Abstract
Efforts to control the Human Immunodeficiency Virus epidemic in Rwanda have seen remarkable success over the years. Effective antiretroviral therapy has played great role in improving longevity among people living with HIV/AIDS (PLWH). While this is the case, there are various nutritional challenges, which are often faced, among PLWH. Guided by the Rwanda country guidelines for nutritional management for PLWH and WHO recommendations, this study aimed to explore the perspectives of health care providers (HCPs) working with PLWH on nutritional challenges faced by their clients in Kigali, Rwanda. We conducted a qualitative study using in-depth interviews to collect data. A non-probability purposive sampling was employed to recruit HCPs. Data analysis was based on the naturalistic paradigm. We followed the hybrid approach in conducting thematic analysis. Three themes were identified. First, HCPs had good knowledge on nutritional requirements for PLWH. They demonstrated good communication skills and adequate counseling skills that were necessary for addressing concerns on nutrition from their clients. Secondly, it emerged that HCPs perceived a lack of resources to be the major challenge faced in nutritional management of their clients. From theme three, it emerged that, from HCPs experiences, food insecurity and lack of feeding supplements were the main causes of malnutrition among PLWH in Kigali, Rwanda. From the HCPs perspective, there is a need to improve healthcare institutions capacity to manage nutritional challenges faced by PLWH. To achieve this, policy makers need to channel adequate resources for this cause.
Author Contributions
Academic Editor: Angela Pia Cazzolla, Department of Dentistry and Child Complex Operating Unit of Dentistry at the University of Bari
Checked for plagiarism: Yes
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Copyright © 2020 Tafadzwa Dzinamarira, et al.
This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Competing interests
The authors declare that they have n competing interests, which may have inappropriate influenced them in writing this article.
Citation:
Introduction
Efforts to control the Human Immunodeficiency Virus (HIV) epidemic in Rwanda have seen remarkable success over the years 1, 2, 3. Available evidence shows that as of June 2017, 87% of all people living with HIV (PLWH) in Rwanda know their HIV status. Of those with knowledge of their status, 94.8% were on ART, and 86.4% of those on ART were virally suppressed 4. Not surprisingly, The Joint United Nations Programme on HIV/AIDS (UNAIDS) has reported Rwanda to be one of the countries nearing epidemic control 5. Good nutritional status is critical for PLWH. In 2004, the World Health Organization (WHO) spelt out nutritional requirements for PLWH 6. Since then, various scholars have strived to show the link between good nutrition and quality of life for PLWH 7, 8. Further, poor nutrition has been associated with poor adherence to antiretroviral treatment (ART) resulting in preventable morbidity and mortality 9.
Per Jesson et al., 2015, indicated that lack of nutritional support is an important challenge among PLWH in sub-Saharan Africa 10. Similar findings have been reported by other scholars 11, 12, 13, 14. Other nutrition related challenges reported include food insecurity 11, 12, 13, 14. The health care provider has a primary role in nutritional support for PLWH 15, 16. However, few researchers have explored health care providers’ perspectives on nutritional management of their HIV positive clients.
The aim of our work was to explore health care providers’ (HCPs) perspective on nutritional management for PLWH in Kigali, Rwanda. We guided our exploration based on the Rwanda country guidelines for nutrition management for PLWH 17 and guidance from WHO 15
Methods
Study Design, Setting and Sampling
This study is part of a larger study on assessment of dietary status and associated factors among PLWH in Kigali, Rwanda. The main study protocol has been submitted elsewhere for publication consideration. As part of the main study, we conducted a scoping review on nutrition challenges faced by PLWH in sub-Saharan Africa 18, 19, a qualitative study
assessing PLWH perspectives on factors that affect their feeding habits 20, and a cross sectional study 21 to assess dietary status and associated factors among PLWH in Kigali, Rwanda. Here we present a qualitative study using in-depth interviews with HCPs working with PLWH at three tertiary hospitals in Kigali Rwanda was conducted. For purposes of this study, the term health care provider refers to an individual working at a comprehensive care department as a supervisor or in direct day- to day contact with PLWH. A non-probability purposive sampling was employed for the selection of HCPs. Saturation of information controlled the sample size 22.
