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Community Health
Community health nurses’ HIV health promotion and education programmes: a qualitative study M. Abe1 RN, BN, S. Turale2 T. Supamanee4, RN, PhD
RN, DEd, FACN, FACMHN, A.
Klunklin3
RN, PhD
&
1 Nurse, Bunkyo Health Service Center, Tokyo, Japan, 2 Professor, International Nursing, 3 Associate Professor and Associate Dean, Planning and Community Services, 4 Instructor, Faculty of Nursing, Chiang Mai University, Chiang Mai, Thailand
ABE M., TURALE S., KLUNKLIN A. & SUPAMANEE T. (2014) Community health nurses’ HIV health promotion and education programmes: a qualitative study. International Nursing Review 61, 515–524 Background: Globally, nurses practice in many settings with people with human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS), taking an increasing share of the professional burden of care and helping to reduce morbidity and mortality. International literature is sparse about Thai community nurses providing primary healthcare programmes for people with HIV. Aim: This study aimed to describe background, experiences and strategies of community nurses regarding their design and delivery of programmes for people living with HIV and AIDS in Chiang Mai Province, Thailand. Design: This study used a qualitative mixed-methods study employing a qualitative survey and in-depth interviews. Methods: Twenty community health nurses from 18 small community hospitals completed a survey comprising demographic data and 13 open-ended questions. Four of them later engaged in in-depth interviews using the same questions. Survey, interview data and field notes were analysed using interpretive content analysis. Findings: Four themes and six sub-themes portrayed participants’ rich experiences and knowledge of HIV health promotion and education; challenges of daily work, discrimination and ethical issues; success through programme diversity comprising promotion of community volunteerism, networking and relationships; and holistic connections with Thai cultural traditions and Buddhism. Conclusions and implications for practice: Findings help to recognize the diversity, uniqueness and contributions of Thai community nurses regarding culturally appropriate health promotion and education programmes for people living with HIV and AIDS. Findings inform nurses and health officials in and outside of the country to complement innovation in future HIV health promotion and education programmes. Limitations: Our sample came from one province of Thailand. Findings might not be reflective of nurses elsewhere. Implications for health and nursing policy: Three decades of collective experience in providing holistic and multifaceted HIV and AIDS nursing care, education and health promotion by community health nurses have the potential to effect new and existing policies and protocols on HIV community care in Thailand, but more research is required for this.
Correspondence address: Sue Turale, Faculty of Nursing, Chiang Mai University, Room N4-214, Office of the Dean, 110 Inthawaroros Road, Chiang Mai 50200, Thailand; Tel: +66-(0)53-949130; Fax: +66 (0) 53-217145 ; E-mail: [email protected].
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Keywords: AIDS, Community Health Nursing, Content Analysis, Culture, Health Education, Health Promotion, HIV, Mixed Methods, Nursing
Introduction In 2001 Tlou recognized that, globally, nurses were at the forefront of care for people living with human immunodeficiency virus (HIV) (PLWH), and were involved in many areas of prevention and treatment. Nursing as a profession is now taking greater responsibility for the clinical management of HIV, especially as the global burden of the epidemic continues to grow (Callaghan et al. 2010), and this has implications for the development of nursing education policies, health policies and nursing practice at tertiary, secondary and primary levels of care. Nurses’ work in a range of settings has evolved from the early days of the HIV and acquired immune deficiency syndrome (AIDS) epidemic and includes early assessment and interventions to improve the quality of life of PLWH, providing daily comfort during AIDS-related illnesses, palliative care situations caring for the dying, maternal and child health settings, counselling and mental health, and working with families and communities for whom epidemic has left its toll. Nurses have also been involved in stream-lined counselling and rapid testing for HIV (Anaya et al. 2008). Moreover, in rural and remote areas around the world, health care is often delivered under conditions of poor resources, staff shortages (Dussault & Franceschini 2006) and much hardship. HIV continues to challenge improvements to world health today. Since the start of the devastating epidemic, ≈75 million people have become infected with HIV, and ≈36 million have died from AIDS-related illnesses (UNAIDS 2013a). In 2012, there were ≈35.3 million PLWH; however, mortality levels are falling globally; ≈1.6 million people died from AIDS-related causes in 2012 compared with ≈2.3 million in 2005 per PubMed record (UNAIDS 2013a). Reasons for this include success with primary prevention programmes and better availability of effective anti-retroviral treatment (ART). Today HIV is considered a treatable chronic condition. There are increasing lifespans and reducing co-morbidities; for example, immediate ART among new tuberculosis patients with HIV (regardless of CD4 count) is now the single most important predictor of survival from a tuberculosis episode (UNAIDS 2013a). Further, improvements in ART treatment coverage globally contributed to the decline of AIDS/tuberculosis mortality, which dropped from 20.4/ 100 000 people in 2001 to 3.34/100 000 in 2012 (UNAIDS 2013b). However, such statistics do not portray the contribu-
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tions of nursing in ameliorating morbidity and mortality rates, such as the efforts of community health nurses (CHNs) in HIV health promotion and education programmes, which is the subject of this article. Short history of HIV and AIDS in Thailand
In Thailand, the first case of AIDS was reported in 1984 in Bangkok, and HIV rapidly spread through the population. In 1995, ≈800 000 Thais were infected, and in 2000, ≈1 million (Ruxrungtham & Phanuphak 2001). Healthcare systems were overwhelmed. During this period, Weniger et al. (1991) described a second wave of the epidemic as exploding in 1989 in Chiang Mai Province where 44% of commercial sex workers were found to be infected. Moreover, because of high infection rates and lack of effective treatment, sufferers faced death from AIDS, affecting the socio-economic stability of families and the country, and leaving communities decimated with many orphans to be cared for, often by remaining spouses, ageing grandparents or orphanages. This province is where the present study was located. The epidemic spread across northern Thailand and by 1995, Chiang Mai Province had the largest number of people diagnosed with HIV or AIDS in the country, with 41% of households experiencing an AIDS-related death, especially among the poor and less educated (Pitayanon et al. 1997). Thai government and non-government organizations implemented HIV/AIDS prevention programmes, resulting in a decrease of AIDS-related deaths (Punpanich et al. 2004). This included the ‘100% condoms’ programme in which nurses and health workers distributed and explained the use of condoms, and taught about AIDS in many settings. This programme, as well as government policy that instructed commercial sex workers to use condoms, markedly dropped new infection rates (UNAIDS 2000). Other community-based prevention and treatment programmes began in the mid-1990s (Natpratan 1998). Early primary prevention programmes in Thailand were responsible for helping to reverse the severity of the epidemic (Merson et al. 2008), and the country’s public policy on AIDS was widely cited as one of the few examples of an effective national AIDS prevention programme globally (Ainsworth et al. 2003). In particular, Thai government policy during 2004–2006 to extend ART to a large number of HIV-infected population had a significant effect on reducing morbidity and increasing the lifespan of infected individuals, especially those with
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co-morbidities (Maneesriwongul et al. 2006). As a result in 2012, 232 816 Thais received ART out of a possible 280 000 people with HIV (UNAIDS 2013b). From our collective experiences, we know that Thai CHNs have been involved from the early stages of multidisciplinary attempts to develop and implement HIV prevention programmes, often wrestling with significant problems, especially in resource poor rural areas. Although we believe their work has contributed significantly to Thailand’s successful reduction of morbidity and mortality rates, there are neither few descriptions of this nor evidence in international or Thai literature. It is important to recognize the crucial work of these CHNs and their role in primary prevention and education programmes. This will add to the knowledge base of nursing and that of other health professionals, policy makers and health administrators so that their strategies for HIV promotion and education can be considered for implementation elsewhere, and may encourage more research on the topic.
