Four main themes that emerged from the interview data in relation to experiences of nutritional counselling in the nutritional program are summarised in table 2 and discussed in detail below.
Themes emerged from the qualitative analysis
Frequency and duration of the nutritional counselling
This relates to the frequency of nutritional counselling over the course of participants’ enrolment in the nutritional program. Duration indicates the length of one nutritional counselling session.
Contents of the nutritional counselling
This refers to the actual topics discussed during the nutritional counselling
Acceptability of the nutritional counselling
This theme relates to the acceptability of the nutritional counselling and recommendations by participants
Applicability of the nutritional program
Refers to the actual implementation of the nutritional recommendations given by the health professional
Challenges/barriers in relation to nutritional counselling
This theme identified the challenges of nutritional counselling in HIV care from the perspectives of study participants including applicability
Frequency and duration of the nutritional counselling
Frequency refers to the number of times patients received nutritional counselling during enrolment in the nutritional prorgam. Session duration refers to how long one specific nutritional counselling session lasted.
Comments received about the frequency of nutritional counselling ranged from ‘no counselling at all to more than one counselling. The majority of study participants noted that the nutritional counselling was provided as a one-off session, commonly at the beginning of the nutritional program.
…At the beginning when they give you [the nutritional support], they [the health providers] tell you that it is a medication: that is all, nothing else after… (Adult male, #7).
A small number of adults and caregivers reported receiving no nutritional counselling at all and said that they had been sent home only with the nutritional support:
Maybe since I am coming from far away, I may not reach the teaching session. Otherwise, I have not yet come across any counselling or teaching session (Adult female, #6).
We did the counselling at each visit. For example, when we have many clients. We send them to the case manager [peer counsellors] for counselling about ART adherence, cleanliness, or personal hygiene and so on” (Health provider #4)
Contents of the nutritional counselling as experienced by participants
Even though the nutritional counselling is meant to cover the seven elements mentioned in the introduction , participants reported that the nutritional counselling focused on three elements : a) nutritional support (Plumpynut/Plumpysup); b) dietary practice; and c) sanitation and hygiene, with a particular emphasis on the nutritional support.
In general, the nutritional counselling mainly focused on the nutritional support (Plumpynut/Plumpysup); including why the nutritional support is given and its benefits as stated by a caregiver below:
They [health providers] told me that my child’s weight has been decreased and told me to give him the Plumpynut properly. They said, "this [the plumpynut] will improve his weight as well as general health status and told me to follow him properly"(Caregiver #5).
An adult female also reiterated the focus of the nutritional counselling around the nutritional support, specifically on the benefits of the nutritional support in terms of improving weight and wellbeing.
They [health providers] counsel me that the Plumpynut contains important nutrients including Plumpynut and vitamins. They told me that it is very important and beneficial for your weight and overall health (Adult female #1).
Discouraging patients to share and sell the nutritional support were also stated as part of the nutritional counselling regarding the nutritional support.
The health providers also advised us to take it (the Plumpynut) properly and not to share it with others. Selling, sharing or giving it to other persons is not allowed (Adult male #6)
The second content focus of the nutritional counselling identified in HIV care related to dietary practice and increasing the frequency and diversity of foods to improve nutritional wellbeing. Even though the lack of access to adequate food was a problem in many participants, counselling to diversify dietary practice with whatever food available at home was another element of the nutritional counselling.
They counsel us about everything. For instance, they tell us ‘it is not only meat that we [herself and her child] should take, we can also take other foods like grains and vegetables which are equally important (Caregiver #4).
We counsel them how their dietary pattern looks like and they are counselled to take balanced foods (Health provider #2).
The third component covered in the counselling sessions was on mechanisms to maintain hygiene and food safety including handwashing, hygienic handling of the nutritional support and other foods as well as consuming cooked foods:
They [health providers] tell us to maintain our personal hygiene and environmental sanitation, to wash our hands before use of the nutritional support and to use Woha Agar to treat water (Caregiver #2).
Hygiene, to drink clean and safe water and to use Woha Agarto treat the water or boil it (water) before use, otherwise I didn’t remember any specific counselling session (Adult male #6).
The health providers advised us to eat balanced food, drink clean water, and seek care for any sickness (Adult female, #4).
In a small number of instances, during the nutritional counselling other topics such as minimizing stress to improve overall health, wellbeing, and quality of life and ART adherence were also covered.