Data Collection and Analysis
Nutrition Care and Support for People Living with HIV/AIDS 15 guided our interview guide content and structure. Interviews were conducted by the researchers in a private room at the study site. Interviews were conducted in Kinyarwanda, the local language, tape-recorded and transcribed verbatim. We conducted translation and back translation of the transcripts to ensure no loss of data. Study participants checked and validated the transcripts. We used prolonged engagement 23, 24 to ensure credibility. Prior to data collection, pilot testing of the interview guide 25, 26 by conducting three interviews with HCPs working with PLWH at a non- study site was done to ensure dependability. Data analysis was based on the naturalistic paradigm. We followed the hybrid approach in conducting thematic analysis 27. With this approach; some themes were based on the interview guide, while others were derived directly from the text data. Hybrid approach limits researcher bias due to pre-conceived ideas or theoretical perspectives 27, 28, 29. We used NVivo version 12 software to manage the data.
Results
Saturation was reached after a total of 15 interviews were conducted with heath care providers. Of these, 12 were nurses working with PLWH on a day- to-day basis while three 3 were clinic managers. More information on the informants is available on Table 1 Three major themes emerged from the analysis.
Table 1. Presentation of informants by job title and years of experience working with PLWH| Informant number | Job title | Years of experience |
| HCP-1 | Counsellor/Nutritionist | 4 |
| HCP-2 | Counsellor/Nurse | 3 months |
| HCP-3 | Counsellor/Nurse | 6 |
| HCP-4 | Counsellor/Nurse | 1 |
| HCP-5 | HIV Clinic Manager | 15 |
| HCP-6 | Counsellor/Nurse | 4 |
| HCP-7 | Counsellor/Nurse | 7 |
| HCP-8 | Counsellor/Nurse | 10 |
| HCP-9 | HIV Clinic Manager | 12 |
| HCP-10 | Counsellor/Nutritionist | 2 |
| HCP-11 | Counsellor/Nutritionist | 4 |
| HCP-12 | HIV Clinic Manager | 13 |
| HCP-13 | Counsellor/Nurse | 1 |
| HCP-14 | Counsellor/Nurse | 9 |
| HCP-15 | Counsellor/Nurse | 6 months |
Theme one showed HCPs had good knowledge on nutritional requirements for PLWH. They demonstrated good communication skills and adequate counselling skills that were necessary for addressing concerns on nutrition from their clients.
“adequate nutrition, which means consumption of a balanced healthy diet, is vital for health and survival for all individuals particularly our clients living with HIV. We make sure to assess their nutrition status on each visit and provide relevant message to them regarding their diet”.
Theme two revealed HCPs perceived a lack of resources to be the major challenge faced in nutritional management of their clients. From their responses, it also emerged that health care facilities experienced a shortage of information, education, and communication (IEC) materials, necessary resources for providing nutrition education to PLWH.
‘‘while many resources have been allocated to diagnosis and treatment, I feel the aspect of nutrition is neglected. I would say policy makers have to shift focus to improving quality of life for people living with HIV and nutritional support is the first step. The last report showed that we are doing well on 90-90-90.’’
‘‘at our health facility we provide only the sosoma porridge but unfortunately it is not for all patients because we have limited sponsors. Now we have one main sponsor to our clients supporting nutrition. Sometimes the government provides for only the pregnant women and those with severe malnutrition. In addition, for the sponsor, support is limited to those as special cases identified by health care provider and Ubudehe categories.’’
From theme three, it emerged that from HCPs experiences, food insecurity and lack of feeding supplements as main causes of malnutrition among PLWH in Kigali, Rwanda. Under the same theme, a sub- theme exposed the cycle of poor nutrition leading to poor health that in turn leads to PLWH unable to seek employment and afford food. Not surprisingly, HCPs reported that in their experience PLWH who had disclosed their HIV status to family members tend to receive more nutritional support from family members that their counterparts who would have not yet disclosed. ‘‘in my experience, I have never encountered a client who told me they do not eat any food item because it is considered to be for the low class people.
In fact, I think majority of the clients actually do not have adequate food to eat. This is a serious issue. I would call on MoH Ministry of Health to see how they can help us to do fund food supplements at all health centers in Rwanda so that all people living with HIV/ AIDS may get it accordingly as it help them while taking the ARVs”.
