Villagers Perspectives on Home based Care for HIV AIDS Patients in Kep Cambodia

. Delivering Home Based Care to PLHA in Rural Kep, Cambodia Villagers’ Perspectives Revah G, Zakus D, Greewal S. Centre for International Health, University of Toronto, Toronto, ON April 1, 2005 Introduction - Background   Cambodia has one of the fastest growing HIV/AIDS rates in the world Prevalence rate of 2.6%  Government steps to control spread – NCHADS 1998: National Centre for HIV/AIDS, Dermatology and STDs – NAA 1999: National AIDS Authority, to implement and evaluate the national response to HIV/AIDS.  Strategic Plan for HIV/AIDS and STI Prevention and Care 2001-2003: – home based care (HBC) as key component in comprehensive care for PLHA  HBC programs exist but need to be scaled-up Introduction - Definition and Benefits Definition: “care given to sick people in their homes. This includes people caring for themselves, or care given by family, friends, neighbours, health and social service workers and others. Such care can be physical, psychosocial, spiritual and palliative.” - WHO Benefits:  decreased likelihood of exposure to other infections • nosocomial transmission of TB       palliation at home nursing care cheaper and more convenient care of minor illnesses relieves the overload of hospitals entry point for education and HIV prevention Finally accessible Introduction - Cambodia’s HBC model   Cambodia’s HBC teams are mostly URBAN Team composition: A. trained government health workers B. NGO members C. trained community members  Team responsibilities: A. clinical management B. nursing care C. counseling, psychosocial support D. social support Communicates with other institutions contributing to care: – – – voluntary confidential counseling and testing centres(VCCT) health institutions PLHA support groups  Introduction - Study Goals  Need for HBC in RURAL areas – poverty – Limited access to HIV treatment centers  To implement the most effective program: – What are the key components of HBC that need to be in place so that the program works for rural Cambodians? – Can the existing model, the one endorsed by the ministry of health, be replicated in rural Cambodia?  specific needs and desires of rural Cambodian communities with regards to HBC This study seeks to discover what a specific rural community in the province of Kep, Cambodia, wants with respect to HBC for PLHA.  Methods Study Site   The small coastal province of Kep Rural: – – – – fishermen and subsistence farmers poor road quality spread over flat land and mountains Scant health and other governmental and non-governmental organizations  Kep’s administrative health system: – headed by the office of the operational district (OD) – three health centers acting under the direction of the OD.  Study: Pong Tak health centre – services 8905 adults and 264 children – five villages – 30 minute walk - 2-hour walk to health centre Data Collection    Questionnaire: close-ended, multiple-choice in English (trans) investigate different components of HBC MoH criteria used as a guideline Methods - Questionnaire categories Demographics Baseline Knowledge Fear of PLHA Team Selection  of villagers with respect to HIV/AIDS  team composition  characteristics of team members  villager’s comfort level with having community members on the team  how much training?  what incentives will ensure attendance at training session(s)?  which clinical care activities are acceptable to be done at home?  should the community receive HIV/AIDS education?  how this education can be carried out?  attitudes towards emotional counseling  the emotional needs of PLHA  how honest PLHA will be during counseling sessions?  the type of social assistance needed by PLHA  how to best care for Orphans and Vulnerable Children (OVC)?  what are the roles of each of the team members?  will an activity have more clout if it is done by a HCW versus a village volunteer?  time commitment of team members  frequency of visits to the homes of PLHA  remuneration to village volunteers  community mechanisms of referring PLHA to the HBCT Training of the village volunteers Program Activities Roles of HBCT Members Logistics Referral to the HBCT Results Summary    N= 119 majority of villagers encourage the creation of a HBCT believe that care from the HBCT will surpass care from the hospital. Team Selection      2 part-time health care workers/ 4 village volunteers M=F Selected based on: knowledge of HIV/AIDS VV training: 11 days VV refresher courses: every two months and their attendance should be financially remunerated. Logistics      3 visits/month; attend to the severely ill more often. 