Aim This study aimed to explore the background, experiences and strategies of CHNs providing HIV health promotion and education programmes in Chiang Mai Province, northern Thailand.
Methods
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being a registered nurse, working as a CHN based in one of 23 community hospitals located across the province and being a provider of HIV health education and promotion programmes. We used a purposive sample (Holloway & Wheeler 2013) of CHNs who had first-hand knowledge and experiences about the topic. Recruitment was undertaken at a provincial meeting of CHNs, where verbal and written information about the study and a survey were disseminated, and participation invited. Data collection
Qualitative data were collected in 2011–2012 through The Health Promotion and Teaching for People living with HIV Survey (hereafter ‘the Survey’) and in-depth interviews. Surveys and interviews are two common data collection strategies in qualitative research (Speziale & Carpenter 2011) and can be used for mixed methods to gain deeper insight into the phenomena. After a literature review, we designed the Survey to include 13 open-ended qualitative items (see Table 1). The Survey was first developed in English, and two bilingual members of our research team translated it into Thai. It was then back-translated, and the cultural appropriateness and understandability of questions were confirmed by three Thai nurses with expertise in HIV and AIDS before being distributed. Respondents were asked to answer open-ended questions in the spaces provided and to indicate if they would like to engage in an in-depth interview by providing separate personal contact
Design and framework
This qualitatively driven mixed-method study (Morse & Cheek 2014) employed a qualitative survey, followed by in-depth interviews. This mixed-method design, as described by Morse & Niehaus (2009) and (Morse 2003), consisted of a project that could be published by itself (the qualitative survey) and an additional supplemental strategy (in-depth interviews) that was incomplete in itself, for such data can only be interpreted in the context of the core component (the survey). Further, data from the in-depth interviews were incomplete because qualitatively they lacked saturation (Morse & Cheek 2014). Moreover, qualitative research assists in providing a context to explore the social, cultural, political and temporal context in which participants work (Holloway & Wheeler 2013). The theory of social integration (social networks and social support) and social relations in health provided theoretical foundations (Berkman et al. 2000) for this study in that community nurses provide social support (care, health promotion and education) and draw together social networks to assist people in need.
Table 1 Items used in survey and in-depth interviews with community health nurses How were you educated to be involved in this programme? How many years of experience do you have with HIV/AIDS education/health promotion? Please describe what other kinds of work you do, besides teaching HIV/AIDS education? What is your main role in your current employment? What kinds of images do you have about HIV/AIDS? What are the main elements of your teaching programme? Where do you teach it and how do you teach it? Please describe about your participants. What aspects of the programme work well? What aspects need to be improved? What are the main issues in delivering this education programme to people with HIV/AIDS in rural areas? What was the feedback, if any, from communities or individuals about the programme? Is there anything else you would like to say?
Participants and setting
The regional setting for this study is mountainous and home to Thais and ethnic minorities. Inclusion criteria were threefold:
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AIDS, acquired immune deficiency syndrome; HIV, human immunodeficiency virus.
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information. The Survey posted was back or collected confidentially by a CHN leader. Field notes were also written during the study. Interviews were digitally recorded in English or Thai, or both, depending on an interviewee’s language abilities and preference. Except for demographic data, the same survey questions were used in interviews, with additional prompting questions to ensure in-depth responses and clarity about explicit phenomena. All research team members were present during interviews. The two Thai researchers were known to them, so they were comfortable in their presence, willing to answer questions or elaborate in English and/or Thai, and participants clearly stated they did not feel uncomfortable or intimidated about four people being present. When required, the two Thai researchers interpreted questions and answers in English and Thai to make sure that understanding was accurate (Squires 2008) across cultures with the native English-speaking and native Japanesespeaking researchers. Interviews lasted ∼60–75 min. Ethical considerations
The study was approved by the Ethics Committee of the Faculty of Health Sciences, Yamaguchi University, Japan, and endorsed by the research ethics committee, Faculty of Nursing, Chiang Mai University, Thailand. Approval was also given by a leader of CHNs in the province. Every attempt was made to protect participant confidentiality and anonymity in the study, and return of the completed Survey assumed participant consent. Participants did not disclose their name on the Survey but completed a separate page if they were willing to be interviewed. Before interviews, participants were again given verbal and written information about the study, and written consent was obtained. They were asked not to reveal any information that could identify any of the people they were educating or caring for. Participants could refuse to answer any question during interview or withdraw from the study at any time without negative consequences. Data analysis
Relevant survey and interview data in Thai were translated and back-translated from Thai to English independently by two bilingual researchers, and demographic data analysed using descriptive statistics. All members of the team were involved in data analysis in English. The qualitative descriptive approach employs interpretative content analysis, oriented towards summarizing information arising from data (Sandelowski 2000), and we used this method for combined data analysis of the Survey open-ended questions, transcribed interviews and field notes to attempt to provide rich description of the CHNs’ experiences and work practices in health promotion and health
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education. Data were read several times, before coding and synthesizing ideas line by line by the researchers separately. Next, interpretation of findings was undertaken between the researchers to determine the major themes and sub-themes arising from the data. At last, data outputs were re-contextualized and discussed until consensus was reached within the team, and confirmed by member checking.
Rigor and trustworthiness
We believe that rigor and trustworthiness (Lincoln & Guba 1985) were obtained in this study through the principles of dependability, credibility and confirmability. Interviews were conducted by same investigators using an interview guide, and we were all involved in data analysis. Credibility was maintained by interviewing those who knew most about the topic and member checks were undertaken with findings. We followed systematic data collection and analytic processes, comparing survey data with interview data and field notes, and wrote thick description of the findings to best describe the experiences and activities of the CHNs, and this was confirmed by member checking. These all helped to ensure rigorous study processes.
Findings Of the 30 surveys distributed, respondents returned 23 fully completed survey, a return rate of 76.6%. Four respondents volunteered for in-depth interviews. Three themes and related sub-themes are described next.
Theme 1: Rich experiences and knowledge of HIV health promotion and education
Demographics of respondents are contained in Table 2. The majority were female (n = 22, 95.7%), >41 years (n = 12, 52.8%) and 19 (82.6%) had a bachelor degree in nursing. Four (17.4%) had a master degree with specializations in HIV/AIDS and community health. Half had >11 years of experience working with PLWHA, with three (13.04%) having 21–25 years of experience. Seven (43.4%) had between 1 and 5 years of experience teaching HIV education programmes, while seven (30.43%) had 6–10 years. The remainder (n = 6, 28%) had >11 years of experience, while one (4.34%) had >21 years of experience. All respondents had undertaken advanced courses of various kinds and regularly attended HIV courses and updates in the province and elsewhere, such as Ministry of Public Health (2012) training on ART, choosing healthy foods or family planning. Two of four interviewees and 14 (65%) of those completing the Survey had studied HIV ‘train the trainer’ courses. This was an important part of CHN work since:
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Table 2 Demographics of participants (n = 32) Demographic characteristics
Numbers (n = 23)
Percentage
concentrating their nursing efforts with people with HIV or in HIV prevention due to diverse health problems in their communities. Theme 2: Our challenges
Gender Female Male Age (year) 20–30 31–40 41–50 51–60 Education level Bachelor’s degree Master’s degree HIV/AIDS worker experience 1–5 6–10 11–15 16–20 21–25 HIV/AIDS teaching experience 1–5 6–10 11–15 16–20 21–25
22 1
95.65 4.34
Sub-theme 1: Ordinary work 5 6 11 1
21.73 26.08 47.82 4.34
19 4
82.60 17.39
7 4 3 5 3
30.43 17.39 13.04 21.73 13.04
10 7 2 3 1
43.47 30.43 8.69 13.04 4.34
AIDS, acquired immune deficiency syndrome; HIV, human immunodeficiency virus.
