African Health Sciences, Vol. 5, No. 2, June, 2005, pp. 114-118
Sexually transmitted diseases in Zimbabwe: a qualitative analysis of factors associated with choice of a health care facility
Seter Siziya1*, Everisto Marowa2, Lovemore Mbengeranwa3 Ahmed Latiff1
1 University of Zimbabwe Medical School, P O Box A 178, Avondale, Harare, Zimbabwe 2 Ministry of Health and Child Welfare, The National AIDS Coordination, Programme, P O Box CY 1122, Causeway, Harare, Zimbabwe 3 City of Harare Health Services Department, P O Box 596, Harare, Zimbabwe *
Correspondence author: Seter Siziya University of Zambia, School of Medicine Department of Community Medicine P O Box 50110 Lusaka, Zambia Tel/Fax: 260-1-256181 Tel (cell): 260-96-748988 e-mail address: email@example.com
Code Number: hs05022
Background: The control of sexually transmitted diseases (STDs)
through rapid and effective treatment is critical in reducing the transmission
of HIV infection. This is only possible when STD patients access appropriate
STD care services.
The prevalence of the human immunodeficiency virus (HIV) is highest in southern Africa. Zimbabwe is one of the worst affected countries in the region and the world over. By the end of 1999 about a quarter (25.1%) of its adult (15-49 years) population was living with HIV/AIDS 1. In spite of this high prevalence rate, the transmission of HIV continues at an alarming rate. In Zimbabwe, HIV infection is mainly transmitted heterosexually. Some sexually transmitted diseases (STDs), such as genital ulcer disease, facilitate the acquisition and transmission of HIV 2-6. Hence, the control of STDs is critical in the reduction of HIV transmission. One way of achieving this is the rapid and effective treatment of STDs which is only possible when persons with STDs do have access to appropriate STD care services.
STD services in Zimbabwe are available in both the formal public and private sectors. In the formal publicsector, services are available at all primary health care and reproductive health facilities, including primary care clinics, maternal and child health care centres, family planning clinics and antenatal and postnatal clinics. STD care services are also available at the outpatient department of the district, provincial and central hospitals and at the categorical STD clinics in Harare and Bulawayo. In the private sector all registered doctors are able to treat persons with STDs. Persons with STDs may also seek care in the informal sector. They may be able to access antibiotics and other drugs from friends, market places and from drug peddlers. Some people when they have STDs may visit traditional healers and faith healers who profess to treat STDs.
In the light of so many health care facilities, it is important to determine factors associated with choice of a health care facility for treatment of STDs so that persons with STDs may be encouraged to access appropriate health services. Although some studies have shown that in general access to health care is determined by factors such as the ability to pay for services, education, religion, gender, and what the health personnel and services have to offer 7-8, these factors may not hold in determining the choice of a health care facility for treatment of STDs. This is a report on factors associated with the choice of a health care facility for treatment of STDs.METHODS
Focus group discussions were used to collect field data. The group discussions were conducted in seven provinces/towns: Harare, Mashonaland East, Mashonaland West, Midlands, Gweru, Bulawayo, Masvingo and Manicaland. Sites for FGDs were selected according to geographical location and size of population served. The FGDs were organised as follows:Women attending for antenatal care
A total of 281 pregnant women took part in 26 FGDs of which 21 were conducted in urban areas and five in rural areas.Women attending well-baby clinic
Altogether 350 women attending well baby clinics were enrolled in 34 FGDs of which 32 took place in urban areas and two in rural areas.Women from the general community
This group comprised of 82 women who participated in eight FGDs of which six took place in urban areas and two in rural areas. Participants were recruited at long distance bus stops and market places.Commercial sex workers
A total of 115 sex workers entered nine FGDs. Most of these women participated in rural areas where 7 FGDs took place as opposed to two in urban areas. These women were enrolled from bars and from the areas (compounds) behind the bars where they usually lived and worked.
Male factory workers
FGDs with factory workers were carried out only in Harare. One hundred and twenty four male factory workers took part in 11 FGDs during the course of the study. The venues for the discussions were the factory sites.