About our dietary practice, they told us to take foods that go with the ART medication such as eggs, meat, and milk. As I told you about that, if you have enough you will eat, if not you will use whatever you have with the ART (Caregiver #16).
Acceptability of the nutritional counselling
”Acceptability refers to determining how well an intervention will be received by the target population and the extent to which the new intervention might meet the needs of the target population and organizational setting”.
The majority of caregivers and adults felt that the nutritional counselling they received was acceptable and benefited them in terms of providing information about the nutritional support.
Since I understand the benefits of the Plumpynut, I believe that the counselling service has benefited me to take the Plumpynut accordingly (Adult male #6).
… counselling is very important. It helps me to understand its [the nutritional support] benefits to him [the child]) and use it properly, on time and get the necessary next ration (Caregiver #1).
Most adult and caregiver participants reported improved knowledge about food and nutrition as the benefit of the nutritional counselling, as described by an adult male below:
If you are taking the ART medication or the Plumpynut accepting it will benefit you, you will get the intended benefits. All the counselling is good for me for my weight and health. I fully practice the counselling provided because I understand that all the benefits of counselling are to improve my weight. When they counsel you, they [the health providers] are giving your life not to get sick and weaker (Adult male, #13).
Sharing the information received from nutritional counselling with other adults and caregivers was an indication of a high level of acceptability amongst people living with HIV. This was noted by an adult male:
As a volunteer, I also transfer information to people who are taking Plumpynut not to share it instead to consume it to themselves (Adult male #5).
I also teach a mother who have children who are taking the Plumpynut not to share it with others (Caregiver #3).
Challenges for the provision of nutritional counselling in HIV care setting
A number of challenges were identified for the provision and implementation of nutritional counselling including a lack of understanding by recipients, training issues and inconsistent delivery, and a lack of consideration of the context of people’s lives.
Despite the reported acceptability of the nutritional counselling by most adults and caregivers, some health providers said that nutritional counselling was not well implemented by some patients, particularly by older adults. It was believed that this may be partly due to a limited understanding of the nutritional counselling:
This is because we may not provide them with adequate counselling as well most HIV patients are uneducated which may result in poor or slow understanding of the counselling service (Health providers #1).
We give them similar counselling service to all patients, but some people understand you quickly and others didn’t understand you at all despite the intensity of counselling. Some of those who didn’t accept and apply the counselling are those old and uneducated ones who may not pay it adequate attention(Health provider #2).
Health providers also noted a range of issues relating to the training of staff and training materials and inconsistent delivery of the nutritional counselling. The lack of training of health providers related broadly to the general nutritional program provided in the HIV care service, with implications also for nutritional counselling:
Issue related to the health system, one is the professional. In order to give good service; their training should also be good. The health professional should know the contents of the two food supplements. The knowledge of the health provider is low (Health provider #10)
“There are problems related to the health provider especially if they didn’t take training about food by prescription (Health provider #4).
Adults further reported that there was no detailed assessment of household socioeconomic status and family situation during the nutritional counselling but underlined that they have been told to eat whatever food available at home. An adult female described the lack of socioeconomic consideration of the nutritional counselling below:
They [the health providers] didn’t say about this [household socioeconomic consideration]. They didn’t ask about what we have and haven’t. They [health providers] only tell us to diversify our dietary practice. There is nobody who asks about our household situation (Adult female #19).
A lack of detailed assessment of household socioeconomic status and socioeconomic consideration of the nutritional counselling constrained the acceptability, applicability, and adherence of the nutritional counselling in HIV care setting with poor access to adequate food, for some participants, a key barrier to fulfilling the key messages promoted in the nutritional counselling:
About my dietary practice, I think you have to eat what you get at your home; otherwise, you can’t live according to the counselling given here in this health facility (caregiver #16).
A small number of caregivers did report the experience of assessment of their household socioeconomic status during the nutritional counselling as stated below:
It [household socioeconomic status] is considered. They ask me and write it down on my card and they have done everything. They know about my income and my job as well as other things about my family (Caregiver #3).
These overall challenges associated with nutritional counselling were seen by health providers to have a significant impact on program outcomes:
Had it been that they apply all the counselling services given to them like the ART medication, they may get the necessary benefits from the nutritional program: as well we may not have default or loss to follow up from the nutritional program (Health provider #6).
 Woha Agar is a water treatment chemical used in Ethiopia mainly distributed by health providers to people living with HIV