This enables us to train community volunteers or other health care providers. (Interviewee 1) Participants described their work in five different nursing roles: counsellor, care provider, nurse educator, coordinator and case manager. When work experiences and advanced knowledge were combined, they felt they could give effective care or teaching, for example: To do my work well, I join national conferences to update my knowledge and find more knowledge from research and the Internet, and learn from patients. (Respondent 10) Community nursing work involved providing health promotion and care for community members with a diverse range of health needs apart from those who were HIV infected, for example, in disease screening, aged care and mental health education, promotion and counselling. Care was directed across the lifespan, including that for children with HIV, so this emphasized the need for many kinds of required training and updates. Few respondents and interviewees seemed to have the luxury of just
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This theme had three sub-themes described next.
Various nursing challenges occurred daily, but many positive achievements were often underestimated by community nurses. Their descriptions of ‘ordinary’ work were often recognized by us researchers as ‘extraordinary’ work for we observed that they remained positive and committed under difficult circumstances. For example, in three community hospitals we visited, there were very crowded, very hot and noisy areas where clients and health workers had little privacy to deal with sensitive issues. The CHNs had little office space nor quiet places for education or counselling sessions. Moreover, because they were dealing with the impact of HIV in rural communities, their work involved all age groups, spread across wide geographic areas and they had high caseloads of people infected with HIV. They often relied on volunteers to transport patients as hospital vehicles and human resources were limited. Three interviewees explained about their community nursing caseloads of people with HIV: We have about 150 cases, 90 are women; . . . about 300 cases, 150 women; Heavy workloads here . . . 365 cases, about half women. There were ongoing competing pressures from wide-ranging activities in health education and health promotion, and the community nurses’ image of HIV was that it was a complex condition, a process that required continuing educational updates; for example, interviewees said: . . . it is a chronic disease. It needs continual care . . . It is challenging. We have to continue to update knowledge . . . The work is a process . . . we have to continually develop ourselves. Sub-theme 2: Women, discrimination and truth telling
Issues of discrimination against people with HIV was an ongoing challenge with clients, and especially within the rural communities. Three interviewees considered the ‘truth telling’ of clients, HIV infected, as an ethical concern. For example, some female clients had remarried after their previous husband
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had died of AIDS but did not tell their new husband of their positive HIV status. Nurses tried to persuade them to tell the truth to their husbands to prevent cross-infection: We try to convince them to tell their husband, but (we) cannot force them . . . cannot. (Interviewee 2) Such women needed a partner in life to understand and share their feelings, to take care of them and their children emotionally and materially, and they wanted to be ‘normal’ married women. They worried that if they told the truth about their HIV status, they would lose their new husbands whom they relied on heavily for socio-economic support. These women had knowledge about HIV prevention, but sometimes were not concerned with getting regular Pap smears or avoiding unplanned pregnancies. In Thai culture women are the main caregivers for their family and those with HIV often put their own personal needs to one side. Participants believed that women were clearly worried about possible discrimination and rejection by their husband or others. In trying to prevent the spread of HIV, community nurses were clearly confronted by this ethical issue on a regular basis. Sub-theme 3: Other challenges of care
This included delays in or stoppage of treatment, for example, a person infected with HIV: . . . might move to another province and does not continue HAART. This causes delays in treatment and our lack of continuing (care) with them . . . (Interviewee 2)
Sub-theme 1: Volunteerism and developing good relationships
Survey and interview data revealed that the development of interconnected community relationships with a wide range of individuals, families and organizations was foundational to participants’ success in health promotion and education programmes. Participants strived to maintain wide-ranging networks and good working relationships with hospital staff, community leaders and village health workers, as well as other health professionals within Chiang Mai City. Survey responses did not mention about volunteerism; however, all four participants interviewed talked in-depth about this. In the province, over many years, volunteers had helped communities and health professionals deal with the impact of HIV and AIDS and in spreading health promotion information. The large caseloads of people with HIV could not be managed without volunteers, who provided CHNs with assistance of many kinds, for example: Some volunteers are infected themselves (but) . . . help in home care or transporting patients to hospital. (Interviewee 4) They meet regularly with us . . . volunteers come to hospital to meet and talk with nurses every week. (Interviewee 3) Volunteers also helped with housework and socialization activities with clients where needed. Interviewees and respondents on the survey emphasized that they endeavoured to always maintain good relationships with volunteers and highly valued their support for activities and programmes within the community hospital clinics and communities.
On other occasions: . . . a woman might not seek help until she is really sick because she does not know the treatment is free. (Interviewee 2) . . . (we) have a campaign for everyone who gets pregnant.. . . They should come with their husband to the hospital . . . 85% come with husband, but these are not infected. Around 2% of women are infected while pregnant. (Interviewee 1) Participants also had issues involving migrant workers as well as hill tribe groups in their community hospital region; these added a layer of cultural challenge to CHNs’ work. Field notes revealed observations of several clients in community hospitals from different ethnic backgrounds, but time and access issues did not permit the in-depth exploration of HIV-related matters regarding these people. Theme 3: Success through programme diversity
This had two sub-themes described as follows.
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Sub-theme 2: Connecting with cultural traditions.
Participants worked within a holistic framework of community care, connecting with cultural and social practices. Complementary therapies were commonplace, for example: We work directly with Mommaungs (traditional Thai healing doctors). (Respondent 5) . . . (we) give care using Thai herb medicines . . . (Respondent 10) There were harmonious working relationships with Buddhist monks at local temples to assist HIV-related programmes such as: Monks provide spaces for health promotion within their temples . . . (Interviewee 4) Monks also complemented the work of CHNs in HIV. Apart from giving important spiritual support, they encouraged HIVinfected people to seek care and help one another, and they
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assisted in providing HIV information and counselling. They also encouraged people in health promotion, generally. Because Buddhism is the major form of religious and spiritual practice in Thailand, CHNs also relied on monks to help reduce discrimination. It was clear that the CHNs made good use of their traditional networks and resources where possible, and connected with traditional values and spiritual practices. A reflective field note from one of the researchers explicated that: I had the sense that they (the CHN) had a profound awareness of what they had to do to provide holistic care, despite having difficult working environments. Their cultural connectedness was amazing. Theme 4: Our teaching programmes
This had two sub-themes described next.
