortality and enhancing workforce retention. Reducing stigmatizing attitudes may also improve the quality of health services.

Tracking and monitoring the health workforce: a new human resources information system (HRIS) in Uganda

BACKGROUND

Health workforce planning is important in ensuring that the recruitment, training and deployment of health workers are conducted in the most efficient way possible. However, in many developing countries, human resources for health data are limited, inconsistent, out-dated, or unavailable. Consequently, policy-makers are unable to use reliable data to make informed decisions about the health workforce. Computerized human resources information systems (HRIS) enable countries to collect, maintain, and analyze health workforce data.

METHODS

The purpose of this article is twofold. First, we describe Uganda's transition from a paper filing system to an electronic HRIS capable of providing information about country-specific health workforce questions. We examine the ongoing five-step HRIS strengthening process used to implement an HRIS that tracks health worker data at the Uganda Nurses and Midwives Council (UNMC). Secondly, we describe how HRIS data can be used to address workforce planning questions via an initial analysis of the UNMC training, licensure and registration records from 1970 through May 2009.

RESULTS

The data indicate that, for the 25 482 nurses and midwives who entered training before 2006, 72% graduated, 66% obtained a council registration, and 28% obtained a license to practice. Of the 17 405 nurses and midwives who obtained a council registration as of May 2009, 96% are of Ugandan nationality and just 3% received their training outside of the country. Thirteen per cent obtained a registration for more than one type of training. Most (34%) trainings with a council registration are for the enrolled nurse training, followed by enrolled midwife (25%), registered (more advanced) nurse (21%), registered midwife (11%), and more specialized trainings (9%).

CONCLUSION

The UNMC database is valuable in monitoring and reviewing information about nurses and midwives. However, information obtained from this system is also important in improving strategic planning for the greater health care system in Uganda. We hope that the use of a real-world example of HRIS strengthening provides guidance for the implementation of similar projects in other countries or contexts.

Performances of sexuality counselling: a framework for provider-client encounters

OBJECTIVE

Adequately assessing quality of care poses enormous challenges. While conducting fieldwork, we were struck by the need for a framework that encapsulates provider-client encounters. Little evidence exists concerning the most effective training, and management of health staff engaged in sexuality, reproductive health and HIV related health services. This paper proposes a framework for analysing these encounters.

METHODS

This paper is based on five studies. Mixed method studies were carried out in Uganda and Kenya. Two additional studies looked into the effect of HIV on health worker performance in Uganda and Zambia. As a result of the findings, a desk review looked into factors affecting provider-client encounters in order to improve the responsiveness of programs.

RESULTS

Positive encounters between provider and client are built on trust and respect, consist of communication, practice and process, and are influenced by space, place and context. Combining these facets allows for a better understanding of their interactions.

CONCLUSION

A holistic perspective in which the breadth of dynamics and processes are described should be used when assessing the quality of provider-client encounters.

PRACTICE IMPLICATIONS

Within training, management and human resource planning, these dynamics need to be utilized to realize the best possible care.

Experiences of stigma in healthcare settings among adults living with HIV in the Islamic Republic of Iran

Background

People living with HIV (PLHIV) sometimes experience discrimination. There is little understanding of the causes, forms and consequences of this stigma in Islamic countries. This qualitative study explored perceptions and experiences of PLHIV regarding both the quality of healthcare and the attitudes and behaviours of their healthcare providers in the Islamic Republic of Iran.

Methods

In-depth, semi-structured interviews were held with a purposively selected group of 69 PLHIV recruited from two HIV care clinics in Tehran. Data were analyzed using the content analysis approach.

Results and discussion

Nearly all participants reported experiencing stigma and discrimination by their healthcare providers in a variety of contexts. Participants perceived that their healthcare providers' fear of being infected with HIV, coupled with religious and negative value-based assumptions about PLHIV, led to high levels of stigma. Participants mentioned at least four major forms of stigma: (1) refusal of care; (2) sub-optimal care; (3) excessive precautions and physical distancing; and (4) humiliation and blaming. The participants' healthcare-seeking behavioural reactions to perceived stigma and discrimination included avoiding or delaying seeking care, not disclosing HIV status when seeking healthcare, and using spiritual healing. In addition, emotional responses to perceived acts of stigma included feeling undeserving of care, diminished motivation to stay healthy, feeling angry and vengeful, and experiencing emotional stress.

