Role of health care workers in the care and support of women living with HIV/AIDS experiencing intimate partner violence: the case of women attending care and treatment clinic in Singida region, Tanzania

INTRODUCTION

Intimate partner violence (IPV) is one form of violence against women, and is defined as ‘behaviour within an intimate relationship that causes physical, sexual, or psychological harm, including acts of physical aggression, sexual coercion, psychological abuse and controlling behaviours.^1-6 The world health organisation multi-country study on women’s health and domestic violence identified lifetime prevalence of physical and/or sexual partner violence ranging from 15 to 71%, and past year’s prevalence between 4 and 54%.^4,7 IPV is also a problem in Tanzania. In 1998, about 10,000 cases of wife beating were reported to the ministry of home affairs.⁸ An increasing number of IPV incidents are being reported to the women’s legal aid centre in Dar es Salaam, sometimes going up to 80% per day.⁹ According to the WHO multi-country study conducted in 10 countries around world between 2002-2003, lifetime prevalence of physical violence in urban and rural areas was 47 and 31%, respectively. The reported figures for sexual violence were 31% in urban and 23% in rural areas.⁷

Health care workers (HCW) have a pivotal role to play for IPV as they meet women in their daily work who may be exposed to IPV. Hence, understanding the HCWs’ attitudes and perceptions is necessary in the provision of integrated and holistic health care. Knowing the HCWs’ ability to recognise IPV clients and how the HCWs perceive their role in the care and prevention of IPV is important for developing interventions within the health sector.^9,10 The HIV pandemic has placed additional strain on health service provision through the extra burden of increased testing and counselling, treating opportunistic infections and providing antiretroviral treatment (ART). HCWs have been affected by HIV/AIDS as some of their family members have died of the disease. Also, by caring for women LWHA, some HCW shave contracted disease.

Through caring for HIV-positive patients and relatives, this has added further stress to their profession.^11-13 The quality and effectiveness of ART provision will be significantly affected by the country’s shortage of human resources in the health sector. The impact of under-staffing is that one person has to do the tasks of two or three people, including those of high skilled workers.¹⁴ Little is done on the role of HCWs in the care and support of women living with HIV/AIDS experiencing IPV, and who are attending care and treatment clinics in Tanzania. This study aimed to explore HCWs in the care and support of women LWHA experiencing IPV attending care and treatment clinics in Singida Region, Tanzania.

METHODS

This was a qualitative study in which data was collected through in-depth interviews (IDI) and focus group discussion (FGDs). Purposive sampling was employed to selected HCWs working at care and treatment centres (CTC) and prevention of mother to child transmission (PMTCT) of HIV in Singida regional hospital in Central Tanzania. Inclusion criteria/eligibility for participation was defined as HCW working at CTC and PMTCT with experience of caring for women LWHA. Exclusion criteria of study participants were health care workers working in other departments which are not HIV/AIDs related. Study period was September 2014 to October-2015.

Data analysis

The transcribed and translated interviews were read several times for familiarization and for formulation of codes. The interview guide provided key themes and sub-themes emerged; these were coded and developed for each key theme and its sub-categories which, effectively, systematically mapped the data before interpretation. The audio-recorded interviews were transcribed by the first author and translated from Kiswahili into English. A sample of translated interviews was back-translated to Kiswahili to ensure that the translation had been done correctly and accurately. The transcriptions were recorded verbatim in Kiswahili and later translated into English to help the researcher during writing. The meaning of the participants’ experience was maintained because the translation was done by two people, and comparison was made to ensure that the original meaning was maintained. The transcripts and field notes were analyzed manually by reading and re-reading the text to ensure familiarity with the data. Similarities and differences were examined to determine the relationship between the codes and the meaning. Content analysis was used in a wide range of analytical approaches to analyses the data, and jargon was avoided. NiVO version 8 statistical package was used to analyze the data. Back-and-forth review of the text ensured that appropriate units, codes, and themes were generated to interpret the latent content and thereby respond to the specific research questions.