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majority of caregivers were women, ‘. . .some who have HIV/ AIDS themselves’ (Interviewee 1). Sub-theme 2: Programme bases and teaching methods
Health promotion/education programmes were based around current policies of the Thai Health Ministry, for example, national guidelines for HIV. Some programmes had been modified by CHNs over the years based on their extensive experiences, tailored to suit clients’ needs, and there was a general sense that they were making progress in caring for people with HIV despite challenges raised above. Where time permitted, face-to-face teaching involved individuals or groups of different sizes in locations described above. Teaching methods included: . . . role plays, demonstrations, group discussions and lectures, using paper, flip charts, models, computer powerpoints or the Internet, pamphlets, charts . . . handouts. (Respondent 15)
Subtheme 1: Different teaching programmes
Programmes required significant planning. For example, preconsideration was given to:
When teaching, the CHNs considered it important to help clients ‘to learn easily without pushing’, and they had to keep in mind their clients’ health literacy skills. Another said:
. . . specific training needed to deliver a program, the actual content, the client with HIV/AIDS, the method of teaching, the types of teaching media required and the appropriate time and place. (Respondent 11)
For those women with HIV, the teaching focus is on self-care, family planning, sexual health, adherence with treatment and looking after general health. (Respondent 8)
Many teaching spaces were utilized: . . . in a client’s home, a temple, schools, a hotel or resort, or at the hospital in the HIV/AIDS Clinic or counselling room. (Respondent 7) The content of education programmes included a wide range of topics such as: Exercise, acupuncture, holistic care, safe-sex promotion, activities of daily living, Thai herbal medications . . . (Respondent 8) Family planning, avoiding maternal-child infections, Pap smears, use of condoms, and pregnancy. (Respondent 9) Health education programmes were also held for people without HIV in a variety of places, schools, villages, primary care units, temples, hotels and resorts. For example, programmes for school students involved safe sex promotion, ‘say no’ skills to sexual activity outside of marriage, and anatomy and physiology for women and younger age groups. Participants also described their numerous education and counselling programmes for family members and caregivers, and for staff and volunteers of healthcare centres and hospitals about HIV and AIDS; medication; home visits; and psychosocial support. The
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After teaching in the clinic, and when time permitted, CHNs visited clients’ homes to deal with issues such as noncompliance with treatment and counselling. Because geographical areas of responsibility and caseloads were large, they relied on the advice and help of the volunteers regarding client problems and drew significantly on social networks for help and assistance. Aspects of programmes that the participants believed worked well were giving information on drug adherence to clients and on sexual health to prevent increasing rates of HIV, choosing a healthy diet, and the importance and encouragement of having a supportive group for clients. However, participants also believed that counselling skills, teaching media, content and evaluation of courses could be improved, as well as their own teaching skills. Individual and community feedback was often sought on the programmes, and Respondent 19 explained this indicated: . . . a continual need to teach and to make program improvements.
Discussion CHNs in Thailand have been significant leaders in primary health care since the start of Thailand’s HIV epidemic, working on ground-level projects and delivering health promotion,
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education and care for individuals, their families and communities (Limprasutra et al. 2011). Many of our participants had been involved with HIV health promotion/education programmes from the beginning of their career and had developed a wealth of experience, and were able to pass this to younger generations of CHNs. Assessment of nurses’ contributions to HIV/AIDS care should include their ability to influence patient experience of care, given the long-term nature of the illness (Tunnicliff et al. 2013). In this study, it was clear that the care they provided was both long-term and holistic in nature. They described a wealth of aspects related to the education programmes they provided in combination with community members, and worked hard to ensure that these were focused within a strong community-oriented framework. Their health promotion and educative activities were spread across the lifespan. This is especially important, given, for example, that care and ART for increasing numbers of children with HIV/ AIDS is a priority in Chiang Mai Province (Chantavichitwong 2008). The CHNs reported using a wide range of educational methodologies to help ensure that clients, community members and volunteers understood and could contribute to better health, and the understanding and acceptance of HIV by the various communities they worked in. This concurs with Merson et al. (2008) in that Thai early prevention successes evolved from collective responses generated by people infected with HIV and community groups, enabling the confrontation of stigma, discrimination and denial associated with the disease. Moreover, CHNs used a wide range of cultural practices for their clients. There was no doubt in our minds that they were challenged by high caseloads of people with HIV and AIDS, in addition to dealing with and caring for people with many other health issues. From a primary health perspective, they truly dealt at the grass roots community level across the lifespan, but believed that the diversity of their programmes and involvement of many in the community help lead to successes in programmes. The CHNs roles involved helping communities accept people with HIV and/or AIDS diagnoses, training and supporting volunteers, and providing education programmes for them; helping to establish community networks; and improving healthcare delivery as well as trying to improve the socioeconomic conditions of these people. Natpratan et al. (1996) described 18 years ago that the early goal of the Thai government was to improve the lives of people with HIV, but today stigma is still a significant issue leading to poor adherence to ART in Chiang Mai (Fongkaew et al. 2014); and discrimination against people with HIV was still a reality for the CHNs in this study. Moreover, discrimination and stigma are still prevalent in Northern Thailand even though, overall, there are now signifi-
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cantly lower rates of HIV infections (Genberg et al. 2009) and this has also been reported within the narratives of nurses in Bangkok (Chan et al. 2008) and in our study. The importance of CHNs working with community volunteers was a consistent theme in our study. Volunteers from all walks of life aspired to help their work, including Buddhist monks. This is a form of merit making, for Thai Buddhists believe that if they perform good deeds in this life, this will please Buddha and improve their karma or fate (Klunklin & Greenwood 2005). In traditional Thai families, women take on multiple roles even if they are infected with HIV themselves, yet their needs tend to be disregarded (Singhanetra-Renard et al. 2001; Songwathana 2001). Northern Thai women with HIV/AIDS expect to experience at least some discrimination (Klunklin & Greenwood 2006) and our four interviewed participants shared their concerns about women not informing their husbands about their prior infection. The CHNs explained that the majority of women depended on marriage to a man who could help support them and their children, providing them with socio-economic and close relationship support. This is consistent with the findings of Klunklin & Greenwood (2005) who reiterated the importance of normalizing a husband and wife relationship for women participants who are infected with HIV. Lastly in the Northern Thailand border areas, there are many hill tribes including those who have fled over the border from Myanmar and among these people, some of our participants provided care for those who were HIV infected. There are also a lot of foreign workers in Chiang Mai Province who need community care and support; however, more research is required about community nursing care for these vulnerable minority groups, and we did not explore these phenomena in detail.
Limitations Our sample was a group of nurses from one province in Thailand, and their perceptions and experiences about HIV education and health promotion maybe quite different to elsewhere in the country. However, the rich findings can be used to inform nurses and other health professionals about innovations in the field of CHN in northern Thailand that might enhance programmes elsewhere.
Conclusion and implications for nursing and health policy We conclude that CHNs in this study had significant and lengthy periods of instructive experiences and in-depth knowledge, and offered a wide variety of health promotion and education for those with HIV, despite having high workload with many kinds of clients. We believe that the findings of this study
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will enhance nursing’s knowledge base about how nurses around the world are attempting to deal with the impact of HIV and the measures used to incorporate culturally driven interventions in health promotion and education in Thailand. Over the last three decades nurses and midwives, including those in Thailand, have had significant roles in the development, implementation and evaluation of primary prevention programmes for people with HIV. Because of their experiences and knowledge, they have developed original, culturally relevant measures for clients, and strong relationships with a variety of key players in HIV and AIDS care. Rich data from this study help to shed light on aspects of health education and health promotion in a province in northern Thailand. This might help community health, education and nursing policy makers with insights regarding enhancing community programmes for people with HIV and AIDS in other parts of Thailand or in other settings internationally. Community nurses in other countries may benefit from the experiences, challenges and successes of their Thai community nursing colleagues.
Conflict of interest No conflict of interest has been declared by the authors.
Acknowledgements We thank the community health nurses for sharing their valuable insights. This study was funded in part by the Faculty of Health Sciences, Yamaguchi University Japan.
Author contributions Design: MA, ST, AK, TS Research supervision: ST Data collection: MA, ST, AK, TS Data analysis: MA, ST, AK, TS Manuscript writing: ST, MA, AK, TS Critical revision and intellectual content: ST
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Community Health
Community health nurses’ HIV health promotion and education programmes: a qualitative study M. Abe1 RN, BN, S. Turale2 T. Supamanee4, RN, PhD
RN, DEd, FACN, FACMHN, A.
