ACCEPTABILITY OF THE BSC INTERVENTION
Provider attitudes towards the BSC Intervention
Health care providers consider the BSC intervention to be a potentially effective tool that can contribute to the orientation and counseling of clients, especially with adolescents in search of a space where they can get answers about their sexuality and SRH without fear of being judged. Additionally, it would be a very useful tool to face the current landscape in sexual and reproductive health in the country.
“It would be excellent because it is always important to handle this situation with young people who are quite disoriented; apart from the fact that they lack privacy, they have nobody to approach for help; they are afraid to ask parents, who also feel insecure to talk to them about these issues. So, who better than health professionals to offer them the confidence they need and help them with these issues? And to prevent pregnancy among adolescents, (a problem) that never ceases to grow”. (Interview 6, Female)
As a manner of self-criticism, providers manifest that despite having previously worked with different person-centered behavioral change techniques, they have not seen significant changes in the incidence of HIV and STI cases. Therefore, providers feel the urgent need to work with new strategies and techniques aimed at behavior change that are effective in the prevention of HIV and STIs.
“Of course, because by focusing on the person we can change behaviors; because so many strategies have been implemented, so many activities to prevent STIs and HIV… and the statistics continue to show new cases, then something happens and we can’t change anything fundamental, because the most difficult thing in someone is to achieve behavioral change”. (Interview 5, Female)
Perceived Utility of the BSC Intervention
Health care providers consider that it would be very useful to address directly with clients the possibility of improving their sexual and reproductive health care by using innovative strategies. Providers also consider that clients in general would greatly benefit from this intervention because they would perceive the empathy and interest from providers to help them solve their sexual health issues and improve their wellbeing.
“Yes, I think so, because they are going to feel that they care about you, and that you want to do something for him or her and that you really listen to them. People come here because they want to be heard”. (Interview 18, Male)
“Of course, because when you open it up, the client talks to you about other topics that are also suddenly generating anxiety at that moment and they are a little more liberated from suddenly believing that what they were thinking was something strange and not. Talking about sexuality is part of ourselves and we are also a consequence of our sexuality”. (Interview 3, Female)
In this way, health care providers consider that the BSC intervention will be of great help to deal more fully with risky situations. Furthermore, they state that the intervention addresses comprehensive care, including other personal and emotional aspects. This would reinforce prevention work at a deeper and more complex level.
“…It will help us greatly (to promote) changes in our patients’ sexual behaviors, which is what we also seek with our counseling, to change or help prevent risk behaviors more than anything, offering them the knowledge and helping them avoid risky behaviors”. (Interview 13, Female)
“It would be like doing prevention work in many aspects, because one thing they come here for is to rule out if they have any STIs. So, it would be to prevent with comprehensive information, because not only are we going to give them information about STIs, but we are also going to talk about the personal part, about controlling your drive, your emotions, and about your self-esteem, so that then they use protection and can take care. So that would be preventive, it seems very good to me”. (Interview 20, Female)
Concerns and doubts about BSC Intervention’s impact
However, health care providers stated that, depending on the capabilities of who delivers the intervention and how it is delivered, it will have a positive impact on the clients, helping them to recognize strengths and weaknesses and to generate concrete behavioral changes (to improve) their sexual health.
“I think it would be very useful, because depending on the counseling, they will apply it in their lives, and that will help them to know what strengths they have that they did not even know about, or that they had not even perceived they had. And weaknesses that they were not conscious about either”. (Interview 18, Male)
On the other hand, health providers expressed various doubts and concerns about the real impact the intervention can make to tackle sexual health issues. They comment on clients who re-engage in the same risk behaviors, stating that a single session of the intervention can’t be sufficient to generate significant behavioral change, because it is a long and constant process in which the health provider accompanies the client. In addition, providers manifest that clients’ final decisions regarding their sexual health issues are also influenced by their environment, which is not under the providers’ control.
“Well, it is assumed that, if we are going to take some time to work on a single topic, it is because we have to do it, and (that decision) will be effective to (ensure we) achieve something little by little, to make a change, because changes among people do not happen overnight, and because we can say one thing, but when we go home, father, mother and the whole environment may influence our decisions (to do otherwise)”. (Interview 14, Female)
“In the case of patients who have an STI, we also try to follow the same procedure a bit, but we must insist on why they had an STI, and what can happen if they continue with the same behaviors. Obviously what counseling is looking for is a change in behavior, but we know that it will not be achieved with counseling only or in a few months. Rather it is a whole process that takes some long time”. (Interview 15, Female)
PERCEIVED WILLINGNESS TO IMPLEMENT THE BSC INTERVENTION
Willingness to perform the BSC Intervention
Health care providers expressed their willingness to implement the BSC intervention by saying that it can benefit both clients and themselves as long as the methodology to be implemented meets the criteria of confidentiality, privacy and respect while being focused on the welfare of the client.
“… If the intervention continues to meet the criteria of confidentiality, privacy, then, (if) used by health staffing search of the same results, it will be beneficial for the health provider and the patient”. (Interview 15, Female)
Similarly, healthcare providers remain open to learning new methods and techniques that can help them address sexual health issues with their clients, and they are happy to receive this support from various health institutions.