Study area

The selection of the sites was based on HIV prevalence, availability of HIV care and treatment clinic services as well as adequate number of clients attending CTCs. The research assistant was recruited in Singida Region to assist the research team in recruiting a total of 24 HCWs working at CTC and PMTCT.

Selection of the study participants

Recruitment purposively targeted HCW who spent a substantial amount of time in the CTC and PMTCT. The qualitative design aimed to describe HIV care and services as perceived by HCW in the selected regional hospital. Purposive sampling was used to get a sample of HCWs working at CTC and PMTCT.

Data collection

Data was collected through in-depth interviews (IDIs) and FGD. IDIs were conducted in the CTC office in the hospital and FGDs were conducted at the social training centre hall. At total of 24 IDIs and four FGDs were conducted. All interviews were conducted in Kiswahili, were recorded and later transcribed and translated into English. The interview guide followed a number of research themes including socio-demographic characteristics, meaning and understanding of IPV from HCWs’ perspective, role and support among women living with HIV/AIDS (WLWHA) experiencing IPV attending CTC and PMTCT. The researcher explained the purpose and importance of the study, and assured respondents that all of the information provided would be handled carefully and that confidentiality would be maintained throughout. Permission for note-taking and tape-recording was requested and granted by the participants.

Trustworthiness of data

In this study, trustworthiness of the data was assured by the researcher who had engaged in data collection and conducted all IDIs and FGD’s. Triangulation of methods was employed using IDIs, FGDs, field notes, and a pre-defined protocol to ensure the validity of the findings. By involving the research team in peer-debriefing sessions to reflect on and discuss the procedures and interpretations of the data, we strove to ensure confirmability and consistency. The findings of this study were therefore shaped by the respondents rather than by researcher bias, motivation, or interest.

Ethical consideration

Ethical clearance for the study was obtained from the Muhimbili university of health and allied sciences (MUHAS) and permission to conduct the study was sought and granted by the district medical officers at the district level. At hospital level, permission was granted by the medical officer in charge. Participation was voluntary and all participants, after receiving verbal and written information about study, signed consent forms. They also received assurance of anonymity and confidentiality.

RESULTS

Socio-demographic information of healthcare workers

This section describes the distribution of the 24 participants in the study across the health care professions working in Singida care and treatment and PMTCT clinics. The HCWs were medical professionals who were working at CTC and PMTCT with working experience ranging from two to 20 years. They had various roles and responsibility. Some were administrators and supervisors in addition to their health care roles. Men were 3, women were 21, doctors were 4, and nurses were 20; 15 HCWs were working at CTC and 9 were working at PMTCT. Their age was ranging between 20-75 years. The analysis of the role of HCWs in the care and support of women LWHA experiencing IPV has generated the following themes: Meaning and understanding of IPV from HCWs perspective, roles of HCWs in caring for WLWHA experiencing IPV with sub-themes: Provision of emergency medical services, health education, counselling services and referral services for WLWHA experiencing IPV.

Meaning and understanding of IPV from HCWs perspective

In this study, HCWs who were interviewed in the FGD and IDIs had their own understanding of IPV among WLWHA. They understood IPV to be when the husband or male partner does something wrong to her female partner which is unusual to their everyday life such as being raped or sodomised against her will, beaten and spoken to using abusive words from her male partner. Others HCWs said that IPV occurs when love is lost between couples, and the male partner decides not to care for her female partner, refusing to provide basic needs such as food and shelter, failing to pay school fees for their children’s, and refusing to send her female partner to the hospital while knowing that she is a HIV/AIDS victim. One participant had this to say: “What I understand from that term is when a male partner maybe beats up the female partner for any reason; or when he mistreats the other partner by using abusive language, or by denying her the basic requirements e.g., food, for any reason. FGD1.”

