Feasibility studies
Out of eighteen healthcare professionals in the intervention arm of the study, fifteen of them (which included 4 Doctors, 4 Pharmacists, 1 Nurse and 6 Medical Laboratory Scientists) participated in the in-depth interview.
The other three were on several attempts not available for the interview. The responses to the interview questions were classified using the thematic content analysis into major themes, including their sub-themes (Table 3).
Table 3
Themes and sub-themes from the interview
S/N
|
Theme
|
Sub-Theme
|
No of Persons Who Reported this
|
1.
|
Improved adherence
|
• The incentives encouraged them to adhere to treatment
• The consequent reduction in viral load encouraged them the more
• The adolescents became more open during motivational interviewing
• Peer pressure from those who received the incentives encouraged others
• The economic incentives spurred them to keep monthly appointments
• Some of them used their incentives to supplement their transportation fares as this was a challenge
|
15
|
2.
|
Attitude towards the disease
|
• The adolescents and their parents/caregivers gained a better understanding of the disease condition
• A few of them showed a negative attitude by being rebellious, especially those who still blamed their parents for infecting them
|
.
15
|
3.
|
Sustainability concerns
|
• Intervention implementation is very possible but would require a deep sense of commitment from the government, healthcare providers and other actors
• Intervention may not be feasible in the long run
• Too much workload on healthcare staff thus may require an increase in remuneration
• Lack of political will from the government as other costs of HIV care are already being covered by the government
• Economic incentives may not be available in a real-life setting, therefore other types of incentives may have to be considered for example skill acquisition programs for the adolescents.
• Modification of the traditional adherence counselling to an intensified adherence counselling such as motivational interviewing.
• May require capacity building for the motivational interviewers
|
15
|
4.
|
Healthcare provider-adolescent relationship
|
• The motivational interviewing and regular visits brought about an improved relationship between the healthcare providers and the adolescents
|
10
|
5.
|
Caregivers’ influence
|
• Some adolescents depend on their caregivers who may not be disposed to bring them to the hospital for care and for laboratory investigations when needed.
• Poor disclosure habit which inhibited the adolescents’ proper understanding of the disease condition.
|
15
|
6.
|
Cost implication
|
• Phone calls and short message service (SMS) to remind the adolescents of their monthly appointments/laboratory investigations
• Use of phone consultations for those living far away.
|
13
|
Seven major themes and twenty-six sub-themes were identified. The identified themes were improved adherence, attitude towards the disease, sustainability concerns, healthcare provider-adolescent relationship, caregivers influence, cost implications and intervention implementation challenges.
Some of the excerpts from the themes as stated by the healthcare professionals interviewed are shown below:
Improved adherence
From the perspective of the healthcare professionals interviewed, the economic incentives and motivational interviewing played a huge role in improving ART adherence and reducing viral load. Even though not all the adolescents achieved the target viral load of < 20copies/ml, there was a marked drop in the HIV- RNA (Human Immunodeficiency Virus-Ribonucleic acid) of most of the adolescents. One of the trial implementation doctors stated the following
“Before we started implementing the intervention, many of the adolescents always had one excuse or the other for not coming for appointments. However, when they were made to understand what the program was all about, and that there would be incentives for those whose viral loads were < 20copies/ml, they became interested and increased the frequency at which they presented for their appointments.” (Doctor, Immaculate Heart Hospital and Maternity, Nkpor, Nigeria).
Positive peer group influence was observed as an adherence-stimulating factor as those who didn’t receive the monetary benefits felt compelled to do so on seeing their peers rewarded. A medical laboratory scientist involved in the trial stated that:
“The economic incentives spurred them to adhere to their treatments, especially those who had not been adhering. Out of 14 enrolled adolescents in our arm, 9 achieved viral load suppression. Those who didn’t achieve suppression felt remorse on seeing others get monetary benefits and were challenged to do better.
The parents/caregivers of those who did well were very happy and more willing to encourage their children/wards”.
(Medical Laboratory Scientist, Community Health Centre, Neni)
Attitude towards the disease
The intervention brought about a positive attitude in the participants. When the adolescents got enrolled in the study, they were made to understand what it was about. As they experienced a drop in their viral load, they understood the relationship between adherence to treatment and virological and immunological outcomes. They, therefore, became more optimistic about their health outcomes. A medical laboratory scientist involved in the trial stated that
“Before their enrollment into the study, some adolescents didn’t know what they were taking drugs for. But during the intervention implementation, we made them understand how the ART worked and how their health conditions would improve upon adhering to treatment. Hence, they became eager to take charge of their health.”(Medical Laboratory Scientist, Community Health Centre, Neni).
Some participants in the intervention still displayed a negative attitude.
Although there was high patient acceptability of the intervention, a few others who still blamed their parents for infecting them were indifferent. A doctor involved in the trial informed us that:
“Some of the adolescents still exhibited a nonchalant attitude towards the incentive scheme. They still felt animosity towards their parents for infecting them and felt they would, therefore, be doing them a favour by taking their drugs religiously.” (Doctor, Nnamdi Azikiwe University Teaching Hospital, Nnewi).