Klunklin3
RN, PhD
&
1 Nurse, Bunkyo Health Service Center, Tokyo, Japan, 2 Professor, International Nursing, 3 Associate Professor and Associate Dean, Planning and Community Services, 4 Instructor, Faculty of Nursing, Chiang Mai University, Chiang Mai, Thailand
ABE M., TURALE S., KLUNKLIN A. & SUPAMANEE T. (2014) Community health nurses’ HIV health promotion and education programmes: a qualitative study. International Nursing Review 61, 515–524 Background: Globally, nurses practice in many settings with people with human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS), taking an increasing share of the professional burden of care and helping to reduce morbidity and mortality. International literature is sparse about Thai community nurses providing primary healthcare programmes for people with HIV. Aim: This study aimed to describe background, experiences and strategies of community nurses regarding their design and delivery of programmes for people living with HIV and AIDS in Chiang Mai Province, Thailand. Design: This study used a qualitative mixed-methods study employing a qualitative survey and in-depth interviews. Methods: Twenty community health nurses from 18 small community hospitals completed a survey comprising demographic data and 13 open-ended questions. Four of them later engaged in in-depth interviews using the same questions. Survey, interview data and field notes were analysed using interpretive content analysis. Findings: Four themes and six sub-themes portrayed participants’ rich experiences and knowledge of HIV health promotion and education; challenges of daily work, discrimination and ethical issues; success through programme diversity comprising promotion of community volunteerism, networking and relationships; and holistic connections with Thai cultural traditions and Buddhism. Conclusions and implications for practice: Findings help to recognize the diversity, uniqueness and contributions of Thai community nurses regarding culturally appropriate health promotion and education programmes for people living with HIV and AIDS. Findings inform nurses and health officials in and outside of the country to complement innovation in future HIV health promotion and education programmes. Limitations: Our sample came from one province of Thailand. Findings might not be reflective of nurses elsewhere. Implications for health and nursing policy: Three decades of collective experience in providing holistic and multifaceted HIV and AIDS nursing care, education and health promotion by community health nurses have the potential to effect new and existing policies and protocols on HIV community care in Thailand, but more research is required for this.
Correspondence address: Sue Turale, Faculty of Nursing, Chiang Mai University, Room N4-214, Office of the Dean, 110 Inthawaroros Road, Chiang Mai 50200, Thailand; Tel: +66-(0)53-949130; Fax: +66 (0) 53-217145 ; E-mail: [email protected].
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Keywords: AIDS, Community Health Nursing, Content Analysis, Culture, Health Education, Health Promotion, HIV, Mixed Methods, Nursing
Introduction In 2001 Tlou recognized that, globally, nurses were at the forefront of care for people living with human immunodeficiency virus (HIV) (PLWH), and were involved in many areas of prevention and treatment. Nursing as a profession is now taking greater responsibility for the clinical management of HIV, especially as the global burden of the epidemic continues to grow (Callaghan et al. 2010), and this has implications for the development of nursing education policies, health policies and nursing practice at tertiary, secondary and primary levels of care. Nurses’ work in a range of settings has evolved from the early days of the HIV and acquired immune deficiency syndrome (AIDS) epidemic and includes early assessment and interventions to improve the quality of life of PLWH, providing daily comfort during AIDS-related illnesses, palliative care situations caring for the dying, maternal and child health settings, counselling and mental health, and working with families and communities for whom epidemic has left its toll. Nurses have also been involved in stream-lined counselling and rapid testing for HIV (Anaya et al. 2008). Moreover, in rural and remote areas around the world, health care is often delivered under conditions of poor resources, staff shortages (Dussault & Franceschini 2006) and much hardship. HIV continues to challenge improvements to world health today. Since the start of the devastating epidemic, ≈75 million people have become infected with HIV, and ≈36 million have died from AIDS-related illnesses (UNAIDS 2013a). In 2012, there were ≈35.3 million PLWH; however, mortality levels are falling globally; ≈1.6 million people died from AIDS-related causes in 2012 compared with ≈2.3 million in 2005 per PubMed record (UNAIDS 2013a). Reasons for this include success with primary prevention programmes and better availability of effective anti-retroviral treatment (ART). Today HIV is considered a treatable chronic condition. There are increasing lifespans and reducing co-morbidities; for example, immediate ART among new tuberculosis patients with HIV (regardless of CD4 count) is now the single most important predictor of survival from a tuberculosis episode (UNAIDS 2013a). Further, improvements in ART treatment coverage globally contributed to the decline of AIDS/tuberculosis mortality, which dropped from 20.4/ 100 000 people in 2001 to 3.34/100 000 in 2012 (UNAIDS 2013b). However, such statistics do not portray the contribu-
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tions of nursing in ameliorating morbidity and mortality rates, such as the efforts of community health nurses (CHNs) in HIV health promotion and education programmes, which is the subject of this article. Short history of HIV and AIDS in Thailand
In Thailand, the first case of AIDS was reported in 1984 in Bangkok, and HIV rapidly spread through the population. In 1995, ≈800 000 Thais were infected, and in 2000, ≈1 million (Ruxrungtham & Phanuphak 2001). Healthcare systems were overwhelmed. During this period, Weniger et al. (1991) described a second wave of the epidemic as exploding in 1989 in Chiang Mai Province where 44% of commercial sex workers were found to be infected. Moreover, because of high infection rates and lack of effective treatment, sufferers faced death from AIDS, affecting the socio-economic stability of families and the country, and leaving communities decimated with many orphans to be cared for, often by remaining spouses, ageing grandparents or orphanages. This province is where the present study was located. The epidemic spread across northern Thailand and by 1995, Chiang Mai Province had the largest number of people diagnosed with HIV or AIDS in the country, with 41% of households experiencing an AIDS-related death, especially among the poor and less educated (Pitayanon et al. 1997). Thai government and non-government organizations implemented HIV/AIDS prevention programmes, resulting in a decrease of AIDS-related deaths (Punpanich et al. 2004). This included the ‘100% condoms’ programme in which nurses and health workers distributed and explained the use of condoms, and taught about AIDS in many settings. This programme, as well as government policy that instructed commercial sex workers to use condoms, markedly dropped new infection rates (UNAIDS 2000). Other community-based prevention and treatment programmes began in the mid-1990s (Natpratan 1998). Early primary prevention programmes in Thailand were responsible for helping to reverse the severity of the epidemic (Merson et al. 2008), and the country’s public policy on AIDS was widely cited as one of the few examples of an effective national AIDS prevention programme globally (Ainsworth et al. 2003). In particular, Thai government policy during 2004–2006 to extend ART to a large number of HIV-infected population had a significant effect on reducing morbidity and increasing the lifespan of infected individuals, especially those with
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co-morbidities (Maneesriwongul et al. 2006). As a result in 2012, 232 816 Thais received ART out of a possible 280 000 people with HIV (UNAIDS 2013b). From our collective experiences, we know that Thai CHNs have been involved from the early stages of multidisciplinary attempts to develop and implement HIV prevention programmes, often wrestling with significant problems, especially in resource poor rural areas. Although we believe their work has contributed significantly to Thailand’s successful reduction of morbidity and mortality rates, there are neither few descriptions of this nor evidence in international or Thai literature. It is important to recognize the crucial work of these CHNs and their role in primary prevention and education programmes. This will add to the knowledge base of nursing and that of other health professionals, policy makers and health administrators so that their strategies for HIV promotion and education can be considered for implementation elsewhere, and may encourage more research on the topic.