Roles of HCW in caring for WLWHA experiencing IPV

Provision of emergency medical service

Study respondents from this study provided emergency medical services to WLWHA experiencing physical violence which was associated with physical trauma, requiring HCWs to suture small and big wounds, treat sexual transmitted diseases such as gonorrhoea, provision of anti-tetanus to prevent tetanus for those with big wounds and antibiotics to prevent secondary infection. For those who experienced sexual violence (rape) and they were HIV positive, they were advised to continue with their ARVs and they were provided emergency family planning to prevent unwanted pregnancy as was reported by one participant: “and for the injuries that are a result of being beaten, we usually take legal measures. We fill out a PF3 form and leave it to the police to proceed but we treat her with antibiotics and clean her wounds. If the injuries are serious, we take her to the theatre and suture her. For those women who are raped, who are already known to be HIV-infected and they are on ARV medicines we advise them to continue with their ARV”, HCW aged 58 years old.

Health education

In our study, HCWs reported that they provided IPV health education to WLWHA. Health education is necessary to help WLWHA to understand how they can cope with the IPV situation. One of the HCWs said: “If someone gets education, she expands his/her thinking. We believe the education we provide will assist them to understand what IPV is all about, so that they can live well with their partners. We advise them to watch and benefit from the news on television and other sources because nowadays the issues of violence are mentioned frequently (FGD4).”

On the other hand, HCWs recommended that they needed to be updated on IPV issues so that they could educate their community on the same, and the services available for referrals and networking as IPV issues are concern. The society should understand that it is against human rights to mistreat someone, especially women living with HIV/AIDS, as was emphasised by one participant: “I think the important thing to do is to educate people to get an understanding about the issue of IPV and the education should be for both men and women. As a society they need to understand that it is wrong to mistreat someone else whether depending on gender or anything else, HCW aged 60 years.”

Counselling services

In this study, HCWs reported that apart from their day-to-day work, they provided counselling services to WLWHA experiencing IPV apart from medical services. They needed counselling because they were being overwhelmed by so many thoughts of IPV and other health issues like the need for early treatment of wounds, adherence of ARV medication and CTC, and how they should cope with their family and their children. HCWs provided counselling to WLWHA about adherence to their ARV services to avoid lost to follow-ups due to being chased or abandoned by their male partners. The bad outcome of stopping ARV medications which results into poor health outcome as was demonstrated by one participant: “In brief we do give them a good counselling on ARV adherence in good language. We counsel them on how to live with their husbands. We also counsel their male partners to stop mistreatment to their female HIV positive” HCW aged 43 years.

Referral services

In this study respondent reported that HCW referred women LWHA to social welfare services which has the responsibility to call male partners and ask them to take care of their children and wives. The social welfare section made a critical assessment of the violent male partners who doesn’t provide the basic needs to their families. Some of the Women LWHA who followed HCW advice their children’s were benefited through social welfare services because the children’s started to received basic needs such as school fees, food and clothes from their fathers who abandoned them. Other referral services provided by HCW was legal and police services. They advised women LWHA to report their violence male partner to get legal assistance as was demonstrated by HCW.

“I advised her to go the social welfare office who has a role to make a follow up violent male partners. The women went of course to the social welfare office and the man was summoned. After a serious follow up the man agreed to provide basic need to his family through the social welfare offices. But also, there are those who need legal aid, we also direct them to get legal assistance. Furthermore, we also refer women LWHA for police services because nowadays there is a special gender desk to work on such issues” HCW aged 43 years.

Sympathetic listening and devoted time

HCW took their time to listen to the women LWHA opinions and acknowledged them. Also, they gave them opportunity time to express themselves about their IPV life. HCW become tolerant towards them and took time to get to know them. This made them to feel more comfortable, lead to a far more peaceful and understanding between HCW and their women LWHA. They considered themselves acceptance by HCW regardless of their differences also they got confidence to accept themselves regardless of the IPV life they were going though. HCW also showed the sense of sympathetic listening about the women LWHA they care about. They paid close attention to them so that they can express their IPV sorrow. As demonstrated by one participant.