A total of 44 young women participated in nine FGDs. These young women were not seeking health care but belonged to youth clubs in Gweru and Masvingo.Data collection and analysis
Focus group discussion guides were used for each discussion (Table 1). Discussions centred on preference for facility, reasons for choosing a particular facility and expectations of facilities. In particular discussants were allowed to express their views of facilities they would choose if they required STD care. A note taker recorded the discussion in a note book as the discussion progressed. Initial categories of the themes were identified after reading and re-reading the notes. These initial categories were then further categorised into broader themes. The salient features regarding STD health care seeking behaviour of different groups of the population enrolled in the FGDs were then summarised.Limitations
The moderator's probing may have biased the discussants' responses. Furthermore, the note taker may not have recorded some discussion, despite strict instructions to record all what was said during the FGDs.RESULTS
The salient features regarding health care facility choice and STD care seeking behaviour of the different groups of the population enrolled in the focus group discussions are summarised under the following headings: choice of health care facility for any illness, reasons for choice of health care for any illness, choice of health care facility for STD treatment and reasons for choice of health care facility for STD treatment.Choice of health care facility for any illness
The discussion groups of antenatal clinic (ANC) attendees invariably chose the health facility from which they had been recruited for participation in the group discussions as the health care facility they would go to if they fell ill. The health facility of choice for the care of general medical conditions for most of the women from the general community, women attending well-baby clinics, sex workers and female adolescents was their local clinic. Most male factory worker discussants expressed the view that if they fell ill they would seek care at the factory-based clinic or at their local public sector based health facility. Most sex workers also stated that they would go to a traditional practitioner. They also stated that they would visit private medical practitioners if they could afford the fees. Some of the female adolescents stated that they would seek care in the private sector.
Reasons for choice of health care for any illness Closeness of the facility to the clients
One of the reasons given by most of the ANC attendees, women attending well-baby clinics, women from the general community, sex workers and female adolescents for choice of their local clinic for any illness was that the health facility was close to their homes. Meanwhile, most male factory worker discussants expressed the view that if they fell ill they would seek care at the factory-based clinics or at their local public sector based health facility because these facilities were closest to them.
Other reasons for choice of health care facility for any illness
Other reasons for choosing the health facility stated by the ANC attendees were that they could receive care for all their needs at the same place (Supermarket approach), health care providers at the local clinic were competent and caring.
Choice of health care facility for STD
When asked where participants would prefer to go for care if they had an STD, most women attending ANC clinics agreed that they would go to their local clinic. A considerable number of the ANC attendees felt that they would rather be treated by a private medical practitioner than go to their local clinic provided they had the money. A small number of the ANC clients felt they would seek care from traditional practitioners.
In group discussions on where women would prefer to go for STD care should they require it, most women attending well-baby clinics, women from the general community and female adolescents stated they would prefer to be treated at their local clinic than elsewhere. Some women attending well-baby clinics stated that they would prefer to go for STD care to private medical practitioners, while a smaller number of them mentioned that they would rather be treated by traditional practitioners than by staff at their local clinic.
When discussing where they would go for STD care, most sex workers stated that they would prefer to go to a hospital or a traditional practitioner than to their local clinic.
Most male factory workers in the discussion groups stated that they would seek treatment for STD at the factory-based clinic or at the nearest public sector based health facility. A small proportion of the male factory workers felt that they would prefer to visit a private medical practitioner should they have an STD. Some male factory workers stated that they would visit the Genitourinary Centre in Harare if they were infected.
Reasons for choice of health care for STD Accessibility
It was the general view of groups of women attending ANC clinics, women attending well-baby clinics and female adolescents that the health facility that they would choose should be accessible. Some sex workers stated that they would go to the local clinic because of accessibility.
The majority of women attending well-baby clinics, women attending ANC clinics, women from the general community, female adolescents and male factory workers felt that affordability of fees was important in influencing their choice of health care facility. In most of the discussions women attending well-baby clinics felt that the fees that they paid initially covered both consultation and medications, but often the health facility did not have the drugs and the patient then had to purchase the drugs at pharmacies, hence, increasing the costs of care. However, most women from the general community felt that the costs of private medical care were higher than they could afford. They felt that fees at their local clinics were reasonable.
Stigmatisation by health care providers was a major problem for sex workers. This was raised in all the discussions. Most sex workers in their discussions felt that they would rather go elsewhere than to their local clinic because they would be recognised for their trade and be stigmatised. Most women attending ANC clinics, from the general community and female adolescents felt that the choice of a health care facility would depend on the attitude of health workers, which should be caring and nonstigmatising. In the discussions almost invariably the issue of health worker attitudes was raised by women attending well-baby clinics. Some women attending well-baby clinics had had bad experiences at health facilities such as being scolded by the health care providers. One of the male factory workers stated:
"...if they reported with an STD to the factory-based clinic they could be stigmatised or punished in some way and therefore preferred to seek care for STD elsewhere".
This statement was echoed by a few more discussants in male factory workers' focus group discussions.
