Health providers’ perceptions and experiences of … providers’ perceptions and experiences of...

Health providers’ perceptions and Health providers’ perceptions and experiences of integration in Kenya and Swaziland

Partners' Meeting, 7 Feb 2012, Nairobi

Qualitative Study with Providers

• The study was part of ongoing qualitative work in Integra

• Targeted frontline providers involved in actual provision of health

services, as well as supervisors

With overall purpose to:

• Develop in-depth understanding of provider ongoing experience

with providing integrated HIV/AIDS and reproductive health

services, specifically:

– Pre-intervention expectations regarding integration of HIV and SRH services

– On-going experience with providing integrated services

• Interpret findings from Integra’s quantitative findings on the

efficiency, quality and effectiveness of integrated services.

Qualitative Study with Providers

Which experiences were investigated?

1. Personal level

o e.g., direct benefits or challenges to the individual, and their

personal aspirations

o Is integration considered a threat or an opportunity?o Is integration considered a threat or an opportunity?

2. Operational level

o e.g., systematic improvements or challenges that accompany

an integrated health service

o Effects of integration on efficiency, workload, supervision and

support, emotional strains, satisfaction, monitoring tools.

Methods• Indepth interviews using semi-structured

interview guide

• Opportunistic sampling: interviewed providers

on duty on the days of fieldwork, who

volunteered to participatevolunteered to participate

• Semi-structured in-depth interviews (IDIs)

conducted in intervention facilities, in English

and transcribed verbatim

• Qualitative thematic analysis in Nvivo 8

Providers & Facilities Providers & Facilities Providers & Facilities Providers & Facilities

KENYA: June – July 2010

• Eastern Province: Kitui district (14 providers)

• Central Province: Thika & Nyeri (18 providers)

• For total of 32 interviews

• (21 analysed thus far)• (21 analysed thus far)

Sample characteristics:

• 26 female and 6 male

• 16 registered nurses, 13 enrolled nurses, 3 clinical officers

• Median of 2.5 years (0.5 – 28 yrs) served at the facility

Providers & Facilities Providers & Facilities Providers & Facilities Providers & Facilities

SWAZILAND: Oct - Nov 2010

• Facilities: RFM, Mankayane,

King Sobhuza II, & Mbabane

PHU, for total of 24interviews.

FacilityFacilityFacilityFacility Number of Number of Number of Number of providers providers providers providers InterviewedInterviewedInterviewedInterviewed

RFM 6

Mankayane 5interviews.

• All interviewed providers were

nurses by profession – different

categories

• At each facility, one provider at

supervisor level was

interviewed at each facility

Mankayane 5

KSII 6

Mbabane PHU 7

TotalTotalTotalTotal 24242424

Preliminary findings reported on:

1. Pre-intervention expectations

2. Ongoing experience of integration:

2a. Major positive experiences

2b. Major challenges to effective implementation2b. Major challenges to effective implementation

NOTE: the rest of specific findings are not linked to particular facilities. For two main reasons:

- Not much difference in provider experience between facilities

- Primary aim of the study was to highlight issues, not to ‘assess

and diagnose’ individual facilities

1. Pre-intervention expectations• Workload will increase! Due to expected increase in:• Tasks per provider

• Clinical recording tasks

• Numbers of clients attending facilities“…we expected the workload to be a lot. Because (at the time)

HIV testing was being done in the lab. We found this job was for the lab people. Now we were being handed another job of (HIV) testing mothers. Also counselling.” (Registered Nurse, Hospital, Kitui, Kenya)Hospital, Kitui, Kenya)

• Doubts whether integration would actually work• Especially if the workload increases• Compounded by lack of understanding integration

• Uptake of RH services will increase. Quality of services will improve. Due to expected increase in:• Investments in health facilities

• Personal skills

At the Personal level

• Job satisfaction. Ability to provide multiple services in

one contact is very satisfying to the provider,

especially when this is to the satisfaction of the client

“…the improvement we’ve achieved in this facility makes me

happy...” (Swaziland participant)

“I think with integration, you are able to serve the client better

2a. Positive experiences with Integration

“I think with integration, you are able to serve the client better

and capture each and every detail of a patient (holistically). (The

client) will not go home with a certain problem unattended. That

is very satisfying.” (Enrolled nurse, Health Centre, Kitui, Kenya)

• New challenges and variety at work

“…where there is no integration there is that boredom because

of doing one thing and there is no change. In integration… it

boosts my morale because the monotony is not there.” (Enrolled

Nurse, Hospital, Nyeri, Kenya)

At the Personal level (cont’d)

• Enhanced skills. Allows some providers to practice

skills which they could not practice when they

provided un-integrated specialised services

“Being more competent than before and much more satisfied

with my job. Which I am now.” (Enrolled Nurse, Sub-District

Hospital, Thika, Kenya)


Hospital, Thika, Kenya)


At the Operational level

• Working relationships improved. e.g., Due to increased communication between providers as they work more closely together now“…you find that now we even call the [next] service provider {to

attend to the client] in the next room just to alert her not to miss that client who has just left [for example] my room and miss that client who has just left [for example] my room and she checks to see if [the client] is still in the queue.” (Swaziland participant)

“Nowadays we communicate… and that’s been really helpful I think. You don’t feel alone on the job. It never used to happen before.” (Enrolled Nurse, Health Centre, Kitui Kenya)


At the Operational level (cont’d)

• Has reduced client loss due to reduced client movement from provider to provider, and reduced time client spends at facility

“…integration reduces the time the client [spends] in the facility when they get all the services in the same room.” (Swaziland)

“Clients don’t have to queue 3 or 4 times in the same visit now. They are “Clients don’t have to queue 3 or 4 times in the same visit now. They are happy now. (Kenya)

