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)
2a. Positive experiences with Integration
Hospital, Thika, Kenya)
2a. Positive experiences with Integration
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)
2a. Positive experiences with Integration
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,
2a. Positive experiences with Integration
“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)
2b. Challenges to implementation
• 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
2b. Challenges to implementation
� 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
2b. Challenges to implementation
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
2b. Challenges to implementation
(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
2b. Challenges to implementation
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.
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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