Table 3 Barriers and promoters to delivering prevention of vertical transmission of HIV (PVT) services according to the ecological motivation-opportunity-ability (MOA) framework
Barrier (−), promoter (+) | Construct | Manifestation | Maternal and child health nurses, with other health facility workers from focus group discussions (FGDs) | Activistas | Community health workers (CHWs) | Traditional birth attendants (TBAs) |
|---|---|---|---|---|---|---|
Motivation | ||||||
Health worker factors | ||||||
Intrinsic motivation | ||||||
+ | Highly intrinsically motivated | “…when I help the community. It is what my heart wants” (F Nurse, 7 years) | “in the community there are no longer many people left living with HIV and without treatment…I feel happy that I attended to and helped [these] people” (M activista, 4 years) | “I help the people and my family as well. When health problems arise in my house I can resolve the problems more easily” (M CHW, 20 years) | “I never worked because I wanted money. I first worked because I wanted to help the community and then because I wanted to learn” (TBA, 12 years) | |
− | Dissatisfied when unable to help patients | “I do not like when difficult situations arise that I cannot solve….There was a case of a woman who had complications in birth. We tried to help but could not. The woman ended up dying” (F nurse, 3 years) | “A negative experience that struck me was a woman who refused to go to hospital and when her son died three weeks after birth” (F activista, 4 years) | “After some time, the person left [treatment] and the disease worsened…I counseled and the person agreed to go to the hospital…but lost [his/her] life” (F CHW, 21 year) | Women “refuse” to go to the health facility for delivery, placing TBAs in a compromised position (TBA, 17 years) | |
Extrinsic motivation | ||||||
+ | Recognition from patients | “…when people appreciate my work. There was a case of a women that came up to me in [] and told me that I had saved her life. I did not even remember her” (F nurse, 3 years) | Good relationship with patients | “The people that I help always thank me and respect me” (M CHW, 2 years) | “The fact that I was chosen by the pregnant women to help already shows that the woman has trust in me. And I try to live up to this trust” (TBA, 9 years) | |
± | Recognition from community | “The people acknowledge us” (F nurse, 3 years) | “This patient insulted me, told me to leave, but I did not give up and ended up taking him to the hospital …he ended up dying. Today [at the funeral]…people said that I helped alot when the patient was sick” (M activista, 4 years) | “When the person died the family … said I …forced the person to go to the hospital, while the family wanted to take him to the healers” (F CHW, 21 year) | “I like to work because it gives me prestige in the community. I have recognition in my community. And people in my community trust me” (TBA, 33 years) | |
± | Recognition from other health worker cadres | - | Felt that their work linking patients to care was not valued by facility staff | Concerned that patient non-adherence reflects poorly on their work quality | “When a lot of time has passed between my presence at the health center, they miss me and ask where I have been” (TBA, 20 year) | |
± | Role identification | Data analyst and lay counselors did not have identification badges to signify their roles at health center (FGD participants) | Want T-shirts, hats, identification cards for work in the community | Had bright green vests | Not always recognized as a TBA when at health facility | |
− | Patient complaints | “People always criticize our actions. The people say that they are not attended to well. It is complicated when you always receive criticism” (F nurse, 7 years) | Poor reception in homes (activistas insulted), patient complains activista has not visited often enough | Sick adults questioned why CHW cannot dispense medication to adults (e.g., for malaria) | - | |
− | Dissatisfaction with remuneration | Salary was low for amount of time spent (including late evenings, weekends); “Wages always arrive late” (F nurse, 3 years) | Subsidy spent on transportation to visit patients and attend meetings, to fix bicycles: “When the 850MT arrives, we have a lot of debt” (F activista, 3 years) | Subsidy had been delayed several months but was paid at time of interviews | “A little financial help would be really good, because we work but we do not receive anything” (TBA, 12 years) | |
Opportunity | ||||||
Patient factors | ||||||
− | Patient behavior circumventing care | “[Retaining women in PVT care] is a big war, because some agree to take the [HIV] test, follow the treatment during their pregnancy, but after the birth…the mother prefers to follow-up for the child and the mother abandons the treatment [for herself]” (F nurse, 7 years) | HIV-infected patient gave wrong address to reception so activista will not be seen at their house | - | “Many women say that they have yet to be full term and then have the baby at home” (TBA 443) TBAs feel obligated when called to assist woman in home delivery, even though they know it is against policy | |
Work mandate factors | ||||||
− | Referral systems | Mothers were referred to type III facilities for ART without follow-up | Patients returned to care remain on referral list given to activistas, who sometimes received two different referrals for same patient | - | No formal referral system; concerned about breaking confidentiality if refer a mother for ANC before mother is ready for pregnancy to be public | |
