“It Is Like That, We Didn't Understand Each Other”: Exploring the Influence of Patient-Provider Interactions on Prevention of Mother-To-Child Transmission of HIV Service Use in Rural Tanzania

Abstract

Interactions between patients and service providers frequently influence uptake of prevention of mother-to-child transmission (PMTCT) HIV services in sub-Saharan Africa, but this process has not been examined in depth. This study explores how patient-provider relations influence PMTCT service use in four government facilities in Kisesa, Tanzania. Qualitative data were collected in 2012 through participatory group activities with community members (3 male, 3 female groups), in-depth interviews with 21 women who delivered recently (16 HIV-positive), 9 health providers, and observations in antenatal clinics. Data were transcribed, translated into English and analysed with NVIVO9 using an adapted theoretical model of patient-centred care. Three themes emerged: decision-making processes, trust, and features of care. There were few examples of shared decision-making, with a power imbalance in favour of providers, although they offered substantial psycho-social support. Unclear communication by providers, and patients not asking questions, resulted in missed services. Omission of pre-HIV test counselling was often noted, influencing women's ability to opt-out of HIV testing. Trust in providers was limited by confidentiality concerns, and some HIV-positive women were anxious about referrals to other facilities after establishing trust in their original provider. Good care was recounted by some women, but many (HIV-positive and negative) described disrespectful staff including discrimination of HIV-positive patients and scolding, particularly during delivery; exacerbated by lack of materials (gloves, sheets) and associated costs, which frustrated staff. Experienced or anticipated negative staff behaviour influenced adherence to subsequent PMTCT components. Findings revealed a pivotal role for patient-provider relations in PMTCT service use. Disrespectful treatment and lack of informed consent for HIV testing require urgent attention by PMTCT programme managers. Strategies should address staff behaviour, emphasizing ethical standards and communication, and empower patients to seek information about available services. Optimising provider-patient relations can improve uptake of maternal health services more broadly, and ART adherence.

The Perspective of HIV Providers in Western Kenya on Provider-Patient Relationships

“…We observed, however, that providers thought that patients who expected their complete attention were irritating. As previously reported in the region (Bain, Dierickx, & Hens, 2015; Donatus, 2011; Gourlay et al, 2014), providers expressed preference for a care model in which they had more social power than patients, and expected patients to respect this hierarchy. This paternalist approach to care has raised ethical concerns regarding the professional culture of Kenyan HIV providers (Bain et al, 2015; Donatus, 2011).…”

“…For HIV patients to be engaged, high quality provider-patient communication and relationship dynamics must be fostered and maintained (Flickinger, Saha, Moore, & Beach, 2013). In Kenya, poor provider-patient communication and relationship difficulties have been documented as barriers to optimal HIV care (Geng et al, 2015; Gourlay, Birdthistle, Mburu, Iorpenda, & Wringe, 2013; Gourlay et al, 2014; Posse et al, 2008; Wachira et al, 2014), yet very few studies in the region have focused on the role of provider and patient interactions in promoting HIV care (Wachira, Middlestadt, Reece, Peng, & Braitstein, 2013, 2014). These studies do not explore how Kenyan providers and patients experience and conceptualize provider-patient communication and relationships.…”

The Role of Maternal, Health System, and Psychosocial Factors in Prevention of Mother-to-Child Transmission Failure in the Era of Programmatic Scale Up in Western Kenya: A Case Control Study

“…17,35 This will involve tackling unclear expectations, skill deficits, resource and/or equipment shortages that often underlie negative patientprovider interactions and hamper access to and retention in PMTCT services. [36][37][38] Whatever strategies that are employed, they must strive to improve the productivity, competence, and responsiveness of health care workers. 36 Health system capacity can be strengthened by ensuring autonomy over resources at lower levels; linking performance management interventions to facility-wide human resources management; and developing accountability systems to ensure that health workers and managers are responsible for their performance.…”

Understanding Sustained Retention in HIV/AIDS Care and Treatment: a Synthetic Review

“…Shared-decision making and effective provider patient communication appear to be uncommon in clinics that are often congested and overstretched [18, 19, 20•, 21]. In a qualitative study among women receiving PMTCT services in Tanzania, Binformation from providers was referred to as 'conditions', 'directions', and 'instructions', while phrases like being 'ordered' by health workers, or 'violating the conditions' were also common [21].^Without appropriate transfer of knowledge or support of patient self-efficacy by the provider, the initial growth of activation may not be fully supported. Partnership in ART treatment may also be undermined by beliefs in faith healing and the power of traditional healers and herbal remedies [22].…”