Most sex worker participants stated that health workers did not offer sex workers condoms and if the sex worker asked for condoms then she would "get shouted at in front of everyone else in the clinic". However, some sex workers remarked that "there were some health workers and traditional practitioners who were very good with them and that they were completely satisfied with them". Some female adolescents also reported positive attitudes of health care providers towards them by stating that health care providers were caring.
Privacy and confidentiality
One of the issues raised by most of women attending ANC clinics, women attending well-baby clinics in their group discussions was that they would go to a health facility that would examine and treat them in privacy. This view was supported by most of the sex workers who felt that health facilities should be constructed in such a way that privacy would always be available. Most of the female adolescents also considered the availability of privacy as an important factor in selecting health facilities, and as a result they felt they would seek care from private doctors if they had STD. A number of women from the general community felt that if they needed care for STD they would prefer to visit a private medical practitioner mainly because they felt that they would be afforded privacy. Many women attending well-baby clinics felt that in the public sector facilities, privacy and confidentiality were lacking. In general the male factory workers felt that their choice of facility for STD care would depend on confidentiality.
Waiting time at the health facility
Some women attending well-baby clinics mentioned that the absence of long queues at traditional practitioner facilities made them choose such facilities. They stated that they were kept waiting for long periods of time at their local clinics. The choice of health facility by most women from the general community would be influenced by waiting time.
Competency of health care providers
Interestingly a number of women attending well-baby clinics felt that traditional practitioners provided very good care for persons with STD and that they spent time in counselling their patients. Women from the general community often stated that they would not mind paying fees provided they received satisfactory and quick attention. They felt that the members of staff at the health facilities were well trained.
Female adolescents stated that the members of staff at the local clinics were skilled in managing patients. However one woman and supported by some women in the general community cited:
"Often patients visit public sector based facilities repeatedly for the same illness because they are not given the correct medication or that the health care provider is not capable of making a diagnosis."
In these circumstances some women from the general community stated that they would rather visit a traditional practitioner who usually understands all illnesses and who spends time in talking to the patient. In the discussions almost invariably the issue of health worker professionalism was raised by women attending wellbaby clinics.
Some sex workers raised the issue that some health workers were not able to recognise medical problems and therefore treatments prescribed were not effective.
Other reasons for choice of health care facility for STD
Other issues that were raised by women attending ANC clinics were that the health facility should provide the drugs on site and the health workers should be able to advice and counsel care seekers. Some women attending well-baby clinics had not been given drugs at health facilities. Some sex worker discussants felt that health workers at public sector based health facilities and some private medical practitioners did not spend time counselling their patients.
This study has clearly demonstrated the importance of having services close to where the people live or work. All members of the public, except sex workers, stated invariably that they would attend a facility that is close to them. Although sex workers mentioned that they would prefer to go to the hospital or traditional healer, all participants in the FGDs invariably stated that accessibility and affordability were some of the factors that would be considered in choosing a health care facility.
Accessibility does not only imply closeness of the location. Participants felt that if the hours of opening of the health facility conflicted with the times that they would be able to use the facility, then the services provided at the facility, no matter how good, would not be accessible.
The findings that affordability and confidentiality were associated with choice of STD treatment facility among male factory workers in the current study concur with some of the findings by Benjarattanaporn et al 9 who found that convenience, affordability and lack of embarrassment were associated with choice of treatment site among men with sexually transmitted diseases in Bangkok.
The cost of health care came up often during the focus group discussions. Fees for service was something that people did not complain about. Though they often mentioned that their choice of facility would depend on whether they could afford the fees. This finding agrees with results from other studies that found that access to income 7 and the ability to pay for services 9 are major determinants of access to health care.
In conclusion, the common factors associated African Health Sciences Vol 5 No 2 June 2005 with choice of sexually transmitted diseases (STD) health care facility mentioned by all the study groups were accessibility and affordability. In addition to these two factors, other factors specific to population groups should be considered in determining access to STD health care facility.
We are grateful to Veronica Zimunhu, Clara Chitengu, Sylvia Sanyangowe and Mr Ziwai Mungoni and for their help in focus group discussions (FGDs). The support received from the Provincial Medical Directors, District Medical Officers and the Directors of Health Services of the cities of Harare, Bulawayo, Gweru and Mutare is gratefully appreciated. We are grateful to Dr Francis Ndowa of the UNAIDS program for his advice on the development of the proposal and for support during the study. We thank the Ministry of Health and Child Welfare of Zimbabwe for permission to carry out this study. The study was funded by the Joint United Nations Program on AIDS (UNAIDS).