Sociodemographic characteristics of study participants
In this study, we enrolled 24 participants and 6 key informants. The mean age of the study participants is 38.2 years and the age ranged from 18 to 83 years. The majority (57%) of the participants were female (Table 1)
Table 1 Sociodemographic characteristics of the study participants
VARIABLES
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Description
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Number (%)
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Age Range 18-83 (mean age = 38.2)
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Female
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17 (57)
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Male
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13 (43)
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Education level
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No formal education
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12 (40)
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Primary
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7 (23)
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Secondary
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5 (17)
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Tertiary
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6 (20)
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From the in-depth interviews, we generated two broad themes to utilization of community drug distribution points: facilitators, and barriers. From the two broad themes, we generated three subthemes which are facility related, policy related and patients related barriers or facilitators to utilization of community drug distribution points.
Facilitators and barriers to utilization of CDDPs
The patients reported what motivated them to get enrolled on the CDDP model and even the health workers expressed what made them enrol more patients to the CDDP. The major facilitator reported by most patients was reduced transport cost to access HIV services. Most patients reported that it was so challenging for them to go the facility to get HIV services but since the CDDP was closer their homes, they became motivated and enrolled to the nearest CDDP. The most reported barriers were lack of infrastructure, stigma, lack of comprehensive services, and few visits.
Patient related facilitators and barriers
The patient related facilitators includes; patient’s satisfaction, patient’s preference, convenience and peer influence. The major patient related facilitator was patient’s satisfaction. And the major patient related barrier was stigma.
Patients’ satisfaction
We found that patients’ satisfaction with the services at the CDDP sites made them to continue getting services from the CDDPs. Most participants reported that they get enough drugs for HIV and other care like counselling. The counselling gave them comfort and hope to live. Some of them also said that the time and attention given to them to express themselves and the responses they get from the health workers are satisfactory to them. Some patients also expressed that they are going to live longer because of the services they are getting from the CDDPs. Even the health workers also reported that the patients have trust in them and like their services. As one patient said
“If maybe you feel dizzy after taking the medicine you tell him and he gives you his time and attention to you. so you fell really happy but from the time I came here there is no health worker that has ever treated me badly because if I ask you something that I hadn’t understand and you explain it well for me, I appreciate” participant14
Patients’ preference
We also found that patients’ preference is a facilitator to utilization of community drug distribution points among adult HIV patients. Some of them reported that they prefer going to the CDDP to other places where they also offer HIV services because it is convenience for them. Some patients also reported refusing to be transferred from their CDDP to a facility or other CDDP and preferred to remain to their CDDP because the services are good. Some patients also said that there is no reason for leaving the CDDP or being transferred back to the facility since they are being treated well. Even the health workers reported that patients always refused to be referred to the facility. Health workers noted that patients had developed trust in them and do not want them to leave. Some patients were also reported to go for HIV services at CDDP even if they stay near to a facility offering the same service. One patient said
“I have accessed the same services in different other places but I have never been interested like I did for this place. No way, I will have to stick on services here forever as longer as this program is still here serving us.” participant04.
Peer influence
We also found numerous patients who expressed peer influence as what has motivated them to get enrolled to the CDDP. Some patient reported that they were convinced by their friends to go and enrol to the CDDP. Some also said it was their friends who encouraged them to get tested from a CDDP and after testing positive, they got enrolled on CDDP. The patients also expressed that they normally tell their colleagues in the village to come for refill from the CDDP. Health workers also said that patients normally go and tell their friends in the community about the services at the CDDP and that is why they are many who they have enrolled on CDDP. Patients also expressed that their colleagues sometimes collect the drugs on their behalf. We also found that the patients were put into groups of ten which enabled peer counselling. One health worker reported
“It is actually our clients that are attracting more people to come after telling them about the good services and we also try to incorporate HIV testing so that we can also identify new patients.” Key informant03
Stigma
We found numerous patients who reported that stigma exist among some patient who do not want to disclose their status. Participants expressed that this stigma discouraged some patients from getting enrolled to the CDDP. Patients also expressed that whenever they are seen coming from the CDDP, they are associated to HIV positive people. Both health workers and the participants reported that there are some patients who do not want to disclose their sero-status and are always stigmatized when they come to the CDDP. Some patients said that the people in the community talk a lot about them when they see them coming from the CDDP.
“Such people talk a lot when they see us but we do not care about them and it is not important. We our too exposed and there is no safety, confidentiality and privacy. We usually line outside in the open with too much sun and sometimes it rains on us, it is somehow discouraging and de motivating” participant01
Facility related facilitators and barriers
Health workers’ attitude
We found that the most facility related enabler to utilisation of CDDP reported by most patient was health workers’ attitude. They expressed that the health workers had positive attitude towards them and their work to serve the patients. Patients expressed that the health workers are good, friendly, kind and polite to them. Some patients reported that the health workers are like parents to them. Some said that the health workers do not use bad language on them. In addition, the health workers reported that even though the clients are many sometimes they always commit themselves to patients and are always determined to serve them.