3 members/visit VV work: 14 days/month VV payment: T-shirt +/- bike (if resources allow) team responsible for: symptomatic care, education, medication adherence, referral and transportation to the hospital. Team Composition Choice of the Health Care Worker Team Composition - Health Care Worker 5% 1 9% 1 5% doctor 5% midw ife nurse medic traditional healer 56% Fig 1. Choice of the health centre worker on the HBCT villagers’ preference Team Composition Choice of the HBCT’s Village Volunteer Team Composition - Village Volunteer 23% PLHA Family of PLHA Village Chief Monk Student Red Cross Volunteer 47% 22% 0% 0% 8% Fig 2. Choice of the HBCT’s village volunteer villagers’ preference Results Education      Who: entire village What: HIV transmission, prevention, symptomatic management, hygiene and general nutrition. When: 9 Afternoons Where: Schools/homes for a congregation of villagers Format: informal discussion +/- plays and pictures Counseling No privacy, little confidentiality, risk that PLHA won’t be honest But  emotional counseling and psychosocial support important  90% of villagers claimed they would be honest even with their family and friends attending the counseling session  Privacy and Effectiveness of Emotional Counseling Will PLHA talk about their feelings if their family and friends are listening? 100% 80% 60% 40% 20% 0% y n 10% 90% Fig 3. The villagers’ understanding of how PLHA will respond to emotional counseling, assuming that there is a lack of privacy during the counseling session Results Social Support     Not crucial but if resources allow: food handouts Transportation to hospital, medication and education more important link with other social support community organizations Care for OVC: – monitoring health, – providing them with school supplies – finding them placements when their parents are unable to look after them. Roles  Acceptable that HCW and VV perform any/all of the HBCT activities: –select and dispense medications –psychosocial counseling –social support –community education Roles of HBCT Workers Villagers’ Perception Specific Roles of HBCT members 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% at e up po rt ed uc at e ed ic ou ns . .. Interviewee Responses health care worker village volunteer both ot io na lc Fig 4. em The villagers’ perceptions of how the tasks of the HBCT should be divided so ci al s M Conclusion - Village Volunteer  Villagers are comfortable with acquaintance counseling, medicating and educating vs. professional But Who?  RCV too busy  PLHA as VV: empowerment or further isolation Finances:  Only 10% thought that VV should be paid  VV cannot be expected to work for 14 days per month (as the villagers suggested) without any pay. • MOH’s VV’s were receiving $12/month • wanted an increase to $20/month and a basic package of health coverage.  Payment raises questions of distribution of scare financial resources Conclusion and Discussion Hospital Access  50% thought that above all else, PLHA need transportation to ARV programs, health centres and hospitals. Should the HBCT provide this service? Yes  97% of villagers think that the HBCT should drive severely ill patients to the hospital.  transportation to and from the hospital is seen as the most important contribution of the HBCT to PLHA No  Takes time away from other valuable health services  HBC has low cost effectiveness in rural areas due to the large distance between patients and the extensive time and money spent traveling  Driving patients to the hospital will further exacerbate this problem Conclusion and Discussion Limitations of Research Small sample size of PLHA’s  Integrity of the subject’s answers influenced by the presence of a westerner  meanings may get lost in translation.  The close-ended questionnaire avoids this problem, but it did not allow for answers other than the ones provided to be selected.  Further Directions  Low cost effectiveness of HBC delivery in rural settings, particularly with regards to transporting patients to the hospital  A transport system should be devised.  Payment of the village volunteer.  Research into program implementation: - learning from other community health volunteer schemes such as the British Red Cross. References 1. 2. 3. 4. 5. 6. 7. 8. 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Centre for international Health, University of Toronto, Canada. Submitted March 8, 2004 Acknowledgements We are greatly indebted to Chantha for his translation between Khmer and English. This study would not have been possible without funding from the CIH and the MAA.