− | Record systems | Paper records for PVT (digital only for patients on ART); multiple nurses have to share one book (PO); problematic implementation of mothers’ PVT codes (FGD) | Activista leader compiled 20 activista members' visits and services delivered by hand to generate reports | - | Newly implemented system: women reported facilitydelivery to her local TBA, who recorded information in a notebook and shared with community leader | |
Work environment | ||||||
± | Workload | “It is hard because we are few; when I am attending to a person and other people are complaining about the wait outside. We do the most we can, but it is a lot of things to do” (F nurse, 7 years) | Time spent was appropriate for volunteer position | Majority felt time spent was appropriate; however, sometimes patients came to their home which interrupted their household duties | - | |
− | Supplies | “We always have a lack of medicines” (F nurse, 3 years) | Lacked items for conducting home care (e.g., comb, bucket, soap, gloves) | Wanted gloves, scissors, medications for treating adults | Lacked materials to attend to “emergency” birth (e.g., gloves, mask, scissors, gown), flashlight for nighttime travel | |
− | Infrastructure | Lack of privacy (e.g., child consultations conducted in open air hallways, lack of screens for women in maternity ward), lack of electricity and locks | Lack of office space (for meetings and storage) and equipment (e.g., desk, computer) for report writing | - | - | |
− | Distance | - | “What is difficult are the long distances that run between the houses and [being] without any means of transport” (M activista, 4 years); had bicycles but many now broken and no funds for upkeep | Distance manageable with bicycles but sandy paths were challenging | “It is a long distance to arrive at the health facility….the homes are far away from each other” (TBA 448) | |
Administrative environment | ||||||
PVT service planning and coordination | ||||||
+ | Efforts to streamline care | Implementation of streamlined “one-stop” care and Option B+ (lifelong ART) | - | - | - | |
− | Processes create delays | Long waits for results for CD4 count (7 days), PCR (up to 6 months) due to analysis at regional and national hospitals; type II peripheral facility did not offer ART | - | - | - | |
− | Lack of incorporation into health system | Individual work linking patients to clinical care not recorded at health facility | - | “The women living with HIV, generally they go to the facility but when they…abandon care, I don’t know [about it]” (TBA, 12 years). TBAs’ interactions with health facilities and activities varied widely | ||
Donors | ||||||
− | Financial practices differ from local standards | HIV-specific facility-based staff supported directly by PEPFAR (e.g., data analyst) did not receive raise when others did | - | - | N/A | |
Ability | ||||||
Health worker factors | ||||||
Health worker approach to patient interactions | ||||||
+ | Sensitive to patients’ opportunity challenges | “We sensitize [newly diagnosed HIV-infected woman] that if she does not have the courage to talk wither her husband, we can help” (F nurse, 7 years) | Returned to counsel and care for patients even when verbally abused; encourage feeding complementary foods from farm | Report women experience food insecurity, cost of travel to health center | Discussing family planning: “They see the cost of living each day…if you have a lot of children everything is expensive and it isn’t easy to sustain many children…the women don’t manage to feed themselves regularly.” (TBA, 7 years) | |
− | Language barrier | One nurse did not know local language at her first posting | - | - | - | |
Knowledge | ||||||
± | Infant and young child feeding (IYCF) | Correct, updated IYCF messages | Mix of correct and incorrect IYCF messages for HIV-infected women | Correct IYCF messages for HIV-uninfected women | Incorrect, outdated IYCF messages for HIV-infected and HIV-uninfected mothers | |
Work environment | ||||||
± | Training | “It would be helpful for all colleagues to have the same capacity” (F nurse, 7 years); logistical challenges to training all nurses at once, potential for weariness | - | “There are cases of people who abandon [HIV] care, but I don’t know how to talk to them because I was not trained in this material” (Female CHW 476) | “I didn’t have any training. I worked as an assistant at a local health facility…I learned by observing the births that happened and I began to do them as well, in [nurses’] absence” (TBA, 7 years) | |
± | Supervision | Wanted more supervision to support skill building | Wanted more supervision and accompanying recognition | - | Did not report wanting more supervision | |
± | Collaboration with other cadres | “There are essential elements for good health in the community, we cannot leave anything out” (F nurse, 3 years). Nurses emphasized importance of TBAs to bring women for facility delivery | Sought to work directly with nurses and with neighbors who wield influence | Worked with TBAs, activistas, community leaders in person and via telephone “to harmonize messages” (Male CHW 479) | “It would be important to work with other actors, because that way I could learn from them and I can also teach what I know” (TBA 443) | |
± | Professional community | Interactions varied by facility leadership, facility-wide initiatives, and staff size | Met weekly for reporting; interacted in the field through supervisory visits or visiting patients in pairs | Met regularly or as-needed basis to coordinate activities, depending on community | Interacted at irregularly held trainings | |
− | Incorrect/inconsistent IYCF messages across health worker cadres who provide care for HIV-infected mothers | |||||