Health worker attitudes toward clients
Provider attitudes toward clients can constitute serious challenges to integration. Staff who are unwilling to engage in discussions of sexuality with clients can inhibit service integration (Kennedy et al. 2011). Health workers in prevention of mother-to-child transmission (PMTCT) and HIV treatment settings have a tendency to emphasize condoms and neglect other contraceptive methods (FHI 2010b; Schwartz 2011; Mbatia et al. 2011), and some health workers have misconceptions about the appropriateness of other contraceptive methods for people living with HIV (PLHIV) (FHI 2010a). Some providers believe that PLHIV should not enjoy healthy sexual relationships or become pregnant (FHI 2010a and 2010b; Holt et al. 2011; Wilcher 2011; Gilmer and Baughan 2010; Agadjanian and Hayford 2011). Studies in several African countries, including South Africa and Mozambique, found that health workers often believe that young women shouldn’t have sex and therefore shouldn’t use condoms or even receive FP services; some providers also believe that young women tend to ignore FP information anyway (Holt et al. 2011; Gilmer and Baughan 2010; Agadjanian and Hayford 2011).
|
“If you are not married why [is there any need to] use a condom?” —HIV counselor (Holt et al. 2011, slide 9) |
Provider attitudes unrelated to clients’ sexual behavior are also significant in the context of service integration. Agadjanian and Hayford (2011) considered how sociocultural challenges affect provider-client relationships for FP/HIV services in southern Mozambique. Nurses felt that their salaries and benefits, such as adequate housing, were not commensurate with their increased responsibilities under integration. In addition, nurses have typically completed higher educational levels than have their clients, and many come from urban areas. Negative stereotypes about “backward” rural people therefore persist, such as: rural clients are incapable of making and carrying through optimal decisions about their reproductive health, including choice and use of FP methods; female clients are completely controlled by their husbands; rural HIV-positive women do not disclose their status to their husbands out of fear; and rural men are opposed to fertility regulation and FP use. Agadjanian and Hayford recommended that policies focus on educating staff to foster greater understanding and sensitivity of social and cultural obstacles to FP among the rural population.
Yet health workers’ understanding of the benefits of integration may contribute to their job satisfaction. Health workers interviewed for several studies noted that integration can lead to an increase in client uptake of services and reduce the need for multiple return visits or referrals, which clients may not seek after leaving the first facility (Nielsen-Bobbit et al. 2011; Scholl and Cothran 2011). Health workers in Kenya and Swaziland reported that due to the increased efficiency of services, client satisfaction improves, which in turn has a positive effect on health workers’ own satisfaction (Kuria 2011; Scholl and Cothran 2011; Mengistu et al. 2011). Indeed, Awadhi et al. (2011) found that 97% of health providers surveyed in Tanzania supported FP/VCT integration. Church, Simelane, and Mayhew (2010) described providers as “enthusiastic about the concept and potential benefits of integrating [sexual and reproductive health] into HIV services.”