• More clients coming back for repeat visits due to satisfaction

“…More clients are coming back… I think because, when you see a client in one room, and you’re able to give her the services she wanted, she’ll come back.” (Registered Nurse, Sub-District Hospital, Kitui, Kenya)

At the Operational level (cont’d)• Some providers said that integration has a positive impact on

client confidentiality

“[in un-integrated services], for instance, HIV+ clients have to disclose

their sero-status to more than one service provider and yet when

they’re attended to by one nurse for everything [in integrated

services] would’ve been fine or rather better for them.” (Swaziland)

“They started agreeing to be tested, because whenever they go inside,


“They started agreeing to be tested, because whenever they go inside,

nobody will know the services she is getting inside the room. Before

the services were not integrated, they feared.” (Kenya)

• Some providers reported that receiving most of services from

the same provider (repeatedly) also improves the interaction

& relationship between providers and clients

“When you interact with one service provider it builds a rapport

between client and provider and a bond develops” (Swaziland)

• Many clients openly expressed gratitude to health providers

for changing the format of service delivery.

At the Personal level

• Staff Incentives: most feel they are not adequately

compensated, especially for over-time and that

may be significantly affecting the quality of service

2b. Challenges to implementation

“You realise that the salary you are getting, although we say that nursing is a call, at times you may not even (meet) your needs.” (RN, Kenya)

“Let’s not talk about salary, they are peanuts. This is voluntary work we are doing!” (Clinical Officer, Kenya)

“I also need to be motivated as a service provider in order to provide a good quality service” (Swaziland)

At the Personal level (cont’d)

• Occupational Stress: staff are affected by clients in

distress due to HIV/AIDS or domestic violence“sometimes when the situation is worse I get emotional…and

sometimes it discourages you it’s like you’re not doing your

best (for that person)” (Swaziland)


• Expectations that were not met

– E.g., Anticipated investment in health facilities“I thought materials would be provided and not strain the service

provider, like Population Council gave us equipment, several boxes of

gloves, and that was last year and I thought the project would be an

ongoing thing and we will be getting these supplies and it would not

strain service delivery, but there is a strain.”

(Clinical Officer, Health Centre, Kitui, Kenya)

At the Personal level (Cont’d)

Providers described their ways of coping with the challenges and

stress:

� Discussion with colleagues

� Talk to partner after work

� Prayer


� Prayer

� Surrendering

� Choosing to move because can’t doing anything about the

stress

At the Operational level

• Increase in Workload: main causes:

– Staff shortage: integration might increase the number of clients per provider as clients get re-distributed among the same number of staff as used to serve before integration

– Inadequate physical space: for facilities with staff but unable to allocate workload because of lack of rooms


allocate workload because of lack of rooms

– Providing more services to each client

“[Workload] has gone up because in the past, I would provide that service [to a client] and refer her to the other department and yet now I have to provide everything to that client” (Swaziland)

– Amount of clinical reporting necessary

“It is a challenge because now you find you have so many registers, like now you... have a separate STI register, you have the FP register, you have the post-natal register, so it is a challenge (to make entries) in all those books for each client.” (RN, Kenya)

• Increase in Workload (cont.)– Again, some providers learnt to cope, e.g., by deriving psychological benefit from their work or accepting the situation as their professional responsibility.

“...For workload it is still there but we have learnt to cope with it. I myself have learnt to cope with it and when it comes to the (service)...I feel the client goes home satisfied...so me I go home


(service)...I feel the client goes home satisfied...so me I go home satisfied.” (Registered Nurse, Hospital Nyeri, Kenya)

“(Increase in workload) did happen, yah. There is a lot of work. Before I expected that, but now I’m okay with it.” (Enrolled Nurse, Health Centre, Kitui, Kenya)

At the Operational level (cont’d)

• Increase in Client Waiting Time: three main

causes:

– Perceived increase in client numbers per provider

– Increase in contact time with each client due to

multiple services provided per contact


multiple services provided per contact

– Fragmented M+E system: providers report a separate

register for each service, which take time to fill:

“I feel like paperwork is taking the patient’s time because...you have a lot to write with one client and the waiting period for other clients is prolonged”

“You find that many of us even forget to record sometimes” (Swaziland)

• Clearly, integration does affect the work environment around the

provider

• Generally, good understanding of integration among providers

interviewed

• Staff generally enthusiastic about integration but weighed down by

the challenges** courtesy bias

Further observations

the challenges** courtesy bias

• Almost every interviewee said availability of clinical supplies was

not a major concern

• For many providers, the challenges and disappointments (unmet

expectations) did not affect their commitment to their work.

• Without formal support mechanisms, providers found individual

coping strategies to deal with high stress and workloads and low

salaries.

Դ膀

Recommendations thus far...

• Need to address issues around workload: low staffing levels and

inadequate physical room space in facilities are important challenges

• Long waiting times are problematic but may be resolved by re organizaton

of care, provider incentives and strategies to enhance provider

performance, provision of adequate and effective tools

• Clinical information system needs re-alignment with integration: current

problems with recording means routine assessment of performance of

integration cannot be reliably conducted

• There is also need to look into the problem of occupational stress.

Formalising regular debriefing sessions in the workplace may provide a

start.

��

More detailed analysis to follow...

• Analysis of integration experience by: facility level, cadre,

region/province, district, Integra intervention (mentee/mentor)

• Also where more than one staff interviewed at a facility,

triangulate and check consistency in experience – investigate if any

variations in experience exist

• Long-term: link findings to those in other Integra project data streams e.g. Cohort, health facility assessments, economics

• Inclusion of these issues in future data collection rounds for

measurement

鴐�

Asante Sana!

Siyabonga !Siyabonga !

Thank you!

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