Conclusions

While previous studies demonstrate that most Iranian healthcare providers report fairly positive attitudes towards PLHIV, our participants' experiences tell a different story. Therefore, it is imperative to engage both healthcare providers and PLHIV in designing interventions targeting stigma in healthcare settings. Additionally, specialized training programmes in universal precautions for health providers will lead to stigma reduction. National policies to strengthen medical training and to provide funding for stigma-reduction programming are strongly recommended. Investigating Islamic literature and instruction, as well as requesting official public statements from religious leaders regarding stigma and discrimination in healthcare settings, should be used in educational intervention programmes targeting healthcare providers. Finally, further studies are needed to investigate the role of the physician and religion in the local context.

"Just like fever": a qualitative study on the impact of antiretroviral provision on the normalisation of HIV in rural Tanzania and its implications for prevention

BACKGROUND

Once effective therapy for a previously untreatable condition is made available, a normalisation of the disease often occurs. As part of a broader initiative to monitor the implementation of the national antiretroviral therapy (ART) programme, this qualitative study investigated the impact of ART availability on perceptions of HIV in a rural ward of North Tanzania and its implications for prevention.

METHODS

A mix of qualitative methods was used including semi-structured interviews with 53 ART clinic clients and service providers. Four group activities were conducted with persons living with HIV. Data were analyzed using the qualitative software package NVIVO-7.

RESULTS

People on ART often reported feeling increasingly comfortable with their status reflecting a certain "normalization" of the disease. This was attributed to seeing other people affected by HIV, regaining physical health, returning to productive activities and receiving emotional support from health service providers. Overcoming internalized feelings of shame facilitated disclosure of HIV status, helped to sustain treatment, and stimulated VCT uptake. However "blaming" stigma - where people living with HIV were considered responsible for acquiring a "moral disease" - persisted in the community and anticipating it was a key barrier to disclosure and VCT uptake. Attributing HIV symptoms to witchcraft seemed an effective mechanism to transfer "blame" from the family unit to an external force but could lead to treatment interruption.

CONCLUSION

As long as an HIV diagnosis continues to have moral connotations, a de-stigmatisation of HIV paralleling that occurring with diseases like cancer is unlikely to occur. Maximizing synergies between HIV treatment and prevention requires an enabling environment for HIV status disclosure, treatment continuation, and safer sexual behaviours. Local leaders should be informed and sensitised and communities mobilised to address the blame-dimension of HIV stigma.

Impact of a peer-group intervention on occupation-related behaviors for urban hospital workers in Malawi

Using a pre- and posttest design with no control group, the authors evaluated the impact of a peer-group intervention on work related knowledge and behavior for health workers at an urban hospital in Malawi. The authors surveyed unmatched random samples of health workers, observed workers on the job, and interviewed clients about hospital services at baseline and at 6 months after the intervention. Universal precautions knowledge, reported hand washing, and reported client teaching were significantly higher at the final evaluation. The outcome differences remained robust in multivariate analyses with controls for demographic factors of age, gender, education, food security, and job category. Observations reported consistently greater use of universal precautions, more respectful interactions, and more client teaching at final evaluation. Patient surveys reported more discussion with health workers about HIV at the final evaluation. Peer-group interventions can prepare health workers in Malawi for HIV prevention and offer a potential model for other African countries.

