Peer counselors' role in supporting patients' adherence to ART in Ethiopia and Uganda.

Our aim was to explore peer counselors' work and their role in supporting patients' adherence to antiretroviral treatment (ART) in resource-limited settings in Ethiopia and Uganda. Qualitative semi-structured interviews were conducted with 79 patients, 17 peer counselors, and 22 providers in ART facilities in urban and rural areas of Ethiopia and Uganda. Two main categories with related subcategories emerged from the analysis. The first main category, peer counselors as facilitators of adherence, describes how peer counselors played an important role by acting as role models, raising awareness, and being visible in the community. They were also recognized for being close to the patients while acting as a bridge to the health system. They provided patients with an opportunity to individually talk to someone who was also living with HIV, who had a positive and life-affirming attitude about their situation, and were willing to share personal stories of hope when educating and counseling their patients. The second main category, benefits and challenges of peer counseling, deals with how peer counselors found reward in helping others while at the same time acknowledging their limitations and need of support and remuneration. Their role and function were not clearly defined within the health system and they received negligible financial and organizational support. While peer counseling is acknowledged as an essential vehicle for treatment success in ART support in sub-Saharan Africa, a formal recognition and regulation of their role should be defined. The issue of strategies for disclosure to support adherence, while avoiding or reducing stigma, also requires specific attention. We argue that the development and implementation of support to peer counselors are crucial in existing and future ART programs, but more research is needed to further explore factors that are important to sustain and strengthen the work of peer counselors.

Immigrants and health system challenges to TB control in Oman.

BACKGROUND: During the past three decades, Oman has made significant progress in controlling TB within it's borders. However, the national TB control program elimination target has yet to be reached. This study aims to explore the perceived roles played by the immigrant population and the private health sector in relation to TB control in Oman. METHODS: We conducted seventeen interviews with different health care providers. The verbatim transcripts were processed using content analysis. RESULTS: Three main themes emerged. Firstly the threat of repatriation faced by underprivileged expatriates, secondly the criticized and forgotten private health sector as a key player and thirdly the user and provider barriers faced by Omani patients in the Omani public health system. CONCLUSIONS: The study has identified some of the challenges and barriers to TB control in Oman. These challenges are mainly related to unintended negative consequences arising from the current repatriation policy of immigrants and to and the lack of involvement of the private sector in TB control. TB control strategies designed to address these challenges are needed, for Oman to reach its TB elimination targets.

Voices on adherence to ART in Ethiopia and Uganda: a matter of choice or simply not an option?

This paper explores HIV patients' adherence to antiretroviral treatment (ART) in resource-limited contexts in Uganda and Ethiopia, where ART is provided free of charge. Qualitative semi-structured interviews were conducted with 79 patients, 17 peer counselors, and 22 providers in ART facilities in urban and rural areas of Ethiopia and Uganda. Interviewees voiced their experiences of, and views on ART adherence both from an individual and a system level perspective. Two main themes emerged from the content analysis: "Patients' competing costs and systems' resource constraints" and "Patients' trust in ART and quality of the patient-provider encounters." The first theme refers to how patients' adherence was challenged by difficulties in supporting themselves and their families, paying for transportation, for drug refill and follow-up as well as paying for registration fees, opportunistic infection treatment, and expensive referrals to other hospitals. The second theme describes factors that influenced patients' capacity to adhere: personal responsibility in treatment, trust in the effects of antiretroviral drugs, and trust in the quality of counseling. To grant patients a fair choice to successfully adhere to ART, transport costs to ART facilities need to be reduced. This implies providing patients with drugs for longer periods of time and arranging for better laboratory services, thus not necessitating frequent revisits. Services ought to be brought closer to patients and peripheral, community-based healthworkers used for drug distribution. There is a need for training providers and peer counselors, in communication skills and adherence counseling.

Conflicting accountabilities: Doctor's dilemma in TB control in rural India.

OBJECTIVE: The aim of this study was to analyse how the implementation strategy of direct observed treatment short course (DOTS) has shaped and influenced patient-provider encounters in a district tuberculosis centre (DTC) in a rural district of India. METHOD: Qualitative methods, combining observations and interviews, were carried out in a DTC focusing on the medical encounters between a TB doctor and his patients. RESULTS: The findings showed that the TB doctor seemed to be working with a dilemma, defined as conflicting accountabilities, in the medical encounters. In an organization perceived as inefficient and resource-constrained, the doctor struggled to find a balance between meeting the obligations of the DOTS programme and meeting the needs and expectations of the patients. Strategies to deal with these conflicting accountabilities were identified as limiting patients' involvement, struggling to maintain authority, and transferring responsibility. CONCLUSION: Professional involvement and patient participation were seen as part of a linked process in this study, and the importance of empowering doctors and health care workers who are implementing DOTS is emphasized. The development of DOTS guidelines needs to be based on the actual process of health care delivery, and staff empowering efforts should also include strengthening of public health care infrastructure.

Power imbalance and consumerism in the doctor-patient relationship: health care providers' experiences of patient encounters in a rural district in India.

The aim of this study is to explore health care providers' experiences and perceptions of their encounters with male and female patients in a rural district in India with special reference to tuberculosis (TB) care. The authors conducted semistructured interviews with 22 health care providers, 17 men and 5 women, from the public and private health care sectors. Findings reveal that doctors adopted an authoritarian as well as a consumerist approach in the medical encounter, indicating that power imbalances in the doctor-patient relationship are negotiable and subject to change. Gender was identified as an influencing factor of the doctor's dominance. A patient-centered approach, acknowledging patients' own experiences and shared decision making, is called for and should be included in TB control activities. This seems to be especially important for female patients, whose voices were not heard in the medical encounter.

Reasons for leaving nursing care and improvements needed for considering a return: a study among Swedish nursing personnel.

Based on two research projects in Sweden during the 1990s, the aim of this study was to identify former nursing personnel's main reasons for leaving nursing care, and to find out under what circumstances they would consider returning. Two open-ended questions in a questionnaire were analysed. The results showed that different aspects of working conditions, mainly working schedule, management and status of profession were the dominating reasons both for leaving and considering a return. The findings indicate that interventions required for retaining personnel in nursing care need to be addressed both at the political and at the local level.

Factors contributing to the decision to leave nursing care: a study among Swedish nursing personnel.

BACKGROUND: An ageing nursing workforce raises questions of recruitment strategies and how to prevent nursing personnel from leaving their jobs. AIM: The aim of this study was to examine factors contributing to the decision to leave nursing care with special reference to work conditions related to nursing care. METHODS: This paper is based on data from a survey of nursing personnel who were employed at various county hospitals in Sweden from 1992 to 1995 (n = 1507). A self-administered questionnaire was used to identify those who had left nursing care voluntarily (n = 158) and to examine factors contributing to their decision to leave. RESULTS: Results showed that unsatisfactory salary contributed most to the nursing personnel's decision to leave, followed by lack of professional opportunities and restricted professional autonomy. CONCLUSION: The fact that nursing personnel leave because of unsatisfactory salary and lack of professional opportunities underpins the importance of making nursing more attractive in terms of financial and professional development. However, the sample size of this study was relatively small and larger studies are thus required to further investigate the importance of these factors in the decision to leave nursing care.