“Women living with HIV/AIDS when they come to us, because we already knew them, we dedicate extra time to listen them very careful, some time they don’t explain to us their family if we treat them like other patients. Through tentative listening and devoted time, they tell us all their problems of violence”, HCW aged 28 years Old.

Respect regardless of their cultural differences

In this study HCW reported that they respected their women LWHA regardless of their cultural difference. HCW reported that they did very basic intervention by treating women LWHA in high respect and dignity the same level they would like to be treated themselves with same degree of respect. They didn’t embrace them, neither to afraid them, they didn’t judge them on their first impression how they look like. They took the time to get to know them. They didn’t pre-judging them on their appearances alone. They came to know them better and for them it was rewarding experience. As was demonstrate by participants.

“In our care and treatment clinic, we respect our women LWHA regardless of their cultural difference, we accept them as they are. Through this we came to know each other better and they feel free to express their problems to us, and for us we feel very comfortable if we meet their needs”. HCW 43 years.

DISCUSSION

The study examined role of health care workers in the care and support of women living with HIV/AIDS experiencing IPV: The case of women attending CTC in Singida region. We hope that the information in our study will contribute to improve roles and responsibility of HCW who are attending women LWHA experiencing IPV in Tanzania. This section is organised into two main themes one is meaning and understanding of IPV from HCW perspective, second is the roles of HCW in caring women LWHA experiencing IPV and four subsections which are: provision of emergency medication, health education, counselling services, and referral services.

In our study we found that HCW had their own perception and understanding of IPV which was when a male partner does something wrong to his female partner like raping, sodomized, beat her and use of abusive words to them that was meaning and understanding of IPV. Our study is in line with other study done in Malaysia on health providers perspective on services for victims of intimate partner violence which defined IPV as a state of both physical and emotional harm caused to the woman, and included acts such as scolding, hitting, beating, threats, emotional stress and deprivation. ^6,10.15,16

In our study HCW provided IPV health education to the women LWHA. To help them to understand how to cope and protect themselves and their children against violent. Our study in agreement with the study done in South Africa showed that health education is the stepping stones is a participatory programme aiming to prevent HIV through improving gender equity in relationships, thereby decreasing sexual risk behavior.⁶ Literature review done on the intervention to address HIV and IPV in Sub Saharan Africa showed effective health education provided to women LWHA have shown a short-term improvement in HIV related knowledge and behavioural intention.¹⁷ On other hand, the study found that HCW they were not well knowledgeable about IPV and they were requested if they will be updated with IPV knowledge now and then. Our finding is in similar stud done in Tukey which showed that 89.8% of HCW had no training regarding how to approach the IPV victim professionally. Among the group who had training, 70.9% believed that the training was not adequate to satisfactorily help the victims of IPV.¹⁰ Also, study done in the United Kingdom showed that there is a strong relationship between women LWHA and their health care provider which resulted into a stronger bond and adherence of ARV, there has been growing interest in assessing the extent to which the quality of patient provider interactions supports adherence to ART regimens.¹⁸

In our study we found that HCW had various roles in care and support of women LWHA experiencing IPV such as provision of counselling services which helped women LWHA to relieve their tension which was associated with IPV and HIV disease. Our findings are in line with other studies done in Sri Lanka and Malaysia which shows nurses roles in caring of IPV was provision of psychological information and support, advise on taking legal action to higher authority also financial support.^15,19,20 In our study HCW provided emergency medical services to the women LWHA experienced IPV such as physical trauma, treatment of sexual transmitted diseases, family planning services to prevent unwanted pregnancies and counselling women LWHA on adherence of their medications and care and treatment clinic. Our study is similar with study done in Namibia which showed that HCW had a role to provide ongoing counselling to women LWHA as the most intervention in ART adherence. Regular counselling should be done daily basis in sustainable manner to all the ART patients as this has been found to have a significant impact.²¹ Also, our study is similar with other study done in the USA on transforming the healthcare response to IPV showed that HCW integrate family planning services with health education and IPV.²²