Impacts of a peer-group intervention on HIV-related knowledge, attitudes, and personal behaviors for urban hospital workers in Malawi

This report describes the effects of a peer-group intervention on Malawian urban hospital workers' HIV-related personal knowledge, attitudes, and behaviors. More than 850 clinical and nonclinical hospital workers received the intervention. Evaluation used independent surveys of a sample of workers at baseline (N = 366) and postintervention (N = 561). Compared with the baseline survey, after the intervention, workers had higher knowledge of HIV transmission and prevention; more positive attitudes including more hope, less stigmatization of persons with HIV, more positive attitudes toward HIV testing and condom use, and higher self-efficacy for practicing safer sex and for community prevention; more reported recent personal HIV tests, more discussion of safer sex with partners, and more reported community HIV prevention activities. However, health workers' risky sexual behaviors did not differ at baseline and postintervention. The intervention should be strengthened to support more sexual risk reduction and be made available to all health workers in Malawi.

Effects of HIV/AIDS on maternity care providers in Kenya

OBJECTIVE

To explore the impact of HIV/AIDS on maternity care providers in labor and delivery in a high HIV-prevalence setting in sub-Saharan Africa.

DESIGN

Qualitative one-on-one in-depth interviews with maternity care providers.

SETTING

Four health facilities providing labor and delivery services (2 public hospitals, a public health center, and a small private maternity hospital) in Kisumu, Nyanza Province, Kenya.

PARTICIPANTS

Eighteen maternity care providers, including 14 nurse/midwives, 2 physician assistants, and 2 physicians (ob/gyn specialists).

RESULTS

The HIV/AIDS epidemic has had numerous adverse effects and a few positive effects on maternity care providers in this setting. Adverse effects include reductions in the number of health care providers, increased workload, burnout, reduced availability of services in small health facilities when workers are absent due to attending HIV/AIDS training programs, difficulties with confidentiality and unwanted disclosure, and maternity care providers' fears of becoming HIV infected and the resulting stigma and discrimination. Positive effects include improved infection control procedures on maternity wards and enhanced maternity care provider knowledge and skills.

CONCLUSION

A multifaceted package including policy, infrastructure, and training interventions is needed to support maternity care providers in these settings and ensure that they are able to perform their critical roles in maternal healthcare and prevention of HIV/AIDS transmission.

Patient satisfaction with antiretroviral services at primary health-care facilities in the Free State, South Africa--a two-year study using four waves of cross-sectional data

Background

The study's first objective was to determine the levels of patient satisfaction with services at antiretroviral treatment (ART) assessment sites. Differences in patient satisfaction with several aspects of service over time and among health districts were measured. The second objective was to examine the association between human resource shortages and levels of patient satisfaction with services.

Methods

Four cross-sectional waves of data were collected from a random sample of 975 patients enrolled in the Free State's public-sector ART programme. One-way analysis of variance (ANOVA) with the Bonferroni adjustment for multiple comparisons was used to assess the differences in patient satisfaction among the Province's five districts and among the four waves of data. Correlation coefficient analysis using Pearson's r was used to assess the association between ART nurse vacancy rates and patient satisfaction with the services provided by nurses over time.

Results

With respect to both general services and the services provided by nurses, our results indicate high overall satisfaction among Free State patients receiving public-sector ART. However, our data present a less positive picture of patient satisfaction with waiting times. Patients in Fezile Dabi District were generally slightly dissatisfied with the waiting times at their assessment sites. In fact, waiting times at assessment sites were the most important predictor of discontent among ART patients. Significant geographical (P < 0.001) and temporal differences (P < 0.005) were observed in these three aspects of patient satisfaction. Patients were most satisfied in Thabo Mofutsanyana District and least satisfied in Motheo District. Patients in Fezile Dabi District were generally slightly dissatisfied with the waiting times at their assessment sites. Finally, our analysis revealed a strong negative association (r = -0.438, P < 0.001) between nurse vacancy rates and mean satisfaction levels with services performed by nurses at baseline. Patients attending facilities with high professional nurse vacancy rates reported significantly less satisfaction with nurses' services than did those attending facilities with fewer vacant nursing posts.

Conclusion

Collectively, our findings show high levels of patient satisfaction with ART-related services, but also confirm claims by other studies, which have identified human resource shortages as the most important obstacle to a successful South African AIDS strategy.