Previous qualitative studies about antiretroviral therapy (ART) adherence have largely focused on patient experiences. Less is known about the perspective of health care providers -particularly in low-income countries -who serve as gatekeepers and influencers of patients' HIV care experiences. This study explored patients' and providers' perceptions of important ART adherence determinants. Interviews were conducted at HIV treatment sites in Tanzania and Uganda, with adult patients on ART (n=148), and with health care providers (n=49). Patients were asked about their experiences with ART adherence, and providers were asked about their perceptions of what adherence challenges are faced by their patients. All interviews were conducted in local languages; transcripts were translated into English and analyzed using a codebook informed by the social ecological model. Themes were examined across and within countries. Adherence-related challenges were frequently reported, but patients and providers did not often agree about the reasons. Many patients cited challenges related to being away from home and therefore away from their pill supply; and, in Uganda, challenges picking up refills (access to care) and related to food sufficiency/diet. Providers also identified these access to care barriers, but otherwise focused on different key determinants (for example, they rarely mentioned food/diet); instead, providers were more likely to mention alcohol/alcoholism, stigma, and lack of understanding about the importance of adhering. These findings suggest areas of opportunity for future research and for improving clinical care by aligning perceptions of adherence challenges, to deliver better-informed and useful ART counseling and support.
Background: In urban Kenya, couples face a wide variety of choices for delivery options; however, many women end up delivering in different facilities from those they had intended while pregnant. One potential consequence of this is delivering in facilities that do not meet minimum quality standards and lack the capacity to provide treatment for obstetric and neonatal complications. Methods: This study investigated why women in peri-urban Nairobi, Kenya deliver in facilities they had not intended to use. We used 60 in-depth audio-recorded interviews in which mothers shared their experiences 2-6 months after delivery. Descriptive statistics were used to summarize socio-demographic characteristics of participants. Qualitative data were analyzed in three steps i) exploration and generation of initial codes; ii) searching for themes by gathering coded data that addressed specific themes; and iii) defining and naming identified themes. Verbatim excerpts from participants were provided to illustrate study findings. The Health Belief Model was used to shed light on individual-level drivers of delivery location choice. Results: Findings show a confluence of factors that predispose mothers to delivering in unintended facilities. At the individual level, precipitate labor, financial limitations, onset of pain, complications, changes in birth plans, undisclosed birth plans, travel during pregnancy, fear of health facility providers, misconception of onset of labor, wrong estimate of delivery date, and onset of labor at night, contributed to delivery at unplanned locations. On the supply side, the sudden referral to other facilities, poor services, wrong projection of delivery date, and long distance to chosen delivery facility, were factors in changes in delivery location. Lack of transport discouraged delivery at a chosen health facility. Social influences included others' perspectives on delivery location and lack of aides/escorts. Conclusions: Results from this study suggest that manifold factors contribute to the occurrence of women delivering in facilities that they had not intended during pregnancy. Future studies should consider whether these changes in delivery location late in pregnancy contribute to late facility arrival and the use of lower quality facilities. Deliberate counseling during antenatal care regarding birth plans is likely to encourage timely arrival at facilities consistent with women's preferences.
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