Healthcare personnel and HIV adolescents’ relationship
The motivational interviewing fostered the relationship and allowed for better interaction between the healthcare providers and adolescents. A pharmacist involved in the trial implementation stated that
“The monthly motivational interviewing made the adolescents open up the more and enabled me to gain a better understanding of the challenges to adherence that they faced. Therefore, we were able to work together to address these challenges for a better outcome.” (Pharmacist, Nnamdi Azikiwe University Teaching Hospital, Nnewi)
Sustainability of the intervention
Most of the interviewees saw the intervention as worthwhile but expressed doubts about the possibility of sustaining the intervention in the long run unless there is a great sense of commitment on the part of both the government and the healthcare providers. A pharmacist and a nurse involved in the trial implementation stated the following
“This intervention and its benefits can actually be maintained over time. The implementers which include the government, healthcare providers and even the beneficiaries (ALHIV) need to be truly and actively committed. (Pharmacist, Nnamdi Azikiwe University Teaching Hospital, Nnewi).
“The government already has a lot on their plates as regards HIV/AIDS management. Some of the costs of care that were initially borne by HIV support agencies are now born by the HIV clients, Therefore, I don’t think it will be feasible for the government to sustain these economic incentives in the long run”. (Nurse, St. Joseph’s Hospital Adazi-Nnukwu)
One of the interviewees, however, stated that instead of monetary rewards which may be stopped halfway, other forms of incentives which can help build entrepreneurial skills in these adolescents and thus a source of financial empowerment could be combined with motivational interviewing to achieve the intervention sustainability. He said:
“Sustainability would require more than financial incentives. Skill acquisition programs could be designed for these adolescents as a way of empowering them to make some money to take care of their transportation fares to the hospital”. (Doctor, Community Health Centre, Neni)
Another participant suggested that an increase in the healthcare personnel’ remuneration may boost their morale as it will be extra work added to their already loaded schedule.
She said:
We already have a lot of workloads here at the HIV unit, therefore additional remuneration could serve as a form of encouragement”. (Pharmacist, General Hospital Onitsha)
Caregiver’s influence
Because younger adolescents lacked the autonomy to get themselves to the hospitals for appointments or laboratory investigations, they had to wait on their caregivers who may be pre-occupied with other activities/engagements.
A medical laboratory scientist involved in the trial stated that
“The adolescents didn’t present for laboratory tests as and when due. Most of them depended on their parents who may not be disposed to bring them to the hospital when they are supposed to.”(Medical Laboratory Scientist, St. Charles Borromeo Hospital, Onitsha)
Cost implications
Fear of stigmatization was found to influence parents’/caregivers’ choice of hospitals to enrol their children/wards in. They, therefore, preferred hospitals far away from their neighbourhood. This came with the challenge of the high cost of transportation, thus impacting negatively on their attendance at the monthly appointments. A doctor involved in the trial informed us that
“Some of the caregivers are afraid of being seen as HIV positive when they are not.
Some who do not want their children/wards to be identified by friends or relatives as HIV client would rather enrol in hospitals far from their places of residence.
This made it difficult for them to keep up with their monthly appointments due to the increased cost of transportation.” (Doctor, Immaculate Heart Hospital and Maternity, Onitsha)
Also, the healthcare providers had to continuously use phone calls or text messaging to remind the adolescents and/or their parents/caregivers about monthly appointments/laboratory investigations. A nurse involved in trial implementation stated that:
“I always send text messages or make phone calls to remind them to come for monthly appointments and they are always happy to attend because of the expectations of winning incentives.” (Nurse, St. Joseph’s Hospital, Adazi-Nnukwu).
Intervention implementation challenges
A lot of challenges were experienced by the program implementers during the trial and they include low attendance for the quarterly laboratory investigations, distance barriers, death of some clients, failure of samples to show results and difficulties in tracing lost-to-care clients. A medical laboratory scientist stated that
“Some of the adolescents didn’t understand that the laboratory investigations benefitted them more than it even benefitted the investigators. They felt that they were being pressured to attend compulsory laboratory investigations.” (Medical Laboratory Scientist, St. Joseph’s Hospital Adazi Nnukwu, Nigeria)
Some healthcare providers found it difficult to get those who were lost-to-care to initially enrol in the clinical trial and also for continuation in the study for those enrolled as their phone numbers remained unavailable.
A doctor involved in trial implementation stated that:
“Tracking some lost-to-care patients was difficult as some of their phone numbers were unreachable.
Some of them were nonchalant and would always give reasons for not coming for appointments.”(Doctor, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria).
Besides, some samples for viral load assay kept failing. Therefore, it was burdensome for the affected adolescents to continue coming for repeated laboratory investigations and yet not knowing his or her viral load status and eligibility for the financial incentive. A laboratory scientist involved in the trial stated that:
A particular sample kept on failing on the test without a reason. The client felt reluctant to repeatedly present for more tests. An investigation is still on however to know the cause of that in a particular client in my facility. Only his baseline viral load result was successful.” (Laboratory Scientist, Community Health Centre, Neni, Nigeria)