“If there are changes for the good of the population, welcome. We are happy to support them, because now they are with the WHO, but the idea would be for the Ministry of Health to take it, and if they are also going to support us with some logistics, in good time. We should not say no to the changes that are coming”. (Interview 14, Female)
Willingness to participate in the training for the BSC Intervention
Likewise, health providers consider it necessary and essential that they are able to carefully review the BSC intervention in depth. Therefore, the training is crucial so that the team can learn, evaluate and adapt the strategy in depth. In addition, health providers report that it would be very useful for them to learn, as well as to reinforce the topic of social skills.
“Well, any project or program that you want to logically implement, you have to first receive the training to implement it. (Then you) present it as a group in a technical meeting, with the whole team, and I think the whole team would also agree. With anything to improve the consultation and patient care I think there would be no problem”. (Interview 13, Female)
“First is the issue of what the BSC intervention is (or consists of). Everything that corresponds to the technical part, strengthening the skills issue as well, in the search for information about the different populations that we deal with, it seems important to me, how to reach that client who is different”. (Interview 5, Female)
Necessary aspects to reinforce in the training of the BSC Intervention
For the training sessions, health providers suggest that concepts related to gender, gender identity, and other issues that allow them to address the specific needs of each of the client populations should be reinforced.
“There should be much more in itself, addressing gender issues, gender identity, so that we have much more to talk about when intervening the population, we manage”. (Interview 10, Female)
Similarly, they consider it vital to reinforce the strategies for approaching issues of sexual rights, the use of contraceptive methods, the resolution of partner conflicts and especially the issue of violence, since these are the cases they frequently deal with.
“Sexual rights, especially the issue of violence, the issue of sexual rights, the issue of the couple relationship, the issue of contraceptive methods”. (Interview 8, Female)
CONSIDERATIONS TO IMPLEMENT THE BSC INTERVENTION
Feasibility of the BSC Intervention
Health care providers stated that human and material resources as well as training of the team of health professionals are vital for intervention implementation. Taken together it will play a crucial role in the feasibility of the BSC intervention.
“Well, I believe that as long as there are human resources and the necessary materials to implement it and maintain it, then we will all be able to do it”. (Interview 13, Female)
In order to perform the intervention in the best possible way, the interactions between health care providers and clients must meet certain conditions by which the clients feel comfortable, safe and confident enough to address their sexual health issues. It will depend on the provider’s skills to apply the principles of the intervention and their capacity to reach clients with empathy, compassion and respect.
“It all depends on who speaks to them... rather, the people who are going to give this type of intervention must be suitable people, who have that freedom, who know how to gain empathy, who know how to reach the patient, who have those qualities”. (Interview 4, Female)
“Many times they shy away from telling you many things, or you do not give them confidence because of the tone of voice, or sometimes how you ask, because they may think that you are judging them”. (Interview 7, Female)
Conditions for the Sustainability of the BSC Intervention
Providers state that for the intervention to be sustainable, it is necessary to build communication networks between health services and those responsible for making decisions in health facilities. It is vital that a commitment is maintained by decision makers to guarantee the supply of necessary material conditions, as well as the availability of staff to carry out the intervention in health services.
“(We) try to get others involved… one of the things we do in this HIV and STI REFERENCE CENTER (CERITS), despite the fact that we do not have an assigned population, and that we are not a health network, is to share the information we have, all the time. We are personally committed to transfer to other health networks any training we receive”. (Interview 5, Female)
“That also depends on the head; it is a bit complicated… It depends on the Director, because sometimes a director comes up with a new idea, the other director says no, and many colleagues abide by that”. (Interview 9, Female)
Barriers and difficulties to implement the BSC Intervention
However, there are some structural barriers that represent difficulties in care, related to reduced spaces and inadequate infrastructure of the health facility, which hinder confidentiality; inflexible schedules, and staff shortages, which generate long waiting times for clients.
“We don’t have the ideal facility; in other words, space is a limitation ... another is the time we have to offer counseling”. (Interview 7, Female)
“Barriers include time - because patients do not have much time; and also a waiting list; logically that will cause discomfort. Another potential barrier is the rejection of patients, who suddenly do not want to receive the necessary guidance or who are in a hurry, basically that”. (Interview 13, Female)
Providers’ perceived self-efficacy to implement the BSC Intervention
Health providers state that, depending on their capabilities, it will take time for them to tailor the BSC intervention to their regular work, but stated that they are willing to learn the intervention to benefit their clients and address their sexual health issues in the best possible way.
“Maybe at the beginning yes, more than anything on the part of the health personnel, as in everything, it is a process, and for the health personnel also if it is a new methodology, a new strategy, it will take a little bit of time to adapt, but if it is so beneficial and effective, it is okay to implement it”. (Interview 15, Female)
Time can be a factor that hinders intervention, as clients often prefer short visits. While there are clients for whom longer visits would not represent a problem, health providers still recommend to keep visits as short as possible.
“Sure, as long as it doesn't last long. Because, when the visit takes much longer, some clients may feel uncomfortable…, but it is very diverse…on the one hand there are patients who want to listen to you and want to continue talking; on the other hand, there are those who come in a hurry and have to go to work immediately. That really depends on each patient”. (Interview 13, Female)