‘‘One of the main factor that affects their nutritional status is availability of the food for our clients are, some even report lack of energy for doing some physical work so you see unemployment issues are common among them”.
Discussion
Based on the findings of the study, the HCPs had good knowledge on nutritional requirements for PLWH. They demonstrated good communication skills and adequate counselling skills that were necessary for addressing concerns on nutrition from their clients. A study, which was carried out by Weldegebrealet al. noted that some of the main nutritional issues for PLWH include healthful dietary principles and food safety 30. As a result, HCPs should be in a position to have solid knowledge on the nutritional requirements of their clients. Earlier work done by 31 also substantiate the finding of the current study which revealed the huge role of communication in the continuum of HIV care and treatment.. The study generally noted that health communication is capable of improving HIV treatment, care, and prevention. Similar findings have been reported by Walsh et al. 32. HCPs charged with dissemination of information concerning various nutritional aspects to PLWH should thus use effective communication strategies to ensure that the messages are delivered. This is similar to the findings of a 2014 case report by Storey et al. 33. Further, In Uganda, a study by Bukusuba et al. noted that support groups of the PLWHA are effective strategies, which can be used for the communicating nutrition information and for the implementation of various projects, which are linked to nutrition 34.
The findings of the study also revealed HCPs perceived lack of resources as one of the major challenges faced in nutritional management of their clients. The study noted that health care institutions experienced a shortage of IEC materials and other resources necessary for providing nutrition education to PLWH. Similar findings have been demonstrated by studies carried out in Iran and Lesotho 35, 36. For instance, the findings of a study, which was done by Hamzeh et al. noted that inadequate food intake because of limited resources is one of the main causes of malnutrition among PLWH in Kermanshah, Iran 35. In a separate study, which was carried out by Koto and Maharaj 36, the findings indicated that poor infrastructure, as well as shortage of supplies in various healthcare organizations in Lesotho have significantly hindered the HCPs from carrying out their duties in an effective manner. The study also noted the heavy workload, as well as the severe time constraints that put huge stress on HCPs and in particular those working with PLWH. In Mozambique, Jaiantilal et al. also noted that the healthcare institutions grapple with various work environment barriers, which are linked to limited resources 37. In this qualitative study, HCPs cited high patient load, time constraints, as well as frequent staff turnover 37. In China, Laiyi Kang 38 also noted that lack of adequate resources is a key hindrance when it comes to HCPs carrying out their works. It can thus be concluded that lack of adequate resources at health care facilities to support nutritional management of PLWH is a key challenge. This calls for adequate resource allocation to ensure improved health outcomes for PLWH.
The current study also noted that based on the HCPs experiences, food insecurity and lack of feeding supplements were noted to be the main cause of malnutrition among PLWH in Kigali, Rwanda. This is similar to the findings of the study, which was done by Anema, which noted that food insecurity is a huge barrier when it comes to nutritional management of PLWH 39. The study noted that various nutrition interventions should be integrated into HIV/AIDS treatment and care programs. This is consistent with calls from other scholars in Senegal 14 and Zimbabwe 13. There is need to address food insecurity among PLWH to improve health outcomes 12, 40.
Conclusion
This study mainly aimed to explore HCPs’ perspective on nutritional management for PLWH in Kigali, Rwanda. From the HCPs perspective, there is need to improve healthcare institutions capacity t manage nutritional challenges faced by PLWH. T achieve this, policy makers need to channel adequat resources for this cause.
Consent to Publish
Not applicable
Availability of Data and Materials
If needed the raw data used for this article i available upon reasonable request in writing to th corresponding author with approval from The University Teaching Hospital of Kigali and Rwanda Military Hospital Ethical Committees.
Funding Statement
No funding was received for this study.
Authors’ Contributions
TD conceived and designed the study and data analysis, contributed analysis tools, performed the analysis, and wrote the paper.
GP collected the data and contributed to data analysis
MH supervised data collection and contributed to data analysis
RO supervised data collection and contributed to data analysis
All authors read and approved the final manuscript
Acknowledgements
We thank all participants who took time to participate in the interviews for this study.