In this study we found that HCW provided referral and linkages to the social welfare section which was within their hospital which had a responsibility to call the violent male partners. The linkages process was in this study was between the CTC, PMTCT, within other hospital service and community and follow of women LWHA experienced IPV. Our findings are similar with study done in Zimbabwe which showed that development of referral tools (e.g., referral forms, registers) and strengthening the follow-up system could facilitate the link between PMTCT and ART programmes.²³ Linkages can improve care and reduce missed opportunities for key interventions such as HIV testing, provision of ART, PMTCT, and adherence support. Integration of care is an important strategy to improve patient retention in long-term HIV care and treatment.²⁴ The implementation of simple referral system using referral forms has been effective in linking diagnosed patients with ART clinics in rural Tanzania.²⁵

In our study we found that HCW they had sympathetic listening to the women LWHA. They have shown them a sense of humour, they understood them, they gave them a chance to express their feelings and anger. This made them to feel comfortable, made them to accept their situations.

Our study is line with the study done in literature review in Cape town in South Africa on the health sector responses to IPV.⁶ Similarly, in this study we found that HCW respected their women LWHA regardless of their cultural differences. They treated them with dignity and respect the same way they would like to be treated. This made women living with HIV/AIDS experiencing IPV to be their closest friends. For HCW they felt they were rewarded in their works. Our findings are in agreement with the which was done in Netherlands showed that how health care environment may affect patients experience of quality of care.²⁶ The study also found that HCW improved their documentation of women LWHA. Through training provided it improved their IPV documentation because they were provided with registers and monthly summary from to record all the IPV cases. This helped them to have improved clinical documentation, follow and linkages. Our study is same with other study done in Spain on developing a program theory to explain how primary HCW teams learn to respond to IPV.^27,28

In this study we had limitations. We only interviewed HCW working at CTC and PMTCT at Singida regional hospital to see their roles and support they provide to women LWHA experienced IPV. Also, we used qualitative study design to explore their views and experiences in caring and support of women LWHA experiencing IPV. The funding of the study can’t be generalized. We recommend larger quantitative study to look at various thematic area and other clinics in Singida region.

CONCLUSION

This study concludes that HCW had a very important role in provision of care and support for women LWHA experiencing IPV attending their CTC and PMTCT. Their understanding and perception towards women LWHA who experienced IPV helped them to be able to provide their care and support such as provision of emergency medical services which was associated with IPV, health education in terms of how to cope with their IPV life and their HIV diseases, counselling services which helped women LWHA to relieve their psychological pains, helped them to adhere to their ARV medication and their CTC clinics, and also HCW provided referral services to the social welfare where women LWHA were helped to get their basic need of their children’s from their violent male partners, legal services where they can claim their right and police as the initial process understanding of the HCWs’ attitudes and perceptions is necessary for the provision of integrated and holistic health care. Furthermore, HCW had a sympathetic listening which helped women LWHA to express themselves and feel more relaxed when they come to their care and treatment clinics. HCW respected women LWHA experiencing IPV regardless of their cultural differences made women LWHA experiencing IPV to be valued and respected. We recommend government of Tanzania ministry of health, community development, gender, elderly and children to provide training of IPV to HCW working at CTC and PMTCT, regular IPV updates of IPV, community health education to create IPV awareness so that the whole community will understand how to prevent IPV at the community and at the facility level among women of all age regardless of their HIV status.

ACKNOWLEDGEMENTS

The authors acknowledge the Singida regional administrative secretary, the Singida regional hospital administration, the field assistant, all health care workers working at CTC and PMTCT section who provided their precious time and useful information for this study.

Funding: This study was conducted with support from the Swedish agency for research co-operation (SIDA) under capacity building.

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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