“Health workers of the CDDP program are so good, friendly, faster and they really treat us very well despite the fact that some of us patients are not well behaved and we inconvenience health workers while doing their work.” participant02
Quality HIV services
We also found that the quality of services offered at CDDP sites facilitated patients to utilise the delivery model. Patients expressed that the services they get from the CDDP are of good quality, short waiting time, and always meet their expectations. Patients expressed that the way they are served, and serving process by the health workers are convenience. Patients reported that they are counselled, educated and guided on how to take their ARVs. The patients reported that they get a complete service from the CDDP and even the health workers reported that they always take the whole team to the CDDP. The team comprises of laboratory technicians, counsellors, medical doctors, and nurses. As one says
“HIV services that we access from here are very good and excellent, we get our HIV drugs every time that we come here and then we go back home without any problem.” participant01
Drug availability
Our findings also show that drug availability is a strong facilitator to utilisation of the CDDP because many participants reported they normally come and get dugs without fail when it is time for their visits. Patients noted/reported that HIV drugs are always available at CDDPs. Some said they have never missed drugs at any one visit. Patients also expressed that sometimes they have other illnesses and the drug are always given or if not available they are told to go and buy. Even the health workers said that if a patient has other illnesses, they are treated from the site if the drugs are available or they go and buy. One of patient reported like this
“HIV drugs are always available and enough, when we come, we cannot miss getting HIV drugs at any one point. Personally from the time I started with this program, I have never failed to access my HIV drugs.” Participant 02
Reduced transport expenses
We also found that another facilitators to utilization of the CDDPs that numerous patients reported was reduced transport expenses. Reduced transport expense was expressed by most patient as what has motivated them to use the CDDP because they are poor. Patients reported that the services is now near them and they do not have to spend on transport again or they spend very little on transport. The health workers also said patients used to miss visits at the facility due to distance of the facility from their homes. One patient reported like this
“People are poor meaning they could not afford the high transport costs that were involved, a lot of people in this community are poor and they even cannot afford to support themselves in terms of financial stability.” participant03.
Lack infrastructure
We found that lack of infrastructure was expressed as a major barrier facility related barrier and the overall major barrier by both the patient and the health workers. Due to lack of shelter, patients reported that they are exposed to some other people who are not patients, there is no privacy and bad weather sometime interfere with service delivery at the CDDP sites. Health workers also reported that they usually operate from an open place in the community. Most patients suggested that they should be provided with a structure at the CDDP.
“I wish God would rewards us and gets us a place of our own with a better shelter, which would be very excellent. The biggest challenge here is that we do not have a shelter, we are so many and exposed to passer-by near the road, and we need some kind of privacy, safety and confidentiality.” Participant 04
Overcrowding and fear of stigma
We found that overcrowding was also reported by the patients and health worker as barrier to utilization of the model. Participants expressed that they are always many at the site and that means you are seen by very people whom you may not like to know your status. One patients reported that they could be over 200 per visit. The health workers expressed that they spend the whole day at some sites working on the patients. One health worker reported that they serve between 60 and 80 patients on average yet the policy recommends between 30 and 45 patients per community drug distribution points.
“Sometime we get over crowded, line of patient gets so long and even the health workers get tired. Participant 14”
Lack of comprehensive services
We also found out that lack of comprehensive services at the community drug distribution points was reported by both patients and health care workers as a barrier. Some patients reported they want other services like TB screening and treatment for other conditions to be brought at the community. Patients reported that they are always prescribed medicines to go buy whenever they have other symptoms and signs. Health workers also reported that they are unable to take a comprehensive service to the community because resources in term of staff, finances, and transport means are limited. Health workers expressed that all the cost of implementing the CDDP is on the facility which need big funding. As one said
“Yeah... there are costs in delivering the CDDP model like transport, then also is fuel and facilitation of staff. We cannot have other services at site because we lack enough staff so we advise them to come to the facility where different services are offered.”Key informant02
Policy related facilitators and barriers
Policies from central government, ministry of health, local government, facility level policies or even cultural and societal policies can affect delivery of health care positively or negatively. The most reported positive policies were long contact hour with health workers, follow up, and free HIV services.
Long contact hour with health worker
We found that patients had long contact hour with the health workers. This time a patient had with the health worker was used to take history from the patient, counselling and answer patient’s questions. The patient reported that the health workers give them opportunity to ask them and give them their time to listen to them. Health workers also expressed that they take their time to review patients’ files and listen to each and every patient because they are few per visits.
“But when you are with the client, this client comes in, you have to review the file and do everything and find that the time you take on one client is much key” informant 01
Free HIV and other medical services
We also found that the HIV services as well as other medical services were given free of charge to the patients which has enabled them to get enrolled to the CDDP. Most patient reported that the free services that get they from the CDDP has encouraged them to go there and get treated. Participants expressed that the health workers use their own money to buy fuel and bring them the drugs to their villages. Health workers expressed that they are given vehicles and incentives when they are going to a CDDP point. This is evidenced by
“I used to see health workers every month coming to this place without fail, giving drugs to patients free of charge, they did not have to spend any money or go through a lot of troubles, I also got motivated and decided to join, ever since I enrolled.” Participant03
Follow up
We found that follow up was a facilitator to utilization of community drugs distribution points among the patient in Bushenyi district. The health workers reported that they usually do follow up of lost to follow up patients or even patients who have missed to come for a visit by either making a phone call or driving to the patient’s home. Many patients reported that they have been visited at home or being called on phone by the health workers. Patients are groups in a group of ten with a leader who link them to the health workers. Follow up is also done through assistant counsellor who is also a patient living in that village. This is evidenced by one health worker reporting
“Health workers would therefore take the initiative to drive and locate such people wherever there are, give them the required services and come back.” Participant04.
Few visits
We found that there is only one visit per month at a given CDDP site. And some participants reported few visits as a barrier to utilisation of the model. The client might want to see the health workers but you find that the policy guidelines require the facility to go out for out reaches only ones or twice in a month to a particular CDDP site. One patient reported that they need more than one visit in a month. The health workers reported that they go either on the first or the last Friday of the month. This makes the clients to wait with their health challenges until the stipulated date of the out reaches.
“But if they can also increase on the number of visits the make every month from one to two or three, it will make it easier and more comfortable.” participant04