Aim This study aimed to explore the background, experiences and strategies of CHNs providing HIV health promotion and education programmes in Chiang Mai Province, northern Thailand.
Methods
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being a registered nurse, working as a CHN based in one of 23 community hospitals located across the province and being a provider of HIV health education and promotion programmes. We used a purposive sample (Holloway & Wheeler 2013) of CHNs who had first-hand knowledge and experiences about the topic. Recruitment was undertaken at a provincial meeting of CHNs, where verbal and written information about the study and a survey were disseminated, and participation invited. Data collection
Qualitative data were collected in 2011–2012 through The Health Promotion and Teaching for People living with HIV Survey (hereafter ‘the Survey’) and in-depth interviews. Surveys and interviews are two common data collection strategies in qualitative research (Speziale & Carpenter 2011) and can be used for mixed methods to gain deeper insight into the phenomena. After a literature review, we designed the Survey to include 13 open-ended qualitative items (see Table 1). The Survey was first developed in English, and two bilingual members of our research team translated it into Thai. It was then back-translated, and the cultural appropriateness and understandability of questions were confirmed by three Thai nurses with expertise in HIV and AIDS before being distributed. Respondents were asked to answer open-ended questions in the spaces provided and to indicate if they would like to engage in an in-depth interview by providing separate personal contact
Design and framework
This qualitatively driven mixed-method study (Morse & Cheek 2014) employed a qualitative survey, followed by in-depth interviews. This mixed-method design, as described by Morse & Niehaus (2009) and (Morse 2003), consisted of a project that could be published by itself (the qualitative survey) and an additional supplemental strategy (in-depth interviews) that was incomplete in itself, for such data can only be interpreted in the context of the core component (the survey). Further, data from the in-depth interviews were incomplete because qualitatively they lacked saturation (Morse & Cheek 2014). Moreover, qualitative research assists in providing a context to explore the social, cultural, political and temporal context in which participants work (Holloway & Wheeler 2013). The theory of social integration (social networks and social support) and social relations in health provided theoretical foundations (Berkman et al. 2000) for this study in that community nurses provide social support (care, health promotion and education) and draw together social networks to assist people in need.
Table 1 Items used in survey and in-depth interviews with community health nurses How were you educated to be involved in this programme? How many years of experience do you have with HIV/AIDS education/health promotion? Please describe what other kinds of work you do, besides teaching HIV/AIDS education? What is your main role in your current employment? What kinds of images do you have about HIV/AIDS? What are the main elements of your teaching programme? Where do you teach it and how do you teach it? Please describe about your participants. What aspects of the programme work well? What aspects need to be improved? What are the main issues in delivering this education programme to people with HIV/AIDS in rural areas? What was the feedback, if any, from communities or individuals about the programme? Is there anything else you would like to say?
Participants and setting
The regional setting for this study is mountainous and home to Thais and ethnic minorities. Inclusion criteria were threefold:
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AIDS, acquired immune deficiency syndrome; HIV, human immunodeficiency virus.
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information. The Survey posted was back or collected confidentially by a CHN leader. Field notes were also written during the study. Interviews were digitally recorded in English or Thai, or both, depending on an interviewee’s language abilities and preference. Except for demographic data, the same survey questions were used in interviews, with additional prompting questions to ensure in-depth responses and clarity about explicit phenomena. All research team members were present during interviews. The two Thai researchers were known to them, so they were comfortable in their presence, willing to answer questions or elaborate in English and/or Thai, and participants clearly stated they did not feel uncomfortable or intimidated about four people being present. When required, the two Thai researchers interpreted questions and answers in English and Thai to make sure that understanding was accurate (Squires 2008) across cultures with the native English-speaking and native Japanesespeaking researchers. Interviews lasted ∼60–75 min. Ethical considerations
The study was approved by the Ethics Committee of the Faculty of Health Sciences, Yamaguchi University, Japan, and endorsed by the research ethics committee, Faculty of Nursing, Chiang Mai University, Thailand. Approval was also given by a leader of CHNs in the province. Every attempt was made to protect participant confidentiality and anonymity in the study, and return of the completed Survey assumed participant consent. Participants did not disclose their name on the Survey but completed a separate page if they were willing to be interviewed. Before interviews, participants were again given verbal and written information about the study, and written consent was obtained. They were asked not to reveal any information that could identify any of the people they were educating or caring for. Participants could refuse to answer any question during interview or withdraw from the study at any time without negative consequences. Data analysis
Relevant survey and interview data in Thai were translated and back-translated from Thai to English independently by two bilingual researchers, and demographic data analysed using descriptive statistics. All members of the team were involved in data analysis in English. The qualitative descriptive approach employs interpretative content analysis, oriented towards summarizing information arising from data (Sandelowski 2000), and we used this method for combined data analysis of the Survey open-ended questions, transcribed interviews and field notes to attempt to provide rich description of the CHNs’ experiences and work practices in health promotion and health
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education. Data were read several times, before coding and synthesizing ideas line by line by the researchers separately. Next, interpretation of findings was undertaken between the researchers to determine the major themes and sub-themes arising from the data. At last, data outputs were re-contextualized and discussed until consensus was reached within the team, and confirmed by member checking.
Rigor and trustworthiness
We believe that rigor and trustworthiness (Lincoln & Guba 1985) were obtained in this study through the principles of dependability, credibility and confirmability. Interviews were conducted by same investigators using an interview guide, and we were all involved in data analysis. Credibility was maintained by interviewing those who knew most about the topic and member checks were undertaken with findings. We followed systematic data collection and analytic processes, comparing survey data with interview data and field notes, and wrote thick description of the findings to best describe the experiences and activities of the CHNs, and this was confirmed by member checking. These all helped to ensure rigorous study processes.
Findings Of the 30 surveys distributed, respondents returned 23 fully completed survey, a return rate of 76.6%. Four respondents volunteered for in-depth interviews. Three themes and related sub-themes are described next.
Theme 1: Rich experiences and knowledge of HIV health promotion and education
Demographics of respondents are contained in Table 2. The majority were female (n = 22, 95.7%), >41 years (n = 12, 52.8%) and 19 (82.6%) had a bachelor degree in nursing. Four (17.4%) had a master degree with specializations in HIV/AIDS and community health. Half had >11 years of experience working with PLWHA, with three (13.04%) having 21–25 years of experience. Seven (43.4%) had between 1 and 5 years of experience teaching HIV education programmes, while seven (30.43%) had 6–10 years. The remainder (n = 6, 28%) had >11 years of experience, while one (4.34%) had >21 years of experience. All respondents had undertaken advanced courses of various kinds and regularly attended HIV courses and updates in the province and elsewhere, such as Ministry of Public Health (2012) training on ART, choosing healthy foods or family planning. Two of four interviewees and 14 (65%) of those completing the Survey had studied HIV ‘train the trainer’ courses. This was an important part of CHN work since:
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Table 2 Demographics of participants (n = 32) Demographic characteristics
Numbers (n = 23)
Percentage
concentrating their nursing efforts with people with HIV or in HIV prevention due to diverse health problems in their communities. Theme 2: Our challenges
Gender Female Male Age (year) 20–30 31–40 41–50 51–60 Education level Bachelor’s degree Master’s degree HIV/AIDS worker experience 1–5 6–10 11–15 16–20 21–25 HIV/AIDS teaching experience 1–5 6–10 11–15 16–20 21–25
22 1
95.65 4.34
Sub-theme 1: Ordinary work 5 6 11 1
21.73 26.08 47.82 4.34
19 4
82.60 17.39
7 4 3 5 3
30.43 17.39 13.04 21.73 13.04
10 7 2 3 1
43.47 30.43 8.69 13.04 4.34
AIDS, acquired immune deficiency syndrome; HIV, human immunodeficiency virus.
