Factors affecting the implementation of nurse-initiated antiretroviral treatment in primary health care clinics of Limpopo Province, South Africa

Figures & data

Table 1: Themes and sub-themes

No.	Theme/sub-themes	Description of the theme/sub-theme	Quotations
1	Lack of resources	This theme included sub-themes such as shortage of nurses, drugs, stationery, telephone communication and limited workspace in the clinics	See sub-themes
1.1	Shortage of health workers (Fg and Ii)	The participants felt they were short-staffed and had an overwhelming workload	‘The nurses who are trained on NIMART, there’s a big shortage. So if there are two nurses who are initiating, the patients does come and their blood is collected and everything … but they cannot be initiated if the nurse who is trained is not there. They have to come on a certain day for the initiation.’ (TN, 55 yrs, 16 yrs’ experience in PHC, NIMART trained)
1.2	Shortage of drugs (Fg and Ii)	Shortage of drugs was a common challenge at all primary health care facilities. Nurses were faced with having to turn away patients and having them return for their medication on another day. Other patients were given medication for only a week at a time. These patients had to return frequently to collect medication. Some participants travelled to the hospital pharmacy at their own expense to request drugs for their patients	‘Shortage of drugs … . You see that the patients are full at the clinic … we use our own cars to go to pharmacy.’ (VJ, 47 yrs, 3 yrs’ experience in PCH, not NIMART trained)
1.3	Shortage of stationery (Fg)	There was insufficient stationery, making record keeping difficult for participants	‘You just have to use a piece of cardboard … as long as you have recorded, so that the patients can know that I’m going to the clinic on the 30th.’ (NN, 54 yrs, 16 yrs’ experience in PHC, NIMART trained)
1.4	Poor clinic infrastructure (Fg and Ii)	The clinics are poorly designed: there are not enough consulting rooms for all the activities	‘The counselling room … HCT room … tomorrow we’re issuing ARV’s … so the one working here has got to move around, find a corner … there is not enough space.’ (MK, 49 yrs, 12 yrs’ experience in PHC, NIMART trained)
1.5	Lack of telephone communication (Fg)	Telephones were unavailable in most clinics and nurses struggled to refer emergency patients to the hospital	‘If you are having a serious problem, we’re using 112 to call for an ambulance.’ (JM, 48 yrs, 16 yrs’ experience in PHC, NIMART trained)
1.6	Insufficient training (Fg)	The participants were not computer literate and had to learn to capture patient information electronically themselves as there were no data capturers	‘We are having a computer in our facility but unfortunately we don’t have data capturers. The training is not intensive. ‘ (ML, 44 yrs, 16 yrs’ experience in PHC, NIMART trained)
2	Factors affecting adherence to treatment (Fg and Ii)	The participants mentioned several factors contributing to poor adherence of patients to treatment posing barriers to the ARV programme including: stigma, poverty, bad roads, movement of patients between health facilities, sharing of medication, the urgent initiation of ARVs and the restrictions on the single drug regime	See sub-themes
2.1	Stigma (Fg and Ii)	Patients did not want to disclose their status because they were afraid of how they would be treated by the community	‘Usually at the clinics we let those patients who are collecting ART come on a certain day, we make sure that NIMART trained personnel is there. So some are afraid to be labelled that this is an AIDS person.’ (SH, 52 yrs, 25 yrs’ experience in PHC, NIMART trained)
2.2	Poverty (Ii)	Poverty due to unemployment resulted in non-adherence. The patients did not have enough food and therefore did not adhere to their treatment	‘Poverty … you find that patient comes to the clinics, you initiate him or her, but he doesn’t have food to eat, you refer to a social worker just knowing that sometimes they will be given some food packets … not knowing when.’ (NN, 54 yrs, 16 yrs’ experience in PHC, NIMART trained)
2.3	Poor roads (Ii)	During the rainy season, the roads were too bad to travel on and bridges were flooded. Therefore, patients missed out on their follow-up dates until the water levels had subsided	‘Because here is in the rural areas, you find that people are staying high on top of the hills and when it’s raining, they can’t afford to come to clinics … the little bridge is full, the river is full, its overflowing, so they can’t come to the clinic.’ (MK, 49 yrs, 12 yrs’ experience in PHC, NIMART trained)
2.4	Movement between facilities (Fg and Ii)	Patients changed clinics between provinces, which made it difficult to follow them up — patients would move from one clinic to another without requesting transfer letters	‘They are working in Gauteng province, when they come, some of them don’t come with anything to show that they are collecting treatment.’ (PK, 25 yrs, 1 yr’s experience in PHC, NIMART trained)
2.5	Urgent (same day) initiation of ART (Fg)	Participants believed that patients who were initiated on the same day they were tested felt overwhelmed and that this might lead to poor adherence to treatment	‘When the patient comes today and you find that the patient is positive, that same day, as a pregnant woman you initiate that day …. I see it’s a problem because she’s still concerned about her results being positive, whereas you must explain about taking of the ARV … that’s why there are many defaulters at our clinic.’ (SA, 50 yrs, 17 yrs’ experience in PHC, NIMART trained)
2.6	Restrictions on the ‘single drug’ regime(Fg)	The restrictions on the ‘one pill’ (fixed dose combination) regime created conflict with patients who wanted the single drug but did not meet the criteria	‘Patients are desperate to get the one drug because definitely it’s frustrating for them to take all those three drugs.’ (MN, 50 yrs, 19 yrs’ experience in PHC, NIMART trained)
2.7	Sharing of medication	Some participants mentioned that patients were sharing their medication with a spouse, which meant they could run out of medication before receiving their next supply. This affected their adherence to treatment regimes	‘You start the wife on treatment, they are going to share with the husband and you find that the treatment ends before the return date.’ (NC, 39 yrs, 13 yrs’ experience in PHC, NIMART trained)
3	Support visits (Fg and Ii)	Participants felt supported when the doctor and management visited their clinics, but they also felt frustrated that some of their problems could not be solved	See sub-themes
3.1	Visiting doctor (Fg and Ii)	Support from the visiting doctor was helpful to the nurses because they were able to discuss complicated patients with him	‘There are people who take the rounds around the clinics and health centres, they are the ones who support us the most, the visiting doctor.’ (TN, 55 yrs, 16 yrs’ experience in PHC, NIMART trained)
3.2	Management support (Fg and Ii)	Management listened to the participants’ challenges, though their problems could not be solved	‘We have them, the assistant managers … we really communicate with them … they know we are short staffed, they say there is nothing they can really do …’ (NN, 54 yrs, 16 yrs’ experience in PHC, NIMART trained)
4	Nurses’ work satisfaction (Fg and Ii)	The participants experienced satisfaction in being able to initiate treatment of patients on their own at the clinics. They felt a sense of accomplishment because they were making a difference in patients’ lives and improving their quality of life	‘If a person comes, you know she was not able to walk … and the following month if she comes for check up, you see that person now is walking on his or her own, you become happy … . At least I can save lives.’ (JM, 48 yrs, 16 yrs’ experience in PHC, NIMART trained)

Notes: Fg = focus-group interviews; Ii = individual interviews.