This enables us to train community volunteers or other health care providers. (Interviewee 1) Participants described their work in five different nursing roles: counsellor, care provider, nurse educator, coordinator and case manager. When work experiences and advanced knowledge were combined, they felt they could give effective care or teaching, for example: To do my work well, I join national conferences to update my knowledge and find more knowledge from research and the Internet, and learn from patients. (Respondent 10) Community nursing work involved providing health promotion and care for community members with a diverse range of health needs apart from those who were HIV infected, for example, in disease screening, aged care and mental health education, promotion and counselling. Care was directed across the lifespan, including that for children with HIV, so this emphasized the need for many kinds of required training and updates. Few respondents and interviewees seemed to have the luxury of just
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This theme had three sub-themes described next.
Various nursing challenges occurred daily, but many positive achievements were often underestimated by community nurses. Their descriptions of ‘ordinary’ work were often recognized by us researchers as ‘extraordinary’ work for we observed that they remained positive and committed under difficult circumstances. For example, in three community hospitals we visited, there were very crowded, very hot and noisy areas where clients and health workers had little privacy to deal with sensitive issues. The CHNs had little office space nor quiet places for education or counselling sessions. Moreover, because they were dealing with the impact of HIV in rural communities, their work involved all age groups, spread across wide geographic areas and they had high caseloads of people infected with HIV. They often relied on volunteers to transport patients as hospital vehicles and human resources were limited. Three interviewees explained about their community nursing caseloads of people with HIV: We have about 150 cases, 90 are women; . . . about 300 cases, 150 women; Heavy workloads here . . . 365 cases, about half women. There were ongoing competing pressures from wide-ranging activities in health education and health promotion, and the community nurses’ image of HIV was that it was a complex condition, a process that required continuing educational updates; for example, interviewees said: . . . it is a chronic disease. It needs continual care . . . It is challenging. We have to continue to update knowledge . . . The work is a process . . . we have to continually develop ourselves. Sub-theme 2: Women, discrimination and truth telling
Issues of discrimination against people with HIV was an ongoing challenge with clients, and especially within the rural communities. Three interviewees considered the ‘truth telling’ of clients, HIV infected, as an ethical concern. For example, some female clients had remarried after their previous husband
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had died of AIDS but did not tell their new husband of their positive HIV status. Nurses tried to persuade them to tell the truth to their husbands to prevent cross-infection: We try to convince them to tell their husband, but (we) cannot force them . . . cannot. (Interviewee 2) Such women needed a partner in life to understand and share their feelings, to take care of them and their children emotionally and materially, and they wanted to be ‘normal’ married women. They worried that if they told the truth about their HIV status, they would lose their new husbands whom they relied on heavily for socio-economic support. These women had knowledge about HIV prevention, but sometimes were not concerned with getting regular Pap smears or avoiding unplanned pregnancies. In Thai culture women are the main caregivers for their family and those with HIV often put their own personal needs to one side. Participants believed that women were clearly worried about possible discrimination and rejection by their husband or others. In trying to prevent the spread of HIV, community nurses were clearly confronted by this ethical issue on a regular basis. Sub-theme 3: Other challenges of care
This included delays in or stoppage of treatment, for example, a person infected with HIV: . . . might move to another province and does not continue HAART. This causes delays in treatment and our lack of continuing (care) with them . . . (Interviewee 2)
Sub-theme 1: Volunteerism and developing good relationships
Survey and interview data revealed that the development of interconnected community relationships with a wide range of individuals, families and organizations was foundational to participants’ success in health promotion and education programmes. Participants strived to maintain wide-ranging networks and good working relationships with hospital staff, community leaders and village health workers, as well as other health professionals within Chiang Mai City. Survey responses did not mention about volunteerism; however, all four participants interviewed talked in-depth about this. In the province, over many years, volunteers had helped communities and health professionals deal with the impact of HIV and AIDS and in spreading health promotion information. The large caseloads of people with HIV could not be managed without volunteers, who provided CHNs with assistance of many kinds, for example: Some volunteers are infected themselves (but) . . . help in home care or transporting patients to hospital. (Interviewee 4) They meet regularly with us . . . volunteers come to hospital to meet and talk with nurses every week. (Interviewee 3) Volunteers also helped with housework and socialization activities with clients where needed. Interviewees and respondents on the survey emphasized that they endeavoured to always maintain good relationships with volunteers and highly valued their support for activities and programmes within the community hospital clinics and communities.
On other occasions: . . . a woman might not seek help until she is really sick because she does not know the treatment is free. (Interviewee 2) . . . (we) have a campaign for everyone who gets pregnant.. . . They should come with their husband to the hospital . . . 85% come with husband, but these are not infected. Around 2% of women are infected while pregnant. (Interviewee 1) Participants also had issues involving migrant workers as well as hill tribe groups in their community hospital region; these added a layer of cultural challenge to CHNs’ work. Field notes revealed observations of several clients in community hospitals from different ethnic backgrounds, but time and access issues did not permit the in-depth exploration of HIV-related matters regarding these people. Theme 3: Success through programme diversity
This had two sub-themes described as follows.
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Sub-theme 2: Connecting with cultural traditions.
Participants worked within a holistic framework of community care, connecting with cultural and social practices. Complementary therapies were commonplace, for example: We work directly with Mommaungs (traditional Thai healing doctors). (Respondent 5) . . . (we) give care using Thai herb medicines . . . (Respondent 10) There were harmonious working relationships with Buddhist monks at local temples to assist HIV-related programmes such as: Monks provide spaces for health promotion within their temples . . . (Interviewee 4) Monks also complemented the work of CHNs in HIV. Apart from giving important spiritual support, they encouraged HIVinfected people to seek care and help one another, and they
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assisted in providing HIV information and counselling. They also encouraged people in health promotion, generally. Because Buddhism is the major form of religious and spiritual practice in Thailand, CHNs also relied on monks to help reduce discrimination. It was clear that the CHNs made good use of their traditional networks and resources where possible, and connected with traditional values and spiritual practices. A reflective field note from one of the researchers explicated that: I had the sense that they (the CHN) had a profound awareness of what they had to do to provide holistic care, despite having difficult working environments. Their cultural connectedness was amazing. Theme 4: Our teaching programmes
This had two sub-themes described next.
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majority of caregivers were women, ‘. . .some who have HIV/ AIDS themselves’ (Interviewee 1). Sub-theme 2: Programme bases and teaching methods
Health promotion/education programmes were based around current policies of the Thai Health Ministry, for example, national guidelines for HIV. Some programmes had been modified by CHNs over the years based on their extensive experiences, tailored to suit clients’ needs, and there was a general sense that they were making progress in caring for people with HIV despite challenges raised above. Where time permitted, face-to-face teaching involved individuals or groups of different sizes in locations described above. Teaching methods included: . . . role plays, demonstrations, group discussions and lectures, using paper, flip charts, models, computer powerpoints or the Internet, pamphlets, charts . . . handouts. (Respondent 15)
Subtheme 1: Different teaching programmes
Programmes required significant planning. For example, preconsideration was given to:
When teaching, the CHNs considered it important to help clients ‘to learn easily without pushing’, and they had to keep in mind their clients’ health literacy skills. Another said:
. . . specific training needed to deliver a program, the actual content, the client with HIV/AIDS, the method of teaching, the types of teaching media required and the appropriate time and place. (Respondent 11)
For those women with HIV, the teaching focus is on self-care, family planning, sexual health, adherence with treatment and looking after general health. (Respondent 8)
Many teaching spaces were utilized: . . . in a client’s home, a temple, schools, a hotel or resort, or at the hospital in the HIV/AIDS Clinic or counselling room. (Respondent 7) The content of education programmes included a wide range of topics such as: Exercise, acupuncture, holistic care, safe-sex promotion, activities of daily living, Thai herbal medications . . . (Respondent 8) Family planning, avoiding maternal-child infections, Pap smears, use of condoms, and pregnancy. (Respondent 9) Health education programmes were also held for people without HIV in a variety of places, schools, villages, primary care units, temples, hotels and resorts. For example, programmes for school students involved safe sex promotion, ‘say no’ skills to sexual activity outside of marriage, and anatomy and physiology for women and younger age groups. Participants also described their numerous education and counselling programmes for family members and caregivers, and for staff and volunteers of healthcare centres and hospitals about HIV and AIDS; medication; home visits; and psychosocial support. The
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After teaching in the clinic, and when time permitted, CHNs visited clients’ homes to deal with issues such as noncompliance with treatment and counselling. Because geographical areas of responsibility and caseloads were large, they relied on the advice and help of the volunteers regarding client problems and drew significantly on social networks for help and assistance. Aspects of programmes that the participants believed worked well were giving information on drug adherence to clients and on sexual health to prevent increasing rates of HIV, choosing a healthy diet, and the importance and encouragement of having a supportive group for clients. However, participants also believed that counselling skills, teaching media, content and evaluation of courses could be improved, as well as their own teaching skills. Individual and community feedback was often sought on the programmes, and Respondent 19 explained this indicated: . . . a continual need to teach and to make program improvements.
Discussion CHNs in Thailand have been significant leaders in primary health care since the start of Thailand’s HIV epidemic, working on ground-level projects and delivering health promotion,
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education and care for individuals, their families and communities (Limprasutra et al. 2011). Many of our participants had been involved with HIV health promotion/education programmes from the beginning of their career and had developed a wealth of experience, and were able to pass this to younger generations of CHNs. Assessment of nurses’ contributions to HIV/AIDS care should include their ability to influence patient experience of care, given the long-term nature of the illness (Tunnicliff et al. 2013). In this study, it was clear that the care they provided was both long-term and holistic in nature. They described a wealth of aspects related to the education programmes they provided in combination with community members, and worked hard to ensure that these were focused within a strong community-oriented framework. Their health promotion and educative activities were spread across the lifespan. This is especially important, given, for example, that care and ART for increasing numbers of children with HIV/ AIDS is a priority in Chiang Mai Province (Chantavichitwong 2008). The CHNs reported using a wide range of educational methodologies to help ensure that clients, community members and volunteers understood and could contribute to better health, and the understanding and acceptance of HIV by the various communities they worked in. This concurs with Merson et al. (2008) in that Thai early prevention successes evolved from collective responses generated by people infected with HIV and community groups, enabling the confrontation of stigma, discrimination and denial associated with the disease. Moreover, CHNs used a wide range of cultural practices for their clients. There was no doubt in our minds that they were challenged by high caseloads of people with HIV and AIDS, in addition to dealing with and caring for people with many other health issues. From a primary health perspective, they truly dealt at the grass roots community level across the lifespan, but believed that the diversity of their programmes and involvement of many in the community help lead to successes in programmes. The CHNs roles involved helping communities accept people with HIV and/or AIDS diagnoses, training and supporting volunteers, and providing education programmes for them; helping to establish community networks; and improving healthcare delivery as well as trying to improve the socioeconomic conditions of these people. Natpratan et al. (1996) described 18 years ago that the early goal of the Thai government was to improve the lives of people with HIV, but today stigma is still a significant issue leading to poor adherence to ART in Chiang Mai (Fongkaew et al. 2014); and discrimination against people with HIV was still a reality for the CHNs in this study. Moreover, discrimination and stigma are still prevalent in Northern Thailand even though, overall, there are now signifi-
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cantly lower rates of HIV infections (Genberg et al. 2009) and this has also been reported within the narratives of nurses in Bangkok (Chan et al. 2008) and in our study. The importance of CHNs working with community volunteers was a consistent theme in our study. Volunteers from all walks of life aspired to help their work, including Buddhist monks. This is a form of merit making, for Thai Buddhists believe that if they perform good deeds in this life, this will please Buddha and improve their karma or fate (Klunklin & Greenwood 2005). In traditional Thai families, women take on multiple roles even if they are infected with HIV themselves, yet their needs tend to be disregarded (Singhanetra-Renard et al. 2001; Songwathana 2001). Northern Thai women with HIV/AIDS expect to experience at least some discrimination (Klunklin & Greenwood 2006) and our four interviewed participants shared their concerns about women not informing their husbands about their prior infection. The CHNs explained that the majority of women depended on marriage to a man who could help support them and their children, providing them with socio-economic and close relationship support. This is consistent with the findings of Klunklin & Greenwood (2005) who reiterated the importance of normalizing a husband and wife relationship for women participants who are infected with HIV. Lastly in the Northern Thailand border areas, there are many hill tribes including those who have fled over the border from Myanmar and among these people, some of our participants provided care for those who were HIV infected. There are also a lot of foreign workers in Chiang Mai Province who need community care and support; however, more research is required about community nursing care for these vulnerable minority groups, and we did not explore these phenomena in detail.
Limitations Our sample was a group of nurses from one province in Thailand, and their perceptions and experiences about HIV education and health promotion maybe quite different to elsewhere in the country. However, the rich findings can be used to inform nurses and other health professionals about innovations in the field of CHN in northern Thailand that might enhance programmes elsewhere.
Conclusion and implications for nursing and health policy We conclude that CHNs in this study had significant and lengthy periods of instructive experiences and in-depth knowledge, and offered a wide variety of health promotion and education for those with HIV, despite having high workload with many kinds of clients. We believe that the findings of this study
Community health nurses and HIV/AIDS programmes
will enhance nursing’s knowledge base about how nurses around the world are attempting to deal with the impact of HIV and the measures used to incorporate culturally driven interventions in health promotion and education in Thailand. Over the last three decades nurses and midwives, including those in Thailand, have had significant roles in the development, implementation and evaluation of primary prevention programmes for people with HIV. Because of their experiences and knowledge, they have developed original, culturally relevant measures for clients, and strong relationships with a variety of key players in HIV and AIDS care. Rich data from this study help to shed light on aspects of health education and health promotion in a province in northern Thailand. This might help community health, education and nursing policy makers with insights regarding enhancing community programmes for people with HIV and AIDS in other parts of Thailand or in other settings internationally. Community nurses in other countries may benefit from the experiences, challenges and successes of their Thai community nursing colleagues.
Conflict of interest No conflict of interest has been declared by the authors.
Acknowledgements We thank the community health nurses for sharing their valuable insights. This study was funded in part by the Faculty of Health Sciences, Yamaguchi University Japan.
Author contributions Design: MA, ST, AK, TS Research supervision: ST Data collection: MA, ST, AK, TS Data analysis: MA, ST, AK, TS Manuscript writing: ST, MA, AK, TS Critical revision and intellectual content: ST
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